Implementing Smart Pumps to Enhance Patient Safety

In the report by the Institute of Medicine, safe medication practices must be implemented in patient care.¹ Many hospitals routinely review many processes within their organization to identify opportunities for medication improvement. Technology plays a large part in the medication process.² There have been numerous technological advances in the process of medication administration such as intravenous (IV) smart pumps. One process that hospitals and organizations may consider reviewing for improvement is implementation and/or optimization of IV smart pump technology. By utilizing smart pumps, safer care for patients may be provided.^2,3 Smart pumps do not eliminate errors; however, they reduce programming mistakes.⁴ Features of smart pumps may include drug libraries, profiles of care areas, and soft and hard limits.⁵ When implementing or optimizing an IV smart pump, there are numerous factors to review and consider. Ensuring the success of smart pumps includes drug concentration standardization, monitoring, and identifying improvement opportunities.⁶

Standardizing Drug Concentrations

One of the first items to consider when implementing smart pumps is standardization of drug concentrations. By limiting the number of concentrations available with evidence-based recommendations, one could potentially reduce errors not only through the smart pump but through compounding as well. Standardizing concentrations can occur within one hospital or within an organization which involves multiple hospitals. If multiple hospitals are standardizing concentrations at a division or corporate level, key stakeholders should be available to discuss evidence-based best practices as it relates to concentrations. Choosing the most appropriate concentrations, which are suitable for multiple hospitals, could be a challenge, and some facilities may need to change their concentration if they are an outlier. Formulary changes may be required at an individual facility. For instance, facility A may have a medication designated as double strength, while facility B has the same concentration listed as a standard strength. Changes to long-standing nomenclature may provide opportunities for medication errors if not properly communicated to health care providers. With the key personnel at the meeting, a consensus may be reached, which could help improve patient care and set the foundation for smart pumps.

The benefits of standardizing or limiting available concentrations for specific medications are that it provides standardization of protocols and may prevent errors in selecting appropriate concentrations both at the facility and system level. Most hospitals in a health care system often share staff, for example, physicians, nurses, and pharmacists. Through standardization, health care team members may work at multiple facilities and with the same process reduce the potential of concentration errors in dosing. Continuity of care is also maintained if a patient is transferred from one facility to another for their drug infusions.

Medication Limits

Once a foundation has been established with concentrations, the next step may include setting soft and hard limits on the smart pumps. Soft stops have an upper and lower setting which alerts the user and may be overridden.⁵ Soft stops could potentially reduce errors by alerting the nurse, thus double-checking the administration rate. Hard stops will notify the nurse if a dose is outside the hospital’s predetermined range for safety and not allow the medication to be infused.⁵ In a study by Mansfield et al, 1664 potential errors were avoided by the smart pump in 6 months.⁷ Smart pumps can provide clinical support for registered nurses.⁸ When establishing limits for the smart pumps, multidisciplinary teams that include providers, nursing, and pharmacy may be essential in setting up evidence-based limits, which improves patient safety. Prior to the meetings, reviewing the literature, current processes, and proposed limits may benefit the multidisciplinary team discussions. If smart pumps are being implemented across multiple hospitals, individual representation from each facility is crucial in determining the appropriate limits.

When incorporating multiple hospitals, standardizing limits may require more discussions due to different service lines and practice. Having clinical care area–based teams which are knowledgeable is vital to providing infusion parameters for medication limits that will work for patients across multiple facilities. If higher limits were required for specific facilities with different patient populations, additional care areas would need to be created to accommodate those needs. If changes are required in an individual care area, the multifacility group that those changes will affect must approve the request.

Drug Library

Once concentrations and limits have been implemented, the drug library will need to be disseminated. Updating the drug library has been identified as an area of improvement with regard to determining when the update will occur and increasing communication.⁹ Where an organization is with implementation may affect how often you update your drug library. See Table 1 for Smart Pump Implementation Checklist. For instance, if you have recently implemented a new smart pump, you may identify opportunities for improvement and determine an update needs to happen monthly for a few months. After a few months, an update need not occur monthly and the facility can determine whether the drug library pumps will occur quarterly or yearly. Reviewing the drug library at least annually will help improve patient care and identify any areas that need adjusting. In addition, adding new medications to the drug library when added to formulary will help prevent workarounds by nursing staff. One study found that nurses may utilize a basic mode for administering infusions when they are unable to find a medication in the smart pump.¹⁰ Deviation from utilizing the smart pump and its limit features may cause harm if an error occurs with programming.¹⁰

Table 1.

Checklist for Smart Pump Implementation.

Smart pump checklist
Preimplementation
Involve key stakeholders
Set a timetable
Standardize concentrations
Set upper and soft alerts
Select care areas
Develop drug library
Provide education
Develop plan for requested revisions to the smart pump
Implementation
Provide education
Upload the drug library
Obtain Feedback
Postimplementation
Obtain feedback
Evaluate care areas
Review and revise alerts if needed
Review and revise drug library if needed
Review requested revisions
Provide utilization to all nursing leaders
Set up dates for a drug library update

When drug library updates are made, it is helpful to provide a log of changes to each care area from the previous library and a full copy of all medications in each care area. Providing the most current library allows the nurses and pharmacists to know what drugs and concentrations are available for their care area.

Having a division or system based library allows for pump updates to be performed or pushed out to all IV pumps at the same time for all facilities.

Quality Checks

After smart pumps have been implemented or optimized, quality checks will help continue to improve the medication administration process. Identifying the time and personnel for collecting and analyzing data is essential prior to implementing smart pump technology.¹¹ In one study, through analyzing the alerts, they were able to identify issues such as adjusting limits and the need for additional training.¹² There are many ways in which hospitals or corporations may choose to perform quality checks. Some analysis may include the percentage of medications being chosen from the smart pump. This data may also be provided by unit to nursing leaders. One hospital was able to increase their pump compliance from 37% to 70.5% in 5 months by implementing numerous interventions.¹³ Some of the interventions included, but were not limited to, identifying the clinical issue, collecting feedback from nurses, reviewing usage reports, adding an “IV fluid” and “IV antibiotic” to the drug library, and ensuring all IV medications on formulary were on the smart pump.¹³ In another study, compliance of smart pumps was different between and within health care systems.¹⁴ Some of the differences may be due to configurations of the pump, training, and safety culture.¹⁴ Standardization within a health care system may improve compliance. Other analysis that may be reviewed are soft and hard alerts. The top 10 to 20 medications which are overridden may be reviewed and a multidisciplinary team convened to discuss the alerts and best practices. In one study, the top medications were chosen based on the frequency and number of total alerts.¹⁵ If a decision is made to adjust the drug library, a formal proposal may be required by the hospital or division. When analyzing infusion pump data between multiple hospitals, it may be helpful to have oversight from a nonbiased individual such as a division clinical lead.

Smart Pump Technology

There are many options for IV Smart pumps today and it is important to understand the differences between their features. Some pumps have wireless connectivity for pump library updating and reporting. There are also options for defaulting to drug library versus basic infusions, as well as syringe mode infusions, concurrent infusions, and IV bag and tubing options. When selecting a system, all factors need to be considered.

Conclusion

Implementing smart pumps requires planning and involvement from key stakeholders. When implementing smart pump technology for multiple hospitals, including representatives from all facilities and care areas is vital to the success. Smart pumps are one way in which hospitals can provide safety checks for their health care center.