Standard concentration infusions and ‘smart’ pumps in PICU: the challenge of change

Introduction Arising from reviews of critical incidents, many leading organisations, such as the Institute of Safe Medical Practice in the US and the National Patient Safety Agency in the UK, have advocated the use of standard concentration infusions. This is a significant departure from the traditional method (‘rule of six’) for calculating such infusions. These ‘high alert’ drugs include inotropes, opioids and benzodiazepines. In our paediatric intensive care unit (PICU), a decision was made to move to standard concentration infusions. Drug library software had previously been installed on the infusion pumps in PICU but no further work had been completed on it. The change management process had to be secure so that the change itself did not jeopardise patient safety. Aims To compile a drug library of standard concentration drugs administered via continuous infusion in PICU. To assign each drug soft and hard upper dose limits, as well as loading or bolus doses as appropriate. To measure the impact of its introduction though comparison of medication incident data and staff feedback survey. Method Review medication safety reports for 2 month period, profiling errors associated with continuous infusions in PICU. All stakeholders were identified and briefed on the project. A PICU consultant and pharmacist devised a list of proposed standard concentrations. This took into account clinical factors—rule of six concentrations, dose ranges for different indications, loading and bolus doses, dosing in theatre and most importantly, soft and hard dosing limits. Drug-related factors were also considered—minimum and maximum concentrations, limitations for administration via peripheral line. For each weight band, a standard and fluid-restricted concentration was provided. It was realised that this technology could also improve safety around IV potassium chloride and IV paracetamol. The proposed standard concentrations were circulated for feedback to all stakeholders. Sample patient profiles were used to compare total daily volumes infused using ‘rule of six’ versus standard concentration infusion. Once agreed, the logistics around roll out were discussed, agreed and communicated to all stakeholders (PICU, theatres, cardiac wards.). Post implementation, a repeat review of medication safety reports was conducted. A survey of users was conducted to assess satisfaction and ongoing issues. Results The change to standard concentration infusions with smart pump technology was successfully introduced. The drug library included 42 drugs. While one single concentration for each drug was the ideal, this was not achievable due to the diverse profile of patient sizes in the unit. We report on the comparison of infusion-related medication safety reports pre and post implementation as well as user feedback. We also report on some of the resistors to change and challenges encountered along the way. Conclusions A switch to standard concentration infusions is achievable with smart pump technology. Single concentrations were not achievable for most drugs. Retrospective review may facilitate a reduction in choices of concentration currently available. This technology should also be considered as an aid in making IV paracetamol and potassium administration safer.