CNAs starting IVs

[BSMSCCRN]

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?

[Hoosier_RN, MSN]

1 hour ago, brownbook said:

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.

in any case, any state, you will need to look at the nurse practice act, because it does vary. Yes, it's a skill, but each state determines who practices that skill

[caliotter3]

Based on my recent experience in a hospital where the nursing assistant acted more professional than the nurse, I would have to say I would prefer that the nursing assistant start the IV. In my case, at least I would know that the nursing assistant would care enough to assess the site when necessary and not try to sweep unpleasant findings under the rug of "if I don't say anything, nobody will know the difference".

[Crystal-Wings, LVN]

This is why they never should have replaced LPN's with CNA's in the hospital setting.

[NurseBlaq]

On 7/6/2019 at 9:57 AM, brownbook said:

The whole issue is as clear as mud.

I couldn't make it any further. Never heard this one before but I'm stealing it. ?

[NurseSpeedy, ADN, LPN, RN]

I would think that the medication given IV had a lot more to do with the IV sites needing to be replaced than the fact that a CNA inserted the IV. Phenergan is horrible IV and the last time I worked in a hospital setting (about 1 year ago) we were not permitted to give it IV. It was IM only per policy.

Many years prior I remember it routinely given IV. I also remember IVs needing to be replaced after Phenergan was given-more often if the RN did not dilute the medication and/or pushed the medication too fast. When I first started working as an LPN we could only start IVs with a mandatory state approved 30 hour certification course. With this certification we could also administer certain medications IV but a facility had the right to further restrict our role if they chose to do so. One hospital allowed LPNs to start the IV, hang fluids and piggyback medications but the RN has to do anything IV push. Often times there was one RN with several LPNs. This meant several IV pushes. I remember the injection being finished too quickly (injected more like an IM than slow IV push would be administered) or undiluted and needing to replace the IV site shortly after the medication being given.

For what it’s worth I have not encountered a facility that has allowed CNAs to insert IVs. I’m not saying that I think it’s okay that the task has been delegated. I do think that too much frustration and blame is being put on the fact that the CNA started the IV. Either a different medication or different administration route May have been a better alternative. Often times recently working as an RN with patients that needed frequent IV replacement a PICC nurse would insert a midline or obtain a PICC order for harsh IV medications such as the antibiotic vancomycin which is also very hard or peripheral IV sites.

[PollywogNP, ADN, BSN, MSN, LPN, NP]

My daughter is an EMT working in stepdown ICU in the role of NA & she does start IV's.

[BSMSCCRN]

As I said before, I have n problem with a individuals who start IVs on a daily basis to start them, such as Paramedics. This would include EMTs.

[Crash_Cart]

On 7/5/2019 at 3:58 PM, BSMSCCRN said:

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!

RN's don't want to work at the bedside anymore. They think their higher level degrees means they don't have to wipe any butts or do other mundane bedside tasks anymore.

Did you somehow expect things to remain the same as it was before?

I'm not disagreeing with you and in fact i'm from the old school way of doing things myself, but I am merely pointing out an observation of what has been transpiring in recent years in the professional practice of nursing.

Like it or not CNA's are replacing these RN duties of the past and who's fault is that exactly anyways?

[StevieRay BSN RN]

To be honest, I don't really feel strongly on this topic either way. If I worked with a veteran CNA who was great at IV insertions, I would have absolutely no issue going up to them & asking if they'd be willing to get a stick for me while I got one of their patient's off the bedpan etc.

However, I am wondering how you all feel with the assessment that goes along with IV insertions, or do most of you believe it's just a task that anyone can learn?

When I'm starting IV's, I usually try to think about what the IV will be needed for. Does my patient need maintenance fluids, a bolus? Will they be receiving vasicant medications such as vancomycin, potassium? Do you think CNA's would think about gauge size, the best anatomical location, the property of the meds that will be administered? Or maybe the most important thing is that we're just able to get IV access in the first place?

I'd be interested to hear what everyone thinks.

[canoehead, BSN, RN]

BSMCCRN

You went right off the deep end. Its one thing to start an IV in an adult, and you then started talking about CNAs managing drips and PICU pediatric patients. That's not happening. Look at it from the other direction- phlebotomy is a relatively easy skill, and its just a step further to leaving a cannula in a vein and flushing.

Once the IV is in, your assigned nurse needs to continually assess the site, including before and after the meds she gave. So complications can't just be blamed on the CNA.

[kbrn2002, ADN, RN]

I wish our work policy would allow staff other than RN's to access veins. Even LPN's are not allowed to draw blood for labs much less the CNA's. Probably the best stick in the building would be one of our CNA's that is going to nursing school, he was formerly a medic in the service and can hit a vein in a moving vehicle over rough terrain. Sadly we can't take advantage of this but he has walked me through finding that elusive vein more than once, pointing out exactly where I should insert the needle and it's worked every time. If I needed an IV I'd trust him over most RN's.

[HealthCog]

The last time I had an IV in, the RN butchered me. Finally the phebotomist popped in to get my blood, only to find that access wasnt there. She took the tray from the nurse and had the line in 1-2-3.