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by Steve Ward
Published on June 25, 2018

The medication process is composed of vital medication activities performed by a collaborative team of clinical professionals practicing across the entire health system and continuum, from patient intake through community monitoring. Pharmacist team members play key roles within this process, and the clinical pharmacist can positively impact cost and waste within the intravenous (IV) medication therapy process.

Hospital pharmacists have long been responsible for the management of compounded IV preparation. Timely delivery of an adequate supply of medication to the bedside is important for care of the patient. Pharmacists also serve as stewards of the medication cost to both the patient and health care organization. Unfortunately, too often, ensuring adequate supply while minimizing the cost of waste can be opposing goals resulting in conflicting outcomes. 

One potential solution for this is using smart IV pumps in the medication process. When connected to the electronic health record (EHR), smart IV pumps improve awareness of medication levels and communication among members of the care team. These pumps can also streamline processes, getting closer to a true just-in-time preparation and driving down the cost of medication waste. Various studies have estimated the cost of wasted IV medications to exceed 3 percent of total IV costs and close to an FTE in wasted personnel productivity. With reduced reimbursement rates and decreasing margins, this can create a significant impact on a hospital pharmacy’s budget.

Challenges of centralized IV admixture services

Since the emergence of hospital centralized IV admixture services in the 1960s, and expanded with the current United States Pharmacopeia (USP), there have been 797 regulatory standards for sterile preparation put in place. Many IV therapies ordered for acute care hospital patients must be prepared in a compliant IV compounding room located within the hospital pharmacy. These compounds require pharmacy staff to obtain materials, prepare the medication and be reviewed by a pharmacist prior to delivery to the patient care area for use. 

Due to the time needed to prepare, pharmacies use various strategies to prioritize and schedule doses to be prepared in advance. The timing of preparation must be early enough to allow for preparation time prior to the dose being required, but late enough to account for the stability time and expiration dating. A lack of visibility to current IV therapy status often leads to waste or delays in therapy and impacts staffing. 

There are two common approaches to combatting this issue: batch processing and on-demand preparation. Each pose their own challenges.  

Batch processing relies on the ordered infusion rate of the IV bag and the scheduled start time of the order for the pharmacy information system to calculate when the bag would be empty and schedule one or more bags to be prepared in advance. However, the pharmacy information system has historically been unable to have knowledge of delays in the start of the infusion, pauses in the infusion or changes in the IV rate when adjusting to clinical parameters. These variations, which occur directly on the IV pump, often result in doses being prepared and delivered prior to being needed, resulting in expired or unused doses – which means waste.

On-demand preparation, in which the nurse would contact the pharmacy when the next dose is needed, is a common approach to address batch preparation barriers. The nurse at the bedside takes the current infusion rate, volume remaining and overall patient status for titration or pending orders to discontinue the IV into account when requesting the next dose. While this approach can eliminate some of the issues associated batch processing, new failure points are created when the request for the next bag may not occur with enough advance notice, requiring an emergency preparation. Frequent unplanned emergency preparations impact the pharmacy workflow, as pharmacists are not able to plan and prioritize workload. This can cause delays in treatment, as the next dose may not reach the patient care area in adequate time.

Improved communication through “new closed loop” technology

Over the last five to 10 years, several information system approaches have been developed to improve the IV preparation process within the hospital pharmacy. Most of these systems focus on accurate IV medication compounding through validation of proper ingredients and dosages used in the preparation with barcoding, image capture and weight-based technologies. A work queue is often a part of these solutions and is designed to prioritize preparation sequence. However, many of the same barriers exist in these work queues as with the batch IV process, due to a lack of awareness of current IV pump status to accurately prioritize continuous and variable rate IV infusions.

Over the last five to eight years, the health care IT industry has seen increased adoption of interoperable smart IV pumps into the hospital EHRs. These implementations have focused on the communication of the physician’s order electronically to the pump to decrease manual programming and related errors. In addition, integration of smart IV pumps to the EHR allows for improved documentation from the IV pump, providing infusion rate and volume information into the EHR to speed nursing documentation. With infusion pump information communicating to the EHR, communication within the pharmacy is also improved. This means that, for the first time, the pharmacy can have automated, near real-time awareness to infusion pump status. The infusion status allows the pharmacy staff to prioritize and prepare IV admixtures based on actual time remaining for the current bag, using the advantages of the on-demand model while removing the associated challenges around a lack of communication, which often occurred in that model. These pharmacy dashboards support calculating time remaining of previously delivered doses, using the current rate and remaining volume to prioritize IV preparations.

In my career in hospital pharmacy and informatics, I have focused on the Closed Loop Medication Management (CLMM) system, which includes computerized physician order entry (CPOE) medication, pharmacy verification and dispensing through barcode medication administration. With advances in technology and device connectivity across systems, the CLMM is expanding to include automated dispensing, pharmacy inventory management and smart IV pumps as connected parts of the EHR.

We are approaching an era where IV preparation replenishment service in hospitals will become similar to the technology that we experience in our daily lives. For example, my home printer knows when an ink cartridge is running low and, because it is connected to a cloud-based account service, can automatically place the order for a new cartridge to be shipped and delivered before it is completely out of ink and unable to print. It’s far more important to administer medication at the right time and before it completely runs out, and there are much greater consequences if the medication is wasted and the patient does not receive the appropriate treatment. 

Hospital leadership should take heed. Technology that enables IV smart pump integration with the EHR reduces the cost of medication waste and provides timelier patient care. This valuable addition to the care process should not be underestimated or overlooked.

Cerner’s CareAware Smart Pump Auto Programming Infusion Management connects infusion pumps to the electronic heath record to create the safest, fastest medication administration process in the industry today. Learn more here. 
 

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