Smart Pumps: Driving change through data
Joseph T. Moss, Jr., PharmD, MBA
System Clinical Informatics Pharmacist
University Hospitals
Cleveland, OH
Learning Objectives
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Learning objectives (Pharmacists):
– Describe factors leading to smart pump alert fatigue
– Identify data elements to make drug library changes
– Develop a review process to decrease nuisance alerts
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Learning objectives (Technicians):
– Describe factors leading to smart pump alert fatigue
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What is a Smart Pump?
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Alerts versus Alarms
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Alerts
– Medication/IV Fluids Limits
• Soft/Hard
• Duration
• Concentration
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Alarms
– Air-in-Line
– Patient side occlusion
– Free flow
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Medication Alert Fatigue Causes
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Parameters set for most patients
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CPOE orders inconsistent with pump
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New indications and practice changes
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Pharmacy Label volume vs Pump Volume
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Renal doses
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Lack of staff education
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Group Structure
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Develop an interdisciplinary group
– Members
• Nursing
• Pharmacy
• Ad Hoc members
– Review alert and alarm data
– Recommend changes
– Monitor invention impact
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Medication Alert Data Considerations
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Indicators for review:
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–
–
–
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Facility and Profile
Primary/Secondary/Basic Infusion
Medication Name
Therapy
Dose, Duration, Concentration, Rate
Times the Limit
Action Taken
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Example Alert Data
Alert Limit = Drug Library Guardrail Limit
Alert Value = Value user initially programmed
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Medication Review
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Infliximab
– High number of medication alerts in outpatient
infusion areas
– Data review
• Nurse entering small volume-to-be-infused (VTBI)
with the ordered dose
• Pump alerted to a volume-diluent mismatch
• Nurse overrode the alert
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Medication Review
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Clinical Alarms
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Preconfigured by the vendor
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Require clinical review prior to system implementation
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Alarms are usually set to trigger once either a low or
high limit is exceeded
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Clinical Alarms
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Indicators for review:
– Air-In-Line
• Detected single air bubble in IV line larger than the single
bolus AIL limit
– Patient Side Occlusion
• Pressure has exceeded the alarm threshold setting
– Free Flow
• Pump door is open and flow stop clamp is not closed
– Check IV Set
• Infusion set is misloaded
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Clinical Alarms
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The Joint Commission National Patient Safety Goal
06.01.01 to improve the safety of clinical alarms:
• Minimize the potential for harm associated with
clinical alarms by reducing nuisance alerts for
clinicians
• Improve the management of alarm settings pre-set by
vendors
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Clinical Alarms
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UH developed a NPSG Alarm Committee to review:
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Cardiac and fetal monitoring
Respiratory monitoring
Bed/chair/commode monitoring
Smart Pumps for Air-In-Line and Patient Side
Occlusion
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Clinical Alarm Considerations
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Settings:
– Air-In-Line
– Patient Side Occlusion
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Alarm Data Considerations
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Air-In-Line Findings:
• Limit set to detect the smallest air volume (i.e. the
most sensitive setting), which resulted in an
excessive number of alerts.
• The committee determined that the number of alarms
could be safely reduced through improved staff
education
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Alarm Data Considerations
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Air-In-Line Resolutions:
– Do not stretch the tubing
– Close the roller clamp on the tubing set
– Gently fill the drip chamber at least two-thirds full and hang
vertically
– Slowly prime the tubing to avoid turbulence
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Alarm Data Considerations
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Air-In-Line Resolutions:
– Allow solutions to warm to room temperature because air
bubbles may form as a chilled solution warms
– Place the pump level with or slightly lower than the patient
– Pause the channel before replacing a fluid container to prevent
air from entering the IV tubing
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Alarm Data Considerations
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Patient Side Occlusion:
– Limit configured to the highest pressure setting (i.e. the least
sensitive setting) for adult patients.
– Upon review, the group discovered that 10% of these alerts were
occurring at a volume range of 0.1 mL to 1.0 mL
– Alarms were firing while the nurse was still at the patient bedside
but prior to the nurse closing the IV roller clamp.
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Alarm Data Considerations
Moss, J. (2016, February). Reducing Excessive Smart Pump Alarms. Pharmacy Purchasing & Products, 13(2), 2-5.
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Key Takeaways
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Develop an interdisciplinary group to design and review
the medication limits/parameters and clinical alarms
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Review alert and alarm indicators for changes
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Track interventions over time and report the impact
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