Running head: THE USE OF SMART PUMPS AND INFORMATICS 1

The Use of Smart Pumps and Informatics

Amanda Scott

Delaware Technical and Community College

NUR 410-2W1 Nursing Informatics

Dr. Karen Wagamon

January 25, 2021

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With the use of informatics, the administration of intravenous (IV) medications has

changed considerably throughout the years. Nurses would have to physically calculate and

count drip rates before the development and institution of IV pumps. While there is no longer

a need to physically calculate drip rates, there are still many different dosages, some using

weight. Nurses still need to input some of the information themselves, and by manually

inputting these numbers, it leads to higher risk of medication errors. Accidentally

programming in a decimal where it does not belong can mean life or death for a patient.

“Compared with medications delivered via other routes, i.v. medications are twice as likely to be

involved in errors that cause patient harm” (Biltoft & Finneman, 2018). The technology of IV

pumps improves patient safety by making the administration of these more efficient and

accurate. One advancement in IV administration technology is the smart pump. These smart

pumps will help to reduce the amount of medication errors.

Implementing smart IV pumps in the hospital setting is a great way to improve upon

patient safety. These pumps can communicate wirelessly by pharmacy. They also can be set

up as patient specific, communicating with the patient’s electronic medication administration

record (EMAR). Smart pumps utilize dose error reduction systems (DERS) and prepopulated

medication libraries with infusion settings (Giuliano, 2015). Prepopulated drug libraries are

useful for patient safety. They allow the nurse to select a medication from an approved list,

and then the IV pump can calculate the appropriate infusion rate. While it does save time for

the nurses and is safer for the patient to utilize the medication library, it is important that

nurses still double check the selected medication and prepopulated rates for accuracy.

The DERS alerts are also useful for patient safety. They alarm when the pump is

manually set by the nurses outside of the programmed limits. Soft limits alert when something
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is too high or if something has been titrated drastically. These alerts can be overridden. Hard

limit alerts cannot be bypassed and will alert when something is unsafe and can cause patient

harm. Hard limits cannot be overridden. DERS and prepopulated medication libraries are

beneficial to both patient safety and to nursing productivity but utilizing EMAR

interoperability would improve upon the patient safety and nursing productivity.

During a study of the effect of implementing smart pumps with EMAR interoperability in

the hospital setting, it was found that they were able to “reduce manual keystrokes by 86%, thus

resulting in fewer medication error opportunities (Biltoft & Finneman, 2018). The patient’s

information would be directly input/scanned into the pump for communication with the EMAR

interoperability system. This system communicates directly with the patient’s specific EMAR.

Documentation of infusion titrations also go directly to the EMAR, limiting the need for

nurses to chart each titration change. “It has been reported that nurses spend 4 hours per shift

documenting and completing forms. We estimated that reducing documentation by just 5%

would free up 40 minutes per shift, or 1.2 hours per day” (Biltoft & Finneman, 2018). While

EMAR interoperability greatly improves nursing productivity, nurses cannot rely solely on the

pumps. They do need to check the pumps and ensure that the populated information is correct.

While smart pumps provide many benefits to patient safety by aiding in decreasing

medication errors and by helping with nurse productivity by automatically charting on the IV

medications, there are still barriers and complications to using smart pumps. One notable

complication may be the medication errors that could occur and the patient harm that would

come from the errors. By not using built in safety technology, by overriding an alert,

therefore, administering a dose that is outside of the preprogrammed dosing limit that would

result in patient harm, or by entering information into the pump manually instead of using the
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prepopulated medication and patient information, nurses could be considered not compliant

with the correct usage of smart pumps. “Clinicians report that pump programming is

frequently rushed, and alerts are overridden because of time constraints, competing work

demands, and patient acuity” (Giuliano & Ruppel, 2017). By disregarding and overriding

pump programming, patient safety is compromised. As health care professionals have a

fiduciary relationship with patients in which the professional should seek the best for patients.

The Code of Ethics for nursing is a set of professional ethics that nurses are expected to

follow. They are the values, responsibilities, and obligations that govern the conduct of all areas

of nursing. It is a measure that ensures that nurses carry out quality nursing care. The Code of

Ethics is the standard of right and wrong, and they are the standards by which a nurse should

conduct themselves. It should always be a nurse’s priority to advocate for the patient, this

includes patient safety. By participating in unsafe behavior, the nurse would not be promoting

non-maleficence, and nurses are to be accountable for the care that they provide (ANA, 2019).

This includes overriding pumps. Nurses are promoting good and not causing harm by using good

nursing judgement and by being accountable for their decisions and actions. Nurses must be

responsible for using their own knowledge and judgement to be sure to identify any errors and

to utilize medication rights (right patient, drug, dosage, route, time, and for the right purpose).

It is also important to not override the pump’s preprogramming and alerts, unless absolutely

justified, and reporting problems with smart pumps and with incorrect drug library settings

should be the responsibility of the nurse (Giuliano & Ruppel, 2017). Nursing standards of care

should not be ignored.

Smart pumps do have limitations, and many of these limitations directly impact patient

safety. They should not be taken advantage of. The drug library and safety features can be
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overridden and entered manually. “Soft stop alerts can be easily overridden, generally with

one keystroke”, and “If hard stop alerts aren’t set appropriately, they force users to engage in

workarounds in order to administer medication” (Giuliano & Ruppel, 2017). Nurses and

pharmacists must work closely together, in both pump programming and administration to be

sure that the IV infusions are safe for the patient. “By understanding the limitations of smart

pumps, nurses can take appropriate steps toward avoiding medication errors” (Giuliano &

Ruppel, 2017). One important way to improve on patient safety is to implement a hospital

policy on the use of IV smart pumps.

It would be crucial to implement a policy that was very specific on the utilizing the

given parameters of a medication and not exceeding those limits. Not overriding soft limits,

unless for specific needs such as a patient crisis or by MD order, would be another critical

addition to a policy. It may be beneficial to set within the policy specifics of titrations,

specifically in the ICU. For example, an order for a pressor may state that the med can only be

titrated by 5mg every 20 minutes. Nurses should be titrating based on those orders, however,

during patient crisis, the medication may need to be titrated by larger doses or titrated more

quickly. This needs to be stated in the policy to protect nurses.

To implement a new IV smart pump system in a hospital, the hospital would want to

review its current policies and procedures, day-to-day use of its current system, the

costs/revenue associated with the current system, and what the costs/revenue would be with

the new system. While patient safety and nursing productivity are important to the hospital

administration, new IV pumps can be costly, and that may be a deterrent for hospital-wide

implementation. Hospital administration will want measurable rationale for implementation. One

could argue for maximizing patient safety.

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Among all types of drugs involved in medication errors. i.v. medications pose particular

risks because of their greater complexity and the multiple steps requires in their

administration. Preparation and i.v. medications are associated with 54% of potential

adverse drug events (ADEs). Of the most serious and life-threatening potential ADEs,

61% are associated with i.v. medications. Compared with medications delivered via other

routes, i.v. medications are twice as likely to be involved in errors that cause patient

harm. (Biltoft & Finneman, 2018)

EMAR interoperability open communication between the EMAR and the IV pumps so that all

patient-specific information, like medications with exact dosing, rates, and parameters and

documented weights, can be sent directly to the IV pump (Biltoft & Finneman, 2018). In this

case all, this decreases manually entering information which in turn decreases room for errors.

Decreasing manual input of information into IV pumps increases nursing productivity as

well. “Interoperability frees nurses from the burden of manual documentation yet keeps them

involved in the process, as they must use their clinical expertise to verify the infusion

information before committing it to the patient record” (Biltoft & Finneman, 2018). Nurses

spend much of their shift documenting, time that could be spent in patient care. Smart pumps

would improve workflow.

Whether there is a potential for generating revenue would be a very important rationale.

There would be several ways to increase revenue by instituting smart pumps with EMR

interoperability. One way would tie into the rationale of increasing nursing productivity and the

decreasing of documentation requirements.

Given that the health system is staffed by an average of 1,200 nurses each day, we

calculated that a 5% savings in staff time would represent $6,720 in cost savings on a
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daily basis, or $2,452,800 annually—time and expenditure that could be repurposed for

other activities such as direct patient care. (Biltoft & Finneman, 2018)

Billing of IV medications also depends on accurate documentation of said medications. If

infusion start and stop times are not properly documented, the hospital is unable to bill

appropriately. Biltoft and Finneman were able to provide information on these improvements by

testing in outpatient infusions.

EMR interoperability provided accurate infusion start and stop times in the patient

record. This reduced mean lost charges for outpatient infusions for 11.9% to 7.4% and

lost revenue from $980,000 to $610,000 (a decrease in approximately 40%), which

represented $370,000 in incremental revenue with greater safety. (2018)

By implementing EMR interoperability systemwide, there could be a significant increase in

revenue for the hospital.

Using a flowchart will help to visually communicate all the steps needed to make the

process successful. A flowchart will also allow for any problems to be identified and improved

upon. Each department and their importance to the process would be easily recognizable. The

flowchart will be a useful tool in implementing the smart pumps.

Flow chart #1 below represents the steps for IV infusions without using the EMAR

interoperability. In this chart, the nurse will open the patient chart to the EMAR. Next the

nurse would retrieve the medication, scan the patient armband (confirming identity), then scan

and sign off the medication. After this, they would prepare to hang the medication, turn on the

IV pump, place tubing into the pump, and use the drug library to select the correct medication.

If the medication is in the pump, the nurse would select the drug and the appropriate rate. The

pump calculates the rate, and the infusion can be started. If the med is not in the library, the
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nurse would use the “Basic” function to select the rate (mL/hr, etc.), input the correct numbers

based on the med order, and then start the infusion. If the medication is titratable, the nurse

would use pre-set parameters to judge whether to titrate the med. If they do need to titrate,

they must write down or remember the times so that they can document this later.

Flow Chart #2 represents the steps for IV infusions with using the EMAR

interoperability. In the instance, the nurse would open the patient chart, retrieve the correct

medication, prepare the med for infusion, and place tubing in the pump. Afterwards, the nurse

would scan the patient and medication into the pump. The med should be readily available for

selection in the pump as pharmacy inputs patient-specific data. The nurse would then select

the medication and correct dose, and the pump calculates the rate. The nurse confirms that

everything is correct and selects “Run.” If the medication is titratable, the nurse would use

pre-set parameters to judge whether to titrate the med. If they do need to titrate, the pump will

automatically chart titrations into the EMAR.

Implementing IV smart pumps with EMR interoperability will require much work. It will

be important to have a multidisciplinary team, including IT, nurses, physicians, and pharmacy,

committed to establishing and monitoring the process. In the beginning of implementation, there

would be more staffing needs to ensure a transition that would be as smooth as possible, but it

will be beneficial for all involved long term.

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Flow Chart #1

Open pt. Retrieve Scan pt.

Begin
chart medication arm band

Turn on Prepare to “Sign” med. Scan IV

pump hang med. administ. medication

Use drug
Place
library to select
tubing
med.

Is med. in
drug library?

Select med. Select

& correct rate Yes No
“Basic”

Pump Select rate

calculates rate (mL/hr, etc.)

Confirm
rates &
calculations
Input correct
numbers

Push “Run”
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Is med.
titratable?

Use parameters
to titrate
Yes No

Note/remember
time and rate
change

Continue
monitoring
When able, pt. during and
document
after infusion
changes

Stop
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Flow Chart #2

Open pt. Retrieve Turn on

Begin
chart medication pump

Scan pt. and

Use drug library medication into Prepare to
Place tubing
to select med. pump hang med.

Med. should be
readily available
as pharmacy
inputs patient
specific data.

Select med.
& correct rate

Pump
calculates rate

Confirm rates
& calculations

Push “Run”
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Is med.
titratable?

Use parameters
to titrate
Yes No

System will
automatically chart
titrations in real
time.

Continue
monitoring pt.
during and
after infusion

Stop
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References

ANA. (2019). Code of ethics for nurses with interpretive statements. Retrieved from:

https://www.nursingworld.org/coe-view-only

Biltoft, J. & Finneman, L. (2018, July 15). Clinical and financial effects of smart pump:

Electronic medical record interoperability at a hospital in a regional health system.

American Journal of Health-System Pharmacy, 75(14), 1064-1068. doi:

10.2146/ajhp161058

Guiliano, K. (2015). IV smart pumps: The impact of a simplified user interface on clinical use.

Biomed Instrumentation & Technology, Supp, 13-21. doi: 10.2345/0899-8205-49.s4.13

Giuliano, K. & Ruppel, H. (2017, March). Are smart pumps enough. Nursing, 47(3), 64-66. doi:

10.1097/01.NURSE.0000512888.75246.88