Operating since 1962, Memphis, Tennessee-based St. Jude Children’s Research Hospital is considered a top pediatric cancer hospital and research center, with nearly 8,000 patients seen yearly.
St. Jude is the only National Cancer Institute Comprehensive Care Center devoted solely to children, having received the NCI’s highest ranking of “exceptional.” The hospital also has been designated as achieving Magnet status by the American Nurses Credentialing Center, which is based on an evaluation of patient care, safety and satisfaction as well as attracting top nursing talent and demonstrating a collaborative culture among nursing staff.
This collaborative culture and commitment to quality and safety has been the driving force behind a recent interoperability initiative by clinical and informatics leaders at the hospital to integrate the electronic health record (EHR) and bedside patient care devices for infusion management and vital sign transmission. These initiatives have helped to eliminate manual pump programming errors, a top patient safety issue. Because of their cutting-edge work, the editors of Healthcare Informatics have chosen the leaders of St. Jude Children’s EHR-device interoperability initiative as the co-third-place-winning team in the Healthcare Informatics Innovator Awards Program, Providers Division.
According to St. Jude executive leaders, with the hospital’s 2016-2021 institutional strategic plan, one of St. Jude’s initiatives is to strengthen its focus on patient quality and safety practices. To move this forward, nursing, pharmacy and IT leaders have been collaborating on two major projects focused on increasing efficiencies with the EHR—infusion pump interoperability and automatic transmission of vital signs to the EHR from outpatient clinics.
Prior to this EHR-IV pump integration project, which started about three years ago, St. Jude nurses manually programmed infusion pumps with patient identifiers and IV medication orders. Once complete, the nurses then had to electronically sign the medication administration and infused volumes in the hospital’s Cerner EHR. This manual intervention and movement between disparate systems created a cumbersome process that reduced nurses’ time for clinical duties and created opportunities for manual errors, according to Keith Perry, senior vice president and CIO at St. Jude.
“The biggest challenge with infusion management is the human factor,” says Robin Mobley, R.N., inpatient nursing director at St. Jude. “Even though you’ve got a pump that is delivering the medication and it’s delivering it accurately, when you go to that pump and you are entering the rate, the time frame, the volume that is to be infused, every time you do that, every stroke you make on that pump, is an opportunity for error. With interoperability between the EHR and IV infusion pumps, you are taking away that human factor.”
She adds, “The fact that we’re dealing with some really dangerous drugs makes it even more important for us to have that extra security in our workflow processes.”
According to the Agency for Healthcare Research and Quality (AHRQ), adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. The greatest potential for harm lies with medication errors related to intravenous (IV) infusion. Hospitals are faced with the challenge of finding ways to reduce these serious and life-threatening errors. The use of smart IV pumps has helped to improve infusion safety, and many healthcare quality and safety experts advocate that closed-loop interoperability between the smart pump and EHR can significantly reduce medication errors. However, EHR-IV interoperability technology is considered a relatively new innovation and it is a challenging IT issue for most hospitals and health systems.
As St. Jude is a pediatric oncology hospital, a major focus on the project centered on complex chemotherapy IV orders that often involve many different medications. About 95 percent of St. Jude inpatients are on infusion pumps and IV medications also are used in the outpatient setting as well.
The initiative was a strategic collaboration between nursing, clinical informatics, pharmacy, biomedical engineering and enterprise informatics teams. “It wasn’t only interoperability between the devices and the EHR, but it was also between departments,” notes Barbara Gingras, R.N., project manager, clinical informatics within St. Jude’s information services department.
While there were many IT-related challenges, some of the largest challenges were identifying and operationalizing the nursing and pharmacy workflows for all IV infusion orders due to the complicated infusion process, such as chemotherapy protocols, as well as workflows for specific drugs and types of infusion.
“Being a pediatric oncology facility, we likely give, on average, 50 percent more medications than a regular pediatric hospital. We have processes that we use to be able to get all those medications in on time,” Mobley says. “So, sitting down with nursing, with pharmacy, and IT and clinical informatics, we had to look at all those processes put together and map those out; that was a crucial step to getting this implemented.”
She continues, “Even during the implementation, there were challenges that we ran into with trying to take technology that is meant for complex infusions but also geared to a more regular workflow. We really had to work closely with Cerner and Alaris [an infusions systems vendor] and with our clinical informatics and pharmacy team to figure out what processes we can use. We didn’t want the technology to determine our process, but for our process to work with the technology.”
As part of this project, pump formularies and associated pharmacy and nursing processes had to be rebuilt and tested. Multiple iterations of testing took place as issues were found and bugs were fixed. “We had to test every drug, because of the rebuild of the Alaris pump system, and to make sure we had the processes right,” Gingras says.
Teresa Browning, R.N., clinical informatics senior reengineering analyst, information services, adds that one of the biggest lessons learned was the critical need for ongoing testing. “You need to have the time and resources to do the testing, it’s essential. We had nursing test it with their workflows. It’s important that you test, test, test.”
The ultimate aim of the project was to create interoperability between the EHR and wireless pumps, which in turn would send patient information and orders via Cerner’s CareAware module to the pump. The pumps then complete the loop by sending IV infused data, via CareFusion technology, to Cerner’s Infusion Management tool and the EHR.
The EHR-IV pump interoperability initiative went live in August 2017, and, as a result, nursing workflow efficiency has increased as 10 out of 15 manual steps have been eliminated, leading to a 50 percent improvement in compliance with Guardrails, a dose-error-reduction system, Browning says.
Electronic infusion orders for complex chemotherapy orders are now sent directly from the clinician’s electronic order to the infusion pump, eliminating manual pump programming errors. Actual infused volumes are automatically populated in the medical record, which eliminates manual entry and associated errors. In addition, nursing and pharmacy now have access to monthly compliance reports for ongoing quality improvements, Gingras says.
“Over the past several years, we have championed a focus on providing a frictionless experience to our patients and their caregivers. In fact, it is our first priority in the Information Services strategic plan,” Perry says. “More times than not, technology teams implement an application or system and walk away believing it has optimized workflow. The challenge that we face in healthcare IT is that work continues to evolve, people and processes change, and technological advances are released at a rapid pace.” And, he adds, “The team that implemented the project was able to recognize this challenge.”
Automatic transmission of vital signs to reduce medication errors
As part of this broader project to increase efficiencies with the EHR, clinical, IT and biomedical engineering leaders at St. Jude also collaborated to implement automatic transmission of vital signs, including patient height and weight, into the EHR from the outpatient clinics. The hospital serves 300 to 400 outpatient visits a day at 10 clinics.
According to Perry, in the clinic setting, nurses previously transcribed the documented vital signs into the EHR. Because of the weight-based dosing and body surface area (BSA) calculation in the majority of medications and complex chemotherapy orders administrated at St. Jude, clinical leaders felt that these inefficient, manual processes needed to be remediated.
“In pediatric organizations, about 10 percent of medication errors that occur are attributed to a discrepancy in weight documentation. We were looking at challenges related to possible data error entry and we were looking at ways to remove that potential risk,” Dana Matheny, R.N., nursing manager for the ambulatory care unit, projects and quality, says.
The original scope of the project was to implement new wireless devices, such as weight scales, stadiometers and vital sign monitors, and Cerner’s CareAware VitalLinks platform in the assessment triage areas of the clinics. Cerner’s platform enables a barcode-driven process on an integrated device for clinicians to chart vitals data directly into the EHR.
The wireless transmission of height and weight in ambulatory care was new for St. Jude, and also new for Cerner and for the hospital’s medical diagnostic equipment partner, Welch Allyn, according to Perry. No other Cerner site had implemented this type of data integration using these specific devices and platforms. The project required extensive collaboration with vendor partners, and there were a number of challenges related to deploying new equipment, changes in nursing workflow and infrastructure issues around wireless connectivity, project leaders say.
St. Jude went live with the implementation in March 2017, and, as a result of this work to link vital signs directly into the EHR, manual entry errors have decreased, Perry says. What’s more, the project has decreased patient turnaround times at the outpatient clinics by enabling nurses to quickly scan patients and devices, then wirelessly submit patient data.
“At face value, this initiative reduced the manual processes in the delivery of complex care to our pediatric patients and challenged the status quo,” Perry says. “Understanding a patient’s weight (body surface area) is extremely important as it is used to calculate the chemotherapy agent dosage, therefore, reducing the likelihood of errors. As a result, the nursing team is now able to focus on the child rather than a process.”
And, Perry adds that this project to enable automatic transmission of vital signs ties into the organization’s strategic focus on providing a “frictionless experience” for patients and caregivers. “The key to focusing on a frictionless experience begins with fostering cross-departmental partnerships, building a culture of improvement that challenges the status quo, and recognizing that how we did something yesterday will not be good enough for tomorrow.”
Matheny says, “We try to align our projects with our organization’s strategic initiatives, and we look at what are the clinical outcomes we’re trying to achieve and where we can make the biggest improvements? We’re fortunate at St. Jude that we have such great teams working together, across all the departments.”
Project leaders emphasize that senior executive leadership support for the interoperability project was a critical key to success. “The direction is coming from the top down and this is a quality initiative and part of enhancing patient care, so we get the support and the resources that we need,” Gingras says.
