Anatomy of a Code - page 3

You're standing at your computer, charting on your patients. The end of the shift is nearing, and you really want to get this done so that you can get home. As you are typing, you hear a loud... Read More

  1. by   Lynda Lampert, RN
    Hi all,

    Actually, in my facility, not all patients had IV access. For instance, those staying overnight after a procedure would not usually have access. However, when I worked telemetry, they all had access, but most of the time that access was poor. It would be, like, a 22 in the hand or something. Not conducive to the pushing that is needed in a code, so access would usually be started anyway. The whole situation was confusing, but I do remember both the IV nurse and the phelb there.

    As for drawing from an IV site, when I was working the bedside, this was strictly not allowed. I was told that it had something to do with the sample becoming too diluted from the flush, even when using a discard. It was also thought that the peripheral IV could not handle the vacuum of the tube. Again, I'm not sure if this is different for codes. I know in the ER at my hospital, they could draw from IVs. I know that floor nurses were absolutely not allowed to because I had to fight with many patients over it.

    Like I said, there was both an IV start and a blood draw. That's how I remember it, but, like I said, it was a very crazy and nerve wracking situation. Practice has changed since then, and it has been a few years since this happened. I stayed true to my memory, but sometimes memory doesn't make sense, especially in a code.

    Lynda
  2. by   VANurse2010
    Quote from Lynda Lampert, RN
    Hi all,

    Actually, in my facility, not all patients had IV access. For instance, those staying overnight after a procedure would not usually have access. However, when I worked telemetry, they all had access, but most of the time that access was poor. It would be, like, a 22 in the hand or something. Not conducive to the pushing that is needed in a code, so access would usually be started anyway. The whole situation was confusing, but I do remember both the IV nurse and the phelb there.

    As for drawing from an IV site, when I was working the bedside, this was strictly not allowed. I was told that it had something to do with the sample becoming too diluted from the flush, even when using a discard. It was also thought that the peripheral IV could not handle the vacuum of the tube. Again, I'm not sure if this is different for codes. I know in the ER at my hospital, they could draw from IVs. I know that floor nurses were absolutely not allowed to because I had to fight with many patients over it.

    Like I said, there was both an IV start and a blood draw. That's how I remember it, but, like I said, it was a very crazy and nerve wracking situation. Practice has changed since then, and it has been a few years since this happened. I stayed true to my memory, but sometimes memory doesn't make sense, especially in a code. That stuff about saline dilution is baloney if you do it right.

    Lynda
    Labs are drawn off PIVs in ICUs all the time without it being an issue. You don't necessarily have to flush it first if it's been previously flushed and draws well (just draw some waste, then you sample, then flush). Are percutaneous sticks better? Sure, but this is an emergency we're talking about here.

    It is RIDICULOUS that you have hospitalized patients without access, unless they are indeed a DNR. I think your facility needs to seriously rethink it's policies on access and what type of access is acceptable. A 22 in the hand is not OK on telemetry unless it's well documented that it was the only obtainable access.
  3. by   K+MgSO4
    Im not putting an iv in someone who is stable, simply waiting for a rehab bed, risks out weigh the potential benefits
  4. by   Lynda Lampert, RN
    I don't work there anymore, but that was the policy. They had a lot of policies that I didn't agree with. For instance, bedside nurses were not allowed and not trained to change central line dressings. It was pretty strictly enforced about drawing from the PIV. When I was in the ICU, we always had central access, so I never got to see if we could do it from a PIV. Still, I remember phlebs in the ICU, too, so someone must have been having blood draws.

    In addition, not everyone in the hospital had an IV and many tele patients had a 22 in the hand as their only access. Sometimes it was hard to get anything else. Sometimes, it was all that particular nurse was able to get. Like I said, I don't work their anymore and decided to pursue my own business about five years ago. They have since been taken over and may well have changed those policies. Someone may have complained, too, because it was a crappy policy. I just went with it and told my patients they had to have sticks for blood despite having a peripheral in their arm. Not very happy patients because of that, I can tell you!

    Patients on less acute floors may or may not have had access. It depended on their condition, but it certainly was not required. I got a patient with afib with RVR from a less acute floor, and I had to get access before I could even begin the Cardizem. I could see from tele that they were in the 120s, but there was nothing more I could do until we got access. And he was a tough stick, too. The other floor nurse noticed his HR was fast and irregular, and that tipped her off. Then we got the emergency transfer and had to deal with the cluster of stabilizing the patient.

    Lynda
  5. by   MsNuFayth
    very well written and I felt as if I was there!!! Thank you for sharing. Being a new Grad RN i haven't been the primary nurse in a code yet, and I feel that I would be terrified if I did. I seen maybe 3 so far on my unit in the pass 5 months, But I want to learn and better prepare myself so I signed up for ACLS and will participate in mock codes if its available.
  6. by   whofan
    I work at a teaching hospital so luckily we have residents and fellows to help.This does not always lead to a good outcome but we do have a great survival rate. The pharamacist on hand at night is a wonderful luxury we do have, especially since we do have residents running codes at times and they need a nudge on what med to give next.
  7. by   CamillusRN
    Very well written and engaging, but I had to laugh to myself while reading. Critical access hospital night shift = 3 RN's and 1 CNA in total. Radiology, Phlebotomy, Physician, and other available nursing staff all up to 1/2 hr's drive away. Thankfully, we have comprehensive protocols and experienced nursing staff. But when you have 15+ patients of varied acuity already on the floor and add a code to the mix, things can get incredibly harried. Code team? LOL - we're it!
  8. by   VANurse2010
    Quote from K+MgSO4
    Im not putting an iv in someone who is stable, simply waiting for a rehab bed, risks out weigh the potential benefits
    A person in acute care that' s a full code and has no IV access is unacceptable. How does a well-placed PIV outweigh the infection risks of a drilled IO?
  9. by   thenightnurse456
    Quote from VANurse2010
    A person in acute care that' s a full code and has no IV access is unacceptable. How does a well-placed PIV outweigh the infection risks of a drilled IO?
    Wow nursing culture is so different in the US!

    I've worked in hospitals where policy dictated all telemetry patients had to have access, but to put a PIVC in someone just because they are in the acute setting is completely foreign to me and such an unnecessary risk. (This is just my opinion and how I was trained, in no way am I picking a fight)

    PIVC are used when indicated. Ie: medication/antibiotics or if a patient warranted a PIVC due to their clinical condition.

    I know all patients have the potential to deteriorate and code, but it would be at that time of deterioration in my assessment as a nurse that I would put one in/get an order (however it works in US).

    But we wouldn't ever put one in someone "just because". I've seen patients get horrible infections from PIVC.

    Very interesting!
  10. by   RNsRWe
    Quote from VANurse2010
    Labs are drawn off PIVs in ICUs all the time without it being an issue. You don't necessarily have to flush it first if it's been previously flushed and draws well (just draw some waste, then you sample, then flush). Are percutaneous sticks better? Sure, but this is an emergency we're talking about here.

    It is RIDICULOUS that you have hospitalized patients without access, unless they are indeed a DNR. I think your facility needs to seriously rethink it's policies on access and what type of access is acceptable. A 22 in the hand is not OK on telemetry unless it's well documented that it was the only obtainable access.
    It might be worth noting, for context, that the writer of the article stopped working as a nurse four years ago, after working three years in the settings she described. The policies might have been in place during the short time she was there, but now...? Who knows. Hopefully improvements
  11. by   Lynda Lampert, RN
    Yes, the bold faced summary at the top states that things have changed, especially with the ACLS protocols. I haven't had that class in years, but I would take it again because I thought it was fun. I hope things have changed since then, but I needed to get away from the bedside because of nights like this.

    And, yes, we had all of that staff available. We were a trauma center and the floor held about 50 patients when full. I think I had six that night and four CNAs were assigned to the floor. So, it is different everywhere. As for whether or not that patient should have had an IV, it sounds like every place has a different policy for it! In short, your milage may vary. The important point to take away is the emotion, grief, and pressure of this type of situation.

    Lynda
  12. by   VANurse2010
    Quote from thenightnurse456
    Wow nursing culture is so different in the US!

    I've worked in hospitals where policy dictated all telemetry patients had to have access, but to put a PIVC in someone just because they are in the acute setting is completely foreign to me and such an unnecessary risk. (This is just my opinion and how I was trained, in no way am I picking a fight)

    PIVC are used when indicated. Ie: medication/antibiotics or if a patient warranted a PIVC due to their clinical condition.

    I know all patients have the potential to deteriorate and code, but it would be at that time of deterioration in my assessment as a nurse that I would put one in/get an order (however it works in US).

    But we wouldn't ever put one in someone "just because". I've seen patients get horrible infections from PIVC.

    Very interesting!
    PIV infections are pretty rare. However, this really has more to do with medical professionals being far more exposed to liability in the US than they are in other countries.
  13. by   suga_junkie
    Quote from VANurse2010
    PIV infections are pretty rare. However, this really has more to do with medical professionals being far more exposed to liability in the US than they are in other countries.
    Phlebitis is really common though. I can't imagine having to stick IVs in patients not requiring IV meds, especially those with fragile veins. I could see how you could end up using up all their peripheral access when the unused IVs tissue/blow/fall out etc during a hospital stay and then not being able to find access easily during a code! I'm in Australia, we definitely do not put IVs in every patient. In fact, our docs are big on taking out IVs as soon as our post-op patients are not on IV fluids/antibiotics/analgesia etc anymore due to infection risk. They can get quite irritated if a patient has an IV in that hasn't been used for 24 hours. Such a different nursing culture in the US!

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