IV medications: Push should not become a permanent solution

As one of more than four million nurses in the U.S. today, I think I speak for many of us in saying that it is a great time to be a nurse! The advances in nursing and patient care that we have experienced over the last 40 years are incredible, and we are caring for sicker patients with more and more successful outcomes. No single profession can claim accountability for the improvement in patient care outcomes, instead, this success should be shared by the entire multidisciplinary team. While I want to celebrate all things good in nursing, it’s important to also recognize the challenges ahead, especially in medication management.

This past year healthcare faced an unprecedented shortage of commercially available medications and IV solutions, which presented an opportunity for innovation and creativity in order for patients to receive safe care. For example, when small volume IV bags weren’t available, hospitals delivered drugs via IV push syringes.  Suddenly, the nursing staff was routinely preparing sterile compounds at the bedside for immediate use and administration. As a result, nurses’ responsibilities were stretched beyond capacity, specialized training had to be done quickly for nurses unfamiliar with the process and safety requirements for preparing IV medications, and existing equipment had to be shared between care settings. Regrettably, IV push medications were often given too quickly or incompletely by the busy nurse.

However, now that the shortage is over many hospitals have not resumed their previous process of pharmacy preparing IV piggyback products. Nurses continue to use their limited time to prepare IV medications, despite the availability of commercially available products. The reasons for this are unclear. One possibility is that the nursing team has not yet provided feedback to the pharmacy about the impact on nursing workload.  Another possibility may be the inconvenience of changing electronic medical records back to giving the drugs IVPB instead of IV push. Neither of these reasons seems to outweigh the importance of adhering to best practices.

In fact, the preparation of continuous and intermittent IV medications by the pharmacy is one of the improvements in care that has evolved over the last few decades. The pharmacy is the most appropriate place for compounding, and preparing intermittent drugs via IV piggyback helps to ensure the appropriate dilution and rate of infusion for the medication. The IV room pharmacist is less apt to be interrupted or distracted which leads to fewer medication errors.   The IV room pharmacist is highly-trained in the ever-changing, complex safety standards for compounding which protects the patient, the care team and the community. While many of us in nursing remember the days when we made our patients’ IVs (mixed the KCl into the glass IV bottles, reconstituted and gave IV piggyback medications through a Buretrol or Soluset), I for one would not want to go backwards. There are very good reasons why medication management evolved from these practices. 

In order to get back to best practices for patient care, nurses need to speak up. While this was a creative solution meant to manage a temporary shortage, it, unfortunately, came with an increase in risks for patients. Nurses need to recognize the value of using the best methods for IV medication preparation and administration. We aren’t pharmacists, we don’t practice in a clean room, and it makes sense for us to collaborate with the pharmacy experts to design the best solutions before, during, and after a shortage. Clear and timely communication with the pharmacy team will help to improve safe delivery of medications and optimize patient care.

Nursing workload is dynamic and is affected by many variables. Drug and supply shortages are a variable that must be accommodated in order to maintain safe and effective care. Active, ongoing engagement between nursing and pharmacy can prevent short term solutions from becoming permanent practices.  If nursing resources are short, workload increases may inadvertently contribute to the cycle of nursing shortages. We have worked hard to make significant improvements for our patients, let’s not let workload and nursing shortages take us back in time. We are 4 million voices strong, let’s remember to speak up.