Optimizing medication administration on the medical/surgical floors of hospitals is an area in which only a small number of hospitals and health systems have gone full-bore to date, as the processes in that area are complex and require a multidisciplinary approach in order to achieve success. Yet the potential to create far greater efficiency, while at the same time improving care delivery quality, is strong, and open to extensive innovation.
One organization that has been making progress is South Jersey Health Care (SJHC), a four-hospital, 400-bed integrated system based in Vineland, N.J. Betty Sheridan, R.N., who is chief operating officer of flagship facility SJH Regional Medical Center, and the corporate nurse executive for the entire SJHC; and Joseph Alessandrini, assistant vice president for clinical services for the health system, spoke recently with HCI Editor-in-Chief Mark Hagland about their ongoing initiative in this area. Below are excerpts from that interview.
What made you and your colleagues decide to move forward in this complex area?
Betty Sheridan, R.N.: Our strategic plan drives our goals. And providing an environment of patient safety, reducing costs, and providing a high level of medications to our patients, those were three key goals, and Joe led this initiative in terms of medications.
Medications are a skyrocketing part of our budget. So we started work on a five-year strategic plan around 2000, looking at planning for the future, and brought technology in in different phases. We’ve been a partner with [the Mountain View, Calif.-based] Omnicell, and utilizing their technology for patient safety and revenue cycle has been a big part of it.
Betty Sheridan, R.N.
Joseph Alessandrini: We started in early 1998 with Omnicell; we were with a competitor’s product, but wanted to partner long-term with someone to provide a total solution from a patient safety and distribution standpoint. And Omnicell worked best for us from a flexibility standpoint, from a drug standpoint, and from the standpoint of leveraging technology. Initially, we started with automated dispensing cabinets to hold our medications. That was our first phase. We started out using Omnicell’s automate dispensing cabinets, with just 10 percent of meds coming out of the cabinets; then we partnered with Omnicell on their Omnilink Rx scanning technology, prior to CPOE [computerized physician order entry]. We found that to be a very nice bridge, and it served us well for a number of years. The nurse anywhere in the system scans the orders into a digital format, so the pharmacist has the order, is able to magnify the order to see decimal points and to avoid any potential orders.
So paper orders were scanned into the system, and then communicated to the pharmacy that way?
This summer, we began implementing CPOE, and there will still be a need for a limited use of it. What it was able to do is what telepharmacy systems can do, as described in the pharmacy literature, where orders are scanned into the system. And we were able to do this back in 2003. So we’ve been operating our Bridgeton facility without a pharmacy since 2003. And we’re hearing now about telepharmacy being up-and-coming, but we’ve been doing it with Omnicell for about eight years. At Elmer, our pharmacy closes, so our pharmacists at the flagship are able to fill the orders and process them seamlessly.
We went to a point-of-care distribution model, so that 95-plus-percent of the medications the nurses need are available following a pharmacist’s review, through the cabinets on the floors. So a lot of rework has been eliminated. And the meds are there when the patient and nurse need them. What we found out was that the nurses wanted the meds when they needed them. And when you look at traditional pharmacy dispensing systems, even with a robot, turnaround time is at best 2-4 hours. You have to put in the orders, pharmacy has to pick up those orders, check the orders, and then the meds are delivered back to the patient care unit. So a two-hour turnaround time is considered good with that kind of system.
So now under your current system, the meds are essentially available almost immediately?
As soon as the pharmacist receives the order and verifies the order, the nurse has access to that med. The average turnaround time from the time the med is ordered until administration is 28 minutes. And with CPOE, the physician will put the order in, and the order will go right into the system.
So you wanted to create new efficiencies on the way towards CPOE?
And the process encompasses barcoded meds administration?
Sheridan: Yes. We have an electronic record for medication, so the nurse will pull up her or his meds on the screen, the put in the patient’s name into the Omnicell, it will tell you where the meds are, and they go to the patient’s bedside and scan the patient, the nurse, and the meds, at the bedside, so there’s full barcoding.
So you have an eMAR [electronic medication administration record], then?
Yes, we do. We’ve had that about a year. And our eMAR is totally interfaced with the pharmacy system and the Omnicell. And we’ve begun the implementation of CPOE.
Have you documented any metrics on patient safety, like medication error rates?
Alessandrini: They’re extremely low. We were low to begin with, because of a lot of safety measures that were already in place. And even now, we’re probably approaching a four or five sigma now in terms of errors. We talk about errors per 1,000 patient days now, we no longer talk about individual errors. Because of the closed-loop system we have in place, most events are close calls now.
But it has improved since barcoding and the eMAR, right?
Sheridan: And since the shift to the Omnicell. Sometimes, if a patient was in the ICU and was moved, you had to move meds with the patients, and there might be problems. But our errors are extremely low. The benchmarking nationally is not really available, because of variations in reporting patterns, etc. But we monitor that on every level, and the error level remains extremely low. And that’s why we insisted and insist on having nursing partnering with pharmacy, as we go through trials on new technologies. So we have some pretty good research data on that.
I’m sure with CPOE that you brought the physicians in to sit down with the nurses and pharmacy to strengthen things further, right?
Sheridan: We have a physician implementation team working with all the other teams; and IT has been wonderful. And physicians are driving that process around order entry, so that there’s ownership and buy-in in that process.
What are you hoping will happen once you’re fully implemented on CPOE?
Alessandrini: One of the things we’ve learned is that for clinical pharmacists to intervene, they would have to be there with the physicians, or you’d lose the opportunity. We are working closely with physicians and pharmacists on creating appropriate, but not burdensome, speed bumps, so that the appropriate interventions will happen while the physician is at the terminal, to appropriately adjust for height and weight, renal function, etc., so that the pharmacist will be freed up for other opportunities, such as antibiotic stewardship, a program for selection of the correct antibiotic for the culture.
Sheridan: And having CPOE will enhance that opportunity.