Title: Professional Practice Concepts for Infusion Therapy Infusion Related Infection Control and Occupational Risks
1Professional Practice Concepts for Infusion
TherapyInfusion Related Infection Control and
Occupational Risks
2Infusion 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
3Evidenced 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)
4Components 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
5Nursing 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)
6Assessment
- Assessment includes
- Collection of data
- Critical laboratory values
- Allergies
- Environmental issues
- Presence of adverse reactions or complications
7Assessment 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
8Diagnosis
- 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)
9Planning
- Planning involves three components
- Setting priorities
- Writing expected outcomes
- Establishing appropriate interventions
10Implementation 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
11Evaluation
- 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
12 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
13Legal 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)
14Legal 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
15Legal 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)
16Rule of Personal Libility
- The rule of personal liability is every person
is liable for his own tortuous conduct (his own
wrong doing.)
17Legal 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
18Legal 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.
19Legal 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
20Ethics
- 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.
21Infusion 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)
22Risk 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
23Standards 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
24Standards 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
25Risk 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
26Medication 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)
27Medication 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.
28Risk 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
29Risk 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
30Risk 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
31Risk Management Components (cont)
- Provision of risk management education
- Compliance with state risk management and
applicable federal statutes, including the Safe
Medical Devices Act
32Clinician 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.
33Clinician and Patient SafetyBarriers to
Improvement
34Clinician and Patient SafetyPathophysiology of
error
- Reliance on weak aspects of cognition
- Interruptions
- Fatigue
- Time Pressure
- Hand-offs
- Medication terminology
- Standardization
- Knowledge Base
- Paradigm Shifts
35Risk Management Strategies
- Informed consent
- Unusual occurrence reports
- Sentinel events
- Documentation
- Professional Liability insurance
- Patient relations
- Quality Management
36Risk 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.
37Risk Management Strategies
- Documentation
- Accurate, timely, and complete written account of
the care rendered to the patient. - Professional liability insurance
- Patient relations
- Quality management
38Dimensions 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
39Dimensions 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
40Quality 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.
41INFECTION CONTROL
42Basic 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
43Chain 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.
44Chain 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
45Chain 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
46Chain of Infection
47Breaking 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)
48Infusion-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
49Catheter 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
50Organizations 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
51BIOFILM
- THE STUFF YOU SEE IN YOUR DOGS WATER,
52Catheter 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
53CRBSI
- Secondary Risk Factors
- Secondary bacteremia
- Host defense status
- Contaminated infusate,
- Number of catheter lumens
-
54CRBSI
- 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
55Strategies 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
56Notes
- 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.
57Strategies 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
58Strategies 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
59Sources of Infection
60SAVE THAT LINE
- Scrupulous Hand Hygiene
- Aseptic Technique
- Vigorous Friction to Hubs
- Ensure Patency
- Association of Vascular Access