Small Volumes, Big Problems: A Patient Safety Approach to Secondary IV Medications
Tonja G. Schroder, BSN, RN, CPN and Julie Bell, MS, RN, CPN
Situation
If you asked ten nurses on our pediatric units
how they set up, infused and flushed a small
volume intermittent medication, you would
get ten variations, all within policy.
Background
• Priming and Flushing
- Nurses might prime tubing with medication or normal saline (NS), creating variance in when the medication reached the patient, especially at low rates
- Flushes might be infused by pump or pushed possibly at a different rate than the medication infused (e.g., bolus push of NS)
- Nurses who floated to Pediatric units from NICU had a different protocol for priming and flushing
• Tubing and Pumps
- Tubing was changed with each intermittent medication and connected at a Y-port near the insertion site
• Frequent opening of line may increase infection possibility
• Manipulation of the line close to the insertion site may increase
risk of dislodging catheter
• Frequent tubing changes increases cost
- Some small volume medications were administered via secondary (“piggyback” infusion set with large volume tubing) and some were
administered by syringe pump with various tubing volumes
Assessment
• Multiple opportunities for improvement existed
• A work group of staff nurses, nursing professional development
specialists, and pharmacists from pediatrics, pediatric ICU, and
neonatal ICU developed a unique solution
Medication Safety: • Accurate delivery rate and volume
Standardized flush procedure • Medication & flush infusions supported
by smart pump
• Nurses know next step when pump alarms
Infection Control: • Decrease opening line
Closed system • Decrease infections
• Decrease manipulation of line
Cost Savings: • Standardize tubing volume
Streamline tubing • Decrease tubing changes to save money
• Save nursing time
Outcomes
Implications for Nursing Practice
• Standardized flush and procedure
– Improved consistency of process for nurses
– Medications delivered at ordered rate
• Infection control – closed system
– Loss of peripheral lines were minimal before and after implementation
– Compliance with maintaining closed system high
• Cost savings
– One unit’s medication tubing costs (3 months)
Before implementation................................... $894
After implementation..................................... $216
Cost savings...................................................... $678
Implementation
Pump: Use the syringe channel rather than piggybacks for all secondary IV
medications < 60 mL
Tubing: Use microbore (1 mL) tubing; use a multi-lumen extension set when
needed. Only one set of tubing is needed for all intermittent medications for
72 hours, saving an average of 6 sets of tubing per day for 3 days.
Closed system with less manipulation at site: Both the medication
and flush syringes are attached at the end of the microbore tubing rather than
at a Y-port near the insertion site. The flush syringe remains in place until the
next medication to keep the site closed.
Priming: The first mL of the next medication is pushed and the pump is
programmed for the rate and volume prescribed for the medication.
Flush: When the medication has infused, a new pre-filled NS flush syringe
is attached and 1.5 mL is infused at the same rate as the medication by using
<resume> function on pump.
Standardization: Any nurse responding to the pump alarm, seeing that
an intermittent medication is complete, knows to attach the NS flush, restore
the rate, and set the volume. Any nurse responding and seeing that the flush
has infused, also knows to turn off the syringe pump channel (large volume IV
continues at programmed rate).
Staff Education – Quick Tips
IV Medication Delivery
Meds ≤ 60 mL
use Closed Med System
Syringe
Microbore tubing (1 mL)
Push 1st mL
Infuse
Flush 1.5 mL at same rate as med
Tubing lasts 72 hours if not
removed from Y-port & capped
Meds > 60 mL
Piggyback
Secondary tubing
Back prime
Infuse
Leave tubing connected;
primary resumes
Tubing lasts 24 hours
•Improving medication safety, decreasing infection risks, standardizing
nursing process, and decreasing cost were all realized by this
improvement
•Sharing this trans-disciplinary, multi-unit process and the procedure
with nurse colleagues can assist them in achieving these same
outcomes
Transdisciplinary Team
Pediatric/PICU Staff Nurses
•Karen Joyce, BSN, RN, CPN, Pediatrics
•Meg Kerr, BSN, RN, CPN, Pediatrics Nursing Supervisor
•John Liberatos, BS, RN, PICU
•Donna Lingerfelt, BSN, RN, CPN, Pediatrics
•Elaine Mordenti, BSN, RN, CPN, Pediatrics Nursing Supervisor
•Lisa Penland, RN, CPN, PICU
•Allison Taylor, BSN, RN, CPN, Pediatrics
Pediatric Pharmacists
•Marci Bemis, PharmD
•Jamie Hogerheide, PharmD
Nursing Professional Development Specialists
•Tonja Schroder, BSN, RN, CPN
•Julie Bell, MS, RN, CPN
NICU Colleagues
•Anne Ramirez, MSN, RN, Clinical Nurse Specialist
•Brianna Bridges, BSN, RN