Transcript PIV Harm Prevention: Downloadable PowerPoint

Preventing Pediatric Intravenous
Extravasation Injuries
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Neil Johnson, MD
Barb Tofani, RN, MSN
Sylvia Rineair, RN, MSHA, VA-BC
Mary Haygood, RN, BSN (Retired)
Julie Stalf, RN, MSN, VA-BC
Darcy Doellman, MSN, RN, CRNI, VA-BC
March, 2014
Objectives
• High Level Overview:
– Cincinnati’s 4 Year Intra Venous Extravasation Harm
Reduction Initiative
• Our 4 Components
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Reliable Hourly Bedside PIV Checks
Evidence Based 3 Tier Medication Tissue Toxicity List
“No Grade” 2 Component Assessment / Documentation Tool
Real Cross-Cultural Leadership
• Discussion - Questions
Basic Principles
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It takes a Team
Culture change is really hard work
“What would we do for our own children” ?
No-one has all the answers
Basic Principles
•
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It takes a Team
Culture change is really hard work
“What would we do for our own children” ?
No-one has all the answers
What would we do for our own children ?
CCHMC Safety Culture
CCHMC infusion and Vascular Access Governance (iVAG)
Cabinet Sponsors
•Medical Members of Cabinet
•Bob Carpenter J.D.
Leadership Group
•Barb Tofani R.N.
•Neil Johnson M.D.
•Sylvia Rineair R.N
•Mary Haygood R.N.
•Tracey Blackwelder
•Darcy Doellman R.N.
Bi-Monthly
•Derek Wheeler M.D.
•Denise Adams M.D.
•Vicki DeCastro, RN
•John Hingl RPH
•Ranjit Chima M.D.
•Steve Muething M.D.
•Rich Falcone M.D.
•Sam Kocoshis M.D.
•Lauren Solan M.D.
Permanent Working Groups
Ad-Hoc Working Groups
Tofani
Doellman
Devices
6
Weeks
Tofani / Johnson
Johnson
Doellman / Rineair
Operations and
Safety
Blood Stream
Infections
Process
Improvement
and
Monitoring
Rineair / Stalf
Training
Johnson / Tofani
Research
Johnson / Haygood / DD
Example:
Education
PIV Infusion
Public Relations
Working Group
R/Y/G List
January 25, 2011
CCHMC infusion and Vascular Access Governance (iVAG)
Cabinet Sponsors
•Medical Members of Cabinet
•Bob Carpenter J.D.
Leadership Group
•Barb Tofani R.N.
•Neil Johnson M.D.
•Sylvia Rineair R.N
•Mary Haygood R.N.
•Tracey Blackwelder
•Darcy Doellman R.N.
Bi-Monthly
•Derek Wheeler M.D.
•Denise Adams M.D.
•Vicki DeCastro, RN
•John Hingl RPH
•Ranjit Chima M.D.
•Steve Muething M.D.
•Rich Falcone M.D.
•Sam Kocoshis M.D.
•Lauren Solan M.D.
Permanent Working Groups
Ad-Hoc Working Groups
Tofani
Doellman
Devices
6
Weeks
Tofani / Johnson
Johnson
Doellman / Rineair
Operations and
Safety
Blood Stream
Infections
Process
Improvement
and
Monitoring
Rineair / Stalf
Training
Johnson / Tofani
Research
Johnson / Haygood / DD
Example:
Education
PIV Infusion
Public Relations
Working Group
R/Y/G List
January 25, 2011
Definition
• HARM
– Institute for Healthcare Improvement (IHI)
• “Unintended physical injury resulting from ….medical
care…”
– Canadian Disclosure Guidelines
(JAMA 2012 Vol 307 #20)
• “an outcome that negatively affects a patient’s
health / quality of life…”
CCHMC I/V Extravasation HARM
“hVAG”
OUTCOME
or
TREATMENT
Based
Definition
• SAFETY
Institute of Medicine (2000):
“….no commonly accepted definition of the
safety net exists…..”
Institute of Medicine,2000 America’s Health Care Safety Net: Intact but Endangered. National Academy Press p3-4
Definition
(CCHMC Vascular Access Team )
• SAFETY:
• The Processes, Policies, People and
Systems which seek to:
•MINIMIZE Necessary Risk
•AVOID Unnecessary Risk
Definition
• SAFETY:
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(CCHMC Vascular Access Team )
The Processes, Policies, People and Systems which seek to:
• MINIMIZE Necessary Risk
• AVOID Unnecessary Risk
“NOTHING in Life or Medical Practice is Risk Free”
The ONLY way to achieve Zero Risk is to close the Hospital
“PIV” Peripheral Intravenous
• PIV
– A “simple” device for administration of
medical fluids directly into a peripheral vein
– A simple procedure not worthy of the
attention of an MD
• Common Medical Procedure
– 70 – 80% of Hospital Inpatients
When A PIV Goes Wrong
• Extravasation:
– Inadvertant Deposition of Intended
Intravenous Fluids Into Surrounding Tissues
Source: Google Image Search
Terminology:
Extravasation (Vs Infiltration)
• Cincinnati Only Uses “EXTRAVASATION”
• EXTRA = “Out Of or Outside”
• VASCULAR = “Vessel”
• EXTRAVASATION = “Out of the Vessel”
“Infiltration”
Better used to describe purposeful subcutaneous injection of fluids
Example:
“The skin was infiltrated with local anesthetic solution before incision”
PIV Extravasation
• Basic Mechanisms of Injury
1. VOLUME
• “Simple” PIV Fluids Leak into Subcutaneous Tissues
• Pressure Compresses Local Veins and later, Arteries
• Reduces then Blocks Blood Supply To The Limb
PIV Extravasation
• Basic Mechanisms of Injury
1. VOLUME
• Pressure Compresses Arteries and Veins Reducing Blood Supply To The Limb
2. LOCAL TISSUE TOXICITY
• Chemical: Acid – Base (pH)
• Osmolality [H2O]
• Biological Activity “Drugs doing what Drugs do”
– Vasoactive Drugs
– Chemotherapy
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VOLUME (Pressure)
TOXICITY
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Chemical (pH – Acid/Base)
Osmolality
Biological Activity
Mechanisms of Extravasation Injury
• VOLUME
– Massive Amounts of I/V Fluid in Tissues
– Compartment Syndrome
• Fluid Pressure Occludes Veins
• Venous Occlusion  More Swelling
• Progressive Swelling  Arterial Compromise
• Dead Limb
Our WORST Extravasation Injury was caused by Normal Saline
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VOLUME
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TOXICITY (Local Tissue)
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(Pressure)
Chemical (pH – Acid/Base
Osmolality
Biological Activity
Google Images
Mechanisms of Extravasation Injury
• TOXICITY: Chemical (Acid / Base)
• pH
Acid – Base [H+]
– Blood pH = 7.4
– High or Low pH
pH = 12
Google Images
pH = 2
• Damages Proteins and Kills Cells
pH = 11
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VOLUME (Pressure)
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TOXICITY (Local Tissue)
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Chemical (pH – Acid/Base
Osmolality
Biological Activity
Mechanisms of Extravasation Injury
• OSMOLALITY:
– Non-Isotonic Solutions Destroy Cells / Tissue
Blood
Source: Wikipedia
EXAMPLES: TPN, 8.4% Na Bicarbonate, 20% Dextrose
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VOLUME (Pressure)
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TOXICITY (Local Tissue)
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Chemical (pH – Acid/Base
Osmolality
Biological Activity
Mechanisms of Extravasation Injury
• BIOLOGICAL ACTIVITY:
– Vasopressors
(Epinephrine / Dopamine)
• CONSTRICT Vessels
– Chemotherapy Drugs
• KILL Cells
• Other
“Drugs doing what they are
supposed to do”
Journal of Hand Surgery
Vol 36, Issue 12, Dec 2011. pg: 2060-2065
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VOLUME (Pressure)
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TOXICITY (Local Tissue)
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Chemical (pH – Acid/Base
Osmolality
Biological Activity
Preventing PIV Extravasation Injuries
• Two Simple Ideas
– AVOID Unnecessary Risk
• Give Tissue Toxic Drugs Centrally
– MINIMIZE Necessary Risk
• Catch Extravasations Early
• Use Oral Medications When Indicated
Preventing PIV Extravasation Injuries
• Two Simple Ideas
– AVOID Unnecessary Risk
• Give Tissue Toxic Drugs Centrally
– MINIMIZE Necessary Risk
• Catch Extravasations Early
• Use Oral Medications When Indicated
“It’s not that simple”
“Give Tissue Toxic Drugs Centrally”
- But What Is A Tissue Toxic Drug ?
CCHMC Modified
INS Extravasation
Grading
Where Do I Find The Official
INS List Of “Vesicants”?
• There Isn’t One !
– “Each Institution Develops Its Own”
– Each CCHMC Nursing Subspecialty Had Its Own
– “We Know One When We See One”
• Cincinnati Medication Risk Stratification
– 18 Month Project
– Multi-Disciplinary
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Pharmacy
Nursing (VAT)
Physicians
Evidence Based PhD
Nutrition Service
NICU
“rVAG”
Medication Risk Stratification
• Literature Evidence Search
• MEASUREMENT
– pH
– Osmolarity
• Measurement of COMMON
Pediatric Formulations
• Blood Products Excluded
– Blood = Bruise
– Not Tissue Toxic
RED Criteria
• pH <5 or >9
• Strong Published Evidence
• >950 Mili Osmoles
Journal of Infusion Nursing Vol 36,
Number 1. Jan/Feb 2013
Each Update
has a Different
Color Border
Available at every clinical
workstation
Unexpected Positives
• Universal Availability R/Y/G
– Hard To Avoid
– At Every Clinical Workstation
• Nurses Strongly Influence Doctor Behavior
– Trend  Central Access for Red Drugs
– Increased Awareness of IV Risks of Red Drugs
– “Pseudo Policies” are Sometimes a Positive Phenomenon
Preventing PIV Extravasation Injuries
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Two Simple Ideas
– AVOID Unnecessary Risk
• Give Tissue Toxic Drugs Centrally
– MINIMIZE Necessary Risk
• Catch Extravasations Early
• Use Oral Medications When Indicated
Journal Pediatric Nursing (2012) 27, 682-689)
Hourly PIV Checks
• Peripheral I/V (PIV) Policy Revision
• Nursing Staff Education
– Significant Institution-Wide Effort
– TLC Methodology for Hourly Checks
• Nursing Unit Hourly Checks AUDIT
– If >90% Compliance (after 3 months)  STOP Manual Audit
– If <90% Compliance  Continue Audit until >90% Achieved
• PROBLEMS:
– Manual Data Collection
– Variable Documentation
– Two Electronic Data capture Systems
Reliable Hourly Checks
Result: Good But Not Sustained
Reliable Hourly Checks
New Efforts: Reliable Hourly Checks
• EPIC EMR Implemented
• All I/V Documentation now in ONE place
• 18 month “CVAT” Project with I.T.
All Vascular Access Data Abstraction Project (CVAT)
• >60% Extravasation = 1 Month Manual Audit
– Unpopular!
• Immediate Feedback System
• “Personal Interview” (>60%)
Immediate PIV Extravasation Feedback System
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> 30% volume or R drug extravasation charted in EPIC
Automatic messaging to VAT and Med Director
VAT Team nurse visits bedside 24/7
Immediate Feedback Advice to bedside nurse
Treatment if appropriate
VAT follow-up in 1-2 weeks
– Personal interview (Nurse, supervisor, VAT leader)
– Information Gathering for Analysis by VAT Improvement Team
Compare Is SO Important
EPIC Feedback Strategy Identified “Compare” Not Done Reliably
Compare Is SO Important
EPIC Feedback Strategy Identified “Compare” Not Done Reliably
PIV
“Compare”
Not Done Reliably
-Recent Change: Based On Interviews
So…. TLC Poster Revised
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VOLUME
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TOXICITY
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(Pressure)
(Local Tissue)
Osmolality
pH (Acid – Base)
Biological Activity
Reliable Hourly Checks
The INS Grading System
(Briefly)
• Mostly Descriptive
– Grades 1-4
• Adult Based
– Fixed Measurements regardless of Patient Size
• Poor Harm Correlation with “Grades”
– All Bad Outcomes were Grade 4 (Sensitive)
– BUT….Very Few Grade 4’s had Bad Outcome (NOT Specific)
• Combines TWO Separate Harm Components Into One “Grade”
– VOLUME (“Edema”)
– Medication TOXICITY
• No official “Vesicant” list
• Blood products included  Instant Grade 4
The INS Grading System
(Briefly)
• “Vesicant” Extravasation = Instant / Automatic Grade 4
– 1ml or 100 ml • Same Grade, Very Different Outcomes
Grade 4
The INS Grade 4 Problem
Assumption: Highest Grade = Highest Harm ??
2008
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CCHMC Safety Leaders Assumed “GRADE 4” =“Serious Harm”
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2009
“It’s the HIGHEST Grade.. Why not ??”
Grade 4 PIV “Harm” was >40% of “Total Hospital Harm”
Pressure on VAT to “Reduce Serious Harm” was Substantial
The CCHMC Extravasation
Documentation Tool
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It’s ONLY a Tool
Does NOT Change Outcomes Itself
Requires Leadership and Accountability
Informs Change and Quality Processes
Separates The Two Major Harm Components
Used for ALL Extravasations, Not Only PIV
Compulsory at CCHMC - INS Grades Not Available
EMR (EPIC) Very Helpful
CCHMC Extravasation Coding System
• Step 1 - VOLUME Measurement
• Step 2 - MEDICATION (If Any)
• Step 3
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DOCUMENTATION
Step 1: VOLUME
Step 1a: VOLUME
• Measure Max Dimension
• Includes ANY Extravasation
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PIV
PICC
CVC
PORT
Scalp / Chest
Step 1b: VOLUME
• Measure ARM Length
• “Y” is ARM length
– Surrogate for Patient Body Size
– Easy To Measure
– Allows Consistent Quantification
• Even If Extravasation is Scalp, Leg or Chest
– Never Measure Leg or Other Part for “Y”
– No Arms?  CCHMC VAT Master Policy #1
Step 1b: VOLUME
• Measure ARM Length
• “Y” is ARM length
– Surrogate for Patient Body Size
– Easy To Measure
– Allows Consistent Quantification
• Even If Extravasation is Scalp, Leg or Chest
– Never Measure Leg or Other Part for “Y”
– No Arms?  CCHMC VAT Master Policy #1
CCHMC VAT Master Policy #1:
“Common sense and good judgment
will be used at all times”
Step 1c: Calculate
Step 1c: Calculate
An Extravasation can be > 100%
Step 2: MEDICATION
Step 3: DOCUMENT
• Other Institutions
Step 3: DOCUMENT
• Other Institutions
http://cincinnatichildrens.org/vascularaccess
Implementation
• BIG Education Effort
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Julie Stalf, RN
Sylvia Rineair, RN
Mary Haygood, RN
Barb Tofani, RN
• CCHMC Education Team
• Institution Wide Initiative
CCHMC System: Driving Treatment
In Plain English
TREAT
unless very good reason
not to
Probably TREAT
unless good reason
not to
Probably NOT Treat
unless good reason to do
so
NO Treatment
Consult and TREAT
Result: Hyaluronidase Rx
• $350
• 4-5 Needle Sticks
• Previously Widely Recommended
• 75% DECREASED Use
– No Serious Harm Events
CCHMC I/V Extravasation HARM
OUTCOME
or
TREATMENT
Based
Results: Calendar 2012-13
• ZERO Severe Harm
• Moderate Harm = 0.55/1000 Line Days
• Red Drugs
– Most Red Drugs Now Only Given PIV in
Code Situations
– Even In A Code  Early Intraosseous Rx
Results: Calendar 2012-13
• ZERO Severe Harm
• Moderate Harm = 0.55/1000 Line Days
• Red Drugs
– Most Red Drugs Now Only Given PIV in
Code Situations
– Even In A Code  Early Intraosseous Rx
“No one has all the answers.
Severe Harm is only one slip up away” (2013)
Results: 2014
• ZERO Severe Harm
• Moderate Harm = 0.55/1000 Line Days
• Red Drugs
– Most PIV Red Drugs Now Only Given PIV in
Code Situations  Early Intraosseous Rx
– BUT:
Recent Case:
4.2% PIV Bicarbonate
“No one has all the answers.
Severe Harm is only one slip up away”
Documents Available:
• http://cincinnatichildrens.org/vascularaccess
Did We Change Anything?
INS Grades 3-4 (2008 -2009)
INS Grades 3-4 (2010 -2011)
Probably ………
No R Drugs
2014
Did We Change Anything?
INS Grades 3-4 (2008 -2009)
INS Grades 3-4 (2010 -2011)
Probably ………
Only 1 Case of Serious PIV Harm
In 5 Years
No R Drugs
2014
“Still Working On It………..”
• AVOID
Unnecessary Risk
• MINIMIZE Necessary Risk
Summary
• Overview:
– 4 Year IV Extravasation Harm Reduction:
• Most Effort is Culture Change / Leadership
• Hard Work: MD / Nursing / Administration Silos are SOLID
• Our 4 Components
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Reliable Hourly Bedside PIV Checks
Evidence Based 3 Tier Medication Tissue Toxicity List
“No Grade” 2 Component Assessment / Documentation Tool
Real Cross-Cultural Leadership
Thanks
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iVAG (Our Governance Group)
The Whole Extraordinary CCHMC VAT Team
“rVAG”
Dallas Children’s Vascular Access Team
John Racadio MD
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“Why Don’t You Just Abolish Grading ???”
Glen Minano – Graphics
Marshall Ashby Quality Improvement Consultant
Steve Muething MD
– Vice President of Safety, CCHMC
Manuscript In Preparation:
Thanks
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iVAG (Our Governance Group)
The Whole Extraordinary CCHMC VAT Team
Dallas Children’s Vascular Access Team
John Racadio MD
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•
“Why Don’t You Just Abolish Grading ???”
Glen Minano – Graphics
Marshall Ashby Quality Improvement Consultant
Steve Muething MD
– Vice President of Safety, CCHMC
What would we do for our own children ?
Preventing Pediatric Intravenous
Extravasation Injuries
• Questions – Discussion
…….