Abstract
Aim To design, build and implement Cerner EPMA for all drugs and infusions required in neonatal units across a regional Integrated Care Service (ICS).
Situation The ICS comprises four NHS Trusts, two of which already shared the Cerner domain with the remaining trusts joining in autumn 2023. Cerner was in use in adult and paediatric areas, with neonatal units the last to join due to complexities of prescribing.
The multi-disciplinary approach from all four trusts included nurses, consultants and pharmacy (EPMA and Women and Children’s). The teams collaborated over an 18 month period in order to align prescribing practices and to design and build neonatal medication order sentences, powerplans for continuous infusions (such as inotropes and sedation), intravenous fluids and parenteral nutrition.
Key prescribing guidelines were shared between trusts and the teams worked together to identify and harmonise differences in local practice. The trusts use the ‘standard flow rate, variable concentration’ system of prescribing drug infusions, some with different calculation ‘factors’. Sharing the Cerner domain required alignment of these. All sites were prepared to make changes. One site used both 25 mL and 50 mL syringe volumes (depending on weight). However, this contributed to variation in practice and it was agreed to use the 25 mL volume, with the benefit of reducing drug wastage in certain situations.
Stakeholders from the two trusts with level 3 neonatal units, (already live with adults and paediatrics), met in person in late spring 2021 to harbour professional relationships that continued to develop through virtual collaborative working on Microsoft Teams®. One senior pharmacist had experience of working at both trusts, further strengthening collaboration.
Sharing the Cerner domain between four trusts and six neonatal units required compromise. The neonatal medicine build was standardised but as with the adult and paediatric build, excluded dose range checking and no guidelines were embedded. Optimisation of the existing Cerner build for paediatrics included adding order sentences for many drugs with options for neonatal ‘units of measure’ (such as micrograms) and ‘frequencies’. Governance around each build was approved from representatives of all disciplines from each trust.
The neonatal medications build involved creation of approximately 200 new order sentences and 30 specific neonatal intensive care unit (NICU) ‘powerplans’ (for example, continuous variable rate infusions specifying dose range, concentration and diluents).
Continuous variable rate infusions allow the weight-based dose to be prescribed in a choice of diluents as well as documentation of dose (rate) changes (x-y microgram/kg/hour or minute) without a new prescription which reflects previous practice on paper.
In autumn 2022, the two trusts already sharing the Cerner domain went live with EPMA on all four neonatal units with the rest of the region joining in autumn 2023.
Conclusion The successful implementation of a complex Cerner EPMA neonatal build, with complexities and intricacies of level 3 neonatal unit settings, as well as level 1 and 2 units was attributed to successful stakeholder engagement, multidisciplinary collaborative working and negotiation. The benefits of sharing a Cerner domain should lead to greater standardisation of care across the ICS.
