Transcript Presentation Title

Risk Benefit Analysis of
Central Venous Access
Devices
Julie D. Painter RN MSN OCN
Clinical Nurse Specialist
Community Health Network
Indianapolis, IN
[email protected]
Dallas, TX • November 2–4, 2012
Risk-Benefit Analysis of CVAD’s
Session Code:102 Contact Hours: 0.8 CRNI Units: 2
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Tonight’s Event:
Industrial Exhibition and Networking Reception
3:30-5:30pm
Dallas, TX • November 2–4, 2012
Objectives
•
List the steps in the process of riskbenefit analysis
•
Describe risk-benefit analysis as it
applies to various CVADs
Dallas, TX • November 2–4, 2012
Retrospective View
• Until the late 1970’s CVAD’s were not common in our
patients
• Peripheral IV’s were the mainstay of intravascular
therapy –most were made of metal and not flexible
• Central lines were commonly temporary subclavian &
femoral caths & dialysis shunts for patients with
leukemia
• Broviac and Hickman developed devices to assist in
long term infusion that would meet the needs of our
patients(right atrial silastic catheters)-most had only
been used in the world of pediatrics to this point
• Venous ports, peripherally inserted central catheters
Dallas, TX • November 2–4, 2012
Current State of Practice
• In 2012 we are at a point in practice where CVAD’s
are common place
• Commonplace and so that perhaps we have lost our
respect and diligence of the CVAD
• 500,000 CLABSI’s per year in the United States
• Increased length of stay 11-23 days
• Cost to healthcare per episode $33,000-$55,000New info from VHA states potentially >$100,000
• Mortality 5-7%
Dallas, TX • November 2–4, 2012
A solid venous access
device program will result
in the least amount of risk
to institution & patient
with the greatest benefit
to the institution & patient
Dallas, TX • November 2–4, 2012
So how does one go about
analyzing the risk and
benefit of central venous
access devices and
processes??
Dallas, TX • November 2–4, 2012
Value = Cost/Quality
Cost is More than Money!!
Quality=Risk/Benefit
ratio
Dallas, TX • November 2–4, 2012
Definition of Risk
1. A possibility of loss or injury; peril
2. Someone or something that suggests
hazard
3. The degree of probability of loss or
potential of peril
Meriam-Webster Dictionary, 2012
Dallas, TX • November 2–4, 2012
Definition of Benefit
1. Something that promotes well-being
2. A good or helpful result or effects
Meriam-Webster Dictionary, 2012
Dallas, TX • November 2–4, 2012
Risk & Benefit
• Viewed as institutional/facility risk
benefit
OR
• Viewed as personal risk & benefit for
the patient
Dallas, TX • November 2–4, 2012
Weighing risk vs. benefit
Dallas, TX • November 2–4, 2012
Institutional or Facility Risk
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Inability to meet CMS measures with CLABSI’s
Increased hospital acquired infections(HAI’s)
Increased length of stay
Increased cost from HAI & length of stay
Reduction in reimbursement
Loss of insurance contracts due to CLABSI
Public reporting influences consumer choice &
marketing(e.g. HCAPHS
Dallas, TX • November 2–4, 2012
Patient Risk
• Increased morbidity
• Complications upon insertionpneumothorax, hemothorax
• Infection, thrombosis, & migration up to
30%
• Superior vena cava obstruction
• Pulmonary emboli
Dallas, TX • November 2–4, 2012
Patient Risk with Central Venous
Access Device
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Infection
Phlebitis
Thrombus/DVT
Infiltration
Breakage
Dislodgement/disconnection
Increases in morbidity & mortality(due to HAI)
Unnecessary risk due to inappropriate selection of
venous access device
Dallas, TX • November 2–4, 2012
Infection Risk & Sources
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Intraluminal
Skin
Extraluminal
More lumens greater risk
Diameter
Duration of placement
Dallas, TX • November 2–4, 2012
Infection Risk-Sources of
Infection-Intraluminal
• Intraluminal-the catheter hub;
stopcocks; injection ports; needle free
connectors; connecting and
disconnecting IV tubing's-without proper
technique & devices to reduce infection
introduction the bacteria are directly
injected into the lumen and directly into
the blood stream
• As we introduce bacteria into the
bloodstream
Dallas, TX • November 2–4, 2012
Infection Risks
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Endocarditis
Osteomyelitis
Septic joints
Septic emboli
Abscesses in remote locations
Dallas, TX • November 2–4, 2012
How do we break the cycle of
introducing infection?
#1 Look at the product and the design of your needleless access
device-proper technique
#2 Look at the process of disinfecting the access device-proper
technique
#3 Look at the frequency of access device exchange
Ryder studies related to access devices and factors that influence
greater risk of a blood stream infection; have looked at design
such as split septum and the shape of the top of the cap and
a) Access mechanism
b) Flow path
c) Fluid displacement
Dallas, TX • November 2–4, 2012
Infection Prevention
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Hand washing
Meticulous respect of all central lines
Dressings-occlusive
Dressing change and care procedurechlorhexadine, masks, sterile technique
• Cleansing of injection caps
• Tubing changes
• Reduction of interruptions & opening of lines
Dallas, TX • November 2–4, 2012
Thrombosis
Research notes that position of catheter
tip determines risk of thrombosis
Incidence of proven thrombosis corelated
due to tip placement:
2.6%
Distal
5.3%
Intermediate
41.7%
Proximal(16 Xmore)
Dallas, TX • November 2–4, 2012
Thrombosis
• Greater risk in females
• Greater risk when placed in left side vs.
right side
• History of hypercoagulability or DVT’s
Dallas, TX • November 2–4, 2012
Institutional Benefit
• Appropriate line selection & care results in
best possible quality outcomes
• Best outcomes results in meeting CMS and
other payer expectations(contracting &
reimbursement)
• Enhanced patient satisfaction when
appropriate line selected and best outcomes
occur
• Reduced costs related to LOS; CLABSI
Dallas, TX • November 2–4, 2012
Patient Benefit
• Satisfaction
• Quality, safe outcomes without
compromise from the desired state of
care & well-being
• The expectation of our patients is that
the care we provide is competent and
state of the knowledge
Dallas, TX • November 2–4, 2012
Benefits of CVAD
• Reduction of peripheral IV sticks for
labs, medications, etc
• Reduced discomfort & anxiety related to
PIV sticks
• Enhanced patient satisfaction
Dallas, TX • November 2–4, 2012
Types of Peripheral Access
• Peripheral IV line
• Midline-duration of placement can last
up to 30 days
Dallas, TX • November 2–4, 2012
Types of CVAD’s
• Temporary non-tunneled caths such as
subclavian or femoral lines
• Right atrial silastic (groshong, hickman)
• Venous port
• Peripherally inserted central catheters
(PICC)
Dallas, TX • November 2–4, 2012
Is there a need for a CVAD?
Every institution needs a systematic
approach to determining appropriate
venous access
Determine tools/algorithms to use to
evaluate patient needs
Dallas, TX • November 2–4, 2012
Before we place CVAD’s in
our patients we must know
that we have done our due
diligence & have the best
interest of the patient at
the forefront of every
intervention in care!
Dallas, TX • November 2–4, 2012
Unique Patient Characteristics for
Consideration
• History of DVT
• Previous Central Venous Access
Devices
• Risk of Infection-Immunosuppression
• Hypercoagulability
• Previous lymph node removal
• Pacemaker placement
• Work or lifestyle
Dallas, TX • November 2–4, 2012
Evaluation of Patient for a CVAD
• Duration of therapy
• Exhausted peripheral options including
Midline
• Type of medication & fluids
• Irritant vs. non-irritant vs. vesicant
• Lab draws
• Patient co-morbid conditions
Dallas, TX • November 2–4, 2012
Patient Case Situation #1
• 65 year old male; admitted for
osteomyelitis due to dog bite
• Teaches golf at the local country club
and amateur golfs at least 3-4 times per
week
• Will need 45 doses of intravenous
antibiotics
• Has excellent peripheral IV status but
antibiotic is considered an irritant
Dallas, TX • November 2–4, 2012
Patient Case Situation #2
• 48 year old female admitted with newly
diagnosed stage III breast cancer
• 6 weeks post right mastectomy with
total lymph node dissection &
reconstructive surgery
• Will need every 3 week chemotherapy
treatments and lab draws,
chemotherapy regimen includes 2
vesicant agents
Dallas, TX • November 2–4, 2012
These were examples of
individualized risk benefit
analysis but let’s consider a
broader facility view of risk
benefit analysis
Dallas, TX • November 2–4, 2012
Process for Risk Benefit
Analysis
1. Understand the definition of risk & benefit
2. Be open to looking at everything & leave “no stone
unturned”
3. Determine the processes and practices that are
taking place within your facility
4. Know your data and measurements that reveal
outcomes of quality, safety and satisfaction related
to central venous access devices
5. Utilize structured mechanisms to compare &
contrast your practice to evidence based practice
and national standards
Dallas, TX • November 2–4, 2012
Have we done due
diligence?
• Evaluate the number of central line days
in comparison
(National Healthcare Safety Network
benchmark)
• Are peripheral IV starts being utilized
first
• Are vein enhancement devices used to
assist in peripheral IV starts
• Are the central lines appropriate
Dallas, TX • November 2–4, 2012
What components in central venous
access devices must be considered in
our analysis?
• Line selection-algorithm or
process
• Process for ordering &
requesting
• Practice-is it evidence
based? Does it match
national benchmarks? Does
it adhere to national
standards(e.g. CDC)
• Line data-what does it
show? What is it telling you?
Types of lines; # of line
days;
• Products
• Number of persons involved
in process
• Validation of expertise &
competency of those
inserting lines
• Process for monitoring
outcomes-what does the
data show?
• Risk events/reports-trends
• Use of central line bundle for
placement
• Use of central line bundle
practices
Dallas, TX • November 2–4, 2012
Pitfalls in Analysis Process
• As we analyze our processes we often
want “the quick fix”
• We want to take the “broad brush”
approach to just start changing and
adjusting the process
• Making any change or variation in a
process influences outcomes
Dallas, TX • November 2–4, 2012
Analysis-Takes Time
• There is no quick fix yet the problems
that you find may appear small, you
must look at the entire process
• Look at the way the process is
“supposed to be” to the “way that
actually is occurring”
• This requires us to be out there and
work with each person who touches the
process
Dallas, TX • November 2–4, 2012
The Team
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Clinical Leadership(example CNS)
Infection Prevention
Quality Risk Management
Bedside Staff
Nursing Education
Epidemiology & Physician
Expert in process improvement-if
available
Dallas, TX • November 2–4, 2012
Analysis-Review the
Process
Review the process from A to Z- from the assessment &
decision point to place a central line in a specific patient
to the point of removal or discharge of the patient
Include a review of the processes utilized to determine
type of line; process for placement scheduling;
timing;etc.
Process for all line care from cap changes; dressing
changes; line accessing; tubing changes; fluids and
discontinuation
Dallas, TX • November 2–4, 2012
Analysis-Diagram & Audit
Diagram the process(es) from the perspective of policy;
then meet with the persons who do the process; those
who select the lines; those who place the lines; those
who care for the lines; and anyone who touches the
lines
Audit the process-often best to have a set of “fresh
eyes” a person who is naïve to the process and without
preconceived notions
Dallas, TX • November 2–4, 2012
Analysis-Ask Questions
Questions:
• How did the processes map out?
• Do the 2 processes match?-Reality
meets perception!
• What are the areas of conflict or
concern?
• Any breaks in the system or areas of
risk?
• In the review were products consistent?
Dallas, TX • November 2–4, 2012
Determination of Change
• Once items have been reviewed by the
team & actual practice auditeddetermine the process for enhancing
outcomes
• What items are not meeting best
practice & need changed a.s.a.p.
• Take standards and evidence based
practice to improve policy &
competency
Dallas, TX • November 2–4, 2012
Determination of Change
• Meet with unit staff & leadership to help
make the change
• Education-multi-modalities
• Implement
• Audit
• Evaluate and continue the process to
sustain the gain!
Dallas, TX • November 2–4, 2012
Remember the care we mentor &
teach today will be the care “we”
as patients & our loved ones will
receive today & in the future. If the
care you see is not what you would
want then be a part of making the
CHANGE
Dallas, TX • November 2–4, 2012