Transcript Presentation Title

Peripheral Infusion
Complications
Leading to
Sentinel Events
Presented by Pam Ohls, MSN, RN
RN Director, Clinical Education
Banner Health System
[email protected]
Dallas, TX • November 2–4, 2012
Peripheral Infusion Complications
Leading to Sentinel Events
Session Code:101 Contact Hours: 0.8 CRNI Units: 2
Please use session code shown above when completing
your speaker evaluation and CE form.
Return the evaluation to the registration desk or receptacles located
outside meeting rooms at the end of the day.
Handouts for this session are available online at www.ins1.org.
Session recordings will also be available post-meeting courtesy of
B.Braun Medical/Aesculap Academy.
As a courtesy to both presenters and attendees, please turn off all cell phones and refrain
from talking during the session.
Tonight’s Event:
Industrial Exhibition and Networking Reception
3:30-5:30pm
Dallas, TX • November 2–4, 2012
Objectives
• Discuss complications associated with
peripheral IV therapy
• Discuss strategies to improve outcomes
for patients receiving peripheral IV
therapy
Dallas, TX • November 2–4, 2012
Case Presentation
• Geriatric-aged Caucasian female
presented to ED-auto accident-back
pain
• IV started, CT Head, pain meds, labs
• Pain meds, K+, procedure for back
scheduled Monday. IV restarted on
Friday on day 3.
• Old IV site continues to become more
reddened over 2 days, wound consult.
Dallas, TX • November 2–4, 2012
Case Presentation
• Procedure cancelled on Monday.
Pt febrile, BP dropped. To ICU.
• Diagnosis-Sepsis
• Patient expired 24 hours after admit to
ICU
• Final diagnosis-sepsis from infected IV
site-per Infectious Disease Physician.
Dallas, TX • November 2–4, 2012
Sentinel Event
• Defined by the Joint Commission (TJC)
• Unanticipated event
• Results in death, serious physical or
psychological injury
Dallas, TX • November 2–4, 2012
Root Cause Analysis
• Involves interdisciplinary experts from the
departments associated with the event
• Involves those who are the most familiar with
the situation
• Digs deeper by repeatedly asking why at
each level of cause and effect.
• Identifies changes needed to be made to
systems
• Be impartial as possible
Dallas, TX • November 2–4, 2012
Goal of RCA
• What happened?
• Why did it happen?
• What do you do to prevent it from
happening again?
Dallas, TX • November 2–4, 2012
Effective & Thorough
• Determine human factors
• Analysis of related processes
• Analysis of underlying cause and effect
systems through a series of why
questions
• Identification of risks & their potential
contributions
• Determination of potential improvement
in processes or systems
Dallas, TX • November 2–4, 2012
Cause & Effect Diagram
Equipment and
Environmental Factors
Barriers/Safeguards
Human FactorsCommunication
Event
(Septic IV Site)
Rules, Policies,
Procedures,
Leadership
Human FactorsFatigue / Scheduling
Human FactorsTraining
Dallas, TX • November 2–4, 2012
Define PIV Terms for Team
• Phlebitis-expected/anticipated?
• Infiltration-expected/anticipated?
• Infection source from PIV?
Dallas, TX • November 2–4, 2012
Phlebitis
• Defined as erythema, pain, swelling and or venous cord
along the PIV site.
• Classified as:
– Chemical
– Mechanical
– Bacterial
Dallas, TX • November 2–4, 2012
Phlebitis
• Rates range from 2-80%
• INS recommendation rate 5% or less
• Risk factors
– Drug related
– Patient related
– Health care related
Dallas, TX • November 2–4, 2012
Phlebitis Scale
0
No clinical symptoms
1
Erythema,
with or without pain
2
Erythema and pain,
with or without edema
3
Erythema, pain,
and/or edema
and palpable cord
4
Erythema, pain
And/or edema
Palpable venous cord > 1 inch
Streak formation
Purulent drainage
Dallas, TX • November 2–4, 2012
Chemical Phlebitis
• Typically associated with peripheral-short venous
access devices, i.e., peripheral IV or Midlines.
Dallas, TX • November 2–4, 2012
Infiltration/Extravasation
• Infiltration: inadvertent administration of a non
vesicant into the surrounding tissue.
• Extravasation: an inadvertent delivery of a vesicant
into the tissues. Vesicants cause blistering, severe
tissue damage, and even necrosis if extravasated.
Dallas, TX • November 2–4, 2012
Infiltration Scale
Grade
Clinical Criteria
0
No signs or symptoms
1
•Skin blanched
•Edema less than 1 inch
2
•Cool to touch
•With or without pain
•Skin blanched
•Edema 1-6 inches in any direction
3
•Cool to touch
•With or without pain
•Skin blanched
•Edema greater than 6 inches
4
•Cool to touch
•Mild-mod pain
•Possible numbness
•Skin discolored
•Gross edema greater than 6 inches
•Circulatory impairment
•Infiltration of any blood product, irritant, or vesicant
Dallas, TX • November 2–4, 2012
Extreme pH IV Medications
pH <5
Ciprofloxin 3.3-4.6
Dopamine 2.5-5.0
Doxycycline 1.8-3.3
Morphine 2.5
Potassium 4.0
Pentamidine 4.1-5.4
Phenergan 4.0
Taxol 4.4-5.6
Vancomycin 2.4
Zofran 3.0-4.0
pH >9
Acyclovir 10.5-11.6
Ampicillin 8.0-10
Bactrim 10
Cerebyx 8.6-9.0
5FU 9.2
Ganciclovir 9-11
Phenytoin 12
Protonix 9-10.5
Dallas, TX • November 2–4, 2012
Classified Vesicant Infusates
•
•
•
•
•
•
•
•
•
•
•
Acyclovir
Amiordarone
Ampho B
Ampicillin
Aramine
Bactrim
Calcium chloride
Calcium Gluconate 10%
Ciprofloxacin
Cerebyx
Contrast media
•Daptinomycin
•Dextrose >10%
•Digitoxin
•Dobutamine
•Dopamine
•Doxapram
•Doxycycline
•Epinephrine
•Erythromycin
•Gancyclovir
•Gentamycin
Dallas, TX • November 2–4, 2012
Vesicant Infusates
Levophed
Lorazepram
Magnesium sulfate
Mannitol 10% and 20%
Morphine
Nafcillin
Norepinephrine
Phenergan
Phenytoin
Phenylephrine
Pentamadine
Phenytoin
Piperacillin
Potassium chloride
Protonix
Sodium Bicarbonate
Taxol
Thiopental
Valium
Vancomycin
Vasopressin
Zofran
Zosyn
Dallas, TX • November 2–4, 2012
Mechanical Phlebitis
• Associated with placement of device or extremity
movement resulting in irritation of vein intima
• Early-stage mechanical phlebitis caused by
mechanical irritation of vein endothelium
– Signs and symptoms are tenderness, erythema,
and edema
Dallas, TX • November 2–4, 2012
Bacterial Phlebitis
• Inflammation of the vein intima associated with
bacterial infection
• Less frequently seen but more serious because it
predisposes patient to systemic complications
Dallas, TX • November 2–4, 2012
Review of Literature
• 30-80% PIV during hospitalization
• 50% PIV placed in ED-routine
procedure, but not used
• 150 million PIV placed annually
– 15x higher than central lines
• Most literature focuses phlebitis and
infiltration
• IV site change or needed
(ZIngg & Pittett, 2009)
Dallas, TX • November 2–4, 2012
Maki, Kluger, Crnich (2006)
• Meta-analysis of 200 prospective
studies
• PIV BSI rate: 0.5 per 1000 device days
• Over 330 million PIV in US each year
Dallas, TX • November 2–4, 2012
Pujol, Hornero, Saballs et al.
(2007).
•
•
•
•
Prospective study-catheter related BSI
2001-2003
Non-ICU patients
147 patients
– 77 PIV (0.19/1000 patient days)
– 73 CVC (0.18/1000 patient days)
• PIV infections
– Inserted in ED, Staph aureus,
27% mortality rate
Dallas, TX • November 2–4, 2012
Zingg & Pittet, (2009)
• Current data report PIV incidence
density rates of 0.2-0.7 episodes per
1000 device days.
• 5-25% PIV colonized with bacteria at
time of removal.
• Rare event or serious health care
problem?
Dallas, TX • November 2–4, 2012
Trinh, Chan, Edwards, et al.
(2011).
• Retrospective study-adult patients2005-2008
• 24 PIV, median duration 3 days
• Site-antecubital, placed in ED or outside
facility (p=.005)
• Treatment-19 days antibiotics
Dallas, TX • November 2–4, 2012
Replacement of PIV
• Current HICPAC Recommendations
– No need to replace PIV more frequent to
reduct risk of infection and phlebitis
• Category 1B
– No recommendation of placement of PIV
when clinically indicated
• Unresolved issue
– Replace PIV in children when clinically
indicated
• Category 1B
Dallas, TX • November 2–4, 2012
Policies & Procedures
Current Practice
• Change IV sites every three days,
sooner if reddened
• Check for blood return for
chemotherapy
• Check for blood return for vesicants
• Contrast Media is a vesicant?
Dallas, TX • November 2–4, 2012
What Effect Did Contrast
Have on the PIV?
• What is the practice of Medical
Imaging?
• What is the policy?
• How old are the IV’s used for Contrast?
• Did the nurse change the IV site
according to policy?
• Do we have a policy on Contrast Media
and what do we know about Contrast?
Dallas, TX • November 2–4, 2012
Contrast Media Osmolarity
Dallas, TX • November 2–4, 2012
Equipment/Patient
;;;;;
• Contrast Injected 1-6mL
per second
Dallas, TX • November 2–4, 2012
CT Rates of Injection
•
•
•
•
•
•
1mL per second = 3600 mL/hour
2mL per second = 7200 mL/hour
3mL per second = 10,800 mL/hour
4mL per second = 14,400 mL/hour
5mL per second = 18,000 mL/hour
6mL per second = 21,600 mL/hour
Dallas, TX • November 2–4, 2012
Contrast Extravasation
Dallas, TX • November 2–4, 2012
Facts About
Contrast Media
• Vesicant
• Continues to burn intima of veins for 48
hours after administration
• Administration of contrast via IV in place
longer than 20 hours increases risk of
extravasation and phlebitis
• Multiple attempts at IV access at same
site increases risk of extravasation
Patient Safety Advisory (2004), Extravasation of Radiologic Contrast
Dallas, TX • November 2–4, 2012
National Guidelines
for Vesicants
• Avoid using sites more than 24 hours
• Avoid areas of flexion
– Radiology Guidelines recommend AC for
administration of Contrast Media
• Flush with Saline before and after
• Check blood return before and after
Infusion Nurses’ Society
Oncology Nurses’ Society
Standards of Care
Dallas, TX • November 2–4, 2012
Question
• What affect did Contrast have with the
other medications she was receiving
– Morphine
– Potassium
– Zofran
Dallas, TX • November 2–4, 2012
Ask Questions
•
•
•
•
•
•
What is the practice of CT Techs?
Check for blood return?
Check for patency?
Scrub hub?
Flush with Saline before and after?
How old the IV site?
Dallas, TX • November 2–4, 2012
The questions
•
•
•
•
CT check for blood return?
Power injected?
What other medications through IV site?
How long do IV’s last after
administration of Contrast Media
Dallas, TX • November 2–4, 2012
Results
• Collected data on 60 patients for CT &
MRI
• Magnevist MRI-1960milli/osmL
• Omnipaque 350-844milli/osmL
• 60 patients, 63% (n=38) no
extravasation or phlebitis
• 69% no blood return prior to injection
Kirschner, R. (2010).
Dallas, TX • November 2–4, 2012
Results
• 60 patients, 31% (n=22) had concurrent
vesicant therapies
• 100% (n=22) developed phlebitis within
24 hours contrast and another vesicant
– (n=10) MRI contrast
– (n=12) CT contrast
• All CT patients power injected
• No MRI patients power injected
Dallas, TX • November 2–4, 2012
Which Medications?
•
•
•
•
•
Zofran
Potassium
Morphine
Protonix
Vancomycin
Dallas, TX • November 2–4, 2012
Action Plans
• All PIVs need to be started with 24
hours of contrast media
• All CT techs check for date of insertion
before administration of contrast
• All CT techs check for blood return
before administration of contrast
• If not within 24 hours and no blood
return-restart PIV
Dallas, TX • November 2–4, 2012
Post Administration
• Discern alert placed
in electronic
documementation
for nurses, alerting
them to
administration of
contrast and top 5
medication. Site
may develop
phlebitis and may
need changed within
24 hours.
Dallas, TX • November 2–4, 2012
Resource Team Assistance
Personal Care
Rapid Reponse
Assistance
5%
1% In the Count
0%
Crashing
Communication to
Patient
Highter
SWAT
0%
Level
of
3% Code Support
Care
1%
7%
Central Line Placement
0%
Admission
1%
CVVH consultation
1% Intubation
1%
Change of Shift
Patient
Consultation
Care coverage
5%
Lunch 1%
support
1%
Stroke Alert
0%
Trouble
shooting Lines
1%
IV Starts
45%
Sepsis Bundle
6%
Sepsis Alert
5%
Rounds
6%
Transferring a patient
1%
Unit Support
8%
Lab Draws
Dallas, TX • November 2–4, 2012
4%
Literature
• 90% of patients require PIV for
procedures/medications
• IV education and skills have removed from many
nursing school curriculum after Hegstad and Zsohar
(1986) study showed no difference in outcomes from
simulation versus live practice for IV skills
• Mentoring with an expert has been shown to improves
skills and confidence (McGee, 2001)
Dallas, TX • November 2–4, 2012
Experience with IV’s
16 participants (n = 16)
The mean age of participants was 30 years (range 23 – 44 years).
The majority of participants were female (n = 15)
Most staff nurses had one to five years of RN experience (n = 9)
About half of the participants worked on a med/surg unit as a staff RN (n = 8), while
the other half were staff nurses in PCU or ICU (n = 7). One participant was from
WIS.
Participants’ highest level of nursing education was equally divided
ADN (n = 8) and BSN (n = 8).
All but one participant had experience inserting IVs in nursing school.
The majority of participants (n = 14) had experience inserting IVs on both patients
and mannequins / IV arms.
Practice with IV in nursing school varied
never (n=1)
one to two times (n=1)
three and five times (n = 8)
six to ten times (n = 4)
more than ten times (n = 2)
Dallas, TX • November 2–4, 2012
Human Factors-Training
•
•
•
•
Ultrasound IV insertions
Education
Competency
Outcomes
Dallas, TX • November 2–4, 2012
IV Cannulation Outcomes
Using 1 ¼” needles with US
622 IVs
242-41% failed in under 24 hours
531-90% failed in under 48 hours
62-10% made it to 72 hours
After 24 hours
Upper arm fails 78%
Antecubital fails 41%
Lower arm fails 28%
Unpublished data, Royer, T. (2006).
Dallas, TX • November 2–4, 2012
Length and Size of Needles
•
•
•
•
The deeper the vein, the less needle in the vein.
Use longer catheters: 1 ¾ inch
No deeper than 1cm
Site selection:
– Lower arm
– Upper arm-Cephalic veins
– Antecubital
Dallas, TX • November 2–4, 2012
Bacterial Phlebitis
• Inflammation of the vein intima associated with
bacterial infection
• Less frequently seen but more serious because it
predisposes patient to systemic complications
• Type of ultrasound gel for assessing and accessing
the vein
– Clean to assess
– Sterile to access
sterile
clean
Dallas, TX • November 2–4, 2012
sterile
Claims and Dollars for the System
for Claims where
Medication Error was the Primary Event
Year
• 2005
• 2006
• 2007
No.
130
130
130
Amount Incurred
$ 2 million
$ 5 million
$ 7 million
Dallas, TX • November 2–4, 2012
Common Problems
Identified in Claims
• Infiltration of IV contrast 14 of 58 claims
• Poor charting of IV site assessment
• IV not changed when patient complains
• IV not changed per policy
• MRSA infections after IV removed
Dallas, TX • November 2–4, 2012
Scope of Practice
• Anatomy and physiology limbs, to include vein,
artery, and nerves
• Assessment of vessels
• Appropriate vessels and cannulation techniques
• Aseptic technique
• Appropriate length and size of needles
• Complications, management, and troubleshooting
Dallas, TX • November 2–4, 2012
Strategies
• Assessment of nurses’ IV knowledge
and skills on hire
• Precepting and mentorship IV skills and
knowledge
• Education, skills, competencies for US
IV insertion
• Assessment of IV practice in your
facility for vesicants/contrast media
Dallas, TX • November 2–4, 2012
Guidelines for
PIV insertion
Dallas, TX • November 2–4, 2012
Algorhythm for Right Line?
Dallas, TX • November 2–4, 2012
Competencies
Dallas, TX • November 2–4, 2012
Summary
• Assessment of knowledge,
competencies, practices, and policies
• Policies and Procedures
• Documentation
• INS Standards of Practice
• All nurses who start IVs are Infusion
Nurses, not just nurses who are on IV
teams and insert PICC lines
Dallas, TX • November 2–4, 2012
References
•
•
•
•
•
•
•
•
ECRI (2004). Extravasation of Radiologic Contrast, Patient Safety
Advisory, 1(3), 1-5.
Infusion Nurses Society Standards of Practice, (2011).
Kirschner, R. (2010). Contrast media-Phlebitis implications. US
Radiology, 27-30.
Maki, D., Kluger, D., Crnich, C. (2006). The risk of bloodstream
infection in adults with different intravascular devices: A systematic
review of 200 published prospective studies. Mayo Clin Proc, 81(9),
1159-1171
Pujol, M., Hornero, A., Saballs, M., et al. (2007). Clinical epidemiology
and outcomes of PIV related blood stream infection at a universityaffiliated hospital. Journal of Hospital Infection, 67(1), 22-29.
Royer, T. (2006). Unpublished data for US IV Insertion.
Trinh, T., Chan, P., Edwards, O, et al. (2011). Peripheral venous
catheter-rated staphylococcus aureus bacteremia. Infection Control and
Hospital Epidemiology, 32(6).
Zingg, W. & Pittet, D. (2009). Peripheral venous catheters: An underevaluated problem. International Journal of Antimicrobial
Dallas, TX Agents,
• November34S.
2–4, 2012
S38-S42.