Pharmacy Technology Report (September 2020) by McMahon Group

Best practices in automation, informatics and patient safety

SEPTEMBER 2020 â&#x20AC;˘ Vol. 6 No. 2

Telepharmacy:

A Portal to Care During COVID-19 Page 6

Make the most of IV compounding robots Page 12

Cutting back on medication alerts Page 14

Restocking cart trays during pandemic Supplement to

Page 16

Smart pump safety tips Page 18

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Managing Inventory During a Pandemic ‘We’ve had to manage PPE W very closely, monitoring and

hen some people began talking about a “second wave” of COVID-19 in June and July, James Stevenson, PharmD, the vice president of medication systems strategy for Omnicell, could only shake his head. “We’re not in a second wave,” he told Pharmacy Technology Report. “We’re in a resurgence, and in some places in the country, they’re still waiting on a first wave. But it will come.” As that happens, Dr. Stevenson maintained, clinical intelligence on the pharmacy supply chain will be invaluable to all hospital and health-system pharmacies. “There is tremendous disruption in the supply chain as the pandemic moves through an area,” he said. “The demand for certain medications increases substantially, yet when you stop doing elective surgeries, the need for other medications declines. These rolling changes in product demand require a number of different mitigation strategies, and understanding and having good control of your pharmacy inventory is critical to being successful in that.” Pharmacy leaders at Vanderbilt University Hospital and Clinics, in Nashville, Tenn., can attest to the importance of a well-crafted inventory management plan. But they started out the pandemic with ground to make up. On March 3, just 10 days before COVID-19 was declared a national emergency in the United States, Nashville was struck by a tornado that badly damaged Vanderbilt’s primary pharmacy supply storage facility, which held substantial amounts of the hospital system’s personal protective equipment (PPE), as well as fluid supplies. “We reached out to ASHP and colleagues in the Northeast

modeling our supplies just as we do with on-shortage drugs, which is nothing we’ve ever had to do before.’ —Mark Sullivan, PharmD right away, knowing that the pandemic was already affecting them and wanting to understand their experience and what we could expect,” said Mark Sullivan, PharmD, Vanderbilt’s associate chief pharmacy officer and a member of the Pharmacy Technology Report editorial board. “They shared a medication list for us to give to our procurement team, and we started assessing our ICU medications, such as paralytics and antibiotics. That enabled us to build up a reserve to meet projected patient surges.” As of mid-July, Dr. Sullivan said, Vanderbilt had seen what he called “stable surges”—slow upticks in COVID-19 patients—rather than an overwhelming increase. “So far, we feel good about our inventory, and continue to use data analytics to help model what we need to have in stock.” Despite this preparation, he acknowledged potential shortages of medications and PPE. “The biggest issue to date is that we have had to switch to sterile reusable see INVENTORY, page 4

Editorial Board Informatics Karl F. Gumpper, MMI, RPh, BCPS, CPHIMS, FASHP Pharmacy Informatics Manager Boston Children’s Hospital Boston, Mass.

Jerry L. Fahrni, PharmD

Automation

Pharmacy and Informatics Consultant Fresno, Calif.

Mark Sullivan, PharmD, MBA, BCPS

Beth Prier, PharmD, MS, CPHIMS

Director of Pharmacy Operations Vanderbilt University Hospital Nashville, Tenn.

Associate Director, Pharmacy Informatics The Ohio State University Columbus, Ohio

Ellen F. Secaras, MBA, RPh Corporate Director of Pharmacy Systems Integration, Corporate Pharmacy RWJBarnabas Health West Orange, N.J.

Pharmacy/Point of Care

Kevin A. Clauson, PharmD

Mark Neuenschwander

Associate Professor, Pharmacy Practice Lipscomb University College of Pharmacy Nashville, Tenn.

President The Neuenschwander Company Bellevue, Wash.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

INVENTORY continued from page 3

gowns from disposable for our sterile products operation,” Dr. Sullivan said. “We’ve had to manage PPE very closely, monitoring and modeling our supplies just as we do with on-shortage drugs, which is nothing we’ve ever had to do before.” On the medication side, Vanderbilt is most closely watching fentanyl, hydromorphone and propofol. “So far, we’ve been able to keep supplies on hand, which is very fortunate,” Dr. Sullivan said. A pharmacist dedicated solely to drug shortages, added to the procurement team approximately five years ago, along with a pharmacist project manager position, have proved highly useful in tracking Vanderbilt’s needs during the pandemic, he noted.

Several institutions have converted recovery rooms to ICUs in response to the pandemic. “But those settings were not designed to manage drug supply in a safe digital manner,” Dr. Stevenson said. “Typically, there is about a three-month time line to install secure storage solutions provid‘The use of neuromuscular blockers, opioids and ing digital visibility, such as new sedatives goes up between three- and sixfold over automated dispensing cabinets. Obviously, we don’t have that kind the normal run rate [during COVID-19 surges], so of time right now. So we have it’s important to plan ahead and anticipate that as developed a series of standardized solutions to deliver to cusyou come into a peak in your area.’ tomers in about 10 days, so that —James Stevenson, PharmD they can get these units up and running very quickly. Usually we Dr. Sullivan’s inventory advice to other institutions fachave to go on site to do this, but we’ve been able to innoing a potential surge: “Have good processes in place to vate to do most of this virtually so that customers can do track your inventory and medication use. You need good most of the setup without having us on site.” lines of communication with your key manufacturers and Omnicell also has been studying usage pattern data to wholesalers to stay abreast of issues with medication determine if the results could serve as a proxy to indicate supplies and PPE.” a city, state or region’s recovery. “We know that certain drugs are used in different types of elective surgeries, and Responding to COVID-19 Surges during the height of the pandemic, the use of those drugs went down to almost zero. Increasing usage patterns of Omnicell has been using insights gleaned from custhose medications could provide an indicator of ramp-up tomers who were hard hit during the early stages of the time, how quickly an organization or an area is recoverpandemic, such as in New York and New Jersey, to guide ing,” Dr. Stevenson said. institutions in areas with more recent surges, such as the Beyond the pandemic, digital visibility into a hospital or Sun Belt and Midwest. “The use of neuromuscular blockers, health system’s pharmacy inventory is important to optiopioids and sedatives goes up between three- and sixfold mizing medication use over time, Dr. Stevenson noted. “A over the normal run rate, so it’s important to plan ahead crisis like this magnifies the need,” he said, “but there is and anticipate that as you come into a peak in your area,” so much pressure on health systems today from economic Dr. Stevenson said. “To try to preserve products, we advise constraints and drug shortages. If you have drugs just sitcentralizing where inventory is maintained to reduce ting on open shelves or in boxes in a central pharmacy, waste.” That process, he noted, often requires using digital you can’t manage them effectively.” tools to track inventory across a health-system, “so you —Gina Shaw can move it around intelligently rather than [relying on] manual searches and having to have people go out and search on shelves.” The sources reported no relevant financial relationships.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Telepharmacy in the Time of COVID-19 I n March, with a potential surge in COVID-19 VID-119 case ca cases ase sess o on n the horizon, the Geisinger Health system realized very m re eali ea lize ze ze ed d ve v e ery ry ry early that it needed to make some changes. es. As the system implemented several initia initiatives atiive es in n iits ttss clinics and hospital sites, Geisinger’s pharmacy worked arma acy y wor orke ked ked aggressively behind the scenes to keep e employees mp m plo oyees yee ye ess ssafe affe a without compromising patient care. By mid-March, 78% off d-Ma darc ch, 7 8% %o its specialty pharmacy staff were working from home; only fro ho om me; e; onl nly those staff needed to fill and ship orders remained on emaine em ne ed o n ssite. iitte. e. Home-based pharmacists focused on remote order entry mo ote t o rderr e rd ntrry nt y and verification, precertification and priorr a authorizations, uth hori riza za attiion ons, s, and telephone-based assessments and cl clinical lin inicall tteaching. ea ac ch hin ng g.. Clinical pharmacists across the system sched scheduled video dul uled uled e v ide id eo o conferencing appointments with their patients filled ents and d fi illlle ed d iin n any gaps in care, and inpatient pharmacists home t moved dh whenever possible, implementing virtual rounding with the medical team and patient education sessions using Skype. These initiatives happened fast, according to Gerard Greskovic, BS Pharm, Geisinger’s system director of ambulatory pharmacy programs. “Pharmacy began working with our system’s telemedicine team, and within three days of starting these conversations, staff at 12 pilot sites were trained and equipped to use the technology. Two weeks later, all 70 of our ambulatory clinical pharmacists went live with the functionality.”

What About Reimbursement?

ince the pandemic’s arrival, the Centers for Medicare & Medicaid Services has expanded coverage of telehealth with an 1135 waiver, enabling providers to be reimbursed for office, hospital and other visits, even for patients outside of remote areas (go.cms.gov/2DfPFxB). Unfortunately, pharmacists are not one of the recognized providers under this waiver, said Bonnie Kirschenbaum, MS, a pharmacy consultant based in Boulder, Colo. So, as usual, pharmacists can bill for completing medication orders. “The time and effort they spend using telepharmacy to teach patients how to use those medications as well as other outpatient clinical services they provide would need to be billed in an ‘Incident-to’ manner as part of an established relationship with a provider such as a physician,” she said. At Geisinger, pharmacists have mirrored their billing and documentation process off of what physicians within the system were doing. For example, when ambulatory care pharmacists conduct a video conference, they use a modifier that can be attached to a traditional office visit billing code for reimbursement. To manage the up-front costs of telepharmacy, Monument Health Deadwood Hospital, in South Dakota, used federal funding for COVID-19 to purchase tablets for pharmacists to collect patients’ medication history and perform reconciliation remotely. —A.M.

Source: Cardinal Health

Telepharmacy allows pharmacists to conduct remote counseling, prescription entry and product verification during the COVID-19 pandemic.

Telepharmacy has long been a staple of providers whose patients don’t always have easy access to a local drugstore. But since the arrival of COVID-19, this mode of practice has increased dramatically. “In general, pharmacists are just trying to minimize the touch points for the patient,” said Toni Fera, PharmD, a senior consultant with expertise in ambulatory care, based in Pittsburgh. “Anything that doesn’t require an urgent, face-to-face visit is being shifted to telepharmacy.” Patients and providers have been asking for more remote connections for years, she said. COVID-19 “just kicked everything into high gear. It was like somebody turned a switch on.” As for who is throwing that switch, about one-fourth of telepharmacy customers are health systems—a proportion that hasn’t changed since the pandemic, according to Adam Chesler, PharmD, the director of TelePharm regulatory affairs at Cardinal Health. But some new customers now hail from different parts of the country, as additional states have begun allowing pharmacists to conduct remote counseling, prescription entry and product verification during the pandemic. “This has enabled us to help our pharmacy customers get vital medications to their patients without having to risk the health and safety of the patients and pharmacy employees,” Dr. Chesler said. At Geisinger, pharmacists have relied on the InTouch Health app and desktop computers or tablets with cameras to perform these visits, Mr. Greskovic said. EPIC software makes things even easier, he noted, because it links pharmacists to patients’ labs and radiology results. “It’s basically no different taking care of a patient 45 miles away than 10 floors up,” he said. see TELEPHARMACY, page 8

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Source: Cardinal Health

TELEPHARMACY continued from page 6

Mr. Greskovic added this advice: Figure out what you need and design the process around it. For instance, he said he realized too late that he should have had his softwareenabled pharmacists and technicians save a picture of the final product to the patient’s file to verify it was prepared correctly. Instead, they have to manually enter the initials of the person who verified the order, and whether the verification was electronic. “Make sure you know what you need so you can design your equipment around it,” he said.

Checking Technicians Remotely At Monument Health Deadwood Hospital, in South Dakota, a motorized base with a camera linked to another facility scans the pharmacy, watching technicians fill and verify orders. The pharmacist in charge of the camera—possibly located dozens of miles away, at another Monument Health facility in Spearfish—moves the camera over the technicians’ shoulders as they prepare medications under the hood, talking them through something they might have never made before. Telepharmacy has been a feature at Monument Health for about 10 years, as a way to serve remote areas of the state. But even here, things have changed since COVID-19, said Dana Darger, RPh, the director of pharmacy at Monument Health’s Rapid City Hospital. He has split his previously onsite staff in two, with half doing order entry from home for one week and then rotating. The hospital also added iPads to the floors so remote pharmacists and technicians can take patients’ medication history and perform medication reconciliation. Experience helped with the transition, Mr. Darger said. “It wasn’t a huge paradigm shift for us because we’ve been doing remote patient care for a long time.”

Health systems—some in rural, underserved areas—are using telepharmacy software to check orders remotely.

she added. “Without telepharmacy services, it can take three to five outbound phone calls, leaving messages and awaiting responses to gathering clinical, lab or necessary data from a patient to schedule a refill. Texting a refill reminder, offering patients a form to securely schedule their refill, and having a real-time chat with one of our clinicians to support counseling or clinical data collection is a tremendous time saver, allowing us to serve our patients faster.”

Tracking Outcomes Dr. Fera agreed that data collection on telepharmacy is key—particularly in the case of clinical outcomes. But be ready for mixed results, she noted. It may be easier to reach patients by phone when they are staying at home, for example, but pharmacists can sometimes build better rapport with patients when they are face-to-face. Other patients may be nervous or hard of hearing in a retail setting, but have amplifiers on their phones, and be more relaxed at home. “We don’t yet know how effective telepharmacy will be from an overall care standpoint, but the anecdotal experience has been quite positive,” Dr. Fera said. Mr. Greskovic also underscored the important of tracking outcomes. So far, video appointments have been going very well at Geisinger, he noted. It has become a factor in boosting patient satisfaction, and in some cases has even demonstrated a reduction in “no-show” rates compared with traditional clinic office visits, he said.

Launching New Services BioMatrix, a specialty pharmacy based in Florida and with locations across the country, provided most of its services over the phone before COVID-19, but has since launched new telepharmacy services that offer patient counseling via secure chat as well as refill and clinical management activities. “Our use of telepharmacy services increased by 45% since the middle of March 2020,” said Meagan Sampogna, PhD, the chief operating officer. Switching to a new workflow can bring challenges in any setting, let alone amid a global pandemic. In specialty pharmacy, providers have to coordinate care with other providers, Dr. Sampogna said. Some therapies require inhome nurse visits, and lab work and other clinical data. “We continue to collaborate with our technology partners to connect … many health care providers, patients and other clinical team members to our technology services, so we can leverage our telepharmacy platforms to coordinate care in as seamless a manner as possible,” she said. Having the right technological setup and tools is key,

Next Steps Although Monument Health’s Mr. Darger sees the value of remote patient care—and documenting that value—he said he is looking forward to bringing the staff back to the hospital, where they can have more regular interactions with nurses, providers and other pharmacists. “There are obvious benefits to being on site,” he said. But he may keep the iPads, which allow pharmacy technicians—who are trained to collect medication history—to keep doing this task, rather than passing it to busy ED nurses. “That piece, I think we may continue doing.” Some aspects of telepharmacy will outlast the pandemic, Dr. Rim agreed, because patients and providers appreciate “the convenience factor,” he said. “If you can get what you need from technology, I don’t think we will go back to pre–COVID-19.” —Alison McCook The sources reported no relevant financial relationships.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Telepharmacy: 5 Tips for Getting Started E very American health facility is scrambling mbling to figure out the best way to fight the COVID-19 pandemic. Recently, the CDC suggested that providers use telemedicine whenever possible (bit.ly/2Uklk5x; Uklk5x; bit.ly/2U3yrsN). But adopting the technology isn’t sn’t as simple as adding some video equipment and nd smiling for the camera. Here are some imple-mentation tips for making a good start.

Keep it simple. For pharmacists accustomed to treating patients in a tradi-tional brick-and-mortar setting, a rapid d transition to telepharmacy may seem daunting. ing. Indeed, there are many barriers that prevent pharmacists harmacists from quickly providing all services to patients in n a remote fashion, but even simple phone calls enable pharmacists to remotely check in on patients and answer their questions, according to Timothy P. Stratton, PhD, RPh, a professor of pharmacy practice at the University of Minnesota College of Pharmacy, in Duluth. “For patients, telepharmacy can be provided through a number of different formats,” Dr. Stratton told Pharmacy Technology Report.

Keep privacy top-of-mind. There are many reasons why traditional pharmacists can’t quickly switch all of their services to a remote format, but one oft-cited roadblock is privacy requirements such as those stipulated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any communications between provider and patient—video chat, emails and text messaging—have to be compliant with HIPAA, and that isn’t easy to do, acknowledged David Bush, RPh, a telepharmacist and the owner of Medicap pharmacy in Hancock County, Ind. Fortunately, software can go a long way in satisfying the basics of HIPAA, he noted. Mr. Bush’s telepharmacy set-up, for example, employs tablets with proprietary encryption software that ensures any communications are secure. (Of note, federal officials recently extended telehealth services to Medicare patients as a result of the COVID-19 pandemic, and indicated they would stop enforcing some aspects of HIPAA that might impede remote communications.)

Be ready to wrestle with reimbursement. Telepharmacy has a long way to go before it becomes an easy way to work, Dr. Stratton said; beside the issues with HIPAA compliance, there are problems with reimbursement. “Many states do not pay pharmacists for providing telepharmacy services, nor are all private insurers willing to pay pharmacists for providing telepharmacy services.” Fortunately, the Department of Health and Human Services is helping on the payment front by developing and implementing a new payment rule

for federally qualified health centers and rural health clinics that provide telehealth services to eligible patients, as reported in Pharmacy Practice News (bit.ly/2EcB4mY). (For more details on reimbursement, see page 6.) Know your state regulations. Telepharmacists who want to use more than a telephone will have to do some research, because regulations on telepharmacies vary state by state (J Pharm Pract 2020;33[2]:176-182). In Minnesota, for example, pharmacies can use the state Department of Human Services’ Vidyo video conferencing network to provide telepharmacy services, such as medication therapy management, to patients who have a mental health diagnosis, Dr. Stratton said. “But to do so, the pharmacy may need to purchase hardware that is compatible with the state system.”

Be ready for workflow tweaks. Although telepharmacy often can save providers time, they may struggle with time management, noted Dr. Stratton, because telepharmacists often are juggling other responsibilities. For instance, St. Luke’s Hospital in Duluth serves as the hub hospital for the “Wilderness Coalition,” a consortium of small critical access hospitals throughout Northeast Minnesota’s Arrowhead Region. Eight of these small hospitals used St. Luke’s pharmacists to remotely review orders during nights and weekends and then release medications through automated dispensing cabinets at the remote hospitals—all while keeping up with their regular duties at St. Luke’s. “The hospital had to ensure that those shifts were adequately staffed,” Dr. Stratton said, “so the telepharmacist would be able to focus on the needs of the remote hospitals when needed.”

—Alison McCook The sources reported no relevant financial relationships.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Make the Most of IV Compounding Robots I ntravenous (IV) chemotherapy compounding robots can yield important operational and safety benefits for health-system pharmacies, including greater productivity and reduced error rates. However, according to experts, reaping those gains requires close observation, careful consideration and ongoing finetuning processes.

Maximizing Robot Productivity

shift by further optimizing the balance between batch compounding and patientspecific orders. He said over time, his staff also has been able to reduce their robotic compounding error rate, from roughly 2% when they first implemented the robot to 1.1%. “Most of the errors we see with the robot happen when preparation volumes deviate from the gravimetric validation process by 10% or more, which is the range beyond which we consider unacceptable,” Mr. Cohen said, noting that the inclusion of gravimetric validation in the robot “assures both safety and quality of the chemotherapy preparation.”

For example, when it comes to optimizing the productivity of an IV compounding robot, “if you buy a robot with the intention of compounding everything with it, you’re not A pharmacy technician programs the KIRO system at Yale New going to maximize the effi- Haven Health Smilow Cancer Center Hospital in Connecticut. ciency of the device,” said Howard Cohen, RPh, MS, the executive director of oncology Can’t Put a Price on Safety pharmacy services at Smilow Cancer Hospital at Yale New Haven Health, in Connecticut. Although Mr. Cohen’s team did not present a return on In a recent study, Mr. Cohen and his colleagues described investment (ROI) analysis for the robot, he noted that his how they implemented an IV compounding robotic sysinstitution saves on closed system drug-transfer devices tem (KIRO Oncology) for chemotherapy compounding. (CSTDs), which the robot does not require. The system’s He noted that some pharmacies use robots strictly for self-cleaning feature also means staff spend less time batch compounding, but the complex nature of cancer cleaning the unit, he said. “However, the greatest ROI—and drug preparation requires them to prepare a large proporthe one that’s hardest to put a price on—is the added safety tion of patient-specific orders. that automated compounding provides by reducing staff “We use the robot for batch compounding in the early exposure to hazardous drugs and reducing drug errors.” morning and late evening hours for advance orders and Rachel Gilbert, an independent health care consultant dose-banding of chemotherapy, and then we do patientin Toronto, agreed that protecting staff from cytotoxic specific compounding during the day,” Mr. Cohen said. drug exposure is a critical benefit of robotics. But she said “We decide which patient-specific orders should be the error reduction Mr. Cohen cited is another major plus. mixed robotically based on several parameters, such “There is a great opportunity for automated workflow as dissolution rate and the number of needle insertions support and robotics to help reduce or even eliminate required into the drug vial.” compounding risks to patients,” she stressed. Mr. Cohen and his team compared the productivity Ms. Gilbert should know, because she and several coland accuracy of 52,858 products compounded during an leagues spent about three days observing manual comeight-month period, either with the robot or manually, pounding processes at four cancer center pharmacies with the help of an IV workflow system including barcodin Canada between 2013 and 2015. The sites ranged in ing technology and digital photography. They found the compounding volume from 15 to 300 products per day robot averaged five to six doses per hour, with a daily (J Oncol Pract 2018;14[5]:e295-e303). Ms. Gilbert said volume of 80 doses compounded, and accounted for up her group did not witness actual errors occur during their to 22.4% of the total daily volume. “relatively short observation period,” but they did identify That level of productivity was similar to the average 11 potential errors due to wrong drug, dose or diluent, of 5.6 doses per hour that pharmacists compounded which carried the risk for “catastrophic consequences,” manually, but Mr. Cohen believes his team can safely such as patient death or permanent loss of function. increase robotic production to 100 doses per 12-hour Ms. Gilbert cautioned, however, that “no system is

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

A close-up of the robotics system (IV Station, Omnicell) in use at Cone Health in Greensboro, N.C.

fail-safe. The little details of implementation are always key to reducing human error, and institutions need to analyze their automated processes and ensure that previous mechanisms of error are truly eliminated, and to identify new sources of error.”

Examining Details at Cone Health Scrutinizing their robotic processes is precisely what pharmacists at Cone Health, a health care system based in Greensboro, N.C., did when they installed two robotic systems (IV Station; Omnicell) in mid-2019. “The first thing I did when the robots arrived was spend time in the room watching them operate,” said Christopher Boiallis, PharmD, a quality assurance pharmacy coordinator who oversees the two units. To maximize productivity, he documented the time to compound specific preparations and other process considerations, like loading and unloading time. “Based on these observations, I picked the products that made the most sense to compound,” Dr. Boiallis said. That careful process meant that since Cone Health installed the robots, the machines have compounded roughly 100,000 products—an average of 500 daily— during their 14.5 hours of operation each day. In fact, Dr. Boiallis said their devices are the two most productive IV Station units in the country, based on internal Omnicell data, with an output 20% higher than the third most productive IV Station.

“When it comes to reducing errors and rejected doses, we also work very closely with our Omnicell engineer, to the point where if we see any hint of production falling or an increase in compounding failures, we get them on the phone and tweak the robot either remotely or in person,” Dr. Boiallis said. Minor problems that can be easily fixed can have significant downstream implications, he noted. For example, a pincer that takes hold of a vial 1 mL off its target can result in a needle entering at the wrong angle, leading to variations in volume and increasing the rejection rate of products. By tending to such operational problems, Dr. Boiallis and his colleagues increased their successful preparation rate to 98%, he said.

Cozy Up To Your Robot Based on his interactions with other sites, the one piece of advice that Dr. Boiallis would give institutions considering a robot is to spend time with their IV robots. “Get in there and get your hands dirty,” he said. “Try and scan the wrong product or trick the system into doing something that it shouldn’t do, for example. Once you get a good idea of how the products run, you can really optimize output and reduce errors and rejections.” —David Wild

Dr. Boiallis and Mr. Cohen reported no relevant financial relationships. Ms. Gilbert reported serving as an advisor to, and receiving honoraria from, BD, and receiving research funding from CareFusion Canada.

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

A Way to Cut Back on Medication Alerts E veryone agrees: Medication alerts about patient safety are annoying. Most of the time (in ≥96% of cases, some research shows), providers simply override the warning, thereby defeating the whole purpose of the alerts. One hospital in the Netherlands has a possible answer to so-called “alert fatigue.” Within two years, St. Jansdal Hospital, in Harderwijk, reduced the number of pop-up alerts received by pharmacists by 70%. For prescribers, the number of alerts has fallen even more dramatically: For every 100 orders, prescribers receive only 3.2 pop-ups. This marked reduction came about through a series of changes, such as removing alerts that don’t apply to a hospital setting, adding clinical decision support (CDS) software, and creating a centralized queue for alerts, which is monitored by an on-call pharmacist. “We can dramatically

‘If you’re only seeing a few pop-ups during your eighthour shift, they will get noticed.’ —Pieter Helmons, PharmD reduce our alerts because we have much better tools to monitor our patients,” Pieter Helmons, PharmD, a hospital pharmacist and the chief pharmacy informatics officer at St. Jansdal, told Pharmacy Technology Report.

Switching Off Nuisance Alerts As a first step to cut back on alerts, St. Jansdal took a critical look at the pop-ups that providers were receiving. Not surprisingly, many of the alerts were irrelevant for hospitalized patients—such as warnings to take medication at bedtime, or the need for blood glucose monitoring, which happens at hospitals regardless. “Those kinds of warnings can be switched off in a hospital setting,” Dr. Helmons said. So St. Jansdal did just that. The hospital added a CDS algorithm to its electronic health record (EHR), which interfaces with the lab system and regularly monitors patients’ status. The software “knows these issues faster and more accurately” than a busy provider, Dr. Helmons said. For instance, if a prescribed drug combination requires regular potassium checks, the EHR only alerts the on-call pharmacist if the patient’s potassium levels are not being

monitored or are out of range. The system dramatically saves time, Dr. Helmons noted; his analysis showed this algorithm cut down on alerts by 55%, and reduced the time spent checking on drug–drug interactions by 45% (J Am Med Inform Assoc 2015;22[4]:764-772). The system diverts every pop-up that doesn’t require immediate action to a central pharmacy alert queue, monitored constantly by an on-call pharmacist who also verifies medication orders. The hospital has built in some “hard stops” in the EHR for orders that pose serious safety issues. In such cases, prescribers are interrupted primarily if something has gone catastrophically wrong at the time of prescribing—such as ordering 10 times the normal dose, for instance, or a contraindicated drug combination, Dr. Helmons explained. As a result, even though the on-call pharmacist has been tasked with monitoring the central alert queue, the number of generated alerts has decreased by 70%, said Dr. Helmons, largely the result of the CDS software. “It’s surprisingly simple to decrease the number of alerts,” he said. “You just need the right system.” Setting up a central pharmacy queue required purchasing the CDS algorithm, but no new staffers, he noted, as the hospital just moved people around to ensure one pharmacist could always monitor the queue.

But Is It Safe? Alert fatigue is a real problem that can interfere with workflow and put patients in danger, and St. Jansdal should be commended for taking a close look at its alerts and eliminating those that did not require immediate attention from the workflow, said Sandra L. Kane-Gill, PharmD, a professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy, who has studied the issue (Crit Care Med 2017;45[9]:1481-1488). This is something every institution can do, she told Pharmacy Technology see ALERT FATIGUE, page 16

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Restocking in the COVID-19 Era

anitizing crash cart trays and medical kits while restocking them was a routine procedure before COVID-19 arrived. Efforts have grown more formal and intensive in recent months to help prevent transmission of the highly infectious coronavirus, according to operations pharmacists at two hospitals. Physicians and nurses caring for COVID-19 patients under stressful conditions need assurance that sanitization took place, and if and when a patient codes, they can reach in quickly for what they need without extra anxiety. “Sharp objects are passed around, and

After the sanitization process is complete, trays go into the Kit Check scanner for restocking.

ALERT FATIGUE continued from page 14

Report. Although it takes resources to do a close review, dealing with unnecessary alerts is time-consuming, as well. If every institution took that approach, “it would help streamline the alerts people are receiving.” Reducing the number of alerts by 70% is a huge achievement, Dr. Kane-Gill added, but it should come with assurances that it hasn’t affected patient safety. It’s a balancing act, she noted: Alerts remind providers about patient safety, but if there are too many alerts, the message gets lost. “There is value in promoting safety in patients by using alerts. But there also are data that say overloading with alerts—causing alert fatigue—can compromise care [JAMA 2019;322(7):601].” St. Jansdal hasn’t done any quantitative studies to investigate the effect of the change in the alert system on patient safety, Dr. Helmons acknowledged. But he said he hasn’t noticed a spike in medication errors, and anecdotally, the program is yielding benefits: A nephrologist recently told him he’s seen fewer patients with renal

‘We have to be the ones to prevent infections. Sanitizing is one more step so we’re not transmitting COVID to healthy, uninfected patients.’ —Tyson Frodin, PharmD they need to know things are clean,” said Alan Portnoy, PharmD, the operations manager at Reading Hospital, in Reading, Pa., which has averaged a daily census of 400 or more patients this year. “We don’t always know if trays or kits coming back to us are from a COVID-19–positive patient, including many patients in isolation whose tests haven’t come back yet. So we treat each one as if it’s contaminated,” Dr. Portnoy stressed. In the fume hood area, which the hospital’s pharmacy designated years ago for tray and kit cleaning, a technician or pharmacist now runs every tray, kit and component under ultraviolet C light for 15 minutes, and rubs down everything with 70% isopropyl alcohol. These steps are among sanitization and safety processes initiated by the pharmacy when the hospital peaked at nearly 100 COVID-19 patients and isolated another 150 to 200 individuals suspected of having the infection see RESTOCKING, page 22

failure after heavy use of nonsteroidal anti-inflammatory drugs after surgery, perhaps because the software monitors patients, only alerting the central pharmacy queue if potassium levels rise. Before, regular alerts asking providers to check patients’ potassium levels may have gotten lost during hectic shifts, he noted. “Our patients are much safer because we can specifically pinpoint those issues that can result in adverse outcomes.” Alerts still occur. They just get diverted away from providers who shouldn’t be interrupted, said Dr. Helmons, who presented his hospital’s strategy to reduce alerts at the 2019 ASHP Midyear Clinical Meeting, in Las Vegas. “Any harm that is intended to be prevented is still being prevented by alerts. They’re just going to different people,” he noted. As a result, prescribers and pharmacists receive only a handful of alerts per shift, all of which need their attention; that should increase patient safety, he said. “If you’re only seeing a few pop-ups during your eight-hour shift, they will get noticed.” —Alison McCook The sources reported no relevant financial relationships.

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PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Optimizing Smart Pump Safety I mplementing smart infusion pumps is a good step toward improving patient safety, but many hospitals can do more to optimize the value these devices offer. “It’s not a given that simply because an organization has smart pumps, they are using the technology to its fullest potential,” said Michelle Mandrack, MSN, RN, the director of consulting services at the Institute for Safe Medication Practices (ISMP). “Many organizations still have room to push this technology further.” Ms. Mandrack highlighted measures recommended in recent ISMP guidelines (bit.ly/3l390Dd), such as greater use of built-in dose error reduction software (DERS) for every IV medication and fluid infusion, including secondary and intermittent infusions, IV bolus infusions, loading doses, patient-controlled analgesia pumps and epidural infusions, as well as in perioperative, procedural and radiology settings. Despite such guidances, “We see in many organizations that clinicians are not yet programming all of their infusions using DERS,” Ms. Mandrack said. In addition to wanting health systems and hospitals to rely more heavily on DERS, ISMP is asking organizations to make sure they have soft and hard limits for a host of

medication use parameters, from dosing to concentration, infusion rates, duration and patient weight, for example. “Not every pump is programmable for all of these parameters, but to the degree that they are, make use of what your system can do,” Ms. Mandrack said. The ISMP guidelines also state that all organizations should implement electronic health record (EHR) pump interoperability and strive for 95% compliance with pump autoprogramming for IV medications and fluids. These targets are far from what the ASHP found in its 2017 survey, when 9% of responding institutions reported using EHR-to-pump autoprogramming and the same percentage said they use the autodocument function, which pulls infusion pump data into the EHR.

Yuma Regional Medical Center Mark Jordan, PharmD, the director of pharmacy at Yuma Regional Medical Center, in Arizona, said his 406-bed hospital has added interoperability functionality to its large-volume pump platform (Spectrum IQ; Baxter), which accounts for 90% of the center’s infusions. For these infusions, DERS library compliance is at 95%, he said.

A National Snapshot of Smart Pump Usage

ata from REMEDI Operations, an information-sharing collaborative of infusion pump users, researchers and vendors, offer a picture of how hospitals and health systems are doing in their use of smart infusion pumps and interoperability functions.

Source: REMEDI Operations.

In a 2018 survey of 414 participating hospitals in the collaborative, 28.8% of respondents said they had implemented pump–EHR interoperability and another 15.6% planned to implement this feature the following year. Of 172 million infusions administered by REMEDI participants in 2019, 88% were run through dose error reduction software (DERS), and the rest were manually programmed without checks (catalyzecare. org/remedi). “The trend line is good, but it’s still below the 95% as per ISMP [Institute for Safe Medication Practices] smart pump guidelines, which is what we’d like to see,” said Richard Zink, MBA, the managing director of REMEDI Operations at Purdue University, in West Lafayette, Ind. The highest rates of compliance were seen in periop-

erative areas (98%) and adult patient care areas (89%), whereas DERS use for chemotherapy and hospice infusions was 85% and for pediatric infusions was 84%. Infusions of experimental drugs and unique chemotherapy cocktails, for example, make 95% compliance with DERS in this setting less realistic, Mr. Zink noted. Another REMEDI analysis of more than 192,000 drug library entries from participating hospitals showed that 36% of entries included “wild card” options, and 19% had wild card options without limits, most commonly for intermittent infusions and for fluid rate (catalyzecare.org/remedi). “Having a single concentration or as few choices as possible is much safer than including a wild card, which comes with the risk of input errors,” Mr. Zink said. Finally, of nearly 9 million soft limit alerts and approximately 840,000 hard limit alerts reported by REMEDI participants over a roughly 10-year period, 95% of soft alerts were overridden, and in half of these cases, it was done within three seconds. “We need to ask ourselves, are we training nurses to override these as quickly as they can?” Mr. Zink said. “If 99% of the alerts they’re responding to are for saline and then they get an alert for fentanyl, will they be hitting the override button as quickly as they can and moving on, or will they pause and think about this particular drug?” Organizations should examine their reports on pump alerts and overrides to make sure their soft limits are appropriate, particularly focusing on their unique top 10 alerting drugs, Mr. Zink advised. —D.W.

Photo credit: Christianacare

PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

Over a four-month period after implementing interoperability-related autoprogramming, his hospital eliminated 36,500 “risk opportunities,” due to reduced manual keystrokes, which decreases the risk for entering data and infusion rates incorrectly, Dr. Jordan said. “Achieving a high level of compliance with interoperability has required lots of information sharing, user training, build and testing, and user and technical support,” he said, noting the achievement has been “a huge project and a significant success for us, given the added patient safety that comes with this. With autodocumentation, we’ve also saved time, had more accurate and complete infusion data, and have enhanced revenue capture opportunity thanks to more precise documentation of infusion start and stop times.” Autoprogramming also has slashed the number of alerts, Dr. Jordan said, noting that their soft limit alert rate was 13.8% before interoperability and now is 6%. “Because medication orders go through the EHR’s clinical decision support software—assuming due diligence has been done—the pump programming is accurate and falls within appropriate limits, so there should be far fewer alerts,” said Dr. Jordan, adding that some infusions are still programmed manually. When alerts do occur, facilities can reduce the number of overrides by making sure soft and hard limits align with the content of EHR order sets and also reflect safe medication practices and patient care protocols. Once limits are in place, organizations should examine data from their smart infusion pumps to ensure they remain appropriate, Dr. Jordan said. “Infused medications and infusion systems are dynamic things and you need to dedicate resources for data review and system optimization.” His hospital standardized the number of drug formats and concentrations available in its drug library and reduced the use of “wild card” custom concentrations for smart pumps, he said, noting that both measures were important in bringing out the safety potential of these devices. “For high-alert drugs like heparin and insulin, there’s only one concentration and no wild card option, since errors with these drugs can be so consequential, and we still require dual nursing sign-off,” Dr. Jordan said. “When there is a need for options—with vasopressors, for example—we offer more choices, but even there it’s a limited set of available concentrations.”

Parkview Health Similar to Dr. Jordan, Rebecca Mahuren, BSN, RN, a medication safety integration nurse at Parkview Health, in Fort Wayne, Ind., said standardizing the drug library before implementing interoperability was important for her institution, which started interoperability for 80% of its smart pumps (ICU Medical) in 2017. According to Ms. Mahuren, the health system has one drug library for each specific infusion device—large-volume pumps, syringe pumps, epidural pumps and patientcontrolled analgesia pumps, as well as MRI pumps. “Some organizations have multiple drug libraries for a particular pump to accommodate different formularies within their system, which becomes a risk, particularly when patients are being transported between hospitals,” she said. Compliance with use of DERS for smart pump medication and fluid infusions is 99.5% at her organization, but is “a bit lower in perioperative and procedural areas, where anesthesiologists might be using a drug that is specific to a particular procedure and might not be included in the drug library,” Ms. Mahuren said. Wild card entries are permitted for pediatric syringes and intermittent infusions, which vary in dosing, bag size and infusion duration, and therefore require unlimited programming options, but, as is the case at Yuma Regional Medical Center, the hospital does not offer this option for high-alert medications. “That reduces the chance of manually entering the wrong concentration,” Ms. Mahuren said. One piece of advice she shared for organizations building their drug library is to not set their lower limits too high or upper limits too low, because this can lead to a high volume of alarms and result in alarm fatigue, thus encouraging bedside nurses to find workarounds when the alerts sound. Also echoing need for data review, Ms. Mahuren said hospitals should read through their infusion pump reports for usage trends, including compliance and frequency of hard stops and overrides. When Ms. Mahuren and her colleagues looked at data on 43,013 heparin and insulin infusions at their institution in 2019, they found 300 alerts, including 14 lower soft limits, three upper soft limits and 283 hard limits. They were reassured when they examined the hard limit alerts and found that all of them were triggered by keying errors made during manual programming in the midst of trauma, code or rapid responses. “The infusion pumps did what they were supposed to do—prevented a medication error,” Ms. Mahuren said. “So there was no need to revise the limits.” —David Wild Dr. Jordan reported a financial relationship with Baxter Healthcare. The other sources reported no relevant financial relationships. This article is based in part on a smart infusion pump symposium sponsored by the Institute for Safe Medication Practices, held at the 2019 ASHP Midyear Clinical Meeting, in Las Vegas.

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20 PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

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BUYER’S GUIDE 2020 13

MEDI-DOSE/EPS High Alert and Line Tracing Labels Address: 70 Industrial Drive Ivyland, PA 18974 Phone: (800) 523-8966 Email: customerservice@medidose.com Website: www.medidose.com Product Description: Confusion of IV lines can have catastrophic results. Standard organizations have long recommended labeling and reconciling IV lines, but facilities have struggled with implementing workable systems. MediDose/EPS Line Tracing Labels help pharmacy and nursing overcome this challenge, enabling line traces for all IV and catheter lines.

RESTOCKING continued from page 16

at the time: It made its own hand sanitizer, using alcohol donated by a local distillery, and “began to pneumatically tube medication to COVID-19 care areas to minimize the number of people going there,” Dr. Portnoy said. In April, the Reading institution also became one of the first hospitals in the United States to add a sanitization confirmation feature to its radiofrequency identification (RFID) medication tray and kit tracking and restocking solution, Sanitization Check, from Kit Check. By late May, 33 hospitals were using the sanitization feature and 91% of them made its use mandatory for every tray and kit, a Kit Check spokesperson said. Sanitization Check doesn’t detect any virus or COVID-19. Instead, it is an optional check box on the user’s workflow dashboard—a final step before pharmacy restocks, scans and dispatches a tray or kit with a charge sheet to a patient care area. The sheet lists the date and time of restocking, the contents, and the first expiring medication—and when the check box is clicked, an additional statement that pharmacy cleaned and sanitized the specific tray or kit, and the name of the person who did it. “When nurses see this, they feel more confident. The dispatch button won’t engage unless the user acknowledges that the tray or kit has been cleaned,” Dr. Portnoy said. “It’s a no-brainer for me. It doesn’t slow us down, and we have no extra technology to invest in or maintain because it’s all on the Kit Check server. We just log in. Our pharmacy always has five trays and kits ready to go. We can sometimes go through that many in an afternoon, but a typical day is between three and five.” Dr. Portnoy said the Kit Check RFID restocking solution

22 PHARMACY TECHNOLOGY REPORT • SEPTEMBER 2020

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that Reading started to use last February reduced a 20to 30-minute process down to two to three minutes, and enabled the hospital to track manufacturer lot numbers in case of recalls. “If we sought clearance from critical care teams to reduce items from crash carts prior to Kit Check, we usually got a lot of pushback because we had no concrete data on utilization. After six months, real data enabled us to reduce items overall by 10% while increasing items that were used more often,” he said.

Rural Facility Benefits Like Reading, the 19-bed critical access Benawah Community Hospital, in St Maries, Idaho, is a rural facility— a status that adds urgency to operating in the COVID-19 era, noted Tyson Frodin, PharmD, MHA, the chief operations officer and director of pharmacy. “We have to be the ones to prevent infections. Sanitizing is one more step so we’re not transmitting COVID-19 to healthy, uninfected patients,” he said. Benawah Community Hospital has had no COVID-19 patients yet, but acts as if it does. “After any patient leaves, regardless of their illness, our environmental services department does a floor-to-ceiling terminal cleaning of the room, including crash carts, shelves, bedding, and any instruments or medications in there. It takes 60 to 90 minutes,” Dr. Frodin said. “As health care workers, we can’t leave the county except for essential reasons, and they take our temperature and ask us about symptoms every day.” Of the tray and kit sanitization feature used at Reading Hospital, Dr. Frodin said, “Any step you can take to ensure sanitization is what you need to do to provide the best possible care.” The sources reported no relevant financial relationships.

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