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DENISE123
Multiple IV attempts on patients
I am interested in feedback and other facilities guidelines concerning the number of IV attempts allocated for patients.  This problem has recently escalated and our physicans have a strong reluctance to use central lines.  INS stantards allow for two attempts, then we call on another IV nurse hoping that she will be able "see" something we didn't or have better success on insertion.  However there are only 2 IV nurses on days, 1 on evenings, and no night coverage.  What is happening is that "multiple" nurses, paramedics and NP's are trying to place IV's either before or after the IV team has been called.  For example:  Pt. comes into the ER, and two different nurses or paramedics are unsuccessful (each having tried x2) so the IV team is called.  If the IV nurse is also unsuccessful----this patient has now been stuck 6 times.  The MD then informs the ER nurse to have others try---sometimes this results in more than 10 attempts!!   I have even seen this happen with neonates!  At what point can we say the line has been crossed.  I need specific data and or legal rulings in order to have a strong foundation to stand on with the MD when I advocate for the patient.  "The patient has poor access and no available veins.  They need a central line"  just doesn't cut it with these guys.  Anyone else have the same problem and how did you rectify it.   Thanks in advance,  Denise
lynncrni
I can not give you

I can not give you evidence-based data or a legal ruling in this issue. I doubt that you will ever have the information from a lawsuit as most of these are settled out of court and therefore are totally private matters. 

I can tell you what policy I have worked under back in the 1980's and 1990's. Our policy was a total of 5 attempts before we stopped and called the physician. This was 5 attempts by IV nurses as there were no other nurses on med-surg units doing venipuncture in this hospital at that time. Once we started placing PICCs, this problem greatly decreased but this policy remained in place. As a nurse you must always act as the patient advocate and you may have to simply, firmly, professionally say a big fat NO when asked to continue sticking a patient.

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

DENISE123
Lynn; I appriciate your
Lynn; I appriciate your prompt reply.  I have no problem saying no when asked to continually stick a patient, my concern is the MD's asking others to continually stick patients before & after the IV team has made an assessment and made attempts.  Their refusal to consider options other than peripheral IV's creates a situation which I consider unethical.   I'll give you an example using my best recollection of all the details as it was some time ago.  A child was born and the MD wanted an IV for antibiotics immediately.  Two nursery nurses tried 2 times each, and phlebotomy had tried to draw labs x2 (unsuccessfully) before I was called.  Therefore the infant had already had 6 sticks before I got there.  I spent a great deal of time searching, finally making two attempts both of which were unsuccessful.  I spoke with the two nurses and the MD about the need for a new plan considering the child had already been stick 8 times without success for either labs or IV.  To make matters worse neither of the parents had been informed or consented about the problem and were upset that their child was continually being stuck with needles since the father was watching all this through the window.  The MD insisted I continue trying since the child's health was precarious & they suspected a serious infection (and to say she was impolite is an understatement....not to mention the guilt trip that she attempted to lay at my door)---part of the job I know.  I told her I would LOOK again but unless I was able to find something that I was 99% sure would be successful I would not stick the child again. (We do not insert pediatric central lines so that was not an option)  I found nothing (no surprise since by now the child had multiple bruises and veins with previous attempts).   Angry, the MD made her own attemt, and when she was unsuccessful, she called for a pediatric nurse from the ER to come and attempt again.  This neonate who had been born less than 90 minutes ago had now been stuck OVER 10 times!!!!   What I am looking for is a way to put a policy together that states the TOTAL number of times nurses can attempt IV insertions within the facility, so that the MD's can not call for nurses from all areas of the hosptial to continueouly stick patients.  This does not happen at just my facility---last week a patient came through the ER that had been to another hospital the night before that had made over twelve attempts before a femeral line was inserted, and she could point out each place.  Granted we always educate patients as to their right to refuse if they feel they have been stuck too many times, but what about the ones who are too sick, weakened, or mentally impaired and can't voice their refusal?   I truely feel this is an ethical issue that needs to be addressed.  Even though the IV nurses may only be attempting two insertions apiece (we never have more that two in the hospital at a time), the MD's don't see a problem with multiple people (including RAD tech's) trying as long as the end result is a peripheral line.   Please send me your thoughts, this is really bothering me.    Thanks, Denise
lynncrni
I totally agree that you

I totally agree that you have  a serious issue. I can think of 3 things to do. Immediately create a policy that a total of X number will be attempted before a physician is called and no more after that. I would suggest no more than 5 attempts. I would educated all nurses about this policy and the ethics that you discussed and find some way to ensure that their managers stick to this policy. Then using the average of around $40 operational cost per attempt, you can go to the financial officers about this practice and what it is costing your facility. If you do not want to use that $ amount, then calculate your own cost, not charges. Don't forget to add in nursing labor. $40 X 10 times is $400. That is not what you are billing the patient. Also you can try to learn if your facility has ever had any of these excessive charges denied by insurance companies. For a Medicare patient, this would consume a huge chunk of the DRG. So that would be easy to show the problem. Hope this helps. 

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

DonnaS
Our facility has a IV

Our facility has a IV Protocol that only allows 5 sticks total.  For the most part this is followed but every now again things fall through the cracks but we do file an occurance report as well as a peer review report.  I completely understand your frustration and have felt it as well.  The MDs certainly are reluctant to place central lines in kids.  In healthcare we cannot focus on the task at hand without considering the consequence to the patient.  When we stick a patient multiple times we are focusing on the task at hand.  This is wrong! 

We also purchased a Veinviewer this past fall and I have been educating the physician's on the point that if I don't see anything with the machine, we should not be sticking the patient.  I have already noticed that when the ER docs call for me and I can't find anything they will go right to a central line if they are going to be admitted.  We work together to problem solve the patient's poor venous status and their IV needs.

Our IV program is really in its infancy but we are making headway.  It takes continue diligence.  I would be happy to share my protocol and policy with you if you are interested.  I do have some articles that I have found in writing a paper on VAP for my Master's Program that I could share with you.

 

 

Cherokee people
Could you send the policy to
Could you send the policy to my email address? [email protected] Thanks, Vickey
SherryB103
Donna- Would you please send

Donna-

Would you please send me a copy of your Policy and Protocols?

Thank You

[email protected]

Diane C Lauer
advice needed on peripheral IV starts

I insert PICC catheters via ULT in a community hospital.  Several MD's are inserting PICCs as well.  One of the doctors asked me Shouldn't there be some step between failed peripheral IV attempt on the general ward and referral for PICC?  Some patients are ordered for PICC simply for lack of venous access.  Has anyone had luck with illuminators or vein finders?  Can you email me.  Donna S from 2/16/2009 did this product improve the ability of the staff nurse to start a peripheral IV? 

Thanks  l

Celia Brown

Dawn1
I would be very much

I would be very much interested in your iv protocol & policy. I am trying to put together a eary vascular access program.

Thanks,

Dawn Lentz RN CRNI

Dawn1
My e-mail is
My e-mail is [email protected]
DENISE123
Dear Lynn & Dawn;  thank
Dear Lynn & Dawn;  thank you for your replies!  I am going to persue this and your suggestions were great starting points.  What material (books, outlines etc) would be the best sources for formulating a policy, and presenting it to the appropriate committee.   Dawn: Please send me a copy of your protocols & policy along with the article you mentioned.  Thanks, Denise
lynncrni
Any of the textbooks or

Any of the textbooks or materials from the Infusion Nurses Society, especially the Infusion Nursing Standard of Practice. This is the document to which you and your staff will be held accountable in the event of a lawsuit. go to www.ins1.org

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

AKRN70
Hi, I found this site while

Hi,

I found this site while trying to find a policy and procedure for IV starting.  I am on a policy and procedure committe at the hospital I work at and we do not have one and are trying to implement one.  Would it be possible to have you email a copy of your facilities?  I have searched the web and found nothing.  We are also thinking about implementing one of body piercing/jewerly and storage of patients belongings if you have any suggestions in those areas.  Thanks so much for your time and help.

Kim 

musicfan_rn
This really bothers me

This really bothers me too.  We only have two IV nurses here during the day 9-5 and none on evenings or nights.  The resource to help start IVs during the off hours is the house supervisor, but they usually don't call them until the patient has been stuck multiple times by several nurses.  Then anything the supervisor might be able to cannulate has been shot.  We have an unwritten rule to limit the number of sticks per nurse to two.  Nothing about the total number of sticks per patient.  This is definitely something to consider.  Thanks.

 

Sally RN

karrenberg
I wll ultimately refuse too

I wll ultimately refuse too many sticks because the rationale is this: if it took  10 sticks to start an IV THIS time, what happens NEXT time??  What if Do get an IV after multiple sticks and it infiltrates 4 hours later?? You're back to square one but worse because NOW you have multiple multiple  previoulsy stuck sites and an infiltrated IV. If the patient is THAT sick, they need something more reliable than a shaky PIV.

Also another point.  Some nurses will tell me, well I stuck the patinet twice even though I knew I couldn't get it, cause I know it's hospital policy that a nurse has to try twice before they can call someone. I don't know about other places, but it certainly is not our policy.  I don't want anyone messing with a patients veins if they don't think they can get it.  So if you don't have that kind of policy, nurses need to be educated.

ncosta
Very interesting discussion

Very interesting discussion - seems to be a universal problem.  We are so busy trying to get central lines out and prevent CRBSI - the pendulum has swung to the opposite extreme.  Denise, I'd appreciate a copy of your P&P along with the articles you mention.   Nancy

[email protected]

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