Weeknotes #5
NICU ePMA series (episode 3) — using the correct ‘weight’, NICU drug catalogue and go-live training
Our NICU go-lives are imminent — ePMA, clinical pharmacists, clinicians, nurse educators, PMO and transformation have all worked tirelessly, bringing everything together over the last few months.
Before I say more, I would like to extend a HUGE thank you to everyone involved in this project.
Good luck CWFT and ICHT NICU teams — we’ve got this!
Weight
In my previous Weeknotes, I promised to deliver a bit more information on ‘weight’. In all our previous meetings, this seemed to be a tricky subject but as time wore on, the elephant in the room certainly shrunk!
I guess, practice makes perfect. And what ePMA, pharmacists, clinicians and nurse educators have continued to do is — mention ‘weight’ and where to find the correct ‘weight’ for prescribing. In fact, at every opportunity we talk about ‘weight’. It has become our greeting and opening statement — do you know about ‘weight’ and where to find ‘working weight’ for prescribing?
If you repeat something enough times it becomes second nature, right? Well, we’ll soon see!
There are three weights documented for babies on most NICUs (local variation exists) but at CWFT we document ‘birth weight’, ‘working weight’ and ‘actual weight’. Cerner has only one ‘clinically’ defined ‘weight’ and on our domain this is ‘actual weight’.
This means ‘actual weight’ appears in the blue banner bar and ‘actual weight’ pulls through into the continuous variable rate infusion, fluid orders and ‘dose calculator’.
Cerner is an American system and ‘working weight’ will be documented as ‘adjusted weight’ on our domain. We have kept the Cerner wording to avoid unnecessary variation.
On my ward round as a NICU pharmacist, I first looked for the baby’s ‘weights’. Sometimes, I’d be scrambling around looking for the paper drug chart — Is the most recent weight on there? No, perhaps on the big paper fluid balance charts? Yes, wait a minute — there it is!
This was many years ago, and our current paper drug chart has seen huge improvements since the days I looked after NICU. Each drug section has an area on the side to document the ‘working weight’ and a ‘date’.
I’m pleased to say Cerner is not far off! We have moved ‘adjusted weight’ and ‘birth weight’ to join ‘actual weight’ in the ‘Quick View’ tab — the first tab in ‘Results’. So, at the ‘click’ of a button, all the relevant ‘weights’ (if documented) are displayed. An audit trail with clear visibility in date columns and the option of graphical presentation.
We have trained our nurses, doctors and pharmacists on ‘weight’ documentation (frequency as per local processes) and where to find the various ‘weights’ before prescribing a drug.
The important points to remember are:
1. Continuous variable rate infusions / fluids / PN — check the ‘weights’ in the Results tab first — if ‘adjusted weight’ is required, do NOT use the ‘weight’ pulling through onto the order. This is the ‘actual weight’. Change the ‘weight’ manually to the ‘adjusted weight’ — this is important for the nurse administration and rate calculation on the drug administration chart. NOTE: Cerner does not calculate doses on our domain and neither will it tell you if the incorrect dose has been prescribed!
2. General NICU drug prescribing from the order catalogue — check the ‘weights’ in the Results tab first — if ‘adjusted weight’ is required, do NOT use the ‘weight’ displayed in the banner bar as this will be the ‘actual weight’.
Moral of the story — before doing any NICU prescribing, check the baby’s documented ‘weights’ in the Results tab and use the appropriate ‘weight’ for manually calculating drug doses.
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NICU drug catalogue
The NICU ePMA element consists of two distinct workflows:
1. Continuous variable rate infusions e.g. dopamine, adrenaline (Weeknotes #4)
2. NICU drug catalogue e.g. standard antibiotics gentamicin, benzylpenicillin
The NICU drug catalogue forms part of the existing adult and paediatric drug catalogue. A gap-analysis was undertaken using the existing paediatric order sentences on our domain. These were compared to the NICU drug stock list of all four Trusts including our North West London (NWL) colleagues, joining our domain in 2023 — The Hillingdon Hospitals NHS Foundation Trust (THH) and London Northwest University Healthcare NHS Trust (LNWH).
There were more than 300 drug lines to review:
· For each drug — are the existing paediatric / adult order sentences appropriate for NICU?
· For each drug — do we need any extra NICU order sentences? E.g. new frequency options?
· For each drug — are the dose units appropriate for NICU?
In the end, we had about 50 new order sentences to build for NICU.
Since our doctors rotate around NWL and also paediatric wards and ED, we intended to keep the NICU workflow much the same as paediatrics. On our domain, we use a ‘dummy’ order sentence to note a ***Paediatric Dosing*** section.
Order sentence filtering by age is an option and has been used in many of our drugs. And also, as we continue to optimise the drug catalogue. However, Rome wasn’t built in a day and our priority was to ensure safe prescribing options were available for NICU and not to change the existing build.
Special ***Neonatal Unit Dosing*** sections were added where the dose unit was different e.g., micrograms instead of mg or where dosing was sufficiently different to warrant a neonatal section.
Once again, our governance was complete with review and sign-off from all four Trusts’ clinicians and pharmacists.
NICU training
Lastly, I would like to discuss training.
NICU ePMA training covers highly specialist workflows. The training content consists of video demos and Quick Reference Guides (QRGs). We spent a lot of time and resource dedicated to getting these ‘just right’ with the help of our immensely talented Head of Training, Kenny.
The NICU videos and QRGs are on our intranet under the Cerner section in our specialist ePMA webpage. These will shortly be on our Chelwest Me app for easy access via the user’s mobile phone.
The ePMA team ran a series of in-person and on Teams specialist training sessions for nurses and doctors. After which, we provided the tools to continue individual ‘learning’ by practising on our NICU test patients, pre-filled with NICU drug scenarios. Our NICU nurse educators and NICU clinicians continued leading their teams with refresher training scenarios and checking competencies, in the week’s commencing go-live.
Here is a short summary of our ePMA training sessions:
• ePMA summary demo started in the summer and continued for 2 months: Teams: weekly 30min session for 8 weeks for all of CWFT and ICHT
• Nurse training started 3 weeks prior to go-live: CW: 4x in-person and on Teams, WM: 5x in-person and on Teams
• Doctor’s training — September new doctor’s induction and continued refreshers up to go-live: CW: junior doctor induction and consultant training sessions, WM: consultant training session as junior doctors already use Cerner in paediatrics
After implementation, the unit will provide in-house training for new starters using competencies and training material provided by ePMA.
Go-live
And that’s a wrap folks!
Good luck to everyone on our NICUs and thank you teams for all your hard work.
[Views/opinions are my own]
