Editor's Note: Intravenous Admixture Pharmacists: A Thing of the Past?

SEPTEMBER 01, 2008
James C. McAllister III, MS, FASHP

Mr. McAllister is a health-systems consultant based in Chapel Hill, North Carolina.

I was surprised last week when a friend confided that she was on the verge of outsourcing her intravenous (IV) admixture services to a nearby company. Directors of pharmacy and their staffs have been challenged by the need for space and getting funding for capital and renovation costs to come into compliance with USP 797 standards. Similarly, the Joint Commission has promulgated standards that have shifted the additional IV compounding workload from staff (usually nurses) in environments such as procedure clinics and labs, the emergency department, and ambulatory clinics. We also strive to limit nurse compounding to emergent IV preparations and have assumed preparation of as many first doses as possible to comply with the same standard. Medication errors associated with IV admixtures are more visible than ever before, and quality improvement efforts commonly translate to more effort expected from staff without additional staff. My colleague had most of this under control or plans in place, but her decision was primarily driven because she could not hire pharmacists who were willing to work in the IV admixture service. What a shame!

Regrettably, pharmacy leaders, faculty, and even professional associations have contributed to this phenomenon. Over the past 2 or 3 decades, we have appropriately promoted the notion that pharmacists should focus their attention on optimizing drug therapy and spending the majority of their time on patient care units with patients and other providers. The flaw in this approach has all too often been to glamorize pharmacists' practices that are patient-focused at the expense of practices that have historically restricted their efforts to centralize functions. We have not taken an entrepreneurial look at the responsibilities of IV admixture pharmacists to enable them to assume patient-specific drug therapy oversight responsibilities. What a shame!

I wrote an editorial a couple of years ago in Pharmacy Times about IV compounding services and called for innovation and cooperation with the industry to reexamine products available and make efforts to improve IV admixture systems. Even then, intelligent pumps were available, and some IV automation had come to market. Infusion devices with decision support software have continued to evolve and improve, and more recently, IV compounding robots have become available to further support IV admixture services. From my perspective, this is a truly exciting time when our profession can reinvent IV admixture services to more closely meet current health care trends and prepare for the future.

We know that medication errors related to IV therapy are a phenomenon that must be significantly improved. As more complex care requiring IV therapies is provided in clinics and similar environments, pharmacy departments must be prepared to support the patient's medication needs appropriately. The genomics evolution will likely result in pharmacy departments being asked to provide never before seen IV compounding services to support individualized therapy. Finally, the quality of the final compounded admixture is another dimension that has not enjoyed the focus that it deserves.

I suggest that what is needed is for pharmacy leaders and practicing pharmacists to realize the expertise and professional commitment that IV admixture pharmacists contribute to our departments. Schools of pharmacy need to enhance curricula to reflect not only current but future IV therapy expertise that health-system pharmacists need to provide. Most importantly, we need to strategically plan for the practice evolution of pharmacists whose practices are based in IV admixture services. Could these staff assume oversight of all IV therapy in terms of monitoring and recommending appropriate therapeutic changes? Could they coordinate the development of IV administration rate databases for intelligent pumps with their decentralized colleagues and then monitor overrides? I suspect they could assume many other activities that would validate the expertise they have deserved. What do you think?