mp:Kickstart Workflow Intravenous Therapy

1 Introduction

The Medication Transfer Programme works together with healthcare providers and software suppliers to realise comprehensive medication data across the healthcare chain, with the aim of improving medication safety. The information standard for Medication Process 9 (MP9) has not yet been fully developed. Further development is required, particularly regarding the exchange of data relating to infusion therapy. At present, it is unclear when this further development will take place.

Until further development has taken place, specific agreements apply to the exchange of infusion therapy data, based on chain agreement VO37. However, this agreement does not provide sufficient clarity as to which infusion data are exchanged and which are not. Further development has been achieved in collaboration with the administration sectors, Medical Specialist Care and various software suppliers. This is explained below for various situations.

This approach applies to the Kickstart and remains valid throughout the scale-up phase until further development of infusion therapy data exchange has been completed.

2 Prescribe

The following agreement applies to the prescription of infusion therapy containing a single active substance:

The active substance is recorded in the medication agreement (MA). A reference to a protocol or schedule indicating how the infusion should be prepared, as well as the solvent and infusion fluid, may be included in the ‘Explanation’ data element or in the designated fields within the healthcare information system (XIS). In the exchange, however, this information can only be communicated through the ‘Explanation’ data element.
In the ambulatory setting, an infusion fluid may also be prescribed and exchanged as a separate MA.

If multiple active substances are prescribed, an infusion preparation included in the G-Standard (Dutch drug database) should be used whenever possible. This specific product can be selected in the MA.
If such a product is not available, the active substances are either included in a magistral preparation or prescribed in multiple MAs.

3 Dispense

3.1 Clinical Setting

In a clinical setting, the solvent or infusion fluid is usually not prescribed in a separate administration agreement (TA). A reference to a schedule of protocol indicating how the infusion should be prepared, as well as the solvent and infusion fluid, may be included in the ‘Explanation’ data element or in the designated fields within the XIS. In the exchange, however, this information can only be communicated through the ‘Explanation’ data element. See practical example 4 for details.

3.2 Ambulatory Setting

In an ambulatory setting, the way of recording depends on whether the medicine is prepared for administration by the supplier or by the administrator.

3.2.1 Preparation of infusion by the supplier

When, in an ambulatory setting, the infusion is prepared for administration in the pharmacy, the supplier creates a TA for a magistral preparation. This records the medicine, the solvent used and, where applicable, the packaging material as ingredients. This results in a single entry on the administration list. See practical example 1a for details. Practical example 1b illustrates the situation in which the supplier supplies a ready-to-use product.

3.2.2 Preparation of infusion by the administrator

When, in an ambulatory setting, the infusion is prepared by the administrator, the supplier does not only dispense the medicine. Associated aids are also provided, such as a solvent and/or an agent for flushing the line. For the medicinal product and the solvent, two separate, parallel TAs and medication dispensings (MVEs) are created under a single pharmaceutical treatment (MBH). This results in two separate lines on the administration list. Any TA for the flushing agent is recorded under a separate MBH. For these aids, it must be clearly specified for what purpose they are to be used. See practical examples 2 and 3 for details.

4 Administer

Not all MTDs and other infusion data are exchanged and are therefore not available throughout the healthcare chain, for example, for an administration overview. The following agreements apply to the exchange of MTDs:

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

• Dual active substances: MTDs of infusions with two active substances can be registered but are not exchanged. The associated MAs and TAs, containing the individual active substances, are exchanged. If two active substances are recorded as a magistral in a single MA and TA, the MTD can be exchanged.

• Infusion rate: The infusion rates specified 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 examples 5, 6, and 7 for more information.
  However, if infusion rates are not specified in the MA or TA and are adjusted by the administrator, these changes are not exchanged in the MTD, for example in the case of a perfusor pump.

• Volume: When replacing a syringe in a syringe pump or attaching a new infusion bag to the patient, the total volume is recorded 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 recorded. This remaining volume is recorded as a negative number, for example -200. This enables the total administration to be calculated. For example, an original volume of 1 litre minus a residual volume of 200 ml results in a total administered volume of 1000 – 200 = 800 ml. See practical example 6 for details.

In situations involving 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.

These agreements remain applicable until further development of the exchange of infusion therapy data has been completed.

Please note: These limitations apply only to the exchange of Medical Administrations (MTDs), not to their registration. For example, some healthcare information systems allow the registration of MTDs involving multiple active substances or infusion rates, even though these cannot currently be exchanged.

5 Practical Examples Infusion Therapy

5.1 Practical example 1: Preparation of an infusion by the supplier

In practical example 1, an infusion administered via an elostomeric pump is prescribed.
For both the MA and the TA, there are two possible approaches:
• use of a ready-to-use product included in the G-Standard;
• an alternative method of prescribing, such as a magistral preparation or inclusion of the elastomeric pump in the ‘Explanation’ data element.
To illustrate these options clearly, the example has been divided into Examples 1a and 1b. These examples demonstrate that different choices can be combined.

5.1.1 Practical example 1a: Prescriber selects a G-Standard product, supplier delivers a magistral preparation

This practical example applies to both ambulatory and clinical settings.

The prescriber issues a prescription for ceftriaxone 2000 mg, to be administered in a 100 ml elastomeric pump that delivers the medication over 30 minutes. The prescriber selects this as a complete product from the G-Standard. The dosage is one unit once daily for a period of six weeks.

The elastomeric pump is filled in the pharmacy. The supplier creates a TA for a magistral preparation, including the active substance, the solvent and the elastomeric pump.

A healthcare professional records the administration of ceftriaxone each time a new elastomeric pump is connected.

Note*: in the ambulatory setting, reimbursement of the elastomeric pump is handled through the MVE whenever possible, in order to maintain the separation between therapy and logistics. If this is not possible, the TA must be split into multiple TAs. As a result, multiple MTDs must be recorded for each administration event.

5.1.2 Practical example 1b: Prescriber includes the elastomeric pump in the Explanation, supplier selects a G-Standard product

This practical example applies to both ambulatory and clinical settings.

The prescriber issues a prescription for ceftriaxone, 2000 mg, daily for a period of six weeks. In the Explanation of the MA, the prescriber specifies that the ceftriaxone must be supplied in an elastomeric pump.

The pharmacy orders a ready-to-use elastomeric pump. The supplier creates a TA using the commercial product.

A healthcare professional records the administration of ceftriaxone each time a new elastomeric pump is connected.

5.2 Practical example 2: Preparation by the administrator – Different solvent and flushing agent

Ceftriaxone 2000 mg intravenous therapy has been prescribed for a period of seven days. The patient receives this treatment at home, administered by home healthcare services via a PICC line, a centrally inserted venous catheter that can remain in place for an extended period. This line must be flushed daily after administration of the antibiotics.

The prescriber creates an MA and a VV for the active substance, ceftriaxone. The supplier creates two TAs for administering the medication: one for the antibiotic and one for the solvent, a 100 ml infusion bag containing 0.9% NaCl. In addition, a third TA is created for 0.9% NaCl mini-plasco containers to flush the line. This third TA falls under a separate MBH. All three dispensings are recorded in a separate MVE.

The administrations of the antibiotic and the solvent can easily be grouped on the administration list, as they fall under the same MBH. The flushing agent may not be grouped, as it belongs to a different MBH. Recording both the administration and the flushing procedure results in three separate MTDs.

5.3 Practical example 3: Preparation by the administrator – Identical solvent and flushing agent

An ambulatory patient is prescribed intravenous antibiotic therapy for the treatment of pneumonia. The medicinal product will be prepared by the administrator.

The prescriber creates an MA for amoxicillin 1000 mg. Under the same MBH, the supplier creates three TAs: one for the amoxicillin, one for the 0.9% NaCl ampoules used to dissolve the amoxicillin, and one for the infusion fluid. The additional instruction in the TA for the 0.9% NaCl ampoules specifies that these are intended for preparing the amoxicillin for administration.

Additional 0.9% NaCl ampoules are also required for flushing the line. A separate TA must therefore be created for this purpose. As only one dispensing of a particular product may be recorded per day, the dispensing of the 0.9% NaCl ampoules must be sufficient for both purposes.

The administrations of the antibiotic, the solvent, and the infusion fluid fall under a single MBH, allowing them to be grouped on the administration list. The flushing agent may not be grouped, as it falls under a different MBH.

Recording the administration and the flushing procedure results in four separate MTDs. In this practical example, the MTDs are not illustrated, as they are handled in the same way as in practical example 2. This example focuses specifically on the dispensing process.

5.4 Practical example 4: Clinical setting – Preparation by the administrator

In the hospital, amoxicillin 500 mg intravenous therapy has been prescribed for a period of seven days. The patient receives this treatment via a PICC line, a centrally inserted venous catheter that can remain in place for an extended period. This line must be flushed daily after administration of the antibiotics.

The prescriber creates an MA for the active substance. The prescriber may also record the solvent (water) and the infusion fluid (a 50 ml infusion bag containing 0.9% NaCl) in the XIS. The clinical XIS may provide dedicated fields for this purpose.

The supplier records this information in the TA in the same way.

The MA and TA are made available for exchange. However, MP9 does not contain structured fields for exchanging information recorded in the dedicated fields mentioned above. This information can only be exchanged through the ‘Explanation’ data element. Note: The illustration only shows information that can be exchanged in a structured manner through MP9.

In the clinical setting, no VV is required. The supplier ensures that the medication remains available for as long as the MA is active.

Optionally, flushing of the line may be recorded in an MA, TA, and MTD, under a separate MBH.

5.5 Practical example 5: Continuous infusion with bag changes

A clinical patient is prescribed a continuous infusion of amoxicillin at a dose of 12,000 mg per day. The prescriber records this in an MA.

The total daily dose is divided across three infusion bags, each administered over a period of eight hours. As a result, a new infusion bag must be connected three times per day. The supplier records this in a TA.

The administrator records an MTD each time a new infusion bag is connected.

The active substance, administration rate and administration duration are exchanged through the MA, TA and MTD.

5.6 Practical example 6: Recording a partial infusion administration by means of a correction

This practical example applies to both ambulatory and clinical settings.

A prescriber creates an MA for morphine 1 mg/ml, volume 100 ml, to be administered by infusion. The administration rate is set by the prescriber at 10 mg/hour.

The supplier creates a TA for Sendolor 1 mg/ml with an administration rate of 10 mg/hour.

When the infusion is connected, a TA for the full contents of the infusion bag (100 mg) is made available for exchange.

After one hour, the patient experiences adverse effects and the medication is discontinued. After one hour of infusion time, 10 mg has been administered, and 90 mg remains in the infusion bag. This is recorded in a new MTD as -90 mg. From the two MTDs, it can be derived that 100 – 90 = 10 mg has been administered.

See practical examples 64 and 65 in the Functional Design (FD) of MP9 for similar correction scenarios.

5.7 Practical example 7: Recording a correction in an MTD following a change in administration rate

This practical example applies to both ambulatory and clinical settings.

In this example, the prescriber records the administration rate in the MA, and the supplier records it in the TA. This is not mandatory; the administration rate may also be recorded in an administration order. This practical example illustrates how the administrator can record a correction in the MTD following a change of administration rate.

The prescriber creates an MA for morphine 1 mg/ml, volume 100 ml, to be administered by infusion. The administration rate is set by the prescriber at 0.5 mg/hour.

The supplier creates a TA for Sendolor 1 mg/ml with an administration rate of 0.5 mg/hour.

The healthcare professional who connects the Sendolor infusion to the patient records the MTD.

After just over three days, the prescriber increases the administration rate to 1 mg/hour. At that point, the infusion has been running for 76 hours, and 38 mg of morphine has been administered. The infusion bag therefore contains 100 – 38 = 62 mg remaining. The healthcare professional corrects the MTD by recording the remaining quantity as a negative value in a new MTD, in this case -62 mg. From these two MTDs, it can be derived that 100 – 62 = 38 mg of morphine was administered at an administration rate of 0.5 mg/hour.

Subsequently, an additional MTD is recorded with the new administration rate of 1 mg/hour and the remaining quantity of 62 mg.