VAD Guidelines for Home Infusion: Creating a Resource. Care for Pediatric Patients 4/12/2012

Transcription

1 VAD Guidelines for Home Infusion: Creating a Resource to Address Our Unique Site of Care for Pediatric Patients Darcy Doellman, RN, BSN, CRNI, VA BC, Team Leader, Cincinnati Children s Hospital, Cincinnati, OH Top 4 Things to Know for CE 1. Make sure your BADGE IS SCANNED each time you enter a session to record your attendance. 2. Carry your Evaluation Packet with you to EVERY session. 3. Pharmacists, Pharmacy Technicians and Nurses need to track their hours on the Statement of Continuing Education Form as they go (the 2-page triplicate form, so press firmly!). 4. FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Form. Keep the PINK copy for your records and place the YELLOW and WHITE copies in your CE Envelope. Make sure an Evaluation Form is in your CE Envelope for each session you attended (extra forms are available at the registration desk if you forgot to pick one up). Write your name and unique ID number (six digit number at the bottom of your name badge) in the designated area on the outside of the envelope, seal it, and place it in the drop box located near the 4/12/ registration area. Darcy Doellman declares no conflicts of interest or financial interest in any service or product mentioned in this program. Clinical trials and off-label/investigational uses will not be discussed during this presentation. 4/12/

2 Cincinnati Children s 550 beds Level 1 trauma center Transplant center Level 4 NICU Vascular Access Team (PIV, PICC, CVC) 200 PICCs/month Pediatric home care Starshine hospice 4 Objectives Discover the key differences between pediatric vascular access device (VAD) care in the home versus the acute care setting Explore the development of a guideline for VAD care and maintenance in the home that addresses the needs of a pediatric patient at each developmental stage Acquire valuable insights into the specialized care of pediatric VADs in the home setting including dressing changes, securement, flushing and needleless device considerations 5 Challenges of Pediatric VADs Age and size of patient Small vessel diameter Pediatric patients have fewer veins to choose from than adults Variation in developmental and activity levels 6 2

3 Challenges of Pediatric VADs Longer survival of chronically-ill children often leads to repeated need for venous access Insertion of appropriate catheter size to meet infusion needs of the young patient 7 Current Resources 8 VAD Guideline Development Pediatric patients are not little adults Lack of standardization Current guidelines that specifically address the unique needs of home-based pediatric VADs do not exist 9 3

4 Pediatric VAD Guidelines Work Group Mary E. Brown-Kelly, RN, Pediatric Home Service, Roseville, MN Doreen L. Carson, RN, Pediatric Home Service, Roseville, MN Michelle Curley, RN, CRNI, Infusion Nurse Manager, Pediatric Home Service, Roseville, MN Darcy Doellman, RN, BSN, CRNI, VA-BC, Team Leader, Cincinnati Children s Hospital, Cincinnati, OH Pam Dyer, RN, Seattle Children's Home Care Services, Seattle, WA Nancy Kramer, RN, BSN, CRNI, Vice President of Clinical Affairs, National Home Infusion Association, Alexandria, VA Jaclyn Moll, RN, Seattle Children's Home Care Services, Seattle, WA Lynne Sailer, RN, BSN, Nurse Manager, Seattle Children's Home Care Services, Seattle, WA Jill L. Wall, RN, Pediatric Home Service, Roseville, MN Renae Wedlake, RN, CRNI, Seattle Children's Home Care Services, Seattle, WA 10 Golden Rule... Insert one catheter Early on Lasts throughout therapy No complications Promote Catheter Salvage 11 Types of VADs Peripherally Inserted Central Catheters Non-Tunneled Central Venous Catheters (CVCs) Tunneled CVCs Implanted Ports 12 4

5 VAD Tip Placement Superior Vena Cava (SVC) Inferior Vena Cava (IVC) Pediatric PICCs N=1266 Central N=1096 Non-central N=170 Complications 3.8% 28.8% 13 VAD Device Selection Type and length of therapy Availability of vessels Developmental level Parent/patient preference Practitioner experience 14 VASCULAR ACCESS DEVICE SELECTION ALGORITHM Expected duration > 3 months? NO YES Determine length of therapy, type of therapy and availability of appropriate veins Determine length of therapy 3 months-1 year > 1 year 0-6 days Is infusate or solution appropriate for a PIV?* 6 days-3 months Choose PICC, Port, or Tunneled CVC Choose Port or Tunneled CVC YES NO Is there adequate vessels for intended therapy? YES NO Choose Peripheral IV Choose PICC and reassess or Nontunneled daily* CVC Choose PICC *Infusate appropriate for peripheral IV: < 600 mosm/l ph 5-9 Non irritant Non vesicant Additional Considerations: 1. Consider the need for single, dual, or triple lumen CVC, select the least number of lumens to deliver the required therapy. 2. Consider dedicated lumen for TPN 3. Consider power-injectable CVC if patient receiving CT contrast studies 4. Consider patient s current and future care setting; (e.g. Home Care) 5. Interdisciplinary approach in selecting appropriate access device 6. Consider anticipated changes in patient s medical status? 7. Review daily need for CVC, promptly remove unnecessary CVCs 5

6 VAD Dwell Time Promptly remove catheter that is no longer essential (Category 1A, CDC Guidelines, 2011) 16 Dwell Time: PICCs 0 to 180 days (Frey, 2002) Independent predictors of CLABSI (Advani et. al., 2011) PICC dwell time > 21 days TPN Prior history of CLABSI Admitted to PICU during hospitalization 17 PICC Assessment Monitor extremity for swelling, pain, cording of vein Avoid BP or phlebotomy in affected extremity 18 6

7 PICC Removal Consider applying warm compresses to arm while setting up supplies Withdraw catheter slowly Apply digital pressure to site until hemostasis is achieved 19 PICC Removal Apply a petroleum based ointment dressing to site Reduces risk of air embolism Record catheter length and condition of tip, compare to insertion length 20 Difficult PICC Removal May be due to anxiety, phlebitis Stop if catheter is difficult to remove Apply dressing over catheter Apply heat to arm Reattempt after a minimum of 15 minutes 21 7

8 Difficult PICC Removal If catheter remains resistant, wait 24 hours and reattempt If unable to remove, contact prescriber 22 PICCs Avoid heavy lifting, repetitive motion Encourage ROM of extremity with PICC Secure PICC to avoid damage 23 Non-Tunneled CVCs Account for the majority of CLABSIs (CDC, 2011) 24 8

9 Removal of NT CVAD Rarely used in home care setting in pediatrics Removed with physician s order by nurses who have demonstrated competency Consult organizational P & P for removal guidelines 25 Dwell Time: NT CVCs Author # of Pts CVCs Dwell Time Conclusion Levy et al., pts 0-18 yrs Control: 71 standard dsgs Study: 74 dsg with CHG sponge Not reported CHG sponge decreases CVC colonization Subha Rao et al., pts 103 PIVs 32 CVCs SC catheters had higher ALL CVCs in place > 11 rate (68.2%) of colonization days were colonized vs femora (40%) Chelliah et al., pts 69 MR-CVC 156 NC-CVC Time to infection: MR-CVC 18 days NC-CVC 5 days MR-CVC time to infection 3 times longer than NC-CVC Rey et al., pts 825 CVCs Not reported Reyes et al., ,512 pts Subclavian, IJ, and femoral Not reported Mechanical complications are common Femoral sites not associated with increased risk of CLABSI 26 Dwell Time: Tunneled CVC Optimal dwell time is unknown 27 9

10 Dwell Time: Tunneled CVCs Author # of Pts CVCs Dwell Time Conclusion Elihu & Gollin, pts 308 ports Tsai et al., pts 94 ports Ports more likely to be d/c d for CLABSI vs tunneled CVC EJ vein has decreased complications compared to IJ Ruggiero et al., pts 190 CVCs mean dwell 330 days Low complication rate Shah et al., pts 175 CVCs 125 to 803 days Tunneled CVC removed for CLABSI more often than ports Herrera et al., pts Not reported Increased risk of CLABSI with short bowel syndrome 28 Maximizing CVC Dwell Times Robust infection control practices CVC securement Standardized VAD practices 360 degree collaboration 29 CVAD Repairs Tunneled CVCs can be repaired with a manufacturer-specific repair kit Competent clinician Increase in CLABSI after repair: CHOP: 2 fold CLABSI increase Seattle Childrens: 2 to 4 fold CLABSI increase within 30 days post-repair (Lundgren, 2011) 30 10

11 Implanted Ports Reaccess every 7 days Use only non-coring Huber needle Aseptic technique 31 Flushing - Port Maintenance: Monthly flush of 5mL of heparin (100u/ml) For intermittent use: Flush with 5mL of heparin (10u/mL) after each medication 32 Developmental Issues Preparation of the child and caregiver Security items Distraction Bundling of infants Comfort hold 33 11

12 CVAD Flushing Flush volume: at least 2 x s the internal volume of the CVAD + any add-on devices (extension piece) CVAD internal volume can be located on the catheter lumen, manufacturer s webpage, or contact referral institution Document catheter priming volume in permanent medical record 34 CVAD Flushing Flush before and after each medication Flush volume a minimum of 3 to 5 ml of preservative-free normal saline or compatible solution Assess for catheter occlusion Treat sluggish lumens Treat partial occlusions 35 Syringe Size Use a 10mL syringe for initial flush to establish CVAD patency With patency confirmed, smaller syringes may be used if needed for IV push drug-dose accuracy (INS, 2011) 36 12

13 CVAD LOCK Lock solution: instilled as a final flush to maintain patency Instill 1 to 3 ml heparin (10 u/ml) when CVAD is not in use Flush/lock CVAD at least once per day when not in use 37 Valved CVADs Valved CVADS: Flush with 5 ml of saline only This device requires a weekly flush when not in use Valved CVADs may need heparin lock when used long-term 38 Needleless Connector Many terms: Needleless connector Injection cap/port Cap 39 13

14 Needleless Connector Antisepsis Vigorously scrub needleless connector with 70% alcohol prep or CHG/alcohol prep for at least 15 seconds Allow to dry before each use 40 Antiseptic Cap Protectors New technology, bathes needleless connector in alcohol Needleless connector is always clean This device dwells for a minumum of 3 to 5 minutes up to 1 week Discard after removal of protector Promotes compliance 41 Needleless Connector Change Every 3 to 4 days, with each primary tubing/set change Anytime cap is removed, damaged, or malfunctioning Evidence of a precipitate, cracks, or leaks 42 14

15 Needleless Connector Change After blood sampling through a cap or with obtaining blood cultures Per institutional P & P or manufacturer s recommendations 43 Needleless Connector Change Organizational differences: Clean the connection between the catheter hub and cap/tubing, some clean in the presence of dried blood Utilization of cap change kits - facilitates aseptic technique Consider use of a mask for nurse and patient 44 Blood Sampling Blood sampling is safe and effective for 3Fr VADs and larger Limit total volume of blood drawn to 3mL/kg/day Blood discard amount: 1 to 3mLs or 2x s the internal volume of the catheter and add-on devices No discard when sampling for blood cultures 45 15

16 Blood Cultures Remove needleless connector prior to obtaining blood sample for culture Use discard for culture With any blood sampling, flush CVAD with 10 to 20 ml of saline unless fluid restricted Follow saline flush with lock solution if CVAD will not be used for continuous infusion 46 Assessing Patency Assess CVAD for brisk blood return before medication delivery Patients/caregivers are not routinely taught to assess for blood return unless administering a high risk infusate e.g. chemotherapy 47 IV Tubing DEHP-free tubing is preferred for all IV tubing and add-on devices All tubing and add-on devices should luerlock 48 16

17 IV Tubing Change Blood or blood produts: change tubing every 4 hours Parenteral Nutrition (PN) with lipids: change tubing every 24 hours PN without lipids: change tubing every 96 hours 49 IV Tubing Change Continuous infusions: change tubing for continuous infusions every 96 hours Intermittent infusions: change tubing every 24 hours 50 Dressing Changes Dressing change indications: Damp or soiled Loosened Presence of drainage Necessary to visualize site 51 17

18 Dressing Change Antisepsis Combination skin antisepsis is recommended: Chlorhexidine (CHG) 2 to 3.5% + 70% IPA Povidone-Iodine 1 to 10% + IPA or EtOh 62 to 74% 52 Dressing Change With each dressing change, measure external length of catheter Compare measurement with recorded external catheter length Concern is catheter migration 53 Special Considerations CHG Sensitivity Consider povidone iodine until skin irritation resolves FDA: CHG Infants < 2months of age 54 18

19 Special Considerations Irritation to dressing or tape Avoid adhesives on skin til healed Avoid alcohol in antisepsis or skin protectant (stings) 55 Special Considerations If skin irritation persists after changing the antiseptic or TSM, apply a gauze dressing Two-person procedure for dressing change 56 Antimicrobial Product Impregnated dressing or patch may be indicated for patients at increased risk of CLABSI 57 19

20 CVAD Securement Purpose: To stabilize or secure CVAD Prevention of catheter movement 58 Securement vs. Stabilization Critical factor with CVADs in pediatrics High activity level Developmental level concerns Environmental - humidity Patient factors - diaphoresis 59 Securement vs Stabilization Change securement device per policies and procedures or manufacturer s recommendation Change during dressing change 60 20

21 CVAD Dressings Transparent Semi-Permeable Membrane (TSM) dressing Change every 7 days and prn Gauze dressing every 48 hours Does not include gauze used to support Huber needle 61 Avoid Reinforcing Dressings 62 Current Trends Antibiotic Locks Vancomycin/Ciprofloxacin/Heparin Vancomycin/Heparin 5 studies on pediatric oncology patients Reduction in CLABSI rates 63 21

22 Current Trends Ethanol Locks For long-term patients (GI, liver) Lock for 4 to 6 hours Mon/Wed/Fri 92% effective in reducing CLABSI 77% effective in salvaging catheter 64 Current Trends Coated catheters Minocycline/Rifampin Chlorhexidine/silver 2 randomized studies in PICUs suggest coated catheters decrease CLABSI (Valentine, 2011) 65 Current Trends Power CVADS Ability to use CVAD for high pressure CT studies Avoids unnecessary venipunctures Includes all types of CVADs Flush protocols are the same 66 22

23 Lessons Learned for Implementing Best Practices Engage the right people Build the case - sell the vision Drive change with data Make it personal (case studies) Accountability 67 Strategies for Success Standardizing practice Continuous quality improvement projects Embed improvements in daily home care visits Summarize knowledge (experience/pitfalls) 68 Ongoing process Interdisciplinary committees Updating P & P Competencies Educating Staff 69 23

24 Conclusion Everyone in healthcare really has two jobs when they come to work everyday: to do their work and to improve it 70 Learning Assessment Questions & Answers Please refer to the 2012 NHIA Annual Conference & Exposition On-Site Program for a brief post-test. darcy.doellman@cchmc.org 4/12/