AN INTEGRATED APPROACH TO PRIORITIZE EFFECTIVE AND SAFE ALTERNATIVE INFUSION METHODS TO VOLUMETRIC INFUSION PUMPS AT CSSS DU LAC-DES-DEUX-MONTAGNES Gnahoua Zoabli, P.Eng., M.Eng., Ph.D. Chief of biomedical engineering depertment CSSS Du Lac-Des-Deux-Montagnes Vancouver, May 21-23, Collaborators Sylvain Marcil 1, Liane Rouiller 1, Nathalie Bigras 1, Chantale Séguin 1, Nancy Chabot 1, France Granger 1, Arielle Katia M. Bada 2, and Lucie Dugré 1 1 CSSS du Lac-des-Deux-Montagnes; 2 École Polytechnique de Montréal

O VERVIEW I.Summary of the problem II.Methodology III.Results IV.Discussion V.Conclusion 2 Vancouver, May 21-23, 2014

3 Service du génie biomédical Développements en cours – Plan stratégique Agrandissement du Bloc endoscopique (C) Agrandissement de l’ urgence (E) 35 civières 4 salles de choc Nouvelle Unité d’ophtalmologie (A) Médecine nucléaire (M) Nouveau Centre de télénéphrologie (M) Nouveau Centre d’hémato-oncologie (M) 361 lits de courte durée lits en hébergement employés, employées, 22 pharmaciens 257 médecins 180 bénévoles moncsss.com

P ROBLEMATIC I.Issues regarding current models of volumetric pumps - software francization of their new model - compliance to Health Canada - availability estimated in 2015 (no replacement, no new purchase) 4 Vancouver, May 21-23, 2014

O BJECTIVE Find a contingency plan allowing CSSS LDDM to maintain an optimal intravenous therapy care to patients during this period. Vancouver, May 21-23,

1 (Need to )know actual clinical use of volumetric pumps 2 Consult the Guide for IV administration with associated clinical surveillance (GIVACS) 3 (From the GIVACS) identify the medications absolutely requiring a volumetric pump; 4 (From the GIVACS) identify drugs that can be safely administrated with other technological methods (gravity, mini-infusion pump, syringe pump, ambulatory pump, patient controlled administration, injection); 5 Consult the collective directive for the installation of an injection plug if the solute is prescribed in keep vein open (KVO) infusion mode; 6 With a team of seven individuals, inventory of our park of volumetric pumps in 30 min (consider the mobility of these devices); 7 Prepare a consultation platform of the care units to determine their effective infusion practice; Vancouver, May 21-23, M ETHODOLOGY

8 Collect data from these care units with the platform to get an idea of the current medications administration practice and to identify the gaps with the GIVACS; 9 From the information gathered, identify in accordance with the pharmacy and the concerned nursing units, how many volumetric pumps are used instead of the proper infusion technique, according to the GIVACS instructions; 10 Based on the number and frequency of medications used on each unit with volumetric pumps, calculate a weighted Pump/Medication ratio to take into consideration the actualized need of volumetric pumps on each nursing unit; 11 This ratio will help determine for the two-year period, if there are Too many, Acceptable or Less pumps on the unit; 12 Submit a report of our consultations to a Multidisciplinary Committee composed of clinical and medical directorates, and purchasing services. Vancouver, May 21-23, M ETHODOLOGY (C ONT ’ D )

S OME ILLUSTRATIONS Vancouver, May 21-23,

C ONSULTATION OF THE MEDICATION ADMINISTRATION GUIDE The medication administration guide is developed by the pharmacy to associate each drug to be administered by IV to the suitable infusion technique. Vancouver, May 21-23, NameAdministration mode Side Effects

M EDICATION S URVEY QUESTIONNAIRE / U NIT Vancouver, May 21-23, Recommended mode is not Volumetric pump Actually used with Volumetric pump ? How often ? Mini-infusion pump is recommended

RESULTS Vancouver, May 21-23,

I NVENTORY OF THE VOLUMETRIC PUMPS May 21, 2013 from 2:00 PM to 2:30 PM 27 volumetric pumps missing Vancouver, May 21-23,

O UR CURRENT PRACTICE IN IV THERAPY Drugs administered by Volumetric pumps are mainly used in critical care units. Vancouver, May 21-23,

IV T ECHNOLOGY S ELECTION D ECISION T REE In collaboration with the managers of medical care units and pharmacy, a decision tree has been developed Vancouver, May 21-23, Objective: To determine the recommended infusion technology

Vancouver, May 21-23,

W EIGHTED P UMP /M EDICATION RATIO Vancouver, May 21-23,

Vancouver, May 21-23, W EIGHTED P UMP /M EDICATION RATIO

1 Improved collaboration between units regarding volumetric pumps 2 Some counter-effects between OR and MED-SURG. 3 Revised complementary need according to the decision tree and the actual needs for volumetric pumps Vancouver, May 21-23, D ISCUSSION

4 Solute drop calculation is forgotten  provide drops calculation strips and support the nursing personnel to master the bases of gravity infusion practice 5 Medical history of patient is risky  renal failure, cardiac history, chronic obstructive pulmonary disease, degenerative disease, etc. 6 Reduced Nurse-to-patient ration during night shift. Vancouver, May 21-23, M AIN REASONS OF V OLUMETRIC PUMPS OVERUSE

ADDITIONAL NEEDS FOR VOLUMETRIC PUMPS (April 1, 2014) Vancouver, May 21-23, May 21, 2013

1 This study brought together all local expertise in intravenous therapy to establish a contingency plan based on current best practices in IV therapy 2 The decision tree is planned to be part of the continuing education of nurses to maintain IV best practices standards at CSSS LDDM 4 Another CSSS which benefited from our approach has told us about its successful application 5 We share our experience, hoping it will help to better manage the two-year waiting in other Quebec CSSS and hospitals across Canada 6 The success of this approach requires that any volumetric pump transferred with a patient to another care unit will return to its original unit.  This remains a perpetual challenge with infusion pumps in any hospital. Vancouver, May 21-23, C ONCLUSION

We thank the following members of the multidisciplinary team and managers whose involvement has led to develop the decision tree for IV therapy at CSSS LDDM. Medical units Michelle Dufour, Jacob Lalanne, and Nathalie Comtois Surgery Mélissa Pagé, and Jocelyne Sanscartier Counselors in nursing Chantal Laperriere, and Dany Maheux. Their contribution has helped make more realistic the application of this IV therapy decision tree, facilitating thus its clinical acceptability. Vancouver, May 21-23, A CKNOWLEDGMENTS

Q UESTIONS ? 23 Vancouver, May 21-23, 2014