title: Nebulized bronchodilator formulations: unit-dose or multi-dose?
abstract: BACKGROUND
  Nosocomial infections linked to the use of multi-dose bronchodilator nebulizer formulations have been reported in the literature.
  
  
  OBJECTIVE
  Survey American hospital respiratory therapy services to determine practice patterns, opinions, and awareness regarding unit-dose and multi-dose bronchodilator formulations.
  
  
  METHODS
  A quota sample targeted 4 hospital size categories (0-100 beds, 101-200 beds, 201-400 beds, and > 400 beds) using a listing of general medical/surgical hospitals from the American Hospital Association. Hospitals were contacted via telephone to identify the director of respiratory therapy services, who was invited to complete a 29-item Web-based survey of their hospital practices and their opinions about and knowledge of issues with multi-dose and unit-dose bronchodilator formulations.
  
  
  RESULTS
  One thousand forty-seven hospitals were recruited and 409 valid surveys were completed (completion rate 39%). The reported mean +/- SD percentage of unit-dose nebulizer treatments was 80.2 +/- 26.2%. Seventy-two percent (296) of respondents indicated having a policy and procedure manual that deals specifically with nebulized bronchodilator solutions, but only 107 reported having internal monitoring guidelines for compliance with those policies and procedures. Multi-dose bottles of bronchodilator concentrate were used with multiple patients in 77% of cases, and on average 9.7 +/- 8.5 patients were treated with the same multi-dose bottle. Eighty-one percent of respondents reported that treatments from multi-dose bottles are prepared at the bedside. The length of time a multi-dose bottle was kept (after being opened) ranged from 24 hours (8%) to 1 month (11%), and only 3% of respondents reported following manufacturers' recommendations. In the respondents' opinion the chief advantage of multi-dose was cost per dose (84%), and the chief advantage of unit-dose was less risk of contamination (92%). With other factors (therapist time, cost of saline diluent for multi-dose concentrate, dose-error, and contamination) considered, 73% thought that unit-dose vials were more cost-effective. Three hundred thirty-six respondents (82%) thought that a sterile, low-volume (0.5 mL) unit-dose vial of bronchodilator concentrate would be useful, and 249 (74%) of those 336 respondents indicated that such a formulation would replace multi-dose bottles. Only 56% of respondents knew about the evidence regarding the risk of contamination with multi-dose bottles.
  
  
  CONCLUSIONS
  Multi-dose bottles of bronchodilator solution are used in approximately 20% of nebulizer treatments, and without strict adherence to infection control procedures they are a potential source of nosocomial infection. A sterile, low-volume unit-dose vial of bronchodilator concentrate would be a useful alternative to multi-dose concentrate for modifying doses or mixing drugs in nebulizer therapy.
authors.affiliation: Cardiopulmonary Care Sciences, MSC 8R0319, Georgia State University, 33 Gilmer Street SE, Unit 8, Atlanta GA 30303-3088. resjlr@langate.gsu.edu
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Rau
authors.forename: Ruben D
authors.initials: RD
authors.lastname: Restrepo
mesh_terms: D001291:Attitude of Health Personnel; D001364:Awareness; D001993:Bronchodilator Agents / Q000008:administration & dosage*; D004349:Drug Packaging; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D009330:Nebulizers and Vaporizers; D019999:Pharmaceutical Solutions; D012139:Respiratory Therapy Department, Hospital / Q000706:statistics & numerical data*; D014481:United States
chemical_list: D001993:Bronchodilator Agents; D019999:Pharmaceutical Solutions