| a) Limit the concentration in stock to 25 mg/mL |
| 1 |
2% |
| 2 |
3% |
| 3 |
10% |
| 4 |
19% |
| NA |
2% |
| No |
28% |
we were already doing this
Not available on formulary
Plan to discontinue the 50mg vial
Recently removed 50 mg/ml from formulart
l
Pending P&T Approval
We plan to do this. Great idea!
GOING TO IMPLEMENT
Implementing now
only 25mg/ml for iv 50mg/ml for im
After your article we have put this into place
Changed after review of newsletter
not currently
Considering recommendation at this time
Plan to remove
if they want 50 mg they have to call the pharmacy for a piggy back
Submission to P&T committee pending
plan to review for implementation
Home Infusion
Good idea.
Stock 50mg in emergency room pyxis
for each of the following, we did not have any restrictions on dilution/admnistration until we read your article. the following reflects our current practice after we made the changes to make administration safer.
Will refer to P&T to remove 50 mg
Prior to removal from formulary
hosp committee looking at use
Not yet.
50mg was removed from all automated machines with the exception of ER and Surgery. Plans to remove them are in place.
Pyxis machines contain 25mg/ml; the 50mg /ml is available from pharmacy
Omarion
|
| b) Limit the starting dose to 6.25 to 12.5 mg IV |
| 1 |
3% |
| 2 |
10% |
| 3 |
22% |
| 4 |
26% |
| NA |
4% |
| No |
72% |
Not a present time but are addressing with the medical staff.
Not available on formulary
Pediatric hospital
Evaluating the ability to police this type of policy
Default dose is 12.5 mg - MD can choose 6.25 or 25 or type in another dose
In OR only
Mostly, but not all follow
Is there data demonstrating a decreased risk with this recommendation?
Pending P&T Approval
We plan to do this.
Very importan for the"sedation issues" connected with the drug.
Most doses are 12.5mg
Instituted to also limit the development of CNS side effects which was a significant issue in our institution
Evaluating now
6.25 for pt's over 65
Will present to P&T Committee
facility not helping pharmacy to accomplish
We do not allow the IV use.
the md's won't do it.
Sent notice to MD's
Usually 12.5-25
Home Infusion
In most cases, but not all yet
12.5 - 25mg dose max.
12.5mg is our MAX IV dose -- 25mg MAX IM dose
Is a recommendation
reviewing at this time
Moving to 6.25 mg only
Will revise pre-printed orders
We recommend
Plan to take all suggestions to Pharmacy/Nursing Subcommittee
Not yet
Max dose 25mg
This is not a manufacturer recommended strategy to minimize risk of extravasation.
ED & other OP areas may often initiate with 25mg dose
For only 2-3 wks and the physicians are overriding 6.25 saying higher doses are required
Limit to 25mg IV via Central Line
majority of doses are 12.5mg
Layton
|
| c) Dilute the drug in 10 to 20 mL of normal saline |
| 2 |
6% |
| 3 |
11% |
| 4 |
24% |
| NA |
5% |
| No |
42% |
Writing a policy as well.
We will be starting to do this.
we were already doing this
Not available on formulary
Plan to do so.
We indicate to dilute in nursing admin. insructions
Except in OR
previous hospital I did have this manditory
Again, is there data demonstrating a decreased risk?
UNSURE
UNSURE
We do this or via a running line
Just started 8/23/06
We dilute in 10 ml; some of our nurses feel that this is not especially effective.
After the article this was put into place
Changed after review of newsletter
if not being administered into an existing IV line
Instructions on MAR, have not evaluated if staff doing it.
for doses larger than 25mg only
Considering recommendation at this time
Not yet
Mostly
Working on implementing
drug is diluted in 3ml normal saline
Currently evaluating these recommendations
Home Infusion
we've req'd 5ml till now.
Under consideration
Good idea.
Dilution does not minimize phelibitis risk
If not adding to running line
reviewing at this time
Not consistently
Moving to 50 mL preferred
We dilute in 10 ml
Just approved at 9/06 P&T
We dilute in 5ml ns
not good for peds
Protocol is being developed
Tried this, still had patietn go to surgery due to seriour tissue damage
today all doses are diluted, prior to your article so long as it was pushed through a running IV it was allowed
Jordon
|
| d) Prepare the drug in minibags containing normal saline |
| 1 |
18% |
| 2 |
16% |
| 3 |
24% |
| 4 |
21% |
| NA |
4% |
| No |
83% |
have done this for many years
Not available on formulary
Too much volume for kids
this could allow nurses to hang bag and then leave the room, they wouldn't be there to stop infusion quickly if pain is expreienced.
See above.
Evaluating
extravasation is more likely if not watched -- in PB, nurses are more likely to walk away
No need if always diluted in a 10 to 20ml syringe volume.
use a mini infuser- syringe pump
like to avoid this option
This recommendation would likely take too long for our patients with nausea
for doses higher than 25 mg
will revise admin. IV guidelines
Working on implementing
Currently evaluating these recommendations
To be discussed at P&T meeting
Home Infusion
Limited pharmacy hours
do sometimes
also under consideration
when mixed in a Piggyback
RN prepares at time of admin.
Recommend IVPB when possible
Do not use
we are still reviewing to see what we will do. This is a possibility
reviewing at this time
Moving to 50 mL preferred
we still allow IV push via PICC line only when the pharmacist explicitly labels the drug that way. We are a home care agency and 99% of our patients have PICC lines.
Most doses prn, impractical
Stability?
Not yet
Not feasible
Impractiable due to increase labor time involved and JCAHO mandate on no mixing on the nursing units.
not good for pediatric pts
Turn around time for an antinausea drug used infrequently is not optimal
Compatibility data exists but impractical, would require 250 ml diluent for each 25 mg dose too much fluid for the usual frequency.
for doses larger than 12.5 mg we are implementing this practice
10 or 20ml syringes via B-D360 infuser pump
Syringe with 10ml or more NS
Minibags would have to be prepared in pharmacy. This would significantly delay a medication that usually needs to be administered quickly after symptoms are reported. This would adversely affect patient satisfaction and nursing satisfaction. We would consider purchasing premix bags if they were available.
Samuel
|
| e) Do not allow administration via hand or wrist veins |
| 1 |
2% |
| 2 |
5% |
| 3 |
18% |
| 4 |
29% |
| NA |
5% |
| No |
76% |
Will be including these recommendations in new policy
added this to our safety info for labels and MAR/Automated disp cabinets
indicated in nursing admin instructions
Nurses educated, practice not monitored
We are a pediatric hospital and overall use is low.
Not yet, but will implement
strongly recommended
Have asked nursing to review policy
recently encountered incident when this was not followed
This recommendation would eliminate promethazine usage in the vast majority of our patients
I ma not sure of what is being done on the floors, but we have stared inservicing the nurses
Not yet
what if they only have that access
But encourage
Working on implementing
Currently evaluating these recommendations
Home Infusion
under consideration
Going to be implemented
Need to investigate further.
Not always an option
This has worked for a long time
Encouraged not to
Adding that suggestion to education
Placed as a warning on label-but it could be ignored by a nurse.
reviewing at this time
Patient IV sites vary
We try to avoid
Need to include in protocol
recommend against
Controversial, not consistent with best practices "extravasation" precautions, if you extravasate when IV access is higher up the limb and significant extravasation and tissue damage occurs you stand too loose more of the limb effected.
"whenever possible"
20 ga or larger cathlon
good point
Quinten
|
| f) Give the drug through a central venous site only |
| 1 |
14% |
| 2 |
24% |
| 3 |
29% |
| 4 |
19% |
| NA |
4% |
| No |
92% |
not practical
see above
We use a central line if there is one
Fine if pt has a central line
Have asked nursing to review policy
not cost-effective if existing IV line established
most patient do not have central access
This recommendation would eliminate promethazine usage in the vast majority of our patients
should we put central lines in our total knee patients?
Working on implementing
Currently evaluating these recommendations
Home Infusion
CV catheter if available
Not realistic. Bad idea.
most of our patients do not have central lines
reviewing at this time
NOT PRACTICLE
Not all patients have central lines
Not all patients have a central line
Catheter tip can migrate..
25 mg.
Earnest
completely non-practical
|
| g) Inject the drug through a running IV line |
| 1 |
2% |
| 2 |
4% |
| 3 |
12% |
| 4 |
36% |
| NA |
5% |
| No |
49% |
Inconsistent practices amongst RNs
Planning to change policy
UNSURE
UNSURE
Or in 10-20 mls of fluid
We sometimes do this
Working on implementing
After PRN on Picc running
Currently evaluating these recommendations
Home Infusion
Nursing resists
too many saline locks
Good idea.
This is our usual practice, will add to education piece and policy
we are still reviewing to see what we will do. This is a possibility
reviewing at this time
Not all pts have "running IV"
Inconsistencies noticed, will be addressed in protocol
we recommend for
We have explored use of burretrols, expensive, time consumptive to set up, requires change every 48 hours in our facility.
"whenever possible"
Grady
I can not answer this question completely - in L&D yes, in Acute Care areas or ER I do not know
|
| h) Inject the drug through a running IV line at the port furthest from the patient’s vein |
| 1 |
2% |
| 2 |
8% |
| 3 |
19% |
| 4 |
38% |
| NA |
7% |
| No |
69% |
cannot enforce
Inconsistent practices amongst RNs
added to safety info for labels,MAR,automated disp cabinets
UNSURE
UNSURE
By practice, not policy.
the wording to this may be difficult to understand without further explanation/example
good idea
Encourage
Currently evaluating these recommendations
Home Infusion
will be doing so
If the patient has a running IV
Good idea.
as above
placed as a label comment on the drug-could be ignored by a nurse
we are still reviewing to see what we will do. This is a possibility
reviewing at this time
Will incorporate
When possible
not sure
Not yet
Not always done, need protocol
we recommend for
"whenever possible"
Perry
there is no nursing guidelines that state the must do this that I am aware of - in L&D several nurses verbalized that this is their practice
most commonly one iv access
|
| i) Administer the drug slowly over 10-15 minutes |
| 1 |
4% |
| 2 |
9% |
| 3 |
18% |
| 4 |
32% |
| NA |
5% |
| No |
61% |
Inconsistent practices amonst RNs
will have probs w/nursingcompliance due to time involved-most nurses don't want to spend 10-15min for ivpush
plan to do so.
Again, this long of an infusion would require the minibag that could be hung and left unattended
Recommending, but is not policy yet
Does this reduce risk?
30 Minutes
Over at least 5 min
Over 5 min
Resistance encountered from nursing due to time involved and staffing issues.
Modified: over 5-10min
Was recommended after reading your article
Would only work if we convert to mini bag
only if no IV fluid is being administered and the medication is diluted in a piggyback
Considering recommendation at this time
Not yet
Working on implementing
administered over 3 minutes
Currently evaluating these recommendations
Home Infusion
longer than our current recommed
Will come with above implementation
not when given IVP
5-10 minutes more realistic.
over 5 minutes
Recommend over 3-5 minutes
We compromised with bedside RNs. The drug is given, diluted w/NS in a large, patent vein over 5 minutes.
More like 5 minutes
We dilute, and push over 3-5 minutes
25 mg/min.
reviewing at this time
administer over 20 minutes
We do not require this on our PICC only adminsitration guidelines
Not sure
We use 2 to 5 minutes
We recommend 3-5 min infusion
Nursing will resist due to time involved and staffing issues.
Recommendations state 3-5minutes at this time
no pushes over 5 minutes
Requires more time to be spent administering medication, less time available to address other patient care needs.
FDA PI approved for 25mg over 1 minute
Abram
|
| j) Require the person administering the drug to remain with the patient to assess the IV site during the entire injection/infusion |
| 1 |
4% |
| 2 |
8% |
| 3 |
27% |
| 4 |
32% |
| NA |
7% |
| No |
65% |
not practical
More the reason to allow in a syringe instead of minibag
would be difficult given nursing shortage
if pushing it - the individual would need to be at the bedside
Unknown
not possible, especially on rregular Rn units (none ICU)
Not possible
Working on implementing
Currently evaluating these recommendations
Home Infusion-PIV only
Nursing resists
Staff too busy. Will return in 15 min.
We provided assessment and action guidelines.
If IV push, the nurse is there the entire time
reviewing at this time
NOT PRACTICLE
This will mostly be administered in our PACU where nurses will not be at the bedside but are within voice range; when used on nursing units, we feel a call bell is sufficient). Plus, pulls nursing staff away from other issues were may be of higher priority. Provided the dosage, dilution, rate and site recommendations are followed, we hope this will not be necessary.
Pending
Not always practical
again nursing will resist due to staffing issues
This may not occur with minibag infusions
no minibag, only RIVA
applicable only when RN is pushing the med
Jarrod
|
| k) Standing orders for promethazine IV reflect the current safety requirements |
| 1 |
3% |
| 2 |
4% |
| 3 |
17% |
| 4 |
26% |
| NA |
15% |
| No |
60% |
but warnings are present in EMR/e-MAR
Will change with new policy.
MAR will reflect this information
Pending
working on it but requirements implemented are in effect now
PLAN TO IMPLEMENT
UNSURE
UNSURE
Don't use standing orders
Working on
THis is in our IV policy on who can admin & how to administer
Working on getting these changed after reading your article
Will present to P & T committee
Unknown
Soon
Working on implementing
Currently evaluating these recommendations
Home Infusion
No standing orders yet working
No standing orders
Order sheets = No. IV Guidelines = Yes
Promethazine was not part of any current standing orders
No standing orders
Will add the dilute and push times to the order
reviewing at this time
In progress
workingon CPOE changes currently
Pending
not supported by the medical staff
No standing orders
We have no standing orders
We are revising all order sets
Not all of them
No standing orders
Mathew
|
| l) Patients are advised to report burning or pain |
| 1 |
0% |
| 2 |
1% |
| 3 |
11% |
| 4 |
21% |
| NA |
7% |
| No |
43% |
Will change with new policy
probably not being done
plan to do so
Nursing staff inservice, practice not monitored
Not possible for all patients
working on new policy
UNSURE
UNSURE
RN's prompted to monitor iv site
Recommended after reading your article
I don't know what RN tells pt.
Working on implementing
Will education nursing
Currently evaluating these recommendations
Home Infusion
Pain scale follow-up mandatory.
Will incorporate that specific phrase
label comment on drug-could be ignored by nurse
reviewing at this time
At present not specific to this drug
Not sure
Not consistent. Information includes "burning may occur"
Not consistenly followed
Armani
unknown what nurses advise patients of
|
| m) An alert appears on MARs reminding staff of safety precautions |
| 1 |
2% |
| 2 |
4% |
| 3 |
14% |
| 4 |
25% |
| NA |
5% |
| No |
52% |
We do not have electronic MARs
Beginning this next week
JUST IMPLEMENTED
working on new policy
Not able to with current system,
are in process of
The order would indicate the route is IM
Considering recommendation at this time
Plan to implement
Will be soon
Not until electronic MA
Mostly
Can add
Currently evaluating these recommendations
PRINT OUT
Home Infusion
RE: Proper dilution
Not on MARs. Not realistic.
we are still reviewing to see what we will do. This is a possibility
not currently using MARs
Online formulary
Not on Mar on IV
Home infusion
Space on the MAR is limited.
Nurse written paper MARS
Darian
until recently (past 2 months) the use of an alert was sporadic but this does not reach those areas that take supplies from ADM's
|
| n) An alert appears on automated dispensing cabinet screens reminding staff of safety precautions |
| 1 |
3% |
| 2 |
4% |
| 3 |
21% |
| 4 |
23% |
| NA |
20% |
| No |
53% |
Will do this as soon as we determine how.
No automatic dispensing cabinets
JUST IMPLEMENTED
working on new policy
Acudose systems do not have alerts
Will prob add- unfortunately wiht our machines the maessage doesn't appear until after you hear the "boing" of the drawer opening. We keep trying to educate the nurse to look at the sreen after the draw opens- not bend to get the drug. So these in general haven't been that helpful. We have tried to put messages that they have to answer questions. I think we will consider this for the ED, which unlike the rest of the hospital may admin diluted IV push over 5 min.
Added warning after reading your article
Will address.
Reminder that promethazine injection is not for IV use
Considering recommendation at this time
Plan to implement
Not avalable accurately
Currently evaluating these recommendations
Home Infusion
No automated cabinet
Other ways to inform RN's.
Working with IT.
Will do with updated system
Good practice, sometimes the alerts are so many they are not seen
we are still reviewing to see what we will do. This is a possibility
note placed where product
In process
Will proceed with doing so
Alert fatigue; to many already
Not in cabinet
Do not use
Home infusion
Will not appear when nurse override access
Shaun
|
| o) Remove promethazine from the formulary |
| 1 |
37% |
| 2 |
26% |
| 3 |
17% |
| 4 |
6% |
| NA |
3% |
| No |
94% |
not realistic
This is being discussed
Considering
We had these safety procedures in & almost never used. After the compazine recall, we felt forced to use. NOw we still use a significant amt- evn though we are discouraging it.
Currently being contemplated
Pending -evaluating at this time
Remove the injectable form of the drug
Easier said than done ... and, it has its place in therapy
Are you kidding?
Currently evaluating these recommendations
Home Infusion
Effective IM
but it's in our plans
Bad idea! Would hurt patients more.
Considering.
we have gone thru P&T and medical staff and IV promethazine is NOT used no matter where in the hospital
not likely at this time
We are exploring this route, with summer holidays haven't got to it yet
considering
Vast majority of cases were from inappropriate dosages/rates of infusion - we will be using exclusively 6.25 mg by infusion with the precautions recommended. We feel that removing this drug from use is an exaggered response + would eliminate a valuable drug for the treatment of post-op nausea and vomiting. Alternate drugs carry risks also - dexamethasone (avascular necrosis), droperidol (QT warning/black box), ondansetron (5HT3s; QT prolongation), dimenhydrinate (EPS, anticholinergic)
We had 5 cases of extravasation in one year and removed the drug from formulary
Promethazine is widely used in L&D
Just not realistic. Promethazine is inexpensive and very effective. Physicians would strongly resist this recommendation.
Recommendations to P&T for alternate
Cost impact can be substantial, Reduces available antiemetic options for the patient.
Dakota
Several case reports do not necessitate formulary removal
|
| p) Ban IV use of promethazine |
| 1 |
37% |
| 2 |
19% |
| 3 |
18% |
| 4 |
9% |
| NA |
2% |
| No |
92% |
not realistic
did remove 50mg/ml strength
Just voted to do this in P&T
See ans to #9. We are discouraging its use due to sedation issues. After the long comapzine backorder. IT would be hard to totally eliminate- in case that happens again. Zofran works grat- but the financil impact was great. I think phenergan could be reserved with guidelines for these type of occasions.for
Currently being contemplated; action by FDA would help greatly
Are you kidding?
Currently evaluating these recommendations
Home Infusion
considering via P&T
under consideration
but in our future plans
Bad idea! Would hurt patients more.
the only solution
We annually administer over 4,000 doses IV and have not had any problems. Despite this, education is helpful
not likely at this time
If I can't have it removed, we will look at this option next
considering
WHICH DRUG NEXT?
Still have listed for IM use
We encourage IM administration for post-op & hyperemesis patients
Not sure.
We may restrict inj Phenergan to IM route of administration only.
Allen
|
q) Use alternative rescue antiemetics
Specify:
ondansetron, etc.
alternate route, compazine, ondansetron
Anzemet
Anzemet & Zofran IV available.
anzemet for iv/reglan/decadron
Anzemet, Zofran
Cason
Compaine or Zofran or Kytol
compazine
Compazine or Anzemet
compazine, 5HT3's
Compazine, Anzenet
compazine, Dexamethasone, Reglan, Kytril
Compazine, Kytril, Reglan
compazine, reglan
compazine, reglan, zofran
Compazine, Tigan, Zofran
compazine, zofran
compazine/droperidol/zofran
dimenhydrinate, haloperidol, prochlorperazine, ondansetron/granisetron
DOLASETRON
Droperidol, Compozine
hydroxyzine
IM/PR/PO phenergan, IV zofran, IV Compazine, IV dolasetron
Kytrel, Zofran, Thorazine
kytril, reglan, compazine & droperidol
lorazepam, metoclopramide, droperidol
metoclopramide, dexamethasone, zofran, compazine
metoclopramide, granisetron
ondanestron
ondansetron
ondansetron is the most used antiemetic at our hospital
ondansetron, haloperidol,
ondansetron, metoclopramide
Ondansetron,Dolasetron,
ondasetron, prochlorperazine
Phenergan topical gel (compounded), Haldol injection, the 5HT3's
Prochlorperazine
prochlorperazine (Compazine), dolasetron (Anzemet), granisetron (Kytril)
prochlorperazine , ondansetron, dexamethasone, metoclopramide, diphenhydramine
prochlorperazine, dolasetron, ondanestron
prochlorperazine, ondansetron
prochlorperazine, tigan, zofran
prochlorperazine/metoclopramide
Reglan or Zofran
Reglan, Zofran, Tigan
SH-T3 - not automatic
vistaril
zofran
Zofran or Anzemet
zofran, anzemet
zofran, compazine
Zofran, Phenerangel, compazine
zofran, reglan
Zofran, Zantac
Zofran,Kytril
|
| 1 |
13% |
| 2 |
13% |
| 3 |
28% |
| 4 |
21% |
| NA |
9% |
| No |
53% |
are changing standing orders
Promethazine first; rescue after failure
There are few alternatives which are FDA indicated.
There are not enough cost-effective agents available for interventional n/v. Your recommendation to switch to zofran was ill-conceived.
Being reviewed by P&T at next meeting
Not realistic once nausea present
Zofran to be used if only IV access is in hand or wrist
No more droperidol, now no more promethazine?
We probably will encourage other antiemetics
Just voted to do this in P&T
It would be ashame to loose a very useful class of antiemetics, when only alterations in administration techniques could add safety
Therapeutic interchange policy not in place as of yet; currently educating physicians and intervening when possible.
Pending evaluation at this time
each have their own "flaws", especially 5HT3 are non-effective for rescue therapy
We do not require one over another
Many alternatives in this category of medications are either very cost prohibative or not good alternatives to promethazine.
The cost is very prtohibitive for it to replace Promethazine
zofran, kytril,etc.
Sme insurances won't pay
Home Infusion
Zofran very expensive
we encourage compazine,zofran,etc
Currently being done.
Provided ER physicians with antiemetic chart
It is frustrating conundrum. Even the "preferred" IM route for promethazine can result in neuronal damage. Our patient population is typically >65 y and at high risk for CNS side effects of compazine... and ondansetron ODT and injection is about $17/dose...
Encourage
change is like moving a freighter
Droperidol is still an excellent antiemetic, but we don't use it. I think the FDA acted inappropriately in the way they addressed its use. All of the drugs (5HT3's, Haldol, Phenergan) have the potential to alter the cardiac function. I think the changes in labeling were too strict. I also suspect some of the decisions were financially advantageous to the companies producing the 5HT3's meds.
Available to MDs
Promethazine use was uncommon before these warnings
limited effectiveness
we have zofran available already. However, there is a large price difference
for patients on PCA narcotics
considering
Make alternates available
prochlorperazine
Compazine
Physician preference
Current guidelines call for using agents from different categories when a patient fails on one agent.
High cost vs promethazine
Now that compazine is available, order sets include option of Compazine, Tigan or Zofran
Exploring restriction of inj phenergan to IM route of administration, encouraging other routes of phenergan adminisration (po,pr), other inj alternatives (compazine, zofran, dolasetron).
both ondansetron and now prochlorperazine are available
compazine & zofran are alternates
Benito
we have many antiemtics on formulary for IV use - but some doctors still use IV promethazine
|
2). At your current or past facility, have there been any cases of serious tissue damage in the past 5 years that occurred after IV administration of promethazine? |
| No |
57% |
| Not sure |
22% |
3). Do you believe FDA should withdraw approval of the IV route of administration of promethazine? |
|
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