For at least 2 decades, the American Society of Health-System Pharmacists (ASHP) has been strongly encouraging hospital pharmacists to assume complete responsibility for intravenous (IV) compounding through its statements and guidelines. Most of us have been studying the USP/NF 797 guidelines and developing strategies to comply. Most recently, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made their expectations for the pharmacy assuming this responsibility abundantly clear for patient safety and standard of care reasons. Severe restrictions on the availability of concentrated electrolytes by JCAHO also increase pressure on their profession to assume full responsibility.
While most hospital pharmacies offer IV admixture compounding services, I would guess that the majority of us are not yet fully and completely compliant, but almost all of us are now working towards that end. We are finding that our past practice of deferring some IV compounding to the medical and nursing staffs have created new challenges. Providers in our most challenging environments (ie, emergency departments, intensive-care units, pediatrics, and operating rooms) have become used to immediate availability of compounded admixtures because they have shouldered the responsibility. They are thrilled that pharmacy will be assuming this responsibility but they still expect instant availability. Little wonder.
I know we face many obstacles as we make plans to provide comprehensive IV admixture services. Additional staff is difficult or impossible to get approved. Space limitations in the pharmacy and throughout the hospital are difficult to overcome. Production and delivery of finished products needed on a "stat" basis further complicate our progress. We must admit in our hearts that this is the right thing to do.
I can remember when intermittent IV drugs were administered through an in-line burette set and the system challenges and failures that ensued. Baxter's "minibags" and Abbott's (now Hospira) Advantage bags were creative and much needed alternatives to minimize burette set use. The creativity has stopped, however. More recently, research and development resources have been focused on infusion pump technology where profit margins could support developmental costs. Significant progress has been made to minimize free-flow events, enable sophisticated programming for potent IV therapy, facilitated efficiency and accuracy of total parenteral nutrition compounding and, most recently, building pumps with decision-support software to avoid system failures related to minimum and maximum dosing.
It is time for hospital pharmacists and the pharmaceutical industry to get creative and entrepreneurial again to refocus on IV solutions and admixtures. Is the Advantage bag and minibags the "end of the line" from an engineering perspective? I doubt it. Can hospital pharmacies take a step back and re-examine all processes related to IV therapy from prescribing to administration to redesign IV therapy systems? I hope so. We should make collaborative efforts to improve with physicians, nurses, and the industry at the table. The "bottom line" is that improvement in our systems is now an imperative.
I would encourage readers to submit their plans, aspirations, and successful implementations regarding IV admixture service improvements to Pharmacy Times or other professional journals. Learning from each other will enable us to learn from mistakes and make more rapid improvements. I look forward to hearing from you.
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