Planning for Anticipated Shortage of Smart Infusion Pumps and Dedicated Administration Sets
With the significant increase in the number of critically ill patients admitted to hospitals due to the coronavirus (COVID-19) pandemic, some organizations are already experiencing unprecedented shortages of smart infusion pumps and dedicated administration sets, while others are still anticipating such shortages. The following information is intended to support organizations that are considering various alternatives, including gravity flow of infusions, and careful allocation of smart infusion pumps for intravenous (IV) drug delivery for the patients most in need. Many of these alternatives might be unfamiliar to current staff, so the availability of just-in-time education and instruction manuals is key to avoid misuse.
Identify medications requiring smart pumps. The first step to smart infusion pump and administration set conservation is for hospitals to develop a list of medications that absolutely require delivery via smart infusion pumps, with an understanding that those not on the list may be administered using alternative means, if necessary, as described below. Medications to include on the list should be identified carefully by considering those on the ISMP List of High-Alert Medications in Acute Care Settings, and those on the organization’s list of high-alert medications. The list will likely include at least IV infusions of vasopressors, antiarrhythmic agents, opioids, sedation and anesthetic agents, neuromuscular blocking agents, antithrombotics, and insulin. When developing the list of infusions that require administration via a smart infusion pump, also consider patient criteria, such as age, severity of illness, and comorbidities; infusion rate criteria, such as very low infusion rates; and vascular access criteria (e.g., central lines).
Take inventory of all available pumps. In addition to smart infusion pumps used in typical patient care units, some pumps may be located “off the beaten path,” both on- and off-site, in settings such as interventional radiology, perioperative areas, ambulatory care/procedural areas, and surgery centers. Don’t forget to take inventory of syringe pumps, including those unused in anesthesia supplies due to postponement of elective procedures. Syringe pumps might be used to administer small volume medications; however, clinical staff may require training if unfamiliar with syringe pumps, some of which require the use of validated syringes and volumes, as well as specific processes for priming administration sets. Some facilities may still have older, general purpose pumps without a drug library, particularly in outpatient locations, that may be considered for use. If it is necessary to obtain additional pumps, it is best to buy or rent the same models currently used; however, pumps from other manufacturers might need to be considered, along with plans to limit the locations where the different pumps are used. Biomedical staff should be consulted if introducing pumps that are not already in mainstream use (e.g., for calibration prior to use), and instruction manuals should be available for all pumps in use on a shared online site for easy access by staff.
IV to oral (or IM) conversion. Organizations should switch patients from IV to oral therapies as soon as possible. This should be considered for all appropriate patients who can swallow and meet other facility-defined criteria (e.g., no fever), including patients in the emergency department (ED) and long-term care facilities associated with the health system. If oral administration is not possible, another option might be intramuscular (IM) injections instead of IV administration for certain medications.
Use IV push instead of infusions. Administering medications via IV push instead of as a secondary infusion should also be considered when appropriate. Hospital-specific IV push guidelines, along with the ISMP Safe Practice Guidelines for Adult IV Push Medications, should be consulted before considering this alternative. To support IV push administration, prefilled and/or ready-to-administer syringes of medications should be dispensed whenever possible; nurses should dilute the syringe contents only when necessary according to hospital policy or the product labeling. Also, it would be helpful for pharmacy staff to indicate how fast to administer the drug (e.g., “give over 3 minutes”) on the pharmacy label (if space permits) and on the medication administration record (MAR). Those administering IV push medications should also be cautioned about inadvertent bolus injections when flushing the line, particularly with extension sets or when the port closest to the patient cannot be used for IV push administration. The timing of actual medication administration to the patient must be considered when administering IV push medications through extension sets.
Administration set change policy. Another item that should be reviewed is the hospital’s current administration set change policy. The Infusion Nurses Society (INS) Frequently Asked Questions Related to COVID-19 Health Care Challenges notes that, primary and secondary administration sets used for continuous infusions (other than lipids, blood, or blood products) should be changed no more frequently than every 96 hours. According to the Centers for Disease Control and Prevention (CDC), this may be extended, as long as the administration set is changed at least every 7 days. However, tubing used to administer propofol infusions should be replaced every 6 or 12 hours, when the vial is changed, per the manufacturer’s recommendation. Extension sets are “add-on devices,” so precautions must be taken to limit the potential for contamination and misconnection.
Potential role for gravity infusions. Readers may recall a time when IV medications and solutions were administered by gravity infusion. With an anticipated infusion pump shortage, it is now time to again consider gravity administration of certain infusions. Examples may include IV hydration, some IV antibiotics, medications that are not high-alert, and others that might be appropriate for gravity infusion upon assessment during the ordering and dispensing process. To gauge the rate of flow in mL/hour for gravity infusions, it is necessary to know how many drops per mL the administration set delivers (e.g., 10, 15, 20, 60 drops per mL). The number of drops delivered is controlled by the roller clamp (gravity flow control clamp). In last week’s newsletter, a Table from B. Braun was included to help nurses count the number of drops of fluid needed for the required flow rate (mL/hour) using sets delivering varying drops per mL. This same Table can be viewed by clicking here.
Tubing with integrated dial-calibrated IV flow rate regulators (e.g., RATE FLOW regulator, DIAL-A-FLOW) can be used to regulate the flow rate instead of the roller clamp. Add-on regulators are also available. Although these devices make it easier to set the flow rate by dialing the mL/hour, they are only marginally more accurate, providing just an estimate of the flow rate based on compression of the tubing. Even when these flow regulators are used, staff still need to count the number of drops and adjust the flow rate as necessary.
A time tape should be affixed along the vertical edge of the infusion bag to assist in visual checking of the total volume infused at a given time. Practitioners should be reminded that gravity flow rates may be influenced by a number of factors, including the bag height, type of IV access, position of the patient’s arm, and length of the tubing.
Subcutaneous infusions. Subcutaneous gravity infusions may be an option for parenteral delivery of medications and solutions for some patients. This is mainly appropriate for hydration in locations such as the ED, urgent care, long-term care, and other non-acute care settings where patients do not require rapid fluid administration in large amounts. Subcutaneous infusions may be considered for certain drug infusions, such as potassium chloride replacement administered in hydration fluids. Up to 3,000 mL per day (1 mL per minute via two administration sites) has been given using this technique, also known as hypodermoclysis (Humphrey P. Hypodermoclysis: an alternative to i.v. infusion therapy. Nursing 2011. 2011;41:16-7). The upper arms, chest, abdomen, and thighs have been used as sites. Hyaluronidase can be used in conjunction with this method, given locally or via a Y-connector, to increase the rate of absorption from subcutaneous tissue. Subcutaneous infusions are contraindicated in patients at increased risk of pulmonary congestion or edema, and in patients with clotting disorders.
Other alternatives. Other alternative types of infusion devices should be considered during infusion pump shortages, such as volumetric burette tubing (e.g., BURETROL, SOLUSET), elastomeric devices, and other non-electronic rate controllers.
ISMP greatly appreciates the support of Shawn O’Connell, RN, MS, Director, Medical Affairs, from the B. Braun Corporation, for outlining and assisting in the development of this article.