free technology with the added advantage of a
significantly wider fluid path. This leads to a much
lower force needed to push/pull syringe plungers
and as a result, can decrease the rate of RSI and
improve productivity.
Despite the obvious values of maintaining
a completely closed system, as much as one-third
of the institutions where the respondents worked
did not use devices that assured a completely closed
system on a regular basis, with the majority pin-
pointing ease-of-use and cost as major bottlenecks
for their implementation.
Syringes are also used to administer some HDs
on the oncology ward, which involves the nurse
sitting beside a patient and slowly pushing a syringe
manually for a number of minutes until all the
drug is administered. However, the participants
discussed new pump technology that can control
the administration of a syringe concurrently with
fluids, which can reduce the potential to cause RSI
at the administration stage while also freeing up the
nurses’ hands and giving them more time to focus
on caring for the patient.
The need to keep
a closed system
between each
step from
beginning to end
was a unanimous
view in the
meeting
Promoting safety and efficiency
In a majority of the institutions to which
respondents are affiliated, pre-compounding
occurred mostly in a ‘clean’ room. Challenges
associated with this particular step included risk of
exposure, compromise of sterility, loss of valuable
time and staff shortage, with 60% of respondents
stating a need for an automated compounding
process at their institutions.
To facilitate efficiency, almost all (90%) the
represented institutions had either a protocol in
place to ensure that drug delivery is conducted
according to the pharmacy order or systems for
tracking medication errors. Interestingly, the
process of documenting infusions was nevertheless
considered to be time-consuming for nurses,
with up to 3 hours spent per day on this. A total
of 60% of respondents further reported that the
infusion pumps used at their units are not currently
connected to pharmacy systems or electronic health
records (EHRs).
Altogether, these results highlight the current
need for new and improved systems and processes
that can increase productivity and reduce safety
hazards.
When an air-in-line alarm occurs, there are
various techniques used to remove the air in the
line, some of which are complex and potentially
dangerous techniques. It can be a challenge to
maintain a closed system and still manage not to
disconnect the line from the patient; moreover, in
some cases, the lines and drugs need to be discarded
as the air cannot be removed.
To ensure a closed system is maintained, it
was generally accepted that there is a need for
a safer and quicker way to remove air without
disconnecting the line from the patient.
Value of closed systems – safety and efficiency
There is no doubting the safety risk posed by HDs
hence the need for standardised protocols that
provide protection from exposure, not just during
the preparation but also the administration of HDs.
4 | 2019 | hospitalpharmacyeurope.com
The
environmental
contamination
was higher with
respect to nurses
relative to
pharmacists and
occurred more in
the day units
compared to the
pharmacy
Prior to the meeting, the attendees took part in
a pre-meeting survey exploring issues around the
benefits of closed systems in terms of promoting
safety and efficiency of HD handling. In total there
were nine respondents (nurses and pharmacists) and
the key outputs of this survey are presented below.
Current handling practices and concerns
Most of the respondents were moderately concerned
about current practices for handling HDs at their
institutions, with pharmacists showing a higher
level of concern and about one-fourth of the
nurses reporting not being concerned at all. The
underlying reasons for these concerns include a lack
of awareness/knowledge of risk, poor adherence to
existing protocols, as well as the unavailability of
adequate equipment, leading to increased risk of
HDs exposure and errors during administration.
All respondents reported that they were aware
of air-in-line alarms happening in their respective
facilities. Nurses reported witnessing disconnection
of lines with HDs when removing air bubbles.
Pharmacists indicated a higher level of concern
about these disconnections than nursing.
Repetitive strain injuries (RSI) were also a
concern and the respondents believed that this had
a negative impact on productivity by increasing
the time needed to prepare HDs for infusion (two
pharmacists and four nurses had this view). These
types of injuries have a significant impact on HCPs
and are hard to diagnose and treat.
The implementation of a completely closed
system implies the use of needle-safe technology.
While most CSTDs that are currently available
do prevent the exposure of the internal needle,
some have incorporated a completely needle-
Advantages of closed systems
There was clear group consensus from the meeting
participants around the safety benefits of having
a fully closed system in place. It was suggested
that if certain parts of the systems implemented
at the different represented hospitals were brought
together, you could almost develop the perfect
closed system from the pharmacy to delivery and
to documentation.
There are a number of benefits associated with
CSTDs and semi-automated compounding systems
including increased safety for clinicians and
patients, improved productivity and efficiency as
well as reduced drug wastage.
To facilitate meeting discussions, some devices*
for HD handling and administration manufactured
by ICU Medical were described. The semi-automated
HD compounding system, Diana 6 allows remote
verification of each preparation by the pharmacist
outside of the clean room and reduces drug errors
by matching drug and patient order through
barcode scanning. The ChemoLock system, 7
a needle-free CSTD for preparation of HDs, can
also be connected to a pump for administration.
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