I recently had a physician colleague tell me that "our" , meaning IV Nurses, concern with drug pH as an indicator of the need for central access is just over-reacting. She said this was particularly true with Vancomycin. She said she had done an extensive internet search and spoken with both our pharmacy director and an pharmacy instructor at our University and they all agreed that " the literature just does not support placing a PICC for Vancomycin unless it's for greater than one week. There is no way the benefits outweigh the risk until you know for certain that it's going to be for an extended period." When I pointed out that our last CRBSI was three and a half years ago and our last Vancomycin infiltration was last week, she responded that " a vancomycin infiltration just isn't that bad. It's not like it's Phenergan..."
Just last week I gave her our Standards of Practice, the new CDC Guidelines and a half dozen articles recommending CVADs for Vanco but apparently that wasn't "the literature" because they were nursing journals. I'm speechless. I just don't know how to formulate a response. Even using Google, I can't a single source that indicates that it it a Best Practice to use peripheral IVs for Vancomycin.
I just don't understand how drug pH isn't an indicator for the type of device or that infiltrations just " aren't that bad".
I can think of several ways to approach this but none of them may work. You may never be able to convince all physicians about this. That is when I would do an end run around the physician and find a way to educate the patient directly about his/her choices. For instance, if you are infusing vanco and having to change the peripheral site every day and the patient is complaining about being stuck, that would be a perfect time to educate the patient about the alternatives of a PICC and let the patient talk to the physician.
You can also point out that the list of references in both INS and CDC include medical studies as well as nursing studies. If they have no respect for nursing research they should for medical research.
I do strongly believe in the SOP of a CVC for vanco but there is a place for a risk/benefit assessment in many cases. Vancomycin would not produce a simple infiltration that heals quickly. It is a vesicant and therefore it will produce an extravasation injury with the distinct potential for tissue necrosis. Have any of your cases gotten to this point? You may need to speak with your risk manager to see if there have been any such cases as you may not see these while in the hospital. Necrosis takes weeks to develop and the patient has long been discharged.
From an antibiotic stewardship standpoint, why are they using vanco for less than a week of therapy? If you are waiting on cultures to determine if a lengthy course of vanco will be needed, I can see giving it peripherally until you know the culture results. You would then need to use only a 24 g in the largest vein possible, adequate stabilization, no areas of joint flexion, and correct infusion times. Then if cultures show that vanco is needed, a PICC is indicated. So I don't think we can totally eliminate infusing vanco thru peripherals all the time. And there is a risk for insertion of any CVC. So it should be a patient-specific decision. 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
Hello Dan, Sounds to me like you have enough information to put together statistics demonstrating patient problems with Vancomycin. I think your MD does not want papers to read, they want a paper that includes the details along with your own patient risk statistics. While it will be a bit of work it is something you could publish later. Creating a paper that includes Vancouver issues (use Lynn Hadaways' article on Vancomycin as a starting point), blend in the new CDC and INS statements specifically that a central line should be considered if treatment needed greater than 5 days, ph and vescicant/irritant statements and other pertinent statements. Then add in your own infiltration, phlebitis, delays in treatment due to excessive line loss and any lawsuits. that material will provide ammunition for a definitive decision both from the MD and from risk management. Nancy Moureau [email protected]
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
I definitely agree that it is a patient specific decision. I think if the patient has had an opportunity to have risks and benefits explained and has chosen peripheral access, then their choice must be respected. "i'm not ordering a PICC because it might discourage them from going on hospice" or "I don't want them to have a PICC because they will want to stay inpatient" without regard for the patients therapys or their wishes are the times I have difficulty with providing access that disregards my Standards of Practice.
Daniel Juckette RN, CCRN, VA-BC
Yes, I would definitely agree with you on those points. These responses from physicians would suggest that the physician is not communicating well with the patient and family about the true nature of the situation. Either that or the physicians are simply not making any sense. Sometimes you just have to wonder that they are actually thinking when they come out with these so-called rationales! 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