Different Piggyback Antibiotics, Same IV Tubing??

[Pinky89]

Hey all,

I just had a quick question about something I was taught in nursing school and was wondering if you learned the same thing, or practice this yourself.

You have 2 different IV piggyback antibiotics (compatible or incompatible, doesn't matter) with NSS as the primary, and one is due at 1200 and the other is due at 1800. You hang the one due at 1200 then leave everything hooked up until you come back again at 1800 when the other antibiotic is due. Instead of getting all new secondary tubing for the new antibiotic, we learned to just back prime the NSS into the piggyback line a few times to flush what's left of the 1200 antibiotic into the old antibiotic bag, then disconnect and reconnect the new antibiotic. I was told that you don't have to worry about the 2 antibiotics mixing because you back primed with NSS and all that's left is saline in the now reprimed piggyback tube.

Does anyone do this to save time and cost to the patient? Just wondering...thanks!

[wanderlust99]

I use the same secondary tubing for all piggybacks, unless they aren't compatible. Backprime.

I thought it was so strange my 2nd nursing job to see 10 different secondary tubings hanging on the IV pole. A lot of people don't want to change their habits.

[iluvivt, BSN, RN]

It is the frequent connections and disconnections that is the concern here when you use multiple secondaries or one for each drug.This really increase the opportunity to introduce bacteria into the line. Biofilm gets attached to the catheter and/or connectors,breaks off and then can cause a bloodstream infection. Yes.... this can happen with peripheral IV therapy too. Dr Marcia Ryder explains this very well if you would like to read more. The Biofilm has been found in needleless connectors as well,pointing out why it is really important to changes these per your policy especially on all central lines and scrub the connections for 15 seconds before applying new caps. I see this step skipped often.

So back to the point...by using the same secondary and not disconnecting (backpriming instead) you are performing best practice. If you feel that you must use multiple secondaries then they should be treated as if they were a primary intermittent in terms of the tubing changes. That is why INS states that secondaries used in that manner need to be changed every 24 hrs. This is the current and best recommendation to date so far. If and when there are more studies that show something else is better INS will stick with this recommendation .

So if you are doing anything else then make sure you have policies in place for more frequent tubing changes of the secondaries,never use the sloppy practice of" looping",ALWAYS put a sterile new end cap on disconnected IV tubing (a cap from an NS or heparin pre-fill does not count or qualify) and date the tubing so it gets changed in a timely manner.

Yes the 2004 article still applies as no new studies to prove there is a better way.

[Overland1, RN]

The back-priming a few times takes a fair amount of time, and we all (should) know the wise old saying about "time is money". From a simple cost perspective, calculate the actual amount of time used to use a separate secondary tubing and switching it at the appropriate port on the pump set as needed versus back priming (several times) the tubing. Compare that with the actual cost of a secondary tubing set. By running the numbers (I tend to do that quite often... could have been an accountant ), you will likely see that using a different secondary set is less expensive.

I just checked the cost of the secondary IV pump tubing; it is $0.70/ea.

[imintrouble, BSN, RN]

We just use different tubing for every piggyback.

Maybe it's just a resistance to change I'll own it.

Maybe it's a safety thing. There's always going to be one person who "forgets" to back prime with the worst possible medication.

[Serlait]

The CDC issued new guidelines as to the time a primary set should remain in use in 2011, this is the conflicting information in the cited article. Also it is noted in the 2010 Lynn Hadaway Associates Inc. link r.e. backpriming "Unfortunately, this is an area of clinical practice that has received no attention and no research." (First line of author's response). And further down in the authors response to a post "Of course there are no studies to refer to about this practice. I would recommend that your practice council consult with a pharmacist knowledgeable about IV drug compatibility information just to be sure. I just checked some recent compatibility information on Vancomycin and found conflicting compatibility information when given with ampicillin, several of the cephalosporins, nafcillin, piperacillin, ticarcillin and tigecycline. I would recommend that you assess the common combinations prescribed by physicians in your facility and then assess the compatibility of those combinations."

Additionally, per the 2011 CDC guidelines, "No recommendation can be made regarding the frequency for replacing intermittently used administration sets.Unresolved issue " (#2 under Replacement of Administration Sets).

Hence, the use of backpriming cannot be claimed to be evidence based, therefore, how can it be best practice? I don't see it as not wanting to change habits, but in following the protocols established. It seems to boil down to using the practice that your hospital or agency establishes as best practices. If your agency says a new secondary for each drug and 24 hour use for each secondary and you wanted to argue the issue, what evidence would you present? What research could be presented? At this point, per Lynn Hadaway, "The absence of studies means that we are left to base practices on general principles of infection prevention." (Paragraph 3, author's response).

It would be extremely interesting to look at the rates of blood stream infections in hospitals with varying practices to see if there is a greater incidence of infection when multiple secondaries are used vs limited access for secondaries. Perhaps a good research topic?

[Serlait]

"Yes the 2004 article still applies as no new studies to prove there is a better way."

But the 2004 article was not supported by evidence based research. Again, there has been no research to support either practice. How can one claim "best practices" with a dearth of research to support such a claim.

I find it interesting that if someone is unwilling to switch to another practice, especially when there is absolutely no evidence to support the change, they are accused of being unwilling to "change their habits". Very simply, if you want me to change my "habits" then show me the evidence that supports that change. Please don't site an eight year old article that does not include the most recent recommendations of agencies cited in the article. Both the CDC and INS revised their recommendations in 2011. If I were not willing to change my "habits" in the face of research, THEN I would be deserving of your censure, until then or until I have the evidence to argue for a change, I will follow the protocols of my hospital. I can't imagine trying to defend myself if there were some sort of problem or compatibility issue by saying that I based my practice on an article written in 2004 that was not current.

[Pinky89]

Thank you everyone for all of your input! Reading all of your comments has been very helpful. I'm happy to know that others have heard of this practice, as when I asked some of my co-workers they had no clue what I was talking about! Obviously the most important thing is following the policy of our hospitals (which I don't believe mine has a specific policy for or against using a separate IVPB tube), but I did ask an IV therapy nurse what she thought and she said I should use a dedicated line for each IVPB, so I guess that is what I'll do until I'm told otherwise or any evidence-based research is done. This would certainly be an excellent evidence-based practice project for our unit if there were more evidence to support it!

[hodgieRN]

I always back prime. When you do that, you technically keep the system closed. The more you plug syringes and extra tubing into the ports (despite using alcohol), the higher the chance of contaminating the line or the IV access. That also includes exposing the piggyback lines to the air every time it disconnected. The more closed the system is, the better. Not every nurses scrubs the port with alcohol like they should. Think of how many times a PICC line has come back with a positive culture.

[corky1272RN]

Someone can backprime all you want, the spike still has the previous med on it. Are the backprimers looking up compatability or just assuming since they backprimed it is as good as new? At my facility, if I heard that someone was using the same line for each PB, I would start to question their nursing standards. I have never looked at the P&P regarding this because I never thought it was an issue. Definitely food for thought.

[nurseprnRN, BSN, RN]

Lynn Hadaway is a nationally-known expert in all aspects of IV therapy, testifies as an expert in court, and has authored textbooks. If she promulgates it as safe, she would have the evidence to support it, and you can take it to the bank.

[turnforthenurse, MSN, NP]

Back priming is okay, however, I would never use the same piggyback tubing for two different antibiotics. That just doesn't sound right to me. And what if the different antibiotics happen to be incompatible with each other? It doesn't take that much time to grab a new secondary set and prime the line and hang it.

[Serlait]

Regardless of her credentials, Ms. Hadaway stated on her website, Lynn Hadaway Associates Inc. Lynn Hadaway Associates, Inc.: Studies on Backpriming

"Unfortunately, this is an area of clinical practice that has received no attention and no research." (First line of author's response).

Until there is evidence based on research, I'll follow my hospital's policies so I have a paycheck to take to the bank.