SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE. SUMMARIZED PROTOCOL FOR THE MANAGEMENT OF INTRAVENOUS THERAPY FOR THE ADULT PATIENT (inv01)

Transcription

1 [ SARASOTA MEMORIAL HOSPITAL TITLE: ISSUED FOR: NURSING PROCEDURE SUMMARIZED PROTOCOL FOR THE MANAGEMENT PATIENT (inv01) Nursing DATE: REVIEWED: PAGES: RESPONSIBILITY: RN, LPN I, LPN II 12/80 3/18 1 of 7 Table of Contents Topic Page Purpose 2 Definitions 2 Knowledge Base 2 Infection Prevention 2 Needleless Connectors 2 Flushing and Heparin 3 Labels 3 Procedure Attaching Administration Set and Needleless Connector Changes 3 Infusion Related Assessment 4 Infusion Regulating Devices Mini-Infuser 4 Dial-A-Flo 4 Electronic Controller 5 IV Pushes 5 Pre-Surgical Patients 5 Documentation 5 References 5 Appendix A Administration Set Guidelines 6 Appendix B Flushing Guidelines 7 Related Procedures Title Management of Vascular Access Complications Parenteral Nutrition Peripheral IV Care, Maintenance, Insertion & DC Implanted Port, Care, Maintenance, Insertion & DC Central Lines Care, Maintenance & DC PICC & Mid Line Care, Maintenance, Insertion & DC Hickman Care & Groshong Care & Maintenance Chemotherapy Extravasation Intraosseous Needles Procedure Number cen05 inv11 inv02 vad01 cen01 pic00 hic01 onc10 inv08

2 TITLE: SUMMARIZED PROTOCOL FOR THE MANAGEMENT Page 2 of 7 PURPOSE: To summarize administration set changes, needleless connector changes, flushing, labeling, and infusion delivery methods for the adult patient. DEFINITIONS: 1. Administration Set: Any tubing or infusion related administration set used to deliver intravenous medications or fluids. 2. Needleless Connector: The device placed on the end (hub) of any intravenous access device used to access the circulation for the delivery of medications or intravenous fluids or is used to lock a catheter used intermittently. 3. Hub: The female section of the vascular access device that the needleless connector is luer locked into. 4. Primary Set: The tubing that is used to deliver the main intravenous fluid. 5. Secondary Set: The tubing that is used to deliver a secondary medication such as antibiotics. 6. Continuous: An infusion that runs uninterrupted 7. Intermittent: An infusion that will be started and stopped at different times. 8. Red Cap: The device used to protect the ends of the administration set when not in use. 9. Curos Cap: The device used to protect and disinfect needleless connectors when not in use. KNOWLEDGE BASE: Infection Prevention: 1. Fluids and IV solution bags will be changed within 96 hours unless the expiration date or time is less than 96 hours. (See Appendix A) 2. Infection prevention entails keeping the system closed and minimizing the amount of accesses and connections. 3. Administration sets and needleless connectors will be changed when vascular access sites are initially inserted, changed or moved. Re-connecting the administration set to a different site is not permitted. 4. All intravenous medications and fluids will be prepared on a surface cleaned with a germicidal wipe. 5. All handling of intravenous medications and fluids will be preceded by hand hygiene. 6. Intravenous medications and fluids will not be administered if contamination is suspected. 7. Administration sets that have touched the floor or are contaminated in any way shall be discarded and a new set obtained. Administration sets suspected of being the source of infection may be cultured 8. The ends of administration sets, not in use, shall be protected with a red cap. 9. All needleless connectors shall be protected with a Curos cap when not in use. Needleless Connectors (refer to Administration Set Guide- Appendix A) 1. Needleless connectors will be changed by the primary nurse (not by the Vascular Access Team) for all vascular access devices including PICC s, Midlines, other central lines and peripheral lines. The Vascular Access Team nurses will be responsible to change the needleless connectors for the extended dwell catheters. 2. Needleless connectors will be changed when the administration set is changed (Sunday, Thursday and PRN) for suspected or actual contamination or with any new site changes (including when the peripheral site is rotated, the administration set should be changed (INS, 2016). Connectors should also be changed when two 10-ml flushes do not clear blood or precipitate using pushpause. (INS 2016 Policies & Procedures pg ).

3 TITLE: SUMMARIZED PROTOCOL FOR THE MANAGEMENT Page 3 of 7 3. If a Curos cap (disinfection cap) is present, remove cap and connect IV line to the connector. If no Curos cap is present, cleaning of the hub shall commence with a vigorous 15 second scrub with alcohol and allowed to air dry before attaching new primed needleless connectors. Flushing (refer to Flush Guide-Appendix B) 1. Any saline flushes drawn up by the nurse will only be used one time for one patient and will then be discarded. 2. When administering incompatible medications, flush with at least 2.5 ml normal saline between the medications. 3. Use only a 10ml syringe or larger when flushing central lines and midlines. 4. Flushing of all lines will require the use of the push-pause technique. 5. When flushing- follow the change rule after blood draws or blood administration change rule: Flush with 10ml of NS twice and if not clear, change the connector. 7. All intermittent infusions through a central line or a midline will be flushed once per shift with saline and then heparin (unless contraindicated) and documented on the emar. 8. Apply Curos cap to any needleless connector not in use. NOTE: CT Techs and Vascular Access Team nurses flush only with normal saline. Labeling 1. Plain solution IVs and those IVs mixed in Pharmacy will have a white label. IV solutions retrieved from the Pyxis Towers will either have a white label affixed to the solution bag or a Pyxis receipt attached. Information on the label will include patient s name and date/time that the bag was hung. 2. White labels will also appear on the syringes issued from pharmacy for the Harvard Mini-Infuser System. Information on the label will include the drug, dose, and expiration date. The pre-filled syringes will be packaged in a labeled bag. The bag label will contain the patient s name, identification number, room number, drug, dose, route (IV, MI), frequency of administration, and expiration date. 3. All IV tubings will have a tubing label indicating day the tubing is to be changed. PROCEDURE: Attaching Administration Set and Needleless Connector Changes 1. Obtain administration set, including extension tubing and add on devices as needed. 2. Perform hand hygiene. 3. Attach the solution bag to the tubing and prime the line. 4. Stop electronic regulator and close the clamps on the existing administration set if relevant. 5. Don gloves. 6. Scrub the needleless connector with vigorous friction for 15 seconds with an alcohol swab and allow to air dry unless the Curos cap is in place. 7. Place an alcohol swab under the catheter hub and loosen the tubing and catheter connection. 8. Disconnect tubing. 9. Remove the previous needleless connector and extension set. 10. Clean the hub with an alcohol swab with friction for 15 seconds and allow to air dry naturally. 11. Attach a new primed needleless connector. 12. Attach the new tubing. 13. Open clamps and resume IV infusion at the ordered rate. 14. Check to see that all of the connections are secure. 15. Protect the IV tubing ends by applying a red cap. 16. Apply Curos cap to all needleless connectors of the new tubing if not in use. 17. Apply tubing label indicating day the tubing is to be changed. 18. Document on the medication record and in the electronic record. On the IV Lines flow sheet, document the needleless connector change.

4 TITLE: SUMMARIZED PROTOCOL FOR THE MANAGEMENT Page 4 of 7 PROCEDURE: Infusion Related Assessment Initial shift assessment will include: 1. Identify patient per SMH Policy Patient Identification: Inpatient/Outpatient (01.PAT.09). 2. Perform hand hygiene and observe standard precautions. 3. Explain procedure to patient. 4. Visualize and palpate the site and the dressing. The site assessment should include skin, tenderness and pain. 5. Confirm that the site is labeled with date of the last dressing change. 6. Verify that the solution ordered is infusing at the correct rate. 7. Confirm the IV tubing is labeled with the day (Sunday or Thursday) for the next IV tubing change. 8. Follow the administration set down to the vascular access site assuring all connections are secure and without compromise. 9. Visualize that all needleless connectors have a Curos cap in place. PROCEDURE: Infusion Regulating Devices Infusion regulators will be used on continuous intravenous infusions. Always check patient allergies and compatibilities of medication and solutions before administering. A. HARVARD Mini-Infuser Pump will be used to deliver controlled intermittent intravenous medications, which are supplied in pre-filled syringes. B. DIAL-A-FLO To use a DIAL-A-FLO, connect it to the end of the IV primary tubing and open clamps on the primary tubing to maximum flow position. Attach the male adapter end of the tubing to the venipuncture device. Dial the desired infusion rate in ml/hour on the DIAL-A-FLO. EXCEPTIONS: (to DIAL-A-FLO use) 1. Intravenous infusions, which by procedure, requires the use of an electronic control regulator. 2. Intravenous infusions for patients in labor and delivery. 3. Intravenous infusions for specific diagnostic procedures (Endoscopy procedures, Radiology procedures, Electrophysiology cases with anesthesia, cardioversion/tee procedures, or cases except those cases with compromised cardiac disease that may be affected by a fluid imbalance such as CHF, triple vessel disease, or valvular problems). 4. Intravenous fluids for pre-operative patients started less than 24 hours prior to the scheduled surgical time. 5. Intravenous infusions ordered for post-operative patients if the physician has specified to discontinue the infusion at a certain time, when awake, when tolerating fluids, or when infused. C. Electronic IV controllers/pumps may be used: 1. When the physician specifies stringent IV fluid regulation based on diagnosis or condition. 2. For parenteral medications requiring close rate control and observation. 3. Patients suffering from congestive heart failure, kidney dysfunction or pulmonary edema D. Electronic IV controllers/pumps must be used for: 1. All central lines: e.g., subclavian, multi-lumen, Hickman, Implanted Ports, PICCs, etc.(exception to this if patient is having a procedure or surgery in perioperative services or procedural areas) 2. Midline catheters.

5 TITLE: SUMMARIZED PROTOCOL FOR THE MANAGEMENT Page 5 of 7 Exception: Platelets may be infused by gravity or hung via an electronic pump for peripheral or central lines. E. IV Medications that must have an electronic controller include, but not limited to, the following: Alcohol drips Heparin infusions Bumex Insulin infusions Investigational drugs Large volume parenteral IV solutions with >40 meq. KCL Pitressin Potassium Flashes Magnesium Flashes Theophylline (for constant infusion) Any other new and/or potentially hazardous drugs NOTE: All of the IV medications listed in Nursing Department Policy , Administration and Nursing Care of Adult Patients on Specific Intravenous Medications must have an electronic controller. PRESURGICAL PATIENTS: (refer to nursing procedure (pso01) Preparation of the Patient for Surgical Operation for pre-operative IV care. DOCUMENTATION: a. All intravenous infusions and IV Pushes are to be documented on the electronic medication record. b. Enter a nursing protocol flush order that includes Normal Saline and Heparin (unless the patient has a heparin allergy) for all central lines including PICC and Midlines and Implanted Ports. c. Document needleless connector changes in the IV Lines flow sheet. d. Enter a nursing protocol flush order for normal saline for peripheral IV lines. REFERENCES: 1. Perry & Potter. (2018). Clinical Nursing Skills and Techniques. 9 th edition. Chapter 29. Elsevier: St. Louis: Mo. 2. Infusion Nurses Society. (2016). Infusion Nursing Standards of Practice. Cambridge, MA: Author. 3. CDC. (2016). Guidelines for the Prevention of Intravascular Catheter Related Bloodstream Infections. Final Issue Review. REVIEWING AUTHOR(S): APPROVAL: Gregory Reisinger, RN, Vascular Access Team Nurse Karen Van der Weert, RN, Vascular Access Team Nurse Mary Moretti, BS, RN, Vascular Access Team Greta Backstrom, RN, Vascular Access Team Clinical Practice Council 3/1/18

6 TITLE: SUMMARIZED PROTOCOL FOR THE MANAGEMENT Page 6 of 7 Appendix A Administration Set Changes (INS 2016 Guidelines) Administration Set Device Infusion Status Frequency of Administration Set & Needleless Connector Change Primary & Secondary Sets Continuous & Intermittent Every time an access site is initially inserted, changed or moved and PRN diminished flow rates due to drug or blood precipitates, damage, and actual or suspected contamination Primary & Secondary Sets Continuous & Intermittent Every Sunday and Thursday, with new catheter placement, and PRN Add on devices including Dial-aflo, filters and all other add on devices Continuous or Intermittent Exception: IV PCA tubing will be changed every 96 hours with the bag changes With each device change or administration set change Type of Infusate Administration Set Frequency of Administration Set & Needleless Connector Change Parenteral Nutrition with or Continuous or Intermittent Every 24 hours without Intravenous Fat Emulsion Propofol Continuous Every 12 hours Vasoactive drugs Continuous Every 96 hours Ativan Continuous Every 96 hours

7 TITLE: SUMMARIZED PROTOCOL FOR THE MANAGEMENT Page 7 of 7 Appendix B Flushing Table Device Normal Saline Amount Before Infusate Normal Saline After Infusate Heparin Concentration and Amount Lab Draws Flushing Frequency with no therapy Peripheral 2.5 ml 2.5 ml None Only during insertion Every shift Midline (in 5ml of 10 (ten) units per ml = 50 units Only during insertion Every shift Extended Dwell Catheters (in None Only during insertion Every shift PICC Triple Lumen or Non-Tunneled including Internal jugular (IJ) and Subclavian Hickman, Broviac, Leonard or other Tunneled (in (in 5 ml of 10 (ten) units per ml = 50 units 5 ml of 10 (ten) units per ml = 50 units Stop infusion for 2 Stop infusion for 2 Every shift Every day Tunneled Groshong (in None Stop infusion for 2 Every day Implanted Ports, Lifeport or Passport to 20 ml 5 ml of 100 (hundred) units per ml = 500 units Stop infusion for 2 Every day