9.3 Medication Delivery Devices, Home Infusion & Patient Education
Key Takeaways
Smart infusion pumps with dose error reduction software check programmed doses against a drug library. A hard limit cannot be overridden, while a soft limit can be overridden after confirmation.
Elastomeric pump flow depends on temperature, fill volume and solution viscosity. A warmer reservoir or a less viscous diluent speeds the infusion, so compounding must match the manufacturer's specified fill volume and diluent.
Implanted intrathecal pumps are refilled with preservative-free CSPs at exact concentrations; refill errors such as pocket fills or wrong concentrations can be fatal, so concentrations and volumes are independently verified.
Home infusion needs BUDs long enough for the delivery schedule (often Category 2 or 3 CSPs, or 503B products), validated shipping, and clear home storage instructions.
Patient education uses teach-back and covers storage, hand hygiene and scrub-the-hub technique, pump operation and alarms, warning signs of infection, occlusion or extravasation, disposal of sharps and HD waste, and who to call.
9.3 Medication Delivery Devices, Home Infusion & Patient Education
The BCSCP outline pairs compounding with administration (task 2A3): routes, delivery devices, home infusion and patient education. The device often decides the concentration, the volume, the container and the BUD, so the compounding pharmacist has to understand how each device works.
Infusion devices and what they require from the CSP
| Device | Key features | Compounding implications |
|---|---|---|
| Large-volume smart pump | Drug library with dose error reduction software (DERS); hard and soft limits | Use standardized concentrations that match the library entries |
| Syringe pump | Precise low flow rates; startup delay with small syringes | Syringe size and brand must match the pump; neonatal concentrations standardized |
| PCA pump | Patient-activated boluses with lockout | Standard opioid concentrations; tamper-resistant cassettes; high-alert double checks |
| Ambulatory electronic pump (e.g., cassette pumps) | Programmable continuous or intermittent home infusion | Cassette volume, concentration and BUD must cover the interval between deliveries |
| Elastomeric pump | Nonelectronic balloon reservoir; fixed flow restrictor | Fill to the specified volume with the specified diluent; flow varies with temperature and viscosity |
| Implanted intrathecal pump | Programmable reservoir refilled through the skin | Preservative-free CSP at the exact concentration; volume and concentration verified independently |
| Gravity infusion | Rate set by roller clamp and drop counting | Simple, but inaccurate for high-alert drugs |
Smart pumps and DERS
A hard limit blocks programming beyond a set dose or rate and cannot be overridden. A soft limit warns and requires confirmation. Drug library entries only work if the compounded concentration matches the library exactly. A nonstandard concentration forces a "basic infusion" with no safety net. Pump interoperability with the electronic health record, where the order auto-programs the pump, reduces keying errors.
Elastomeric pumps
Their stated flow rate assumes a particular temperature, fill volume and diluent, usually 0.9% sodium chloride or dextrose 5%. A reservoir worn close to the body runs faster than one at room temperature. A more viscous solution runs slower, and underfilling or overfilling changes the rate. Compound exactly to the manufacturer's volume and diluent, and teach patients where to wear the device.
Implanted intrathecal pumps
These pumps deliver drugs such as morphine, baclofen and ziconotide straight into the cerebrospinal fluid. Only preservative-free CSPs are used, and endotoxin limits are strict (). Refill errors are deadly. A pocket fill means drug injected into the tissue pocket instead of the reservoir. Other errors are a wrong concentration or programming that does not match the concentration in the reservoir. Label the concentration clearly, verify it independently, and make sure the programmer's settings match the CSP.
Delivery details that change the dose
- Residual tubing volume: An IV piggyback run through a secondary set can leave several milliliters in the tubing. If that line is not flushed, part of the dose is never given, which matters most for small-volume antibiotics and chemotherapy.
- Overfill: Commercial bags contain overfill, which changes the true concentration of an admixture. Standardized recipes should account for it when concentration matters.
- In-line filters and sets: Some drugs need specific filters (0.2 µm for many; 1.2 µm for lipid-containing PN) or PVC-free, light-protected sets (see 8.2).
- Route-specific connectors: Use NRFit for neuraxial devices and ENFit for enteral ones (see 7.2).
Home infusion
Home infusion moves sterile therapy (antibiotics, PN, inotropes, chemotherapy, biologics) into the patient's home. It adds several demands:
- Patient selection: A safe home environment, a willing and capable patient or caregiver, reliable vascular access, and a way to reach help 24 hours a day.
- Dating for the delivery schedule: Weekly deliveries need BUDs of 7 days or more. That often means Category 2 CSPs with sterility testing, Category 3 CSPs, or outsourced 503B products with expiration dates, in each case supported by stability data.
- Shipping and storage: Validated coolers and temperature indicators for transport (see 7.6), and a clear place for refrigerated storage at home, away from food.
- Coordination: Home health nursing, the prescriber, the laboratory for monitoring, and the supplier of pumps and supplies (see 9.7).
Patient and caregiver education
Use teach-back: have the learner explain or demonstrate each step, rather than just asking, "Do you understand?" Core content:
- Storage and preparation: refrigeration, bringing the CSP to room temperature, checking the label and BUD, and inspecting for particles, cloudiness or leaks
- Aseptic handling: hand hygiene, clean work surface, scrub the hub with alcohol and friction, never touch connectors
- Pump operation: starting and stopping, common alarms (occlusion, air in line, low battery) and what to do
- Line care: flushing (saline-administration-saline sequences, with heparin only if prescribed), dressing protection
- Warning signs: fever or chills (possible bloodstream infection), redness, pain or swelling at the site (phlebitis or extravasation), line occlusion, and allergic reactions
- Disposal: sharps containers, and for hazardous drugs, gloves and the disposal method provided
- Who to call, around the clock
Education and each teach-back are documented, and understanding is rechecked at follow-up visits.
A patient receiving ertapenem through an elastomeric pump wears the device under their clothing, close to the body, instead of on a bedside table. How will this likely affect the infusion?
It will run slower, because body heat thickens the solution
It will run faster than labeled, because warmer temperature increases elastomeric pump flow
It will not change, because elastomeric flow is fixed
It will stop, because body heat seals the restrictor
In smart-pump dose error reduction software (DERS), what is the difference between a hard limit and a soft limit?
A hard limit cannot be overridden and blocks the programming; a soft limit warns and can be overridden after the clinician confirms
Both simply record the rate for later review
A soft limit cannot be overridden; a hard limit is advisory
Hard limits apply only to gravity infusions
A pharmacist is teaching a caregiver to give home IV antibiotics through a PICC. Which technique best confirms that the teaching worked?
Asking, "Do you have any questions?"
Giving a printed handout and asking the caregiver to sign it
Teach-back: having the caregiver explain and demonstrate hand hygiene, scrub-the-hub, connection, flushing and alarm responses
Showing a video without further discussion
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