Dallas, TX November 2–4, 2012 Peripheral Infusion Complications Leading to Sentinel Events Presented by Pam Ohls, MSN, RN RN Director, Clinical Education

Dallas, TX • November 2–4, 2012

Peripheral Infusion

Complications Leading to

Sentinel EventsPresented by Pam Ohls, MSN, RN

RN Director, Clinical Education

Banner Health System

[email protected]


Peripheral Infusion Complications Leading to Sentinel Events

Session Code:101 Contact Hours: 0.8 CRNI Units: 2Please use session code shown above when completing

your speaker evaluation and CE form.

Return the evaluation to the registration desk or receptacles located outside meeting rooms at the end of the day.

Handouts for this session are available online at www.ins1.org. Session recordings will also be available post-meeting courtesy of

B.Braun Medical/Aesculap Academy.

As a courtesy to both presenters and attendees, please turn off all cell phones and refrain from talking during the session.

Tonight’s Event:Industrial Exhibition and Networking Reception

3:30-5:30pm


Objectives

• Discuss complications associated with peripheral IV therapy

• Discuss strategies to improve outcomes for patients receiving peripheral IV therapy


Case Presentation

• Geriatric-aged Caucasian female presented to ED-auto accident-back pain

• IV started, CT Head, pain meds, labs• Pain meds, K+, procedure for back

scheduled Monday. IV restarted on Friday on day 3.

• Old IV site continues to become more reddened over 2 days, wound consult.


Case Presentation

• Procedure cancelled on Monday. Pt febrile, BP dropped. To ICU.

• Diagnosis-Sepsis

• Patient expired 24 hours after admit to ICU

• Final diagnosis-sepsis from infected IV site-per Infectious Disease Physician.


Sentinel Event

• Defined by the Joint Commission (TJC)

• Unanticipated event

• Results in death, serious physical or psychological injury


Root Cause Analysis

• Involves interdisciplinary experts from the departments associated with the event

• Involves those who are the most familiar with the situation

• Digs deeper by repeatedly asking why at each level of cause and effect.

• Identifies changes needed to be made to systems

• Be impartial as possible


Goal of RCA

• What happened?

• Why did it happen?

• What do you do to prevent it from happening again?


Effective & Thorough

• Determine human factors • Analysis of related processes• Analysis of underlying cause and effect

systems through a series of why questions

• Identification of risks & their potential contributions

• Determination of potential improvement in processes or systems


Cause & Effect Diagram

Human Factors-Communication

Barriers/SafeguardsEquipment and Environmental Factors

Event

(Septic IV Site)

Human Factors-

Training

Human Factors-

Fatigue / Scheduling

Rules, Policies, Procedures, Leadership


Define PIV Terms for Team

• Phlebitis-expected/anticipated?

• Infiltration-expected/anticipated?

• Infection source from PIV?


Phlebitis• Defined as erythema, pain, swelling and or venous cord

along the PIV site.• Classified as:

– Chemical– Mechanical– Bacterial


Phlebitis

• Rates range from 2-80%

• INS recommendation rate 5% or less

• Risk factors– Drug related– Patient related– Health care related


Phlebitis Scale0 No clinical symptoms

1 Erythema, with or without pain

2 Erythema and pain, with or without edema

3 Erythema, pain, and/or edema and palpable cord

4 Erythema, painAnd/or edemaPalpable venous cord > 1 inchStreak formationPurulent drainage


Chemical Phlebitis

• Typically associated with peripheral-short venous access devices, i.e., peripheral IV or Midlines.


Infiltration/Extravasation• Infiltration: inadvertent administration of a non

vesicant into the surrounding tissue.

• Extravasation: an inadvertent delivery of a vesicant into the tissues. Vesicants cause blistering, severe tissue damage, and even necrosis if extravasated.


Grade Clinical Criteria0 No signs or symptoms

1 •Skin blanched•Edema less than 1 inch

2 •Cool to touch •With or without pain•Skin blanched •Edema 1-6 inches in any direction

3 •Cool to touch•With or without pain•Skin blanched•Edema greater than 6 inches

4 •Cool to touch•Mild-mod pain•Possible numbness•Skin discolored •Gross edema greater than 6 inches•Circulatory impairment•Infiltration of any blood product, irritant, or vesicant

Infiltration Scale


Extreme pH IV Medications

pH <5

Ciprofloxin 3.3-4.6

Dopamine 2.5-5.0

Doxycycline 1.8-3.3

Morphine 2.5

Potassium 4.0

Pentamidine 4.1-5.4

Phenergan 4.0

Taxol 4.4-5.6

Vancomycin 2.4

Zofran 3.0-4.0

pH >9

Acyclovir 10.5-11.6

Ampicillin 8.0-10

Bactrim 10

Cerebyx 8.6-9.0

5FU 9.2

Ganciclovir 9-11

Phenytoin 12

Protonix 9-10.5


Classified Vesicant Infusates

• Acyclovir• Amiordarone• Ampho B• Ampicillin• Aramine• Bactrim• Calcium chloride• Calcium Gluconate 10%• Ciprofloxacin• Cerebyx• Contrast media

•Daptinomycin•Dextrose >10%•Digitoxin•Dobutamine•Dopamine•Doxapram•Doxycycline•Epinephrine•Erythromycin•Gancyclovir•Gentamycin


Vesicant InfusatesLevophed

Lorazepram

Magnesium sulfate

Mannitol 10% and 20%

Morphine

Nafcillin

Norepinephrine

Phenergan

Phenytoin

Phenylephrine

Pentamadine

PhenytoinPiperacillinPotassium chlorideProtonixSodium BicarbonateTaxolThiopentalValiumVancomycinVasopressinZofranZosyn


Mechanical Phlebitis• Associated with placement of device or extremity

movement resulting in irritation of vein intima • Early-stage mechanical phlebitis caused by

mechanical irritation of vein endothelium– Signs and symptoms are tenderness, erythema,

and edema


Bacterial Phlebitis• Inflammation of the vein intima associated with

bacterial infection• Less frequently seen but more serious because it

predisposes patient to systemic complications


Review of Literature

• 30-80% PIV during hospitalization

• 50% PIV placed in ED-routine procedure, but not used

• 150 million PIV placed annually– 15x higher than central lines

• Most literature focuses phlebitis and infiltration

• IV site change or needed

(ZIngg & Pittett, 2009)


Maki, Kluger, Crnich (2006)

• Meta-analysis of 200 prospective studies

• PIV BSI rate: 0.5 per 1000 device days

• Over 330 million PIV in US each year


Pujol, Hornero, Saballs et al. (2007).

• Prospective study-catheter related BSI

• 2001-2003

• Non-ICU patients

• 147 patients – 77 PIV (0.19/1000 patient days)– 73 CVC (0.18/1000 patient days)

• PIV infections– Inserted in ED, Staph aureus, 27%

mortality rate


Zingg & Pittet, (2009)

• Current data report PIV incidence density rates of 0.2-0.7 episodes per 1000 device days.

• 5-25% PIV colonized with bacteria at time of removal.

• Rare event or serious health care problem?


Trinh, Chan, Edwards, et al. (2011).

• Retrospective study-adult patients-2005-2008

• 24 PIV, median duration 3 days

• Site-antecubital, placed in ED or outside facility (p=.005)

• Treatment-19 days antibiotics


Replacement of PIV

• Current HICPAC Recommendations– No need to replace PIV more frequent to

reduct risk of infection and phlebitis• Category 1B

– No recommendation of placement of PIV when clinically indicated

• Unresolved issue

– Replace PIV in children when clinically indicated

• Category 1B


Policies & ProceduresCurrent Practice

• Change IV sites every three days, sooner if reddened

• Check for blood return for chemotherapy

• Check for blood return for vesicants

• Contrast Media is a vesicant?


What Effect Did Contrast Have on the

PIV?• What is the practice of Medical

Imaging?

• What is the policy?

• How old are the IV’s used for Contrast?

• Did the nurse change the IV site according to policy?

• Do we have a policy on Contrast Media and what do we know about Contrast?


Contrast Media Osmolarity


Equipment/Patient

;;;;;

• Contrast Injected 1-6mL per second


CT Rates of Injection

• 1mL per second = 3600 mL/hour

• 2mL per second = 7200 mL/hour

• 3mL per second = 10,800 mL/hour





Contrast Extravasation


Facts About Contrast Media

• Vesicant

• Continues to burn intima of veins for 48 hours after administration

• Administration of contrast via IV in place longer than 20 hours increases risk of extravasation and phlebitis

• Multiple attempts at IV access at same site increases risk of extravasation

Patient Safety Advisory (2004), Extravasation of Radiologic Contrast


National Guidelines for Vesicants

• Avoid using sites more than 24 hours

• Avoid areas of flexion– Radiology Guidelines recommend AC for

administration of Contrast Media

• Flush with Saline before and after

• Check blood return before and after

Infusion Nurses’ Society Oncology Nurses’ SocietyStandards of Care


Question

• What affect did Contrast have with the other medications she was receiving– Morphine– Potassium– Zofran


Ask Questions

• What is the practice of CT Techs?

• Check for blood return?

• Check for patency?

• Scrub hub?

• Flush with Saline before and after?

• How old the IV site?


The questions

• CT check for blood return?

• Power injected?

• What other medications through IV site?

• How long do IV’s last after administration of Contrast Media


Results

• Collected data on 60 patients for CT & MRI

• Magnevist MRI-1960milli/osmL

• Omnipaque 350-844milli/osmL

• 60 patients, 63% (n=38) no extravasation or phlebitis

• 69% no blood return prior to injection

Kirschner, R. (2010).


Results

• 60 patients, 31% (n=22) had concurrent vesicant therapies

• 100% (n=22) developed phlebitis within 24 hours contrast and another vesicant– (n=10) MRI contrast– (n=12) CT contrast

• All CT patients power injected• No MRI patients power injected


Which Medications?

• Zofran

• Potassium

• Morphine

• Protonix

• Vancomycin


Action Plans

• All PIVs need to be started with 24 hours of contrast media

• All CT techs check for date of insertion before administration of contrast

• All CT techs check for blood return before administration of contrast

• If not within 24 hours and no blood return-restart PIV


Post Administration

• Discern alert placed in electronic documementation for nurses, alerting them to administration of contrast and top 5 medication. Site may develop phlebitis and may need changed within 24 hours.


Resource Team Assistance


Literature

• 90% of patients require PIV for procedures/medications

• IV education and skills have removed from many nursing school curriculum after Hegstad and Zsohar (1986) study showed no difference in outcomes from simulation versus live practice for IV skills

• Mentoring with an expert has been shown to improves skills and confidence (McGee, 2001)


Experience with IV’s16 participants (n = 16)

The mean age of participants was 30 years (range 23 – 44 years).

The majority of participants were female (n = 15)

Most staff nurses had one to five years of RN experience (n = 9)

About half of the participants worked on a med/surg unit as a staff RN (n = 8), while the other half were staff nurses in PCU or ICU (n = 7). One participant was from WIS.

Participants’ highest level of nursing education was equally divided

ADN (n = 8) and BSN (n = 8).

All but one participant had experience inserting IVs in nursing school.

The majority of participants (n = 14) had experience inserting IVs on both patients and mannequins / IV arms.

Practice with IV in nursing school varied

never (n=1)

one to two times (n=1)

three and five times (n = 8)

six to ten times (n = 4)

more than ten times (n = 2)


Human Factors-Training

• Ultrasound IV insertions

• Education

• Competency

• Outcomes


IV Cannulation OutcomesUsing 1 ¼” needles with US

622 IVs

242-41% failed in under 24 hours

531-90% failed in under 48 hours

62-10% made it to 72 hours

After 24 hours

Upper arm fails 78%

Antecubital fails 41%

Lower arm fails 28%

Unpublished data, Royer, T. (2006).


Length and Size of Needles

• The deeper the vein, the less needle in the vein.• Use longer catheters: 1 ¾ inch• No deeper than 1cm• Site selection:

– Lower arm– Upper arm-Cephalic veins– Antecubital


Bacterial Phlebitis• Inflammation of the vein intima associated with

bacterial infection• Less frequently seen but more serious because it

predisposes patient to systemic complications• Type of ultrasound gel for assessing and accessing

the vein– Clean to assess– Sterile to access

cleansterile

sterile


Claims and Dollars for the Systemfor Claims where

Medication Error was the Primary Event

Year No. Amount Incurred

• 2005 130 $ 2 million

• 2006 130 $ 5 million

• 2007 130 $ 7 million


Common Problems Identified in Claims

• Infiltration of IV contrast 14 of 58 claims

• Poor charting of IV site assessment

• IV not changed when patient complains

• IV not changed per policy

• MRSA infections after IV removed


Scope of Practice

• Anatomy and physiology limbs, to include vein, artery, and nerves

• Assessment of vessels• Appropriate vessels and cannulation techniques• Aseptic technique• Appropriate length and size of needles• Complications, management, and troubleshooting


Strategies

• Assessment of nurses’ IV knowledge and skills on hire

• Precepting and mentorship IV skills and knowledge

• Education, skills, competencies for US IV insertion

• Assessment of IV practice in your facility for vesicants/contrast media


Guidelines for PIV insertion


Algorhythm for Right Line?


Competencies


Summary• Assessment of knowledge,

competencies, practices, and policies

• Policies and Procedures

• Documentation

• INS Standards of Practice

• All nurses who start IVs are Infusion Nurses, not just nurses who are on IV teams and insert PICC lines


References• ECRI (2004). Extravasation of Radiologic Contrast, Patient Safety Advisory,

1(3), 1-5. • Infusion Nurses Society Standards of Practice, (2011). • Kirschner, R. (2010). Contrast media-Phlebitis implications. US Radiology,

27-30. • Maki, D., Kluger, D., Crnich, C. (2006). The risk of bloodstream infection in

adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc, 81(9), 1159-1171

• Pujol, M., Hornero, A., Saballs, M., et al. (2007). Clinical epidemiology and outcomes of PIV related blood stream infection at a university-affiliated hospital. Journal of Hospital Infection, 67(1), 22-29.

• Royer, T. (2006). Unpublished data for US IV Insertion.• Trinh, T., Chan, P., Edwards, O, et al. (2011). Peripheral venous catheter-

rated staphylococcus aureus bacteremia. Infection Control and Hospital Epidemiology, 32(6).

• Zingg, W. & Pittet, D. (2009). Peripheral venous catheters: An under-evaluated problem. International Journal of Antimicrobial Agents, 34S. S38-S42.

Documents

Dallas, TX November 2–4, 2012 Peripheral Infusion Complications Leading to Sentinel Events Presented by Pam Ohls, MSN, RN RN Director, Clinical Education