More thoughts on standardization

I’ve mentioned this before several times on this blog, but feel like I have to say it yet again; we need to start standardizing certain things about health information technology. The lack of standardization reared its ugly head at me again last week when our Pyxis med stations kept dropping medications off of patient’s active profiles. It appeared to always be the same drug, IV ketorolac. It took me a while to figure out the problem, but it turns out that Pyxis and our pharmacy system don’t agree on certain basic elements of time. Go figure.

Here’s an HL7 feed from a ketorolac order. Note the red lettering:

PID|||0000194291^9^M10^KDHCD^PN~3017197^^^KDHCD^MR|3017197|ZZZTESTINGDRAEGRXXXX, ZZZTESTING||19740525|F|||361 N ABC AVE^^VISALIA^CA^93291|||||S|UNK|00001942919|||
PV1||I|3N^29^A||||TEST, A DOCTOR|||OP|||||||TEST, A DOCTOR |||||||||||||||||||||||||||200810231335||||||
ORC|NW|1|||||^Q6H&0600,1200,1800,2400&^^201004292400^201004302400^^^11111110||201004281226||JFT|TEST, A DOCTOR|||201004290000||
RXE||543^KETOROLAC TROMETHAMINE^2502190|30||MG|VIAL|THIS IS ONLY A TEST…..|||1|||AM1405427|JFT|||||||||||
NTE|||EVERY 6 HOURS|RXR|IV||||

Pyxis doesn’t recognize 2400 as a “real” time, and rightfully so. For those of you that don’t know, 2400 hours doesn’t exist in military time. Midnight is 0000 hours. Why would Siemens use 2400 hours to represent midnight? I have no idea, but Pyxis didn’t like it so it refused to deal with the order and simply discontinued it. The fix was a programmatic change by Siemens.

The idea of standardization isn’t new or limited, yet its use continues to elude healthcare. The concept is applicable to not only data, but processes as well. Unfortunately not everyone buys into the idea. I’ve even heard some argue that standardization removes clinical decision making from healthcare. What? That doesn’t even make sense. Standardized processes can actual create clinical decision making time by simplifying a repetitive task and creating consistency designed to prevent errors.

I spent several wonderful years working in a compounding pharmacy in the Bay Area; 3 years as an intern and about 2 years as a pharmacist. Many extemporaneous compounding formulas are complex so the owner of the pharmacy, whom I had tremendous respect for, had a rule that ingredients were placed to the left of a compound prior to use and to the right after use. If you’ve ever worked in a busy pharmacy then you understand interruptions and how easy it is to forget something in a hectic environment. The rule was a simple one, but saved my bacon on more than one occasion. And it certainly didn’t impair my clinical judgment. Similar standardized systems are used in hospital cleanrooms where attention to ingredient detail is paramount.

Other standardized processes that I’ve found beneficial over the years include:

• Standardized doses for pediatrics. I spent a few years working in a pediatric ICU. The facility I worked for had a robust set of policies that allowed the pharmacist to round doses ordered in mg/kg to the nearest “standardized dose”. For example let’s say a physician orders metoclopramide 0.15 mg/kg in a 1.85kg child. The resulting dose is approximately 0.28mg. As a pharmacist I was allowed to round that dose to 0.3mg, which was an available standardized dose. The advantages were obvious: fewer dosage sizes meant less waste, less labor for preparation and fewer opportunities for error, i.e. grabbing the wrong dose. In addition, many of the dosing increments requested were too small to be accurately measured by a syringe and would have been an estimate anyway.
• Standardized drip concentrations. Many hospitals use standard drip concentrations for pressors and other vasoactive medications, i.e. dopamine, norepinephrine, dobutamine, etc. This makes order entry easier and faster, reduces waste, reduces the risk of programming errors on pumps and creates a less complex process for drug dictionary maintenance on smart pumps.
• Standardized administration times. I love the use of standardized administration times. What’s a standardized administration time? I’m glad you asked. That’s when a hospital defines the times a drug will be administered based on the latin sig used, i.e. Q6H may be represented by 0000, 0600, 1200, 1800 or TID may be 0700, 1300, 1800. There are many possibilities. The use of standardized administration times has many advantages including easier and quicker order entry, consistency among nursing staff and less variability for the patient. Those that argue that this is a bad idea because it is difficult to get on a standardized schedule, just give me a call. There is absolutely no pharmacokinetic or pharmacodynamic reason why medications cannot be administered on a standardized schedule while in an acute care setting. You can try to argue that you can’t wait an extra 12 hours to give a multi-vitamin or that you can’t give cefazolin 2 hours early, but you won’t win based on any science that I’ve studied.

One thing to remember when creating a standardized process is to keep it simple. We often forget that complicated processes are fraught with opportunity for error. Everything we do should be broken down into the fewest possible steps and still remain safe and effective. Personal experience tells me that we’ve done a poor job of simplification in healthcare. We tend to complicate a process more often than simplify it; double and triple checks with multiple initials, paper trails, sign-off sheets, pharmacokinetic tracking forms, SBAR forms, manual lot number tracking, etc. If you’re using a paper form in this age of technology, you’re doing something wrong.

Don’t feel bad, we’re not the only ones responsible for creating a bloated and oftentimes overly complex system. Every time something goes wrong in healthcare the federal, state and local governments enact new regulatory processes that requires a barrage of paperwork and complex procedures. It’s an all-out assault on simplification, standardization and common sense.

Have you ever wondered why it takes so long to train a pharmacist after they’ve been hired? Every pharmacist has a similar core skillset that can be applied to most situations, right? Right. Their lengthy on the job training has nothing to do with their drug knowledge or decision making skills, but everything to do with learning all the idiosyncrasies associated with practicing pharmacy in an acute care setting. They have to spend time learning the rules, then the exceptions to the rules, then the exceptions to the exceptions and so on down the line. I’ve worked in six different hospitals during my benign career, so believe me when I tell you that it’s true. Some of the systems I’ve been exposed to were so old and complex that no one could remember when they were implemented, but everyone was afraid to change them.

It has been a busy month, so I won’t make any promises, but over the next couple of weeks I hope to present a couple of additional examples of where standardization is needed in pharmacy and why it’s necessary. Stay tuned.