Let’s get clinical! Best practices for determining appropriate hang time for IV fluids

Cardinal Health is one of the nation's leading employers of hospital pharmacists - and leverages the deep clinical expertise of its on-staff pharmacy experts to share best practices in medication safety. In this "Let's Get Clinical" series on Essential Insights, we'll share some of their expert knowledge on specific medication safety challenges that hospital pharmacists face, every day.

Hospitals often struggle with determining policies for the appropriate length of time to allow intravenous (IV) solutions to hang while being administered to a patient. USP <797> Pharmaceutical Compounding - Sterile Preparations deals with the time from preparation of the IV until the point of administration. Sterility time limits noted in USP <797> stop when administration of the IV is initiated.

There is no nationally accepted length of time hang time for most IV fluids. The Center for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections, 20111 provides some information concerning replacement of IV administration sets, but has no recommendations on the hang time for the majority of IV fluids. The Infusion Nursing Standards of Practice, Revised 2011 from the Infusion Nurses Society (INS) provides more detail, and uses the CDC recommendations as the basis for its standards. However, they also do not have specific guidance for hang time.

CDC Recommendation Categories

CDC recommendations are categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. CDC has a standard method of listing recommendations. Their guidance regarding IV tubing changes (note: not hang time) include those in Category 1A, Category 1B, and unresolved issues.

  • Category 1A recommendations - strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies;
  • Category 1B recommendations – Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence;
  • Unresolved issue – for which evidence is insufficient or no consensus regarding efficacy exists

The previous version of the CDC document (from 2002) included an appendix summarizing recommendations, including limited information on hang time of IV solutions. Though no longer included in the current document, it provides some guidance for policy development.

Recommendations from CDC and INS

  • Manufacturer’s recommendations should be followed for specific medications
  • Parenteral nutrition (with or without fat) hang time should not exceed 24 hours
  • Fat emulsion hang time should not exceed 24 hours
    • Note: the INS standards limit fat emulsion hang time to 12 hours
  • Propofol infusion hang time should not exceed the manufacturer’s recommendations (which vary based on manufacturer) and should be changed at the same time as the tubing

Issues, Answers, and Perspectives on Quality

Tubing changes are listed in the CDC recommendations:

  • In patients NOT receiving blood, blood products, or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals but at least every 7 days. This is a Category 1A recommendation.
  • Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours of initiating the infusion. This is a Category 1B recommendation.
  • Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer’s recommendations. This is a Category1A recommendation.

Information to Consider for Policy Development

A hospital committee should review national recommendations (such as those from the CDC and INS) and procedures performed in the organization. The organization should address the tubing change guidance in the CDC recommendations, and determine if the IV hang time should match or differ from the hang time policy. Many organizations have different allowances for hang time, based on different levels of infection risk:

  • In emergencies - such as in the field, during a code, etc.
  • For immediate use (outside of USP <797> compliant conditions)
  • Pharmacy-compounded (in USP <797> compliant conditions)
  • Manufacturers' plain or premixed solutions (with no additions to the fluid)

Many organizations change IVs started in emergency situations as soon as possible after the patient is stabilized, and change IVs prepared under the Immediate Use provision of USP <797> within 24 hours. Some organizations permit longer hang times for manufactured (plain and premixed) IVs than they do for pharmacy-prepared sterile preparations. Ensure that all practices are reviewed, and that infection prevention practices support the policy developed.


REFERENCES

1. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, CDC, available at www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
2. Infusion Nursing Standards of Practice, Revised 2011, Infusion Nurses Society, information available at www.ins1.org/i4a/ams/amsstore/category.cfm?category_id=7 3. Summary of Recommended Frequency of Replacement for Catheters, Dressings, Administration Sets, and Fluids, MMWR, 2002(Aug 16), available at www.cdc.gov/mmwr/review/mmwrhtml/mm5132a9.htm


Get email updates


Enter your e-mail address to receive notifications when new articles are added to Essential Insights.
*