Implementing Smart Pumps for Epidural Infusions in an Academic Medical Center

Julie Kennerly; Alex Jenkins; Ashley N. Lewis; Stephen F. Eckel

Disclosures

Am J Health Syst Pharm. 2012;69(7):607-611. 

In This Article

Abstract and Introduction

Abstract

Purpose A hospital's initial experience with the implementation of new smart-pump technology for epidural drug delivery is described, with a discussion of challenges and lessons learned during the implementation process.
Summary After a focused review of epidural medication use and prescribing patterns at the University of North Carolina Hospitals and Clinics (UNCH), a multidisciplinary team guided the selection of new smart pumps and the development of associated software tools. The new devices were programmed to display a "master drug library" of recommended drug concentrations, doses, and rates, which were consistent with newly created order sets intended to standardize prescriber ordering and nurse administration intended to help standardize prescriber ordering and nurse administration of adult and pediatric epidural infusions. However, data retrieved from the new units after several months of use indicated that nurses were still programming about 60% of epidural smart-pump infusions without using the onboard drug library (in effect circumventing the units' patient-safety software). In a survey of UNCH nursing staff, respondents indicated they were having difficulty in accessing the library and (when necessary) in manually programming the new devices. The hospital's experience highlighted a number of key points for institutions to consider during the implementation of new smart-pump technology.
Conclusion The implementation of new smart-pump technology for epidural infusions at UNCH revealed the importance of pump features and design in determining the devices' impact on patient safety. In particular, factors pertaining to ease of use (e.g., protocol-selection functions, programming procedures, data recording and retrieval capabilities) are crucial to the overall success of smart-pump implementation.

Introduction

The widespread implementation of smart pumps in recent years has resulted in overall improvements in the process of medication administration. Reported improvements have included decreased nurse workloads, increased staff satisfaction, decreased costs, increased patient safety due to a reduction in preventable adverse drug events, and increased quality of care.[1–5]

While there are reports in the professional literature discussing the benefits of using smart pumps for various types of i.v. medication administration, published information on the use of smart-pump technology for epidural drug delivery is limited. Despite a relative lack of supportive evidence, it is believed that smart-pump technology for epidural infusions has the potential to yield the same types of benefits documented with other smart-pump applications. The successful implementation of smart-pump technology is predicated on the development of a standardized pump library of medication dosages and concentrations, with preset "hard" and "soft" infusion-rate limits.

Computerized prescriber-order-entry (CPOE) order sets developed by multidisciplinary groups have been used to facilitate the programming of smart pumps for epidural infusions. While these order sets have been in use for a number of years at the University of North Carolina Hospitals and Clinics (UNCH), most prescribers preferred to use paper orders as opposed to the CPOE system, consequently bypassing the safety checks that standardized order entry provides. At UNCH, the implementation of new smart-pump technology for all epidural infusions, coupled with updated epidural order sets within the facility's CPOE system, was undertaken to improve patient care by optimizing the medication ordering process as well as the medication administration process. The optimal use of smart-pump technology depends on prescribers' adherence to approved drug concentrations, dosage strengths, and infusion rates, as specified in the applicable CPOE order sets; in effect, the use of the CPOE system forces the standardization of medication ordering. For the implementation of smart-pump technology to be fully successful, an institution must first review and update its CPOE order sets for infusable drugs; the order sets are then programmed into the smart pumps' onboard drug library to ensure standardized ordering across the organization. Ideally, nurses use the drug library to program the smart pump to deliver the prescribed infusion to the patient.

At UNCH, an 803-bed academic medical center, smart pumps have been used for a number of years to improve the process of medication administration in a variety of situations: small-volume intermittent (piggyback) infusions, administration of maintenance fluids, continuous infusions, syringe-based drug delivery, and patient-controlled analgesia (PCA). However, until recently, UNCH had not implemented standardized procedures for smart-pump delivery of epidural medications. An older pump system, the Baxter (formerly BARD) I ambulatory PCA pump (Baxter, Deerfield, IL), was being used for epidural infusions but did not have smart-pump features such as a drug library, standardized dosing algorithms, dosage limits, or the ability to read the pump face to determine infusion parameters. The existing pumps' lack of safety software emphasized the need to update UNCH processes for smart-pump delivery of epidural infusions in order to ensure the safe administration of epidurals and improved patient care.

The smart pump that was chosen for implementation at UNCH was the Curlin PainSmart IOD with medLIMITS (B. Braun Medical Inc., Bethlehem, PA). This selection was made by a multidisciplinary committee with strong nursing representation, which reviewed the capabilities of several available pump models. The Curlin PainSmart product was chosen because it can be configured for epidural, i.v., and subcutaneous infusions. It can also provide "information on demand" while the pump is active in response to single key presses, as with most PCA pumps. In addition to monitoring the infusion process, the PainSmart software documents and records infusion programming data. The pump is equipped with safety features that include free-flow protection, occlusion detection, and programmable medication limits. The documentation and safety features of the Curlin PainSmart were two of the more important factors considered in choosing the pump to improve patient care at UNCH.

This article describes the process by which standardized procedures for smart-pump delivery of epidural infusions were implemented at UNCH, including the development of the CPOE order sets and pump drug library, the evaluation of smart-pump utilization data, and the resulting impact on nursing staff satisfaction.

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