Infusion nursing standards of practice

2016

1

สุพัตรา อุปนิสากร พยาบาลช านาญการพิเศษ / พยาบาลผู้ปฏิบัติการพยาบาลขั้นสูง (อพย.) หออภิบาลผู้ป่วยอายุรกรรม โรงพยาบาลสงขลานครินทร์ ssupattr@medicine.psu.ac.th mobile 0856781034

We care IV care by Nurses PSU

2014

2016 2012 2008

From Practice with International Standard

• Infusion classical bundle

IV therapeutics

• Patients safety

• A part of nursing quality indicator

– Phlebitis

– Infiltration

– Extravasation

– CLABSI

INS : Infusion team

• The infusion nurse team is structured through its scope of service to meet patient and organization needs for safe, effective, and high-quality infusion therapy

Practice Criteria • IV nurse is accountable for

– Inserting short peripheral catheter increase the success rate for cannulation on the first attempt

– Decrease hospital acquired blood stream infection, local site infection, occlusion and accidental removal

– Manage VADs including daily assessment, dressing change

– IV team is a resource for infusion therapy product evaluation, education, and standard evidence based practice

Current Situation

• A variety of standard of practice in Thailand

• National Benchmarking is not available

• Technology is beyond frontier, current standard of practice need to review and revise

Back to basic

• Skin Preparation

• Insertion

• Maintenance

• Equipment selection

• Complication management

Raising our standard of practice

Skin preparation

• Wash your hand

• Put on Glove >>> ignorance

• Clean the site

• Use antiseptic

• Scrub with friction

• Allow the antiseptic agent to dry thoroughly (15 Sec.)

Clean the site

Don’t wipe !!!

Scrub with friction

https://opentextbc.ca/clinicalskills/chapter/6-7-intradermal-subcutaneous-and-intramuscular-injections/

Clean the site

Back to basic

• Skin Preparation

• Insertion

• Maintenance

• Equipment selection

• Complication management

Raising our standard of practice

IV insertion

PIV Catheter 3 kind of IV catheter • PVC •Tavlon •Polyurethane

Polyurethane : decrease phlebitis rate up to 40%

ETFE catheter tetrafluoroe thelene (Terumo)

Safety I.V.Catheter with wings

sterile iv catheter with port

pen-like i.v.catheter intravenous catheter

IV catheters butterfly medical iv catheter cannula

intravenous heparin cap iv catheter

application

How many attempt we can do?

ประสบการณ ์<100 PIVC แทงส าเร็จเข็มแรก 66% จึงขอใหโ้อกาสคนละ 2 ครั้งเท่าน้ัน

ผงัการตดัสินใจ เปล่ียนจาก PVAD เป็น CVAD (PICC)

Central Venous Access Devices (CVADs)

4-types

nontunneled

tunneled

implanted port

peripherally inserted central catheter (PICC)

central venous access devices (CVADs)

PICC

Back to basic

• Skin Preparation

• Insertion

• Maintenance

• Equipment selection

• Complication management

Raising our standard of practice

Flushing Protocol

• NSS flush > Flush more

• Heparin Flush

• SASH technique

Site Care And Maintenance

prospective controlled trial 0.9% sodium chloride solution (N181) heparin saline solution (N178) flushing and locking solution for PVD Occlusion (7.7% vs. 7.9%) (P = 0.163) Duration (3.6 ± 1.1 days vs. 3.7 ± 1.2 days, P = 0.651)

Sodium chloride solution is as effective and safe

214 medical patients 107 heparin (3 mL of a 100 U heparin/mL) & 107 to saline flushes (control group).

Phlebitis/occlusion were 45 (42.1%) in the heparin group and 68 (63.6%) in the saline group (OR 0.41; 95% CI 0.24-0.72; p= 0.002)

occlusion alone were 23 (21.5%) and 47 (43.9%), respectively (p= 0.03)

phlebitis alone were 28 (26.2%) and 56 (52.6%) respectively (p= <0.001)

subjects with platelet or coagulation defects were excluded

Flushing Protocol

• NSS flush PIV 3ml iv q 8 – 12 hr.

• Heparin Flush

• SASH technique

Flush Volume

• The minimum volume of preservative-free 0.9% sodium chloride (USP) for catheter flushing depends upon the type and size of catheter, Age of patient, and type of infusion therapy being given.

• A minimum volume of twice the internal volume of catheter system is recommended; However, a large volume may be need for blood sampling or blood transfusion procedure (V)

Flush แบบน ้ำวน

• whirlpool

Site Care And Maintenance

• Flushing and Locking

• Single use system include single-dose vial and prefilled syringe are the preferred choice of flushing NSS vs Heparin

Flush the device

• Clean the port : scrub 15 second

• Slow inject, maintain positive pressure

• For heparin lock, no need to maintain positive pressure

• For needless connector : should neutral pressure device

PIV locking

maintain positive pressure

needless connector

Saline Lock with Extension (for Needles)

Needless Connector

• Needless connector are changed if there is blood or debris visible within the needless connector, upon contamination, prior to drawing a blood culture through a catheter, and routine as established by the organization

Site Care And Maintenance

• Flushing and Locking

• Single use system include single-dose vial and prefilled syringe are the preferred choice of flushing

Scrub the hub scrub 15 second

IV dressing

• Gauze and Tape

• Transparent dressing

• Fixed -> displacement

• Sterile -> infection

6RCTs(1539 participants) assess the effects of peripheral venous catheter dressings

and securement devices on the incidence of peripheral venous catheter failure transparent dressings VS gauze bordered transparent dressings VS

a securement device bordered transparent dressings VS tape transparent dressing VS sticking plaster

The quality of evidence ranged from low to very low. Catheter dislodgements or accidental removals were lower

with transparent dressings compared with gauze (two studies, 278 participants, risk ratio (RR) 0.40; 95% confidence interval (CI) 0.17-0.92, P=0.03%).

the relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47-1.68) and infiltration (RR 0.80; 95% CI 0.48-1.33) are unclear.

A single study identified less frequent dislodgement or accidental catheter removal with bordered transparent dressings compared to a securement device (RR 0.14, 95% CI 0.03-0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03-64.02).

There is no strong evidence to suggest that any one dressing or securement product for preventing peripheral venous catheter failure is more effective than any other product.

Document • Patient education • Able to identify the person providing care • Document must be completed with

• Specific site preparation • Device: Length and gauze • Date and time of insertion • Insertion site / Dressing type /Type of therapy • Patient/ relative ‘s understanding, education • Upon removal: condition of site , patient response,

patient education • When multiple access device or catheter lumens are

use, documentation should clearly indicate what fluid/medication are being through each pathway.

Infusion Equipment

• Add-on devices

-Luer-locked design

-Disinfect the port (using friction)

• The use of stop cock is not recommended

-Needleless connector

-Nurse should be knowledgeable about the function

-Nurse should be aware that the catheter hub is a know source of infection

Disinfect the port (using friction)

Disinfect the port (using friction)

IV Cap

• Add on device (INS) The use of stopcock is not recommend to use due to the increased risk of infection

Tourniquets

• The tourniquet should be single-patient use

• Latex allergy should be assesses

• Tourniquets should be loosely applied : patient who bruise easily, risk of bleeding, who have compromised circulation

• Tourniquets should be single-use and latex- free

Tourniquets

Tourniquets technique

Filters

• Filters are use to prevent the passage of undesirable substance into the vascular

• The specific type an size of filter used is determined by the infuscate and may be an add on device or an integral part of administration set

• A 0.2 micron filter that is bacteria and particulate-retentive and air eliminating is used with non lipid-containing solution that require filtration

• A 0.2 micron filter that is surfactant free, particulate-retentive, and air-eliminating is used with intraspinal infusions

• A 1.2 micron that is particulate-retentive and air eliminating is used with lipid infusion or 3 in 1 parenteral infusion

• Small volume infusion of 5 ml or less over 24 hours and IV push medication should not be administered through a 0.2 micron filter INS 2011

Removal PIV catheter

Sterile

• Phlebitis

• Infiltration

• Extravasation

Complication management

malpractice

malpractice

malpractice

malpractice

Reducing the risk for malpractice • Maintain clinical competency

• Assess & monitor

• Prevention infections

• Use equipment properly (failure to use equipment)

• Protect the patient from harm (identify the patient correctly, improve staff communication, use medicines safety, prevent infection)

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