CHEO nurses using new technology to keep children safe
Medication errors are the number one cause of harm to patients in Canadian hospitals. Thanks to the hard work and diligence of nurses, CHEO has substantially reduced adverse drug effects to inpatient children and youth. In October 2017, CHEO Pharmacy and inpatient units began using Epic — the most powerful electronic health record system in the world. This new technology enables nurses to use barcode scanners at the bedside, double checking that the right medication is getting to the right child.
Prior to Epic, physicians handwrote medications orders. These prescriptions would sometimes take time to make their way down to Pharmacy where they would be validated and added to the patient’s Medication Administration Record (MAR) — an official document detailing all medications for all patients created each day by Pharmacy.
On the units, nurses consult the MAR, obtain indicated medications from the unit’s medication cabinet, check to make sure they are correct, verify the patient’s identity, and finally administer the drug. Seems simple but a CHEO study showed that nurses are interrupted an average of 15 times by patients and colleagues between getting medications from the cabinet and reaching the patient. Hospital inpatient units are busy, complex places.
Now, with Epic, when a physician makes a medication order it is instantly transmitted to Pharmacy where it is double checked to ensure the right dose for the age and weight of the patient, the right formulation, and there are no potential drug interactions or allergies. What used to take hours, now takes 7 to 15 minutes. And, the electronic MAR is instantly updated in real time making for with less chance of transcription errors. This speed ensures that all medications are verified by Pharmacy — minimizing the possibility of an error with dosage.
Bar Code Medication Administration (BCMA) is used as a final safety check. In addition to a visual check, nurses scan barcodes on the medication and patient’s armband to ensure it is the correct medicine, correct patient and the correct time to be given. As many families bring prescribed medications with them from home, these too have barcodes added by Pharmacy to ensure they are being correctly administered.
Thanks to speedy, accurate validation of medication orders by the Pharmacy, a final additional BCMA safety check at the bedside, and the daily diligence of nurses CHEO is ahead of the national average and improving every day.
Every day, CHEO leadership puts safety first
CHEO begins each day with the “daily brief.” Seven days a week, 365 days a year, leaders from across the organization — from every department and location — come together for 15 minutes to inform one another of the status of their unit and the challenges they expect to face in the coming 24 hours.
The daily brief is an integral practice of safe, reliable organizations that are part of Solutions for Patient Safety — a network of over 135 North American pediatric hospitals and facilities who share best practices with one another.
The daily brief helps CHEO leadership understand, virtually in real time, the remarkably complex needs of the organization. Why, for instance, a repair in Medical Imaging might not get dealt with immediately since Facilities Management staff are required for a more pressing need in the Emergency Department. Why administrative offices are too warm because cooling must be temporarily redirected to patient occupied spaces. Why there may be a temporary shortage of some materials because CHEO’s supplier in Puerto Rico has been damaged by hurricanes. And so on…
“I was the first to admit that I was not a fan when this idea was first proposed,” says Mari Teitelbaum, Chief Innovation Officer. “I was worried that we would be adding yet another meeting but in fact I am now the daily brief’s biggest fan. Those 15 minutes are often the best 15 minutes of the day.”
For instance, the daily brief has made everyone aware of the constant challenge of staffing a busy pediatric organization. In a restaurant, when a staff person calls in sick and cannot be replaced, customer service suffers but that’s all. At CHEO, when a nurse is sick, they must be replaced by a properly qualified colleague or there is a risk to patient safety — a nurse from Emergency may not have the right qualifications to be called in to replace a nurse from Mental Health. In peak cold and flu season, staff sick calls increase and each needs to be replaced by precisely the right person.
“The daily brief keeps us better able to stay ahead of our needs,” says Dr. Ken Farion, Medical Director, Strategy, Quality and Systems Improvement. “We can better anticipate where there may be staff or equipment shortages and plan ahead, even if it’s just 24 hours in advance.”
Adding the daily brief is one of several CHEO initiatives that puts safety first, not only for children, youth and families but also for staff and medical staff.
It may be brief… but it’s mighty.
It’s been one Epic year at CHEO
The introduction of Epic, the most powerful electronic health record in the world, has been gradual. Way back in 1994 CHEO became the first Canadian hospital to partner with Epic, using it for patient registration and scheduling. Then, five years ago in October 2013, Epic became part of CHEO’s electronic medical records, rolling out in waves to all of the Ambulatory Care clinics. Learning from this experience, on October 18, 2017, CHEO expanded Epic to include inpatient units, the Emergency Department and Pharmacy.
“Always looking to improve care and put safety first, we all agreed to work towards consolidating all of a child’s medical information in one virtual place, making it available to every clinician in our organization exactly when it is needed,” says Tammy DeGiovanni, Director of Ambulatory Care and Chief Nursing Information Officer. “We rallied around the idea of one patient, one chart.”
Epic makes a child or youth’s health information available enterprise-wide in real-time. If a family visits the orthopedic clinic Tuesday morning and then the plastic surgery clinic Wednesday afternoon, all of the information from Tuesday will be ready for the plastic surgeon on Wednesday. Before Epic, this information would have been in one paper chart which might have languished on someone’s desk or been updated days after a clinic visit. Now, updates occur in real-time.
Families appreciate the convenience — they don’t have to tell their story over and over again because there it is… in Epic. Clinicians appreciate the comprehensiveness — all the important information they need is there… in Epic.
DeGiovanni cites three big changes since Epic was expanded one year ago:
Information in a child or youth’s chart is integrated throughout the system in real-time. For instance, when a child is admitted, their allergies are instantly transmitted to Dietary Services to restrict their diet and ensure their safety — that they are not accidentally given food that contains the allergen. When a child is discharged from the hospital or makes a visit to the Emergency Department, a summary is automatically forwarded to the child’s physician. These summaries are sometimes sent even before the child has left the hospital. When a child or youth is seen overnight in the Emergency Department, a summary of the visit including recommendations for follow-up will be waiting for their family physician in the morning.
Medication orders are accurate and much faster. When a physician orders a medication in Epic, the order is instantly transmitted to Pharmacy where it is verified — ensuring there are no potential interactions with other medications, there are no allergies, and the dosage is correct. In adults, medication can usually be standardized (“take two tablets every six hours”) but with tiny children, the dosage must be carefully adjusted for each child to match their weight. With Epic, ordered and verified medications are delivered within an hour. This process used to take four hours.
Epic has enabled barcode medication administration (BCMA). Every medication is scanned prior to being given to a child or youth, ensuring that it is the right medication in the right dose at the right time for the right child. BCMA puts the safety of children and youth as our first priority. It reduces human error and ensures that medications are exactly what was ordered.
The expansion of Epic to inpatient units, Emergency and Pharmacy one year ago has brought CHEO very close to the promise of one patient, one chart. Four months ago, in June 2018, Epic expanded again, this time to include Surgery and parts of Development and Rehabilitation. In 2019 Epic will expand to include Anesthesiology in February 2019, Ophthalmology in June 2019, and Dentistry shortly after that.
Moving CHEO from paper health records to Epic has been the biggest transformational initiative in the organization’s history. There have been countless hours of renovating, training, programming, testing and practicing. The result is safer, more reliable and continuously improving care for children and youth.
Solutions for Patient Safety is a big part of Safety First at CHEO
CHEO is improving our care by improving safety for every patient, every day. We are in our third year as a member of Solutions for Patient Safety (SPS).
SPS is a network of over 130 children’s hospitals across the United States and Canada who work together — sharing information, best practices and research — to eliminate preventable harm to children and youth.
Despite our efforts, we sometimes cause harm to young people in our care. That sounds ominous but what does it mean? Just that health care can occasionally be so complex that children and youth acquire conditions that they would not have otherwise, except for coming in to our care.
For instance, some children in the Pediatric Intensive Care Unit require a “central line” — a catheter in a large vein near the heart. Medications and fluids administered by a central line are very fast acting. But, all catheters can introduce bacteria into the bloodstream and bacterial infections from central lines can be more serious than infections from an IV in the forearm or foot.
This is an example of the complexity of health care: a patient requires a central line despite the risks associated with it. CHEO’s goal is to ensure that no children or youth ever acquire a central line associated blood stream infection (CLABSI) because of something that we did, or did not do.
Membership and adherence to SPS protocols has reduced CLABSI rates in member hospitals by 21.1% since 2015. This is a big project involving lots of staff and physicians but is well worth it as we anticipate that CHEO will see similar results — good science gets good results.