I had a conversation with an experienced access nurse about lines placed in extended care facilities that wanted me to work for him prn. His practice primarily consists of PIVs and midlines with the occasional PICC placement. He reported to me that an estimated 95% of the infusions are vancomycin. I have the CRNI and VA-BC certifications and I told him that both of these organizations support the appropriate device for the prescribed therapy. I explained a midline placed for week of vancomycin is an inappropriate use of this device. He made some shocking statements to me. "This is long tern care and nobody is going to pay for a PICC when they can use a midline." "The pharmacies who provide the nursing support make the decision about what access device to use and is lible for any negative outcomes." "This pharmacy does not allow the nurse to review the MAR prior to placing the line" "I've been doing this a long time and never see something bad happen from infusion vanco through a midline"
I feel like I would be exposing myself to a lawsuit by placing this line for this purpose related to the fact that I have the CRNI and VA-BC certifications. I do carry independent libility insurance and I feel that also make me a payor source for a negative outcome. Thoughts?
Can someone help me here? This goes against everything I have been taught through my pursuit of the above certifications. Anyone in long term care that can tell me about a lawsuit from vanco through a midline I would appreciate. Any data that any one has to support this I would like someone to share this with me.
Matt Gibson RN, CRNI, VA-BC
So many red flags. My short reply.... (many more issues are seen here)
1 As placing a line is a nursing, not a pharmacy duty, why would the pharmacy have the liability...Not likely in any scenario I can think of. 2 As a nurse it is your duty to check for a valid order to provide care.
3 Practicing in opposition to the standards without a specific reason would bring the liability to you.
This is really concerning. Hold on to your practice values.
Ann Zonderman, BSN, JD, CRNI
Ann's comments are right on the money. No other professional (e.g., pharmacists, physician) or other agency (e.g., hospital, pharmacy, etc) can assume the liability for a nurse. Nurses have an individual license so we can and are named in lawsuits continually. Financial reimbursesment for the type of catheter should have no bearing on the clinical decision about the most appropriate catheter based on the patient and therapy needs. The prevailing fact is that the vesicant nature and pH of Vancomycin prohibitis the use of a midline for this drug. This will always be the nurses judgment, not that of the pharmacist or pharmacy. Any facility that does not allow the nurse to have full knowledge of all patient information such as access to the MAR is not someplace that I would be working. It is totally ridiculous to think that the nurse can make the most appropriate decision without access to the medication information. Stick to the evidence-based practice that you know and run from this person who is going to put you at great legal risk if you do insert these lines in their nursing homes. 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
The previous responses have provided excellent reasons to seriously consider the impact of a decision to deviate from the standard of practice. One only needs to look to the 2011 Infusion Standards of Practice, page S37 in the section discussing 'Vascular Access Device Selection and Placement' 32-II-B to find the answer to your question. "Therapies not appropriate for midline catheters include continuous vesicant therapy, parenteral nutrition, infusates with a pH less than 5 or greater than 9, and infusates with an osmolality greater than 600 mOsm/L" Although rated a V on the scale for strength of the Body of Evidence, "this includes a standard of practice that is generally accepted..."
The latin phrase of 'primum non nocere' may historically be related to the medical profession that encompasses physicians, but it most certainly applies to all healthcare professionals who have been entrusted to deliver a standard of care to their patients in any setting and any specialty. Even beyond the discussion of standard of care, this is an ethical debate at its very core. Just because there are those who will find excuses and reasons to bend the moral and ethical delivery of care standards does not mean we must accept their reasoning and defensively respond to what we know to be right and true.
Andrea K. Owens, RN, BSN, CRNI, VA-BC
Chief Operations Officer
President, IC-INS 2011
Vascular Access Specialists
4950 Stop 11 Rd., Suite F
Indianapolis, IN 46237
Toll Free: 866.520.PICC
Local: 317.888.0303
Fax: 317.888.0300