Professional Practice Concepts for Infusion Therapy

Infusion Related Infection Control and Occupational Risks

Infusion Nursing

Infusion nursing is defined as the nursing process relating to technical and clinical application of fluids, electrolytes, infection control, oncology pediatrics, pharmacology, quality assurance, technology and clinical application, parenteral nutrition, and transfusion therapy

Evidenced Based Nursing Practice

Evidence-based nursing practice (EBNP)Conscientious use of current best evidence in making decisions about patient care (Source: Sackett, Straus, & Richardson, 2000)

Components of Evidence-based Practice

Evidence from research/evidence-based theories and opinion of leaders/expert panels

Evidence from assessment of patient’s history, physical exam, and availability of health-care resources

Clinical expertiseInformation about patient preferences

and values

Nursing Process Related to Infusion Therapy

A study by NCSBN found that newly licensed RNs indicated their time is spent as follows 30% on assessments 12% on analysis 14% on planning 30% on implementing client care 14% on evaluation(Source: NCSBN, 2003)

Assessment

Assessment includes Collection of data Critical laboratory values Allergies Environmental issues Presence of adverse reactions or complications

Assessment Prior to Infusion Therapy

Subjective Information Patient’s related fears of infusion Patient’s experiences with prior infusion therapy Patient’s needs and stated preferences Disclosure of indications, including anticoagulants

Objective information Review of patient’s past and present medical history Physical assessment, including evaluation of periphery for poor vascular

return Review of laboratory data and radiographic studies Assessment of level of growth and development for neonate and

pediatric clients

Diagnosis

Problem list is based on assessment data NANDA-I (2007) provides a clear distinction

between nursing diagnosis and medical diagnosis Examples of infusion-related problems

Fluid volume deficit related to failure of regulatory mechanism

Infection, risk for related to compromised host defenses

NOTE: Nursing diagnosis provides a basis for selection of nursing interventions (nursing actions)

Planning

Planning involves three components Setting priorities Writing expected outcomes Establishing appropriate interventions

Implementation of Interventions

Nursing actions Interventions are the concepts that link specific nursing

activities and actions to expected outcomes Independent activities are those actions that the nurse

performs using his or her own discretionary judgment Collaborative activities are those actions that involve

mutual decision making between two or more health-care practitioners

Evaluation

Evaluation loops back to assessment Once new data is collected a nursing judgment is

made on what modification in the plan of care is needed

Three judgments can be made• The evaluation data indicates that the health-care problem

has been resolved

• Revise the plan of care; outcomes have not been met

• Continue the plan of care based on progress toward goal

Note …..

If an act of malpractice does not create harm, legal action cannot be initiated

However: Coercion of a rational adult patient to place an intravenous catheter constitutes assault and battery

Legal Terms CRIMINAL LAW: an offense against the general

public caused by the potential harmful effect to society as a whole

CIVIL LAW: effect the legal rights of private persons and corporations. Contract Law and Tort law are most applicable to nursing practice

NEGLIGENCE: Failure to do something that a reasonable person would do

MALPRACTICE; Subset of negligence, committed by a person in a professional capacity. (nonadherence to the accepted standard of care)

Legal Practice

Breach of dutyLegal perils related to infusion therapy

practice Failure to monitor and assess clinical status Failure to prevent infection Failure to use equipment properly Failure to protect the patient from avoidable injury

Legal Terms

Four components needed to prove liability for malpractice It must be established that the nurse had a

duty to the patient A breach of standards of care or failure to

carry out that duty must be proven The patient must suffer actual harm or injury There must be a causal relationship between

the breach of duty and the injury suffered (O’Keefe, 2000)

Rule of Personal Libility

The rule of personal liability is “every person is liable for his own tortuous conduct” (his own wrong doing.)

Legal Action

Two most common causes for legal action in nursing Unprofessional practice: conduct that is a

departure from or failure to conform to the minimal standards of care

Professional malpractice: professional misconduct or unreasonable lack of skill that results in harm

Legal Issues

Breach of duty: Failure to observe, failure to intervene, and

verbal rather than written orders are potential risks for all nursing areas

A breach of application of standards of care can be the basis for negligence. Always ask what a reasonable and prudent nurse would do.

Legal Perils of IV Therapy

Not enough IV experience to become comfortable or proficient

Entering the blood stream with a foreign object Litigation for nurses can result from

Infiltration and phlebitis Fractured central venous catheters Nerve injury, infiltration and Extravasation Administering the wrong drug Failure to document appropriately

Ethics

A code of ethics acknowledges the acceptance by a profession of the responsibilities and trust that society has conferred and recognizes the duties and obligations in that trust.

Infusion Nursing Code of Ethics

Autonomy (right to self determination, independence

Beneficence (doing good for patients)Nonmaleficence (doing no harm to

patients)Veracity (truthfulness)Fidelity (obligation to be faithful)Justice (obligation to be fair to all people)

Risk Management

Standards of Practice for Infusion Therapy come from the Infusion Nursing Society New standards published in 2006

Association of Vascular AccessOncology Nursing Forum

Standards of Care

Standards of care describe the results or outcomes of care and focus on the patient

Standards of care are developed within organizations to measure quality based on expectations

Standards of care can be voluntary or mandated by legislation

Standards of Practice

Focus on the provider of care Represent acceptable levels of practice in

patient care deliveryDefine nursing accountabilityProvide a framework for evaluating

professional competency

Risk Management

The Revised Infusion Nursing Standards of Practice define Risk Management as

“a process that centers on identification, analysis, treatment, and evaluation of real and potential hazards”

It is the process of collecting and analyzing scientific data “to describe the form, dimension, and characteristics of risk”

Medication Safety

NOTE Medication error is the most common type of

error affecting patient safety. Preventable adverse drug events (ADEs) are associated with one of every five injuries or deaths occurring in the health-care health care system

(Source: Rozich, et al, 2004)

Medication Errors

Lack of awareness: Between 44,000 and 98,000 deaths annually Approximately 2.5 million nurses and 900,000

Physicians practicing in 7500 Hospitals across the United States

Complex environment: making clear communication even more important.

Risk Management

Risk Management involves all medical and facility staff.

It provides for the review and analysis of risk and liability sources involving patients, visitors, staff and facility property

Risk Management Components

Identification and management of clinical areas of actual and high risk

Identification and management of nonclinical (e.g. visitor, staff areas of actual and high risk)

Identification and management of probable claims events

Management of property loss occurrences

Risk Management Components (cont)

Review and analysis of customer surveys and patient complaints

Review and analysis of risk assessment surveys

Operational linkages with hospital Quality management, safety, and performance improvement programs

Risk Management Components (cont)

Provision of risk management educationCompliance with state risk management

and applicable federal statutes, including the Safe Medical Devices Act

Clinician and Patient SafetyBarriers to Improvement

Two types of errors as identified by James Reason Active errors: “errors at the sharp end of

healthcare” Occur at the point of interaction between the person (nurse) and a larger system (medication cart)

Latent errors: “errors at the blunt end of health care” error that gives rise to the active error and is not necessarily apparent when it happens.

Clinician and Patient SafetyBarriers to Improvement

Culture of Blame

Clinician and Patient SafetyPathophysiology of error

Reliance on weak aspects of cognition Interruptions Fatigue Time Pressure Hand-offs Medication terminology Standardization Knowledge Base Paradigm Shifts

Risk Management Strategies

Informed consentUnusual occurrence reportsSentinel eventsDocumentationProfessional Liability insurancePatient relationsQuality Management

Risk Management Strategies

Informed consent To provide patients with enough information to

enable them to make a rational decision regarding whether to undergo treatment

Unusual occurrence reports Should be filed every time there is a deviation

from the standard. Record of the event Unusual occurrence reports are meant to be

nonjudgmental, factual reports of the problem and its consequences.

Risk Management Strategies

Documentation Accurate, timely, and complete written account

of the care rendered to the patient.

Professional liability insurancePatient relationsQuality management

Dimensions of Performance

Doing the right things includes: The efficacy of the procedure or treatment in

relation to the client’s condition The appropriateness of a specific test,

procedure, or service to meet the client’s need

Dimensions of Performance

Doing the right thing well includes: The availability of a needed test, procedure,

treatment, or service to the client who needs it The timeliness with which a needed test,

procedure, treatment or service is provided to the client

The effectiveness with which tests, procedures, treatments, and services are provided

Quality Patient Management

Quality management is the systematic process to ensure desired patient outcomes

Continuous quality improvement (CQI) Goal to create outcome monitoring and

evaluation processes to assist organization in improving the quality of care.

Is continuous; outcomes are never optimized but may be constantly improved.

INFECTION CONTROL

Basic Principles of Epidemiology Colonization: the presence of a microorganism

in or on a host, with growth and multiplication of the microorganisms with no clinical symptoms or detected immune response

Dissemination: the shedding of microorganisms into the immediate environment from a person carrying them.

Nosocomial Infections: developed within a hospital of are produced by organisms acquired during hospitalization. Now call HAC

Chain of Infection

First Link: Causative Agent The ability of an organism to induce disease is

called its virulence.

Second Link: Reservoir The source of microorganisms.

Other humans Clients own microorganisms, plants, animals, or the

general environment The place where the organism maintains the

presence, metabolizes and replicates.

Chain of Infection

Third Link: Portal of Exit from Reservoir Major portals of exit: respiratory tract, GI tract, skin,

blood.

Fourth Link: Method of Transmission Direct transmission

From person to person, touching, kissing, biting, sexual intercourse

Indirect transmission Vehicle-born: toys, handkerchiefs, soiled linens, clothes Vector-born: animal or flying or crawling insect

Chain of Infection

Fifth Link: Portal of Entry to the Susceptible Host Microorganisms often enter the body of the host

by the same route they use to leave the source

Sixth Link: Susceptible Host Any person who is at risk for infection

Chain of Infection

Breaking the Chain of Infection

New microbiologic methodsAdvancement of Epidemiologic MethodsContinuous Quality Improvement

ProgramsRisk ManagementAntibiotic UsePharmacoepidemiologyEmporiatrics (study of disease in travelers)

Infusion-Relate Infections

150 million intravascular devices are purchased each year.

7-8 million central venous catheters placed each year

More that 200,000 noscomial bloodstream infections occur each year, 90% are related to CVAD

Catheter Related Blood Steam Infections CRBSI

Microorganisms that colonize the skin of hospitalized patients cause the majority of CRBSI

Biofilm “Slime” : extracellular polysaccharide which helps bacteria to adhere to surfaces

Organizations That Set Standards of Practice for Infection Control

APIC: Association of Practitioners in Infection Control

and Epidemiology CDC: Centers for Disease Control and Prevention CMS: Centers for Medicare and Medicaid Services INS: Infusion Nurses Society TJC: The Joint Commission OSHA: U.S. Occupational Safety and Health

Administration

BIOFILM

THE STUFF YOU SEE IN YOUR DOGS WATER,

Catheter Related Blood Steam Infections CRBSI

Primary risk factors include Duration of catheterization (number of

catheter days) Multiple lines Colonization of catheter insertion site by skin

organisms Location of catheter; Subclavin vein, groin Aseptic dressing change Aseptic insertion technique: Total Barrier

Precautions

CRBSI

Secondary Risk Factors: Secondary bacteremia Host defense status Contaminated infusate, Number of catheter lumens

CRBSI

Predisposing factors Duration of placement Multiple lumens Catheters made of polyvinyl chloride Catheters that develop fibrin sheaths Port systems that develop sludge in reservoir Compromised immune status Phlebitis

Strategies for Preventing/Treating Infections

Follow CDC Standard Precautions Guidelines Tier One: Standard Precautions: universal precautions

and body substance isolation Tier Two: Transmission-Based Precautions

Airborn precautions Droplet precautions Contact precautions

Notes

Nursing Fast Fact: Implementation of standard precautions has implications for infusion therapy nurses: Use of I.V. therapy carts and trays may be limited for patients who are on contact transmission precautions.

Strategies for Prevention/Treatment

Follow Hand Hygiene Procedure Nursing Fast Fact: Studies have documented

contamination of HCW’s hands with potential healthcare-associated pathogens. Serial cultures revealed that 100 % of HCW’s carried gram-negative bacilli at least once, and 64% carried S. aureus at least once.

60% of Infections come from the patient, 35% from other sources, and 5% from our hands

Strategies for Prevention/Treatment

Use Appropriate Skin AntisepsisUse Catheter Site Dressing Regimens

Transparent, semi permeable polyurethane dressing

Use Catheter Securement DevicesUse AnticoagulantsUse Antibiotic Locks

Sources of Infection

SAVE THAT LINEScrupulous Hand HygieneAseptic TechniqueVigorous Friction to HubsEnsure Patency

Association of Vascular Access