Should I have accessed her port?

[guest947568]

When I came on shift today in the ER I had a sickle cell patient. Patient had a PIV 20G in the right AC placed in triage (BEFORE my arrival/shift). The PIV in question flushed and drew back fine. She go her fluids and PCA pump through this line without issue. The patient had 2 nurses before me all of which refused to access her port because she had the PIV. the nurse I got report from stated she did not access the port because it was not clinically indicated because the patient had an IV.

The patient requested it be accessed because she can feel the PCA better in the port than the PIV. I asked THREE other nurses who agreed I shouldn't access it due to risk of infection and she already had an IV.

Patient went to floor and ask the nurses there to access it. All of which refused to do so and notified their manager. Management calls me upset saying I gave poor customer service by not accessing the port in the ED when she requested. They said the floor cannot do it as theyre not trained. Mind you this was AFTER she had the PIV placed in triage last night. The PIV that worked fine.

My last hospital I was told not to access ports unless clinically indicated as its an infection risk.

What would you have done?

[Apples&Oranges]

If the pt wanted the port accessed because she has horrible veins, and didn't want to be stuck 50 times for blood draws, yeah, that makes sense. But because the PCA works better in the port?? Oh, hell no. Your ability to get high from the narcs we are giving you for PAIN is not a higher priority than infection prevention.

If you were that hard of a stick, they wouldn't have been able to throw in that peripheral. Sorry, you're getting your meds through the line that was placed. It is, obviously, already there.

[MunoRN, RN]

Sickle cell disease causes progressive kidney damage, it's not uncommon for SCD patients to eventually require dialysis, which is often complicated by the patient's long history of frequent venous access (IV access and lab draws) and the resulting scar tissue which can make fistula placement difficult if not impossible. So even though a PIV was already placed, the port should be accessed rather than using peripheral sticks for repeat labs.

So while the patient may like the port for other reasons, it was likely placed for more legitimate reasons which probably shouldn't be just shrugged off.

[JBudd, MSN]

When I had a port, I wanted it used. I don't have a lot of places left that you can stick me, and I would prefer to keep those from getting scarred by repeated sticks.

If she gets better relief from the PCA into her port, all the better! I really doubt she is there just to "abuse" the system as others seem to imply; we want decent pain control in a SC pt! If it works better, then she might not need as much.

Since she allowed the peripheral stick, fine. But I would have chnaged it over at some point. If you needed to wait until an IV team came on, or someone else who is educated for it, fine.

[Lunah, MSN, RN]

Talk to your infection control department, there is likely a policy related to appropriate port access in your facility related to CLABSI risks.

[iluvivt, BSN, RN]

Yes the port should have been accessed by a qualified RN sooner than later. Patients that have chronic disease states that often require frequent IV therapies have long term VADs placed in order to be used.Just think about it this way, if every encounter with healthcare where the patient needed IV therapy the RN used the rational not to access to avoid a CLABSI well then what's the point.Ports are placed to preserve the venous vasculature from repeated assault and/or when those veins are severely depleted.So from a venous preservation perspective the port needs to be used.Its ok, of course if a PIV is placed until a qualified health care professional can access the port,but then it should be done.Ports have a lower infection rate than tunneled and non=tunneled CVADs.I don't think it should all be on you though because every nurse that continued to use the PIV had a chance to correct the situation and get an RN qualified to access the port to do so.As far as the patient requesting it to get a rush when she gets her medications, just ignore that and still do what is best for the patient and also push it at the prescribed rate.

[turtlesRcool]

13 hours ago, Apples&Oranges said:

But because the PCA works better in the port?? Oh, hell no. Your ability to get high from the narcs we are giving you for PAIN is not a higher priority than infection prevention.

I am bothered by the assumption that if a patient says a PCA 'works better' though a port, that equals 'get high' to some nurses (not just you, though I've chosen this part to quote).

If a patient with an extremely painful chronic condition like Sickle Cell told me a PCA 'works better' though her port, I would assume she got better pain control that way.

Personally, I think we should want patients to have pain medication that works better for them. If a patient gets better relief though her port, this means she doesn't need to hit the PCA button as often to get the same pain control she'd need more hits through a peripheral access to achieve. It decreases side effects from needing more medication, and allows patients to rest.

In real life, I also see this judgmental attitude when another nurse will tell me a patient "likes dilaudid" or something similar, implying that the patient's primary motivation is euphoria. But I think we as nurses should be open to the very real likelihood that when a patient "likes" a medication it's because the patient likes pain relief.

[Jory, MSN, APRN, CNM]

The purpose of the port is to access it and to keep the patient from being stuck...over and over again.

The PIV should never have been started.

[Wuzzie]

4 minutes ago, Jory said:

The PIV should never have been started

In this situation for sure but, just for clarification, if there is nobody trained to access ports it’s best not to wing it. If this is the case in other posters’ circumstances then placing a PIV is completely appropriate.

[turtlesRcool]

Also, a PIV in the right AC is just about the least convenient place for an PIV to be placed when any continuous infusions are running. Our pumps are always alarming when patients fail to keep their arms straight. It's a pain for us to keep going in a room to see what the problem is, but it's also annoying for the patient, especially if the IV is in his or her dominant arm.

Answer the phone? IV pump starts beeping. Bring your fork to your mouth? IV pump starts beeping. Fall asleep and bend your arm? IV pump starts beeping, then beeping louder until you wake up. It's not just a small annoyance, either. Patients need rest when they are sick, and it can be really hard to get that in the hospital. I would like to avoid anything that needlessly interrupts a patient's sleep.

I absolutely don't blame this patient for wanting her port to be accessed rather than deal with a PIV in the AC, plus additional sticks for each lab draw throughout her stay.

Since she has a port, she and her doctor have weighed the risks and benefits of a port vs repeated peripheral access. I find it a bit arrogant for nurses to refuse to access a port when an alert and oriented patient requests it.

[Jory, MSN, APRN, CNM]

8 minutes ago, Wuzzie said:

In this situation for sure but, just for clarification, if there is nobody trained to access ports it’s best not to wing it. If this is the case in other posters’ circumstances then placing a PIV is completely appropriate.

True...but that blows my mind there apparently wasn't a teaching opportunity in the facility. We didn't have a formal class to access ports....this was part of your check off and you learned as you went.

[Wuzzie]

25 minutes ago, Jory said:

We didn't have a formal class to access ports....this was part of your check off and you learned as you went.

When I worked in the ED we weren’t taught to do it because it was such a rare occurrence, at the time, they felt our proficiency would suffer and so would the patients. This is probably still true for many facilities. Given that I access ports on the regular for my current job I can’t really argue with their logic. There is a lot that can go wrong if you are forced to fumble your way through it. That being said I agree that if a patient has a port and there is somebody proficient at accessing then the port should be used.

FTR-accessing ports and care of other CVCs is a formal class at my institution that requires a graded return demonstration as well as a test. This ensures all providers are taught the correct policy and procedure and minimizes the risk of dangerous short-cuts, that put patients at risk, from developing. I have seen it happen where one person teaches another incorrectly then the second person teaches another the same incorrect procedure and so on and so on. Before you know it everyone is unknowingly doing it wrong until something happens. Then all hell breaks loose.

[Emergent, RN]

I learned to access ports when I switched to ED nursing. Usually someone has a port either for chemo or poor veins and a chronic disease.

It's not a complicated procedure. If a patient requests their port used, we do so. If you haven't been trained, then find someone else to do it.

The whole point of a port is to avoid peripheral IVs. The whole point of learning proper technique is to avoid infection of the port.