Where are the 50ml syringes compounded?
Spain
ICU
Pharmacy Other
(if a hazardous drug)
Italy
Germany (Mainz)
Germany (Freiburg) 90%
10%
Netherlands Low volume, short shelf life High volume, long shelf life
France
UK Trust buys the RTU product (to avoid risk and release
nurse time). Entire content of 50mg/50ml vials is drawn
up in a syringe and infused via a syringe driver
syringe, consumes 700 minutes of nursing time
every day (not to mention the risk of miscalculation).
But industry must charge €5 per syringe to cover its
cost, which the hospital is unwilling to pay –
because it is so ‘easy’ to prepare in house.
Other benefits of RTA 50ml syringes of midazolam
include:
– They save preparation time (of between 50 seconds
and nine minutes per syringe, according to one
delegate)
– They enhance patient safety, as there can be no
compounding errors
– They minimise needlestick injury
– They guarantee quality and sterility
– Their 24-month shelf life minimises waste and
facilitates stock management
– They do not require refrigeration space
– No re-programming of syringe drivers is required
– Their clear labelling facilitates easy identification
(benefit of tall man lettering was singled out)
– They release capacity in aseptic units. On the
wards, two nurses are involved in the in-house
preparation: one nurse (or pharmacy technician)
to prepare and another to check calculations
Barriers to buying
• In the past ten years, the rate of drug shortage has
multiplied 20-fold. To guarantee patient treatment,
hospitals must retain the capability to prepare
products in house where practicable and safe.
• Hospital pumps that are programmed for one
company’s syringe may need to be re-programmed
should the decision be taken to use a different
supplier’s syringe, lest there be calculation errors
introduced.
• Ward storage space and refrigeration, when
required, favour the selection of vials over syringes.
So, while storage is a barrier, the fact that RTA 50ml
midazolam ICU syringes do not require refrigeration
is a benefit.
• Diversion is a potential problem, especially for
2mg/ml syringes of midazolam, and they would best
be stored in a safe room.
• Misconceptions of the ‘affordability’ and
‘reasonable pricing’ of an RTA product may be
predicated on a miscalculation in its in-house
preparation
• Re-programming of pumps can be perceived
as a barrier. However, modern pumps can be
re-programmed to accommodate RTA syringes
as required, and are therefore not a barrier
4 | 2020 | hospitalpharmacyeurope.com
• If specific syringes are not on a regional tender,
they cannot be procured
• Within ICU, you have automatic machines for
dispensing, and the placing of high-volume syringes
in these machines is problematical.
• The delegates were of one mind when considering
the advantages and disadvantages of two
concentrations of the 50ml midazolam syringes.
They unambiguously stated that having the choice
of two concentrations invited administration errors
and recommended only 1mg/ml be available
throughout the hospital, and that only 2mg/ml be
available in ICU, where the higher concentration
would mean you would have to replace syringes less
often. Smart pump libraries would have to be
rationalised accordingly.
Criteria for new candidates for ICU RTA
syringes
• First, we need to look at the nature of the products
and at what is currently available, to see where we
should be targeting resources.
• Products to be considered for ICU RTA syringes
include those that are:
– High risk in terms of either complex preparation,
complex calculation or microbiological risk (risk
calculation as to be found in the UK defined by
National Patient Safety Agency, NPSA 20)
– High volume (e.g. 50ml KCl)
– Anything used in ICU (in standardised
concentrations)
RTA IV oncology bags
Who are the stakeholders and what is the
procurement process?
Across the EU, it is the hospital
pharmacist who exercises decision-
making authority, with price
negotiation support on offer
from purchasing groups.
Decisions are taken on the
advice and influence of nurses
(usability), clinicians (including
heads of speciality units) and
the Pharmacy and
Therapeutics Committee.
In the UK, the main
stakeholder/driver is NHS
England, driven by the use of dose
banding tables, the minimisation of
waste through financial incentives,
The benefit is not
to minimise the
cost but to
minimise the risk
for the patient
Alain Astier, France