Is secondary infusion safety practice a challenge in your facility?
If your infusion pumps do not feature a direct secondary connection that can detect whether it is infusing, cannot deliver two medications concurrently, or require a head height differential for secondary infusions, you may have safety issues that your staff may need to compensate for, or constantly monitor.
Automated secondary IV infusion management is defined in the recent Institute for Safe Medication Practices (ISMP) guidelines as, “A smart infusion pump capable of automatic infusion delivery of two different medications or fluids [e.g., plain IV fluid and intermittent IV antibiotic] through the same tubing. This mode ensures that the entire intermittent volume is infused, without the need to adjust the head height of the primary and secondary infusion containers. This mode also detects if the secondary line is clamped.”
These smart pump guidelines recommend: “Use an automated secondary IV infusion management system that is not dependent on head height differential and has the ability to assure secondary flow. In the absence of this technology, at a minimum, organizations should identify particular medications to be administered only as uninterrupted/primary infusions and specifically configure these in the drug library.”
A cassette-based infusion system with a direct connection for the secondary line can help organizations adhere to this guideline and enhance the safety and efficiency of secondary infusion delivery.
The large majority of infusion pumps in use at hospitals today are dependent on a head height differential for secondary infusions. This requires the clinician setting up the infusion to hang the primary bag at a given distance lower than the secondary bag. This manual workflow is required because these pumps rely on gravity to support the preference of delivery from a secondary container.
In contrast, a cassette-based system that leverages a volumetric pumping mechanism is not reliant on gravity. The secondary line connects directly to the cassette, and the secondary infusion is managed separately from the primary. With this type of system, there is no need for head height differential. Infusion bags can be placed where convenient, with no risk of the primary infusing instead of the secondary.
The ability to assure secondary flow is a result of the direct pull of a medication from the secondary infusion bag with a precisely measured push, or administration, to the patient.
Secondary lines on gravity-driven pumps connect to a primary line at a Y-site above the pump. The height differential between the primary and secondary container is required to ensure fluid is sourced from the secondary rather than the primary container. If the differential is insufficient or an occlusion of the source occurs in the secondary line, the pump may begin drawing fluid from the primary bag at the programmed secondary rate. These types of secondary setup errors have been shown to occur in 48% of secondary infusions. The failure to deliver the secondary medication as ordered is a medication error and can also result in additional nurse burden in resolving the problem, addressing the delay, and documenting interruptions.
IV fluids that are not administered as ordered by the physician can have serious negative effects on the patient. A piggyback infusion setup involves pausing the primary solution while the piggybacked secondary solution infuses and resuming the primary solution when the secondary infusion is complete. Doctors may not be aware that hydration infusion orders are paused because of piggyback deliveries. The direct connection of a secondary line to a cassette-based infusion system can allow for concurrent delivery of primary and secondary medications at independent rates, helping to assure that both the primary and secondary are delivered as ordered. Systems without this direct connection cannot do this.
Interoperability between smart infusion pumps and an EHR can create significant safety and efficiency enhancements. This interoperability means documentation of infusion start and stop times can be added into the caregiver’s flowsheet is an automated process. Events are transmitted by the pump, rather than manually documented, and are stored in the flowsheet of the EHR, bringing a high level of trust in the accuracy and integrity of the data recorded.
However, when a pump without assured secondary delivery is used and a secondary setup error occurs, the pump doesn’t recognize the error. The events reported to the EHR by the pump reflect an infusion of the secondary as programmed, rather than what was actually delivered, or not delivered. The error is two-fold—a failure to deliver the medication as ordered and incorrect documentation of the administration.
With automated infusion documentation, the information displayed in the patient’s record is assumed to be accurate and timely. When this documentation does not accurately reflect what the pump actually delivered, clinical decision-making can be impacted. Consider, for instance, a hypothetical care team at a hospital may decide to discharge a patient because their record noted the administration of the final medication required. If there was a secondary setup error and the medication was not infused, the discharge decision is made on inaccurate data.
Advances in interoperability bring benefits as well as unintended consequences. Physical product design must be factored into the hospital’s infusion safety product choice. Utilizing a cassette-based delivery system with direct control of the secondary line might be key to maximizing the impact of an interoperable infusion platform. Accuracy of data can lead to more confident decision-making, stronger documentation of research medications and opportunities for safer patient care.
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