Administration vs nurses: priming lines with normal saline

[delilas]

There is a huge blowup at my hospital lately about the practice of priming an antibiotic line with normal saline first.

The nature of our EMR system automatically names some things - like Zosyn, Iron, and K-riders - piggybacks. As I've always understood, a piggyback should be administered as a secondary line, but these are often ordered on patients who are saline locked and do not have a primary line.

In addition, even when running as a primary, we were taught initially to prime the line with a small amount of normal saline to avoid wasting medicine when trying to get bubbles out. It is, after all, part of our protocol to flush lines a couple times a day with a 10CC flush, so no one thought any differently of a few CCs of saline to prime tubing.

However, our hospital has decreed that this is "nurses practicing medicine" and that we are not allowed to do so. I do understand their point, but I also see how frustrating it is from the point of a nurse to waste small piggybacks like iron in an attempt to get air bubbles out of the line.

I've worked in several places and had never had an issue with line priming with saline, so I wanted to see, from the allnurses standpoint, your thoughts and how things typically work at other facilities.

[VANurse2010]

Is not the hospital admin practicing medicine by virtually ensuring that the full ordered dose is never delivered? What a bunch of dolts. I'd quit.

[loriangel14, RN]

We always run antibiotics as a secondary and we always establish the primary with NS running. Would you not usually run the antibiotics piggyback?

[LogCabinMom]

This is extremely timely! I was going to post along these same lines... I have always run abx as secondary lines, when an abx is ordered I simply hang a primary of NS at KVO if none is currently running, and then run the abx as secondary, then flush through for an hour with NS on the primary, then turn it off. I can ask my MD for an order for a NS 100ml bag for this and they usually have no problem. However, our VP of nursing and I just got into a disagreement about this because she is "old-school" and doesn't understand why anyone would not just run the abx as a primary. When I tried to explain to her that 15-30ml of med is left in the primary tubing, not to mention you then need another primary tubing for each abx the pt is on, she wouldn't listen. And, in my unit, I have older nurses who still practice this way as well, ticking me off when I come on because I change it around.

I am currently trying to gather information/evidence that hanging a primary of NS with a secondary for the abx is the way to go.

My other question is, how does everyone out there run their drips? If I have a Lasix drip running at 5mg/hr (5ml/hr), would you run this as a secondary?

[netglow, ASN, RN]

It's not about better or best practice or any SILLY thing like that.

It's about money.

[jadelpn, LPN, EMT-B]

I always learned to run antibiotics as a secondary. So that none of the antibiotic is left in the tubing and the patient gets the entire amount. Especially important with Vanco when you need to get to a theraputic level.

[loriangel14, RN]

I don't need an order for NS as a primary line, we just do it.

[Sun0408, ASN, RN]

My other question is, how does everyone out there run their drips? If I have a Lasix drip running at 5mg/hr (5ml/hr), would you run this as a secondary?

I run all my gtts as primary. If the pt had MIVF and a gtt running as secondary, they do not get the ordered fluids. Not to mention, some gtts are too dangerous to run as secondary..

[meandragonbrett]

Does your pharmacy not over fill by 5-10mls? I've never gone out of my way to hang NS at KVO and then to run ABX as a IVPB. Maybe we do things different in the ICU but in the ICUs I work we rarely run anything as a IVPB but everything has a bit of overfill that is mixed by pharmacy.

[Tait, MSN, RN]

It's not about better or best practice or any SILLY thing like that.

It's about money.

I am with NG on this one. They don't want to pay for the 250ml NS PB bag.

[MunoRN, RN]

Infusion Nursing Society literature recommends running intermittent infusions as a secondary for the purpose of ensuring that the full dose of medication is delivered and also to maintain a closed system, which we know reduces infection risk.

When used for device maintenance, such as priming and flushing, NS isn't considered a medication, it's actually classified as a device. It's no different than flushing an IV before an after a medication, no MD order is needed.

I would congratulate your administrators for taking bold initiative in going against basic rationale and practice recommendations, particularly since they are now responsible for paying all costs associated with CL infections, or maybe not, maybe less snarky would be better.

[Tait, MSN, RN]

I run all my gtts as primary. If the pt had MIVF and a gtt running as secondary, they do not get the ordered fluids. Not to mention, some gtts are too dangerous to run as secondary..

I agree with Sun on drips likes Lasix/Cardi/Insulin etc I would run primary. Better to be safe on those, plus those are continuous, so I wouldn't be as concerned about wasting a bit to prime the line effectively. Abx and small one time runs of potassium or iron I wouldn't want to waste much of. As far as I know there was not an overfill on acute care floor bags of these items.