What are your feelings on placing IVs without a doctors order? for example just in case IVs, telemetry IVs, additional line to keep meds on time?
Each time I ask at my workplace about this Im told its in an order set but I can not find it.
I feel uncomfortable establishing sites without an order.
Since you asked for "feelings" - it makes me want to scream. Over and over I hear "if the patient qualifies for telemetry, they have to have an IV at all times". Then, there are no iv meds ordered, so no iv is needed. I've searched the so called "policies" and have yet to find one that states the patient must have an iv. I have seen in physicians standing orders for ICU "two large bore IV sites at all times", but those are outdated standing orders as most of those patients have piccs now.
And! How many times do we show up at a code and the existing iv actually works? In my experience, rarely. Almost every code I have attended has required a new iv start, maybe it's just me but it has been consistent.
another practice that makes my head explode is keeping a questionable iv "just in case we need it".
It is my belief that in this area nurses are working from traditions and opinion rather than evidence based practice.
My sentiments exactly. I want to say if you need it you put it in!!!!!
Cheryl Ferraro RN, CRNI
If a Doctor writes Start vancomycin 500mg/250ml q12 hours IV does this count for an IV order????? Now this is a med order. What if the patient is wearing telemetry? If there is no specefic reason to use the IV dont the doctor have to write Establish and maintain peripheral IV????? per my previous question Doctors orders
Im getting ready to take the higher ups to the table and I want my facts clear. Any procedure Ive checked first step is verify order!!!! I also want to start telling my coworkers I need an order for IVs
thanks
Cheryl
Cheryl Ferraro RN, CRNI
I firmly believe that the assessment for the most appropriate type and location for any vascular access device is the responsibility of the inserter. If this is being done by a staff nurse, they carry the burden of knowing when a peripheral catheter is the most appropirate. If they are not qualified to do that, then they can not meet the standard of care. I do not believe that a doctor or LIP order is required for insertion of a short peiprhal catheter. You have the order for the medication and the decision of what size and where it is placed is a nursing decision. I never want an order that would conflict with my nursing judgement and I can see that happening if an order is required. The order for the fluid or meds mean that some type of vascular access is required. What, and where is based on a nursing assessment. If a midline or PICC or other CVAD is the best, an order should be obtained. 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
Hi Lynn
I agree that I should be the one to determine what size , what site etc but Im concerned that the liability if there is no order from a provider that says to establish and maintain peripheral IV, or insert IV, especailly for saline locks that may not be used. My worksite is slowly doing away with our IV team, Im an CRNI, RN on days, I establish venous access, trouble shoot PICC lines, do site care on picc and central lines, and our evening and night shift has LPNs that mostly do IVs. They have cut out weekend coverage, holiday coverage unless one of the LPNs sign up which is supposed to allow the floor nurses to practice their own IVs. We had an incident in the past where we received a pt that had an 18g in ea AC. We did not document to protect us or get us in trouble but the patient died somewhere else from septicemia. He was only here for a weekend. Of course I left out many details of this situ but even though an IV is not that big of a deal that is only when you have an expert putting them in. A novice putting in a line could have consequences. The patient could refuse after a number of attempts because it does not feel good to get stuck especially when it doesnt work. I just always thought that I needed an order to do an invasive procedure on a patient as well as their consent. Now Im hearing it is a nurses call. I do understand you to say if the MD writes order for transfusion of meds or drugs that is considered an order for IV insertion. I also see vancomycin given a lot peripherally I dont like putting in a line for them to infuse vanc when I know its best ran through a picc.
Misled in Richmond
Cheryl Ferraro RN, CRNI
I have practiced infusion nursing for 42 years in numerous places. I have never seen a policy that required a separate LIP order for insertion of a short peripheral catheter plus an order for fluids/meds. The fluids and med order implies the need for some type of VAD, a decision made by the person inserting the device. Traditionally we have always begun each patient with a short peripheral catheter, then gone to some other type of VAD if needed. Anyone placing any type of VAD and giving any fluids or meds must have documented competency that they can do this aspect of care. If they are not competent, they should not be doing it. It is that simple, regardless of whether we are talking about an LPN, new or experienced RN, APRN, PA, med tech of some type, etc. The presence of a physician order will not add any benefit because the person doing the procedure will be held accountable for the outcome of their actions regardless of whether there is an order stating to insert a PIV or not. 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
Cheryl,
I work for a company which DOES say that the specifics of the catheter MUST be included in the MD/LIP's orders. Therefore, if a patient has an order for 10 days of IVAB rx, then it should be 'spelled" out what line is needed, ie.. May place peripheral IV catheter and rotate q 96hrs and prn, or May place Midline IV catheter. Our surveyors are looking for a complete order. Therefore, if a patient is getting 3 days of IV hydration therapy, I will have them write an order for "may place peripheral IV catheter, or utilize hypodermoclysis".
As a vascular access clinician, if I have an order for something that is inappropriate for that patient, I will get the floor nurses to call the MD and get a different order. For instance, I've been asked to place a PICC for one liter of IVF. The reason why they have asked for this is because they, (the floor nurses) can't get a line in, and they think then that is there only choice. I will then tell them to obtain an order for a short term peripheral as I will place the line successfully. If all they have on the chart is a PICC order, the surveyors are going to wonder why vascular access put in something different without an MD order.
In another scenerio, I've had nurses ask for a midline for 6 weeks of Vancomycin. Again, I ask them to contact the MD and get an appropriate order for a PICC as this is actually what the patient needs.
Would JACHO come in and pick a pt to follow and say ok show me the orders for his Infusion therapy?
Show me where you document your care.
Where is the insertion note?
How many IVs has he had since he has been here.
How do we know the saline lock is being flushed? (we dont have orders for that either)
How do we know the picc is being flushed and assessed for blood return?
Last inspection they asked to show maintenance on a picc. It was hard to find because it was hidden in a nurses note. Now we have a IV care note and an Vascular access note.
CF
Cheryl Ferraro RN, CRNI
All I am saying is that in hospitals, I have never seen a policy for, or the practice of requiring the LIP to write a separate order for "PIV catheter" or short peripheral catheter or any variation of that. If there is an order for fluids or meds IV, then that is what is put in without the separate order. Home care requirements may be different. In hospitals a PICC does require an LIP order. A midline could go either way depending upon the hospital policy. 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