How to confront physicians who use outdated IV info
A first-person account and the resulting changes
By Deborah Ward, RN
IV Therapy Specialist
IV Team McLaren Regional Medical Center
Flint, MI
Nurse Consultant, Becton-Dickinson Nursing Support System
Inappropriate physician orders present a great challenge to nurses who must be knowledgeable and alert to orders that could result in patient harm. Advocating for the patient can be the nurse’s greatest role. However, confronting a physician who may perceive himself or herself as superior can be difficult. The problem often lies in the fact that nurses and physicians frequently approach patient care from different perspectives: Physicians at times see only the clinical picture, while nurses more often than not see the patient as a whole.
Recently, I had the opportunity to act as a patient advocate when I was notified of an order to administer a 30% total parenteral nutrition (TPN) in a peripheral vein. This was very alarming, as recent studies have shown that solutions with high osmolarities are very thrombogenic. Trissels’ Handbook of Injectable Drugs states, "Parenteral nutrition solutions, composed of amino acids and dextrose, that are strongly hypertonic may be safely administered only through an indwelling intravenous catheter with the tip in the superior vena cava."1 Our hospital pharmacy and physician told the staff it was acceptable to infuse a 30% dextrose solution peripherally because the patient was also receiving lipids. The reasoning was the lipids would reduce the osmolarity of the TPN solution, thereby protecting the vein from damage.
Even a small amount can harm a vein
However, 19 years of infusion therapy have taught me that even a 10% solution will cause vein destruction. Many references report the normal osmolarity of blood ranges between 280-295 mOsm/L.2,3 It is also widely followed that partial parenteral nutrition (PPN) solutions containing 5% to 10% dextrose typically have an osmolarity no greater than 600mOsm/l. Admixtures greater than 450mOsm/L are considered to be thrombogenic and should be administered via a central catheter.2
In this particular case, an astute floor nurse knew the prescribed TPN would be detrimental to the patient. She contacted the surgical resident on call and convinced him to reduce the solution to 10% until a PICC line could be placed. He accepted her recommendation and changed the order.
As I was preparing to place the PICC line, the patient’s attending physician arrived and revoked the PICC line order. At that time, I was able to discuss the situation with the physician face to face. I expressed my concern of potential vein destruction, as well as my concern regarding the preservation of the venous system. I shared with him my 19 years of IV therapy experience in which I have seen vein destruction caused by infusing inappropriate solutions and drugs into the peripheral venous system.
The physician countered by quoting a study done in 1975 that showed TPN in peripheral veins to be a safe method of administration. However, I had recently returned from the Intravenous Nurses’ Society’s National Academy and Annual Meeting in Salt Lake City where I attended an excellent presentation on "Vein Pathology Related to Vascular Access Devices," by Robert Schelper, MD, PhD, a member of the department of pathology at the Syracuse University of New York Health Science Center.
Stick to your data
Schelper had presented very impressive evidence of vein destruction caused by inappropriate vascular access devices and solutions. I shared this information verbally with the physician and offered to send him written material if he desired to see it. I also shared my experiences inserting PICC lines and my belief that early insertion of PICC lines in a patient’s treatment can prevent vein destruction. I explained to him my goal as an IV therapist is to preserve the patient’s venous system so it may be used again in the future.
The physician again countered by addressing the PICC line complications he had seen at our hospital and his personal belief that they were unsafe.
I asked him to provide me with the details of these complications, to which he replied he could not remember the specific cases or details. I enlightened him to the fact that our IV Team has kept data on every PICC line inserted since the beginning of their use at our institution in 1991. Our data has proved PICC lines as a safe method of administering TPN solutions.
Although we debated the subject at length and without reaching common ground, he agreed to look at the more recent publications I could provide. In the meantime, he did not allow me to place the PICC line, reasoning that the patient was doing well and could start eating that day, so the TPN would be discontinued. We parted on good terms. I thanked him for his time and told him I would look forward to continuing our discussion when I had my materials available.
Unfortunately, I was on vacation the next two weeks. Upon my return, I was very disappointed to find that the patient had endured 10 more days of PPN in my absence. She continued to receive the treatment in a peripheral vein.
Looking back on this incident I would have approached it just as I did. My concern was diminished because the PPN was to be discontinued that day. Although I apparently did not have a great impact on this particular physician, I would not hesitate to approach him again should the situation reoccur.
However, as a result of the situation, we have made improvements in our office so information will be readily available for use in discussions with physicians who may make decisions based on outdated studies.
Procedure for treatment discussion
As a result of this dilemma, we have updated our library with appropriate studies. We have also created a procedure for handling such a situation by taking the following steps:
* Request a meeting with the attending physician, preferably face-to-face, although this could prove difficult for a home infusion nurse.
* Listen carefully and respectfully to his or her rationale for the prescribed therapy.
* Have hard copies of the studies we are relying on that refute the physician’s stand. If a phone conversation is scheduled, fax the studies to the physician ahead of time, and request copies of any studies or research on which they are basing their opinion.
* Provide the physician with our own collected data on PICC lines inserted at our institution.
* Establish a follow-up interview or meeting for a later date so the physician can review the provided materials and make a judgment after reviewing them.
* Use all available resources to collect the latest data. This includes various Internet Web sites, the infusion therapy listserv, as well as traditional sources for printed copies of studies and other research.
It is important that nurses, as patient advocates, take a stand to prevent harm that can occur from inappropriate treatment. In order to do this, we must continue to educate ourselves with the most up-to-date information available, as well as having such information readily available. We should not hesitate to share this information with our co-partners in health care delivery-physicians. By doing so, nurses and physicians can work together as colleagues rather than competitors, keeping our ultimate goal of patient health as the top priority.
References
1. Trissel, L. Handbook on Injectable Drugs. Ninth edition. Bethesda, MD: American Society of Health-system Pharmacists; 1996.
2. Booker M, Ignatavicius D. Infusion Therapy Techniques & Medication. 6th ed. Philadelphia, PA. Lippincott-Raven Publisher; 1997.
3. Metheney, N. Fluid and Electrolyte Balance. 3rd ed. Philadelphia, PA. Lippincott-Raven Publisher; 1996.
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