1. Optimizing ‘Bolus from Bag’ functionality Margaret Schmidt April 19, 2017

2. Agenda Background Best Practices Examples Implementation
Electronic Medical Record (EMR)
and
Smart Pump Library (MDL)

3. Background Allina Health (MN, WI) 12 hospitals
61 clinics, 23 hospital-based clinics
49 rehabilitation locations
2 ambulatory care centers

4. Background Electronic Medical Record (EMR) Smart Pumps (MDL) Epic
Inpatient, Clinics, Hospice, Retail Pharmacies, Affiliates
2004 – current
Bolus/Load doses built as IV Piggyback (or IV Push)
Smart Pumps (MDL)
Baxter Sigma Spectrum
2500 pumps across all hospitals, some clinics, and EMS
2013 (6 mo timeline)
MDL records built for existing
IVPB Bolus/Load doses
Short timeline so didn’t have time for full assessment and impact of change
New pumps for existing workflows vs New pumps and new workflows
IV Fluid was the only record for which Bolus was allowed upon implementation of the new Smart Pumps
Optimize
‘Bolus from Bag’
at later date

5. Best Practices – Bolus/Load from Bag
EMR
Drug records for Bolus/Load
Separate record
No charge
Naming conventions
drug (concentration) ‘Bolus from the Bag’
Dose and Frequencies for Bolus/Load records
Units (eg, mg, mg/kg)
One Time, One Time PRN
Multiple doses, PRN
MDL
One record for Infusion with Bolus (or Load) Allowed
Mimic name in EMR on Medication Administration Record (MAR)
Units
Load Allowed
Bolus Allowed
Nurses expressed interest in functionality for other medications
Heparin was developed at one hospital, but impacted standards within EMR and MDL (order sets, drug record build, MDL records, etc)
HOLD on additional requests until Best Practices defined to minimize re-work and confusion
Gathered nurses, pharmacists, EMR Pharmacy developers, Epic and Baxter technical support to develop Best Practices during 3-hour, face-to-face session.

6. Best Practices – Bolus/Load from Bag
EMR
Default Administer Over or Rate
Barcode for BCMA
Pre-made Infusions have manufacturer barcode that works for Infusion and Bolus/Load
Pharmacy-prepared mixture has barcode that is specific to Infusion order; does not work for Bolus/Load
MDL
Starting Rate to minimize key strokes
Soft Limits to provide guidance
Hard Limits if needed for patient safety
Used REMEDI to identify other health systems’ limits

7. Bolus/Load Barcode 2-D barcode for infusion order
Linear barcode for Bolus order(s)

8. Continue to pursue interoperability
Build
EMR
New ‘Bolus/Load from Bag’ records
Concentration of Bolus/Load = Infusion
Charge on Administration of Bolus/Load = NO
Add Bolus/Load barcode to label of pharmacy-prepared Infusion records
Remove existing IVPB Bolus/Load records
MDL
Update Infusion records
Allow Bolus
Allow Loading Dose
Determine limits for Bolus/Load
Remove separate record for Bolus/Load
Continue to pursue interoperability

9. Take into consideration dosing algorithms
Example - heparin
EMR
New Bolus/Load record
Update order sets with new record
Consider dosing algorithm
Dose recommendations
,000 units
MDL
Update Infusion record to Allow Bolus/Load
Pump limit, UHL = 9999 units
Take into consideration dosing algorithms

10. Example - heparin
EMR/MAR
MDL
Bolus or Load?

11. glucose mgmt. technology and changes to order sets
Example - insulin
EMR
New glucose management technology
Bolus 0-50 units over 3-5 min
Infusion 0-50 units/hr
New order sets included
D10% ‘bolus’ mL (IV infusion)
D50% ‘bolus’ 0 – 100 g (IV Push)
MDL
Update insulin Infusion record to Allow Bolus
Determine workflow for units/hr
Update pump library
to coincide with
glucose mgmt. technology and changes to order sets

12. Example – IV Fluid ‘Bolus’
EMR
Update with Best Practices
New records
NaCl 0.9% Bolus from Bag
LR Bolus from Bag
Rate
NOTE: Rate > 999 mL/hr, infuse without pump
Charge on Administration
From Bag (No Charge)
New Bag (Charge)
MDL
IV Fluids without KCl always Allowed Bolus
Update current workflow(s) to follow
Best Practices

13. Implementation EMR MDL Scenarios Training/demonstration
Playground environment
Order Entry
MAR documentation
MDL
Training/demonstration
zzzTraining Care Area
BOLUS–Train
LOAD-Train
Align with nursing initiative for documentation of start/stop times in EMR

14. Summary Define Best Practices with all stakeholders engaged
Align Best Practices across technologies (EMR, MDL, algorithms, dosing tools)
Optimize existing workflows with Best Practices
Implement as bundle rather than one-off
Take time to do it right, but schedule time to optimize post-implementation
Optimize workflow
Assess workflow from Order Entry to Administration (including BCMA)
Optimize ‘Bolus’ IV fluids in ED to eliminate need to retrospectively review charges
Bundle with other initiatives to train nurses regarding improvements for IV Administration
Saturate their workflow with the Best Practices instead of infrequent encounters
SUCCESS!!!