TELL US ABOUT YOUR FACILITY AND THE SCOPE OF YOUR RESPONSIBILITY.
ScrippsHealth is a non-profit system that includes five unique hospitals providing a wide range of services. These hospitals primarily specialize in a few major areas including med/surg, cancer, bone marrow transplants, kidney transplants etc. There are about 300,000 patient days in the system with the two largest hospitals providing about 100,000 each and the smaller three about 35,000 each. There are more than 11,000 employees and 2,600 physicians serving ScrippsHealth. The pharmacy departments are managed centrally by an executive management team to ensure continuity in both operational and clinical services.

WHAT CHANGES HAVE YOU SEEN SINCE YOUR ARRIVAL IN 1998?
The pharmacy has been moving toward a more clinical model. Pharmacists cover almost every floor in a clinical capacity – even in the smallest hospital. One accredited residency program is in place that trains two clinical pharmacists annually. We have plans for a joint residency program at two of the other hospitals. We have a clinical director of pharmacy, with five clinical managers and one operations manager at each facility. Six med safety officers (3 pharmacists and 3 technicians), plus an information services educator, have been hired for specialized services. The hospital system pharmacy service includes more than 200 full time equivalents of pharmacist and technician staff.

ALL GOOD PHARMACY DECISIONS START WITH A FOCUS ON SAFETY AND EFFICACY. WHAT WERE THE MAJOR REASONS DRIVING YOUR MOVE TO IV PUSH ON APPROPRIATE SMALL-VOLUME PARENTERALS (SVPs)?
Sherry and Sweeney published a study in 1993¹ that suggested IV push may actually extend the life of IV lines. The authors found a 9% decrease in phlebitis in outpatient settings and 26% on the inpatient side. Then, once our primary concerns of safety and efficacy were addressed, it was obvious that total costs would decrease by using such a simple system. Other obvious benefits were decreased fluid intake, more mobile patients less tethered to IV poles for extended infusions, decreased medication incompatibilities and easier scheduling of multiple medications because so much less time was being spent on the process.

WHAT ABOUT THE IMPACT ON NURSING?
The impact on nursing was a more surprising benefit. Nursing found that they actually spent less time with IV push than their previous SVP systems. Nurses no longer had to find pumps, secondary tubing, check drip rates, etc. Time and motion studies later proved that less time was in fact spent. A surprise subjective benefit appreciated by nurses was the ‘quality time’ spent right at the bedside interacting so closely with the patient. Nurses also were better able to detect any potential adverse drug reactions by stopping the push immediately versus coming back into the room after a 30-minute piggyback infusion was fully completed.

WHAT DRUGS DID YOU CONVERT TO IV PUSH?
High-use cephalosporins, H2 antagonists and certain anti-nausea drugs like Zofran. Drugs were selected for their chemical and clinical compatibility and positive impact on cost and patient care. IV push drugs must be able to be infused in one to two minute periods, but with dilutions that provide an osmolarity similar to blood and have an acceptable final pH. These critical criteria were met by diluting the more-concentrated drug in sterile water versus the minibag system of using less-concentrated drugs, but in normal saline or dextrose.

OVER WHAT PERIOD ARE THESE DRUGS TYPICALLY INFUSED?
Garrelts reported in a landmark 1988 Clinical Pharmacy article², updated in 1992, that one-gram cephalosporin doses can actually be injected over one minute and two-gram doses over two minutes. The specialized IV team involved in the studies evaluated each patient thoroughly, found no adverse drug reactions, and actually concluded that IV push should be the recommended method to infuse appropriate drugs.

WHAT INTERMITTENT SMALL-VOLUME PARENTERAL SYSTEM WERE YOU USING BEFORE IV PUSH?
It was a mixed bag of multiple systems in the pharmacy and nursing, much like many hospitals. We had ADD-Vantage® and Add-A-Vial^® minibags, frozen and premixed minibags, plain minibags and even syringe infusers in 1997.

HOW LONG HAVE YOU BEEN USING IV PUSH?
10 years, since IV push was introduced in 1997.

ABOUT HOW MANY DOSES HAVE YOU DELIVERED IV PUSH DURING THAT PERIOD?
About 50,000 doses were pushed in the first year. That number has risen to more than 85,000 doses in 2006. It would be conservative to say that over 750,000 IV doses have been pushed during that period.

WHAT WOULD YOU ESTIMATE YOUR COST SAVINGS ARE PER DOSE?
The very short answer is a savings of $2.95 per dose. The savings by going to IV push were calculated by first considering what it takes to provide doses in the current system. It’s easiest to start with obvious hard costs such as materials like minibags, specialty minibags and drug vial proprietary up charges and secondary tubing costs. There are also costs involved in tying up infusion pumps, IV poles and of course nursing labor. Our system determined that the weighted average cost of the pre-IV push systems was $6.38 per dose. IV push was calculated to be $3.43 per dose, yielding a savings of $2.95 per dose by converting to IV push.

WHAT DO YOUR NURSES THINK ABOUT IV PUSH?
We performed nursing surveys across five hospitals that showed tremendous and widespread satisfaction with the decision to convert to IV push.

HAVE THERE BEEN ADVERSE EVENTS FROM INFUSING CONCENTRATED DRUGS OVER VERY SHORT PERIODS?
Only one adverse drug report has been written regarding IV push during our 10-year program and that was in the first year. The problem was that the syringe was not warmed prior to injection and the patient experienced a transient stinging sensation.

DID YOU EXPERIENCE ANY OTHER CLINICAL ISSUES RESULTING FROM THE CHANGE TO IV PUSH?
No, resulting blood drug levels appear to be exactly the same from either 30-minute infusions, or one-minute boluses.

WHAT ABOUT PERIPHERAL IV LINES THAT DON’T HAVE LARGE-VOLUME IVs RUNNING TO PROVIDE ADDITIONAL DILUTION AND VEIN PROTECTION? DOES IV PUSH WORK FOR THOSE?
Yes. Our experience confirmed what is written in the literature – that absolutely no additional fluid protection is required for using IV push. The key is the focus on safety and efficacy. Mix the doses in sterile water to create solutions with acceptable osmolarity and pH. Vein irritation is actually more likely when concentrated drugs are mixed in normal saline or dextrose, creating hypertonic solutions.

WHAT DO PATIENTS THINK ABOUT IV PUSH?
Patients appreciate the ambulatory freedom, but also value the quality time spent face-to-face with nurses during the IV push process. It’s a rare and non-rushed time when real communication is possible.

HOW MANY HOSPITALS/SYSTEMS HAVE YOU CONVERTED TO IV PUSH?
I’ve personally converted 10 hospitals in two systems to IV push since the mid 1990s.

IF IV PUSH IS SUCH A SUPERIOR INTERMITTENT DELIVERY METHOD, WHY ISN’T IT MORE COMMON?
Education is the number one reason. Most pharmacy directors simply have not been exposed to different delivery methods and place far too much emphasis on the status quo. Furthermore, it’s human nature to resist change.

WHAT ADVICE WOULD YOU GIVE TO A PHARMACY MANAGER CONSIDERING CONVERTING TO IV PUSH?
You have to sell the idea to nursing and hospital administration before the program can even become a serious possibility. Start with the basic values of any good pharmacy decision making. Push the safety and efficacy benefits of IV push first. Then follow up with cost savings to have an all-win situation for patients, nursing, pharmacy and hospital administration.

RICK, THANK YOU FOR YOUR INSIGHTS. ANY FINAL COMMENTS?
Baxa is in an ideal position to educate pharmacy managers about the ‘low-hanging fruit’ of cost-savings programs such as IV push that also result in patient care improvements. IV push has worked exceptionally well for our hospitals for more than 10 years and could do the same in many other institutions.

Baxa Corporation offers a number of products that support a program for IV push compounding. These include the Repeater™ Pump for automating vial reconstitution, syringe filling and other fluid drug applications; the Rapid-Fill™ Automated Syringe Filler for automating syringe filling, capping and labeling; and our devices for more efficient preparation of IV admixtures. For more information on converting to IV push or for a Baxa product catalog, please contact Baxa at responses@baxa.com. Information about Baxa products that can assist your IV push program can be found online at www.baxa.com/products.

1 Sherry PO, Sweeney CW. Incidence of phlebitis in oncology patients. J Vasc Access Networks. 1993; 3:9, 10, 14-7.

2 Garrelts JC, Ast D, LaRocca J e al. Postinfusion phlebitis after intravenous push versus intravenous piggyback administration of antimicrobial agents. Clin Pharm. 1988:7:760-5.


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