Knowledge Sharing from AVA 2016

Transcription

1 Knowledge Sharing from AVA 2016

2 Introduction Nutcharee Jungvanichar Pawilai Pitakwong Somporn Poolpanitoopatum Agnes Chiachuabsilp Leadership Perspective in IV Care Adult IV care Pediatric IV care Moderator

3 Knowledge Sharing from AVA 2016 Nutcharee Jungvanichar RN, MBA Senior Division Director, Bumrungrad International Hospital ประธานฝ ายว ชาการ ชมรมเคร อข ายพยาบาลผ ให สารน าแห งประเทศไทย

4 Sharing Topic Vascular access in Leadership perspective

5 Expectation อยากเห นอะไร ม คาถามอะไรในใจท เราจะไปตามหา ม อะไรท เขาม แล วม อะไรท เราอยากร กล บมาแล วจะทาอะไร

6 อะไรบ างค อส งท ผ นาควรร ประเด นป ญหาค ออะไร มาตรฐานในโลกน ไปถ งไหน ถ าจะเร ม ควรจะเร มอย างไร อะไรบ างท เป น pitfall ม tool อะไรบ างท จะช วยหน างาน

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8 Chart review : Trigger point ท ทาให เห นประเด น ป ญหา Discharged patient records Hospital stay > 3 days Every IV Documentation Insertion date Number of attempt Gauge and length Location Removal date Reasons for removal

9 Reduce risk Risk of disconnection Add-on devices are luer lock or integrated design Risk of infection from catheter manipulation ( จากการถอดสายนาเหล อเข าออกๆบ อยๆ) Consider use needleless connector

10 Needleless connector Needleless system integrated or interlinked Pro and Con

11 Needleless connector No design preference Vigorous scrub prior to every access ( scrub the hub)

12 Sterile technique? : pitfall It should be recognized that the external surfaces of all peripheral IV catheter hubs become contaminated during the insertion process, because the hub is grasped with non sterile gloves that topically touched multiple nonsterile surface This surface is then simply covered over by the transparent adhesive film dressing

13 New technology and new standard

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15 ต วอย าง tool

16 Vascular Access device algorithm

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18 What s new Securement device Needleless system

19 Thank you for. Dr Broviac Dr. Patrick Park K. Steve Hineke

20 Q& A

21 Pawilai Pitakwong, DNPc, RN Siriraj Hospital 27 Jan 2016

22 IV Education IV Research IV Innovation From AVA conference!

23 3M Company Department of Nursing, Siriraj Hospital ชมรมเคร อข ายพยาบาลผ ให สารน าแห งประเทศไทย

24 30th Annual Conference Association for Vascular Access Sep 16-19, 2016 at Disney Coronado Springs Resort, Orlando, Florida, United States of America. The target audience for this medical event Clinical Educators Critical Care Physicians and RNs Hemodialysis RNs Infusion Nurse Specialists IV Therapists and Team Supervisors Nurse Practitioners etc.

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26 Patient safety Prevent complications CABSI Central line PICC line Peripheral line Clinical Practice Guideline IV therapy and care

27 Loss of cells and loss of physiologic reserve make up the dominant processes of aging Major Changes Homeostatic changes Immune system Cardiovascular changes Skin and Connective tissue changes

28 Skin turgor forehead or sternum Temperature Rate and Filling of veins in had or foot Daily weight Intake and output Tongue Orthostatic Swallowing ability Functional assessment

29 Site selection Equipment selection To prevent hematoma, avoid over distention Avoid multiple tapping of the vein Use the smallest gauge needle necessary Lower the angle of approach Pull the skin taut and stabilize the vein Use the one handed technique

30 Alterations in Skin Surfaces Hard Sclerosed Vessels Obesity Edema

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32 Use prefilled saline and heparin flush syringes Heparin flush concentrations available: - 100u/ml (5ml in a 10ml syringe) - 10u/ml (2ml in a 3ml syringe) Flushing intervals and amounts Adults: q 8hrs w/3ml. 0.9%Nacl

33 Physician orders are required if a peripheral catheter is left in the same site for more than 3 days. It is best to have the pharmacy add medications to the infusion bags under laminare flow to reduce contamination Changing dressings Gauze q 2 d normally every 3d TSM q 7 d Changing bags and tubing normally every 3d Changing Sites 24 hrs If respiked or meds added outside pharmacy Every 7 d c MD order

34 Percutaneous Tunneled PICC s Implanted Ports Dialysis Insertion bedside w/x-ray confirmation MD in OR under fluoroscopy MD/trained w/x-ray confirmation MD in OR under fluoroscopy MD in OR under fluoroscopy Location Visible externally. Enters subclavian, ext. juglar,or int. juglar vein near clavicular area Visible ext. usually midway bet. clavicle and nipple. Tunneled under skin & threaded through subclavian or IJ Visible externally around antecubital fossa, upper arm or neck Completely internal. Titanium or plastc port is implanted in a surgically created pocket and catheter is threaded into subclavian or int. juglar vein. Access is through skin into self sealing port using special non coring needle Visible externally. Arm or leg placement Material/Cost Polyurethane $200-$400 Silicone $3500-$5000 Silicone / polyurethane $350-$500 Silicone catheter. Port is titanium or plastic w/self sealing diaphragm $3500-$5000 Various materials Lumen Sutured Yes/entire life Yes, until internal Dacron cuff healed No Yes Yes Duration Short term 4-10 days Long term Long term Long term Mid term Flushes 5-10ml NaCl after use and daily 5-10ml NaCl after use and daily 5-10ml NaCl after use and daily 10ml NaCl followed by 4.5ml heparinized saline (adults-100units/ml; peds-10units/ml) after ea. use or monthly if not accessed Done ONLY by IV team or dialysis nurses Brands/ Names Arrow Howe, Triple Lumen, Subclavian, IJ Hickman, Broviac PICC, PIC, EDPC, Arrow Howe, Gesco, PASV Bard, Accces Port-A-Cath Bard, Tesio, Vescath, Quinton Discontinue MD or speically trained bedside MD in OR Specially trained bedside MD in OR MD in OR

35 PICC (Peripherally inserted Central Catheter) Percutaneous (Subclavian) Implanted Port (single or double lumen) Tunnelled (Hickman) Percutaneous (IJ-Int. Jugular)

36 Percutaneous Flush after each access or daily for catheters, or q 6 hrs. Adults: 10ml saline Transparent dressing change q 7 days & prn Tunneled PICC

37 Flush after each use and weekly while accessed; monthly when not accessed - 10ml saline (preservative free for pts. <1yr) - Followed by 4.5ml-5ml heparinized saline 100units/ml for adults. Transparent dressing/ access needle change q 7days Implanted Port

38 Monitor and document site condition: Q 2 hrs for adult Indicates complication: Infiltration Phlebitis Thrombosis Cellulitis Septicemia

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40 The most common cause is damage to the wall during insertion or angle of placement. STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book. Notify MD and document

41 Chemical Mechanical Bacterial

42 Inflammation of loose connective tissue around insertion site. - Caused by poor insertion technique - Red swollen area spreads from insertion site outwardly in a diffuse circular pattern - Treated w/antibiotics

43 Vascular access device will not flush/can t draw blood - Evaluate for kink in tubing or catheter tip against vein wall. Vascular access device (VAD) leaking when flushed - Verify that hub access cap is connected correctly Patient complains of pain while VAD being flushed - Assess for infiltration VAD broken - PICC s may be repaired. All other devices must be replaced

44 Patient safety Infection ** Innovations tools Quality of IV care Quality of patient outcomes Future research Improve IV therapy and care Satisfaction Patient s experience **Reference: Safdar, N., O Horo, J. C., Ghufran, A., Bearden, A., Didier, M. E., Chateau, D., & Maki, D. G. (2014). Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Critical Care Medicine, 42(7),

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46 A chlorhexidine-impregnated dressing for prevention of central venous catheter-related colonization and CRBSI** Chlorhexidine gluconate (CHG) IV securement **Reference: Safdar, N., O Horo, J. C., Ghufran, A., Bearden, A., Didier, M. E., Chateau, D., & Maki, D. G. (2014). CHLORHEXIDINE-IMPREGNATED DRESSING FOR PREVENTION OF CATHETER-RELATED BLOODSTREAM INFECTION: A META-ANALYSIS. Critical Care Medicine, 42(7),

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49 Patients and families experiences Clinicians: positive practice for IV care

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51 IV Care for Pediatric Patient AVA 2016 SOMPORN POOLPANITOOPATUM,HN DEPARTMENT OF PEDIATRICS RAMATHIBODI HOSPITAL

52 Vascular Access in Children Comparison of Options for Vascular Access in Children Method Duration of Use Advantages Disadvantages Peripheral intravenous (IV) access Short term Ease of insertion Low cost Minimal complications Easily occluded Potential for local tissue injury Use limited to certain antibiotics or medications Peripherally inserted central catheter (PICC) Short-tointermediate term Ease of insertion (bedside) Can be used with variety of medications Relatively safe and inexpensive Potential for occlusion Can be difficult to position in central vein

53 Vascular Access in Children Comparison of Options for Vascular Access in Children Method Duration of Use Advantages Disadvantages Silicone central venous catheter (eg, Hickman, Broviac) Long term Less thrombogenic Decreased infection rate Safe with most medications Increased cost Requires surgical insertion Implantable vascularaccess device (ports) Long or permanent Low visibility, improved body image Lowest rate of infection Increased cost Requires surgical insertion

54 PICC

55 Neonatal and Pediatric PICC Placement: Challenges : - Knowledge - Understanding and proficiency to ensure patient safety and promote optimal outcomes Pediatric PICC Team

56 Sticking with Success: Increasing PICC Insertion Success Rate Within a Pediatric PICC Team Cook Children s Medical Center Why Build a Specialized PICC Team? Increased need for PICC lines Increased consistency - Improved bundle compliance - Increased skill through repetition - Decreased complications through line maintenance - Maintained best practice focus Decreased need for additional resources

57 Sticking with Success: Increasing PICC Insertion Success Rate Within a Pediatric PICC Team Cook Children s Medical Center Why Build a Specialized PICC Team? Decreased Need for Sedation with PICC Placement Decreased cost - Increased Patient Satisfaction = reimbursement - Capability to perform bedside and outpatient PICC insertion with PICC team - Imaging

58 Construction Zone Cook Children s Medical Center Increasing insertion success within the PICC team - Developing a starting point - Establishing support starts driving demand - Orientation and competencies revised - Competencies created for mid-thigh and EJ PICCs placed by senior staff in difficult access patients requiring immediate or emergent access - Addressing growing pains - Focusing on team education and skill development Results = Increased Insertion Success!

59 Pediatric CVC Maintenance Bundles Leadership--Bundle Recommendations Education Education of all clinicians responsible for managing CVC should include : - Compliance of the CVC insertion checklist - All aspects of the CVC care and maintenance strategies - Early identification and management of complications - Educate and monitor compliance of CVC maintenance bundles

60 Leadership--Bundle Recommendations Competency Complete and document initial and annual competencies for all aspects of CVC care by all clinicians who provide care for CVCs. Complete and document annual education for education on central line associated blood stream infection. Specialty Teams Consider use of a specialized teams for performing CVC maintenance procedures e.g. - Dressing changes - Catheter clearance - Catheter repairs

61 Leadership--Bundle Recommendations Routine surveillance of CVCs Collect and benchmark CVC data with the CDC,National Healthcare Safety (NHSN) network Review CVC data for complications or trends

62 Leadership--Bundle Recommendations Leadership support Engage C-Suite leadership support for infection prevention and control efforts with: - Oversight of educational efforts and competencies - Financial and personnel resources to support CLABSI reduction initiatives - Support of product trials and innovation to improve CVC practice and complications Ongoing revision of policies and procedures based on best practice and recent standards,guidelines,and publications

63 Leadership--Bundle Recommendations Leadership support Implementation of the evidence based insertion and maintenance bundles Prompt and continuous review of CVC outcome data Adequate nurse-patient staffing ratios

64 Dressing Selection Troubleshooting in the Presence of Dermatitis And/or Non-Intact Skin What is Standard? There are no exact/universal standards surrounding central line cares HOWEVER, certain recommendation are fairly consistent - Protection form opportunistic infection - Securement

65 Basic Principles of Wound Care Treat underlying condition affecting skin integrity as able Protect from opportunistic infection Prevent additional skin irritation/breakdown Focus on patient comfort Minimize frequency of care as able

66 Applying Basic Skin Care with Vascular Access Device Dressing/Securement Assess the overall condition of the person s skin Ask about prior skin issues with adhesives and/or devices Anticipate length of need for device, if able Consider effects of dehydration-rehydration and/or edema-diuresis Previous reactions or sensitivities to adhesives and/or products may not be isolated Need to avoid limping along

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