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Advocating for and Implementing IV-WMS
Advice from the experts
Advocating for and Implementing IV-WMS
By Gina Shaw
According to a recent ASHP national survey of pharmacy practice in hospital settings, IV workflow management systems (IV-WMS) remain underused in U.S. hospitals, particularly at smaller institutions.
Overall, 16.4% of hospitals reported having adopted IV-WMS; when broken down by size, 57.6% of the largest hospitals (≥600 staffed beds) are using the technology, versus 4.6% of hospitals with fewer than 50 beds. Only the largest group of hospitals broke the threshold of 50% or more using IV-WMS. However, IV-WMS adoption increased from 6.5% in 2014 to 12.8% in 2017, and the adoption rate of certain key components was higher than that of the systems overall. For example, 31.6% of all hospitals reported barcode scanning to verify the ingredients of sterile compounded IV preparations. (For adoption data from a 2020 ISMP report, see page 8.)
“With most institutions having incorporated computerized physician order entry [CPOE] and barcoded medication administration [BCMA], the next area of safety is the pharmacy’s IV room,” said Dennis Killian, PharmD, the vice president of clinical operations for Peninsula Regional Health System, in Maryland. “There is a lot of risk associated with IV room processes; however, no authorities are saying that you have to adopt IV workflow management systems, whereas if you want to obtain incentives under meaningful use, you have to incorporate BCMA and CPOE. IV workflow technology takes effort to implement and costs money; without a mandate, some pharmacy practices just won’t do it. We’ve relied on pharmacy leaders and organizations such as the Institute for Safe Medication Practices to push this technology and say this is what we need to keep patients safe.”
IV-WMS advocates are hopeful that calls for its implementation from pharmacy standard-setters will get louder. The THRIV Coalition for IV Accuracy, launched in 2019 to champion the “universal adoption ... of IV-WMS healthsystem pharmacies,” recently succeeded in getting several proposed resolutions accepted by USP for consideration to be adopted into USP’s 2020-2025 objectives and goals.
“One proposal argues that IV-WMS should meet or exceed the criteria outlined in the coalition’s Technology Checklist,” said Mark Neuenschwander, THRIV’s founding director. “Another seeks to ensure that all medications, including those used for preparing IVs, have barcodes that include lot number and expiration date. Compounders need to know if the diluents and ingredients have been recalled or are out of date. Humans easily miss these things, but barcode scanners will not, and this is one more layer of safety that IV workflow can bring to the equation.”
“These resolutions have been incorporated into the formulation process for USP’s next five-year goals,” Mr. Neuenschwander added. “So we’re on their radar, and we are hopeful that we will be able to work with their scientific committees to formulate policy that will achieve those two goals.”
A USP spokesperson confirmed that IV-WMS “is very much on the radar of the Compounding Expert Committee.” For more details, see page 6.)
Barriers and Considerations
In addition to the often cited issue of cost, many institutions struggle with culture change and adaptation as a barrier to the adoption of IV-WMS. “They say, ‘What is it going to do to my process?’ Things to consider include, how do I have to restructure my room, do I need to change where I store drugs, and how would not having the final label before making a dose change the process?” said Thomas Moniz, PharmD, the director of pharmacy operations at Northern Light Eastern Maine Medical Center, in Bangor. “Yes, initially it will take time to adjust; depending upon the size of your operation, it may take a few weeks or a month. But you do hit your new normal, and there is evidence to suggest it is possible to achieve time savings.”
Those increased efficiencies require a full walk-through of how your system will change. “If you slow people down in one area, they will find shortcuts in another, so you have to be careful about your impact on workflow, in the same way we couldn’t just turn on barcoded medication administration in nursing without understanding their workflow,” Dr. Moniz said. “For example, you will no longer have labels printing out that you’re putting on a tray with your vials and bags; in some systems, the labels don’t print until you’re almost done compounding.”
Eastern Maine Medical Center designed its new sterile compounding space, which went live in November 2019, with its upcoming acquisition of IV-WMS in mind. “We made sure internet connections were available, and some of our hoods even have USB ports in them,” Dr. Moniz said.
Marianne Ivey, PharmD, a professor emeritus at the University of Cincinnati James L. Winkle College of Pharmacy, stressed that hospitals considering IV-WMS need to “look
see ADVOCATING, page 12
continued from page 10
carefully at the functionality of each system you’re considering; the devil is in the details.”
As just one example, “do you want digital visualization at intervals or do you want it continuous? You should also get a feel for the vendor’s reputation, based on your own or colleagues’ experience with that vendor—how they represent the product and how they support it once it’s implemented,” said Dr. Ivey, a former pharmacy services vice president for a multihospital system. “In my experience working with pharmacy technology companies, there’s a pretty wide spectrum of quality in those who represent the company to help implement, utilize and maintain the systems you’re installing.”
Gravimetrics to verify dose amount/volume is one of the least-adopted elements of IV-WMS: 5.4% of all hospitals and 21.2% of the largest hospitals are using it, according to the ASHP survey. But that may change; newer iterations of some IV-WMS products have improved on their integration of this function into the overall workflow.
“For some earlier systems, gravimetrics was kind of retrofitted in and never quite worked right, but newer technologies are incorporating gravimetrics from the ground up into a push-type system that makes the workflow easier, with fewer steps and actions required of the user,” said Peninsula Regional Health System’s Dr. Killian. “Once you weigh the product, you don’t need to click a button to say, ‘Hey, I’m weighing this.’ The system acknowledges the weight automatically and moves to the next step.”
Although some hospitals have tried to incorporate IV workflow management into their electronic health record (EHR) systems, Dr. Killian said that the functionality still lags those built specifically for the purpose. “The jury is still out on EHRs and their ability to work in this space as a comprehensive offering,” he said. “Some sites seem to feel what they offer is good enough, but it can’t replace a true IV workflow system.”
Dr. Ivey reported that she is on the advisory board of ConsortiEx and previously was a co-investigator of a study that was funded by Baxter. Dr. Killian reported that he has spoken for Baxter on IV workflow.
IV-WMS MANDATE
continued from page 8
from USP, Anne Bell, the group’s senior communications manager, said the “topic is very much on the radar of the Compounding Expert Committee, and is one of the considerations being discussed for the proposed revisions to the compounding chapters.”
Robert Campbell, PharmD, the clinical director of standards interpretation and director of medication management at the Joint Commission, Oakbrook Terrace, Ill., wrote in an email that “with exception to the National Patient Safety Goal requiring the use of smart pumps for the IV infusion of heparin, The Joint Commission standards focus on processes of care and do not identify a technology that must be used to achieve desired outcomes.”
Not Necessarily Regulatory
As for nonregulatory bodies jumping into the fray, Mr. Neuenschwander noted that many have managed to boost implementation rates for several patient safety technologies, and he hopes THRIVE can convince them to do the same with IV-WMS. For example, although neither CPOE nor BCMA systems are mandated, both technologies are part of the Leapfrog Group’s grading structure, “which is no small reason why using these two technologies have become de facto standards of practice,” he said.
ISMP is yet another nonregulatory body that is a staunch advocate of IV-WMS, arguing in an online article (bit.ly/ 3tdDrg3) that the technology should be “both a leadership and regulatory mandate.” Furthermore, the organization’s 2022-2023 Targeted Medication Safety Best Practices for Hospitals includes a recommendation to employ IV-WMS (bit. ly/3pJa1kX). As for which specific vendor or IV-WMS technology to choose, one useful approach is to consider the experiences of other health systems that already have implemented an IV-WMS system (sidebar, “URMC’s Experience,” page 6).
Although ISMP holds sway within the pharmacy community and among patient safety experts, Christina Michalek, BSPharm, RPh, FASHP, a medication safety specialist at ISMP and the administrative coordinator for the Medication Safety Officers Society at the organization, said “the bottom line is that people respect what’s regulated.”
“People in the pharmacy community look to ISMP and other professional organizations, and they follow the literature in pharmacy, so they have a sense of the value of this technology,” she added. “But it’s people outside of pharmacy that need to see the value, and that is most effectively done if it’s required.”
Administrators “might question the value of these systems because they might not see a clear association between IV compounding errors and patient safety.”
If compounding errors occur and go undetected, they may not be linked directly with a patient’s change in condition, Ms. Michalek said. “Errors are happening; administrators just might not know about them.”
The sources reported no relevant financial disclosures.
