Chinese centralised intravenous admixture service (CIVAS), an emerging pharmaceutical industry: survey of the recent advances of CIVAS in China

Long-term stability of esketamine in polypropylene syringes at 5 ± 3°C

OBJECTIVE

Esketamine (Vesierra) is a molecule, used alone or in combination, to induce and maintain general anaesthesia and to relieve pain in emergency medicine. The aim of this study is to evaluate the long-term physicochemical stability of a 1 mg/mL solution of esketamine diluted in 0.9% sodium chloride (NaCl) and stored in polypropylene syringes at 5±3°C during 65 days (64+1 day at 22±3°C) and 72 hours at 22±3°C (room temperature), in order to centralise preparation under aseptic conditions in hospital pharmacy.

METHODS

Ten syringes were prepared under aseptic conditions. Five syringes were stored at 22±3°C for 3 days, and the five others were stored at 5±3°C for 64 days (+ 1 day at room temperature). The stability was periodically investigated. Particle appearance or colour changes were checked by visual inspection. A research of crystals was performed under the microscope. pH was followed to assess its stability. The turbidity of the solutions was estimated by a measure of optical densities at 350, 410 and 550 nm. The molecule concentrations were measured by ultra-high performance liquid chromatography (UHPLC) coupled with a photodiode array detection (PDA), using a newly developed method.

RESULTS

Based on microscopic examination, no crystals were observed, during the observation period. pH and absorbances at 350, 410 and 550 nm were also stable. Macroscopically, there was no change in colour and appearance of opacity, turbidity or precipitation. Statistical analysis indicates that 1 mg/mL esketamine solutions were chemically stable under these conditions, given that less than 5% of the solutions have lost more than 10% of their initial content during the study based on the prediction interval.

CONCLUSIONS

One mg/mL solutions of esketamine hydrochloride are physically and chemically stable after production, for at least 72 hours at 22±3°C and 64 days at 5±3°C (+ 1 day at room temperature).

Intelligent supervision of PIVAS drug dispensing based on image recognition technology

Pharmacy Intravenous Admixture Services (PIVAS) are places dedicated to the centralized dispensing of intravenous drugs, usually managed and operated by professional pharmacists and pharmacy technicians, and are an integral part of modern healthcare. However, the workflow of PIVAS has some problems, such as low efficiency and error-prone. This study aims to improve the efficiency of drug dispensing, reduce the rate of manual misjudgment, and minimize drug errors by conducting an in-depth study of the entire workflow of PIVAS and applying image recognition technology to the drug checking and dispensing process. Firstly, through experimental comparison, a target detection model suitable for drug category recognition is selected in the drug-checking process of PIVAS, and it is improved to improve the recognition accuracy and speed of intravenous drug categories. Secondly, a corner detection model for drug dosage recognition was studied in the drug dispensing stage to further increase drug dispensing accuracy. Then the PIVAS drug category recognition system and PIVAS drug dosage recognition system were designed and implemented.

Statistical analysis of the storage time of finished product infusion

OBJECTIVE

This retrospective study determined the storage time of finished infusion in each hospital ward and assessed whether the storage time of finished infusion was within an acceptable range.

METHODS

The research object was the finished infusion (one bag of infusion with only one drug) that is centrally dosed at the Pharmacy Intravenous Admixture Service (PIVAS) of Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences. We used an automatic scanner to assess the placement time of finished infusion products in various wards of the hospital. We classified the drugs used in various wards, analyzed whether their placement times were reasonable, assessed the reasons for unreasonable placement times, and took intervention measures. Similarly, the storage time of finished infusion was deemed reasonable or unreasonable, the reasons for unreasonable storage times were analyzed, and intervention measures were taken.

RESULTS

In September 2021, the proportion of infusions stored for an unreasonable time was 12.69%, a decrease of 5.37% compared with August 2021, indicating the effectiveness of intervention measures.

CONCLUSION

By using statistical analysis and intervention measures, our PIVAS improved the standardized use of finished infusion products and ensured the safety of medication for patients.

Real-world study of the leakage of two types of infusion bags in multicenter pharmacy intravenous admixture service (PIVAS)

Background: This study sought to analyze the leakage rate, economic loss caused by leakage, leakage reasons, and usage of upright polypropylene infusion bags and non-polyvinyl chloride (PVC) infusion bags, two types of closed intravenous infusion containers used in pharmacy intravenous admixture service (PIVAS), to improve the product quality of drug infusion packaging materials, reduce drug and clinical economic losses, and reduce the safety hazards of medication. Method: A real-world study was used to collect statistics for these infusion containers. The study was conducted in 21 hospitals in China from September to December 2022. Upright polypropylene infusion bags or non-PVC infusion bags in PIVAS of these 21 hospitals were chosen as the research material. Results: In total, 2,349,899 upright polypropylene infusion bags and 3,301,722 non-PVC infusion bags were collected. Eleven cases of upright polypropylene infusion bag leakage occurred (with a the leakage rate of 0.05‱), and 394 cases of non-PVC infusion bag leakage occurred (with a leakage rate of 1.19‱). The leakage rate of non-PVC infusion bags was significantly higher than that of upright polypropylene infusion bags (p < 0.01). The main reason for leakage in upright polypropylene infusion bags was sharp objects such as glass fragments or aluminum caps piercing the bag. The main reason for leakage in non-PVC infusion bags was squeezing, stacking, and uneven arrangement that causes folding of edges. For non-PVC bags, additional reasons for leakage included leakage at the nozzle joint, excessive manual or machine throwing force, and excessive dosage. The economic loss of upright polypropylene infusion bags was 1,116.56 CNY. The economic loss of non-PVC infusion bags was 32,210.86 CNY. Conclusion: Based on real-world study data on the leakage of upright polypropylene infusion bags and non-PVC infusion bags in multicenter PIVAS, it can be concluded that the leakage rates of upright polypropylene infusion bags are significantly lower than those of non-PVC infusion bags in PIVAS, and the economic losses due to upright polypropylene infusion bags are lower than those due to non-PVC infusion bags in PIVAS. Therefore, we can infer that upright polypropylene infusion bags are superior to non-PVC infusion bags.

Investigation of the status of depression and anxiety among leaders and staff in pharmacy intravenous admixture services in China

We aimed to investigate the status of depression and anxiety among leaders and staff in pharmacy intravenous admixture services (PIVAS) and analyze influencing factors to provide a reference for improving their mental health status. This study involved a multi-center cross-sectional survey. PIVAS leaders and staff from across China were invited to participate. The Generalized Anxiety Disorder-7 and 9-item Patient Health Questionnaire were used to measure the status of anxiety and depression. A multiple linear regression model was used to analyze influencing factors. In total, 137 PIVAS leaders and 501 staff were included in this study. The results showed that 43.8% (60/137) of the leaders had anxiety and 38.7% (53/137) had depression. Among staff, 47.3% (237/501) had anxiety and 46.5% (233/501) had depression. Multiple linear regression showed that for PIVAS leaders, the degree of recognition by doctors was associated with anxiety scores, whereas PIVAS charge standard, PIVAS profit and loss situation, and the degree of recognition by doctors were associated with depression scores. For PIVAS staff, satisfaction with working in PIVAS was associated with anxiety scores, and job title, working hours per day, and satisfaction with working in PIVAS were associated with depression scores. Depression and anxiety are common among PIVAS leaders and staff working in hospitals in China. Hospitals should implement measures to improve the mental health of PIVAS leaders and staff.

An ultra-high-performance chromatography method to study the long term stability of gemcitabine in dose banding conditions

Gemcitabine is an analogue of cytidine arabinoside, used alone or in combination chemotherapy to treat various type of cancer. The dose-banding of gemcitabine provides the opportunity to anticipate the preparation of this anticancer drug on condition of carrying out stability studies. The aim of this study is to develop and validate a stability-indicating ultra-high-performance Liquid Chromatography (UHPLC) method for measuring the concentration of gemcitabine and to evaluate its stability at standardised rounded doses in polyolefin bags. The UHPLC with photodiode array (PDA) detector method was developed and validated (linearity, precision, accuracy, limits of detection and quantification, robustness and degradation test). Thirty polyolefin bags of gemcitabine (1600 mg/292 ml (n = 10), 1800 mg/297 ml (n = 10) and 2000 mg/303 ml (n = 10)) were prepared under aseptic conditions and stored at 5 ± 3 °C and 23 ± 2 °C for 49 days. Physical stability tests were periodically performed: visual and microscopic inspection and optical densities. The chemical stability was evaluated through pH monitoring and chromatographic assays. The results confirm the stability of Gemcitabine at selected standardised rounded doses of 1600 mg, 1800 mg and 2000 mg in NaCl 0.9% polyolefin bags for at least 49 days at 5 ± 3 °C and 23 ± 2 °C, allowing in-advance preparation.

Application of information-intelligence technologies in pharmacy intravenous admixture services in a Chinese third-class a hospital

Background

Pharmacy intravenous admixture service (PIVAS) center has emerged as an important department of hospital as it can improve occupational protection and ensure the safety and effectiveness of intravenous infusions. However, medication errors were considered to be a significant challenge in PIVAS, so information-intelligence technologies were introduced to optimize the management of PIVAS. Our article summarized the application of information-intelligence technologies in PIVAS of a large third-class A hospital in China, and provided an example for PIVAS in other hospitals at home and abroad.

Methods

Prescription-reviewing rules containing intravenous medications and infusion solution guideline were recorded in the database of prescription-cheking system. Drugs information were recorded in the PIVAS management system with special identification and warning labels to reduce intravenous infusion errors. Automatic labeling device was used to label the infusion bags, and the quality control program database of intelligent compounding robot for cytotoxic drugs was established ingeniously. Automatic sorting devices were applied for the third batch of finished infusion admixtures, and intelligent logistics robots were used to transport the infusion to the ward.

Results

After establishing and implementing of prescription-reviewing rules in the prescription-cheking system database, the number of prescriptions checked by pharmacists increased from 18 to 43 per minute. The success rate of intervention with irrational medical orders increased from 85.89% to 99.06% (P < 0.05). By introducing various intelligent devices, automatic labeling significantly enhanced work efficiency and reduced the error rate (P < 0.001). Furthermore, the use of intelligent intravenous compounding robots significantly reduced the risk of errors (P < 0.001).

Conclusions

The application of information-intelligence technologies in PIVAS can improve work efficiency and reduce error risk. However, some intelligent devices have failed to achieve the expected effect in practical use, and further improvements are needed to meet the demands of PIVAS in the future.

Practical value analysis of nursing risk management in intravenous drug allocation

OBJECTIVE

To explore the practical value of nursing risk management in intravenous drug allocation.

METHODS

A total of 1200 patients who received infusion therapy in our hospital were prospectively selected and divided into an observation group (n=600) and a control group (n=600) using a random number table method. The former was given nursing risk management, while the control group was not. The incidence rate of intravenous infusion errors, the incidence rate of infusion reactions, the scores of near-miss items in pharmacy intravenous admixture services and subjective satisfaction were observed and compared between the two groups.

RESULTS

The incidence of intravenous infusion errors and infusion reactions in the observation group were lower than those in the control group (P<0.05), while the scores of near-miss items in pharmacy intravenous admixture services and subjective satisfaction were higher than those in the control group (P<0.05).

CONCLUSION

Nursing risk management can reduce the incidence of errors in clinical pharmacy intravenous admixture services and the incidence rate of infusion reactions, improve infusion safety, and promote the improvement of the subjective satisfaction of patients.

The impact of pharmacist oriented mode on risk control in a Chinese centralized intravenous admixture service centre

Centralized intravenous admixture service (CIVAS) centres, which are pharmaceutical departments found in Chinese hospitals, provide high-quality intravenous fluids and pharmaceutical services for patients, and errors in their working procedures can lead to adverse consequences. Pharmacists, the primary CIVAS centre personnel, play a role in risk control; however, to date, the effect of pharmacists' participation in risk management has not been reported. The main aim of this study was to evaluate the pharmacist's role in risk control and evaluate its impact. A retrospective observational study was designed to assess the principal working process in the CIVAS centre of a provincial healthcare setting. Errors in the main working process were identified, and intervention measures were formulated. The pharmacist intervention effect was evaluated by assessing the identification rate of improper prescriptions; the incidence rate of drug preparation, compounding, packaging and delivery process errors; and expenditures on wasteful drugs. There was a higher identification rate for improper prescriptions after the intervention (P < 0.05), while the incidence of drug preparation (P < 0.05), admixture (P < 0.05), and packaging and delivery errors (P < 0.01) was significantly lower; the total wasteful medication expenditure was also dramatically reduced. The potential creativity of pharmacists in error control can provide dependable intravenous drugs for patients and reduce the running expenditures for CIVAS.

Construction situation, costs and charges associated with pharmacy intravenous admixture services: multi-center cross-sectional survey based on 137 medical institutions in mainland China

Background

To investigate the construction situation, costs and charges associated with pharmacy intravenous admixture services (PIVAS) to provide references for the construction and development of PIVAS in mainland China.

Methods

A multi-center cross-sectional survey was conducted via a WeChat Group targeting PIVAS leaders in hospitals to investigate the basic situation of PIVAS, including opening time, area, number of PIVAS, equipment, management mode, PIVAS costs and charges, as well as numbers of beds, open wards, and staff, and analyze differences in PIVAS construction at different provincial and hospital levels.

Results

137 questionnaires were collected from 29 provinces, representing a response rate of 99.3%. Most participants (88.4%) were from Level III Hospitals. The number of years of operations of PIVAS ranged from 1 to 22 (median: 6). PIVAS site area ranged between 100 and 1973 m²; daily average infusion volume was concentrated in the ranges 0–1000 bags (29.9%, 41/137) and 1001–2000 bags (26.3%, 36/137). In terms of PIVAS management mode, the vast majority used separate pharmacy management (65.0%, 89/137). Only 52.6% (72/137) of PIVAS have standardized charges, and 70.1% (96/137) operate at a loss. The median costs of mixed tumor chemotherapy drugs, total parenteral nutrition, general medicine, antibiotics were 20, 35, 4 and 5 RMB, respectively. With the exception of a few features, PIVAS construction does not obviously differ among different regions and hospital levels.

Conclusions

In recent years, PIVAS in China has developed rapidly and become relatively large. The main problems are that most provinces lack standards for charges and PIVAS construction differs among hospitals. Therefore, standards for PIVAS construction and charges should be developed to provide a reference for the future development of PIVAS.