Weeknotes #4
NICU ePMA series (episode 2) — continuous variable rate infusions on Cerner (a deep-dive)
The discussions on design for the NICU continuous variable rate infusions have come a long way. In fact, on the 4 December 2018 we had our first NICU Drugs Working Group Meeting. I dug out the minutes from that meeting where we made the initial decisions on ‘how to build a continuous variable rate infusion’ on Cerner. We were still on our legacy system LastWord and this was nearly a year before we went live with Cerner in November 2019. Our Cerner consultant from Kansas, USA was in the UK and joined us at our Chelsea hospital site to facilitate the meeting and show us what he had in mind, using our build requirements:
Build Requirements
‘’We would like to prescribe a drug in a diluent, as a continuous infusion. Where the concentration of the fluid is worked out using the ‘weight’ and a ‘fiddle factor’. Where ‘weight’ can be one of 3 weights (‘actual weight’, ‘working weight’, ‘birth weight’). Where volume is fixed at 25mL and an ‘Infusion Range’ and the ‘Dose Range’ are documented allowing the nurse to change rates according to decisions made on the ward round without having to ask for prescription to be changed. Where prescriptions are discontinued and re-prescribed when a change in ‘weight’ occurs’’
Before expanding on the Cerner build, I’d like to give you some background to prescribing a continuous variable rate infusion in NICU, an example of a paper drug chart using insulin and going into a bit more detail regarding ‘fiddle factor’ and ‘rate’.
Paper drug chart
The above paper example of insulin is a great way to show how ePMA can improve on patient safety. The ‘Infusion’ and ‘Dose’ range should be documented clearly on the prescription and on Cerner these details will be pre-filled in the ‘Infusion instructions’ field, along with the ‘NICU formula’ for calculating the amount of drug going into the diluent. The nurse will have the above information displayed in the ‘clinical display line’ visible at the point of signing for administration and hence will be able to cross-check the details are correct. The nurse can amend the rate as discussed on the ward round as per the ‘Infusion’ and ‘Dose’ range displayed on the prescription, without the need for the doctor to re-prescribe the ‘order’.
Fiddle Factor
Insulin is a great example to continue with as different protocols existed between the two organisations. We had long discussions on appropriate protocol, concentration and much collaboration went on between ICHT and CWFT clinical teams. Eventually a shared and agreed protocol was landed on:
Insulin infusion instructions
NICU formula: 12.5 x weight (kg) = __ units of Actrapid insulin to be diluted to 25mL
Rate range: 0.05–0.2 units/kg/hr = 0.1–0.4 mL/hr
For our non-neonatal colleagues out there, our NICUs at CWFT and ICHT use variable rate infusion where the concentration of the drug in the infusion fluid is calculated by a ‘fiddle factor’ multiplied by the patient ‘weight’ . In the above example using insulin our ‘fiddle factor’ is 12.5. We call this the ‘NICU formula’ — which is calculated manually by the prescriber, using the appropriate patient ‘weight’. This will not automatically be calculated using the ‘dose calculator’ and I will expand on this later (Hint: it refers to the BIG question of ‘which weight’ to use?)
Rate:
Rate is the volume over time infused e.g. mL/hr
Let’s get back to the meeting from 2018, before we went live with Cerner in 2019. Here is an extract from the meeting minutes — you might want to refer to the screenshot above as a guide.
Two options were discussed:
1. Add rate with a freetext comment — ‘see infusion instructions’
2. Leave ‘Rate’ field blank — prescriber needs to add rate as microgram/kg/minute in the ‘Normalised Rate’ field
Option 1 allows the nurse to change the rate as per the doctor’s instructions, according to the ‘dose range’ detailed in the NICU drug protocols for each infusion. This option most closely follows the paper workflow.
Option 2 requires the doctor to enter the rate e.g. 5microgram/kg/minute in the ‘Normalised Rate’ field. The ‘Rate’ field remains blank when built. This workflow means the nurse will get a pop-up every time the rate is changed on administration, as it will be different from the rate that was prescribed. If a rate change was needed, the doctor will need to ‘cancel / reorder’ the prescription to maintain a clear audit trail. This option was deemed unsafe, different to current NICU practice and results in a messy drug chart.
We went for option 1— and it’s fascinating looking back 4 years, seeing how we managed to maintain the same design principles first discussed at that initial meeting. In fact, the above design principals formed the basis of our continuous variable rate infusion build for our Adult Intensive Care Units (AICU). And having been live with our AICUs across both our Chelsea and West Middlesex hospital sites for nearly 3 years, we have proof of concept that the nursing workflow regarding ‘rate changes’ within a prescribed rate range, does indeed work well.
In a nutshell — how many hours of face-2-face (including Teams, phone, in-person chats) do you think it takes to discuss these complex continuous variable rate infusions?
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Here is an approximate break-down summary (and we are not live yet):
- 25 drugs e.g. insulin, adrenaline, dopamine, dobutamine etc
- 30 NICU PowerPlans
- 3–50 order sentences per PowerPlan
- 200 individual drug IV sets / order sentences
- Hours of discussions per individual drug
- Many BIG meetings with clinicians, pharmacists, nurses from all 4 Trusts
- Many BIG pharmacy only meetings
- Weekly ad-hoc chats with neonatal pharmacists
- Weekly ad-hoc chats with clinicians from CWFT, ICHT, THH and LNWH
- DAILY NICU catch-ups with myself and Holly
The above does NOT include the Data Collection Workbook (DCW) reviews or the backwards and forwards decision conversations via lengthy emails before work could begin on a drug PowerPlan. The time for those will most likely double the above!
Governance
I cover this often, but on a shared domain, with two NHS Trusts live on Cerner and two NHS Trusts joining in 2023, all decisions for every single drug need to be agreed by everyone. As you can imagine, we had similarities in protocols but also some slight and some not so slight differences. We are not introducing variation into the drug catalogue and therefore had to align prescribing protocols across NWL between our 3x Level 2 units; 3x Level 3 units. Building drug protocols was — ONCE and better for all.
This was a true cross-Trust collaboration. The ePMA ‘drug build’ element of the project was led by myself and the CWFT ePMA team where Holly managed the entire build and clinical decision & sign-off process and the rest of the team Bunsi, Karl and our ICHT colleagues completed the ePMA validations. As mentioned previously, both ePMA pharmacy and clinical pharmacy validations are required for a ‘drug build’ sign-off. The ePMA check ensures the functionality works as expected and the build matches the DCW and the clinical pharmacy check ensures the clinical details are correct and matches the joint decisions made and visually the build is as expected. This bit had input and sign-of from all the Women and Children’s pharmacy teams across NWL but was led by the Senior Lead Women and Children’s Pharmacist at ICHT, the magnificent Penny Fletcher. I think everyone in the Paediatric pharmacy world knows Penny or at least has been trained by her at some point in their career. Myself included.
Penny was the reason I joined the Women and Children’s Pharmacy Team at CWFT back in 2005. There are not many people in this world who have inspired me more by their constant energy and enthusiasm. Penny is by far the best teacher I have ever had the pleasure of learning from and thinking back, I have based much of my ‘clinical pharmacy style’ on how Penny taught me to think.
During de-clutter week at our hospital, and in an attempt to wade through some of our files in the ePMA office (where we still have the go-live implementation planning from our LastWord ePMA roll-out back in 2009) I found my pre-registration pharmacist clinical audit — ‘’An Audit of Inhaler Devices vs NICE Guidance in 5–15 Year Olds’’ supervised by none other than Penny Fletcher in 2003.
Not long after I joined paediatrics, Penny left CWFT and became the Senior Lead Pharmacist for Women and Children at St Mary’s Hospital which later became part of the merged Imperial College Healthcare Trust. However, time has passed but Penny and I have re-united and it has been a blast working with my mentor on this very exciting and complicated project. Thank you Penny for your drive, enthusiasm and passion. We are proud of having the opportunity to learn from you once again.
And lastly, ‘weight’ — here is a little taster
On NICU we can sometimes use 3 different weights for a patient. Certainly 3 weights can be recorded:
- Birth weight
- Actual weight
- Working weight
A perfect place to conclude episode 2 in the NICU ePMA series with some…
“Thoughts of the day’’
Which ‘weight’ do you use for prescribing drugs, infusions and fluids? Which ‘weight’ do you have as your clinically defined weight on Cerner? And how do you ensure all the baby weights are entered on Cerner, but only the appropriate type of ‘weight’ is used for prescribing?
Do not forget, Cerner is shared by adults & AICU, paediatrics, PHDU & NICU, also not forgetting two NHS Trusts (soon to be four)!
Weight will be covered in detail in the next Weeknotes — stay tuned, as this definitely deserves a section of it’s own.
[Views/opinions are my own]
