Something my clinical instructor said...

[Dnap22]

I was wondering if it is normal for a nurse to run a primary of NS at 10ml/hr when you are hanging a small bag of antibiotics (50ml), when there is no order for the NS to begin with. My pt had no fluids running or any order for fluids but my instructor said to hang the NS and back prime to avoid wasting a significant amount of the atb priming and then just set the rate for the NS at 10ml/hr. She said some nurses don't feel comfortable doing this...is it because it's illegal?

[JBudd, MSN]

I'm actually asking about the legalities of hanging fluid without an order.

Dnap, it wasn't meant to be a shot at you...... sorry about that. It was the nurse who wasn't thinking it through, as your instructor did do.

The legality in MHO is that you are expected to give meds in a safe and complete manner, using the skills you have. Nurses are expected to do things well, completely and safely; without having to have someone write out every step and detail. You aren't "hanging fluids" as an infusion, you are administering the med ordered, in such a way as the pt gets the complete dose.

[MB-mom.RN]

it's fine to hang NS @ 10ml/hr without an order, it keeps the line patent. our icu's run carrier fluids (thats what we call it) @ 30ml/hr to keep the central lines patent and its just easier on us to do that when the pt has multiple iv abts. if you think about it, it's a 10ml flush given over 1hr.. that's definitely not gonna hurt anyone

[HouTx, BSN, MSN, EdD]

It is very good practice to question medication admin that is not specifically ordered by a physician. OP should check the hospital's policies & procedures because this practice may reflect a 'standard protocol' that has been approved by medical staff. If not, it should NOT be done because it is outside the nursing scope of practice.

[psu_213, BSN, RN]

My guess as to why some nurses don't like to run their ABX as a secondary (IVPB)--they think it is faster (albeit by about 30 seconds) to just prime the primary line with the ABX rather than setting up a primary and they back priming the ABX. Our hospital's written policy is to run all ABX as secondary infusions, but I still see many nurses run the ABX as the primary.

[nurseladybug12]

It is also ok on my floor to hang a bag of 500 ml or 250 ml NS with abx, we use it to back prime the line and set it for KVO with VTBI 20ml which will flush the line when it is done so no air enters the line when it is finished, it will also give you time to disconnect it so you dont have to run in the room right at 30 minutes when the pump beeps. I always charge the pt for the NS.

[S.G.]

It was policy at my last facility to run all minibags as a secondary with a NS flush bag that was changed every 24h. I would set the pump to run 30mL at the rate of the abx. That was the policy. Several nurses set the bag to run in at 10ml/h for patients with frequent abx or patients with IVs that were 24ga. They would sporadically get an order for fluids at kvo if it went on more than a day just to cover the legalities.

[KelRN215, BSN, RN]

do you routinely get orders to flush with an IV push med? It's sort of the same thing, IMO.

Precisely. It's a standard of care thing.

[IrishIzCPNP, MSN, RN, APRN, NP]

It is protocol where I worked...no order needed.

[Guest219794]

Legalities aren't really the issue. There is no potential harm in doing this practice correctly. In fact, many who simply use primary tubing are doing it wrong. Primary tubing itself holds a lot of volume. Where I work, 17 ml. If you have an ABX bag with primary tubing, you have to figure out some way to deliver all of what is in the tubing- up to 1/3 of the dose. No matter how you slice it, the patient is going to get some saline, or get only a partial dose of the ordered ABX. Assuming you are using a pump, the pump will not deliver anything, once it gets air. That means what is in the line between the pump and the patient is not getting delivered. I often see nurses giving only a partial dose because off a lack of understanding of the volume in a line.

As stated before, in an ideal world, there will be a protocol. In the real world, sound judgement and acting in the best interest of your pt will go a long way to protect you. Nobody ever lost a license from giving somebody an extra 20 cc's of saline.

[KelRN215, BSN, RN]

Legalities aren't really the issue. There is no potential harm in doing this practice correctly. In fact, many who simply use primary tubing are doing it wrong. Primary tubing itself holds a lot of volume. Where I work, 17 ml. If you have an ABX bag with primary tubing, you have to figure out some way to deliver all of what is in the tubing- up to 1/3 of the dose. No matter how you slice it, the patient is going to get some saline, or get only a partial dose of the ordered ABX. Assuming you are using a pump, the pump will not deliver anything, once it gets air. That means what is in the line between the pump and the patient is not getting delivered. I often see nurses giving only a partial dose because off a lack of understanding of the volume in a line.

As stated before, in an ideal world, there will be a protocol. In the real world, sound judgement and acting in the best interest of your pt will go a long way to protect you. Nobody ever lost a license from giving somebody an extra 20 cc's of saline.

You can do it correctly by hanging the antibiotic as a primary, provided you hang a normal saline flush afterwards. That's pretty much how we did it when I worked in the hospital. We had 25 mL saline bags and hung one of those afterwards to flush the line. As you said, no matter what the patient WILL receive some saline if he is to receive the full dose of medication.

[withpurpose]

You cannot run an IV fluid without an order unless the organization has a policy that allows for this practice. While the instructors rationale makes sense, this practice is out of scope for the nurse. IV fluids are considered medications and all medications require a physician (or LIP) order. It would also be a problem for billing. They can't bill for the IVF administered if there's not an order for it. Many organizations have some sort of policy or protocol (approved by medical staff) for running IV medications that allows for NS as a primary with a 20-50 cc "flush" following the completion of the antibiotic. Also, some organizations have some sort of policy or protocol (approved by medical staff) for running NS as a to keep open (TKO) rate (usually 15-20cc/hour) on anyone receiving periodic IV medications that otherwise would not have an IV running.

[withpurpose]

You can help protect yourself and the organization by recommending (or even drafting) a protocol to be implemented. While I agree that there probably hasn't ever been anyone to lose their license over this practice, it is still out of scope and has the potential to cause patient harm. For example, a patient receiving several IV medications and also at risk for fluid overload. The additional fluid received could be just enough to push them into overload. Granted, this could happen even if there was a policy or protocol in place. The difference is that the nurse would be protected for her actions if there was a policy or protocol in place.