Reply To: Methotrexate infusion

  • Chris Donaghey

    February 10, 2020 at 8:59 pm

    We started on Alaris bidirectional functionality in late 2018/early 2019. We use Cerner but same concerns and considerations.

    We challenged organizational and system policy often as we married our new hazardous drug policy both to bidirectional and USP <800>.

    Also, we needed to address the scope of nursing practice. Our previous MTX orders allowed nurses to manipulate the rate fairly liberally and we had to eliminate that practice. Infusion rates can’t be changed by our nurses.

    Regarding pharmacy, in the end, pharmacy has proven their tested and retested calibrations enough so that what is in the bag is accurate in our eyes.

    Finally, when we use our pumps and Alaris says it’s done but there’s 50 mL left, we must get an order to infuse the remainder at the ordered rate.

    Chris Donaghey, MSN, RN, PCNS-BC, CPN, CPHON
    Clinical Nurse Specialist – Riley Cancer Center
    Riley Hospital for Children at IU Health
    Indianapolis, IN
    Original Message:
    Sent: 02-07-2020 03:34 PM
    From: Sheila Tobin
    Subject: Methotrexate infusion

    ​Hi Loucine,

    I agree with the other nurses who have replied- it’s been a problem for the last 20 years.  About 5-8 years ago, our team met with the Alaris pump representative, and learned there is a 5-7% variability of what actually gets infused each hour, no matter how you program the pump. We modified our chemotherapy policy, and state that at the beginning of the infusion of any 24 hour bagged IV chemotherapy, the nurse can adjust the rate up to 10% to allow for more accurate stop times.  The nurse adjusts the rate at the beginning, only once, and cannot slow down or increase it again (to ensure steady exposure to methotrexate).

    I’ve done a quick survey of nurses– most increase the rate by 7-10%, and state that the infusion ends somewhere between 23 and 24 hours.  We have done a lot of education that the 24 hour level is whenever the infusion is complete.

    It would be an interesting project/poster for an organization who has already done EPIC and Alaris pump integration (where the pump sends the hourly volume infused information to EPIC instead of the nurse manually entering the rate into EPIC that was programmed in pump).  To see what actually is infused versus what we all think has been infused would be telling.  It may end our nationwide belief that our MTX bags are overfilled by pharmacy! 😉

    Thank you,

    Sheila Tobin BSN RN CPON
    Clinical Nurse Educator
    Rady Children’s Hospital
    San Diego CA

    Original Message:
    Sent: 02-07-2020 05:57 AM
    From: Loucine Kaplanian
    Subject: Methotrexate infusion

    Dear Members,
    Please, it is highly appreciated if you provide us feedback on the following inquiries:

    We are facing problems with accuracy in the chemotherapy infusion volume, especially methotrexate. Are you facing issues with chemotherapy bags? When the infusion time of the chemotherapy is over while the chemotherapy bag is still full? Note that we know that all bags could have an additional 10% or minus 10% volume. However, the remaining amount that we are having left after the infusion is over is more than 10%.
    Do you run the remaining amount ? or you only run the volume and the rate you initially set on the of the pump?

    Loucine Kaplanian, RN