TPN admixture verification question

[scottygonzo]

I was wondering what other infusion pharmacies that prepare TPNs handle the check of micronutrients in the cleanroom. Our process is for the technicians to pull out the ingredients (KCl, Mag, etc) in a syringe and lay them all in a row. Then the pharmacist gowns up and enters the cleanroom and makes sure that all of the quantities are correct. The technician then adds all of it to a bag to be mixed in with the macros. So, essentially pharmacists have to go through the process of gowning, etc and then ends up being in the cleanroom for a few minutes and then leaves. It's a little bit of a waste of time. The idea has been thrown around to add a camera/video feed so that these quantities can be checked remotely.

Any ideas on how this can be done more efficiently? Do other infusion pharmacies match up all of the syringes with the vials for the pharmacist to check after the TPN is checked?

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[smilePRN]

At a home infusion pharmacy and this is exactly what we do too. It's such a waste of time AND resources! We make 7-8 patients a day, so there's quite a bit of traffic in and out of the clean room too - not something that should be happening. We only do this for things compounded on the pinnacle. Fancy hydration orders dont get checked - even if they have multiple fluids and ingredients added to them. Makes no sense to me but i didn't make the rules.

We had a former tech who would take a picture of the set up on their personal phone (vials and drugs drawn into syringes) and send to the rph personal phone for verification. This was at a time that techs were allowed to take their phones into the cleanroom in a ziplock bag, however, we no longer allow that. They continued with this for a short time and then stopped, idk if they were told by management or what... seemed efficient but I never directly participated in that process. Occasionally I have to compound TPNs (we have staffing issues), but I always make another rph check the micronutrient pool, just so there's another set of eyes and another signature lol. We use the pinnacle, which is pretty outdated. I'm sure there are more advanced systems out there that could possibly eliminate the need for an rph to physically have to go in to check the pool. I heard exactamix is pretty good but i dont have personal experience with it.

The cancer center affiliated with the hospital I'm prn at uses doseedge. I've never used it myself but I've seen others use it and it seems like it would solve the problem of having a pharmacist have to gown up just to verify quantities. I believe there are multiple checkpoints - but the general gist I got was tech sends pictures of the drug vial, diluent, solution, amount in the syringe, etc, through the doseedge system and aren't able to proceed each step until the rph verifies. I heard from the techs this was a pain and time consuming (positioning things for each image and then waiting on rph for each step), but I'm sure it provides peace of mind!

Another option would be to have an rph in the clean room to, idk, actually supervise the techs lol. I appreciate that we are able to check the micronutrients before they are pooled- but what about milrinone? narcs? chemo? fancy orders with multiple ingredients? Aren't they all important? We still use the 'syringe pull back method' and tbh that means nothing to me. I make it as clear as I can that I'm signing off on instructions and the final product, not the compounding process. Not sure if thats helpful in anyway to cover myself but I genuinely don't know what the tech did - not gonna assume things.

Since we're discussing the topic- how are you guys dealing with the infuvite backorder situation lol

 

[owlegrad]

We still use the 'syringe pull back method' and tbh that means nothing to me.

That’s what we use as well and I agree it is worthless. How do I know that is really the amount they used and not just what they pulled back to for the check?

What’s really bizarre to me is we make the technicians show us what they’re going to mix for non-sterile compounding before they mix it but not for IV. But like you I don’t make the rules I just work there.

 

[smilePRN]

That’s what we use as well and I agree it is worthless. How do I know that is really the amount they used and not just what they pulled back to for the check?

Exactly! Our new tech will use whatever syringe sizes they want to compound (based on ease, math, etc) and then get new syringes with a more appropriate volume, pull back to the indicated volume on the order and send out to us. I honestly just don't understand. How is that helpful? What makes you think I believe you? And why waste syringes like that?
Also - if the amount is greater than 50 mls (largest syringe size we currently have), they just send out 1 syringe pulled out to 50 ml. They've allegedly reused the syringe multiple times to get the accurate dose. But the instructions say to add 232 mls, how is one syringe pulled up to 50 mls of any use for me lol. Other techs draw up the whole amount in separate syringes and pull back all syringes and send out (so if the dose of 232 ml, they'd send out 4 syringes pulled up to 50 ml and 1 pulled up to 32 mls) which I'd much prefer eventhough its wasting lots of syringes.

What’s really bizarre to me is we make the technicians show us what they’re going to mix for non-sterile compounding before they mix it but not for IV. But like you I don’t make the rules I just work there.

Its mind blowing that techs aren't allowed to reconstitute amoxicillin in retail but they can make IV chemos on their own with no direct supervision.

 

[Deja]

so you guys knows the problems but haven't really thought of a solution? or you guys just can't be bothered with thinking of a solution since this is how it's always been done

 

[PharmDBro2017]

Your process seems odd and a waste of cleanroom PPE.

-Pharmacist pulls micronutrients, ideally with another pharmd giving a double check
-Tech makes TPN
-Tech shows the syringe drawback method after completion

I'm lucky to have a sterile compounding certified tech of 20yrs that I trust.

 

[Dred Pirate]

We used to do it that way - until (probably 8 years ago) we got one of those fancy machines that pumps all of the micro's as well. So much of a time saver. Simply scan a bar code and the bag pumps everything.