Implementing Smart Pumps for Epidural Infusions
Implementing Smart Pumps for Epidural Infusions
In December 2008, to prepare for the implementation of the new smart pumps, data on patients who received epidural infusions at UNCH from March 1, 2008, through September 1, 2008, were collected retrospectively. Orders for epidural medications were identified via the pharmacy information system (Cerner Millenium PharmNet, Cerner Corporation, Kansas City, MO), and the corresponding patient charts were reviewed. The data collected included the number of orders, the patient type (adult or pediatric), the medication selected, the concentration used, and the administration rate. The data on drug concentrations and administration rates were specifically evaluated to identify opportunities for standardization.
A total of 409 epidural orders during the designated six-month preimplementation period were identified. Approximately 83% (n = 341) of these orders were written for adult patients, and 17% (n = 68) were written for pediatric patients. Notably, 26 (6%) of the total number of epidural infusion orders evaluated were not documented as having been administered to the patient.
Most epidural orders evaluated specified the use of a combination of medications in varying concentrations. Individual medications were evaluated to determine the most commonly used concentrations and administration rates. Infusions containing morphine sulfate 40 μg/mL accounted for 84% (n = 198) of the 236 evaluated morphine orders for adults. Of the 45 pediatric infusions containing morphine sulfate that were evaluated, most were for a concentration of 40 μg/mL (40%, n = 18) or 20 μg/mL (29%, n = 13). About 74% (n = 175) of the evaluated morphine sulfate orders for adults indicated an administration rate of 4–8 μg/min; in comparison, the rate of epidural morphine administration to pediatric patients was typically maintained at <6 μg/min (84%, n = 38).
The large majority of bupivacaine-containing epidural orders for both adult (256 of 305 [84%]) and pediatric (49 of 57 [86%]) patients that were evaluated, called for the use of bupivacaine hydrochloride at a concentration of 1%. Among the adult bupivacaine orders, 82% (249 of 305) specified bupivacaine hydrochloride infusion rates of 5–11 mg/hr, whereas 81% (46 of 57) of orders for pediatric patients called for infusion rates of 2–8 mg/hr. Fentanyl orders accounted for only 6% (24 of 409) of the evaluated orders, and clonidine was only administered to pediatric patients, complicating the evaluation of dosing trends for these medications.
To enable a comparison of nursing staff satisfaction with epidural infusion procedures before and after the implementation of the PainSmart pumps and associated CPOE and pump programming enhancements, nurses were asked to complete a preimplementation questionnaire. The survey consisted of items eliciting nurses' concerns regarding the Baxter pumps, suggestions on addressing those concerns, and their overall opinions of the pumps and the quality of care provided to patients receiving epidural infusions. The questionnaire was made available to all nurses at UNCH via a listserver; participation in the survey was optional.
Sixty-six nurses responded to the preimplementation survey; all respondents did not complete all questionnaire items. The majority of the responding nurses were working in the department of surgery or medicine; only 1 nurse from a pediatrics unit responded to the survey. In response to a questionnaire item asking nurses to indicate any concerns they might have with regard to using the Baxter pumps for epidural infusions, the area of concern cited most frequently by responding nurses who indicated any concerns was pump programming (Table 1). Substantial proportions of respondents indicated that efficiency and patient safety were also areas of concern in using the older pumps. When asked for suggestions on improving the process of using smart pumps for epidural administration, the two most common suggestions were (1) the purchase of new, different pumps and (2) efforts to make the pumps easier to use. Of the nurses who responded to the applicable survey item, 72% expressed the view that they were providing good patient care with the Baxter pump. The information obtained in the preimplementation survey was useful in determining key criteria for evaluating various candidate replacement pumps.
A clinical pharmacist initiated the process of compiling the drug library for the new Curlin PainSmart pumps. First, the CPOE system in place at UNCH was reviewed for epidural order sets; that information was used to identify medications for inclusion in the epidural pump library. Only a portion of the existing epidural order sets in the CPOE system included infusion-rate and dosage limits.
After the compilation of a current list of epidural drugs, multiple clinical references and input from UNCH clinical pharmacists were used to determine initial guidelines for the upper limits of epidural boluses and continuous infusions. The consulted references included textbooks specifically addressing the use of anesthetic medications, general pharmacy references, and articles identified through a search of the biomedical literature. Based on the evaluated information, proposed bolus and infusion limits were developed and presented to key end-users, including attending physicians from the departments of pediatric anesthesiology, labor and delivery anesthesiology, and adult pain anesthesiology; those department representatives presented the proposed limits to their respective staffs for review and comments. After further revisions to accommodate current practices at UNCH, a final drug library was compiled and organized according to four categories of epidural use: adult, pediatric, labor and delivery, and peripheral nerve block.
Preimplementation Evaluation
Epidural Prescribing and Dosing
In December 2008, to prepare for the implementation of the new smart pumps, data on patients who received epidural infusions at UNCH from March 1, 2008, through September 1, 2008, were collected retrospectively. Orders for epidural medications were identified via the pharmacy information system (Cerner Millenium PharmNet, Cerner Corporation, Kansas City, MO), and the corresponding patient charts were reviewed. The data collected included the number of orders, the patient type (adult or pediatric), the medication selected, the concentration used, and the administration rate. The data on drug concentrations and administration rates were specifically evaluated to identify opportunities for standardization.
A total of 409 epidural orders during the designated six-month preimplementation period were identified. Approximately 83% (n = 341) of these orders were written for adult patients, and 17% (n = 68) were written for pediatric patients. Notably, 26 (6%) of the total number of epidural infusion orders evaluated were not documented as having been administered to the patient.
Most epidural orders evaluated specified the use of a combination of medications in varying concentrations. Individual medications were evaluated to determine the most commonly used concentrations and administration rates. Infusions containing morphine sulfate 40 μg/mL accounted for 84% (n = 198) of the 236 evaluated morphine orders for adults. Of the 45 pediatric infusions containing morphine sulfate that were evaluated, most were for a concentration of 40 μg/mL (40%, n = 18) or 20 μg/mL (29%, n = 13). About 74% (n = 175) of the evaluated morphine sulfate orders for adults indicated an administration rate of 4–8 μg/min; in comparison, the rate of epidural morphine administration to pediatric patients was typically maintained at <6 μg/min (84%, n = 38).
The large majority of bupivacaine-containing epidural orders for both adult (256 of 305 [84%]) and pediatric (49 of 57 [86%]) patients that were evaluated, called for the use of bupivacaine hydrochloride at a concentration of 1%. Among the adult bupivacaine orders, 82% (249 of 305) specified bupivacaine hydrochloride infusion rates of 5–11 mg/hr, whereas 81% (46 of 57) of orders for pediatric patients called for infusion rates of 2–8 mg/hr. Fentanyl orders accounted for only 6% (24 of 409) of the evaluated orders, and clonidine was only administered to pediatric patients, complicating the evaluation of dosing trends for these medications.
Staff Satisfaction Survey
To enable a comparison of nursing staff satisfaction with epidural infusion procedures before and after the implementation of the PainSmart pumps and associated CPOE and pump programming enhancements, nurses were asked to complete a preimplementation questionnaire. The survey consisted of items eliciting nurses' concerns regarding the Baxter pumps, suggestions on addressing those concerns, and their overall opinions of the pumps and the quality of care provided to patients receiving epidural infusions. The questionnaire was made available to all nurses at UNCH via a listserver; participation in the survey was optional.
Sixty-six nurses responded to the preimplementation survey; all respondents did not complete all questionnaire items. The majority of the responding nurses were working in the department of surgery or medicine; only 1 nurse from a pediatrics unit responded to the survey. In response to a questionnaire item asking nurses to indicate any concerns they might have with regard to using the Baxter pumps for epidural infusions, the area of concern cited most frequently by responding nurses who indicated any concerns was pump programming (Table 1). Substantial proportions of respondents indicated that efficiency and patient safety were also areas of concern in using the older pumps. When asked for suggestions on improving the process of using smart pumps for epidural administration, the two most common suggestions were (1) the purchase of new, different pumps and (2) efforts to make the pumps easier to use. Of the nurses who responded to the applicable survey item, 72% expressed the view that they were providing good patient care with the Baxter pump. The information obtained in the preimplementation survey was useful in determining key criteria for evaluating various candidate replacement pumps.
Development of a Drug Library
A clinical pharmacist initiated the process of compiling the drug library for the new Curlin PainSmart pumps. First, the CPOE system in place at UNCH was reviewed for epidural order sets; that information was used to identify medications for inclusion in the epidural pump library. Only a portion of the existing epidural order sets in the CPOE system included infusion-rate and dosage limits.
After the compilation of a current list of epidural drugs, multiple clinical references and input from UNCH clinical pharmacists were used to determine initial guidelines for the upper limits of epidural boluses and continuous infusions. The consulted references included textbooks specifically addressing the use of anesthetic medications, general pharmacy references, and articles identified through a search of the biomedical literature. Based on the evaluated information, proposed bolus and infusion limits were developed and presented to key end-users, including attending physicians from the departments of pediatric anesthesiology, labor and delivery anesthesiology, and adult pain anesthesiology; those department representatives presented the proposed limits to their respective staffs for review and comments. After further revisions to accommodate current practices at UNCH, a final drug library was compiled and organized according to four categories of epidural use: adult, pediatric, labor and delivery, and peripheral nerve block.
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