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?

[murseman24, MSN, CRNA]

Did you tell them they had the wrong number, as you work in a hospital, not in "customer service." That would be my response ALL DAY LONG.

[Here.I.Stand, BSN, RN]

3 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.

So she had a small surgical procedure to place this port, for nothing? Would any rational person actually never raise an issue if healthcare staff are refusing to utilize the access that her physicians have deemed indicated?

I’m sorry... that makes no sense. I will go so far to say it is ignorant. If it were me I would raise a HUGE issue if “no one was accessing it in the first place.”

I am not typically one to scream discrimination... but I wonder if it were someone like Olivia Newton John with breast cancer and wanting their port accessed, would anyone be refusing?

[murseman24, MSN, CRNA]

51 minutes ago, LovingLife123 said:

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.

She wasn't withholding pain medicine. "it works better in the port" is a pretty poor reason for accessing it. I understand your concern, but there is a risk/benefit for using them. There IS an increased risk for serious infection, and the best thing for a nurse to do in this situation is follow the policy of the hospital. The purpose of port insertion may not have been for ease of venous access for random hospitalizations, but rather transfusion therapy that requires large reliable access, or other undisclosed reasons other than "ease of access."

I never learned to access them myself, and felt bad for the patients that would get poked a million times or required IV team PIV placement after going through the port insertion (as our policy stated peripheral access was preferred). But it is a risk vs. benefit decision, and as nurses we are not entitled to make an informed and educated decision, we are supposed to follow the "policy."

[murseman24, MSN, CRNA]

20 minutes ago, Here.I.Stand said:

So she had a small surgical procedure to place this port, for nothing? Would any rational person actually never raise an issue if healthcare staff are refusing to utilize the access that her physicians have deemed indicated?

I’m sorry... that makes no sense. I will go so far to say it is ignorant. If it were me I would raise a HUGE issue if “no one was accessing it in the first place.”

I am not typically one to scream discrimination... but I wonder if it were someone like Olivia Newton John with breast cancer and wanting their port accessed, would anyone be refusing?

If whoever had their port placed for chemotherapy, then that's why it was placed and is for. Not for pain medicine. CLABSI to avoid a needle stick is the ignorant thing to do.

[GSDlvrRN, MSN]

Does your manager expect you to give patients whatever they want??? You did the right thing by using your judgement.

[studentnurseASN]

Hope this post will clarify what I meant:

5 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.

It depends on the unit and the hospital. One med surge floor for a specialty hospital, nurses would use the PIV if patients were stable. In med surge units that transfer patients from ER, or ICU, there would be IV teams in that would handle ports instead of nurses working on the unit.

My thinking is each unit and each hospital has different protocols for CLASBI with the overall goal to decrease risk.

But in this case, I think it is best to follow protocol even if it means compromising 'customer service' for patient safety related to getting a better PCA flow.

[Here.I.Stand, BSN, RN]

1 hour ago, murseman24 said:

If whoever had their port placed for chemotherapy, then that's why it was placed and is for. Not for pain medicine. CLABSI to avoid a needle stick is the ignorant thing to do.

This pt’s port — unless I am missing something, and I did re-read the OP to make sure — appears to have been placed specifically FOR her access needs during sickle cell crises. She didn’t have it placed for chemo and just happened to need pain meds for something else.

Again, unless I missed that she is both a CA pt and a SCA pt.

It makes no sense to refuse to use something for the very reason her hematologist decided she needed it.

[Party_of_five, BSN]

As an ER nurse here is my view: she already has a working line, she's already getting treatment. I'm not messing with the port unless I need to. If she would have come to my room without a line then I would have used the port. She can go to the floor and if they want to port accessed then they can do it. Now if there is a problem with the line or it is interfering with treatment and/or I have the time, then fine, I'll do it. If I have 10,000 other things to do then no, sorry, BYE.

[LovingLife123]

7 hours ago, murseman24 said:

She wasn't withholding pain medicine. "it works better in the port" is a pretty poor reason for accessing it. I understand your concern, but there is a risk/benefit for using them. There IS an increased risk for serious infection, and the best thing for a nurse to do in this situation is follow the policy of the hospital. The purpose of port insertion may not have been for ease of venous access for random hospitalizations, but rather transfusion therapy that requires large reliable access, or other undisclosed reasons other than "ease of access."

I never learned to access them myself, and felt bad for the patients that would get poked a million times or required IV team PIV placement after going through the port insertion (as our policy stated peripheral access was preferred). But it is a risk vs. benefit decision, and as nurses we are not entitled to make an informed and educated decision, we are supposed to follow the "policy."

No, you are mistaken. The reason why the port was placed wa because the pt has sickle cell and ends up in the hospital frequently. Ports are not just used for chemo. It absolutely should have been accessed.

The nurse’s reasoning was that the pt told her she got better pain relief from using the port. I’m guessing she does as her veins are probably crap. Plus she doesn’t want to be stuck a hundred times. I’m sure the PIV was working at that time. As we all know AC PIVs go bad quickly because of placement. They are great, quick access in the ER, but not appropriate for the floor. The Op saw the patients statement as “drug seeking” behavior. Therefore, they are using the infection reasoning as an excuse not to use it.

Any central line has a risk for a CLABSI. But they are necessary for certain patients. The whole point of the placement was for this situation.

It angers me that people are questioning this and causing a sickle cell patient more pain and discomfort because people think she is getting a high from a flipping PCA. Give me a break.

Also, sometimes people with ports needs additional access. Not everything is compatible. It is perfectly acceptable for a person with a port to also have a PIV. They are not a big deal to access. I call our oncology nurses all the time to come and access when I get a pt with one.

[NurseBlaq]

Many of you are saying you wouldn't have accessed the port because the patient said she gets the pain meds better. You're immediately assuming she's looking for a "high" but sickle cell is extremely painful. I would hate to be a patient who has a debilitating medical issue with pain as a main symptom and have a nurse who doesn't want to use my port because she's worried about me getting "high" and not about properly treating my pain, which should be known as a common symptom/side effect of my sickle cell diagnosis. I would also hate to have that same nurse who refuses to access the port because they're unaware every stick has the potential to create further complications for me.

Who decided to give this patient a PIV in the first place and why? Was it a nurse unfamiliar with sickle cell or was the nurse just lazy or had some inherent bias and didn't care? These things matter. Also, the education department at your facility needs to do some in-services on sickle cell and all its encumbrances, and also accessing ports in general. Every nurse in that facility should be trained on proper port access and when it should be done.

This patient's rights were ignored and they were exposed to potential further complications and unnecessary dilemma. There's plenty of teaching lessons in this scenario.

OP, I don't mean to sound hateful but the situation was handled wrong by just about all involved. Take it as a lesson learned. We all do things differently but reflection and learning from it is what makes us better nurses.

[kp2016]

Am I the only one who is left wondering why you are the only nurse singled out as at fault here? It’s seems to me that she had multiple other nurses who also could have accessed this port.

To answer your actual question I would have accessed the port. It’s a very quick easy process and a lot more conformtable for a patient than a PIV in the AC of their dominant arm. I’ve had loads of experience with ports and have seen almost no CLABSI associated with them so I don’t accept that as a valid reason for refusing to access a port that was placed specifically to spare the patient PIV sticks. For the record I think the Triage nurse should have accessed the port instead of starting a PIV, if anyone needs be answering to management about this it really should be that nurse.

[JKL33]

I'm going to interrupt this convo for a minute:

People with SCA are dealing with a disease that is as deserving of our professionalism (and compassion, if you will) as any other. If we take a moment to learn about their experiences, caring for them appropriately is rarely difficult.

But. Some of us seem to be getting really riled up and judging each other over things that some patients with SCA will freely and pointedly tell you themselves. I have had dozens++ of these conversations. I remember very clearly the first time I was asked to slam demerol 150mg and phenergan 25mg AFAP through the closest port of a CL after placing the hydration infusion on pause and kinking the tubing. I decided to learn more rather than judge. I have been requested to use this method of pain medication administration innumerable times in these circumstances over the years, in whole or in part. For the most part, I am able to decline and still maintain a good working rapport with patients and relieve their pain.

Treat people therapeutically and with compassion, and at the same time be real. Some of you need to think about what overall good you are doing by pretending that a perfectly functioning AC IV delivers sub-par pain relief. According to your rationale, pushing pain medication through a central line the regular way (according to accepted nursing practice) also delivers sub-par pain relief...compared to slamming it as I described above.

When you don't learn about people and their lives, you are less likely to deliver non-harmful, compassionate care.

That said - this patient has a port so that it can be used for any necessary therapies during SCC and/or pain-related admissions. PERIOD. As in, that is seriously the end of the story here. Access the stupid port and take care of people. It is your job to figure out how to therapeutically navigate these situations without begrudging people their disease circumstances.