Department of Pharmacy Policies & Procedures

Number: 5:13

Effective Date May, 1990

Revisions: 4/98; 4/01; 4/08

Approval: 4/15/98

Subject: INFUSION PUMPS

A. POLICY

Hill-Rom Asset Advantage manages the distribution, cleaning, storage and maintenance of infusion pumps for general hospital use. All pumps for general use in the hospital or ambulatory areas will have free-flow protection.  Only pumps authorized for use at the UAMS Medical Center will be used on patients in the hospital.

 B. GUIDELINES FOR THE USE OF INFUSION PUMPS

1.      Infusion pumps are to be used for the following:

a.      Peripheral line infusions and drug administrations

b.      Total Parenteral Nutrition solution and other IVs given via a central line catheter.

c.      Administration of solutions or drugs in high risk patients where accuracy is necessary

d.      Epidural infusions

e.      Potent and dangerous drugs such as heparin, insulin, magnesium for obstetrics patients, chemotherapy drugs, vasopressor agents, etc.

f.        Potassium IV concentrations greater than 40 mEq/liter or rate greater than 10 mEq/hr

2.  When possible pumps should also be used for:

a.      Renal transplant fluid replacements

b.      Multiple antibiotics

c.      Positional IV fluids

d.      Fluid restricted patients

e.      Patients on strict intake and output

f.        Cerebral edema patients

g.      Ambulatory outpatients on chemotherapy or antibiotics

3. Pumps should be used primarily on patients with a central line or other intravenous catheters. They should be avoided in patients who have scalp vein or butterfly needle sets because of the potential to dislodge the needle due to the pressure of the pump.
4. Pumps should be plugged into an electrical outlet except during patient transport to prevent failure of the pump due to battery rundown.

C. GUIDELINES FOR USE OF PCA PUMPS

1. PCA pumps are dispensed through CSS.  
2. Pumps may be used for acute or chronic pain.
3. All PCA orders should originally be documented in the electronic medical record.  An electronic equipment order is sent to CSS.
4. Morphine will be ordered on all patients unless there is a documented problem prohibiting its use. In this case hydromorphone is available for use.
5. Orders changing rates or continuing the pump will serve as an order to continue the drug as well. A renewal order or revision in dose must be entered at least every 10 days.

D. GUIDELINES FOR USE OF EPIDURAL PAIN MANAGEMENT PUMPS

1. The epidural Pain Management Pumps will only be distributed to patients receiving epidural doses of narcotics written by the anesthesia pain management team and for L&D patients.
2. A pump will be dispensed with the first bag of medication prepared. When the pump is dispensed, new batteries will be inserted in the pump.
3. All pumps will be dispensed in a locked container which allows secure storage of the epidural medication.
4. When the medication is discontinued, any remaining medication should be wasted on the nursing unit according to hospital policy.
5. The pump shall be returned when the medication is discontinued.

E. PROCEDURE FOR OBTAINING PUMPS AND SUPPLIES

1. Sets for all pumps are stored in the automated supply cabinets and are charged to the patient as used.
2. Infusion pumps and PCA pumps are obtained from the equipment management staff using an electronic equipment request.
3. Epidural Pain Management pumps are dispensed on receipt of a physician’s order for the epidural fluid to be administered via the pump.
4. When the pump therapy is completed, the pumps should be placed in the dirty utility room. The equipment management staff will pick them up twice daily for cleaning and maintenance before reuse.
5. An exception to this procedure are the stand-by infusion pumps which are kept in designated areas and the pain management pumps which are kept on Labor and Delivery. These must be cleaned by the holding unit. There are nine epidural pumps located in L&D anesthesia workroom (labeled L&D 1-9).  These pumps are for Labor & Delivery patients only.  These pumps are cleaned and returned to the OR satellite pharmacy as well.  The OR satellite pharmacy then takes them to the L&D anesthesia workroom for storage again.

 F. MALFUNCTIONING INFUSION PUMPS

1. Any type of infusion pump which does not function correctly should be returned to the equipment management staff. An equipment/furniture repair tag is attached describing the problem is to be taped to the pump.
2. An infusion set which does not perform correctly should be returned with an equipment/furniture repair tag attached describing the problem. The outside wrapper should also be returned if at all possible.
3. In the event that a pump/set malfunctions during the course of a patient’s therapy, a Patient Safety Net (PSN) report shall be completed.  The pump should be tagged and all accessories (tubing, IV bag, modules) sequestered and held in a secure area for Clinical Engineering.  Nursing staff should contact the manufacturer or representative of the equipment involved in an event.
4. Nursing process:

 G. CLEANING AND TESTING THE INFUSION PUMP

1. Epidural Pain Management pumps will be wiped clean in CSS but can also be cleaned in pharmacy or labor and delivery.
2. Infusion pumps and PCA pumps will be cleaned in CSS after each use on a patient.

H.  AMBULATORY CARE PUMPS

1.      All pumps used in the outpatient chemotherapy room will be the standard infusion pumps carried within the hospital.

2.  All pumps sent home with patients must meet JCAHO standards for free flow by having an antisiphon valve attached before the pump is dispensed. No pump will be dispensed without an antisiphon valve on the set.