Hospitals collaborate on IV meds standards
Hospitals collaborate on IV meds standards
Goal is to reduce variation in IV therapy
Collaborations among hospitals to improve the delivery of care is a growing trend in U.S. health care, but a group of facilities in San Diego County, CA, has joined forces to address an area they claim has not previously been targeted in this manner: The delivery of IV medications.
The "San Diego Campaign for Safe Administration of High-Risk IV Medications" involves local hospitals, the San Diego Patient Safety Consortium, and the Cardinal Health Center for Safety and Clinical Excellence. The task force has created countywide standards for safe administration of IV medicines by using a common drug identifier and standardizing the concentration and dosage units for each drug.
When the task force first began its work in June 2005, the 15 participating hospitals used a combined total of more than 85 different concentrations and 57 different dosage units for 34 IV medications. Today, those totals have been pared down to 34 standard, single-strength concentrations and 34 standard dosage units.
Inspired by IHI
The task force got its impetus from the IHI's 100,000 Lives campaign, says Tim Vanderveen, MS, PharmD, vice president of Cardinal Health's Center for Safety and Clinical Excellence.
"It came out of a conversation with Dr. Joe Sherger of the University of California at San Diego, who is the director of the San Diego Patient Safety Consortium," he recalls. "He talked of a tragic error that had occurred recently with intravenous medication and suggested we should develop a similar bundle to those used by IHI."
In June 2005, they hosted a conference of 60 local representatives, who agreed to set up a smaller task force to meet periodically on target areas. "At about the same time, I and others had published an article on [meds] variation," says Vanderveen. "Because we had 'smart' infusion pumps that helped hospitals control the way they administered a particular drug, we could measure the dosages, and we saw tremendous variation.1 It was real music to our ears that the task force said they wanted to measure variability, and if they found it, to develop standards."
Cardinal played a key role in helping the task force get started, notes Nancy Pratt, RN, MSN, senior vice president of clinical effectiveness for Sharp HealthCare (the largest system in San Diego) and chairperson of the task force.
"We had had the San Diego Patient Safety Consortium together for a few years and done a few things together, exchanging best practices in a variety of areas," she notes. "However, we had run out of our funding from AHRQ and were not sure of the future of the organization, when Cardinal Health stepped forward and offered to support the initiative to give us the space to meet."
Representatives from the 15 hospitals met together to look at current practices and found the variations noted above — which did not surprise Vanderveen.
"It's an area we've never really focused on in the past," he observes, noting that this variation is exacerbated by the fact that nurses may move from one hospital to another, as do traveling and agency nurses, and of course, doctors may work at more than one facility.
"These multipliers are huge," he continues. "If one hospital administers doses per minute, and another administers doses per hour, that's a multiplier of 60. Or, one might use micrograms per minute and another in milligrams per hour; these are really potentially very large errors."
Leading the way
Task force participants had a solid model to follow in Sharp HealthCare, which already had instituted its own standards for its four acute care and three specialty hospitals.
Sharp had installed a new computerized pharmacy system in 2004, and because it used one pharmacy product for the whole system, it wanted to standardize the way meds were prepared. "We have a couple of thousand people in our floating pool staff, so it was important to standardize the concentrations," Pratt says.
Pharmacy heads, the therapeutics committees and nurse executives from all of the facilities met together, identified where the variations were, and reviewed the evidence to determine which approach was better.
Pratt concedes that at first it was a "knock-down, drag-out fight" to get facilities to change. "It took some tough conversations, but at the end of the day it had to be done. We had to change all the electronic order sets that mention those drugs, all of the mixing procedures in the pharmacy, and any standard order sets that are printed on paper. Then, we had to flip the switch — and change all the configurations in the IV pumps."
There were a few "holdout" pieces of really high-risk drugs that needed to change at one facility, which was designed to coincide with the installation of upgraded IV pumps, notes Pratt. That process has just begun.
How did Sharp's standards mesh with the rest of the group? "All the hospitals came together, compared notes on where all the variations were, and what emerged was a de facto community standard," says Pratt. "For every single drug, there was a majority doing it one way. That was the risk that we had — to perhaps need to make some changes — but we put our hat in the ring like everybody else."
Aside from the changes Sharp was already making, "there were only a couple of changes we had to make," Pratt notes.
Initiative spreading
The program is taking hold throughout the community, with Scripps Health having nearly totally adopted the new standards, according to Vanderveen. "They have the smart pumps in their five hospitals," he notes. According to Pratt, Cardinal Health is providing the pumps for those facilities making the change. "The majority of systems are now using them," she says.
It is far too soon to measure the success of the program, she continues."Once the changes are all implemented, we will track medication events, participate in the national database for MEDMARX, and we will see whether or not it is having any impact," she says.
Nevertheless, the San Diego initiative already is garnering attention. "The IHI has asked if they could put our toolkit on their web site," notes Vanderveen, adding that he also has had discussions with representatives from the Joint Commission, as standardized concentrations are part of its National Patient Safety Goals. "We would ultimately love to see some kind of national standard," he concludes.
Having met their goal of standardizing IV concentrations and dosage units, the task force is now working to standardize dosage ranges and drug libraries involved in the use of computerized "smart" pumps, says Vanderveen. "In addition, we are going to start a new initiative; we will probably focus on pain management," he says.
[Editor's note: The toolkit is available at http://meded.ucsd.edu/SDCPS/ and at www.cardinalhealth.com/clinicalcenter.]
Reference
- Bates DW, Vanderveen T, Seger D, Yamaga C, Rothschild J. Variability in Intravenous Medication Practices: Implications for Medication Safety. Joint Commission Journal on Quality and Patient Safety; Apr. 2005, 203-210.
For more information, contact:
Nancy Pratt, RN, MSN, Senior Vice President of Clinical Effectiveness, for Sharp HealthCare, San Diego, CA. E-mail: [email protected].
Cardinal Health: Troy Kirkpatrick. Phone: (614) 757.6225. E-mail: [email protected].
Collaborations among hospitals to improve the delivery of care is a growing trend in U.S. health care, but a group of facilities in San Diego County, CA, has joined forces to address an area they claim has not previously been targeted in this manner: The delivery of IV medications.Subscribe Now for Access
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