ABSTRACT
The “Kitzuki” System was developed to produce an infusion system in place of traditional infusion pumps to prevent errors in infusion rates. This study investigated this system`s advantages and disadvantages in a medical setting. The system works to monitor the drip rate and send alerts to the nurse call system in cases where there are deviations from preset parameters. The system was trialed with 24 nurses and a survey was conducted to assess its usability in practical settings. All 24 respondents (100%) reported that the system's specifications and usability were satisfactory. Thirty-five percent of the alert notifications were due to the infusion stoppage. Furthermore, it was noted that alerts were also generated during patient movement including postural changes or attendance to the ward toilets. The results of this study suggest that the drip rate monitoring system can support nurses with infusion management when the infusion rate continues at over 150 mL/h, or less than 5 mL/h for three minutes. However, challenges remain, such as the need to expand the alert notification's operating range.
Key words: over-infusions, drip rate monitoring system, usage, specifications
INTRODUCTION
In nursing work, incidents related to manual drip adjustments for intravenous (IV) management are not uncommon.[1] These incidents include both over- and under-infusion. Specific examples include the accidental, rapid infusion of albumin solutions or anticancer drugs. There are also cases where the infusion was unintentionally paused, resulting in the prescribed fluids not being administered.[2] Factors contributing to these incidents include insufficient checks, lack of knowledge and/or skills, and environmental factors such as night shifts or heavy workloads.[3–6] Preventive measures, such as enhancing education and training or utilizing information and communications technology (ICT), have been previously proposed to prevent errors.[7–9]
At Hospital A, over- and under-infusion incidents have also occurred. Hospital A is an acute care hospital in Tokyo with approximately 600 beds. A previous study was proposed using infusion speed adjustment aids as a preventive measure.[10] While Hospital A typically uses infusion pumps for IV administration, there are limitations, such as the number of available pumps and the need to select which patients can use them due to the equipment’s weight. Additionally, due to the lack of communication between the pump alarms and the nurse call system, there are still issues with alerts in the case where infusion pumps are utilized. This study aimed to evaluate the drip rate monitoring system (Tritech, Inc.)[11] as an alternative to infusion pumps to prevent incorrect infusion rates and identify both the benefits and challenges of implementing this system in clinical settings.
METHODS
The drip rate monitoring system monitors the drip rate and sends an alert to the nurse caller if deviations from the preset rate occur. Unlike infusion pumps, the drip rate is not adjusted. To assess the system performance in a clinical setting, a questionnaire survey was conducted.
Drip infusion rate monitoring system
The drip rate monitoring system comprises of two devices: a sensor attached to the infusion tube of the infusion line and a receiver called a nurse call gateway. To use the system, the receiver is plugged into an electrical outlet and the sensor attachment point on the nurse call and the sensor is attached to the drip tube (Figure 1). The drip is adjusted manually. An alert is sent out 3 minutes after the drip is detected. The sensor sends information to the nurse call on five different occasions:
Figure 1. Outline of the drip rate monitoring system.
- when the infusion rate is 150 mL/h or higher due to over-infusion;
- when the infusion rate remains below 5 mL/h for 3 minutes due to the infusion stopping;
- when the sensor and the receiver are more than three meters apart due to a transmission error;
- when the remaining battery power reaches 30 minutes and
- when a sensor error occurs.
The alert flow rate for excess infusion and infusion stoppage was defined by the hospital.
The alert information is transmitted by the sensor unit in the event of any excess and an alarm is triggered. The alert name is shown on the receiver unit and the nurse call unit shows the same sound and display as the bed release sensor.
Clinical setting evaluation
To evaluate the drip rate monitoring system in a clinical setting, the targeted participants were patients confined to their own rooms who had previously received manual drip infusions. The objective was to assess the system with 100 such cases and the trial was deemed complete when each nurse had initiated at least three installations. The study included 24 ward nurses. The survey period extended from April 19, 2023 until all eligible nurses had responded and was conducted anonymously using Microsoft Forms.
The survey addressed seven items related to the usability and specifications of the drip rate monitoring system (Table 1). Regarding the alert transmission, eight items evaluated the causes and utilization of the alerts (Table 2).
| Ease of viewing screen | Ease of use |
| Weight | Size |
| Durability | Sensor activation (lighting/flashing) |
| Installation of components |
| Factors | |
| Specifications | |
| Infusion stop alert | Over-infusion alert |
| Communication error alert | Sensor failure alert |
| Battery level alert | Nurse call display |
| Reminder firing time | Drip infusion rate confirmation time |
Survey methods
The survey used descriptive statistics for each item. Free-response items were categorized according to the specific survey questions.
RESULTS
The drip rate monitoring system was deployed in 76 instances where each nurse set up and started the system in at least three cases over a 49-day period from February 1 to March 21, 2023. The questionnaire response rate was 100%, with responses received from all 24 targeted nurses.
Usability and specifications of the drip rate monitoring system
Positive feedback was received regarding “Size” from all 24 respondents (100%), “Weight” and “Durability” from 23 (96%) and “Method of Installing Components” from 22 (92%) (Figure 2).
Figure 2. Usage and specifications of the drip rate monitoring system.
Transmission of alert information
During the survey period, 154 alerts were sent out (Figure 3).
Figure 3. Alert information sent out (total number of alerts).
The causes of the alerts included 54 cases (35%) of infusion stoppage, 52 cases (34%) of over-infusion and 32 cases (21%) of transmission errors (Table 3 and Figure 4).
Figure 4. Factors that trigger transmission of alerts.
| Infusion stop alert |
| End of infusion, change in patient’s condition, infusion stopped |
| Over-infusion alert |
| Patient’s posture change, drip adjustment, overdose, unstable rate |
| Transmission error alert |
| Transfer out of patient’s room, transfer to indoor toilet |
| Sensor error alert |
| Inappropriate removal |
| Low battery alert |
Conditions for sending alert information
“Lag” and “reminder time” were selected by 22 respondents (92%), The “Infusion Stop Alert Alerting Lag” and “Reminder Alerting Time” were selected by 22 respondents (92%) and “Infusion Stop Alerting Flow Rate” by 19 respondents (79%) (Figure 5).
Figure 5. Conditions for sending alert information.
DISCUSSION
No concerns regarding the usability of the drip rate monitoring system were expressed and the current specifications were deemed satisfactory. The most frequent triggers for the transmission of alerts were infusion stops and over-infusions. Consequently, it is assessed that the drip rate monitoring system can effectively support nursing staff in managing infusions when the rate exceeds 150 mL/h or drops below 5 mL/h for a duration of 3 minutes. However, under the current system, the reasons for alerts are not known until a nurse visits the patient’s room. With this in mind, future enhancements could include displaying the alert causes directly on the nurse call system for immediate clarification.
Moreover, the primary reasons cited for transmission errors were movements outside the patient’s room and to the bathroom within the room. Furthermore, 14 respondents (58%) cited inadequate “transmission error reporting distance”, attributing this to the system’s operational range being limited to three meters from the receiver. Expanding this range will require the development of new specifications to accommodate broader coverage.
We believe that the IV drip rate monitoring system is useful for countermeasures against over- and under-dosing in manual infusion. To ensure the system can be used in clinical practice, a mechanism to understand the system’s operating range and the reason for sending alert information must be developed.
DECLARATIONS
Author contributions
Shuko Muraoka conceived the study. Shuko Muraoka and Hazuki Matsuo developed the theoretical framework and performed the experiments. Takao Orii supervised the project. All authors discussed the results and contributed to the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to disclose.
Data sharing statement
No additional data is available.
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