IV DripAssist: An Innovative Way to Monitor Intravenous Infusions Away From an Outlet? Free

Abstract

Intravenous (IV) administration of fluids and medications are a significant part of patient treatment. In austere environments, typical methods of counting drops from gravity drips or infusion pumps both have limitations such as accuracy, weight, and need for power. The DripAssist device calculates drip rates by counting drops in IV tubing drip chambers and may provide a useful patient safety monitor adjunct. The protocol was IRB approved, prospective, and designed as a pilot study involving 28 Madigan Army Medical Center Emergency Department personnel. After a brief didactic introduction to the device for clinical staff with no prior experience using the device, participants were timed setting three normal saline infusions at rates of 250 mL/h, 125 mL/h and 83 mL/h with 15gtt/mL tubing. Participants filled out a survey on perceived ease of use and utility of the device compared to pumps and manual counting. Most participants felt the DripAssist device was easy to understand and set up, but nurses and physician assistants were more likely than medics to perceive a benefit versus IV pumps or gravity drips. The DripAssist device may offer a safe, low-weight, functional tool which could improve care in a variety of resource-limited environments. However, additional studies using the device during actual field exercises would be beneficial.

INTRODUCTION

Intravenous (IV) administration of fluids and medications are a significant part of patient treatment. They are classically set through gravity with roller clamps and drip counts, or smart pump technology. In austere environments, both have respective limitations such as accuracy, weight, or need for power. Smart pumps are bulky, add weight, require direct power or interval battery charges, and on average cost $4,000/each. When smart pumps are not available, providers/nurses traditional use IV roller clamps to control rates. Several studies have revealed IV fluid administration controlled by roller clamp/gravity has limited accuracy.^1–7 In a 2000 study by Hubble et al, paramedics only calculated the correct drip rate 68.8% of the time.¹ Another study indicated only 21% of fluid bags infused at the correct rate in one hospital ward over 4 weeks when using gravity/roller clamps.^2,3 Lastly, in 2005 Han et al identified a median deviation of 47 mL/h with roller clamps, and indicated IV infusion control devices greatly reduced the likelihood of error.⁴ Laboratory simulation of clinical situations indicated flow can very broadly based on fluid column height, non-laminar flow, and venous pressure of the patient.^5,6 Additionally a concept known as “plastic creep” has been hypothesized as a potential mechanism for “auto-changing” administration rates after initial setting.⁶ Overall, this results in poor minute to minute accuracy of IV drips controlled by roller clamps.⁷ The World Health Organization essential medications list has several medications for which an accurate rate would be essential: ketamine, propofol, phenytoin, midazolam, heparin, and multiple cytotoxic medications.⁸ In addition, all vasoactive medication requires strict rate control. These studies indicate that reliable infusion rate monitoring has the potential to decrease medication errors and increase/improve patient safety.⁹

The DripAssist device (Fig. 1) is a small, portable IV monitoring device that monitors IV infusion rates using infrared light technology to count drops in the drip chamber and displays a traditional rate/total infused. It securely attaches to most commercially available IV tubing, lasts 290 hours on a single AA battery, drip count accurate within 1%, costs ~$400/each, and will alarm for a ±13% change in rate from the set rate. Because of these features, we theorized this may provide a useful patient safety adjunct in the austere, pre-hospital, or battlefield patient care environments.

The primary objective of this pilot study was to compare the perceived ease of use the DripAssist device with traditional roller clamp methods. We also explored perceived functionality of this technology for use in austere, pre-hospital, battlefield, and electrical power deficient environments.

METHODS

The design of this prospective pilot study was drafted by the study authors. The study protocol was approved by the Madigan Army Medical Center (MAMC) Institutional Review Board in 2016. We acknowledge and appreciated the assistance provided by Shift Labs with the logistical and technical support for the devices.

The Study was completed at MAMC, a Level II Trauma Center that cares for >70,000 patients annually, which employs military and civilian personnel, many with experience in pre-hospital, military and austere environments. Thus, the composition of the eligible ED personnel offered perspectives from a diverse group of medical personal.

The study was designed in 2016 and completed throughout March of 2017. Study participants were recruited from Emergency Department staff while on shift. Any MAMC Emergency Department Employee (Medic, Paramedic, Nurse, or Physicians Assistant) was eligible to participate. This was completed on a voluntary basis and no compensation was provided.

The participants were given a 5-minute standardized didactic presentation by one of the authors. This included instruction regarding the device setup, use, and monitoring. Each participant was then timed while setting three normal saline infusions at rates of 250 mL/h, 125 mL/h, and 83 mL/h with 15gtt/ml tubing. Individuals were monitored individually by one of the authors and timed using a standard stopwatch. These results were collected on a standard individual participant data sheet.

Lastly, participants were then asked to fill out a survey (Table I) on perceived ease of use and utility of the device. Each question contained a quantitative Likert Scale of 1–5. The data were analyzed with averaging and standard deviation (Tables II and III).

RESULTS

Twenty-eight MAMC Emergency Department personnel (RNs, EMTs, Paramedics, Army Medics, and Physician Assistants) volunteered to participate (Table IV). The average years’ experience exceeded a decade, but varied slightly by vocation. Average time to completion of the 83 mL/h, 125 mL/h, and 250 mL/h infusions were 68, 120, and 114 seconds respectively (Table III). In general, lower rates appeared easier to obtain secondary to the drip factor (rate of drops) in the tubing chamber.

Table II depicts the survey results. Most participants thought that the DripAssist device was easy to set up (4.8/5), understand (4.7/5) and were confident in their ability to use it after limited training (4.7/5). Compared to IV infusion pumps, participants thought that it was slightly easier to use (3.7/5). In comparison to traditional roller clamps EMTs/Paramedics and Army Medics in the study found the device neither easier nor harder to use (3.1/5, 3.6/5) whereas nurses and Physician Assistants found that it much easier to use (4.6/5, 4.8/5). Nurses and Physician Assistants were more likely to see potential for the device in pre-hospital and austere environments (4.6/5, 4.8/5) than EMTs/paramedics and Army medics (3/5, 3.6/5).

DISCUSSION

The primary objective of this pilot study was to compare the perceived ease of use the DripAssist device with traditional roller clamp methods. The survey results (Table III) demonstrated that various levels of health care personnel thought that the DripAssist device was easier to use than these traditional methods. The majority of the participants felt that this technology has potential uses in austere environments. Perceptions of increased accuracy, safety and applicability were highest among nurses and physician assistants. Military Medics and EMTs/Paramedics found the device neither easy nor difficult to use, and cited this was due to perceived limitations in moving vehicles. The device does require a relatively stable environment to function well, and has yet to be studied in mobile platforms.

There were some limitations to this study. First, it was completed indoors in a calm section of the emergency department. We attempted to seek input from people who have functioned in less resource rich settings. Second, our sample size was a small convenience sample, though it did include a wide breath of vocations and practitioners with numerous years of experience. Lastly, this was not a head-head trial. We obtained times and sought input from perceived comparison with the current standard (when infusion pumps are not available) gravity/roller clamp methods. Though the time to completion of setup was over a minute in general, future studies may consider timing (drip calculation/setup/rate confirmation) when using gravity/roller clamp methods and the DripAssist device.

In our own use/review of the device, we found it to be a lightweight (3.8 oz), intuitive to use, and equally easy to orient others to it. In an era of increased focus on prolonged field care, we feel this may be a valuable tool. Further studies could focus on direct comparisons, use in austere environments, mobile platforms, or in regions with extremes of temperature.

CONCLUSION

The DripAssist device may offer a safe, low-weight, functional tool through which care could be improved in resource-limited environments. Various levels of health care personnel thought that the DripAssist device was easier to use than these traditional roller clamp/gravity methods. Additional studies further confirming ease of use, and/or direct use in austere environments would be beneficial.

Previous Presentations

Presented as a Poster at the 2017 Military Health System Research Symposium, MHSRS-17–0668.

Funding

No funding was utilized for this study. The study devices were provided by Shift Labs, Seattle, WA. The devices were returned after use. This supplement was sponsored by the Office of the Secretary of Defense for Health Affairs.

Acknowledgments

The authors have no conflicts of interest to disclose. Shift Labs provided the devices but had no involvement in the study design, or data collection/analysis. We appreciate their generosity with the study devices, and their technical support throughout.

References

Author notes

The views expressed in this paper are those of the authors and do not necessarily represent the official position or policy of the U.S. Government, the Department of Defense, or the Department of the Army, or Madigan Army Medical Center.