Man vs machine : how the pharmacist must adapt to improve the robot performance ? The example of subcutaneous (SC) daratumumab

Background
The SC form of Daratumumab is particularly oily, making its administration difficult. In order to promote proper use of the product and to limit the occurrence of musculoskeletal disorders, a setup compatible with the use of an electric syringe pump has been validated. For this purpose, the daratumumab syringes prepared at the chemotherapy preparation unit (CPU) are provided to the ambulatory care unit directly mounted with a three-way stopcock and an extension set purged with saline.
The unit will acquire the APOTECAChemo^® robot from Loccioni for chemotherapy preparation, but it will not be able to perform the setup of daratumumab syringes as currently prepared.

The aim of this work was to propose a solution for the setup of SC daratumumab syringes compatible with the use of the robot for preparation and the use of the electric syringe pump for administration.

Material and method
An evaluation of the various setup proposals was carried out, considering 6 technical and practical criteria: preparation constraint for the CPU, proper use of the product, risk of microbiological contamination, risk of chemical exposure for the nurses, administration constraint for the nurses and change in practices for the nurses. The cost of each setup was evaluated. The different setup solutions that met at least 4 criteria were then presented to the pharmacists seniors managers to decide on the selected setup to be proposed to the nurses and implemented upon the robot’s arrival.

Results
Six setup solutions were developed, out of which 2 were directly discarded. The remaining 4 setups included the use of an extension set purged with saline and a three-way stopcock, with one of them additionally involving the use of a SPIROS^® connector. These differed in the actions (purged the extension, adding various medical devices, etc.) performed by the pharmacy technicians or the nurses. All of them met 5 out of 6 criteria, 4 of which were common. They allowed the proper use of the product, did not entail any administration constraints for the nurses, did not entail any risk of chemical exposure or microbiological contamination. Two setups involved a change in practices for the nurses and two other setups involved a preparation constraint for the CPU. Two setups had similar cost, whereas the other 2 setups had higher costs. The selected setup included the addition of a three-way stopcock by a pharmacy technician to the syringe prepared by the robot, followed by the addition of the extension set and its purging by the nurses.

Conclusion / Discussion
The selected setup does not meet all the criteria and leads to a modification of practices for the nurses but will not be too restrictive in terms of preparation for the CPU and administration for the nurses. It also combines practice security and patient safety. It was presented to the pharmacy technicians as well as the ambulatory care unit, which gave its approval for its use.