AN INTEGRATED APPROACH TO PRIORITIZE EFFECTIVE AND SAFE

ALTERNATIVE INFUSION METHODS TO VOLUMETRIC INFUSION PUMPS AT CSSS DU LAC-DES-DEUX-MONTAGNES

Gnahoua Zoabli, P.Eng., M.Eng., Ph.D.Chief of biomedical engineering depertment

CSSS Du Lac-Des-Deux-Montagnes

www.zoabli.com

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1Collaborators

Sylvain Marcil1, Liane Rouiller1, Nathalie Bigras1, Chantale Séguin1, Nancy Chabot1, France Granger1, Arielle Katia M. Bada2,

and Lucie Dugré1

1CSSS du Lac-des-Deux-Montagnes; 2École Polytechnique de Montréal

OVERVIEWI. Summary of the problemII. MethodologyIII. ResultsIV. DiscussionV. Conclusion

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Service du génie biomédical

Développements en cours – Plan stratégique 2010-2015

• Agrandissement du Bloc endoscopique (C)

• Agrandissement de l’ urgence (E)• 35 civières• 4 salles de choc

• Nouvelle Unité d’ophtalmologie (A)

• Médecine nucléaire (M)

• Nouveau Centre de télénéphrologie (M)

• Nouveau Centre d’hémato-oncologie (M)

361 lits de courte durée74+192 lits en hébergement2 316 employés, employées, 22 pharmaciens 257 médecins180 bénévoles

moncsss.com

PROBLEMATICI. Issues regarding current models of volumetric pumps

- software francization of their new model- compliance to Health Canada - availability estimated in 2015

(no replacement, no new purchase)

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OBJECTIVEFind a contingency plan allowing CSSS LDDM to maintain an optimal intravenous therapy care to patients during this period.

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1• (Need to )know actual clinical use of volumetric pumps

2• Consult the Guide for IV administration with associated clinical surveillance

(GIVACS)

3•(From the GIVACS) identify the medications absolutely requiring a volumetric pump;

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• (From the GIVACS) identify drugs that can be safely administrated with other technological methods (gravity, mini-infusion pump, syringe pump, ambulatory pump, patient controlled administration, injection);

5• Consult the collective directive for the installation of an injection plug if the

solute is prescribed in keep vein open (KVO) infusion mode;

6• With a team of seven individuals, inventory of our park of volumetric pumps

in 30 min (consider the mobility of these devices);

7• Prepare a consultation platform of the care units to determine their

effective infusion practice;

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METHODOLOGY

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• Collect data from these care units with the platform to get an idea of the current medications administration practice and to identify the gaps with the GIVACS;

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• From the information gathered, identify in accordance with the pharmacy and the concerned nursing units, how many volumetric pumps are used instead of the proper infusion technique, according to the GIVACS instructions;

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• Based on the number and frequency of medications used on each unit with volumetric pumps, calculate a weighted Pump/Medication ratio to take into consideration the actualized need of volumetric pumps on each nursing unit;

11• This ratio will help determine for the two-year period, if there are Too

many, Acceptable or Less pumps on the unit;

12• Submit a report of our consultations to a Multidisciplinary Committee

composed of clinical and medical directorates, and purchasing services.

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METHODOLOGY (CONT’D)

SOME ILLUSTRATIONS

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CONSULTATION OF THE MEDICATION ADMINISTRATION GUIDE

The medication administration guide is developed by the pharmacy to associate each drug to be administered by IV to the suitable infusion technique.

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Name Administrationmode

Side Effects

MEDICATION SURVEY QUESTIONNAIRE/ UNIT

Référence Nom générique Nom commercial Mode d'administration recommandéAdministré dans

cette unité de soinsAussi administrée par pompe volumétrique

Fréquence d'utilisation

M1 Ampicilline Ampicin ®Via mini-perfuseur: diluer ad 10 mL

avec NS

M2 Calcium gluconateCalcium

gluconate

> 1 g : 1,5-3 mL/min d’une solution à 10% ou via mini-perfuseur: compléter

ad 20 mL avec NS.

OUI

NON

OUI

NON

Frequent Moyen Rare

Frequent Moyen Rare

NON

OUI

NON

OUI

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Recommended

mode

is not

Volumetric pump

Actually used with

Volumetric pump ?

How often ?

Mini-infusion pump is

recommended

RESULTS

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INVENTORY OF THE VOLUMETRIC PUMPSMay 21, 2013 from 2:00 PM to 2:30 PM

27 volumetric pumps missing

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Department #

single channel

#double

channels

#triple

channels

#single

channel

#double

channels

#triple

channels

# being repaired

OR 4 1 5CLINI-AMBU 1

CLSC-MIRABEL 1MED-1C 9 1 10 1MED-1E 10 2 9 1MED-2C 5 8MED-2E 7 6 1MED-3C 19 5 1MED-3E 11 1 1 10 1

PEDIATRICS 4 4 1ICU 6 14 6 16 1

STERIL 1 1BIRTHING 8 2 7 2

ER 22 2 4 8 2 3DAY-MED 2 3 1

110 5 24 81 0 20 11

139 112

THEORETICAL REPARTITION ACCORDING TO BIOMED

INVENTORY

TOTAL

SURVEYVolumetric

pumps

ACTUAL # OF VOLUMETRIC PUMPS(May 21, 2013, 2:00 PM to 2:20 PM)

Actual Usage on Units

Care UnitNuimber of

drugs

Drugs by volumetric pump (%)

How often (%)

Drugs by volumetric pump (%)

How often (%)

Drugs by volumetric pump (%)

How often (%)

Number of drugs by

volumetric pump

How often (%)

MED-1E 3 12% 67% 5% 67% N/A 100% 0 100%

MED-1C 4 16% 75% 0% 100% N/A 100% 9 89%

MED-2E 4 16% 50% 24% 78% N/A 100% 5 87%

BIRTHING 4 16% 33% 7% 67% 100% 67% 2 100%

MED-3C &MED-3E

5 20% 60% 26% 56% N/A 100% 8 96%

MED-2C (Infection Control Unit)

7 28% 57% 18% 67% 100% 33% 3 67%

PEDIATRICS 7 28% 24% 100% 67% N/A 100% 0 100%

OR 18 72% 35% 12% 33% 100% 33% 3 78%

ICU 21 84% 68% 9% 83% 100% 33% 0 100%

ER - - - - - - - - -DAY-MED - - - - - - - - -

CLINI-AMBU - - - - - - - - -CLSC-MIRABEL - - - - - - - - -

STERIL - - - - - - - - -

RECOMMENDED PERFUSION TECHNIQUE IS

Volumetric Pump Mini-infuser Seringe Pump Gravity

OUR CURRENT PRACTICE IN IV THERAPY

Drugs administered by Volumetric

pumps are mainly used in

critical care units.

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IV TECHNOLOGY SELECTIONDECISION TREE

• In collaboration with the managers of medical care units and pharmacy, a decision tree has been developed Va

ncou

ver,

May

21-

23, 2

014

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• Objective: To determine the recommended infusion technology

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End

Gravity

Syringe Pump(60 ml et moins)

Clinical judgment(medical history)

?

IV TechnologySelection Decision Tree

Mini-Infuser

Solute +

Additive (drug)

Volumetric Pump

Basic solute without additive

Antibiotic

Analgesic, Sedative, Painkiller, Additive

NoNo

YesYes

PCA PumpAmbulatory Pump

Antibiotic > 60 ml

YesYes

NoNo

Baxter Colleague CADD-Legacy PLUS CADD-Solis VIP

Medfusion 3500 / 4000ESP Excelsior

Secondary

Perfusion

(Piggyback)

YesYes

YesYes

Solute Bag

15.7 – 77.5 ml/hr 5 - 60 ml ±3% 0.03 -300 ml/hr 60 ml ±2%

0.1 - 125 ml/hr 9 999 ml ±6% 0.1 - 500 ml/hr 0.1 - 500 ml ±6%0.1 - 1200 ml/hr 0.1 – 9 999 ml ±5%

(0.1 – 500 ml/hr Piggyback)

(Variable)250 ml/hr 50 – 4000 ml

±15% à ±20%

Consult the GIVACS

Installation of an injection plug if the solute is prescribed in KVO

WEIGHTED PUMP/MEDICATION RATIO

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# Drugs by Volumetric Pump

Total # of Channels

Weighted Pump/Medication

Ratio

More Pumps needed?

(Clin. Manager Opinion)OR 18 5 0.3 Less Pumps

PEDIATRICS 7 5 0.7 Less Pumps

MED.2C 7 8 1.1 Just Acceptable-

MED.2E 4 7 1.8 Acceptable

ICU 21 56 2.7 Just Acceptable+

MED. 1E 4 11 2.8 Acceptable

BIRTHING 4 13 3.3 AcceptableMED.SURG 3 10 3.3 AcceptableMED.3C+3E 5 6 3.4 Acceptable

ER - - -DAY MED - - -

CLINI-AMBU - - -CLSC-MIRABEL - - -

STERIL - - -

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Too

Man

yPu

mps

Less

Pum

psAc

cept

able

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

WEIGHTED PUMP/MEDICATION RATIO

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• Improved collaboration between units regarding volumetric pumps

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• Some counter-effects between OR and MED-SURG.

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• Revised complementary need according to the decision tree and the actual needs for volumetric pumps

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DISCUSSION

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• Solute drop calculation is forgotten provide drops calculation strips and support the nursing personnel to master the bases of gravity infusion practice

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• Medical history of patient is risky renal failure, cardiac history, chronic obstructive pulmonary disease, degenerative disease, etc.

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• Reduced Nurse-to-patient ration during night shift.

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MAIN REASONS OF VOLUMETRIC PUMPS OVERUSE

ADDITIONAL NEEDS FOR VOLUMETRIC PUMPS(April 1, 2014)

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May 21, 2013

1• This study brought together all local expertise in intravenous therapy to

establish a contingency plan based on current best practices in IV therapy

2• The decision tree is planned to be part of the continuing education of nurses

to maintain IV best practices standards at CSSS LDDM

4• Another CSSS which benefited from our approach has told us about its

successful application

5• We share our experience, hoping it will help to better manage the two-year

waiting in other Quebec CSSS and hospitals across Canada

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• The success of this approach requires that any volumetric pump transferred with a patient to another care unit will return to its original unit. This remains a perpetual challenge with infusion pumps in any hospital.

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CONCLUSION

• We thank the following members of the multidisciplinary team and managers whose involvement has led to develop the decision tree for IV therapy at CSSS LDDM. • Medical units

• Michelle Dufour, Jacob Lalanne, and Nathalie Comtois• Surgery

• Mélissa Pagé, and Jocelyne Sanscartier• Counselors in nursing

• Chantal Laperriere, and Dany Maheux.

• Their contribution has helped make more realistic the application of this IV therapy decision tree, facilitating thus its clinical acceptability.

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ACKNOWLEDGMENTS

QUESTIONS ?

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