What happens if IV med does not finish on time?

IVRUS, BSN, RN · May 14, 2012

Well before anything can be assessed in this situation, I'd like to know a couple of things:

1. Are they infusing via pump, or via gravity or an on-line-regulator like a dial-a-flow?

2. What type of IV catheter does the patient have in?

3. Is the catheter positional?

4. Does the patient get up and move around when you are NOT there while infusing, vs. remaining stationary while you are there?

5. What medication are you infusing?

umharhar · May 14, 2012

1. Dial-a-flow2. Picc line3. Im not sure what you mean by positional...4. pt said he does go to restroom 2-3 tmes and he would go like once when im there5. Zyvox 600mg/300ml over 2 hrs q12h

IVRUS, BSN, RN · May 14, 2012

Okay,

My first thought after reviewing your answers is this:

If the patient is up and down several times throughout the 2 hour infusion your rate will slow as he moves namely because you are utilizing a D-A-F, instead of a pump.

Pumps have an accuracy of + or - 3 to 5% whereas DAF's can be 10-25% off... and as the person is up and ambulating, there is a resistance to flow inside the vein and the catheter.

Using a pump aids in the correct deliver of a medication as it will continue with a preset PSI in it deliver of the medication. I understand the whole, "rental amounts" which some HHA dislike and therefore just want a cheap dial-a-flow... But please remember that this is a primary intermittent tubing and should be changed daily.

The heaight of the container in relationship to the PICC insertion site is also a factor. Ideally, the bag should be about 36 inches above the VP site.

So, I don't believe that your patient is doing anything wrong perse', but that his increased movement is slowing the rate.. So he may want to limit ambulation, or have it so a BSC is something that he can swivel onto while he is infusing. ( Keep alcohol foam by his chair so that he can "wash" s/p. )

umharhar · May 14, 2012

Wow thank you for suuch a thorough answer :) The tubing is changed daily but it seems like some tubings are more accurate than other ones. I was with patient today but it was still slow so i raised the pole higher but im not sure if it was helpful cuz it ended up taking 2.5 hrs to finish...so since the accracy of rate can be off by 10-25% off, would it be ok to increase the rate if it takes too long?

IVRUS, BSN, RN · May 14, 2012

Well, remember that with a PICC, you have a 40-60cm in length catheter and it works much better with a Pump because of the added resistance. Your pharmacy has set the infusion time of one hour, I suppose, however, know that many times a 600 mg in 300ml dose is infused over ONE hour.

Hope this helped.

umharhar · May 14, 2012

Ok Thank you so much IVRUS!!! :)

Your comments are very helpful!!! if you don't mind, I would like to learn more about about the whole infusion mechanism...is it a book or a research article?

When I asked my supervisor about increasing the rate, she was hesitant because of possible cardiac overload...and she told me to raise the rate slowly if I have to...

And my patient also told me when the IV was finished in 1.5 hrs, he had some cramps in his stomach...which happened like 30 minutes after but disappeared after a while but I'm not sure if this is related...

Asystole RN · May 14, 2012

This situation would be easily resolved with a Homepump/balloon pump. Ask your pharmacy if they can fill his meds with them.

I've used them in the past and they are perfect for ambulatory home health patients. There is no extra tubing needed, no particular head height, and no extra pump. The infusion bag IS the pump.

snfmybut · Sep 21, 2016

Old post but wanted to put in my two cents to clarify.

1. Your agency wont need to rent a pump. PPS payments for HHA cover medical care not pharmaceuticals

2. The infusion company that provided the drug should also provide a pump.

3. I agree with Asystole RN in that a "grenade" "infusa-bulb" which is a pressurized iv balloon are the best! Always ask for these.

4. D-A-F, "dial a flow" aka inline flow regulators are junk in my opinion. They are basically glorified drip rate dials.

(IMHO)If that is all I have then I will run one but I cant stand them. They are hardly accurate and tend to run slower than the drip rate stated on the dial and that's assuming a 22ga x 1.0 with a easily flushed line running anything from ABX to NS bags. Don't even think of using IVIG with one.

My experience hasn't been great with them; and its a cheap alternative to a pump which I believe should be used because medications can cause reactions if given too fast.

Now I will say, when I have nothing else Ill use it.

In reference to your patient. Explain to them or future patients that if a med runs over time its ok. Its actually safer. Running too fast will get you in trouble when you least expect it. I agree with the change in body position changing the rate of drip however your using a flow regulator so have fun with that because your drip isn't running at the rate you think either way.

Tell your patients that infusion times aren't accurate with flow regulators and to just be patient. If they are running half the time till their next dose. I.e. gentamycin 66mg/100ml NS q 8 hrs and your bag is taking 4 hrs on a flow regulator. Have them call you to trouble shoot. Whole point of these devices is to not have to be present for the infusion.

Now I am no longer a VP of Ops for home health agencies and currently work as a DON for a SNF/LTC. I tell my pharmas that they will provide pumps with every infusion. Yeah it costs more but not as much as a lawsuit on a state reportable. Pumps are consistent and deliver with relative ease if you know what your doing. Sure you'll get occlusion alarms sometimes but at least you know what your delivering and how fast. Never leave a pump unattended for long. I've seen them pump air without an occlusion and luckily I caught it on my IVIG patient before we had any trouble.

IVRUS, BSN, RN · Sep 21, 2016

Yes, I agree that an elastomeric device is a wonderful thing, but it is cost prohibitive in many cases. Each one only delivers a single IVAB and then it is pitched. So, anything over a q day infusion can eat into your reimbursement quickly.

snfmybut · Sep 22, 2016

How is that possible IVRUS? Home Health agencies follow CMS guidelines for billing through fiscal intermediaries.

They recieve pps payements for episodic care over a case mix rate. This has absolutely nothing to do with medications or supplies to deliver such medications.

All IV supplies and medications are provided via an infusion pharmacy and billed through Medicare part D. Home Health is paid through Medicare A or B.

So I am confused on what you are talking about.

Umharhar stated he was a home health new grad not a pharmacist or infusion nurse.

Infusion companies where I live are more than happy to use elastomeric devices.

IVRUS, BSN, RN · Sep 23, 2016

How is that possible IVRUS? Home Health agencies follow CMS guidelines for billing through fiscal intermediaries.
They recieve pps payements for episodic care over a case mix rate. This has absolutely nothing to do with medications or supplies to deliver such medications.
All IV supplies and medications are provided via an infusion pharmacy and billed through Medicare part D. Home Health is paid through Medicare A or B.
So I am confused on what you are talking about.
Umharhar stated he was a home health new grad not a pharmacist or infusion nurse.
Infusion companies where I live are more than happy to use elastomeric devices.

I am merely speaking to the fact that this modality of administering a IVAB can be much more expensive than the diluent bag and the dry drug powder delivery. The cost is comparable if the dose is q 24, but any thing of a greater frequency may be cost prohibitive. It will really eat into the per-diem amount one gets in reimbursement.