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IV spiking recommendations from The Joint Commission

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 [1],” webcast, answered that question [2], 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 [3] 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 [4].”

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.