Infusion Insight: Small Volume Parenteral Shortages Shouldn’t Mean Big Problems for Pharmacists and Nurses

This fall’s twin hurricanes in Puerto Rico wreaked havoc on the island territory, and their aftermath has set off yet another storm–in hospital pharmacies across the continental U.S. The ominous shortage of small volume parenterals (SVPs) has cast a dark cloud on infusion productivity and patient safety. A major U.S. SVP supplier has three factories on the island whose productivity fell victim to the damage and difficulties following the storms. As a result, to properly dilute and administer vital medications, hospitals are struggling with SVP workarounds that are often unfamiliar, time-consuming and at times, potentially dangerous.

This situation was a major topic of discussion at the December ASHP Clinical Meeting, where we heard many attendees talking about how their hospitals were dealing with the challenges.

Infusion therapy is a complex and error-prone process, even without the SVP shortage. Compounding IV medications is time-consuming for pharmacists, and administration is fraught with challenges for busy clinicians. Yes, into every life, a little rain must fall. But when the accumulation amounts to a true disaster–literally and figuratively as it has today–shouldn’t infusion pumps offer a back-up plan? At Ivenix, we believe they should.

SVPs are infusion containers holding between 50 mL and 250 mL of fluid and they are typically used for intermittent medications administered through a secondary or piggyback set up. Often, SVPs are utilized for medications vital to a patient’s health, for example, antibiotics and electrolytes.

Today, without a ready supply of SVPs, many healthcare organizations are relying on frozen products or alternative solutions with integrated vial adapters.¹ Other organizations may be using alternative point-of-care dilution methods or larger bag sizes, resulting in risks due to non-standard practices.

Many hospitals also are changing practice to recommend or require dilution of some medications, for example antibiotics, in smaller volumes such as 10 – 20 mL, followed by an abbreviated, manual IV push delivery via syringe. This shifts more of the infusion burden to front line clinical staff, who must mix the medication and diluent at the bedside and remain with the patient until manual administration is complete. Some antibiotics used in high volume, such as cefepime, require three to five minutes for administration. Considering the typical nurse’s patient load, this adds up to significantly more time spent managing infusions. Under increased pressure to care for multiple patients, clinicians may overestimate the elapsed time when manually delivering medication and end the process too soon, leading to potential adverse events. Small volume dilution of some medications can lead to phlebitis due to higher osmolarity of the final product and a faster than intended administration rate. Complications can lead to additional unplanned for medical interventions and in severe cases, increased length of stay.

As though anticipating the current need for education surrounding IV push medications, two years ago, the Institute for Safe Medication Practices (ISMP) held a summit elucidating some of the challenges facing hospitals today. Pharmacists may need to take the lead in advocating for more information. For example, ISMP noted that many clinicians may not be aware of the difference between the terms IV push and slow IV push and will fail to administer all medications appropriately. Clinicians also should be made aware of pump design flaws and tubing set-up that may affect medication flow. Providers may also need to institute educational and quality control programs to standardize IV push delivery and minimize mistakes. ² From a management perspective, departmental nursing workflows also should be examined and any necessary changes made to ensure nurses have sufficient time to manage manual processes.

In a perfect world, in situations such as this, syringe pumps would be readily available to eliminate this manual workflow—and, of course, hurricanes would never happen. However, as we all know, in most hospitals syringe pumps are primarily restricted to pediatric and neonate care areas, while large volume devices are ubiquitous throughout the enterprise.

Discussions at the ASHP Meeting left no doubt that hospitals are struggling and innovation is needed to address the SVP problem. Hospital staff find it particularly difficult to keep up with the number of drugs that must be switched to IV push administration and reflecting those changes in the pump drug library, as well as making syringe pumps available for accurate delivery.

An effective back up strategy would be a flexible large volume infusion pump that automatically accommodates multiple drug administration options, including syringe delivery, without special tubing or adapters. Effectively supporting this, the pump’s drug library also would be flexible and include such options as specifying custom concentrations. Rapid deployment of library updates would accommodate day to day changes in administration practice.

How has the SVP shortage affected workflow in your hospital? Are the systems in place able to safely support this transition?

Ivyruth Andreica, PharmD, BSN, FISMP, is Clinical & Medication Safety Pharmacist for Ivenix

1. Small-Volume Parenteral Solutions Shortages Suggestions for Management and Conservation-Accessed 11/17/17- https://www.ashp.org/Drug-Shortages/Shortage-Resources/Publications/Small-Volume-Parenteral-Solutions-Shortages
2. ISMP Safe Practice Guidelines for Adult IV Push Medications: A compilation of safe practices from the ISMP Adult IV Push Medication Safety Summit. 2015. Accessed 11/17/17- https://www.ismp.org/Tools/guidelines/IVSummitPush/IVPushMedGuidelines.pdf