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Introduction ⬇

An intermittent infusion device, or saline lock, eliminates the need for multiple venipunctures or maintaining venous access with a continuous IV infusion. This device allows intermittent administration by infusion or by the IV bolus injection method.

When administering IV fluids to older adults, keep in mind that these patients commonly have compromised cardiac, hepatic, or renal systems, which puts them at high risk for heart failure, shock, or cardiac arrest if IV fluids are administered too rapidly or in too great a volume. Furthermore, older adult patients in particular may be unable to articulate symptoms because of such underlying conditions as stroke, intubation, tracheostomy, dementia, or delirium; monitor these patients closely during all IV infusions. Speed shock may also result from rapid administration of a bolus medication or an infusion. Symptoms of speed shock, such as dizziness and headache, occur rapidly, which may make it difficult for the older adult patient to articulate them. These early symptoms may progress to chest tightness, hypotension, irregular pulse, and anaphylactic shock. Close observation and careful control of medication or solutions administered parentally to older adults is crucial.1

Sterile no-touch technique should always be used when administering a drug through an intermittent infusion device to reduce the risk of vascular catheter–associated infection.

HOSPITAL-ACQUIRED CONDITION ALERT Keep in mind that the Centers for Medicare and Medicaid Services considers vascular catheter–associated infection a hospital-acquired condition because it can be reasonably prevented using a variety of best practices. Make sure to follow evidence-based infection prevention practices, such as performing hand hygiene, using sterile no-touch technique, performing a vigorous mechanical scrub of needleless connectors, and discontinuing the device as soon as it’s no longer needed, to reduce the risk of vascular catheter–associated infections.2,3,4

Equipment ⬆ ⬇

Equipment

Gloves • antiseptic pads (chlorhexidine-based, povidone iodine, or alcohol) • 10-mL syringe(s) prefilled with preservative-free normal saline solution • prescribed medication in an IV container (for IV infusion) or in a syringe (for IV bolus injection) • IV administration set • needleless connector(s) • sterile male Luer covering device • Optional: electronic infusion device, pulse oximeter and probe, capnography equipment, standardized sedation scale, disinfectant-containing end cap.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all IV equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.5

Implementation ⬆ ⬇

Implementation
  • Avoid distractions and interruptions when preparing and administering medications to prevent medication errors.6,7
  • Verify the practitioner’s order.8,9,10,11,12
  • Gather and prepare the necessary equipment and supplies.
  • Compare the medication label with the order in the patient’s medical record.8,9,10,11,12,13
  • Check the patient’s medication record for an allergy or other contraindication to the prescribed medication. If an allergy or other contraindication exists, don’t administer the medication; instead, notify the practitioner.8,9,10,11,12
  • Check the expiration date on the medication. If it has expired, return the medication to the pharmacy and obtain a new medication.8,9,10,11,12
  • Visually inspect the medication for particles, discoloration, or any other loss of integrity; don’t administer the medication if its integrity is compromised.8,9,10,11,12
  • Discuss any unresolved concerns about the medication with the patient’s practitioner.9,10,11,12
  • Verify that you’re administering the medication at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors.9,10,11,12
  • Perform hand hygiene.3,14,15,16,17,18,19,20
  • Confirm the patient’s identity using at least two patient identifiers.21
  • Provide privacy.22,23,24,25
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.26 If the patient is receiving the medication for the first time, teach the patient about potential adverse reactions and discuss any other concerns related to the medication.27
  • Raise the patient’s bed to waist level before providing patient care to prevent caregiver back strain.28
  • Perform hand hygiene.3,14,15,16,17,18,19,20
  • Put on gloves to comply with standard precautions.29,30,31
  • Prepare the medication and administration set: For an IV infusion, remove the protective cover of the administration set’s spike and the infusion container, insert the spike from the administration set into the infusion container, attach a needleless connector to the opposite end of the administration set tubing, and then prime the tubing and needleless connector.1,32 For an IV bolus injection, attach a needleless connector to the syringe containing the prescribed medication and prime the needleless connector.1,32
  • Assess the intermittent infusion device site to ensure that it’s free from signs of infection (tenderness, erythema, and induration within 2 cm of the insertion site, and purulent drainage at the exit site), phlebitis (tenderness at the site, erythema, warmth, swelling, induration, purulent drainage, and palpable venous cord), and infiltration (blanching, bruising, or redness around the insertion site); edema in any direction from the insertion site; skin temperature changes; pain, burning, or stinging with injection or infusion; blisters; impaired mobility; numbness or tingling; slowed capillary refill time; and fluid leaking from the insertion site.1,32,33
  • If your facility uses a bar code technology, use it as directed by your facility.
  • If required by your facility, before administering a high-alert medication,34 have another nurse perform an independent double-check to verify the patient’s identity and make sure you have the correct medication in the prescribed strength or concentration; the medication’s indication corresponds with the patient’s diagnosis; the dosage calculations are correct and the dosing formula used to derive the final dose is correct; the prescribed route of administration is safe and proper for the patient; and the prescribed time and frequency of administration are safe and proper for the patient.35
  • After comparing results of the independent double-check with the other nurse (if required), administer the medication if there are no discrepancies. If discrepancies exist, rectify them before administering the medication.35
  • If a disinfectant-containing end cap is covering the end of the needleless connector, remove and discard it.36,37
  • Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely.36,38
  • While maintaining sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure.) Unclamp the device clamp, if present, and slowly aspirate for blood return that is the color and consistency of whole blood. If no blood return is obtained, take steps to locate an external cause of the obstruction.39
  • If a blood return is obtained, slowly inject preservative-free normal saline solution into the intermittent infusion device. Use a minimum volume of twice the internal volume of the catheter system. Don’t forcibly flush the device; further evaluate the device if resistance is met.39 Insert a new intermittent infusion device at another location if needed. (See the "Intermittent infusion device insertion" procedure.)1,32
  • Remove and discard the syringe.29,40
  • Perform a vigorous scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely.36,38

Administering an IV Bolus Injection

  • Attach the syringe containing the prescribed medication to the needleless connector of the intermittent infusion device.1,32

NURSING ALERT After confirming patency of the vascular access device by using a 10-mL syringe (or a syringe designed specifically to generate lower injection pressure) filled with preservative-free normal saline solution, administer the medication by IV bolus injection in a syringe of an appropriate size that allows you to measure and administer the required medication dose.41 Do not transfer the medication to a larger syringe.39

  • Administer the medication at the rate indicated on the medication label; consult with the pharmacist if the rate isn’t specified.1,32
  • Remove and discard the syringe.29,40

Administering an IV Drug Infusion

  • Remove the protective cover from the distal end of the administration set tubing.1,32
  • Connect the IV administration set tubing to the intermittent infusion device’s needleless connector.1,32
  • Trace the tubing from the patient to its point of origin to make sure that you’re connecting it to the proper port.8,42 Route the tubing in a standardized direction if the patient has other tubing and catheters that have different purposes. Label the tubing at the distal end (near the patient connection) and proximal end (near the source container) to reduce the risk of misconnection if multiple IV lines will be used.8,42
  • Slowly open the clamp of the administration set tubing, and adjust the flow rate to begin the infusion. Alternatively, turn on the electronic infusion device and begin the infusion at the prescribed flow rate.1,32 Use an electronic infusion device for infusions that require precise flow control to maintain patient safety. Consider the use of a smart pump with dose-error reduction software and interoperability with electronic health records to reduce the risk for infusion-related medication errors.43 Make sure alarm limits are set appropriately and that alarms are turned on, functioning properly, and audible to staff.43,44,45
  • If using a gravity-flow administration set, monitor the drops per minute by counting the drops and using a clock with a second hand; if using an electronic infusion pump, watch the device display for 1 to 2 minutes to ensure the proper administration rate.1,32
  • When the infusion is complete, clamp the IV administration set tubing and disconnect the tubing from the intermittent infusion device. If you’re reusing the IV administration set tubing, close the clamp on the tubing and aseptically attach a new, sterile, compatible covering device to the male Luer end of the administration set. Don’t attach the exposed end of the administration set to a port on the same set.44 If you won’t reuse the tubing, discard it appropriately with the IV container.29,40

Completing the Procedure

  • Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely.36,38
  • While maintaining sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the intermittent infusion device’s needleless connector. (Use a 10-mL syringe or a syringe specifically designed to generate lower injection pressure). Unclamp the catheter and inject preservative-free normal saline solution into the catheter at the same rate of injection as the prescribed medication. Use the amount of flush solution needed to adequately clear the medication from the administration set lumen and the catheter. Don’t forcibly flush the device; further evaluate the device if resistance is met.
  • Consider using a pulsatile flushing technique, because short boluses of the flush solution interrupted by short pauses may be more effective at removing deposits (e.g., fibrin, drug precipitate, intraluminal bacteria) than a continuous low-flow technique. Alternatively, if the medication is incompatible with normal saline solution, use dextrose 5% in water followed by preservative-free normal saline solution. Don’t allow dextrose 5% in water to remain in the catheter lumen, because it provides nutrients for biofilm growth.39
  • Close the clamp and remove the syringe according to the needleless connector used, following the manufacturer’s instructions. For a positive-pressure needleless connector, clamp the catheter after disconnecting the syringe.1,32 For a negative-pressure needleless connector, maintain pressure on the syringe while clamping the catheter.1,32 For a neutral needleless connector, clamp the catheter before or after disconnecting the syringe.1,32 For an antireflux needleless connector, clamp the catheter and then disconnect the syringe; a specific clamping sequence isn’t required.45,46
  • If available in your facility, place a new disinfectant-containing end cap on the end of the needleless connector to reduce the risk of vascular catheter-associated infection.36,37
  • Return the bed to the lowest position to prevent falls and maintain patient safety.47
  • Discard used supplies in appropriate receptacles.29,40
  • Remove and discard your gloves.29,30,40
  • Perform hand hygiene.13,14,15,16,17,18,19,20
  • Monitor the patient closely for adverse reactions to the prescribed medication.8,48
  • If the patient is receiving an IV opioid medication, frequently monitor the patient’s respiratory rate, oxygen saturation level by pulse oximetry, end-tidal carbon dioxide level by capnography (if available), and sedation level using a standardized sedation scale to decrease the risk of adverse events associated with IV opioid use.48
  • If the patient is receiving an IV opioid medication, explain the assessment and monitoring processes to the patient and family members and tell them to alert staff if breathing problems or sedation occurs.27,48
  • Perform hand hygiene.14,15,17,18,19,20
  • Document the procedure.49,50,51,52,53

Special Considerations ⬆ ⬇

Special considerations
  • Before administering an injectable drug, make sure you know the prescribed infusion rate and infusion time period.8
  • The Joint Commission issued a sentinel event alert related to managing risk during transition to new International Organization for Standardization tubing standards that were designed to prevent dangerous tubing misconnections, which can lead to serious patient injury and death. During the transition, make sure to trace each tubing and catheter from the patient to the point of origin before connecting or reconnecting any device or infusion, at any care transition (such as to a new setting or service), and as part of the hand-off process; route tubes and catheters having different purposes in different, standardized directions; when the patient has different access sites or several bags hanging, label tubing at both the distal and proximal ends; use tubing and equipment only as intended; and store medications for different delivery routes in separate locations.42
  • The Joint Commission issued a sentinel event alert concerning the transmission of pathogens related to the misuse of vials that have caused viral and bacterial infections, including hepatitis B, hepatitis C, meningitis, and epidural abscesses. These infections have been attributed to the reuse of single-dose vials that typically don’t contain preservatives, re-entering multidose vials with used syringes and needles, and using multidose vials for multiple patients. To prevent these infections, follow evidence-based best practices, such as disinfecting the vial’s rubber stopper before piercing it, using single-dose vials only once and then discarding them, dedicating multidose vials to a single patient, and using a new syringe and needle when re-entering a multidose vial. Assign the appropriate "beyond-use" date when first entering a multidose vial, and store multidose vials as directed by your facility and according to the manufacturer’s instructions.54

Complications ⬆ ⬇

Complications

Infiltration, infection, phlebitis, and reactions specific to the infused medication are the most common complications.

Documentation ⬆ ⬇

Documentation

Document the type, concentration, dosage, and volume of drug administered and the time of administration. Document the date, time, amount, and type of flush solution used, patency of the catheter, presence of blood return, lack of resistance when flushing, and absence of signs and symptoms of complications. Record any adverse reactions to the prescribed medication, the name of the practitioner notified, the date and time of notification, your interventions, and the patient’s response to those interventions.55 Document teaching provided to the patient and family (if appropriate), their understanding of that teaching, and any need for follow-up teaching. On the intake record, record the type and volume of all IV solutions used to dilute the medication and to flush the line.50

References ⬆

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  2. JarrettN., & CallahamM. (2016). Evidence-based guidelines for selected hospital-acquired conditions: Final report. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/2016-HAC-Report.pdf
  3. Centers for Disease Control and Prevention. (2011, revised 2017). Guidelines for the prevention of intravascular catheter-related infections. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html (Level I)
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  51. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

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  52. Accreditation Association for Hospitals and health Systems. (2018). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  53. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  54. The Joint Commission. (2014). Sentinel event alert 52: Preventing infection from the misuse of vials. https://www.jointcommission.org/en/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-52-preventing-infection-from-the-misuse-of-vials/ (Level VII)
  55. The Joint Commission. (2021). Standard RC.02.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)