CNAs starting IVs

Forest2 · Jul 2, 2019

I never heard of it before.. Perhaps they had special training as techs, IDK.

RNNPICU, BSN, RN · Jul 5, 2019

Starting an IV is not an RN task. It can be performed by anyone who has been trained per hospital or unit protocol.

There could be many reasons why the IV went bad withing 24 hours, epecially if they were placed in the AC, i. e meds, fluids, movement, plus many many more reasons.

BSMSCCRN · Jul 5, 2019

I am very well aware of all the reasons an IV may go bad. Never have I had all 3 gone out within 2 IV injections of Dilaudid and Promethazine. And never have I had cellulitis from an IV before this visit. The immediate burning would tell me (after over 30 years as a Trauma Critical Care RN in all Critical Care areas) that the IVs were really not in the vein to begin with. No continuous fluids. P.O. antibiotics!

RNs would be fools to dedicate something invasive where the skin is being punctured, to a nursing assistant or CNA, where that function is not their only responsibility. Some Trauma ERs are now using Paramedics to start IVs and that is fine as it is a regular function (thus skill experienced).

If the RN is too busy with admissions and discharges, maybe healthcare facilities should hire a nurse on each unit for just those things so the RN could get back to patient care (assessments, meds distribution and calculations), education, IV starts,etc. Three things a patient remembers, and will quickly tell others about, is their experiences with IV insertion, lab draws and prompt assistance to a request! These areas will give a facility a good rating/reputation OR a very bad one. Where patient opinions are at an all time high and this affects their view of the quality of care they feel they received and this is an area which is high on JACHO’s list, it would be prudent for facility staff (including RNs) to care about the areas that can make a patient’s visit a success. Many nurses gripe about their pay but cannot wait to give up important and crucial functions that contribute to a successful patient visit and outcome.

It is no secret that the RN who does not frequently start IVs will never become really competent. As a house Supervisor and Trauma ER Manager, I cannot tell you how many times Critical Care Nurses made crucial mistakes when the pumps began doing all the drip calculations (as they no longer were doing their own calculations as a second double check). They lost the ability to figure out how to set the equation up to find what the patient was really receiving. Especially in critical care areas where you may be increasing the drip rate quickly due to crashing patients. Some drips come with a preset chart, others do not. How many times have physicians entered the room and asked the nurse how many mg, mcg, etc the patient is receiving, of a critical drug, and the nurse could not tell them and had to find someone else who could help them figure it out. Way too many!

While healthcare technology is increasing at a fast pace, nurses must not let go of certain skills (IVs, medication -except suppositories distribution, assessment skills, double checking pump calculations for accuracy using their math ability). You tell me you work in a PICU. I can say if I ever saw a CNA brought in to start my grandchild’s IV in a facility, that is the last time I would patronize the facility. Especially since I, as an adult, having this happen to me with such poor results (this has never happen before with experienced RNs starting my IVs -however it has when a new nurse has). Someone said, why don’t you just ask for an RN to start the IV. Great question! My answer- skills such as starting an IV need to be kept up! If the RNs at this facility have felt it better to delegate the task to a CNA (who usually has many more patients than the RN and this unit the RN had 4 patients and the CNA 11), the RNs IV insertion skills are, most likely, seriously lacking.

If the CNA is in a patient’s room, how long is another patient waiting who really needs assistance to the bathroom, changing the bed of an incontinent (setting them up for infection or bed sores, not to mention the absolute anger of the patient’s family member who found them) or keeping the CNA from one of their other many equally important tasks. Who is really suffering from the quality of care! The patient!

If this is one of the type of changes that are coming to healthcare within this country, the patient’s are in huge trouble. When physicians had to become more paperwork savvy and had to see more patients in a day to make up for the ever increasing constraints on insurance payment allocations, the amount of time spent with the patient declined. They had to see more patients in the same amount of time? What suffered? The patient’s healthcare! Even in the physician’s office. Thus, patient’s are much sicker than ever before. But what about the physician? The respect individuals had for physicians has decreased significantly since I began as an RN. Quality of care declined and lawsuits increased!

If the RNs in your facility no longer want to start IVs, I suggest an IV team be set up where all they do are IV starts, central line dressings, etc. If nurses want to begin delegating things really important to patients and their perception of the quality of care they received, tasks that they expect an RN to do, it is only a matter of time til nurses are seen only as lazy and incompetent and loss of respect for their occupation is lost.

By the way, I am only in 4th year of retirement.

Good luck in you nursing career!

Hoosier_RN, MSN · Jul 5, 2019

as this may be something that is being done per the facility and their p&p, it is best to direct it towards them. Many are using what they consider the most cost effective measure for all healthcare tasks. Many of us don't like it either, but TPTB and state practice acts determine who may do what. Look at your state practice act and determine whether or not this is legal. Either way, let the facility know. Call the unit manager and/or fill out the survey when it comes. Survey comments always get their attention

BSMSCCRN · Jul 5, 2019

I have recently done both. My next step is to try to get the Board to tighten up what may be delegated. VA laws are unfortunately very broad on what RNs may delegate which is very sad. Hopefully, RNs will step up to protect the patient and their profession. This is one facility under a corporate umbrella who owns many facilities. As Virginia has never been a State I worked in, I have never experienced this type of delegation in the more than 8 or so states that I have.

My original question was to find out if others are experiencing this particular practice within their facilities across the country. But, after another’s response, I, again primarily directed my response to nurses within all states to beware what skills they are willing to delegate. To protect critical skills, thus protecting the patient and the nursing profession as a whole!

Thank you for your response.

Hoosier_RN, MSN · Jul 5, 2019

@BSMSCCRN I 100% agree with you. But as a dialysis nurse who works in a clinic, the techs cannulate the patients or access the tunneled chest catheter unless there is an issue. That's a necessity or patients would never get treatment as there is usually only 1 nurse (or 2 in larger clinics). They are thoroughly trained before they ever touch a needle though. But outside of that, I don't think that anyone should be doing an invasive task that doesn't have the licensure to back it! What's driving this garbage is the corporate (and even small and nonprofits) hospitals trying to use the cheapest resources available, and it's the patient that pays. I was active in my states nurses association until I watched the money that talked was what made the decisions, and well educated leaders would then justify some things that would make Florence flip 100 times in her grave. It's just getting worse every year...I hope you make headway, there will be patients out there that thank their lucky stars

MunoRN, RN · Jul 6, 2019

On 7/2/2019 at 5:22 AM, BSMSCCRN said:
I am a retired Critical Care RN and was recently hospitalized for 5 days in Northern VA. I had 3 IVs and all were started by CNAs. All 3 went bad within 24 hours. Worse yet was that 2 were in my the AC veins. I have never experienced that before. I cannot believe that an RN task like this is being relinquished to CNAs. I am certainly not impressed with their skill. Is this becoming a common practice? And has their scope of practice changed?

Unlicensed staff have been allowed to start IV's (with an IV certificate) in every state I've worked in, I have no problem with it.

First, it's a task involving a skill, it does not in any way represent the unique role and value of nurses in patient care, most of the core of nursing practice takes place between the ears.

As a nurse, my role involves ensuring the patient is receiving appropriate and quality care, and one of the best way to ensure consistently good IV starts is to limit this task to a subgroup of staff so that they can do enough IV starts to maintain the skill, many times designating non-RN staff makes more sense than limiting this to nurses since this potentially time consuming task may interfere with a nurse's ability to devote time to the more complex aspects of nursing practice.

Promethazine is an extreme vesicant and will typically burn despite it being in even a large vein. As a result, it's not unheard of for facility policies to require blood return in the IV it's being injected it, and long term (more than an hour) blood return in a peripheral IV is more likely to be found in the AC than other sites below the elbow, which is possible why 2 of your IVs were placed there. Even so, blood return even in the AC does not typically extend beyond about 24 hours, regardless of who placed it, which is quite possibly why your IV's had to be replaced within 24 hours.

BSMSCCRN · Jul 6, 2019

Thank you. It is nurses who need to stand up for the patient and heir profession!

brownbook · Jul 6, 2019

The whole issue is as clear as mud. I worked in a free standing ambulatory surgery clinic in California. We had a tech who had been a veterinary tech. She was one of our go to staff when we had a difficulty starting an IV. I was very happy to pass off hard sticks to her.

One day I come to work and am told she can't start IV's anymore?

As other's have posted it is a skill. Many tasks are being delegated to CNA'S, MA'S, Tech's, etc. It would be nice to have a consistent policy that cleares up some of the confusion.

K+MgSO4, BSN · Jul 6, 2019

IV insertion is a task. Anyone can be taught a task and assessed on their competence in completing it. What the RN should be doing is assessing the site before medication administration.

brownbook · Jul 6, 2019

13 minutes ago, K+MgSO4 said:
IV insertion is a task. Anyone can be taught a task and assessed on their competence in completing it. What the RN should be doing is assessing the site before medication administration.

This! Whoever started the IV......a RN is responsible for assessing the site.