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?

[catsmeow1972, BSN, RN]

Some years ago, I had a foray into ER nursing in a small rural facility. I had a young lady who was a “frequent flyer” with SCD. She had her port and hideous vasculature. I’d had experience with port access from prior jobs so I was fine with doing it, plus finding the thing was easy as like many with her dz, she was very thin. The first time I walked in with supplies, she said “you need the short Huber needle, do you have a biopatch and you need to stick right here” pointing to a spot right on the end of a leaf on her tattoo. Moral of the story? Especially with folks with chronic diseases, they frequently know more about thier care than we do.

I’ve walked in to start an IV and asked ‘where do they stick you’ and had them point to a particular spot. It saves me the time of looking elsewhere where I won’t find something. I’ve been a patient where I’ve told them where to stick and been ignored. 3 failed pokes later...Where do they eventually go? Right where I said. Again, moral of the story? Listen to your patient.

[Kallie3006, ADN]

2 hours ago, catsmeow1972 said:

I’ve been a patient where I’ve told them where to stick and been ignored. 3 failed pokes later...Where do they eventually go? Right where I said. Again, moral of the story? Listen to your patient.

This right here. So much frustration and time is lost that could have been prevented if these steps had been taken.

[40isthenew30]

I probably would have documented each time patient requested it, and also documented educated re infection risk etc. Make sure to cover your butt and refer to policy and procedure . But ultimately I would have accessed it because at my facility the administration far favors press gainey and cust Complaints over proper care. I’ve seen it many times unfortunately. So I’d CYA with documentation to cover why I accessed it. If the patient is to be admitted I can’t blame her for wanting to use her port.

[DextersDisciple, BSN, RN]

7 hours ago, turtlesRcool said:

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.

But is that even a thing? EBP shows analgesia to be more effective in smaller amounts in a port compared to a peripheral? That’s why the pt came off as “looking for a high”.

I’m the first person to avoid placing a PIV if I see a port (I call it the “one stop shop”). However the piv was already placed by someone else so she must have not been that difficult of a stick.

[studentnurseASN]

A few nurses on the floor have told me that if no one was accessing the port in the first place, then the patient can't raise an issue.

[turtlesRcool]

4 hours ago, DextersDisciple said:

However the piv was already placed by someone else so she must have not been that difficult of a stick.

The PIV is in the right AC. Being able to get an IV into the most obvious vein of the, presumably, dominant side isn't an indication of good vasculature. In fact, it's usually where people go when they can't get anything else to pop up on a patient.

But it's also a seriously inconvenient place to have an IV with anything continuous running. Most SCD patient have fluids going in addition to any pain meds.

For the sake of argument, let's assume she's really "not that difficult of a stick." Presumably, she'd like to keep it that way. The wear and tear on her peripheral veins associated with multiple sticks throughout repeated hospital stays will lead her to have crap veins over time, if she doesn't already.

She has a port. She wants to use it. I'm sure her physicians discussed the risks and benefits before placing the port. If it makes you feel better, go ahead and reeducate her regarding the risks of infection, but ultimately it's her body and her informed choice should be respected.

[turtlesRcool]

5 hours ago, DextersDisciple said:

But is that even a thing? EBP shows analgesia to be more effective in smaller amounts in a port compared to a peripheral? That’s why the pt came off as “looking for a high”.

I have no idea if any studies have been done on port vs peripheral IV access with pain relief.

But pain is incredibly subjective. What works for one person might not work for another patient.

I can believe this patient finds analgesia to work better in her port. Maybe it's something to do with her individual circulation or body chemistry. Maybe it's just a placebo effect. Who knows? If it works better for her and there is a legitimate argument to be made for port access (preserving the integrity of her vasculature), then it should be accessed.

[JKL33]

2 hours ago, studentnurseASN said:

A few nurses on the floor have told me that if no one was accessing the port in the first place, then the patient can't raise an issue.

studentnurse,

Could I kindly ask you to clarify your take on what those nurses meant. No sarcasm; I just don't understand what they were telling you (and I suspect their comments might be a bit off and would like the opportunity to tell you otherwise if that happens to be the case ?).

TY

[LovingLife123]

What do you think the point of having the port is? This post makes me crazy. The patient is a sickle cell patient for crying out loud. And you won’t access her port because you are afraid of infection? Do you think the doctor just put it in, never meaning for it to be used?

Why is it so hard to believe that those with chronic pain are actually in pain? Why is it so hard to treat people in pain?

By the way, I absolutely hate IVs in the AC. Hate them. They are the worst. The patient bends their elbow as we all do naturally and they don’t get their meds because the pump pauses until we can go in to restart it.

[LovingLife123]

8 hours ago, 40isthenew30 said:

I probably would have documented each time patient requested it, and also documented educated re infection risk etc. Make sure to cover your butt and refer to policy and procedure . But ultimately I would have accessed it because at my facility the administration far favors press gainey and cust Complaints over proper care. I’ve seen it many times unfortunately. So I’d CYA with documentation to cover why I accessed it. If the patient is to be admitted I can’t blame her for wanting to use her port.

Then what is the point of a port? If the infection risk is so high from accessing it, why would they ever be used? The reasoning on here makes no sense.

[40isthenew30]

10 minutes ago, LovingLife123 said:

Then what is the point of a port? If the infection risk is so high from accessing it, why would they ever be used? The reasoning on here makes no sense.

The reasoning is OP stated their policy is to not access a port if they have a working PIV. So if you do, and the patient gets a raging clabsi and you get deposed for the malpractice suit that follows, your documentation is clear on why you are violating the policy. The port should have been used from the start but it appears they may not have had anyone to do it in triage. A lot of times patients want things that differ from best practice or policy. Always follow your policies and procedures and if you don’t you better have documentation to back your choice up.

[JKL33]

5 minutes ago, 40isthenew30 said:

The reasoning is OP stated their policy is to not access a port if they have a working PIV.

I did not see that stated. Maybe I'm overlooking it but I read back through a couple of times and couldn't find it.

The decision was made by personal reasoning (no doubt influenced by all the CLABSI hubbub, but personal reasoning nonetheless). I very highly doubt that the place has a policy stating that the ports of SCA patients will not be used if a PIV can be obtained.

The patient has the port *for this situation.*