COMMENT
Infusion pumps: constantly evolving
An evolving technology The volumetric infusion pumps such as those produced by Baxter, Fresenius and Hospira can be bulky, need to be on an infusion stand, and can only deliver rates from 0.1 ml/minute to 999 ml/hour. Syringe drivers, which can give controlled infusion rates of 0.1 ml/minute, deliver patient-controlled analgesia (PCA) or supportive care for control of nausea, vomiting and pain. These are the pumps most medical/ nursing staff are familiar with and are routinely used in the hospital setting. Many thousands of infusion devices are now in use in hospitals and in the community. Developments in infusion technology have seen pumps being made smaller and therefore more portable, able to be easily stacked (e.g. Fresenius Agilia®), and also enabling more than one infusion to be given at the same time via the same pump (e.g. Baxter Colleague Triple Channel CXE Pump v1.7), so instead of three pumps, or Alaris MedSystem® III, only one pump needs to be used.
Ambulatory infusion pumps Complex high-dose chemotherapy regimens requiring more than once-a-day dosing and subsequent supportive care, either of the chemotherapy drug itself or of supportive medication, have until recent years routinely been given in the inpatient setting, requiring many patients to travel long distances to receive chemotherapy and be away from home on repeated occasions (NHS England, 2013). The development of the ambulatory infusion smart pump has enabled these complex regimens for some patients to be given in the outpatient or hotel setting (Sive et al, 2012; Newton and Ingram, 2014). Ambulatory infusion pumps such as the
S6
CADD® Solis VIP have enabled more complex regimens to be delivered out of hospital. The pump is relatively small and can be used either with a cassette pre-filled via pharmacy with the chemotherapy drug required, or to infuse fluids. The pump has many functions, which include continuous delivery, intermittent delivery, step delivery, tapered delivery or PCA (Smiths Medical, 2010). These pumps are designed to be tamper-proof for patients, and they combine ‘smart technology’. Smart technology means that the chemotherapy regimens can be made into a therapy-based protocol library, which is pre-loaded into the pump via connection to a computer—this reduces user error, as the user can select the regimen to be given, and the pump will infuse according to this information.
Backpacks and patient mobility Two pumps can be used at the same time: one with intravenous fluids to ensure patients remain well-hydrated, particularly when nephrotoxic chemotherapy drugs are being infused, or to maintain line patency during intermittent delivery while the chemotherapy is given via the second pump. These pumps can be worn in a backpack, which come in different sizes, enabling full mobility for the patient. In the unit where I work, we have begun exploring the use of ambulatory pumps with backpacks and developing protocols for ambulatory care, which have been well-received by the patients who have used them. Similar infusion pumps are also produced by Hospira and Sapphire™.
Mortality and morbidity risk There is, however, a mortality and morbidity risk associated with the use of infusion pumps. Between 2005 and 2010, the Medicines & Healthcare products Regulatory Agency (MHRA) investigated 1085 incidents in the UK alone involving infusion pumps (MHRA, 2013). User error was found to be the most significant contributing factor. In 2004, the National Patient Safety Agency (NPSA) issued a safety alert relating to the management and use of infusion pumps (NPSA, 2004). The MHRA document, Managing Medical Devices, first published in 2006 and updated in 2015, details the responsibilities of institutions in reducing error and managing devices. It includes procurement, risk assessment, development of policies, staff training, maintenance, and ensuring that safety warnings have been acted on.
Reducing the risk of errors With all this new technology in infusion pumps, it is essential that all nursing and medical personnel involved in their use are properly trained and competent in using them. In an effort to reduce further the risk of drug/ infusion errors, smart pump technology has been evolving since its introduction in the late 1990s, using dose-error-reduction software and drug-infusion libraries. Newer pumps on the market are wirelessly linked to hospital dispensing systems and incorporate the use of barcode technology. The pumps have infusion libraries and automatic alerts, which prevent staff from programming them incorrectly. These are being introduced into healthcare systems, particularly in the USA, and are similar to the barcode systems now in use for blood and blood-product transfusions.
Barcodes: the future of infusions? In the future, we may well be giving all infusions using a barcode scanner, ensuring that the five rights of drug administration are maintained (the right patient, the right drug, the right dose, the right route, and the right time). The progress of infusion-device standardisation in the UK is quite high, but the use of dose-error-reduction software BJN remains low (Iacovides et al, 2015). Conflict of interest: none Iacovides I, Blandford A, Cox A, Franklin BD, Lee P,Vincent CJ (2015) Infusion device standardisation and dose error reduction software. Br J Nurs 23 Suppl 14: S16–24. doi: 10.12968/bjon.2014.23.Sup14.S16 Medicines & Healthcare products Regulatory Agency (2015) Managing Medical Devices. Guidance for healthcare and social services organisations. http://tinyurl.com/opnhehm (accessed 11 May 2015) NHS England (2013) NHS Standard Contract for Cancer Chemotherapy (Adult) http://tinyurl.com/k4oejef (accessed 11 May 2015) National Patient Safety Agency (2004) Safer practice notice 01: Improving infusion device safety. http://tinyurl.com/k8jalma (accessed 11 May 2015) Newton C, Ingram B (2014) Ambulatory chemotherapy for teenagers and young adults. Br J Nurs 23(4): S36, S38–42 Sive J, Ardeshna KM, Cheesman S, et al (2012) Hotel based ambulatory care for complex cancer patients: a review of the University College London Hospitals experience. Leuk Lymphoma 53(12): 2397–404. doi: 10.3109/10428194.2012.694430 Smiths Medical (2010) CADD®–Solis Ambulatory Infusion Pump Operator’s Manual, Model 2120. Smiths Medical MD Inc, St Paul. http://tinyurl.com/o8q4ysj (accessed 11 May 2015)
Nikki McKeag
Lead Nurse Blood and Marrow Transplantation, University Hospital Southampton NHS Foundation Trust
© 2015 MA Healthcare Ltd
I
nfusion pumps have revolutionised the way chemotherapy is given, enabling very complex high-dose intravenous chemotherapy regimens to be developed and delivered to patients. The first commercially available infusion pumps were developed in the 1960s and made modern infusion therapy possible. Nowadays, there is a huge variety of infusion pumps, including volumetric and syringe drivers, and more recently ambulatory infusion pumps, manufactured by a large number of companies (e.g. Alaris, Arcomedical, Baxter, BBraun, CME, Fresenius, Hospira and Smiths/Graseby).
British Journal of Nursing, 2015 (Oncology Supplement), Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
Infusion pumps: constantly evolving
An evolving technology The volumetric infusion pumps such as those produced by Baxter, Fresenius and Hospira can be bulky, need to be on an infusion stand, and can only deliver rates from 0.1 ml/minute to 999 ml/hour. Syringe drivers, which can give controlled infusion rates of 0.1 ml/minute, deliver patient-controlled analgesia (PCA) or supportive care for control of nausea, vomiting and pain. These are the pumps most medical/ nursing staff are familiar with and are routinely used in the hospital setting. Many thousands of infusion devices are now in use in hospitals and in the community. Developments in infusion technology have seen pumps being made smaller and therefore more portable, able to be easily stacked (e.g. Fresenius Agilia®), and also enabling more than one infusion to be given at the same time via the same pump (e.g. Baxter Colleague Triple Channel CXE Pump v1.7), so instead of three pumps, or Alaris MedSystem® III, only one pump needs to be used.
Ambulatory infusion pumps Complex high-dose chemotherapy regimens requiring more than once-a-day dosing and subsequent supportive care, either of the chemotherapy drug itself or of supportive medication, have until recent years routinely been given in the inpatient setting, requiring many patients to travel long distances to receive chemotherapy and be away from home on repeated occasions (NHS England, 2013). The development of the ambulatory infusion smart pump has enabled these complex regimens for some patients to be given in the outpatient or hotel setting (Sive et al, 2012; Newton and Ingram, 2014). Ambulatory infusion pumps such as the
S6
CADD® Solis VIP have enabled more complex regimens to be delivered out of hospital. The pump is relatively small and can be used either with a cassette pre-filled via pharmacy with the chemotherapy drug required, or to infuse fluids. The pump has many functions, which include continuous delivery, intermittent delivery, step delivery, tapered delivery or PCA (Smiths Medical, 2010). These pumps are designed to be tamper-proof for patients, and they combine ‘smart technology’. Smart technology means that the chemotherapy regimens can be made into a therapy-based protocol library, which is pre-loaded into the pump via connection to a computer—this reduces user error, as the user can select the regimen to be given, and the pump will infuse according to this information.
Backpacks and patient mobility Two pumps can be used at the same time: one with intravenous fluids to ensure patients remain well-hydrated, particularly when nephrotoxic chemotherapy drugs are being infused, or to maintain line patency during intermittent delivery while the chemotherapy is given via the second pump. These pumps can be worn in a backpack, which come in different sizes, enabling full mobility for the patient. In the unit where I work, we have begun exploring the use of ambulatory pumps with backpacks and developing protocols for ambulatory care, which have been well-received by the patients who have used them. Similar infusion pumps are also produced by Hospira and Sapphire™.
Mortality and morbidity risk There is, however, a mortality and morbidity risk associated with the use of infusion pumps. Between 2005 and 2010, the Medicines & Healthcare products Regulatory Agency (MHRA) investigated 1085 incidents in the UK alone involving infusion pumps (MHRA, 2013). User error was found to be the most significant contributing factor. In 2004, the National Patient Safety Agency (NPSA) issued a safety alert relating to the management and use of infusion pumps (NPSA, 2004). The MHRA document, Managing Medical Devices, first published in 2006 and updated in 2015, details the responsibilities of institutions in reducing error and managing devices. It includes procurement, risk assessment, development of policies, staff training, maintenance, and ensuring that safety warnings have been acted on.
Reducing the risk of errors With all this new technology in infusion pumps, it is essential that all nursing and medical personnel involved in their use are properly trained and competent in using them. In an effort to reduce further the risk of drug/ infusion errors, smart pump technology has been evolving since its introduction in the late 1990s, using dose-error-reduction software and drug-infusion libraries. Newer pumps on the market are wirelessly linked to hospital dispensing systems and incorporate the use of barcode technology. The pumps have infusion libraries and automatic alerts, which prevent staff from programming them incorrectly. These are being introduced into healthcare systems, particularly in the USA, and are similar to the barcode systems now in use for blood and blood-product transfusions.
Barcodes: the future of infusions? In the future, we may well be giving all infusions using a barcode scanner, ensuring that the five rights of drug administration are maintained (the right patient, the right drug, the right dose, the right route, and the right time). The progress of infusion-device standardisation in the UK is quite high, but the use of dose-error-reduction software BJN remains low (Iacovides et al, 2015). Conflict of interest: none Iacovides I, Blandford A, Cox A, Franklin BD, Lee P,Vincent CJ (2015) Infusion device standardisation and dose error reduction software. Br J Nurs 23 Suppl 14: S16–24. doi: 10.12968/bjon.2014.23.Sup14.S16 Medicines & Healthcare products Regulatory Agency (2015) Managing Medical Devices. Guidance for healthcare and social services organisations. http://tinyurl.com/opnhehm (accessed 11 May 2015) NHS England (2013) NHS Standard Contract for Cancer Chemotherapy (Adult) http://tinyurl.com/k4oejef (accessed 11 May 2015) National Patient Safety Agency (2004) Safer practice notice 01: Improving infusion device safety. http://tinyurl.com/k8jalma (accessed 11 May 2015) Newton C, Ingram B (2014) Ambulatory chemotherapy for teenagers and young adults. Br J Nurs 23(4): S36, S38–42 Sive J, Ardeshna KM, Cheesman S, et al (2012) Hotel based ambulatory care for complex cancer patients: a review of the University College London Hospitals experience. Leuk Lymphoma 53(12): 2397–404. doi: 10.3109/10428194.2012.694430 Smiths Medical (2010) CADD®–Solis Ambulatory Infusion Pump Operator’s Manual, Model 2120. Smiths Medical MD Inc, St Paul. http://tinyurl.com/o8q4ysj (accessed 11 May 2015)
Nikki McKeag
Lead Nurse Blood and Marrow Transplantation, University Hospital Southampton NHS Foundation Trust
© 2015 MA Healthcare Ltd
I
nfusion pumps have revolutionised the way chemotherapy is given, enabling very complex high-dose intravenous chemotherapy regimens to be developed and delivered to patients. The first commercially available infusion pumps were developed in the 1960s and made modern infusion therapy possible. Nowadays, there is a huge variety of infusion pumps, including volumetric and syringe drivers, and more recently ambulatory infusion pumps, manufactured by a large number of companies (e.g. Alaris, Arcomedical, Baxter, BBraun, CME, Fresenius, Hospira and Smiths/Graseby).
British Journal of Nursing, 2015 (Oncology Supplement), Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
