IV question

Animal3 · Jul 2, 2012

Thanks all I was just curious if this was OK, I will continue to pull a secondary out of the med room when I a primary hooked up as a secondary, Thanks for all who understood what I was asking!

iluvivt, BSN, RN · Jul 3, 2012

Maybe I was not clear..once a seconday is attached..it can stay in play however long your policy says it can. My point is that once the nurse starts disconnecting it and reconnecting it it should be treated as an intermittent tubing and whatever your policy happens to be..ours is 24 hours for primary intermittents. What bad practice are you talking about?..all of their standards are evidenced based..the whole point of standards are to have guidelines that promote good practice.

MunoRN, RN · Jul 6, 2012

Maybe I was not clear..once a seconday is attached..it can stay in play however long your policy says it can. My point is that once the nurse starts disconnecting it and reconnecting it it should be treated as an intermittent tubing and whatever your policy happens to be..ours is 24 hours for primary intermittents. What bad practice are you talking about?..all of their standards are evidenced based..the whole point of standards are to have guidelines that promote good practice.

There is no reason to disconnect a secondary, it should be considered part of the primary once attached and should only be changed at the same time as the primary.

The INS IV tubing change recommendations are essentially a policy cluster... and as Nurses we should all hang our heads in shame.

When communicating practice recommendations the first rule is to communicate effectively, which the INS failed to do. They use two parameters to describe different types of tubing; primary vs secondary and intermittent vs continuous, both of which they use incorrectly. When referring to infusions and tubing, "continuous" and "intermittent" is commonly understood as referring to whether or not it is running continuously or intermittently, not whether or not it remains connected to the patient.

"Primary" and "secondary" are even less flexible definitions. The INS defines a secondary as tubing that connects to the primary set for a specific purpose, such as intermittent infusions. Actually secondary infusions are ONLY for intermittent infusions. There can be multiple primary infusions; just because you "Y" two primaries together below the pumps does not mean one is a secondary and one is a primary, whether you Y levo into vaso or the other way around makes no difference, they are both primaries. We learned how this incorrect terminology can go horribly wrong. We had adopted the INS recommendation as our policy including the terminology. We had a Nurse (new to our facility but experienced Nurse) who referred to our policies when programming a NTG infusion into a pump. Our policy actually used NTG as an example of a secondary infusion since you would often use a NS infusion to "carry" the NTG, since the NTG was referred to as a secondary infusion, she programmed the NTG into the pump as a secondary. Luckily another Nurse caught her mistake before the volume on the NTG infusion reached zero and it reverted to the stored primary rate (125cc/hr) left in the pump from a previous patient.

The confusion created by the terminology, leaves most Nurses with the impression that secondary tubing should changed every 24 hours, even if it remains connected, which not only has no benefit, the evidence shows an increased risk in contamination when tubing (other than blood and lipid emulsions) is changed more often than every 72 hours.

Even when understood as the INS intended, their policy is still more likely to harm the patient than it is to help. If a continuous infusion is disconnected, to go for a walk for instance, then it suddenly becomes an "intermittent" infusion and needs to be changed 24 hours from that point, which often result with a manipulation of connections that would not have otherwise occurred, increasing contamination risk far more than it mitigates it.

The INS rationale for this is that the studies the CDC used for their recommendation specifically included intermittent tubing, even though they did not, they excluded tubing used for antibiotics, regardless of whether or not it was continuously connected. The INS argues that because they excluded "intermittent" tubing, that the extensive amount of evidence that shown no increased contamination risk with changes greater than 72 hours don't reflect common practice which includes occasional, sometimes excessive, tubing disconnections even though all of the studies were done in real clinical situations and included the practice of disconnecting for various reasons. The golden rule of IV care is to keep a closed system closed whenever possible, which the INS completely ignores without the support of any evidence whatsoever and completely ignoring the evidence that does exist.