Q: What is the most common problem encountered when using IV workflow management for manual additions, and how did you overcome it?

Teel: When implementing our IV workflow management (IVWFM) system, we opted against using inline verification for parenteral nutrition (PN), which means when there is a too-much dose error, we are forced to remake the bag. Note that with post hoc verification via syringe pullback, remaking doses is also required when a too-much error occurs.

Hellinga: On the other hand, if we encounter an issue where there is a too-little dose error, we will add the correct amount into the PN using the system’s Rework option.

Q: Since the system tracks and records all activity, is it difficult to find specific pieces of information when searching for a transaction?

Teel: Searching for transactions is simple. Our IVWFM has a Search for a Dose function that can be used to find all recent PN doses or a specific PN dose. To find all recent PN doses, I use “2-in-1” as the search term in the description field because it is part of every dose label from the PN dose calculation software at our facility. When searching for a specific patient’s dose, we have several options to quickly locate the information we need. We can search the patient’s name or account number from the electronic medical record (EMR), the IVWFM Dose ID, or the PN dose calculation software’s order number from the PN bag label.

The Clinical Order and Compounder Result can be found on the local server for 45 days and in the data archive for 30 years. Within that data, anyone can find the PN’s ingredients and doses; order entry pharmacist’s ID; PN preparer’s ID; and the verifying pharmacists’ IDs (order entry verifier and compounding verifier); as well as compounder data (bubbles, container swaps, occlusions, weight variance). Conveniently, the Clinical Order and Compounder Result screens contain links to each other on the IVWFM’s local server.

Hellinga: I have found our IVWFM interface easy to use. As Teel mentions, there are a variety of ways that the pharmacy team can find doses within the system. Of note, our setup uses the account number associated with the patient versus the medical record number (MRN). Once you become familiar with the use of the system, it is very easy to find information therein.

Q: What quality assurance do you have in place for dealing with occlusion errors?

Teel: When an occlusion occurs, we repump the bag. The technician can cancel and repump immediately, or if the technician finishes preparation, the pharmacist can reject and place the bag back in the queue while reviewing the Mix-Check Report (the Compounder Result screen in the IVWFM).

Q: What has been your experience with regulatory inspections since using IVWFM?

Hellinga: We have had both accreditation visits and state board visits since implementing our IVWFM. During those inspections, neither the regulatory nor accreditation bodies asked any questions about the use of the IVWFM for PN or our processes associated with it.

Q: Was there a learning curve when you first began using IVWFM?

Teel: When we began using this IVWFM, there was a bit of a learning curve. For technicians familiar with IVWFM for sterile prep, switching to PN manual additions was a simple and intuitive change. For pharmacists, using this system required adjustment to workflow changes. At our facility, one of the differences between the previous system and our current workflow included a change from verifying order transcription via paper order and label printout to paper order and computer monitor. Another difference for pharmacists is that now they review the compounder result on the computer monitor instead of on paper. Fortunately, our pharmacists adjusted to these changes quickly.

Hellinga: Truly, the learning curve depends on how technologically savvy a person is. Overall, the IVWFM is quite intuitive and provides clear instructions to the technician as to what steps they need to take. Most of our staff, both technicians and pharmacists, felt comfortable and confident using the IVWFM within a few days to a week.

Q: What steps would you recommend taking to compound multiple PN bag doses for a single patient in home care with this system?

Teel: While we do not compound multiple bags for a single patient at one time, it would be possible to do so through the use of IVWFM. The steps I would recommend would include first sending the IVWFM a batch of PN doses for one patient and instructing the technician to focus on that batch. The technician can then decide either to pump the compounder ingredients for the batch of PN first and then do the manual additions or pump and do manual adds for one bag at a time. The preferred order of operations could be specified by policy, but to my knowledge, neither method can be forcibly locked out.

Q: What was the most challenging part of getting the system to work with the combination of the automated compounder, PN software, and IVWFM?

Teel: Since our compounder, PN software, and IVWFM are all from the same vendor, we did not have any significant trouble getting the systems to work together. Our vendor was quite supportive in walking us through the necessary steps. The most time-consuming part of the build for the pharmacist/pharmacy systems analyst was ensuring concordance between each of the systems for the PN ingredient names and building the needed product groups. Another challenge was matching the IVWFM label to the format of our PN system label; however, the vendor handled this expertly. The final challenge was deciding whether to use inline verification. We opted to skip inline verification to streamline workflow for our PN technicians. As a result, all manual addition errors involving too much volume require the bag to be re-pumped as noted previously.

Q: What is your process for visual inspection of PN, and how do filters come into play?

Teel: We only compound 2-in-1 PN bags. Accordingly, the verifying pharmacist, usually the pharmacist in closest proximity to the compounding process, can complete a visual inspection for cores or particulates as they would do for 2-in-1 PN without IVWFM integration. Before moving to IVWFM, the pharmacist would visually inspect all bags they check during the approval step. With the IVWFM, because the verification process can be done remotely, the inspection process becomes its own step. However, we have not yet incorporated an expectation of that into our P&Ps. We do by policy filter all 2-in-1s via a 0.22 micron filter, and we filter fat emulsion via a 1.2 micron filter.

Hellinga: While we have not incorporated any expectation to do a visual inspection of the final product into our P&Ps, we always filter our PN bags. For example, the standard order comment on PN in our EMR includes the following details:

• If infusing PN and lipids in the same line via Y-site, a 0.2 micron filter needs to be attached prior to the Y-site and after the pump for the PN line. A 1.2 micron filter needs to be attached after the Y-site.
• If infusing PN and lipids via separate lines, a 0.2 micron filter needs to be attached on the PN line after the pump, and a 1.2 micron filter needs to be attached on the lipid line after the pump.

Notably, the American Society for Parenteral and Enteral Nutrition (ASPEN) has published updated recommendations regarding the filtering process which may impact some of these processes.1

Reference

1. Worthington P, Gura KM, Kraft MD, et al; ASPEN PN Safety Committee. Update on the use of filters for parenteral nutrition: an ASPEN position paper. Nutr Clin Pract. 2021 Feb;36(1):29-39.

Andy Teel, PharmD, is a pharmacy systems analyst at the University of New Mexico Hospitals (UNMH). He earned his bachelor of pharmacy and PharmD from the University of New Mexico and has experience installing, upgrading, and managing automated dispensing cabinet systems and IV workflow management systems, as well as maintenance of the inpatient pharmacy aspects of a large EHR system.

Robert (RC) Hellinga, PharmD, BCPPS, is the pediatric clinical lead pharmacist, pediatric ICU pharmacist, and pediatric antimicrobial stewardship pharmacist at UNMH. He graduated from the University of Utah College of Pharmacy and completed two years of pharmacy residency with a focus on pediatrics.