Patient with zofran pump and no orders

[BSNbeauty, BSN, RN]

There are 2 patients on our floor that was admitted with zofran pumps. There were no orders in place neither is their a policy on how to maintain the pumps. Both patients came to the hospital with these pumps and the docs just wrote orders to maintain the pump without any dosage, directions or anything. The nurses were basically told not to touch them. Thankfully, pharmacy brought this to our NM attention and demanded that the pumps be discontinued so that the hospital would not be held liable if anything went wrong.

My question is: How does your facility handle patients that come in zofran pumps that was not placed by the facility?

[blondy2061h, MSN, RN]

I have honestly have never heard of such a thing, despite working with a lot of patients with chemo related nausea.

[ArtClassRN, ADN, RN]

Never seen a zofran pump either. But I can think of better ways to get orders or a plan for something than threatening to suddenly discontinue patients' medications. Would you do this with an insulin pump too?

[blondy2061h, MSN, RN]

I looked it up. Looks like a subq pump that continually delivers zofran for hyperemesis gravidarum. I guess I don't understand how this is more beneficial than q6h IV push zofran ATC.

[BSNbeauty, BSN, RN]

Never seen a zofran pump either. But I can think of better ways to get orders or a plan for something than threatening to suddenly discontinue patients' medications. Would you do this with an insulin pump too?

Oh my goodness, ofcourse we would not discontinue the patients zofran pump without having IV zofran ordered. Just like if an insulin pump was to malfunction we would use administer insulin using syringes right? The docs did write orders to D/C the pumps since no one had a clue how to manage them. The outside company had to come in and actually discontinue the pump and the patients were ordered IV zofran instead. This was not my patient but I'm sure the doctors had figured out a way to make sure the patient was safely getting the dose they are used to with the pump.

[BSNbeauty, BSN, RN]

I looked it up. Looks like a subq pump that continually delivers zofran for hyperemesis gravidarum. I guess I don't understand how this is more beneficial than q6h IV push zofran ATC.

Agreed. The pump is great for when the patients are at home but I don't see the point if they are hospitalized. Like I said, they came from home with these pumps and the nurses on our unit has never worked with these pump or been trained on how to use them. If they were to malfunction we would have to switch over to IV zofran anyway.

[Esme12, ASN, BSN, RN]

just like insulin pumps....the physician write an order for the patient to maintain their own pump.

[BSNbeauty, BSN, RN]

just like insulin pumps....the physician write an order for the patient to maintain their own pump.

Thanks Esme12, I think this is where all of the confusion came in. The doc did write that order, however pharmacy felt as though we needed specific orders and directions. This whole thing was just a mess yesterday.

[blondy2061h, MSN, RN]

Thanks Esme12, I think this is where all of the confusion came in. The doc did write that order, however pharmacy felt as though we needed specific orders and directions. This whole thing was just a mess yesterday.

Do you have an insulin pump policy? I'm guessing it could be applied to this. Our insulin pump policy says that the patient must be able to self manage it, and the doses being used must be confirmed and written in the order. Infusion set assessment must be documented qshift, and glucoses must be checked at least QID. Everything except tinge glucoses makes sense with a zofran pump too. Or any pump. We occasionally get patients using home pca's as well.

[T-Bird78]

I was on a zofran pump for my hyperemesis during my pregnancy. It's supplied by a home health agency so you can try to call them or the pt's OB for dosing instructions and let your MD know. It's a subcu pump that administers zofran 24/7--even has a waterproof bag for showering. The dose is adjusted daily or qod based on the pt's phone consult with the home health agency. The med is a prefilled 10ml syringe and the admin rate is how the dose is adjusted. There's a little screw-type plunger that slowly pushes the zofran over whatever time frame is programmed. The pt calls the home health agency, updates their s/s, weight, and ketone levels (yes, I had to dip my urine and weigh daily). If a dose adjustement is necessary, the home health nurse will advise the pt on what to change the pump rate to. At my highest, I was going through the 10ml syringe in about 8 hours; at my lowest it was 10ml lasting just under 24 hours. The max dose equaled out to 12mg/day. The reason for the subcu pump is for the more continuous flow versus an IV push. I'd had IV zofran in the ER and hospital admissions, along with oral zofran, reglam, and phenegran and those still didn't help. Even with the zofran pump I was on oral meclazine, then oral zofran qd after the pump was finally d/c. It's a much bigger device than an insulin pump and the infusion site has to be changed daily--that's a LOT of sticks!! The infusion sites get very red and sore and the zofran "lumps" under the skin, hence the daily site change, and it's no fun, but it beats the uncontrollable vomiting and fatigue and fear that accompanies HG!

[dudette10, MSN, RN]

Do you have an insulin pump policy? I'm guessing it could be applied to this. Our insulin pump policy says that the patient must be able to self manage it, and the doses being used must be confirmed and written in the order. Infusion set assessment must be documented qshift, and glucoses must be checked at least QID. Everything except tinge glucoses makes sense with a zofran pump too. Or any pump. We occasionally get patients using home pca's as well.

Agree with using the insulin pump policy as a guideline.

It upsets me that pharmacy was "demanding" that the pumps be discontinued, but it's also not surprising. Pharms are not bedside and not patient advocates. In this case, the pharm, nurse and doctor should work together to do what's best for the patient, not just the hospital re:liability.

ETA: The pump would be better than ATC IVP to maintain a constant level of antiemetic, even while hospitalized. The risk of electrolyte loss, dehydration, and lower level of pt comfort, I believe, would override any fear of liability and, for the sake of the patient, should make pharm and the MD think twice about discontinuing it.

[MunoRN, RN]

Oh my goodness, ofcourse we would not discontinue the patients zofran pump without having IV zofran ordered. Just like if an insulin pump was to malfunction we would use administer insulin using syringes right? The docs did write orders to D/C the pumps since no one had a clue how to manage them. The outside company had to come in and actually discontinue the pump and the patients were ordered IV zofran instead. This was not my patient but I'm sure the doctors had figured out a way to make sure the patient was safely getting the dose they are used to with the pump.

They probably aren't actually getting the same effect with IV pushes that they are with the pump. The plasma concentrations when giving IV have a distinct peak and trough, while continuous SQ dosing produces a more consistent plasma concentration that is higher than it is with IV pushes. In other words, they would only be getting equivalent effect from the zofran for maybe 25 or 50% of the time, otherwise they're getting less effective coverage from the zofran without the pump.

The pumps I've seen say what the rate is, and the syringes have the concentration. As far as managing them it's actually very easy, keep in mind that non-RN patients manage these at home all the time, it's really not so complicated that it needs to be D/C'd in exchange for less effective therapy.