Infusions

Corey Diamond, PharmD

Bringing together an electronic health record (EHR) system, an infusion smart pump library, and an I.V. infusion policy to share consistent information can be a challenge for any large hospital system. When the standard concentration policy, pump library, and EHR are out of sync, it creates confusion for pharmacy and nursing staff. As discrepancies between these systems are bound to occur, clinicians are looking for guidance.

A new process improvement method published in Supplement 3 (September 1, 2023) of the American Journal of Health-Systems Pharmacy may provide valuable insight into how EHRs, I.V. infusion policies, and infusion smart pump libraries may be proactively harmonized to avoid harmful medication errors.

Christensen and colleagues conducted a process improvement project at the five hospitals, including a flagship level I trauma center with 546 beds, of the University of Utah health center. The system delivers over 1 million infusions annually.

The health system already had processes in place to update the infusion policy, the pump library, and the EHR; there was, however, a need for a more proactive and formalized process to ensure medication listings are harmonized between them.

“Standardizing these resources can help reduce confusion, improve efficiency in both pharmacy operations and nursing workflow, and improve patient safety,” said the researchers.

Process improvement methodology

The project’s goal was to evaluate the differences between these three sources and to create a new process within existing frameworks to maintain uniformity.

This involved proactively evaluating and synchronizing I.V. infusion guidance data across their health system’s I.V. administration policy, infusion smart pump library, and EHR.

The researchers amended their institution’s processes so that when a medication-related change was requested in one of the three sources—the I.V. infusion policy, pump library, or EHR—it was shunted through both the institution’s drug information system and pharmacy informatics system so that any change to one source would force an update to the remaining two sources.

In other words, prior to releasing changes to the EHR, pump library, or policy, the new method allowed the institution’s pharmacy informatics team to perform a prospective double-check to ensure that all three resources were concordant with one another at the time a medication change was requested.

Data evaluation

The researchers evaluated a total of 187 entries consisting of 84 I.V. infusion medications. They identified a need for 48 policy updates, with the most common themes being updating concentration units and adding medications to the policy.

There were also a few instances of concentrations being available in the EHR but not included in the infusion  policy.

As an example, the researchers point to dobutamine, which had its concentration listed in “µg/mL” in the EHR, but as “mg/ml” in the policy.

Recommendations

The investigators recommended 30 updates to the pump library, primarily adding dosing concentration units for nursing staff.

In a few instances, medications needed to be added or the concentration updated in the pump library. For example, a concentration of isoproterenol was programmed in the library but was not available in the EHR or the policy. They recommended removing the pump programming option.

When multiple resources disagreed, the researchers chose to update the EHR. For example, there was no hard volume limit in the EHR build for bivalirudin, which made it possible to change the base volume of the infusion, thereby changing the concentration.

Next steps

Next steps for this study include stakeholder review of the appropriatenessfeasibility of the 82 recommendations, along with a review of the infusions that were not evaluated in this study, including pediatric snd neonatal, intermittent, PCA/epidural, and continuous/extended antibiotic infusions as well as any infusions in procedural areas.  ■