IV Push Meds in Skilled Nursing Facilities

By Marc Stranz, PharmD, RPh

Ask the Pharmacist...

Q: We recently were asked to accept a patient that required Dilantin to be administered via IV push. We did not feel comfortable accepting this patient. We thought there was a regulation that states you can't "push" IV medications in a Skilled Nursing Facility, but couldn't find it. Do you know of any such regulation in California?

A: I searched the California nursing and skilled facility regulations and queried infusion nurses working with skilled facilities there. I found nothing that precluded IV push medication administration in skilled facilities. It is being done in skilled facilities with adequate and competent staff.

The Code of Federal Regulations requires facilities to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident (42 CFR § 483.60). If the facility cannot meet those needs, they should not accept the resident.

The facility must be appropriately staffed to provide IV push medications. That could include nurses on the shifts the IV push medications are administered. Some states require nurses to be present on all shifts when residents have intravenous access.

The California nursing regulations require that the licensed individual administering IV push medications be competent to administer medications by that route.

Now, that being said, let’s address the issue of Dilantin (phenytoin ) in a Skilled Nursing Facility. I posed this question to a nurse-colleague who directed the Infusion Therapy programs for a national long-term care pharmacy company. Her response: "in most Skilled facilities, LVNs may not administer IV push medications. Our policy was that our serviced homes' IV push medications would be limited to those agreed to be appropriate by the Consultant Pharmacist, the Medical Director, and the Director of Nursing (and the Infusion Coordinator, when the facility had one). The drugs usually picked for inclusion were things like Valium (for Status Epilepticus - NOT DILANTIN), Solu-Medrol, Lasix, and occasionally morphine. Our criteria excluded pushing any drugs that would require cardiac monitoring , and our VP for Pharmacy Services believed in following the recommendation from Trissel's Handbook of Injectible Drugs that called for cardiac monitoring in patients receiving IVP Dilantin. Likewise, our policy excluded pushing any drugs via a peripheral IV incompatible with the Infusion Nurses Society Standard requiring a Central Line if the final tonicity of the drug was >500 mEQ/L or if the pH was <5 or >9. Dilantin, even diluted in a mini-bag, has a pH of around 12. That, combined with the potential for purple glove syndrome from extravasation from a peripheral site, made us exclude Dilantin as a choice for IV push.

Some facilities (mostly sub-acute who worked with a lot of head injury patients) did administer IV Cerebryx (fosphenytoin) - fewer issues with it, other than the cost (always an issue in LTC!)." Sounds to me like you did the right thing in refusing this patient.