Infusion Nurse Society

MunoRN, RN · Mar 8, 2011

In my experience the INS is not a "go to" place for anything, they are out of touch with current practice, have little respect for evidence based practice, and fail to uphold the basic standards that a group making practice recommendations needs to meet.

IVRUS, BSN, RN · Mar 9, 2011

WOW... Out of touch. Hmmm. Is this the pot calling the kettle black? I'm just saying!! Are you even a part of Infusion Nurses Society, or just its critic because you have little to no knowledge about this organization?

jb2u, ASN, RN · Mar 10, 2011

Reminder: Topics are to be debated, but no personal attacks. Please read the terms of service for this website.

IVRUS, BSN, RN · Mar 10, 2011

Yes, I agree, and no intended attack toward anyone intended. If one has knowledge to share with others, then cool... if not, it's merely assumptions and speculations.

MunoRN, RN · Mar 11, 2011

I'm not really sure who the attacker/attackee is supposed to be but nothing intended and/or nothing taken.

My concern with the INS lie in two main areas. The first is not only that they seem to lack a basic familiarity with current practice, but that the manner in which they deal with these mistakes lacks the integrity that should be expected of any group the claims to be an "authority" in any type of Nursing practice. The second is that they appear unfamiliar, or even worse uninterested, in the responsible use of Evidence Based Practice.

Prior to a couple of years ago, I hadn't found the INS useful due to vague and out out of date info, but I didn't despise it either. Then my hospital made the ill-fated decision of basing it's IV policy on a direct interpretation of the INS standards. This was at first merely annoying, since the INS clearly didn't understand the difference between primary and secondary tubing among other things.

Then we had a near sentinel event that was directly due the INS's incorrect terminology. We had a nurse float to the tele unit (she normally worked in the outpatient unit which rarely used IV pumps) so when she needed to start a NTG gtt she referred to our IV policy. We run slow running gtts with a carrier fluid, and according to the INS definitions this meant that the NTG was the "secondary", so the nurse programmed the NTG into it's pump as a "secondary". When the VTI on the secondary program reached zero, the pump then reverted to the old primary rate from the last patient (100ml/hr). Luckily the error was caught early (due to the hints provided by the patient vomiting and then passing out).

If it was just an issue of incorrect terminology it would have been an easy fix in terms of our policy, but we were still left with trying to reconcile the CDC tubing change recommendation that both primary and secondary tubing changes should be changed no more often than every 72 hours with the INS recommendation that secondary "intermittent" tubing be changed every 24 hours. The CDC recommendation is category 1A and based on evidence that tubing changes more often than 72 hours not only has no benefit but actually appears to increase contamination risk. The INS's contradiction of the CDC's evidence based recommendation was not based on any evidence whatsoever, so we tried to at least understand their rationale, which was apparently that they were concerned that repeated manipulations at the catheter hub had an assumed risk due to the going under the dressing and the possible leakage of blood at the hub itself. This was again perplexing since it's been common practice for some time to not use the actual catheter hub for routine access, every IV should have an extension, and many IV's are now "hubless" so accessing at the hub isn't even an option. Beyond that, real secondary lines aren't connected at the hub but at a port above the pump, making this even more confusing. As far as we could tell, these false assumptions about current practice were from a source that had not been updated on these topics since 1977, that source was the INS's own previously published reference. Sourcing yourself isn't acceptable in an English 101 research paper, I'm really not sure why the INS thought they didn't need to follow the same basic standard and refer to an outside source.

Everybody makes mistakes, it's how a person or group deals with those mistakes that helps define their character. I made multiple attempts to address the issues of terminology, safety, and clarifying the basis of their recommendations and got no response to phone calls or e-mails. We then tried again as our hospitals practice council as a whole, again no response. We had two different members of our practice council that are also members of the INS attempt to clarify these issues with the INS, again no response. Any self-proclaimed "authority" that puts out recommendations and then refuses to address concerns or clarify doesn't have the responsibility and integrity required to play that role. I realize it takes up time, particularly with so many issues the need to be addressed, but it's part of the deal.

The INS's difficulty with Evidence based practice extends beyond just the secondary tubing change frequency. Responsible use of Evidence based practice requires basing major practice changes on some basic level of evidence or at least properly qualifying the recommendations based on the level of evidence, otherwise we develop a distrust of Evidence based practice, which is something it is already too prevalent. The most recent example is that of the 15 second scrub. The Maki et al study was designed to to determine if IV tubing with valved ports posed a greater risk for contamination than non-valved tubing sets, and found that indeed the valved sets pose a significantly greater risk of infection. While the study brings up the issue of whether or not a 3-5 second scrub is really sufficient, citing this study as the main basis for declaring a 3-5 second scrub to be insufficient is a bad use of supposed evidence when this is not what the study was designed to determine. What this should have prompted, was a study designed specifically to compare the efficacy of a 3-5 second scrub with long scrub durations. Instead, the INS made a major practice change based on the Kaler, Chinn study.

The Kaler study is an excellent example of bad research and the sort of thing that a true EBP "authority" should have no problem evaluating and qualifying appropriately. The Maki et al study was an RCT, which took place in a real clinical setting using multiple clinicians, and since it's purpose was to compare two different types of tubing, both types were included in the study, if the study only looked at the new valved tubing without using the old tubing as a control, it would have been essentially useless. The Kaler study, meant to compare a 3-5 second scrub with a 15 second scrub, only included the 15 second scrub and did not include a shorter scrub duration as a control. It was also conducted in a conference room and all the scrubbing was done by the same person (Kaler), effectively eliminating the known variables that existed in the Maki et al study such as cross contamination and variations in technique. It also only used a 10^2 inoculum, comparatively weak to other studies meant to evaluate the effectiveness of a disinfection technique.

If the INS felt that the limited evidence available was sufficient to justify hasty action, which I tend to agree with, the action should have been to advise that valved tubing sets not be used until it's safety has been better established, since the only thing we knew at that point was that valved tubing was more likely to be contaminated, and there was no reliable evidence that a longer scrub time made any difference. I realize this would have been a difficult position to take when a large portion of your funding comes from Braun, a supplier of valved tubing.

Since the Kaler study, there have been subsequent studies that include multiple scrub durations between 3 and 15 seconds and show no difference between them, suggesting that that the increase in contamination rates seen in valved tubing is not mitigated by a longer scrub duration. Spending an extra 10 seconds scrubbing a hub when it may not be necessary is not a horrible thing, but further contributing to a cynical view of any evidence and essentially crying wolf does have potentially serious consequences.

I'm not a member of the INS and while it's possible that someday I would value the work of the INS enough to contribute financially, currently they aren't exactly on my list of groups that I value enough to share my spare cash with.

jb2u, ASN, RN · Mar 11, 2011

It was just a friendly reminder before things get off track, as many times it does when people are passionate about their beliefs.

MunoRN...that is a very informative post!!

IVRUS, BSN, RN · Mar 12, 2011

Muno,

First, let me state that I do NOT believe that INS is unfamilar with, or uninterested in, evidence based practices.

I also do NOT believe that they are ignorant of the delineation, or care of IV tubing, be it primary or secondary.

The problem is the lack of established, reputable studies. Without this, INS will take a conservative approach on each subject. Because previous studies didn't include secondary tubing dwell, INS choose to take, as stated, a conservative approach and delinieate the tubing change time of q 24 hours. If backpriming isn't used, the constant disconnect and reconnect increases bacterial counts. The CDC hadn't made the distinction either, but did say that the hub should only be accessed with sterile equipment. Heck, that may be an issue after a single use, much less repeated usage.

Though focusing on Maki's study of scrub cleaning time is important.. It is not the "end all". Bottom line, you can scrub the hub repeatedly, but if you connect a contaminated piece of tubing, for instance, you've defeated the intended process. In the Kaler study, (though albeit, a study in a lab) they reviewed scrubbing the hub with both chlorahexidine and alcohol and then a combo of both, and it did not show any difference in bacterial counts, though remember that CHG is for skin antisepsis and not for hub scrubbing. And this study did not include drying time. CHG "cidel" effects occur upon drying, while alcohol works while wet, and has no residual effect once dry. Dr. Maki has stated numerous times that a 10-15 second scrub was needed. Kaler did as well. The author of the Kaler study said that they choose the 15 second cleansing recommendation, in hopes of getting 10 seconds in real time, clinical practice.

Also remember that all injection caps ARE NOT created equal. Though the FDA had concerns regarding positive displacement device and CRBSI's, I believe that one needs to look deeper... I think they need to be assessed: the positive displacement device, the negative and the neutral design. Does the injection cap have gaps visible on its end, or is it smooth? Should we all return to the split septum devices? Do you have a firm, and consistant policy in place which outlines how these caps should be cared for? There are studies which show that many CRBSI's are directly related to inappropriate, or lack of hub cleaning/maintenance. I have seen caps as flat as a pancake, whereas the pt has chewed it like this... Hello, way past a prn injection cap change, huh. I've seen them covered in feces... Yuch again.

I am confused as to your comment regarding the nitro gtt... first, if the person was using the nitro gtt as a secondary infusion, why didn't she program the pump for the primary solution as well as the secondary, if she had both a primary and a secondary? And how is that a fault of INS? What did I miss?

Also, everytime I have asked INS a question, whether in an email or a phone consult, I've never NOT received the information I'm attempting to garnish from them. Could it be that I've been a member for years, and hold credentials by them as well? Maybe, but remember that all of their publications are available to all medical professionals. I am sorry that your questions to them apparently fell on "deaf ears".

iluvivt, BSN, RN · Mar 13, 2011

I agree with IVRUS. I have never had any problems with the INS. When hospital and health care companies make policies and procedures they need to look at many resources ..not just one. I look at everything including new sutudes then I write the policies or revise them based on new standards and research. I think if you purchase the INS textbook you may find that more helpful. Yes I know the CDC does not directly address secondary tubing. My understanding is that primary intermittent tubing per INS should be changed q 24 hrs and secondary q 24 hrs only if you are connecting and disconnecting. If you connect it and backprime if it is indicated that hang time is longer. I am not sure what you are saying about the NTG? The CDC...INS...SHEA/IDSA and the ONS have very similar recommendations and standards.They can not all be wrong. Research costs money and IVRUS is correct in all aspects of nursing and medicine there are just not enough studies. in a lot of areas of practice. Also new products are constantly being invented and reworked and often put into the marketplace with little or no studies.

MunoRN, RN · Mar 13, 2011

I agree that we need more evidence, in fact pretty much everything we do is based on a pathetic amount of evidence. Because of this, a cautious approach is generally warranted. Although in the case of intermittent tubing, the 24 hour recommendations appears to the less cautious approach.

It used to be thought that the more we changed things out, the less risk for contamination and infection. Take vent circuits for example, we used to change them out regularly based on an unsubstantiated belief that this was safer, we now know that routine replacement of vent circuits significantly increases contamination and VAP rates. The same is true for IV tubing.

The INS seems to believe that the purpose of less frequent tubing changes is purely to save money based on a lack of evidence that less frequent tubing changes was significantly more risky. What they seem to have missed were the studies that showed not only a lack of increased risk, but actually an increased risk of contamination and colonization with more frequent tubing changes. Basically, what we now know is that a closed system is best left as a closed system unless there is a justification for opening that system. The INS recommendation calls for additional tubing connection manipulations that would not have occurred otherwise, without any justification, effectively increasing contamination risk.

What I find particularly perplexing, is if the INS believes that once tubing is disconnected it should be considered contaminated, why would you then continue to use it for another 24 hours?

I don't advocate going back to split septum caps, mainly because I still haven't moved to split septum caps. We still use interlink tubing (smooth diaphragm ports, no valves) due to the lack of proven benefit to tubing with valved ports combined with the safety concerns.

The problem with the NTG gtt was that the INS defines a "secondary" infusion as one that attaches to another infusion, which is incorrect. A "secondary" infusion is limited to intermittent infusions that attach above the pump of the primary solution only. The nurses confusion, which is hard to comprehend, was that our policy is that anything running at less than 15cc/hr needs to run with a carrier fluid (usually NS) so that the total running through that lumen is at least 15cc/hr (except for blood thinners). This means a NTG gtt at 5 cc would be y'd in to an NS infusion running at 10cc/hr. According to the INS definitions, the NTG would appear to be a "secondary" infusion. Based on that, when programming the rate for the NTG into the pump, the nurse programmed it as a "secondary" infusion. This usually isn't possible without setting up primary settings first (the NS was of course on it's own pump), but we use the old Baxter Flo-gards, which will retain all settings for 6 hours, even when off. So when the volume to be infused reached zero on the NTG pump, which was running on a secondary program, it reverted to the primary settings still in the pump from the last patient which was 100ml/hr; way, way too fast for a NTG gtt. Essentially, the INS definitions is that a secondary is a secondary, except for when you are programming the IV pump you have to remember that the secondary is actually a primary, or if you disconnect it then it magically becomes an intermittent primary.

iluvivt, BSN, RN · Mar 14, 2011

Yes I see what you are saying and now understand what happened. If you understand how the pump you use works it would seem reasonable and prudent that all nurses in that setting should have and understanding of that pump. I am surprised that you are still using such an old pump. My interpretation of the secondary tubing is the same as yours.I would not want to use a primary intermittent tubing for more than 24 hours based upon the care or lack thereof that I have seen with these tubings. We have struggled to get the nurses to apply a new sterile end cap after use. they still continue to loop the tubing into an injection port and use the syringe caps or anything handy. I would prefer if the nurses would learn how to backflush properly.What I see more often is multiple secondaries hanging.

MunoRN, RN · Mar 31, 2011

The issue of multiple secondary lines also came up in our attempts to update our policy. Bringing our policy up to date was again not only not helped but rather hindered by the INS.

The obvious question that comes up with the INS recommendations is why you would need to identify secondaries as "continuous" or "intermittent" (and why you would use terms that most would assume refer to a continuously running IV vs intermittently running, especially since the correct definition of a secondary is one that runs intermittently).

Correctly named "secondaries" should never be detached from the primary and should be taken down with the primary set. Even incompatible fluids can go through the same secondary with a proper backflush. Here's where the INS is not only fails to be helpful, but is actually just a nuisance. The INS makes no comments or even acknowledges, much less makes a recommendation on using multiple secondary lines vs using the same line for the purpose of maintaining a closed system. We found 8 different nursing fundamentals textbooks, all of which recommended the use a primary/secondary setup for intermittent infusions as well as the use of a backflush for priming as well as in between infusions. I wondered then why the INS seemed oblivious to these techniques. I noticed that their recommendations on IV tubing was based on only one source: Their own textbook. While the textbook was last published in the early 2006, the IV tubing and pump section had clearly not been updated since it was first published in 1974. The book only mentions IV pumps in passing as some sort of futuristic concept yet it does devote an entire page complete with pictures to the use and care of reusable glass containers that were apparently the precursor to plastic IV bags. This is why a basic premise of responsible of evidence based practice is to use outside sources and preferably more than 1, their use of evidence wouldn't earn a passing grade on an English 101 research paper.

Anyway, we weren't able to include in our policy that the backflush method is the preferred method and that we shouldn't be disconnecting secondary lines unnecessarily because we have a couple of nurses and a CNS who refuse to believe that the INS may not be the "authority" they claim to be. A true authority on a subject should have an answer to any question they are the "authority" of, or at least be capable of understanding and acknowleding the question when there is no known answer. By claiming to be the authority on infusion nursing, yet seeming to have no idea what the practice questions are much less the answers, we're left with a mish-mosh of good and bad practice with the only effect of the INS being as a roadblock to defining best practices.