mp:Kickstart Workflow Intravenous Therapy

1 Introduction

The information standard for Medication Process 9 (MP9) has not yet been fully developed. Further development is needed, particularly for the exchange of data relating to infusion therapy. Specific agreements have been made for the Kickstart based on decision VO37 of the Core Team. However, this decision does not sufficiently clarify what infusion data is and is not exchanged. Further development has been achieved in collaboration with the administration sectors, Medical Specialist Care and various software suppliers. This is explained below in various situations.

This approach applies to the Kickstart and will be further developed simultaneously.

2 Prescribe

The following agreement applies to the prescription of infusion therapy in the Kickstart:

The active substance is stated in the medication agreement (MA). A reference to a schedule or protocol indicating how the infusion should be prepared, as well as the solvent, can be included in the 'Explanation' data element. This also applies to (short-acting) insulins.

If multiple active substances are prescribed, this usually results in the same number of MAs or a magistral. In the case of an infusion preparation that is included in the G-standard and contains multiple active substances, that specific product can be selected in the MA. This does not result in multiple MAs.

3 Dispense

3.1 Clinical situation

In a clinical situation, the solvent is usually not prescribed separately. A single administration agreement (TA) containing the active substance is typically sufficient.

3.2 Ambulatory Situation

In an ambulatory situation, both the pharmacy and the administrator are able to prepare the medicine for administration.

3.2.1 Preparation of infusion by pharmacist

The pharmacist prepares a TA with compounded medication, in which both the drug and the solvent are registered as ingredient. This results in a single entry on the administration list. See practical example 1 for details.

3.2.2 Preparation of infusion by administrator

When the infusion is prepared by the administrator, the pharmacist does not only dispense the medicine. Associated aids are also provided, such as a solvent and an agent for flushing the line. Therefore, two separate, parallel TAs and medication dispensings (MVEs) are created under one pharmaceutical treatment (MBH): one for the medicine and one for the solvent. This results in two separate lines on the administration list. This must also clearly state what the aid is intended to be used for. See practical examples 2 and 3 for details.

4 Administer

Specific agreements have been established for medication administrations (MTDs) that only apply during the Kickstart. Not all MTDs and other infusion data will be exchanged and are therefore not available in the chain, for example, for an administration overview. Below are the details:

• Single active substance: MTDs of infusions with a single active substance, whether or not prepared for administration, are recorded in the information system and exchanged. Associated MAs and TAs are also exchanged.

• Dual active substances: MTDs of infusions with two active substances can be registered but are not exchanged. Unless it is registered as a magistral in one MA and TA. In that case, the MTDs can be exchanged. Associated MAs and TAs are also exchanged here.

• Infusion rate: The infusion rates described in the MA and TA are also included in the MTD and can be exchanged. This applies to both continuous infusions and bolus doses. See practical example 5 for more information.
  However, if infusion rates are not specified in the MA or TA and an administrator makes a change themselves, this is not exchanged in the MDT, for example in the case of a perfuser pump.

• Volume: When attaching a new syringe pump or infusion bag to the patient, the total volume is registered in the MTD and exchanged. If only part of the total volume has been administered, this can be updated by correcting the MTD. This is done by creating an additional MTD, in which the remaining volume of the infusion bag is registered. This is recorded as a negative number, for example -200 ml. With this, the total administration can be calculated. The original volume of for example 1 litre, minus the residual volume of 200 ml, results in a total administration of 1000 – 200 = 800 ml. See practical example 4 for details.

• Admission/discharge: In situations of admission or discharge, it may be necessary to provide a written transfer of MTDs or other infusion data that cannot be exchanged. Relevant MTDs from the past 24 hours can be provided. In addition, the volume of an infusion that is being taken along can also be stated.

5 Practical Examples of Infusions

5.1 Practical example 1: Preparation of infusion by pharmacist

The prescriber writes a prescription for ceftriaxone 2000 mg, once daily for 6 weeks. The prescriber indicates in the MA annotation that the ceftriaxone must be delivered in an elastomeric pump.

The pharmacy prepares the ceftriaxone 2000 mg in the elastomeric pump and creates a TA for a compounded medication that includes both the active substance and the solvent.

If the elastomeric pump is registered as an aid from the G-Standard (Dutch drug database) in the TA, it will be made available. It is up to the receiving system to filter this TA and not display it on the medication overview.

A healthcare professional records the administration of the ceftriaxone at that moment when the pump is connected.

5.2 Practical example 2: Administration with a flushing agent other than the solvent

Ceftriaxone 2000 mg intravenously has been prescribed for a minimum of 7 days. The patient will receive this at home via a PICC line administered by home care. This is a central venous catheter suitable for extended use. The line must be flushed daily after administering the antibiotics.

The prescriber creates an MA and VV for the active substance, ceftriaxone. The pharmacist creates two TAs for administering the medication: one for the antibiotic and one for the solvent, water for injection. In addition, a third TA is created for NaCl 0,9% infusion bags for flushing the line, categorized under a separate MBH. Each of these dispensings are recorded in its respective MVE.

The administrations of the antibiotic and the solvent can easily be grouped together on the administration list, as they fall under the same MBH. The rinsing agent may not be grouped together, as it concerns a different MBH. This will result in three separate MTDs.

5.3 Practical example 3: Administration with the same flushing agent as the solvent

Due to pneumonia, a patient is prescribed an intravenous course of antibiotics. The administration will be prepared at the bedside. The prescriber creates an MA for amoxicillin 1000 mg.

Under that MBH, the pharmacy prepares a TA for both the amoxicillin powder for injection and the NaCl 0.9% ampoules for dissolving the amoxicillin. The annotation specifies that these are intended for preparing the amoxicillin for administration.

NaCl 0.9% ampoules are also required for flushing the line. A separate TA must be created for this. The quantity of NaCl 0.9% ampoules must be sufficient for both preparing the amoxicillin for administration and flushing the line. Since only one dispensing of a medicine is allowed per day.

The administration of the antibiotic and the solvent fall under the same MBH, which means they can be grouped together on the administration list. The rinsing agent may not be grouped together, as it concerns a different MBH. This will result in three separate MTDs.

5.4 Practical example 4: Registering incomplete infusion administration by means of a correction

A prescriber creates an MA for morphine 1 mg/ml, 100 ml administration per infusion. The prescriber sets the infusion rate at 10 mg/hour. The pharmacist creates a TA for Sendolor 1 mg/ml with an infusion rate of 10 mg/hour. During administration, the patient experiences discomfort from the infusion and after 1 hour the medication is subsequently stopped. At that point, 90 mg of medication remains in the infusionbag. This is recorded as -90mg, indicating that 100 - 90 = 10 mg of medication has been administered. See section 4.3.15 of the FO for similar corrections.

5.5 Practical example 5: Document the correction in the MTD following a modification in the infusion rate

A prescriber creates an MA for morphine 1 mg/ml, 100 ml administration per infusion. The infusion rate is set by the prescriber at 0.5 mg/hour. The pharmacist creates a TA for Sendolor 1 mg/ml with an infusion rate of 0.5 mg/hour.

The caregiver who connects the Sendolor to the patient records the MTD.

After three days, the prescriber increases the administration rate to 1 mg/hour. The caregiver corrects the MTD by registering the remaining amount as a negative number in a new MTD, in this case –62 mg. This allows us to calculate that 100 - 62 = 38 mg of medication has been administered at an infusion rate of 0.5 mg/hour.

This is followed by an additional MTD stating the new infusion rate of 1 mg/hour with a remaining amount of 62 mg.