Evolution of a Closed Loop Medication Use Process

Transcription

1 Evolution of a Closed Loop Medication Use Process Paul J. Vitale, Pharm.D. pvitale@mdmercy.com Vice President and Chief Pharmacy Officer The Mercy Medical Center Baltimore, Maryland

2 Agenda Hospital Background Decisions for EMAR, BMV, and ADCs Description of Closed Loop Medication Use Process Accomplishments Data Capture and Applications Future Opportunities and Challenges

3 Mercy Medical Center, Baltimore, Maryland Nonprofit Community Hospital Sponsored by the Sisters of Mercy 278 Available Inpatient Beds 29 Beds Transitional Care Teaching Hospital Affiliated w/ U of MD School of Med Disproportionate Share Hospital Inpatient pharmacy 24 hours/7 days Complete unit dose and IV admixture program Anticoagulation clinic Outpatient service Outpatient Infusion Center Pharmacy Primarily oncology related therapies

4 About Mercy Medical Center Pharmacy enters approximately 45,000 medication orders monthly Dispenses approximately 200,000 doses/ month- cart fill & ADC EMAR and BMV ADC- controlled substances and certain other line items Plan to migrate to all ADC with new tower MediTECH MOE; CPOE on the very near horizon

5 Decision Process For EMAR, BMV, and ADC Technology Organizational Factors Plans to build a new hospital tower adjacent to current building- standardization of medication management process and maintaining service level at multiple sites Commitment to enhancing patient safety at the Board Level and C Suite Medication errors, lab specimen mislabeling Maryland Patient Safety Center MedSAFE Project- Utilizing the ISMP Medication Safety Self-Assessment R tool Recruitment and retention of professional staff

6 Change is coming in Medication Administration in Hospitals (CMS and meaningful use of an EHR) Old fashioned approach: Doctor Pharmacist Nurse Patient Writes Rx Reads the handwriting (or tries to) Deliver the medicine to a patient Takes the medicine New approach: Computerized Physician Generated Order; Order Entry (MOE, CPOE) ADC/Robotic/Cart Scan Pharmacist Bedside-Medication-Verification Nurse Patient

7 Mercy s Approach to EMAR and BMV Initiate bar code technology for medication administration and lab specimens collections Initial process- patient identification bracelets and bar coding Financial concerns for implementation and maintenance Robotic approach- financial, space, design restrictions Bar coding process was the fundamental key to success Format, scanning process, end user acceptance Reliability at the POC Ability to track each medication dose- FedEx Integration throughout hospital data resources Laboratory, allergies, disease states Future plans for all ADC dispensing and medication dose tracking

8 A Few Factors To Consider When Implementing a Bar-Code Scanning Process FDA Regulations Institutional requirements Availability of unit-of-use bar-coded products Format of bar codes to be used Choice of scanners Drug dictionary issues Scan ability issues including patient ID bands A few obstacles for implementation: Human factors Infrastructure issues Work arounds

9 Hospital-Applied Bar Codes Must provide the same level of safety and documentation for all medications the patient receives Unit-of-use tablets, capsules, and oral solutions when not commercially available If manufacturer-applied bar code is not compatible with system chosen Multiple-dose products (inhalers, cream, etc) Multiple-dose containers (e.g., Antibiotic suspensions) Non-formulary medication Patient s own medication from home Dose prepared in specific amount or volume for a specific patient and order Specially measured pediatric doses; Breast milk Doses prepared from multiple components Admixed LVP, IVPB, TPN, Chemotherapy, Extemporaneous compound Investigational drugs

10 Cross- Functional Planning and Implementation Team Pharmacy Nursing Medical Staff Information Technology Nursing and pharmacy background Patient Access- Registration and Admission Patient ID bracelets- restrictions, re-issues Laboratory- initial meetings Finance

11 Some of the Particular Applications for MMC Barcode (now and future) Institutional Pharmacy Applications to be further developed Support Bedside-Medication-Verification Medication Refill Cart Scan and Tracking System Crash Code Cart Scan and Tracking System OR Medication Tray Scan and Tracking System Bar code repackaging system Screen Medication-Lab Abnormalities Tracking the Medication Management Process using ADCs Patient specific pharmacokinetics (Document, Tracking, Calculations) Aminoglycosides, Vancomycin, Renal impairment dose adjustment, Hepatic impairment dose adjustment. Pharmaceutical calculations (link to patient s medication profile and lab test results) Drug dosing, Creatinine clearance, etc)

12 MMC Barcode Model with Clinical Pharmaceutical Data Mining and Bar Code Technology Pharmacy Nurse Unit Bedside Initial Dose Dispensing Error-Free Med Filling Refill Cart Dispensing Automated Dispensing Cabinet Distribution Scan Med vs Rx Bedside Medication Verification (BMV) Automated Dispensing Cabinet Crash Cart Distribution OR Cart Distribution Clinically Right Dose (Clinical Pharmaceutical Data Mining) Right Patient Right Drug Right Dose Right Form Right Time Clinical kinetics Medication Tracking

13 Refill Cart Process - Scan medication bar code vs patient s treatment

14 Medication Refill Cart Scan and Tracking System Striving For Error Free Refill Cart Filling Lowers pharmacist labor Curtails missing medications Increases pharmacist interventions Faster, more accurate picking and checking Ensures each dose is scannable prior to delivery to nurse Under Development Prevents dispensing of expired medications with Image scanner Track and document (FedEx Type) capability for each medication dispensed.

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16 Pharmacokinetics and Clinical Applications

17 Medication Tracking All Units

18 Medication Tracking Specific Unit

19 Medication Tracking Specific Clinician

20 Tracking Specific Medication and Clinician

21 Tracking Specific Medication and Clinician

22 Tracking Specific Medication and Clinician

23 Tracking Specific Medication and Clinician

24 Med Administration Workload

25 WHAT WE ACCOMPLISHED.. 100% of all doses bar coded (oral, injectable, topical, rectal etc) Oncology the exception Pharmacy infrastructures for Bedside-Medication-Verification Unit dose cart filling and tech checking via scanning Scan-ability of doses for nursing approximately 99% Refill code carts and operating room medication supplies using bar coding technology for expiration tracking and medication utilization Universal mapping process eliminates need for mapping of new products in intra-pharmacy applications, i.e., repackaging and cart checks Tracking of medication doses from ADC to patient administration times CPDM incorporates information regarding scanned doses administered and pertinent lab data Provide more accurate kinetic dosing recommendations

26 Some Future Applications for MMC Barcode Institutional Pharmacy Applications to be further developed Replicate Cart Fill Efficiencies for the ADC refills, inventory controls and scan ability of all doses Screen Medication-Lab Abnormalities Patient specific pharmacokinetics (Document, Tracking, Calculations) Aminoglycosides, Vancomycin, Renal impairment dose adjustment, Hepatic impairment dose adjustment Pharmaceutical calculations (link to patient s medication profile and lab results) Drug dosing, Creatinine clearance, etc) Tracking the Medication Management Process using ADCs All medications Enhance nursing workflow through tracking of medication administration process Enhance pharmacy workflow and tracking of staff functions True closed loop medication management process with CPOE implementation and BMV and all ADC dispensing Financial grants from CMS

27 A Nursing Executive s Comments Regarding Collaboration and Medication Administration Tracking at MMC It is becoming increasingly difficult to balance cost, quality and performance management with patient and staff satisfaction. Sometimes the latest electronic solution becomes the next headache. Developed by the Pharmacy, in conjunction with others at MMC, the software program links information from three separate software programs which until recently could not be linked, resulting in a clear, complete and extremely informative data set. Reports can be run to be as general or as specific as necessary. Each month reports are generated that provide time line information about the nursing practice for obtaining and administering narcotics. Within minutes, areas of concern, if any, become apparent. More detailed reports can be generated depending on what additional information is needed. The information can be used as the basis for process improvement discussions. To date we ve been able to uncover the need to enhance the orientation program for all nurses and to provide additional follow-up training for individual nurses. We also identified bad habits, poor performers, those who are very good at creating work-arounds as well as those who medicate to their advantage rather than the patient s need. The data have uncovered suspicious narcotic usage and have been used to help in the identification of individuals at risk, allowing us to provide support and guidance if welcomed.

28 Thank You Pharmacy Staff Responsible for MMC s Program Awarded the Maryland Society of Health System Pharmacist 2008 Medication Safety Award David Park, RPh., Informatics Pharmacist david.park@mdmercy.com Kathryn Higbee, MS, RPh., Director, Pharmacy Operations khigbee@mdmercy.com Nicholas Smith, Barcode Specialist nsmith@mdmercy.com