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Standard concentration infusions (SCIs) and ‘smart-pumps’ are recognised as best practice for delivering high-risk medications in the paediatric setting. Implementation is complex, requiring multi-stakeholder involvement – a factor leading to delays in implementation into European hospitals. Children’s Health Ireland (CHI) developed a smart-pump drug library of SCIs and led a project to expand its use across acute paediatric and neonatal settings in Ireland. Here, Dr Moninne Howlett PhD, chief pharmacy information officer at CHI, shares how this project came together.
Critically ill paediatric patients routinely require the delivery of high-risk medications via infusion pumps. Key medication error prevention strategies include the replacement of traditional individualised weight-based infusions with standard concentration infusions (SCIs), and the use of computerised infusion devices known as smart-pumps.1,2
Using customised drug libraries, pre-set dose limits and dose calculations based on programmed patient weights, smart-pumps can be highly effective in reducing serious and occasionally fatal medication errors.3 Before initiation of our project, weight-based infusions and traditional pumps were used in all paediatric and neonatal intensive care units in Ireland.
Development of the CHI infusion drug library
In 2012, a smart-pump drug library of paediatric SCIs was developed and implemented into Ireland’s largest paediatric intensive care unit (PICU) in CHI at Crumlin and its operating theatres. This initiative was in response to substantial evidence on the inaccuracies and risks associated with individualised weight-based infusion preparations4–7 and aligned with recommendations from safety bodies including the Institute for Safe Medication Practices.2,8
At the time of initial drug library development, the use of traditional infusion pumps and weight-based infusions – requiring complex calculations during prescribing, preparation and administration of paediatric infusions – was still common in many European hospitals.9,10
A key consideration during initial development, and subsequently during its iterative expansion, was safety and usability across the full spectrum of the paediatric patient population. Within individual wards, and even in adjacent beds, patient weights can range from <1 kg to >100 kg.
The CHI drug library has, from the outset, been designed by specialist paediatric pharmacists, with multidisciplinary input, to mitigate against the particular risks associated with this complex patient cohort.
The use of a range of weight bands, care areas and judicious setting of concentrations, safety limits and naming conventions allowed the original library (four weight bands and 42 drug lines) to be extended to continuous and intermittent infusions for more than 250 medications, presented within five weight bands and four care areas.
This level of drug library development also highlights the expanding role of the hospital pharmacist and evolution of pharmacy informatics as a specialist field.
Expanding use of the drug library
Having invested a significant amount of time and expertise in this endeavour, CHI sought to distribute the output as widely as possible throughout acute neonatal and paediatric services. Initial efforts focussed on the other PICU and theatres within CHI’s second large tertiary paediatric hospital, in addition to paediatric transport services, which are run out of the two CHI PICUs.
Simultaneously, through a multidisciplinary collaboration with neonatal ICU (NICU) specialist pharmacists, nurses and doctors, a neonatal-specific sub-library was developed to support the specific needs of infants in NICU and the neonatal transport services.
This component of the project received endorsement from Ireland’s National Clinical Programme for Paediatrics and Neonatology. Key factors leading to this national health service level support were the high volume of movement of sick infants and children across services and access to evidence derived from research undertaken in the originator site.
This research identified a reduction in prescribing error rates from 27.5% to 5.1% on implementation of SCIs and smart-pumps, drug library compliance of 98.9% and with high levels of user satisfaction.11,12
Following the success of these early phases of expansion, achieved between 2014 and 2019, the use of smart-pumps and the SCI drug library was extended to the emergency departments and urgent care centres in the CHI hospitals, subsequently followed by their general wards.
This latter phase occurred during the Covid-19 pandemic, by which time a CHI-funded dedicated smart-pump team was in place, consisting of 1.5 whole time equivalent (WTE) nurses and a 0.5 WTE pharmacist. This team developed and co-ordinated a highly structured nurse training programme involving a two-stage training process.
This training model, used within CHI and external hospitals, utilises a train-the-trainer component and incorporates infusion pump training, followed by drug library training, including SCI preparation and competency self-assessment. Amended training sessions are offered to nursing students, pharmacy and medical staff.
Subsequent phases of the project included expansion to the care of children across Ireland’s paediatric network of 19 hospitals and within adult ICUs. This required revision of existing governance structures, ultimately leading to formal recognition and approval of the CHI drug library as a national standard of care by Ireland’s Health Service Executive; operational control remains with CHI.
Overcoming infusion challenges
The absence of a defined national governance structure to support such a concrete operational level intervention was one of the more difficult elements of the project and necessitated an innovative and iterative approach to governance.
Another key challenge was the lack of centralised funding or allocated budgeting. This challenge persists with responsibility for financing infusion pump hardware remaining with individual sites.
Differences between individual hospitals in aspects such as access to dedicated paediatric and/or neonatal nursing staff and location of care for infants and children within non-specialist paediatric hospitals are further challenges.
Furthermore, patients journey within and between sites depending on their needs, transitioning to and from centres of greater or lesser specialisation and scale according to the nature and stage of their illness and the proximity of these facilities to their homes. This can significantly impact and complicate the choice of drug library, pump management and delivery of training.
Despite these difficulties, this project continues to successfully improve patient safety and support clinicians in the delivery of highly complex, challenging and often urgent delivery of what can be life-saving medication infusions.
To date, implementation has occurred in all areas of CHI, all level-3 NICUs, paediatric and neonatal transport services, 58% of Ireland’s 19 neonatal units, and 23% of paediatric network sites.
The success of this project, recently published in the International Journal of Clinical Pharmacy,13 has been recognised not only in Ireland but also referenced internationally by other regions looking to achieve standardisation of paediatric infusions.14–16
A key benefit of progressing the standardisation of infusion processes at a national level is the opportunity it provides to move away from nurse-prepared infusions at the bedside to centralised preparation by hospital pharmacies or commercially prepared ready-to-administer infusions.1
Conclusions
Specialist hospital pharmacists, working effectively within multi-disciplinary teams, can effectively lead on the delivery of standardisation of infusions at a national level.
This multi-phase project has successfully developed a smart-pump drug library of standard concentration infusions suitable for paediatric and neonatal patients across the Irish acute hospital sector.
In a constrained public health service with limited pharmacy and other specialist resources, collaboration and innovative governance structures have enabled wide-scale implementation of internationally recognised best practices for the safe administration of IV medications in paediatrics.
Author
Dr Moninne Howlett BSc (Pharm) PhD
Chief pharmacy information officer, Children’s Health Ireland, and honorary clinical associate professor, Royal College of Surgeons in Ireland
Dr Howlett would like to thank her fellow study authors:
Sharon Sutton MPharm MPSI
Senior pharmacist, Children’s Health Ireland
Eimear McGrath RGN RCN
Clinical nurse education facilitator, Children’s Health Ireland
Cormac V. Breatnach MRCPI, FJFICMI
Consultant paediatric intensivist, Children’s Health Ireland
References
1. Neonatal Paediatric Pharmacists Group. Standardising intravenous infusion concentrations in children in the UK 2023.
2. American Society of Health-System Pharmacists. Standardize 4 Safety Initiative – Pediatric Continuous Infusion Standards 2020.
3. Institute for Safe Medication Practices. ISMP Targeted Medication Safety Best Practices for Hospitals 2024.
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6. Parshuram CS et al. Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med 2003;31(10):2483–7.
7. Aguado-Lorenzo V et al. Accuracy of the concentration of morphine infusions prepared for patients in a neonatal intensive care unit. Arch Dis Child 2013;98(12):975–9.
8. Institute for Safe Medication Practices. 2018-2019 Targeted Medication Safety Best Practices for Hospitals 2018.
9. Campino A et al. Medicine preparation errors in ten Spanish neonatal intensive care units. Eur J Pediatr 2016;175(2):203–10.
10. Oskarsdottir T et al. A national scoping survey of standard infusions in paediatric and neonatal intensive care units in the United Kingdom. J Pharm Pharmacol 2018;70(10):1324–31.
11. Howlett MM et al. The Impact of Technology on Prescribing Errors in Pediatric Intensive Care: A Before and After Study. Appl Clin Inform 2020;11(2):323–35.
12. Howlett MM et al. Direct Observational Study of Interfaced Smart-Pumps in Pediatric Intensive Care. Appl Clin Inform 2020;11(4):659–70.
13. Howlett MM et al. Implementation of a national system for best practice delivery of paediatric infusions. Int J Clin Pharm 2024;46(1):4–13.
14. Crowley K. Standard Drug Concentrations in the Cardiac Intensive Care Unit. In: Critical Care of Children with Heart Disease (eds Munoz R et al) 2020;Springer:pp 725–8.
15. Sutherland A et al. Developing Strategic Recommendations for Implementing Smart Pumps in Advanced Healthcare Systems to Improve Intravenous Medication Safety. Drug Saf 2022;45(8):881–9.
16. Howlett M. Reducing medication errors for children. Health Manager [Internet]; Nov 2016.
