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mkalapach
patients admitted inpatient with CI via ambulatory pump: best practice for inpatient RN re: port management/pump management

Hi,

Long post alert:  Recommendations for inpatient nurse role in managing port site, infusion?

Situation: Inpatient oncology units on occasion have patients admitted for 23 hours obs that have a 46 hour (or longer) continuous infusion of chemotherapy via an ambulatory pump. The oncologist wants to continue the ambulatory infusion in the inpatient setting, so the patient can be discharged in the am. Our network does not have a procedure/policy for nursing in  managing the port IV site that has been accessed in an outpatient facility, or address the management of an ambulatory pump in the inpatient setting. The Oncology Nursing Society (ONS) refers to follow institutional policies for just about everything, and ours does not address this, yet.

Background:Our current practice is to convert ambulatory pump infusion to an inpatient hospital pump. This can lead to longer length of stay (LOS) for the patient, increased healthcare cost due to LOS, use of resources to convert infusion and manage, and risk of dosing error in converting ambulatory pump dose using VI/VTBI to inpatient hospital pump infusion.

Assessment: ONS recommends a policy/procedure be in place to address this situation, but doesn't really give much guidance. Our current CVC policy does not address IV site management of ports when access was done in a non network facility. Inpatient nurses are not trained on any ambulatory pumps and will not be trained. A process in place to address obtaining orders to continue chemotherapy in the inpatient setting, just not a process for managing the central lines or ambulatory pumps.

Recommendations:???

Questions in regards to inpatient nursing role in managing central lines/ports and pump in this situation:

  1. Is it an issue that the port was access outside the facility and now our facility is managing it?
  2. Is it acceptable practice to only assess the port site, during this infusion, for s/s of pain/swelling/leaking, etc... and not check patency, since disconnecting the line would "contaminate" the ambulatory pump system?
  3. Would inpatient nurses need documentation that patency was checked prior to the initiation of the 46 hour infusion in the outpatient setting, or is documenting "infusing without alarming, leaking, etc..." acceptable?
  4. If our CVC policy requires port dressings have CHG or biopatch, needleless connector, and this patient's port  accessed in the ambulatory setting did not have a CHG, biopatch, or needless connector, would we be required to reaccess, per our policy? Can we write in an exception to this for this situation? or is that not adviseable?
  5. If any reaccessing needs to be done, would there be a timeframe from admission to do it? within 24 hours? end of the infusion? 48 hours?
  6. If there is a CLABSI, how would we know if it originated from the port access prior to admission, or the second access upon admission?
  7. We are working on a patient agreement form that patient acknowledges:
  • have received education and training on the pump in the ambulatory setting , will provide make/model, 1800 number, and will show the nurse the VI, VTBI, and rate at handoff and when asked.
  • are responsible for the pump, if discontinued
  • that ambulatory pump can be discontinued, or  converted to inpatient pump if patient has a change in MS, or other reason per nursing/oncologist judgement.
  • Is something like this needed? or a waste of time?

 The ONS forums have not been helpful in determining inpatient practices...Variation in practices makes it difficult to determine what is best practices.

Anyone out there have this issue? How do you address these questions?

Thank you,

Mary

 

lynncrni
1. no issue IMHO

1. no issue IMHO

2. Patency assessment for all continuous infusions should only be done when there is a clinical indication to do it and if there are any other meds piggybacked or push through the continuous infusion. Patency assessment without a cause or a med to give is entering the line for no apparent reason. 

3. See #2. Patency assessment  for all CI - inpatient , outpatient, etc - should only be done when there is a clinical indication to do it and not on a routine schedule. 

4. I would not disrupt what is there unless there is a clinical indication that a problem exisits. No continuous infusion needs a needleless connector IMHO. 

5. Don't understand the question. Repeating the access should only be done if there is a problem to be corrected. 

6. Time frame of more than 48 hours. 

7. So inpatient nurses will not do anything with these pumps? Sounds weird to me. Don't think you can put the entire responsibility on the patient. 

As of Dec, 2019, all hazardous drugs will require use of closed system transfer devices and chemo attire to manage it. So I would not disrupt the setup on admission unless there is a problem. And I would say your nurses are going to have to learn how to assess the port site, and pump. Just don't see how you can get around that. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

mkalapach
Thank you Lynn for your
Thank you Lynn for your responses. Your clarifications are appreciated.
 Generally patients manage their IV site/pump at home, and agree, that once inpatient, nursing does need to make sure the site is assessed, and ambulatory pump is still functioning.  I have put together an outline to hopefully address the inpatient nursing

1.     Ensure there is a written order to continue the chemotherapy/biotherapy via ambulatory pump, that includes: indication, medication, dose/m2/day, total dose for duration of infusion, duration of infusion, rate of infusion, and start date/time of infusion. Faxed orders are acceptable.

2. Follow CVC policy for tip placement verification on admission for non-tunneled VADs (cxr on admit)

3.     Visually inspect the entire ambulatory pump system from the infusate container, progressing down the administration set to the vascular access device (VAD) insertion site, on admission and all handoffs.

4. Assess and document on admission and all handoff:

  • type of VAD, location, date accessed or dressing date, and dressing
  • integrity of the system; i.e., leakage, luer connections secure, needless connector, closed system transfer devise, etc…

  • infusate per chemotherapy order

  • accurate flow rate per order, including VI/VTBI

  • expiration dates of the infusate and administration set

5. Do not assess VAD patency unless clinically indicated; continuous infusions (i.e; occlusion alarms the patient cannot fix, leaking, etc…). Notify the chemotherapy RN:

  • for any required disconnects or discontinuations of chemotherapy.
  • with any questions or issues.

     

6. Instruct patient to show the nurse the medication label, pump settings, and any “self-tests” to ensure that it is working properly, when requested.

7. Instruct the patient to report:

 

 

 

  • infusion site is red, swollen, or warm to touch
  • bleeding and/or discomfort is noted at the site
  • a “no delivery alarm” or other alarm that will not resolve

8.     Assess need for secondary venous access. VAD used for ambulatory pump infusion is a dedicated line not to be used for medication administration or blood draws.

9.     Prior to stopping/discontinuing an ambulatory infusion pump before the planned completion of the infusion (i.e., status changes, MRI, PET, or procedure requirement, etc…), the chemotherapy RN will notify the Specialist to obtain orders for stopping/discontinuing the infusion via ambulatory pump.

 

 

·         ForCAT scan or plain film x-rays, the patient may stay connected to ambulatory pump.However, pump should be kept outside of the radiation field.

Note: Any re-initiation of this medication will require conversion of remaining dose by pharmacy, to be infused via hospital infusion pump, with approval and as directed by the Specialist

10.         When infusion is complete or to stop infusion:

a.     Request patient/caregiver stop/pause pump and/or turn off. Alternatively, remove batteries if needed to stop pump.

 

 

 

 

b.     Don appropriate PPE per chemo policy and disconnect ambulatory chemotherapy from VAD.

c.     Flush VAD and lock per CVC policy.

d.     Remove infusate container from the ambulatory pump and dispose appropriately in a chemotherapy waste bin. Alternatively, place entire ambulatory pump with empty infusate container intact, in a chemotherapy ziploc bag and placed in another chemotherapy waste bag (double bagged). Dispose of PPE per chemo policy. Pump should be given to patient, designated caregiver/family member for safekeeping if disconnected; or, as directed by the Specialist.

***

Also, as a side note, your response to # 2 and # 3 leads me to ask if this includes CI of vesicant infusions.

Our current policy for continuous infusion of anthracyclines (inpatient hospital pump) is to check blood return q 2 hours at distal lumen (empty syringe to pull back just enough to get BR (no flushing due to not wanting to bolus dox on flush). The rationale being that if there is no blood return (even for patient without s/s of pain, edema at site, etc...), we treat as potential extravasation. The antidote for anthracycline is dexrazosane and per drug insert, recommends infusion within 6 hours of potential/actual extravasation detection. We feel we need to check blood return in a frequency that allows for detection, for pharmacy to obtain drug (stored off site), and for nursing to administer in that 6 hour time frame. If positive BR at 1200, no BR at 1400, then 6 hours starts from 1200. In the interim while waiting for the antidote, we are obtaining stat (depending on type of VAD) CXR for tip placement, dye study for port function, patency, tip placement, and possibly CT chest r/o fluid pocket, per MD orders.
ONS recommendations is to assess CI frequency per institutional guidelines. So I look for literature to help determine what is evidence based and safe practice for vesicant CI site/patency assessment with the recommendations for antidote infusion administration. 
Would our policy for BR checks be considered overkill?

 

Any and all input/feedback is welcome.

Thank you,

Mary

lynncrni
No time to read all of this.

No time to read all of this. Checking blood return on a continuous infusion has no frequency recommended in the literature. It is by clinical indication or by a policy your facility creates. 

Lynn Hadaway, M.Ed., 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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