IV Therapy Experts,
I am looking for clarification on 2 specific issues:
1) when administering IVPB or IVP medication is it necessary to wear gloves?
I say "NO" siting infection control guidelines, we wear gloves to protect ourselves. Aside from chemotherapy agents, is it necessary to protect ourselves from the unlikely drop of saline or lasix or antibiotic? One hospital uses Lippincott for policies, states YES we need to wear gloves in accordance with OHSA standards on "bloodborne pathogens". I don't see how bloodborne pathogens relate to administration of IVP or IVPB medications. Can you please clarify or point me in another direction.
2) evidently there is a statement in the Infusion Nurse Society guidelines which states that transferring medications from one syringe to another increases the risk for error, therefore it is not recommended. We however teach students that medication must be drawn up in "an appropriate size syringe" and then transferred to a 10 ml saline (flush) syringe in order to accomplish 2 things 1) dilute medication, 2) facilitate rate of administration. This latter is the practice at our clinical facilities. We however have non-practicing faculty who insist on teaching from the INS guidelines witrhout regard to the context.
An example might be 0.5 mg Hydromorphone (2mg/ml) IVP which would equate to 0.25ml to be given over 2 minutes. The med is best drawn up in a 1ml syringe (we use TB syringes which have a non-removable needle) If it is not considered safe practice to transfer the med into a flush syringe, how does the nurse administer this med to a needleless port over 2 minutes? Administering to a Central line requires the use of a 10ml syringe.
If you can help clarify these issues, it would be greatly appreciated. I am trying to get us all on the same page when teaching students safe practice for IV med administration.
Thank you,
Glenna J Bayer, RN, BSN, MPA
MaricopaNursing
Mesa Community College
1833 W. Southern Ave.
Mesa, AZ 85202
480-461-7233
[email protected]
I will be happy to provide clarification as I worked on the INS standards committee.
First, gloves ARE needed when giving any IV medication to prevent possible contact with blood=tinged fluid. Before each and every medication is given through any type of VAD, the nurse must aspirate for a blood return. This means that blood may easily enter the syringe and blood-tinged fluid may leak from the syringe upon disconnection. For this reason gloves are necessary.
The statement about syringe-to-syringe transfer comes directly from the Institure for Safe Medications Practices which is referenced in the Standards document. You bring up some valid points about small volume doses but transfer to another syringe is never best practice. ISMP sites may reasons. Medication should never be transferred into a prefilled flush syringe as these syringes have different gradation markings. A regular 10 mL syringe is marked every 0.2 mL and a larger mark at each mL. A prefilled flush syringe is only marked every half mL. These syringes are also labeled with the manufacturer-filled content of heparin or saline. There is no way to alter that label to indicate what med was added. This is a huge med error waiting to occur! Finally drug transfer poses the risk of loosing a portion of the measured dose and increases the risk of contamination. Administering a medication through a CVAD does not require a 10 mL syringe. Again see standard #45 Practice Critera H. You must assess patency with a 10 mL syringe then use a syringe appropriately sized for the specific dose to give the med. Most meds do not always require additional dilution but again that is determined by the medication and the type of VAD. With a syringe of traditional design, you could measure half and whole mL volumes. The issue would come with smaller volumes or pediatric doses. You can also measure small volumes with a 3 or 5 mL syringe which would allow for further dilution.
Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks Lynn for the speed response. The PICC nurse at my hospital told me to check this site for help with my questions. She also mentioned your name, so I was happy to see your response. I can see by scanning the forum items that most participants are dealing with central lines, ports and PICCs. When students are introduced to intravenous medication administration during clinical, we first focus on peripheral lines.
Regarding gloves , if we are working with a closed system, IV pushes are administered thru the port closest to the patient and of course IVPBs are connected above the IV pump. Most patients have a primary IV infusion, we check for patency by assessing the site by visualization, palpation and asking the patient about pain/tenderness for signs of infiltration or occlusion. With saline locks, we teach to flush with saline, through a J-loop or Y-loop, while assessing the site, but not to routinely aspirate in that failure to aspirate blood does not necessarily constitute infiltration or occlusion. (For instance, aspiration through a 22 gauge catheter rarely results in blood return in that the catheter often collapses during aspiration). We of course teach the use gloves for initiating an IV site, drawing blood from a central line, hanging blood and blood products, administering chemotherapy agents (advanced practice), removing/changing IV site dressings and discontinuing an IV site.
Regarding the transfer of medication to a flush syringe, we use the GAHART text which requires dilution for many meds or recommends dilution to facilitate the appropriate rate of administration for others, generally 2 minutes, up to 4 minutes for morphine sulfate, for example. Our supply of morphine is a 5mg/ml vial. If the order is morphine 2mg, we instruct the student to draw up 0.4ml in a 1ml syringe, then after expelling approximately 1ml from the saline flush syringe, transfer the morphine into the flush syringe and create a label for that syringe. No syringe leaves the med room without label. This assures that patient is getting the correct dosage of ordered medication. It its diluted form that med can now be delivered over the appropriate time to a needless port. We also teach students to carry wrapped saline flushes, unwrapping them at the point of care.
Our IV Therapy text (Phillips?) maintains that 10ml syringes are necessary for use with central lines due to the lower psi which decreases the risk for catheter fracture. I know the Purple Power products are built to withstand the pressure of injectors, however, the “sticker” instructions that accompanies the product which is then placed in the chart, instructs users to access with 10ml syringes.
I have worked in a Magnet hospital system in Arizona for 7 years. Our nurses dilute almost everything, except for diazepam and sometimes furosemide. I am anxious to learn how we might close the gap between best practice and workplace practice, if there is one, based on these scenarios. And yes, I do know how to spell “academia”…sorry. I have been a member of the INS for 2 years and a subscriber to the ISMP newsletter for the last 5 years.
Thanks for your response,
Glenna
You have some thing right but some aspects of what you are teaching will get your students in deep trouble.
For IV pushes you will need gloves because of blood aspiration and the possibility of having blood tinged fluid leak upon disconnection. For IVPBs connected above the pump, what you are teaching does not meet the standards. See Standard 61, Practice Criteria B RE aspiration for a blood return. This does not specific aspiration for one method of delivery but not the other. Before all medications, the blood return should be checked.
Your assessment for infiltration/extravasation is not complete. A blood return alone is not indicative of infiltration or its absence from a peripheral catheter, however it is one component of the total assessment. This is a big problem in most of the legal cases I review. Infiltration and extravasation are the most frequent cause of infusion-related lawsuits. There is no infusion pump on the market currently that will detect infiltration and extravasation. The pump can not tell you where the fluid is going. In fact, the pump will continue to pump fluids regardless of the fluid pathway. This will increase the amount of fluid in the tissue. There are now several publications about this. So checking for a blood return even for IVPBs is necessary.
I am very glad you mentioned the Gahart book as I think this is the best resource for IV medications. Many meds monographs in that book state, "Determine absolute patency of vein." So checking for a blood return prior to giving all meds is critical, regardless of how they are delivered. This is an important component of a full assessment of the site. Just because the absence or presence of a blood return does not concretely tell you if infiltration is present does not lessen its importance in your full assessment, therefore it should never be omitted. Vancomycin, nafcillin, KCl, sodium bicarb, all calcium preparations are known vesicants. Many drugs are known irritants. So a full assessment for patency includes a blood return.
I know there is a lot of confusion about the whole issue of pressure and syringe size. But syringe size is one, and only one factor in what can create an increase in intraluminal pressure. This is a matter of physics. When the force applied to the plunger of a syringe meets some type of obstruction in the lumen, the intraluminal pressure will increase. If enough force is applied and the obstruction is a complete one with the lumen totally blocked, catheter damage can result. This type of damage to a VAD appears as a linear slit along the length of the catheter but there are very few reports of this actually occurring. However, if there is no resistance determined by manual flushing with a 10 mL syringe, then there will be no increase in intraluminal pressure and thus no risk of catheter damage. It requires an obstruction and excessive force applied to the syringe plunger to cause this rise in intraluminal pressure. Even with a 10-12 mL syringe one can cause this catheter damage if enough force is applied to the syringe plunger against an obstruction. So we can not teach nurses to rely on syringe size alone. They must understand the physics of flow.
This has been discussed in several articles and textbooks. Lynn Phillips book is a good one, but again, not the only one. You also need to have Plumer's Principles and Practices of Infusion Therapy, the original infusion therapy textbook and Infusion Nursing-An Evidence based Practice from the INS. .
I realize narcotics and drugs such as Phenergan must be diluted for administration. Also small peds doses require dilution. But I just checked a couple of drugs in Gahart's and there is no requirement for dilution on drugs like Solu-Medrol and Decadron for instance. Dilution in a syringe may not be totally necessary for every drug you are giving. Again, prefilled flush syringes are not designed for the addition of other medications. I am not sure if that is what you are teaching but I would immediately stop that practice if it is. If you are talking about a traditional syringe that the nurse has filled from a single dose vial of normal saline, that is different from a prefilled flush syringe. So I am not sure we are communicating correctly on that issue. Multidose vials should not be used for this purpose either. Numerous outbreaks of infection have been reported with these vials. They also contain benzyl alcohol which is limited to no more than 30 mL per day in an adult. Some drugs are not compatible with this preservative. Also, I hope you are teaching that any medications diluted by the nurse must be totally infused within 1 hour of the beginning of the dilution. This is coming from the United States Pharmacopeia Chapter <797> Compounding Sterile Preparations. I hope any IVPB meds are compounding by your pharmacy under a laminar flow hood as they will be meeting these USP requirements. But many nurses do not understand that they also must be compliant with these mandatory rules.
I would recommend you obtain these other textbooks, especially the large text published by INS with about 35-40 authors. There are more details about many questions in that book. For any nurse that is involved with any type of infusion therapy, they are held accountable to the INS Standards. This document is written for all nurses. There can not be 2 levels for the standards - one for primary care nurses and one for infusion nurses. I assure you that the INS standards are based on the available published evidence. We did not take an academic approach as all committee members have been in clinical practice for many years. Practice changes such as syringe-to-syringe transfers may have been common practice in the past but is now recognized to carry many risks. With the emphasis on patient safety, I would bring this issue to the appropriate committess, speak with the pharmacy and risk management and try to reduce the need for this practice as much as possible. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn, what is the title of the book you are speaking of in your last post? The INS book with numerous authors?
Thank you.
Infusion Nursing - An Evidence-Based Approach, edited by Mary Alexander, Ann Corrigan, Lisa Gorski, July Hankins, and Roxanne Perucca. This is the 3rd edition and its published by Saunders. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you.
Glenna,
First of all thank you for being a teacher! As we all know the track record of catheter related bloodstream infection is terrible in the USA. Many thousands of preventable deaths!! Over the past few years many nurses involved with vascular access have had important roles in changing behaviors. As an educator in this great profession obviously you also have a crucial role. Regarding infusion therapy and your students I would ask that you also focus on the need to protect patients from the spread of pathological organisms from the most common vector in the hospital setting...healthcare providers.
I believe your statement "we wear gloves to protect ourselves" needs to be amended to include we also protect our patients. Off the top of my head I cannot think of any evidence based practice stating we should wear gloves. Is there any out there that says we shouldn't? OSHA actually has a law stating that all healthcare workers performing vascular access procedures shall wear gloves. When I called OSHA to inquire what was a vascular access procedure they stated any procedure that accesses the bloodstream, yes even IV push! Common sense and a basic knowledge of microbiology dictate that more bacteria will be transferred by skin contact on catheter hubs. Every nursing student and nurse should knows the mantra....wash your hands, wear gloves, scrub the hub! 2 out of three does not cut it, the costs and lives lost are too high.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I agree that patients need to be protected from us as much or more than we need protection from them. That is why I am so impressed with Aseptic Non-Touch Technique (ANTT) that is the practice standard in the UK and is rapidly gaining appreciation internationally. It not only provides a theoretical framework that bridges the gap between what we know about the mechanisms of infection transmission and the clinical practices that can break the chain of infection. (Academia vs Clinical Expertise) The first of it's ten principles is the acknowledgement that health care workers and the environment where we work are the most significant risk for infection that patients at every level of care will face. All HAIs are, by definition, the result of our interactions with people when they are most fragile and vulnerable. We can extrapolate from what we know about infection transmission mechanisms to say that active infections are more likely to occur from us carrying them to a patient or from us spreading one they already have to another site, than occur from, say, going the the cafeteria or walking in the hallway. Microbes don't jump, and very few drift off into the air. The primary mode of transmission is contact. We are the ones who have contact with everyone and everything in the healthcare environment. As soon as you see yourself as a cause rather than a treatment, you begin the grasp what you must do to quit being a cause. Hand hygiene and gloves are the first and easiest way to break the chain of infection. Protecting the patient's key sites of vulnerability from contact with anything that could cause an infection is the next. Protecting anything that is going to touch something that could then contact a patient's vulnerable key site is next.
Our evidence will always be limited by the fact that it is wrong to do something logic tells you is wrong in order to compare it with something logic tells you should be right. There will always be areas where we just don't have gold standard evidence but we will always have replicable evidence about how the microbial world functions and have to build from there to practices where we can gather and publish evidence.
Daniel Juckette RN, CCRN, VA-BC