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Abstract
In 2017, a severe shortage of infusion bags resulted in a paradigm change in medication administration practice from intermittent infusion to intravenous push. The Institute for Safe Medication Practices proposed safe practice guidelines for adult intravenous push medications. A different study showed that ready-to-administer medication prepared in the sterile area of a pharmacy reduces the risk of harm, nurses’ time for medication administration and the cost of medications. Based on the recommendation of the Institute for Safe Medication Practices, we decided to conduct a pilot study on the implementation of sterile compounding and administration of intravenous push medication in adult patients admitted to the hospital. In the study, the stability of five intravenous push antibiotic syringes was also determined in the syringes.
- pharmacists
- medication safety
- nurses
- clinical pharmacology
- antibiotic management
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Background
Parenteral therapy, in particular, intravenous administration of medication remains the major choice of treatment in the healthcare system.1 Research shows that over 80% of admitted patients receive intravenous medication.2
However, in 2017, the practice of intravenous intermittent infusion was challenged due to the severe shortage of intravenous piggybacks. It was later determined that intermittent infusion may result in underdosing of medication due to residual in the drip tube.3 This resulted in a paradigm change in medication administration practice from intermittent infusion to intravenous push. The Institute for Safe Medication Practices (ISMP) proposed guidelines for the safe practice of intravenous push medications in adults. The guideline strongly recommended that intravenous push medications be prepared in a pharmacy sterile compounding area and dispensed as ready-to-administer (RTA) medication.4 RTA medications do not require any further dilution or changes by the nurse. Prefilled RTA syringes are commonly used in hospital settings.5 It was reported that in the USA around 61% of RTA syringes were dispensed for intravenous push by the pharmacy.6 This pharmacy programme is considered of high essence in the pharmacy practice. RTA prefilled syringes not only provide uniformity and reduce medication errors but also provide a fast delivery system to the patient. A major factor for the success of the programme is drug-long stability that allowed pharmacies to maintain larger batches and deliver medication timely.7
The healthcare system of Pakistan functions with limited resources and depends highly on private hospitals.8 Similar to other countries, data from different institutes in Pakistan show that 59% of prescribed medications are intravenous. In Pakistan, pharmacy services are at the infancy stage, and most of the private and public sector hospitals do not provide RTA medication.9 Few hospitals that do have the services of sterile compounding, supply intravenous intermittent infusion bags. The RTA intravenous push medication is yet to be implemented in any hospital. The rationale for preparing RTA intravenous push medications rather than intermittent infusion bags is that it is not only cost-effective than intermittent but also saves time for the nursing staff. If the pilot of intravenous push is successfully implemented and accepted then most of the developing countries would be able to initiate such programme as cost-saving project. Hence, we plan to conduct a pilot study on the implementation of sterile compounding and administration of intravenous push medication in adult patients admitted to the hospital. This paper describes the results of the pragmatic observational study that aimed to assess the implementation process of intravenous push syringes in adult admitted patients.
Methods
This is a prospective, single-centred pilot study aimed at establishing intravenous push medications practice in the adult population which was initiated from December 2022 till March 2023. The objective of the 4-month pilot project is to develop a workflow for developing intravenous syringes, ensuring their stability and transportation to the ward for administration. The project was conducted in one of the largest renal transplantation centres in the country, the Sindh Institute of Urology and Transplantation (SIUT) located in Karachi, Pakistan. SIUT is a 700-bed tertiary care hospital and caters mainly to nephrology, urology, uro-oncology and gastrointestinal disorders. The Department of Pharmacy Services provided sterile compounding preparation to oncology products and a few specialised products only. A specific location was identified in the department and human resources were allocated for the project. Two pharmacists, a pharmacy trainee and a technician were allocated to the project.
Project process
The project underwent the following steps or processes:
Step 1: selection of medications for RTA syringes
The selection of the medications for the project was based on consumption, stability and intravenous push approval. With the consultation of senior pharmacists, a few medications were selected. The selected medications had high consumption, had long stability after dilution, and intravenous push administration was approved.
Step 2: pilot production of RTA syringes
A literature review was conducted to determine the stability of the selected medication. Stability parameters such as pH and osmolarity were also determined by the hospital laboratory. The stability of intravenous push syringes was determined by literature review and laboratory testing. The laboratory testing was carried out using the intravenous push syringes prepared by the pharmacy. These products were maintained at a fridge (2–8°C) and room temperature. The solutions were analysed using High Performance Liquid Chromatography (HPLC) assays on the 3rd, 5th, 7th and 10th day. The intravenous push syringes were considered stable if the solutions maintained ≥90% of the initial concentration.
Step 3: dispensing of RTA syringes
The pilot was initiated from a single ward for 15 days where the nurses were educated relating the RTA syringes. This allowed us to review the process of ordering, dispensing and administration processes. With time, more wards were added to the project. Education relating to the use of intravenous push was provided to the nurses of different wards and regular feedback was taken from them.
The ethical review was accepted, as no human life was involved in the study.
Results
Selection of antibiotic
Four medications were selected for the study, which were meropenem, piperacillin–tazobactam (piptaz), omeprazole and ceftriaxone. These medications were the most moving injectables as shown in table 1 in the number of intravenous push administered. The literature survey showed that all these intravenous push medications have stability of more than 2 days.
Drugs selected for intravenous push formulation
Stability of intravenous push syringes
Tables 2 and 3 provide information relating to the stability of the solution at the refrigerated condition and room temperature. All solutions of meropenem stored in refrigerated were found to be stable for 5 days maintaining concentration above 90%. However, none of the solutions were found to be stable at room temperature. The stability of the solutions piperacillin–tazobactam at refrigerated and room temperature was found to be 10 days and 5 days, respectively.
Stability of formulations at refrigerated condition
Stability of formulation at room temperature
Distribution of intravenous push prefilled syringes
After establishing stability and ensuring other parameters, the preparation and distribution of intravenous push syringes were initiated from January to March 2023 shown in figure 1. During this time, 31 206 intravenous push syringes were administered to around 8000 patients. No adverse drug reaction form relating to these medications or complaints were received from physicians or nurses for phlebitis or any other side effects. Physicians, also, did not raise any concern about any difference in health comes.
Monthly distribution of intravenous push medication.
Discussion
Our study provides evidence for the successful implementation of intravenous push medication delivery and administration in hospitalised patients as recommended by ISMP guidelines. Intravenous push delivery has been experimented with in various settings such as outpatient10 and emergency department.11 To the best of our knowledge, this is the first study relating intravenous push in admitted patients. No such study has been conducted in developing countries yet. Our study also includes the stability testing of four major antibiotics at different concentrations in syringes. Our study found that intravenous push delivery is safe in admitted patients.
One of the concerns of intravenous push remains the risk of phlebitis due to high osmolarity.12 The standard of practice for infusion therapy has recommended the intravenous solution with osmolarity greater than 900 mOsm/L shall be administered via central line.13 Moreover, the data relating to osmolality are rarely available in the product literature or tertiary resources.14 In our study, the osmolarity of all the intravenous solution was determined from the laboratory. All solutions except, both concentrations of piptaz had osmolarity below 900 mOsm/L. However, no complaint was raised for any solution from nurses or patients. A similar study was conducted to evaluate the safety of different strengths of piptaz with high osmolarities (1278 and 930 mOsm/L). Similar to our study, this study reported that intravenous push piptaz was well tolerated.11 The lack of phlebitis due to high osmolarity may be due to the reason that the recommendation of 900 mOsm/L was based on a weak level of evidence.15 Another study compared the occurrence of Adverse Drug Reaction (ADR) between intravenous push and intermittent infusion of antibiotics. The study did not find any major differences among the delivery modes and concluded intravenous push to be safe as intravenous intermittent infusion.16 The safety of intravenous push of different antibiotics was also evaluated by another study. The study reported only one phlebitis while the rest of the adverse effect was not attributed to intravenous push.17
The data relating to the cost-effectiveness of intravenous push are scarce.18 Few studies have shown that intravenous push provides a cost-saving method.19 20 Our study found that intravenous push preparation reduces cost. The cost reduction was due to reduced wastage of drugs and materials. It was estimated that US$0.35 was saved on each intravenous push preparation. Other similar studies also found intravenous push cost saving.15 Bulk compounding would have assisted in reduced human resources. ‘RTA preparation also allowed for reduced nurse time to prepare intravenous medications.
One of the major drawbacks of intravenous push medication is the risk of errors. It is estimated that 48% of medication errors are related to intravenous medication preparation or administration in particular intravenous push.21 Hence, most safety programmes such as Joint Commission and ISMP have strongly recommended to dispense RTA medications. Pharmacists can play a major role in reducing these errors. The role of pharmacists in Pakistan has been developing over the years.22 In our study, all medications were prepared as per the protocol under the sterile area with medication labels which may have contributed to the high acceptance of nurses. The implementation of RTA syringes within a health system improves care, efficiency and patient safety and reduces cost.18
Irrespective of high cost, intermittent infusion is the preferred method of drug delivery in most institutions in Pakistan since this method provides standardisation, convenience for the pharmacy and greater shelf life. Our study has shown that intravenous push is a cost-effective alternative to intermittent infusion. Using intravenous push can also reduce patient treatment costs.
Barriers and limitations
The development of RTA syringes posed no major barriers; however, the acceptability of the intravenous push posed few concerns among nurses. Few nurses raised the concern of discolouration and stability of medication. Such queries were resolved by regular education. Once such concerns were resolved, the intravenous push was highly acceptable by the nurses as the prefilled syringes tremendously reduced nurses’ workload.
The scope of the study was to establish intravenous push medication practices in the hospital; however, determining the clinical impact of intravenous push compared with intravenous intermittent was not determined. However, simulation studies of the intravenous push of different antibiotics have shown to achieve similar results as intermittent infusion.23 Another limitation was that the RTA syringes were prepared for adults only, paediatric patients were excluded from it.
Conclusion
Medication administration plays a vital role in the treatment of the disease particularly intravenous. Intravenous medications are prone to medication errors; therefore, extensive care should be taken in their preparation in terms of dilution, stability and compatibility. Nurses are the forefront health professionals for medication administration; however, they lack the time and resources to ensure the complete safety of intravenous medication. RTA of drugs not only reduces nurse workload but also helps reduce the risk of medication errors. Pharmacists suited to education and training can play a vital role in RTA medication. Our study has shown that intravenous push medications supplied as RTA by the pharmacy not only improve the delivery system but also reduce nursing time in preparation. Our study has also shown the pathways to establishing intravenous infusion services and the role of the pharmacist in developing RTA intravenous push in terms of dilution, stability and education. A Dutch study estimated that RTA syringes prepared in the pharmacy have the potential to save around US$342 million on the national level.20 Hence, it is recommended that national guidelines should be prepared to benefit from these services.
Ethics statements
Patient consent for publication
Acknowledgments
I would like to acknowledge the team of pharmacy staff for their support in establishing the services.
Footnotes
Contributors MA conceptualised and supervised the project and wrote the manuscript. AD and SH collected the data and reviewed the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.