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IV Therapy Policy Changes & Highlights: FAQs

September, 2013

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IV Therapy FAQs

September, 2013

POLICY REMINDERS

What are the required components of a Med Infusion Time Out?

• Patient Identity

• Original Order

• IV Bag Label (i.e. patient name & fluid/medication/concentration)

• Infusion pump settings including: Body weight (when applicable), Concentration, Dose, Rate

• Trace infusion line back to its origin

When is a Med Infusion Time Out performed?

1. On all initial pump set-ups for continuous med infusions in DOSE Mode

2. Upon receiving a patient with a new medication infusion started in a procedural area (e.g. OR, IR, etc.)

3. With a change in drug concentration

4. With a physical change of pump (i.e. current pump is replaced with new pump)

MED INFUSION TIME OUT – FAQs, ANSWERS, & CLARIFICATIONS

Do I need to do a Med Infusion Time Out with any rate changes for any IV medications/drips (including Heparin and Insulin)?

No.

If I am uncomfortable making an IV rate change shouldn’t I have another nurse do a Med Infusion Time Out with me just to cover myself?

No “formal” Med Infusion Time Out is needed. It is acceptable and expected practice that if a nurse is uncomfortable making an IV rate change, he/she should ask a second nurse to verify pump settings, etc.

I currently have all my drips “double checked” by another nurse and I have the other nurse document the “double check” all the time, isn’t this good practice?

No, the best practice is to follow hospital policy and only have a Med Infusion Time Out performed at the times designated by policy. It is more detrimental to have inconsistencies in practice and to not follow SLUHN policy. In addition, it is not acceptable to always “expect” another nurse to check your work; remember this practice means you are taking other nurses away from patient care unnecessarily.

Do I need to do a Med Infusion Time Out when I receive a transfer from another unit or another level of care?

No formal Med Infusion Time Out is needed. Remember: For all IV infusions, the RN assigned to the patient will verify at the beginning of his/her shift, upon receiving a patient from another unit/department, and with any change to physician orders: patient identity, original order, IV bag label (i.e. patient name and fluid/medication/concentration), infusion pump settings (including body weight (when applicable), concentration, dose, and rate), and trace infusion line back to its origin.

Why aren’t we doing a Med Infusion Time Out with rate changes and on transfer?

More double checks are not better… “Fewer double checks strategically placed at the most vulnerable points of the medication use process will be much more effective than an overabundance of double checks.” (ISMP, June 2013) Another important reason is that SLUHN history has proven that most of our errors have occurred at the initiation of IV med infusions.

Will Med Infusion Time Outs be completed in the Emergency Department and PACU when continuous IV drips are started?

Yes.

Is a Med Infusion Time Out needed when I receive a transfer from another facility?

No Med Infusion Time Out is needed if the infusion pump is not physically changed upon receipt of the patient (e.g. patient received from SLUHN facility). A Med Infusion Time Out is needed if the infusion pump is physically changed upon receipt of the patient (e.g. patient received from non-SLUHN facility and pump does not remain with patient).

How do I know if the Med Infusion Time Out was done?

It is not an expectation that nurses verify (check) that a Med Infusion Time Out was done or documented appropriately. The Med Infusion Time Out is a practice expectation that all nurses have been educated on.

Who can perform a Med Infusion Time Out?

The Med Infusion Time-Out process includes one RN and one qualified individual, (e.g. RN, Pharmacist, Physician) independently checking all components in the presence of the patient.

Are Physician Assistants and Nurse Practitioners considered “qualified individuals”?

PAs and NPs can be considered qualified to do a Med Infusion Time Out if familiar with the process and components of the Med Infusion Time Out.

When I receive a patient from a procedural area (e.g. OR, IR) who does the Med Infusion Time Out? Does it need to be one nurse from the procedural area and one nurse from the receiving unit?

The Med Infusion Time-Out process includes one RN and one qualified individual, (e.g. RN, Pharmacist, Physician) independently checking the all components in the presence of the patient. There is no specific requirement for one of the nurses to be from the procedural area.

Where is the Med Infusion Time Out documented?

For nurses who use Horizon Clinicals, the “IV Drip Calc” is changing to “Med Infusion Time Out.” The second nurse will enter his/her number and password as is current practice. There will be a box to free text the IV med name(s) being double checked. For the Emergency Department and PACU, the Med Infusion Time Out will be documented in the medical record according to unit procedure.

If I have an IV med infusion (e.g. Heparin drip) that is stopped for an extended period of time (e.g. patient going for a procedure in GI Lab, OR, etc.), when I start the drip again do I need to perform a Med Infusion Time Out?

A physician’s order is needed to stop an IV med infusion. Therefore a new order is needed to start the drip again which would require a Med Infusion Time Out at that time (i.e. this is considered an initial pump set up). Note: If a Heparin drip is stopped/held due to a high PTT, restarting the drip does not require a Med Infusion Time Out because this is part of the existing Heparin order and rate change.

When a medication is listed in the drug library but I am only infusing it as an intermittent infusion, is a Med Infusion Time Out needed?

No. Examples…

Pitocin, Amiodarone, and Protonix are in the drug library. When they are infused in an intermittent fashion, Dose Mode will be used if they infuse longer than 1 hour but no Med Infusion Time Out is needed. When they are infused as a continuous drip, Dose Mode must be used and a Med Infusion Time Out must be done.

Potassium, Magnesium, and Vancomycin are also in the drug library. When they are infused in an intermittent fashion, Dose Mode will be used if they infuse longer than 1 hour but no Med Infusion Time Out is needed.

I have a patient on a weight-based med infusion (e.g. Propofol, Dopamine). The patient’s current weight varies greatly from the weight used to initiate the med infusion and I need to change the rate. How do I handle this situation?

Depending on the medication, the rate of the infusion may or may not change based on the new weight. When the med infusion rate is changed because of the new weight (e.g. Propofol), no Med Infusion Time Out is needed because this is a continuation of a med infusion and only involves a rate change (i.e. this is not an initial pump set up).

I received a patient from another unit on a Heparin drip… I weighed my patient and the weight is very different from that used to program the weight-based Heparin initially. What do I do?

Once weight-based Heparin orders are received from the physician who selected the patient weight, follow weight selected on the orders. The PTT results will drive the Heparin rate adjustments accordingly. Note: Remember there are times when the physician may select a weight that is different from the patient’s actual weight.

What about the Med Infusion Time Out and Heparin? When are the Med Infusion Time Outs done?

1. On all initial pump set-ups for continuous med infusions in DOSE Mode

• Change from Heparin non-weight based to weight-based Heparin (ACS/Low or VTE/PE)… A Med Infusion Time Out is needed because this is an “initial pump set-up” (i.e. nurse needs to change from one drug name to another drug name in the drug library and re-program the pump)

• Change from weight-based Heparin (ACS/Low or VTE/PE) to Heparin non-weight based… A Med Infusion Time Out is needed because this is an “initial pump set-up” (i.e. nurse needs to change from one drug name to another drug name in the drug library and re-program the pump)

• Change from Heparin ACS/Low to Heparin VTE/PE or from Heparin VTE/PE to Heparin ACS/Low… A Med Infusion Time Out is needed because this is an “initial pump set-up” (i.e. nurse needs to change from one drug name to another drug name in the drug library and re-program the pump)

2. Upon receiving a patient with a new medication infusion started in a procedural area (e.g. OR, IR, etc.)

• Patient comes from Cath Lab on Heparin drip started in the Cath Lab (unit does the Med Infusion Time Out)

3. With a change in drug concentration

• Not likely with Heparin

4. With a physical change of pump (i.e. current pump is replaced with new pump)

PRACTICE REMINDERS – FAQs, ANSWERS, & CLARIFICATIONS

So what about PCA & Epidural pumps? Why are we continuing with frequent checks?

Due to the high risk and low volume of PCA & Epidural pumps, the frequency of PCA & Epidural Time Outs will continue.

There is a column for two sets of initials on the Anticoagulation Administration Record, why?

The Anticoagulation Administration Record is not used to document the Med Infusion Time Out. The column for initials is used only to place the initials of the nurse entering the data on the record. Note: The “double” initials column will be changed to a “single” initials column with the next form revision.

What do I need to remember about peripheral IVs started in the field?

IV sites initiated pre-hospital by paramedics in the field must be changed as soon as the patient’s condition stabilizes or within 24 hours. The ED staff will affix a “pre-hospital IV” sticker noting the date/time initiated on the dressing of all pre-hospital IVs.

If a peripheral IV is started in the Emergency Department, does it need to be changed within 24 hours too?

No.

What about IV sites started in another facility?

Patients transferred from other health care facilities are not required to have their IV access changed if: the patient’s medical record reflects that the IV site was started within 96 hours of transfer, and the IV site assessment indicates no complications, and the equipment can be immediately adapted to current SLUHN products.

If my patient is performing ADLs, going off the unit for a test or procedure, or performing physical therapy is it OK to disconnect a continuous IV infusion temporarily to perform this task?

No, any disconnection is an infection risk and an interruption in ordered IV therapy.

Is it OK to stop a continuous IV infusion when my patient is going to MRI?

Options for this situation include: obtain a physician’s order to stop the infusion during

the MRI or use the Medrad infusion pump (MRI compatible). Remember, when there is

a physical change in pump (i.e. change to Medrad) a Med Infusion Time Out is

needed.

What needs to be labeled?

All IV infusion bags (including flush bags), all tubing, and all IV sites need to be labeled with the date and time of initiation as well as the nurse’s initials. The TIME is what alerts the nurse to the exact time the bag, tubing, or site needs to be changed. Date, time, and initials must be on the labels even if there is not a designated space to put this information.

What about IV med compatibilities?

Nurses should check current approved references including MicroMedex and Gahart. However, nurses should call pharmacy for any clarifications and especially if there is any doubt. If there is any question of incompatibility (i.e. “conflicting data”) IV meds should be deemed incompatible. 

We lost our access to Micromedex or our shortcut to Micromedex does not work, what should I do?

A new shortcut may need to be created ⋄ delete old shortcut then go into Micromedex through MyNet under the Learning tab.  Once there select Micromedex 2.0, highlight the address and right click on the website page itself (above the search box area), select “create shortcut”.   Micromedex shortcut will appear on the EAD screen. Remember, Micromedex can be accessed directly through MyNET under the Learning tab. 

What do I need to remember about restarting an IV site?

All new tubing and attachments (i.e. J-Loop/extension) need to be used when restarting an IV site.

Do I need a new IV bag when I restart an IV site?

Although it would be ideal to have a new IV bag (along with the new tubing and attachments) if it is not feasible or practical to obtain a new IV bag, it is acceptable to

re-spike the current IV bag.

What do I need to remember about flushing after intermittent (secondary, piggyback) medication on primary tubing?

• The IV NSS flush bag is spiked after medication infusion is complete.

• The RN infuses 40mL of NSS flush at the same rate as the intermittent infusion to clear medication from tubing. Note: This volume covers various tubing lengths used at SLUHN.

• For patients with saline locks, after medication administration and flush conclude, tubing can be disconnected allowing patient to mobilize freely. (**see below)

• After flushing the primary tubing with NSS, different or multiple meds can be infused via the same primary tubing.

Is there a need to flush the secondary (short, above the pump) tubing when infusing an intermittent medication piggybacked into a continuous primary infusion?

No, the volume left in secondary (short) tubing is not considered significant.

What do I need to remember about any tubing used in an intermittent fashion?

• ** Tubing used in an intermittent fashion (i.e. intermittent disconnection from site/port or intermittent disconnection from primary tubing) is changed every 24 hours.

• Need to label the tubing used in an intermittent fashion with a 24 hour (pink) tubing label. Be sure to note the date and time on the label.

What do I need to remember about “back flushing”?

• When back-flushing is done, only one secondary tubing set is needed for all piggyback solutions compatible with the primary IV solution which are delivered in a 96 hour period. The secondary tubing set can be used for up to 96 hours however needs to be changed when the primary tubing is changed. Remember, the secondary tubing set is not disconnected from the primary tubing.

• Back-flushing is not performed with any primary IV solution containing electrolytes or medicated drips. For example, “Lactated Ringers” and “D5 ½ + 20mEq KCL” cannot be used to back-flush a secondary tubing set.

• Primary IV solutions which can be used to back-flush are any plain saline and/or 5% dextrose combinations including the following: (NS = normal saline; D5W = 5% dextrose in water) – NS, D5W NS, D5W, D5W ¼ NS, ½ NS, D5W ½ NS.

• References on back-flushing: Process described on B.Braun Secondary IV Set package; “Setting up an automatic intravenous ‘piggyback’ procedure” guidelines found in Lippincott.

I need to administer Vancomycin 250 mg over 90 minutes… The concentrations in the drug library do not allow me to easily program this med administration in Dose Mode. What do I do?

Currently, the best option for this is to not use DOSE Mode for this infusion because this concentration of Vancomycin is not in the drug library.

How long do I need to prep the skin prior to an IV start and what is the dry time?

With our current chlorhexidine product, swab skin 15 seconds using repeated back and forth strokes and allow a 30 second dry time.  If you forget this important information, it is found on the Prevantics Swab packet.

If my patient’s IV infiltrates during a blood transfusion, do I need to get/use new tubing when starting a new site to finish the transfusion?

Blood tubing can be used for up to 4 hours. The same blood tubing can be used as long as no obvious contraindications or contamination is evident.

If I have a continuous IV infusion of NSS and I give a PRN IV push medication, is it necessary to follow the IV push med with a NSS flush with a syringe?

No.

If I follow an intermittent infusion with a NSS infusion (flush), do I need to follow with a NSS flush with a syringe?

No.

I have heard that all patients who are “full codes” are required to have IV access, is this true?

No, this is not written into any policy. Remember, a physician order is needed for an IV. The following is directly from our policy:

A peripheral IV is initiated upon physician’s order. Exceptions exist including the following:

1. Existing order for IV fluid(s)

2. Existing order for IV medication(s)

3. Emergency situations

The only IV order my patient has is for PRN IV Zofran… Should I start an IV saline lock right away or should I only start the IV saline lock if my patient needs the Zofran?

If a patient has an order for an IV med, PRN or not, an IV access needs to be available and typically should be started right away.

What do I do if my patient wants to take a shower and he/she has a saline lock? …a continuous IV infusing?

IVs should not be discontinued or disconnected in order to shower. Therefore, cover the IV site with available glove/sleeve and secure in place while the patient showers.

Can I draw blood/labs off the peripheral IV?

Currently, it is acceptable practice to draw blood with the first/initial stick only.

Is it OK to leave the tourniquet in the patient’s room in case I need it again for the same patient?

No, best practice is to discard the tourniquet after each use. Remember, tourniquets are single patient use and should never be placed in the IV tote after use or used on another patient.

If I have a patient with a Dopamine infiltration (extravasation), who administers the antidote, Regitine?

Often the physician will administer the antidote when an extravasation occurs. A nurse is permitted to administer an antidote provided he/she has received complete orders and is familiar with the administration technique. Please be sure to discuss antidote administration with the physician, pharmacy, your manager, and/or the hospital supervisor if you have any concerns or questions.

SEPTEMBER, 2013

Nursing Policy & Procedure Manual:

IV Therapy, Administration of Solutions and Medications [D-18]

IV, Peripheral – Insertion, Care, and Maintenance [D-19]

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Thank you for your participation in the IV Therapy Policy Changes & Highlights – 2013 education.

Be proud of the job you do!

The best safety device is a safe worker.

Don’t forget your Med Infusion Time Out!

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