The University of South Alabama Children’s and Women’s Hospital, (USACW) located in Mobile, Ala., has an average daily census of about 190 patients, and its pharmacy department encompasses 35 FTEs, half of whom are pharmacists and half of whom are pharmacy technicians.
What’s more, USACW, a teaching facility for the University of South Alabama College of Medicine and an extension site for Auburn University, and a sister hospital to the University of South Alabama Medical Center, serves a high-acuity patient population; USACW’s neonatal intensive care unit is a level 3 NICU, the highest level type, and has an average daily census of 80 babies. USACW is the leading option for high-risk-pregnancy deliveries in southern Alabama, and regularly handles multiple births, pre-eclampsic mothers, addicted mothers, and other high-risk cases.
Given all this, it’s not surprising that the USACW pharmacy staff has been involved in clinical performance improvement work for a number of years. In that context, Robby Smith, R.Ph., M.S., the hospital’s director of pharmacy for over four years, has been leading a multi-year patient safety initiative, with a special focus on such areas as liquid medication storage, optimization of barcoded medication labeling, and automation-facilitated medication administration. USACW has been working with the Mountain View, Calif.-based Omnicell to implement technologies to support optimization in all of these areas. Smith spoke recently with HCI Editor-in-Chief Mark Hagland regarding his team’s efforts in this critical arena. Below are excerpts from that interview.
Tell us about your hospital’s journey towards optimizing medication safety.
We have an average daily census in our NICU of 80 babies. There’s probably not another one that big anywhere in our area. You’d have to go to Birmingham or Atlanta to see another one that size. We also have pediatric intensive care and pediatric hematology and oncology, so those areas treat very high-acuity patients. And we also take care of the moms. And being a part of a university setting, a lot of the more complex, high-risk pregnancies come here—triplets, quadruplets, pre-eclampsic moms, addicted moms, come here. That’s the kind of environment that we have.
So we have a satellite pharmacy dedicated to the neonatal intensive care unit, and we have specialized pharmacists in that area, who work there seven days a week. We also have a clinical pharmacist who works primarily with the pediatric hematology/oncology group, but also with some of the other areas. And then Auburn’s pharmacy school will have some of their faculty instructors come through occasionally, including to the pediatric intensive care unit.
So from a safety standpoint, about five years ago, we started moving forward with several clinical information system implementations that we wanted to try to accomplish. And the first thing we wanted to accomplish was bedside barcode scanning.
Robby Smith, R.Ph., M.S.
Do you have an EMR?
Our electronic medical record really just started. We were a Siemens Invision customer. This spring, we switched from Invision to Soarian; we’re now live on Soarian, and all of our electronic nursing documentation is done in Soarian. So we have a system-wide electronic medical record. But even before that, we had gone live with bedside barcode scanning about five years ago, with a separate system. That was really challenging for pharmacy, and it still is a challenge, as far as culture, for nursing. Nursing wants to see it as a documentation tool, but really, it’s a safety tool.
And we have eCare, which encompasses an electronic medication administration record (eMAR), an EMR and computerized physician order entry, and nursing physician documentation.
Who’s the vendor for your eMAR?
It’s Siemens, except for the Pyxis system, which will change to Omnicell. We also using a program called CribNotes for our nurses, and we use a program called OB TraceView in our labor and delivery rooms, because Soarian isn’t robust enough in those very unique areas. The OB TraceView shows the mom and baby together, for example.
How does that play out in practice?
The nurses have to understand that you have to scan the medication before you’ve given it, because if you scan it after you’ve administered it, you could have made a mistake. So if your view is that this is a tool to document what we’re already done, then you’re missing the point. And you constantly have to keep that in front of the nurses, and that you have to scan your medication before you administer it. From a pharmacy standpoint, it means that every product that leaves the pharmacy has to have an accurate, scan-able barcode on every dose of every medication.
How does that play out in terms of hand-mixed liquids, etc.?
It means that we’re going to do everything possible in the pharmacy, whether it means mixing a liquid, or halving or quartering a tablet, and then putting a barcode on it. Still, you’ll occasionally have situations where the nurse is opening a packet, and putting a medication into breast milk or apple juice, to get the patient to take it. So we caution them that they still need to scan the medication before it’s put into the solution it needs to go into. So we’re constantly harping to them about correct labeling at all stages. And with regard to automation, we are in the process of converting from the CareFusion/Pyxis to the Omnicell product. The go-live will take place this fall.
Which solutions are involved?
There are a couple of different solutions involved. One is a label printer that’s directly on the Omnicell machine. So on those products that the nurse is getting out of the Omnicell, that she has to manipulate in order for the patient to take it, the Omnicell machine will generate a label that’s an exact duplicate of the barcode on the original package. So she has something that’s scan-able, to take to the patient’s room. In the past, if the nurse had to open the package and manipulate it, she had to do her best not to rip the package, and had to carry the empty package to the bedside. Because we require the nurses to do the manipulation or preparation in the meds room, not at the bedside, in order to avoid distraction. So with the label generated by the Omnicell, it will put a brand-new barcode on her new label so that when she goes to the patient’s room, she can scan the actual drug she’s just prepared.
What are a couple of typical patient care situations in which that happens?
One would be where a medication needs to be added to a bottle of formula, or breast milk, or applesauce, or juice. Another would be that the patient can’t swallow a tablet, but the medication only comes in tablet form, and there’s no stability data involved, so the nurse is having to crush the tablet or put it into a solution, because there’s no stability data to help me prepare it in advance. The label printer element is going live with our new Omnicell solution. What’s important to note is that, often, you have situations where the nurse hasn’t completely filled out all the information that might be required by the Joint Commission. And a lot of times, nurses will try to create workarounds to save time, such as taping labels to new packages, but those aren’t optimally safe solutions. This will save time and be much safer.
What do you hope overall will happen in the next year or so, once you’ve gone live?
There are a couple of things that we track that we’re hoping this will improve. One will be, we will be able to track through our bedside barcode scanning software the number times a nurse tries to scan something and the machine doesn’t read it and she overrides it.
When does something like that happen?
Typically, a couple of things might happen. One might be that the nurse has destroyed the barcode when she administers the med. Now, I’m hoping those overrides diminish, because of the availability of a new barcode. Or, the nurse might scan something, and it’s not on that patient’s profile. If there are several different sizes of something and she’s having to prepare a different dose, and that doesn’t match the patient’s profile, the dose could be made from different original dosages; and my system will be looking for a specific drug. Often, a nurse has to create a new dose through mixing two different originals. So I’m hoping that proper labeling from the machine will decrease the number of times that the machine creates an error of logic.
What should CIOs and other healthcare IT leaders understand about this topic?
I think there are a couple of things that are very important for clinicians and IT folks to understand. And one is that computerizing something doesn’t automatically make something safer: garbage in, garbage out. So for example, if a patient’s weight was inaccurately entered into the computer, you could now have an inaccurate weight in the computer. So you really have to look at processes, and is a certain person or process the correct one to enter data into the system? So you have to look at who’s going to enter information, and is a process accurate? I know that we could potentially generate reports hundreds of pages long, and trying to filter through a report that big to figure out the real problems, can just eat up time.
So, keeping reports simple and short is very important. The IT people really have to help the clinician understand, what am I looking at, and why is that important? What does this override number mean? Why am I generating so many overrides? It could be that 90 percent of a clinician’s overrides are totally appropriate, but 10 percent aren’t. And if you can give me a three or four page report that’s meaningful, that’s great. But if you generate a 100-page report, clinicians won’t have time for that. So provide information, not just data. And a lot of times, IT people don’t really know what is important in terms of the data, and what in the data clinicians are looking for. And that’s where having clinical informaticists helps. We have a pharmacist who’s dedicated full-time to IT. And we’re in the process of interviewing for a second person.
Many even large hospitals don’t have a full-time pharmacist informaticist yet.
That’s correct. But we’ve got a lot of information systems here—an EMR; and we just went live with CPOE in July, and we’ve got the bedside medication administration solution, and we’re going live with the Omnicell solution soon and are still on the Pyxis solution. So we’ve just got way too many information systems not to have this support. And a pharmacist informaticist can put things into a language that pharmacists can understand, and into a language that IT people can understand. And it’s very important to have a culture of verification of things; just being automated alone isn’t enough.