Advanced Nurse Practitioner Intensive Care

Frimley Park Hospital

Suman Shrestha MSc BSc RN

Meeting the NEW RCN Standards

for Infusion Therapy in practice

suman_sr sumanshrestha@nhs.net

• 720 Beds • District General Hospital • Surrey, England

FRIMLEY PARK HOSPITAL

80% of hospitalised patients receive

intravenous therapy at some point

during their admission

Waitt et al (2000)

Infusion Therapy

Risks

Microbiological contamination

Altered physiology

Sharp injury

Drug Incompatibility

Medication Error

Air Embolism

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

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)

Phase 1 : RCTs and systematic reviews

Phase 2: Other quantitative studies

Phase 3: Evidence relating to the

patient perspective of infusion therapy

The resulting evidence review

Patient Perspective

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

Contents

Key Findings

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)

Flushing and locking of infusion devices

Key Findings

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)

Infection prevention and control

Key Findings

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)

Placement of device

Key Findings

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)

PICCs and midline catheters

Key Findings

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)

Infusion therapy in non-acute setting

Implement Evidence based

practice

• Clarity in clinical practice

• Standardisation

• effectiveness

Training & Education

• Framework

• Resource

• Reference

Clinical Governance

• 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

• Clarity in clinical practice

• Standardisation

• Clinical effectiveness

Training & Education

• Framework

• Resource

• Reference

Clinical Governance

• 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?

The safe administration of medicines is an

important aspect of the professional practice.

Implement Evidence based

practice

• Clarity in clinical practice

• Standardisation

• effectiveness

Training & Education

• Framework

• Resource

• Reference

Clinical Governance

• 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

• Clarity in clinical practice

• Standardisation

• effectiveness

Training & Education

• Framework

• Resource

• Reference

Clinical Governance

• 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?

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.

1. Help nurses deal with personal grief

and reactions

2. Systematic exploration of

practice

Managerial actions

JAN (2007) 60(3):317-324

Patient/caregiver education and involvement

Electronic Prescribing and Medicine Administration

97%

73%

From international perspective ……….

India

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

Advanced Nurse Practitioner Intensive Care

Frimley Park Hospital

Suman Shrestha MSc BSc RN

Meeting the NEW RCN Standards

for Infusion Therapy in practice

suman_sr sumanshrestha@nhs.net