ICU Nurses, Clear The Pumps q1hr and Document Or...

[Aloe_sky]

I am at a new facility where the nurses clear pumps q1 and document continuous fluid intake instead of clicking in the prescribed volume in the computer. They say it's "not accurate" but this is really frustrating. I get it if a patient for example is on a bicarb drip and pharmacy hasn't delivered the medication yet and it runs dry and is off for a bit BUT for the most part that is rare. Management says they are supposed to click in the intake but the nurses don't agree. The manager is young and new, these nurses are new to computer charting and very resistant to change.

I have told the nurses that if they change the rate of a drip and document it in actual time in the computer and click the volume infused at the end of the hour it IS accurate. They don't agree.

Another problem I told the nurses is that they are not programming the pumps to the pharmacy dosing weight so if pharmacy has the clinical weight as 100kg the pumps need to be programmed to that weight for the volume to be accurate.

These nurses are changing the patient's weight daily in the pumps and it is driving me crazy!

My patient has been admitted to the ICU for 2-days and it is documented that the patient had OVER 600 THOUSAND mls of Norepinephrine in less than 48hrs, I told the nurse when she came back that she documented the patient was getting 11000mls of Levo an hour and it needed to be fixed. 

The next day a nurse documented she gave 2200mls of Levo, 1200 of bicarb in ONE hour because I didn't clear the pump. Even if we had to go by pump infused clearing intake hourly, I would think common sense would tell her that should not be documented. 

We also have THREE patients in our ICU so the calculated dose of eg. Levo going in on the pump is 75ml/hr, that correlates with pharmacy dosing in the computer, they will document 200ml 1 hour and 25ml the next hour because they can't clear it at the exact top of the hour. A bicarb gtt ordered to run at 100ml/hr ranges in their charting. 

1 time scanned meds are a fixed rate in the computer, they can't adjust the intake on BUT they will add an "other" column and document the IVPB intake, even tho it is clearly documented already.

I was curious if this is done in your ICU because this is honestly bizarre to me. I don't want to be that new nurse that think she knows it all, I'm honestly trying to understand. Any answer from them is "that's how I was taught", it's a small hospital, these nurses have been there forever, I need help wrapping my head around this.

[JBMmom, MSN, NP]

Do the pumps interface with the EMR? It can be very important for accurate hourly intake and output in the ICU as you know, but it sounds like the system they have could do more harm than good. Clearing the pump every hour seems like an unnecessary step to me, but I'm not sure how they're connected to your EMR. If it's not then the MAR in the chart should be capturing the appropriate intake, with the exception of the primary fluid volume that doesn't run when a piggyback is hung.

And patient weights should always be the admission weight in the chart according to my hospital's policy. Every drip that is weight based has to have the weight manually entered. Sometimes new orders are entered in error using the daily weight that day instead of admission weight and we have to get it fixed. And for some patients the difference between admission weight and current weight is huge, so this could lead to a big error. The only thing that makes it less important is that for many infusions, the only thing affected by the weight is the starting dose and then they are titrated on other endpoints after that. Like heparin has to be therapeutic based on blood tests and other medications are titratable based on things like RAAS or CPOT. 

Good luck in getting to the best practice for your unit! 

[Aloe_sky]

JBMmom said:

Do the pumps interface with the EMR? It can be very important for accurate hourly intake and output in the ICU as you know, but it sounds like the system they have could do more harm than good. Clearing the pump every hour seems like an unnecessary step to me, but I'm not sure how they're connected to your EMR. If it's not then the MAR in the chart should be capturing the appropriate intake, with the exception of the primary fluid volume that doesn't run when a piggyback is hung.

And patient weights should always be the admission weight in the chart according to my hospital's policy. Every drip that is weight based has to have the weight manually entered. Sometimes new orders are entered in error using the daily weight that day instead of admission weight and we have to get it fixed. And for some patients the difference between admission weight and current weight is huge, so this could lead to a big error. The only thing that makes it less important is that for many infusions, the only thing affected by the weight is the starting dose and then they are titrated on other endpoints after that. Like heparin has to be therapeutic based on blood tests and other medications are titratable based on things like RAAS or CPOT. 

Good luck in getting to the best practice for your unit! 

We use cerner, when the medication is scanned and rate adjusted and documented, it calculates the volume infused that hour. These nurses "unchart" or clear the computer calculated volume infused. 
 

I spoke to my manager about this because I'm honestly irritated, the fluid balances are always way off, the I&O aren't accurate and yes, pTT are affected. My manager said he has tried to talk to the staff and they are very resistant to change. Therefore nothing will be done, I will continue to chart the way I do and try not to get irritated.

Thanks for the response! 

[Delia37, MSN]

To answer your question, personally I've never come across this practice (been in ICU for 21 years). I agree with JBM; this seems unnecessary and frankly, very unsafe. The manager and the educator (s) need to step up and provide guidance and counseling to those nurses "resistant" to change. However, based on your manager response (and his lack of backbone); at the end of the day, you need to decide for yourself if sticking your neck out like that is worth it for you. You can only do so much, especially without support.