Canadian Journal of Nursing Informatics

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This article was written on 20 Mar 2021, and is filled under Current Issue, Volume 16 2021, Volume 16 No 1.

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Smart Pump Implementation to Meet Anticipated Surge Needs During the COVID-19 Pandemic

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Susan C. Johnson, RN PhD
Smart Pump Implementation Lead, Nova Scotia Health

Citation: Johnson, S. C. (2021). Smart Pump Implementation to Meet Anticipated Surge Needs During the COVID-19 Pandemic. Nova Scotia Health. Canadian Journal of Nursing Informatics, 16(1). https://cjni.net/journal/?p=8576

Smart Pump Implementation to Meet Anticipated Surge Needs During the COVID-19 Pandemic

As part of COVID-19 response planning, Nova Scotia Health (NSHA) leadership identified a significant deficit in the number of infusion pumps that would be required to administer intravenous fluid, medication, blood and blood products, or nutrition to the volume and acuity of patients anticipated during the COVID-19 pandemic. It was determined that expedited implementation of Fresenius Kabi Agilia® ‘smart’ pumps would help to meet these needs.

Background

In 2018, a provincial contract was awarded to the vendor, Fresenius Kabi (FK) for the provision of approximately 5,000 infusion pumps to replace the existing fleet of Hospira and Alaris pumps that were coming to the end of their service. Extensive planning for the implementation of the new pumps included the formation, between January and November 2019, of a ‘Smart Pump Implementation Team’ (implementation Team). This team, comprised of two dedicated smart pump pharmacists, a clinical lead, a non-clinical lead, a smart pump coordinator, a project manager, and an implementation lead was charged with preparing for the safe and effective implementation of the new pumps province-wide between April 2020, and July 2021. This included:

  • Creation of a validated drug library, including processes for monitoring library use, reporting of Drug X use, and requesting drug library changes
  • Development of processes for supply chain, including determining supply usage and projected needs, as well as sourcing and evaluating products
  • Building capacity within biomedical engineering departments to prepare the pumps for deployment, and respond to faults
  • Identifying best practices in infusion therapy and smart pump use, including development of standardized practices with relevance to practice areas, and clinical and environmental contexts across NSHA
  • Writing policies to direct safe practice in the use of the pumps, including policies and procedures for related practice changes in line with practice standardization
  • Formulating an education model and creating teaching and learning materials for staff training and education
  • Planning and operationalizing an implementation strategy incorporating all of the above elements

This work was close to completion, with a planned implementation at the first sites within the Western Zone (WZ) on April 1, when the first cases of the novel coronavirus, COVID-19, were diagnosed in Nova Scotia on March 8, 2020.

Surge capacity planning

Nova Scotia was one of the last areas in Canada to identify cases of COVID-19 within the population. Lessons learned from other areas of the world initiated a planned emergency response strategy that anticipated a surge in the number of patients hospitalized with COVID-19, including many patients who were acutely-to-critically ill and therefore requiring significant clinical interventions. It was expected that this population of patients would require significant resources, including equipment to monitor them and equipment to provide patients with fluid and medications.

The Implementation Team anticipated a request for a roll-out of the Agilia pumps in order to meet these needs. It was determined that the implementation needed to be ‘targeted’ and ‘expedited’.

  • Targeted Implementation – the implementation would need to be targeted to clinical areas with sufficient Hospira Pumps that could be redeployed to meet surge needs elsewhere within NSHA. Additionally, there would need to be strong support from local leadership to engage staff in training, and reinforce good practice.
  • Expedited Implementation – Unless implementation could occur prior to the anticipated surge, staff would be too busy and overwhelmed in caring for multiple isolated patients, to be able to safely learn and adapt to using the new technology. Further the risk to the training team of infection by COVID-19 would be significantly increased, and the possibility of a workforce significantly reduced (some models projected up to 35% of frontline staff might be infected) would affect the capacity of the training team, as well as the frontline staff.

There were identified risks to both these approaches.

  • Complexities at transitions in care between areas using Hospira pumps and those using Agilia pumps.
  • Rotation of staff into and out of the transitioned unit so that staff need to be familiar with both (contrasting) technologies
  • Integration of new technology at a time of increased acuity and increased patient numbers is an added stressor to staff and a challenge to learning
  • Adoption of new practices with a novel patient population may expose unanticipated risks
  • Training would need to be adapted to meet tight timelines; inevitably reducing the content to core elements of pump functionality

However, the identified benefits of implementation included:

  • enhanced patient safety functions to reduce errors in times of high acuity and increased patient numbers
  • release of Hospira pumps to support surge capacity in other areas of the province

Implementation Timeline

DATETASKS AND ACTIONS
March 18Communication was distributed following a decision to delay the planned April 1 implementation of the Agilia pumps in WZ. Members of the Implementation Team were tagged for redeployment for COVID-19 response.
March 19A deficit was identified in the number of infusion pumps to meet surge requirements.
March 20The Implementation Team identified to NSHA senior leadership a number of requirements for a safe localized implementation of the Agilia pumps within Critical Care in Central Zone, as well as risks and benefits of this approach to implementing a new technology locally and in a time of unprecedented change.
March 23A decision was made to adopt the proposed implementation model for select Critical Care and Heart Health units at the Halifax Infirmary and Victoria General sites in Central Zone.
March 26Further discussion added 5.1CVICU and CVOR to the affected areas
March 26A group of nurses redeployed from OPOR/IMIT underwent 2.5 hours of training.
March 27Training of frontline staff commenced at both sites.
March 31Go-live: 3AICU (VG site)
April 1Go-live: 3IMCU, 6.4CCU
April 2Go-Live: 5.2ICU
April 3Go-live: Cardiac Cath Lab
April 14Go-live: CVICU
April 15Go-live: CVICU; CVOR

Training Model

Training requirements:

Appropriate attainment of competence in the use of infusion pumps is an Accreditation Canada Required Organizational Practice. The NSHA requirements for attaining competency includes: review of the Smart Pump Policy & Procedure; successful completion of the online learning module via the LMS; and hands-on training.

The Implementation Team identified a training model that would meet the expedited timeline for implementation. Training would be for one hour. To put this into perspective, the original training model was to have combined training (in pump functionality, including hands-on scenario-based practice) with education around practice impacts of smart pump use and standardized infusion practices for a total of 3.5 hours in the classroom.

Under normal circumstances, the vendor is responsible for providing the training component. However, in the face of a pandemic, the vendor’s trainers were prohibited from entering NSHA facilities. In response to this, FK produced a 22-minute video describing the pumps’ main features and functionality. Split into sections, the video was designed to be paused to allow learners to have hands on practice. Trainers from the Implementation Team were present in the room to show the video, guide practice, and answer questions.

Training Schedule:

A schedule was devised with the following parameters:

  • Training rooms would accommodate up to 6 trainees, plus two trainers
  • Training would occur every hour on the hour from 0700-2200 (with a meal break at noon and 1800)
  • Training would occur at each site, with up to 4 rooms providing training concurrently
  • There would be enough training spaces to allow for all staff on the affected unit to attend a session and to allow for flexibility in scheduling

Enough training places were scheduled for up to 814 staff to attend.

Managers registered their staff directly into the schedule via the smart pump SharePoint site. Staff were asked to sign into the sessions and the schedule was updated to reflect those who attended the sessions. Managers were then able to compare the list of attendees against their own staff lists to identify any gaps.

All equipment, seats, and supplies were wiped down with antiseptic wipes between sessions.

Support Model

Because of the abridged training model, staff had almost no opportunity to practice with the pumps, nor did they receive education on the practice impacts of adopting smart pump technology in their own clinical context. Although competent to use the pumps, staff lacks proficiency. This limits staff’s ability to problem-solve with the pumps and increases anxiety and risk. Additionally, under normal implementation circumstances, post-go-live support would primarily fall to the vendor to be on site for problem-solving, just-in-time training/coaching, and cataloging issues and concerns.

To address these gaps in proficiency and support, the Implementation Team developed a support model that relied heavily on the combined clinical expertise, knowledge of the pumps, and experience within the organization of the training team. Although resource-intensive, providing 24 hour on-site (and in many cases on-unit) support was determined to be the best mitigation strategy for identified risks arising out of the expedited implementation. This level of support was provided for 72-96 hours. Following on-site support, a roster of trainers-on-call was developed to provide a point of contact for staff for a further week. FK trainers were the first point of contact during this phase, with trainers from the Implementation Team available to respond to practice-related questions.

Learnings

Training Model

Timing of the implementation:

Nova Scotia declared a State of Emergency in response to the COVID 19 pandemic on March 22; training for the smart pump implementation started 5 days later. Staff were anxious about managing multiple patients requiring droplet precautions, the availability of Personal Protective Equipment (PPE), and adopting new processes at the same time as learning to use some new technology. Again and again, we heard questions and comments about why the technology was to be implemented in such high acuity areas, at this time. Naturally, there was some resistance, and staff would openly say that they would simply use drug X to avoid any changes in their current practice.

However, staff expressed that they felt much better about the implementation once they had undertaken the training. They recognized that there would be some ‘quirks’ that they would get used to, and most thought that they just needed some time using the pumps to feel comfortable.

Things that helped:

  • Being told the context – release of pumps in order to provide care in the event of a surge
  • Receiving training specific to their practice area – examples all relevant to practice
  • Having chance to practice with pumps on the units, and then coming back with questions
  • Understanding that implementation of the pumps is driven by patient safety

Areas of complex infusion therapy:

It was clear that learning was easier and richer when staff was trained with their peers from similar areas of practice. This raises questions about how a general implementation can be planned to best meet the needs of areas with complex infusion therapy, such as critical care areas and oncology units. Pediatrics is another area with unique practices.

How do we meet their needs?

  • Is it possible to offer cohort training sessions to specific practice areas?
  • Have trainers who are familiar with practices in these areas and can speak confidently to the drug libraries. This might be achieved through engagement with local clinical leaders (team leads, educators, etc.)
  • Prepare practice scenarios specific to these areas
  • Have practice pumps for staff to use before and during the implementation phase.

Training Video

The video was developed to be specific to the critical care context – in that the examples used were from the critical care library. This created some complexity with the 3IMCU staff who understood that they should be using the critical care library, rather than med/surg and IMCU libraries.

What we might do better:

  • Be more specific in training about choice of library to meet the patient needs and the care context
  • Ensure, where targeted implementation continues, FK prepares a range of videos that are applicable to different care areas.
  • Or, have FK prepare a training video that is more generic and has examples from different libraries/care areas
  • Have different practice scenarios in the room to guide trainers to different examples. These cannot cause the training duration to be extended during the expedited implementations.

Expedited Training

One hour of training is categorically insufficient to train staff to safely use the pumps without a robust support model to accompany it. Although there are questions around pump use, most questions relate to navigating the drug libraries, and practice impacts of the new pumps. This cannot be neglected for expediency.

How do we strengthen the support model?

  • Set up support teams with strong clinical backgrounds, good teaching and problem-solving skills, and broad knowledge of the practice impacts and responses.
  • Train multiple super-users. Super-users were not trained as part of this initial implementation. This was a mistake. Super-users are part of the practice peer group, leaders, and champions for change. They are a constant in the units and will be a vital part of the sustainability of good infusion practices.
  • Build local capacity by engaging additional clinical leaders, such as educators and managers.

Training Schedule

Time between sessions was insufficient in some locations to manage sanitizing the equipment between groups, answering final questions, and preparing for the next session. Trainers were working 15-hour days to meet the schedule, and this turn-around was tiring and stressful.

What we need to do:

  • Plan to have two members of the training team in each training room.
  • Create a training schedule with 15-minute breaks between sessions to allow for sanitizing and preparing equipment, as well as to allow self-care for the trainers.
  • Augment the training team with local super-users.  As a result of adding 15 minutes between sessions, there will be a reduction in number of training sessions that can occur in each room each day. Adding super-users to the team, allows for more training rooms as trainers pair up with a super-user.
  • Additionally, this allows super-users to consolidate the learning from their own training and broaden their knowledge through hearing and responding to questions.

Social Distancing

Although every effort was made to maintain a distance of six feet between all individuals in the room, when problem-solving or providing remediation, smaller distances were inevitable. Learners based on the same units seemed very comfortable to train together in quite close proximity to each other, and the trainers. Those who were training alongside learners from other units were more anxious about physical spacing.

How can we consistently maintain social distancing?

  • Work with local leaders to ensure rooms are sufficiently proportioned to accommodate the number of learners (no more than 6, but ideally 4) with a distance between each learner of 6 feet
  • Work with local leaders to ensure there is a supply of masks and that trainers wear masks when within 6 feet of learners.
  • Where possible, cohort sessions to staff from a single unit or area of practice

Registration

Registration was managed by the Health Services Manager (or designate) by having them populate a master copy of the scheduling spreadsheet via the Pumps Implementation Project SharePoint site. Challenges arose around ensuring that all individuals with responsibility for registering staff had access to the site and were made aware of the need to promptly save and close the document after completion.

How can we better manage registration processes?

  • Explore local registration processes to see if there is already an option that is functioning well.
  • Ensure that managers and designates are quickly identified, and have early access to SharePoint, as well as directions for use.

Training numbers/implementation areas

Areas that were to be implemented changed twice during the implementation period, increasing the number of staff to be trained, adding anaesthetists to the group to be trained, and ultimately causing a significant delay in implementation of two practice areas, such that the implementation team had to return for a second week of support after the implementation was to have been completed. This had significant resource implications.

How can we prevent this from happening again?

  • Senior leaders responsible for the decision to implement smart pumps in a targeted and expedited model need to identify the scope of the implementation required to meet the equipment needs, and to communicate the finalized plan to all concerned prior to committing the implementation team to the planning phase.

Infection Prevention and Control

Sourcing the necessary supplies to sanitize the equipment between training sessions, and the scrubs and face masks required for support in clinical areas was a challenge. Face masks were particularly challenging, having to be received each shift from the manager or charge nurse.

How do we get sufficient supplies in a timely manner?

  • Identify a local leader who is accountable to source the necessary equipment. The Implementation Team should be clear in the necessity of having this equipment for the safety of trainers and learners.

Support Model

The support model that was identified was entirely necessary to compensate for the abridged training model. Having staff visible and available on site was incredibly valuable to help staff consolidate their knowledge and increase their proficiency with the pumps as well as to enhance confidence and comfort at a time when there is so much uncertainty and anxiety.

The main role for trainers was to validate staff’s problem-solving, and to provide just-in-time teaching and coaching to reinforce practice changes and infusion best practices. However, it was exhausting for the small group of trainers, and is not sustainable over time without increased resources.

How do we maintain adequate support during an expedited implementation?

  • Minimize the number of sites implemented at the same time
  • Do not implement and train at the same time: training should be complete across all sites and units before go-live sequence begins
  • Utilize super-users to provide post-go-live support, with access to the Implementation Team for support as required.

Rounding Tool

The rounding tool was developed by the Implementation Team and adapted to the Quick Tap ® survey platform by Fresenius Kabi. The number of responses was very small, but the data were helpful in validating the training and support models. Detailed analysis was not provided by FK, and the Implementation Team did not have access to the platform.

How can we maximize the rounding tool?

  • The rounding tool should be shortened and simplified to make it more palatable to respondents to complete.
  • Trainers need to put more focus on gathering these data; responses typically followed a single trainer’s efforts.
  • A tablet should be provided to the trainers so that the survey can be completed in the moment, without relying on the staff having their smart phones in patient care areas.
  • The Implementation Team should have access to the platform to do more detailed analysis of the data; to refine responses by clinical area and date.

Implementation Challenges

The following were questions, concerns or observations during the implementation period. These concerns should be addressed in the training content for subsequent implementations.

Drug Library

Staff were unsure which library they could/should use for some medications. Trainers will need to reinforce the process for determining which library is needed to meet the patient needs and appropriate to the practice context. Additionally, trainers need to be aware of which commonly used drugs are available in which libraries, and if drugs (such as antibiotics) may be IV push, so not available in the drug libraries.

Drug Library Change Requests

There were some requests for changes to the drug libraries to match existing practices. Staff were unfamiliar with the process for both the development of the drug libraries, and for requesting amendments. Trainers should be clear that the drug libraries were developed and validated by clinical experts; changes should be requested via the drug library modification request form.

Pressure Settings

Although this issue may be resolved with the latest data set scheduled to be pushed out by April 27, the following are important for trainers to know – pressure settings should be the same on all pumps entering a single port; low rate infusions may need to have an increase in the rate of the driver fluid, especially when there is central line access; pressures should be set at least 50 mmHg greater than the measured pressure.

IV Direct Medications

The critical care library does not contain intermittent medications that can be safely administered by IV Direct in under 5 minutes.

Multiple Infusion Management

The new Multiple Infusion Management Policy was posted during this implementation. Trainers should draw learners’ attention to this new policy. It requires that a multi-port connector (bridge or manifold) be used for 3 or more infusions via a single access port, and that lines all be labelled proximal to the patient.

Air-in-Line Management

There were multiple questions about air-in-line management. Important points to reinforce include:

  • The best way to manage air-in-line alarms is to avoid them by priming the line carefully. The drip chamber should be filled to the line.
  • The bolus key, when used to advance an air bubble, does not ‘bolus’ the medication – it moves the bubble along at the rate at which the infusion is programmed
  • The bolus key will only work for this process twice. Staff should press and hold the key. Pressing hesitantly will cause the pump to register an attempt to advance the air while only moving a minimal amount of fluid/air in the line.

Amiodarone

Most drug-specific questions arose out of the use of Amiodarone. If the learners are expected to administer the 3-step protocol, trainers must understand the three steps (bolus, maintenance dose and loading dose), and be able to explain it to the learners.  

Implementation Successes

Targeted implementation enables targeted education

Having education targeted to specific areas of practice is beneficial to staff’s learning. Questions are relevant to the whole group, and non-relevant content can be omitted.

Staff engagement/manager support

The link between manager support and staff engagement was extremely clear. Where a manager was not engaged in the implementation, registration of staff at the training was poor, and staff attempted to circumvent the Drug Error Reduction Software (DERS) with innovative (and laborious) work-arounds, rather than adapt practice. Conversely, in the majority of areas, managers were extremely positive and motivated, and staff engagement was high with most learners demonstrating an openness to learn and change.

Use of Drug X – other CQI data

CQI data was very useful to show staff’s compliance with the DERS, and to congratulate staff for achieving Drug X use of less than 7%. Additionally, changes to the data set during the implementation period to raise pressure thresholds in the critical drug library, clearly showed a significant reduction in the amount of occlusion alarms, with the expectation that this will have a positive impact on staff acceptance of the new pumps and alarm fatigue.

Concerns log

Although the concerns log wasn’t filled in quite as diligently as it may have been, it was a useful tool to record questions and issues as they arose during training and post-go-live support. Written answers allowed for consistent responses from the trainers. The log also enabled development of an FAQ document that is available to staff on the Infusion Therapy Intranet site.

Rounding Tool results

Having staff complete the rounding tool received varying measures of success. There were a total of 19 responses to the survey tool. Results were very good, with 100% of all those who responded feeling that they were adequately prepared to use the pumps in their practice setting.

Teamwork

Teamwork was fantastic as part of this implementation! The Implementation team, augmented by trainers from the OR in the Western Zone, OPOR nurses, and IMIT nurses, was cohesive and supportive of each other. They maintained a positive, can-do attitude, despite the long days and challenges inherent in an expedited roll-out. All members became experts in all aspects of pump use.

Additionally, the larger team, including Biomedical Engineering staff, Supply Chain, and FK trainers, communications professionals all played a vital part in the success of this implementation.

Communications were essential in this fast-moving landscape, for which the daily check-in meetings were extremely valuable to keep all of the trainers connected and informed.

Leadership support

Organizational support, and individual leaders, were essential components to the success of the implementation. Although sparse for the scale of the project, resources were optimized, and targeted to areas of particular need.

Of particular note, the importance of the Project Manager role in ‘greasing the wheels’ to acquire scrubs and hand sanitizer, and to arrange access to the clinical areas for those from outside Central Zone should not be under-estimated. Further, the senior Project Leadership was essential to navigating the political landscape. Leadership was visible, involved, and supportive of the training and support team.

Next Steps

In the current pandemic situation, it is unlikely that there will be time between this implementation and the next one to make significant changes to the training content or processes. However, it is important to address those aspects that can be changed in an incremental fashion in order to increase the efficiency and effectiveness of the targeted and expedited model.

Of importance, and not specifically addressed above:

Building local capacity to continue support after implementation

Opportunities to build capacity in this first implementation were not capitalized upon. Although there are a few individuals who have been engaged with the Smart Pump Project throughout, they are insufficient to provide the breadth and depth of support to staff that is necessary to address and reinforce best practice. It will be imperative, moving forward, that local champions and leaders are given the tools to provide the support that staff needs.

Building capacity within Implementation Team

As the pandemic progresses, it is anticipated that there will be more calls upon the Implementation Team to conduct targeted and expedited implementations across the province. It is unlikely that the need will progress in a sequential fashion, and current resources do not allow for concurrent implementations at different sites/zones. If we are to meet the needs for equipment, we will need to look at procuring and optimizing resources, and building leadership capacity from within the Implementation Team, by developing a second Implementation Lead.

This will be of equal importance when the pandemic is ended. The disruption to the plans for a full implementation will have put the project significantly behind in its timelines, and concurrent implementations will be necessary to complete roll-out of these new pumps. We should not lose sight of the implementation of smart pumps as a patient safety initiative, and the benefits that a swift and timely implementation will bring.

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