99The infusion administration method is selected and based upon multiple factors including the type of infusion, the frequency of administration, infusion rate requirements, drug stability in solution, patient safety and lifestyle concerns, patient preference, and reimbursement. Patient safety is maximized by teaching the patient and family how to administer the infusion therapy, how to use an infusion pump, how to identify potential problems, and when/whom to call with problems. For patients who require a continuous infusion and are “hooked up” to an infusion pump 24 hours a day, teaching must also address how to manage activities of daily living. Other issues related to infusion administration addressed in this chapter include the administration set and filtration.

After reading this chapter, the reader will be able to:

100NONINFUSION PUMP METHODS: IV PUSH AND GRAVITY DRIP

IV Push

Direct injection of an intravenous (IV) medication, called “IV push,” is the administration of the medication in a syringe directly into the patient’s vascular access device (VAD) or through the injection port of a continuous infusion. In home care, IV push is used most often for certain antimicrobials, including some in the cephalosporin group (e.g., ceftriaxone, cefazolin, and cefapime). Other examples of medications that may be administered by IV push include antiemetics (e.g., ondansetron) or diuretics (e.g., furosemide).

Advantages to IV push administration include less administration time, cost-effectiveness in terms of supplies, and a relatively simple administration method. However, nurses often administer IV push medications too rapidly (Carter, Gelchion, Saitta, & Clark, 2011; Institute for Safe Medication Practices, 2015). It is important to recognize the risk of “speed shock,” a systemic reaction that occurs when a medication is too rapidly administered into the circulation. Symptoms include dizziness, facial flushing, headache, and medication-specific symptoms that can progress to chest tightness, hypotension, irregular pulse, and anaphylaxis (Phillips & Gorski, 2014). It is critically important to administer IV push medications over the appropriate time frame. The medication syringe should be labeled with the administration time (e.g., “administer over 3 to 5 minutes”).

Fast Facts in a Nutshell

Gravity Drip

Gravity infusion is a common method used to deliver intermittent medications. It is cost-effective, using an infusion container (e.g., mini-bag with antibiotic) and simple IV tubing. An IV pole is required or, 101alternatively, the infusion container can be hung from a home structure such as a drapery rod. For some antibiotics, the medication is contained in a separate compartment with a premeasured drug and diluent that is mixed just prior to administration (Figure 7.2). This method is used for medications that have a limited shelf-life after admixture.

Figure 7.1 Administering an IV push medication. Source: Photograph courtesy of Sherry Lokken, RN.

Note: To reduce the risk of complications associated with rapid administration, always use a watch or other timer device to ensure an appropriate administration rate.

IV, intravenous.

The IV drop rate must be calculated. Necessary information for calculation includes the volume of the infusion, the time frame for infusion in minutes, and the number of drops per milliliter as listed on the container of the IV tubing set. Calculate the IV drop rate as follows:

102

Figure 7.2 Use-activated container.

Note: In accordance with the specific manufacturer’s directions for use, the medication container is connected to the port of the solution bag and the medication is mixed with the diluent. It is used for infusions that have a limited shelf-life once admixed (e.g., ertapenem).

A manual flow regulator is often used in lieu of the built-in roller clamp of the IV tubing. The regulator allows the nurse or patient to set the flow rate in milliliters per hour (Figure 7.3). Advantages may include easier regulation, more consistent flow, less drifting of flow compared to using the roller clamp, and less risk of accidental free-flow. However, the accuracy is about the same as the roller clamp (± 10%).

103

Figure 7.3 Administration set with manual flow regulator.

Note: It may be used in lieu of the built-in roller clamp of the IV tubing, allowing the nurse or patient to set the flow rate in milliliters per hour.

For patients who require multiple doses per day, the IV tubing is changed every 24 hours as recommended by the Infusion Nurses Society (INS; Gorski et al., 2016). From a procedural standpoint, the infusion is stopped when the infusion container is empty but fluid still remains in the drip chamber. With subsequent infusions within the 24-hour period, a new infusion container is aseptically respiked to the existing tubing.

Patient Selection Considerations: IV Push and Gravity Drip

■  Safety is a concern due to rate management and risk for reactions with IV push.

■  Gravity drip is a more complex procedure as it involves more steps in accordance with attention to infection prevention including maintenance of aseptic technique. Key steps include:

       Removing the protective cap from the tubing spike

       Inserting the tubing spike into the infusion container

       Filling the drip chamber and priming the IV tubing while protecting the male luer end of the tubing from touch contamination

       Managing the infusion rate by drop counting

104Fast Facts in a Nutshell

Fast Facts in a Nutshell

INFUSION PUMP ADMINISTRATION: ELASTOMERIC BALLOON “PUMPS”

The elastomeric balloon pump is a portable device that consists of an elastomeric reservoir, or balloon (Figure 7.4). Made of a soft rubberized material that is inflated to a predetermined volume, the balloon is encapsulated inside a rigid, transparent container. The balloon exerts positive pressure to administer the medication; control over fluid flow rate is maintained by IV tubing with varying tubing diameters. These devices are used to deliver a variety of infusion therapies, including IV antibiotics, chemotherapy, and analgesics. Volumes range from 50 to 250 mL. Elastomeric pumps can infuse at rates from 0.5 to 500 mL/hr.

Patient Selection Considerations: Elastomeric Balloon Pumps

■  A portable, disposable, nongravity-dependent infusion device that is often ideal for active patients or children who continue to work or go to school

■  Easier to learn compared to gravity infusion as the steps of bag spiking and rate monitoring are eliminated

105

Figure 7.4 Elastomeric pump. Source: Photo courtesy of Halyard Health, Alpharetta, Georgia.

Note: These pumps come in a variety of volumes and may be used to administer medications such as antibiotics, chemotherapy, and analgesics.

Fast Facts in a Nutshell

106ELECTRONIC INFUSION PUMP ADMINISTRATION: SYRINGE, STATIONARY, AND AMBULATORY INFUSION PUMPS

Syringe and Stationary Electronic Pumps

Syringe pumps use a traditional syringe as the solution container, which is filled with prescribed medication and positioned in a special pump designed to hold it. Syringe pumps control the infusion rate by drive speed and syringe size, thus eliminating the variables of the drop rate. In home care, syringe pumps are used for delivery of antibiotics, subcutaneous immune globulin infusions, and small-volume IV therapy. The volume of the syringe pump is limited to the size of the syringe; a 60-mL syringe is often used. However, the syringe can be as small as 5 mL. The tubing usually is a single, uninterrupted length of kink-resistant tubing.

Stationary electronic pumps are mounted on an IV pole. They allow for large infusion volumes and a wide range of infusion rates. They may be less expensive than other pumps. Mobility is an issue and these pumps are usually used for longer, larger intermittent infusions (e.g., amphotericin B, IV immunoglobulin [IVIG] infusions, and continuous infusions in a patient with limited mobility).

Because IVIG infusions require precise rate control, careful product selection, and close monitoring for reactions, many home infusion teams coordinate closely with a specialized IVIG pharmacy that handles patient-specific compounding, premedication planning, and pump programming guidance. This support is particularly valuable for stationary electronic pump setups, where infusion volumes are larger and slower titration steps are often needed to keep patients comfortable and reduce the risk of rate-related adverse events.

Patient Selection Considerations: Syringe and Stationary Electronic Infusion Pumps

■  Must be able to learn the steps of loading the syringe and using the pump correctly

■  Nurse-administered infusions when patient independence is not appropriate due to infusate risks (e.g., IVIG infusion)

Ambulatory Electronic Infusion Devices (EIDs)

Ambulatory EIDs are lightweight and compact infusion pumps that are capable of delivering most infusion therapies including continuous infusions (e.g., chemotherapy and inotropes), intermittent antibiotic therapy, analgesic infusions with patient-controlled analgesia (PCA), and continuous infusions with tapering functions (e.g., parenteral nutrition [PN]). For intermittent antimicrobial infusions, a “keep vein open rate” is programmed to maintain flow between the drug administrations. Features include programmable memory, lock-out functions for safety, and alarms. “Smart pumps” that include drug libraries are available. Ambulatory pumps function on a battery system that requires recharging or replacement of disposable batteries. The pump 107along with the infusion container is placed in a pouch or backpack, providing the patient with full mobility during the infusion.

Patient Selection Considerations: Ambulatory EIDs

■  Patients who require frequent (every 4- to 6-hour) dosing or continuous infusions

■  Those who lack manual dexterity, who have impaired cognitive function, and/or are unwilling or unable to learn the necessary techniques for self-administration, and those who lack a support person at home

Fast Facts in a Nutshell

Although the infusion pharmacy usually makes initial decisions regarding the best infusion method or device for the type of infusion therapy, the home care nurse may also make recommendations. After assessing the patient and home situation, the nurse may advocate for a better method; for example, recommending an elastomeric pump to facilitate the patient’s independence, mobility, and return to work. Collaboration between the home care nurse and home infusion pharmacist is an important aspect of home infusion therapy, contributing to positive patient outcomes as well as health care provider satisfaction.

Decision Making: The Best Infusion Method

The initial decision regarding the best infusion method or device for the type of infusion therapy is generally made by the home infusion pharmacy. A number of factors that drive infusion administration method choice include:

■  Drug or infusion solution:

       Compatibility with infusion device (e.g., elastomeric)

       Need for accurate rate control (e.g., continuous infusion requiring an EID)

       Safety of rapid infusion (e.g., IV push)

■  Drug stability in solution:

       May limit ability to use an ambulatory, programmable pump because the infusion container is generally prepared for a 10824-hour infusion; for example, intermittent doses of ampicillin have limited stability of only 4 to 8 hours once admixed (Gahart, Nazareno, & Ortega, 2016)

■  Patient safety and lifestyle concerns and patient preference

■  Cost/reimbursement:

       Some insurance companies will have restrictions (e.g., some will not cover an elastomeric device)

Fast Facts in a Nutshell

OTHER INFUSION ADMINISTRATION ISSUES: ADMINISTRATION SETS AND FILTRATION

The INS standards (Gorski et al., 2016, pp. S84–S85) provide guidance on filtration and how often to change the administration set, commonly called “tubing,” as follows:

■  Intermittent infusions: Change the set every 24 hours. Make sure the male luer end of the tubing is not touched and that a sterile, compatible cap is placed on the end when used for more than one infusion per day. When systems such as elastomeric pumps are used, the tubing is inherent to the container with the whole unit discarded after use.

■  Parenteral nutrition: Change the set every 24 hours. If IV fat emulsions are administered as a separate infusion, change that tubing every 12 hours.

■  Continuous infusions: Change the administration set no more often than every 96 hours. With home infusion, the infusion container may provide a week’s worth of medication (e.g., morphine infusion); while not addressed in the INS standards, 109it is not atypical to change the entire infusion system (drug reservoir and tubing) on a weekly basis.

■  Filtration:

       The purpose of filtration is to prevent the administration of particulate matter, air, microorganisms, or endotoxins that may be in the infusion system. Filters are available as separate add-on devices or as in-line components as part of the IV administration set. The filter is changed with the administration set.

       PN and separate lipid infusions are always filtered. A 1.2-μm filter is required for PN solutions with lipids or lipid infusions alone. A 0.2-μm filter is used for PN solutions without lipids.

       Intraspinal infusions are filtered using a surfactant-free 0.2-μm filter.

       Some medications require filtration based upon manufacturer’s guidelines (e.g., infliximab and some immunoglobulin infusions). Always refer to the drug package insert and consult with the infusion pharmacist regarding any filtration questions.

PATIENT EDUCATION: KEY POINTS

General Guidelines

Ensure that copy of the infusion pump manual is in the home:

■  May also provide additional personalized teaching handouts

■  Consider use of online infusion pump patient education, if available

Instruct in:

■  Whom to call with problems, alarms, or questions (home care nurse vs. home infusion pharmacy)

■  Infusion pump profile (e.g., drug infused, rate or duration of each dose and when each dose kicks in for intermittent antibiotics, duration of infusion, and any tapering time for total PN)—leave written copy in home

■  Alarms and actions to take:

       How to change the battery, if used

       Check the pump and IV reservoir/cassette one to two times per day

           Check that numbers on the pump screen are increasing (or decreasing) as the infusion progresses

           Check that the volume of fluid in the drug reservoir is decreasing

       110Activities of daily living issues, especially for patients on continuous infusions

       Bathing or showering, if allowed. Teach patient how to secure and protect infusion pump and IV catheter/dressing from moisture

       How to dress and undress, handling IV tubing and threading through clothing, and avoiding tension (and potential dislodgement) at IV site

       Importance of picking up and carrying the pump when ambulating

Infusion Pump Risk Reduction Strategies for Patients Using Infusion Pumps at Home

The Food and Drug Administration (FDA) has provided guidance to both clinicians and patients related to safe infusion pump use. Nurses and physicians can refer patients to the FDA website (www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/ucm205412.htm) or print out this information to guide patient education:

Reduce risk: plan ahead

■  Work with your home health nurse (or other outpatient antimicrobial therapy [OPAT] team member) to develop a back-up plan in case of an infusion pump failure.

■  Know if your plan includes calling 911.

■  Know where your infusion pump back-up battery is located and how to access an emergency power supply, if applicable.

■  Refer to Home Healthcare Medical Devices: Infusion Therapy—Getting the Most out of Your Pump (www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ucm070208.htm) for more information.

Learn about your infusion pump and medication. Ask your home health care provider:

■  About the infusion pump:

       What is the name of my infusion pump?

       Is this infusion pump already set up?

       Do I need to look at anything on the infusion pump to make sure it is correct? If so, what?

       How do I start and stop the infusion pump?

       111Do I need training to use this infusion pump?

       Will any electrical items in my home interfere with my pump?

■  About your medication:

       What is the name of my medication?

       What does the medication do? How should it make me feel?

       What are the side effects?

       What is the dose of my medication?

       How long should my medication take to complete?

       Can there be medication left in my tubing or in my bag when the infusion pump stops?

■  What to do when there are problems:

       What should I look for if I am getting too much medication too fast?

       What should I look for if I am getting too little medication?

       Whom should I call with questions or problems?

       What should I do if the power goes out?

Check:

■  Make sure you can read the infusion pump’s displays and hear the alarms, if applicable.

■  Verify the settings when starting or changing the rate of a medication or fluid, if applicable.

■  If they are not correct, or if you have questions, call your home health provider.

Report problems—call your home health care provider to obtain further instructions if:

■  The infusion pump appears broken or damaged or has small chips or cracks

■  An unfamiliar alarm sounds or is displayed

■  An alarm is unable to be cleared to which you have been trained to respond

You are also encouraged to file a voluntary report (www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/ucm202503.htm) with the FDA for any problems you may encounter with the infusion pump.

112TEST YOUR KNOWLEDGE

1.  The simplest and most cost-effective infusion administration method for a patient who requires a daily infusion of ceftriaxone is:

     a.  IV push

     b.  Elastomeric pump

     c.  Gravity drip

     d.  Stationary bedside infusion pump

2.  Symptoms of “speed shock” associated with too rapid IV administration include:

     a.  Headache and nausea

     b.  Dizziness and facial flushing

     c.  Nausea and vomiting

     d.  Nausea and diarrhea

3.  Calculate the drop rate per minute for a patient who requires an infusion that includes 100 mL of ceftriaxone over 30 minutes. The drop factor of the administration set is 15 drops/mL.

     a.  50 drops per minute

     b.  75 drops per minute

     c.  100 drops per minute

     d.  200 drops per minute

4.  Elastomeric infusion devices may be used for administration of:

     a.  Parenteral nutrition

     b.  Dobutamine infusions

     c.  Chemotherapy infusions

     d.  Immunoglobulin infusions

5.  The use of an ambulatory infusion pump is definitely limited by:

     a.  Patient preference

     b.  Physician preference

     c.  Drug stability in solution

     d.  Cost

6.  Filtration is required for:

     a.  Most chemotherapy drugs

     b.  Parenteral nutrition

     c.  Most antibiotics

     d.  Morphine infusions

113ANSWERS

1.  a

2.  b

3.  a

4.  c

5.  c

6.  b

References

Carter, A., Gelchion, K., Saitta, P., & Clark, D. (2011). Dyeing to identify IV medication errors: A clinical nurse specialist group identifies factors contributing to IV push medication errors, and the resulting housewide education initiative. Clinical Nurse Specialist, 25(3), 140–152.

Gahart, B. L., Nazareno, A. R., & Ortega, M. Q. (2016). Gahart’s 2016 intravenous medications: A handbook for nurses and health professionals (32nd ed.). St. Louis, MO: Elsevier.

Gorski, L. A., Hadaway, L., Hagle, M., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy standards of practice. Journal of Infusion Nursing, 39(1S), S1–S159.

Hilbers, E. S. M., de Vries, C. G. J. C. A., & Geertsma, R. E. (2013). Medical technology at home: Safety-related items in technical documentation. International Journal of Technology Assessment in Health Care, 29(1), 20–26.

Institute for Safe Medication Practices. (2015). ISMP safe practice guidelines for adult IV push medications. Retrieved from http://www.ismp.org/Tools/guidelines/ivsummitpush/ivpushmedguidelines.pdf

Phillips, L., & Gorski, L. A. (2014). Manual of IV therapeutics: Evidence-based practice for infusion therapy. Philadelphia, PA: F.A. Davis.

Skryabina, E. A., & Dunn, T. S. (2006). Disposable infusion pumps. American Journal of Health System Pharmacists, 63(13), 1260–1268.114

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