It may be time to consider robotic IV preparation at the bedside

Hospitals make a lot of intravenous (IV) preparations. That makes sense when you consider that most people admitted to the hospital are there because their acute illness requires more care than can be administered at home; not always, but in most cases. This is especially true for patients in the intensive care unit, i.e. the ICU.

A fair number of the medications used in the ICU are prepared on demand for a host of reasons including stability, differences in concentration, difficulty in scheduling secondary to rate variability, etc. Any pharmacist or nurse reading this will understand what I’m talking about. Example medications that fall into this category include drips like norepinephrine, epinephrine, phenylephrine, amiodarone and nitroprusside.

Last year I mused about using devices on the nursing stations designed to package oral solids on demand at the point of care. I still like the idea for several reasons, all of which can be found in the original post.  Based on currently available technology the same concept could be applied to preparation of IV products at the bedside. Robotic IV preparation has come a long way and these devices could be used at the point of care to make a nurses, and patient’s, life a whole lot easier. The use of robotic IV preparation at the bedside could reduce wait times for nurses and lesson the workload on pharmacy.

The device would function much like automated dispensing cabinets do now. Pharmacy would evaluate the order and enter it in to the pharmacy system. With all appropriate clinical checking complete, the nurse could go to the automated IV preparation robot (AIVPR), pull up the patient and select the appropriate infusion to be made. Based on the needs of the nurse and patient the AIVPR would compound the preparation on the spot. If you really wanted a pharmacist to lay eyes on the product you could utilize remote monitoring to observe preparation of the product. Something similar to DoseEdge comes to mind. As long as appropriate quality assurance programs were in place, and you had a good audit trail, I don’t see a problem.

Some currently available AIVPRs include:

IntelliFill I.V. by ForHealth Technologies, Inc

Patient Safety Benefits

  • Multiple safety steps assure the correct drug is prepared for the correct patient with precision and speed often not attainable by manual processes
  • Vision system captures images of the source vial for each syringe for manual review and verification
  • Weight confirmation performed for each dose
  • Automated dosage-preparation trail for each dose dramatically reduces time and labor required to check doses for accuracy
  • Barcode-verified drug selection at multiple locations
  • Automated syringe labeling with verification
  • WYSIWYG label formatting is drug specific to minimize errors
  • Patient-specific labeling of first and routine orders
  • Barcode-scanning capability for final bedside check
  • Drug-specific labeling of flush and pre-made doses
  • Unobstructed syringe barrel facilitates QC checks
  • Eliminates risks of decentralized syringe manufacturing (unlabeled syringes and sterility)
  • Syringe delivery benefits for fluid-restricted patients

RIVA by Intelligent Hospital Systems
I mentioned the RIVA device a little over a year ago. It is definitely too large for use on nursing units, but the concept and design are cool.

RIVA enhances the care of patients and health of your pharmacy team by improving the safety and accuracy of IV admixture compounding. By using state of the art safety features and practices, detailed electronic auditing, and integration to current hospital systems, RIVA ensures that hazardous and non- hazardous doses are accurate for paediatric, neonatal, and adult patients.

i.v. STATION by Health Robotics
I blogged about the CytoCare System from Health Robotics earlier this year, but I’m actually more interested in their i.v. STATION product.

i.v.STATION represents a revolutionary approach in the quest for safe, accurate, efficient, cost effective, and ready-to-administer IV Admixtures.

Constructed around a scalable, distributed, and fail-safe architecture, i.v.STATION offers unprecedented final container flexibility, life-critical patient safety, and robotic precision and performance.

i.v.STATION may be deployed in a variety of locations, including central and satellite pharmacies and direct patient care areas, due to its self-contained form, ISO Class 5 environment, and small “foot print”.

i.v. STATION actually looks like an ideal start to the system I’ve imagined. It even offers a decentralized architecture that allows modules to be installed in remote locations while remaining under the control of the central pharmacy via a network interface. It really is a neat setup.

I would have liked to provide video content for i.v. STATION in action, but the company website required registration to access the videos. And I just don’t feel like getting sales calls for the next twelve months. I’m just sayin’.

4 thoughts on “It may be time to consider robotic IV preparation at the bedside”

  1. Jerry,
    Your consideration of bedside automation is indeed timely considering the upcomning ASHP summit on a new pharmacy practice model.

    To my understanding, the original IV Station rhetoric included this possibility for on-demand, just-in-time preparation. I must confess that I, too, found this idea intriguing.

    Further exploration of this idea, however, uncovered some barriers to implementation that deserve mention:

    1) The variety of carrier fluids (and diluents) required to service the doses needed in a critical care unit, much less a general medicine ward, is quite high. Part of the reason for RIVA’s size is its need to handle such a variety and even then a technician spends considerable time “feeding” the device. It is frankly hard to imagine a nurse feeding stuff into the device to keep it running when they could, in the same period of time, just make it by hand. So, unless you have a significant space in which to put such a device on each unit, it is likely that the application of such a unit would be limited to a few doses. Not that that is entirely bad.

    2. Such a device would be considered to be a medical device, regulated by the FDA, and operation unattended would require extensive validation both by the vendor up front, and on a regular basis for each device to ensure that it was operating properly.

    3. Current pharmacy practice acts would require significant modifications to permit this kind of activity. While the advent of Hospira ADDVantage, Mini-Bag Plus, and Braun ADDEase indicates that pharmacists are increasingly willing toabdicate admixture activities back to Nursing, it is hard to see the profession moving away from that activity and questionable whether or not it should.

    4. As noted in a recent ASHP article, the packaging of injectables is not designed for robotic manipulation, with the result that current technologies for extracting injectables from vials (even mine!) are pretty slow. One wonders what ‘automation friendly’ packaging might look like and what it would do to cost.

    There can be no doubt that the application of robotics to what are currently nurse admixtures would significantly improve the quality of that admixture process. Glad you brought this one up!

  2. Thanks for the feedback DATdoc. I did consider some of the barriers that you mention in your comment, but was unaware of the issues with the FDA. Would the FDA regulation still be an issue if pharmacists had remote oversight of the system? Just a thought.

    I think one could work with the variety of carrier fluids and diluents by restricting the items made in such a device. Using it as an adjunct to current practice rather than trying to use it to replace current practice might be one way to approach the issue.

    You bring up a great point about ADDVantage, Mini-Bag Plus, etc in that many of the piggybacks would not be considered in such a system. However, many of the drips I speak of would be limited to NS or D5W in 250mL size for example. In addition many of the pressors used in an ICU scenario don’t require reconstitution making them a bit easier to manage. Large volume fluids would simply be too problematic for the reasons you list.

    I hope to see faster, more user friendly systems in the future. The technology certainly has the potential to be a game changer for pharmacists. If nothing else, it would be an interesting discussion and something to consider for the future. Thanks for the information and for the thoughtful comments. Good stuff.

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