In this article, insights on IV push antibiotics are discussed by an infectious diseases physician.
Authored by: Kruti Yagnik, DO
Article Posted: 1 June 2022
Most outpatient parenteral antimicrobial therapy programs (OPAT) use intravenous (IV) infusions via pump or drip, which involves either a premixed solution or an un-reconstituted dry powder drug vial attached to an 50-100 mL IV NS fluid bag. These are given as intermittent infusions (e.g., over 30 minutes), extended infusions (e.g., over 4 hours), or as a continuous infusion (e.g., over 20-24 hours). However, a reasonable antibiotic delivery alternative can be using IV syringe bolus (i.e., IV push, over a few minutes) using a concentrated drug solution.
There have been studies comparing clinical outcomes of IV push with IV drip infusion for OPAT. While there was no difference found in frequency of adverse events between methods, the IV push method was found to have several advantages including less training time, lower cost of materials, and reduced waste. Despite these findings, IV drip infusion continue to be the preferred method of drug delivery in both inpatient and outpatient settings due to standardized administration of therapy, convenience for pharmacy, longer medication shelf-life, beta-lactam PK/PD optimization, and the ubiquitous use of infusion pumps.
Puerto Rico is one of the nation’s main suppliers of IV fluid agencies and after Hurricane Maria made landfall there in September 2017, hospitals and providers had to adopt measures of conservative use due to fluid bag shortages. One of the hospitals I worked at during fellowship, Parkland Health, serves a largely uninsured or underinsured patient population residing in Dallas County, Texas. The self-administered OPAT (S-OPAT) program was developed in 2009 to provide uninsured patients requiring long-term IV antibiotics for complex infections the ability to transition earlier from hospital to home to complete a prescribed treatment course. Patients are taught to self-administer IV antibiotics by gravity (ie, without an infusion pump or device) in the hospital and tested for competency before discharge from the hospital to home.
In response to the national IV fluid shortage, Parkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV push antibiotic and transitioned those that were appropriate (cefazolin, ceftriaxone, cefepime, and daptomycin). No additional agents were converted. Antimicrobials were selected for IV push administration based on a number of key factors, including published safety and efficacy data, as well as extended syringe stability data of 7 days or longer.
In an effort to understand our experience, we completed an evaluation that was published in Open Forum Infectious Diseases, the full text is available here open access (as the journal name suggests!):
Kruti J Yagnik, L Steven Brown, Hala A Saad, Kristin Alvarez, Norman Mang, Cylaina E Bird, Fred Cerise, Kavita P Bhavan, Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria, Open Forum Infectious Diseases, Volume 9, Issue 5, May 2022, ofac117.
In our project the electronic medical record (EMR) was used to identify hospitalized patients discharged to the S-OPAT program before and after the change of method from IV drip (11/2016–06/2017) to prefilled syringes for IV push (11/2017–06/2018). All patients had a bone and joint infection. We extracted many data points which are detailed in our OFID article.
Here in this post we share some of the key lessons learned from our findings and some other blog-worthy insights…
1. We observed a statistically significant decrease in median hospital length of stay
Among patients discharged on the IV push method vs standard IV drip infusion, the average hospital length of stay was reduced from 15 days to 12 days between pre and post IV push implementation groups.
Reducing length of stay can offer important benefits of reducing healthcare costs, improving hospital operations, and allowing patients to receive care in the comforts of their own home.
2. There was no difference in clinical outcomes between both groups
Between the two treatment groups we saw no difference in 30-day readmission rate, 1-year readmission rate, ED visit within 30 days, ED visit within 1 year, or mortality. These data bolster our confidence in IV push during times when fluid shortages don’t dictate therapeutic options.
3. The pre-discharge teach-back competency pass rate was higher with the IV push method
While in the hospital, patients were taught how to administer IV antibiotics by both methods by their nurses, and they had to “teach-back” the method to their nurses (before discharge) to demonstrate proficiency in administering their own antibiotics. The number of times they had to teach-back this method was recorded.
The pre-discharge teach-back competency pass rate was higher with the IV push method; the IV push method was learned more quickly by patients. The IV drip infusion method requires more steps to administer compared with the IV push method. The IV push method already has a prefilled syringe of the medication made, so patients only had to take this syringe and inject it into their PICC line.
By eliminating multiple steps, the IV push method was significantly easier to learn.
4. The IV push method had greater patient satisfaction
Over 96% of the patients indicated that they preferred the IV push method compared to the IV drip infusion method.
Reasons for IV push preference given by patients and nursing staff included reduced administration times (5–10 minutes for push vs 30–60 minutes for slow infusion), convenience, and clear instructions.
5. The IV push method provided significant cost savings
The shift to IV push via the S-OPAT program saved 504 liters of normal saline, which, along with a reduction in infusion supplies and direct drug costs, resulted in an additional savings of $43,652 over a 6-month period.
In addition to conserving IV fluid bags, decreased nursing time required to teach this method to hospitalized patients and reduced length of stay for some patients led to an additional $550,000 in cost avoidance over 6 months. The reduced length of stay was attributed to shorter teaching time for patients to learn the IV push method compared with IV drip.
The abrupt IV fluid shortage challenged clinicians to think differently about standard practices. This shift in practice to a more efficient care delivery method is generalizable and can be more widely adopted even outside the setting of a fluid shortage. Parkland Health is a safety net setting, so the applicability of this is likely more generalizable. There is potential for even greater savings than those reported in the Parkland S-OPAT population because delivery methods for insured patient populations include even more costly devices such as infusion pumps, which the infusion by gravity method in the safety net setting does not.
What started as a response to a national disaster led to identification and implementation of a high-value care model that was found to be safe, effective, and sustainable, without affecting safety, efficacy, or efficiency. Given cost savings, increased patient satisfaction, and equal clinical outcomes, the IV push model is not only a viable alternative initiated in a time of crisis, but preferable in standard situations; it improves utility and provides high-value care.
Finally, we refer readers to our OFID publication for additional details on this topic.
References & Readings
1. Kruti J Yagnik, L Steven Brown, Hala A Saad, Kristin Alvarez, Norman Mang, Cylaina E Bird, Fred Cerise, Kavita P Bhavan. Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria. Open Forum Infectious Diseases, Volume 9, Issue 5, May 2022, ofac117.
2. Poole, S M et al. Intravenous push medications in the home. Journal of intravenous nursing: the official publication of the Intravenous Nurses Society vol. 22,4 (1999): 209-15.
3. Nowobilski-Vasilios, A, and S M Poole. Development and preliminary outcomes of a program for administering antimicrobials by i.v. push in home care. American journal of health-system pharmacy: AJHP : official journal of the American Society of Health-System Pharmacists vol. 56,1 (1999): 76-9. doi:10.1093/ajhp/56.1.76.
4. Bhavan, Kavita P et al. Self-Administered Outpatient Antimicrobial Infusion by Uninsured Patients Discharged from a Safety-Net Hospital: A Propensity-Score-Balanced Retrospective Cohort Study. PLoS medicine vol. 12,12 e1001922. 15 Dec. 2015, doi:10.1371/journal.pmed.1001922.
5. Marsh, Kassandra et al. Safety of intravenous push administration of beta-lactams within a healthcare system. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists vol. 77,9 (2020): 701-708. doi:10.1093/ajhp/zxaa044.
ABOUT THE AUTHOR
Kruti Yagnik, DO is an infectious disease staff physician and co-director of antibiotic stewardship at Cleveland Clinic Florida- Indian River Hospital. She completed her undergraduate studies at the University of Florida, medical school at Nova Southeastern University, internship/residency in internal medicine at the University of Florida, and infectious disease fellowship at UT Southwestern Medical Center in Dallas, Texas. She is dual board certified in internal medicine and infectious diseases. She has a personal interest in antibiotic stewardship, general infectious diseases, and HIV care/opportunistic infections. You can find her on twitter @KrutiYagnikDO.
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