I know I am not part of the initial conversation, but may I add a comment. I have been working diligently to make my Nurses aware of the INS Standards and other documents Lynne mentioned; if a "New" member is reading this, I think they may be very confused. Yvette
>>> "Lynn Hadaway" <[EMAIL PROTECTED]> 06/09/2006 5:37:58 PM >>> I do find Tim's statement: >The INS "Standard" is obviously wrong, which is why it is ignored as a serious over-generalization, inflammatory, severely confusing to nurses who are honestly trying to sort out the issues, and very misleading. Obviously the standards are not entirely wrong since they are in line with so many other published documents. If they are wrong then, CDC, ONS, ASHP, JCAHO, USP etc are also wrong. I will defend everyone's right to make any statement they wish to make, but I will also vehemently object if I feel there are false impressions being propagated. I strongly agree that the standards, as all influencing documents, will always be in evolution. I strongly agree that scientific evidence is needed. But I also realize that we are in the middle of a transition period. In the early 1990's, the edition of the standards plainly stated that the standards were based on practice. So we had to develop our practice with techniques, technologies, methods etc based on empirical evidence, then the standard was based on that by experts in the field. We now recognize the importance of scientific evidence but we also do not have the necessary science to use for many decisions. So I would agree that we have a standard based on a mixture of the old method and the new. But I would also suggest that this is necessary until science provides the answers we need. The question is should the practice criteria in the standards document be ranked with categories such as the CDC guidelines are? That might make things clearer but it could also add to the confusion. Many nurses wish to have extremely prescriptive answers to all their questions. So there could still be a high level of frustration with a ranking. I also know that using such a ranking system will require much longer than the 2 year process we employed to revise the document. Most of the discussion we have had about these issues are statements from the practice criteria statements and not the standards statements. Standards statements are a yes or no issue. Yes we did that or no we did not - should be very clear. The practice criteria statements are additional statements to guide the nurse to meet the standard. I would agree that our frequent discussion on a listserv is not producing any meaningful progress. Lynn At 4:31 PM -0400 6/9/06, Marilyn Hanchett wrote: >Well, you are exactly right about stating opinion. That is why >statements put forward as "standards" but lacking evidence are just that >- only opinions. And we are ALL entitled to our opinions. . . > >And remember, even the Founding Fathers were all criticized for their >"inflammatory" words and actions. Messages are only labeled inflammatory >if you don't agree with them. What is inflammatory to one may be >completely neutral to someone else. Another matter of opinion! Do you >find Tim's comments inflammatory? I do not and therefore will object to >any efforts to censor him (or anyone else who has something to say). > >We need a better forum for productive disagreement in order to move the >standards issue forward. > >Marilyn Hanchett RN > > > >-----Original Message----- >From: Lynn Hadaway [mailto:[EMAIL PROTECTED] >Sent: Friday, June 09, 2006 3:42 PM >To: Marilyn Hanchett; Brenda Seaver; Tim Talbert; Donna Fritz; Ann >Williams; ann marie parry; IV Listserv; vascular >Subject: RE: Blood Returns,INS standards > >It is obvious to me that you and I are talking to vastly different >professional experts because the majority of the ones I talk with do >support the standards. I think we also must recognize that there are >experts in infusion therapy and experts in vascular access. There are >areas where the expert knowledge overlaps but knowledge of vascular >access alone does not make one an expert in infusion therapy. A great >example is the interventional radiologist who are great experts at >inserting catheters but have little to no knowledge of all the infusion >therapy techniques, technology, practices etc that are required to >safely administer the huge number of drugs and fluids through those >catheters. > >All nurses are entitled to make any statements they wish to make as Tim >has done, but I do think we have the responsibility to include that one >is stating their opinion. I also think that current thinking can be >challenged in a way that is less inflammatory. > >I was a member of the recent committee that revised the INS standards, >so yes I am biased in defense of our hard work. So let this serve as my >disclosure to everyone. Lynn > >At 2:54 PM -0400 6/9/06, Marilyn Hanchett wrote: >>And how I wonder, Lynn, do you support such a sweeping claim? Most of >>the vascular access professionals I know think that the INS Standards >>are at best, very weak. Other descriptors are far more derogatory and I > >>will not repeat them here. >> >>The difference seems to be is that Tim is willing to make a public >>statement AND offer a reasonable and clinically appropriate >alternative. >> >>Rather than trying to correct or reprimand him, we should congratulate >>him on his willingness to challenge current thinking in the advancement > >>of science and the improvement of patient care. >> >>In your role with INS you are not, after all, unbiased when it comes to > >>"defending" the content & quality of this document. >> >>Marilyn Hanchett RN >> >>-----Original Message----- >>From: [EMAIL PROTECTED] >>[mailto:[EMAIL PROTECTED] On Behalf Of Lynn Hadaway >>Sent: Friday, June 09, 2006 1:21 PM >>To: Brenda Seaver; Tim Talbert; Donna Fritz; Ann Williams; ann marie >>parry; IV Listserv; vascular > >Subject: RE: Blood Returns,INS standards >> >>Tim is expressing his opinion and what he chooses with regard to the >>INS standards, however that is not the case with most nurses, >>healthcare facilities, etc. in the US. Lynn >> >>At 9:02 AM -0400 6/9/06, Brenda Seaver wrote: >>>Tim, What do you mean by this? >>>Brenda >>> >>>-----Original Message----- >>>From: Tim Talbert [mailto:[EMAIL PROTECTED] >>>Sent: Thursday, June 08, 2006 7:29 PM >>>To: Donna Fritz; Ann Williams; ann marie parry; IV Listserv; Brenda >>>Seaver; vascular >>>Subject: RE: fill volumes, Blood Returns >>> > >>The INS "Standard" is obviously wrong, which is why it is ignored. >>> >>>Tim >>> >>>>>> "Fritz, Donna" <[EMAIL PROTECTED]> 6/8/06 >>> >>>Since you mention oncology nurses and their seemingly cavalier >>>attitude >> >>>about blood return, comments from ONS on blood return from CVCs do not > >>>seem to be as strong as INS statements, interestingly. Our own policy > >>>is that we need to have blood return or we need a good explanation as >>>to why we don't (x-ray confirmation of a kink, etc) >>> >>>From Access Device Guidelines (2nd ed) from ONS: >>> >>>"No studies to date have provided a research-based answer to when to >>>give medications through a device without a blood return. >>>1. It is generally recommended in various clinical settings that >>>prior >> >>>to administering medications through VADs, in which no blood return >>>exists, placement verification should be accomplished either through >>>x-ray or dye studies. Peripheral and midline catheters should be >> >reinserted if there is no blood return. >>>2. Administration of vesicants should be prohibited unless catheter >>>tip placement, catheter body intactness, and catheter patency are >>>determined. If the catheter tip is determined to have a fibrin sheath > >>>or clot resulting in backflow, vesicants should not be administered. >>>Backtracking of a vesicant can result in extravasation. A physician >>>order should be obtained to use a VAD when there is no blood return if > >>>the VAD is determined to be intact, in correct position, and patent." >>>p. 99 >>> >>>INS standard # 45 on implanted ports: >>> >>>C. ". . . In the absence of a positive blood return, infusion therapy > >>>should be withheld until the problem can be diagnosed and treated." >>>p. >>>S46 >>> >>>INS standard # 42 on catheter placement: >>> >>>N. "If the patient is receiving long-term or chronic therapies, >>>repeat >> >>>radiographic study should be performed to confirm catheter tip >>>location, >>>according to organizational policies and procedures." p. S43 >>> >>>________________________________ >>> >>>From: [EMAIL PROTECTED] >>>[mailto:[EMAIL PROTECTED] On Behalf Of Brenda Seaver >>>Sent: Thursday, June 08, 2006 2:05 PM >>>To: Ann Williams; ann marie parry; Listserv, IV; vascular >>>Subject: RE: fill volumes, Blood Returns >>> >>> >>> >>>Thank you Ann for your response. We are privately owned, no hospital >>>affiliation. We have a hard time convincing case managers and >>>discharge >> >>>planners that this is important for us to have before admission. As >>>far >> >>>as the Oncology nurses, It surprises me that They are not concerned. >>>We >> >>>hook up the 5FU, but they're giving the "Big Boys" there. They joke in > >>>front of the patients about how particular we are. Isn't that a GOOD >>>thing when it comes to patient care? I don't get it. We don't want to >>>loose this account, but patient safety has to come first. Do you or >>>anyone out there have a policy I could look at? >>> >>>Thank You so much >>>Brenda >>> >>>-----Original Message----- >>>From: [EMAIL PROTECTED] >>>[mailto:[EMAIL PROTECTED] Behalf Of Ann Williams >>>Sent: Thursday, June 08, 2006 3:29 PM >>>To: Brenda Seaver; ann marie parry; Listserv, IV; vascular >>>Subject: RE: fill volumes, Blood Returns >>> >>>Yes, Brenda, we do require a tip placement verification before we >>>begin >> >>>therapy. We are fortunate in that most of ours come from our "mother" >>>hospital and I can view the results in the computer. Our referral >>>nurses are good about copying the report from the chart when they are > >>gathering the chart parts. >>> >>>Your beginning statement sounded like it was written by me! (The 5-FU > >>>patients). But I haven't heard any problems from our nurses. So >>>either >> >>>there is no problem, or they are ignoring it, in which case I will >>>have >> >>>to hunt them down and hurt them!! :) I think, like you, I would also > >>>want to see the report. >>> >>>If I can be of any help, let me know. >>> >>>ann >>> >>>Ann Williams RN CRNI >>>Infusion Specialist >>>Deaconess Home Services >>>600 Mary St. >>>Evansville, IN 47747 >>>812-450-3828 >>>812-450-4665 FAX >>> >>> >>>________________________________ >>> >>>From: [EMAIL PROTECTED] >>>[mailto:[EMAIL PROTECTED] On Behalf Of Brenda Seaver >>>Sent: Thursday, June 08, 2006 11:25 AM >>>To: Brenda Seaver; ann marie parry; Listserv, IV; vascular >>>Subject: RE: fill volumes, Blood Returns >>> >>> >>>-----Original Message----- >>>From: Brenda Seaver [mailto:[EMAIL PROTECTED] >>>Sent: Thursday, June 08, 2006 11:47 AM >>>To: ann marie parry; Listserv, IV; vascular >>>Subject: RE: fill volumes, Blood Returns >>> >>> I was wondering if anyone has a policy they would be >>>willing to share on validating line placement or usability. We are a >>>home infusion company. We have many patients that we hookup to 5FU via > >>>a CADD prizm for 48 hour continuous infusion at an Oncology suite >>>after their chemo there. These patients all have accessed ports when >>>we get there. Our nurses flush, check for patency, and hooks up pump, >>>then we see patients >>>2 days later for disconnect and deaccess. Problem is we're finding >>>many >> >>>patients don't have a blood return when we go to hookup. We have been >> >told there OK to use by MD, they flush easily, some say studies have >>>been done -but we have no report to back that up. We are seen as a >>>nuisance when we push for studies. We don't want to take chances with >>>our patients like this. Lately we have been reaccessing (which of >>>course the patient hates-another stick), then we tpa, Chemo hookup is >>>delayed and everyone is upset. One patient still had no blood return, >>>we were told studies were done, ports OK, unable to find report? What >>>do we do? >>>Our Nurse Educator and myself have scheduled a meeting with the office > >>>manager, I want to go in there with a good policy. Please help; I >>>learn >> >>>so much from all of you. One more question, when a new patient comes >>>on >> >>>service With Central line do you all require placement reports before >>>infusing? >>>Again we are home infusion. >> > >>>Thank you so much >>>Brenda >>> >>>-----Original Message----- >>>From: [EMAIL PROTECTED] >>>[mailto:[EMAIL PROTECTED] Behalf Of ann marie parry >>>Sent: Wednesday, June 07, 2006 9:25 AM >>>To: Listserv, IV; vascular >>>Subject: fill volumes >>> >>>Our hospital is considering trialing Ethanol locks - there is a debate > >>>about the fill volume to use - will be used in PICCs, tunneled and >>>non-tunneled lines as well as some dialysis catheters. They want to >>>keep it standardized as much as possible for adults. They will also >>>be >> >>>using it in the peds population. I have done some limited research >>>but >> >>>I would like to hear what others have to say. >>> >>>Thanks >>> >>>Ann Marie >>>----- Original Message ----- >>>From: Heather Nichols <mailto:[EMAIL PROTECTED]> >>>To: Listserv, IV <mailto:[EMAIL PROTECTED]> ; Peng, Kathleen >>><mailto:[EMAIL PROTECTED]> >>>Sent: Wednesday, May 24, 2006 1:16 PM >>>Subject: Re: FW: Need article references >>> >>>Kathleen, >>> We just put a policy into effect on your number one question. >>>We evaluate tip location on any line that comes in house for use. It >>>does >> >>>not matter what type of line it is. We had an issue just last week >>>where a man came in for chemo and said he had a PICC. It was barely a > >>>mid-line, and the man was to get Vinchristine What a disaster that >>>could have been. Our policy also reads that a central line of any >>>kind >> >>>must have a good blood return and flush easily. If not, we can tPA, >>>by >> >>>either stop cock for solid occlusion, or drip for no blood return. If > >>>the tPA does not work, the patient is to go for a dye study in IR to >>>find out what is wrong with the line. IR, and the primary team has >>>final say. >>> We use stop cock to avoid putting too much pressure on the line, >>>and the ability to agitate the clot slowly. >>> Hope all is going well with you guys! >>> >>>Heather Nichols RN BSN CRNI >>>Infusion Services >>>University of Louisville Trauma Institute 530 S. Jackson St. >>>Lou. Ky. 40202 >>>(502)562-3530 >>> >>>>>> "Peng, Kathleen" <[EMAIL PROTECTED]> 5/24/2006 11:56 >>>>>> AM >>>>>> >>> >>> >>>________________________________ >>> >>>From: Peng, Kathleen >>>Sent: Wednesday, May 24, 2006 10:53 AM >>>To: IV Listserv; '[EMAIL PROTECTED]' >>>Subject: Need article references >>>I was just asked by one of our educators for some input on two of our >>>policies that are being worked on: >>>1). Central Line Care: need for initial CXR on a pt that is admitted >>>with a CVL already in place (PICC, Jugular, Subclavian) Currently, it >>>is not actually in our policies that a CXR NEEDS to be done prior to >>>use but we have educated staff on the need in the case of PICCs. What >>>is everyone else doing and what are your references to support your >>>practice? >>>2). Obstructed Catheters/Use of TPA >>>Currently our policy just basically states to use TPA 2 mg, let dwell, > >>>etc. The question is whether to use the stopcock method or hook the >>>syringe directly to to the lumen. We have been instructing to just >>>hook >> >>>the syringe to the lumen and it has been working well. What are others > >>>doing? Are there references out there to support one practice over >>>another? >>>Thanks, >>>Kathleen Witt, RN, BSN >>>Nutrition Support >>>Presbyterian Hospital of Dallas >>>214-345-7468 >>>[EMAIL PROTECTED] >>> >>>The information contained in this message and any attachments is >> >intended only for the use of the individual or entity to which it is >>>addressed, and may contain information that is PRIVILEGED, >>>CONFIDENTIAL, and exempt from disclosure under applicable law. If you >>>are not the intended recipient, you are prohibited from copying, >>>distributing, or using the information. Please contact the sender >>>immediately by return e-mail and delete the original message from your > >>>system. >>> >>>----------------------------------------------------- >>>Confidentiality Disclaimer >>> If you are not the intended recipient(s), you are notified that >>>the dissemination, distribution, or copying of this message is >>>strictly prohibited. If you receive this message in error, or are not > >>>the named >> >>>recipient(s), please notify the sender or contact the University of >> >Louisville Health Care I.S. helpdesk at 502.562.3637 to report an >>>inadvertently received message. >>>----------------------------------------------------- >>> >>> >>>---------------------------------------------------------------------- >>>- >>>- >>>-------------------------------------------- >>>This email and any files transmitted with it are confidential and >>>intended solely for the use of the individual or entity to whom they >>>are addressed. >>>If you have received this email in error please notify the originator >>>of the message. >>> >>>Any views expressed in this message are those of the individual >>>sender, >> >>>except where the sender specifies and with authority, states them to >>>be >> >>>the views of Deaconess Health System. >>> >>> >>> >>>********************************************************************** >>>* >>>***** >>>* >>>This communication is for the use of the intended recipient only. It >>>may contain information that is privileged and confidential. If you >>>are not the intended recipient of this communication, any disclosure, >>>copying, further distribution or use thereof is prohibited. If you >>>have received this communication in error, please advise me by return >>>e-mail or by telephone and delete/destroy it. >>>********************************************************************** >>>* >>>***** >>>* >>> >>>Notice from St.Joseph Health System: >>>Please note that the information contained in this message may be > >>privileged and confidential and protected from disclosure. >> >> >>-- >>Lynn Hadaway, M.Ed., RNC, CRNI >>Lynn Hadaway Associates, Inc. >>126 Main Street, PO Box 10 >>Milner, GA 30257 >>http://www.hadawayassociates.com >>office 770-358-7861 > > >-- >Lynn Hadaway, M.Ed., RNC, CRNI >Lynn Hadaway Associates, Inc. >126 Main Street, PO Box 10 >Milner, GA 30257 >http://www.hadawayassociates.com >office 770-358-7861 -- Lynn Hadaway, M.Ed., RNC, CRNI Lynn Hadaway Associates, Inc. 126 Main Street, PO Box 10 Milner, GA 30257 http://www.hadawayassociates.com office 770-358-7861 CONFIDENTIALITY NOTICE: This email, including any attachments, contains information which may be confidential or privileged. 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