Different Piggyback Antibiotics, Same IV Tubing?? - page 4
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... Read More
Feb 11, '13Quote from VespertinasI'm not sure what "several times" means. Our instruction was to backprime a significant amount into the old piggyback bag, then take that off, throw it away and put the new piggyback on. And this is acceptable at my facility, which is not exactly in podunk city and is part of one of the largest private Hospital Corporations in the universe, even if the piggybacks are incompatible with each other.Isn't that a given? Several people have made this point but I figured that nurses were using new tubing strictly for that reason to begin with. It sounds like some people here are saying that it's okay to use the same tubing even if the solutions are incompatible because the backpriming should take care of it. What's the verdict?
When folks are saying "backprime several times" do you mean to reinstill the secondary line with primary solution, wait for it to infuse, and repeat? That DOES sound time-consuming.
Feb 11, '13Hehe, if anyone knows how to save a buck, it's one of the largest private Hospital Corporations in the universe....
Feb 12, '13I've always been taught. Each secondary gets its own tubing. You cap it, keeping it clean if it gets unhooked and not capped its trash.depending on your facility polo y how often you change those sencondary. Currently where I work its every 4 days. One place I worked if fluids where intermittent it was every 24 ( unless it was the only piggyback hooked up to continous)
And continous changed every 3
Feb 12, '13Quote from redhead_NURSE98!If they do charge the patient account for each one, they should charge sufficiently above cost (make a profit and remain solvent, or go out of business... Accounting 101); that they charge for each piggyback tubing means they are likely spending more money in accounting and billing for each such item. While certain, larger, and/or more expensive items should be individually billed, many hospitals include (and do not itemize billing for) the small stuff within the cost of (and billing for) care. Often, the cost of the paperwork and billing exceeds reason.Ha! You'd puke if you saw what our hospital charges the patient for them. If I'm admitted y'all can stand there and backprime and count the seconds because you're not charging me for all your wasted secondaries! lol
Feb 12, '13None of the 3 hospitals in which I have worked have charged the pt for each set of secondary tubing used. My guess is that this is included in the billing for IV infusion time (which is why, at my hospital, we have to document the start and stop time of each IV infusion).
Feb 12, '13I have no idea. I just know what the alleged "cost" is when we get the report of "items not scanned," and each item must be scanned to a particular patient. I'm not sure how it's billed or where it goes to after that.
Feb 12, '13Quote from corky1272RNSomeone 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.
If there is no issues of the agents being compatible, there shouldn't be an issue. Aseptic technique is aseptic technique. Compatibility is compatibility. The issue is the technique and the allotted time for keeping the secondary and primary lines. You could easily argue this issue for using the same port for various medications. If the medicine cannot be given in the same port, that is a compatibility issue, regardless of PB line backwashing. In the units we give multiple IV meds that are flushed as per protocol. You could argue the physics, the force of the flush through a particular port in terms of how much residual stays or not.
It's an incredible expense use multiple piggy back lines. I know of no issues, after decades of using this technique unless 1. There are issues of compatibility in the first place or 2. There is an issue in aseptic technique in the first place or 3. The lines are not being switched out by CDC standards/protocol. For compatible medications, whatever nanograms of an agent left on the in line port or the port that one is using going directly into the patient in the first place are negligible.
What hodgieRN states is true too. Not every nurse really the ports each time. So you are needlessly breaking the clean line each time you change it for multiple PBs. Of course it goes without saying that spiking must involve maintaining sterile technique.
I don't have time to do a database search on this right now, but I encourage those that question the approach to look into one or to find a strong systematic review or meta-analysis on it.
Again, what does or doesn't sound right is not material. The question should be are the different antibiotic lines properly back-primed, and ARE THE VARIOUS ANTIBIOTIC AGENTS COMPATIBLE.
That's the main issue other than the obvious nature of following appropriate aseptic technique--are the other antibiotics compatible and are people back-priming the secondary PB lines appropriately.
Even when you use a medfusion pump, you keep the same line as long as it is still good--a microbore or in some cases a line for pressurized lines. Now, you can put, say, a NSS flush on the line after the antibiotic goes in (What's often done for kids), but once again, one could argue what percentage of the previous antibiotic is going into the port that leads directly/proximal to the patient? And again, it wouldn't usually be enough of a problem--unless you are talking about agents THAT ARE CLEARLY INCOMPATIBLE. Nurses give tons of IV agents and antibiotics in the ICUs. It is mandatory to know what is compatible and what is not, and pharmacy is usually helpful with reviewing this with you, if you don't have a chart or immediate computer data access. In general, hospital pharmacies are MUCH more hands-on today as compared with 20 years ago. Shoot, we used to mix EVERYTHING. Today, pharmacy, in most places, mixes everything for you--including, at least in the pediatric units--emergency infusions.
Feb 12, '13No, it is NOT recommended ANYWHERE that you use the same line for an agent that is incompatible, period, end of story.
Many antibiotics are compatible, but you still back-prime. Whatever is left after proper back-priming is considered negligible and not an issue. Now, you have to use good sense.
Example: Say a patient has no know allergy to said antibiotic. You start to to infuse it, and you notice S&S of anaphylaxis. Obviously, when the patient receives another antibiotic or agent you use a new and properly primed line. I mean this seems like a no brainer, but it has to be said. You don't keep that line, but you get a new one and prime it and use it for the new antibiotic or agent.
Feb 12, '13Quote from nureliWell there may be a number of reasons for this, but one is that a patient may not have a primary line of infusion running, so you have nothing with which to back-prime. Some places might clear a PB line for compatible meds with a 50mg bag of saline, but that seems like a waste, and some people don't need the extra fluid. You would have to compare the costs of using the NSS to the cost of a new line for each antibiotic. Now buying in bulk, the 50 ml Nss bags are about $3.00 and the Braun IV PB admin sets were about $5.00. But then you have to take the difference between $5.00 per 72 hours (3 days) four days seem too much to me versus $3.00 for 50 ml flush bag after each infusion. It seems clear that the former would end up being cheaper than the latter.I've always been taught. Each secondary gets its own tubing. You cap it, keeping it clean if it gets unhooked and not capped its trash.depending on your facility polo y how often you change those sencondary. Currently where I work its every 4 days. One place I worked if fluids where intermittent it was every 24 ( unless it was the only piggyback hooked up to continous)
And continous changed every 3
Like I said, I have worked in recovery rooms and units that use Solusets,(buretrols or burettes) and you add the medication into the Soluset and clamp off from the top of the IV (which is one with the primary bag). You can still have the IV line capped and disconnect the primary-which is one with the Soluset. You just make sure you fill with the primary IV fluid into the soluset. That's good for intermittent infusions and where you may have to be giving boluses of Mg or K+ or Ca++.
Some Open Heart Units I've worked in use the solusets for general IV fluid, certain antibxs, and small range electrolyte bolus replacement.
Feb 12, '13Quote from samadams8Why, because you say so? Your authority apparently does not extend to my facility.No, it is NOT recommended ANYWHERE that you use the same line for an agent that is incompatible, period, end of story.
Feb 13, '13Hence, the use of backpriming cannot be claimed to be evidence based, therefore, how can it be best practice?
Best practice includes data in which the goal is to decrease hub manipulation. As long as there are no drug incompatibities, back priming can accomplish this goal. Both INS and the CDC advocate best practice to include a decrease in hub manipulations. Is your institution JCAHO certified, if so, check out there publicated book on Central Line Associated Blood Stream Infections (CLABSI) which also includes the goal to decrease manipulations. Sometimes changes in practice can freak some individuals out, but if the changes are benefiting the patient, they deserve a closer look.
Feb 14, '13I think some people are incorrectly seeing this as weighing two different risks, when really it's a pretty straightforward decision. Numerous studies have found a clinically significant risk to every connection manipulation, yet there's no measurable risk in terms of compatibility. In other words; changing tubing for different antibiotics, even incompatible ones, creates only risk for the patient and yet provides no benefit.
One thing to remember about antibiotic compatibility is that it's concentration based. The dilution caused by even a half-hearted backflush is enough to negate any compatibility issues. The practice of changing the secondary tubing is also poorly thought through. Remember, the antibiotic also flows through the primary tubing at the same concentration and is then only flushed with fluid, just like what happens with a backflush, yet the primary tubing doesn't need to be changed (if people are doing that too then that's even worse practice). Same goes for the IV itself which is only flushed, or more accurately thoroughly diluted, between incompatible meds.
It's unlikely we'll ever see RCT's on this topic. There's not a single RCT proving it's safer to jump out of an airplane with a parachute than without, although that doesn't mean I don't have enough information to make a well-supported decision, which is what best practice is.
Feb 15, '13Quote from redhead_NURSE98!No, you maybe misunderstand. I agree with the right use of back-priming. I am just saying that I have never worked anywhere where pharmacy would be cool with using a line with something that was incompatible, even if its flushed through.Why, because you say so? Your authority apparently does not extend to my facility.