Weeknotes #3
NICU ePMA series (episode 1)— The journey from paper drug charts to ePMA begins
Over the next few Weeknotes, I would like to focus on the theme of our ePMA (electronic prescribing and medicines administration) implementation planning for our NICU (Neonatal Intensive Care Unit) go-lives later this year. We share our Cerner domain across two NHS Trusts — Chelsea and Westminster NHS Foundation Trusts (CWFT) and Imperial College HealthCare NHS Trust (ICHT) — each with two Neonatal units. Soon to be joined in 2023 by the other two NHS Trusts in our North West London (NWL) Integrated Care Service (ICS) — The Hillingdon Hospitals NHS Foundation Trust (THH) and London Northwest University Healthcare NHS Trust (LNWH).
I can hear you asking, ‘‘How on Earth do you get six Neonatal units across four NHS organisations to collaborate on drug prescribing practices?’’
Firstly, I must confess I thought — with difficulty!
However, of all the ePMA projects I have ever worked on, I have never come across a group of more intelligent, caring, compassionate and kind individuals (did I mention super intelligent?) — And this includes everyone; the Neonatal consultants, the Neonatal nurses and the highly specialist Neonatal clinical pharmacists. All super keen to collaborate, share and align drug protocols and get their NICUs live with ePMA across North West London.
The outcome of more than 18 months preparation and gap-analysis work which included all of the continuous variable rate infusions (approximately 25 drugs, landing on more than 200 individual IV sets) and the neonatal drug catalogue (which filled the gaps of the existing paediatric prescribing options on Cerner, more than 300 lines reduced to about 30 requiring building).
In essence, Cerner designed predominantly for adults, had to be re-designed from the ground up for NICU.
Governance around drugs
A little bit on governance, this is not an easy task but thankfully well established on our shared domain. For every drug change on Cerner, as part of the NICU project (ball-park figure 300 lines) a clinical pharmacist checks and signs-off on the drug name (Cerner terms: primary and synonyms), dose, dose unit, route, frequency and freetext additional information sections. For the continuous variable rate infusions, this contained information on the ‘NICU formula’ and ‘fiddle factor’ by weight — used to calculate how much drug is added to the 25mL infusion fluid.
Neonatal consultant approval and agreement in addition to Neonatal pharmacist approval and agreement was required across the two NHS Trusts with Level 3 units (Chelsea Hospital site and ICHT) and the two NHS Trusts with Level 2 units (West Middlesex Hospital site, THH and LNWH). Where differences in prescribing practice existed, a single shared regimen was agreed. A remarkable undertaking, successfully achieved. We also involved our THH and LNWH colleagues in the decision making process (as they will be joining us on Cerner in 2023). Not an easy feat by any means! A huge and complex challenge for all involved.
And once built, all of the above gets rigorously and meticulously checked by the keen eyes of the ePMA teams (thanks Karl, Bunsi and our colleagues in ePMA at ICHT and NWL) — the prescribing, nurse and pharmacist workflows are validated on both domains: our pre-production domain CERT and production domain PROD.
The process of building a NICU drug catalogue on Cerner
The NICU ePMA element consists of two distinct workflows:
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1. Continuous variable rate infusions e.g. dopamine, adrenaline
2. NICU drug catalogue e.g. standard antibiotics gentamicin, benzylpenicillin
Both of which will be discussed in more detail. Before I tell you about how hard the amazing Holly (Highly Specialist ePMA Pharmacist) worked in arranging meetings across four NHS Trusts, collated prescribing and stock information from all the NICUs, conducted a comprehensive gap-analysis, meticulously updated Data Collection Workbooks (DCWs), built and documented all decisions for every single drug and order sentence…
(Yes! I have converted her into a Neonatal Pharmacist). I would like to take a few steps back and start from the very beginning…
My personal journey to the NICU
My background as a specialist clinical pharmacist started in the Women and Children’s directorate. For many years, I was the specialist NICU pharmacist covering our Neonatal Intensive Care Unit, High Dependency Unit (HDU) and Special Care Baby Unit (SCBU). Later years, I also covered the specialist Parenteral Nutrition (PN) and Paediatric Gastroenterology Pharmacist role, often looking after our ex-NICU graduates on long term PN with short-gut syndrome. My ward cover also included our Private Maternity Ward — The Kensington Wing, high-risk obstetrics, our antenatal ward and Maternity High Dependency Unit.
In fact, 12 years ago one of our current DCIOs Mark Thomas (Neonatal Consultant) and I worked on the NICU drug formulary of our legacy system LastWord. We were ready to go-live with ePMA on NICU but disappointingly were let down by the IT Infrastructure. Fast forward 12 years, the wonderful clinical team led by Neonatal Consultant Walton D’Costa, Mark and I have once again embarked on this journey. This time with a brand new NICU, state of the art equipment and by the end of this year — free of paper drug charts.
I visit the NICU often and strangely still feel like I am coming home. You see, this project is very personal and dear to my heart. Not least because I am a Neonatal Pharmacist by background and this used to be my ward, but also because of my own complicated obstetric history. I will not go into detail but having experienced the grief, trauma and near-death of a misdiagnosed ruptured ectopic pregnancy, pregnancy loss, delivering my son via emergency C-section due to placental abruption, nearly resulting in a NICU admission — I would do anything to help improve the patient safety and care we provide as an organisation to our tiniest patients. My contribution many years later — taking the NICUs across NWL live with ePMA.
My obstetrician, colleague and frankly ‘my hero’ Professor Mark Johnson looked after me for many years on my journey to motherhood — I was terrified of getting pregnant again. Mark reminded me that at 37 weeks and query placental abruption, there was a chance that my baby may need admission to the NICU. My most vivid memory of that day was me begging Mark to take him out of me as quickly as possible. Truly believing that he will be safer in the NICU, than staying one minute longer inside me. What do you give the man who gave you everything? I do not think my husband or I could ever give back to Prof Mark Johnson what he gave to us. However, in my maternity leave year and for a short time after, I helped Mark in the infancy of his charity Borne. Nothing big, but I enjoyed introducing and raising their social media profile and helped develop a snappy tag line. Borne — Research to prevent premature birth.
Check out their website: Borne — Research to prevent premature birth
The night of the Purple lights
As you can see, the colour purple featuring in all our NICU PowerPlans (more on that in Weeknotes to follow) represents World Prematurity Day — 17 November. Perhaps, whilst I am taking you on the journey of NICU and ePMA, I hope as an added benefit to raise the profile of charities like Borne and the importance of their research into finding answers to why women go into premature labour. Moreover, what can be done to stop babies being born too soon?
This was a long introduction. However, my next Weeknotes will start the process of a deep-dive into what it takes to align and collaborate on continuous variable rate infusions. The Order Entry Format (OEF) for these complex builds, streamlining the nurse ‘rate change’ workflow, dare I say it ‘actual weight’, ‘working weight’ and ‘birth weight’ and many more insights and tips of taking a NICU Level 2 and Level 3 unit live with ePMA.
