SmartPump Audit

Purpose

OBJECTIVE: The Smart Pump Audit is a quality improvement initiative that records how the Colleague smart infusion pumps are being used. The objective is to assess compliance and identify barriers to the use of the Guardian Software for the Baxter Colleague Pump within the Critical Care and Medicine Programs in the Regions (WRHA).

BACKGROUND: The Guardian Software provides the capability to detect when pre-defined dosage limits are exceeded. If the dosage limit is exceeded, an alert is provided to the individual who programming the pump. One of the limitations of the pump is that the Guardian Software must be chosen by the pump operator. It is well documented (local use and in literature) that the Guardian Software is at times not utilized. The WRHA regional policy for the Parenteral Drug Therapy Manual (which provides recommendations for IV administration of medications) has incorporated the mandate that the Guardian Software be used when the infused medication is contained within the software library.

METHOD: The data collector at each will RANDOMLY select two NON CONSECUTIVE days during each week of the three weeks audit period and will audit every Colleague Pump that is in use on their unit for the following:

• A. drug type
• B. Guardian Software used: YES or NO (on PDA check mark is YES, blank if NO).
• provide a reason why Guardian Software is NOT being used for a selected drug.
  • This information will be obtained by asking the bedside nurse.
  • Reason for NOT using Guardian is listed in a Guardian NO COMMENT KEY. List of comments emailed to collectors and should be printed out and kept with PDA as a reference. There are 8 options to choose from. The only time that a collector must type addition comments is when option 8 has been selected.
    • 1. Reason unknown
    • 2. Nurse FORGOT to use Guardian
    • 3. Nurse NOT AWARE of POLICY to use Guardian
    • 4. Nurse NOT AWARE that DRUG is in the Guardian Software library
    • 5. Drug item is MISSING from the Guardian Software libaray
    • 6. IV TKVO only
    • 7. Difficult to use Guardian software for a specific drug because of frequent bolus and med changes which include antibiotics
    • 8.OTHER (if you choose this option as to why reason Guardian not used, you must TYPE in addition comments in the PDA under COMMENT section).
  • This comment number is entered into the field just below where you can put a check mark YES or leave blank for for Guardian.

• The PDA will automatically stamp the date and time of the the audit when you select the drug item. No need to manually enter the date and time when you audited the items.
• the information is collected in the TMP tab on your PDA (which is L_tmpV2 file on your PDA)
• data is sent in once per week (every WEDNESDAY as per scheduled send date).
• the date goes into an ACCESS database TMPV2 on the Regional Server.
• Statistician anyalyzes the data once study is complete.

• NOTE 1: RE: two random non consecutive days: 2 or more days between pump audit days.

example:

• • week 1: Monday Thursday
  • week 2: Tuesday, Friday
  • week 3: Wednesday, Monday

• NOTE 2:
  • As data collectors we are not policing the use of the Software, we are simply their to gather information in order to allow management to access where improvements and changes may be required.

Audit Dates

• Once per year
• started 2006