Smart infusion pump

Smart infusion pumps are smart devices that infusion pumps that collect data and then aggregate them into a database on central server. This includes records of the administration warnings and alerts that have fired and the administering clinicians responses to those alerts.

Overview

It is important to distinguish the different types of pumps by modality. The common modalities are (1) large volume parenteral infusions (LVPs), (2) syringe infusions, (3) epidural infusions and (4) patient-controlled analgesia infusions.

Some pumps are purpose-built exclusively to be used for only a single modality, whereas other pumps have been engineered to support multiple infusion modalities.

Klas recently (2008) reviewed several pump vendor products. The represented vendors were B. Braun, Baxter, Cardinal Health, Hospira, Sigma and Smiths Medical.

Some smart pumps have become network devices, connecting to wireless networks in hospitals and clinics using IEEE 802.11 standards for wireless local area network communications.

Safety Features

Smart Infusion Pumps have many safety features that have promoted them to “must have” technology in the healthcare setting. The most popular feature of the smart pump is the drug library. The library is the database that holds the drug dosing information, including dosing limits, infusion parameters, and drug specific advisories.

Dosing Limits

Dosing limits can be described by upper or lower limits as well as hard or soft stop. Upper dosing limits are the highest dose that is acceptable for a safe patient dose, and lower limits are the lowest doses that are acceptable. Exceeding upper limits could potentially cause an over dose to occur. Administering a dose that is less than the lower limit could cause a suboptimal dose resulting in an ineffective treatment.

Hard limits are upper or lower dosing limits that are set in the drug database that cannot be overridden. If the clinical programming the pump enters a dose that is over the hard limit, the pump will not allow the infusion to continue. Soft limits are upper or lower dosing limits that provide a warning prior to hitting the hard limit, so they can be overridden and the infusion can continue. Some infusion devices require a reason to be entered into the pump prior to overriding the soft limit, so overrides can be tracked and evaluated.

There are infusion devices with software that uses patient specific weights to calculate drug doses and compare them against the upper and lower limits set in the drug library. This feature is most important in pediatric settings where a majority of doses are based on weight, however there are critical drips and other drugs used in adult medicine that also require weight based dosing. Infusion device software may also use different libraries for various patient types or sizes (i.e. pediatric vs. adult) and compare drug doses to the chosen library for the patient size (i.e. less than 15kg, 15-20kg, 21-30kg, etc). This requires the pump programmer to choose the correct library in the original stage of set up to make sure the appropriate dose ranges are used. Infusion rate limits can be set in the drug library programming to match a drug with the appropriate infusion time. Just like drug dose limits, infusion rates could be set with upper and lower limits or for a single specific time frame (i.e. 30 min). Any deviation from the programmed infusion rate will provide a warning to the user and stop the infusion from continuing. Additional infusion alerts include line occlusions and air bubble warnings. Just as in traditional pumps, smart infusion pumps provide the same notifications of infusion troubles. Other safety measures include the use of Tallman lettering and the use of Brand and Generic drug names.

Technology Integration

Many smart infusion pumps are increasingly able to integrate with hospital’s electronic health records. This includes using bar code medication administration (BCMA) and computerized provider order entry (CPOE) programs. Safety increases when medications can be matched to a patient’s medication profile by barcodes. The infusion pumps can provide a further layer of safety when they can read a medication barcode and provide the clinician with verification that the drug dose matches the drug in the patient’s active medication list.

Drug infusion data can also feed from the infusion pump back into the patient’s medical record. Data such as infusion rates and doses for titratable drugs can instantly be updated in the record to show dose increases or decreases exactly when they happened. Otherwise, the system is reliant on the nurse or provider to input dose and rate changes into the patient profile manually, at a time that he/she can open the record and enter the data.

CPOE integration allows physicians to enter dosing information into a patient record that will transfer to the infusion pump to increase or decrease the dose on demand. It will also allow patient specific dose titrations to be set up according to clinical lab data for the patient.

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Management

The network distribution of new data set information wirelessly to widely distributed smart infusion pump devices is an area of particular concern. While it seems convenient to distribute drug library data set updates for new drugs, changes to standard concentrations and upper and lower infusion rate bounds to infusion pumps using a wireless network, one must consider that this type of distribution will NOT be completed quickly. Instead, the pump devices must be turned on and connected to the network to receive a data set update. Therefore it can take a period of days or longer to disseminate a new data set wirelessly. This lag time for data set updates could cause problems but it can be managed and diminished through policies and procedures that require locating each and every smart infusion device in circulation and validating data set downloads over a much shorter period of time, perhaps requiring only a few hours.

Smart Infusion Pump quality data

One fascinating advantage of smart infusion pump technology is the ability to capture information from the pump programming process for later review and analysis. Typically, smart infusion pumps include drug libraries or databases of drug-specific information. These drug libraries can include lower and upper bounds governing safe and appropriate infusion rates for standard infusions as they are defined by the hospital, health-system or clinic. These lower and upper infusion rate bounds are then used to provide administration decision support at the point-of-care. Overridable soft stops and rigid hard stops are both supported by some of the smart pump software.

Maddox et al. report some of these data in a paper on smart infusion devices for patient-controlled analgesia (PCA). In this study, the PCA pump system included a novel, integrated, continous capnographic quality of respiration monitoring system augmented by pulse-oximetry (see Am J Health-Syst Pharm Vol. 63: Jan 15, 2006). These authors present several cases where automated respiratory monitoring by the PCA smart pump system alerted clinicians early-on to potential narcotic-induced repiratory depression before life-saving measures were needed. The authors also report "examples of averted programming errors" from the smart PCA pump activity database.