Incidence and Causes of Infusion Alarms in a Neonatal and Pediatric Intensive Care Unit: A Prospective Pilot Study

Determinants of Intravenous Infusion Longevity and Infusion Failure via a Nonlinear Model Analysis of Smart Pump Event Logs: Retrospective Study

BACKGROUND

Infusion failure may have severe consequences for patients receiving critical, short-half-life infusions. Continued interruptions to infusions can lead to subtherapeutic therapy.

OBJECTIVE

This study aims to identify and rank determinants of the longevity of continuous infusions administered through syringe drivers, using nonlinear predictive models. Additionally, this study aims to evaluate key factors influencing infusion longevity and develop and test a model for predicting the likelihood of achieving successful infusion longevity.

METHODS

Data were extracted from the event logs of smart pumps containing information on care profiles, medication types and concentrations, occlusion alarm settings, and the final infusion cessation cause. These data were then used to fit 5 nonlinear models and evaluate the best explanatory model.

RESULTS

Random forest was the best-fit predictor, with an F1-score of 80.42, compared to 5 other models (mean F1-score 75.06; range 67.48-79.63). When applied to infusion data in an individual syringe driver data set, the predictor model found that the final medication concentration and medication type were of less significance to infusion longevity compared to the rate and care unit. For low-rate infusions, rates ranging from 2 to 2.8 mL/hr performed best for achieving a balance between infusion longevity and fluid load per infusion, with an occlusion versus no-occlusion ratio of 0.553. Rates between 0.8 and 1.2 mL/hr exhibited the poorest performance with a ratio of 1.604. Higher rates, up to 4 mL/hr, performed better in terms of occlusion versus no-occlusion ratios.

CONCLUSIONS

This study provides clinicians with insights into the specific types of infusion that warrant more intense observation or proactive management of intravenous access; additionally, it can offer valuable information regarding the average duration of uninterrupted infusions that can be expected in these care areas. Optimizing rate settings to improve infusion longevity for continuous infusions, achieved through compounding to create customized concentrations for individual patients, may be possible in light of the study's outcomes. The study also highlights the potential of machine learning nonlinear models in predicting outcomes and life spans of specific therapies delivered via medical devices.

Assessment of drug delivery devices working at microflow rates

Almost every medical department in hospitals around the world uses infusion devices to administer fluids, nutrition, and medications to patients to treat many different diseases and ailments. There have been several reports on adverse incidents caused by medication errors associated with infusion equipment. Such errors can result from malfunction or improper use, or even inaccuracy of the equipment, and can cause harm to patients' health. Depending on the intended use of the equipment, e.g. if it is used for anaesthesia of adults or for medical treatment of premature infants, the accuracy of the equipment may be more or less important. A well-defined metrological infrastructure can help to ensure that infusion devices function properly and are as accurate as needed for their use. However, establishing a metrological infrastructure requires adequate knowledge of the performance of infusion devices in use. This paper presents the results of various tests conducted with two types of devices.

Metrology in health: challenges and solutions in infusion therapy and diagnostics

The significance of Metrology in infusion therapy and diagnostics, both critical in health care safety and quality, is discussed in this article. Although infusion therapy is the most used form of drug administration, infusion errors are often made with reported dramatic effects in different applications, especially in neonatology. Adverse incidents, morbidity, and mortality have often been traced back to poor or inaccurate dosing. For critical infusion applications to vulnerable patients, well-controlled medication administration might be accomplished by improved dosing accuracy, traceable measurement of volume, flow, and pressure in existing drug delivery devices and in-line sensors operating at very low flow rates. To this end, the contribution of recently upgraded metrological infrastructures in European Metrology Institutes to a safer infusion therapy in health care is described in detail. Diagnostics, on the other hand is a sector characterized by rapid developments further triggered recently by the necessity for the management and prevention of infectious diseases like COVID-19. In this context, the impact of metrology in future large-scale commercialization of next generation diagnostics (e.g., point-of-care) is highlighted. Moreover, the latest contributions of Metrology in the development of traceable testing methods and protocols to ensure the sensitivity and accuracy of these devices are described.

Y-site administration of electrolyte solutions and injectable acetaminophen-A physical compatibility study with combinations frequently used in pediatric intensive care and anesthesia

AIM

Determination of the physical compatibility of acetaminophen and two different electrolyte solutions (an isotonic, balanced electrolyte solution and a hypotonic, glucose containing electrolyte solution) with drugs frequently used in routine pediatric intensive care.

METHODS

Analytical investigations for frequently used combinations without pre-existing data were performed. Visual and microscopic observations according to the European Pharmacopeia as well as pH measurements and ultraviolet visible spectrometry at wavelengths of 350, 410 and 550 nm were conducted to analyze physical compatibility. All measurements were performed immediately after mixing as well as 1, 4, and 24 h after.

RESULTS

In total, 42 combinations were analyzed. Visual incompatibilities were found with pantoprazole and diazepam with both electrolyte solutions. For furosemide, a particle formation in mixture with the hypotonic glucose-containing electrolyte solution and a change in pH ≥ 0.5 after 24 h with both electrolyte solutions were observed. Ampicillin, cefuroxime, diazepam, furosemide, linezolid, meropenem, and pantoprazole showed an aberration of the absorbance ≥0.04 (350 nm/410 nm) or ≥0.01 (550 nm) in the photometric measurements with the electrolyte solutions. For acetaminophen, a physical incompatibility was observed with ampicillin, diazepam, furosemide, and pantoprazole.

CONCLUSION

Most of the analyzed combinations showed no signs of physical incompatibility and may therefore be administered via the same Y-site. However, diazepam, furosemide, and pantoprazole should not be administered simultaneously with acetaminophen or both electrolyte solutions.

Critical care nurses’ knowledge of correct administration line types for common intravenous medications: Assessment and interventions. (Preprint)

Background

There is a paucity of information in the literature on core nursing staff knowledge on the requirements of specific intravenous administration lines for medications regularly given in critical care. There is also a lack of well-researched and appropriate information in the literature for intravenous administration line selection, and the need for filtration, protection from light, and other line-material selection precautions for many critical and noncritical medications used in these settings to maintain their potency and efficacy.

Objective

We aimed to assess the knowledge gap of clinicians with respect to intravenous administration line set material requirements for critical care medications.

Methods

Data were drawn from a clinician knowledge questionnaire, a region-wide database of administered infusions, and regional data on standard and special intravenous administration line consumption for 1 year (2019-2020) from an enterprise resource planning system log. The clinician knowledge questionnaire was validated with 3 groups (n=35) and then released for a general survey of critical care nurses (n=72) by assessing response dispersal and interrater reliability (Cronbach α=.889). Correct answers were determined by referencing available literature, with consensus between the team’s pharmacists. Percentage deviations from correct answers (which had multiple possible selections) were calculated for control and test groups. We reviewed all 3 sources of information to identify the gap between required usage and real usage, and the impact of knowledge deficits on this disparity.

Results

Percentage deviations from correct answers were substantial in the control groups and extensive in the test group for all medications tested (percentage deviation range –43% to 93%), with the exception of for total parenteral nutrition. Respondents scored poorly on questions about medications requiring light protection, and there was a difference of 2.75% between actual consumption of lines and expected consumption based on medication type requirement. Confusion over the requirements for low-sorbing lines, light protection of infusions, and the requirement for filtration of specific solutions was evident in all evidence sources. The consumption of low-sorbing lines (125,090/1,454,440, 8.60%) was larger than the regional data of medication usage data would suggest as being appropriate (15,063/592,392, 2.54%).

Conclusions

There is no single source of truth for clinicians on the interactions of critical care intravenous medications and administration line materials, protection from light, and filtration. Nursing staff showed limited knowledge of these requirements. To reduce clinical variability in this area, it is desirable to have succinct easy-to-access information available for clinicians to make decisions on which administration line type to use for each medication. The study’s results will be used to formulate solutions for bedside delivery of accurate information on special intravenous line requirements for critical care medications.

Quantifying the Impact of Infusion Alerts and Alarms on Nursing Workflows: A Retrospective Analysis

BACKGROUND

Smart infusion pumps affect workflows as they add alerts and alarms in an information-rich clinical environment where alarm fatigue is already a major concern. An analytic approach is needed to quantify the impact of these alerts and alarms on nursing workflows and patient safety.

OBJECTIVES

To analyze a detailed infusion dataset from a smart infusion pump system and identify contributing factors for infusion programming alerts, operational alarms, and alarm resolution times.

METHODS

We analyzed detailed infusion pump data across four hospitals in a health system for up to 1 year. The prevalence of alerts and alarms was grouped by infusion type and a selected list of 32 high-alert medications (HAMs). Logistic regression was used to explore the relationship between a set of risk factors and the occurrence of alerts and alarms. We used nonparametric tests to explore the relationship between alarm resolution times and a subset of predictor variables.

RESULTS

The study dataset included 745,641 unique infusions with a total of 3,231,300 infusion events. Overall, 28.7% of all unique infusions had at least one operational alarm, and 2.1% of all unique infusions had at least one programming alert. Alarms averaged two per infusion, whereas at least one alert happened in every 48 unique infusions. Eight percent of alarms took over 4 minutes to resolve. Intravenous fluid infusions had the highest rate of error-state occurrence. HAMs had 1.64 more odds for alerts than the rest of the infusions. On average, HAMs had a higher alert rate than maintenance fluids.

CONCLUSION

Infusion pump alerts and alarms impact clinical care, as alerts and alarms by design interrupt clinical workflow. Our study showcases how hospital system leadership teams can leverage infusion pump informatics to prioritize quality improvement and patient safety initiatives pertaining to infusion practices.