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

Compounding

     
Compounding Method  
    Other:
    Compounder attached to Hospital LAN
    Remotely monitored compounding
     

Home Pharmacy

     

Pharmacy IS Vendor

 
    Other:
    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
www.montereymedicalsolutions.com


Copyright © Monterey Medical Solutions, Inc.