HPE What price can you put on safety? - Page 4

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