Help/Advice Needed - KCL without pump/Oncology clinic

[AliC]

I was hired at an oncology clinic where they do outpatient chemotherapy 5 days a week. I just graduated and have no experience actually working as a nurse. It's a great M-F schedule, and it pays well. I was pretty shocked that they wanted a new grad. (This clinic is in a rural area, and certified oncology nurses are apparently scarce.)

The oncologist mixes the chemo and the RN's are responsible for administering it. The patients all have implanted ports. The problem is that there are no infusion pumps at this clinic! So, some days we are having to administer KCL infusions (20 mEq in 500 mL NS) over the course of 3 1/2 hours without a pump. Yesterday was my first day, and I just found this out. I am freaking out about this a bit.

Does anyone have any advice? Is it ok for me to be administering chemo without certification? Is it possible to administer potassium this way and still be considered a good, ethical nurse? There is not a nursing shortage where I live, and I was starting to feel pretty desperate by the time I found this job, so I don't think I want to just quit. However, I don't want to be setting myself up for disaster either. I would appreciate help from others who have been in similar situations.

[Dan's Sunshine]

You need to check with your BON to see if you can hang chemo. I am an LPN in Florida - according to the state I can hang chemo but my hospital will only allow oncology certified RNs to hang chemo. As for the KCL, I would be comfortable hanging that without a pump. You can do a max of 20meq in 1 hour on a regular med surg floor. If it is 500ml I don't think you would be able to infuse it too fast unless you were trying to. Even if it ran faster than you wanted and infused in 2 1/2 hrs it would still be fine. Hope that helps.

[Ginger's Mom, MSN, RN]

Oncology clinic should have pumps for chemo never mind KCL. This is unsafe nursing and medical practice, the costs of the pumps would avoid a very large lawsuit. The clinic is trying to cut costs by unsafe practices and to make it worse the infusions are going in by a port ( which should have a pump attached for even IV fluids).

I would not work in this clinic, and I would notify Department of Public health this is an accident waiting to happen.

[heron, ASN, RN]

First ... CALM DOWN! We were giving chemo and kcl long before pumps were available. It can be done.

I can't answer your question about chemo certification ... I suspect that, as an employee of a private practice, you're covered there, legally. BUT you're still responsible for giving the chemo safely. Perhaps experienced oncology nurses can give you references to study. Meanwhile, use your PDR whenever you have to give chemo ... it would take just minutes to look up the specific drug and skim the precautions section. It can't hurt to investigate the availability of certification courses in your area. Even though your employer doesn't require it, it's great on the resume and would make you feel more confident regarding your skills.

As for the potassium, 20mEq over 3+ hours is pretty safe. You need to find out how many drops per cc is delivered by your IV sets. From there you can figure out how many drops/minute you need to set your iv in order to deliver 500cc over 3.5 hours. Convert 3.5 hours into minutes and divide that number by 500 = cc/minute ... multiply by #drops/cc on your infusion sets = #cc/minute you need to deliver. From there, it's just a matter of counting drops and adjusting the roller clamp until you get the right rate.

Here's how I would do it:

3.5x60=210 minutes, div by 500=0.42cc/minute, if your sets are 60 drops/minute, then 0.43 x 60=25.2 drops/minute.

Round that down to 24, divide by 4 = 6 drops/15 seconds. Just adjust the roller clamp until you can count 6 drops in 15 seconds and your infusion will run in a bit over 3.5 hours. (I rounded to a number that was divisible by 4 ... easier to count over 15 seconds and multiply x 4 than to count over one minute. Also, it's impossible to count a fraction of a drop. I rounded down rather than up on principle ... a hair slow is theoretically safer than a hair fast. You have a big margin of safety here, since most facilities consider 20mEq over an hour to be safe.) Watch those decimal points and, yes, I used a calculator!

The key to working without pumps is monitoring. Try to check your rates frequently ... it can change with position changes, even with implanted ports. You especially don't want to have them speed up. Always remember that you don't have alarms to tell you when there's a problem.

Meanwhile, you are correct to worry about safety when giving chemo and kcl by gravity. It really isn't ideal. Many pharmacies have infusion pumps available to rent ... my hospice unit used them for over a year. You might mention your concerns to the oncologist, she may not have considered the liability issues involved.

There are also flow meters available that can be attached to the infusion set and will allow you to set a flow rate by turning a dial. If your employer doesn't have them, she may be willing to order them as an alternative to renting pumps.

[Roy Fokker, BSN, RN]

heron,

That was a great post.

Thanks!

cheers,

[Lacie, BSN, RN]

Heron gave great advice! Wow someone that remembers Dial Flows lol!! I think we're telling our age here Heron :chuckle

[SuesquatchRN, BSN, RN]

Heron gave great advice! Wow someone that remembers Dial Flows lol!! I think we're telling our age here Heron :chuckle

I couldn't pass my clinical exam last year without setting an IV to the correct rate just by the clamp.

[heron, ASN, RN]

I just hope I didn't insult the OP with the dissertation on figuring flow rates! I just wasn't sure if it was stressed as much, or even taught anymore, as when I was in school. If I did, I apologize ... meant no disrespect.

The take home message is that it is possible to be a good ethical nurse without iv pumps. The key is know your drugs, careful with the math and monitor, monitor, monitor.

Did I mention monitoring is important?

Can't say as I blame the OP for being nervous about the situation. If the standard of care assumes the availability of a pump and she doesn't have one, she really has to know what she's doing.

I shudder to remember what I used to run by gravity back in the 70's on a general medical floor - lidocaine and levophed spring immediately to mind, with cardiac monitors in the hallway outside the door connected to the pt with loooong cables ... all with a patient load of 11(on eves) to 22(on nites). Eesh!

Personally, I think a good iv pump is better than sliced bread!

[morte, LPN, LVN]

remember, all thoughs "drips" are called drips for a reason,lol.......and i think it was a "dial a flow" saw one of those in the ccu at "the general" in the eighties when my hospital transferred a patient there....

Abbott Dial-A-Flo

[Ginger's Mom, MSN, RN]

I have questioned why we teach the drip rate in school since it is almost obsolete.The rationale being in case of emergency a nurse would know how to calculate a drip rate.

I have been a nurse since the 1970's and even then the standard of care was central line one must have a pump, now you are talking about chemo and KCL. On top of this the nurse who posted this is a newly licensed nurse. I personally would question the doctors who ascribe to this practice.

[SuesquatchRN, BSN, RN]

Why didn't you mention monitoring?

[MurseMikeD]

20 mEq over 3.5 hours should be fine. 20 in one hour, not okay without a pump. Standard of care, more that 10/hour requires cardiac monitoring and a pump.