Implementing smart pump technology in a pediatric intensive care unit: a cost-effective approach

Evaluating the Economic Impact of the PedAMINES App in Reducing Medication Errors in Pediatric Emergency Care: Cost-Effectiveness Analysis

BACKGROUND

The administration of drugs in pediatric emergency care is a time-consuming process and is associated with a higher occurrence of medication errors compared with adult care. This is attributed to the intricacies of administration, which involve calculating doses based on the child's weight or age. To mitigate the occurrence of adverse drug events (ADEs), the PedAMINES (Pediatric Accurate Medication in Emergency Situations; Geneva University Hospitals) mobile app has been developed. This app offers a step-by-step guide for preparing and administering pediatric drugs during emergency interventions by automating the dose calculation process. Although previous simulation-based randomized controlled trials conducted in emergency care have demonstrated the efficacy of the PedAMINES app in reducing drug administration errors, there is a lack of evidence regarding its economic implications.

OBJECTIVE

This study aims to evaluate the cost-effectiveness of implementing the PedAMINES app for 4 emergency drugs: epinephrine, norepinephrine, dopamine, and midazolam.

METHODS

The economic evaluation was conducted by combining hospital data from 2019, previous trial outcomes, information extracted from existing literature, and PedAMINES maintenance costs. The cost per avoided medication error was calculated, along with the number of administrations needed to achieve a positive return on investment. Subsequently, Monte Carlo simulations were used to identify the key parameters contributing to result uncertainty.

RESULTS

The study revealed the number of preventable errors per administration for the 4 examined drugs: 0.513 for epinephrine, 0.484 for norepinephrine, 0.500 for dopamine, and 0.671 for midazolam. The cost-effectiveness ratios per ADE prevented were computed as follows: US $4808 for epinephrine, US $9705 for norepinephrine, US $6957 for dopamine, and US $2074 for midazolam. Accounting for the economic impact of ADEs, the analysis estimated that 16 administrations of epinephrine, 17 of norepinephrine and dopamine, and 13 of midazolam would be required to attain a positive return on investment. This corresponds to roughly one-third of the annual administrations at a major university hospital in Switzerland. The primary factors influencing the uncertainty in the estimated cost per ADE include the cost of maintenance of the app, the likelihood of an ADE resulting from an administration error, and the frequency of underdosing in the trial's control group.

CONCLUSIONS

A dedicated mobile app presents an economically viable solution to alleviate the health and economic burden of drug administration errors in in-hospital pediatric emergency care. The widespread adoption of this app is advocated to pool costs and extend the benefits on a national scale in Switzerland.

Protocolization of Analgesia and Sedation Through Smart Technology in Intensive Care: Improving Patient Safety

BACKGROUND

The risk of medication errors in intensive care units is high, primarily in the drug administration phase.

LOCAL PROBLEM

Management of high-alert medications within intensive care units in the study institution varied widely. The aim of this quality improvement project was to protocolize and centralize the management of high-alert medications in acute care settings and to implement smart intravenous infusion pump technology in intensive care units.

METHODS

The project was conducted in 4 phases: (1) protocolization and standardization of intravenous mixtures, (2) centralization of intravenous mixture preparation in the Pharmacy Department, (3) programming of the smart pumps, and (4) dissemination and staged implementation of intravenous mixture protocols. Smart pumps (Alaris, CareFusion) were used to deliver the medicines, and the manufacturer's software (Alaris Guardrails, CareFusion) was used to analyze data regarding adherence to the drug library and the number of programming errors detected.

RESULTS

Morphine, remifentanil, fentanyl, midazolam, dexmedetomidine, and propofol were included. After implementation of the smart pumps, 3283 infusions were started; of these, 2198 were programmed through the drug library, indicating 67% compliance with the safety software. The pumps intercepted 398 infusion-related programming errors that led to cancellation or reprogramming of drug infusions.

CONCLUSIONS

Protocolization and centralization of the preparation of high-alert sedative and analgesic medications for critically ill patients and the administration of these drugs using smart pump technology decrease variability of clinical practice and intercept potentially serious medication errors.

A framework for the estimation of treatment costs of cardiovascular conditions in the presence of disease transition

The current research aims to aid policymakers and healthcare service providers in estimating expected long-term costs of medical treatment, particularly for chronic conditions characterized by disease transition. The study comprised two phases (qualitative and quantitative), in which we developed linear optimization-based mathematical frameworks to ascertain the expected long-term treatment cost per patient considering the integration of various related dimensions such as the progression of the medical condition, the accuracy of medical treatment, treatment decisions at respective severity levels of the medical condition, and randomized/deterministic policies. At the qualitative research stage, we conducted the data collection and validation of various cogent hypotheses acting as inputs to the prescriptive modeling stage. We relied on data collected from 115 different cardio-vascular clinicians to understand the nuances of disease transition and related medical dimensions. The framework developed was implemented in the context of a multi-specialty hospital chain headquartered in the capital city of a state in Eastern India, the results of which have led to some interesting insights. For instance, at the prescriptive modeling stage, though one of our contributions related to the development of a novel medical decision-making framework, we illustrated that the randomized versus deterministic policy seemed more cost-competitive. We also identified that the expected treatment cost was most sensitive to variations in steady-state probability at the "major" as opposed to the "severe" stage of a medical condition, even though the steady-state probability of the "severe" state was less than that of the "major" state.

Error Detection and Cost Savings With an Image-Based Workflow Management System Connected to a Computerized Prescription Order Entry Program for Antineoplastic Compounding

OBJECTIVE

The aim of the study was to analyze both the prevalence of errors with the implementation of an image-based workflow management system during the antineoplastic compounding process, and the estimated costs associated with the negative clinical outcome if the errors had not been intercepted.

METHODS

Three months after the implementation of Phocus Rx system at a hospital pharmacy department, the identification, classification (type, preparation stage, and cause), and potential severity degree (from negligible to catastrophic) of the errors intercepted were determined. The probability of an error causing an adverse event if it had reached the patient (from nil [0] to high [0.6]) and its consequences was estimated by a team of clinical pharmacists and physicians. Cost-effectiveness analysis from the hospital's perspective was performed.

RESULTS

Overall, 9872 antineoplastic medications were prepared using Phocus Rx. The total compounding error rate was 0.8% (n = 78, 56 [69.2%] were related to incorrect dose, 20 [28.2%] to incorrect drug preparation or conditioning technique, and 2 [2.6%] were wrong drugs). Approximately 70% of the detected errors were classified as undetectable via the previous verification practice, with 11.55% judged to be potentially severe (n = 9) and 51.3% moderate (n = 29). Likelihood of occurrence of an adverse event was medium (0.4) to high (0.6) for 37.2% of the errors. Estimated cost ratio and return on investment were €4.21 and 321%, respectively.

CONCLUSIONS

The implementation of Phocus Rx prevented antineoplastic preparation errors that would have reached the patient otherwise. In addition, acquisition of this technology was estimated to be cost-effective.

Implementation of Smart Infusion Pumps: A Scoping Review and Case Study Discussion of the Evidence of the Role of the Pharmacist

"Smart" infusion pumps include built in drug error reduction software which uses a drug library. Studies have reported the drug library build should be undertaken by a multidisciplinary team, including a pharmacist; however, the extent or nature of the input required by the pharmacist for greatest benefit is unknown. This review aimed to identify key factors for the implementation of the smart infusion pumps, with a focus on the role of pharmacists and compare this to the experience from a case study. A literature review was conducted using Embase and Ovid Medline, and 13 eligible papers were found. Predominant themes relating to the pharmacist's role and successful implementation of the smart infusion pumps were determined. Key factors for success included team involvement across the entire process from procurement, set-up through to implementation including risk assessment and device distribution, and training, which were comparable to the case study experience. Few studies described the extent or details of the pharmacist's responsibilities.

Role and impact of pharmacists in Spain: a scoping review

Background The role of the pharmacist has evolved greatly over the last decades, expanding to patient-oriented activities, administrative tasks and public health functions. However, considerable differences emerge across regions. Aim of the review To gather evidence in order to describe and highlight the different characteristics of the pharmacists' role and the impact of their activities in Spain. Method A review of the existing literature was conducted. The literature search was undertaken in PubMed between 01/01/2006 and 15/08/2017. Results were screened and reviewed to extract previously established criteria such as author(s), publication year, language, study design, setting, pharmaceutical activity, patient care programs, targeted diseases and intervention description using DEPICT2 tool. Pharmaceutical intervention were classified into eight outcome measures and categorized by types of outcomes reported: descriptive or impact evaluation regarding the effect of the service (positive, neutral or negative). Results The search strategy resulted in 473 articles and 108 articles met the inclusion criteria. The most common design was observational (n = 76, 70%). Most articles were published after 2011 (75%), in English (69%). Studies were conducted in hospitals (60%) and community pharmacies (30%). Of the 24 pharmaceutical activities identified, medication review was the activity most frequently studied (n = 42), followed by patient education (n = 29), risk and prevention (n = 27) and medication reconciliation (n = 19). Only 39 articles (36%) had outcome measures with impact evaluation. Of the 223 impact outcome measures, 48% (107/223) had a positive effect. Conclusion This review shows the substantial scientific production focusing on pharmacy practice in Spain over the last years. The evidence reviewed reflects the pharmacist role at various professional settings, providing a wide variety of activities on diverse targeted diseases and patient care programs, in line with the increasing specialization of clinical pharmacists over the last years.

Impact of Implementing Smart Infusion Pumps in an Intensive Care Unit in Mexico: A Pre-Post Cost Analysis Based on Intravenous Solutions Consumption

Background: The use of smart pump technology has shown to be profitable in the intensive care unit (ICU) because it avoids costs from prevented medication errors and allows for savings on disposables and medications by establishing standardized concentrations and dosing units. Objective: The objective of the study is to evaluate the economic impact of the implementation of smart infusion pumps in the consumption of intravenous (IV) solutions in an ICU. Methods: A retrospective observational study was conducted with a pre-post design. The study occurred in the adult ICU of the Hospital Juárez de México. The pattern of consumption of IV solutions (sodium chloride 9%, Hartmann's solution, dextrose 5% and 10%, sodium chloride 0.9% with dextrose 5%) was analyzed preimplementation and postimplementation of 50 Plum A+™ pumps with Hospira MedNet™ security software. Using the TreeAge Pro 2016 software, deterministic and probabilistic analyses were carried out (10 000 Monte Carlo simulations) to confirm the robustness of the annual consumption comparison and the associated expenses before and after implementing smart technology. Results: The implementation of the smart pumps reduced the annual consumption of IV solutions to 8994 units (18%) and 3649 liters (22.3%). In the first year, MXN$55 850.97 were saved. From an institutional perspective and with a probability of 0.63, the use of MedNet™ technology proved to be a lower cost alternative (17.1% saved) with respect to the conventional infusion systems. Conclusion: The implementation of smart infusion pumps allows savings, specifically for the IV solutions used in ICU.

Practice Change From Intermittent Medication Boluses to Bolusing From a Continuous Infusion in Pediatric Critical Care: A Quality Improvement Project

OBJECTIVES

To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost.

DESIGN

This is a pre- and postimplementation quality improvement study.

SETTING

An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital.

PATIENTS

Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion.

INTERVENTIONS

Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs.

MEASUREMENTS AND MAIN RESULTS

Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p < 0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p > 0.05). Annualized cost avoidance was $124,160.

CONCLUSIONS

Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.

[The roles and the impacts of pharmacists in the management of medical devices at the hospital: A literature review]

OBJECTIVES

Identify the training profile and the published evidences about the roles and the impacts of hospital pharmacists in medical devices.

METHODS

A literature review was conducted using Google, Google Scholar and Pubmed for 1990-2016 associated with a manual search conducted in three non-indexed pharmaceutical journals for 2000-2016.

RESULTS

The analysis of training programs available did not allow us to identify a specific training profile. A total of 72 articles related to the roles and the impacts of the pharmacist were identified, 52 of which came from non-indexed journals. Those articles did not deal specifically about the roles and the impacts of pharmacist; however, articles were analyses for three spheres including the referencing of medical devices (n=36), the evaluation (n=19) and the distribution system (n=13).

CONCLUSIONS

French pharmacists have many theoretical and practical training opportunities. There are a few articles describing precisely the roles and the impacts of hospital pharmacists in medical device. It appears urgent to better document this activity in professional and indexed literature.

Adding value through pharmacy validation: a safety and cost perspective

RATIONALE, AIMS AND OBJECTIVES

Prescribing errors (PE) are frequent, cause significant harm to patients and prove costly. Few studies demonstrate the impact of pharmacist interventions. The objectives of this study were to characterize the severity and cost of the potential outcome of PE that pharmacists can prevent and to develop an economic analysis.

METHOD

We performed a non-randomized, prospective, observational study of all prescriptions made to adult patients admitted to a 1300-bed tertiary teaching hospital in Madrid (Spain) by means of a computerized physician order entry tool combined with a clinical decision support system. We analysed PE intercepted through the pharmacist validation process between January and June 2013. An independent team determined the severity of the potential adverse drug event (ADE) and the probability of causing an ADE (PAE). We estimated the cost avoidance and performed an economic analysis. A kappa statistic was used to verify inter-observer agreement.

RESULTS

484 PE were intercepted: 36.2% of PE were classified as being of minor severity, 59.1% as moderate and 4.7% as serious. The most common type of moderate-serious PE found was excessive dose (30%, 94/309), followed by insufficient dose (20%, 62/309), and omission (19%, 58/309). The most frequent families of drugs involved in moderate-serious PE were antineoplastic agents (22.3%, 69/309) and antimicrobials (17.2%, 53/309). The PAE was higher than 40% in 49% of PE. We estimated a cost avoidance of €291,422 and a return on investment of €1.7 for each €1 spent on a pharmacist's salary. The overall inter-rater agreement for the participants was moderate for severity (κ = 0.57; P <0.005) and strong for the PAE (κ = 0.77; P <0.005).

CONCLUSIONS

Pharmacists add important value in preventing PE, and their interventions are financially beneficial for the institution.

Safe intravenous administration in pediatrics: A 5-year Pediatric Intensive Care Unit experience with smart pumps

OBJECTIVES

To estimate the impact of smart pump implementation in a pediatric intensive care unit in terms of number and type of administration errors intercepted.

DESIGN

Observational, prospective study carried out from January 2010 to March 2015 with syringe and great volumen infusion pumps available in the hospital.

SETTING

A tertiary level hospital pediatric intensive care unit.

PARTICIPANTS

Infusions delivered with infusion pumps in all pediatric intensive care unit patients.

INTERVENTIONS

Design of a drug library with safety limits for all intravenous drugs prescribed.

MAIN VARIABLES

Users' compliance with drug library as well as number and type of errors prevented were analyzed.

RESULTS

Two hundred and eighty-three errors were intercepted during 62 months of study. A high risk drug was involved in 58% of prevented errors, such as adrenergic agonists and antagonists, sedatives, analgesics, neuromuscular blockers, opioids, potassium and insulin. Users' average compliance with the safety software was 84%.

CONCLUSIONS

Smart pumps implementation has proven effective in intercepting high risk drugs programming errors. These results might be exportable to other critical care units, involving pediatric or adult patients. Interdisciplinary colaboration is key to succeed in this process.

New technologies as a strategy to decrease medication errors: how do they affect adults and children differently?

BACKGROUND

Medication error can occur throughout the drug treatment process, with special relevance in children given the risk of adverse effects resulting from a medication error is more prevalent than in adults. The significance of medication error in children is also greater because small error that would be tolerated in adults can cause significant damage in children. Moreover, the likelihood of injury is higher than in adults.

DATA SOURCES

Based on the data published, most medication errors take place in prescribing and administration stages in both populations. Taking in account that child's risk factors are different from those of adults, with some specific causes to pediatrics, we have reviewed available data about new technologies as a strategy to reduce pediatric medication errors.

RESULTS

Even though there is a lack of standardized definitions and terminology that makes studies difficult to compare, we checked that new technologies have proven to be effectives in reducing medication errors, mainly computerized physician order entry (CPOE) and platforms to aid decision-making. However, we also observed that the use of these informatic tools can also generate new errors.

CONCLUSIONS

Implementation of CPOE programs for pediatrics, communication improvement between healthcare professionals taking care of admitted children and the knowledge of these programs should be the mayor priorities for the safety of hospitalized children.

Smart pumps and random safety audits in a Neonatal Intensive Care Unit: a new challenge for patient safety

Background

Random safety audits (RSA) are a safety tool enabling prevention of adverse events, but they have not been widely used in hospitals. The aim of this study was to use RSAs to assess and compare the frequency of appropriate use of infusion pump safety systems in a Neonatal Intensive Care Unit (NICU) before and after quality improvement interventions and to analyse the intravenous medication programming data.

Methods

Prospective, observational study comparing the frequency of appropriate use of Alaris® CC smart pumps through RSAs over two periods, from 1 January to 31 December 2012 and from 1 November 2014 to 31 January 2015. Appropriate use was defined as all evaluated variables being correctly programmed into the same device. Between the two periods they were established interventions to improve the use of pumps. The information recorded at the pumps with the new security system, also extracted for one year.

Results

Fifty-two measurements were collected during the first period and 160 measurements during the second period. The frequency of appropriate use was 73.13 % (117/160) in the second period versus 0 % (0/52) in the first period (p < 0.0001). Information was recorded on 44,924 infusions; in 46.03 % (20,680/44,924) of cases the drug name was recorded. In 2.5 % (532/20,680) of cases there was an attempt to exceed the absolute limit.

Conclusions

Random Safety Audits were a very useful tool for detecting inappropriate use of pumps in the NICU. The improvement strategies were effective for improving appropriate use and programming of the intravenous medication infusion pumps in our NICU.