Angele Caporicci, RN, CVAA©

Labour Relations Officer

Ontario Nurses Association

Karen Mallet, RN, CVAA©, CON©

Stem Cell Transplant Nurse

North East Cancer Centre, Sudbury

Disclosure: no existing conflicts

Objectives Review standards which govern our practice

Case study scenarios from Canada ( & USA) that involve vascular access incidences

Review Canadian Statistics

Examine the current issues

Look at practical ways to minimize risks for the practitioner & better outcomes for our patients

“ I ordered an IV, not an ivy!”

-Nurses have a duty to provide reasonable , prudent care as required. The care delivered by the nurse must comply with what is expected, given the circumstances in which the care is provided. This is known as Legal Standard of Care

-Standards can be voluntary such as those identified by professional groups, or mandated legislatively

•Regulated Health Professions Act (RHPA)

• Nursing Act (Colleges of Nurses)

•Health Protection and Promotion Act

•Employment Standards Act

•Occupational Health and Safety Act

•Professional Standards Established by Associations

(INS, CVAA, RNAO)

Controlled acts are activities that are considered to be potentially harmful if performed by unqualified persons. Section 27 of the Act identifies the 13 controlled acts that health professionals can do. This includes “performing a procedure on tissue below the dermis, below the surface of a mucous membrane.”

This is the legislation that gives rise to the self governing bodies of health professionals and creates the Act that the professionals work from. For nurses, it is the Nursing Act.

The RHPA also creates the Colleges of Nurses, identifying its duties and responsibilities.

Nursing’s Scope of Practice Statement

The practice of nursing is the promotion of health

and the assessment of, the provision of, care for, and

the treatment of, health conditions by supportive,

preventive, therapeutic, palliative and rehabilitative

means in order to attain or maintain optimal function.

(Nursing Act, 1991)

• The Colleges or Associations of Nurses in each province are the governing bodies for Registered

Nurses (RNs), registered practical nurses (RPNs) and nurse Practitioners (NPs)

•Some provinces have Colleges (NS, MB, AB, BC PQ) while the others have A Governing

Association (PEI, NB, SK, NFLD).

The nursing profession has been self-regulating in Ontario since 1963

Its duties and responsibilities include a duty to serve and protect the public interest by regulating the practice of the profession and to govern the members in accordance with the Health Profession Act

The Colleges create Standards of Practice and hold nurses accountable to those standards

•Accountability

•Competency

•Ethics

•Knowledge

•Knowledge Application

•Leadership

•Relationships

•Act that provides legal framework of the Internal Responsibility System and the obligations of workers, employers and Supervisor to work in a safe work environment.

•Regulation 834/92 of the Ontario Act explains what must be done if critical injuries occur in the workplace.

•Sometimes errors in practice occur because safe practices are not established in the workplace, there are faulty policies and procedures that in fact put not only a patient but a nurse at risk of injury. These may be addressed through this forum.

•Infusion Nurses Society (INS) Standards

•RNAO Best Practice Guidelines

•CVAA Guidelines

•These professional standards are the forerunners of our legal standards. What has become the customary usual nursing practice, as defined by our profession, later translates into the legal duty a nurse has with her patient.

•These represent an established level competencies that are expected by our profession and recognised by the courts.

• The Standards that INS, RNAO and CVAA have established for the speciality practice of infusion therapy are reviewed routinely and subsequent revisions reflecting clinical practice and new technological advances are based on evidence-based practice and research.

•Workplace policies ,procedures, protocols and/or guidelines should reflect these accepted standards of practice.

•Those failing to meet those standards risk being involved in legal processes and charged with negligence (or malpractice)

•-Medication Administration

•-Equipment Use

•-Failure to Act

•-Failure to Assess and monitor a patient’s status

•-Failure to communicate appropriately

•-failure to prevent infection

NEGLIGENCE leads to:

•Civil or Criminal court (fines, Jail)

•College of Nurses Discipline (fines, suspension or loss of license)

•Employer disciplinary actions (suspensions or termination)

-College of Nurses Case : M.T. vs. K.K., RN. Alleged failure to provide proper care, assessment, of a paediatric peripheral IV.

-The committee reviewed the patient’s hospital record, doctor’s notes, nurse’s charting, the employer policy and procedures, emails between the nurse and management and interviews.

- Decision: The nurse did indeed perform the proper vascular access evaluation, thus mitigating her disciplinary actions against her by the College of Nurses.

-The Nurse was disciplined and received a caution due to poor communication with the family, as she failed to listen to the concerns of the family member , and failed to do so with sensitivity or empathy.

-Bethania Mennonite Personal Care Home vs. Local 103 Manitoba Nurses Union member (re-instated)

--Royal Victoria Regional Health Centre vs. ONA member (re-instated)

--Peterborough Regional vs. ONA member (re-instated)

Watershed Case that effected change

Let’s Talk Peripheral Venipuncture is a common procedure performed by regulated HCP’s these include lab techs, di/radiology techs, physicians, nurses, paramedics

IN 1992 75% of nurses time

IV’s per day……….

CVAA national KN&JH 2011

Use the Experts

What is the leading cause of malpractice action against nurses? Complications related to venipuncture

These can include medication errors, infiltration, extravasation, nerve injury or tissue damage

With the decrease in # of IV teams, increased risk to front line staff

“Masoorli, S 1998, 2006”

Canadian Statistics 65,000 x 365= 23,725,000

360,000 /3 x 365= 43,800,000

2.7 million 85,000 USA 1/32

200+ Canada 1/1800 “Health Canada Stats 2013”

Case Study A.S. female age 40 required IV access for anesthesia

Nurse made 8 attempts to start peripheral access

2 attempts were on the inside of Rt. wrist causing sharp shooting pain in her hand

1/52 later pain numbness to Rt. hand and wrist

Tests=median nerve damage

Patient subsequently lost the use of her hand

Both Hospital and Nurse found guilty of malpractice

“Nursing journal Sept 98”

Types of nerve damage NICKING This is the inadvertent nerve puncture that can occur

during vascular access, particularly in the arm, there is a major nerve lying near every major vein

NERVE COMPRESSION This can occur from hematoma in the subcutaneous tissue

or by infiltration of iv fluid placing pressure on the nerve: compartmental syndrome

“Massorli,S 2006”

How long does it take for nerve damage to be noticed?

Immediately

Within 24 hours

1 to 4 days

Up to one month

What is the correct answer???

“Hadaway,L 2008”

What can affect risks? 1. Mechanical factors Veins small or poor condition

Large catheter size relative to size of vein

Choice of site (joint flexion or dominant hand)

Stability of catheter or device

Choice or technique of securement

Patient Activity

Multiple Venipuncture Sites

Use of an infusion pump

Line/catheter separates or fractures

2. PHYSIOLOGICAL FACTORS

Clot Formation above cannulation site

Thrombus or fibrin sheath at catheter tip

Lymphedema

3. PHARMOCOLOGIC FACTORS

Ph, osmalarity, cytotoxicity, vasoconstrictive potential

Doellman, Haddoway Bowes-Geddes et al 2009

Case Study Female patient requires

PICC line for antibiotic post-op

Presents to D.I. and attempts made to Rt arm unsuccessful

Successful PICC insertion to Lt arm

Postop 1-2/52 pain and numbness Rt arm

Case Study 30 year old male presents for routine phlebotomy Accessed vein at antecubital fossa, dry gauze and bandage were applied No pain during or immediately post, Pt discharged 30 minutes post pain numbness and swelling with discoloration to his arm Patient assessed told “not to worry it would resolve” and discharged Experiences ongoing and increasing pain for next several days and presents to ER = warm soaks and ibuprofen IN spite of extensive physio partial loss of use of arm/hand on affected side due to nerve damage from compartmental syndrome

How to avoid problem areas

Avoid the inner wrist and base of the thumb-Use the three finger rule

Listen to the patient

Apply pressure

“RNAO Assessment & device selection for vascular access”

Choose the appropriate vein (consider volume) Assessment is KEY

Choose the best suited equipment

Defer to the experts

# of attempts

INS Standards

Infiltration or Extravasation Leaking of potentially tissue damaging medication outside

of the vein Proper vigilance

Pain out of proportion c/o numbness &/or tingling with swelling Temperature changes ie cool to touch Skin and nail changes ie blanching Check for pulse Hematoma=delayed nerve compression

Involve patient and family Don’t rely on “smart” pumps (Masoorli, S 2007)

Management of infiltration Know your facility P&P or advocate to establish one Teach your patient and family S&S Pay attention to patients c/o & be prepared to act Assess the condition of the site prior med admin AT THE FIRST SIGN OF INFILTRATION IMMEDIATELY STOP

THE INFUSION/INJECTION Apply warm or cold compresses as required for the drug

administered Estimate the volume of drug escaped in subcutaneous tissue

related to flow rate, condition of site and length of time between site assessments

“AJN August 2007”

Prevention is preferable to cure

Careful adherence to proper procedures and timely identification of signs and symptoms are critical to avoiding potentially life-altering complications

“Journal of Infusion Nursing 2009”

Frequency of Assessment of the Short Peripheral Catheter Site 2012 INS Positon Paper

minimizing the complications associated with risks of vascular access demands regular assessment for

1. Signs and Symptoms &

2. Prompt Removal when evident

Assess for : redness, tenderness, swelling, drainage, and/or the presence of paresthesias, numbness or tingling-----any site related changes

INS standards of 2011 recommends “routine” assessment for s&s of Inf/extra

Frequency of Assessment Cont’d Review of Literature 1-4 hrs ***** many factors

Adult –At least every 4 hrs non vesc/non irritant- in an alert/oriented and able to notify nurse

Every 1-2 hrs for critically ill pts, sensory or cognitive deficits or unable to notify nurse or high risk location

EVERY hour for neonatal and pediatric patients

Every 5-10 minutes for vesicants + assess blood return

With every home/outpatient visit-educate pt & family

DOCUMENTATION OCN

“complete record of nursing care provided”

“objective and subjective data”

“documenting advice, care or services given”

“completed by the individual who performed the action”

INS Standards for Documentation Specific site prep

All infusion devices-type length gauge/size VAD

Additionally for CVAD manufacturer # and Lot #

Date, time, number and location of attempts

Functionality of device and insertion methodology (local anesthetic or assistive device)

Insertion site by anatomical descriptors, landmarks, measurements

Midlines or PICC- external and internal length

INS standards continued……. Confirmation of anatomical location of tip of CVAD prior

to 1st use and PRN for catheter dysfunction

Condition of the site, dressing, site care, stabilization device

Patient reports of discomfort or pain on insertion & with each regular assessment of the VAD site.

Condition of venipuncture or access site PRIOR to and Post infusion therapy

Patency of the VAD

“Infusion Nursing Society Standards 2011”

Peripheral IV started: 1130 hr IV started to Rt forearm #22 cathlon , 500mls

N/S tba @100 mls/hr. K.Mallet RN

OR

1130 hrs. Attempt x 2 to start peripheral IV 1st attempt dorsum of Rt hand unsuccessful. 2nd attempt #24 cathlon to inner aspect of Rt forearm 6 cms above base of wrist in cephalic vein, good blood return, site intact, well tolerated by patient. Patient advised to report any feelings of discomfort asap. 500 mls N/S @100 mls/hr. K.Mallet RN

Mistakes occur in 7/100 admissions IHI

System errors – 20 steps in process = error is not one person ISMP

Errors in Medication Administration

MEDICATION ERRORS Preparation to administration preparation administration or combination prep/admin errors LASA= wrong drug Mixing volumes/concentration/dose= wrong dose Rate of delivery=smart pump vs. over-ride Omission of dose National Data shows same rate of error across the country-not all

provinces have mandatory reporting “Causes of IV med errors,quality of safe health care 2003” CBC news article Aug 21, 2013

ERROR Producing conditions 1. Handling technology-lack of knowledge and

experience in drug prep and admin 79% Most common error: delivering bolus doses too fast

2. Design of technology-equipment, labels, environment and procedures 32%

3. Communication-between nurse/pharmacy, nurse to nurse or physician 16%

4.Workload-multi-tasking, end of shift, lack of qualified and experienced staff 15%

5. Patient related factor-limited venous access, non-cooperative

6. Lack of supervision student/agency nurse 3%

“Causes of IV med errors 2003 Quality Safety UK”

Common errors in delivery Secondary clamp Errors – IV setup Connection Errors – above or below the pump, multiple infusions Pressure Differential Errors (gravity and some pumps) Mismanagement of Residual Volume did not adequately flush residual prior to adding new secondary medication (25%) disposed of residual medication (50%)can=Underdosing &/or mixing of incompatible sol’ns Pre vs Post test improved from 46% to 76% post training across the board K.Chan, U of T. Mitigating Risks Associated with Secondary Infusion 2011”

REMEMBER HUMANS ARE NOT PERFECT- even with enough skill, enough knowledge, enough experience and enough prudence errors will occur given the right circumstance

HUMAN ACTIVITY IS NOT EVER GOING TO BE FREE FROM ERROR---LEARNING FROM OUR MISTAKES IS KEY

NOVICE TO EXPERT---- EVEN THE BEST CLINICIANS MAKE ERRORS !!!

In Summary Legislation, Standards and Guidelines to practice-We are held accountable for our actions

Use your Knowledge of anatomy/technique for best site/equipment choice

Focus on medication prep and administration

Be Vigilant in Assessment of ongoing IV therapy

Know how to take appropriate action

Involve the patient

Document specifics

Don’t expect smart pumps to replace the need for VAD and site assessment

Participate in Ongoing Education and Training

QUESTIONS??