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Ben Fidler
EPMA Project Lead
King’s College Hospital, London, UK
King’s College Hospital NHS Foundation Trust is one of London’s largest and busiest teaching hospitals, with a unique profile of strong local services and a focused set of specialist services. This includes providing specialist care to patients across a wide catchment, and we are recognised nationally and internationally for our work in liver disease and transplantation, neurosciences, cardiac and haemato-oncology.
King’s College Hospital (KCH) has been using iSOFT Clinical Manager (iCM) as their electronic patient record for the past 12 years. KCH has expanded on iCM’s native functionality and built a framework that allows in-house applications to be hosted inside iCM. The KCH development team has developed and implemented a discharge notification solution, letter-writing and storage solution, clinical notes and other bespoke software. KCH plans to remove all paper from the hospital and instead store all patient information in the electronic patient record. A full CISCO wireless network had been installed throughout the hospital and KCH has brought in a third-party company RedStone to help manage the network.
Electronic Prescribing and Medication Administration (EPMA)
EPMA allows prescribers to order medication electronically. These medication orders can then be viewed by members of the multidisciplinary teams and the pharmacy can make its endorsements. The nursing staff can record the administration of the patient’s medication electronically to create a full audit trail of medication usage.
In 2008, KCH began a six-month pilot study of inpatient EPMA. The success of this pilot has resulted in EPMA currently being rolled out across 20 wards including general medicine, neurology, cardiology and renal. KCH plans to complete its hospital-wide roll-out in 2011. At KCH, many wards use patients’ own drug (POD) lockers and all medication is stored inside the locker by the bedside. These wards require a computerised device that can be easily brought to the locker. Other wards have a drug trolley which contains stock items that are administered to patients. Wards with a drug trolley need to have a device to access the electronic drug chart from the trolley.
KCH has three main groups of users of EPMA: nurses, prescribers and pharmacy. Table 1, on the previous page, shows the main use of the computerised equipment and the requirements to be considered when deciding on the type of equipment.
Hardware trials and assessment
Computers on wheels (COWs): KCH has been using COWs for the past eight years and has purchased from two main suppliers, RDP Health and Parity Medical. At the beginning of the EPMA project, KCH had 80 units in active use and it was identified that the project would require 120 more mobile wireless devices. The EPMA team, in conjunction with our ward users, began the process of sourcing and testing equipment deemed suitable for our project. There are many suppliers of COWs in the UK and abroad, but we decided to compare RDP Health, Parity Medical and the Distec Health carts only, as the cost was a similar level.
The ward users were happy with all the carts trialled. The powered height adjustment was not deemed important enough to justify the additional cost at this time. RDP health and Parity Medical were equally favoured and price and build quality led to our final decision.
COW assessment
COWs were deemed to be perfect for prescribers and pharmacy, but unsuitable for nurse drug rounds using drugs trolleys or POD.
Motion C5: As a drug chart replacement, the C5 seems a good option. It is small and at 1.2kg is lightweight and ultra-portable. KCH opted for the 1.3KHz model with 1GB RAM. With our initial configuration, the units did not seem powerful enough and feedback about the speed of the units became flooding in. The units were also prone to suffer from the operating system freezing up and could only be fixed by taking out the battery. We later learnt that a BIOS update and driver update resolved the hanging issues and after uninstalling all but essential software, we had a leaner and faster unit.
At 10”, the screen was deemed too small for some users to see the electronic drug chart clearly and so users requested devices with larger screens. They also felt that the onscreen keyboard meant that data entry took a long time. The C5 has now been mounted on the RDP Simple-Smart Laptop trolley, which means that the keyboard and mouse can be used when the C5 is docked.
Panasonic Toughbook: User feedback for the Panasonic Toughbook was initially good. The users favoured the keyboard over the onscreen keyboard and the screen was slightly bigger. The unit was not easy to use as a handheld solution and the ward staff had issues as to where the unit was placed as they administered drugs. The units were placed on the shelf at the back on the drug trolley, but the nurses had to lean over to be able to see the screen clearly. Final feedback agreed that the screen needed to be bigger.
Toughbook was assessed as being unsuitable for our nurses or prescribers. While it could be useful to the pharmacy, a larger screen would be favoured.
Dell XT2: With a 12.2” screen, fast processor and touch screen, the Dell XT2 looked to be a good choice. Administration of medication could be completed with the pen or by using the laptop touchpad. KCH has had a good history with support from Dell and the products are trusted. KCH acquired a telescopic laptop arm to attach the XT2 to the drug trolley, but health and safety issues were raised as to whether these could hit staff and patients.
The original Dell network cards were problematic and users began to loose faith in the XT2s. We replaced the network cards with Cisco cards and connectivity improved. However, the ward staff no longer wanted the units and thus they were given to pharmacy to support their ward rounds.
The Dell XT2 was viewed as unsuitable for our nurses or prescribers. Although it proved useful to pharmacy, a standard laptop could do a similar job for a fraction of the price.
Computerised drug trolleys: After reviewing what we had learnt in the mobile device trials, it was felt that a drug trolley with an integrated computer and a large screen was favourable. When we looked at the computerised drug trolleys from the USA, they all had individual trays for each patient. Unfortunately, individual trays were not suitable for storing the stock medication. We discussed our requirements with our two cart suppliers Parity Medical and RDP Health, and visited the pharmacy to discuss how medicines are stored.
Parity showed us a small cart they had designed with a lockable door and integrated PC. The unit did not have enough storage space for the amount of medicines needed on the wards and so Parity Medical said they would redesign the current trolley.
In discussions with RDP, they agreed to loan us lockable drawers that could be retro-fitted onto our current COWs. After trialling the retro-fitted drawers, we decided that this solution was not right for the medicine rounds. However, we could see that these could be beneficial for other storage.
RDP came back to us with the first computerised drug trolley suitable for a medication round. This was piloted on our main EPMA ward and the ward team were much happier, as they no longer had to push the drug trolley and the COW at the same time. Due to the size of the carts, there was plenty of room to store all their medication plus additional gloves, syringes and other equipment. This added to the weight of the unit and it was advised that some should be removed. The installation and the use of the PC were favoured and so we purchased five to use on the wards.
As we continued with our EPMA roll-out, we found wards that did not have the space to store the larger trolley and so a smaller trolley was required. We returned to RDP and asked them to design a smaller product.
Parity finished the redesign of their med cart and a trial unit was delivered to the ward for testing. The unit was very well received; it was small and easy to push and could be stored easily. During testing, however, we noticed that the temperature inside the cart was distinctly higher than the ambient temperature and thus arranged for temperature testing to be carried out. The testing revealed that the unit became 3ºC higher than the ambient temperature. As many medications should not be stored at greater than 25ºC and the wards were already hot, this trial was stopped. A new Parity ‘cool’ cart is now being trialled at KCH.
RDP also redesigned their trolley to make a taller and thinner unit. The cart had the PC located at the top, which meant that the nursing staff had to lean down to access the medication. Feedback was given to RDP and they agreed to move the PC enclosure to the bottom.
Computerised drug trolleys were assessed as being ideal for replacing drug trolleys. The variation of sizes means that all types of wards can be catered for. Prescribers and pharmacy can also use these when not in use.
RDP ‘Simple-Smart’ laptop cart: In 2010, RDP Health introduced the ‘Simple-Smart’ laptop cart which could accommodate a laptop or mobile clinical assistant such as the C5. The cart has an optional antimicrobial membrane to protect the laptop’s keyboard. The price of a cart is a quarter of the cost of a COW.
RDP’s ‘Simple-Smart’ laptop carts were deemed perfect for prescribers and pharmacy and for wards with PODs. Their low cost and ease of cleaning make this a viable COW replacement.
Conclusion
Each of the products trialled had their strengths and weaknesses and a device may be perfect for one area but not suitable for another. One size does not necessarily fit all when it comes to equipment and I would recommend you test as many devices as you can and get your ward staff to give you feedback. Many suppliers allowed us to ‘try before you buy’, which ensured we did not purchase the wrong type of product.
Build a good relationship with your cart suppliers and share your knowledge with them so they can build products that can be used across the health service. KCH has built an excellent relationship with RDP Health and Parity Medical and we thank them for all their help with creating and building products for us.
New products are being created every day as technology evolves. With the iPad and Blackpad set to corner the market in touch-screen tablets, they could become a regular sight on KCH wards.
Whatever happens, we will ensure our equipment is tested on our wards by our users. Equipment should not be the weak link in the progression of Electronic Prescribing and Medication Administration.
