Perceptions, Challenges, and Improvement Strategies for the Standardized Use of Intravenous Infusion in Chinese Medical Institutions: A Qualitative Interview Study

doi:10.21203/rs.3.rs-4833078/v1

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Research Article

Perceptions, Challenges, and Improvement Strategies for the Standardized Use of Intravenous Infusion in Chinese Medical Institutions: A Qualitative Interview Study

https://doi.org/10.21203/rs.3.rs-4833078/v1

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Purpose

This study aims to evaluate the awareness of standardized intravenous infusion use among medical professionals and inpatients in Chinese medical institutions and to explore effective strategies to improve the rate of standardized use, thereby enhancing patient safety and medical quality.

Methods

Utilizing a qualitative research design, the study conducted semi-structured interviews to deeply understand the perceptions and challenges faced by medical professionals (pharmacists, doctors, nurses) and patients regarding standardized intravenous infusion use. The sample was selected through purposive sampling to ensure diversity. The interviews covered perceptions, challenges, and improvement strategies, with data analysis performed using Nvivo 12 plus.

Results

The study found variations in medical professionals' awareness of standardized intravenous infusion use. Physicians' clinical decisions were influenced by patient expectations and medical insurance policies, while nurses believed that standardization could reduce their workload, and pharmacists faced difficulties in implementation. Patient attitudes toward intravenous infusions were diverse, with some preferring them. The study also revealed that education and training, medical insurance policies, pharmacists' professional development, clinical pathways, specialized drug management, and inter-departmental collaboration significantly impact the standardization of intravenous infusion use.

Conclusion

This study uncovers the multi-dimensional challenges of standardized intravenous infusion use among inpatients in Chinese medical institutions and emphasizes the importance of strengthening education, training, and inter-departmental collaboration. It is recommended that relevant departments engage in joint discussions to ensure the consistency of medical insurance policies with clinical practices, promoting the efficient use of medical resources and insurance funds.

standardized intravenous infusion use

China

qualitative interview study

Intravenous infusions are critical in the treatment of hospitalized patients, capable of swiftly correcting electrolyte imbalances, replenishing nutrients, and administering medications. However, improper use of intravenous infusions not only contravenes the World Health Organization's principles of rational drug use but can also lead to the wastage of medical resources, increased financial burdens on patients, and even safety incidents[1]. In China, with the advancement of healthcare reforms, the regulation of intravenous infusion practices has become particularly urgent. According to the "National Adverse Drug Reaction Monitoring Annual Report (2023)" released by the National Medical Products Administration, injections accounted for 56.3% of adverse drug reaction/event reports, with intravenous injections making up 91.1% of that total[2]. Additionally, research has found that in 2023, the intravenous infusion usage rate in tertiary and secondary hospitals in the city where the author is located exceeded 90%, surpassing the national average. Excessive infusion has become one of the more prominent issues in Chinese medical management[3, 4]. The National Health Commission of China has listed reducing the rate of intravenous infusion use among hospitalized patients as one of the key targets for improving national medical quality and safety [5–8], particularly in the "Medical Quality and Safety Improvement Goals" for 2023 and 2024 [7], where it emphasizes the importance of enhancing the rational use management of intravenous infusions in terms of connotation. Despite this, research on the role and influencing factors of medical professionals in promoting standardized use of intravenous infusions is still lacking. This study aims to fill the research gap by conducting semi-structured interviews with doctors, nurses, pharmacists, and hospitalized patients in the author's region to assess their perceptions of standardized intravenous infusion use and to explore effective strategies to improve the rate of standardized intravenous infusion use among hospitalized patients. This will contribute to enhancing patient safety and medical quality, while providing a scientific basis for the development of targeted improvement measures.

2.1 Research Design

This study employs a qualitative research design, utilizing semi-structured interviews to gain an in-depth understanding of the perceptions, challenges encountered in practice, and effective strategies for improving the standardized use of intravenous infusions among medical professionals (pharmacists, doctors, nurses) and patients. The study was approved by the Ethics Review Committee of the Affiliated Hospital of Southwest Medical University and obtained informed consent from all participants.

2.2 Participants

Participants include pharmacists, doctors, nurses, and hospitalized patients from medical institutions in a region of China. The selection of the sample is based on purposive sampling to ensure representation of participants of different ages, genders, disease types, and treatment needs, thereby enhancing the transferability and generalizability of the study results.

2.3 Data Collection

Data collection is conducted through semi-structured interviews, covering perceptions of standardized intravenous infusion use, challenges in practice, and improvement strategies. Each participant's interview lasts an average of 30-40 minutes and is recorded with consent.

2.4 Development of the Interview Guide

The development of the interview guide is based on an extensive literature review, combined with the research objectives and anticipated characteristics of the participants. We carefully designed the types and order of questions to ensure that the introduction and tone during the interview were neither threatening nor disrespectful. The questions were designed to guide participants to deeply share their views, experiences, and challenges regarding the standardized use of intravenous infusions.

To ensure the clarity and comprehensibility of the questions, we conducted a pilot test with a small sample. Feedback from the pilot participants helped us adjust the interview outline, ensuring the logical flow and accuracy of the questions. In the formal interviews, we used a standardized outline to explain the research background, overall objectives, and methods. Additionally, we encouraged participants to freely discuss their experiences and views, with sufficient flexibility for the interviewer to ask follow-up questions as needed. The interview outline is shown in Table 1, the main interview topics are presented in Table 2.

2.5 Data Analysis

Data analysis in this study was conducted through the following steps: Initially, interview recordings were transcribed and reviewed for accuracy, then the texts were imported into the qualitative analysis software Nvivo 12 plus. Two researchers independently carried out open coding to identify key concepts and form themes through continuous comparison methods and team discussions. Axial coding and selective coding were utilized to further refine the thematic framework. The research team met regularly to ensure consistency in analysis and employed various validation methods to ensure the reliability and validity of the results. The software's visualization tools were used to assist in understanding data relationships and to deeply explore specific topics. Ultimately, the analysis results were integrated into a report, with participant privacy protected throughout the process.

2.6 Research Quality Assurance

To ensure research quality, the following measures were taken:

-Training the research team to standardize data collection and analysis methods.

-Recording and transcribing interviews for review and re-examination.

-Maintaining the originality and authenticity of data during analysis to avoid subjective conjecture.

2.7 Ethical Considerations

The study was approved by The Affiliated Hospital of Southwest Medical University institutional review board (protocol number KY2024279). All participants provided written informed consent. Study data were coded (ie, all identifying information was removed) to protect participant privacy

We engaged 60 participants who qualified for inclusion criteria and were eligible to participate in the interviews. This group comprised 20 patients (with an average age of 52 years; 50% female), 10 nursing staff members (average age 40 years; 90% female), 10 physicians (average age 45 years; 30% female) and 20 pharmacists (10 of whom were clinical pharmacists and 10 were heads of pharmacy departments; average age 44 years; 60% female). All medical professionals had over three years of work experience. The demographic characteristics of the participants are detailed in Table 3.

3.1 Perspective of Physicians

Variations in awareness of standardized intravenous infusion practices were observed among the interviewed doctors. Half of the physicians were not aware that improving the standardized use of intravenous infusions is one of the national medical quality and safety improvement goals. As one doctor stated, "I am indeed not very clear about the specific requirements and strategies for the standardized use of intravenous infusions." This indicates that despite national guidelines, there are still barriers in the dissemination and comprehension of information. Meanwhile, those who have participated in relevant training demonstrated a deeper understanding of the standardized use of intravenous infusions, highlighting the importance of education.

In clinical decision-making, two-thirds of the doctors typically opt for intravenous infusions based on the severity of the patient's condition. One physician emphasized, "For critically ill patients, intravenous infusions are a key intervention to rapidly address their medical conditions." Additionally, the dependency of patients on intravenous infusions also influences the prescribing decisions of doctors. Another doctor mentioned, "Patients expect to receive infusion treatments; sometimes, even when it is not necessary, I will comply with their expectations to avoid medical-patient conflicts."

Medical insurance policies also impact the prescribing decisions of doctors. The majority expressed concerns, saying, "During medical insurance audits, if patients have not received infusion treatments, they might be judged as being admitted under low standards, leading to economic penalties for the hospital." This could lead doctors to opt for intravenous infusions even when they are not necessary.

Physicians believe that more education and clear policy guidance are needed to enhance the standardized use of intravenous infusions. As one doctor pointed out, "We need more education and clear policy guidance to assist us in making better decisions in clinical treatment."

3.2 Perspective of Nursing Staff

Half of the nursing staff were not aware that improving the standardized use of intravenous infusions has been included as one of the national medical quality and safety improvement goals. One nursing staff member stated, "I am aware that intravenous infusions are one of the routes of administration with the most adverse reactions, but I was not informed that it has been listed as a national goal for improving medical quality and safety."

Nursing staff widely believe that the standardized use of intravenous infusions can help reduce work intensity. A nurse commented, "If we can reduce unnecessary infusions, we will have more time and energy to provide more meticulous nursing services, thereby enhancing patient satisfaction."

In terms of patient education and trust-building, nursing staff play a crucial role. One nurse mentioned, "We need to patiently explain to patients why, in some cases, oral medications might be a better therapeutic choice." Another nurse emphasized, "Through education, we help patients understand the treatment plan, and the establishment of trust makes them more willing to accept our recommendations." This indicates that nursing staff, through education and communication, contribute to patients accepting and trusting standardized treatment regimens.

3.3 Perspective of Pharmacists

Pharmacists widely recognize the importance of standardized intravenous infusion practices but encounter numerous challenges in implementation. One pharmacist noted, "Changing medical habits faces multiple obstacles, including the prescribing habits of doctors and the expectations of patients." While assisting physicians in rational drug treatment, pharmacists also bear supervisory responsibilities. A clinical pharmacist expressed his dilemma: "We need to ensure the rational use of drugs while also wishing to support the work of doctors; this dual role sometimes puts us in a difficult position."

The pharmacy department strives to promote standardized use through participation in working groups and multi-departmental collaboration. One pharmacist emphasized, "This requires the support of hospital management and coordination between departments." However, a pharmacist pointed out, "In actual work, the pharmacy department often bears the burden of promoting standardized use alone, increasing the difficulty of the task." A senior pharmacist mentioned, "Developing clinical pathways is an effective measure for standardized intravenous infusions, but due to the limited clinical knowledge of pharmacists, only a minority of pharmacists participate in the development of clinical pathways."

To reduce reliance on intravenous infusions, hospitals have established a list of diseases that do not require intravenous medication, and the pharmacy department has optimized drug supply to ensure the rationality of various routes of administration. A pharmacist mentioned, "We have increased the supply of oral and topical medications." Pharmacists generally agree that implementing specialized drug management is an effective approach to reducing unnecessary intravenous infusions, such as targeted management of antimicrobials, proton pump inhibitors (PPIs), traditional Chinese medicine injections, parenteral nutrition, antiemetics, and other medications.

The pharmacy department has set target values for the use of intravenous infusions in clinical departments and linked them to the performance of these departments. A pharmacist explained, "This increases the motivation to implement standards but also requires us to continuously communicate with clinical departments to reach a consensus." Pharmacists use regular data analysis to identify and solve problems in a timely manner. A pharmacist described, "Continuous monitoring helps us maintain the standardization of treatment."

Pharmacists play a key role in standardized use but face the challenge of insufficient human resources. A pharmacist pointed out, "The shortage of clinical pharmacists in secondary medical institutions limits the depth and breadth of our work." Pharmacists working in secondary medical institutions often feel a lack of confidence in their clinical skills. "This may be because we have fewer opportunities for professional training and continuing education, or because the types and complexity of cases we encounter in daily work are limited. This lack of confidence may affect our communication with doctors and our initiative and decisiveness in the supervision of rational drug use."

Pharmacists actively participate in patient education, using materials such as popular science videos to improve patients' understanding of treatment plans. A pharmacist shared, "This helps patients make wiser treatment choices."

Pharmacists are aware of the necessity for continuous learning to improve professional communication skills. One pharmacist stated, "A deep understanding of diseases and drug knowledge allows us to communicate more effectively with doctors." Pharmacists are passionate about their work but also face pressure and challenges. A senior pharmacist said, "We love our work, but we also need to cope with work pressure and professional burnout."

3.4 Perspective of Patients

Patients exhibit a range of attitudes towards intravenous infusions, with two-thirds willing to follow their doctors' advice. One-third prefer intravenous infusions, believing in their rapid therapeutic effects: "If I'm hospitalized, why not have an infusion? I think infusions are more effective." There is a divergence in patients' awareness of the potential risks and side effects associated with intravenous infusions. Half of the patients are unaware of the risks involved, stating, "I always thought infusions were a safe and effective method of treatment." In contrast, those who are aware of the risks mention various issues: "I've heard that infusions can cause infusion reactions and other side effects." Additionally, some patients mention the inconvenience of infusions: "You can't move around freely when you're on an infusion, which is very inconvenient."

This study, through qualitative research methods and in-depth interviews with medical professionals and patients, has revealed multi-dimensional challenges in the standardized use of intravenous infusions at the levels of cognition, practice, and policy. The following are discussions and suggestions based on the research findings:

4.1 Cognition Differences and Educational Needs of Medical Professionals

The study results show that there are differences in medical professionals' awareness of standardized intravenous infusion use, with some doctors and nurses lacking sufficient understanding of the national medical quality and safety improvement goals and their specific strategies. This highlights the urgency of strengthening in-service education and training. It is recommended that medical institutions regularly organize professional training to ensure that medical professionals can access and apply the latest guidelines and practical recommendations in a timely manner.

4.2 Medical Insurance Policies and Clinical Decision-Making

During the interviews, doctors expressed concerns about the medical insurance audit standards, especially the possibility that not performing intravenous infusions might be misjudged as substandard hospital admission, which could hinder the autonomy of clinical decision-making. The use of intravenous infusions must be strictly based on the patient's condition and treatment needs, not as a standard for admission. To ensure the consistency of medical insurance policies with clinical practice, it is recommended that the Health Commission and the Medical Insurance Bureau hold joint discussions to formulate clear guidelines to guide medical institutions in the rational allocation of medical resources and ensure the efficient use of medical insurance funds.

4.3 The Dual Role of Pharmacists and Their Professional Development

In the standardization of intravenous infusion use, pharmacists play an essential role, especially in tertiary medical institutions where their impact is particularly prominent, consistent with the conclusions of previous studies [9]. Our research reveals a practical issue: secondary medical institutions often face a shortage of pharmacist human resources and insufficient training, and pharmacists in secondary medical institutions lack confidence in their clinical skills. This lack of confidence may stem from a lack of professional training and continuing education opportunities, or because of limited exposure to case types and complexities in daily practice. To enhance the professional capabilities of clinical pharmacists, from 2019 to 2024, China's Ministry of Finance and other departments issued the "Budget for Subsidies to Improve Medical Services and Guarantee Capacity (Health and Wellness Talent Training)," which included grassroots clinical pharmacists in the urgent talent training program. The National Health Commission's Department of Science and Education also issued the "Pilot Implementation Plan for the Training Program of Urgent Talents (Clinical Pharmacists)," aiming to promote the standardization and standardization of clinical pharmacist training systems. In light of this, it is recommended that medical institutions, especially secondary medical institutions, strengthen pharmacist training and team building, improve professional skills and communication abilities, to participate more efficiently in drug treatment and supervision, and promote the standardization of intravenous infusion use.

Many countries have recognized the importance of pharmacists in medical insurance and have formulated corresponding laws and regulations [10–13]. Compared with pharmacists in Western countries, Chinese pharmacists face different challenges and working environments [14, 15]. Zuo Genyong and others' research emphasizes that pharmacists are not only supervisors of doctors' behavior but also an important force in helping doctors improve clinical decision-making behavior [16]. However, against the backdrop of China's medical insurance payment, the role ambiguity and conflict of clinical pharmacists highlight the urgent need for professional development and clear responsibilities. At present, China is promoting the high-quality development of pharmaceutical services through a series of policies to enhance the professional capabilities and service quality of pharmacists [17, 18]. To advance the legislation of the pharmacist law, China has formulated the "Pharmacist Law (Draft for Comments)," which is currently undergoing more in-depth research and deliberation [19]. However, before the official release and implementation of this law, it limits the professional development of pharmacists.

4.4 DRG/DIP and Clinical Pathways

With the extensive promotion of the DIP/DRG payment model, the role of clinical pharmacists in the management of rational drug use is becoming increasingly prominent. They need to be familiar with medical insurance policies and standardize the selection of drugs in clinical pathways, thereby reducing unnecessary intravenous infusions and lowering medical risks and patient costs. Research shows that under the DRG/DIP system, clinical pharmacists can effectively reduce the rate of intravenous infusions in hospitalized patients and alleviate the economic burden on patients by participating in clinical pathways[20–22]. It is recommended that hospital management should encourage pharmacists to participate more in the formulation and evaluation of clinical pathways, allowing their professional knowledge and experience to be fully utilized.

4.5 Special Drug Management

Globally, there is an overuse of prophylactic treatment for stress ulcers, especially in the use of intravenous PPIs[23–25]. Studies indicate that special management of PPIs can improve the rational use of medication, reduce patients' dependence on intravenous PPIs, and reduce drug costs[26–28]. Our research also found that special drug management is an effective strategy to reduce the rate of intravenous infusions, and this effect also applies to other drug categories such as antimicrobials, traditional Chinese medicine injections, parenteral nutrition drugs, and antiemetic drugs. In addition, by formulating special guidelines for the use of intravenous infusion drugs, it can guide rational clinical medication use and strengthen supervision. For example, the "Guiding Principles for Clinical Application of Proton Pump Inhibitors" issued by the National Health Commission of China in 2020[29], provides a strong basis for pharmacist intervention.

4.6 The Importance of Patient Education and Communication

Patients' attitudes and preferences further highlight the key role of education in promoting the standardized use of intravenous infusions. A questionnaire survey conducted on 663 hospitalized patients revealed that the awareness rate of knowledge related to intravenous infusion was only 39.73%[30]. Given patients' expectations and dependency on intravenous infusions, as well as their lack of understanding of risks and alternative treatment methods, it is recommended that medical professionals adopt a more active educational strategy in clinical practice to improve patients' understanding and participation in treatment plans. In addition, developing patient education materials, such as brochures and videos, and regularly pushing scientific popularization and education on the rational use of intravenous infusions through WeChat public accounts and WeChat groups can raise public awareness[31].

4.7 Multi-department Collaboration

Intravenous infusion, as a medical activity that covers the entire treatment cycle, relies on the integrated collaboration of medical, pharmaceutical, nursing, and patient departments for standardized management. Research shows that multi-departmental joint intervention can effectively reduce the intravenous infusion indicators of inpatients and improve the effectiveness of clinical rational medication use[32]. However, most medical institutions currently leave the standardization of intravenous infusion to the pharmacy department alone, which limits the comprehensive implementation of standardized management. To improve this situation, it is recommended that medical institutions establish cross-professional collaboration mechanisms, conduct joint training, clarify division of responsibilities, establish communication channels, strengthen patient education, implement continuous quality monitoring, and provide incentives for medical professionals who actively participate.

To further improve the standardized use rate of intravenous infusions, continuous improvement strategies need to be adopted, including but not limited to: developing a list of diseases that do not require intravenous infusions based on the hospital's situation, optimizing the drug supply chain to support the use of oral and topical drugs, and establishing more effective monitoring and feedback mechanisms.

This study has achieved certain results in exploring the standardized use of intravenous infusions among inpatients in medical institutions in specific areas of China, but there are also some limitations. First, there may be understanding biases in the process of translating research materials from Chinese to English, affecting the accurate delivery of information. Second, the geographical concentration of the research may limit the universality of the findings; future research needs to expand the sample size to cover a wider area. In addition, reliance on semi-structured interviews may lead to respondent bias, with participants providing answers that meet the researchers' expectations rather than completely truthful ones. Finally, differences in clinical practices among various medical institutions may affect the consistency of cognition regarding the standardized use of intravenous infusions. These limitations point out the directions that future research needs to focus on.

This study reveals the multi-dimensional challenges of standardized intravenous infusion use among inpatients in Chinese medical institutions, including cognition differences among medical professionals and patients, the impact of medical insurance policies, and restrictions on the professional development of pharmacists. The research results emphasize the importance of strengthening education, training, and cross-departmental collaboration to enhance the standardization of intravenous infusions and clinical rational medication use. At the same time, it is recommended that relevant departments hold joint discussions to ensure the consistency of medical insurance policies with clinical practice, and promote the efficient use of medical resources and medical insurance funds. By comprehensively considering the needs of medical professionals, patients, policy makers, and managers, this study provides insights and suggestions for the continuous improvement of standardized management of intravenous infusions.

Funding

There was no funding for this study

Contributions

Xiaoyan Zhong, Yilan Huang designed the study. Yuexi Huang, Shurong Wang, Qiming Wei wrote the analysis plan, performed the data analyses, and interpreted the results, with feedback from Xiaoyan Zhong, Yilan Huang, Kun Chen cross-checked the results. Xiaoyan Zhong wrote the first draft of the manuscript with critical feedback and revisions from Yuexi Huang, Shurong Wang, Qiming Wei, Kun Chen, Yilan Huang. All authors read and approved the final manuscript.

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Table 1 The interview outline

Stage

Interview Content

Purpose

Introduction

-Researcher's Personal Introduction

-Introduction of the research project

-Overview of the purpose and importance of the research

-Establish trust

-Ensure participants informed consent

Background

Information

Collection

-Collect basic information of participants

-Inquire about preliminary views on intravenous infusions

-Understand participants backgrounds

-Collect preliminary attitudes towards standardized use of intravenous infusions

In-depth

Discussion

-Cognition and experience

-Challenges encountered

-Suggestions for improvement strategies

-Needs for education and training

-Policies and systems

- Patient role and participation

-Inter-departmental collaboration

-Gain a deep understanding of participants' cognition and experience regarding standardized use of intravenous infusions

-Discuss challenges and improvement strategies in practice

-Discuss the importance of education,. policy and collaboration

Summary and

Feedback

-Review key points of the discussion

-Ask if there are any additional opinions or suggestions

-Thank participants

-Ensure the completeness of information

-Collect final feedback and suggestions

Table 2 The main interview topics

Interview Topic	Content and Objective
Cognition of Standardized intravenous Infusion Use	Understand participants'basic understanding and recognition of standardized intravenous infusion use,including its importance, purpose,and specific execution requirements
Challenges Encountered in Practice	Discuss the specific problems,difficulties,and challenges encountered by medical professionals in the execution of standardized intravenous infusion use.
Suggestions for mprovement Strategies	Propose possible improvement strategies and suggestions in response to the challenges encountered in practice.
Patient Role and Participation	Study the role,expectations,and degree of participation of patients in the standardized use of intravenous infusions,and how they influence clinical decision-making

Table 3 The demographic characteristics of the participants

Role	Number of Participants (n)	Average Age	Age Range (years)	Female (%)	Average Years of Experience (years)	Experience Range (years)	Professional Background
Patients	20	52	40 - 65	50	3	3 - 30	No specific requirements
Nursing Staff	10	40	30 - 50	90	8	3 - 15	Nursing major
Doctors	10	45	35 - 55	30	10	5 - 20	Internal medicine or related fields
Pharmacists	20	44	35 - 55	60	11	4 - 25	Pharmacy major (10 clinical pharmacists, 10 heads of pharmacy departments)

No competing interests reported.

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Perceptions, Challenges, and Improvement Strategies for the Standardized Use of Intravenous Infusion in Chinese Medical Institutions: A Qualitative Interview Study

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Abstract

Purpose

Methods

Results

Conclusion

1 Introduction

2 Methods

3 Results

4 Discussion

4.1 Cognition Differences and Educational Needs of Medical Professionals

4.2 Medical Insurance Policies and Clinical Decision-Making

4.3 The Dual Role of Pharmacists and Their Professional Development

4.4 DRG/DIP and Clinical Pathways

4.5 Special Drug Management

4.6 The Importance of Patient Education and Communication

4.7 Multi-department Collaboration

5 Conclusion

Declarations

References

Tables

Additional Declarations

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