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By Jodi Amendola
Intermittentdosing has long been the most common method to infuse b-lactam cephalosporin andpenicillin antibiotics. Intravenous doses are typically given over about 30minutes, one- to four-times daily, depending on the drug. Continuous infusiontherapy, the administration of these antibiotics and other drugs intravenouslyover an extended period of time, is a recent innovation that reduces drug costswhile improving patient outcomes.
Fast becoming the most popular protocol for the provision of thesemedications in the acute care setting, whether used in concert with antibioticsto fight infection or as preventive drug therapy in the post-operativeenvironment, continuous infusion offers distinct cost saving benefits formedical facilities while simultaneously improving patient outcomes.
Greenbrier Valley Medical Center, located in Ronceverte, West Virginia, is a122-bed community hospital serving the emergency, surgical, and acute caremedical needs of the southeastern region of West Virginia. The Medical Centeraverages 15 surgeries daily in general; orthopedic; obstetrics and gynecology;and ear, nose, and throat. The hospital is the epitome of a bustling small-townhealth center and, like its big-city colleagues, it faces a constant struggle tobalance costs while maintaining or upgrading quality patient services. In 1995,Greenbrier focused these efforts on improving the outcomes of their intravenousantibiotic program. A review of medical literature showed that some clinicianswere experiencing significant cost reductions and improved clinical results bymoving intermittent b-lactam regimens to single-drug bolus doses followed bycontinuous infusions. As part of the effort to improve results and controlcosts, the Medical Center wanted to alter the way it administered intravenousantibiotics and other drugs. Greenbrier worked with a continuous infusiontechnology vendor to cut down on infections.
The Medical Center worked with Baxa Corporation (Englewood, Colo), a companythat produced products to deal with many aspects of compounding and dispensingfluid medications, including oral unit dosing, IV admixture, syringe infusion,and TPN compounding. One of Baxa's more recent Baxa product innovations is theMicroFuseO Infuser. Designed for intermittent, fixed-rate drug delivery, thesyringe infuser provides a simple alternative to proprietary minibag deliverysystems and expensive infusion pumps. Specialized infusers offer delivery forniche drugs and 24-hour infusion therapies. Greenbrier began using 72 of theindividual Direct Dual Rate Infuser units in 1995 and upgraded more durable andefficient MicroFuse Extended Rate Infuser in early 1999.
Initially, Greenbrier decided to try continuous infusion with cefuroxime forcommunity-acquired pneumonia infections. After developing dosing protocols, thesearch began for an appropriate infusion pump. A selection committee reviewedthe available options. Micro pumps, with dedicated disposables, were notselected due to cost. Similarly, full-size infusion pumps had dedicateddisposables and were considered to be too restrictive for patient ambulation.The result of the infusion pump selection process was to purchase 72 Baxa CustomDual Rate Infusers (DRI).
The DRI unit, less complicated than comparable pumps, allows for the use oflow-cost generic syringes and microbore tube sets. The initial custom DRIs werespecialized versions of the catalog DRI syringe infuser, with two fixed infusionrates. Rate one was used for bolus infusion over about 20 to 40 minutes. Ratetwo infused specific syringe sizes and volumes continuously over 24 hours.
In 1999, Greenbrier upgraded their infusers to the new MicroFuseO ExtendedRate Infuser (ERI) model.
Controlling the ever-increasing costs of pharmaceuticals and related suppliesis a challenge facing not only smaller, rural acute care hospitals likeGreenbrier, but also larger hospitals. Tight budgets and labor markets requirehospitals to provide more services with less labor. Continuous infusion providedopportunities to reduce drug and supply costs as well. Consequently, Greenbrierwas able to cut labor costs by reducing the number of daily doses.
Keeping the required medications on the shelves and maximizing the use ofstock and supplies became critical for meeting budget requirements. "Withthe continuous infuser, we use one $0.25 syringe instead of multiple, $0.90 IVbags," says Michael Barnes, Director of Pharmacy at Greenbrier.
Continuousinfusion reduces the number of doses required each day. In turn, this decreasesthe chance for human error by nurses, technicians, hospital pharmacists, andeven physicians. When using the MicroFuse Extended Rate Infusers, only oneantibiotic syringe is administered each 24-hour period. This eliminates multipledaily interventions required in intermittent dosing to monitor and replace IVbags. Nurses make one stop at the bedside to load a syringe, returning only ifpatients require other assistance. With the constant demands during a nursingshift, this results in significant workflow efficiency.
"Continuous infusion concept allow us to prepare medication syringes inadvance, saving valuable nurse time and eliminating frequent references topatients' charts," Barnes says. "Furthermore, the infuser has helpedour nurses and pharmacy staff to reduce drug waste. Our nurses have more timefor direct patient care and essential administrative tasks."
Through continuous infusion therapy, Greenbrier's patients have enjoyed adecreased patient length of stay with lower drug doses. Continuous infusioneliminates the blood level peaks and valleys seen with intermittent dosing. Drugblood levels are maintained consistently above the minimum inhibitoryconcentration (MIC) required to kill the infection with lower daily doses.Greenbrier has experienced a length-of-stay reduction, averaging a half-day, forits continuous infusion therapy patients.
The compact size and ease of portability of the unit makes handling easy. Aslong as the physician agrees, and the medical condition does not warrant againstit, the MicroFuse Infuser can be detached from the IV pole mount or hanger andplaced in a specially designed "waist pack," which can be worn by thepatient. This new mobility frees patients to satisfy their own bathroom needs,move easily throughout the hospital for ancillary tests, or attend physicaltherapy sessions without the unwieldy pole apparatus that often tethers them totheir beds or hospital rooms.
Previously, Greenbrier suffered extensive malfunctions and equipmentbreakdowns because of incidental damage due to patient product mishandling. Byworking with nurses at Greenbrier, Baxa developed a more durable unit, limitingthe number and severity of repairs, and extending the service life of theinfuser. The complete upgrade to the new model - the MicroFuse Extended RateInfuser - was completed in early 1999.
"The original model did not withstand the rigors of a fall to thefloor," Barnes says. "We often had large numbers of units out ofservice for repairs."
Jodi Amendola is the regional VP, CPR Communications for Baxa Corporation(Englewood, Colo).