Experience-based vs evidence-based practice - sub q drugs

[bethem]

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

[castens]

All of this from UpToDate:

Metoclopramide: Drug information

ADMINISTRATION-Injection solution may be given I.M., direct I.V. push, short infusion (15-30 minutes), or continuous infusion; lower doses (10 mg) of metoclopramide can be given I.V. push undiluted over 1-2 minutes; higher doses to be given IVPB over at least 15 minutes; continuous SubQ infusion and rectal administration have been reported. Note: Rapid I.V. administration may be associated with a transient (but intense) feeling of anxiety and restlessness, followed by drowsiness.

Ondansetron: Drug information

No information about SubQ administration

Dexamethasone: Drug information

No information about SubQ administration

[All emphasis mine.]