Operating since 1962, Memphis, Tennessee-based St. Jude Children’s Research Hospital is considered a top pediatric cancer hospital and research center, with nearly 8,000 patients seen yearly.
St. Jude is the only National Cancer Institute Comprehensive Care Center devoted solely to children, having received the NCI’s highest ranking of “exceptional.” The hospital also has been designated as achieving Magnet status by the American Nurses Credentialing Center, which is based on an evaluation of patient care, safety and satisfaction as well as attracting top nursing talent and demonstrating a collaborative culture among nursing staff.
This collaborative culture and commitment to quality and safety has been the driving force behind a recent interoperability initiative by clinical and informatics leaders at the hospital to integrate the electronic health record (EHR) and bedside patient care devices for infusion management and vital sign transmission. These initiatives have helped to eliminate manual pump programming errors, a top patient safety issue. Because of their cutting-edge work, the editors of Healthcare Informatics have chosen the leaders of St. Jude Children’s EHR-device interoperability initiative as the co-third-place-winning team in the Healthcare Informatics Innovator Awards Program, Providers Division.
According to St. Jude executive leaders, with the hospital’s 2016-2021 institutional strategic plan, one of St. Jude’s initiatives is to strengthen its focus on patient quality and safety practices. To move this forward, nursing, pharmacy and IT leaders have been collaborating on two major projects focused on increasing efficiencies with the EHR—infusion pump interoperability and automatic transmission of vital signs to the EHR from outpatient clinics.
Prior to this EHR-IV pump integration project, which started about three years ago, St. Jude nurses manually programmed infusion pumps with patient identifiers and IV medication orders. Once complete, the nurses then had to electronically sign the medication administration and infused volumes in the hospital’s Cerner EHR. This manual intervention and movement between disparate systems created a cumbersome process that reduced nurses’ time for clinical duties and created opportunities for manual errors, according to Keith Perry, senior vice president and CIO at St. Jude.
“The biggest challenge with infusion management is the human factor,” says Robin Mobley, R.N., inpatient nursing director at St. Jude. “Even though you’ve got a pump that is delivering the medication and it’s delivering it accurately, when you go to that pump and you are entering the rate, the time frame, the volume that is to be infused, every time you do that, every stroke you make on that pump, is an opportunity for error. With interoperability between the EHR and IV infusion pumps, you are taking away that human factor.”
She adds, “The fact that we’re dealing with some really dangerous drugs makes it even more important for us to have that extra security in our workflow processes.”
According to the Agency for Healthcare Research and Quality (AHRQ), adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. The greatest potential for harm lies with medication errors related to intravenous (IV) infusion. Hospitals are faced with the challenge of finding ways to reduce these serious and life-threatening errors. The use of smart IV pumps has helped to improve infusion safety, and many healthcare quality and safety experts advocate that closed-loop interoperability between the smart pump and EHR can significantly reduce medication errors. However, EHR-IV interoperability technology is considered a relatively new innovation and it is a challenging IT issue for most hospitals and health systems.
As St. Jude is a pediatric oncology hospital, a major focus on the project centered on complex chemotherapy IV orders that often involve many different medications. About 95 percent of St. Jude inpatients are on infusion pumps and IV medications also are used in the outpatient setting as well.
The initiative was a strategic collaboration between nursing, clinical informatics, pharmacy, biomedical engineering and enterprise informatics teams. “It wasn’t only interoperability between the devices and the EHR, but it was also between departments,” notes Barbara Gingras, R.N., project manager, clinical informatics within St. Jude’s information services department.
While there were many IT-related challenges, some of the largest challenges were identifying and operationalizing the nursing and pharmacy workflows for all IV infusion orders due to the complicated infusion process, such as chemotherapy protocols, as well as workflows for specific drugs and types of infusion.
“Being a pediatric oncology facility, we likely give, on average, 50 percent more medications than a regular pediatric hospital. We have processes that we use to be able to get all those medications in on time,” Mobley says. “So, sitting down with nursing, with pharmacy, and IT and clinical informatics, we had to look at all those processes put together and map those out; that was a crucial step to getting this implemented.”
She continues, “Even during the implementation, there were challenges that we ran into with trying to take technology that is meant for complex infusions but also geared to a more regular workflow. We really had to work closely with Cerner and Alaris [an infusions systems vendor] and with our clinical informatics and pharmacy team to figure out what processes we can use. We didn’t want the technology to determine our process, but for our process to work with the technology.”