QUALITY & SAFETY ASSOCIATE EDITOR BARBARA JAGELS, RN, MHA, CPHQ
The administration of 24-hour
continuous chemotherapy infusions
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is common in certain regimens, such
as EPOCH (etoposide, prednisone,
vincristine, cyclophosphamide, and
doxorubicin). Such regimens are
notorious for clinically insignificant
air-in-line (AIL) alarms because of
the naturally bubbly composition of
the drugs involved. An antisiphon
valve, placed at the end of the IV
tubing to pressurize the infusion and
to minimize air bubbles, was found
to decrease clinically insignificant
AIL alarms. The positive outcomes of
the current study could be applied to
other infusions known for frequent
clinically insignificant AIL alarms.
AT A GLANCE
ɔɔ Nuisance AIL alarms may prolong
infusion times, disrupt patients’
sleep, and increase nursing
workflow.
ɔɔ A 92% decrease in AIL alarms was
observed when comparing four
weeks of infusion data before and
after antisiphon valve implemen-
tation.
ɔɔ The antisiphon valve must be
manually primed via syringe or
IV pump because it cannot be
primed by gravity.
KEYWORDS
antineoplastic protocols; drug
delivery; infusion pumps;
clinical alarms
DIGITAL OBJECT
IDENTIFIER
10.1188/19.CJON.209-211
CJON.ONS.ORG
Air-in-Line Alarms
Decreasing alarms through antisiphon valve
implementation
Karen Meade, MS, APRN-CNS, AGCNS-BC, CPAN®, OCN®, Kimberly Catania, MSN, APRN-CNS, AOCN®,
Ben Lopez, PharmD, MS, MHA, BCPS, and Ryan Connell, CPhT
C
hemotherapy infusions
are one of the pillars
of oncology treatment.
However, some infusions
are notorious for trigger-
ing frequent and clinically insignificant
air-in-line (AIL) alarms. These alarms can
contribute to alarm fatigue, negatively
affecting nurses and patients. In a compre-
hensive review, Shah, Irizarry, and O’Neill
(2018) evaluated alerts and alarms with
smart infusion pumps, finding no consen-
sus regarding the amount of air a patient
may safely receive via an infusion and no
published evidence addressing strategies
to decrease AIL alarms.
Alarm fatigue is a ubiquitous problem
in hospitals and may desensitize clini-
cians to medical device sounds, leading to
workarounds, such as turning down alarm
volume or adjusting device settings (Joint
Commission, 2013). Despite the generally
positive intentions of technologic en-
hancements, nurses have described the
increasing amount of medical device alarm
and alert sounds as constant, noxious, and
a nuisance (Honan et al., 2015). In a 2016
survey of more than 1,200 healthcare team
members, respondents stated that alarms
occurred frequently (87%) and disrupted
patient care (86%), causing caregivers to
distrust and disable the alarms (Ruppel et
al., 2018).
The Joint Commission (2013) rec-
ommends various strategies to reduce
nuisance alarms, including identifying
opportunities for improvement through
a review of trends and patterns of alarms.
In addition, nuisance AIL alarms have the
APRIL 2019, VOL. 23, NO. 2  CLINICAL JOURNAL OF ONCOLOGY NURSING  209
potential to prolong infusion times, dis-
rupt patients’ sleep (AAMI Foundation,
2015), and increase nursing workflow.
Clinically Insignificant
Air-in-Line Alarms
There is a paucity of primary litera-
ture addressing the topic of gaseous
chemotherapy infusions and the resultant
clinically insignificant AIL alarms. Based
on a literature search of CINAHL®, Google
Scholar™, and PubMed®, the clinical
rationale for why some infusions are gas-
eous and prompt small air bubbles during
the infusion is not documented.
Notable discussion has taken place in
the Oncology Nursing Society’s (ONS’s)
online community, particularly its All ONS
Member Community board, regarding the
management of AIL alarms. Community
members have described nuisance AIL
issues with infusions including etopo-
side, rituximab, IV immunoglobulin, and
mixed chemotherapies (Atkins, 2017;
Fischer-Cartlidge, 2017; Schumann, 2017).
According to posts from community mem-
bers, some organizations have instituted the
use of an antisiphon valve to pressurize the
infusion, decreasing air bubbles in the line
and, ultimately, the number of AIL alarms
(Rodriguez, 2017; Sunago, 2017). In addi-
tion, through interactions and discussions
with infusion pump consultants, knowledge
was shared regarding the successful use of
the antisiphon valve in other organizations.
Valve Implementation
Some chemotherapy regimens require
continuous 24-hour infusions (National
QUALITY & SAFETY

Comprehensive Cancer Network, 2018).

An example of this is EPOCH (etoposide, FIGURE 2.
prednisone, vincristine, cyclophospha- EPOCH INFUSION AIR-IN-LINE ALARM TRENDS
mide, and doxorubicin), which includes
a component administered as a combi- 1,200
nation chemotherapy (i.e., doxorubicin,
etoposide, and vincristine) that is known 1,000
for triggering frequent clinically insignif-

EPOCH INFUSION AIR-IN-LINE ALARMS

icant AIL alarms (Chemo Experts, 2019;
800
Sunago, 2017).
At the James Cancer Hospital and
Solove Research Institute at The Ohio 600
State University Wexner Medical Center in
Columbus, practice was changed to feature 400
the use of an antisiphon valve installed at
the end of the primary tubing containing
the EPOCH combination chemotherapy 200
and connected to a closed-system transfer
device (see Figure 1). The average month- 0
ly number of inpatient infusions of this 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 10/18 11/18
combination chemotherapy was 110 (over DATE (MONTH/YEAR)
three months).
EPOCH—etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin

Procedures
The goal of this project was to decrease
the number of clinically insignificant AIL
alarms specifically with EPOCH com-
bination infusions to enhance nursing
workflow, patient experience, and drug
delivery. Because the in-house pharmacy
prepares all chemotherapy drugs at the
cancer center, it was essential to collabo-
rate with pharmacy leaders to implement
the antisiphon valve. After successful
buy-in from pharmacy stakeholders and
obtainment of adequate supply, the anti-
siphon valve was trialed on a hematology
FIGURE 1.
ANTISIPHON VALVE
Note. Image courtesy of Karen Meade. Used with
permission.
inpatient unit that frequently and pri-
marily administered EPOCH regimen
infusions. The lead pharmacy technician
provided in-service sessions on the use
and administration of the antisiphon
valve prior to the July 2018 go-live date.
Focused nursing education was provid-
ed to the unit. After implementation,
positive responses were received from
nursing staff regarding the use of anti-
siphon valves with continuous EPOCH
regimen infusions. Nurses found that
the valve decreased nuisance AIL alarms,
helping to decrease alarm fatigue.
Results
The infusion pumps used within the au-
thors’ organization allow for automatic
infusion pump data collection via an online
portal. This portal provides in-depth data
on numerous metrics, including alarms
and alerts, specific to each drug. For the
purposes of this project, AIL alarms were
assessed. After reviewing the EPOCH in-
fusion data, a 92% decrease in AIL alarms
was found when comparing four weeks of
infusion data before and after antisiphon
valve implementation (see Figure 2). The
data confirm a total of 1,087 AIL alarms
associated with 108 unique EPOCH admin-
istrations preimplementation compared to
a total of 90 AIL alarms associated with 115
unique EPOCH administrations postim-
plementation. In aggregate time, EPOCH
infusions in the AIL alarm state decreased
from 25 minutes to 5 minutes. No other
nursing practice changes were identified
during these time frames.
Considerations and Challenges
for Nursing Practice
Based on this project’s results, the
practice of using an antisiphon valve
reduced AIL alarms. However, it was
found that the antisiphon valve inad-
vertently prevented the nurse from
being able to check blood return via the
normal means of withdrawing through
the primary tubing during the infusion.
Normally, per institutional policy, the
nurse would verify blood return through
the lowest infusion port, the one that is

210   CLINICAL JOURNAL OF ONCOLOGY NURSING  APRIL 2019, VOL. 23, NO. 2 CJON.ONS.ORG
closest to the patient (Menonna-Quinn,
2014). Because the antisiphon valve was
installed between the patient and the
tubing infusion port, blood return could
not be assessed using standard meth-
ods. This problem was addressed with
the addition of a dual-lumen extension
device (see Figure 3). This device allowed
for one lumen to connect directly to
the primary chemotherapy line with the
antisiphon valve, leaving the other free
for the nurse to check for blood return.
It is now the nursing practice expectation
to use the dual-lumen extension device
when administering EPOCH infusions.
Nurses must be educated on the proper
use of the antisiphon valve when adminis-
tering infusions. A practice consideration
that must be noted is that the antisiphon
valve cannot be primed by gravity. The
device requires manual priming. This can
be achieved by flushing with a prefilled sy-
ringe or attaching the valve at the end of
a primed set and using an infusion pump
to force-prime the valve (BD, n.d.). The
antisiphon valve requires only 0.5 ml of
prime solution, has little to no risk to pa-
tient safety outcomes, and needs minimal
education to operationalize (BD, n.d.).
The authors’ organization has found that
the antisiphon valve has been easy to im-
plement, is safe to use, and has improved
satisfaction among patients and nurses.
FIGURE 3.
DUAL-LUMEN EXTENSION
DEVICE
Note. Image courtesy of Karen Meade. Used with
permission.
CJON.ONS.ORG
Conclusion
Use of an antisiphon valve can dramati-
cally decrease clinically insignificant AIL
alarms during EPOCH regimen infusions.
Implementing antisiphon valve use in
"Nurses have described the increasing
amount of medical device alarm and
alert sounds as constant, noxious,
and a nuisance."
clinical practice may be effective for select
gaseous infusions, but additional research
is needed.
Karen Meade, MS, APRN-CNS, AGCNS-BC, CPAN®,
OCN®, and Kimberly Catania, MSN, APRN-CNS,
AOCN®, are clinical nurse specialists, Ben Lopez,
PharmD, MS, MHA, BCPS, is the director of pharmacy
operations, and Ryan Connell, CPhT, is a pharmacy
technician, all at The Ohio State University Wexner
Medical Center in Columbus. Meade can be reached
at karen.meade@osumc.edu, with copy to
CJONEditor@ons.org.
The authors take full responsibility for this content
and did not receive honoraria or disclose any relevant
financial relationships.
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