IV push meds

[CapeCodMermaid, RN]

With the new Medicare regs that will penalize hospitals for patients who are re-admitted in 30 days of discharge for certain diseases...CHF being one of them, the push (no pun intended) will be on for Skilled facilities to do more and more. The director of Case Management at our local hospital said she is expecting that nurses in SNFs will be doing IV Lasix and IV solumedrol. Neither I nor my staff is happy about this. I'm pretty sure only RNs can do IV push and I've never worked in a facility that allowed nurses to do IV Lasix. Any thoughts from you all?

[debRN0417]

In the LTC setting there will have to be an RN available to do the pushes. It is going to require training and new policies and procedures, which is just what LTC needs, more stuff to keep up with and an RN on duty 24 hours a day seven days a week, which in some areas is very hard to do. I'm all about keeping folks out of the hospital, but how are they going to reimburse facilities for this service, taking into account the added burden of stafing and paying that RN...needless to say the extra training that will be required. There is also the increased monitoring and 1:1 nursing care that will need to be provided should a resident be in a situation that required the use of an IV push medication. To me, anyone who is sick enough to require IV push, is sick enough to be hospitalized, but that is just my opinion. I know there are many nurses who can meet this challenge and who are knowledeable and well trained on the requirements/risks of IV push, but it sets the LTC up also for any problems that may come from this as well. If there is a problem that arises from the IV push and then the resident is sent to the hospital, and the LTC has to report why the resident was sent out, then the state could come in poking around to find out what happened...and thats just aggrivating for everybody. Medicare never ceases to amaze me....

[CapeCodMermaid, RN]

Thanks for your thoughtful (and thought provoking) answer. I'm all for teaching nurses new skills. When I first started in long term care, IVs were a rarity and only the 'best' places did them. But,I wouldn't want to be the one pushing lasix in a SNF. I'm going to have be having many long talks with the corporate people if they expect us to be doing this.

[kids]

I've given 'push' meds including lasix, in SNFs going back to the early 90s. This has come up in the past and I think it's a regional thing.

If your nurses are really, really resistive to pushing meds have them request orders doing it (when it comes up) have them request orders to mix it in 50cc of an appropriate fluid and give it over 30 minutes.

[NurseKatie08, MSN]

I've given IV Lasix in my SNF setting...not push though, it was mixed in 100ml and I believe it was over an hour. I was nervous enough about that, stayed in the room with the patient the entire time basically checking VS (this was on a TCU, I had 7 other patients who were thankfully pretty stable...can't see this working on a long term floor). I'd be way too nervous to push Lasix, but I've also never given an IV push.

[CoffeeRTC, BSN, RN]

Wow...I guess I never realized how regional things are. We are a smaller facility and operate with at least one RN on duty at all times (sometimes not on 11-7 tho) We've been doing iv pushes for years.have done pain meds, lasix, steroids. Its really not that hard to teach (you could have the pharmacy come in to do an inservice) but I can see how it would mess with staffing.

In larger facilities where I was the only RN for the floor or builiding, I would just have to float around and do the IVs and my other duties (supervise or work the cart or even do both)

[debRN0417]

Thanks for your thoughtful (and thought provoking) answer. I'm all for teaching nurses new skills. When I first started in long term care, IVs were a rarity and only the 'best' places did them. But,I wouldn't want to be the one pushing lasix in a SNF. I'm going to have be having many long talks with the corporate people if they expect us to be doing this.

You're so welcome!

I worked in ER and ICU and on various units in a hospital setting (as well as LTC) and I have always been very careful with IV push meds. It always made me nervous. Once that med goes in main-line, its effects are immediate and can be devistating...I have worked with nurses who were very careful and I have worked with those who did not seem to realize how serious this procedure is. They would just go in and pop that stuff in there and it would scare me to death. I think with good training and emphasis on safety and monitoring it can be done. I guess we have to reckon with the fact that skilled nursing is changing and is going to be a very "skilled" and technical part of nursing. I'm okay with that, just concerned also about the costs that will filter onto the facilities who are already stressed with the burdens of increasing costs of care and decreasing reimbursement to provide that care. I just wonder where they think all that money is going to come from when the acuity levels increase, the requirements for technical expertise increase and the reimbursement does not change. I know I am talking about money, money, money, but it all boils down to being able to financially provide the needed services as well as being able to attract and retain staff when all these additional demands are placed on them. I mean, if I can make 50 bucks an hour in a step-down unit of a hospital versus 20 bucks on a skilled unit, where I am required to perform the same nursing functions, for most people in this economy the decision is the money. There are those, though that still would choose LTC/skilled, but those are few. There will be such a big push with facilities to attract the Medicare client that it may cause some positive changes in corporate thinking about the quality of care provided and that they have to "put out" in order to reap the benefits. Staffing levels will have to change with the added responsibilities...who knows.

[susanthomas1954]

Interesting. I (MDS) had a reality check conversation with a unit manager yesterday, saying she was uncomfortable about an IV med. I explained the reality of hospitals not wanting the patients back, secondary to re-imbursement issues. She was unaware that we will now have to take "sicker" people in order to maintain our re-imbursement levels. Some of the sub-acute transfers we receive are less stable than people we had in ICU back in the 70's and 80's. And the nurses receive much less clinical training in school. Our corp. CEO did a managers meeting this past week and explained it to everyone, but I don't think they get it until they experience it. This is the real deal, and it's not that pretty. IV meds are only the beginning. VENTS are where it's at and where it's going. Seriously, with our nurses, I am worried about a lot of things, from skin breakdown to pneumonia and un-noticed full blown CVA's. It is amazing to me that in the last month there have been TWO CVA's and the first reaction is to get a UA! If you didn't learn about STROKES in school, you should have learned from all the aspirin commercials on TV for heaven's sake. Took a full 24 hrs to get the first one out, and a full TWO HOURS to get the second one across the street to the hospital yesterday. So much for the golden hour.

[mikijam03lpn]

I think some medications are safe to give in a skilled nursing facility, like zofran, solumedrol, decadron, d50, pepcid, lasix 20-40mg (accurate I/O and >sbp 110). reglan, and that's it. Any medication that requires close monitoring should not be given at a snf. The administrator asked to help them create a policy for IV push medications. But I was only able to come up with those medications. I have Hospital ER experience, but i been working in snf for almost 10yrs. I think these are safe medications to given IV push. We still have to show it to the medical director and pharmacist. I will let you know how it goes.

[MunoRN, RN]

I don't think the need for IV lasix or steroids alone is sufficient reason to admit someone to a hospital, that's always been in the realm of what nursing homes can do for as long as I can remember. I'm not really getting what the monitoring concerns are?

[wanderlustnurse88, RN]

My facility usually has the community nurse come in to do the IV meds. Sometimes they will set them up with a pump which only needs to be changed every 24 hour and will give the dose of antibiotics and then just run TKVO for the other hours. We are lucky to be attached to an emergency room (same building) so often the emerg nurse will come over and re start an IV or give the push.

[mikijam03lpn]

I dont think you should give cardiac medications like potassium IV 10meq or 20 meq in 100 ml bags, cardizem.. All those medications require cardiac monitoring, everything else like (IV ABT, fluids, tpn..) could be given at nsf.