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RNs Should Check IVs Every 4 Hours to Avoid Malpractice

Monday May 18, 2009
Myung Sung, RN
Myung Sung, RN
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Lawsuits involving problematic intravenous lines are the third most common cause of medical malpractice litigation in the United States, so nurses who maintain IVs must take personal accountability when managing complications, says an internationally known expert in infusion therapies.

Because most complications from peripheral IVs are considered preventable and thus indefensible to the courts, the best defense a nurse can present is vigilant assessment and care of intravenous lines, says Sue Masoorli, RN, founder and president of Philadelphia-based Perivascular Nurse Consultants.

“There are no specific guidelines for how often to check a site, and that’s the problem,” says Masoorli, who has served as an expert witness in nearly 100 court depositions and trials. “Nursing standards of practice and hospital policies are all over the place. Many hospitals say to check two times a shift, which is a big problem because some shifts can go 12 hours.”

For Masoorli, the gold standard for minimizing peripheral IV complications — the most common are infiltration, extravasation, and phlebitis — is checking the lines every four hours.

“It’s the nurse’s duty to check the site frequently to catch the early signs,” Masoorli says. “While we can’t prevent all of them, we can prevent the big ones, so that’s the objective.”

At Sound Shore Medical Center in New Rochelle, N.Y., nurses examine and document their patients’ IVs every two to three hours, says nurse educator Camille Drago, RN. “It can be fine this hour and an hour later be totally bad,” she says.

If a complication is observed, the nurse documents the problem, reports it to the physician, and administers localized care, says staff educator Sue McLeer, RN, BSN, of Sound Shore.

But frequent and regular site inspections are just part of the assessment process, Drago says. “We tell the nurses to listen to the patient because they know themselves best,” she says.

At Vassar Brothers Medical Center in Poughkeepsie, N.Y., nurses also are trained to conduct IV assessments on every round — typically every two hours, says education coordinator Myung Sung, RN, BC, MS.

Observed complications are documented and the affected line immediately removed. When interventions such as warm or cold compresses are needed, the physician is notified, Sung adds.

In certain units at Vassar Brothers, such as critical care and medical-surgical, actual care of lines is provided by a 35-member, 24-hour specialized IV team. Trained and certified in starting, assessing, maintaining, and removing both peripheral and central lines, the team has been operating in the facility for close to 30 years, Sung says.

She adds that as a result of the team’s expertise, Vassar Brothers continually posts below-average rates of infections and other complications.

Because virtually all peripheral IV complications are preventable, the more fastidious the care the fewer complications will arise, Masoorli says. The exception to the rule is infiltration, which also is the most common peripheral IV complication.

During infiltration, nonvesicant solution seeps into the surrounding tissue because of fragile veins, dehydration, poor access, or patient movement. Frequent checks of the line, examining the skin around the catheter, and questioning the patient about numbness or tingling will help minimize symptoms should infiltration occur.

Averting extravasation, which is the active infusion of a vesicant solution into the surrounding tissue, entails ensuring the catheter is secure in the vein and properly functioning before administering the vesicant solution.

“Once in the tissue, such solutions cause necrosis, which can require major skin grafts and possibly amputation. It’s considered a Class 4 chemical burn,” Masoorli explains.

Phlebitis, or vein inflammation, can be avoided by choosing the most appropriate-sized vein for the infusion and diluting medications that cause vein irritation.

When patients who have suffered preventable complications, such as phlebitis or extravasation, take their claims to the legal system they typically settle out of court, Masoorli says. “Because they’re considered to be preventable, they’re considered indefensible,” she says.

But factors such as speed and documentation can play a role in the settlement, Masoorli adds.

“It is the standard of practice that for every extravasation the physician needs to be notified immediately, and the nurse needs to receive instruction from the physician for the intervention and care,” Masoorli says. “Not to do that in a timely manner is malpractice.”

With non-preventable problems such as infiltration, the court often will base its ruling on the size of the swollen tissue, Masoorli says.

“If it was a little one, then they say you were checking the site frequently and picked up on the problem early and were doing your job,” she explains. “But if it’s larger and led to serious tissue damage, it’s implied that the site was not checked appropriately and can lead to a ruling of negligence. It’s important that the nurse measure in centimeters and document the area of swelling, which the courts will use to determine negligence.”

But the best defense a nurse can possess is assuming personal responsibility and using common sense while caring for and treating complicated IV lines.

“Nurses need to know that the responsibility falls on them. You’re the trained professional, and you need to know what your duty is,” Masoorli says. “It often comes down to the nurse’s judgment, and you have to be able to defend your decision making.”

Robin Huiras is a freelance writer.


To comment, e-mail editorNJ@nursingspectrum.com.
Avoid Complications

According to Sue Masoorli, RN, founder and president of Perivascular Nurse Consultants, preventing complications on peripheral IV lines is not always possible. But frequent and thorough line assessments are essential to catching early signs of problems.

“The main thing for nurses is that they assess the site frequently — every four hours at a minimum — for early symptoms of complications because once they become advanced they can be very damaging to the patient. So that’s key and it only takes seconds to do that.”

This involves visual and tactile confirmation that the catheter is functioning correctly.