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.”
And, referring to the broad range of potential medication problems, she adds, “We didn't want anything that would cause problems with inappropriate product picks. So I had the opportunity to work with Kathleen (McLaughlin) on building order sets. We didn't even know at first what the system would look like, so we started by using Word texts. So Kathleen and I and our teams developed initial order sets based on disease state,” and then worked with the neonatologists and pharmacists on staff to build files, create the medication ordering system, and interface the various system elements.
The result? “We've eliminated many different kinds of errors that once occurred across the system, but especially in the neonatal area,” Lulic-Botica reports.
One key element, from the pharmacy standpoint, is that the organization can now package and label every medication possible in clearly marked dosages. “We want to make sure that the final product the nurse has is ready to go, in terms of its ability to be attached to a feeding tube or otherwise administered.”
Lulic-Botica and her colleagues have thus measured, labeled and barcoded medications to an extraordinary extent, and have taken the additional step of color-coding labels, so that all medications destined for the NICU have blue barcoded labels on them, while those for adult patients have white.
Such intensive work on the pharmacy side means, “We've eliminated the decimal-point errors, the dosaging errors,” that still plague most NICUs. And when combined with the system-wide EMR/CPOE implementation (using Kansas City, Mo.-based Cerner Corporation), Lulic-Botica says the organization is also benefiting from the elimination of transcription and communication errors and clinical decision support capabilities.
At the same time, McLaughlin points out that the entire initiative “forced us to standardize our practices,” to achieve a single standard across all four NICUs in the Detroit Medical Center system. From the beginning, McLaughlin says, “We agreed that we would establish one standard of care, and it would be evidence-based.”
Clinicians must drive
It is very important to consider the magnitude of what has been done and why at Detroit Medical Center, says Thomas Malone, M.D., who became president and CEO of Harper-Hutzel last September. Malone, who for years practiced as a neonatologist, says the real breakthroughs in patient safety come with the implementation of comprehensive systems such as EMR and CPOE. It is that kind of innovation that has made DMC a safer place for patients, he says, noting that recent high-profile cases have made the public more aware of patient safety risks.
Of course, Malone says, “We were planning to do this completely apart from the headlines anyway. This was a part of our development of a system-wide standard of care. But what has amazed me has been talking to other executives from other hospitals that have physician order entry and scanning at the bedside, but they haven't linked those systems. And the reason they haven't done so is because of the difficulty involved.”
What's clear at DMC is that LeRoy takes a team approach to everything, including working hand-in-hand with the clinician leaders.
Malone says that such an approach pays dividends. “What made this (initiative) so successful is that it was a clinically driven project supported by a strong IS team,” he says. “At the end of the day, everything done was done to support our clinical vision. And that's why all of our clinicians bought into the implementation, because they knew it was IS supporting our clinical practice as opposed to IS handing them implementations.”
Malone adds, “Mike (LeRoy) is very supportive. What he does with his team is that he sits down with you and figures out a way to support the rest of the hospital.”