At the annual Academy of Medical-Surgical Nursing conference, where I taught a legal preconference, I picked up a flyer created by a clinical nurse specialist. She reported on a project her hospital started to look into the cost and effectiveness of using Heparin to flush central venous access devices (CVAD). Here are the reasons this project was started.

• Heparin is a blood thinner that when used in low doses is supposed to keep central lines open.
• Heparin is a high-risk drug that can cause deaths or reactions such as heparin-induced thrombocytopenia.
• In a six-month period, 20% of the central catheters developed blockages when the heparin flushing protocol was in effect.
• Costs associated with removing the blockage were high. In one year, the hospital spent $150,000 on Alteplase to declog blocked CVADs.
• Flushing with heparin does not prevent clots or fibrin from forming on the tip or outside of the catheter, thus blockages can still occur in the blood vessel.

The hospital embarked on a change in flushing to eliminate heparin and instead, flush with normal saline three times a day.

The Results

Initially the number of blocked central lines went down to 11% but within 5 months, the trend reversed, and the number of blockages increased. Within 10 months, 34% of the catheters were becoming blocked. The IV team concluded that “The flushing technique was the number one reason for the increase in occlusions.”

I found puzzling the conclusions of the clinical specialist who presented this study. She wrote, “As evidenced above, CVADs were flushed unnecessarily with heparin causing potential harm to the patient. This project increased patient safety while helping to decrease the cost to the hospital. More education will be done with the staff to decrease cost and occlusions and increase safety to the patient.”

Unless I am missing something, it looks like the increased rate of occlusions resulted in increased cost to the hospital. How does a 34% blockage rate show an improvement over a 20% blockage rate? What caused the initial drop in the rate of blockages? Was it really the nurses who should bear the brunt for the poorer results, or the fact that heparin is actually more effective than normal saline for flushing catheters?

When I was in staff development, I quickly learned that there are two reasons why nurses don’t do what they are supposed to do. First, they lack the knowledge. The solution is to teach them. Second, they know how to do something, but there are no consequences for not doing the correct thing. The solution is a management and supervision plan.

In the Heparin study, the author implies that the results were poorer because of the technique the nurses were using (or not). Does this mean the nurses were not following the protocol, even though it was recorded on the medication administration record with spots to sign off three times a day? The write up of this study does not provide enough (or any) explanation for the rise in occlusions. But charging ahead and asserting or implying that the nurses were the reason fail to take into account that saline may be an inadequate substitute for Heparin.

Nursing expert witnesses are used to define the standard of care and become involved in evaluating whether nurses followed the protocols. This interesting study raises questions about the reasons for the results.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.