Download Metrics up to and during Go Live

IV Pump Post Go Live
After Action Report
CareFusion/Alaris IV Pump Project
Go Live Date: April 26th, 2016
Contents
Guiding Principles ......................................................................................................................................... 3
Metrics up to and during Go Live.................................................................................................................. 3
Project Team ............................................................................................................................................. 3
Pharmacy .................................................................................................................................................. 3
Training ..................................................................................................................................................... 3
Go Live....................................................................................................................................................... 4
Post Go Live............................................................................................................................................... 4
Lessons Learned ............................................................................................................................................ 5
Project Team ............................................................................................................................................. 5
Pharmacy ................................................................................................... Error! Bookmark not defined.
Education .................................................................................................................................................. 5
Subject Matter Experts ............................................................................................................................. 7
Supplies ..................................................................................................................................................... 7
Guiding Principles
The goal of the Infusion Pump Project is to design and implement a medical-grade network of infusion
pumps that is secure, efficient, scalable, reliable and wirelessly-networked. This system of infusion
pumps will replace the three types of pumps currently in use.
Phase I April 26, 2016: Pump replacement (Including wireless connectivity, automated drug library, and
other safety features)
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Replacement of LV, Syringe, and Pain pumps on integrated platform
Replacement of IV administration sets
Release of an automated drug library based upon the UVA formulary.
Ability to make real time updates to the drug library.
Phase II 6-9 Months after Phase I is Complete: Bi-directional integration with Epic (Connectivity to
CPOE, Automated programming of pumps, Automatic documentation of infusion medication
administration, etc.)Synopsis of Go Live Model (Pre-deploy, Day of Deploy, Post deploy).
Metrics up to and during Go Live
Project Team
IV Pump project was started on December 1st, 2015. This provided an aggressive time table to Go Live
of 5 months. During this time the project team had 189 meetings (including 34 breakout sessions with
specific units/areas, 46 status update meetings) since kickoff.
The team comprised of 52 Subject Matter Experts and up to 27 project team members (including staff
from Supplies, IT, Nursing Professional Development Services, Equipment Transport, Clinical
Engineering, Anesthesia, and Nursing Practice).
Pharmacy
Pharmacy created three library profiles, Adult, Pediatrics and Neonatal, each with their own
configuration and library of drugs.
Library consisted of:
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Total number of entries = 1236
Adult library = 618
Pediatrics library = 426
NICU library = 192
Training
From March 28th until April 22nd 1663 Staff trained on new the new Alaris IV Pumps (consisting of 362
Super Trainers and 1301 End Users). They were taught in two rooms of University Hospital (4614 &
7614) which consisted of a total of 202 Training Classes (comprised of 20 Super Trainer Classes, 160 End
User Classes, and 22 Specialty Classes [Anesthesia, Cleaning, and Pharmacy])
We ended with a Training Completion Rate of 89.6%.
Go Live
The day of Go Live started at 0400 in the Command Center (G103). The Command Center provided
phone and in person support for all Go Live Issues. During the day we received a total of 18 calls, the
majority of which were minor issues that were taken care of immediately.
For the day of go live we had 7 cart teams totaling 52 members that deployed 1089 PCUs, 1625 Large
Volume Modules, 254 PCA Modules and 300 Syringe Pump Modules. The teams deployed to a total of
79 units and offsite areas (30 – UH Inpatient Areas, 25 Specialty Areas, 24 Offsite Areas).
Our main stumbling block was around 1000am, when EPIC was supposed to change over to its new
order set for the PCA Modules. This placed Go Live on hold for about 30 minutes as we dealt with this
issue. The issue was resolved and no other issues with EPIC during go live.
Post Go Live
Following Go Live there have been few issues that the project team have been resolving. The following
is an illustrative issues and solutions list of the types of issues the project team has been dealing with.
1) Issue: Entering a dosing rate on the PCA module for a fraction of a dose needs to be entered by
pressing the decimal point first prior to entering in the number. Merely entering in the number
provides a whole number dosing rate.
a. Solution: CareFusion Support has reinforced this workflow. Communication to staff
and managers also reinforced this message.
2) Issue: Incorrect BOLUS caused an issue in 3rd Floor MICU.
a. Solution: Project Team downloaded info from pump to understand if the pump was
programmed incorrectly. There was no indication of a pump malfunction. Issue seems
to be connected to human error.
3) Issue: Several Requests for Library Changes with Pharmacy. Nothing that was life threatening
or would cause a patient safety issue.
a. Solution: Library Updates were quickly pushed out with the requested changes.
Communication sent out to staff and managers to update the libraries by restarting the
IV Pumps. Additional library changes will now be accepted through the Pharmacy web
site.
4) Issue: PCAs and Lockboxes are being left locked, preventing Equipment Distribution and CVS
from effectively cleaning them.
a. Solution: Communication to staff and managers reminding them to leave them
unlocked. If locked, Equipment Distribution and CVS will return the equipment to the
nurses for unlocking.
5) Issue: Some nurses have been changing the PCA configuration to allow the dosing cord to
reflect when a new dose is available. This is against UHAHS Policy and best practice.
a. Solution: Reminder to staff and managers that this is not an allowable practice and that
the PCA Configuration should not be changed.
6) Issue: There has been some report of air in line errors happening with the new pumps. This
seems to be attributed to the height of the Large Volume bag and the IV pump.
a. Solution: Communication sent out to staff and managers on the best practice for height
for IV pumps and Large Volume bag placement.
7) Issue: Received a call from 4th floor; received a patient from PACU. The patient had been
started on a PCA. However the medication did not have a driver fluid and the PCA dose control
cord was NOT on the device. They were trying to give the patient a Clinical Bolus to get pain
under control.
a. Solution: Attached PCA Cord to PCA Module which solved the issue.
8) Issue: We have been having issues this morning with secondary infusions not running. I think
we finally figured out that we are stocked with the old secondary tubing (has the blue hanger to
drop the height of your primary infusion). I believe we need to be stocked with the new
secondary tubing b/c the hanger is longer. We have doubled the blue hangers for now and
things are working (7 Central) but would really like to get this supply item switched out.
a. Solution: Once more distance was put between the secondary bag and the primary bag
the secondary seemed to run fine.
Lessons Learned
Project Team
Contract – Effective Contract negotiations at the start of the project gave us the resources we needed
when we had to have clinical and technical support. This helped UVAHS and CareFusion follow up with
any issues when they came up.
Key Milestones – Signing an agreement to key milestone dates kept both UVA and CareFusion on track
and moving towards a mutually agreed upon go live date.
Phase 2 – Knowledge that we needed to attach bar codes to the Syringe and Large Volume modules for
Phase 2 would have been very useful when we were unboxing and setting up the pumps in the
warehouse. Now that they have been disseminated throughout the hospital it will be very difficult to
find and attach a bar code to every device throughout the hospital.
Pharmacy
CareFusion & UVA interface – Pharmacy did not feel like CareFusion fully understood the level of
complexity and collaboration that is required in UVAHS. UVAHS culture continually seeks input from
many sources to garner full hospital support which was essential as it related to input for library build.
Training on Pumps for Pharmacy – The only people that got trained on the parameters of the pump had
to go through the 8 hours of training. It would have been useful to have some type of 1 hour
webinar/tip sheet for the folks providing input for the data set. Staff couldn’t effectively answer
questions on the data set without knowing some base knowledge on the pumps. Staff needed to take
the time to learn the system before making decisions on it. Kickoff meeting was very superficial and did
not show how to work with the pumps. How do you assess and track against the roadblocks identified
in pump selection process? If folks did some clinical observations prior to start of project could have
identified these issues prior to making decisions.
Training in Classrooms - When people were training they wanted to work through the pump as if they
were trying to take care of a patient on their unit. This would have identified issues with the libraries.
However, trainers wanted to stick to their specific script. We needed to customize earlier, hate the rush
of library changes at the end, which could cause safety concerns due to the quick turnaround and lack of
standard vetting processes. If the issues were found sooner we could have not had as many last hour
changes. More time to play/socialize with the pumps could have alleviated some of this concern.
Finalizing initial data set - Pharmacy felt pressured for completing the library on a specific date (which
seemed artificial). Some recognition from CareFusion that folks have other duties they need to work on
as well.
Go Live - Overall the Go Live day went very well, CareFusion only getting a tenth of the calls they
typically get post go live.
Controlled Substances Workflow - UVAHS did not initially understand the full ramifications of the new
PCA workflow (impact to Pyxis, lockboxes, move from CADD cassettes, etc.). This would have been a
good thing for CareFusion to give a heads up on.
Education
Training Room Location - Ability to get 4614 and 7614 for the entire duration of the classes allowed us
to setup the rooms effectively and to create the setup for a whole month made it a lot easier for
clinicians to attend.
Last Minute Rush to Training – Majority of training happened at the end of the training schedule. Many
classes early on were sparsely attended. This issue is hard to fix as it is part of the ‘UVAHS Culture’.
Recommend we communicate earlier and more often to help drive folks to earlier classes. Also need to
convey classes are mandatory and communicate repercussions if staff do not make it to training.
Planning Education – Good pre-work with education team got us to a consistency in the education
training. In collaboration with CareFusion and NPDS there was created the custom education plan that
worked well for the staff.
Training Communication – The message that came out of NPDS on how we are going to address
becoming IV Pump competent (CBL, hands on, and CVR) and if they did not complete this training then
what would be the ramifications. That made a big difference in attendance. Even with this
communication there were often questions on folks not knowing the CVR was required, or if even the
training was mandatory. In the future it would be better to share the whole of training from beginning
to end with staff so they know the whole process of training.
Training Pumps on Unit - Rolling out the training pumps for the units during the class training time
would have helped socialize folks to the pumps and helped with the CVR signoff. This was mitigated by
there being training pumps for sign out for units that requested them. This helped deal with working
through issues before go live.
Tracking Attendance - Need to do a better job of accountability during the signup and class attendance.
The final weeks of data analysis and communication to managers on who has attended classes helped
push the training percentage to where it needed to be. There were challenges to get a total count of
number of folks that needed to be trained. Creates the accountability to show managers who has
attended and who has not.
Class Signup – Titles of classes were not as searchable as it could have been. In the future be sure to
include all key words in the class title to allow for easier searching. In addition there number of classes
available cascaded them onto multiple pages. Often staff were confused and would only sign up for
classes on the first page. In NetLearning, it was also forgotten to turn on the reminder emails to staff 24
hours prior to training which could have helped alleviate some of the no show issues.
CareFusion Team - The CareFusion team exceeded expectations. Lead trainer (Frank Luther) had a great
attitude, well versed and very engaged. Push to teach towards the ‘UVA Way’.
Subject Matter Experts
Height of Bags & IV Pumps – Some staff were unclear on the correct height for hanging large volume
bags and IV pumps on the IV Poles. Additional clarity could have been given during training for this
issue.
PCA Light for Dosing Cord – Some staff are changing the configuration around the PCA light on the
dosing cord. They fail to understand ‘why’ this is the current best practice. Recommend to include the
'Why' for the decisions to attain acceptance of policy change.
Spacing Issues in PYXIS – Some spacing issues with the Pyxis machine makes it difficult to retrieve the
necessary medications. Pharmacy is reviewing the setup and moving bins around to provide additional
space.
Supplies
Organizational Structure – Allowed team to determine leader for functional areas which helped a great
deal. Rounding on organization any issues identified from a supplies perspective were very minor (i.e.
mapping supplies to use, IV pole issues)
Practice Change - Understanding of our audience of what practices were going to change, and what
tubing & combinations are needed. Supplies got many requests along the lines of 'I need X because I'm
doing Y'. Additional focused training could have reduced these requests.
Training vs. Supplies - Some confusion came from teaching from CareFusion recommending directly to
nursing a certain tubing set, but not including Supplies in on the new change tubing needs, so supplies
was unaware of the change. SME was planned to be used to marry old and new practices but was not as
effective as it could have been. Chemo changes complicated this whole issue.
Supply Decision - Much earlier decisions on supplies (Feb timeframe) on what we would be transferring
too to give Supplies enough of a heads up. Nursing should have gotten the pumps earlier so they could
look at the tubing in actual practice and decide if it actually meets their needs. Without having the
pump it was really hard to have effective responses to the tubing needs.
ED Issue - They trained on 8W tubing. But they needed slightly different tubing, which caused some
confusion.
Meeting Frequency - Should have met more frequently, we had a CareFusion storyboard, but needed to
have UVA's customization added to it.
Changes to supply needs - Unanticipated new uses for the pumps could change supplies and tubing
needs. Sometimes folks wanted new tubing even when old tubing is fine. Some incorrect teaching
around tubing (i.e. for CADD pumps on Epidural)
Old vs. New supplies – Overall document showing change from old to new tubing was very useful.
Could have been more useful if it provided a list of what we are keeping the same so nurses know what
wouldn't change.
Downstream Impact - Recognize there are downstream impacts that we need to try and account for (i.e.
additional port on tubing increased the use of wipes)
Pump Training - Would have had value for project team to have gone through the IV Pump training. In
Training classes they were using the wrong secondary set, which Supplies could have caught if they
attended a class.