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Ahead of the curve

Ahead of the curve

Cross-department effort addresses 30-minute rule changes and challenges

After reading this article, you will be able to:

  • Describe the challenges occurring at Baystate Health that led to an early analysis of the 30-minute rule
  • Identify ways the CMS change to medication administration verified the organization's research
  • Identify key stakeholders in an analysis of medication administration
  • Discuss the bedside staff's role in targeting medication ­administration challenges


There are certain requirements and regulatory factors that pose perpetual challenges for hospitals, familiar burdens that elicit nods of understanding and sympathy when organizations discuss the barriers to successfully keeping themselves in compliance. The recently relaxed "30-minute rule" from CMS-which had, until recently, required all medications to be administered within 30 minutes of their scheduled time, regardless of the medication's own time sensitivity-is one of those universally problematic requirements.

For one organization, though, the recent CMS updates to medication administration timing had an interesting side effect: The organization had already been analyzing the problems and dangers related to the 30-minute rule and was in the perfect place to respond to the CMS changes. In fact, the CMS announcement validated the group's own research.

Over the past few years, the staff at Baystate Health in Springfield, Mass., especially within nursing and pharmacy, have been working toward the common goal of providing excellent care by conducting their own examination of medication administration timing.

"When this requirement was first announced, I knew Baystate Health would be one of the leaders in the medical community to design a model that would work," says WendySue Woods, RN, MHSA, CSHA, who is the organization's senior consultant from The Greeley Company. "Nothing is done in isolation at this facility."

Both nursing and pharmacy struggled with meeting the former CMS requirement and saw flaws in the process, says Mark Heelon, PharmD, medication safety specialist with Baystate Health Pharmacy Service in Springfield. "The 30-minute rule resulted in so much rushing, especially for noncritical medications," says Heelon. "This kind of rushing predisposes everyone to medication errors."

Under the 30-minute rule, everything was essentially a stat medication-even items like vitamins that are not time-sensitive.

"We had these discussions before the Institute for Safe Medication Practices [ISMP] report came out," says Heelon. "Our concerns were validated by the ISMP survey in that it agreed the 30-minute rule predisposed nurses to medication errors."

The team created to review this issue comprised key figures from across the hospital, including:

  • Deborah Provost, RN, vice president of surgery, ­anesthesia, and ­emergency services
  • Karen Johnson, RN, director of performance ­improvement services
  • Denise Schoen, RN, nursing education specialist, nursing practice and professional development
  • Aaron Michelucci, PharmD, director of pharmacy
  • Joan McGirr, RN, total joint coordinator


The improvement process

"Nursing and pharmacy started to collaborate about a year before the CMS changes were announced trying to better understand missing mediation requests," says Heelon.

During an initial discussion, the observation was made that five or six years ago, staff had more time to dispense noncritical medications, such as famotidine or vitamins.

"The nurse would have more leeway to administer these medications," says Heelon. "They could use more of their clinical judgment and common sense. What would happen was that they would let the processes play through with pharmacy, the medications would be delivered to the floor or unit in a reasonable time, and then the nurse would administer that medication."

With the advent of the 30-minute rule, however, the nurses had to make frequent calls to the pharmacy to get noncritical medications up to the floor. This meant that the pharmacy did not have time to follow the established flow of medications out to the units.

"Everything was handled as a stat," says Heelon. "We were rushing. Nursing was rushing."

Obviously, this was not a good process for staff or particularly safe for patients. So the team began trying to put their finger on the pulse of medication flow. Why were nurses missing medications? What was the effect of pharmacy not having the time to go through the proper processes before each call for medications?

"If everything is an emergency, it's difficult to filter out what a true emergency is," says Heelon.


Allocation of resources

Identifying the core issue-that success is difficult when there is no clear differentiation between emergency and nonemergency calls-made it clear that part of the challenge was resources being tied up.

"If you have to call because of a 30-minute rule for a noncritical medication, you're going to tie up not only that nurse, but also tie up the pharmacy department," says Heelon.

From here, the team conducted a root cause analysis for missed medications to identify how and where rushing was coming into play.

"This was beginning to rise to the top of our concerns," says Heelon. "We read the ISMP report and when we heard that CMS was going to change administration times, we were already meeting as a team to look at this. It all lined up for us."

A core group of pharmacy, nursing leadership, and performance improvement professionals examined missing medication calls.

"We were pretty savvy about what was going on with concerns in our own institution," says Heelon. "With the new rule change, we sat down for several meetings to review the changes and develop processes to meet them."


The processes

The first of these processes was an educational piece called a medication frequency time zone period.

"In the future when this rolls out, it will help nurses understand the difference between 30-minute and two-hour window medications," says Heelon.

Essentially a chart, it is meant to educate nurses at a glance about categories of medications and their respective timing.

The second component was a flow chart describing the new regulations. The chart was based on a document shared on a listserv and then reworked to suit the organization's unique needs.

"It details critical medications versus noncritical medications and how it all flows out to the patient," says Heelon. "What we did was tailor that flow chart to our own processes in the hospital."

Baystate Health needed to come up with its own defined medication categories.

"The flow chart identified time-critical medications, those that need to be administered within 30 minutes of their scheduled time, and exceptions to the noncritical medication list," says Heelon.

Clinical operations policy

The organization is 99% finished with developing a clinical operations policy addressing the new CMS guidelines for administering medications. The wordsmithing stage of policy development is finished, and now it will head out to professional development for review.

After that, it will be passed down to unit managers who will ensure that the information is distributed to and understood by the nurses at the bedside.

Much of the discussion in the field has been about how the 30-minute rule changes will impact nursing, but there is a cause and effect that carries over distinctly to the pharmacy as well, says Heelon.

"If the nurse is rushing to give a noncritical medication, they end up calling the pharmacy," says Heelon. "Then the pharmacy rushes to review and dispense the medication. Lastly, constant interruptions concerning missing medications when verifying medications may predispose pharmacists to errors.

"This whole process lends itself to errors. So these changes will help us by allowing us, in both the nursing and pharmacy disciplines, more time to administer these noncritical medications."


Reaction to the CMS changes

Most organizations will want to create an educational component to explain the CMS changes rather than rely on the CMS documentation itself.

"Reading through the changes, if you were to send this out as is to frontline staff, it's pretty confusing," says Heelon. "There's a lot of terminology to work through."

The contents of the changes, however, will work in the hospital's favor.

For those who haven't started the process of addressing the 30-minute rule changes, the most important step is getting the right people at the table, Heelon says.

"When we first met, each discipline stated their interpretation of the new CMS administration guidelines to make sure we were all aiming for a common goal," he says. "Sometimes the approach between departments can be a little different, so you really want to ­examine your healthcare institution, figure out who the key players are and who needs to be at this meeting." ­

Engaging frontline staff is also critical to establish buy-in and sustainability when implementing the new policy changes, Heelon adds.

No matter how well crafted a policy, if it is inefficient, staff will find work-arounds to increase efficiency. By ­including the staff who will be involved in the process, you can identify potential barriers to ­success and ensure there won't be a need to create work-arounds.

"The inclusion of the frontline staff at the beginning of this process ensured ownership and accountability on the part of the nursing staff," says Woods. "They can speak to the process and its success, which ensures compliance."

Pharmacists and nurses function as the dedicated professionals entrusted with medication safety. Both ­professions share the common goal of providing excellent patient care.

Achieving this common goal is dependent on their ability to embrace an attitude of mutual ­respect and teamwork. The staff at Baystate Health was able to work collaboratively to address the new CMS 30-minute rule change to help reduce rushing and ultimately reduce errors involving patients.