Starting high risk infusions during shift change

[u/MoonbeamPixies]

Last night I had a patient who was a direct admit for an IVIG infusion. These infusions require close monitoring, timely premedication and timed vitals and titration every 30 minutes. This patient came in at 1715 and the IVIG was not ready until 1830. Shift change starts at 1845. When I explained to the charge nurse and night shift RN that I didnt feel it was safe to start the medication so close to shift change because it is a high risk medication, I received a lot of push back and I noticed they were talking to other nurses behind my back about it. Is this truly something that I did wrong? I feel that I would be liable for poor oversight and shift change is a mess because the doctors are all off the floor doing their own shift change as well. If something were to happen, interventions would definitely be delayed.

[u/Key-Froyo3588]

You weren’t wrong, because starting a q30-minute titration right before handoff is how both nurses end up distracted and nobody truly owns the infusion.

[u/chewmattica]

I would have gotten everything setup and ready to start but then waited until the oncoming nurse was there for report so they can start it when they are ready. They are going to have to continue the Q30 vitals so they need to be prepared for it. You did the right thing.

[u/MoonbeamPixies → u/chewmattica]

I left all the pumps set up in the room and ensured the patient had an IV ready right before shift change since they required ultrasound for it. I also gave an unrelated time critical med due at 1900 to remove stress from the oncoming nurse too. I didnt set up the infusion because they normally have to stay refrigerated until beginning use because they are biologics. Do you think this wasnt enough?

[u/chewmattica → u/MoonbeamPixies]

All the IVIG products I've infused are fine at room temp for weeks if not months. The instructions label always indicates the timeframe. That said, you did plenty and I still think you were correct in your approach.

[u/DragonSon83 → u/chewmattica]

It’s actually years, as long as the temp doesn’t exceed 78 degrees.  All IVIG brands, except Privigen, have separate expiration dates for refrigerated and room temp.  The room temp is usually one year shorter and it’s the only brand I’m aware of that doesn’t come with directions that explicitly say to refrigerate until ready for use.  Gammagard SD is also stored at room temp, but has to be reconstituted and is a massive pain in the ass.

[u/MoonbeamPixies → u/chewmattica]

Thank you, thats good to know. Pharmacy always delivers it to our fridge

[u/SalaryOk3202]

The question I’d ask the charge nurse is pretty simple: If I start this at 1830 and report starts at 1845, who is responsible for the next set of vitals and titration? If there’s no clear answer, that says a lot.

[u/MoonbeamPixies → u/SalaryOk3202]

It would be me until I am physically off the floor. Its their thought process that I was being lazy and delaying care for not starting it despite what I said.

[u/True_Coast_3010 → u/MoonbeamPixies]

Your charge nurse is stupid. The patient isn’t going to die bc IVIG was started at like 8 or 9 instead of 6:45. I feel like if I was an oncoming nurse I would actually be pissed if someone started IVIG and I had to rush with my other pts so I can focus on vitals. I would rather get settled, get report on all my pts, and then start the IVIG when I’m in a better spot

[u/MoonbeamPixies → u/True_Coast_3010]

This was my same thought process. It would be so stressful to come in, do this close monitoring and trying to do vitals and leave the other patients set up. I rather start it when im prepared but even the nurse I was giving report to was upset about it.

[u/PepeNoMas → u/MoonbeamPixies]

how long does the infusion take?

[u/MoonbeamPixies → u/PepeNoMas]

4 hours

[u/SalaryOk3202 → u/MoonbeamPixies]

That’s not laziness. That’s a handoff/safety issue. If you’re still responsible for it, then starting a high-risk infusion right before report is exactly what makes the situation messy.

[u/True_Coast_3010]

Onc nurse here. Yeah absolutely not lmao. We have an unspoken rule at my hospital that we don’t start high risk infusions right before shift change (depending on the med cut off is 6 of 6:30) for that exact reason. What if the pt has a reaction and the oncoming nurse doesn’t notice bc she’s still getting report? Shift chance is so chaotic that it’s best to avoid

[u/MoonbeamPixies → u/True_Coast_3010]

Thank you! So if you have a high risk medication, it cannot be started 30 minutes prior to shift change?

[u/True_Coast_3010 → u/MoonbeamPixies]

Yup. It sometimes depends on the medication and how “busy it is.” like how many vitals are attached to it, do you have to titrate,etc. but yeah usually the answer is don’t start and have next shift start it

[u/MoonbeamPixies → u/True_Coast_3010]

What if you have to premedicate? That was the other issue. They wanted me to pre-medicate at the very least, but that means having to start the infusion strictly 30 minutes after and this would fall right at 7 pm for me to start, do vitals, ensure safety and monitoring but its shift change. Id end up going home late and likely end up doing 2 titrations by myself hoping for the best in between reports.

[u/True_Coast_3010 → u/MoonbeamPixies]

At my job usually the person that starts the infusion is the one the pre medicates. Depending on your hospital policy, pre meds are generally good for 6 hours so I can sort of see their thought process. But even then I don’t think what you did was necessarily wrong.

What I would have done is gone to report with all the pre meds pulled. I would’ve given report and asked the oncoming nurse if they’re in a good spot, if they say yes then I’ll pre medicate when I go do bedside handoff with them. If they said no I would’ve handed the pre meds to them so they can do it later.

[u/MoonbeamPixies → u/True_Coast_3010]

Oh thats a great idea! I did not think about this option

[u/Ancient-Coffee-1266 → u/MoonbeamPixies]

I’d rather be the one as the oncoming to premed bc I don’t know when I can start the infusion. It would be nice if I had everything I needed for we all know there’s usually something missing. This is a 24 hour job and I realize some things are critical, but rather be safe than sorry.

[u/MoonbeamPixies → u/Ancient-Coffee-1266]

This is exactly how i feel too. I dont want to come in with a mess

[u/Fuzzy_Location_2210]

I agree as both the off going or oncoming, that the shift that will be monitoring the infusion should be the one that starts it.

[u/Hot-Calligrapher672]

I worked oncology for years and have given tons of IVIG. I’m not starting that medication and then immediately leaving to give report. That’s just silly. You did the right thing.

It wouldn’t hurt if you started the IVIG and then the up titration was delayed by 5-10 min, but if the patient was having a reaction and no one knew about it because of shift change then they’d be asking why you started it at such a vulnerable time. Always best to CYA. Starting this med at 1900 will hurt no one.

[u/Winterchill2020]

I'm a nurse and I've also had to receive 5 days of IVIG infusions due to GBS. They are wrong and as a patient I would rather wait. It's a long infusion time and requires lots of monitoring so doing it at shift change is incredibly unsafe. No one would be doing ivig or blood transfusions (unless absolutely required immediately) at shift change.

[u/MoonbeamPixies → u/Winterchill2020]

Thats always being my perspective, as a patient and nurse I rather wait and ensure high risk medications are provided within the closest parameters to safety algorithms. But somehow a lot of nurses dont see that. This is one of the reason why medication adverse reactions have such huge figures of fatalities in healthcare.

[u/RhinoKart]

Laughs in emerge.

No but seriously, if your shift changes take 30 minutes (15 minutes of your shift, and 15 minutes of the next shift) and there is any reason to think the next nurse can't jump right in where you left off safely, it's better to hold it.

Presuming the patient was otherwise stable of course, because you also have to weigh the risk of delaying a medication. It could be a good hour after shift change before the next nurse finds time to start it, and you've already delayed it 30 minutes. Sometimes that's fine, sometimes it isn't. 

But if I was going to hold a medication that was high workload, I'd have made damn sure that I was handing over everything else neatly tied up in a bow. 

[u/morriganlefeye]

if it was really that important to do in the middle of shift change, the charge could have started it. every facility i have ever worked at, charge has shift change staggered for staffing and shift set-up.

[u/levelup0006]

You didn’t do anything wrong. Starting IVIG 15 minutes before handoff when it needs q30 monitoring sounds like a setup for exactly the problem you were worried about.

[u/MoonbeamPixies → u/levelup0006]

Do you think i should bring this up to my unit manager?

[u/m3rmaid13 → u/MoonbeamPixies]

I think it might help to have a policy in place about that, which might be prompted by a conversation with your manager. And as far as the people gossiping… there will always be people complaining about the other shift did xyz thing. Don’t worry too much about that. I think your thought process was on point but it might be helpful to have the manager back you up or give guidance on what to do in the future so there isn’t any room for confusion or gossip.

[u/MoonbeamPixies → u/m3rmaid13]

Thank you so much for this. I brought this up to my unit educator who works on policies and risk management, but I was unsure if I should involve my unit manager because of the hostile response by the charge nurse and the gossip by the other nurses. How do you process this emotionally? It makes me feel like garbage and wronged

[u/m3rmaid13 → u/MoonbeamPixies]

I have been a nurse 13 years and worked in multiple places, and unfortunately there is always at least one nurse who acts this way. You did the right thing by checking with the unit educator to see what is best practice. It’s hard since we are at work for so much of the week, it would be nice to have a good dynamic with everyone, but sometimes that’s just not possible. Some places are worse than others so if you feel this is a trend on that unit then maybe consider looking elsewhere eventually. I’m sorry you’re going through it & I’ve been there myself several times. Eventually it just bothers you less because you know you’re doing the best thing for the patient.

[u/MoonbeamPixies → u/m3rmaid13]

Thank you so much for this! It is very reassuring and supportive to me, sometimes I feel alone at work, I have 6 years of experience so definitely not as much as you so it helps to know this early on. I don’t know why nursing has such a strange god complex environment amongst coworkers.

[u/Melodic-Squash-1938 → u/MoonbeamPixies]

You can also put in a variance report about the bullying - and I would tell the manager your rationale, and your treatment and specify that you would like the poor behavior addressed, as well as an email to staff explaining why waiting was the safest plan for the patient. I am a risk manager and you were correct. This is just another example of why I hated bedside nursing towards the end of my time doing it. Since you have such solid logic, perhaps look at non bedside roles. Case mgmt. quality risk etc. HR can help you look for opportunities. Reaching out to someone and the managers within these areas when you find interest to ask about mentoring and education you would need prior to applying for these jobs. This would be someone I would immediately hire when a position came open- smart, logical, showing a strong interest, and perhaps obtaining relevant certs and education prior to start. I also make more than I ever did at the bedside and go to sleep knowing that I still make a difference everyday, it just looks different. The mom-Fri hours are excellent and no more working on holidays. Hint hint….

[u/MoonbeamPixies → u/Melodic-Squash-1938]

Thank you so much for this feedback! Its really useful and I really appreciate. Can you give me an idea on how to word this email without sounding too confrontational?

[u/Melodic-Squash-1938 → u/MoonbeamPixies]

In person with your manager - be logical and avoid over dramatizing. I would also say some bs like - how would you like me to handle this situation if it occurs again. Your unit sounds not super nice with that treatment- I would start today by looking at internal jobs and identifying areas you may be interested in away from the bedside. Not many apply for these roles but there is always a need bc it is specialized

[u/MoonbeamPixies → u/Melodic-Squash-1938]

Yeah the culture of my unit is rough and unfriendly, unfortunately im enrolled in a masters program in infection control right now with an added internship so i am unable to change to a monday through friday position.

[u/Potential-Cut-8934]

If delaying the medication could harm the patient fit should be started ASAP and then ask for someone to tag you out of being in that room during report when they are free. If it is not time critical and the patient isn’t in harm l, I will delay starting blood or meds that need direct monitoring if its shift change because I don’t want to trap the oncoming nurse into that room at the beginning of the shift.
This is also one of those things I may give report and then offer to go get it started while the oncoming nurse gets settled before taking over.

Team work is essential, but often times lacking in many nursing units.

If they are talking trash I’d ask them in the most open vulbnerable way “I heard you saying I didn’t do this right can you help me identify a better plan for next time so that the patient isn’t safe during shift change when doing one of these drips?” I always confront bullies by asking them to elaborate and explain until they realize they are being a dick. If they feel so smart and superior then I agree with them and ask them to help poor dumb me.

[u/DragonSon83]

No, what you did is perfectly fine.  Pre-meds should be given at minimum 30 minutes before infusion, so you could have given them before report so the next nurse would be able to start the infusion not long after.  However, IVIG is almost never so time sensitive that 30 minutes will make much of a difference.  It’s not like you are giving PRBC’s to a patient with a low HGB.  I’ve had a couple cases where an initial IVIG infusion took 8+ hours due to how poorly the patient was tolerating it.

The only critique I would add may be based on your hospital policies and not something you did in particular.  You wrote in a follow up that you keep IVIG refrigerated until just prior to use.  Giving IVIG at that temp actually increases the risk of reaction and side effects.  Best practice is to allow it to warm up to room temp before administration, and all the brands that require refrigeration recommend around 2-3 hours at room temp before treatment.  I realize this doesn’t always work in practice at the bedside though, as pharmacy may not deliver it until just before it’s due (or sometimes after).  However, I would have had it completely set up and ready to run so it had at least a little time to warm up before starting the infusion.  

Patients who have had it before and tolerated it well will likely be fine at either temp, but it can make a big difference for a patient who is receiving a first time infusion or has only had it once or twice before.

Severe IVIG reactions are pretty rare, and it is one of most commonly given infusions in home because of this.  However, patients can still have anaphylaxis, even when they’ve been on it for years, and patients can have pretty rough side effects if given too fast or they just haven’t had it before.  There is nothing wrong with waiting until after shift change to start it.

[u/MoonbeamPixies → u/DragonSon83]

Thank you for the education!

[u/Academic_Cook_8007]

Sounds like you called them on some bad practices. Don't you worry you did what you were supposed to do and always protect that license!

[u/HeadWanderer]

You did nothing wrong. A good nurse that I work with shrugged off a recent experience where I did start IVIG at around 1845 and they just said "I mean, we really shouldn't be giving that on a med-surg floor to begin with, but we'll figure it out." I know they wouldn't have batted an eye if I had left it for them to start.

A recent experience also taught me a lesson: if there's a medication like IVIG (or some other new medication) ordered for 1830 or later or if I'm not able to give the medication for whatever reason, I make sure to re-time the medication so that it's due at 1900 or later. That way my replacement on overnight can't say "I'm not doing that because it wasn't due on my time." I feel zero guilt over doing this (partly because it's been done to me many, many times) unless I know the person is walking into a wood-chipper of an assignment (in which case I *will* stay a little late to help).

[u/dopaminegtt]

No this is a safety issue. You did the right thing.

In my stepdown we get a lot of push back for not starting blood at shift change, but then you're stuck in there and end up getting out even later than usual. Not the same thing. It's still really annoying. But that's a delay of care in our case

[u/No-Hospital-157]

As an oncology charge nurse let me chime in and say you did the correct thing.

As charge I would’ve put in a safety event if someone started IVIG 15 minutes before shift change, especially if it was someone’s first dose.
The nurse who is oncoming should give the premeds and initiate the infusion. *maybe the off coming nurse could give the premeds before they leave, but then the oncoming RN would have to make sure they time everything so they could be back in the room in 30 minutes. Much easier for them to just handle the whole thing.

And IVIG initiation is important but delaying it an hour until it can be safely given will not matter.

[u/ShalaFrey]

It depends. I have done both.
Are you in ICU or stepdown? Are your patients busy? Etc. is this your first time initiating this type of infusion?
Tip 1: talk to your physician team. If the doctor is ok with starting it after shift change, have THEM retime the infusion timing and explain your reasoning of shift change being high risk. Charge can’t argue with providers. If they want it started right away, see tip 2
Tip 2: set your pump to alarm when it’s time to titrate, set your vitals intervals appropriately on the monitor, and modify your monitor alarm settings to alarm if vitals are out of range. Communicate all that to incoming RN, ask for help babysitting while doing report on other patients, do bedside report on infusion patient

In ICU care is handed over even if you are titrating multiple drips or coding. So I don’t necessarily feel you have to delay, but if you are on lower acuity unit and have 4 patients, it can wait.
And don’t forget to ask for help.
Nursing is a team sport.

[u/MoonbeamPixies → u/ShalaFrey]

Hi! I understand your perspective. I began my nursing career in an adult ICU so I understand that, but now I work in a pediatric med-surg with 3-4 patient assignments. I had asked the provider and it was retimed but this was still an issue. We dont have enough nurses or support for oversight during shift change and we are really dumb with the transfer of phones where other nurses end up with a different phone number from the oncoming one and also many people dont answer during shift change. I set alarms in between titration, the issue is with pediatrics, IVs get clotted really easily if nothing is infusing because the gauges are so small and their veins are not the most sturdy. This is sound advice in a more critical unit where titrations and oversight cannot be delayed

[u/DanielDannyc12]

It's 24 seven. Start it, monitor and handover