The 2011 Infusion Nurses Society Standards of Practice

Transcription

1 The 2011 Infusion Nurses Society Standards of Practice Lisa A. Gorski MS, HHCNS-BC, CRNI, FAAN Chairperson Infusion Nurses Society 2011 Standards of Practice Clinical Nurse Specialist Wheaton Franciscan Home Health & Hospice Milwaukee, WI Objectives 1. Describe the scope of the Infusion Nurses Society (INS) Infusion Nursing Standards of Practice 2. Differentiate between the different levels of evidence 3. Discuss at least five selected Standards as applicable to home health care 1

2 About INS International nursing organization founded in 1973 ~7000 members Internationally >250 members representing 38 countries Mission Develop and disseminate standards of practice Provide professional development opportunities and education Advance best practice through synthesis and research Support professional certification Advocate for the public History of INS Standards Initial Standards published in 1977 Subsequently revised/published in 1982, 1990, 1998, 2000, 2006, and 2011 Scope of infusion therapy Intravenous, subcutaneous, intraosseous, intraspinal access devices & infusions 2

3 Home Infusion Therapy: Benefits A well accepted practice for over 25 years. Patient satisfaction Decreased cost Diminished risk of infection Home Infusion Therapy: Trends Increasing number of biological therapies targeted towards specific diseases More complex therapies Shorter acute care stays/no acute care New/improved products Needleless connector technology, infection prevention products such as antiseptic covers for needleless connectors, coated catheters, & antiseptic dressings, power catheters New/changing standards Example: post-insertion care bundles / peripheral site rotation 3

4 Home Infusion Therapy: Challenges Is the home always the optimal setting? Are nurses adequately educated and competent to administer/teach infusion therapy? Are Standards of Infusion Nursing consistently adhered to and incorporated into agency practice and agency policies and procedures? Are nurses prepared to deal with difficult patients & families, adherence issues, functional limitations to self-care? Why Standards of Practice? Create a system of accountability and standards for safe practice in infusion therapy Provide a foundation for organizations in establishing infusion nursing policies & procedures Minimize risk Improve patient outcomes 4

5 Process for revision of Standards Committee representative of the country and the various sites of infusion therapy delivery Review of literature/research supporting each Standard Extensive peer review: >60 nurse, MD & pharmacist reviewers Format of the Standards Standards Expectations of practice applicable to infusion therapy in all settings Address areas such as need for organizational policies and procedures, nurse competency, need for orders etc. Example: Standard 39 Implanted Vascular Access Ports 39.2 The nurse shall be competent in implanted vascular access port use and maintenance, including port access, identification of potential complications, and appropriate nursing interventions including patient and caregiver education. 5

6 Format of the Standards i Provide specific guidance in the implementation of the corresponding Standard Each Practice Criterion is rated as reflecting the strength of the evidence; references specific to each criterion listed Table of Contents 68 Standards divided into the following sections Nursing Practice Patient Care Documentation Infection Prevention and Safety Compliance Infusion Equipment 6

7 Table of Contents (continued) Access Devices Site Care & Maintenance Infusion Related Complications Note 4 new Standards: Air/catheter embolism, catheter-associated venous thrombosis, CVAD malposition Other Infusion-Related Procedures Nonvascular Infusion Devices Infusion Therapies A few highlight/changes Needleless Connector Standard much expanded Flushing and Locking Standard much expanded VAD removal routine replacement of short peripheral catheter when clinically indicated (vs. at 72 hours in 2006) More infection prevention guidance including evidence-bundle implementation 7

8 New to 2011 Standards Evidence Rating Scale Evidence used for each Practice Criterion is rated Reflects the body of evidence available and retrievable at the time of review Rating Scale: I, IA/P, II-V, Regulatory References for each Practice Criterion are listed Standards are not rated Expectations of practice applicable to infusion therapy in all settings Evidence Description: Excerpts I: Meta-analysis, systematic literature review, guideline based on RCTs, or at least 3 well-designed RCTs I A/P: Includes evidence from anatomy, physiology, and pathophysiology as understood at the time of writing III: One well-designed RCT, several multicenter welldesigned clinical trials without randomization, or several studies with quasi-experimental designs focused on the same question/includes 2 or more well-designed laboratory studies 8

9 Evidence Description: Excerpts V: Clinical article/professional book/consensus report, case report, guideline based on consensus, descriptive study, well-designed QI study, theoretical basis, recommendations by accrediting bodies and professional organizations or manufacturer recommendations for products/services. Also includes standard of practice that is generally accepted but does not have a research basis (e.g., patient identification) Regulatory: Regulations and other criteria set by agencies with the ability to impose consequences such as state boards of nursing, OSHA, AABB Review of selected Standards of Practice NOTE: Information provided includes selected excerpts of Standards and Practice Criteria, not the complete content from any Standard. 9

10 Standard 1: Practice Setting The INS SOP shall be applied and met in all practice settings where infusion therapy is administered (INS, 2011, p. S12) Standard 5: Scope of Practice Previous title Infusion Nurse (INS, 2006) Much more content t Addresses scope of practice for any personnel involved in infusion delivery Nursing Assistive Personnel Medical Assistants LPN/LVN RN Infusion Nurse Specialist (CRNI ) Advanced Practice 10

11 Standard 5: Scope of Practice Standard The role of nursing assistive personnel (NAP) involved with infusion therapy shall be limited to non-invasive and administrative tasks. NAP should not have the responsibility to perform invasive infusion therapy procedures such as catheter insertion, catheter maintenance procedures, or administration of any fluid, nutrition, blood, or medication. A practice analysis for NAP identified 119 activity statements, however there were no infusionrelated tasks, activities or procedures. (IV) (INS, 2011, p. S8-9) Standard 6: Competence and Competency Validation Standard As a method of public protection, the nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice. Competency validation shall be performed initially and on an ongoing basis. (INS, 2011, p. S11) 11

12 Standard 6: Competence and Competency Validation A variety of different methods should be used for competency validation including but not limited to, written tests, clinical scenarios, observation in skill lab, and observing the skill in the work environment which is the preferred method for invasive infusion therapy procedures (V) The 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 (V) (INS, 2011, p. S11) Home Care Implications: Clinical Competency Validation Never assume that the nurses you hire are competent based on self-reported past experiences Evaluate performance of procedures with attention to proper technique Hand hygiene Aseptic technique Understanding of aseptic (sterile) vs. clean technique in the home misconceptions Aseptic technique: A set of specific practices & procedures performed under carefully controlled conditions in order to minimize contamination by pathogens (INS, 2011, p. S101) Attention to the catheter hub Attention to the skin around the catheter 12

13 Home Care Implications: Clinical Competency Validation Ensure competence in the use of the products & equipment Work WITH local/national home infusion pharmacies to ensure consistent dispensing of appropriate home care products/equipment. Examples: Catheter stabilization devices Infusion pumps Needleless connectors Peripheral IV catheters and non-coring needles How to use safety devices PROPERLY Home Care Implications: Clinical Competency Validation Understanding the science of and rationale for procedures good technical skills are not enough! When to consider thrombolytic drug instillation Reducing blood reflux Flush solutions antibiotic lock, innovative flush solutions Understanding potential complications prevention, monitoring, intervention Patients at high risk Catheter occlusion, sepsis, medication-related adverse events 13

14 Standard 9: Policies, Procedures, and/or Practice Guidelines Standard Infusion policies, procedures, and/or practice guidelines shall describe the acceptable course of action, including performance and accountability, and provide a basis for clinical decision making. Infusion policies, procedures, and/or practice guidelines should encompass all applicable areas of infusion therapy and should ensure patient safety, as well as minimize or mitigate patient harm. (V) (INS, 2011, p. S14) Standard 11: Patient Education Important in all settings However home care is a unique setting in which the importance of patient education is especially critical In most cases, patients or caregivers learn to care for their catheters, administer their own infusion therapy, & recognize potential complications/problems 14

15 Standard 11: Patient Education Development of teaching methods based upon assessment of age, developmental/cognitive level, literacy, culture, language, readiness to learn (V) Attention to health literacy with written patient education materials and verbal presentation - materials as simple as possible avoid medical jargon use simple terminology. (V) Patient education should address proper p access device care, precautions for preventing infection, signs/symptoms to report, ensuring that all health care providers employ proper infection prevention methods (e.g. hand hygiene) when providing their care (V) Standard 11: Patient Education Patient or caregiver comprehension and performance should be initially evaluated and periodically reevaluated at established intervals. (V) Effective patient education critical to safe provision of infusion therapy and in reducing the risk of infusion related complications (IV) (INS, 2011, p. S16) 15

16 Home Care Implications: Patient Education Good technical infusion skills on the part of the nurse are not enough! Home care nurse skill set must include: How to effectively teach laypersons to perform infusion procedures How to deal with anxiety, resistance to learning, functional limitations that limit independence The importance of re-evaluating technique The importance of re-evaluating technique after a negative outcome Home Care Implications: Patient Education The home health care nurse needs to ask his or herself: After I leave this home and until the next home visit, is this patient safe with his/her catheter, running infusion etc.? If the infusion is running on a pump, does s/he know how the alarms sound, what the screen might read, how the call the agency or to troubleshoot? Does the patient know how to dress/bathe with a catheter &/or running infusion pump? 16

17 Standard 14: Documentation Good documentation Protects t the nurse Ensures that essential information is communicated to all nurses/other appropriate clinicians involved in the patient s care Standardized forms with cues ensure that documentation is comprehensive and meets INS Standards Standard 14: Documentation What should be documented examples: Teaching participation in and understanding of therapy, interventions, and patient education Type, brand (if placed), gauge/size of vascular access device placed Date/time of insertion, # / location of attempts Site care and preparation Therapy drug, dose, rate, time, route, method of administration 17

18 Standard 14: Documentation What should be documented examples: Multiple l lumens/catheters t what is being administered--which lumen which device Patient s response to therapy, including symptoms and lab tests Daily assessment of need for continuation of the VAD INS, 2011, p. S20-21 Standard 18: Infection Prevention Standard The nurse shall be competent in procedures to prevent infusion- and vascular/nonvascular access device related infections Standard precautions.. Maximal sterile barrier precautions during CVAD insertion Hand hygiene Single patient use items shall be used whenever possible (INS, 2011, p. S25) 18

19 Standard 18: Infection Prevention Infusion related infection surveillance should be analyzed to serve as one component of a quality improvement plan of action, and is currently a major focus of patient safety initiatives related to health-care associated infections. (V) Calculate per 1000 catheter days -- example No. of BSIs in patients with central lines X 1000 = CLABSI rate Total no. of home catheter days The nurse should reduce the manipulation of all components of the entire infusion system (e.g. administration set junctions, catheter hub) to as few as needed to deliver the infusion therapy. (V) (INS, 2011, p. S25) CLABSI = central line associated bloodstream infection rate Standard 20: Compounding of Parenteral Solutions and Medications Standard..shall be in accordance with state t and federal regulations and the American Society of Health-System Pharmacists (ASHP) and United States Pharmacopoeia (USP) standards. Procedures for compounding sterile parenteral solutions and medications shall be established in organizational policies, procedures, and/or practice guidelines. 19

20 Standard 20: Compounding of Parenteral Solutions and Medications Immediate-use medications should be initiated iti t within one hour of preparation or discarded. (V, Regulatory) Whenever possible, the nurse should administer pharmacy-prepared or commercially available products. (V)..use 5-micron needle to withdraw from ampoules/discard in sharps container. (V) Standard 20: Compounding of Parenteral Solutions and Medications..label l any multidose vials used with date opened and store according to manufacturer s directions for use multidose vials for single patients only prefilled syringes strongly preferred (V) cleanse tops of multidose vials and neck of glass ampoules before inserting needle or breaking ampoule (V) 20

21 Standard 21: Scissors Standard Shall not be used to remove vascular and nonvascular device dressings, tape, stabilization devices due to potential for severing catheter or administration set and patient injury Limit to suture removal and during catheter repair procedure only Practice Criteria i Disposable scissors only (IV) (INS, 2011, p. S28) Standard 27: Needleless Connectors Be aware of characteristics of the products you use: simple vs. complex design, negative vs. positive vs. neutral fluid displacment Protocols need to be in place for disinfecting, accessing, changing needleless connectors (Standard) The catheter hub and needleless connector are recognized sites for microbial contamination (II) Disinfect using alcohol, tincture of iodine, chlorhexidine gluconate/alcohol prior to each access (III) (INS, 2011, S32-33) 21

22 Standard 27: Needleless Connectors should be changed in the following circumstances: if removed for any reason, if blood or debris present within connector, prior to drawing a blood culture sample, upon contamination, per organizational p/p or practice guidelines or per manufacturer s directions for use the optimal time frame for routine changing of the needleless connector has not been determined (IV) Standard 32: Vascular Access Device Selection Short, peripheral catheters For infusates with ph Hbetween 5 and d9 and osmolality less than 600 mosm/l (IV) Midline catheters same criteria as above Indications: infusion therapies anticipated to last 1-4 weeks (V) CVADs (tunneled, nontunneled, nneled PICC, port) Review placement: termination in central vasculature such as SVC or IVC 22

23 Peripheral IV catheters & safety The nurse should use short peripheral p catheters equipped with a passive or active safety mechanism to provide sharps injury protection (INS, 2011, p. S37) Active safety mechanism: require the nurse to manually activate the safety mechanism Passive safety mechanism: automatically activated during product use. Passive devices were associated with the lowest rate of needlestick injury (Tossini et al., 2010). Home healthcare safety reference: Occupational Hazards in Home Healthcare NIOSH report (2010) Needlestick injury underreported in home healthcare Home care nurses must take an active role Understand the type catheters used in your agency Actively participate in agency plan to reduce needlestick injury Be an advocate for passive safety engineered devices 23

24 Standard 33: Site Selection Peripheral IV catheter placement Upper extremities Avoid lateral surface of wrist for ~4-5 inches Avoid ventral surface of wrist Start distal with subsequent cannulations proximal to previous site Avoid areas of flexion or pain, compromised veins, near valves, on side of breast surgery with axillary node dissection, after radiation therapy to that side, when lymphedema present, affected extremity of stroke (V) 35. Vascular Access Site Preparation & Placement Standards The nurse shall be competent in insertion technique; infection prevention measures, potential complications and nursing interventions, and in assisting the LIP with device placement. prepare the intended peripheral VAD insertion site with antiseptic solution utilizing aseptic technique. Maximal sterile barrier (MSB) precautions. shall be used with the insertion of central VADs. During VAD placement requiring patient repositioning, the nurse shall ensure that the patient is maintained in a safe position and that sterility related to the procedure is not compromised. 24

25 35. Vascular Access Site Preparation & Placement Prior to inserting a vascular access device, the nurse should provide patient education addressing: rationale for VAD placement, insertion process, expected dwell time, maintenance/care of device, and signs and symptoms of complications to report. (V) Clipping should be performed to remove excess hair at the insertion site with single patient-use scissors or disposable head surgical clippers; microabarasions produced from shaving increase the risk for infection. (V) 35. Vascular Access Site Preparation & Placement If an artery is inadvertently accessed or if the patient If an artery is inadvertently accessed or if the patient complains of paresthesias, numbness, or tingling upon VAD insertion the catheter should be immediately removed and the LIP promptly notified as rapid attention may prevent permanent injury; nerves and arteries are often located in very close proximity of the venipuncture site. (V) Chlorhexidine solution is preferred for skin antisepsis. 1-2% tincture of iodine, iodophor, and 70% alcohol may also be used. Chlorhexidine is not recommended for infants under 2 months of age. (I) 25

26 36. Vascular access device (VAD) stabilization: Standards VAD stabilization shall be used to preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgment and loss of access. VADs shall be stabilized using a method that does not interfere with assessment and monitoring of the access site or impede vascular circulation or delivery of the prescribed therapy. The use of stabilization methods shall be established in organizational policies, i procedures and/or practice guidelines. The nurse shall be competent in proper use and application of VAD stabilization methods and devices. 36. Vascular access device (VAD) stabilization The use of catheter stabilization devices should be considered as the preferred alternative to tape or sutures when feasible. Several studies have demonstrated a reduction in overall complications and improved dwell time with peripheral IV catheters. One study demonstrated reduced risk of infection with PICCs when catheter stabilization devices were used. Sutures were associated with fewer complications when compared to use of tape with PICCs in pediatric patients in a randomized controlled trial that excluded use of stabilization devices. (III) 26

27 36.Vascular access device (VAD) stabilization: Practice Criteria TSM or other dressings are often cited as helpful in stabilizing the catheter, however, there is insufficient evidence supporting their benefits in stabilization at the IV hub alone. A RCT with peripheral IV catheters demonstrated that use of a peripheral IV catheter with an integrated stabilization feature in combination with an IV securement dressing performed as well as a standard d peripheral IV with a stabilization ti device. It is important to recognize that these results cannot be generalized to all types of short peripheral catheters. (III) 36. Vascular access device (VAD) stabilization: Practice Criteria Use of any stabilization method should be based on evidence as well as analysis of risks versus benefits. While sutures may increase risk of needlestick injury and/or risk of infection due to the presence of suture wounds near the insertion site and development of biofilm on the sutures, sutures may be considered appropriate in special populations such as pediatric patients or those with skin integrity problems precluding use of tape or a catheter stabilization device (V) 27

28 39. Implanted Vascular access ports When planning to use an implanted port for power injections, power injection capability should be identified at the time of access and immediately prior to power injection..at least 2 identification methods should be used..presence of ID card, wrist band or key chain from manufacturer, review of operative procedure report, palpation (cannot be only method used..) Aseptic technique, including use of sterile gloves, should be used when accessing a port. The use of a mask is often recommended however remains an unresolved issue due to lack of research (V) Prior to use, patency should be confirmed presence of blood return and ability to flush with saline Standard 43. Administration Set Change Primary intermittent administration sets should be changed every 24 hours; when an intermittent infusion is repeatedly disconnected and reconnected for the infusion, there is increased risk of contamination at the catheter hub, needleless connector, and the male luer end of the administration set, potentially increasing risk for catheter related blood stream infection; there is an absence of studies addressing administration set changes for intermittent infusions. (V) 28

29 Standard 43. Administration Set Change Pi Primary and secondary continuous infusions i Fluids other than lipids or blood products no more often than every 96 hours May extend to every 7 days with anti-infective CVAD or fluids that do NOT enhance microbial growth are administered Parenteral nutrition Total nutrient admixtures (TNA) or lipids only change administration set every 24 hrs. Standard 44. VAD Removal The 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 (I) 29

30 Standard 45. Flushing & Locking Standards VADs shall be flushed prior to each infusion i as part of the steps to assess catheter function VADs shall be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between compatible medications VADs shall be locked after completion of the final flush solution to decrease the risk of occlusion Standard 45. Flushing & Locking excerpts Single use systems preferred if multidose containers must be used, each container dedicated to a single patient (IV) Flushing is accomplished with preservative free 0.9% sodium chloride.if medication incompatible 5% dextrose in water should be used and followed by 0.9% sodium chloride dextrose should be flushed from catheter lumen because it can provide nutrients for biofilm growth (IV) 30

31 Standard 45.: Flushing & Locking excerpts The nurse should aspirate the catheter for blood return as a component of assessing catheter function prior to administration of medications and solutions (V) While many studies report equivalent outcomes in CVADs when locked with heparin lock solution or preservative free 0.9% sodium chloride, others have reported greater complications with saline locking. Due to risk and costs associated with CVAD insertion, heparin lock solution 10 units per ml is the preferred lock solution after each intermittent use (III) Positive fluid displacement within the lumen of the catheter should be maintained to prevent reflux of blood upon luer disconnection. This is accomplished with either a flushing technique or a needleless connector designed to overcome blood reflux (V) New Standards on complications Standards statements for all of the complication standards address nursing knowledge and competence in preventing, identifying, and managing the complication 31

32 Standard 47. Phlebitis If phlebitis occurs, the nurse should: Assess the vascular access site for s/s and severity of phlebitis using a standardized scale. Determine potential etiology of the phlebitis chemical, mechanical, bacterial, post-infusion and implement appropriate interventions.. The nurse should use a standardized di d phlebitis scale that is valid, reliable, and clinically feasible. Two scales have demonstrated validity and reliability and have been used in adult patients. Standard 48: Infiltration & extravasation Immediately stop all infusions i with c/o pain, burning, stinging at or around insertion site, catheter tip, or entire venous pathway (IV) Do not rely on alarms from EID to identify infiltration/extravasation not designed to detect (V) 32

33 Standard 48: Infection Standard The nurse shall implement infection prevention measures with the goal of preventing all infusion related and VAD related infections. Practice criteria Immediately notify of s/s of infection including but not limited to erythema, edema, induration, drainage at site and/or body temperature elevation (V) Standard 50: Air embolism Standard Patients and/or caregivers managing infusion therapy in non-acute care setttings shall be taught to prevent an air embolism and how to manage the catheter if an air embolism is suspected Practice criteria immediately take necessary action to prevent more air from entering bloodstream by closing, folding, or clamping the catheter or by occluding the puncture site if catheter removed (V) 33

34 Standard 51: Catheter embolism Practice criteria excerpts Prevent by never re-inserting stylet, correct syringe size use, no power injection unless VAD designed for this use, be aware of early signs of catheter pinchoff (subclavian vein catheters) (II) Examine catheter for signs of damage/possible fragmentation upon removal (II) Standard 52: Catheter-associated vein thrombosis Practice criteria excerpts Reportable s/s Pain and/or edema in extremity, shoulder, neck, chest Engorged peripheral veins on the extremity, shoulder, neck, chest Difficulty with neck or extremity motion (II) Note that VAD flushing/locking have no effect on catheter-associated vein thrombosis (V) 34

35 Standard 53: CVAD malposition Practice criteria excerpts Secondary CVAD malposition (tip migration) may occur at any time during placement and is relation to sporadic changes in intrathoracic pressure, presence of HF diagnosis, neck/arm movement, high pressure injection, flushing techniques (V) Assess for catheter function prior to each use observing for clinical s/s such as lack of blood return, difficulty/inability to flush, edema, c/o hearing gurgling, flow stream sounds with flushing, paresthesia, neurological effects (V) Standard 56. Catheter Clearance: Occluded Central Vascular Access Devices Standard 56.3 The nurse shall assess the patient t and the patient s CVAD for appropriateness of the use of catheter clearance medications and/or solutions in relation to the suspected cause.. The nurse should assess for and identify signs of CVAD occlusion including inability to withdraw blood, sluggish flow or inability to flush or infuse through the device (III) 35

36 Standard 56. Catheter Clearance: Occluded Central Vascular Access Devices Standard 56.3 The nurse shall assess the patient t and the patient s CVAD for appropriateness of the use of catheter clearance medications and/or solutions in relation to the suspected cause.. The nurse should assess for and identify signs of CVAD occlusion including inability to withdraw blood, sluggish flow or inability to flush or infuse through the device (III) Standard 56. Catheter Clearance: Occluded Central Vascular Access Devices Instillation of low dose alteplase l is effective in restoring blood flow and has been found to be safe in both adult and pediatric patients (II) If catheter clearance does not result in patency, the LIP should be notified; alternative actions such as a referral to an interventional radiologist should be considered and catheter removal should be considered if catheter patency is not restored (V) 36

37 Standard 57. Phlebotomy Caution should be exercised when interpreting drug levels with a CVAD obtained blood sample. When questionable results are obtained (e.g. unexpected high levels that would necessitate a medication dosage change), the nurse should collaborate with the LIP in retesting via direct venipuncture. Some studies have shown elevated drug levels with blood sampling from CVADs; factors negatively influencing accuracy include sampling from implanted ports, silicone catheters, and from the same catheter lumen used for drug infusion. (IV) Standard 57. Phlebotomy Only the volume of blood needed for accurate testing should be obtained; phlebotomy contributes to iron deficiency and blood loss in critically ill patients and neonates; efforts to conserve blood should be considered. These may include use of low volume blood collection tubes, recording the volume of blood obtained for laboratory testing, and avoidance of routine testing, use of point-of-care of testing methods, consolidation of all daily tests with one draw, and consideration of the use of the mixing method for blood sampling from CVADs (See Practice Criteria E above). (IV) 37

38 Standard 60. Continuous Subcutaneous Infusion and Access Devices Site selection for subcutaneous access should include areas with adequate subcutaneous tissue with intact skin such as the upper arm, subclavicular chest wall, abdomen, upper back, and thighs. (III) Non-metal subcutaneous access devices are preferable to metal devices; advantages include extended dwell time and decreased risk for healthcare provider needlestick injury. (IV) Standard 61. Parenteral Medication and Solution Administration The nurse administering parenteral medications and solutions should have knowledge of indications for therapy, side effects, potential adverse reactions, and appropriate interventions (V) Reduce manipulation of all components of infusion system to as few as needed to deliver the infusion therapy (V) Trace administration set from patient to point of origin before making connections (V) 38

39 Standard 61. Parenteral Medication and Solution Administration Nurse should exercise particular care when administering solutions/medications to pediatric/neonatal patients medication errors significantly higher in this population (IV) Nurse accountable for evaluating and monitoring the effectiveness of prescribed therapy, documenting patient response, adverse events and interventions, communicating lab test results, and achieving effective medication delivery (V) Future Work Strength of the Body of Evidence Rates the evidence Need more and better evidence in next 3 years INS Research Priorities Strength of the Practice Recommendation? Useful when weak evidence but highly hl recommended based on consensus 39

40 Every day you may make progress. Every step may be fruitful. Yet there will stretch out before you an ever- lengthening, ever-ascending, everimproving path. You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb. Sir Winston Churchill British politician ( ) 40