Angele Caporicci, RN, CVAA Labour Relations Officer Ontario Nurses Association Karen Mallet, RN, CVAA, CON Stem Cell Transplant Nurse North East Cancer Centre, Sudbury Disclosure: no existing conflicts
Objectives Review standards which govern our practice Case study scenarios from Canada ( & USA) that involve vascular access incidences Review Canadian Statistics Examine the current issues Look at practical ways to minimize risks for the practitioner & better outcomes for our patients
I ordered an IV, not an ivy!
-Nurses have a duty to provide reasonable, prudent care as required. The care delivered by the nurse must comply with what is expected, given the circumstances in which the care is provided. This is known as Legal Standard of Care -Standards can be voluntary such as those identified by professional groups, or mandated legislatively
Regulated Health Professions Act (RHPA) Nursing Act (Colleges of Nurses) Health Protection and Promotion Act Employment Standards Act Occupational Health and Safety Act Professional Standards Established by Associations (INS, CVAA, RNAO)
Controlled acts are activities that are considered to be potentially harmful if performed by unqualified persons. Section 27 of the Act identifies the 13 controlled acts that health professionals can do. This includes performing a procedure on tissue below the dermis, below the surface of a mucous membrane. This is the legislation that gives rise to the self governing bodies of health professionals and creates the Act that the professionals work from. For nurses, it is the Nursing Act. The RHPA also creates the Colleges of Nurses, identifying its duties and responsibilities.
Nursing s Scope of Practice Statement The practice of nursing is the promotion of health and the assessment of, the provision of, care for, and the treatment of, health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function. (Nursing Act, 1991)
The Colleges or Associations of Nurses in each province are the governing bodies for Registered Nurses (RNs), registered practical nurses (RPNs) and nurse Practitioners (NPs) Some provinces have Colleges (NS, MB, AB, BC PQ) while the others have A Governing Association (PEI, NB, SK, NFLD).
The nursing profession has been self-regulating in Ontario since 1963 Its duties and responsibilities include a duty to serve and protect the public interest by regulating the practice of the profession and to govern the members in accordance with the Health Profession Act The Colleges create Standards of Practice and hold nurses accountable to those standards
Accountability Competency Ethics Knowledge Knowledge Application Leadership Relationships
Act that provides legal framework of the Internal Responsibility System and the obligations of workers, employers and Supervisor to work in a safe work environment. Regulation 834/92 of the Ontario Act explains what must be done if critical injuries occur in the workplace. Sometimes errors in practice occur because safe practices are not established in the workplace, there are faulty policies and procedures that in fact put not only a patient but a nurse at risk of injury. These may be addressed through this forum.
Infusion Nurses Society (INS) Standards RNAO Best Practice Guidelines CVAA Guidelines These professional standards are the forerunners of our legal standards. What has become the customary usual nursing practice, as defined by our profession, later translates into the legal duty a nurse has with her patient. These represent an established level competencies that are expected by our profession and recognised by the courts.
The Standards that INS, RNAO and CVAA have established for the speciality practice of infusion therapy are reviewed routinely and subsequent revisions reflecting clinical practice and new technological advances are based on evidence-based practice and research. Workplace policies,procedures, protocols and/or guidelines should reflect these accepted standards of practice. Those failing to meet those standards risk being involved in legal processes and charged with negligence (or malpractice)
-Medication Administration -Equipment Use -Failure to Act -Failure to Assess and monitor a patient s status -Failure to communicate appropriately -failure to prevent infection NEGLIGENCE leads to: Civil or Criminal court (fines, Jail) College of Nurses Discipline (fines, suspension or loss of license) Employer disciplinary actions (suspensions or termination)
-College of Nurses Case : M.T. vs. K.K., RN. Alleged failure to provide proper care, assessment, of a paediatric peripheral IV. -The committee reviewed the patient s hospital record, doctor s notes, nurse s charting, the employer policy and procedures, emails between the nurse and management and interviews. - Decision: The nurse did indeed perform the proper vascular access evaluation, thus mitigating her disciplinary actions against her by the College of Nurses. -The Nurse was disciplined and received a caution due to poor communication with the family, as she failed to listen to the concerns of the family member, and failed to do so with sensitivity or empathy.
-Bethania Mennonite Personal Care Home vs. Local 103 Manitoba Nurses Union member (re-instated) --Royal Victoria Regional Health Centre vs. ONA member (re-instated) --Peterborough Regional vs. ONA member (reinstated) Watershed Case that effected change
Let s Talk Peripheral Venipuncture is a common procedure performed by regulated HCP s these include lab techs, di/radiology techs, physicians, nurses, paramedics IN 1992 75% of nurses time IV s per day. CVAA national KN&JH 2011 Use the Experts
What is the leading cause of malpractice action against nurses? Complications related to venipuncture These can include medication errors, infiltration, extravasation, nerve injury or tissue damage With the decrease in # of IV teams, increased risk to front line staff Masoorli, S 1998, 2006
Canadian Statistics 65,000 x 365= 23,725,000 360,000 /3 x 365= 43,800,000 2.7 million 85,000 USA 1/32 200+ Canada 1/1800 Health Canada Stats 2013
Case Study A.S. female age 40 required IV access for anesthesia Nurse made 8 attempts to start peripheral access 2 attempts were on the inside of Rt. wrist causing sharp shooting pain in her hand 1/52 later pain numbness to Rt. hand and wrist Tests=median nerve damage Patient subsequently lost the use of her hand Both Hospital and Nurse found guilty of malpractice Nursing journal Sept 98
Types of nerve damage NICKING This is the inadvertent nerve puncture that can occur during vascular access, particularly in the arm, there is a major nerve lying near every major vein NERVE COMPRESSION This can occur from hematoma in the subcutaneous tissue or by infiltration of iv fluid placing pressure on the nerve: compartmental syndrome Massorli,S 2006
How long does it take for nerve damage to be noticed? Immediately Within 24 hours 1 to 4 days Up to one month What is the correct answer??? Hadaway,L 2008
What can affect risks? 1. Mechanical factors Veins small or poor condition Large catheter size relative to size of vein Choice of site (joint flexion or dominant hand) Stability of catheter or device Choice or technique of securement Patient Activity Multiple Venipuncture Sites Use of an infusion pump Line/catheter separates or fractures
2. PHYSIOLOGICAL FACTORS Clot Formation above cannulation site Thrombus or fibrin sheath at catheter tip Lymphedema 3. PHARMOCOLOGIC FACTORS Ph, osmalarity, cytotoxicity, vasoconstrictive potential Doellman, Haddoway Bowes-Geddes et al 2009
Case Study Female patient requires PICC line for antibiotic post-op Presents to D.I. and attempts made to Rt arm unsuccessful Successful PICC insertion to Lt arm Postop 1-2/52 pain and numbness Rt arm
Case Study 30 year old male presents for routine phlebotomy Accessed vein at antecubital fossa, dry gauze and bandage were applied No pain during or immediately post, Pt discharged 30 minutes post pain numbness and swelling with discoloration to his arm Patient assessed told not to worry it would resolve and discharged Experiences ongoing and increasing pain for next several days and presents to ER = warm soaks and ibuprofen IN spite of extensive physio partial loss of use of arm/hand on affected side due to nerve damage from compartmental syndrome
How to avoid problem areas Avoid the inner wrist and base of the thumb-use the three finger rule Listen to the patient Apply pressure RNAO Assessment & device selection for vascular access Choose the appropriate vein (consider volume) Assessment is KEY Choose the best suited equipment Defer to the experts # of attempts INS Standards
Infiltration or Extravasation Leaking of potentially tissue damaging medication outside of the vein Proper vigilance Pain out of proportion c/o numbness &/or tingling with swelling Temperature changes ie cool to touch Skin and nail changes ie blanching Check for pulse Hematoma=delayed nerve compression Involve patient and family Don t rely on smart pumps (Masoorli, S 2007)
Management of infiltration Know your facility P&P or advocate to establish one Teach your patient and family S&S Pay attention to patients c/o & be prepared to act Assess the condition of the site prior med admin AT THE FIRST SIGN OF INFILTRATION IMMEDIATELY STOP THE INFUSION/INJECTION Apply warm or cold compresses as required for the drug administered Estimate the volume of drug escaped in subcutaneous tissue related to flow rate, condition of site and length of time between site assessments AJN August 2007
Prevention is preferable to cure Careful adherence to proper procedures and timely identification of signs and symptoms are critical to avoiding potentially life-altering complications Journal of Infusion Nursing 2009
Frequency of Assessment of the Short Peripheral Catheter Site 2012 INS Positon Paper minimizing the complications associated with risks of vascular access demands regular assessment for 1. Signs and Symptoms & 2. Prompt Removal when evident Assess for : redness, tenderness, swelling, drainage, and/or the presence of paresthesias, numbness or tingling-----any site related changes INS standards of 2011 recommends routine assessment for s&s of Inf/extra
Frequency of Assessment Cont d Review of Literature 1-4 hrs ***** many factors Adult At least every 4 hrs non vesc/non irritant- in an alert/oriented and able to notify nurse Every 1-2 hrs for critically ill pts, sensory or cognitive deficits or unable to notify nurse or high risk location EVERY hour for neonatal and pediatric patients Every 5-10 minutes for vesicants + assess blood return With every home/outpatient visit-educate pt & family
DOCUMENTATION OCN complete record of nursing care provided objective and subjective data documenting advice, care or services given completed by the individual who performed the action
INS Standards for Documentation Specific site prep All infusion devices-type length gauge/size VAD Additionally for CVAD manufacturer # and Lot # Date, time, number and location of attempts Functionality of device and insertion methodology (local anesthetic or assistive device) Insertion site by anatomical descriptors, landmarks, measurements Midlines or PICC- external and internal length
INS standards continued. Confirmation of anatomical location of tip of CVAD prior to 1 st use and PRN for catheter dysfunction Condition of the site, dressing, site care, stabilization device Patient reports of discomfort or pain on insertion & with each regular assessment of the VAD site. Condition of venipuncture or access site PRIOR to and Post infusion therapy Patency of the VAD Infusion Nursing Society Standards 2011
Peripheral IV started: 1130 hr IV started to Rt forearm #22 cathlon, 500mls N/S tba @100 mls/hr. K.Mallet RN OR 1130 hrs. Attempt x 2 to start peripheral IV 1 st attempt dorsum of Rt hand unsuccessful. 2 nd attempt #24 cathlon to inner aspect of Rt forearm 6 cms above base of wrist in cephalic vein, good blood return, site intact, well tolerated by patient. Patient advised to report any feelings of discomfort asap. 500 mls N/S @100 mls/hr. K.Mallet RN
Errors in Medication Administration Mistakes occur in 7/100 admissions IHI System errors 20 steps in process = error is not one person ISMP
MEDICATION ERRORS Preparation to administration preparation administration or combination prep/admin errors LASA= wrong drug Mixing volumes/concentration/dose= wrong dose Rate of delivery=smart pump vs. over-ride Omission of dose National Data shows same rate of error across the country-not all provinces have mandatory reporting Causes of IV med errors,quality of safe health care 2003 CBC news article Aug 21, 2013
Causes of IV med errors 2003 Quality Safety UK ERROR Producing conditions 1. Handling technology-lack of knowledge and experience in drug prep and admin 79% Most common error: delivering bolus doses too fast 2. Design of technology-equipment, labels, environment and procedures 32% 3. Communication-between nurse/pharmacy, nurse to nurse or physician 16% 4.Workload-multi-tasking, end of shift, lack of qualified and experienced staff 15% 5. Patient related factor-limited venous access, noncooperative 6. Lack of supervision student/agency nurse 3%
Common errors in delivery Secondary clamp Errors IV setup Connection Errors above or below the pump, multiple infusions Pressure Differential Errors (gravity and some pumps) Mismanagement of Residual Volume did not adequately flush residual prior to adding new secondary medication (25%) disposed of residual medication (50%)can=Underdosing &/or mixing of incompatible sol ns Pre vs Post test improved from 46% to 76% post training across the board K.Chan, U of T. Mitigating Risks Associated with Secondary Infusion 2011
REMEMBER HUMANS ARE NOT PERFECT- even with enough skill, enough knowledge, enough experience and enough prudence errors will occur given the right circumstance HUMAN ACTIVITY IS NOT EVER GOING TO BE FREE FROM ERROR---LEARNING FROM OUR MISTAKES IS KEY NOVICE TO EXPERT---- EVEN THE BEST CLINICIANS MAKE ERRORS!!!
In Summary Legislation, Standards and Guidelines to practice-we are held accountable for our actions Use your Knowledge of anatomy/technique for best site/equipment choice Focus on medication prep and administration Be Vigilant in Assessment of ongoing IV therapy Know how to take appropriate action Involve the patient Document specifics Don t expect smart pumps to replace the need for VAD and site assessment Participate in Ongoing Education and Training
QUESTIONS??