Professional Practice Concepts for Infusion Therapy Infusion Related Infection Control and Occupational Risks

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Professional Practice Concepts for Infusion
TherapyInfusion Related Infection Control and
Occupational Risks
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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

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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)
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Components of Evidence-based Practice

• Evidence from research/evidence-based theories
  and opinion of leaders/expert panels
• Evidence from assessment of patients history,
  physical exam, and availability of health-care
  resources
• Clinical expertise
• Information about patient preferences and values
  

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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)

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Assessment

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

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Assessment Prior to Infusion Therapy

• Subjective Information
• Patients related fears of infusion
• Patients experiences with prior infusion therapy
• Patients needs and stated preferences
• Disclosure of indications, including
  anticoagulants
• Objective information
• Review of patients 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

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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)

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Planning

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

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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

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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

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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

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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)

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Legal Practice

• Breach of duty
• Legal 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

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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 (OKeefe,
  2000)

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Rule of Personal Libility

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

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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

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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.

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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

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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.

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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)

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Risk Management

• Standards of Practice for Infusion Therapy come
  from the Infusion Nursing Society
• New standards published in 2006
• Association of Vascular Access
• Oncology Nursing Forum

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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

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Standards of Practice

• Focus on the provider of care
• Represent acceptable levels of practice in
  patient care delivery
• Define nursing accountability
• Provide a framework for evaluating professional
  competency

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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

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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)

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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.

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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

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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

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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

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Risk Management Components (cont)

• Provision of risk management education
• Compliance with state risk management and
  applicable federal statutes, including the Safe
  Medical Devices Act

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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.

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Clinician and Patient SafetyBarriers to
Improvement

• Culture of Blame

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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

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Risk Management Strategies

• Informed consent
• Unusual occurrence reports
• Sentinel events
• Documentation
• Professional Liability insurance
• Patient relations
• Quality Management

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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.

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Risk Management Strategies

• Documentation
• Accurate, timely, and complete written account of
  the care rendered to the patient.
• Professional liability insurance
• Patient relations
• Quality management

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Dimensions of Performance

• Doing the right things includes
• The efficacy of the procedure or treatment in
  relation to the clients condition
• The appropriateness of a specific test,
  procedure, or service to meet the clients need

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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

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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.

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INFECTION CONTROL
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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

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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.

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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

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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

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Chain of Infection
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Breaking the Chain of Infection

• New microbiologic methods
• Advancement of Epidemiologic Methods
• Continuous Quality Improvement Programs
• Risk Management
• Antibiotic Use
• Pharmacoepidemiology
• Emporiatrics (study of disease in travelers)

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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

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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

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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

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BIOFILM

• THE STUFF YOU SEE IN YOUR DOGS WATER,

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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

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CRBSI

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

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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

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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

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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.

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Strategies for Prevention/Treatment

• Follow Hand Hygiene Procedure
• Nursing Fast Fact Studies have documented
  contamination of HCWs hands with potential
  healthcare-associated pathogens. Serial cultures
  revealed that 100 of HCWs 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

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Strategies for Prevention/Treatment

• Use Appropriate Skin Antisepsis
• Use Catheter Site Dressing Regimens
• Transparent, semi permeable polyurethane dressing
• Use Catheter Securement Devices
• Use Anticoagulants
• Use Antibiotic Locks

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Sources of Infection
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SAVE THAT LINE

• Scrupulous Hand Hygiene
• Aseptic Technique
• Vigorous Friction to Hubs
• Ensure Patency
• Association of Vascular Access