IV spiking recommendations from The Joint Commission

By: July 30th, 2010 Email This Post Print This Post

There have been a number of questions regarding the time frame for spiking IV bags prior to administration. Libby Chinnes and Dawn McLane, our experts in the “Infection Prevention Survey Strategies for ASCs: Comply with CMS’ Conditions for Coverage,” webcast, answered that question, explaining that the guidelines according to U.S. Pharmacy standards is that IVs should not be spiked more than one hour before administration.

But they also note that the APIC position paper on safe injection practices identifies this as a controversial and unresolved issue.

To clear things up from a regulatory standpoint, I asked The Joint Commission for their perspective. This was their response:

Q: What is the Joint Commission’s stance on pre-spiking IVs? I know “US Pharmacopeia (USP 2008), A General Chapter <797> Pharmaceutical Compounding – Sterile Preparations,” recommends administering the IV no more than an hour before spiking it. APIC also has a position paper that advices administering “as soon as possible,” but identifies this as a controversial issue.

What would a Joint Commission surveyor look for?

A: Joint Commission standards do not specifically address this issue. However, IC.01.05.01 EP 1 requires that, “When developing infection prevention and control activities, the hospital uses evidence-based national guidelines or, in the absence of such guidelines, expert consensus.” CDC/HICPAC addresses this issue in its document entitled “Guidelines for the Prevention of Intravascular Catheter-Related Infection.”

Recommendation IX.C.4 states, “No recommendation can be made for the hang time of other parenteral fluids. Unresolved issue.”

Therefore, The Joint Commission does not require that an organization place a specific time restriction on IV fluids (other than those specified in IX.C.1-3). However, if an accredited organization has a policy that specifies a hang time, or delineates how quickly fluids must be hung after being spiked, a surveyor may issue a Requirement for Improvement related to compliance with the organization’s own policy.

Additional guidance can be obtained from the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) or U.S. Pharmacopeia. State health departments, pharmacy boards or hospital licensing acts may also contain further regulations.

Comments

By Alan Oscher on November 14th, 2011 at 8:24 pm

what is the states protocol for leaving an opened not spiked IV bag hanging in an or suite taht is unattended. there are no dates on the bag and some bags are being pre-hung in trauma rooms.

By Bob Burke, RN CIC on April 11th, 2013 at 10:31 am

The Massachusetts Board of Registration in Nursing adds a caveat that speaks to situations where the practice is to pre-spike and prime many IV bags (e.g. ED or Chemo clinic).

Q: Is it in accordance with accepted standards of nursing practice for one nurse to prepare (remove from sealed container and/or spike and prime) intravenous solutions for other nurses to retrieve and administer to a patient?

A: No. The nurse administering the intravenous solution must be able to validate the integrity of the intravenous solution throughout the entire medication administration process.

By Bob Burke, RN CIC on April 11th, 2013 at 10:32 am

The Massachusetts Board of Registration in Nursing adds a caveat that speaks to situations in which practice has been to pre-spike and prime many IV Set Ups (e.g. ED or chemo clinic, etc)

Q: Is it in accordance with accepted standards of nursing practice for one nurse to prepare (remove from sealed container and/or spike and prime) intravenous solutions for other nurses to retrieve and administer to a patient?

A: No. The nurse administering the intravenous solution must be able to validate the integrity of the intravenous solution throughout the entire medication administration process.

By Lois Ott, RN,CAPA on March 28th, 2014 at 2:04 pm

Is it required that plain IV solutions be labeled when ordered and used in a peri-operative setting?

We have recently taken on IVIG infusions in our chemotherapy room. Many of our patients have 5-7 bottles of Octogam, and the nurses are spiking the 5 gm 200ml glass vials in our open room. I recommend pooling the bottles in the pharmacy, but the pharmacy says that “will take all our time”. I need data and stats, please.

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is it ok to spike the bag, and prime the set 24 hours before the patient goes on the pump ? This seems like a long time to me, and there appear to be micro-bubbles developing which drive the nurses crazy with air in line errors.

what is the BUD set for a premixed bag of Milrinone, spiked and primed under ISO 5 conditions, and delivered to a facility?

 

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