Evidence based vs experience based practice - sub q drugs

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Specializes in Med onc, med, surg, now in ICU!.

Hi all.

I am a new grad working in a medical oncology ward. A lot of our doctors write up metoclopramide, ondansetron and dexamethasone as sub-q. As an educated nurse, I consult my 'evidence' - the drugs book, I ring pharmacy, read the manufacturer's recommendations, whatever, and they unfailingly say that these drugs are not recommended to be given by that route.

My senior nurses, including hospice nurses, have given and do give these drugs via the sub-q route. I would really rather not do that, because I know that "But Di told me it was OK" is not an adequate defence in court (if it comes to that). My problem is that I am not confident telling the doctors I don't want to do it the way they have charted, and that I don't want to undermine the experience of the senior nurses. I have found that, despite the recommendations, the patients don't have any adverse effects from sub-q administration of these drugs, but all the same, it doesn't sit that well to go against the hard-copy evidence.

I guess I could just ask the docs to chart IM or IV as alternative routes as well as sub-q, and give them IM or IV when they are my patients, but that leaves the other nurses who do give them sub-q. It's part of my role as an RN to identify 'unsafe' practice and do something about it - but what can I do? These nurses are very good at their jobs and have years of experience.

What do other new nurses suggest I should do? Or, does anyone have any good evidence to say that these drugs can be given sub-q?

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Maybe ask this in the "Med Savvy" forum (under the General Nursing forums). I'd be interested to hear responses to your question!

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Specializes in Community Health, Med-Surg, Home Health.
Hi all.

I am a new grad working in a medical oncology ward. A lot of our doctors write up metoclopramide, ondansetron and dexamethasone as sub-q. As an educated nurse, I consult my 'evidence' - the drugs book, I ring pharmacy, read the manufacturer's recommendations, whatever, and they unfailingly say that these drugs are not recommended to be given by that route.

My senior nurses, including hospice nurses, have given and do give these drugs via the sub-q route. I would really rather not do that, because I know that "But Di told me it was OK" is not an adequate defence in court (if it comes to that). My problem is that I am not confident telling the doctors I don't want to do it the way they have charted, and that I don't want to undermine the experience of the senior nurses. I have found that, despite the recommendations, the patients don't have any adverse effects from sub-q administration of these drugs, but all the same, it doesn't sit that well to go against the hard-copy evidence.

I guess I could just ask the docs to chart IM or IV as alternative routes as well as sub-q, and give them IM or IV when they are my patients, but that leaves the other nurses who do give them sub-q. It's part of my role as an RN to identify 'unsafe' practice and do something about it - but what can I do? These nurses are very good at their jobs and have years of experience.

What do other new nurses suggest I should do? Or, does anyone have any good evidence to say that these drugs can be given sub-q?

I am interested in this, also, because I certainly understand your dilemma. Everything is 'okay' until something goes wrong. From that point, here are the arguments and the accusations.

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Drug books don't always hold the most accurate information. I read a while back that Dilaudid dosing has been incorrect in the med books for years. Check with the package inserts, micromedex, and the drug manufacturer for the most up-to-date information.

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Specializes in Oncology/Haemetology/HIV.

As a question. Since most vials of ondenestron and reglan are based on an average dose being 2ml, does this mean that you are giving multiple doses per day of 2mL sub-q?

That's a rather large volume to be giving subQ, especially in multiple doses daily. Barring neupogen (which is only once daily), that is a bit much especially when many oncology patients have little to no fat reserves.

Second, on most oncology units, the trend is towards as few IM/SQ injections as possible. This is to minimize discomfort, bleeding/bruising (secondary to thrombocytopenia), and infection risk(secondary to neutropenia). If a drug is clearly indicated as safe to give IV, there is little to no logical reason to give it via an unapproved route which poses MORE danger to the patient and MORE pain to the patient.

The HC providers that order this way may be doing a disservice to their patients unless thay show a logical reason why this practice is better than IV, barring a one-off if IV access is not available. They also need to provide concrete evidence that it is safe and approved to give it SubQ.

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Specializes in Med-Surg/Tele, ER.

Did this get posted under the MedSavvy forum? I'd be interested to hear the responses there as well. This seems like a difficult question.

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Specializes in Med onc, med, surg, now in ICU!.
Did this get posted under the MedSavvy forum? I'd be interested to hear the responses there as well. This seems like a difficult question.

Sorry, I've been inateentive. I'll do it now. Thanks for the replies so far, I might subtly quiz some of the senior nurses today.

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