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

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


1
Professional Practice Concepts for Infusion
Therapy Infusion Related Infection Control and
Occupational Risks
2
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

3
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)
4
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

5
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)

6
Assessment
  • Assessment includes
  • Collection of data
  • Critical laboratory values
  • Allergies
  • Environmental issues
  • Presence of adverse reactions or complications

7
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

8
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)

9
Planning
  • Planning involves three components
  • Setting priorities
  • Writing expected outcomes
  • Establishing appropriate interventions

10
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

11
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

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

13
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)

14
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

15
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)

16
Rule of Personal Libility
  • The rule of personal liability is every person
    is liable for his own tortuous conduct (his own
    wrong doing.)

17
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

18
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.

19
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

20
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.

21
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)

22
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

23
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

24
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

25
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

26
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)

27
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.

28
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

29
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

30
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

31
Risk Management Components (cont)
  • Provision of risk management education
  • Compliance with state risk management and
    applicable federal statutes, including the Safe
    Medical Devices Act

32
Clinician and Patient Safety Barriers 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.

33
Clinician and Patient Safety Barriers to
Improvement
  • Culture of Blame

34
Clinician and Patient Safety Pathophysiology of
error
  • Reliance on weak aspects of cognition
  • Interruptions
  • Fatigue
  • Time Pressure
  • Hand-offs
  • Medication terminology
  • Standardization
  • Knowledge Base
  • Paradigm Shifts

35
Risk Management Strategies
  • Informed consent
  • Unusual occurrence reports
  • Sentinel events
  • Documentation
  • Professional Liability insurance
  • Patient relations
  • Quality Management

36
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.

37
Risk Management Strategies
  • Documentation
  • Accurate, timely, and complete written account of
    the care rendered to the patient.
  • Professional liability insurance
  • Patient relations
  • Quality management

38
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

39
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

40
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.

41
INFECTION CONTROL
42
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

43
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.

44
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

45
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

46
Chain of Infection
47
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)

48
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

49
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

50
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

51
BIOFILM
  • THE STUFF YOU SEE IN YOUR DOGS WATER,

52
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

53
CRBSI
  • Secondary Risk Factors
  • Secondary bacteremia
  • Host defense status
  • Contaminated infusate,
  • Number of catheter lumens

54
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

55
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

56
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.

57
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

58
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

59
Sources of Infection
60
SAVE THAT LINE
  • Scrupulous Hand Hygiene
  • Aseptic Technique
  • Vigorous Friction to Hubs
  • Ensure Patency
  • Association of Vascular Access
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