When executives at the 2,000-bed Detroit Medical Center (DMC) agreed to spend $31 million on an EMR and roll it out across eight hospitals in 13 months, no one blinked. That's because the health system had in place a culture focused on collaboration, continuous quality improvement, and technology-facilitated innovation.
But when the decision to implement closed-loop medication administration came up, a number of thorny issues arose, specifically with regard to its implementation in the neonatal intensive care unit (NICU) at Hutzel Women's Hospital. (That facility, together with Harper University Hospital, forms a key anchor within DMC's downtown campus; combined, the two encompass 685 beds.) As is the case at NICUs nationwide, clinicians faced multiple obstacles in implementing barcode-scanning-based medication administration for its smallest patients. Hutzel has neonates who can weigh less than 1 pound, so working with standard-sized barcodes is impossible.
“For me, this was a show-stopper; we just had to figure out with a core team how to do this,” says Valerie Gibson, R.N., who at the time was vice president of patient care services, Harper-Hutzel Hospitals (since then, Gibson has been promoted to chief operating officer for Harper-Hutzel). “So we launched a sub-project to make this work,” she says, adding that a major challenge was executing the project while simultaneously launching an EMR across its facilities.
And Lisa Gulker, R.N., director of clinical transformation at Harper-Hutzel, adds, “There wasn't an automatic assumption that it was doable.”
If it was deemed doable, it would have to be doable for all patients, according to Michael LeRoy, senior vice president and CIO of Detroit Medical Center. He explains that, “As part of the EMR launch, DMC made a conscious decision to include not only physician orders and a whole list of capabilities, but also medication scanning. And if we did medication scanning, it was not only going to be for our adult patients at Harper-Hutzel, but also for our NICU patients, because that population needed to be safe just like our adult population.”
As a result, everyone went to work, with teams led by LeRoy and Gulker. It quickly became clear that the patient band itself was a big obstacle to overcome. It needed to be small enough for premature ba bies, and had to be composed of materials suited for the humid climate and other special conditions of the neonates' isolettes. Fortunately, IT professionals and clinicians were able to work together through several iterations until they had designed a patient wristband for the neonates that met all requirements.
The IT group's work on the wristband was reinforced by other innovations, including the implementation of wireless scanners. As it turned out, using corded barcode scanners was simply too complicated for the NICU, giving rise to physical-use challenges (reaching over and around objects) and infection-control issues.
Many issues had to be dealt with, notes Kathleen McLaughlin, N.N.P., an advanced practice nurse who worked on the project. “There are special issues in the NICU,” she points out, “including the fact that patient bands used there have to withstand the humidity in the isolettes; the fact that our term babies suck on their wrists and their feet, so the bands have to withstand that element; and they have to withstand what we call the ‘pee-and-poop’ test. So we did a three-week trial here, trying out various test bands.”
Ultimately, the solution that worked best in the NICU - the use of two-dimensional barcodes, leveraging an “Aztec” barcode design - was implemented system-wide.
At the same time, clinicians in the NICU worked with the organization's clinical pharmacists and IT staff members to develop order sets and other elements related to dosaging.
Neonatal clinical pharmacist Mirjana Lulic-Botica, R.Ph., explains how it all began. “It really started with the order sets the physicians were going to use,” she says. “We almost wanted a separate catalog for the NICU.”