Nurses need as much say and control as pharmacists over the selection and implementation of a closed drug transfer system if it is to be effective, several experts asserted. Ron Ozuna, PharmD, BCPS, clinical coordinator of Pharmacy Services at Doctors Hospital at Renaissance in Edinburg, Texas, led a team that recently transitioned to a preparation strategy that employed closed system transfer devices (CSTDs). He said that, “ultimately, you need buy-in from the end-users of CSTDs.”

Similarly, Dr. Ozuna’s colleague, Gavino Garza, RPh, director of pharmacy at Doctors Hospital at Renaissance, believes pharmacists considering a closed system should solicit as much feedback from nursing staff as possible and address any of their concerns. “We found out our nurses were worried about the practicability and impact of CSTDs on their workflow,” Mr. Garza said. “For example, it was important for them to have the same systems in place in both the adult and pediatric oncology units while allowing them to continue using secondary infusion sets in adults but primary sets in pediatric patients.”

A six-month pilot and evaluation period of the product they ultimately chose provided nurses with an opportunity to familiarize themselves with the new system and to make workflow process modifications, according to Dr. Ozuna. “After an initial learning curve, nurse and pharmacy staff have become efficient despite the added steps with a closed system and they feel safer and comfortable,” he told Pharmacy Practice News.

The evaluation period also provided a chance for nurses to see the benefits of a CSTD for themselves. For example, they noticed that there was much less residual medication in drug vials using a CSTD, and that this could potentially have positive effects on patient care, Dr. Ozuna explained. The trial period also provided a chance to observe the reduced potential for drug exposure with CSTDs, he said.

Adaptability a Concern for Nurses
According to Ryan Forrey, PharmD, MS, associate director of Pharmacy and Infusion Services at the Ohio State University (OSU) Comprehensive Cancer Center-Arthur G. James Cancer Hospital, in Columbus, if the concerns of nurses are not taken seriously, the entire project of implementing a closed system risks failing. “CSTDs are only as good as the actual compliance with them,” said Dr. Forrey, an expert on CSTDs. “Pharmacists tend to think about the pharmacy side” but neglect the nurses’ perspective, he noted. A better approach, he said, is to adopt a shared governance model that includes nurses as equal partners in the transition to a closed system.

The multi-stakeholder team responsible for the transition to a closed system at the National Institutes of Health Clinical Center (NIH CC) in Bethesda, Md., is a successful case study in the shared governance model that Dr. Forrey recommended. Daniel Zlott, PharmD, an oncology pharmacy clinical specialist for the National Cancer Institute Surgery & Immunotherapy programs at the NIH CC, and the pharmacy lead on the CSTD transition team, said the sheer size of the nursing contingent at the NIH CC—numbering more than 400 staff—left no question that nursing needed to be as involved in the selection and implementation of a closed system as pharmacists. Working with a committed nurse representative was a critical factor, he said.

“Finding someone on the nursing end who was willing to learn about all the different line systems we have and to understand why we set them up the way we do really helped me communicate to the nursing staff,” Dr. Zlott told Pharmacy Practice News. “If this had been only been a pharmacy-driven project, it would’ve been much more difficult.”

On the nursing end, Amy Callahan, RN, DNP, AOCNS, an oncology and critical care clinical nurse specialist in the Nursing Department at the NIH CC, framed the implementation of a closed system almost identically. Dr. Callahan said it was a “co-led project” and that, “if it was only a nursing-led initiative, it would have been much more challenging. “I needed to understand all the ins and outs of each preparation and Dan [Dr. Zlott] was the expert in explaining drug delivery in every protocol,” she said. “Where Dan was, I was.”

Both Drs. Zlott and Callahan noted that a top priority was to ensure the added workload linked with implementation to a closed system was spread across their two disciplines. “We found a nice middle ground where nobody was getting everything they wanted,” Dr. Zlott said.

The nursing team modified their infusion processes and the pharmacy team agreed to spike hazardous drugs and attach CSTDs in the pharmacy. “We’ve always spiked and primed certain hazardous drugs, primarily for our pharmacokinetic studies because our investigators want to know precise information,” Dr. Zlott said. “What we agreed to do when the closed system was put in place was to spike, but not prime, all of the remaining hazardous drugs. Not only did it save nursing time, but it was a potential area for drug exposure that we took on in the pharmacy.”

According to Dr. Callahan, there was almost no resistance to a shift to CSTDs, even with the added burden on workflow—a fact she attributed to the strong nursing safety culture at the NIH CC. “We have up-to-date evidence-based safe-handling policies and procedures,” she explained. “We use solid front gowns and we double-glove. This was just another method of ensuring we were doing the best we could as an institute to protect the nurses while they handle hazardous drugs. We don’t fully know the complete hazardous profile of some of the research compounds, so safety is a strong concern for us.”

Perhaps it is indicative of the success of a collaborative model that Dr. Zlott played a pivotal role in training nurses, Dr. Callahan added. “A training video that Dan made was instrumental in the implementation phase of the project,” she said, noting the video is now used to train new nurses in the use of CSTDs.

Post-Implementation Collaboration
According to OSU’s Dr. Forrey, collaboration should not end when a closed system is implemented. He said there is potential for errors and events that come with the introduction of any new technology and that pharmacists and nurses need to work together to determine whether events are a result of product flaws, systemic issues or human error. “For every event, look for the root causes and address these,” he said. “You can’t just tell nursing to use the system and expect they won’t need further education. This is why a collaborative relationship is so crucial to success.”

If necessary, Dr. Forrey said staff should be re-educated; and if there a significant increase in events occurs—as did in his own institution after implementation of a closed system—pharmacy and nursing may need to redesign work processes.

“With re-education and nursing collaboration, we’re now down to baseline spill levels,” he said. “However, if you don’t address the causes early, you can actually increase the number of spills.”

None of the participants reported any financial conflicts of interest.

Other Factors To Consider in the CSTD Evaluation Process

Nursing concerns about the integration of closed-system transfer devices (CSTDs) into their workflow may have been the foremost consideration at Doctors Hospital at Renaissance’s when they decided on a CSTD vendor, but the implementation team evaluated other factors as well, according to Ron Ozuna, PharmD, BCPS.

“The company rep was key in helping make the switch,” said Dr. Ozuna, who is clinical coordinator of Pharmacy Services at the hospital in Edinburg, Texas. His team ultimately chose the Texium closed male lure and SmartSite needle-free valve products (CareFusion Corporation). “We had reps from several companies come in, but the CareFusion rep was most effective in educating and assisting staff with the closed system.”

Dr. Ozuna said the CareFusion representative helped obtain nursing buy-in to the very idea of a closed system by emphasizing the added safety of CSTDs and promptly addressing staff questions, with the goal of minimizing workflow disruptions.

Other institutions have documented rigorous CSTD evaluations, including wipe studies to determine how much a CSTD reduces surface contamination (see Pharmacy Practice News 2009;36:08). However, Dr. Ozuna said his team’s evaluation process was “relatively informal. We did conduct some UV [ultraviolet] light examinations to identify spills and leaks, and we looked to published literature showing that a closed system reduces exposure, but we did not look at product-specific studies. It was mostly a matter of trying out the different products and feeling out how comfortable we were with these products.”

Compatibility was also a consideration that led to choosing CareFusion as their vendor, he noted.

“We already had CareFusion elements in place, including Alaris pumps, so this was a natural fit and staff already felt comfortable with the pharmacy and intravenous line products,” Dr. Ozuna said.

Finally—but not least among the evaluation considerations—there was the cost variable, Dr. Ozuna noted, adding, “CareFusion’s system was the most affordable.”

—David Wild