By Bruce Buckley, David Wild
With shortages of smart infusion pumps rising in hospitals besieged by COVID-19 admissions, the Institute for Safe Medication Practices (ISMP) issued a set of strategies designed to reserve supplies of the pumps for the most critically ill patients, including those on mechanical ventilation. The conservation measures are featured in the second pandemic-focused edition of the ISMP Acute Care Safety Alert! newsletter (bit.ly/3cgmpTk).
In a separate webinar, ISMP issued guidelines on how to use smart pumps safely during the COVID-19 pandemic, including keeping the pumps outside of patients’ rooms to prevent viral exposure.
Conserving a Limited Resource
“What we’re learning is that the [smart pump] situation is very dynamic as these [COVID-19] surges impact individual organizations,” said Michelle Mandrack, MSN, RN, the director of consulting services at ISMP. “These strategies are what we think offer the best use of limited resources.” They include reserving the use of smart pumps for high-alert medications and critical patients and, in certain cases, considering infusion delivery via IV push instead of continuous infusion (bit.ly/2REYuVG).
Another suggested option is to revive the use of gravity flow infusion for medications that can be safely managed without the alerts built into the smart pumps. These cases might involve infusions of IV hydration and some IV antibiotics. Ms. Mandrack pointed out, however, that “on the critical care units, we’re not used to running infusions by gravity. We’re used to having smart pumps with dose error reduction software to safely manage intensive care patients who are receiving many high-alert drugs. So, it’s crucial to continue the use of smart pumps for medication infusions in [the] ICU. At the same time, to preserve pumps and dedicated sets, have a plan to convert to gravity infusion elsewhere as the circumstances begin to dictate.”
Photo courtesy of Lehigh Valley Health Network, Allentown, Pa.
The newsletter also suggested converting some IV patients to oral therapy as soon as possible while following facilities’ specific IV-to-oral protocols, and weighing the use of either syringe pumps, if available, or subcutaneous infusion delivery for hydration and low doses of potassium chloride.
First Steps
One of the first steps for dealing with an active or looming smart pump shortage, according to ISMP, is to inventory all available supplies of the devices, with an eye towards under-recognized locations. “They may be sitting underutilized in interventional radiology, for example, or in perioperative areas, surgery centers and outpatient settings,” Ms. Mandrack said.
Another step is to develop a list of medications that “absolutely require” smart pump delivery. At a minimum, the newsletter stated, the list would include IV vasopressors, antiarrhythmic agents, opioids, sedation and anesthetic agents, neuromuscular blockers, antithrombotics and insulin. Unfortunately, several of these agents are in short supply (see page 1).
Keeping Pumps Outside Of Rooms
Even when smart pumps are available, COVID-19 has necessitated workflow changes to ensure safety. Specifically, some hospitals are stationing the pumps outside the rooms of critically ill patients with COVID-19. Doing so can reduce the number of times health care workers enter patient rooms, preserving personal protective equipment and cutting the risk for SARS-CoV-2 exposure.
However, as experts from ECRI and ISMP said during the webinar, with new workflows come new concerns.
ECRI has tested the five most common smart infusion pump brands using up to 20 feet of microbore extension, which many organizations have opted to use because of the smaller priming volume, noted Erin Sparnon, MEng, a senior engineering manager at ECRI. Ms. Sparnon said the pumps performed as they typically do at the bedside for flow rates ranging from roughly 5 to 300 mL per hour, flow rates that are sufficient for most infusions, she noted. “However, at both ends of the spectrum is where we get problems, specifically with alarms.”
At flow rates below 5 mL per hour and with long tubing sets, she explained, pumps were slow to detect occlusions close to the patient, thus delaying alarms. On the other hand, with flow rates above 300 mL per hour, fluid pushed through the low-volume and small-diameter microbore tubing, leading to higher downstream resistance and more frequent occlusion alarms. “At either end of the spectrum, there’s the risk of the patient not getting the medication they need,” she said, noting that it is impractical for busy nurses to attend to frequent alarms.
A challenge that comes with using microbore extension sets is that when small-volume infusions are administered, much of the drug can remain in the tubing and needs to be flushed when the infusion is complete, according to Ms. Mandrack. “It’s really important to know the total volume of the bag to make sure you get all the drug to the patient access site,” she stressed.
Using extension sets also can affect infusions that require titration, she said, noting that “if titrations are done more proximal to the pump in the hallway and there is a long extension of tubing, there can be delays in the effect of the titration. So you might consider placing these types of infusions closer to the patient.”
Perhaps one of the most important consequences of placing infusion pumps in the hallway is the potential to compromise the safety of the medication administration process, Ms. Mandrack said. “The independent double-check process for high-alert medications has definitely been impacted by this practice,” she said. “The separation of infusion pumps from the patient at their bedside has frequently limited these double checks to verifying the medication, concentration and dose, and pump setting but not the patient’s barcode bracelet.”
A number of hospitals are labeling the pump itself with the patient’s name and date of birth as well as scanning a “proxy bracelet”; a duplicate patient-barcoded bracelet that two nurses have verified is an exact match to the bracelet the patient is wearing, Ms. Mandrack noted. However, she cautioned that “this proxy situation carries its own risks, particularly when you’re using mobile infusion poles and the bracelet may be accidentally left on the pole after it’s been transferred for use for another patient.”
Nurse-to-Nurse Communication
There is at least one novel approach to mitigating the risk for wrong-patient drug administration: having a nurse in the patient room communicate with another nurse in the hallway, as one hospital told ISMP. Ms. Mandrack said the critical care rooms at this particular hospital are glass enclosed, which allows a nurse located inside the room to scan the patient’s bracelet and a second nurse in the hallway to scan the infusion bag through the glass, she explained.
Other organizations reported wrestling with the possibility of allowing nurses to override hard stops that typically require independent double checks before a medication can be administered, she noted. Although Ms. Mandrack acknowledged there can be “really tough conversations” around these topics, ISMP believes health systems can implement workflow modifications to preserve the independent double-check process as much as possible. For example, with some electronic health record (EHR) systems, two nurses can independently double-check the medication and pump settings in the hallway. With the order pending in the EHR, the patient’s nurse can then enter the room to complete the process through the medication administration record on the computer and scanning the patient’s bracelet, she explained.
Ms. Mandrack urged organizations that are using infusion pump extension sets to clearly label lines both inside and outside the room, particularly when there are multiple sets running from the pump. “Once you have two or three different patient infusion pump setups outside a single room, the potential for wrong patient drug administration becomes a real safety hazard.”
Conservation Measures
With the demand for extension sets having “skyrocketed,” some organizations have experienced shortages of these sets and moved pumps back to the bedside, said Mike Cohen, RPh, the president of ISMP. “From our discussions with manufacturers, they are working overtime to meet demand for extension sets,” he noted during the webinar.
Until ample supply is secured, Mr. Cohen said organizations can turn to a number of strategies to conserve pump-related inventory.
For example, he urged organizations to create a list of medications they believe must “absolutely” be administered through infusion pumps, and switch appropriate patients from IV to oral medications and hydration as early as possible. He said organizations also should maximize the length of time they use tubing sets, while still adhering to standards issued by organizations such as the CDC (bit.ly/3bjRzZZ
). Finally, he suggested administering medications through IV push and gravity infusion when possible.The sources reported no relevant financial relationships.
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How COVID-19 Changed Smart Pump Deployment - Pharmacy Technology Report
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