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lamarchm1
Secondary bag for antibiotic infusion vs primary bag for antibiotic infusion

Hi there- We recently moved to Pyxis on our outpatient unit. Our practice has been to hang a 50ml bag of NS on primary tubing with antibiotics hung on secondary tubing and ran via a pump. These 50ml bags came from floor stock prior to Pyxis but are now being charged out via Pyxis to the patient. Insurance companies are denying the 50ml NS bag charge. I am looking for what is best practice and where do I find documentation. We can change our practice to hanging antibiotics on primary tubing and flushing post with a syringe but I want to make sure we are not changing to this practice just because insurance companies are not reimbursing us.

Thanks in advance for your input.

Margo

valoriedunn
So the patients were not

So the patients were not getting charged for the 50ML bag of NS prior to the Pyxis?  Not that that is the issue here, I was just curious.  I have been in home infusion for 3 years now and we have taught our pts. to infuse only the antibiotic via electronic pump, dial-a-flo tubing or from a home pump.  They are taught to flush well before and after infusing.  I do not see why out patient would be any different but I have no documentation as to best practice for this.  Just something to get you started.  Antibiotic only sure would help save the pt if insurance is not paying for the NS.

Valorie Dunn, RN, BSN

Valorie Dunn,BSN, RN, CRNI, PLNC

lamarchm1
The charge for the NS was

The charge for the NS was coming from the floor stock prior to Pyxis. In other words the unit was absorbing the charge and was not getting passed on to the patient. Interesting is that student nurses here are trained to always have a primary set-up and run the med via secondary but the schools do not have "best practice" info on this. I appreciate the info.

Thanks

Margo

ncosta
Unfortunately several

Unfortunately several practices have changed or will change due to lack of insurance reimbursement.

IMHO

Nancy Costa CRNI

Gina Ward
  I am not familiar with this

 

I am not familiar with this process.  I know you are talking charge issues , but I am wondering why clinically you do something like this?

Is it to have a closed system and only change the secondary bag when new dose in place, and decrease the access and reaccessing of the hub? 

Please fiill me in on this process.

thanks,  Gina Ward, R.N., CPAN

 

Gina Ward R.N., VA-BC

Nina Elledge
Payors typically won't

Payors typically won't reimburse for saline flushing with an IV medication no matter how it is administered....i.e. either by syringe flush, minibag flush, or primary tubing flush because it's considered part of that specific medication's therapy. What we do in our Colorado outpatient infusion ctr is hang iv meds on primary line, flush after with 30ml of a 50ml NS bag (to get med from tubing into pt).

The only time we are charging for saline infusion is if we are doing it to treat a condition e.g. dehydration or part of a chemo protocol. That is because we can get paid for that...

This process also allows us to use as few medical supplies as possible, because we only use 1 tubing (supplies to administer meds are considered part of the iv medication charge & aren't billed separately either).

In terms of evidence-based or best practice standards, there really aren't any addressing saline flushing in a specific way, just that it should be done to clear tubing/line.

Does that make sense?

Nina Ellege RN, CRNI, MBA
Fort Collins, CO

 

 

Nina Elledge, RN, MBA, CRNI

[email protected]

lynncrni
You would be changing your

You would be changing your practice back to what has been the tried and true long standing approach used by infusion therapy teams for years. In the 1970's we gave IV meds by manual push from a syringe including ABX. Then we switched to a small volume piggyback system when the patient had primary fluids infusing. But when those continuous fluids are no longer needed, I have always hung the small volume med directly to the catheter and infused it without a pump, without any carrier fluids, without any infusion of fluids to flush the remaining med from the tubing, etc. That is the way it has been successfully done for many, many years. I see no reason to do it differently for most drugs. There are certain meds where you will need to be able to assess the quality of the flow by gravity such as chemotherapy drugs. The quality of the flow will provide information about the catheter and vein patency and the possibility of infiltration/extravasation but you can not make this assessment on a pump. But this is the only time you need these additional fluids. ABX do not need to be regulated on an electronic infusion pump. Many of these drugs are given by IV push in home care or by gravity infusion without such pumps. The risk profile of these antibiotics does not require such accurate control as an infusion pump. It is the excessive pump tubing that requires the carrier fluids to flush the med from the tubing. With the length of tubing that extends from the bag directly to the catheter, the volume left in this tubing is minimal, probably about equal to the overfil in the bag originally. That is the method I have used for years. It is cheap and easy. There is one downside. It does require the nurse to return immediately when infused to disconnect and manually flush with a saline syringe. If you delay this flush, blood will reflux and add to occlusion problems over time. There are 2 methods to address this from a technology viewpoint. You can use a catheter with the PASV- pressure activated safety valve from Navilyst or add the Nexus TKO needleless connector to any catheter. Both of these products have a pressure sensitive internal valve. When the column of fluid in the tubing runs down to about 8-10 inches, the valve automatically closes preventing blood reflux. All other needleless connectors remain open conduits until the physical disconnection of the tubing or syringe. 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

James Merritt
Lynn, I went way back on this

Lynn,

I went way back on this one, and I must disagree with you here. As it may have been practice early on to deliever antibotics as a primary, best practice and the INS would insist that today best practice would be to infuse using a NS as a primary line and piggyback the medication off of the primary line. This practice would ensure two things, one that the patient will recieve all of the medication prescribed for him/her, and 2) when the infusion is done will prevent air from getting to the patient (if using a pump), and will engage the primary to start(at a KVO rate) once the secondary bag is done ensuring a flush of the site as well.

James C. Merritt Jr. RN, BSN, MBA
Sr. Medical Device Specialist
Global Clinical R&D
Hospira, Inc.
275 N Fields Dr.
Lake Forest, Il 60045
224 212-6123 Wrk
773 910-2281 Cell

lynncrni
Sorry but I disagree. First,

Sorry but I disagree. First, I have never seen INS publish anything about this in the form of a position paper and I know it is not included in the Standards of Practice. I am sure there are portions of the new textbook that I have not read, but I would ask that you be much more specific when you state that "INS insists---". Piggybacking into a carrier of saline is common practice in many hospitals, but I still say it is done more for nursing conveneince than for any specific patient need. There will always be a small amount of medication left in the piggyback set so your statement about this allowing for complete infusion of the med is not correct. Use of infusion pumps is also common for intermittent meds, but again, this is for nursing convenience and a pump is simply not mandatory for infusion of most piggybacked meds such as antibiotics or GI drugs. Air emboli is not likely with a straight IV tubing connected to a catheter. Once the infusion pressure is gone, venous pressure causes blood to reflux into the catheter. So the greatest risk is an occluded lumen, not air embolism. Are you suggesting that this carrier fluid should remain connected at a so-called KVO rate and should not be disconnected at all? If so, I strongly disagree with that practice. First, we do not have a specific rate established that will keep any vein open. See 2006 Infusion Nursing Standards of Practice. The patient may not need these fluids and it could cause fluid overload in some patients and never disconnecting from this fluid container, tubing, and pump will prevent the patient from adequate ambulation that will allow them to be discharged faster. So not a good idea at all. The only thing this carrier fluid does is to allow more time for the nurse to return and disconnect and flush properly. I would agree that in ICUs when many intermittent meds are giving, this carrier fluid makes sense as it reduces excessive manipulation of the administration sets and thus reduces risk for BSI. 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

janicer
Secondary Bag for IV infusion

It also depends what your policy is.  Our policy states that all medication will be on an infusion pump except for IV push.  Could you not hang a 250 ml bag instead of the 50 ml (which should be on the floor and avoid the patient charge).  Having multiple patients getting back to the IV just in time when it ends is difficult (to flush).  Also having an IV site which is positional means the medication could stop infusing without alarming (believe me, I remember the days when we did gravity drips and not happily).  Lastly, is it necessary for the 50 ml bags to be in the Pyxis.  We have them available to mix 8 mg Zofran, 50 mg Benadryl and a couple of other PRN medications without charge.

Interestingly we used to charge for almost everything but over 10 years ago quit doing that (I believe it is under $5.00 an item but not really sure) and it dit did not effect the bottom line.

Craig R
I would have to agree with

I would have to agree with Nina's comment.

If the patient did not have maintenance fluids running, just hang the antibiotic in a 50ml "mini-bag" and after it is completed run another plain 50ml bag of N/S to flush the line (the "chaser").  Arguably if you have a port high enough (i.e. close to the drip chamber) you could flush the line with 20ml of saline via a syringe.

While there is arguably some "over-fill" of IV bags, in this case part of the dose is now mixed in with this "over-fill" - so it is important to flush it through.  This is obviously even more important in patients receiving smaller/reduced doses (ie. pediatrics or renal patients) - but the complete dose needs to be flushed through for all patients.

Whether or not it comes from floor stock prior to Pyxis or not reimbursed when taken from Pyxis - the hospital absorbs the cost.  Regardless, you still need to flush the lines.

 

Craig R, RN BSN

James Merritt
Safety and Convience maybe best for our busy RN

Lynn Wrote: The only thing this carrier fluid does is to allow more time for the nurse to return and disconnect and flush properly. I would agree that in ICUs when many intermittent meds are giving, this carrier fluid makes sense as it reduces excessive manipulation of the administration sets and thus reduces risk for BSI.

Lynn you agree that the use of a carrier NS solution during piggyback administration is safer and most convient for our nurses (considering the increased patient acuity, and nurse to patient ratio's). In the issue of reimburstment for the hospital, insurance companies should cover especially if the patient is needing the carrier fluid for maintance purposes (dehydration). So the question is in this case, is the insurance company also not covering patients placed on maintance doses, because we definitely would pggiyback and antibotic dose if the patient already has an existing primary maintance line going?

James C. Merritt Jr. RN, BSN, MBA
Sr. Medical Device Specialist
Global Clinical R&D
Hospira, Inc.
275 N Fields Dr.
Lake Forest, Il 60045
224 212-6123 Wrk
773 910-2281 Cell

lynncrni
You are still missing my

You are still missing my point. When there is no need for any type of IV fluids indicated by the clinical needs for the patient. In other words, I would never choose a so-called KVO fluids simply to have a carrier fluid to piggyback into. It is not reimbursement or nurse-patient ratio that dictate this need. It is having the patient tethered to the fluids, tubing and pump when there is no clear clinical indication for it. So it is possible and in my opinion, preferable, to eliminate the carrier fluid when there is no need for these fluid. 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

Laura Dosen
What if you are running

What if you are running Cubacin followed by Invanz.  IS it safe or best practice to run one right after the other throught he same primary line?  The drug which is run second would mix with the remaining drug from the first infusion and then have the part of it remainin in the bag when complete.

lynncrni
You will need to check the

You will need to check the information on drug compatibility between these 2 drugs. Pharmacy has several resources to assist with this. If there is no information available, and that is often the case with newer drugs like these, you should always assume that they are incompatible until you see documentation otherwise. In any backpriming process, the 2 drugs being infused through the same secondary piggyback set would not mix with each other. You would always use fluid from the primary container to backflush all drug from the secondary line into the empty secondary container, then detach and discard this secondary container. After the first drug has infused, you would allow the plain fluid to flow through the line to prevent contact with the second drug. So the only way I can see a problem would be if the drugs being given actually adheres to the plastic, allowing contact to form a precipitate. The other problem with compatibility would be if there are any additives to the primary fluid container. That is why most facilities that do this use a bag of plain saline as the carrier fluid. 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

Gwen Irwin
secondary bag for antibiotic infusion vs. primary bag

I would have to agree with Craig that the dose needs to be flushed from the tubing into the patient.  If the antibiotic is given with the primary tubing, then depending on the fill volume of the tubing used, the patient isn't receiving the full dose.  What if you are giving a 50 ml antibiotic med?  You could leave 5-20 ml in the tubing, depending on the manufacturer of the tubing.  That would definitely affect dose administration.  Do you know the fill volume of the tubing that you are using?  I would want that info before changing practice, Margo.

Whether charged or not, whether via minibag or syringe, flushes must be done.  Reimbursement has to become secondary reason to using flushes.

Gwen Irwin

Austin, Texas

 

James Merritt
Using a Primary line to piggyback Secondary medication is safer.

For those patients that are prescribed a IV antiboitic and are not currently on a IV maintainance therapy, I have many times went ahead and created a primary line with NS set at a KVO rate (30 to 41ml/hr) then piggybacked my antibotic to that primary line. Once the piggyback is done, I would discontinue the KVO line and detach the patient from the maintainance line. This practice ensures the patient recieves the entire dose of the mediciation prescribed and flushed. The nurse may flush the JLoop if they choose too once the patient has been disconnected. Financially, hospitals may have to consume the cost of the NS and the primary line used to delivery the medication if insurance companies are not, the key here is safety for our patients not who is going to pay for this.

James C. Merritt Jr. RN, BSN, MBA
Sr. Medical Device Specialist
Global Clinical R&D
Hospira, Inc.
275 N Fields Dr.
Lake Forest, Il 60045
224 212-6123 Wrk
773 910-2281 Cell

lynncrni
I must be missing something.

I must be missing something. Wouldn't there still be some fluid remaining in the secondary line? Do you always use a pump to infuse this? Is there something about the pump set-up that allows you to flush all fluid from the secondary line? Also, what about a physician's order for that infusion of saline? I know of hospitals that routinely use this set-up for all patients on only intermittent ABX, although the piggyback secondary tubing still has remaining fluid in it when the secondary fluid container is empty. And this is the policy so all nurses are doing the same thing. Consistency is also a major part of patient safety. 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

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