Adopting Best Practice for Infusion Teams Lori Mayer, DNP, MSN, RN Shirley O Leary, APN-BC Elida Grienel, APN-BC Infusion Therapies Nursing professionals have increasing responsibility in managing multiple sclerosis clinical disease and treatment NPs/PAs/RNs play important roles in educating patients about disease-modifying therapy options, decisions on therapy and managing potential adverse effects
Objectives Discuss practical applications, standards of care, as well as challenges of infusion therapy Framework for professional nursing approach to providing safe infusion care Gain an understanding of the approach to patient selection for infusion therapy Define recognize monitor and manage infusion related reactions Describe a broad understanding in mechanism of action, as well as infusion benefits vs risk Discussion Practical Application in Infusion Therapies Elida Greinel APN/BC University of New Mexico
Nursing: The Professional Standards Administering IV drugs is one of the most legally significant tasks nurses perform State and provincial practice acts guide nurses with regards to their defined limits Many state nurse practice acts do not specifically define scope of practice for RNs, but do address whether LPN or LVN can administer therapy The Infusion Nurses Society has developed standards for IV therapy (see www.ins1.org ) - Site accessed 4/28/2016 Professional Standards cont. Understand and follow facility policy as well as possess the competence and knowledge base to perform IV therapy According to the INS, the goal is to protect and preserve the patient s right to safe, quality care and protect the nurse who administers infusion therapy
Infusion Codes of Conduct ONS, ASHP, OSHA, and INS all have published standards for safe delivery of chemotherapeutics and other infusible medications. Drug preparation can be performed by a trained nurse or pharmacist Equipment requirements are exacting Most facilities require that only chemotherapycertified nurses administer these medications Patient Education in Preparation of IV Therapy Start patient education at point of prescribing therapy Counsel patients with respect to treatment procedure and expectations from therapy Discuss medication side effects Instruct patient to report any discomfort involving the IV site and any chang in overall health status
Purpose Documentation Provides accurate record for facility and legal protection May be used for reimbursement of drug, supplies, etc Becomes part of patient s permanent record Documentation cont. Informed consent Process by which a fully informed patient participates in making decisions about his/her health care Includes information regarding the medication, benefits, type and probability of the risks, alternative treatments (including not having the treatment), and the prognosis
Documentation cont. Initiation of IV therapy Type of equipment used, including gauge and length of inserted device Healthcare provider responsible for insertion, and number of attempted starts Date, time, medication, and rate of infusion Location of insertion site Documentation cont. During IV therapy Condition of insertion site Vital signs according to best practice Any changes in drip rate or site changes
Documentation cont. Discontinuation of therapy Assessment of insertion site and intactness of venous access device being removed Condition of insertion site after access device is removed Any complications, patient reactions, or healthcare provider interventions that occurred Administering Peripheral IV Therapy Preparing the patient Choosing the right equipment Selecting the insertion site Complications of therapy
Preparing the Patient Managing expectations of patient before, during, and after IV therapy Review earlier teaching and encourage open and frank discussion about therapy concerns Explain procedure step-by-step as each task is approached Patients with history of needle phobia may develop a vasovagal response; education, distraction, and elevation of legs are techniques to offset this issue Attention should be given to age, developmental (psychosocial as well as psychomotor) and cognitive levels, and cultural and linguistic sensitivity. Manual of IV Therapeutics, Phillips, L., Gorski, L., p. 348, 2, 2014. Selecting the Right Equipment Generally speaking, IV administration sets used outside hospital settings with a pump are basic sets Volume-controlled sets deliver small, accurate amounts and are very helpful for gravity drip if a pump is not available Because of the many pumps on the market, it is important to refer to the manufacturer s recommendations for setup and troubleshooting guidelines of each EID. Filter use depends on medication requirements, policy, and the risk of phlebitis Supplies for cannulation
Selecting the Right Equipment cont. INS Standard The catheter selected shall be of the smallest gauge and length possible with the fewest number of lumens and shall be the least invasive device to accommodate and manage the prescribed therapy (INS, 2011, p. S37). Vein size, location, and length of infusion will also need to be considered Selecting the Infusion Site
Techniques for Peripheral Infusion Peripheral IV Therapy TECHNIQUES TO ASSIST WITH DIFFICULT VENOUS ACCESS Alterations in skin surfaces: Use tangential lighting. Hard sclerosed vessels: Use multiple tourniquet technique. Obesity: Use ultrasonography to locate and cannulate veins, use 2-inch catheter lateral veins, and/or consider Phillips multiple tourniquet technique. Edema: Displace edema with digital pressure. Fragile veins: Maintain traction using one-handed technique Manual of IV Therapeutics, Phillips, L., Gorski, L., p. 333, 2, 2014.
Skin Antisepsis According to the CDC (O'Grady et al., 2011), acceptable antiseptics for skin antisepsis include 70% alcohol, tincture of iodine, or iodophor or chlorhexidine/alcohol solution. Chlorhexidine/alcohol solution is the standard practice and is preferred antiseptic agent recommended by the INS (2011a); unlike the other antiseptic agents, it has a residual effect on the skin that lasts for up to 48 hours. Manual of IV Therapeutics, Phillips, L., Gorski, L., p. 81 2, 2014. Complications of IV Infusion Access Local complications of therapy can include Infiltration Extravasation Phlebitis, occlusion, pain at site, hematoma, vasovagal reaction, thrombosis, nerve damage Systemic complications of therapy can include Air embolism, sepsis, and allergic reaction
Complications of Infiltration Signs of infiltration Swelling Pain/burning Tight feeling Cool skin Slowing of flow rate Interventions Stop infusion D/C access device Apply ice or warm compress Elevate affected limb Restart in new location Complications of IV Access - Hematoma Hematoma is the most common complication of routine IV starts Symptoms include site swelling, tenderness, ecchymosis, and an ability to flush the IV Treatment includes removing the catheter, applying pressure, and a warm compress The presence of either ecchymoses or hematomas limits future us of the affected veins.
Phlebitis/Thrombophlebitis Chemical - Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Antiinflammatory and analgesic medications are often used no matter what the cause Mechanical - Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied Bacterial - Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany Complications of Therapy Mechanical Phlebitis Causes of mechanical phlebitis include Access device too large Improper taping Cannula is at a location of flexion, poor condition of vein Trauma during insertion Ways to avoid mechanical phlebitis include Using smallest gauge catheter possible Avoiding flexion Good aseptic technique Smooth insertion Anchoring catheter well
Complications of Therapy Chemical Phlebitis Causes of chemical phlebitis include Administering medications with a high ph Medications with a large amount of particulate matter Ways to avoid chemical phlebitis include Sufficient dilution of medication Use of a filter Complications of Therapy Bacterial Phlebitis Bacterial phlebitis is commonly caused by Contaminated equipment Infections in immunocompromised patients can lead to sepsis Ways to avoid bacterial phlebitis include Using aseptic, sterile technique Proper skin preparation will reduce the risk significantly
Complications of Infusion Infiltration Infiltration of a nonvesicant Vein flare Extravasation of a vesicant Leakage of a drug that can cause tissue necrosis and sloughing: THIS IS AN EMERGENCY Extravasation Emergency Stop the infusion policy will dictate whether the access device is removed or left to infuse steroids or an antidote Notify the doctor and follow manufacturer's specifications for antidote treatment Following antidote, remove access device Ongoing care to the site may include topical steroids, silver sulfadiazine (Silvadene ) cream. Serious conditions may require debridement, skin graft, possible a amputation
Infiltration/Extravasation 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 Septicemia: Septicemia/Pulmonary Edema/ Embolism Severe infection that occurs to a system or entire body Most often caused by poor insertion technique or poor site care Discontinue device immediately, culture and treat appropriately Pulmonary edema: Caused by rapid infusion Pulmonary embolism: Caused by any free floating substances that require thrombolytic therapy for several months. Air embolism: Caused by air injected into IV system. Keep insertion site below level of heart
Prevention of Complications Know your medication, i.e., add diluents to irritating drugs Use good educated theory and technique when performing venipuncture Secure site well to prevent movement or friction of the access device Rotate site as much as possible Management of Infusion Therapies - Conclusions The landscape of treatment for MS is changing and evolving Infusion therapy is becoming more a part of this landscape, alone or in combination therapy Healthcare providers will be required to extend their knowledge base and become proficient in IV skills. They should follow the standards of the INS, OSHA, and their health care facility