ins standards of practice 2011 -...

INFUSION NURSINGSTANDARDS OF PRACTICE

Developed by

Infusion Nurses Society

REVISED 2011

315 Norwood Park South, Norwood, MA 02062wwwwww..iinnss11..oorrgg

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Journal of

Infusion NursingInfusion Nursing

Proud Platinum Sponsor of The Journal of Infusion Nursing, the official publication of the Infusion Nurses Society (INS), seeks to promote excellence in infusionnursing by presenting new research, clinical reviews, case studies, and professional development information relevant to the prac-tice of infusion therapy. Articles selected for publication represent the broad scope of the infusion specialty and draw on the expert-ise of all healthcare providers who participate in the delivery of infusion.

EditorMary Alexander, MA, RN, CRNI®,

CAE, FAAN

Editorial OfficeINS315 Norwood Park SouthNorwood, MA 02062(781) 440-9408(781) 440-9409 (fax)www.ins1.org

INS Board of DirectorsPresidentNancy Mortlock, BSN, RN,

CRNI®, OCN®

President-ElectJeanette Adams, PhD, ACNS,BC,

CRNI®

Presidential AdvisorLynn Phillips, MSN, RN, CRNI®

Secretary/TreasurerMarvin Siegel, RN, CRNI®

Directors-at-LargeAngie Sims, RN, CRNI®, OCN®

Mary Zugcic, MS, RN, ACNS-BC,CRNI®

Public MemberDavid Schmick, RPh

INS Chief Executive OfficerMary Alexander, MA, RN, CRNI®,

CAE, FAAN

Infusion Nursing Standards ofPractice ReviewersJeanette Adams, PhD, RN,

ACNS,BC, CRNI®

Teri Aguiar, BSNSteve Bierman, MDCorrine Bishop, RN, CRRN, CRNI®

Paul Blackburn, MNA, RNBeth Bonilla, BSN, MEd, RNCynthia Brown, RN, ARNP, GNP-

BC, CCRN, CRNI®

Heather Buxton, BSN, MSN,CNSRN, CRNI®

Gwen Cole, RN, CRNI®

Ann Corrigan, BSN, MS, RN,CRNI®

Ann Earhart, MSN, ACNS-BC,CRNI®

Charles Edmiston, PhD, CICSeth Eisenberg, BSN, RN, OCN®

Nina Elledge, MBA, RN, CRNI® Beth Fabian, BA, RN, CRNI®

Michelle Fox, RNGina Gilbert, RNKevin Glover, MS, MEdDonna Gordon, MSN, RN, CRNI®

Richelle Hamblin, MSN, RN, CRNI®

Mark Hunter, RN, CRNI®

Pamela Jacobs, BSN, MHA, RN,CRNI®, OCN®

William Jarvis, MDKenn Jones, BSN, RN, CRNI®, Debra Kovasevich, MPH, RN Sandra Kronn, BSN, RN, CRNI®

Elizabeth Krzywda, MSN, ANPMelissa Leone, RNAlicia Mares, BSN, RN, CRNI®

Elizabeth Martinez, RNMary McGoldrick, MS, RN, CRNI®

Karen McKeon, RN, CRNI®

Katherine McKrill, RNPaula McMahon, RN, CRNI®

Nita Meaux, RN, CRNI®

Geno Merli, MDBritt Meyer, RN, CRNI®

Jeannette Meyer, MSN, RN, CCRN,CCNS, PCCN

Crystal Miller, BSN, MA, RN,CRNI®

Susan Miller-Hoover, DNP, RN,CCNS, CCRN

Libby Montoya, MSN, APN, CNS-BC

Nancy Mortlock, BSN, RN, CRNI®,OCN®

Robin Nelson, MEd, RN, CRNI®

Barbara Nickel, APRN-CNS, CRNI®,CCRN

Thomas Nifong, MDShirley Otto, RN, CRNI®, AOCNRoxanne Perucca, MSN, RN,

CRNI®

Lynn Phillips, MSN, RN, CRNI®

Susan Poole, BSN, MS, RN,CRNI®, CNSN, CIC

Debbie Potts, RN, CRNI®, OCNKathy Puglise, MEd, RN, CRNI®

Laura Rutledge, RN, CRNI®

Pam Sabatino-Holmes, ARNP, RN,CRNI®

Ofelia Santiago, BSN, RN, CRNI®

Marvin Siegel, RN, CRNI®

Angie Sims, RN, CRNI®

Marc Stranz, PharmDVirginia Strootman, MSN, RN,

CRNI®

Anne Swanson, RNJoseph Thomas, BSN, RNAlan Tice, MDCora Vizcarra, MBA, RN, CRNI®

Jeffrey Wagner, BSN, RNTimothy Weimken, MPH, CICSharon Weinstein, MS, RN, CRNI®,

FACW, FAANMarcia Wise, RNMary Zugcic, MS, RN, APRN,BC,

CRNI®

*CRNI is a registered trademark of the Infusion Nurses Certification Corporation.

JANUARY/FEBRUARY 2011 Volume 34 • Number 1S

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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011

Acknowledgments S1

About the Standards of Practice Committee S2

Preface S4

Strength of the Body of Evidence S5

STANDARDS OF PRACTICE

NURSING PRACTICE1. Practice Setting S6

2. Neonatal and Pediatric Patients S6

3. Older Adult Patients S7

4. Ethics S8

5. Scope of Practice S8

6. Competence and Competency Validation S11

7. Quality Improvement S12

8. Research and Evidence-based Practice S13

9. Policies, Procedures, and/or Practice Guidelines S14

PATIENT CARE10. Orders for the Initiation

and Management of Infusion Therapy S15

11. Patient Education S16

12. Informed Consent S17

13. Plan of Care S18

DOCUMENTATION14. Documentation S20

15. Unusual Occurrence and Sentinel Event Reporting S21

16. Product Evaluation, Integrity, and Defect Reporting S22

17. Verification of Products and Medications S24

INFECTION PREVENTION ANDSAFETY COMPLIANCE18. Infection Prevention S25

19. Hand Hygiene S26

20. Compounding of Parenteral Solutions and Medications S27

21. Scissors S27

22. Safe Handling and Disposal of Sharps, Hazardous Materials, and Hazardous Waste S28

23. Disinfection of Durable Medical Equipment S29

24. Transmission-based Precautions S29

25. Latex Sensitivity or Allergy S30

INFUSION EQUIPMENT26. Add-on Devices S31

27. Needleless Connectors S32

28. Filters S33

29. Flow-Control Devices S34

30. Blood and Fluid Warmers S35

31. Tourniquets S36

VASCULAR ACCESS DEVICESELECTION AND PLACEMENT32. Vascular Access Device Selection S37

I. Short Peripheral Catheters S37

II. Midline Catheters S37

III. Central Vascular Access Devices (CVADs) (Nontunneled, PICC, Tunneled, Implanted Port) S38

IV. Arterial Catheters S38

33. Site Selection S40

I. Peripheral Venous Access via Short Peripheral Catheters S40

II. Peripheral Venous Access via Midline Catheters S41

III. Central Venous Access via Peripherally Inserted Central Catheters (PICCs) S41

IV. Central Venous Access viaNontunneled Central VascularAccess Devices (CVADs) S42

V. Central Venous Access viaTunneled Central Vascular Access Devices and Implanted Ports S42

VI. Peripheral Arterial Access S42

VII. External Jugular Vein Access S42

34. Local Anesthesia for Vascular Access Device Placement and Access S43

35. Vascular Access Site Preparation and Device Placement S44

I. General S44

II. Short Peripheral and Midline Catheters S44

III. Central Vascular Access Devices (CVADs) S45

IV. Arterial Catheters S45

36. Vascular Access DeviceStabilization S46

37. Joint Stabilization S47

38. Site Protection S48

ACCESS DEVICES39. Implanted Vascular Access

Ports S50

40. Hemodialysis Vascular Access Devices S51

41. Umbilical Catheters S52

42. Apheresis and Ultrafiltration Catheters S53

SITE CARE and MAINTENANCE43. Administration Set Change S55

I. General S55

II. Primary and SecondaryContinuous Infusions S55

III. Primary Intermittent Infusions S55

IV. Parenteral Nutrition S56

V. Intravenous Fat Emulsions (IVFE) and Other Lipid Product Infusions S56

VI. Blood and Blood Components S56

VII. Hemodynamic and ArterialPressure Monitoring S56

Journal of


ContentsN ote: The “S” in page numbers denotes supplement issue and does not refer to a specific standard.

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Journal of Infusion Nursing

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44. Vascular Access Device Removal S57

I. Short Peripheral Catheters S57

II. Midline Catheters S57

III. Nontunneled Central Vascular Access Devices (CVADs) S58

IV. Surgically Placed CVADs:Tunneled/Implanted Ports S58

V. Arterial Catheters S58

45. Flushing and Locking S59

46. Vascular Access Device Site Care and Dressing Changes S63

INFUSION-RELATED COMPLICATIONS47. Phlebitis S65

48. Infiltration and Extravasation S66

49. Infection S68

50. Air Embolism S69

51. Catheter Embolism S70

52. Catheter-Associated Venous Thrombosis S71

53. Central Vascular Access DeviceMalposition S72

OTHER INFUSION-RELATEDPROCEDURES54. Vascular Access Device Repair S75

55. Central Vascular Access Device Exchange S75

56. Catheter Clearance: Occluded Central Vascular Access Devices S76

57. Phlebotomy S77

I. Phlebotomy via DirectVenipuncture S78

II. Blood Sampling via a Vascular Access Device S78

III. Therapeutic Phlebotomy S79

NONVASCULAR INFUSION DEVICES58. Intraspinal Access Devices S81

59. Intraosseous Access Devices S82

60. Continuous Subcutaneous Infusion and Access Devices S84

INFUSION THERAPIES61. Parenteral Medication and

Solution Administration S86

62. Antineoplastic Therapy S87

63. Biologic Therapy S89

64. Patient-Controlled Analgesia S89

65. Parenteral Nutrition S91

66. Transfusion Therapy S93

67. Moderate Sedation/AnalgesiaUsing Intravenous Infusion S95

68. Administration of ParenteralInvestigational Drugs S96

Illustrations S97

Glossary S101

Index S109

ContentsN ote: The “S” in page numbers denotes supplement issue and does not refer to a specific standard.

Journal of Infusion Nursing (ISSN: #1533-1458) is published bimonthly for the Infusion Nurses Society by Lippincott Williams &Wilkins, Inc., at 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Business and production offices are located at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103. Periodicals postage paid at Hagerstown, MD, and at additionalmailing offices. © Copyright 2011 by Infusion Nurses Society. Address for Subscription Information, Orders, or Change of Address (except Japan, India, Bangladesh, Sri Lanka, Nepal andPakistan): 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116; phone 1-800-638-3030; fax 301-223-2400; in Maryland, call collect 301-223-2300. In Japan, contact LWW Igaku-Shoin Ltd., 3-23-14 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; phone: 81-3-5689-5400; fax: 81-3-5689-5402. In India, Bangladesh, Sri Lanka, Nepal and Pakistan, contact Globe Publication Pvt. Ltd. B-13,3rd FL, A Block, Shopping Complex, Naraina Vihar, Ring Road, New Delhi 110028, India; phone: 91-11-25770411; fax: 91-11-25778876.Annual Subscription Rates Worldwide: Individuals – US: $119.99; Canada: $131.43; UK, Australia: $151.11; Rest of World:$235.22. Institutions – US: $341.00; Canada: $390.52; UK, Australia: $420.99; Rest of World: $465.22. (The Canadian GST tax of 7%will be added to the subscription price of all orders shipped to Canada. Lippincott Williams & Wilkins, Inc.’s, GST IdentificationNumber is 895524239. The Canadian Publications Mail [CPM] Agreement Number is 40052291.) Subscriptions outside the UnitedStates must be prepaid. Single copies are $25.00. A $5.49 shipping and handling fee has been added to all subscriptions.Subscriptions outside North America must add $8.73 for air freight delivery. Prices are subject to change without notice. Copies willbe replaced without charge if the publisher receives a request within 90 days of the mailing date, both in the U.S. and worldwide.For commercial reprints and all quantities of 500 or more, e-mail [email protected]. For quantities of 500 orunder, e-mail [email protected] or call 1-866-903-6951. Visit us on the web at www.lww.com.Postmaster: Send address changes to Journal of Infusion Nursing, P.O. Box 1550, Hagerstown, MD 21740.

Text printed on acid-free paper.

The Infusion Nursing Standards ofPractice is intended to reflectcurrent knowledge and practicesof the clinical nursing specialty ofinfusion therapy. Because clinicalpractice continually evolves basedon ongoing research, users shouldmake an independent assessmentof the appropriateness andapplicability of a standard in anyspecific instance, and should alsoconsider the applicable federal andstate laws and regulations, as wellas the standard of care in aparticular jurisdiction, as thesemay take precedence. INS is notresponsible for injury to personsor property, or other harm, arisingfrom the use of the Standards.

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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S1

INS recognizes the significance that the Infusion Nursing Standards of Practicehas to clinical practice. Not only have the Standards been reviewed, revised,and updated, but this edition ranks the strength of the body of evidence to sup-port each standard.

First, I want to recognize the Standards of Practice Committee: Lisa Gorski, chair,Julie Eddins, Lynn Hadaway, Mary Hagle, Marcia Orr, Deb Richardson, and PennyWilliams. Without their knowledge and expertise, plus countless hours of researchand writing, this document would not have been completed. Their commitment tothis project is unsurpassed.

Thanks go to the reviewers of the Standards. From INS members and committeemembers, physicians, pharmacists, legal advisors, health care clinicians, and indus-try partners, their thoughtful reviews and diverse perceptions added a unique perspective.

I want to thank the INS Board of Directors for supporting the efforts of theStandards of Practice Committee during the entire revision process. I am also grate-ful to the INS staff for the assistance and coordination they offered in ensuring thatthis publication was completed.

I also want to recognize BD Medical–Medical Surgical Systems for their contin-uous support over the years of the Standards of Practice revisions. INS thanks themfor the educational grant that helped to fund this project.

Lastly, I want to thank our INS members. It is your passion and commitment toproviding quality patient care that motivates us to continue to provide products andservices that support your practice.

Mary Alexander, MA, RN, CRNI®, CAE, FAANEditor

Journal of


A C K N O W L E D G M E N T S

The Art and Science of Infusion NursingThe Art and Science of Infusion Nursing

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Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

Lisa A. Gorski, MS, HHCNS,BC, CRNI®, FAAN – ChairClinical Nurse Specialist, Wheaton Franciscan Home Health & Hospice,Milwaukee, WI

Ms Gorski has over 25 years of experience in home care and home infusion thera-py, including patient care, nursing education, implementation of evidence-basedpractice in home care, research, and consultation. She is widely published and is theauthor of 3 textbooks specific to home infusion therapy. Ms Gorski also served asINS president from 2007 to 2008.

Julie Eddins, MSN, RN, CRNI®

Staff Nurse, Barnes Jewish Hospital, St Louis, MO

A critical care RN with 35 years in nursing, Ms Eddins has worked as a direct clin-ical provider of infusion therapy to general and intensive care patients, most recent-ly to bone marrow transplant patients. She has presented programs both nationallyand internationally designed to educate professionals in the clinical application ofvascular access devices. She has been a contributing author for several nursing andinfusion therapy publications.

Lynn Hadaway, MEd, RN,BC, CRNI®

President, Lynn Hadaway Associates, Inc, Atlanta, GA

With more than 35 years of experience in infusion therapy, Ms Hadaway broughtclinical experience as well as staff development, consulting, and regulatory expert-ise to this committee. Her areas of expertise include all aspects of vascular accessdevice management, complication prevention and management, and legal and regu-latory issues. She holds national certifications in infusion nursing and professionalstaff development.

Mary E. Hagle, PhD, RN, WCC Nurse Researcher, Clement J. Zablocki VA Medical Center and the University ofWisconsin-Milwaukee College of Nursing, Milwaukee, WI

With 10 years’ experience as a nurse researcher and over 20 years as a clinical nursespecialist in academic and community medical centers, Dr Hagle has worked withpatients and nurses in acute care, ambulatory, and long-term care settings. Her clin-ical and evidence-based practice (EBP) focus has been on vascular access device andpain management with prevention of adverse events in medical/surgical and oncol-ogy practice. She has contributed to several textbooks on infusion nursing and evi-dence-based practice, as well as national guidelines on vascular access devices.

Journal of


A B O U T T H E S T A N D A R D S O FP R A C T I C E C O M M I T T E E


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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S3Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

Marsha Orr, MS, RNDistance Education Faculty Liaison, California State University, Fullerton, School of Nursing(CSUF), Fullerton, CA

Ms Orr is an entrepreneur and consultant in the area of home infusion nursing, home medicalequipment, and medical gases, and is a home accreditation surveyor in these areas. Her specialtypractice areas include infusion therapy, vascular access, and nutrition support. She is currently afull-time faculty member in distance education at CSUF, a member of the technology staff, and apast board member of the American Society for Parenteral and Enteral Nutrition.

Deb Richardson, MS, RN, CNSPresident, Deb Richardson & Associates, Houston, TX

Ms Richardson has over 30 years of experience in the field of vascular access and infusion therapy,including research, education, and evidence-based practices. She is an active member of several pro-fessional organizations; a frequent national and international speaker on vascular access; andauthor of multiple publications related to vascular access.

Penelope A. Williams, MS, RN, CRNI®

Clinical Consultant; Adjunct Faculty for College of Lake County, IL

Ms Williams has over 30 years of experience in infusion therapy, clinical research, education, prod-uct development, management, and consulting in hospital practice, home care, academic, andindustry settings. She is a published author in her special interest of patient advocacy and is anactive member of several professional organizations.

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The Infusion Nurses Society (INS) is recognized as the global authority ininfusion nursing, dedicated to exceeding the public’s expectations ofexcellence by setting the standard for infusion care. One pillar of INS’mission is developing and disseminating standards of practice.

As the science and research of infusion nursing expands and technologyadvances, it is imperative that the Infusion Nursing Standards of Practice be currentand relevant. It provides the framework that guides our clinical practice. Therefore,it is important to integrate the best evidence and research available into each stan-dard.

Each standard provides criteria for nursing action and accountability, while thepractice criteria provide guidance for implementation of the standard. TheStandards are written to be applicable in all patient settings and address all patientpopulations. They are actions that must be followed in order to provide safe patientcare. Clinicians should be advised that the Standards is a legally recognized docu-ment.

In this edition of the Standards, not only are the practice criteria supported bythe latest available research, but the strength of the body of evidence is also ranked.A ranking system was developed to identify the level of evidence and research thatsupports each of the practice criteria. The rankings range from Level I, whichincludes meta-analyses, systematic literature reviews, and guidelines based on ran-domized controlled trials, to Level V, which includes clinical articles, consensusreports, and generally accepted practices. Also, the practice criteria allow for moredetailed explanations for specific patient populations and practice settings.

As nurses strive to meet the infusion needs of their patients in a complex healthcare environment, the Infusion Nursing Standards of Practice will be invaluable toguide decision making and for developing patient-centered plans of care.

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P R E F A C E


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Evidence that is research based is preferred; however, it may come from avariety of sources as needed. The strength of evidence in this documentreflects the body of evidence available and retrievable at the time ofreview, and thus is titled Strength of the Body of Evidence. The strengthof the body of evidence is only as robust as the highest level of a single

item of evidence. Studies and other evidence comprise similar patient populationsunless otherwise noted. Regulatory evidence is kept separate since these criteria maychange based on changes in technology or body of research available.

Journal of


S T R E N G T H O F T H E B O D Y O F E V I D E N C E


Strength ofthe Body ofEvidence

Evidence Description*

I Meta-analysis, systematic literature review, guideline based on randomized controlledtrials (RCTs), or at least 3 well-designed RCTs.

I A/P Includes evidence from anatomy, physiology, and pathophysiology as understood atthe time of writing.

II Two well-designed RCTs, 2 or more multicenter, well-designed clinical trials withoutrandomization, or systematic literature review of varied prospective study designs.

III

One well-designed RCT, several well-designed clinical trials without randomization, orseveral studies with quasi-experimental designs focused on the same question.

Includes 2 or more well-designed laboratory studies.

IV

Well-designed quasi-experimental study, case control study, cohort study, correlation-al study, time series study, systematic literature review of descriptive and qualitativestudies, or narrative literature review, psychometric study.

Includes 1 well-designed laboratory study.

V

Clinical article, clinical/professional book, consensus report, case report, guidelinebased on consensus, descriptive study, well-designed quality improvement project,theoretical basis, recommendations by accrediting bodies and professional organiza-tions, or manufacturer recommendations for products or services.

Includes standard of practice that is generally accepted but does not have a researchbasis (for example, patient identification).

RegulatoryRegulations and other criteria set by agencies with the ability to impose conse-quences, such as the AABB, Centers for Medicare & Medicaid Services (CMS),Occupational Safety and Health Administration (OSHA), and state Boards of Nursing.

*Sufficient sample size is needed with preference for power analysis adding to the strength of evidence.

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