Vascular Access Matters
description
Transcript of Vascular Access Matters
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Clinical strategies to improve patient outcomes
Vascular Access Matters
...because one small act can save - or cost - a life.
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Introduction
Proper care: saves lines, saves lives.
Standardization of Care: new technology, new challenges: how to stay current?
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FMEA: Failure Mode Effects Analysis
Leaders FMEA #1:2007 Central Lines
Project Leader Joan Blondin, Institute for Quality
Inpatient Leaders: Mari Cordes, RN, Nurse Educator, IV Team
Outpatient Leaders: Karen McBride, RPh, Director of Pharmacy Debra Gibbs RPh, Outpatient Infusion
Coordinator Health Center Pharmacy Physician Leaders:
Kemper Alston, MD, Infectious Disease William Raszka. MD, Pediatric Infectious Disease
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Kathy Castello RN, Outpatient Infusion Nurse, HCPDebra Wildermuth, Outpatient Infusion Nurse, HCPJohn Ahern RPh, Inpatient PharmacyHeidi Pentkowski, Clinical Case Manager Heidi Moore, RN, Children's Specialty Center Sally Hess, Infection Control PractitionerJoanne Barton, RN, Baird 5Keven Eriksen, RN VNANicole Courtois, RN, Nurse Educator Outpatient Cindy Gebo, RN, PICU EducatorDeb Kutzko, NP, Infectious Disease Donna Benway, RN, Value Analysis Coordinator, PurchasingSue Goetschius, RN, Nursing Education DirectorEllen Crook, RN, Hematology/Oncology ACC
TEAM MEMBERS
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Process ReviewCentral Line Care
Process review for central line care revealed significant variation in:
medication administration dressing changes flushing process blood draw technique The variation occurred from unit to unit and clinic to clinic.
Education Material Review of the education material at FAHC revealed process
techniques that do not meet nationally acceptable best practice standards for central line care.
Supplies Review of supplies used at FAHC revealed 7 types of needleless
connectors that included positive, negative, and neutral displacement caps, all requiring different flushing techniques.
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Statistics Catheter related bloodstream infections (CRBSI)
are the most costly & life threatening of all healthcare infections.
Between 500-4000 US patients die annually due to blood stream infections.
25% of all CVC usage ends in occlusion. ~ $100,000 of TPA used for PICC catheter
clearance @ FAHC 10/07-03/08. (Does not include expenses of nursing time,
supplies, delay of treatment, catheter replacement.)
1 References: Hadaway L. Flushing vascular access catheters: risks for infection transmission. Infection Control Resource. http://www.infectioncontrolresource.org/past_issues/IC14.pdf
2 Deitcher S, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplace for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. 2003;20(1):317-324.
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Statistics (cont’d)
271 people die from HAI every 24 hours2
40,000/dayibid
271 people die from HAI every 24 hours2
Case fatality rate for CR-BSI approaches 20%1
1www.ihi.org accessed 4/29/20082www.safecarecampaign.org, accessed 4/29/2008
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Problem Solving Central Lines
•Occlusion•Emboli•Extravasation/Infiltration•Infection
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Problem: Emboli
Different types of emboli Air Catheter Wire Thromboembolus
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Occlusion Infection risk Appropriate line flushing – do not force Know your VAD – heparin, or saline
flush? Avoid plunging syringe to bottom Is line positional? Should have blood return each time
catheter is used. Nurse is liable for use of malfunctioning catheter.
tPA for catheter clearance
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Problem: Emboli – Identification
Medical Emergency Deep respirations Coughing Cyanosis Gasping Weak pulse Low or absent BP
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Problem: Embolus -Treatment CATHETER embolus (catheter fragment in
bloodstream): THIS IS CONSIDERED A MEDICAL EMERGENCY:
Immediate medical intervention is warranted. Implement strict bed rest. Immediately apply tourniquet PROXIMAL to the site to
retain the fragment in the arm. Obstruct venous, not arterial flow.
Assess pulses distal to tourniquet every 15 minutes. Initiate oxygen therapy. Notify physician, contact Interventional Radiology to
prepare for emergent procedure. Monitor vital signs. Ensure patient has adequate peripheral IV access. Only MD should remove tourniquet.
AIR embolus Clamp or kink catheter. Position patient on LEFT side in
Trendelenburg. Call MD immediately. Administer oxygen, monitor vital signs,
and setup for code 99.
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Care Giver Audit Is needleless connector disinfected for 15 sec. prior to
flushing and prior to connecting infusions? Are needleless connectors changed every 72 hours
(central lines) and after blood draws? Are needleless connector changes documented
anywhere? Are peripheral and central line dressings dated? Is dressing change documented in HISS caredex? Is dressing dated? If dressing dated, is it current? Is administration set labeled with date? If administration set labeled with date, is it current? Is flushing appropriate for line type? Is flushing appropriate after blood draw?
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Infection Control
97%
55%
100%
0%
20%
40%
60%
80%
100%
120%
Hand Hygene Performed Connector Disinfected 15 sec. Contaminated after disinfected
Infection Control
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Central Line Knowledge
76%79%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Non-valved lines clamped when not in use RN knows what line Pt has RN knows if line is valved or non-valved
Central Line Knowledge
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PrinciplesOf Asepsis
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Problem: Infection pretest
If the nurse touches any pt. object after she performed hand hygiene, she must repeat hand hygiene immediately prior to handling vascular access devices.
T F
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Problem: Infection
pretest Evidence based: A ____ second
scrub of hub will provide adequate disinfection.
Catheter related infections related to inadequate disinfection can most likely be classified as
a. intraluminal b. extraluminal
“All models of needleless access ports were successfully disinfected..” with 15 second scrub with isopropyl alcohol (IPA).
Wendy, MT, MPH, CIC and Chinn, Raymond, MD, FACP “Successful Disinfection of Needleless Access Ports: A Matter of Time and Friction”, JAVA (12; 3) 2006 pps 140-142
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Principals of Asepsis
Medical Asepsis • clean: reduce and prevent spread of microorganisms
Surgical Asepsis • sterile: aim to eliminate microorganisms
Contamination – caused by:•prolonged exposure to air•wicking (capillary action) from wet areas•out of field of vision•objects below waist•touched by non-sterile objects
•bedsheets, skin, contaminated syringes/tubing
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Biofilm
• Fibrin is not necessary to make biofilm• All indwelling devices have biofilm• Biofilm formation begins immediately
“…Biofilm forms when bacteria adhere to surfaces in aqueous environments and begin to excrete a slimy,glue-like substance that can anchor them to all kinds of material…”
Center for Biofilm Engineering, Montana State University
permission P. Stoodly
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Biofilm and Infection
Biofilm clusters with streamers Showing flow in channel (e.g. blood vessel)
Biofilm: slimy glue like matrix created by bacteria that cannot be eliminated and is resistant to antibiotics.1 Planktonic intra or extraluminal ‘clumps’ can be released into the bloodstream.
1Catheter-Related Infections: It's All About Biofilm, Marcia A. Ryder, PhD, MS, RN Topics in Advanced Practice Nursing eJournal. 2005;5(3) ©2005 Medscape, Posted 08/18/2005
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Integration
how you practice.
Transform intowhat you know
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Catheter Site Assessment
Assess all VAD sites for: erythema, induration edema (swelling) pain discharge catheter migration (measure external
length of central lines)
With permissionJ. Bowen-Santolucito
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Perform hand hygiene EVERY time immediately prior to handling vascular access devices.
Chlorhexidine and isopropyl alcohol (e.g. Chloraprep) is FAHC preferred antiseptic for central line insertion and maintenance
MUST use sterile procedure and wear mask (for IVAD accessing as well).
Home patients must wear mask; highly recommended for inpatients as well.
Infection: Managing catheters
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•FAHC IV Therapy 847-3647•Intradoc
NGP0009 Central Venous Access DevicesINFC00003 Prevention of IV Device Related Infections
NGP 119 De-Clotting Central Venous Catheters Using Thrombolytic Agent tPARenal policies•NKF, Safe Care Campaign, and IHI websites•Professional forums
Resources
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Infection: The Impact
A Mother’s Letter to a Hospital CEO safecarecampaign.org
Our son died in your hospital 7 days ago. He died from a bacterial infection he caught there as a result of his medical care while being treated for something else. It created so much pressure around his brain that it caused part of it to be pushed into his spinal column, leaving him a helpless ventilator-dependent quadriplegic and ending his short but unforgettable life among us all…….
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………..Dear CEO, I hope you read this letter to your team aloud. Tell your board that we do not want anything for the loss of our dear son but a dramatic and effective plan for change that will make a difference for others who trust healthcare in general and your hospital specifically. We look to you to partner with us as patients and caregivers so that we may all be safe and well, both now, and in the future.
Sincerely, Victoria Nahum
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Questions?