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lsnjrj.3
flushing protocol post infusion at ambulatory infusion clinics

I am looking for more information on standards of practice regarding flushing after IV infusions are administered in an ambulatory infusion clinic. I know that some medications have manufacturer recommended flushes over a certain time period. We are in the process of developing medication guidelines and have noticed a discrepency in practice amongst the departments within our health system. Being new to the department I would like to develop standardization in post infusion flushing guidelines for the medications that aren't clearly defined by the manufacturer. We are not an oncology infusion department, however we do give some medications that are mabs. Any suggestions would be very much appreciated. 

lynncrni
The national standard of

The national standard of practice is established by the Infusion Nurses Society. A new document has been revised and is expected to be mailed out sometime during the month of January. The section on Flushing and Locking has been greatly expanded with more than 60 references to support the statements made. The contents of this document apply to all infusion therapy performed in all situations, so AIC would be included. I can not recall specific drugs that have special flushing recommendations other than those that are not compatibile with saline and require use of dextrose in water for flushing. The flushing and locking for most meds will not be defined by the drug manufacturer, so I am a little confused on what you are referring to. Maybe you can add more information or some examples. However, this set of standards is what you will be held accountable to, along with all of your facility. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

lsnjrj.3
Sorry if this was confusing.

Sorry if this was confusing. In our Ambulatory clinic we do administer Tysabri and will be starting to give Actemra. Actemra does require a post infusion of 0.9% sodium chloride over 30 minutes. Tysabri requires a 20 ml "tubing line" flush with no time requirement. Our department has evolved this to mean that all medications need a 50-100 ml "flush" bag of saline to be hung to use as the flush after the medication is infused. This has even further evolved to be "this patient is dry today and could use some hydration." They then give "a little extra" flush from the bag. This is clearly in my opinion a violation in scope of practice and would require a doctor's order. We are trying to determine if first of all the "flush" of the tubing is a common practice in any other clinic. And 2 if we can go ahead and remove this practice completely unless it is specifically a requirement of the drug manufacturer. Otherwise, we would have to create order sets that the doctors would have to check off what they want. Or have the nurse call the doctor each time to receive a new order to hang a "flush" bag as they call it. We are trying to seperate factual, evidence based practice, from "this is how we do it" mentality.

lynncrni
OK, I get it now. Sorry if I

OK, I get it now. Sorry if I was just a little slow. These flushes of larger volumes are just for the specific drugs that require this in their instructions and definitely does not apply to all drugs. I do not understand the need for 50-100 ml flush before these specific meds. The book Intravenous Medications does not include a flush of 50-100 ml volume before infusing Tysabri. It simply states Flushed with normal saline before and after infusion without any specific volume listed. The other drug is not in the most recent edition of this book yet. Regardless of what the specific meds recommend, you would still need to do the SASH method. S-Saline, A-administer the med, S-Saline, H-Heparin. The first saline is to flush out the locking solution from the previous dose and to assess the patency of the catheter by obtaining a blood return and checking for resistance. So this would require a saline-filled syringe. The 2nd saline is to remove all remaining drug from the lumen and to prevent contact with the heparin which is the final locking solution. Any volume of fluid other than the 5 to 10 mls of saline flush from a syringe is extra but does not replace these manual assessment flushes. I totally agree with you that the patient's hydration status should not be addressed by these flushes and would definitely require a physician order. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Amy
I am unaware of a 20ml

I am unaware of a 20ml "tubing" flush after administration of Tysabri.  My patient's that come in for Tysabri administration are peripheral IV sticks.  They are flushed per INS standards.  There are no specific post flushing instructions for Tysabri that I have found.  Also, I have researched the 30 minute post Sod. Chloride infusion for Actemra and am curious where you read this information.  I can't locate any info regarding this.  Are these policies that are set forth by your institution?  Thanks -Amy

Amy Tilghman,RN Vital Care

lsnjrj.3
Thank you both for your

Thank you both for your input. As for the Tysabri, the information regarding the 20 mL normal saline line flush came from an article that was in the International Journal of MS Care spring 2007 Vol9, Number1. As for the Actemra, I am still trying to figure out if this is a requirement of the company or just something that our department created. Like I said before, they are doing this type of "flush" for all of their patients. They want them to "get every drop" of medication. I am trying to change this practice since I have never seen it done. Unfortunately, I have to gather as much proof before bringing it to them. We currently do not have policies on this. I am working to create medication infusion guidelines. They wanted me to include a "flush" perameter.... I want to just get rid of it completely and say to flush with 3-5 ml of NS (unless there is a specific manufacturer recommendation). I really appreciate your feedback!

pumelee
Test Tube Baby

The first IVF baby was Louise Brown, born at 11:47 p.m. on July 25, 1978 at Oldham General Hospital, Oldham, England through a planned caesarean section. She weighed 5 pounds, 12 ounces (2.608 kg) at birth. Dr. Patrick Steptoe, a gynecologist at Oldham General Hospital, and Dr. Robert Edwards, a physiologist at Cambridge University, had been actively working on finding an alternative solution for conception since 1966.Test Tube Baby

Dawn1
We administer alot of

We administer alot of biologics in our ambulatory center. A bag of normal saline is often infusing (40ml/hour) along with the medication and 30 minutes post infusion. Primarily to maintain IV access in case of adverse reaction.

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