Impact of Medication Dose Tracking Technology on Nursing Practice

Methods

Results

The CTICU at DUH was responsible for a total of 3,529 medication requests, or 38.4 medication requests per day, during the pre web portal access phase of the study. Orientation to the MDTT and web portal occurred during the CTICU nursing staff meetings in August 2014, whereby a total of 96 nurses were oriented during 12 scheduled meetings. Subsequently, 166 registered nurses were granted access to the MDTT web portal for the postaccess phase of the study.

Primary endpoint results are represented in Table 1. The number of medication requests per dispense to the CTICU for the pre web portal access and post web portal access phases were 0.0579 and 0.0513, respectively (p < .001). This was a statistically significant decrease of 11.4%, resulting in an avoidance of 527 in-basket medication requests during the post MDTT web portal access phase.

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Table 1.

Primary outcome of number of medication requests per dispense pre and post web portal access

	Dispenses to CTICU, n	Medication requests, n	Medication requests/dispense
Preaccess phase b			0.0579 a
June	18,986	1,106		0.0583
July	20,261	1,189		0.0587
August	21,693	1,234		0.0569
Postaccess phase c			0.0513 a
October	24,190	1,271		0.0525
November	26,375	1,413		0.0536
December	29,293	1,412		0.0482

Note: CTICU = Cardiothoracic Intensive Care Unit.

a

Z-test of proportions comparing total pre- and postaccess phase: p < .001.

b

Preaccess phase: June 2014-August 2014.

c

Postaccess phase: October 2014-December 2014.

Results of the modified MAS-NAS survey for pre and post MDTT web portal access are represented in Table 2. A total of 166 nurses were provided MDTT web portal access with 59 (35%) respondents to the preaccess survey. These respondents were then eligible to participate in the post web portal access survey. Results of the post web portal access survey represent 33 respondents or a response rate of 56%. Statistically significant improvement in nurses' satisfaction exists for 2 of the 11 pre-post MAS-NAS survey items. Nurses' satisfaction regarding access to information about location of medications increased after they received access to the MDTT web portal (pre = 4.1 and post = 4.4; p = .009). Nurses also experienced increased satisfaction with the number of distractions in the medication distribution system after receiving MDTT web portal access (pre = 3.8 and post = 4.2; p = .042). The remaining 9 pre-post survey questions showed increased or stable nurse satisfaction; however, for these items, the intervention did not result in statistically significant differences between the pre- and postaccess phases. Item 12 was present only in the postaccess survey and measured nurses' satisfaction with the MDTT system's usefulness. The response to this item showed a mean value of 4 (SD = 1.6), signifying nurses “somewhat agree” that the system is useful overall.

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Table 2.

Modified MAS-NAS survey results

Questions	Preaccess survey (n=33) Mean (SD)	Postaccess survey (n=33) Mean (SD)	p value
1. The current medication distribution system helps me to be efficient at medication administration.	4.1 (0.9)	4.2(1.1)	.742
2. The current medication distribution system is user-friendly to the nurses who administer medications.	4.2(1.0)	4.3(1.1)	.669
3. The turnaround time for receiving medications needed “stat” or for patients newly admitted to the unit is adequate.	3.5(1.0)	3.5(1.1)	.527
4. The current medication distribution system helps me to be time efficient at medication administration.	3.8(1.0)	4.1 (1.0)	.240
5. The current medication distribution system helps keep the number of distractions I encounter low.	3.8(1.2)	4.2(1.1)	.042
6. I have access to the systems that support medication distribution (physicians orders, drug information) when I need them.	4.8 (0.8)	5.0 (0.7)	.457
7. I know where all the medications I need are stored (either on the unit or if they need to be procured from pharmacy).	4.2(1.0)	4.4(1.2)	.145
8. The current medication distribution system provides nurses access to information about location of medications.	3.4(1.3)	4.2(1.1)	.009
9. I have to keep stashes of medications to be sure I have medications I need when I need them.	2.9(1.3)	2.6(1.4)	.172
10 The current medication distribution system helps me to be time efficient at medication administration of intravenous preparations.	3.8(1.0)	4.0(1.1)	.883
11. I am satisfied with the overall medication distribution process.	3.9(1.0)	4.1 (0.9)	.556
12. I find the Pharmtrac.PD medication dose tracking system to be useful.a	N/A	4.0(1.6)	N/A

Note: Responses to items on the modified Medication Administration System-Nurses Assessment of Satisfaction (MAS-NAS) scale were scored on a 6-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = somewhat agree, 5 = agree, 6 = strongly agree. N/A = not applicable.

a

Survey question appeared only on postaccess survey.

During the postaccess study period, 295 queries, or 3.2 queries per day, were performed by 68 unique CTICU nursing staff members (Table 3). The processing time of in-basket medication requests by pharmacy technicians was measured throughout the pre and post MDTT web portal access phases of the study and resulted in a median time of 7 minutes per medication request. After applying a mean pay rate of $17.22 per hour for hospital pharmacy technicians, the resultant cost of processing a medication request by pharmacy technician resource time was calculated to be $2.01 per request. ¹⁰ Pharmacy cost savings estimates are represented in Tables 4 and 5. Total pharmacy cost savings during the post web portal access phase due to pharmacy technician resource time was $1,059, with a potential annualized savings of $4,235 for the CTICU alone. Furthermore, we applied the results of this study to calculate pharmacy cost savings if hospital-wide nursing access to the MDTT web portal were provided, indicating a potential savings of $46,485 per year.

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Table 3.

Nursing utilization of the MDTT web portal

	Queries, n	Queries per day, n
Postaccess phase a	295	3.2
October	159	5.13
November	63	2.1
December	73	2.35

Note: MDTT = medication dose tracking technology.

a

Postaccess phase: October 2014-December 2014.

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Table 4.

Pharmacy cost savings associated with CTICU nursing access to the MDTT web portal during postaccess phase

	Medication requests, a n	Medication requests avoided, b n	Average cost per medication request, c $	Annualized cost savings, $
CTICU	4,096	527	$2.01	$4,235

Note: CTICU = Cardiothoracic Intensive Care Unit; MDTT = medication dose tracking technology.

a

Number of medication requests during postaccess phase of study only.

b

Based on study findings of 11.4% decrease in number of medication requests.

c

Based on US Bureau of Labor Statistics mean pay rate of $17.22/hour at 7 minutes/request for hospital pharmacy technicians.

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Table 5.

Potential annualized pharmacy cost savings associated with hospital - wide nursing access to the MDTT web portal

	Medication requests, a n	Medication requests avoided, b n	Average cost per medication request, c $	Annualized cost savings, $
Hospital d	184,478	21,030	$2.01	$42,250
CTICU e				$4,235
Total				$46,485

Note: CTICU = Cardiothoracic Intensive Care Unit; MDTT = medication dose tracking technology.

a

Number of medication requests annualized based on 6 months of hospital-wide study data.

b

Based on study findings of 11.4% decrease in number of medication requests.

c

Based on US Bureau of Labor Statistics mean pay rate of S17.22/hour at 7 minutes/request for hospital pharmacy technicians.

d

Excludes the CTICU and areas without pharmacy technician in-basket monitoring.

e

Data from Table 4.

Discussion

The findings from this study suggest that nurses' access to an MDTT web portal leads to a significant decrease in the frequency of communications received by pharmacy staff. MDTT web portal access also led to moderate improvements in nursing satisfaction, as measured by modified MAS-NAS pre-and postaccess surveys. Two survey items reached the level of statistically significant improvement in satisfaction. These survey items were the following: “The current medication distribution system helps keep the number of distractions I encounter low,” and “The current medication distribution system provides nurses access to information about location of medications.” CTICU nurses utilized the MDTT web portal multiple times each day, and cost savings due to a decrease in pharmacy technician processing time of medication requests were apparent. Based on study findings, pharmacy cost savings could be much greater if the same results were able to be realized hospital-wide.

The decrease in frequency of in-basket medication requests is a key indicator of the impact of MDTT web portal access on nursing practice. By providing access to the MDTT web portal, nursing staff were empowered to determine the location of their patients' intravenous and oral syringe doses. Study investigators set an a priori goal decrease of 10% in the frequency of medication requests per dispense. This decrease was achieved in the current study. It is also important to note that the number of in-basket medication requests is normalized to the number of doses dispensed to the CTICU. This allowed study investigators to account for seasonal changes in drug volume, with the assumption that an increased number of dispenses would lead to an increased number of medication requests. Additionally, modified MAS-NAS survey results and participation were positive. The pre modified MAS-NAS survey was distributed subsequent to staff meeting training and orientation, but prior to nurses receiving individual access to the MDTT web portal. This timeline was followed in order to increase overall survey participation, while also minimizing bias for survey respondents. Nearly all survey items showed improvements between the pre and post responses. The 2 survey items that achieved statistically significant improvements offer confirmatory evidence regarding the ability of the MDTT system to streamline the medication distribution process and to provide increased transparency regarding the location of medications. Overall, nurses offered positive responses regarding the usefulness of the MDTT system. Frequency of use, and the number of unique users, was lower than expected. Study investigators believe this to be multifactorial. It is speculated that overall satisfaction and use of the system could have been improved if the MDTT system were more accessible within the EHR. At the time of the study, the MDTT web portal link was not located at a convenient location within the EHR. Instead, nurses had to locate the web portal shortcut manually within their computer Start Menus. There was also a high amount of CTICU nursing staff turnover during the postaccess study period, making awareness of the MDTT system difficult to maintain. Pharmacy cost savings associated with nursing access to the MDTT web portal during the postaccess study period were evident; however, the potential pharmacy cost savings for institution-wide implementation of MDTT web portal access could be even higher. Cost savings were calculated utilizing the median processing time per in-basket medication request by pharmacy technicians. The median, instead of mean, was used to censor for outliers in processing time. It is also important to note that cost savings as calculated in the current study do not include other expenses such as drug cost or nurse or pharmacist time associated with medication requests. Implementation cost due to expansion of MDTT web portal access to all nurses was not included in the current evaluation, as there are no incremental expenses associated with providing access to additional users. Due to the aforementioned factors, it is expected that the true savings associated with MDTT would be much greater.

The results of our study correspond with the positive impact evidenced by MDTT in other publications. One publication used MDTT to improve medication distribution turnaround time. ³ Utilizing MDTT, the investigators were able to capture a higher volume of location and time points, allowing for more thorough analysis into potential hindrances along the medication distribution process. ³ The result of MDTT implementation and subsequent workflow changes led to a decrease in the mean turnaround time from 74 to 66 minutes for the study site's central pharmacy. ³ The same study site had not implemented nursing access to the MDTT web portal at the time of publication; however, it was reported that plans were in place to allow for future access. ³ In contrast, our study accomplished the goal of allowing nursing access to the MDTT web portal and provides detailed analysis regarding its impact. Survey data in our study were collected utilizing a modified version of the validated MAS-NAS scale. ⁷ Other studies have successfully assessed nursing satisfaction with changes in the medication distribution process through standard and modified versions of the MAS-NAS survey.^8,11 A study assessing nursing satisfaction after the addition of medication cabinets in patients' rooms used a similar method to our study through the introduction of survey items during the postimplementation phase only. ⁸ Although pre and post analysis could not occur, this method allowed the authors to fully assess the impact of changes made in the medication distribution process. ⁸

Providing MDTT web portal access allowed nurses to gain a better understanding of the location of their medications without the need to contact pharmacy staff. Although not an endpoint in the current study, this more efficient process could lead to an increase in medication availability and subsequent decrease in medication delays. Likewise, a decrease in communications with pharmacy staff has a positive impact on overall interruptions and distractions encountered in the preparation and dispensation of medications. This is particularly important because previously published studies have directly linked interruptions and distractions with medication dispensing errors.^12,13

There are several limitations to our study. Results relied heavily on participation by the nursing staff in the CTICU. This patient care area experienced a high volume of turnover during the post web portal access phase, which could have negatively impacted frequency of use of the system. The high volume of turnover also resulted in many new nurses gaining access to the system without completing the initial training and orientation offered during required staff meetings. Fortunately, additional methods were provided to overcome this limitation, including training brochures and peer super user support. Additionally, the primary endpoint of the study was normalized to the total number of medications dispensed to the CTICU during the study period.

Although not a definite limitation of the study, it should be recognized that normalizing to total number of dispenses assumes the presence of a linear relationship between the number of medications dispensed and volume of in-basket medication requests. Certain potentially important endpoints were not measured in the current study. The impact of MDTT web portal access on medication delays or the number of redispensed medications was not analyzed. Pharmacy staff satisfaction was not assessed, and investigators did not include medication expense or nurse or pharmacist salaries in projections of potential cost savings. Furthermore, the CTICU was responsible for generating the highest volume of in-basket messages at DUH during the pre web portal access phase of the study; therefore, extrapolating study results has the potential to overestimate the hospital-wide benefit of MDTT. Similarly, the current MDTT system at DUH only tracks intravenous and oral syringe preparations. Patient care areas with lower volumes of these preparation types may not experience the same level of benefit as evidenced in our study.

Conclusion

The results of this study suggest that providing nurses access to an MDTT web portal decreased the number of communications regarding location of medications between nursing and pharmacy staff and led to statistically significant improvements in nursing satisfaction for certain aspects of the medication distribution process. Our study represents the first publication concerning the impact of MDTT web portal access on nursing practice. Further research should consider evaluating the impact of MDTT on volume of redispensed medications, satisfaction of pharmacy staff, and reduction in adverse events related to medication delays.