Our PI committee is working on developing a Nurse Driven protocol for placing orders for the insertion/maintenance of peripheral IV access. The order set needs to cover maintaining peripheral IV access based on when there are IV medications or solutions ordered, patient acuity, telemetry monitoring, and so on. Does anyone already have a protocol that they could share? Any feedback is appreciated.
Colleen M. Cavallo, RN, VA-BC
I am not quite sure what you are asking. In all the hospitals where I have ever worked, an order for any type of infusion therapy was all that was required for insertion of a peripheral catheter. Are you mainly asking about the new standard stating that a PIV should be changed when clinically indicated rather than a set number of hours. That would be simple - any sign, symptom, patient complaint is a clinical indication to take it out. When the PIV is no longer essential for patient care, it must be taken out. So maybe I don't understand your question and what you are trying to do. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I was always under that impression also, Lynn. Our autonomy as nurses, and scope of practice emcompass that nursing judgement alone should dictate when patients need IV access. Apparantly, we need a doctor's order in place to actually insert and maintain the catheter. We need to develop a protocol to have an order set stating to place/maintain IV access based on parameters (i.e. IV medications necessary, seizure precautions, telemetry monitoring, level of care, and so on). Even if these parameters are clearly an indication, without a protocol in place nurses cannot place orders to keep the site in. This is what I'm hoping to get some advice on. Seems like it should be simple, but I'm finding quickly that these processes always become quite complicated to cover all of the bases.
Colleen M. Cavallo, RN, VA-BC
Interesting! Could you tell us the source of this mandate? Inside your facility or outside? From a legal problem or other cause? Cost pressures? On the surface it could seem like another attempt to restrict nursing practice. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Interesting! Could you tell us the source of this mandate? Inside your facility or outside? From a legal problem or other cause? Cost pressures? On the surface it could seem like another attempt to restrict nursing practice. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
The issue originates from a DOH mandate that requires a doctor's order for the procedure. That is what our PI people are telling me.
Colleen M. Cavallo, RN, VA-BC
Your state Department of Health? What state are you in? I would wat to see this in a written document and not someone's interpretation for a document. Call me suspicious, but a document could be interpreted differently by different people. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I am in Pennsylvania. I have not seen the actual document. I will ask for it, though. I'll let you know what I find.
Colleen M. Cavallo, RN, VA-BC
I have finally tracked down the answer. The source of the mandate is not DOH, but it is written in the Pennsylvania Code under the State Board of Nursing under Subchapter A: Registered Nurses section 21.12. I am copying in a link so that you can read it if you like. The section on Venipuncture/intravenous fluids reads:
Performing of venipuncture and administering and withdrawing intravenous fluids are functions regulated by this section, and these functions may not be performed unless:
(1) The procedure has been ordered in writing for the patient by a licensed doctor of the healing arts.
(2) The registered nurse who performs venipunctures has had instruction and supervised practice in performing venipunctures.
(3) The registered nurse who administers parenteral fluids, drugs or blood has had instruction and supervised practice in administering parenteral fluids, blood or medications into the vein.
(4) A list of medications which may be administered by the registered nurse is established and maintained by a committee of physicians, pharmacists and nurses from the employing agency or the agency within whose jurisdiction the procedure is being performed if no employing agency is involved.
(5) The intravenous fluid or medication to be administered is the fluid or medication specified in the written order.
(6) The blood is identified as the blood ordered for the patient.
(7) An accurate record is made concerning the following:
(i) The time of the injection.
(ii) The medication or fluid injected.
(iii) The amount of medication or fluid injected.
(iv) Reactions to the fluid.
Here is the link:
http://www.pacode.com/secure/data/049/chapter21/chap21toc.html#21.2.
I would like to know what you think, Lynn. Is this a threat to nursing autonomy?
Colleen M. Cavallo, RN, VA-BC
I think it is an antiquated rule to begin with. "Licensed doctor nof the healing arts"? Does this include NPs and PAs? What is meant by "the procedure"? This could be interpreted to mean that the prescription for fluids and medications, volume and rate and doses have been written. Or it could mean that this doctor has to write simply "perform venipuncture" or it could mean that the order must include exact site, size of catheter, skin preparation, use of gloves, type of securement and dressing, etc. Is the same required for obtaining blood samples by venipuncture? The recording in #7 is badly inadequate according to the INS standards for document and says nothing about the size catheter, location, number of attempts, etc. I would have to bring all of these issues to the Board for clarification and refinement of these statements, along with educating them about the standards. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
It was my understanding that if a patient has IV meds ordered, vascular access was required. Nothing ordered, no access required. That's just about as straighforward as it gets!
There are those nursing tales (on tele floors especially) such as "if the patient meets criteria to be on this floor there has to be an IV at all times". I've searched for such policies and have never seen one. An unstable patient probably has IV meds ordered but if not, why have an IV in place? I couldn't even count the times I've gone to a code, the patient has a dwelling nonfunctioning IV.
The "just in case" IV is a huge pet peeve for me so I'm gonna sit on my hands and see what others have to say.
I was always of the same understanding, Jill. If the route is IV, then in est the IV has been ordered...or so I thought. Evidently, DOH says otherwise, according to our PI group. That goes for intermittent and continuous infusions. There must be an order in place to place and maintain the IV site.
As far as keeping the "just in case" sites...my stance is in the middle of the road. I agree 100% that if a patient has been stable, not received any IV medications and has no other indication than having a tele monitor in place, there is no justification for an IV. However, I have also had my share of patients take a rapid unforseen turn for the worse and end up coding so I see how the risk for developing IV complications outweighs the benefit of not having one.
Colleen M. Cavallo, RN, VA-BC
We all know my opinion as I brought this topic up over a year ago
Sue Mosoorli a legal consultant always indicated that IV meds are not enough to constitute an IV VAD placement. You need a legally written order for type of device for fluids to be administerd. Initiate a vascular access device could be one way to say it as all patients do not consitute PIV usage. As INS now states PIV's can be left in for longer dwell time we will see the necessity of this statement for an actual VAD order set
I agree with the Pennsylvania board
Kathy Kokotis RN BS MBA
Bard Access System
In our Emergency Dept (ED) we use Cerner as our framework for CPOE. To increase efficiency of orders, practitioners have "order sets" that allow them to select a specific work-up. An example of this would be:
ED Abdominal Pain Order Set - now within the actual order set there are pre-selected orders so that the practioner does not have to input each individual order. The practioner can now select or deselect specific orders from the set (i.e common blood work, radiology, nursing orders, and common therapies associated with order set condition). The issue with the CPOE order set is that many practioners forget to un-check the PIV order knowing that there is a high probability the patient may not warrant any therapies via PIV. After thorough assessment of the patient, the nurse usually confirms if the PIV is truly warranted for this particular patient.
As for a specific protocol for placing orders, we generally having a standing order in the ED, based on acuity and clinical presentation. There is no true protocol or decision tree that guides both practioners and nurses on whether the patient warrants PIV.
In an attempt to obtain data on how many PIVs go unused throughout the duration of an ED admission, I have devised a survey that is in the process of being approved. The survey looks like this:
Emergency Department Short Peripheral IV Survey
General Patient Information
1) Patient FIN#__________________________
2) What is the patients acuity level upon admission to emergency department? (Based on ESI scale)
• 1 Emergent • 2 Highly Urgent • 3 Urgent • 4 Non-Urgent • 5 Express
3) What is the patients age?
• Newborn (28 days to 23 Months Old) • Child (2 to 11 Yrs.)
• Adolescent (12 to 21 Yrs.) • Young Adult / Adult (21 to 44 Yrs.) • Middle Adult (>45 to • Older Adult (> 65 Yrs.)
4) Is this patient here for a possible peripheral IV site complication?
• No •Yes
General Treatment Information
5) Was an IV established prior to arrival in the emergency department?
• No • Yes
6) Was a IV ordered on this patient in the emergency department?
• No • Yes
7) Did the patient receive fluids, medications, and/or any other therapy through their IV. (Blood work excluded)
• No • Yes, patient required _____________________________________________________________
Patient Disposition Status
9) What was the patients’ final disposition in the Emergency Department?
• Discharged to Home / Facility
• Observation / Admitted
• Transfer to higher level of care