NURSING PATIENT CARE POLICY & PROCEDURE
July 29, 2016
Nursing Manual (Red)
Policy #: 1.24
Title: Alaris® System (Adult &
To safely administer prescribed fluids, blood products, and medications intravenously,
subcutaneously or arterially. The Alaris® System includes Guardrails® Suite MX safety
software, which contains the UW Health specific drug and IV fluid limits and
configurations with evidence-based dose limits for continuous, intermittent, and bolus
A. The Alaris® System, which includes the Computer Programming Unit (PC), Auto ID
module, Large Volume Pump (LVP) module, Syringe module, and Patient Controlled
Analgesia (PCA) module, is appropriate for use on any adult or pediatric patient.
B. All personnel must be trained to operate the Alaris® System before use on patients.
C. Nurses must perform barcode scanning of Patient ID, Clinician ID and medication
barcode at patient bedside utilizing Alaris Auto ID module whenever possible.
1. If barcode scanning of medication or fluid is not possible due to emergency,
an unreadable barcode or other unexpected occurrence, clinicians are
expected to utilize the drug library by manually selecting the medication or
fluid from the Guardrails® Drug Library or Guardrails® Fluid Library.
2. If a non-scanning medication is encountered frequently, the medication
record may need to be revised. Nurses may submit an Alaris Data Library
Change Request and Report of Non-scanning Medications Form.
3. Anesthesia personnel are not required to scan all medications using Auto ID.
D. Nurses should scan the patient-specific barcode affixed to medication container when
available rather than National Drug Code (NDC) (linear barcode) when available.
NDC barcodes should be scanned when patient-specific barcodes are not attached.
E. The Alaris Basic Infusion application has no Guardrail® safety limits and is
acceptable for use only in emergencies, for custom medication orders or if an ordered
medication or dosage is not in the current drug library profile. Unit-based pharmacists
should be consulted if a medication is not in the current drug library and the Alaris
drug calculation feature should be used for programming.
F. The UWH Alaris System is configured with seven Patient Care Profiles: Adult ICU,
IMC/Cardiac, Oncology/Infusion Center, Medical/Surgical, Pediatric ≥ 8 Kg, Infant
< 8 Kg and Training.
1. Each profile contains a specific Drug Library and IV Fluid library as well as
pump configurations appropriate for each care area. Dosing limits and rate
limits for each Guardrails® drug and IV fluid are customized by the UWH
Pharmacy Department and are based on literature, clinical requirements and
organization-specific medication administration policies.
Page 2 of 6
2. Clinicians must select the appropriate Patient Care Profile upon IV pump
start-up according to inpatient area of care. Refer to Administrative Policy,
8.31, Guidelines for Hospital Location Specific Administration of IV
Medications, and Clinical Guidelines: Intravenous Administration of
Formulary Medications– Adult – Inpatient/Ambulatory, or Intravenous
Administration of Formulary Medications– Pediatric/Neonatal –
3. Transferring patients from one level of care to another:
a. When patients are transferred from a higher level of care to lower level
of care, the receiving clinician must reprogram the pump for the
correct Patient Care Profile as soon as it is clinically safe to stop
infusions, turn off the pump as select the new profile.
b. If patients are transferred from a lower level of care to a higher level of
care, it may be best to obtain an additional Alaris programming unit
and module(s) to access the critical care profile quickly and without
abruptly halting currently infusing medications.
G. The use of Anesthesia Mode on the Alaris® System is solely intended for qualified
anesthesia clinicians. This feature is only applicable to procedural settings where
anesthesia personnel are continuously monitoring the patient.
1. If the pump is in Anesthesia Mode, the Alaris® main screen will display
“anesthesia mode” alternating with other required prompts.
2. To disable Anesthesia Mode (two methods):
a. Plug in power cord or unplug power cord. The pumps will issue this
message: Anesthesia mode was discontinued when AC power cord
was disconnected. Press CONFIRM to continue normal operation.
b. Press OPTIONS key; Press ANESTHESIA MODE soft key; Press
DISABLE soft key; Press CONFIRM soft key. ANESTHESIA MODE
no longer appears on Main Display, indicating it has been disabled.
III. OPERATING INSTRUCTIONS
A. Refer to the Alaris webpage on U-Connect for complete operating instructions:
1. Alaris® System Directions for Use Manual
2. Alaris® System computer-based training (password: Alaris)
IV. EQUIPMENT AND TUBING
PUMP MODULE TUBING SETS CS ITEM NUMB
Large Volume Pump
Set Primary IV Pump Alaris® 4001170
Set Primary IV Pump (IVIG Admin) Alaris® 4009795
Set Blood IV Pump Alaris® 9996195
Set Lo-Sorbing IV Pump Alaris® 9996197
Set Low-Sorbing with Filter IV Pump Alaris® 4012075
Set Secondary Alaris® 4001171
Set Extension Extra Port (IV & Blood) Alaris® 4010436
Page 3 of 6
PUMP MODULE TUBING SETS CS ITEM NUMB
Alaris® Syringe Pump tubing with Pressure Sensing
Disc and micron filter
Alaris® Syringe Pump tubing with Pressure Sensing
Disc without micron filter if infusing blood products,
propofol, or lipids
Alaris® Syringe Pump Lo-Sorbing tubing for
Set PCA Administration Alaris® 2200556
Anti-reflux Y-set extension 2200557
A. Change tubing set every 72 hours. For blood infusions, refer to Administrative Policy
8.12, Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing),
for lipid and propofol infusions refer to Nursing and Patient Care Policy 1.23AP,
Continuous Peripheral Intravenous Therapy (Adult and Pediatric).
B. The Alaris® System IV pump basic tubing sets have three SmartSite® valves: (1) the
first is above the pumping mechanism and is used for secondary tubing set
attachment; (2) the second valve is located distal to the pumping mechanism,
providing access for air-in-line removal; (3) the third valve is near the patient
connection site, for IV push administration. Use of IV Tubing with SmartSite®
1. Prepare valve
a. Prior to every access, scrub the top of the SmartSite® needle-free
valve port with a sterile 70% isopropyl alcohol wipe for 15 seconds
and allow to dry for 15 seconds.
b. For multiple syringes, maintain sterility of needle-free valve port
between each syringe access.
2. Attach syringe
a. Insert the syringe tip into the SmartSite® needle-free valve.
b. If syringe has a luer-lock collar, turn syringe clockwise to secure the
c. If syringe has a slip luer, insert and rotate 1/4 turn to secure the
connection. Inject or aspirate fluid. Do not leave slip luer syringes
d. IMPORTANT: Do not use needles or blunt cannulas to access the
SmartSite® needle-free valve.
C. When delivering IV push medications via the SmartSite® valve, consider pinching
tubing above the valve to force the medication toward the direction of the patient.
Sometimes rapid instillation of fluid injected via syringe can cause backpressure in
the tubing line, which may, in turn cause bulging of the tubing in the pumping
segment. IMPORTANT: Do not perform this method for medications that must be
delivered into a free flowing IV.
A. Hard and Soft Limit Alerts
1. Guardrails® Soft Limits – limits/parameters set that can be overridden.
a. If the pump issues a Soft Limit alert, STOP, check the settings, check
the order, and reprogram the pump. If the Soft Limit alert is reissued,
override the alert by pressing YES. If this happens frequently with the
same medication the guardrail limit may need to be revised. Nurses
Page 4 of 6
may submit an Alaris Library Change Request and Report of Non-
scanning Medications Form. This form is available on the Alaris
webpage and in the UWH Related Resources at the end of this policy.
2. Guardrails® Hard Limits – limits/parameters set that cannot be overridden.
a. If the pump issues a Hard Limit alert, STOP, check the settings, check
the order, and reprogram the pump. If the Hard Limit alert is issued
again, STOP and consult the unit pharmacist or provider. If the
pharmacist or prescriber verifies the medication and the dose as
correct, basic infusion may be used. See Policy section, item E.
b. If Hard Limit alerts are issued frequently with the same medication the
Guardrail® limit may need to be revised. Nurses may submit an Alaris
Library Change Request and Report of Non-scanning Medications
Form. This form is available on the Alaris webpage and in the UWH
Related Resources at the end of this policy.
B. Clinical Advisories and Nurse Response
1. Clinical Advisories are a visual message posted on the main PC display
when a designated drug is selected to remind clinician of specific
hospital/facility standards of practice when programming an IV medication.
2. When a Clinical Advisory is issued, nurses must press CONFIRM after
reading advisory message. Numerous advisories are posted to remind
clinicians that certain medications may:
a. Cause extravasation if infiltrated
b. Require special tubing or filters
c. Be administered subcutaneously rather than intravenously
d. Cause hypersensitivity reactions
C. Patient Weight or Body Surface Area (Adults Only)
1. Patient’s weight is entered into the pump in kilograms. Once a patient
weight or body surface area is entered, for any module, it is automatically
entered for any subsequent weight-based calculations on all associated
2. The patient’s weight in the pump should not be adjusted once therapeutic
affect has been attained regardless of patient’s actual weight.
3. Any patient weight in the Alaris pump, other than noted in IV.C.2, should
not be changed without consultation with the interdisciplinary team
D. Labeling High Alert Medications
1. All high-alert continuous intravenous medication infusions must be
administered via an infusion pump.
2. Each line infusing a high alert medication must be labeled with the name of
the medication being infused at the distal ends of all tubing so that two
providers can independently trace the line back to the insertion for
3. Labels may be handwritten if preprinted labels are unavailable.
4. When multiple high alert medications are infusing simultaneously, it is
recommended that nurses consider labeling the fluid line or “drive line” to
assist in identifying lines that are safe to administer IV push medications.
5. Refer to Administrative Policy 8.33, High Alert Medications.
E. Line Reconciliation
1. Perform line reconciliation by tracing the path from the medication to the
pump module noting infusion rate, channel label, and tubing to the patient’s
access site as part of the initial assessment, counter-signing procedures, and
Page 5 of 6
whenever changes are made.
2. Perform line reconciliation at every change of shift and whenever
transferring patient care to another nurse. Refer to 14.33AP, Nurse-to-Nurse
F. Secondary Infusions
1. Prime secondary set using either gravity or backfill method. Use the backfill
method for multiple piggybacks to prime the secondary tubing.
2. Scrub needle-free connection port with alcohol prep for 15 seconds; allow to
dry for 15 seconds and attach to primary tubing. Open roller clamp before
3. Hang primary bag lower than secondary bag, using hook provided in the
secondary tubing package. Hook must be fully extended. If primary fluid is
not 9.5 inches lower than secondary fluid, primary fluid will deliver at
secondary rate and secondary will not infuse until the primary bag runs out.
a. Automatic switch back to primary occurs after secondary volume is
b. Underestimating the secondary volume will cause the remaining
secondary solution to be infused at the primary rate.
c. Overestimating will result in the primary solution being infused at the
G. Pump Clearing and Documentation
1. All units should clear pump volumes at least every 8 hours.
2. Document pump volumes in the patient’s clinical record (IV/IVMAR).
3. Critical Care areas (ICU/IMC) may clear pump volumes and record data
more frequently (1-2 hours).
4. The RN receiving transfer patients from another area of care should, upon
admission to the unit:
a. Check volumes and last time cleared.
b. If last time cleared was more than 8 hours ago, clear pumps.
c. If last time cleared was within the last 8 hours, clear at the end of shift.
H. Pump Malfunction and Repair
1. If the pump malfunctions, call Clinical Engineering to report and do the
a. Sequester the programming unit, all modules and tubing for
evaluation. Do not take the tubing out of the pump. Do not send this
pump to Central Services.
b. Order a new pump for the patient.
c. Enter a Patient Safety Net (PSN) report describing the occurrence.
PSN must include the device serial number on back of pump or FMIS
2. Refer to Nursing and Patient Care Policy 8.39AP, Repair or Replacement of
Essential Equipment in Case of Breakdown, and Administrative Policy
12.40, Reporting of Device-Related Adverse Events & other Product
I. Return Alaris Components to Central Services
1. Return modules and programming units to Central Services when no longer
needed; do not wait until discharge. This ensures pumps are available when
2. Use Mobile View
a. Double-click the orange button on the tag when the equipment may be
Page 6 of 6
removed from the patient’s room. Housekeeping staff will remove
devices daily when rooms are cleaned.
i. It is important that the equipment be made available for
removal. Remove tubing, fluid bags and/or syringes as soon as
the pump/module is no longer needed.
ii. Alaris modules must be disconnected from the programming
unit. Double click each component of the Alaris system, not
just the programming unit.
b. If the button is double clicked after the Housekeeping staff have
cleaned the room, the equipment will be picked-up the following day.
VI. UWH CROSS REFERENCES
A. Administrative Policy 8.31, Guidelines for Hospital Location Specific Administration
of IV Medications
B. Administrative Policy 8.33, High Alert Medication Administration
C. Administrative Policy 12.40, Reporting of Device-Related Adverse Events & Other
D. Nursing and Patient Care Policy 8.39AP, Repair or Replacement of Essential
Equipment in Case of Breakdown
E. Nursing Patient Care Policy 14.33AP, Nurse-to-Nurse Change-of-Shift Hand-Off -
F. U-Connect Alaris® System Intranet Site
G. Intravenous Administration of Formulary Medications,- Adult-Inpatient/Ambulatory
H. Intravenous Administration of Formulary Medications – Pediatric/Neonatal –
A. Alaris® Directions for Use Manual
B. Alaris® System computer-based training on Alaris webpage on U-Connect
C. Institute for Safe Medication Practices. Proceedings from the ISMP Summit on the
Use of Smart Infusion Pumps: Guidelines for Safe Implementation and Use. 2009.
D. Association for the Advancement of Medical Instrumentation. Infusing Patients
Safely: Priority Issues from the AAMI/FDA Infusion Device Summit. 2010.
VIII. REVIEWED BY
Clinical Nurse Specialist, Infusion
Drug Policy Analyst, Center for Drug Policy
Smart Pump Oversight Committee
Nursing Patient Care Policy and Procedure Committee, July 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer