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Oxford University Hospitals NHS Foundation Trust

Closed-loop medication supports digital maturity

People in a computer lab

As part of the accreditation as a Global Digital Exemplar (GDE), Oxford University Hospitals (OUH) were required to achieve HIMSS Stage 6 at one of their hospital sites. The main outstanding piece of work required to achieve this goal was to implement positive drug identification (PDID) and to maintain a minimum of 50% adoption across the site to demonstrate closed-loop medication.

OUH put together a programme of work to invest in their staff and really drive up the adoption rates with nurses on the wards to not only achieve the required element for HIMSS and GDE accreditation but to exceed and sustain this goal.

Fiona Mills, one of the architects of the project at OUH, talks here about the approach and shares some of the successes and challenges experienced along the way.

Closed-loop medications

The Nuffield Orthopaedic Centre (NOC) was the focus for the initial project, selected due to the existing digital maturity across the hospital and the familiarity with using the EPR. The NOC is already completely paperless in the majority of inpatient areas.

The electronic medication journey actually began back in 2012 and started with PPID, which requires the scanning the patient’s wristband at the point of administration. In order to successfully meet the criteria for HIMSS Stage 6, OUH also needed to be able to demonstrate scanning the medication as part of the process, known as closed-loop medication.

There were a number of increased safety goals associated with this work:

  • Reducing prescribing errors through illegibility
  • Ensuring allergy information is readily available
  • Introducing electronic prescription checking with pharmacy
  • Implementing electronic verification
  • Rolling out electronic documentation with audit trail

Challenges along the way

One thing the team hadn’t accounted for was the amount of variance across the wards, from both a hardware and physical environment perspective. For example, some drug carts didn’t have inbuilt storage for medications, which had a significant impact on efficiency. The team also needed to make sure that barcode readers at the bedside were able to read the actual barcodes on the medications.

To help mitigate issues during the go-live, OUH ensured that they had floor walkers who could support in the event that equipment wasn’t working and could get it fixed/swapped. Clinical educators provided at-the-elbow support to reinforce correct practice and nurse specialists were onsite to listen to concerns and provide in-person guidance, so people felt supported. Engagement, confidence and buy-in of ward managers was almost more important than ensuring the technical challenges of the workflows were met.

There were legitimate circumstances where nurses could not scan the barcode and, in those scenarios, the workflow can override and the user can log the reason why. For example, this happened with antibiotics where the barcode is on the box rather than the individual ampule, with IV fluids and also with patient’s own medications, as the barcode may not be recognised. In order to achieve HIMSS Stage 6, OUH had to demonstrate the technical solution for every scenario where it wasn’t possible to scan the barcode.

The project was not without its complexities as it impacted so many clinical areas, teams and workflows. As chief nursing information officer (CNIO) Simon Noel says: “This project was like a microcosm of the whole digital journey, not just an intervention.” As a result, the team have formed a really strong relationship with the ward managers at the NOC, which will help for future projects.

Monitoring and maintaining

In order to meet and maintain the adoption rate required, the team provided regular feedback to wards on how they were doing with their scan rates – focusing on a carrot rather than stick approach to target training and provide support – creating a positive experience for the wards.

Working closely with reporting and pharmacy teams to pull together data to demonstrate and prove the achievements was an important factor, but this was quite a manual process initially. As a result, the team looked to build out a dashboard to support ward managers and give them ownership across their department in terms of understanding how staff are using the system. As you can see on the graph, the rates prior to 26 October were below the required 50%, but once users became accustomed to the additional support and feedback to the wards (which started at the beginning of October), the rates begin to improve.

PDID rates graph

Figure 1: Manually processed data

PDID overview screenshot

Figure 2: PDID overview

What next?

Building on this success from the NOC, the team are planning to expand to other sites across the Trust and aim for HIMSS Stage 6 more broadly. The lessons learned from the initial implementation have really helped to shape the wider rollout.

Clinical teams have been hugely supportive of the new workflows and have provided really positive feedback. The team recognise that one of the key enablers to engagement was having the digital nursing team lead the implementation, providing the necessary ‘translation’ between clinical teams and technical design. This has proven to be a real success story for digital nursing at OUH.

GDE accreditation means OUH is now an internationally recognised NHS provider that delivers improvements in the quality of care through providing staff, patients and partners with world-class digital tools and information. To learn more about their journey, please refer to the following news article.

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Client outcomes were achieved in respective settings and are not representative of benefits realised by all clients due to many variables, including solution scope, client capabilities and business and implementation models.