Meeting the NEW RCN Standards for Infusion Therapy in practice

Meeting the NEW RCN Standards for Infusion Therapy in practice sumanshrestha@nhs.net Suman Shrestha MSc BSc RN Advanced Nurse Practitioner Intensive Care Frimley Park Hospital suman_sr

FRIMLEY PARK HOSPITAL 720 Beds District General Hospital Surrey, England

80% of hospitalised patients receive intravenous therapy at some point during their admission Waitt et al (2000)

Microbiological contamination Air Embolism Medication Error Infusion Therapy Risks Altered physiology Sharp injury Drug Incompatibility

How Cannula Spread Infection?

IV administration in Sepsis Administer IV antibiotics within 1 hour Mortality increases by 7.9% for each hour delay from antibiotic dosing Administer 30 ml/kg IV fluid (if SBP <90 mmhg or Lactate >2 mmol/l)

HOW SAFE IS INTRAVENOUS INFUSION THERAPY?

Prospective observational study (2006-2008) Direct observation of 107 nurses preparing and administering 568 intravenous medications Teaching hospitals in Sydney, Australia MAIN RESULTS One or more clinical errors occurred in 70% of administrations Wrong mixture, wrong rate, wrong volume or drug incompatibility accounted for 92% of clinical errors

In the 1328 patients: 441 patients (33%) experienced medication error 505/5622 (9%) errors during IV bolus administration 279/5034 (6%) errors during continuous IV infusion Most errors occurred in the classes of: - Antimicrobials - Sedation - Analgesia

Workload/ Stress/ Fatigue n=272 32% Recently changed drug name n=155 18% Written communication n=124 14% Oral communication n= 83 10% Experience/knowledge/supervision n=81 9% Violation of protocol/standards n=76 9% Equipment failure n=0 0%

A total of 4604 adult ICU patients in 5 ICUs Patients with IV adverse drug events had : $6647 greater costs (p=<0.0001) 4.8 day longer stays (p=0.0003)

Published Dec 2016 Update to 2010 version RCN Research and Innovation RCN Library and professional practice team RCN Contractor (Bazian Ltd) Project Board Robust methodology of rapid evidence assessment (REA)

The resulting evidence review Phase 1 : RCTs and systematic reviews Phase 2: Other quantitative studies Phase 3: Evidence relating to the patient perspective of infusion therapy

Patient Perspective

Contents 1. Education and training 2. Patient safety and quality 3. Infection prevention and control 4. Infusion equipment 5. Site and device selection and placement 6. Site care and maintenance 7. Specific devices 8. Infusion therapies 9. Infusion-related complications 10. Service development

Key Findings Flushing and locking of infusion devices 1. No difference between flushing CVC with heparin or normal saline (Lopez-Briz et al 2014) 2. There is no evidence that locking CVCs with heparin is any more effective than normal saline or citrate (Zhao et al 2014)

Key Findings Infection prevention and control 1. Several studies have demonstrated chlorhexidine and silver to be effective antimicrobial agents, when impregnated into catheters, connector devices or securement dressings. 2. Pre and post insertion care bundles are effective 3. The routine replacement of CVCs and peripheral lines every 3 days does not result in decreased infection rates, compared with replacement on clinical indication The Cochrane Database of Systematic Reviews (2013) (2015)

Key Findings Placement of device 1. Avoid femoral site for IV access due to increased risk of infection (Hsu et al 2014) 2. Peripheral access device placed in the dorsum of the hand was shown to increase the risk of phlebitis (Cicolini et al 2013) 3. Using Ultrasound guidance is beneficial (Stolz et al 2015)

Key Findings PICCs and midline catheters 1. There is evidence to suggest that PICCs have double the risk of deep vein thrombosis compared with CVCs (Chopra et al 2013) 2. Hypertension, obesity, an increased PICC arm circumference and oedema are risk factors for upper extremity DVT. 3. In palliative care patients, the placement of PICCs or midline catheters was associated with low levels of distress and resulted in an increased global quality of life (Bortolussi etal 2014)

Key Findings Infusion therapy in non-acute setting 1. There was little research conducted in this setting 2. Provide support for the use of PICCs and midline catheters amongst palliative care in the community 3. No significant differences in infection rates self administered outpatient parenteral antimicrobial therapy vs. administration in a hospital or clinic setting (Barr et al 2012) 4. The patient perspective review found that treatment at home or in the community could be viewed as both a facilitator and barrier (Baillie and Lankshear 2014) 5. Increased need for practical, psychological and emotional support for patient and carers (Combes et al 2015)

How to use the Standards for Infusion Therapy in clinical practice? Implement Evidence based practice Training & Education Clinical Governance Clarity in clinical practice Standardisation effectiveness Framework Resource Reference Governance model Development of local policy Audit, monitoring, review and evaluation Collaboration with Service user and stakeholder Resource planning/implication

How to use the Standards for Infusion Therapy in clinical practice? Implement Evidence based practice Training & Education Clinical Governance Clarity in clinical practice Standardisation Clinical effectiveness Framework Resource Reference Governance model Development of local policy Audit, monitoring, review and evaluation Collaboration with Service user and stakeholder Resource planning/implication

The safe administration of medicines is an important aspect of the professional practice.

5. Wrong route administration of medication The patient receives one of the following: Intravenous chemotherapy administered via the intrathecal route Oral/enteral medication or feed/flush administered by any parenteral route Intravenous administration of a medicine intended to be administered via the epidural route 12. Transfusion or transplantation of ABO-incompatible blood components Unintentional transfusion of ABO-incompatible blood components. Unintentional ABO mismatched solid organ transplantation. Setting: All patients receiving NHS funded care.

JAN (2007) 60(3):317-324 Managerial actions 1. Help nurses deal with personal grief and reactions 2. Systematic exploration of practice

Patient/caregiver education and involvement

Electronic Prescribing and Medicine Administration

From international perspective. 97% India 73%

Summary Intravenous administration of fluid, drugs and nutrition is common in hospital IV medications pose particular risks because of their greater complexity and multiple steps in their preparation, administration and monitoring Implementation of evidence based practice Training & education resource Guidance for Clinical Governance Address organisational issues Future E-prescribing, nurse led services International guideline

Meeting the NEW RCN Standards for Infusion Therapy in practice sumanshrestha@nhs.net Suman Shrestha MSc BSc RN Advanced Nurse Practitioner Intensive Care Frimley Park Hospital suman_sr