- Email: [email protected]
Setting up a central intravenous additive service
Setting up a central intravenous additive service Wendy Hills INTRODUCTION There are many recognized factors that take nurses away from giving direct patient care and lack of time is cited as a reason for not being able to make changes that would improve quality of care (Audit Con~mission 1992). As a result of less time, standards may fall, complications and infections during hospitalization may increase, patients and families may express dissatisfaction with care and nursing staff may express dissatisfaction and disillusionment with their work. Due to dissatisfaction, the numbers of nurses may ultimately fall. The Code of Professional Conduct (United Kingdom Central Council 1992) states that nurses must exercise professional accountability. The first two parts are particularly relevant and state the responsibility of nurses: • •
Promote and safeguard the patient's interest and well-being Ensure that no act or omission is detrimental to the interests, condition or safety of the patient.
As the demands of nursing time increase, nurses need to question their roles and scope of practice to assess who is the most appropriate person to be carrying out specific activities. The Code of Professional Conduct (Part 6) also encourages nurses to work in collaboration with other health care professionals (United Kingdom Central Council 1992). Within any paediatric haematology and oncology unit where children are admitted for modules of chemotherapy, making them susceptible to infections which then require antibiotic treatment, intravenous (IV) therapy is a major component of hospital treatment. It includes administration of:
Wendy Hills BSc (Hons), RGN, RSCN, RCNT,Acting Senior Nurse, Host Defence, Great Or'mond Street Hospital for Children NHSTrust, Great Orrnond Street, London WCI N 3JH, UK
• • • • •
Antibiotics and other medications Complex electrolyte infusions Cytotoxic chemotherapy Total parenteral nutrition (TPN) Blood products.
Antibiotics, other medications and electrolyte infusions are reconstituted immediately prior to administration and checked by two nurses within the ward. This uses a significant amount of nursing
journal of CancerNursing I (2), 96-98 @ PearsonProfessionalLtd 1997
time. It is necessary to establish whether there is a more appropriate way of organizing administration of IVs. It would be possible for antibiotics, other drugs and infusions to be prepared off the ward in advance if a hospital had a Central Intravenous Additive (CIVA) service. It may appear to student nurses passing through a unit that qualified staff spend most of their time giving IV products. During times of high staff turnover, the proportion of time that senior staff spend giving drugs is increased as new and junior staff are becoming competent in the variety of skills needed to carry out the task properly. During busy periods, patients and families may only see qualified staff to administer their drugs and, therefore, they may miss out on skilled observation and assessment, as well as explanations and specific support related to their disease, that experienced staff are best able to give. These issues prompted Great Ormond Street Hospital for Children NHS Trust to undertake an audit of the IV therapy process.
DATA GATHERING Information on nursing time associated with the administration of IV therapy was collected using activity sheets for each patient. An activity sheet was also placed in the areas where IV products were prepared. Activity was recorded over a 7-day period, from 00:00 to 00:00, in an attempt to reflect the changing workload over the week.
A N A L Y S I S OF DATA The IV-associated activities were divided into three categories: •
•
Those activities that could be done by someone other than a nurse, e.g. preparing TPN (prepared by pharmacy), preparing chemotherapy (prepared by pharmacy) and preparing electrolyte solutions. Activities felt to be exclusively nursing included, e.g. connecting lines to patients, disconnecting/heplocking lines and giving blood products.
Setting up a central intravenous additive service
•
Negotiable activities or activities shared between nurses and either technicians or pharmacists, e.g. giving IVs, checking IVs and taking bloods.
From the analysis of results, the best potential area for reducing nursing time spent preparing 1V therapy would be in giving and checking IVs.
Giving drugs Giving drugs included gathering equipment, preparing the drug, calculating the dose and administering the drug to the patient. Drugs could be administered as a bolus injection, continuous infusion or intermittent infusion. The first three activities could be prepared in advance by a pharmacist, leaving nurses to administer the drug and check it. An estimated preparation time from the study was 3 minutes to prepare a bolus injection, 7 minutes to add one drug to a bag and 10 minutes to prepare a syringe for IV infusion. Nurses recorded spending from 290 minutes to 650 minutes a day in giving drugs (average 425 minutes). This is the equivalent of one nurse a day. From the recording method, it is only possible to estimate how much time could be saved. However, if 50% of time could be saved by a pharmacy support service, it would free 0.5 of a nurse a day from this one activity on one ward.
Checking drugs This activity involved minimal practical assistance, but calculations and patient identity would be checked according to hospital policy. This activity could also be reduced by having drugs prepared by a pharmacy service; when drugs are prepared on demand a single drug is checked at a time. Many drugs are part of a course of treatment and so 2-3 days worth of drugs could be prepared and stored together. This would also reduce time spent on calculations. Many of the activities could be done more safely by an improved pharmacy service, and a few by a technician. Giving drugs, checking drugs and preparing electrolyte solutions are the activities that would be most suitable to be undertaken by a pharmacy department, and they were the three activities that accounted for nearly 80% (76%) of the IV workload. For pharmacy to take on this service, there are significant staffing, financial and environmental implications. Many hospitals have a CIVA service and this was felt to offer a suitable alternative.
CIVA service CIVA services were first recommended in 1976 (Breckenridge 1976). The reasons for setting up CIVA services were that IV drugs should be added
97
to fluids in pharmacy where dosages, compatibility and greater sterility could be checked and maintained by persons trained in that area of knowledge. The complexity of the drugs used is a good argument for setting up a CIVA service, as pharmacists can check the dosage, dilutions, compatibilities and calculations. Nurses have been shown to have comparatively high rates of drug calculation errors so it is in the interest of patients to have calculations checked by pharmacists (Laverty 1989). This is an even more important reason in paediatrics, where all dosages are individualized according to weight or surface area, and drug calculations and dosages are more complex. Other benefits of a CIVA service include savings on costs of drug (by cutting wastage of partly used vials or ampoules), greater accuracy (and, therefore, safety) of drugs, increased aseptic technique and the reduction of ward stocks (which has budget implications for expensive drugs). Savings in drug budgets have to be offset against the increased cost of disposables and use of pharmacy staff time, and these savings may be minimal (Cousins et al 1989). However, within a paediatric setting, the wastage of drugs is likely to be considerably higher than in the adult setting where most ampoules contain an adult dose. Not all drugs may be suitable for a CIVA service as drug properties have to include chemical and microbiological stability and they have to be stable when packaged and stored ready for use.
CARRYING O U T C H A N G E S In order to set up a CIVA service, the cooperation of the pharmacy department and managenient are necessary. When the pharmacy department were approached they were understanding and willing to become involved. A working party was set up to prepare for the service, an area on the unit was identified for preparation and storage of drugs; and equipment was hired and ordered. In view of the anticipated saving in nursing time, a pharmacist was employed on the nursing budget.
EVALUATION Information gathered was kept to a minimum but some of the categories were interpreted in different ways. However, when work colleagues are being asked to undertake extra recordings on top of a heavy workload, the method has to be designed to enable them to record it easily. The results obtained were felt to represent the size of the problem. The potential value of the service could be seen by staff and compliance was good. To date, the CIVA service is limited to a selected Journal of Cancer Nursing I (2) 96 98
98
Journal of Cancer Nursing
group of antimicrobials and other high-cost drugs. This is due to a variety of problems related to space and equipment. However, nursing staff quickly adapted to the service and really appreciate the convenience and the time saved by even a limited service. They have been encouraged to reflect on their roles and the nature of the care they give as it allows nurses to spend more time with the families. By selecting drugs carefully, financial savings have been greater than anticipated. The service is due to be fully operational within the next month. When this happens, it will be re-evaluated. It may not be possible to compare all costs accurately from the information gathered due to changes to variables over the period of time. However, it will be interesting to compare nursing time in the next activity analysis, as well as the drugs budget, the
ournal of Cancer Nursing I (2) 96-98 @ Pearson Professional Ltd 1997
nursing staff budget and supplies budget statements.
the
medical/surgical
REFERENCES
Audit Commission (1992) Making Time for Patients : A Handbook for Ward Sisters. HMSO, London. Breckenridge A (1976) Report of the Working Party on the Addition of Drugs to Intravenous Fluids. DHSS Health Circular, HC(76) Cousins D, Lee M, Stanaway M, Neary C (1989) Implementation and evaluation of an IV additive service for antibiotic injections. The Pharmaceutical Journal March: 14 16 Laverty D (1989) Accuracy of Nurses Calculations. Nursing Standard 39 (3): 34-37 United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) Code of Professional Conduct. UKCC, London
Promote and safeguard the patient's interest and well-being Ensure that no act or omission is detrimental to the interests, condition or safety of the patient.
As the demands of nursing time increase, nurses need to question their roles and scope of practice to assess who is the most appropriate person to be carrying out specific activities. The Code of Professional Conduct (Part 6) also encourages nurses to work in collaboration with other health care professionals (United Kingdom Central Council 1992). Within any paediatric haematology and oncology unit where children are admitted for modules of chemotherapy, making them susceptible to infections which then require antibiotic treatment, intravenous (IV) therapy is a major component of hospital treatment. It includes administration of:
Wendy Hills BSc (Hons), RGN, RSCN, RCNT,Acting Senior Nurse, Host Defence, Great Or'mond Street Hospital for Children NHSTrust, Great Orrnond Street, London WCI N 3JH, UK
• • • • •
Antibiotics and other medications Complex electrolyte infusions Cytotoxic chemotherapy Total parenteral nutrition (TPN) Blood products.
Antibiotics, other medications and electrolyte infusions are reconstituted immediately prior to administration and checked by two nurses within the ward. This uses a significant amount of nursing
journal of CancerNursing I (2), 96-98 @ PearsonProfessionalLtd 1997
time. It is necessary to establish whether there is a more appropriate way of organizing administration of IVs. It would be possible for antibiotics, other drugs and infusions to be prepared off the ward in advance if a hospital had a Central Intravenous Additive (CIVA) service. It may appear to student nurses passing through a unit that qualified staff spend most of their time giving IV products. During times of high staff turnover, the proportion of time that senior staff spend giving drugs is increased as new and junior staff are becoming competent in the variety of skills needed to carry out the task properly. During busy periods, patients and families may only see qualified staff to administer their drugs and, therefore, they may miss out on skilled observation and assessment, as well as explanations and specific support related to their disease, that experienced staff are best able to give. These issues prompted Great Ormond Street Hospital for Children NHS Trust to undertake an audit of the IV therapy process.
DATA GATHERING Information on nursing time associated with the administration of IV therapy was collected using activity sheets for each patient. An activity sheet was also placed in the areas where IV products were prepared. Activity was recorded over a 7-day period, from 00:00 to 00:00, in an attempt to reflect the changing workload over the week.
A N A L Y S I S OF DATA The IV-associated activities were divided into three categories: •
•
Those activities that could be done by someone other than a nurse, e.g. preparing TPN (prepared by pharmacy), preparing chemotherapy (prepared by pharmacy) and preparing electrolyte solutions. Activities felt to be exclusively nursing included, e.g. connecting lines to patients, disconnecting/heplocking lines and giving blood products.
Setting up a central intravenous additive service
•
Negotiable activities or activities shared between nurses and either technicians or pharmacists, e.g. giving IVs, checking IVs and taking bloods.
From the analysis of results, the best potential area for reducing nursing time spent preparing 1V therapy would be in giving and checking IVs.
Giving drugs Giving drugs included gathering equipment, preparing the drug, calculating the dose and administering the drug to the patient. Drugs could be administered as a bolus injection, continuous infusion or intermittent infusion. The first three activities could be prepared in advance by a pharmacist, leaving nurses to administer the drug and check it. An estimated preparation time from the study was 3 minutes to prepare a bolus injection, 7 minutes to add one drug to a bag and 10 minutes to prepare a syringe for IV infusion. Nurses recorded spending from 290 minutes to 650 minutes a day in giving drugs (average 425 minutes). This is the equivalent of one nurse a day. From the recording method, it is only possible to estimate how much time could be saved. However, if 50% of time could be saved by a pharmacy support service, it would free 0.5 of a nurse a day from this one activity on one ward.
Checking drugs This activity involved minimal practical assistance, but calculations and patient identity would be checked according to hospital policy. This activity could also be reduced by having drugs prepared by a pharmacy service; when drugs are prepared on demand a single drug is checked at a time. Many drugs are part of a course of treatment and so 2-3 days worth of drugs could be prepared and stored together. This would also reduce time spent on calculations. Many of the activities could be done more safely by an improved pharmacy service, and a few by a technician. Giving drugs, checking drugs and preparing electrolyte solutions are the activities that would be most suitable to be undertaken by a pharmacy department, and they were the three activities that accounted for nearly 80% (76%) of the IV workload. For pharmacy to take on this service, there are significant staffing, financial and environmental implications. Many hospitals have a CIVA service and this was felt to offer a suitable alternative.
CIVA service CIVA services were first recommended in 1976 (Breckenridge 1976). The reasons for setting up CIVA services were that IV drugs should be added
97
to fluids in pharmacy where dosages, compatibility and greater sterility could be checked and maintained by persons trained in that area of knowledge. The complexity of the drugs used is a good argument for setting up a CIVA service, as pharmacists can check the dosage, dilutions, compatibilities and calculations. Nurses have been shown to have comparatively high rates of drug calculation errors so it is in the interest of patients to have calculations checked by pharmacists (Laverty 1989). This is an even more important reason in paediatrics, where all dosages are individualized according to weight or surface area, and drug calculations and dosages are more complex. Other benefits of a CIVA service include savings on costs of drug (by cutting wastage of partly used vials or ampoules), greater accuracy (and, therefore, safety) of drugs, increased aseptic technique and the reduction of ward stocks (which has budget implications for expensive drugs). Savings in drug budgets have to be offset against the increased cost of disposables and use of pharmacy staff time, and these savings may be minimal (Cousins et al 1989). However, within a paediatric setting, the wastage of drugs is likely to be considerably higher than in the adult setting where most ampoules contain an adult dose. Not all drugs may be suitable for a CIVA service as drug properties have to include chemical and microbiological stability and they have to be stable when packaged and stored ready for use.
CARRYING O U T C H A N G E S In order to set up a CIVA service, the cooperation of the pharmacy department and managenient are necessary. When the pharmacy department were approached they were understanding and willing to become involved. A working party was set up to prepare for the service, an area on the unit was identified for preparation and storage of drugs; and equipment was hired and ordered. In view of the anticipated saving in nursing time, a pharmacist was employed on the nursing budget.
EVALUATION Information gathered was kept to a minimum but some of the categories were interpreted in different ways. However, when work colleagues are being asked to undertake extra recordings on top of a heavy workload, the method has to be designed to enable them to record it easily. The results obtained were felt to represent the size of the problem. The potential value of the service could be seen by staff and compliance was good. To date, the CIVA service is limited to a selected Journal of Cancer Nursing I (2) 96 98
98
Journal of Cancer Nursing
group of antimicrobials and other high-cost drugs. This is due to a variety of problems related to space and equipment. However, nursing staff quickly adapted to the service and really appreciate the convenience and the time saved by even a limited service. They have been encouraged to reflect on their roles and the nature of the care they give as it allows nurses to spend more time with the families. By selecting drugs carefully, financial savings have been greater than anticipated. The service is due to be fully operational within the next month. When this happens, it will be re-evaluated. It may not be possible to compare all costs accurately from the information gathered due to changes to variables over the period of time. However, it will be interesting to compare nursing time in the next activity analysis, as well as the drugs budget, the
ournal of Cancer Nursing I (2) 96-98 @ Pearson Professional Ltd 1997
nursing staff budget and supplies budget statements.
the
medical/surgical
REFERENCES
Audit Commission (1992) Making Time for Patients : A Handbook for Ward Sisters. HMSO, London. Breckenridge A (1976) Report of the Working Party on the Addition of Drugs to Intravenous Fluids. DHSS Health Circular, HC(76) Cousins D, Lee M, Stanaway M, Neary C (1989) Implementation and evaluation of an IV additive service for antibiotic injections. The Pharmaceutical Journal March: 14 16 Laverty D (1989) Accuracy of Nurses Calculations. Nursing Standard 39 (3): 34-37 United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) Code of Professional Conduct. UKCC, London