A survey of prefilled, bolus-dose syringes containing single medications compounded in community pharmacies for palliative care patients in Tāmaki Makaurau Auckland, Aotearoa New Zealand

Introduction

The standard international practice when patients receiving palliative care are unable to take medications orally is to administer them via a continuous subcutaneous infusion using a portable device.¹

In Aotearoa New Zealand (NZ), syringes for this purpose can be prepared in community pharmacies contracted to provide aseptic services by Te Whatu Ora Health New Zealand.² Specific training in this area is available.³ The operators use aseptic techniques in an apparatus called a ‘still air box’, which maintains a separate, clean compounding environment and is unique to NZ (Fig. 1).⁴

Fig. 1.

A pharmacist in training to prepare (compound) prefilled syringes in a still air box at Waipapa Taumata Rau University of Auckland, NZ.

For every medication contained in the continuous subcutaneous infusion syringe, a corresponding bolus-dose syringe is usually prescribed in anticipation of worsening symptoms.⁵ These bolus-dose syringes are compounded as single medications in 0.1–2 mL volumes, and current NZ guidelines recommend storage in the refrigerator with an expiry date of 3 days when the syringes are compounded in a still air box.⁶ Tāmaki Makaurau Auckland (Auckland) is the largest region in NZ where this service is available.

The availability of these bolus-dose syringes enables patients’ families to manage patients’ symptoms at home in a responsive way and has the potential to reduce the need for hospital admission during times of high symptom burden.⁷

Bolus-dose syringes are often dispensed in anticipation of need but not always used, and extending the expiry dates could help reduce material wastage. However, limited information exists on community pharmacy compounding processes – such as facilities used, preparation time, or how expiry dates are determined – despite the availability of guidelines.⁶ There is also a lack of data on the stability of unmixed medications over time, as in the preparation of continuous subcutaneous infusions.¹ Therefore, we investigated the range of medications and the compounding process of these bolus-dose syringes prepared by community pharmacies in Auckland.

Methods

A cross-sectional, online survey with 11 questions was conducted among community pharmacies that prepare prefilled syringes. The tool was adapted from an unpublished hospital pharmacy survey previously used to inform pharmacy curricula in NZ. The current version was revised to capture data from community pharmacies and pre-tested by a pharmacy academic experienced in survey design. The survey was created and administered using Qualtrics (Provo, UT, USA).

An electronic database of Auckland community pharmacies known to compound prefilled syringes is maintained by the region’s hospice pharmacists via Auckland Regional HealthPathways, a web-based source of information for clinicians.⁸ At the time of the survey, the database was only available for the Auckland region. A link to the survey (see Supplementary material S1), including an information sheet, was emailed to all 40 pharmacies listed on the database by a researcher known to the pharmacies. Information was requested on the name and number of medications compounded as bolus-dose syringes during a 180-day retrospective period; the method used to determine expiry dates; the facilities used for compounding; and the time spent preparing the syringes. The data requested were derived from pharmacy dispensing records. Opportunities for free-text comments were included after selected questions, and the final question invited further feedback regarding aseptic services in community pharmacy in NZ. Data were also collected on pharmacy location and on the number and type of staff employed.

To ensure anonymity and confidentiality, survey responses were collated via the survey tool by a researcher unfamiliar to the participants. Participation was voluntary, and consent was assumed upon completion of the survey. A reminder email was sent to all pharmacies after 2 weeks by the initial researcher, and no incentives were offered.

Approval for the study was granted from the University of Auckland Human Participants Ethics Committee (Ref. UAHPEC25605).

Data were analysed quantitatively using frequencies; no statistical tests were used due to the small sample size. In preparing this manuscript, we followed the reporting guidelines set forth by the Checklist for Reporting of Survey Studies (CROSS).⁹

Results

A total of 40 community pharmacies were sent the email containing the link to the electronic survey; eight (20%) returned completed surveys. Incomplete surveys were excluded from analysis.

Most respondents were in a suburban precinct of five or more shops (n = 5, 62.5%), and pharmacies were from all geographical locations across Auckland. The pharmacies employed an average of four pharmacists, one intern pharmacist, two pharmacy technicians, and one other staff member, eg shop assistant.

All the respondents (n = 8, 100%) used a still air box to aseptically compound syringes in the study period (1 September 2022 to 28 February 2023). There was no indication that other aseptic facilities were used to prepare the syringes.

Two medications all eight respondents reported compounding as bolus doses were midazolam and haloperidol, comprising 1016 and 733 syringes respectively (Table 1).

The same two medications (midazolam and haloperidol) were each compounded as the same concentration by all eight respondents. Conversely, levomepromazine was compounded as four different concentrations by five respondents (Table 2).

One respondent indicated that diluents were added to all the medications, and a second added diluents for only haloperidol, levomepromazine, and dexamethasone.

All respondents reported that they assigned an expiry date to the syringes based on published guidance (more than one option could be selected), such as ‘textbook, journal reference or website’ (n = 7); ‘clinical experience’ (n = 3); or ‘microbiological testing’ (n = 1). Free-text comments were: ‘hospice guidelines’, ‘training – 72 h’, ‘palliativedrugs.com, sterility testing data’, and ‘3-day expiry assigned as per recommendations, microbiological testing indicates stability [sterility] for 7 days, but uncertainty around chemical stability’.

The average weekly time spent preparing aseptic products – including time spent on paperwork and phone calls – ranged from 5 to 10 h. One respondent reported spending over 20 h per week, whereas another spent less than 5 h. A third respondent noted that this question was ‘very difficult to answer as it is determined by the number of patients we might have at any one time. Could be 3–4 h on weekends or public holidays, but it is not a regular request’. Another respondent indicated that the syringes were ‘often prepared before or after opening hours’.

Three free-text comments were submitted in response to the final question, which invited additional remarks on aseptic services in community pharmacy. One respondent requested: ‘better funding to account for time after hours preparing, also to account for stock and consumables to be held in readiness for preparation’. A second respondent wanted: ‘better communication with prescribers and hospice staff about what is involved – they want to collect in 10 mins’. A third respondent stated that their number of bolus-dose syringes supplied could have been higher: ‘Normally the December period is busy with palliative care and would be a third higher on the numbers I supplied. We had severe staffing issues for the Dec/Jan period.’

Discussion

The preparation of injections for patients to use in the home setting by pharmacists is regarded as the ‘gold standard’ of practice.¹⁰ Our study describes a service in Auckland where a subset of community pharmacies prepare prefilled syringes containing single-medication, bolus doses for palliative care patients. We believe this service is unique to NZ, and hence our study is the first of its kind.

Conclusion

This study provides valuable insight into current data on the bolus-dose single medications compounded as prefilled syringes by community pharmacies in Auckland. There is some consistency with the reported medications and concentrations, but there is variation in time spent on the service with concerns raised about the stability of the compounded medications. Using these results, we plan to undertake studies to determine the stability and sterility of the medications compounded in these prefilled syringes with a view to re-examining their length of expiry.

Supplementary material

Supplementary material is available online.