Workflow Infusion Therapy Kickstart

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: Administration with the same flushing agent as the solvent

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: 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.