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.
Questions in regards to inpatient nursing role in managing central lines/ports and pump in this situation:
- Is it an issue that the port was access outside the facility and now our facility is managing it?
- 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?
- 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?
- 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?
- 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?
- 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?
- 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?