Reflections on the Current State of Infusion Therapy
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© Copyright AAMI 2016. Single user license only. Copying, networking, and distribution prohibited. Features AAMI Foundation is very grateful to its premiere industry Reflections on the Current partners and wishes to thank them for making the work of the foundation possible: National Coalition for Alarm State of Infusion Therapy Management Safety; National Coalition to Promote the Continuous Monitoring of Patients on Opioids; and the Matthew B. Weinger and Andrew Kline National Coalition for Infusion Therapy Safety. Diamond Sponsors: This article reviews the current state of A Brief History of Infusion Therapy About the Authors intravenous (IV) infusion technology and IV infusion therapy has a long and remarkable Matthew B. delineates aspects that would benefit from history. The first recorded attempt to give an Weinger, MD, improved design and development. It infusion was in 1492,4 when physicians tried to is professor and provides context for the current landscape of transfuse Pope Innocent VIII via vein-to-vein vice chair of infusion technology by briefly describing the anastomosis from three young boys—both the anesthesiology history of infusion therapy and highlighting Pope and his donors died. The first working and professor of biomedical key events and innovations that have shaped infusion device was created in 1658 by Sir informatics and medical education modern infusion. Building on previous Christopher Wren who attached a quill to a at the Vanderbilt University School reports that focused on medication errors pig’s bladder to instill a mixture of alcohol and of Medicine in Nashville, TN; director and patient safety,1,2 the current work concen- morphine into the veins of sick dogs.5 Learning of the Center for Research and trates on the limitations of existing of Wren’s success, Richard Lower, a London Innovation in Systems Safety at the Vanderbilt University Medical Center technology and related workflows that cardiologist, infused a man named Arthur Coga and staff physician in the Geriatric constrain clinical efficiency and overall value. with sheep blood to calm him, inciting a Research Education and Clinical Platinum Sponsors: Future innovations that could advance “benign form of insanity.”6 Dr. Lower used Center at the VA Tennessee Valley infusion system safety, efficacy, usability, primitive versions of the same elements of Healthcare System in Nashville, TN. efficiency, and overall value to clinicians and modern-day syringes, needles, and catheters. Email: [email protected] the healthcare system also are discussed. Of As experimentation continued, the proliferation Andrew Kline, note, this article focuses on volumetric of adverse events led both the British Royal BA, is program infusion pumps used in clinical settings. Society and the Vatican to ban transfusions in coordinator in Beyond reducing medication errors, an the late 1660s, and infusion science was put on the Center for important potential benefit of optimal design hold for more than a century.6 Research and Innovation in of infusion technology is the prospect of In 1795, the American physician Philip Syng Systems Safety considerable cost savings. Each preventable Physick once again advocated for human-to- at Vanderbilt University Medical adverse drug event (ADE) has been reported human blood transfusions. However, it was Center in Nashville, TN. Email: Gold Sponsors: to cost nearly $9,000.3 Through built-in not until the 1820s that James Blundell, an [email protected] designs and adherence to the “five rights of English physician and obstetrician, performed medication administration,” smart pumps can the first documented successful transfusion.4 help decrease the incidence of ADEs. Indeed, Blundell also developed two mechanical not only is avoidable patient harm wrong, it infusion devices: the gravitator, which used also has proven to be expensive. Moreover, gravity to deliver fluids in a regulated stream, care process inefficiencies add increased costs and the impellor, which infused fluids under to a healthcare system that is already far too pressure. These devices sound eerily similar costly for the quality of care offered. to current technologies. Biomedical Instrumentation & Technology July/August 2016 253 © Copyright AAMI 2016. Single user license only. Copying, networking, and distribution prohibited. Features Infusion science accelerated in the 1830s pump also included an early version of dose during London’s cholera epidemic. Dr. error reduction software (DERS) that alerted William O’Shaughnessy reported in The the user to potential problems with their Lancet in 1832 that cholera victims lost a high on-pump programming. Mike Cohen and concentration of their saline and alkali.6 In Tim Vanderveen were the first to describe the response, Dr. Thomas Latta performed the smart pump in a 2002 issue of the Institute first nonblood IV infusions of sodium for Safe Medication Practices newsletter.8 In chloride and bicarbonate and was able to save 2010, Sims noted that “since infusion pumps eight of the 25 victims he treated.6 In the are used in so many settings in almost every mid- to late 1800s, numerous clinicians hospital bed, many changes will no doubt be initiated and advocated for IV medication forthcoming in the next few months or administration. The most common IV years.”3 Smart pumps can now be found in medications were narcotic substances, most major hospitals worldwide and have including opium and cocaine. undoubtedly prevented many serious infusion IV medication administration, as well as errors. However, as currently implemented, fluid and transfusion therapy, became part of they only prevent a portion of all infusion- routine military medicine during the Second related harm, leaving many unresolved safety World War.5 The first civilian infusion service and quality issues with IV therapy. may have occurred in 1940 at Massachusetts General Hospital (MGH), where one nurse Cost of Drug Errors served as the infusion “operator.” Clinicians The Society for Actuaries suggested that the returning to civilian practice helped to financial cost of medical errors was nearly $1 proliferate modern IV therapy. While trillion per year when including both the mechanical peristaltic pumps (e.g., for direct and the indirect (e.g., morbidity, cardiopulmonary bypass and dialysis applica- decreased patient quality of life) costs.9 tions) were introduced earlier, and the first Considering the impact of the Institute of ambulatory pump was marketed in the late Medicine’s likely conservative 2001 estimate 1950s, the first modern electromechanical of nearly 100,000 medical error–related infusion pumps became commercially deaths annually, researchers and policy available in the 1960s. An important early experts have called these errors “America’s innovation was the use of an electronic drip most important public health issue.”10 What detector that allowed feedback control to a might seem like a small error can snowball, microprocessor to improve flow accuracy. As producing exponential effects on patients and the market matured, competitors introduced their cost of treatment. Without a systemwide further innovations, including the first focus on quality of care, the moral and “volumetric” infusion pump, whereby the financial burden of avoidable injury and volume being pumped was directly measured death will continue to plague healthcare and recorded (within constraints to be systems worldwide. Technology has a role in discussed later); “air-in-line” and downstream reducing injury and cost, but only if it is (distal) occlusion alarms; and the use of a designed and implemented correctly. Ample proprietary disposable. opportunities exist for infusion technology to So-called “smart” pumps were first con- improve substantially the overall value of ceived by Dr. Nathaniel Sims and his team at healthcare processes. MGH in 1992, then implemented in 1997.7 The first permutation of the team’s fully Drug Library Creation operational smart pump showed the promise and Maintenance of interoperability by connecting the pump to A key finding of a recent survey was that a computer library of infusion medications. hospitals using smart pumps typically Their most important innovation was the adopted this technology due to “inventory age incorporation of a hospital-proctored drug and failure” rather than as part of an over- library into the pump’s software, thereby arching “safety strategy.”11 Moreover, these allowing the user to select specific drugs, hospitals were unable to integrate their new concentrations, doses, and rates. The MGH pumps with other medication management 254 Biomedical Instrumentation & Technology July/August 2016 © Copyright AAMI 2016. Single user license only. Copying, networking, and distribution prohibited. Features technologies (i.e., computerized provider infusions.2,13 Redesigned infusion technolo- order entry, bar-coded medication adminis- gies must consider and address these tration), thereby limiting the ability of their inefficiencies. Given the high cost of nursing pumps to fully address the “five rights.” As care in most facilities, efforts to reduce these one indication of the limitations of DERS, low-value tasks will improve nurses’ job only about one-half of the hospitals surveyed satisfaction and yield substantial cost savings implemented hard limits on their pumps. for the organization. Below, we discuss Further, a major reason for DERS noncom- specific opportunities for improvements in pliance was incomplete or outdated