home infusion therapy: current evidence implications · Ùcompetency example: uses evidence‐based...
Post on 02-Aug-2020
3 Views
Preview:
TRANSCRIPT
9/18/2014
1
Home Infusion Therapy: Current Evidence & Implications
LISA A. GORSK I MS, HHCNS ‐BC, CRNI , FAANCL IN ICAL NURSE SPEC IAL I ST
WHEATON FRANC ISCAN HOME HEALTH & HOSP ICEMILWAUKEE , WI
Copyright Lisa A. Gorski 2014
OBJECTIVES
Identify common complications associated with home infusion therapy.
Discuss available research evidence aimed at complication prevention
Evaluate patient cases for appropriateness of home care.
9/18/2014
2
Gorski Model for Safe Home Infusion Therapy ©Lisa A. Gorski
Patient Selection
Positive patient outcomes Reduced risk for complicationsPatient satisfaction
Focus of today’s
t ti
Patient/CGEducation
Patient care & Monitoring
Healthcare provider satisfaction presentation
COMPLICATIONS ADDRESSED DURING THIS PRESENTATION
“Line‐related”Central vascular access devices (CVAD) or “central lines”( )
4 categories of CVADs: nontunneled; tunneled; PICC; implanted port
Complications addressed within this presentation:
Infection • Major focus of this presentation
Catheter associated venous thrombosis
Catheter occlusion
Peripheral IV catheters (PIV)Peripheral IV catheters (PIV)Infiltration/extravasation
Phlebitis
Nerve damage
Infusion‐related: Drug toxicities – focus on renal and vestibular
9/18/2014
3
SELECTED REVIEW OF PERTINENT HOME CARE
LITERATURE
Patient Risk Factors for Infection
Systematic literature review
25 studies met inclusion criteria
Great variation in risk factor identification and infection rates
Infusion therapyPatients receiving PN at greater risk than those receiving other infusion therapies
Shang et al. (2014) The prevalence of infections and patient risk factors in home health care: A systematic review. AJIC 42, 479‐484.
9/18/2014
4
Adverse Events in Home Care
In another review of home care literature, “line‐related” complications (including catheter‐related BSI d it i f ti ) f 8 t i fand site infections) was one of 8 categories of
adverse events identifiedFew intervention studies identifiedNeed for improved assessmentNeed for system‐level approach that includes focus on caregivers/home environmenton caregivers/home environmentNeed for required data collection/reporting of adverse eventsMasotti et al. (2010) Adverse events experienced by homecare patients: a scoping review of the literature. International Journal for Quality in Health Care 22 (2), 115‐125.
11 year surveillance from the University of North Carolina Health care system – very low annual rates of central line BSI ranging
Selected Home Care Data
from 0‐ 0.73 cases/1000 device daysWeber et al. (2010) Device‐related infections in home health care and hospice: Infection rates, 1998‐2008. Infect Control Hosp Epidem 30 (10), 1022‐1024.
Outpatient antimicrobial therapy (OPAT) in Scotland, 0.4 infections per 1000 OPAT days (n=2233 patients); 10 year studyBarr et al (2012) Self‐administration of outpatient antibiotic therapy and risk of catheter‐related adverse events: a retrospective cohort study. Eur J Clin Microbiol Infect Dis 31 (10), 2611‐2619.
Incidence of BSI in children receiving home PN highest in the firstIncidence of BSI in children receiving home PN highest in the first month after discharge from the hospital; need for care strategies immediately after hospital dischargeMohammed, et al. (2011) Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition. JPEN 35 (5), 581‐587.
9/18/2014
5
Home care Infection Prevention Policies & Procedures
National survey – n= 423 home healthcare clinicians (9.2% response rate)response rate)
Written policies for:MDROs : 26.2%
Dedicated equipment: 62.8%
Teaching patient/family about prevention of spread of MDROs: 78.5%
Takes nursing bag into home of patient with known MDRO: 31%31%
Full time infection prevention/control nurse: 21.4% (but 33% have other job duties)
Kenneley (2012) Infection control in home healthcare: An Exploratory Study of Issues for Patients and ProvidersHome Healthcare Nurse 30(4), 235‐45.
A reduction in PICC infections by 46% in patients receiving home infusions (0.963 to 0.52 infections per
Example: Quality Improvement‐Home Care
g ( p1000 central line days)
Problem: Lack of standardized protocols
Interventions: Education: changes and ongoing education for nurses
Standardized home health central line orders (NC changingStandardized home health central line orders (NC changing and disinfection, flushing, blood draws, site care)
Standardize home care through development of central line care checklist, flushing checklist
Baumgarten, et al. (2013) Bridging the gap: A collaborative to reduce central catheter infections in the home care environment. The Oschner Journal 13: 352‐358.
9/18/2014
6
Available Home Care Guideline
“Standardizing central venous catheter care: hospital to home” from the Nebraska Medical Center
http //www guideline gov/content aspx?id 38459
These guidelines did not evolve out of a comprehensive or exhaustive literature search.Standardizing Central Catheter Care in the Omaha Region: Care from Hospital to Home (SCORCH) Consensus Group
The Consensus Group:examined their respective current agency policiescompared them with what best practices would indicate appropriate care should look
http://www.guideline.gov/content.aspx?id=38459
p p pp plike, based on Centers for Disease Control and Prevention (CDC), Infusion Nurses Society (INS), and Oncology Nursing Society (ONS) guidelinesWhen lack of evidence in established guidelines (e.g., using heparin or not), review of literature to examine complications (e.g. heparin induced thrombocytopenia)
Home Care Malpractice Case Example
Home care patient receiving parenteral nutritionHome care patient receiving parenteral nutrition develops septicemia with grave consequences
Issues in caseFailure to recognize risk factors
Failure to provide relevant patient education
Failure to recognize signs of infectiong g
Failure to analyze/report laboratory findings
9/18/2014
7
INFECTION PREVENTION
Well‐educated nurses – essential!!
Infusion Nurses Society (INS)Standards: The nurse shall be responsible and paccountable for attaining and maintaining competence with infusion therapy
Competence goes “beyond psychomotor skills to include application of knowledge, critical thinking skills, decision making”
The person validating the specificThe person validating the specific skill should be competent with the skill. When no one in the organization has the specific competency, arrangements for a skill validator from outside the organization may be necessary
Infusion Nurses Society. (2011) J Infus Nurs 34 (1 suppl): S1‐S110.
9/18/2014
8
Centers for Disease Control & Prevention (CDC)
Home care question: Do you have specific competencies in place related to infusion
related procedures?
Only trained, competent persons should place and maintain peripheral and central IV devices
Within our home care organizations, we must
O’Grady, et al. Healthcare Practices Advisory Committee (HICPAC). (2011) Guidelines for the prevention of intravascular catheter related infections, 2011. AJIC 39 (4 supp): S1‐S34.
related procedures?
Within our home care organizations, we mustaddress/ensure competence of our staff and “zero tolerance” of infections – we owe this to the patients we serve
American Nurses Association Standards
Hot off the press! Published summer 2014Available at: http://www.nursesbooks.org/Homepage/Hot‐off‐the‐Available at: http://www.nursesbooks.org/Homepage/Hot off thePress/Home‐Health‐Nursing‐Scope‐Standards‐2nd.aspxExample: Standards of Practice
Standard 1: The home health registered nurse collects comprehensive data pertinent to the patient’s health or situation.
Competency example: Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances. (ANA, 2014, p. 45)
Standard 5: The home health registered nurse implements the individualized plan of care.Competency example: Uses evidence‐based interventions, best practices, and treatments specific to the diagnosis or problem. (ANA, 2014, p. 51)
Examples: Standards of Professional Performance:Standard 8: The home health registered nurse attains knowledge and competence that reflect current nursing practice. (ANA, 2014, p. 62)Standard 9: The home health registered nurse integrates evidence and research findings into practice. (ANA, 2014, p. 64)
American Nurses Association (ANA). (2014). Home health nursing scope and standards of practice (2nd Ed.). Washington, DC: Nursebooks.org.
9/18/2014
9
Review: How microorganisms gain access to the bloodstream
Extraluminal: Migration of skin organisms at the insertion i i h h d l h h fsite into the catheter tract and along the catheter surface, gaining access to the external catheter surface.
Intraluminal: Direct contamination of the catheter or catheter hub by contact with contaminated hands or fluids or devices; microorganisms gain access through the internal catheter lumen of the catheter
Hematogenously seeded from another infection – less common
Infusate contamination – rare
O’Grady et al. (2011) AJIC.
CVAD insertion not typical in home care – but we need to understand risk reduction & EBP
Reducing Risk during Catheter Insertion: Central Lines
to understand risk reduction & EBPInserter must follow central line bundle during catheter insertion (hand hygiene, chlorhexidine skin antisepsis, maximal sterile barrier precautions, optimal site selection)
“Bundles that include checklists to prevent central line‐associated bloodstream infections” are: One of the top 10 “Strongly encouraged patient safety practices”encouraged patient safety practices” Agency for Healthcare Policy and Research (AHRQ) (2013) Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices – Executive report. Retrieved from http://www.ahrq.gov/research/findings/evidence‐based‐reports/ptsafetysum.html
58% reduction in ICU CLABSIs from 2001‐09Vital signs: Central line‐associated bloodstream infections – United States, 2001, 2008, and 2009. MMWR 60 (8), p. 246.
9/18/2014
10
Post‐insertion care
The term bundle is often used but there is no well established, well‐tested post‐insertion care bundle yet
More challenging than the central line insertion bundleCentral line bundle mainly focused during time of insertion
Post‐insertion care focused during entire dwell timeInvolves many clinicians and potentially several health care settings
Involves every catheter access/care procedureInvolves every catheter access/care procedure
Challenging to monitor care behaviors
Hand hygieneAttention to aseptic technique with all VAD‐related procedures
Increased focus on and importance of post‐insertion catheter care
Attention to aseptic technique with all VAD related proceduresSpeaker experience/examples
Ongoing assessment of the patient and the catheter siteRegular site care & dressing changesIV administration set changesNeedleless connector accessMaintaining catheter patencyBlood withdrawal from CVADs for laboratory studies – should we do this?Catheter removal as soon as it is no longer neededSafe injection practices
9/18/2014
11
Poor compliance with dressing changes
N=420 CVADs evaluated in a single hospital
N=130 (31%) of CVAD dressings suboptimal and needed changing (e.g. blood under dressing, exposed insertion site, visible moisture)
No correlation with BSIResearchers believe infections complex and require multi‐modalResearchers believe infections complex and require multi‐modal preventative programs
Efforts must address CVAD maintenance – beyond the central line insertion bundle
Rupp, ME et al. (2013) Hospital‐wide assessment of compliance with central venous catheter dressing recommendations. American Journal of Infection Control 41, 89‐91.
Dressings and Risk for Infection
Secondary analysis of a randomized controlled trial 1636 patients (ICU) in initial trial; 1419 with at least one dressing change included in analysis
Home care question: Do we make the extra visit to change non‐intact dressings; are
patients educated about risks?
change included in analysis11,036 dressing changes, 67% unplanned due to soiling/undressingMore than 2 dressing changes for disruption were associated with a greater than threefold increase in risk of infection/BSI Risk factors for dressing disruption included femoral/jugular isitesPost‐insertion bundles are insufficiently implemented/ study reinforces need
Timsit, JF et al. (2012) Dressing disruption is a major risk factor for catheter‐related infections. Critical Care Medicine 40 (6), 1707‐1714.
9/18/2014
12
Needleless Connectors (NC)
Also called “valves,” “injection caps,” “injection ports,” “luer activated devices”luer‐activated devicesMany different NC products ‐‐ categorized into:Simple: No internal mechanisms; fluid flows straight through the internal lumen. Includes those with a split septum
Complex: Characterized by an internal mechanism that controls the flow of fluid through the device, allowing both infusion and
i ti f bl daspiration of blood
Hadaway, L & Richardson, D (2010) Needleless connectors: A primer on terminology. Journal of Infusion Nursing, 33 (1), 22‐31.
Attention to needleless connectors and catheter hubs
Needleless connectors and stopcocks are known sourcesNeedleless connectors and stopcocks are known sources of contamination (O’Grady et al., INS, 2011)
Disinfection of the NC is recognized as a critical prevention strategy
Adequacy of disinfection dependent upon antiseptic agent contact time method of application (friction andagent, contact time, method of application (friction and chemical kill critical)
O’Grady et al. Healthcare Practices Advisory Committee (HICPAC). (2011) Guidelines for the prevention of intravascular catheter related infections, 2011. Am J Infect Control, 39 (4 supp): S1‐S34.
9/18/2014
13
Accessing the needleless connector
Simple but … multiple steps Gathering supplies
Performing hand hygiene
Scrubbing/disinfecting NCWhat solution?
How long?
Dry time?
Home care question: Do your clinical procedures define a disinfection time?
Prior to each access?
Attaching syringe/IV administration set maintaining sterility of syringe/set tip and no touch contamination of disinfected NC
Infusion Nurses Society Standards
“The needleless connector should be consistently and thoroughly disinfected using alcohol, tincture of iodine, or chlorhexidine gluconate/alcohol prior to each access. The optimal technique or disinfection time has not been identified.”
NOTE: INS STANDARDS UNDER CURRENT REVISION (2016)
Infusion Nurses Society (INS). (2011). Infusion Nursing Standards of Practice. Journal of Intravenous Nursing,34(1S), p. S32.
9/18/2014
14
A 5 second scrub with 70% alcohol
Inpatient setting/prospective observational studyC lt f d CVAD ith NC ( lit tCultures performed on CVADs with NC (split septum type) and no active infusionPrior to disinfection, and after vigorous scrub with 70% alcohol for 5, 10, 15, 30 seconds 5 second dry time, cultures by pressing NC onto agar plate
In vitro assessmentSterile NC inoc lated ith S epidermidis and allo ed to dr for 3Sterile NC inoculated with S. epidermidis and allowed to dry for 3 hoursVigorous scrub with 70% alcohol for 0, 5, 10, 15, 30 seconds, 5 second dry time and then cultured
Rupp, ME et al. (2012) Adequate disinfection of a split‐septum needleless intravascular connector with a 5‐second alcohol scrub. Infection Control & Hospital Epidemiology, 33 (7), 661‐665.
Results
363 NCs sampled in clinical phase8/8 C l d i h di i f i h d b i l58/87 NCs cultured without disinfection showed bacterial
contamination
5 second scrub (n=71) – one (1.4%) yielded microbial growth
Similar results with 10, 15, 30 second scrub times
No significant differences in microbial contamination rates between 5, 10, 15, 30 second disinfection times
Rupp, ME et al. (2012) Infection Control & Hospital Epidemiology.
9/18/2014
15
Results
In vitro results100% of NCs sampled after no disinfection showed heavy microbial100% of NCs sampled after no disinfection showed heavy microbial growth
When inoculum size was smaller, all NCs had sterile cultures when scrubbed for 5 or more seconds with 70% alcohol
For larger inoculum, minimal growth after 5 second scrub, sterile culture for 10 second or longer scrub
ImplicationsImplicationsThe 5 second scrub was effective with the type of NC used – cannot be generalized to other types of NCs
Rupp, ME et al. (2012) Infection Control & Hospital Epidemiology.
About alcohol disinfection caps
Photo by Lisa Gorski
9/18/2014
16
Example: Research ‐ Alcohol disinfection caps
Use of an alcohol disinfection cap placed on the needleless connector significantly reduced line contamination, density of organisms, and CLABSIs. 3 phases: phase 1 baseline – standard scrub of needleless connector,phase 2 – disinfection cap placed on all CVADsphase 3 – back to standard scrub. p
Contamination and organism density were measured via an aspirate from the PICC.
Wright, M. O. et al. (2013) Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. American Journal of Infection Control, 41, 33‐38.
2014 SHEA/IDSA Guidelines: Alcohol Disinfection Caps
• NOTE THAT THESE ARE ACUTE CARE GUIDELINES AIMED SPECIFICALLY AT CLABSI PREVENTIONSPECIFICALLY AT CLABSI PREVENTION
• Use an antiseptic‐containing hub/connector cap/port protector to cover connectors (Grade I)
Recommended as a “special approach” i.e. recommended in locations/populations with unacceptably high CLABSI rates despite implementation of basic practice recommendations
Society for Healthcare Epidemiology of America (SHEA)/ Infectious Diseases Society of America (IDSA): Strategies to prevent central‐line associated bloodstream infections in acute care hospitals: 2014 update. Available at: http://www.jstor.org/stable/10.1086/676533
9/18/2014
17
When no one is looking, do you and
your colleagues ALWAYS scrub the
hub?
Most of us KNOW that the needleless connector must be scrubbed before
each access but what each access but what affects our decision to
consistently do it?
“Intention” to Disinfect the NC
Cross‐sectional studyy
N = 171 nurses from 4 Magnet hospitals
Survey: Demographic data
Autonomy and self‐efficacy scales
“Smith‐Becker Attitudes towards Disinfection Techniques” scale
Smith, JS et al. (2011) Autonomy and self‐efficacy as influencing factors in nurses’ behavioral intention to disinfect needleless intravenous systems. JIN 34 (3), 193‐200.
9/18/2014
18
“Intention” to Disinfect the NC
Findings and some implicationsThere was a strong relationship between concern for preventing bacterial migration into bloodstream and propensity to use best practice
Teaching should focus not only on knowledge and skills but also address the affective domain of learning (caring, patient advocacy)
Experienced nurses have greater autonomy and self‐efficacy But recent graduates were more likely to disinfect every timeTenured staff – do they avail themselves of educational opportunities that newer graduates have received?Easy intervention: ready access to supplies
“ensure adequate supply of alcohol swabs at bedside”
Smith, JS et al. (2011) JIN.
Research: Maintaining catheter patency
Optimal catheter flushing protocol remains un‐defined by researchRecent home care study
Purpose: Evaluate most effective flushing solution for PICC maintenance in home care patientsMethod: Randomized study – non‐blinded
Group 1: control group; saline only flushing (10 mL) (n=28)Group 2: SASH high [10 mL saline; lock with heparin 3 mL (100 units/mL)] (n=32)Group 3: SASH low [10 mL saline; lock with heparin 5 mL (10 units/mL)](n=30)
Population: 18 or older; PICC placed at university center; anticipated need for PICC > 1 week
Lyons, MG, Phalen, AG (2014) A randomized controlled comparison of flushing protocols in home care patients with peripherally inserted central catheters. JIN
9/18/2014
19
Research: Maintaining catheter patency
Data collection: Weekly call to patients (any incidence of PICC sluggishness or occlusion, extra RN visits); review of records to validate patient reportsvalidate patient reportsResults:
Only significant finding: longer catheter dwell time (days), the more complications occurred (p=0.003)Overall inconclusive; no statistically significant differences between groupsClinically important findings
SAS protocol highest % of additional visits to assess sluggishnessSAS protocol – highest % of additional visits to assess sluggishness (32%) and use of alteplase for occlusions (25%)SASH low protocol – lowest % of additional visits to assess sluggishness (27%), additional RN visits (13%)SASH low and high protocols, % of alteplase use 10% and 9.4%
Lyons & Phalen (2014) JIN
Research: Maintaining catheter patency
Discussion issuesConfounding issue: 3 mL vs. 5 mL heparin flushesConfounding issue: 3 mL vs. 5 mL heparin flushes
Flushing protocol from hospital stay – no heparin – length of stay issues
Conclusions3 flushing protocols equally effective
SAS group more visits and alteplase use but not statistical significancesignificance
Organization decision – use 5 mL heparin (10 unit/mL) flush
Lyons & Phalen (2014) JIN
9/18/2014
20
An issue of catheter manipulation2011 INS Standards: consider risks vs benefits
CVAD Blood Withdrawal for lab studies
Home care question: If you care for patients on PN, how do you educate the
nurses about this complex infusion therapy?
2011 INS Standards: consider risks vs. benefitsA.S.P.E.N. guidelines “VADs used for PN administration should not be used to obtain blood samples for laboratory tests unless no peripheral access available”PN is an independent risk factor for BSI which means that long‐term care and home care clinicians be especially vigilant in policies addressing VAD carepolicies addressing VAD care
Retrospective study of patients receiving home PNObtaining blood for lab sampling: significant CLABSI risk factor
Buchman et al. (2013) Risk factors for the development of catheter‐related bloodstream infections in patients receiving home parenteral nutrition. JPEN 2013; epub ahead of print.
INS Standard
Catheter Removal
VADs shall be removed upon unresolved complication, therapy discontinuation, or if deemed unnecessary.
Element of the central line bundle
Nurses must be patient advocates in obtaining orders for VAD removal, especially in home care ‐‐case examplescase examples
Infusion Nurses Society (INS). (2011). Infusion Nursing Standards of Practice. Journal of Intravenous Nursing,34(1S), p. S57.
9/18/2014
21
Infection and PIVs; Lower Risk but important, additional preventative interventions include:
Appropriate site (avoid lower extremities)Adequate skin preparation – clean skin, hair removal, skinAdequate skin preparation clean skin, hair removal, skin antisepsis (70% alcohol, tincture of iodine, iodophor, chlorhexidine gluconate)Dressing to protect siteChange PIVs placed in emergent situations as soon as possibleC h bili i d hCatheter stabilization to decrease catheter movement which potentially allows pathogens to migrate into the catheter tractREMOVE PIV WHEN NO LONGER NEEDED
INS, 2011 ; O’Grady et al., 2011
Safe Injection Practices
Aseptic technique during preparation & administrationOne syringe – one patientOne syringe one patientOne syringe – one useNever administer single‐dose, single use vials, ampules, bags, bottles to > one patientDedicate multi‐dose vials to single patient whenever possibleSafe sharps disposal
Centers for Disease Control & Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care. (summary guide) . Retrieved from http://www.cdc.gov/HAI/prevent/prevent_pubs.html
9/18/2014
22
Catheter‐Associated Venous Thrombosis
A L SO R E F E RR ED TO AS DE E P VE IN THROMBOS I S ( DV T ) , VENOUS THROMBOEMBOL I SM ( V T E )
Thrombus Formation
Virchow’s Triad – A time honored pathophysiologic explanationexplanation
ALTERED BLOOD FLOW
BLOOD VESSEL WALL INJURY
HYPERCOAGULABILITY
9/18/2014
23
Increased Risk with PICCs
PICCs are associated with a higher risk of catheter‐associated venous thrombosis than other types of central linesResearch study:Purpose: Define frequency of PICC‐related VTEMethod: Meta‐analysis ‐ 64 studies including 29,503 patients met eligibility criteria (18 years or >, PICC placed in arm, reported DVT, PE or both after PICC insertion)Results: PICCs associated with increased risk of DVT
OR 2.55 (95% CI 1,54‐4.23; p<0.0001)Increased risk in critically ill and those patients with cancer
Chopra, V, Anand, S, Hickner, A et al (2013) Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. The Lancet 382, 311‐325.
Discussion Points
Why do PICCs increase risk?Take up more space in vein?Take up more space in vein?
Smaller diameter PICCs
Injury to intimal layer of vein from repeated arm movements?PICCs placed in internal jugular lower incidence of VTE
Study found no increase in risk for pulmonary embolismThrombophlebitis in vein – physiological barrier to clot embolization?embolization?
More clinically apparent s/s, earlier treatment?
Chopra et al (2013) The Lancet.
9/18/2014
24
INS Standard 52: Catheter‐Associated Venous Thrombosis
…the majority of catheter‐associated venous thromboses are clinically silent and do not produce overt signs and symptoms, although pulmonary emboli have been linkedto catheter‐associated venous thrombosis.
Clinical signs and symptoms of catheter‐associated venous thrombosis are related to obstruction of venous blood flow and include, but are not limited to:
Pain in the extremity, shoulder, neck, or chest;y
Edema in the extremity, shoulder, neck, or chest;
Engorged peripheral veins on the extremity, shoulder, neck or chest wall;
Difficulty with neck or extremity motion. (II)INS (2011) JIN, S71.
Role of the Home Care Nurse
Monitor for s/s
Report s/s to MDReport s/s to MD
Diagnosed via ultrasound or venography
Recognize/understand consequences:Permanent venous obstruction
Increased risk of sepsis
Pulmonary embolismPulmonary embolism
Anticipate treatment: anticoagulationHeparin/low molecular weight heparin/warfarin
9/18/2014
25
PERIPHERAL IV COMPLICATIONS
Risks of PIVs
Prevention of PIV related Phlebitis(not addressed in this section)Infiltration or extravasationNerve injuryInfection (not dd d i thi
complications requires knowledge and attention to: appropriate use of PIVs, appropriate site/device selection, skin preparation, catheter stabilization, and assessment.A WORD ABOUT MIDLINE CATHETERS
addressed in this section)
9/18/2014
26
2013 INS IV Safety Practice Survey: USA
L k f i d i d i i l d PIVLack of consistent education and training related to PIV placement57% of nurses reported not being taught how to place a short PIV
71% reported “on the job” training
11% reported “see one, do one” approach to training
Vizcarra et al, 2014
Home care question: How do you assess the competency of nurses who place PIVs?
When is the PIV an appropriate choice?
Considerations include: Duration of intended infusion therapy
Less than 7 days
Intermittent infusions
Infusate characteristicspH between 5 and 9 – Is this based on evidence?? – Paper submitted to Journal of Infusion Nursing that challenges recommendations related
H f i i di i dto pH range for intermittent medications – new evd
Osmolarity < 600 mOsml/L
Patient characteristics
INS, 2011, p.S37; O’Grady et al., 2011
9/18/2014
27
Site Selection
Adults: dorsal and ventral surfaces of upper extremitiesNew sites always proximal to previous sitesNew sites always proximal to previous sitesAreas to avoid according to INS & CDClower extremitiesareas of flexion; includes antecubital fossaventral surface of wrist; cephalic vein above thumb for 4‐5 incheswhere there is pain upon palpationcompromised veinscompromised veinsnear valvesaffected extremity: axillary node dissection, radiation therapy, presence of lymphedema, stroke affected side
INS, 2011, p.S37; O’Grady et al., 2011
Research: Site Selection
Secondary analysis of randomized controlled trial that addressed PIV dwell timeaddressed PIV dwell time
Findings related to site selectionPIV more likely to accidentally dislodge and more likely to occlude when placed in the hand or the antecubital fossa as compared to forearm
Researchers recommendations: preferential use of f f PIV lforearm for PIV placement
Wallis, MC, McGrail, M, Webster, J et al (2014) Infection Control & Hospital Epidemiology 35 (1), 63‐68.
9/18/2014
28
Catheter Selection
Avoid steel needles; limit to single dose or short term useAvoid steel needles; limit to single dose or short‐term use
Smallest gauge/length of catheter to accommodate prescribed therapyResearch: Increased risk of phlebitis with larger diameter catheters but increased risk of accidental dislodgement with smaller gauge catheters (22 gauge or smaller compared to 20 gauge) (Wallis et al., 2014)2014)
Safety needles ‐ passive vs. activeKnow your product!
INS, 2011, p.S37; O’Grady et al., 2011
Catheter Dressing & Stabilization
INS Standardsil d i h ll b li d d i i dA sterile dressing shall be applied and maintained on VADs.
An inadequately secured site allows increased microbial growth and increases risk of accidental dislodgement, phlebitis, & infiltration
Minimize catheter movement at hub, prevent dislodgment and loss of accessEngineered stabilization device preferred alternative to tapeSome dressings may serve to stabilize catheters
Randomized controlled trial: Use of a peripheral IV catheter with an integrated stabilization feature in combination with an IV securement dressing performed as well as a standard peripheral IV with a stabilization device (Bausone‐Gazsa et al., 2010)
INS, 2011, p. S46‐47
9/18/2014
29
Site Rotation: Based on Clinical Indications, not time
Major change in 2011 INS SOPTh h ld id l t f th h t i h l th tThe nurse should consider replacement of the short peripheral catheter when clinically indicated… the decision to replace the short peripheral catheter should be based on assessment of the patient’s condition; access site; skin and vein integrity; length and type of prescribed therapy; venue of care; integrity and patency of VAD; dressing; and stabilization device. Recommendation based on randomized controlled trials as cited in the Standards
However ‐‐ If placed in emergency situation, replace as soon p g y , pas possible and no later than 48 hours
INS, 2011, p. S57
Clinically Indicated PIV Replacement: Complication rate compared to routine replacement
2014 study published in the LancetHypothesis: Patients with clinically indicated replacement of PIVs would have equivalent phlebitis rates (and no difference in complications) compared to routine replacementN=3283 patients randomized to either routine (n=1690) or clinically indicated replacement (n=1593)No difference in phlebitis rates between groupsRates of infiltration, occlusion, accidental removal equivalent between groupsg pStudy conclusion – safe to remove PIVs based on clinical indications rather than a routine time frame (i.e. every 72 hours) (Rickard et al., 2014)
Rickard, CM, Webster, J, Wallis, MC et al (2012) Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled trial. The Lancet, 380, 1066‐1074.
9/18/2014
30
Regular assessment of the PIV site is a critical factor allowing quick intervention in the eventintervention in the event of a complication
2012 INS position paper: Recommendations for frequency of assessment of the short peripheral
catheter site.GORSK I , L , HA L LOCK , D , KUEHN , S C , E T A L . ( 2 0 1 2 ) J OURNA L OF I N FU S ION NURS ING 3 5 ( 5 ) , 2 9 0 ‐ 2 9 2 .
catheter site.
9/18/2014
31
When an infusion is running (whether continuous or intermittent) PIV sites should be routinelyor intermittent), PIV sites should be routinely
assessed:
For redness, tenderness, swelling, drainage, and/or the presence of paresthesias, numbness, or tingling at the site
Assessment should include visual assessment, palpation, and subjective information from the patientsubjective information from the patient.
If there is tenderness at the site, the dressing may be removed to more carefully visualize the site
Gorski, et al (2012), JIN
INS Recommendations for frequency of Assessment
At least every hour for:o Neonatal patientspo Pediatric patients
Every 5‐10 minutesVesicant infusions
With every home care/outpatient visitFor patients receiving peripheral infusions at home as overseen byFor patients receiving peripheral infusions at home as overseen by home care or outpatient nurses
Gorski, et al (2012), JIN
9/18/2014
32
What about temperature as an aspect of assessment?
The possibility of catheter‐ associated bloodstream infection should be considered when there is fever in anyinfection should be considered when there is fever in any patient with a PIV even in the absence of site redness, tenderness, swelling, or drainage
Check temperature at a frequency according to organizational policy/procedure AND more often based on nursing judgment
Gorski, et al (2012), JIN
PIV COMPLICATIONS
9/18/2014
33
Infiltration/Extravasation
Definition – based on type of infusate, vesicant vs. non‐vesicant
May nurses consider infiltration a routine and almost inevitable complication
BUT… large infiltrations and even small extravasations can result in significant injury – loss of limb, permanent nerve damage, loss of function
Severe extravasation in a one year old child –preventable complication!
Good news ‐ no loss of limb or function however permanent scarring
9/18/2014
34
Infiltration/Extravasation Risk Factors
Mechanical: catheter itself irritates or injures the endothelial cells lining the vein wall
Physiologic: blood clot formation and lymphedema.
Pharmacologic: pH, osmolarity, vasoconstrictors
Doellman, D., Hadaway, L., Bowe‐Geddes, L.A., et al (2009) Infiltration and extravasation: Update on prevention and management. Journal of Infusion Nursing, 32 (4), 203‐211
Infiltration/Extravasation: Signs and Symptoms
Cool skin temperature at the PIV site
Skin that appears blanched and tautSkin that appears blanched and taut
Patient complaints of skin tightness, pain, or discomfort
Swelling at the PIV site
Decreased mobility of the extremity
Leaking of fluid from the insertion site
Changes in the infusion flow quality
Lack of a blood return
INS, 2011, p.S67
9/18/2014
35
Infiltration/Extravasation Interventions
Stop infusion immediatelyAttempt to aspirate any residual drug/IV fluidAttempt to aspirate any residual drug/IV fluid NotifyLimb elevationCold vs. warmthDocument – measurement/descriptionMonitor INS, 2011, p.S67
“An IV infusion should not be painful if the drug is diluted and slowly injected through a catheter that has been properly selected, inserted, and secured. Pain on injection is an immediate indication to stop. Most severe complications occur because the infusion continues while staff consider other explanations for the pain” (Hadaway, 2007)
Infiltration/Extravasation Prevention
Appropriate infusateA i iAppropriate siteNo more than 2 PIV attempts per nurseSmall catheterNever place new PIV proximal to previous siteCatheter stabilizationNever rely on infusion pump – will not detect this complication after infiltration fluid/drug will continue tocomplication – after infiltration, fluid/drug will continue to infuse and worsen problem!ASSESS PIV site
INS, 2011
9/18/2014
36
Nerve Damage
N i j i h l d i iNerve injuries are the most commonly reported insertion‐related complication (direct puncture nerve injury)
Preventable when appropriate IV sites are selected, when proper IV insertion technique is used, and when PIV sites are assessed and monitored
Nerve Damage
Nerve compression injury may occur as a result of infiltration or extravasation of an infusion. A compartment syndrome may occur when the IV fluid or medication collects in tight spaces bound by the fascia, bone, muscle, and skin. The increased pressure of the fluid decreases perfusion in the area which can lead to irreversible nerve damage and loss of function. Early identification and intervention for infiltration/extravasation reduces riskintervention for infiltration/extravasation reduces risk.
9/18/2014
37
Signs and Symptoms: Direct Puncture Nerve Injury
Immediate symptoms sharp acute pain at the venipuncture site.
Sharp shooting pain up or down the arm
Sensation of pain that changes in severity depending on needle position; “pins and needles” sensation or an “electric shock” feeling.
Pain or tingling discomfort in the hand or fingertips
Signs/Symptoms: compartment syndrome due to a severe infiltration/extravasation
May result in nerve compression injury!May result in nerve compression injury!
Pain, pallor, paresthesia (e.g. numbness, tingling), paralysis, and/or pulselessness
Restricted joint movement and resistance to passive motion
(Talbot & Rogers, 2011)
9/18/2014
38
Interventions
If the patient complains of paresthesias, numbness, or tingling upon catheter insertion, the catheter should be immediately removed and the physician promptly notified, as rapid attention may prevent permanent injury
INS, 2011, p.S37
Avoid the lateral surface of the wrist for approximately 4‐
Nerve Damage Prevention
pp y5 inches because of the potential for nerve damage
Avoid the ventral surface of the wrist due to pain on insertion and possible nerve damage Avoid the antecubital area for routine PIV placement
Avoid excessive probing for the vein
Infiltration/extravasation prevention
INS, 2011, p.S44
9/18/2014
39
INFUS ION MEDICAT ION RELATED COMPL ICAT IONS :
DRUG TOX IC IT I ES
Commonly administered drug groups
PenicillinsAllergic reactions most common adverse reaction; up to 10% of population; can be immediate/delayed
C h l iCephalosporinsAllergic reactions; cross allergy may occur in those allergic to penicillins; use should be avoided in patients with anaphylactic reactions to penicillin
VancomycinCommonly administered in home setting; must administer over at least one
Focus in this section on the following. Case examples.
Commonly administered in home setting; must administer over at least one hour; faster infusion can result in “red man (neck)” syndrome caused by a release of histamine‐ hypotension, flushing macupapular rash of trunk, face, and neck may occurototoxic and nephrotoxic
Aminogycosides (gentamicin, tobramycin, amikacin) ototoxic and nephrotoxic
9/18/2014
40
Assess and monitor
Signs/symptoms related to improvement in infectiong y p pResponse to the drug therapyDrug‐related side effects Laboratory testsBe alert to adverse reactions specific to the disease state and the antibiotic regimen (e.g. nephrotoxicity/ototoxicity with aminoglycosides)
VAD for signs of complications.
Renal function
Renal function tests (serum creatinine, BUN, trough levels) should be regularly measured in patients treated with nephrotoxic antimicrobials. Examples:p
Aminoglycosides – twice weeklyVancomycin – once weeklyWhen multiple nephrotoxic agents are used together, increased frequency of monitoring should be considered. (Tice, 2006)
Be aware that renal toxicity can occur even with appropriate serum concentrations, teach patients about signs and symptoms such as decreased urine output. Generally reversible – managed with hydration, discontinuation of drugCase example
Xie, J, Talaska, AE, Schact, J (2011) New developments in aminoglycoside
therapy and toxocity. Hearing Research 281, 28‐37.
9/18/2014
41
Renal Function
Be aware that risk of changes in renal function are more likely in older patients, children, and those taking other nephrotoxic drugs
Patient education adequate hydration
Ensure accuracy of drug levels; trough levels just prior to drug administration; peak levels (less commonly done) generally one hour post infusion
Anticipate adjustments in dosage and frequency with increase p j g q yin creatinine, drug levels Critical Nursing Actions:
•Collaborate/discuss with MD if no labs are ordered•Follow-up to obtain results of labs on the day they were done•Never administer next dose until results verified
Vestibular and hearing dysfunction
Irreversible bilateral sensorineural hearing loss beginning at high frequencies (cochleotoxicity) or as an combination of vertigo, nausea, vomiting, nystagmus, ataxia (vestibulotoxicity)
Due to progressive loss of outer hair cells from base of cochlea to apex; progressive loss of inner ear hair cells in more severe cases
Monitoring for vestibular and hearing dysfunction should be assessed at each visit
Aminoglycosides
Xie et al. (2011) Hearing Research.
Aminoglycosides
Vancomycin
Be aware that ototoxicity can occur even with appropriate serum concentrations
9/18/2014
42
Vestibular and hearing dysfunction
T h i b i kTeach patients about risk
Maintain timing of antibiotics to ensure consistency of serum levels
Critical Nursing Actions:•Ask about changes in hearing, dizziness, tinnitus, fullness in the earsR t fi di i di t l•Report findings immediately
PATIENT EDUCATION
9/18/2014
43
Gorski Model for Safe Home Infusion Therapy ©Lisa A. Gorski
Patient Selection
Positive patient outcomes Reduced risk for complicationsPatient satisfaction
Today’s presentation f d
Patient/CGEducation
Patient care & Monitoring
Healthcare provider satisfaction focused on:
Excellent technical skills & infection prevention actions on the part of the nurse
Infection Prevention in LTC and Home Care: Patient Education
prevention actions on the part of the nurse are not enough!We must teach effectively We must address anxiety, resistance to learning, functional limitations that limit/preclude independenceWe must periodically re‐evaluate technique even in patients who are independent We must re‐evaluate technique after a negative outcomeCASE EXAMPLE – 45 year old patient on home PN who developed a BSI
9/18/2014
44
Patient/Caregiver Education: Do not underestimate its’ importance!
Hand hygieneHand hygiene
Rationale for placement
Insertion process
Expected dwell time
Care and maintenance
Signs and symptoms to report
INS, 2011, S36
Challenges of Implementing Evidence‐based practices
Lack of timeLack of time
Lack of autonomy to change practice
Too much reliance on education and transmission of information as a change strategy
Solomons, NM, Spross, JA (2011) Evidence‐based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review. Journal of Nursing Management 19, 109‐120.Weingart, SN (2014) Implementing practice guidelines: easier said than done. Israel Journal of Health Policy Research 3 (20).
9/18/2014
45
SHEA/IDSA Implementation Strategies
A helpful framework Engage
I l i i h iInvolve organization championsEducate
Address knowledge, critical thinking, behavior , psychomotor skills, attitudes, beliefsDocumented competency
ExecuteStandardize care processes – implement guidelines, bundles, protocolsprotocols
EvaluateLink process and outcome data to competency assessmentsSurveillance
Society for Healthcare Epidemiology of America (SHEA)/ Infectious Diseases Society of America (IDSA): Strategies to prevent central‐line associated bloodstream infections in acute care hospitals: 2014 update. Available at: http://www.jstor.org/stable/10.1086/676533
The trend for patients who require VADs/infusions beyond the hospital will continue to expandAs with acute care, the emphasis on infection prevention is strong ‐‐
Summary
we live in an era of zero tolerance for infectionsA number of factors put patients at risk for infection
Patient related characteristics/factors such as receiving PN Organizational factors ‐‐ uneducated staff, failure to address competency, lack of sound policies and procedures that incorporate evidence‐based practices (site care, aseptic technique, blood sampling)Especially, but not only (!) In the home setting, failure to adequately educate patients and families.
P ti t l t i k f th li ti b d i f tiPatients are also at risk for other complications beyond infection including thrombosis, infiltration, nerve damage, and drug‐related toxicities.
Nursing knowledge, skill, and understanding of potential risks is vital in protecting our patients.
9/18/2014
46
Final Thought
“My view you know is that the ultimate destination is the nursing of the sick in their own homes…I look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2000.”
Florence Nightingale, 1867
Thank you for your attention
L I SAGORSK I@HOTMAI L .COM
top related