Infusion Studio™
Formulary Questionnaire


Please fill in as much information as possible in the form below and press the Submit button. 

This information will remain confidential and will be used to make a custom Infusion Studio
protocol solution based on your current hospital needs.


General Hospital Information

Hospital Name  
Contact Name  
Contact Phone  
Contact Email Address  
Average Census  
Number of Beds  
NICU Beds  
PICU Beds  
Adult ICU Beds  
Adult SICU Beds  

Information System

Hospital IS Vendor  
    Use Computerized Provider Order Entry (CPOE)
    TPN incorporated in current CPOE
Pharmacy IS Vendor  
IT Support  
TPN IS Vendor  
    LAN to WAN Access


Compounding Method  
    Compounder attached to Hospital LAN
    Remotely monitored compounding

Home Pharmacy


Pharmacy IS Vendor

    Use infusion pumps
    Home TPN service

Record Keeping

    Archive data for Clinical and Research review

Protocol Parameters

  Protocols are service specific (GI, Renal, CV, Onc, etc.)
  Protocols are provider specific
  Total fluid management (account for all sources of fluid)
  Fluid ordering in ml/kg
  Fluid ordering in ml/day or ml/hour
  Use Hydration Volume (non-nutritional fluid expansion volume)
  Cycle TPN
  Use Standard Solutions
  Use Standard Electrolyte products
  Administer electrolyte products
  Specify Acetate
  Specify Chloride
  Specify Acetate-Chloride as a ratio
  Ion-based dosing (i.e. Na, K, PO4, Acetate, Cl)
  Salt-based dosing (i.e. NaCl, NaAct, NaPO4, KCl, KAct, KPO4)
  Weight-based dosing of additives (i.e. mg/kg, mEq/l, mM/l, etc.)
  Concentration-based dosing of additives (mEq/l, mM/l, etc.)
  Volume-based dosing of additives (ml/kg, ml/day)
  Order Dextrose in percent (%)
  Order Dextrose in mg/kg/min

Non-TPN Fluid Sources

  Fluid from non-nutritional lines (Arterial, CVP) in fluid order
  Electrolytes and calories from non-nutritional lines in fluid order
  Fluid from Enteral feeds in fluid order
  Calories from Enteral feeds
  Fat emulsion volume in fluid order
  Fat emulsion ordered as a "3-in-one" solution

Work Flow

  Review TPN order
  Review CaPO4 PPT Curves
  Review TPN mixing instructions
  Track serum values daily

QA Measures and Checks

Refractive Index Osmolarity
K Concentration Na Concentration
Ca Concentration PO4 Concentration

Press the Submit button to send your questionnaire to Monterey Medical Solutions.



Monterey Medical Solutions, Inc.
455 Canyon Del Rey Blvd.
Suite 411
Monterey, CA 93940

(800) 651-8836

Copyright © Monterey Medical Solutions, Inc.