Unit practice for heparinizing ports

[hunnybeemay]

Hi all!

I'm a newer nurse (less than 2 years) and have been on my onc/surg floor for about 18 months. Part of that time I was in an RN residency program with a preceptor, which was very helpful for learning.

Our unit is technically a med/surg unit, but we take all varieties of patients, ie trach pts, cardiac drips that aren't titrated, hospice, and any overflow. We also take all general surgical cases and cardiac/ortho-neuro overflow.

My point in saying that is to highlight the fact that we see EVERYTHING on our floor and as a new nurse this has been great learning but also overwhelming. There is SO MUCH to master with so many kinds of patients and such fast-paced work. And honestly, for being an oncology unit (in name) I've had very little experience working with ports in terms of accessing and de-accessing them.

I have accidentally sent home a patient with a port accessed (the patient got dressed before discharge with coat and hat on and demanded to leave!) and recently forgot to heparinize a port before deaccessing. I did a saline flush, but I felt terrible knowing that i didn't follow our protocol. I let my day and night charges know the next morning and as the patient was visiting our infusion center for labs in a few days, they stated that the patient's port should be fine and would be heparinized then. I'm still having a hard time with it, though. I want my nursing practice to be correct and I want to know when I've made an error what I can do to correct it.

Even though I'm technically on an oncology floor, I've only accessed and deaccesed ports a handful of times. and most of the times were with another RN, and I was signed off as competent. Upon reflection I don't believe this was enough training though, and I believe our unit practice for decanulating ports is not best practice.

When we decanculate it is up to the nurse to override the correct heparin dose (and there are lots of options in the pyxis.....you better know which one is right by memory) and it is not an ordered drug so it does not appear on the MAR until it is pulled. This means it doesn't get verified by and MD or a pharmacist. (The patient on whom I forgot the heparin flush was a colon ca patient with a significant gi bleed. The wrong heparin preparation flushed through the port could be disastrous. It seems prudent to me that a medication like heparin should go through several tiers of approval before reaching the patient.)There is nowhere in the flow sheet to document that the port was heparinized, either, when its decannulated.

I think that there is a risk for error for new nurses on our unit like myself to pull the wrong heparin dose on override or forget altogether because of the lack of opportunity to practice the skill and the lack of a proper med order in the chart. I am considering approaching management about changing this. My nursing buddy at work suggested that I propose a change in this to our practice council as it doesn't appear to be a best practice.

Can anyone recommend appropriate resources to help me investigate best practice in this situation, or any other helpful information? I would greatly appreciate feedback on this topic. Thanks!

PS- As a brand new RN I once encountered a subQ heparin dose ordered incorrectly by an MD and approved by the pharmacy. The MD ordered the heparin drip bolus preparation instead of the subQ preparation. I recognized that the vial was different than I was used to and brought it to the attention of my superior and the mistake was corrected. Obviously MDs and PharmD's are not fool-proof, but if a doctor and a pharmacist can make a heparin mistake, then how much more likely an in-experienced RN who's pulling the med without an order?

[Wuzzie]

We use one and only one concentration/amount of Heparin for our ports. We instill 5 ml of 100u/ml when de-accessing. It is written into our protocol and we do not deviate from it so remembering it is not difficult. We no longer have it in the Pyxis because the pharmacy was overwhelmed by having to verify every single saline and Heparin flush on top of all the other meds and chemos. One of the most often referred to resources is the Infusion Nurses Sociey (INS). Some of our members here's in AN belong and I'm sure they will soon chime in.

[hunnybeemay]

So where do you store heparin flushes and saline flushes? How do you access them?

[Wuzzie]

So where do you store heparin flushes and saline flushes? How do you access them?

In a cabinet in a locked med room. When I am assigned to the lab I have a stash in a drawer of my nurse server. They get locked back up at the end of the day. And I'm about to blow your mind. We no longer document saline flushes in the MAR. They are no longer considered a medication.

[psu_213, BSN, RN]

We instill 5 ml of 100u/ml when de-accessing. It is written into our protocol and we do not deviate from it so remembering it is not difficult.

I worked in an ED in a hospital that included a large, fairly well known cancer center. We saw a fair number of ports on a daily basis, and it was up to the ED nurses to access/deacess them as needed in the ED. My training was basically see one, do one, and, eventually, teach one.

Per policy, we hepranized with the concentration/amount of heparin that Wuzzie mentioned above. These flushes were in a box in the med room, not in the Pyxis. There was not an "order" to flush, nor was the flush on the eMAR--it was part of the protocol to deaccess the port.

[hunnybeemay]

I would love to not count saline flushes as a med! It's such a pain to log into the Pyxis and have to guess how many you might need, and then deal with the overdue med on your mar later because you didn't scan the flush! I feel bad charging them individually to patients, as well, when I may not end up using each flush on that patient. It's a just a guessing game how many you'll need when dealing with a misbehaving line.

Having the heparin flushes available with the port supplies would be helpful, I think. I don't know how we would do it on our unit, but not having to override them in the Pyxis with all the other heparin preparations would help prevent confusion. It just seems like overriding a product like heparin to flush into a central line could be dangerous if the wrong preparation were accidentally pulled. Or am I making much ado about nothing.

In your opinions is this something worth bringing up to management? Can anyone comment on what lead to your units handling heparin flushes differently than other meds?

[Buckeye.nurse]

We don't consider saline flushes a med at my facility either. They are dispensed through distribution (not pharmacy), and are stored in our supply room. We do still consider heparin a med. Our computer charting system links a prn heparin flush (100 units/ml) 5 ml flush to the port care protocol order when our patients are admitted.

[iluvivt, BSN, RN]

Are you using computer charting ? If so you should have a central line protocol order set and in that or a separate port order set. In those orders you should have change the non-coring needle every 7 days and whatever your institution has for heparin flush orders. Providers just except you to initiate the protocol orders by calling them up and stating you need to initiate the orders. If you have a continuous IV you do not need any heparin flushes. If you have a locked port and are using it for intermittent primary infusions and/or IV pushes most institutions have a lower strength heparin flush...we use 10 units per ml/5 mls so 50 units preceded by 10 mls of Normal Saline. The final flush prior to deaccess as well as the monthly flush should be 10-20 ml NS followed by 100 units per ml/5mls so 500 units. Others have stated this because it is also what INS recommends. Please always check for a blood return and if you do not have one then further nursing action must be taken...do you know what that is? If not let me know and I will tell you.

[nursephillyphil, BSN, RN]

to avoid this, ask the MD for a verbal for 500 units heparin flush once the patient arrives, that way you'll see it on your MAR until discharge. in addition, please please please be sure to flush first, then heparinize, and then De-access. because flushing after iv push is 2nd nature to us, please be conscious not to flush the heparin into the patient.

[CityofAngelsRN]

Thank you OP for addressing this. I used to work on a hemeonc unit and for some reason we couldn't get straight answers regarding heparin flushes for ports. My questions are 1) with the GI bleeder for example, when they come back for labs and their port is flushed with saline, would that amount of heparin that you just pushed in their system be significant? 2) We had a lot of patients who were getting numerous pushes (like one every hour or two) so that seems like an excessive amount of heparin being pushed into their system? I've had other nurses say it's not so I'm just curious what you guys think (or know). Thanks for all the info guys!

[Wuzzie]

Thank you OP for addressing this. I used to work on a hemeonc unit and for some reason we couldn't get straight answers regarding heparin flushes for ports. My questions are 1) with the GI bleeder for example, when they come back for labs and their port is flushed with saline, would that amount of heparin that you just pushed in their system be significant? 2) We had a lot of patients who were getting numerous pushes (like one every hour or two) so that seems like an excessive amount of heparin being pushed into their system? I've had other nurses say it's not so I'm just curious what you guys think (or know). Thanks for all the info guys!

If I'm reading you correctly you are pushing Heparin into a port that is being kept accessed? Why? The only time you need to use Heparin is before you de-access the port and send the patient home. While the port is accessed only NS is needed to lock it between uses.

[AJJKRN]

There was not an "order" to flush, nor was the flush on the eMAR--it was part of the protocol to deaccess the port.

Where I work we are able to order the heparin flush because it's part of the protocol and we "sign" under hospital protocol and the attending. We have the autonomy (as most seasoned members know) to place the order in the MAR because of the protocol but we also order it to be scanned each time it is used because our protocol states to heparinize after each blood draw/cap change, deaccess, IVP when continuous IVF are not running, etc so there is a record.

As far as the charting goes, in the place where we can chart infusing/capped in our EMR I always type in the free text box "flushed with 500U = 5mL heparin" and call it a day. I'm guessing not all EMR's have that function so if not I would include it in my shift note "port flushed with heparin per protocol".

Disclaimer: I am a float nurse and not an oncology nurse but I still always pay attention to platelet count, etc on any Pt that has heparin products or liver issues, etc.

OP I think you have a really cool chance to get more involved with your unit and your nursing practice and help develop a hospital wide protocol. Do you have shared governance and/or a unit educator?