Please stop! Little things that are just bad practice.

[JBudd]

Little things that are just bad practice.

Like looping IV tubing back into itself (against our policy, and they went to great lengths to hand out caps to carry in pockets). And not even cleaning off the port you looped it into!

Disconnecting a running IV to take a pt to the bathroom.. and just leaving the bare end hanging from the pole. Don't interrupt IVFs ! Take the blinking pump with you!

What are yours?

[MunoRN, RN]

Where I am now the visitors don't have to follow contact precautions at all.

They have even allowed children to visit without following contact precautions.

When they start making kiddie size isolation gowns I will let them visit an isolation patient.

The CDC recommendations for gowning/gloving for contact isolation doesn't include visitors, only for healthcare staff or others who are going from one patient to the next. For other types of isolation, gowning/gloving/etc are recommended for all those entering the room.

The purpose of contact precautions is to keep pathogens from being picked up from one patient and spread to another, which is an issue with staff going from one patient to another, not with visitors.

I've worked in many hospitals, none of which had visitors gown up for contact isolation.

[MunoRN, RN]

Can you show me the evidence that changing IV tubing in an intermittent line Q24 hours does more harm than good? I'd love to see this. :)

This is the CDC recommendation:

1. In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, [177] but at least every 7 days [178-181]. Category IA
   
2. No recommendation can be made regarding the frequency for replacing intermittently used administration sets. Unresolved issue
   

The reason for this recommendation is that there is no evidence that more frequent changes reduce contamination, but there is some evidence (in 3 of the studies they included) that more frequent changes increase the risk of contamination.

It's a pretty logical concept; a closed system should be left closed as much as possible. Opening the system only adds additional risk of contamination, and has little potential to decrease contamination except in fluids that sustain bacterial proliferation, such as TPN or blood.

Part of the confusion surrounding how these recommendations have been interpreted is due to conflicting terminology. The studies the CDC looked at all excluded "intermittent" infusions, mainly because these were almost always antibiotic infusions and you wouldn't want to include antibiotics when trying to measure bacterial contamination. For whatever reason, the INS defines intermittent not as intermittently infusing, but intermittently connected, so they took the exclusion of intermittent infusions to mean infusions that were intermittently disconnected, which is not what the CDC was referring to.

So the general lesson learned is to minimize potential chances to introduce bacteria into the system. If you were to disconnect a line and then decide you're now going to change it 24 hours from now, when it otherwise may have been able to remain connected and therefore a closed system, you are now adding an additional break in the system, potentially adding to contamination.

[~PedsRN~, BSN, RN]

This is the CDC recommendation:

1. In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, [177] but at least every 7 days [178-181]. Category IA
   
2. No recommendation can be made regarding the frequency for replacing intermittently used administration sets. Unresolved issue
   

The reason for this recommendation is that there is no evidence that more frequent changes reduce contamination, but there is some evidence (in 3 of the studies they included) that more frequent changes increase the risk of contamination.

It's a pretty logical concept; a closed system should be left closed as much as possible. Opening the system only adds additional risk of contamination, and has little potential to decrease contamination except in fluids that sustain bacterial proliferation, such as TPN or blood.

Part of the confusion surrounding how these recommendations have been interpreted is due to conflicting terminology. The studies the CDC looked at all excluded "intermittent" infusions, mainly because these were almost always antibiotic infusions and you wouldn't want to include antibiotics when trying to measure bacterial contamination. For whatever reason, the INS defines intermittent not as intermittently infusing, but intermittently connected, so they took the exclusion of intermittent infusions to mean infusions that were intermittently disconnected, which is not what the CDC was referring to.

So the general lesson learned is to minimize potential chances to introduce bacteria into the system. If you were to disconnect a line and then decide you're now going to change it 24 hours from now, when it otherwise may have been able to remain connected and therefore a closed system, you are now adding an additional break in the system, potentially adding to contamination.

But, aren't you already "opening" your system when you disconnect the line from the hub? I see what you're saying... it's one less *opening* (when you change the lines out). But let's be honest here. Those of you who are always taking the line off and on aren't going to do it "just this once" in 96 hours. Which is the basis for my pet peeve.

Let me give you this example, as I see it all the time on my floor. Patient is ordered for IV fluids 10 hours overnight. In that time, they get a liter of fluid thru their *central* line. So this line is not only being connected and then disconnected, but a new bag is being spiked nightly. The line sits dangling from the pole with a red cap and a dry bag thru the day.

I have come on at the start of my shift to three day old tubing for this infusion.

In my mind, this tubing should be hung each night with the infusion.

What say you? :)

[PMFB-RN, RN]

Same at my facility. Anyone can visit isolation patients with no precautions.

It would be silly to insist on precautions for visitors. After all as soon as the patient is discharged to home those same visitors may well be kissing and hugging (or much more) the isolation patient.

Hard for me to take contact precautions seriously. When I work in ER we of course don't have contact precautions for most patients since the MRSA swabs don't come back until the patient has long been admitted. The ones D/Ced to home aren't swabbed at all.

The last time I was an impatient in 2009 I refused to allow my nurse to swab me. She looked confused and said nobody had ever refused the swab before.

[kakamegamama]

I've never seen anyone do this but EW.

"EW" is right.....unfortunately, I have seen it more often than I would like. And, as Pepper the Cat said, they do get somewhat irate when questioned. Reminds me of another---a nurse giving injections without changing gloves per patient. I was on the receiving in of that once upon a time and wouldn't let her touch me until she changed her gloves. She told me it was to protect her more than me. I told her that I didn't care...I didn't want someone else's blood getting on me. So she huffily stripped them off, put on a new pair, and then gave me the most painful flu shot I've ever received. Little toot......

[kaylee.]

Someone mentioned old IVs: It is annoying when a nurse tells me the IV site in report, and when I get there to use it realize that the site no longer worked at all.

So then I have to stop insert a new one before proceeding. I don't have a problem with changing it, just the failure to mention it by the nurse, as if it was perfectly fine.

[joanna73, BSN, RN]

Leaving medication at the bedside "because the patient said they will take it." Some will, but many patients forget or drop it in the sheets, on the floor, whatever. It's not safe.

Either they take the med in front of me or I take the meds back and the patient can take them when I return.

[PMFB-RN, RN]

I totally agree with you.

According to Tom Ahrens of Phillips Life Sciences, there is absolutely no research to support the validity and accuracy of taking the NIBP on the forearm or the thigh.

This another thing that is a bad practice.

Ya but sometimes you gotta do what you gotta do. No choice sometimes. My experience is that it is at least consistantly inaccurate so you can continue to monitor trends. Besides BP measurements are really just to keep the docs and bean counters happy. I don't need to check a BP to tell if my patient is hypo, hyper, or normotensive. It' usually pretty obvious as soon as you walk into the room.

[wheeliesurfer]

"EW" is right.....unfortunately, I have seen it more often than I would like. And, as Pepper the Cat said, they do get somewhat irate when questioned. Reminds me of another---a nurse giving injections without changing gloves per patient. I was on the receiving in of that once upon a time and wouldn't let her touch me until she changed her gloves. She told me it was to protect her more than me. I told her that I didn't care...I didn't want someone else's blood getting on me. So she huffily stripped them off, put on a new pair, and then gave me the most painful flu shot I've ever received. Little toot......

At my personal doctors office I have questioned to myself if the nurse had changed her gloves after handling a UA sample and then going to the front office to call a patient back to the exam room. First of all, I don't think a nurse should have her/his gloves on PRIOR to seeing the patient (they need to put them on while in the exam room), and second, nurses DEFINITELY need to change gloves after handling urine/blood/sputum/stool samples and prior to touching the patient again (esp when the specimen doesn't belong to the patient you are working with!).

I have asked that same nurse to change her gloves prior to taking my vitals since I was unsure how long she had been wearing them and I didn't see her change them prior to me coming into the back office.

[blondy2061h, MSN, RN]

It would be silly to insist on precautions for visitors. After all as soon as the patient is discharged to home those same visitors may well be kissing and hugging (or much more) the isolation patient.

Hard for me to take contact precautions seriously. When I work in ER we of course don't have contact precautions for most patients since the MRSA swabs don't come back until the patient has long been admitted. The ones D/Ced to home aren't swabbed at all.

The last time I was an impatient in 2009 I refused to allow my nurse to swab me. She looked confused and said nobody had ever refused the swab before.

This is the logic. I have a harder time with it because it's BMT. A lot of our patients get to know each other and will talk in the halls with other people's family members or even stop in their rooms. And a lot of family members from long distance all stay in local lodging facilities together. Also, it's not required for any type of isolation, not just contact.

We're already doing away with isolation for a lot of things. We don't isolate for VRE any more and MRSA is probably next on the chopping block. Our infection control department was looking at cultures and realizing that all of the strains we were seeing were different, so it's not spreading person to person, so much as people are all kind of showing their own dormant strain.

[blondy2061h, MSN, RN]

Leaving medication at the bedside "because the patient said they will take it." Some will, but many patients forget or drop it in the sheets, on the floor, whatever. It's not safe.

Either they take the med in front of me or I take the meds back and the patient can take them when I return.

Totally agree! If I'm signing out a med as given, I'm making sure they actually take it.

[Christy1019, ASN, RN]

re: the K+ comment in the ED, it is good practice, that if you are hanging K+ on a peripheral line, you hang it on its own pump and Y port it into carrier fluids (at least 30cc/hr, preferably >50cc/hr) this reduces irritation of the vein... or you could work in an awesome hospital that has lidocaine in the K+ bags!!!

Lol thank you. Luckily that is what we've done in both hospitals I've worked at.