Infusion Therapy Standards of Practice (INS, 2016)

Supplement toJanuary/February 2016 Volume 39, Number 1S ISSN 1533-1458 www.journalofinfusionnursing.com Infusion Therapy Standards of Practice Funded by an educational grant from BD Medical NANv39n1S-Cover.indd 1 31/12/15 4:27 PM 31/12/15 4:27 PM NANv39n1S-Cover.indd 2 Volume 39, Number 1S Supplement to Journal of Infusion Nursing January/February 2016 Seamless Patient Care, with an IV Catheter that Lasts BD Nexiva™ Closed IV Catheter System Longer dwell times can reduce painful restarts. Let’s admit it. Few people look forward to having an IV catheter placed. Patients don’t like it. Clinicians don’t enjoy it. And all that is compounded when a catheter fails or has to be replaced. Use of the BD Nexiva™ Closed IV Catheter System enables longer dwell times and clinically indicated catheter replacement.1* A 2014 clinical study demonstrated that BD Nexiva™ catheters had a median dwell time of 144 hours for catheters in place ≥24 hours.1* The same study showed that longer dwell times of closed systems led to a cost reduction of approximately $1M/year/1,000 beds compared to an open system.1 That’s good for you and for your patients. To order or learn about all the ways BD is caring for you and your patients, visit bd.com/INS today or call (888) 237-2762. * Compared to 96 hours with an open system. 1 González López J, Arribi Vilela A, Fernández Del Palacio E, et al. Indwell times, complications BD Medical and costs of open vs closed safety peripheral intravenous catheters: a randomized study. 9450 South State Street J Hosp Infect. 2014;86(2):117-126. Sandy, Utah 84070 BD, BD Logo and BD Nexiva are trademarks of Becton, Dickinson and Company. 1-888-237-2762 © 2015 BD MSS0932 (12/15) www.bd.com/INS NAN3901S-IFC.indd 2 31/12/15 3:38 PM CRNI®. RN. RN.ins1.org JIN-D-15-00057. MS. INFUSION THERAPY STANDARDS OF PRACTICE Developed by Lisa Gorski. RN. Norwood. FAAN Mary McGoldrick. CRNI® Mary E. RN Darcy Doellman. Hagle. PhD. MS. VA-BC REVISED 2016 315 Norwood Park South. CRNI® Marsha Orr. HHCNS-BC. FAAN Lynn Hadaway. RN-BC.indd 1 05/01/16 11:30 PM . CRNI®. MSN. RN-BC. MEd. MS. MA 02062 www. MSN. BSN. MSN. PhD. PhD. RN AOCNS® Susan Paparella. PharmD Connie Girgenti. CVAA® Crystal Miller. RPh. VA-BC Dora Hallock. ACNS-BC. RN. MN. CRNI®. MSN. BSN. CRNI® Steve Bierman. MD Britt Meyer. MS. DPS(hon). MHA. CRNI®. CRNI®. ACNS-BS. MSN. RPh. CRNI® Loretta Dorn. BSN. RN. CRNI®. MD. RN. BSNc. CRNI® Claire Rickard. OCN® Sharon Weinstein. MSN. RN. BSN. RN. CRNI®. ACNS-BC. VA-BC Cora Vizcarra. Liz Sharpe. MBA. RN-BC. RN. James Joseph. RN. CRNI® Marie Frazier. CWCN. CIC Ann Plohal. ACNS-BC. RN Michael Cohen. LDN Max Holder. MSN. CRNI® Alicia Mares. NE-BC Daphne Broadhurst. OCN® Roxanne Perucca. FASHP Cheryl Wozniak Melissa Leone. RN. RN. BSN. CEN. Ann Corrigan. RD. RN. MPH. CRNI® Robin Huneke Rosenberg. CRNI®. DNP. RN-BC. RN. VA-BC Steve Weber Pamela Jacobs. MSN. BSN. VA-BC Pat Kienle. CRNI®. MSN. MA. CRNI® Claudia Freitag. PharmD. RN. FAAN. BSN. MS. RN Vicky Reith. RN. BSN. RN. RN Mary Zugcic. MS. NNP-BC. CRNI®. MSN. CSP. CRNI® Barb Nickel. CRNI® Laura Rutledge. APRN-BC Cheryl Dumont. OCN®. CRNI® Wes Cetnarowski. Esq. MSN/ED. RN. RN. RN. MPA. RN. RN. RN. MSN. RN JIN-D-15-00057. BA. CEN. RN. VA-BC DAPWCA Marvin Siegel. RN. CHPN Paula Foiw Washesky. ScD(hon). CRNI® Kathy Puglise. BSN. VA-BC Tim Vanderveen. MSc Tina Morgan. APRN. BSN. VA-BC FACW Matthias Kahl Marcia Wise. BScN. MS. CNS. BSN. CCRN Lynn Czaplewski. CRNI® Michelle DeVries. FASHP Russ Nassof. RN. BSN. CRNI® Doreen Gendreau. RN. BSN. Stephanie Fedorinchik. RN Julie DeLisle. RN Marc Stranz. RN.indd 2 05/01/16 11:30 PM . MS. PhD Ofelia Santiago. RN. The Art and Science of Infusion Nursing Infusion Therapy Standards of Practice Reviewers Jeanette Adams. CRNI®. PhD. CRNI® Lynn Gettrust. CNS. RN Beth Fabian. RN. MBA. RN. PhD. RN Vineet Chopra. RN Diane Rutkowski. CRNI®. RN. CRNI®. VA-BC. BSN. ARNP. CRNI® Michelle Mandrack. APRN-CNS. VA-BC VA-BC Michelle Fox. MS. MA. MD Diana Montez. MS. BSN. MPH. BSN. RN. MS Sheila Hale. MS. CRNI® Kimberly Duff. Shawn O’Connell. RN. CNSN Sales Manager BS. RN. RN Michelle Smith. INS CRNI®. and professional development information relevant to the practice of infusion therapy. BSN. FAAN nursing by presenting new research. BSN. MSN. Rhonda Maneval. BSN. BSN. CRNI®. BSN. Patelarou. CNSC. MA. CQA Richelle Hamblin. BSN (415) 603-9197 VA-BC™. VA-BC James Lacy. Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 • Number 1S Editor Editorial Reviewers Peggy Link. CRNI® Lorelei Papke. Wendy L. RN. CRNI® Debra Johnson. MSN. CRNI® RN-BC Michelle L. clinical reviews. RN ACNS-BC. Sharon M. MS CSRN (781) 440–9408 Inez Nichols. RN. ACNS-BC. BSN. CRNI® Marvin Siegel. Britt Meyer. MSN. BA. MA. Keller.taylor@wolterskluwer. RN. CRNI®. DNP. MA. MSN. CRNI® OCN®. BSN. RN. BSN. MBA. BSN. CRNI®. CRNI® Nancy Mortlock. CRNI®. RN. CRNI® Public Member Helen Larson. RN. Corrigan. CRNI®. OCN® Kathleen Wilson. CAE. RN. RN. CSRN. CRNI® Judy G. MEd.barta@wolterskluwer. MPH. Tracey C. C-NAC™ Jodie Lockman-Samkowiak. CRNI® Ann Zonderman. MS. RN. APRN. CRNI® France Paquet. CRNI®. Jones. John Hudson Garrett. BSN. RN. RN. RN. PhD. Dumont. MBA. BSN. MS. Mary Alexander. Articles selected for publication represent the broad scope of the infusion specialty and draw on the expertise of all health care providers who participate in the delivery of infusion. RN. case studies. Williams.com Cheryl J. RN. PhD. CRNI® CRNI®*. RN. Dana Kyles. RN. Senior Account Pamela Clark. OCN®. CRNI® OCN® Cheryl Dumont. Hadaway. CEN. MSN. MPhil. President-Elect Donna Hammond. MS. BC Sales Rep Michaela. CRNI® Editorial Offices Christopher Basnett. NE-BC 315 Norwood Park South Deborah Benvenuto. CRNI® Mary Zugcic. CRNI® Manager Nancy Corbitt. CRNI® West: Michaela Taylor. the official publication of the Infusion Nurses Society (INS). AOCNS®. The Journal of Infusion Nursing. RN. CRNI®. CRNI® INS Board of Directors Catherine Ann Guy. BN. CRNI®. BSN CRNI® CRNI®. VA-BC OCN®. BSN. APRN. RN. Lisa P. CRNI® Alvisa Palese.com MPH. BSN. RN. RN. CIC NEA-BC. RN. FNP. Susan H. BSN. CRNI® FAAN Directors-at-Large Alene J. RN CRNI®. RN. CRNI® Secretary/Treasurer Sarah M. RN. RN. MD Presidential Advisor Mark R. MSN. RN Felicia Schaps. MS. FNP-BC VA-BC. FAAN Jeanette Adams. MA 02062 Georgene Bloomfield. Mohammad Abdollahi. CPNP RN. CRNI® Linda. MSN. FACHE (215) 521-8404 Beth Fabian. CRNI®. PhD. Gaslin.rusch@wolterskluwer. Weaver. Rebecca Anne French. seeks to promote excellence in infusion CAE.com Anne Marie Frey. ARNP-C Jennifer Riesenberg. BSN. DEd Dorothy Lohmann OCN® Mary McGoldrick. MSN. RN. CRNI® Ann Plohal. BSN Fe San Angel. RN. RN. RN Judybeth Crowell.smith@wolterskluwer. ACNS-BC. CRNI® Susan Markel Poole. DON-CLTC™. CRNI®. BSN For advertising information: Tammy Burdeaux. MA. Weinstein. MSN. MSN. ACNS. President Lynn C. BSN. Max Holder. CRNI® Lynn Phillips. MS. RN. Rosenthal. CRNI®. DNP. Judy Hankins. BSN. JD. IgCN BC. PhD. (800) 237-1342 Nancy Fusillo. Jr. MSN. Boersma. BSN. RN. CRNI®. Cora Vizcarra. Field Cynthia Peterson. PharmD. OCN® Nicholas Cardinale. RN Sales Rep Kate Douglass. CRNI® Edward Korycka. CRNI® Mary Alexander. RN. CRNI® CRNI® North/East: Mike Rusch. Kevin Stansbury. CRNI® OCN®. RN. MS. MS. RN. MBA CRNI® INS Chief Executive Officer *CRNI is a registered trademark of the Infusion Nurses Certification Corporation. CEd. CRNI® Christine Pierce. CNS. MSN. MScN michelle. DNS. RN. RHV. OCN®. RN-BC. South/East: Linda Barta. MS. CRNI® Mike. PhD Rose Anne Lonsway. CRNI®. MSN. MSN. MSN Managing Editor Melissa Adler. BSN. Painter. BA. RN. RN. Timothy Royer. Regional CRNI®. C. Advertising Kellianne C. MBA. RN-BC. CRNI® Lauro Manalo. CRNI® Michael Perlow. BSN Lynda Cook. Lisa Bruce. RN. MS. RN. MEd. VA-BC Sandeep Tripathi.indd 3 05/01/16 11:30 PM . MSN. ARNP-BC. Recruitment Advertising Roxanne Perucca. MS. RN. RN. RN. Norwood. Jr. MSN. Donald Filibeck. MSN. Low. MPH. BSN. CRNI®. RN. BS. MSN. RN. PharmD. Hawes. L. CRNI® Julie D. CRNI® Diedre Bird. RN. RN. RN.com Evridiki E. RPh. CRNI® Dora Hallock. ANP. CRNI® Fax: (781) 440–9409 FNP-BC Elizabeth Ann Bonilla. MSN Product Advertising Susan Paparella. Hunter. MSN. JIN-D-15-00057. CRNI® Robin Elizabeth Huneke Rosenberg. CMSRN. PhD. APRN. PhD (646) 674-6537 Ann M. Journal of Infusion Nursing Infusion Nursing Contents Note: The “S” in page numbers denotes supplement issue and does not refer to a specific standard. Foreword S1 SECTION THREE: III. Central Venous Access via INFECTION PREVENTION Peripherally Inserted About the Standards of Central Catheters S55 Practice Committee S3 AND CONTROL IV. Central Venous Access Preface S5 16. Hand Hygiene S38 via Nontunneled Central A Message from BD Medical S6 17. Compounding and Preparation of Vascular Access Devices Parenteral Solutions and (CVADs) S55 Acknowledgments S7 Medications S39 V. Central Venous Access via Methodology for Developing the Tunneled Central Vascular 18. Medical Waste and Sharps Standards of Practice S8 Access Devices (CVADs) Safety S40 Strength of the Body of Evidence S10 and Implanted Ports S55 19. Standard Precautions S41 VI. Peripheral Arterial Access S55 20. Transmission-Based Precautions S42 STANDARDS OF PRACTICE VII. External Jugular Vein 21. Disinfection of Durable Medical Access S56 Equipment S43 SECTION ONE: INFUSION 28. Implanted Vascular Access THERAPY PRACTICE SECTION FOUR: INFUSION Ports S58 1. Patient Care S11 EQUIPMENT 29. Hemodialysis Vascular Access Devices (VADs) S59 2. Special Patient Populations S11 22. Vascular Visualization S44 30. Umbilical Catheters S60 3. Scope of Practice S13 23. Central Vascular Access Device 31. Apheresis Catheters S62 (CVAD) Tip Location S46 4. Infusion Team S17 32. Local Anesthesia for Vascular 24. Flow-Control Devices S48 5. Competency Assessment Access Device (VAD) Placement and Validation S18 25. Blood and Fluid Warming S49 and Access S63 6. Quality Improvement S21 33. Vascular Access Site Preparation SECTION FIVE: VASCULAR and Device Placement S64 7. Evidence-Based Practice and ACCESS DEVICE (VAD) I. General S64 Research S24 SELECTION AND II. Short Peripheral and 8. Patient Education S25 PLACEMENT Midline Catheters S64 9. Informed Consent S26 26. Vascular Access Device III. Central Vascular Access (VAD) Planning S51 Device (CVAD) S65 10. Documentation in the Medical Record S28 I. Short Peripheral Catheters S51 IV. Arterial Catheters S66 II. Midline Catheters S52 SECTION TWO: PATIENT SECTION SIX: VASCULAR III. Central Vascular Access AND CLINICIAN SAFETY Devices (CVADs) ACCESS DEVICE (VAD) (Nontunneled, Tunneled, MANAGEMENT 11. Adverse and Serious Implanted Ports) S52 34. Needleless Connectors S68 Adverse Events S31 IV. Arterial Catheters S53 35. Filtration S70 12. Product Evaluation, Integrity, and Defect Reporting S32 27. Site Selection S54 36. Add-on Devices S71 I. Peripheral Venous Access via 37. Vascular Access Device (VAD) 13. Medication Verification S34 Short Peripheral Catheters S54 Stabilization S72 14. Latex Sensitivity or Allergy S35 38. Joint Stabilization S74 II. Peripheral Venous Access 15. Hazardous Drugs and Waste S36 via Midline Catheters S54 39. Site Protection S75 JIN-D-15-00057.indd 4 05/01/16 11:30 PM Journal of Infusion Nursing Contents Note: The “S” in page numbers denotes supplement issue and does not refer to a specific standard. 40. Flushing and Locking S77 III. Surgically Placed SECTION EIGHT: OTHER CVADs: Tunneled INFUSION DEVICES 41. Vascular Access Device Cuffed/Implanted Ports S92 (VAD) Assessment, Care, and 54. Intraspinal Access Devices S118 Dressing Changes S81 IV. Arterial Catheters S93 55. Intraosseous (IO) Access 42. Administration Set Change S84 Devices S120 SECTION SEVEN: I. General S84 VASCULAR ACCESS DEVICE 56. Continuous Subcutaneous II. Primary and Secondary (VAD)-RELATED Infusion and Access Devices S122 Continuous Infusions S84 COMPLICATIONS SECTION NINE: INFUSION III. Primary Intermittent 45. Phlebitis S95 Infusions S84 THERAPIES 46. Infiltration and Extravasation S98 IV. Parenteral Nutrition S85 57. Parenteral Medication and 47. Nerve Injuries S102 Solution Administration S125 V. Propofol Infusions S85 48. Central Vascular Access Device 58. Antineoplastic Therapy S127 VI. Blood and Blood (CVAD) Occlusion S104 Components S85 59. Biologic Therapy S129 49. Infection S106 VII. Hemodynamic and Arterial 60. Patient-Controlled Analgesia S131 Pressure Monitoring S85 50. Air Embolism S108 61. Parenteral Nutrition S133 43. Phlebotomy S85 51. Catheter Damage (Embolism, 62. Transfusion Therapy S135 Repair, Exchange) S109 I. General S86 63. Moderate Sedation/Analgesia I. General S109 II. Blood Sampling via Direct Using Intravenous Infusion S137 Venipuncture S86 II. Catheter Embolism S110 64. Therapeutic Phlebotomy S138 III. Blood Sampling via III. Catheter Repair S110 Appendix A. Infusion Team Definition S140 a Vascular Access Device S87 IV. Catheter Exchange S110 Appendix B. Illustrations S141 44. Vascular Access Device (VAD) 52. Central Vascular Access Removal S91 Glossary S146 Device (CVAD)-Associated I. Short Peripheral and Venous Thrombosis S112 Index S156 Midline Catheters S91 53. Central Vascular Access II. Nontunneled Central Vascular Device (CVAD) Malposition S114 Access Devices (CVADs) S91 The Journal of Infusion Nursing is a member benefit of the Infusion Nurses Society. INS is a professional association dedicated to enhancing infusion prac- tices that will improve patient outcomes. Through its many member benefits, Articles that appear in the Journal of Infusion Nursing are selected by a process of double-blind peer review. Articles are reviewed by three INS offers access to the latest infusion or more members of the Editorial Review Board or other selected experts. INS retains final approval on all articles published in this journal. research, technology, and education. For INS is not responsible for any statements made or opinions expressed herein. INS does not endorse or recommend any product or service more information about the benefits of discussed or advertised in this publication. Data and information developed by the authors of specific articles are for informational and INS membership, visit www.ins1.org. educational purposes, and are not intended for application without independent, sustaining investigation on the part of potential users. JIN-D-15-00057.indd 5 05/01/16 11:30 PM Journal of Infusion Nursing The Art and Science of Infusion Nursing FOREWORD T hese are exciting times in the field of infusion practice. Never before has there been as much interest, technology, evidence, or cross-disciplinary collaboration in the field as there is today. Whether it’s research that in- forms the safety of a particular vascular access device, guidance for when a device may be appropriate for use, or in-depth reviews of how best to prevent complications—the knowledge, data, and wisdom in our specialty are brim- ming. For infusion and vascular clinicians all over the world, there has never been a better moment to be on the front lines of patient care. Yet, this progress does not come without a price, for with these times also comes great responsibility. For example, our patients have never been more complex in terms of their vascular access needs. Unlike times past, a dizzying array of devices, designs, and technology to meet nuanced needs (eg, power injection-capable midline catheters) or fill key niches (ultrasound-guided devices for patients with difficult access) are now available. The very health care system within which we all operate has transformed—improving in many ways, but also becoming more fractured and misaligned in others. As patients transition through the labyrinth of outpatient, hos- pital, and post-acute care settings, the imperative to do what’s right in their vascular access voyage has perhaps never been more urgent than it is today. In this whirlwind of change, clinicians are expected to not only master the inser- tion, care, and management of vascular access devices but to also inform clinical decisions regarding device choice and venous access route. Although such opportuni- ties present a unique step forward for the field, they also introduce many new and unexpected challenges. For example, what should one do when limited evidence exists to guide clinical decision making? When available data do not support current practice, how should one approach the patient or provider so as to prevent harm? How may one learn, master, and implement the evidence to enact change in her or his facility? And relatedly, what practices are associated with improved outcomes, and which are relics of times past? In the endless quest to improve the care and qual- ity of infusion practice, knowing what we don’t know has become more important than ever before. Highlighting how fortunate we have been to have the Infusion Therapy Standards of Practice serve as the bedrock of our field for so many years is not hyperbole. Rather, the Standards represents the best of our specialty: a tome within which excel- lence, expectations, and enigmas are not only defined but also primed and supported by available data and strength of the evidence. Whether the purpose lies in informing patient care, legal proceedings, or personal edification and growth, no document is more versatile, time-tested, or valuable in the field of infusion practice. As a review- er and contributor to this 2016 update, I am pleased to say the exulted tradition of the Standards continues. With new and improved sections on special patient popula- tions, the definition and role of infusion teams, vascular visualization technologies, and catheter tip location, the 2016 Standards incorporates and assimilates the many advances in our field within a single comprehensive document. Not only have new criteria for practice been added but substantial improvements to the key domains of infection prevention, phlebotomy, and device complications have been included. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S1 JIN-D-15-00057.indd S1 05/01/16 11:30 PM indd S2 05/01/16 11:30 PM . practice. The new Standards is thus not merely recommended. Your patients. and society will thank you for it. This edition continues to provide us with critical answers to the many important questions. and challenges we face today. Foreword These significant enhancements reflect the growth in our field and the ever-changing expectations of the public in infusion care. Vineet Chopra. conundrums. I urge you all to read. but required reading for any clinician interested in infusion or vascu- lar therapy. the questions I ask. there is nothing else like it. and adapt the recommendations within this document to your care and decision making. MSc Ann Arbor VA Medical Center and the University of Michigan Health System October 2015 S2 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. the Standards has informed the work that I do. evaluate. MD. and the clinical care I provide. As a physician researcher dedicated to improving the safety of patients who require vascular access and infusion-based therapies. Quite simply put. MS. and a clinical investigator. CRNI® Home Care and Hospice Consultant. Hagle. WI Ms. She is the author of more than 50 journal articles and has authored several books on the topic of infu- sion therapy. Gorski is a former INS president (2007-2008) who served on the INS Standards of Practice Committee in 2006 and chaired the 2011 committee. FAAN—Chair Clinical Nurse Specialist. RN. Atlanta. and manuals. she has worked with patients and nurses in acute. RN. chapters. Milwaukee. Hagle joined the Standards of Practice Committee for the 2011 edition and returned for this updated version. Inc. Home Health Systems. McGoldrick began her home care career more than 35 years ago. She is a frequent speaker. Mary E. Ms. She served as a committee member for the revision of the 2006 and 2011 Standards of Practice. Milwaukee. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S3 JIN-D-15-00057. Dr. MEd. RN-BC. WI Dr. She is a frequent speaker on the topic of infection prevention in home care and hospice and has authored several books. RN-BC. Journal of Infusion Nursing The Art and Science of Infusion Nursing ABOUT THE STANDARDS OF PRACTICE COMMITTEE Lisa Gorski. FAAN Nurse Scientist. home health care. MS. and long-term care settings. Lynn Hadaway Associates.indd S3 05/01/16 11:30 PM . Hadaway has more than 40 years of experience as an infusion nurse and is internationally known as a consultant and educator. and executive- level positions. management. Inc. HHCNS-BC. Hadaway holds board certifications in nursing professional development and infusion nursing. She has authored more than 75 journal articles and several textbook chapters on infusion therapy. articles. and since that time she has served in a myriad of home care clinical. She is currently serving as the chair for the Infusion Nurses Certification Corporation (INCC) Board of Directors and for the Infusion Team Task Force. on stand- ards development. ambulatory. Hagle is a mentor for research and quality improvement teams. CRNI®. Mary McGoldrick. a leader for translating evi- dence into practice. CRNI® President. both nationally and internationally. Focusing on vascular access device management and prevention of adverse events. GA Ms. including 12 years as a home care and hospice surveyor for The Joint Commission (TJC). With 15 years’ experience as a researcher and more than 20 years as a clinical nurse specialist in academic and community medical centers. and infusion therapy. Saint Simons Island. Zablocki VA Medical Center and University of Wisconsin-Milwaukee College of Nursing. PhD. GA Ms. Clement J. refining the “Strength of the Body of Evidence” document after 5 years’ use and serving as a reference point for the quality of evi- dence. Wheaton Franciscan Home Health & Hospice. Lynn Hadaway. Baxter. Excelsior. Covidien. Cincinnati. education. 3M. and Covidien. and Marsha Orr reported no relationships. central line troubleshooting. She is a past board member and nursing committee chair for the American Society for Parenteral and Enteral Nutrition. STANDARDS OF PRACTICE COMMITTEE CONFLICT OF INTEREST DISCLOSURES The authors have completed and submitted a form for disclosure of potential conflicts of interest. B Braun. S4 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. and Genentech. California State University (CSUF) School of Nursing (SON). Velano Vascular. Lisa Gorski reported relationships with ivWatch. Mary Hagle. Hospira. RN. Doellman’s work over the past 30 years has included short peripheral catheter and peripherally inserted central catheter insertions. Marsha Orr. CA Ms. BD. VA-BC Clinical Manager. VATA. MSN. Christie Medical. CRNI®. Terumo. Orr is a full-time faculty member at CSUF and acts as a resource person to SON faculty in the area of using technology for teaching and for principles of online learn- ing. DEKA. MS. BD. vascular access. and research in the neonatal and pediatric population. Mary McGoldrick. She is an entrepreneur and consultant for home infusion nursing and home medical equipment and is a home accreditation surveyor for these areas. and Bard Access. Her spe- cialty practice areas include infusion therapy. publications.indd S4 05/01/16 11:30 PM . Fullerton. Vascular Access Team at Cincinnati Children’s Hospital Medical Center. Lynn Hadaway reported relationships with 3M. West Pharmaceuticals. SplashCap. She has certification in vascular access and infusion therapy. Elcam. and Darcy Doellman reported relationships with Arrow International. Discrub. Ivera. and nutrition support. RN Distance Education Faculty Liaison and Full-time Lecturer. OH Ms. Darcy Doellman. Infusion therapy does not “belong” to one group of clinicians. Journal of Infusion Nursing The Art and Science of Infusion Nursing PREFACE R ecognized as the premier organization for the specialty practice of infu- sion nursing. With more published research. the Infusion Nurses Society (INS) understands the signifi- cance the Infusion Therapy Standards of Practice (the Standards) holds in relation to the delivery of safe patient care. With more published data and research adding to the science of the practice. This change aligns with the interprofessional approach that is being implemented in health care today. The format remains unchanged with practice criteria and relevant references listed after each set of standards. Recognizing infusion care goes beyond nursing. the percentage of Level V rankings. more strong evidence has provided clinicians with information and data that can justify existing practice or lead to a change in practice. it’s imperative that the Standards is relevant to the clinician’s practice. and innovation in technology. while other sections have been expanded to offer more guidance to clinicians. In contrast. This seventh edition cites 350 more references than the sixth edition of the Standards (2011). that ranking has grown to 5. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S5 JIN-D-15-00057. advances in science. new standards have been added. We still keep in mind that our patients are the reason we do what we do. As we’ve seen over time. there were 3. INS’ focus has never changed. In 2011. The rankings of the strength of the body of evidence have also shifted in this edition. INS is committed to revising the document every 5 years. the highest rating. but it is the responsibility of any clinician who is involved in the practice. A major change in this edition of the Standards is its title.8% of Level I rankings. We want to ensure we’re providing the safe. was 67% in 2011 and has decreased to 46% in this document. In this revision.indd S5 05/01/16 11:30 PM . a testament to the advancing science of infusion therapy. all the more reason to ensure the Standards are applied to one’s clinical practice. Developing and dissemi- nating Standards is one of the pillars of INS’ mission. Infusion therapy is administered to all patient populations in all practice settings. There is an expectation that all clinicians are competent in their practice. As INS continues to “set the standards for infu- sion care. quality infu- sion care that our patients deserve. the title has been changed to the Infusion Therapy Standards of Practice. It provides a framework to guide safe practice to ensure the best patient outcomes. the distribution of rankings has changed based on the nature and robustness of the research.” the Infusion Therapy Standards of Practice is an invaluable guide for all clinicians who are responsible for their patients’ infusion care. the lowest rat- ing. In this edition.8%. evi- dence that there is more robust research with consistent findings in the literature to support the practice. Therefore. BSN. Journal of Infusion Nursing The Art and Science of Infusion Nursing A MESSAGE FROM BD MEDICAL W e at BD feel honored to support the Infusion Therapy Standards of Practice revision for the fifth time since 1998. Catheter Solutions BD Medical S6 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Alicia Mares. as part of our commitment to helping more efficiently deliver health care and improve patient outcomes.indd S6 05/01/16 11:30 PM . With a long history of providing global education and training on best practices. CRNI® Clinical Marketing Manager BD Medical Richard Ji Vice President. We applaud the Infusion Nurses Society (INS) for striving to keep the Standards of Practice current. we award grants for education and research to promote innovative solutions in infusion therapy and across the care continuum. helping millions of clinicians pro- vide quality infusion therapy to their patients. RN. We look forward to working with INS in the future while helping improve infusion therapy around the world. relevant. and evidence based. CRNI®. and revising all the Standards. Mary McGoldrick. I also want to recognize BD Medical for their continuous support over the years of the Standards of Practice revisions. CAE. and writing. RN. and Darcy Doellman. I want to recognize and thank the Standards of Practice Committee: Lisa Gorski. INS VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S7 JIN-D-15-00057. First. Lastly. research. INS thanks them for the educational grant that helped fund this project. From INS members and volunteer leaders. the seventh edition of the Standards would not have been possi- ble.indd S7 05/01/16 11:30 PM . MA. Mary Alexander. Without the following dedicated individuals and their passion for quality patient care. I want to thank our INS members. Journal of Infusion Nursing The Art and Science of Infusion Nursing ACKNOWLEDGMENTS I NS recognizes the significance the Infusion Therapy Standards of Practice has to clinical practice and to all clinicians involved in the delivery of safe infusion care. health care clinicians. reviewing. Thanks go to the reviewers of the Standards. chair. legal experts. Mary Hagle. but their commitment to this important work is also exceptional. and infusion-related knowledge unsurpassed. FAAN Chief Executive Officer. Lynn Hadaway. to physicians. pharmacists. their thoughtful reviews and feedback contributed to the global perspective and interprofessional approach of the document. I want to thank the INS Board of Directors for supporting the efforts of the Standards of Practice Committee during the revision process. Marsha Orr. and industry partners. They spent countless hours researching and critically analyzing the evidence. Not only is the depth of their expertise in clinical practice. It is your passion and commitment to providing quality patient care that motivates us to continue to support the infusion specialty practice. I am grateful to the INS staff for the assistance they offered in ensuring that the publication was com- pleted. it is ranked at a low level of evidence relevant literature. A necessary and foundational study Index to Nursing and Allied Health Literature for learning about a question or a population is the (CINAHL). On occasion. The committee addressed each com- ment and made revisions to the standards. S8 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. and rating. and questions. Each standard had a final review by the committee for agreement on the content. Evaluating Evidence tional evidence as needed. such as randomized controlled trials (RCTs). this is the most robust type of evidence. evidence was included for each of these provided in excess of 790 comments. appropriate sta- that patients deserve infusion therapy based on the best tistical analysis. Other research designs are needed as well for between 2009 and July 2015. Research evidence is disciplines with various educational backgrounds. clinician who provides that therapy while operating Research on research. tives. The Standards of Practice Committee brought together a and the United States Pharmacopeia (USP). the Web sites of professional organiza- tions. and the highest. irrespective of the discipline of the consideration of threats to internal and external validity. The Art and Science of Infusion Nursing METHODOLOGY FOR DEVELOPING THE STANDARDS OF PRACTICE Role of the Standards of Practice Additional sources of evidence included. the evidence rating scale and to discuss methods and sources Centers for Disease Control and Prevention (CDC). examination of the negative cases. but because of its lack of The references of retrieved articles were reviewed for research controls. Only specific study designs are acceptable for a meta-analysis. and Web of Science. Cochrane Library. refer. and available evidence. and licensing. Single studies with strong research A literature search was conducted for each of the stand. and evaluate types of evidence. Throughout the Standards the US Department of Labor (eg. PubMed. but were Committee not limited to. Because standards of prac- interdisciplinary reviewers who are experts in the field.indd S8 05/01/16 11:30 PM . For research evi- ing. ards of practice using key words and subject headings form the basis for research on research or a strong body related to the standard. the study design is the initial means for ranking. seeking addi. pendent practitioners. train- preferred over nonresearch evidence. Searches were limited to of evidence when there are several RCTs with similar English-language. peer-reviewed journals published findings. US sites group of professional nurses with a wealth of clinical included the US Department of Health and Human knowledge and expertise in all the domains of infusion Services for national centers. most robust evidence relating to The standards are written for clinicians of multiple the standards of practice is used. suggestions. certification. such as the Agency for therapy. They initially met to review and agree on the Healthcare Research and Quality (AHRQ). of searching for evidence. manufacturers. The premise is sample size based on a power analysis. because infusion therapy may be Other aspects of evaluation of quality include sufficient provided by any one of these individuals. Databases included. Classic papers by phone. They also agreed on how to and the US Food and Drug Administration (FDA). MEDLINE. areas as available. textbooks consensus on the final strength of the body of evidence served as sources of evidence when clinical research rating for the final draft of the Infusion Therapy and scholarship are widely accepted. descriptive research project. Searching for Best Evidence and with its statistical analysis. such as for Standards of Practice. recommendation. tice are written for all health care settings and all comprising all aspects of infusion therapy. Cumulative can be conducted. such as meta-analyses and within her or his scope of practice. and came to were included as needed. is the highest level of evidence. pharmaceutical organizations. designs. including licensed inde- dence. but a developing area of science and often before an RCT were not limited to. Each item of evidence is evaluated from many perspec- evidence. ences. Occupational Safety review and revision process. Sixty reviewers populations. This draft then was sent to over 90 anatomy and physiology. reviewed each standard in detail. the committee met regularly and Health Administration [OSHA]). for clinical practice. systematic reviews. Nonresearch includes quality improvement pro. practice questions are raised in publica- meta-analysis. It may also be the rating scale. The Standards of Practice document is reviewed and dations to stop an unsafe action. there is a strong preponderance of evidence and specific clinician actions body of evidence indicating a high rating for the type highly recommended. and the practice criteria recommendation is strength of the body of evidence to provide guidance for strong. the body of evidence is within the opinion. from a the findings are inconclusive.” represent. tices with uncertain or low levels of evidence. The last rating is the Regulatory level. OSHA unethical to conduct research on that question or is an example of such an agency that has regulations research is impractical. discussed and agreed to practice criteria. This rating was used in less than 2% of the dence. the occasions. projects can be stimulated during the used to prevent harm to the patient. For a few practice criteria. reflected in the use of the The rating scale for the strength of the body of evi. term consider. the Infusion Nurses Society Standards of of the body of evidence reflects a high rating. at conferences. Often. for large research. clinical articles. nonresearch is often the only available evi. In these instances.indd S9 05/01/16 11:30 PM . tematic review. there is a lack of literature or very low levels Infusion Nurses Society and the Standards of Practice of evidence with conflicting findings. the practice criteria judgment. governing certain aspects of infusion therapy. Many times. The strength of this body of evidence is tions. Thus. or position papers. Last. tion that may guide a novice clinician for safe care based guidelines. Consensus. quality improve. practice criteria. such as Practice Committee developed the rating scale for the a I or II. In this instance. such as for preventing revised based on the best evidence every 5 years. evidence along with her or his expertise and clinical ing a meta-analysis and other research on research to judgment. Practice Criteria Recommendations Rating the Strength of the Body of Evidence When there is a large body of evidence based on robust research with consistent findings. There is also the occasion when there is a sys- clinicians when implementing standards of practice. However. With air embolism through body positioning. which is a robust research design. This may There is also a rating for anatomy and physiology. The committee as well as manufacturers’ instructions for use and con. or through online professional I. Practice Committee provided a consensus recommenda- ies are not cited separately. and as ety of dissemination strategies in the time between a committee decided on a rating of V. but the evidence and conclusions are based on organizational preference and/or clinician undetermined. the individual stud. Nonresearch evidence can be extreme. the lowest level of “V. such as a meta-analysis with infusion therapy when there is little more than expert its accepted methods. recommendation is lower. case reports. However. ments lead to a research question and subsequent study. This is used for recommen. tory agencies that could penalize clinicians and/or ly valuable for certain aspects of practice when it is organizations if the regulations are not followed. When studies are cited within the larger work of a forums. Committee are committed to bringing research-based the Standards of Practice Committee reviewed the evi. the clinician may identify some prac- particular recommendation. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S9 JIN-D-15-00057. jects. fully analyzed case studies. On rare dence for practice recommendations. but This guidance can reflect a range of evidence. and the clinician is advised to use this dence ranges from the highest rating of “I. was aware that many practices are mandated by regula- sensus guidelines. the level of evidence may vary based without harm. In reviewing the practice criteria and the on the strength of the research the guideline uses for a evidence ratings. the strength In 2011. stimulate areas of needed research in infusion therapy which may be based on anatomy textbooks as well as or quality improvement projects to validate practice. such as avoiding intervening years to address some of the gaps in evi- venipuncture around dense areas of nerves. to minimal evidence and actions of evidence cited.” For a standard of practice with Practice criteria also serve as guidance for aspects of a single item of evidence. Committee Standards of Practice publication dates. critical changes for practice to clinicians through a vari- dence. the Standards of meta-analysis or systematic review. May also be noted as Committee Consensus. or narrative litera- ture review. case report. theoretical basis. V Clinical article. well-designed quality improvement project. correlational study. and pathophysiology references as understood at the time of writing. time series study. systematic literature review. or at least 3 well-designed RCTs. Centers for Medicare & Medicaid Services (CMS). Includes 2 or more well-designed laboratory studies. case-control study. guideline based on consen- sus. I A/P Evidence from anatomy. patient identification). although rarely used. II Two well-designed RCTs. or systematic literature review of varied prospective study designs. physiology. S10 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.indd S10 05/01/16 11:30 PM . well-designed clinical trials without randomization. psychometric study. guideline based on randomized controlled trials (RCTs). several well-designed clinical trials without randomization. such as the AABB. Occupational Safety and Health Administration (OSHA). systematic literature review of descriptive and qualitative studies. *Sufficient sample size is needed with preference for power analysis adding to the strength of evidence. recommenda- tions by accrediting bodies and professional organizations. consensus report. IV Well-designed quasi-experimental study. cohort study. or manufacturer directions for use for products or services. Regulatory Regulatory regulations and other criteria set by agencies with the ability to impose consequences. III One well-designed RCT. 2 or more multicenter. Includes standard of practice that is generally accepted but does not have a research basis (eg. Includes 1 well-designed laboratory study. clinical/professional book. and state Boards of Nursing. The Art and Science of Infusion Nursing STRENGTH OF THE BODY OF EVIDENCE Strength of the Body of Evidence Evidence Description* I Meta-analysis. descriptive study. or several studies with quasi-experimental designs focused on the same question. with reference to age. including performance and accountability. weight. acute and provide a basis for clinical decision making.6-9 (V) ized written protocols/orders that describe the acceptable 2. tions. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S11 JIN-D-15-00057. patients.5 Ethical principles are used as a foundation for deci.3.2 (V) ences. SPECIAL PATIENT cation use during lactation. pedi. 1.15 (V) atric. that is individualized. collaborative.2 Infusion therapy is provided in accordance with laws. interac- 1.3. team. The Art and Science of Infusion Nursing Standards of Practice Section One: Infusion Therapy Practice 1.14.4 Infusion therapy is provided with attention to care). 1. tions with attention to: 1. and cable to any patient care setting in which vascular age appropriate.2. and older adult populations)* is compe. set selection (eg. pharmacologic actions. col. py. on drug and nutrient selection. Recognize physiologic characteristics and effect 1. and response to infusion thera- subject to commercial or other conflicts of interest. pediatric. or body my.indd S11 05/01/16 11:30 PM . site selection. dignity. pregnant. practice guidelines.10 (V) patient safety and quality. administration sion making. The clinician acts as a patient advocate. ambulatory. the clinician providing pain and fears associated with infusion therapy infusion therapy for special populations (neonatal. monitor- tice. and surrogates as members of the patient’s health care infusion administration. siderations that may affect the plan for infusion ing knowledge of anatomical and physiological differ. including provision of patient education. and use of specialized infu- 1. and/or standard. including care and main- policies. implications for vascular 5. and diversity. regulatory and accrediting bodies in all patient care settings. 4. other family members.2. Interact with parents. side effects. are not ing parameters.6. and older adult 1. rights. Assess for psychosocial and socioeconomic con- tent in clinical management of such populations. C. safety considerations. height. culturally sensitive. promotes. Anatomic characteristics and their effect on rules.3 Infusion therapy practice is established in organizational sion-related equipment. and security.6 Clinician decisions related to infusion therapy prac. Safety and environmental considerations for course of action. Considerations for neonatal and pediatric patients: laborative. long-term care facility. surface area. tenance practices during infusion therapy. and adverse effects. Provide education to the mother regarding the potential impact and risks/benefits of any medi- 2. Care is individualized. safety. care. VAD planning. therapy. or access device (VAD) planning and management. infusion therapy in all care settings (eg. late [DEHP]). including device and/or product selection.1 The Infusion Therapy Standards of Practice is appli.8.1-5 (V) access devices (VADs) are placed and/or managed and B. and age appropriate. free of Di[2-ethylhexyl] phtha- maintains patient confidentiality.5. includ.8-12 (V) 2. pregnant. Provide care with attention to growth and devel- opmental level. and preserves human autono. Provide infusion therapy to special patient popula- where infusion therapies are administered. dosage and volume limitations and respects.1 To ensure patient safety. home 1. procedures.13 (V) POPULATIONS 3. include nonpharmacological Standard measures for promoting comfort and reducing 2. insertion procedures. which include Standard neonatal. and regulations promulgated by federal and state physical assessment. PATIENT CARE Practice Criteria A. procedures. Provide care to special populations. 2013. 2014. Reference Guide to Fetal and Neonatal Risk. of geriatric nursing care: enduring outcomes from the geriatric 24. Annibale 2. eds. Gray-Miceli D.7. literacy. 2015. American Nurses Association (ANA). and language preferences (see Corrigan A. et al. Cape AV. 1. Complications of central practices in these patient populations. MO: 22. eds. Infusion pregnancy. and Standards of Practice.3. Fabian B. Hankins J. 2014. J Prof Nurs. 2015. Muehlethaler V. narrative review of literature. 2015. et al.201(3):311. MO: Saunders/Elsevier. interactions. tions (eg.31(4):585-586. Silver Spring. Ijkema R.7 (V) nique to control pain in pediatric patients during venipuncture: a 3. Nygardh A. Langelaan M. 2014.19-21 (IV) an interdisciplinary approach. Winkler M. developmental level.7(10):689-697. St Louis. pharmacologic actions. D. 2009. 2015. Guenter P.22-24 (V) 14. 2013. Robinson MK.3. Prospective controlled study of an intervention to reduce errors in neonatal antibiotic orders. In: Alexander M. and response to infusion therapy. team.22-26 (V) 18. Recognize potential for adverse events and drug Saunders/Elsevier. 2013. 3rd ed.20. Scope and Standards of Practice. rogate as members of the patient’s health care 16. Freeman RK. Mogensen KM. MD: ANA. Sokhal D. Martin B. Am J Obstet Gynecol. 2015.16 (V) Nursing: An Evidence-Based Approach. Irving MG. Neonatal Nursing: Scope J Parenter Enteral Nutr.16 (V) Nursing: An Evidence-Based Approach. J Pediatr E.e1-e5. Infusion therapy in children. drug events in older adults: the impact of interventions. scribed multiple medications. Obtain assent from the school-age or adolescent 6.2. St Louis. Angelino F. Hankins J. Cox TH.2015. Gorski L. 23. 2014. venous catheters during pregnancy and postpartum: a case series. eds. Focus on peripherally inserted central fetus. S12 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Evidence-based nutritional support of the elderly can- nursing education consortium. Silver Spring. 3rd ed. Extraction of di-ethylhexyl- enteral nutrition with hyperemesis gravidarum phthalate by home total parenteral nutrition from polyvinyl (see Standard 61. Pettit J. New York. Elliot JP. Perlow JH.49(9):E413-E419. Interact with family members. Comparison between the 2.188(5):1223-1225. Stanley J. Briggs GC. Nursing: An Evidence-Based Approach.indd S12 05/01/16 11:30 PM . et al.38(5):596-601. culture. 13. What impedes and 1. Considerations in pregnancy: 7.3(4):80-94. In: Alexander M. White RO. Distraction as a tech- affect the plan for infusion therapy. Infusion due to mental status. Informed ing context: experiences of facilitating evidence-based elderly Consent). Frey AM. 3. PA: Wolters Kluwer Health. Ogura JM. Bozzetti F. Francois KE.4. side catheters in critically ill patients. Pittiruti M.21 (III) chloride infusion lines commonly used in the home.2. ability to communicate/learn (eg. 2010:71-94. Garner SS. Recognize that there may be increased risk in DJ. with attention to age. Assess for any changes in cognitive abilities. 2014. dex- analgesic effect of two techniques on the level of pain perception terity. Vetri Buratti C. Handling a challeng- patient as appropriate (see Standard 9. Lemay CA. Wann-Hansson C. Consider enteral feedings prior to initiating par. Age-associated general pharmacological aspects. ume limitations and potential impact on the 8. monitoring parameters.10. Long-term home parenteral nutrition: it takes nancy. Fischer CJ.6. Loff S. Infusion Standard 8. St Louis. Wehling M. Hill EG. AIDS Care. 2003. health 5. Wilson LD. et al.1038/jp. Czaplewski L. Blake DR. 2015. Bissinger RL. Am J Obstet Gynecol. Development and *Special populations identified based on a role evaluation of a Web-based assent for adolescents considering an delineation study conducted by the Infusion Nurses HIV vaccine trial. et al. speech). Gerontological Nursing: Springer-Verlag. Complications 2. Advancing informed consent interactions in older adults who may be pre- for vulnerable populations. Phtalates in the the aging process and their effect on drug dosage NICU: is it safe? J Paediatr Child Health. Hankins J. Infusion therapy in the older adult. Drug Therapy for the Elderly. Patient Education). et al. J Infus Nurs. Gupta W. 2010:571-582. Recognize physiologic changes related to preg. Wehling M. side effects. In: Alexander M. pharmacologic actions.17. Gorski L. et al. doi:10. Prof Inferm. Certification Corporation reflecting the current infusion 19. 6. 3rd ed. 11.13 (II) 9. Improving the quality Pharm. 2010:550-570. Nutrition.30(6):447-455. MO: 4. doi:10.135(3):e562-e564. 2015. van de Steef L.5. Kaur A. Peripherally inserted central catheter (PICC) complications during pregnancy. 2014.26(1):41-48. Recognize physiologic changes associated with 12. adverse effects. 2008. effects. Gupta HV. NY: 3. J Nurs Manage. Bickle Graz M. et al. Philadephia. Maranda LS.37(5):389-395. Parenteral Nutrition). and response to infusion therapy. what facilitates a quality improvement project for older hospital- nancy and their effect on drug dosage and vol. Drugs in Pregnancy and Lactation: A interactions. Clinician and patient education. hearing. cer patient. or sur.27(8):1005-1013. MD: ANA. ed. Pediatrics. et al. Nuthalapaty FS. Heerman WJ. changes during venipuncture in children up to 7 years of age: a quasi- in vision. American Nurses Association (ANA). J Perinatol.35(8): central vascular access device (CVAD) complica- 631-635. Cotogni P. Mabie WC. Subotic U. 2nd ed. Gorski L. In: Saunders/Elsevier. 2015. 10th ed. Perucca R. ized patients? Int J Quality Health Care. Perucca R. cial and socioeconomic considerations that may 15. experimental study. Considerations for the older adult patient population: Gastroenterol Nutr. 21.111/jonm12300. 1. 17.68(1):52-62.18 (V) care. Sansoni J. Reinick F. World J Crit Care Med. REFERENCES 20.47(1):81-86. infection and thrombosis) during preg- 10. Barkin SL. caregivers. as well as psychoso. Screening for adverse 2010. and volume limitations. Lukazewski A. with consent of the patient or as necessary Corrigan A. Perucca R. monitoring parameters. associated with peripherally inserted central catheter use during Corrigan A.6.8(8):PC01-PC04. Ahlstrom G. Beck MM. Consult 4. 2nd ed. and appro. to the right person. although specific components of care of practice as outlined by the applicable regula.4 (V) come. 4. Gilden JL.3. a.11 (V) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S13 JIN-D-15-00057.3 (V) Board of Nursing. Nursing Personnel 1. compliance with organizational policies and other methods may be used. Care [AARC]). Recognize that Nurse Practice Acts differ among patient and family. and appropriate infusion therapy. 2015. Erstad BL. and removal are qualified and competent to to allow practice to the full extent of licensure.10 (V) (UAP) in accordance with rules and regulations promul. Complete an organized educational program priate infusion therapy. and delivery of infusion therapy in acute and alternative health care settings.11. UAP). World J Crit Care Med.1-3 g.7 (IV) 3. Regulatory) d. mainte. may be delegated.5 (Regulatory) 3. Frequent application procedures. Non-ICU hospital care of diabetes mellitus of the decision process may be required due to in the elderly population.3 (V) absence of a legal scope of practice (eg. Match the staff within this legal framework. activity. Develop the necessary skills for delegation based on rules and regulations articulated by Practice Criteria state Boards of Nursing. and accountability for patient-centered approach to care. American Association for Respiratory the right task. and components of A. SCOPE OF PRACTICE D. team toward the universal goal of safe. and do not endanger a sions according to the method used by the state patient’s life or well-being.4 Members of the health care team collaborate to 5. Delegate tasks that frequently occur. province. e. including [ASRT]. Competency Assessment and for the tasks delegated to UAP and licensed practical/ Validation). A standardized decision tree for h.11.1 The role. vocational nurses (LPN/LVNs). b. Regulatory) jurisdictions (ie. expansion of practice into professions other populations.3 Clinicians delivering any type of infusion therapy cal thinking skills. Execute independent nursing strategies related to within the boundaries of their legal scope of practice.9 perform the identified functions.12 (V. Advocate for identification and removal of barriers nance. country).6 (V) each type of clinician involved with infusion therapy 2. f. For other professions. activities. B. increasing types of infusion therapies and technolo- 26. do not require assessment or profes- C. know the designated scope cess.11-14 (V. Know the scope of practice for one’s health care care after determination of competency to profession or occupation and provide patient care perform the specific task. use. state. than nursing. Do not delegate any aspect of the nursing pro- 2. effective.8.12 (V) tory agency and/or professional organization (eg. inconsistency of infusion therapy in basic tered nurse (RN) to unlicensed assistive personnel nursing curricula. Collaborate with members of the health care delivery. Delegate tasks. on infusion therapy due to the lack and/or 3. Recognize the overlap between professional groups require little or no modification for each and that no single profession can claim exclusive patient. under the right circumstances. are clearly defined in organizational policy. Designing drug regimens for special intensive care unit gies. Registered Nurse (RN) achieve the universal goals of safe. sional judgment. (V) 3. according to the applicable regulatory boards.4(2):139-151.3. however. infusion therapy using decision-making and criti- 3. and under the right by organizational policies when there is an supervision and evaluation. with the right direction 3. For nursing personnel. Ensure that delegated tasks are completed in determining scope of practice is preferred. Know the boundaries of practice as established and communication.3. Provide infusion therapy based on the compo- Standard nents of the nursing process and principles of delegation and supervision using a holistic. can be (V) performed with an established order of steps. responsibilities. c.2 Clinicians involved with infusion therapy practice 3. 2015. member’s skill to the specific needs of the 1. 3.2 (V) and vascular access device (VAD) insertion.15(5):26. effective. Curr Diabetes Rep.3. Gupta A. are performed with a predictable out- ownership of any skill.indd S13 05/01/16 11:30 PM . Do not accept assignments and tasks when one gated by the state’s Board of Nursing and within the concludes that she or he is inadequately pre- policies and procedures of the organization. or task. 25.5 Infusion therapy tasks are delegated by the regis. make scope of practice deci.3. Use critical thinking and nursing judgment to American Society of Radiologic Technologists apply the Five Rights of Delegation. The RN pared to perform the assignment or task (refer and the organization are responsible and accountable to Standard 5. ment by earning board certification to become although they may be employed in a variety of an infusion nurse specialist (ie. and procedure development of infusion thera- ten policies identify which professional can py derived from best evidence.12 (V) and research related to infusion therapy 6. No regulatory agency includes insertion 2. Regulatory) tice.16 (V) sive procedures are infusion-related tasks that c. Regulations b. educational requirements. scope of practice task list is taken from the Code nance of central vascular access devices of Federal Regulations (42 CFR § 483).19-23 (V) state medical board regulates delegation of tasks c. has no standardized b. devices with documented competence. and licensure. Managing equipment and supplies. Nursing assistive personnel (NAP) is a category of 5. 5. Provide leadership in education. monitor performance.33 (V) S14 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Complete an organized educational program. leader.24 (V) task performance.34 (V) certification including. (IV) medications by the piggyback method. The e. Regulatory) ed. is able to intervene if need. tions are included on this list. mainte. Medical Assistants (MAs) are a different catego- a.24 (V) delegate and to whom they can delegate.33. or maintenance or while 10 states allowed this activity through to the administration of any IV fluid or medica- delegation.26-29 (V) sion therapy. as required for LPN/LVNs in many c. In states without such requirements. organization and/or patient populations including supervised clinical practice on infu. Apply existing rules or regulations. tice to the full extent of education. In settings without an administrative nursing d. includes many job titles.31.17. although The majority of states permit LPN/LVNs to some states have expanded this list.11 (V) 8. No tasks administer IV medications through CVADs. physician office or clinic).1 (V) allowed for UAP dialysis technicians to adminis- 7. if any. Unlicensed Assistive Personnel (UAP) infusion therapy procedures (refer to Standard 1. consulting. and very few identify tice to the full extent of licensure and board any form of scope of practice. Basic nursing care tasks are included.indd S14 05/01/16 11:30 PM .30 (V) program is recommended prior to performing E. Adhere to the state Board of Nursing’s rules delegation of infusion-related tasks to NAP and and regulations regarding the authority to the supervision of their performance. but not limited to. and administration of intravenous applies to care for residents of nursing facilities. Accepting the assignment to super. Practice analysis for LPN/LVNs includes veni.16 (V) Nurse Infusion [CRNI®]) 4. MAs function in assistive roles to physicians by CVAD insertion and determination of CVAD performing administrative and clinical tasks. The tip location on imaging modalities. Licensed Practical/Vocational Nurse (LPN/LVN) according to the needs of the employing a. CRNI®). which (CVADs). ry of UAP. Participate in quality improvement activities from physicians to MAs with tremendous varia- and clinical research in infusion therapy.18. There is delegate by LPN/LVN as this varies greatly much variation among states regarding what is between states. manager.18. served. legal requirements for physician direction or tion. and has the opportunity and proximity to b. An unofficial UAP and removal of peripheral catheters. care. insertion and removal of vascular access vise such tasks requires that the RN is compe.31 (V) supervision of an RN or LIP with appropriate 3. related to VAD insertion.11 (V) specific state Boards of Nursing pertaining to d. and 5 states prohibited this prac. tent with the task. licensed independent legal authority to prescribe infusion therapy.32 (V. Advocate for expansion of professional prac- states. and does not have a puncture for blood sampling and insertion regulated scope of practice. APRNs who are LIPs have the another professional (eg. Infusion Nurse Specialist (Certified Registered ter through CVADs.23. Enhance professional growth and empower. certifica- completion of an infusion therapy educational tion.24 (V) tions among states. Perform infusion-related tasks under the may be assigned to NAP. Know the status of APRNs as LIPs based on supervise a task (eg. gathering of midline catheters or CVADs within the data. and consultant delegating individual is accountable for the on issues related to infusion therapy. Competency Assessment and Validation). vary greatly among states.11. and assisting licensed clinicians with inva- scope of practice for LPN/LVNs.15. i. Serve as educator. practitioner [LIP]) is outside the guidelines for APRNs may perform surgical procedures for delegation. Serve as the primary resource to guide policy structure (eg. from infusion therapy knowledge and skills.18 (V) positions in acute care hospitals. UAP.25 (V. Recognize that accepting an assignment to a. Advocate for expansion of professional prac. accessing an implanted port) delegated by supervision. primarily employed in medical offices. writ. Advanced Practice Registered Nurse (APRN) j. peripheral catheter inser. however.38. H. power injectors. Two levels of certifica- 1. as there may be prohibitions for certain tions. and is credentialed (authorized) radiologic technologists including. nel have historically functioned in a pre- d. and/or certification from the national certify- c. Each individual practices within the identified ally inserted central catheter and other scope of practice and has documented compe. Advanced Emergency Medical access to existing VADs are within the scope Technicians may insert peripheral of practice when an LIP is immediately venous catheters and intraosseous VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S15 JIN-D-15-00057.11 (V) G. A few practice. Note any alterations in the role ricula for each practice area as established when employed in nontraditional settings by ASRT and other radiology organiza. hospital setting. MAs is not typically found in medical offices. especially who will hold account. skill. parenteral injection of personnel perform infusion therapy: contrast media and other medications. available to ensure proper diagnosis and sibility and accountability for the action of treatment of adverse events. Two levels of emergency medical services eral venipuncture. adminis. nurse is required to obtain clarification from and other appropriate regulatory agencies. American Registry of Radiologic there are no national documents address- Technologists [ARRT]). 1. Arterial puncture and obtaining arterial from a national credentialing board (eg. task performance. 6. and licensed nurse may be expected to supervise other guidance documents from ASRT. activities. however. There are numerous practice areas for ing board.42-44 (V) license working in the radiology depart.35-37 (Regulatory) states have addressed the issue of peripher- 2. and urgent care administration are components of the cur. Infusion therapy-related tasks may be delegat. or activity per. coun- tions and after the MA completes education try) and/or certification from the national and competency validation. blood samples are addressed by AARC. Basic techniques of venipuncture.indd S15 05/01/16 11:30 PM . Adhere to regulations on scope of practice from a professional organization or both as questions as determined by the regulatory required by the state board regulating their agency within each jurisdiction. National Board for F.39. Paramedic ment should not have the responsibility for 1. they are now tration of diagnostic contrast agents and/ employed in a variety of settings such as or IV medications. magnetic 2. devices used in radiology including. Know the proper use of all flow-control professional. and a. computed tomography. and nuclear medicine. Respiratory Therapist (RRT).40. formed. province. either positively or negatively. Holds a state license and/or certification 3. Therapist/Technologist/Technician Respiratory Care). but ability for the outcome of the delegated not limited to. cardiovascular and interven. Holds a license from the regulatory agency in venipuncture or administration of any IV the jurisdiction (state.38-40 (V) most states have nothing on record regard- 3. tor to perform the skills or role. f. 3.33 (V) certifying board (ie. a. ing any other aspect of infusion therapy or b. medication. The individual licensed American College of Radiology (ACR). the delegating physician about the role of each g.36. physician offices. Radiologic Technologist ing this practice question. hospital emergency departments. Adhere to recommendations. province. tional. ASRT-issued advisory opinions that periph.41 (V) tasks. hospital ery of patient care during medication units. the statements. Recognize that emergency medical person- resonance. settings. These groups of clinicians have educational tion are available: Certified Respiratory preparation from a variety of schools/colleges Therapist (CRT) and Registered (ie. e. Respiratory Care Practitioner 7. in the jurisdiction (state. Holds a license from the regulatory agency ed to MAs depending upon the state regula. and appropriate deliv. but not by a local emergency services medical direc- limited to. associate’s and bachelor’s degrees). CVAD insertion by respiratory therapists. Individuals hold a state license or certification 2. country). standards of practice. position Following delegation from the physician. Unlicensed and/or uncertified individuals vascular access by respiratory thera- and those holding only an institutional pists. tency for each task. A structured nursing department with respon. 36. Measuring actual scope of 27. ncsbn. Published 2005.org/main/standards-regu- unlicensed patient care technicians and LPNs/LVNs in the hemo. Xia Y. J Pediatr Oncol Nurs. Boev C. Davidson PM. American Nurses Association and the National Council of State 23. 2010. 21. http://www. Broadening infusion specialization as an adjunct to Boards of Nursing. demies. 2010. MD: American state-by-state differences in allowable delegated activities. Okungu LA.15(2). in a neonatal intensive care unit. Crit Care nurses in North Carolina.36 (V) 20. 2008. Resusc. and ambulatory PDF care settings: a primer for clinicians.35(2):66-72.org/TriCouncil_Framing_Document_FINAL.pdf. Joint statement on delegation. 25. http://iom. 4. Sabo B. Institute of Medicine. Rubenstein R. education/EMSScope. National Council of State Boards of Nursing. Infect Control Hosp Epidemiol. Nurs Manage. AMT Events. McCarty MN. The authority for certain clinical tasks performed by federal licensure issues. J Infus Nurs.indd S16 05/01/16 11:30 PM . Advancing Health. Meyer BM. Weydt A. St Louis. J Nurs Regul. 2010:1-9.112(2):19-20. administer comes of three intensive care based catheter placement services. Morales EM. 2012. J Nurs Adm.ems. eter tip placement. Certified Nurse Aide scope of practice: Interpretive Statements. Central venous catheter insertion by a clinical nurse consultant or anaesthetic 1. 9. Geiger-Brown JM. 3. 323-328. Nurses’ and nursing assistants’ reports of 32. 2nd ed. Chicago. et al. Nurse-led central venous catheters and intraosseous devic- venous catheter insertion: procedural characteristics and out- es. Describing 7. 2009. IL: National Council of 34. 29. 2012. 3rd ed. Noonan M. et al. Corrigan A. Crit Care Med. Clinical nurse specialist and evidence-based practice: of Nursing: Leading Change. Thomas L. Published 2007. https://www. https://www. In: Alexander M. ers and demonstration of the value of certification. Infusion nursing certification: identification of stakehold- 50% dextrose for hypoglycemia. 33.42(5):248-255. 2015:68-70. J Infus Nurs. Infusion nursing as a specialty. Fetzer SJ. 19.org/∼/media/Files/Report%20Files/2010/The-Future-of. 35.14(1):14-18. 2015. 2014. 2014. Kleinpell RM.gov/ Magnet® and non-Magnet nurses.112(8):51-55. McMullen TL. Developing delegation skills. 2013.42(3):536-543. Development of an infusion alliance. Nurse practice acts guide and govern nursing prac. Am J Nurs. Practice. J Infus Nurs. 8.nationalaca.31(3):241-248. 2012 update. McLaughlin A. Infusion 2012.org/Joint_statement. IV medications by infusion. and moni. Interstate practice. Int J Nurs Stud. 2010. and preceptors. 2012. TriCouncil for Nursing. J Nurs Adm. Pfeifer GM. Implementing Institute of Medicine Future of 11. 15.37(1):44-54. Corrigan A. Clavelle JT. Nursing Scope and Standards of AACN Adv Crit Care. Markovich MB. 2005.45(2):48-52. O’Keefe C. Nephrol Nurs J. Proulx JR. American Nurses Association. J Am Nurses Association. JONAS Healthc Law Ethics Regul. Paramedics may insert peripheral 2007. Frost SA. 12. b. Am J Nurs. RN-led initiative. et al.pdf. education Saunders/Elsevier. NCSBN. https://www. Spencer TR. radiographic interpretation for peripherally inserted central cath- tice. 2010. dialysis setting: a review. Kring DL. The expanding role of the infusion nurse in 2. Med Dir Assoc. 2012:110-119. Alexandrou E. Alexandrou E. Shifting boundaries in health care.ncsbn. Dubois CA. acute care/critical care. J Nurs Adm. Gravlin G. 31. Continuing education for patient missed care and delegation. 2010.pdf. Others. Perucca R.pdf. Advanced practice nursing scope of https://www. Hudspeth RS. Calabria E. Hillman KM. MD: ANA. Morrison T. http://www. J Infus Nurs. Seidl K.41(3):247-254.3912/OJIN.ncsbn.Vol15No02Man01Found. Russell KA.31(2):96-103. Washington.24(1):23-29. Joseph T. eds. 2014. Zuzelo PR. care technicians: a unit-based. Practice_Analysis_Vol58_updated. managing anthracycline extravasation. practice for hospitals. access indwelling VADs. Working with oth. State and 16. 2015:3-6.42(9):404-407. 2012 LPN/VN practice analysis: linking the NCLEX. 22. D’Amour D. tor blood and blood products. Clin Nurse Spec. organizational sustainability. evolving regulation. 2012. Clin Nurse Spec. Yacopetti N. J Nurs Admin. the medical/surgical setting. NCSBN. Practice patterns of licensed practical medical staff: a single-centre observational study.40(7/8):329-335.33(5):278-290.30(6):332-338.26(6): 2012. Biel M. 2015. Note: All electronic references in this section were accessed September 2014.ncsbn. Nursing: An Evidence-Based Approach.22(5):261-264. 26. Alexandrou E. doi:10. Spencer TR. 2010. The perceived value of certification by National EMS scope of practice model. S16 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Guide to the Code of Ethics for Nurses With Miller N. et al. 2015. Bizzarro MJ. Focus on scope of practice. devices and administer IV fluids and 18. The lawful scope of practice of medical assistants: 15. 10. study. MO: 5.23(6):296-304. Hooke MC.12(2):90-95.16(1):20-24. The forgotten rung: a clinical ladder State Boards of Nursing. 2013. Fowler MDM. Crit Care Nurse. Online J Issues Nurs. 2012.3(3):36-42.45(4):194-199. Small A.org/Working_with_ titioner privileges. In: The Future 28.asrt.49(2):162-168. lations/federal-legislative-affairs/state-and-federal-licensure-issues. 30. 13. 2014. National Highway Traffic Safety Administration (NHTSA). 24. and licensure: changing practice. Gorski L. Mifflin N. Gent PL. American Society of Radiologic Technologists (ASRT). Hadaway L. Silver Spring. executives. Dery J. Nurse-physician collaboration and hospital-acquired saline-lock usage patterns on a telemetry unit: a retrospective infections in critical care. 2015. 6. Qualitative analysis of central and midline care in nursing practice: a new tool for nurse leaders. PN examination to practice. Parnell ER.org/13_LPN_ for UAP. 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(IV) http://webmm. S6.29(6):307-315. Paulinova V. Brumley insertion and/or management within her or his scope of K. 20. 12.24(2):S4. The unfamiliar catheter. Wagner J. Carnan D. Hillman KM. Alexandrou E. Pilpil F.11(4):254-256. Harpel J.gov/case. 13. critical think- 2012.10:S27-S32. Crossing professional boundaries: nurse-led catheter ics. infusion therapy and vascular access device (VAD) 16. Validate initial competency before providing Jun. Spencer TR. C. A review of the nursing role in central venous can- 4. Denson SE. Caguioa J. Pitts S. Competency requires a commitment to lifelong 2013. COMPETENCY ASSESSMENT reduction of catheter-related nosocomial infections.2 The clinician is responsible and accountable for care unit. 2010. Effectiveness of intravenous therapy teams. grams that empower clinicians for educational 27. 18.4 Competency validation is documented in accord- 19. Validate clinician competency by documenting the 31. Khan AM. 23. Reducing risk of air embolism associated with central knowledge. Hadaway L. 26. Frey AM.29(2):e12-e13. 2. 5. Impact of a dedicated IV team. Guerin K. Br J Nurs. Infect Control Hosp Epidemiol. James A.9(2):58-64. PA Saf Advis. Establish transparency in the process of assessing tals: a survey based study. petent and maintaining continued clinical compe- 2009.8(2):1-24. Br J Nurs. A multidisciplin- ary approach to vascular access in children. behaviors. J Clin 5. Orr M. J Spec Pediatr Nurs. Frost SA. et al.2 (IV) insertion. J Pediatr Oncol Nurs. manager acts as the competency validator. Experiences growth and staff development. ment and validation across the health care system to 2006.16(6):32-37. 21. et al. 2011. Hromadkova J. equipment. nulation: implications for practice policy and research. Kuhn L.32(4):281-286. McGrail M. Webster J.9(2)/Pages/58. Azen C. Wagner J. J Assoc Vasc Access. of the first PICC team in the Czech Republic. 2.36(1):46-50. use of simulation.21(14):S4. 2015 NOV10. Kubanda G. patient care (eg. 29. Bolton D. Holzmann-Pazgal G. Walker G. 2007.30(1):33-44. Use a standardized approach to competency assess- 25. 33. accomplish the goal of consistent infusion practices. Dalton L.3 Competency assessment and validation is performed spective pilot study evaluating a central venous catheter team in reducing catheter-related bloodstream infections in pediatric initially and on an ongoing basis. 2012. 2014. Schultz TR. and with the introduction of new procedures. Zemanova K. Ratz D. 2005. learning. case studies. Identify and develop competency assessment pro- 2010. Brunelle D. Chopra V. Rains K. B. J Infus Nurs. when the scope of practice chang- care hospitals: call for a business approach—an Infusion Nurses es. A proactive approach to combating venous depletion safety. Impact of a dedicated infusion therapy team on the 5. A crossover randomized pro- 5. Collaborate with professional development staff. 22. Development of an infusion alliance. 2013. competency. Secola R. J Perinatol.1. the clinician is competent in the safe delivery of in the hospital setting. Reduction in central Standard line-associated bloodstream infections by implementation of a post- insertion care bundle. J Infus Nurs. Nurs Manage.35(1):63-68.18(2):114-120. 2009. agement within her or his scope of practice. skills. Acknowledge the imbalance of power when a Nurs. 3. 2010. PICC teams and CLASBI prevention practices among US hospi. Mercanti-Erieg L. AND VALIDATION 2003. AHRQ Web site.38(6):430-433. http:// the assigned job.22(19):S9-S15. Infusion teams in acute written tests). Davidson PM.19(11-12):1485-1494. Best practices for vascular resource teams. Davis K.indd S18 05/01/16 11:30 PM . Nurse-led PICC insertion: is it cost effective? eral intravenous catheter failure: a multivariate analysis of data Br J Nurs.33(5):278-290. Parr MJ. Link continuing competency assessment pro- 2015. practice. [Epub competency and the requirements for judging ahead of print]. includes application of knowledge. HANDS: standardised 1. Competence goes beyond psychomotor skills and intravascular practice based on evidence. patientsafetyauthority. tral-line-associated bloodstream infections in a neonatal intensive 5. and ability to perform venous access devices. Assess psychomotor skills in a simulation labora- procedures with the potential to be harmful or tory using multiple methods.6. or the work environment as the preferred method expert). Use evidence and national standards to establish 7. I. 7. organization. validation is determined by the organization 4. 6. conducting clinical research. serious safety events. stage of development in their role (ie. efficacy and confidence levels. Use self-assessment processes to promote self- 1. Skill practice in a simulation lab with assistance periodic basis. Establish clear performance expectations for con- (ie. Clinical performance with the procedure under based on the associated risk and known prob. Frequency of ongoing competency from a qualified instructor. Perform a gap analysis to identify educational and/ skills clinically performed on an infrequent basis. Obtain documentation of competency for con- infusion therapy as appropriate: tracted clinicians. Peer evaluation and even life threatening to the patient.15. ment by the frequency of performing those tasks 2.2. 1. personnel practices. learn. all steps performed successfully). or performance needs for each group of clinicians or when observation of performance in the work based on their profession or occupation and their environment is not practical. and outcomes within the has been reached (ie.16 (IV) 4. Employ multiple methods to deliver education (eg.14 (II) and portfolio development.9. Transfusion therapy new procedures within the organization.24 (V) 1.6. or dence before observation by the assessor. Evaluation of prior clinical experience related to L.25. Include the following aspects of 1. Observe performance of knowledge and skills in advanced beginner. and sentinel assessment by using a combination of different mea- events. for E. tracted staff. tracted clinician competencies (eg. (V. and surement techniques: patient satisfaction data. These organization. central vascular access device [CVAD] insertion. Parenteral nutrition2. Obtaining the necessary knowledge and critical cians should be competent with the skill being thinking. Technology and clinical application 2.2. competent. proficient. Prioritize the specific tasks for competency assess. Low.1. CRNI®) is one method for documenting continu. assessed.6.8 (V) methods are beneficial for novice learners.6. Special patient populations 3. Identify procedures/skills/tasks for ongoing compe. F.9-13 (IV) for invasive infusion therapy procedures. 2. Pharmacology qualifications. Include professional activities. self-study). Use a consistent process to manage contracted H. Document compliance of contracted clinicians 2. Use written tests to assess knowledge. venipunc- components of initial competency assessment and ture) on peers due to health risk and the physical and validation including: emotional stress created for the volunteer. tions at seminars and conferences. procedure that will ensure competency. staff. Do not perform invasive procedures (eg. supervision until an objective level of competency lems. 5.17-20 (IV) tency validation by using clinical outcome data. G. Achieving and maintaining board certification J. Enhance the reliability of outcomes of competency adverse events. 1.26 (V) 1.7 (IV) There is no set number of times for performing a D. than weekly).21-23 (IV) apy.7. tency assessment. less skills. such as presenta- lecture. novice. Problem. 3. self-assessment of video-recorded performance prone tasks include those that are documented to reduces stress and anxiety and encourages confi- produce issues for the patient. changing patient populations served. and the risks associated with the tasks. Validate continuing competency on an ongoing 3. Infection prevention policies and procedures. High-risk tasks include invasive 4. Antineoplastics and biologic therapy Committee Consensus) 8. Fluid and electrolyte balance with the organization’s requirements for staff 3. Develop qualifications for the role of competency the specialized skill to determine readiness to assessor. reading materials. simulations.6. maintaining repeated over time and combined with outcome national board certification.24 (V) 5. publishing in a monitoring and feedback to increase their impact on scholarly journal. Expansion of practice to include specialized skills staff and monitor outcomes produced by con- (eg. professional behavior. concerns. Associate performance appraisals with compe- competencies for clinicians providing infusion ther. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S19 JIN-D-15-00057.indd S19 05/01/16 11:30 PM . The person assessing the performance of clini- 2.24 (V) antineoplastic administration) requires multiple K. Ensure supervision of contracted staff learning 6. Use clinical scenarios to assess critical thinking frequency tasks are performed less often (eg. VAD insertion): ing competence. and clinical 4. indd S20 05/01/16 11:30 PM . 2014. Small A. Philadelphia. Cicolini G.29 (II) 12. 2013. Oakbrook Terrace. et al. et al. Pereira CR. Gorski L. Hankins J. IL: Joint Commission ing the educational aspects of competency assess- Resources. A journey to pediatric chemotherapy compe- and no consensus on how to develop. Interventions to improve professional adherence to development needs and patient educational require. Wilkinson CA.110(3): strategy for registered nurses. Nurs. 2014. specific per. Montgomery K. What features of 1. overload. There is no consensus on grading the individual’s of evidence-based guidelines on the prevention of peripheral performance. 2010. Pavia M. Pileggi C. Cherry MG. Coscarelli P. Comparcini D. 2008. Nobile CG. measurable assess. et al. Facilitate culturally competent health care by identify. J Nurs Staff Dev. J Pediatr Nurs.23(9): management. Age-based competency will workers.6. Incorporate competency for specific patient popula- knowledge. S20 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. McAdams C. ity and reliability of specific forms are limited. 15. Continuing education for patient process. Ben Shaw N. Smith M.30 (IV) 18. Assessors should provide services in an unbiased 5. functional. and family-based needs. Beener E. J Infus Nurs. 2010. 20. or critical behav- 10. standardizing annual chemotherapy competencies throughout a 3.3.(3):CD006559. Infusion nursing as a specialty.112(8):51-55. 2003.23(17-18):2578-2588. 9. 2010. Nurse Educ. RN-led initiative.1002/14651858. sus on the insertion of central venous access devices: definition of 2. BMJ Qual Saf. An organizational competency validation minimal requirements for training. The reduc- tion is required. Simonetti V. Mayhew A. Med Teach.84(8):1127-1134. Power inequalities in the assessment of nurs. MO: Saunders/Elsevier. 4th ed. Karshmer J. Sugarman C. Gorski L.27 (IV) 2012. Phillips L. Include the following in a competency form or educational interventions lead to competence in aseptic insertion checklist: the competency statement. 2. 2007. the method of demonstrating performance. Kelly LJ. Evidence-based consen- intravenous therapy. Curriculum for Infusion Nursing. et al. 6. Bianco A. Formats for the form include a simple met/unmet 11. Dissemination of a simula- 3.39(2): ture of the assessor. Cultural competency Nursing: An Evidence-Based Approach.36(4): 31-37. Corrigan A. 4. Home Healthc Nurse. 14.30(2): 347-356.32(3):198-218. eds. Newman LR.29 (II) tion of risk in central line-associated bloodstream infections: N. Barsuk JH. and maintenance of CV catheters in acute care? BEME guide no. 21. Corrigan A. et al. Joseph T. unemployed new nursing graduates entering a community-based the criteria for achieving success. Alexander M.19(1):40-46. Nurse Educ. Beazley B. There is no uniformity in defining cultural competency 17. Corrigan A. and evidence-based practices in health care tions based on age. transition-to-practice program. Berman A. Acad Med. J Nurses Prof Dev. scale). Woody G. or life. O. Conterno LO.6 (V) Database Syst Rev. 2011.28.28.5 (V) 56-61. CD006559.pub2. J Clin mance constitutes competency or when remedia. to performance issues. DeBourgh GA.36(6):413-419. 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Toole BM.4 The clinician obtains approval for research and based practice through the evidence-based practice academy. 2012. S. D. self-determination.3 The clinician uses research findings and current best Continuous Quality Improvement in Healthcare.25. Institute of Medicine. and costs.70(8):680-686. 2011. Speroni K. therapy. In: best evidence. Barber N.24(4):242-243. Smith D. but is not limited to. Utilizing evidence-based research and practice to sup- accountability. journal club and disseminating research findings to 18. The cost of catheter-related bloodstream infec- forth by accrediting agencies and organizational policies tions: implications for the value of prevention.2. Schilling D. EVIDENCE-BASED PRACTICE Infusion Therapy. Hollenbeak C. part 1. Switzerland. 17. Worldviews Evid with patient preferences and values to provide effec. Taylor B. J Infus Nurs. Increasing capacity for evidence- 7. 59. http://www. Guzzetta C. patient outcomes. 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Davis JE.16 effects associated with treatment or therapy. related complications: 4. infusion device. including those that may occur after the infusion device is A. 2014. Gorski LA. Use educational resources that are understand- translation of research-based evidence by nurses. tion for psychomotor skills. Educate patients/caregivers/surrogates about infu- 8. Use and troubleshooting of the electronic infu- rogate will be performing. Wuchner SS. tion.7-11 (IV) 24. Establishing gruence. and use simple 2010. Int J Evid Based 2.10(4):338-346. J Infus Nurs.13 systematic review of facilitators to enhance the uptake of evidence (III) from systematic reviews and meta-analyses.2. developmental and cognitive level.1. Infusion administration as appropriate. Ovretveit J. including safety. Byrne C.28(4):214-223. the traditional approach of teaching nurses: a research project on peripheral IV catheter insertion. Clarke M. cultural influences. including aseptic technique and hand hygiene. usable. accessibility 1. PATIENT EDUCATION and to seek social support.1. Precautions for preventing infection and other needs. knowledge and skill acquisition for all aspects of b. a. Practice Criteria 3.14 (IV) 8. 2011.34(1): such as current stressors. and reports of related care. additional education should also 2. McKinnon J. Integrative review of implementation strategies for C.CD009401. and language preference. therapy and reduce the risk of infusion therapy. Facebook. Wan Q. however. lines). J Prof Nurs. Standard there are challenges. cultural con- 23. Stevens K. Shepperd S. complications. and instructional research priorities for the Infusion Nurses Society. and encompass patient and caregiver learning 2. and func- 55-62. and misinformation risks. removed and after the patient leaves the health tified goals to ensure the safe delivery of infusion care setting (eg.1. clear naviga- pub2.4 (V) 22. For outpatients and those receiving home infu- 1. Limited research has shown benefits and patient engagement. Alexander M. Proper care of the access device. 2012.1002/14651858. 21. supplies.12. The effects Also assess additional factors affecting the patient’s. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S25 JIN-D-15-00057. methods. J Infus Nurs. Zugcic M. purpose edge. potential complications. et al. and/ D. cognitive knowledge (teach-back). Signs and symptoms to report. 20. blogs) to obtain health advice and information 8. Twitter. and effective 26. Wilfong D. caregiver. tional limitations. Establish specific and measurable goals. maintenance. and equipment. Evaluate patient/caregiver/surrogate learning out- or surrogate about the prescribed infusion therapy comes with methods that directly measure knowl- and plan of care including. privacy. 2015. sideration of health literacy levels. Nurs Res Prac. such as demonstration/return demonstra- and expected outcome(s) and/or goals of treatment. optimizing user experience. sion therapy to include. Engage the patient/caregiver/surrogate in the include: development of these goals.2013:article age. incorporate learning 1. benefits and challenges associated with the use of social media (ie. signs of postinfusion phlebitis. or adverse feelings and beliefs for the affective domain.1 The clinician educates the patient. meet Federal Section managers. Advise the patient/caregiver/surrogate about the Healthc. but not limited to. fever) and how/where to report them. sensory deficits. Interventions to improve the use of systematic reviews in decision-making by health system accessibility standards (ie.31(2): surrogate education are reputable. Select effective ways to validate appropriate solutions. accessible to the learner and incorporate national 25. Clarke MJ. but not limited to: gruent with the skills being taught. Cochrane Database Syst 508 accessibility guidelines and usability guide- Rev. Ensure that Web sites used for patient/caregiver/ and application of research in nursing. and disposal of 3. Making evidence more wanted: a page layout and an accessibility statement. E. and risks (V) and benefits. Develop an effective educational plan based on iden. A model for increasing appreciation.(9):CD009401.1-6 (V) sion device (EID)/infusion system. Clin Nurse able and actionable. 37(2):121-124. Infect Control Hosp Epidemiol.39(2):71-79. 2014. 2014.4 The clinician confirms that the informed consent prevention-chronic-care/improve/self-mgmt/pemat/pemat_guide. ment.1 Obtain informed consent for all invasive procedures 5. 9. Sethi A. Corrigan M. The patient educa. Patient education of chil- dren and their families: nurses’ experiences. Assessing the health literacy levels of patients using selected hospital services. Clin J Oncol Nurs. Clin Nurse Spec. 2011. 2014. Use the teach-back g. Miller M. 2015. Mortlock N. tion materials assessment tool (PEMAT) and user’s guide: an 9. Cleary A. Comput Inform Nurs.gov/professionals/quality- limitations and protecting the device while patient-safety/quality-resources/tools/literacy-toolkit/healthlit- performing activities of daily living.gov. Prevention of catheter damage. St Louis.indd S26 05/01/16 11:30 PM . Published November 2013. 9. Perucca R. eds. McHugh S. Saunders/Elsevier. Perucca R. Lane S. Corrigan A. and treatments in accordance with local or state laws http://nnlm.gov/outreach/consumer/hlthlit. 2. Updated August 2014. Househ M.0). Empowering patients management of the catheter if an embolism is through social media: the benefits and challenges. Recognize that obtaining informed consent is an 2010. instrument to assess the understandability and actionability of central vascular access device [CVAD] insertion) facili- print and audiovisual education materials (version 1. 6. is found. Nursing: An Evidence-Based Approach.5 The patient or surrogate has the right to accept or patient education.33(3):150-154. AHRQ tates the process and obtains informed consent. 3rd ed. Corrigan A. Pediatr Nurs.gov/professionals/ 9. Peter D.html. Infusion therapy across the continuum. In: Alexander M. Salas- catheter damage (eg. MO: Saunders/Elsevier. S26 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 16. Smith C. Borycki E.1. Infusion 1.2.30(1):46-54. Walker J. Czaplewski L.2. Cassutt C. Pilcher J. Research-based Web design and ing the procedure. process is completed for the defined procedure or treat- pdf. 2014. e. MA: Jones & Bartlett. however. Practice Criteria 10. publication no. INFORMED CONSENT stream infection. Casey K. Anderson M. Weingart S. 2010:456-479.healthypeople.3.ahrq.2(1):482-495. eds. 2011. http:// 1. Gorski L. Reducing readmissions using teach-back. et al. Richardson D. Zerbel S. In: Alexander M.18(3):321-326. d. Agency for Healthcare Research and Quality. Are hospital- and performance at the beginning of infusion ized patients aware of the risks and consequences of central-line associated bloodstream infections? Am J Infect Control. therapy and periodically thereafter at established 2013. Jordan M. The process begins with dialogue between the www. Note: All electronic references in this section were accessed September 19. General Services Administration. Living with an access device. Vizcarra C. Client Education: Theory and Practice. Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Hankins J. Standard 2013. Gorski L. Marcus C. 9. Kelo M. including activity method: tool #5. Dimitrov B. from scissors). Hankins J. Role of patient aware- ness in prevention of peripheral vascular catheter-related blood. F. J Nurs immediate actions to take if catheter damage Admin. J.32(1):95-96. Gorski L. 2010:71-94. patient and family education websites. practitioner (LIP) or qualified clinician perform- 12.usability. participation in research according to federal rules and 7. Eriksson E. Agency for Healthcare Quality and Research. 2015. Miller C.html.24(1):31-37. http://guidelines. St Louis. 2010:109-126. 20. Yadrich D. A. National Network of Libraries of Medicine. and organizational policy. Fitzgerald S.17-20 (V) toolkit2-tool5. educational process involving the patient in shared 11.5 (V) 18.20(1):50-58. Safdar N. assessment for 15. 15.41(12):1275-1277. 2015. 3rd ed. Stoeckel P. Runde D. Kushniruk A. 8. Lawrence S. Flanders S. 14-0002-EF.gov/2020/topics-objectives/topic/health. 2020: health communication and information technology. Health Psychol Behav Med. Saunders/Elsevier. Infusion Stafford K. and what Lopez D. refuse treatment. Prevention of air and catheter embolism and 2012. Hsieh C. Standardizing central venous catheter care by using observations from patients with 9. Martikainen M. intervals. Healthy People decision making. Creating therapy prescribed.ahrq. patient/surrogate and the licensed independent communication-and-health-information-technology. 3rd ed. Clinician and patient education. http://www. Peripheral venous access devices. 3. other clinicians have usability guidelines.3 The clinician performing the invasive procedure (eg. MO: short peripheral catheters. In: Alexander M. Ottum A. Werkowitch M. Perucca R. Who is Billy Ruben? Health literacy and 9. REFERENCES Perucca R. Infusion Nursing: An Evidence-Based Approach.45(1):35-42. http://www. MO: Sudbury. Corrigan A. Evaluate patient/caregiver/surrogate comprehension 17. 4. Robinson P.2 Informed consent is required for human subject cancer. Corbitt N. f. Gerard PS. Hankins J. regulations. a significant role in the complete process. 14. Signs and symptoms of adverse effects of the 13. Recommendations for improving safety practices with Nursing: An Evidence-Based Approach. Health literacy. St Louis. J Infus Nurs. Neonatal Network. eds. Health Inform suspected. US Department of Health and Human Services. Gorski L. stored.9-13 (I) cations. not fit with cultures where medical treatment choices VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S27 JIN-D-15-00057. or 1. 1. payment for services. Compensation for participation. Continued confirmation of informed consent may of the information by asking the patient/surro- be necessary for ongoing treatments (eg. additional components such as: 2. collaborate with the tries). or has further questions. health care facilities may therapeutic interventions on the patient’s com. Recognize cultural differences that may affect the 5. appreciates the situa.3. common compli. In these required elements: addition to the standard components of informed 1. and potentially serious or irreversible F. Ensure that the process for informed consent includes ing to improve the patient’s ability to understand. tattoos. videos. from the patient/surrogate as regulations vary 8. 9. lenges with adequate security for storage and use not read their primary language. Allow sufficient opportunity for the patient/ process of informed consent. informed consent (eg. proce. and sixth grades and in the patient’s primary lan. and ing as a witness to the patient/surrogate signature variations in the legal approach to evaluation of on the informed consent document. not require informed consent.2-6 (IV) Health Insurance Portability and Accountability D.15 (IV) rogates who have vision or hearing limitations.1-3 (IV) treatment or procedure. and shared. guage. the research consent document includes coercion or persuasion. coun. gate to recount or “teach-back” the proposed alysis or antineoplastic administration).2. For research-informed consent.8 (IV) informed consent. however. 2. This document at a reading level between the fourth consent includes how the images will be obtained. concise. the pro. Recognize that there could be E. choices. 2. risks. fessional performing the consent process. Choose appropriate methods to deliver the infor- signing a consent document or providing verbal mation. which may answers. Clarify and/or reinforce B.7. 5. however. Differences include documentation. provide explana- condition-based exceptions to requirements for tions and a consent document that is clear. tion and can apply it to her or his specific situation.1. potential benefits. managed. Validate the patient’s/surrogate’s comprehension 3. there are chal- English-speaking patients and for those who can. The patient/surrogate is capable of understand. 3.2 (IV) consent documents with a clear layout and text styl- C. Unidentifiable photographs have benefits for 3.14. or computer-based materials. states. or health care operations.indd S27 05/01/16 11:30 PM . G. Use extended dialogue and simplified for managing these situations. 7. Unless the photograph is for treatment purposes. alter. Recognize that photographs of patients may or may risks. Document the informed consent process by serv- dures/treatments requiring informed consent. provinces. Provide educational materials and the consent other anatomically notable scars or lesions. information to understand the procedure/treat. Facilitate the informed consent process by choosing Act (HIPAA) rules when the patient is identifi- learning methods most appropriate for the patient’s able by inclusion of the patient’s face or other age and level of health literacy. The process concludes with the patient/surrogate 6. if any. Provide appropriate resources for patients/sur. and other legal issues such as copyright 4. tion and its consequences. identifiable features such as jewelry. and other HIPAA rules. 3. 5. its purpose. ownership. occurs. The patient/surrogate comprehends the informa. prehension. The anticipated length of participation in the ing relevant information. Provide a qualified medical interpreter for non– educational purposes. hemodi. 4. Management processes for confidential patient 3. 1. Follow requirements for obtaining informed consent information as needed. via phone conversation). research. information. ment. provider about the need for more dialogue. including verbal and paper-based written consent according to organizational policy (eg. The patient/surrogate has received the necessary information and their identity. and is able to make 2. The foundation of surrogate to ask questions and receive informed consent is self-determination. A photograph that does not identify the patient 2. When the patient/surrogate expresses confusion between jurisdictions (ie. Availability of medical treatments if injury native procedures/treatments. The decision is authorized by the patient/surro. written informed consent is required under gate and documented on the signed form. Consent is voluntarily given and is free from consent. have policies that go beyond these rules. Provide information at the most appropriate time would not require informed consent under considering the effect of anxiety. pain. Identification of procedures that are experimental. emergency/life-threatening and an accurate representation of the research situations) and adhere to the organizational policy purpose(s). 4. IL: The Joint Commission. August 27.0.6 (IV) tested in randomized control trials. or disease-related 2013. Ethical implications of digital images for teaching and learning purposes: an integrative the procedure/treatment using language and learn- review. doi:3389/ surrogate response in the medical record. surrogate. evolving issues and legal perspectives. 2005. Viswanathan A. Guide to the Code of Ethics for Nurses: 10. Thomas L. 2015. 14. J Head Trauma Rehabil. Prictor M.20. the patient’s response to 2013. Readability stand. complete. DOCUMENTATION IN THE MEDICAL RECORD 1.4. Tilburt JC. 2012.19 (V) fnevr.accessdata. Cochrane Database Syst Rev. Improving understanding in the research viduals with specific licensure or credentials.15(1):44. The Joint Commission. Brooks CL. and/or practice 11. 5. For neonatal.00129. consent by using tools to evaluate cognitive status or http://www. Cochrane TI. Nishimura A. Plastic Surg Nurs.1. informed consent process: a systematic review of 54 interventions sion. 2014. guidelines. Taylor HA. documented. assessments or collection of data.3 Documentation is legible. Synnot A. Child’s assent in research: tive situations) when exemption from obtaining age threshold or personalisation? BMC Med Ethics. 9. method of discussion (eg. Informed consent for medical treatment Expected side effects and unexpected adverse events and research: a review. New Engl J Med. bility. date. authorized personnel.16 (V) Geneva. diagnosis or problem.2.indd S28 05/01/16 11:30 PM . and efficiently retrievable. memory. medical record regarding the patient’s infusion therapy 7. 10. doi:10. organizational policies. Int J Clin Pract. 4. ciples for nurses. Hall DE. Informed consent issues in traumatic brain stage of the individual. obtain informed consent from a Clinical Research Practice (GCP): Guidance for Implementation. Piasecki J. DeWees J.1. CFRSearch. Parker B.CD003717. 10. procedures. Kornhaber R. and time. Paasche-Orlow MK. US Food and Drug Administration.cfm?CFRPart=50&showFR=1&subpartNode= prehension. ed. Frontiers Neurol. procedure/treatment from the parent or legal guard. 2014. et al. quality. perception of informed consent for IV-tPA during telestroke con- telephone). emergent and time-sensi. pediatric. MD: American Nurses Association. with actions taken and patient response. Del Carmen MG. 12. Can Med Assoc J. trauma-.69(4):401-409. Development. Harting M. 2011. “Sign here”: nursing value and the process of informed consent. are a family decision rather than an individual deci. Fetherstonhaugh D. standards S28 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.15(4):140-144. Handbook for Good capacity. REFERENCES Note: All electronic references in this section were accessed September 15. 10. to whom it was given.18. intervention and monitoring. and adolescent patients. H. and ability to reason. and for participation in clinical trials. and objective information in the patient’s Spring. Interpretation and Application. 2012. 2015. Res 10. the patient does not have the necessary cognitive 13.2012.pub3. Orthop Nurs. Brancati FL. Document details of 18.1002/14651858. Rights and Responsibilities of the Individual: Comprehensive Accreditation Manual for Home Care. timely. 2015. according to the scope of practice for indi- McCormick JB. information and personal data are established in 2010.gov/scripts/cdrh/cfdocs/cfcfr/ asking probing questions to evaluate language com. Joffe S. Johnson-Greene D. 2015. 19. Assess patients with age-.348(8):721-726.184(5):533-540. 2nd ed. Dranseika V. JONAS Healthc Law Ethics Regul.13:175-187. Khirallah R. Ryan R. and plan of care for infusion therapy. Carey J. licensure ards for informed-consent forms as compared with actual reada. Oncologist. Waligora M. I. Erwin PJ. Audio-visual presentation of information for informed consent 10. Fowler MDM. Vela K.25(2):145-150.4 Documentation reflects the continuity.8:299-305. and the patient or sultation.10(8):636-641. safety of care. accessible to 8. verify assent (ie. Murad MH. ing methods appropriate for the age and/or cognitive 16.1 Clinicians document their initial and ongoing 3.14(1):14-28. Informed consent: revisiting the issues.25(3):136-139.34(1):29-33. that intervention. Holist Nurse Pract. From the patient. Silver chronological. ian. 2005:59-71. Betihavas V. BMC Med Ethics. World Health Organization (WHO). Cook WE. 2015.5. this is generally recommendations for safeguards. Standard 2. Informed consent forms growing too complex.5 Documentation guidelines and the policies for Pract.29(4):276-280.(5):CD003717. Define circumstances (eg. Informed consent for clinical treatment. While there is lack of injury research: current status of capacity assessment and consensus over the age of assent. Baber RJ. Variability in the information provided. 2012. Coons S. and vascular access with the clinician’s name.2 Documentation contains accurate. Erlen JA. When 21:1. confidentiality and privacy of the patient’s health care 10. Menendez JB. Oakbrook Terrace. 6. Fink AS.17 (V) 2010. Switzerland: WHO. Considering elderly competence when consenting to that occur. CFR—Code of Federal alterations in cognitive capacity for their ability to Regulations Title 21 Part 50 Protection of Human Subjects. J.fda. Prochazka AV. Medical photogra- verify that informed consent was obtained for the phy: current technology. 2003. are treatment. J Multidisciplinary Healthc. or credential to practice. Informed consent: essential legal and ethical prin. informed consent is allowed. agreement) to 15. considered 7 years old or school age. 17. 2014. External catheter length and length of catheter 14.14. Specific site preparation. assess for 15. Identification of the insertion site by anatomical of the VAD: descriptors.25-29 (IV) report of changes related to the VAD or access 1. Condition of the site. patient education.13 (V) status. 8. required elements of care should be used but lation (eg. initial and ongo- 3. Documentation includes. condition of the inserted. and patient responses should be completed stabilization.17 (V) practices. When multiple VADs or catheter lumens are c. access device (VAD) inserted. the ing patency. Take this measurement ing management for complications. Type of therapy.2 (II) administration.3-5 (IV) 12. Date and time of insertion. drug.15 (V) documentation from clinicians. Results of VAD functionality assessment includ- A. The electronic medical record should capture each subsequent site assessment (see Standard 9. and method of administration. but is not limited to. 1. the presence of edema and possible deep vein date/time of removal. Arm circumference: before insertion of a nursing interventions during removal. ability for maintenance and replacement of tub- and safety precautions taken. results as appropriate.8. Pertinent problem or diagnosis. and without limiting further description as need- extravasation that allows for accurate and reli.12.8. or adverse implanted devices. documentation should clearly indicate catheter tip for all CVADs prior to initial use what solutions and medications are being infused and as needed for evaluation of VAD dys. lack of resistance when flushing.30. age). site care. number of attempts. tion or care. dose. Patient. comes. Regular assessment of the need for continuation 5. accrediting bodies. dressing PICC and when clinically indicated to assess applied. regulations. laterality. patient response. for phlebitis. understanding of. local anesthetic (if used). dressing change.9 (V) catheter and length. Upon removal: condition of site. dressing. length. A standardized assessment. all central vascular access devices (CVADs) and including symptoms.17 (V) function.9-10 (V) 13. reason for device removal. condition of the venipuncture or access site prior to and after infusion therapy. b.14 (V) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S29 JIN-D-15-00057. infection prevention. including visuali. caregiver.8.20-22 (IV) ately marked drawings. document source of the location and other characteristics such as culture(s). a. Type of equipment used for infusion therapy cation.16 (V) Practice Criteria 10. or legally authorized repre. and evaluation of expected out- and the insertion methodology. infiltration. if available. through each device or lumen. laboratory test 4. The type. patient in an electronic health record or other electronic report of discomfort or any pain with each health information system. type of catheter actions. Standardized templates for documentation of policy.16 sentative’s participation in. Documentation of all infusion therapy. absence of signs and symptoms of following: complications. interventions. and gauge/size of the vascular ing assessment. barriers to patient educa- functionality of device. During regular assessment visits in other set- 6. depending on the setting.24 (V) 10 cm above the antecubital fossa. If cultures are obtained. Electronic entries should reflect current patient site.14. with photography as location in the medical record.8.indd S29 05/01/16 11:30 PM . account- 2.17.30 (IV) needed and in accordance with organizational 2. and state and federal 9.6. Daily for acute inpatient settings. and vital signs as appropriate.8. ed. Confirmation of the anatomic location of the used. route. and patient ardized terminologies. For midline catheters and peripherally inserted tings. such as in the home or a skilled nursing central catheters (PICCs): facility.19 (V) zation and guidance technologies.12 (IV) 16.13.31 (IV) able assessment on initial identification and with 3.11. using stand- regular assessment of the access site. (V) and responses to therapy. time. even when an entry is pulled from another 8. the lot number for patient’s response to VAD insertion and therapy. or appropri.14. landmarks.5. using a standardized ing/cassettes as well as identification of caregiver tool for documenting adherence to recommended or surrogate for patient support. and edu.1.17 (V) pitting or nonpitting edema.18.8 (V) b. rate. and presence of a blood return upon aspiration.6-8 (V) events with related interventions.9 (V) B. data for quality improvement without additional Informed Consent).23 (V) a. and any necessary continu- thrombosis (DVT). of care. clinicians’ 7. appropriate for the specific patient popu. side effects. 11. Hunter MR. Klang B. Alexander M. Infusion 2014.38(3):345-349. Ygge BM. Ethical Issues in Nursing. Accuracy in documentation: a study of peripheral venous cathe- 2014. St Louis. 2011.21(9-10):1339-1344. 2014. Wang N. continuum. et al. Saunders/Elsevier. Risk factors associated with catheter- 27. Bullock-Corkhill M. 12. eds. Gorski L. Gorski L. Perucca R. J Infus Nurs. PA: Wolters Kluwer/Lippincott 25. Griffiths R. Tiwari MM. Anderson JR. Burns LA. Basch P. 2009.50(1):87-98. 2015. Infect Control Hosp ACTS. Gorski L. S30 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Nursing Informatics peripherally inserted central venous catheters: a prospective obser- and the Foundation of Knowledge. Chan RJ.18(20):1242-1246. Central venous access devices: access and ME. 2.43(2):154-162. Applying Nursing Process: A Tool for Critical 4. Kalinicheva T. Infusion of quality nursing documentation. for the Medical Informatics Scholarship. Impacts of structuring care. documentation and complications: a point prevention of intravascular catheter-related infections. In: Legal and 9. Hankins J. Committee of the American College of Physicians.html.35(5): Hankins J. Thinking. Skala LC.162(4):301-303. Aziz AM. Johansson E. Intravascular device 5. J Nurs 14. New York. 2010:456-479. 3. MO: Saunders/Elsevier. Kutney-Lee A. Int J Nurs Pract. Hagle ME. Infusion therapy across the approaches to its evaluation: a mixed-method systematic review.41(1):466-472. 6th ed. Berriel-Cass D. Kuehn SC. Epidemiol. Infusion Nursing: An Evidence-Based Approach. maintenance. www. 2010:195-208. MA: Jones & vational cohort study: part 2. insertion. 2009. Saranto K. 2012. eds. Central venous access.67(9):1858-1875. Central venous access devices: 28. New K.33(5):449-455. Hermsen ED. PA: Wolters Kluwer/Lippincott record adoption on nurse-assessed quality of care and patient Williams & Wilkins. catheter care in non-intensive care units: a quasi-experimental 19. Ann paediatric care: an intervention study in electronic patient Intern Med. J Clin Nurs. In: Alexander M. 2011. 2010. Silver 30. 3rd ed. Marsh NM.40(12): 13.46(1):50-57. Nagle LM. Docherty SL. Defining and incorporating Williams & Wilkins. the short peripheral catheter site. 2011. 2011. Documentation and confidentiality. safety. Hankins J. Ahlqvist M. 2014:540-611. eds. Russell E. impact on nurses and nursing care. 2010. an Australian tertiary cancer center. New York. Scand J Caring Sci. Guidelines for the use. Perucca R. high-impact interventions. Wiren M. J Nurs Admin. 2015. MD: ANA. Corrigan A. Taylor CR. http:// prevalence survey. Published 21. Approach. A meta-study of the essentials Corrigan A. Nurs Clin North Am. Davis. records. Russell JM. Spetz J. 3rd ed. 2012. French KS.78(2):128-132. Marsh N. REFERENCES 15. Corrigan A. In: Manual of IV Therapeutics: Evidence-Based Note: All electronic references in this section were accessed September Practice for Infusion Therapy.indd S30 05/01/16 11:30 PM . Förberg U.37(4):260-268. In: Weinstein SM. Webster J. 2010:495-515. PA: FA 16. Philadelphia. Mortlock N. Johansson E. Kivekas E. Aust Health Rev. Berglund B. Philadelphia.28(4):629-647. Perucca R. In: Alexander M. Hewer B. O’Grady NP. 23. NY: Pearson. management.cdc. Jones K. Gorski LA. 2012:147-160. Br J Nurs. Johnson M. Phillips LD. Hailey D. Gorski L. Charlton ME. Alfaro-LeFevre R. MO: Saunders/Elsevier. of cancer nursing practices for managing intravascular devices in 6. Maneval RE. Dugger B. 2014:303-334. Miller C. St Louis. Professional practice concepts for infu- sion therapy. Recommendations for frequency of assessment of 8. Waneka R. Infusion Nursing: An Evidence-Based Approach. Hospital information technology systems’ Saunders/Elsevier. Eur J Oncol Nurs.18(3):231-235. MO: 2010. Peripheral venous access. 6th ed. eds. New KA. 9th ed. St Louis. American Nurses Association (ANA). 2014:335-390. Aldrich K. Peripheral venous access devices. eds. Hagle ME. Rey JE. Kelly D. J Nurs 10. Morris P. Corrigan A. Gorski L. Inappropriate intravascular device use: a prospective study. Electronic nursing docu- Spring. mentation as a strategy to improve quality of patient care. 2014. Philadelphia. nursing records: a systematic review. St Louis. Hagle ME. Rupp 7. Nursing: An Evidence-Based Approach. Perucca R. In: McGonigle D. 22. Documentation. Nursing: An Evidence-Based Approach. Quality of nursing documentation and 17. Hankins J. A point prevalence study April 2011. Transforming nursing care through health literacy controlled study of education and feedback. 18. Scholarship. 20. Hankins J. Information and knowledge needs of nurses in the related upper extremity deep vein thrombosis in patients with 21st century. 3rd ed. mentation in the 21st century: executive summary of a policy Accuracy in documentation of peripheral venous catheters in position paper from the American College of Physicians. Hagle ME. 24. In: Weinstein SM. Perucca R. The effect of hospital electronic health Therapy. Gorski L. Yackel T. Infusion Nursing: An Evidence-Based 290-292. Wallin L. MO: Saunders/Elsevier. 2015. basic nursing care actions into the electronic health record. Clinical docu- 31. 2010:540-549. J Hosp Infect. Sustained improvements in peripheral venous Wilkins. Gorski L. Gorski LA. Bartlett Learning. ANA’s Principles for 509-514. 11. Ehrenberg A. J Nurs Admin. Mikell M.16(2):112-124. Mastrian K. J Clin Nurs. ters. Improving peripheral IV cannula care: implementing 3rd ed. Perucca R. Therapy. Kinnunen UM.gov/hicpac/BSI/BSI-guidelines-2011. 3rd ed. Clemence BJ. 2014. In: Alexander M. Corrigan A. 9th ed. Nursing Documentation: Guidance for Registered Nurses. Kuhn T. Barr M. 1. In: Alexander M. Hallock D. and potential complications. St Louis. Brandon DH. 2010:480-494. eds. Yu P. Jefferies D. Englebright J. 2012. Cook A. Kelley TF. 2010:109-126. 16. Burlington. Plumer’s Principles and Practice of Infusion 2014:153-187. Plumer’s Principles and Practice of Infusion 26. Guido GW. J Infus Nurs. Fakih MG. In: Alexander M. J Adv Nurs.18(13):1945-1952. NY: Wolters Kluwer/Lippincott Williams & Saravolatz LD. MO: 29. Perucca R. eds. The Art and Science of Infusion Nursing Section Two: Patient and Clinician Safety 11. ADVERSE AND SERIOUS E. Immediately investigate serious adverse events to ADVERSE EVENTS ensure prompt action and improve safety. The pro- cess includes a root cause analysis (RCA) or other systematic investigation and analysis to improve Standard quality and safety.1-6 (V) 11.1 The clinician reports and documents adverse 1. Identify cause(s), describe the event, and imple- events or serious adverse events (sentinel events) associ- ment specific strategies and/or actions for ated with infusion therapy. improvement that protects patients. An interpro- 11.2 The science of safety, which includes human errors fessional approach focuses on systems issues, and system failures, along with reporting of adverse procedures, human resources, peer and/or clini- events and serious adverse events, is defined in organi- cal review, products/equipment, processes, and zational policies, procedures, and/or practice guidelines. training gaps.1,6 (V) 2. The clinician actively participates in the develop- ment, implementation, and evaluation of the Practice Criteria improvement plan.1,3,6 (V) A. Report adverse events or serious adverse events (sen- 3. Consider using an RCA or other systemic inves- tinel events), or the risk thereof (ie, “near misses”) tigation or analysis for complex, recurrent prob- associated with vascular access devices (VADs) and/ lems and for “near misses.”6 (V) or infusion products/devices and the administration F. Improve safety within the organization: of drugs and biologics, to the licensed independent 1. Focus on fixing the system(s) and processes, practitioner (LIP) and appropriate department(s) rather than blaming the clinician. (eg, risk management [RM], quality improvement) 2. Advocate for teamwork interventions, includ- and in accordance with organizational policy.1-6 (V, ing training and education (eg, focus on com- Regulatory) munication, leadership); work redesign (eg, B. Report adverse events associated with drugs, biolog- change interactions such as multidisciplinary ics, and infusion devices/products to the US Food rounds); and use of structured tools and proto- and Drug Administration (FDA) through the cols (eg, handoff communication tools and MedWatch reporting system and/or the Institute for checklists). Safe Medication Practices (ISMP). Reports to ISMP 3. Establish a strong “just culture” that continu- are confidentially shared with the FDA and, when ously strengthens safety and creates an environ- applicable, to product vendors to inform them about ment that raises the level of transparency, encour- pharmaceutical labeling, packaging, and nomencla- ages reporting, empowers the clinician to identify ture issues that may cause errors by their design (see and implement appropriate actions to prevent Standard 13, Medication Verification).7,8 (V, adverse events and near misses, and promotes Regulatory) quality patient outcomes (see Standard 6, Quality C. Use valid and reliable tools to identify and measure Improvement).1,2,4-6,11-17 (V) adverse events.2,9,10 (V) G. Communicate unanticipated outcomes and lessons D. Use a standard document developed by legal and learned to organizational leadership and risk management personnel to provide objective and clinicians.1,2,4-6,11-18 (V) specific facts about the adverse event or serious H. Ensure responsible disclosure of errors to patients; adverse event.4,5 (V) promote interprofessional collaboration in planning VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S31 JIN-D-15-00057.indd S31 05/01/16 11:30 PM and discussing information with the team responsi- 12. PRODUCT EVALUATION, ble for disclosing information about the adverse INTEGRITY, AND DEFECT event to the patient, caregiver, or surrogate.3,19 (V) REPORTING REFERENCES Standard Note: All electronic references in this section were accessed September 12.1 Clinician end users are involved in the evaluation 16, 2015. of infusion-related technologies, including clinical 1. The Joint Commission. Sentinel event policy and procedures. application, expected outcomes, performance, http://www.jointcommission.org/sentinel_event_policy_and_ infection prevention, safety, efficacy, reliability, procedures/. and cost. 2. The Joint Commission. 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Elsevier; 2010:22-48. 12.4 Product evaluation, integrity, defect reporting, and 6. Alexander M, Corrigan A, Gorski L, Phillips L, eds. Core product recall are in accordance with organizational Curriculum for Infusion Nursing. 4th ed. Philadelphia, PA: policies and procedures and with state and federal rules Wolters Kluwer/Lippincott Williams & Wilkins; 2014. and regulations. 7. Zastrow RL. Root cause analysis in infusion nursing: applying quality improvement tools for adverse events. J Infus Nurs. 2015;38(3):225-231. Practice Criteria 8. US Food and Drug Administration. MedWatch: the FDA safety A. Include an interprofessional group of direct and information and adverse event reporting program. http://www. indirect clinician end users in product evaluation, fda.gov/Safety/MedWatch/default.htm. and orient and educate clinicians on the new prod- 9. Institute for Safe Medication Practices (ISMP). Reporting a medi- cation or vaccine error or hazard to ISMP. https://www.ismp.org/ uct/device, as well as data collection tools for analy- errorReporting/reportErrortoISMP.aspx. sis and ongoing monitoring.1-5 (V) 10. Institute for Healthcare Improvement (IHI). Global trigger tool B. Obtain reports of internally and externally reported for measuring adverse events. http://www.ihi.org/resources/Pages/ adverse events for the committee/individual manag- Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx. ing product evaluation and product procurement.6-9 11. Classen DC, Resar R, Griffith F. Global trigger tool shows that (V) adverse events in hospitals may be ten times greater than previ- C. Obtain rental or purchased equipment from a prop- ously measured. Health Aff (Millwood). 2011;30(4):581-589. erly qualified vendor.6 (V) 12. Robert Wood Johnson Foundation. Ten years after keeping D. Include the following in product defect reporting: patients safe: have nurses’ work environments been transformed? suspected and known intrinsic and extrinsic con- Charting Nursing’s Future. www.rwjf.org/content//dam/farm/ tamination; product damage; product tampering; reports/issue_briefs/2014/rwjf411417. Published March 2014. 13. Bishop A, Fleming M. Patient safety and engagement at the front- improper, unclear, or confusing patient or user lines of healthcare. Healthc Qual. 2014;17:36-40. instructions or labeling; similar or confusing names; 14. Tocco S, Blum A. Just culture promotes a partnership for patient packaging problems; and errors related to reliance safety. Am Nurse Today. 2013;8(5). http://www.americannurse- on color coding (see Standard 13, Medication today.com/just-culture-promotes-a-partnership-for-patient-safety. Verification).7,10-13 (V, Regulatory) 15. American Nurses Association (ANA). Nursing Administration: E. Retain the product, product overwrap or packaging, Scope and Standards of Practice. Silver Spring, MD: ANA; 2009. and other identifying information (such as model 16. Hershey K. Culture of safety. Nurs Clin North Am. number, lot number, serial number, expiration date, 2015;50(1):139-152. and unique device identification when available) for 17. Wu AW, Steckelberg RC. Medical error, incident investigation further analysis and reporting when a product defect and the second victim: doing better but feeling worse. BMJ Qual is identified before use.1,14 (V) Saf. 2012;21(4):267-270. 18. Pham JC, Aswani MS, Rosen M, et al. Reducing medical errors F. Retain serial and lot numbers used in product iden- and adverse events. Annu Rev Med. 2012;63:447-463. tification, tracking, and product recall, as well as 19. Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of unique device identification when available, in order “nonharmful” medical errors and other events: duty to disclose. to comply with recalls or to file an adverse event Arch Surg. 2012;147(3):282-286. report.7,14 (Regulatory) S32 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.indd S32 05/01/16 11:30 PM G. Include the following information pursuant to US 3. Davis RE, Sevdalis N, Neale G, Massey R, Vincent CA. Hospital Food and Drug Administration Form 3500A when a patients’ reports of medical errors and undesirable events in their product defect results in an adverse event: health care. J Eval Clin Pract. 2013;19(5):875-881. 4. Swayze SC, Rich SE. Promoting safe use of medical devices. 1. Patient information including name, age or date Online J Issues Nurs. 2011;17(1). of birth, gender, and weight. 5. Tay S, Spain B, Morandell K, Gilson J, Weinberg L, Story D. 2. Identification of occurrence, event, or product Functional evaluation and practice survey to guide purchasing of problem. intravenous cannulae. BMC Anesthesiol. 2013;13(1):49. 3. Outcomes attributed to the occurrence or event 6. American Society for Health-System Pharmacists. ASHP guide- (eg, death or serious injury), defined as disability lines on home infusion pharmacy services. Am J Health Syst resulting in permanent impairment of a body Pharm. 2014;71(4):325-341. function or permanent damage to a body struc- 7. US Food and Drug Administration. Medical devices. 3 CFR Title ture, or injury or illness that requires interven- 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/ tion to prevent permanent impairment of a body CFRSearch.cfm?CFRPart=803&showFR=1&subpartNo structure or function. de=21:8.0.1.1.3.3. 8. Stacey S, Coombes I, Wainwright C, Klee B, Miller H, Whitfield 4. Date of event. K. Characteristics of adverse medication events in a children’s 5. Date of report by the initial reporter. hospital. J Paediatr Child Health. 2014;50(12):966-971. 6. Description of event or problem, including a dis- 9. US Food and Drug Administration. Current postmarket surveil- cussion of how the device was involved, nature lance efforts. http://www.fda.gov/MedicalDevices/Safety/ of the problem, patient follow-up or required CDRHPostmarketSurveillance/ucm348738.htm. Revised April 1, treatment, and any environmental conditions 2014. that may have influenced the event. 10. US Agency for Healthcare Research and Quality. Patient safety 7. Description of relevant tests and laboratory data, and quality improvement: final rule. 42 CFR part 3. http://www. including dates. pso.ahrq.gov/statute/pl109-41.pdf. Published November 21, 8. Description of other relevant patient history, 2008. including preexisting medical conditions. 11. US Food and Drug Administration. Medical device safety: recent medical device recalls. http://www.fda.gov/MedicalDevices/ 9. Device information, including brand name; type Safety/default.htm. of device; manufacturer name and address; expi- 12. ECRI Institute. Alerts tracker. https://www.ecri.org/components/ ration date; unique device identifier (UDI) that alertstracker/Pages/default.aspx. appears on the label; model number; catalog 13. US Department of Labor. Occupational Safety and Health number; serial number; lot number or other iden- Administration. Safe medical devices act: medical device report- tifying number; date of device implantation; date ing for user facilities. 21 USC § 360i (1990). of device removal; and operator of the device 14. US Food and Drug Administration. Unique device identification (health professional, patient, lay user, other). (UDI). http://www.fda.gov/MedicalDevices/DeviceRegulationand 10. Whether the device was available for evaluation Guidance/UniqueDeviceIdentification/default.htm. and whether it was returned to the manufacturer. 15. Brady PW, Varadarajan K, Peterson LE, Lannon C, Gross T. 11. Concomitant medications and therapy dates.7 Prevalence and nature of adverse medical device events in hospi- talized children. J Hosp Med. 2013;8(7):390-393. (Regulatory) 16. Emmendorfer T, Glassman PA, Moore V, Leadholm TC, Good H. Use the following prevention strategies in product CB, Cunningham F. Monitoring adverse drug reactions across a evaluation to improve safety and reduce preventable nationwide health care system using information technology. Am adverse events: J Health Syst Pharm. 2012;69(4):321-328. 1. Identify patients or conditions associated with 17. Flewwelling CJ, Easty AC, Vicente KJ, Cafazzo JA. The use of higher risk. fault reporting of medical equipment to identify latent design 2. Facilitate optimal purchase decisions. flaws. J Biomed Inform. 2014;51:80-85. 3. Enable early detection and intervention to 18. Gibson R. Nursing practice and work environment: designing address risk factors.7,15-22 (V) equipment devices for safety: a role for nursing advocacy. Am Nurse Today. 2015;9(11):16. REFERENCES 19. Mattox E. Medical devices and patient safety. Crit Care Nurse. 2012;32(4):60-68. Note: All electronic references in this section were accessed September 20. Polisena J, Gagliardi A, Clifford T. How can we improve the 16, 2015. recognition, reporting and resolution of medical device-related 1. Miller C. Product selection and evaluation. In: Alexander M, incidents in hospitals? A qualitative study of physicians and reg- Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion istered nurses. BMC Health Serv Res. 2015;15:220-228. Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: 21. Reynolds IS, Rising JP, Coukell AJ, Paulson KH, Redberg RF. Saunders/Elsevier; 2010:437-446. Assessing the safety and effectiveness of devices after US Food 2. Kuwabara C, Evora Y, deOliveira M. Risk management in tech- and Drug Administration approval: FDA-mandated postapproval novigilance: construction and validation of a medical-hospital studies. JAMA Intern Med. 2014;174(11):1773-1779. product evaluation instrument. Rev Lat Am Enfermagem. 22. Tsai TT, Box TL, Gethoffer H, et al. Feasibility of proactive 2010;18(5):943-951. medical device surveillance: the VA Clinical Assessment Reporting VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S33 JIN-D-15-00057.indd S33 05/01/16 11:30 PM 14-19 (III) Nurses. http://www.org/ error interceptions (eg. to verify medica- cable. including purpose of medication dosage and concentration. and drug interactions. MEDICATION VERIFICATION and training and assessment of use are recom- mended for both routine users and new staff Standard members.27 izational quality improvement processes. dosing errors. Develop a stan- organization and to the FDA through the MedWatch dard process and educate staff in how to perform reporting system and/or ISMP. including accreditation program. and nomencla- and limitations related to technology through organ- ture issues that may cause errors by their design. 2013. beyond-use date. pumps”) is associated with reduced risk for 2. transfers to different levels of care. perioperative. standard order sets). to product vendors to inform them about tions prior to administration.gov/books/NBK2648 . preparation.22. Color coding can lead users to limited quantities). sound-alike) to implement safeguards to reduce the compared against the medication order. overriding of alerts.2.21 accurate patient identification when administering (V) medications.2 At least 2 patient identifiers are used to ensure (ISMP)-approved tall man (mixed case) lettering. expiration on label. The Joint Commission.20 (II) E. procedural Practice Criteria settings) as soon as prepared with the medication name.9-13 (IV) confidentially shared with the FDA and. including omissions. and changing the appearance of look-alike date. Regulatory) duplications. Do not use color coding. Compounding and discharge to new health care settings) to reduce the Preparation of Parenteral Solutions and risk of medication errors. and Tracking (CART) program. look-alike. Report adverse events associated with medicines and for the organization’s selected high-alert medications biologics to the appropriate department within the that pose the greatest risk of harm. include dose-error reduction software (“smart Published April 2008. 13. National patient safety goals: hospital infusion-related medication errors. Analyze effectiveness pharmaceutical labeling. improving access to color matching as the sole cue for product or medi- drug information. and use of the wrong drug library contribute to the risks associated with smart pumps. tion or discard (see Standard 17.1-6 G. that errors still occur as staff may create “work- 1. or tration (eg. Use of electronic infusion devices (EIDs) that Quality.22-24 (V.1 Medications and infusion solutions are identified. and adminis- H. Rockville. diluent/volume.3. S34 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. (Regulatory) 1. Begin the adminis- transition and when a new medication(s) is ordered tration within 1 hour after the start of the prepara- (eg. and there is emerging research supporting its use Note: All electronic references in this section were accessed September in long-term care settings. ed. appropriate use. Regular education 13. Medication reconciliation. color differentiation. http://www.nlm. using supplementary labels and rely on the color coding rather than ensuring a clear automated alerts. when appli- D. Reports to ISMP are the double check. and brand names.and Instititute for Safe Medication Practices 13. Use a list of confusing drug names (ie.24 (V) as standardizing storage. cation identification. F. Use of bar-code technology is associated with decreased risk of medication errors and is increas- REFERENCES ingly common among acute care organizations. admission.51(3)(suppl 1): adverse drug events. names by using US Food and Drug Administration rate of administration. frequency. Medications).ncbi. route of administration.26. Implement special safeguards to reduce the risk of the patient’s bedside and immediately administered medication errors with high-alert medications such without a break in the process. and preparer initials. quantity. 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FDA and ISMP Document the findings in the patient’s medical record lists of look-alike drug names with recommendations for tall man and communicate a positive screen for latex sensitivity letters. 2011.indd S35 05/01/16 11:30 PM . J Nurs Adm.ismp. nitrile gloves.36(4):54-62. normalization of deviance. 3. Chapter <797>: pharmaceutical compounding—sterile prepara- 5. and medication vial practices in healthcare.pdf. et al. Evaluation of the personalized bar-code identifica. and Inform Nurs. Medication errors during injection. et al.6 (V) Syst Pharm.asp. Bar-code verifica.68(15):1450-1453. equipment.jointcommission. tion. 12.124(3):722-728. J Patient Saf.asp.40(3): minimized. 2102.38(3):291-333. Bar code technology and medi.ascp. 14.3(9):412-421. Published 2014. 25.aspx?id=51. Kerr G. 2010. 14. 8. Bates DW. http://www. Symes L. 2013. and used during patient care.htm.37(12):1011-1020. Polovich M. http://www. Barcode medica- D. Felizardo G.pdf . et al.4. 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Published errorReporting/reportErrortoISMP. ISMP list of high 26. 13. Guenter P. A. fda. USP-NF General assets/1/6/2015_NPSG_OME. Health Administration (OSHA) as required and tion of a bar code medication administration system. 2014. accreditation program. Ayer P. Regulatory) tion card to verify high-risk.ismp. Oncol Nurs Forum. which 19.com/sites/default/files/USP-797. National patient safety goals: ambulatory 22. http://www. F.38:167-172. Lawrence J. A. et al. 2008. http://ismp. Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently 14.39(6):631-632. and supplies are provided to safety consensus recommendations. Review the label on medical devices. Pediatric medica. 2011. latex-sensitive or latex-allergic clinicians and patients 2014. United States Pharmacopeial Convention (USP). Greene SB. allergic reactions to the Occupational Safety and tion administration errors and workflow following implementa. Comput E. 4. Tsourounis C.ismp. et al. The employer will report 17. Dykes PC. allergy. LATEX SENSITIVITY OR avoid chemotherapy errors in in. powder-free gloves. to the US Food and Drug Administration (FDA) 18. 2014.1 Exposure to latex in the health care environment is ment of oral chemotherapy.org/ org/assets/1/6/2015_NPSG_AHC1. MedWatch Program. Heelen M. National patient safety goals: long term tions. Targosz M. infusion. Williams CE. Desai R. Drug Saf.org/Tools/tallmanletters. Graves K. or are breastfeeding to accessdata. state. refrain from exposure to hazardous drugs and cfm?FR=801. and follow direc- containers and disposed of according to local. Safely dispose of hazardous waste and materials 759-772.78(5): C. http://www. and gowns into seal- AND WASTE able. including those with safe the patient/caregiver/surrogate in safe handling: handling guidance from the manufacturer. Report such spills as an occurrence accord- ing to organizational procedures. 4. (refer to Standard 58.html. 1.pdf. ous drugs should be provided appropriate PPE https://www. Educate the 1. Published and engineering controls to reduce exposure February 19. MedWatch: the FDA safety Furthermore. ting.gov/drugs/default. Publication no. store such disposal contain- and manufacturers’ directions for use. US Department of Health and Human Services.indd S36 05/01/16 11:30 PM .2 (V.4 (V. DailyMed (http://dailymed.fr). Safety and Health Information Bulletin 01-28- 2008. Antineoplastic Therapy). are pregnant. Drugbank (http:// REFERENCES drugbank. 2011. Medical Waste and reduction. exposure risk waste (see Standard 18. administered for noncancer indications. Gawchik S. ous drugs and waste. Research on Cancer (IARC) (http://www. and 15. US Department of Labor. 21 CFR §801. Wear double chemotherapy gloves and a disposa- is periodically updated. Ensure that a spill kit is available.4.4 (V) 15. Published February 2012. Published April 1. Mount Sinai J Med. Sharps Safety). Standard Regulatory) 2. leakproof bags or rigid waste containers that are clearly labeled for cytotoxic waste. Regulatory) in accordance with local. 2015. http://www. Large spills Practice Criteria should be handled by health care workers who are A. This list 1. Regulatory) care workers: how to prevent latex allergies. exposure.gov/niosh/docs/2012-119/pdfs/2012. contaminated with hazardous drugs.437. HAZARDOUS DRUGS administration sets.3-8 (V. 2015.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch. toxicities associated with exposure.gov/safety/medwatch/default. Potential for sensitization and possible the US Food and Drug Administration (FDA) allergic reaction to natural rubber latex gloves and other natural (http://www. ceive. While most hazardous drugs are antineoplastic 2012-119. and federal regulations 3. Identify hazardous drugs used in the health care set. drug package inserts. including spills. Allow clinicians who are actively trying to con- labeling for devices that contain natural rubber. Latex allergy. recognize that there are infusion drugs 119. Note: All electronic references in this section were accessed September nih. 2008.4 (V. 2014.9 (Regulatory) 7.4 (V. 2015. and tions for use in the event of a hazardous drug leak federal regulations. and safe handling of waste. hours after receiving a hazardous drug and instruct tion of hazardous drugs.1 Organizational policies and procedures address waste (red) containers because medical waste safe handling of hazardous drugs.2 All hazardous waste is discarded in appropriate 4. Place contaminated materials including needles.cdc. waste. Additional resources used to evaluate the hazard patient on how to avoid latex exposure.gov/recordkeeping2014/faqs. certain antineoplastic drugs are information and adverse event reporting program. The National Institute for Occupational Safety Regulatory) and Health (NIOSH) provides a list of antineoplas. US Food and Drug Administration. 1.2.fda. 97-135.html.437. trained in hazardous waste handling.ca). 2. empty vials/syringes/solution containers. Handle patient body fluids safely for at least 48 tic and nonantineoplastic drugs that meet the defini. Occupational Safety and Health Clinicians in all settings who administer hazard- Administration. fda. International Agency for 16. special health warnings from drug manufacturers. D.osha.cdc. https://www. Update to OSHA’s recordkeeping rules. gloves. National Institute Regulatory) for Safety and Health (NIOSH). Published June 1997. 6.iarc. appropriate use of disposal is handled differently from hazardous personal protective equipment (PPE).htm). Preventing allergic reactions to B. 1. User 2.nlm. or spill.gov/dailymed). http://www. US Food and Drug Administration. Published July 16. ble gown when handling patient emesis or S36 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. required precau- 3.7 (V) potential of a drug include safety data sheets (SDSs). agents.htm. ers in an area away from children and pets.2.fda. National Institute tions. NIOSH fast facts: home health. and rubber products. 5. and what types of PPE to wear to prevent for Safety and Health (NIOSH). incorporate into the patient’s plan of care. Provide education to clinicians who handle hazard- natural rubber latex in the workplace. US Department of Labor. state. US Department of Health and Human Services. Publication no. Education should include http://www. 1.gov/niosh/docs/97-135.l.gov/dts/shib/shib012808. Published other professional groups’ and organizations’ January 28. In the home setting. from other categories classified as hazardous. evidence-based recommendations.osha.2. Do not place drug-contaminated items in medical 15.8. OH: National Institute for the education of the nurse who administers chemotherapy and Occupational Safety and Health (NIOSH). Occupational Safety and Health Administration (OSHA). Menonna-Quinn D.org/ 2004-165.gov/niosh/docs/2004-165/pdfs/2004. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S37 JIN-D-15-00057. DeBord DG. http://www. biotherapy. 165. tions/education/rn. 2011. Reproductive_Developmental_Hazard_Management. 97.indd S37 05/01/16 11:30 PM . 9. 2014. oshaweb/owadisp. excretions. 3. National Institute for Occupational Safety and Health (NIOSH). Occupational hazardous drug expo- and wash twice in hot water. https://www.osha. Oncology Nursing Society. http://www. MacKenzie BA. Task Force on Reproductive Toxicology.4 (V) communication standard 1910.20(2):79- diapers in plastic bags and discard used gloves in 85. Frasier MN. 2014. Medsurg Nurs.cdc.36(3):198-204. Safe handling of chemotherapeutic agents in the treatment of nonmalignant diseases. Home setting: Place contaminated linens into a PA: Oncology Nursing Society. 2011. Discard disposable sure among non-oncology nurses. washable pillowcase separate from other items 5. washable linens should be placed in a 4.org/advocacy-policy/posi- NIOSH publication 2014-138 (supersedes 2012-150).4 (V) Guidelines and Recommendations for Practice. Polovich M. Olsen M. Cincinnati. September 2014. Use disposable linens whenever possible. https://www. reported exposure to chemotherapy. Published September 2004. Friese CR. 2.4 (V) 6. Structures and Note: All electronic references in this section were accessed September processes of care in ambulatory oncology settings and nurse- 16. Gieseker KE. 7. NIOSH List of 753-759. Antineoplastic and Other Hazardous Drugs in Healthcare 8. 3. Reproductive and devel- tic and other hazardous drugs in health care settings.acoem. 2012. Hazard pated. Pittsburgh. Published April 26. Oncology Nursing Society position on Settings. Connor TH.pdf.21(9): 1. in insti. cytotoxic waste container if available.gov/pls/ 2. 2015. Wear a face shield if splashing is antici. et al. tutions. 2014. Publication opmental hazard management guidance.aspx . 4th ed. Himes-Ferris L. LeFebvre K.show_document?p_table=standards&p_ id=10099. Chemotherapy and Biotherapy leakproof bag and handled as contaminated. Published March 2012. J Infus Nurs. et al.ons. Polovich M. REFERENCES 2013. American College of Occupational and Environmental Medicine NIOSH alert: preventing occupational exposures to antineoplas. BMJ Qual Saf. ed with an alternative. Store hand hygiene products in convenient locations Practice Criteria at the point of use. 2015. Clinicians who have 3. or when inserting a central vascular access device 16.1-6 (II) 2. After contact with the patient’s intact or nonin. Perform hand hygiene with either a nonantimicro.1 (III) medical equipment) in the immediate vicinity of I. and skin irritation.1. Keep the nail length short. The Art and Science of Infusion Nursing Section Three: Infection Prevention and Control 16. After contact with body fluids or excretions. Educate the patient/caregiver/surrogate on when soiled.3 (IV) 1. When the hands are visibly contaminated with blood or other body fluids.1-5 (III) forming hand hygiene unless the hands are visibly J.1-8 (III) cian to perform hand hygiene before having direct C. Involve the clinician with the evaluation of hand 2. hygiene. grance. lotions. Do not add soap to a partially empty soap 6. Boyce JM. and moisturizers should be 5. such as gloves. mance. assessed for compatibility with hand antisepsis mucous membranes.1-8 (II) Settings: Recommendations of the Healthcare Infection Control S38 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. E.1. Before eating and after using a restroom. monitor hand hygiene performance. sensitivity to a particular product should be provid- 4. pathogen during an outbreak (eg. and wound dressings (if the products. Perform hand hygiene with an alcohol-based hand rub hand lotions or creams to prevent irritant contact or antimicrobial soap and water during patient care: dermatitis. H. Clostridium dif- ficile). Standard those in intensive care units or operating rooms. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg. G. Guideline for Hand Hygiene in Health-Care 3.1-6 bial soap or an antimicrobial soap and water: (IV) 1. Provide the clinician with education on hand the patient. contact with the patient if it was not observed. and 7. After removing gloves. Before inserting a peripheral vascular catheter.1-4 (III) F. or there is an outbreak of a spore-forming and how to perform hand hygiene. fra- central intravascular catheter. Other products for skin care tact skin.1 Hand hygiene is performed routinely during (CVAD).1 (III) patient care activities. Provide hand hygiene products that have a low irritancy potential and compatible A. HAND HYGIENE D.indd S38 05/01/16 11:30 PM . Before donning sterile gloves when inserting a hygiene products to assess for product feel. After providing care or having contact with REFERENCES patients suspected or confirmed of being infected with norovirus gastroenteritis or a spore-forming Note: All electronic references in this section were accessed September 16. Pittet D.3 (IV) hands are not visibly soiled).1-8 (II) 1. After contact with inanimate objects (including dispenser.1-6 (III) provide feedback regarding hand hygiene perfor- B. Use an alcohol-based hand rub routinely when per. and ask the clini- pathogen or norovirus gastroenteritis. Before having direct contact with the patient. C. http://www. 2014. sterile compounding area. In adults. the Drug Quality and Security Act. Switzerland: WHO. Healthcare and supplies. and the United D. Institute for Healthcare Improvement.org/resources/Pages/Tools/HowtoGuideImproving ulation outside the pharmacy sterile compound- HandHygiene. as common-source including but not limited to General Chapter <797>. Regulatory) Epidemiology of America.int/gpsc/5may/tools/9789241597906/en.aspx.shea-online. http://www.cdc. label each syringe as it is being prepared and prior to the preparation of any subsequent syringes. Burns LA. Dubberke E. immediately label PREPARATION OF each syringe. et al. istration. Umscheid C. (V)5-7 A. Practices Advisory Committee and the HICPAC/SHEA/APIC/ (IV) solution to flush and lock vascular access IDSA Hand Hygiene Task Force.1-4 (V.6 (V) 17. http://www.1-3 (V. and ASHP tion. infusion.5 (V) AND MEDICATIONS 5. Ailello A.6-8 (III) guidelines. prepare each medication or solution rus/001_norovirus. 2011. Ellingson K. commercially available. 1. cartridge-type syringes the American Society of Health-System Pharmacists into another syringe for administration. Use a new needle and syringe for every injec- state pharmacy rules and regulations. The compounding environment is defined 2.int/gpsc/5may/EN_GPSC1_PSP_HH_Outpatient_care/en. as defined by Hygiene in Health Care. 3. Discard a single-dose vial after a single entry. Locking). Atlanta. If preparing several tion. perform these tasks 6. limit preparation to the pharmacy. Administer IV push medication in a safe manner: ated infections through hand hygiene. Geneva. Do not withdraw IV push medications from tions is in accordance with state and federal regulations.jstor. et al. before preparing the PARENTERAL SOLUTIONS next medication or solution. Haas J. prevention of intravascular catheter-related infections.5. Published 2006.org/Portals/0/CDI%20hand%20 IV push medications at a time for sequential IV hygiene%20Update. use IV push medications in a ready-to- guide for improving practices among health care workers. readily available April 2011.html.9% sodium chloride (USP).5. or discard. prefilled flush syringe of 0. If dilution or reconstitution of an IV push medi- and home-based care and long-term care facilities. uncluttered. Rationale for hand hygiene recommen- dations after caring for a patient with Clostridium difficile infec- preparing the next syringe.5-8 able prefilled syringes of appropriate intravenous (V) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S39 JIN-D-15-00057. Dedicate a multidose vial for a single patient.5 (V) 5. COMPOUNDING AND from the patient’s bedside. containers (multiple-dose product) to dilute or reconstitute medications for 1 or more patients in Practice Criteria clinical care areas (see Standard 40. and functionally separate location gov/hicpac/pdf/guidelines/bsi-guidelines-2011. Strategies to prevent healthcare-associ. 1 at a time. 6. within 1 hour after the start of the 3. who. Guideline for 4. Do not use IV solutions in containers intended for States Pharmacopeia (USP) National Formulary (NF). When it is necessary to prepare more than 1 Epidemiol. If more than 1 syringe of medication or solution the prevention and control of norovirus gastroenteritis outbreaks to a single patient needs to be prepared at the in healthcare settings.5 (V) 4. drug information resources and sterile equipment 7. Infect Control Hosp 1. USP <797>. Improving hand hygiene: a 2.pdf.indd S39 05/01/16 11:30 PM . Published using organization-approved. Use sterile medications that were compounded in a E. Flushing and Locking). http://www. October 2002. cation becomes necessary outside the pharmacy Published 2012.html.ihi. B. Hand hygiene in outpatient 3. Guidelines for the immediately prior to administration in a clean. Regulatory) (V) 1. gov/handhygiene/guidelines. Begin the administration of an “immediate-use” 2. If 1 or more medica- tions or solutions needs to be prepared away 17. including minibags.1086/677145. Do not dilute or reconstitute IV push medica- tions by drawing up the contents into a commer- Standard cially available.35(8):937-960. World Health Organization (WHO).who.5-8 by risk category. http://www. push administration. Published 2011. Alexander M. WHO Guidelines on Hand compounded sterile product (CSP). http:// administer form (to minimize the need for manip- www.6 (V) Infection Control Practices Advisory Committee. http://www. Use pharmacy-prepared or commercially avail. 2009. World Health Organization (WHO).pdf. www. and immediately administer it before 8. Use safe injection practices: pharmacy environment that meets USP <797>. GA: Centers for devices (refer to Standard 40.gov/hicpac/norovi- bedside. Society for Healthcare preparation. Flushing and Disease Control and Prevention. O’Grady NP.cdc. separately. Agarwal R.1 Compounding of parenteral solutions and medica.5 (V) (ASHP). MacCannell T.cdc.org/stable/ medication in a single syringe for IV push admin- 10. ing area). et al. Gerding D. 1-3. http://www. Chapter <797>: pharmaceutical compounding—sterile prepara. Replace sharps disposal containers when about 109-6-13. Use safety-engineered devices for needlestick injury prevention. Use a filter needle or filter straw to withdraw medi. Dolan S. tially infectious materials or injury from sharps. APIC position paper: safe injection. Identify.1-4.6 (V.8-10 (V. Educate and train clinicians in the use of safety- ismp. Label a multidose vial with the beyond-use date ling of regulated medical waste that are based on local. follow organizational protocol for postexposure 7. Do not add medications to infusing containers of IV gens hazard are available in the workplace and consist- solutions (refer to Standard 57.1-4. Regulatory) www. C. and discard any leftover priate container and disposed of according to local. Regulatory) Practice Guidelines for Adult IV Push Medications. Monitor and analyze data for trends and Infection Control Practices Advisory Committee. United States Pharmacopeial Convention (USP). puncture-resistant. Medication and Solution Administration). (BUD) and store the vial according to the manufac.org/Tools/guidelines/ivsummitpush/ivpushmedguidelines. G. 2015. and dis- Published 2011. a. Parenteral ently activated or used. Disinfect the vial septum before each entry and the 18. E. D. turer’s recommendations. and federal regulations. F. Safe Injection REFERENCES Practices Coalition. and after the BUD has been met. and medication vial practices in healthcare.8-10 multidrug-resistant organisms in healthcare settings. Barnes S. and allow the disinfectant to dry prior to 18. the sterility is compromised or questiona. Use a multidose vial up to a maximum of 28 days 18. Institute for Safe Medication Practices (ISMP).1 Each organization has protocols for the safe hand- b. medication.5. appropriately 3.cdc. Drug Quality and Security Act.1-4 (Regulatory) REFERENCES B. gov/injectionsafety/PDF/SDVMDF_infographic. leakproof.com/sites/default/files/USP-797.1-3. Regulatory) state. Felizardo G. 2013. ASHP labeled or color coded. three-fourths full to avoid overfilling and dispos- 5.gpo. Pub L 113-54.8. that is in accordance with the Occupational Safety and ble. 18.cdc. MEDICAL WASTE AND of opening or puncture (except for vaccines or SHARPS SAFETY when original manufacturer’s expiration date is shorter) or when the manufacturer’s expiration Standard date is reached if it is not opened in a direct patient care area or a shorter period. and document exposure to poten- 6. 8. engineered devices. card as a single unit after use.pdf. 2015. bly (ie.net/news/compounding-and-reconstituting-drugs-for-infu. Jackson M. et al. such as self-sheathing entry. 2014. Regulatory) sion-in-establishments-other-than-pharmacies-resolution. and large enough to accom- guidelines on compounding sterile preparations.6 (V. Use a 1-handed 1. Place sharps containers in the immediate area ments other than pharmacies (resolution 109-6-13).ascp.1-3.pdf. (V. G. 17. modate disposal of the entire blood collection assem- 4. Do not break or bend sharps.10. state. Centers for Disease Control and Prevention (CDC). Practice Criteria A. 2010. infusion. Management of implement performance improvement as needed.htm.8-10 (V. Healthcare follow-up. report. where sharps are used and are easily accessible. 1.gov/hicpac/pdf/guidelines/MDROGuideline2006. Health Administration (OSHA) blood-borne pathogen Regulatory) standard. Am J Infect Control. Regulatory) pdf.4 Contaminated sharps are discarded in a nonpermea- neck of a glass ampoule prior to breaking the ble.1-4 nabp. Rhinehart E. Activate built-in safety controls during use. National Association of Boards of Pharmacy (NABP).7.2 Each organization has an exposure control plan a BUD. holder and needle). S40 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. ampoule.71(2):145-166. Published 2015.1-4 (Regulatory) 2.pdf. Regulatory) 18. Dispose of sharps in a sharps container that is clos- gov/fdsys/pkg/PLAW-113publ54/html/PLAW-113publ54. Chiarello L. 2. Regulatory) Compounding and reconstituting drugs for infusion in establish.1-3. Published June 5.9. https://www. http://www.3 Regulated medical waste is discarded in the appro- cation from an ampoule.5 Safety engineered devices.6 (V) needles.5. Discard if the vial lacks 18.1-4. able.11 (V. Consider the use of passive safety-engineered devices Note: All electronic references in this section were accessed September for needlestick injury prevention. tamper-proof biohazard container. that isolate or remove the blood-borne patho- H. Regulatory) tions. 2015. and federal laws and regulations. American Society of Health-System Pharmacists (ASHP).6-8 (V. Siegel JD.5-7 (V) 17. puncture resistant. USP-NF General technique for recapping if necessary.12 (V. F. Am J Health Syst Pharm. Single dose or multi-dose? http://www.38(3):167-172.indd S40 05/01/16 11:30 PM . Published Note: All electronic references in this section were accessed September July 13. https://www. http:// (V. 2006.1-3. ISMP Safe al-related injuries. US Food and Drug Administration.gov/dts/shib/shib101503. or body fluids is anticipated. CPL 02-02-069. Ciotti C. excretions except sweat. 2015. or contaminated equipment. 2000-108. and mucous membranes and may con- other sharps injuries. Infect Control Hosp Epidemiol.fda. 2013.4 (III) 6. et al. Wear eye protection. Occupational exposure to bloodborne pathogens: needlestick and nonintact skin. limit reusable patient care VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S41 JIN-D-15-00057. or face shield alone.pdf. Regulatory) 12.1 Standard Precautions are used during all infusion J. Ensure that sufficient and appropriate PPE is avail- 4.indd S41 05/01/16 11:30 PM . and the Centers for Disease Control and 3. 56(235):64003-64282. secretions.osha.show_document?p_id=16265&p_table=FEDERAL_ REGISTER. Disposal of contaminated needles and blood tube holders used Regulatory) for phlebotomy.1 (III) I. https://www. agents. keep the hands away from the estimate of sharps injuries and mucocutaneous blood exposures face. step of removing PPE if the hands become contami- 5. Black L. Fed Regist. Perform hand hygiene immediately in between each Published 2004. implementing and evaluating a sharps injury ing for more than 1 patient.gov/pls/oshaweb/owadisp.T. Regulatory) table=DIRECTIVES&p_id=2570. and limit surfaces touched in the patient’s envi- among healthcare workers in USA. 2013. B. before leaving the patient’s environment.1.O. Change gloves during patient care when torn or no. http://www. Workbook 1. 29 CFR Section 1910. immediately after removing all PPE.1. National Institute for Occupational Safety and Health.2 (III. Grimmond T.: A national survey and D. able and readily accessible at the point of care.1 (III) 19.osha.5 (III.gov/sharpssafety/pdf/ G. Prevention (CDC) isolation precaution guidelines in Compliance directive: enforcement procedures for the occupa. http://www. the nature of the patient interaction and potential 2001. mucous membranes. Wear a gown to protect skin and clothing during Publication 2010-125. (NIOSH). C. body fluids. H.1030(d)(2)(vii)(A). 29 CFR Section 1910. promptly disposing of used tissues. Needlestick injury rates cover the wrist of an isolation gown (if worn). final rule. Published January 2010.(3):CD009740. Practice Criteria 2.66:5317-5325. communicable diseases (eg. Standard Precautions.3 (V. 41(5):427-432.5 (IV) NIOSH hazard review: occupational hazards in home healthcare. Published 2008. show_document?p_table=STANDARDS&p_id=10051# 1910.gov/pls/oshaweb/owadisp. STANDARD PRECAUTIONS mask on the coughing person if tolerated and appro- priate.2. Published July 22. Occupational exposure to bloodborne pathogens: needlestick and A. Occupational Safety and Health Administration (OSHA). Publication 1.osha. Published November 1999. EXPO-S.gov/MedicalDevices/Productsand tions.2 https://www.1. non- 2010.gov/pls/oshaweb/ for exposure to blood. http://www. Published November 27. Centers for Disease Control and Prevention (CDC). or infectious owadisp.4 (V) Healthc. Regulatory) Preventing needlestick injuries in health care settings.CD009740. with a tissue when coughing.htm.html. https:// www. and bore safety-engineered sharps devices. Regulatory) 10. phlebotomy).1.2 (III. Chinks in the armor: percutaneous injuries from hollow nated.osha.cdc. following and body fluids. tain transmissible infectious agents. Devices for preventing percu. Good L. Fed Regist. 2001. 1. Select personal protective equipment (PPE) based on other sharps injuries. Best way to get rid of used needles potential splash or spray of blood. National Institute for Occupational Safety and Health (NIOSH).1 (IV) prevention program. Occupational Safety and Health Administration (OSHA).pub2. heavily contaminated. Educate the patient and caregiver to implement res- piratory hygiene/cough etiquette by placing a face 19. effect at the time of the patient encounter for specific tional exposure to bloodborne pathogens.33(4):31-36. during of a French multicenter study. Tossini W. and performing hand hygiene. Wear gloves that fit appropriately and extend to 7. Standard and performing hand hygiene. or other body fluids from the mouth. MedicalProcedures/HomeHealthandConsumer/ConsumerProducts/ Sharps/ucm263240.gov/niosh/docs/2010-125/ procedures or activities in which contact with blood pdfs/2010-125.1. taminated body site to a clean body site.cdc. Goyer F. In the home setting when caring for a patient with a procedures that potentially expose the clinician to blood multidrug-resistant organism (MDRO). to prevent the 11.2. Ebola virus disease). used tissues.1002/14651858. Do not wear the same gown or gloves when car- for designing.P. Educate the clinician to implement respiratory taneous exposure injuries caused by needles in healthcare person. Pahwa M. when according to different types of safety-engineered devices: results there is potential contact with blood (eg. body fluids. promptly disposing of doi:10.gov/niosh/docs/2000-108 . Lavoie MC. http://www. http://www. or covering the mouth/nose with a tissue when coughing. Verbeek JH.pdf. E. J Assoc Occup Health Prof ronment. intact skin.cdc. F. 2014. When wearing PPE. and eyes. Cochrane Database Syst Rev. with a face mask.31(4):402-407. Am J Infect Control. which may include goggles sharpsworkbook_2008.show_document?p_ (III.1. hygiene/cough etiquette by covering the mouth/nose nel. or if moving from a con- 9. 1991. 8. nose. respiratory secre- and other sharps. Sequence for sprays of blood or body fluids.5 (III. tious when suspended in the air over long distances or Disinfect before removing from the home in a con- as recommended by the Centers for Disease Control tainer (eg. Published 2006.gov/pls/oshaweb/ owadisp. http://www.1. Precautions. equipment and leave in the home until discharged.1. including long-term care 17. and other settings. Perform fit testing prior to its ini- PRECAUTIONS tial use and at least annually thereafter. or infectious agents other sharps injuries. are implemented when strategies mended isolation precautions have been met. Regulatory) Standard E. Droplet Precautions.3. 18. and hand hygiene in healthcare settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and before leaving the patient’s environment. 1. Published 2014. https:// www. nature of the patient interaction and potential for 2.osha. plastic bag) or transport to an appropri- and Prevention (CDC) isolation guidelines in effect at ate site for cleaning and disinfection. Centers for Disease Control and Prevention (CDC). Chiarello L. http://www.cdc. and/or to an infectious agent or the duration of the recom- Contact Precautions. home care. limit reusable patient care the transmission of infectious agents that remain infec. infection spread by airborne route or Ebola virus disease to prevent the potential exposure to infec- tious agents transmitted via the airborne route (eg. In the home setting. and the CDC isolation precaution guidelines in 56(235):64003-64282. and leave in the home until discharged.1 Transmission-Based Precautions.gov/HAI/pdfs/guidelines/ in addition to Standard Precautions. immediately after removing all PPE. a multidrug-resistant organism (MDRO) or on 20.gov/handhygiene/guidelines. Rhinehart E. Centers for Disease Control and Prevention (CDC). http://www.3.cdc.gov/ the patient is suspected or confirmed of having an hicpac/mdro/mdro_0.6 (IV) ronment.3 Droplet Precautions are implemented to prevent REFERENCES transmission of pathogens spread through close respira- tory or mucous membrane contact with respiratory Note: All electronic references in this section were accessed September secretions. cific communicable diseases (eg. Regulatory) donning and removing personal protective equipment. tuberculosis). 2014. http:// D.2 (III.cdc.6 (IV) the time of the patient encounter. TRANSMISSION-BASED M. Siegel JD. equipment.html.4 Contact Precautions are implemented to prevent Clean and disinfect before removing from the home the transmission of infectious agents.pdf.gov/hai/prevent/ppe.html.gov/hicpac/2007ip/ for Transmission-Based Precautions based on the 2007isolationprecautions. step of removing PPE if the hands become contami- 5. S42 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Published 2007. Select and use personal protective equipment (PPE) agents in healthcare settings. Healthcare Infection Control Practices Advisory Committee. 20.1 (III) in addition to Standard Precautions are required to F. including when there are excessive bodily discharges. Healthcare Infection Control and Health (NIOSH) and observe Airborne Practices Advisory Committee. Ebola virus dis- 3. Management of multi-drug. when caring for a patient with reduce the risk for transmission of infectious agents.4 (III) the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Practice Criteria isolation precautions: preventing transmission of infectious A. Published 2002. Rhinehart E. Occupational exposure to bloodborne pathogens: needlestick and exposure to blood.show_document?p_table=STANDARDS&p_id=10051# effect at the time of the patient encounter for spe- 1910. Siegel JD. 20. tions for safe care. Jackson M. potential contact with respiratory secretions and 4. including determined that the cause of the symptoms is not due Airborne Precautions. body fluids. 20. Guideline for nated. which are spread or transport in a container (eg. facilities. when there is Outpatient-Care-Guide-withChecklist. if resistant organisms in healthcare settings. B.2 (III.5 Adapt and apply Transmission-Based Precautions REFERENCES as appropriate for non–acute care settings where Note: All electronic references in this section were accessed September infusion therapy is provided. Fed Regist.cdc.html.html. by the National Institute for Occupational Safety 6. Wear a fit-tested N95-or-higher respirator certified www. 2015.indd S42 05/01/16 11:30 PM . Centers for Disease Control and Prevention (CDC).2 Airborne Precautions are implemented to prevent Contact Precautions.1. in addition to Standard Precautions. 20. Guide to ease). Regulatory) infection prevention in outpatient settings: minimum expecta.1. Maintain Transmission-Based Precautions until it is 20. Published October 16. Jackson M. plastic bag) to an by direct or indirect contact with the patient or the envi- appropriate site for cleaning and disinfection. Perform hand hygiene immediately in between each www. Wear a face mask and observe Droplet Precautions.1030(d)(2)(vii)(A). 1991. 2015. http:// C.cdc. such as wound drainage. 29 CFR Section 1910. Transmission-Based Precautions). Healthcare fected. contamination. by organizational policies and procedures) and at Published 2015. Practice Criteria 3.1030.pdf. Jackson M. Healthcare established intervals during long-term single-patient Infection Control Practices Advisory Committee.html. Weber D. intended or cannot be properly cleaned and disin.134. Healthcare Infection Control Practice accordance with the equipment and manufacturers’ Advisory Committee (HICPAC). VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S43 JIN-D-15-00057. Jackson M.V) SHEA/APIC/IDSA Hand Hygiene Task Force.gov/handhygiene/ Wear personal protective equipment (PPE—eg. on a regular basis (eg. If com- 3. Rhinehart E. flow-control devices. Centers for Disease Control and Prevention (CDC). http:// soiled. 21. Centers for Disease Control and Prevention (CDC). 2006.indd S43 05/01/16 11:30 PM . Siegel JD.3 Infection Control Practices Advisory Committee. Disinfection and sterilization: an overview. Weber D. Clean and disinfect DME surfaces when visibly multidrug-resistant organisms in healthcare settings. F. Clean and disinfect DME surfaces with an EPA- agents in healthcare settings. Healthcare Infection Control Practices Advisory Committee.pdf .html. http://www. Rhinehart E. Chiarello L. Rhinehart E. 2015.1 Durable medical equipment (DME). Healthcare Standard 20. 4. Siegel JD. Guideline for hand E.gov/hicpac/2007IP/ or repair equipment that no longer functions as 2007isolationPrecautions. hicpac/Disinfection_Sterilization/acknowledg.show_document?p_table= D. 1. http:// is unavoidable (eg. Published October for vascular visualization). Respiratory Protection Standard 1910. Jackson M. Rutala W. 2013. https://www. DISINFECTION OF DURABLE Transmission-Based Precautions). flow-control devices) in a plastic bag or decontaminate prior to transport to Standard another location (ie. REFERENCES posable.osha. drug-resistant organisms (MDROs) or on Contact Precautions. soiled utility area or warehouse) 21. Limit the amount of DME that is brought into the resistant organisms in healthcare settings.1 (IV) isolation precautions: preventing transmission of infectious C.2 Cleaning and disinfectant products are used in 1. HICPAC/ (III. Siegel JD.cdc.html.osha. gown). http://www. 18.gov/hicpac/pdf/MDRO/MDROGuideline2006. and other nondis. Guideline for disinfection and directions for use to prevent damage or alteration to the sterilization in healthcare facilities.41(5):S2-S5.html.show_document?p_table= ment and instruments/devices are visibly soiled or STANDARDS&p_id=12716. Am J Infect Control. Rutala W.4 (IV) nous (IV) poles.gov/hicpac/pdf/ registered hospital disinfectant according to the isolation/Isolation2007. 2. Implement patient-dedicated use of DME when a STANDARDS&p_id=10051. when handling patient care equip- gov/pls/oshaweb/owadisp.3. ultrasound or infra- red devices for vascular visualization. Guideline for A. 2008.4 (IV). Management of multi-drug. http://www. Management of B. 21. IV poles. Guideline for use. Place used DME (eg. Discard agents in healthcare settings.3. Siegel JD.1 (IV) Infection Control Practices Advisory Committee.gov/ function or performance of the equipment. patient is placed on Contact Precautions.cdc. MEDICAL EQUIPMENT G. Chiarello L. Occupational Safety and Health Administration (OSHA). ultrasound or infrared devices www. Published 2006.1.2 (V) 2. clean and disinfect the 16.cdc. When possible. Bloodborne Pathogens Standard 1910. according to the level of anticipated 5. https://www.gov/ home of patients infected or colonized with multi- hicpac/mdro/mdro_0.cdc.gov/hai/pdfs/ppe/PPE-Sequence. Rhinehart E. Jackson M. http://www.cdc. may have been in contact with blood or body 6.pdf. gloves. leave DME in the home until the patient is discharged (see Standard 20. for subsequent cleaning and disinfection.cdc. Healthcare Infection Control fluids. http://www. such as intrave. Inspect DME surfaces for breaks in integrity that isolation precautions: preventing transmission of infectious would impair either cleaning or disinfection. infusion-related equip- ment are cleaned and disinfected using an Environmental Note: All electronic references in this section were accessed September Protection Agency (EPA)-registered disinfectant. Handle DME according to Standard Precautions. equipment before use on another patient (see 4. label’s safety precautions and directions for use.1. hard nonporous surface. at a frequency defined www.4 (III) Practices Advisory Committee. gov/pls/oshaweb/owadisp.cdc. Chiarello L. 2014. Sequence for mon use of medical equipment for multiple patients donning and removing personal protective equipment. guidelines. hygiene in healthcare settings. Published 2002. Variations in skin between patient populations. Patient’s age (both neonates and the elderly). location. Disinfection of puncture attempts. the clinician is competent in the skin. Obesity. 2. Darken the room to remove ambient light levels increase the success with peripheral cannulation and when using these devices.8-11 (I) Practice Standard C. appropriate vessels.1. ensure adequate light to decrease the need for central vascular access device (CVAD) observe blood return from the cannula or catheter. No studies have compared S44 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.1 To ensure patient safety. Thermal burns have in the use of vascular visualization technology for vas. Assess the patient’s medical history for conditions ogy to aid in locating viable superficial peripheral that may affect the peripheral vasculature and venous sites and decreasing procedure time for short increase the need for devices to assist in locating peripheral catheter insertion. procedure (refer to Standard 21. the use of infusion equipment. established in organizational policies and procedures. venous or arterial insertion sites. The clini- 1. The use and maintenance of infusion equipment is 6.3 Vascular visualization technology is employed to 3. the clinician is competent for vascular visualization. hypertension). 22. 5. Fluid volume deficit. Use only cold light sources in devices designed 22. This knowledge and the light source when the device emits heat includes. ing and marking the vein location on the skin or 2. To ensure patient safety.1-7 (III) B. insertion. Consider the use of visible light devices that provide 22. (eg. 7. ufacturers’ directions for use. Standard 1. Durable Medical Equipment). Be aware that the light spectrum being used lim- its the successful location of deep veins due to high amounts of body fat. VASCULAR VISUALIZATION transillumination of the peripheral veins and arteries in infants and children with difficult venous access. The Art and Science of Infusion Nursing Section Four: Infusion Equipment Section Standards 3. such as the presence of scars or appropriate indications and contraindications and man- tattoos. II. Factors that increase 1. catheter insertion. diabetes. depth. traditional flashlights). that capture an image of the veins and reflect it pation. History of frequent venipuncture and/or lengthy a dynamic process of using the image to guide courses of infusion therapy. Consider the use of near-infrared (nIR) light technol- A. known as landmark techniques. such as darker skin tones and excessive hair on I. Intravenous drug users. size. include but back to the skin’s surface or to a screen and are not limited to: transillumination projected to a screen. Disease processes that result in structural vessel cian may choose to use a static process by imag- changes (eg.2 Vascular visualization technology is used in patients the potential for blood contamination during the with difficult venous access and/or after failed veni. including knowledge of 4. 4. Disinfect the device after each patient use due to 22.indd S44 05/01/16 11:30 PM . and potential complications. Available technology includes hands-free devices difficulty with locating veins by observation and pal. but is not limited to. Skin alterations. 8. when other factors do not require a CVAD. been reported due to close contact between skin cular access device (VAD) insertion. these various methods of device use, leaving this number of needle punctures, and decrease insertion decision to the discretion of the clinician.1,6,12 complication rates.2,24,25,29-33 (I) (III) 1. Scan the anatomy prior to insertion to identify 2. Consider nIR light technology to identify periph- vascular anomalies (eg, occlusion or thrombosis) eral venous sites and facilitate more informed and to assess vein diameter.2,25,29 (IV) decisions about vein selection (ie, bifurcating 2. Use a “real-time” or dynamic technique for veins, tortuosity of veins, palpable but nonvisi- CVAD insertion.2,31 (I) ble veins). Two nonrandomized studies have 3. For internal jugular insertion sites, the short-axis shown improvement in first-attempt success for view increases insertion success, and the long- peripheral catheter insertion using nIR; howev- axis view is technically more difficult to achieve. er, other studies have not shown this same out- Position the probe vertically to the vein and come. Additional research is needed to address insert the needle as close to the probe as possible the reason(s), which could include differences in to keep the needle within view.25,34 (III) nIR devices, patient-related factors, and skill 4. US-guided saphenous and femoral CVADs placed level of the inserters before using the nIR in critically ill neonates and infants have out- devices.11-19 (I) comes equivalent to insertion under fluoroscopy D. Consider nIR for cannulation of the radial artery at in an interventional radiology suite.35 (IV) the wrist in children. It was slightly more successful I. Using a long-axis view, US-guided subclavian on first attempt with a lower total number of catheters are commonly inserted below the clavi- attempts, although there was no statistical difference cle at the midclavicular line or more laterally. The or clinical improvement noted.20 (V) puncture site may allow the catheter to enter the E. Use ultrasonography (US) for short peripheral cath- axillary vein first or, depending upon the trajec- eter placement in adult and pediatric patients with tory of the needle, may enter the subclavian vein difficult venous access.2 (II) directly.36 (V) 1. In pediatrics, US significantly reduces the number J. Use a large, sterile transparent membrane dressing of venipuncture attempts and procedure time. In over the probe (ie, for peripheral catheter insertion) adults, US studies show a trend toward fewer or sterile sheath cover, and sterile gel.27,37 (V) venipuncture attempts and reduced risk of periph- eral catheter failure. There is significant variation REFERENCES between studies, including use of 1 versus 2 insert- ers, use of the static versus dynamic techniques, Note: All electronic references in this section were accessed September and experience level of the inserters within and 18, 2015. between studies. Failure rates of US-guided periph- 1. Hadaway L. Infusion therapy equipment. In: Alexander M, eral catheters vary between studies, with hemato- Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion ma being the most common complication.21 (I) Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: 2. Choose a catheter length that will allow suffi- Saunders/Elsevier; 2010:391-436. cient length residing inside the vein lumen. Vein 2. Lamperti M, Bodenham AR, Pittiruti M, et al. International evi- depth greater than or equal to 1.2 cm and inser- dence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105-1117. tion into the deep brachial or basilic veins of the 3. Sebbane M, Claret P-G, Lefebvre S, et al. Predicting peripheral upper arm are associated with shorter survival venous access difficulty in the emergency department using body probability; however, vein diameter had no effect mass index and a clinical evaluation of venous accessibility. on catheter survival. Longer catheter length (ie, J Emerg Med. 2013;44(2):299-305. 12 cm) is reported to have longer survival than 4. Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with 5-cm catheter length.22,23 (III) difficult venous access in adult ED patients. Am J Emerg Med. 3. Dynamic, or “real-time,” visualization of the 2014;32(10):1179-1182. needle position is recommended to prevent vein 5. Shahzad A, Naufal Mohamad Saad M, Walter N, Saeed Malik A, wall damage.24 (V) Meriaudeau F. A review on subcutaneous veins localization using 4. Use of short axis (out of plane view) versus long imaging techniques. Curr Med Imaging Rev. 2014;10(2): axis (in plane view) for peripheral catheter inser- 125-133. 6. Peterson KA, Phillips AL, Truemper E, Agrawal S. Does the use tion depends upon the size and depth of the tar- of an assistive device by nurses impact peripheral intravenous get vein and the skill of the inserter.24,25 (V) catheter insertion success in children? J Pediatr Nurs. F. Use US guidance for insertion of midline catheters in 2012;27(2):134-143. patients with difficult venous access.26,27(V) 7. Houston PA. Obtaining vascular access in the obese patient G. Use US guidance for arterial puncture and catheter population. J Infus Nurs. 2013;36(1):52-56. placement in adults and children.2,28 (I) 8. ECRI Institute. Hazard report: common flashlights can cause H. Use US guidance when placing CVADs in adults and burns when used for transillumination. Health Devices. 2003; children to improve insertion success rates, reduce 32(7):273-274. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S45 JIN-D-15-00057.indd S45 05/01/16 11:30 PM 9. Goren A, Laufer J, Yativ N, et al. Transillumination of the palm care unit: a cost-effective proposal for timely central line removal. for venipuncture in infants. Pediatr Emerg Care. 2001;17(2): J Surg Res. 2014;191(1):1-5. 130-131. 27. Warrington J, William G, Penoyer DA, Kamps TA, Van Hoeck 10. Yamazaki S, Tomita S, Watanabe M, Kawaai H, Shimamura K. EH. Outcomes of using a modified Seldinger technique for long Effects of a transmitted light device for pediatric peripheral veni- term intravenous therapy in hospitalized patients with difficult puncture and intravenous cannulation. Med Devices (Auckland, venous access. J Assoc Vasc Access. 2012;17(1):24-30. NZ). 2011;4:189. 28. Gao Y-B, Yan J-H, Gao F-Q, Pan L, Wang X-Z, Lv C-J. Effects of 11. Heinrichs J, Fritze Z, Klassen T, Curtis S. A systematic review and ultrasound-guided radial artery catheterization: an updated meta- meta-analysis of new interventions for peripheral intravenous analysis. Am J Emerg Med. 2015;33(1):50-55. cannulation of children. Pediatr Emerg Care. 2013;29(7): 29. Granziera E, Scarpa M, Ciccarese A, et al. Totally implantable 858-866. venous access devices: retrospective analysis of different insertion 12. Graaff J, Cuper N, Mungra R, Vlaardingerbroek K, Numan S, techniques and predictors of complications in 796 devices Kalkman C. Near-infrared light to aid peripheral intravenous implanted in a single institution. BMC Surg. 2014;14:27. doi. cannulation in children: a cluster randomised clinical trial of 10.1186/1471-2482-14-27. three devices. Anaesthesia. 2013;68(8):835-845. 30. Cotogni P, Pittiruti M. Focus on peripherally inserted central 13. Chiao F, Resta-Flarer F, Lesser J, et al. Vein visualization: patient catheters in critically ill patients. World J Crit Care Med. characteristic factors and efficacy of a new infrared vein finder 2014;3(4):80-94. technology. Br J Anaesth. 2013;110(6):966-971. 31. Shekelle PG, Dallas P. Use of real-time ultrasound guidance dur- 14. Hess H. A biomedical device to improve pediatric vascular access ing central line insertion: brief update review. In: Shekelle PG, success. Pediatr Nurs. 2010;36(5):259-263. Wachter RM, Pronovost PJ, et al, eds. Making Health Care Safer 15. Sun CY, Lee KC, Lin IH, et al. Near-infrared light device can II: An Updated Critical Analysis of the Evidence for Patient improve intravenous cannulation in critically ill children. Pediatr Safety Practices. Rockville, MD: Agency for Healthcare Research Neonatol. 2013;54(3):194-197. and Quality. Published March 2013. http://www.ahrq.gov/sites/ 16. van der Woude OC, Cuper NJ, Getrouw C, Kalkman CJ, de default/files/wysiwyg/research/findings/evidence-based-reports/ Graaff JC. The effectiveness of a near-infrared vascular imaging services/quality/ptsafetyII-full.pdf. device to support intravenous cannulation in children with dark 32. Lalu MM, Fayad A, Ahmed O, et al. Ultrasound-guided subcla- skin color: a cluster randomized clinical trial. Anesth Analg. vian vein catheterization: a systematic review and metaanalysis. 2013;116(6):1266-1271. Crit Care Med. 2015;43(7):1498-1507. 17. Szmuk P, Steiner J, Pop RB, Farrow-Gillespie A, Mascha EJ, 33. Schiffer CA, Mangu PB, Wade JC, et al. Central venous catheter Sessler DI. The VeinViewer vascular imaging system worsens care for the patient with cancer: American Society of Clinical first-attempt cannulation rate for experienced nurses in infants Oncology clinical practice guideline. J Clin Oncol. 2013;31(10): and children with anticipated difficult intravenous access. Anesth 1357-1370. Analg. 2013;116(5):1087-1092. 34. Chittoodan S, Breen D, O’Donnell BD, Iohom G. Long versus 18. Aulagnier J, Hoc C, Mathieu E, Dreyfus JF, Fischler M, Guen M. short axis ultrasound guided approach for internal jugular vein Efficacy of AccuVein to facilitate peripheral intravenous place- cannulation: a prospective randomised controlled trial. Med ment in adults presenting to an emergency department: a rand- Ultrason. 2011;13(1):21-25. omized clinical trial. Acad Emerg Med. 2014;21(8):858-863. 35. Gaballah M, Krishnamurthy G, Keller MS, McIntosh A, Munson 19. Cuper NJ, de Graaff JC, Verdaasdonk RM, Kalkman CJ. Near- DA, Cahill AM. US-guided placement and tip position confirma- infrared imaging in intravenous cannulation in children: a cluster tion for lower-extremity central venous access in neonates and randomized clinical trial. Pediatrics . 2013;131(1): infants with comparison versus conventional insertion. J Vasc e191-e197. Interv Radiol. 2014;25(4):548-555. 20. Cuper N, De Graaff J, Hartman B, Verdaasdonk R, Kalkman C. 36. Perbet S, Pereira B, Grimaldi F, Dualé C, Bazin J-E, Constantin Difficult arterial cannulation in children: is a near-infrared vascu- J-M. Guidance and examination by ultrasound versus landmark lar imaging system the answer? Survey Anesthesiol. 2013;57(2): and radiographic method for placement of subclavian central 80-81. venous catheters: study protocol for a randomized controlled 21. Heinrichs J, Fritze Z, Vandermeer B, Klassen T, Curtis S. trial. Trials. 2014;15(1):175. Ultrasonographically guided peripheral intravenous cannulation 37. Dargin J, Rebholz C, Lowenstein R, Mitchell P, Feldman J. of children and adults: a systematic review and meta-analysis. Ultrasonography-guided peripheral intravenous catheter survival Ann Emerg Med. 2013;61(4):444-454.e1. in ED patients with difficult access. Am J Emerg Med. 2010; 22. Fields JM, Dean AJ, Todman RW, et al. The effect of vessel depth, 28(1):338-345. diameter, and location on ultrasound-guided peripheral intrave- nous catheter longevity. Am J Emerg Med. 2012;30(7):1134-1140. 23. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. 23. CENTRAL VASCULAR ACCESS Am J Emerg Med. 2012;30(5):712-716. DEVICE (CVAD) TIP LOCATION 24. Moore CL. Ultrasound first, second, and last for vascular access. J Ultrasound Med. 2014;33(7):1135-1142. Standard 25. Schindler E, Schears GJ, Hall SR, Yamamoto T. Ultrasound for vascular access in pediatric patients. Pediatr Anesth. 23.1 Tip location of a central vascular access device 2012;22(10):1002-1007. (CVAD) is determined radiographically or by other imag- 26. Deutsch GB, Sathyanarayana SA, Singh N, Nicastro J. Ultrasound- ing technologies prior to initiation of infusion therapy or guided placement of midline catheters in the surgical intensive when clinical signs and symptoms suggest tip malposition. S46 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.indd S46 05/01/16 11:30 PM 23.2 The original tip location is documented in the 2. Assess patient for known history of cardiac dys- patient’s medical record and made available to other rhythmias and the presence of a P wave on ECG organizations involved with the patient’s care. (if available) before planning to use ECG tech- 23.3 The CVAD tip location with the greatest safety nology for placement. Contraindications to the profile in adults and children is the cavoatrial junction use of ECG technology include patients with an (CAJ). abnormal ECG rhythm with an absence or alter- ation in the P wave (eg, presence of pacemakers, Practice Criteria atrial fibrillation, extreme tachycardia). Follow manufacturers’ directions for use in the appropri- A. Determine the desired catheter length for insertion ate patient populations. by anthropometric measurement including, but not 3. Use caution with ultrasound for CVAD tip loca- limited to, external measurement from the planned tion, as its use in replacing chest radiographs is insertion site to the third intercostal space, use of controversial in all ages due to small sample sizes formulas to calculate length based on body surface in available studies and lack of standardized area, or measurement from preprocedure chest techniques. Consider use in neonates and in radiographs.1-3 (IV) emergency departments when immediate knowl- B. Avoid CVAD tip locations in veins distal to the edge of the CVAD tip location is beneficial. superior or inferior vena cava (eg, innominate or 4. Avoid fluoroscopy except in the case of difficult brachiocephalic, subclavian, external, or common CVAD insertions, as it requires exposure to ion- iliac veins), as they are associated with higher rates izing radiation. of complications. These noncentral, suboptimal tip 5. Postprocedure radiograph imaging is not neces- locations are included in data collection for central sary if alternative tip location technology con- line-associated bloodstream infection (CLABSI) firms proper tip placement.3,12-18 (II) surveillance according to the National Healthcare F. Confirmation of tip location by postprocedure chest Safety Network from the Centers for Disease Control radiograph remains acceptable practice and is and Prevention (CDC). Although these tip locations required in the absence of technology used during may be clinically indicated in rare cases due to ana- the procedure. This method is less accurate because tomical or pathophysiological changes, the goal for the CAJ cannot be seen on the radiograph, requiring tip location should be the CAJ.4-8 (IV) identification of tip location by measurement from C. Position the tip of a CVAD in the lower segment of the carina, trachea-bronchial angle, or thoracic ver- the superior vena cava at or near the CAJ for adults tebral bodies. Additionally, a change in the patient and children. position from supine to standing, usually required 1. For upper body insertion sites, respiratory move- for the radiograph, results in movement of the cath- ment, arm movement, and changes in body posi- eter tip by as much as 2 cm.3,11,12,19,20 (II) tion will cause the CVAD tip to move above or G. Recognize that radiographic or ECG tip location below the CAJ, indicating excursion into the upper technology does not differentiate between venous right atrium. Tip location deeper in the right atri- and arterial placement. When arterial placement is um near the tricuspid valve or in the right ventricle suspected, use other methods to confirm or rule out is associated with cardiac arrhythmias.9-11 (II) arterial placement (refer to Standard 53, Central 2. For lower body insertion sites, the CVAD tip Vascular Access Device [CVAD] Malposition). should be located in the inferior vena cava above H. Clinicians with documented competency determine the level of the diaphragm.3 (IV) the tip location of a CVAD by using ECG or assess- D. Avoid intracardiac tip location in neonates and ing the postprocedure chest radiograph and initiate infants less than 1 year of age, as this tip location infusion therapy based on this assessment. When a has been associated with vessel erosion and cardiac postprocedure chest radiograph is used, the radi- tamponade.6,10 (II) ologist as directed by organizational policies and E. Use methods for identifying CVAD tip location dur- procedures authors the complete report.2,21 (V) ing the insertion procedure (ie, “real time”) due to I. Document the CVAD tip location by including a greater accuracy, more rapid initiation of infusion copy of the ECG tracing, chest radiograph report, therapy, and reduced costs. or other appropriate report in the medical record 1. Use electrocardiogram (ECG) methods with (refer to Standard 10, Documentation in the Medical either a metal guidewire or a column of normal Record). saline inside the catheter lumen and observe the ECG tracing to place the CVAD tip at the CAJ. 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The ultrasound-only central venous catheter placement and venous catheter tip placement in infants and children. 2013. Antonio R. et al. Tan C. Kaban NL. be consistent with recommendations for safe and pared with standard radiograph in neonates. Central venous access devices: access and 18. Use of vertebral body dren: tips for the tip. of the prescribed infusion rate and volume. Gosey L. Pittiruti M. J Cardiothorac Vasc Anesth.13(3): 357-365. J Perinatol. Cahill AM. Monitor flow-control devices during the administration tion of above-the-diaphragm central venous catheter placement? of infusion therapy to ensure safe and accurate delivery J Ultrasound Med. Katheria A. 2013. 8. US-guided placement and tip position confirma- reduced risk for infusion-related medication tion for lower-extremity central venous access in neonates and infants with comparison versus conventional insertion. 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Philadelphia. et al.htm. Nunnally M. Corrigan A. hazards 2015. April 22. and Defect 14. Infusion pump risk reduction Infusion Nursing.ecri. 2010. Plumer’s Principles and Practice of Infusion in improving the safety of IV drug administration.gov/ Based Practice for Infusion Therapy. Infusion delivery systems and safety. Carayon P. Do not rely on EID alarms to detect intravenous (IV) 11. J Infus Nurs. St Louis.2 Blood is warmed in a manner to avoid hemolysis. 20. Am J Health Therapy. Philadelphia. 2010. 2. Corrigan A. Nuckols T. 9th ed. alarmed even when your infusion pump isn’t. Smart pump technology: what we have learned. ill patients. J Infus Nurs. Manufacturer and user facil- 4. 7. In: Alexander M. setting about safe and effective use of flow-control Serrano C. Bullock M. 4th ed. with operation. PA: FA scripts/cdrh/cfdocs/cfMAUDE/search.4(3):1-4. Integrity. 8.32(5):257-267. Gorski L. Gorski L. 19. 2005. http://www. Standard tion errors. US Food and Drug Administration.fda. Phillips L. 2014:28-33.6.fda. 2012.109(4):32-33. 3.25 (III) 2009. Becker S. 2009. Home healthcare medical strategies. IV infusion alarms: don’t wait for the beep. US Food and Drug Administration.29(3):184-190. Emergency Care Research Institute (ECRI). An overview of intravenous-related medica- tion administration errors as reported to MEDMARK®. 3rd ed. Murdoch LJ. MO: Saunders/ analytics for intravenous infusion pumps. Hundt A.23(suppl 1):41-45. Alexander M. Davis. 2007. Cook EF. Int J Med Inform. Crit Care Med.46(4):268-277. Am J Nurs. methods (see Standard 8. 2012. through an interprofessional team process. Gorski L. Product Evaluation. In: Alexander M. Chernecky CC. J Infus Nurs. IV infiltration: be Implement evidence-based recommendations (eg.fda. 9. 2008.36(10):2763-2765. et al. 2015. Moss J. Core Curriculum for 26. Phillips LD.79(6):401-411. J Nurs Manage. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S49 JIN-D-15-00057. Wetterneck T. Niccolai C. Hankins J. Rosenkoetter MM. Manual of IV Therapeutics: Evidence. Top 10 technology Comput Inform Nurs. Dickenson A. Cook RI. Nunnally S. 6th ed. Note: All online references in this section were accessed August 25. ity device experience (MAUDE). 25. Adachi W. 12. et al. Weinstein SM. 2006. Between REFERENCES choice and chance: the role of human factors in acute care equip- ment decisions. Paddock S. Gorski LA. E. US Food and Drug Administration. 67(17):1446-1455. Hicks R. Bitan Y. 1. (V) 18. Huber C. 630-636. Updated August 15. Wynn D. US Food and Drug Administration.aspx. Corrigan A. Am J Health Syst Elsevier. Hertzel C. Continuous quality improvement using intelligent 2015. PA: Wolters Kluwer/Lippincott Syst Pharm. http://www. 10. Cameron VL. Updated May 5. 2009. PA: Wolters Kluwer/ strategies for home health nurses. Programmable infusion way.13-15 (V) pumps in ICUs: an analysis of corresponding adverse drug events. Educate patients and/or caregivers in the home care 17. Infusion therapy equipment. Infusion Nursing: 21. https://www. ple electronic monitoring and therapeutic devices. 2010:391-436. infusion pump data analysis. 2013. Patient Saf Advis. 25. Lodolce AE. eds. as these alarms are not smart infusion pumps to improve medication safety in critically intended to detect disruption of the fluid flow path. pumps available in the setting 13. Ferguson ND. Standardize the types of pumps used in an organiza- J Gen Intern Med. htm. Use of smart pumps for preventing medica. 24. Bowcutt M. 15. Perucca R. Infusion pump risk reduction 27. A controlled trial of infiltration or extravasation. Wall J. Williams & Wilkins. 2014: 285-299. alarm parameter settings) from professional agencies 16.35(3):143-151.htm.17(10): devices specifically designed for that purpose. Neville A. Infusion Nursing: An F. 2010. Consult the manufac. http://www. during plasma 4. The risk for clinically impor. ACR Manual on Contrast Media. exchange transfusions. Use blood and fluid warmers only when warranted 2. 29th ed. perature gauges and within the maintenance date. Intra-operative fluid warming in elective caesarean section: a tant hypothermia is increased when blood is trans. ECRI Institute. Slovis C.8 (V) A. D. Storrow A.25(1):20-27. 5. Yentis SM. 659-668. other devices because temperatures and infection 10.4.12 (V) of intravenous fluids prevents hypothermia during off-pump E. Int J Obstet Anesth. 13. Trick N. 8.14 (V) contrast material to 37°. Wang C. When contrast media tion for blood/intravenous fluid/irrigation fluid warmers. 2010:242-262. Suggested guidelines for blood warmer use. clinical condition. Collins S. 2015. Wagner K.13. Maynard K. eds.org/∼/media/37D84 Note: All references in this section were accessed August 26. Hillyer CD. hot water baths. MD: AABB. American for neonate exchange transfusions. 2008. pediatric population. Choi I-C. ment of trauma. Transfusion Therapy).12 (V) 9. ment of large blood volumes. Mohammadi E. and prescribed 2010). contrast material extravasations and allergic-like reactions: turer’s package insert for the specific contrast agent effect of extrinsic warming of low-osmolality iodinated CT regarding whether warming is contraindicated.ecri. http:// exchange for therapeutic apheresis. Thermal management during anaesthesia and ther- (see Standard 62.12 (V) moregulation standards for the prevention of inadvertent periop- C. 2007. and trial. American College of Radiology. Use only a US Food and Drug Administration (FDA). S50 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. ASTM International.astm. St Louis. Westhoff CM. use a temperature log for the warmer.mdsr. Warming risks cannot be controlled. fused through a central vascular access device (CVAD) 2009. Perucca R. REFERENCES 14. West J Emerg Med.22(1):67-70. Bethesda.18(1):71-79. Jeong S-M. follow the device manufacturer’s guidelines for main. Warming of contrast media is sometimes performed in Evidence-Based Approach.pdf. post-operative shiver- directions for use. McNaughton C. Moazzami F. Practice Criteria 1. 428BF1D4E1B9A3A2918DA9E27A3. avoiding or 3. Primer of Blood Administration (Revised September by patient history. J Cardiothoracic Vasc temperature recommended by the manufacturer of Anesth. Principles of fluid and blood warming in treating hypothermia intraoperatively. Best Pract Res Clin Anesth. In: Fung MK.18(4):346-351. Woolnough M. Allam J. microwave ovens. or from exposure. Administration of blood components.1-11 (II) MD: AABB. A. but not limited to. Do not use warming methods not expressly designed Warming intravenous fluids for improved patient comfort in the for blood and fluid warming including. 6. Corrigan the warming device. Radiology. Rate of tenance of the warming device. 2015. Hankins J. Cox M. B. Paulson E. and www. Bethesda. such as with large-volume or rapid ing.htm. Mokhtari M. and recovery in orthopaedic surgery. known to have clinically significant cold agglutinins. blinded randomized controlled trial. therapy including. 2014. trauma.acr. clinically significant conditions. Bethesda. for patients www. 2014:545-559. Hahm K-D. Published 2011. Gorski L. 11.22(4): systems. MD: AABB. emergency department: a pilot crossover randomized controlled ited to. White S. patients with J.262(2): 475-484. or during replace- Association of Blood Banks Technical Manual. 2008.14(5):542-546.indd S50 05/01/16 11:30 PM . In: Alexander M. Yang H-S. AABB. The effects of intravenous fluids temperature cated and in accordance with the manufacturer’s on perioperative hemodynamic situation. Use blood and fluid warmers equipped with warning erative hypothermia. but not lim. Bashir M. Version 10. Jeong Y-B.5. cleared blood warming device when clinically indi. including an audible alarm and visual tem. 3rd ed. 18th ed. Self W. viscosity and may help to reduce extravasation of 12. eds.11.org/Standards/F2172. and the neonate/ 7. Grossman BJ.aspx?doc_id=8269. Do not warm solutions and blood above a set point coronary artery bypass graft surgery. Standards for Blood Banks and Transfusion Services. Hasankhani H. ASTM F2172-02(2011): standard specifica- higher-viscosity contrast media. during treat. Blood component therapy. Naghgizadh MM. AABB.org/summary/detail. Smith C. Torossian A. Int Trauma Care. 2008.1.1. 2013. Hemingway M. 2012.1. http:// is warmed. Davenport M. MO: Saunders/ the radiology or surgical environment to reduce the Elsevier. Can Oper Room Nurs transfusions. 1-3. history of infusion therapy.to 24. days) and availability of peripheral vascular access procedures. Consider the infusate characteristics (eg.to 24-gauge catheter for most infu- preference for VAD location.3 The VAD selected is of the smallest outer diameter 3.2 Selection of the most appropriate VAD occurs as 2. 4.4 Peripheral vein preservation is considered when for a contrast-based radiographic study.1-4 (V) 26. Standard (VAD). comorbidities. Consider a 22. pediatric patients.gauge catheter based on vein 26. and/or practice guidelines and according to sites. and need1. gauge are more likely to cause phlebitis.1 The appropriate type of vascular access device Standard 58. near infrared. peripheral or central. Consider a 20. (VAD) PLANNING 3. minimize insertion-related trauma. vesicant. or infusates Standard with an osmolarity greater than 900 mOsm/L (see 26. the patient. Antineoplastic Therapy. 2.4: (V) patient’s age.10 (IV) planning for vascular access. Parenteral Nutrition). VASCULAR ACCESS DEVICE Standard 22. ultrasound) to increase success for patients with difficult venous access (refer to 26. and older adults to team. 61. irritant.gauge catheter for neo- a collaborative process among the interprofessional nates.1-4.1-7 (IV) manufacturers’ directions for use. The Art and Science of Infusion Nursing Section Five: Vascular Access Device (VAD) Selection and Placement Section Standards Practice Criteria I. size for blood transfusion: when rapid transfu- ently activated and/or used. 1. or a fenestrated catheter 26. when rapid fluid replacement is required. a larger-size catheter gauge is VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S51 JIN-D-15-00057. 6-8 (IV) date the patient’s vascular access needs based on the B.to 24. Use a 20. Vascular Visualization). A. sion is required.9 (IV) 26. Consider a larger-gauge catheter (16-20 gauge) with the fewest number of lumens and is the least inva. parenteral nutrition. and the patient’s caregiver(s). Use vascular visualization technology (eg. including knowledge of anatomy. To ensure patient safety. anticipated will accommodate the prescribed therapy and patient duration of therapy. with trauma patients. VAD. osmolarity) in conjunction with antici- II. and ability and resources sion therapies. Select the smallest-gauge peripheral catheter that prescribed therapy or treatment regimen. Do not use peripheral catheters for continuous vesicant therapy. is selected to accommo. Indications and protocols for VAD selection and pated duration of infusion therapy (eg. such as sive device needed for the prescribed therapy. the clinician is competent in I.indd S51 05/01/16 11:30 PM . Short Peripheral Catheters the use and placement of vascular access devices (VADs).5 Safety-engineered devices are selected and consist.1-4. vascular characteristics. Choose a short peripheral catheter as follows: and appropriate infusion therapies for each type of 1. less than 6 placement are established in organizational policies. Peripheral catheters larger than 20 available to care for the device. physiology. Parenteral Nutrition). long-term infusion therapy (eg.1.20 (III) with anticipated duration of treatment (eg. or critically ill (V) patients). injections) of the device and all attached or add-on stream infection (CLABSI) in hospitalized patients. 1-4 D. History of failed or difficult peripheral venous py. Choose a midline catheter as follows: 3. 3. devices (eg. Clinical instability of the patient and/or complex. implanted port access needle. Emergency insertions. or infusates other preventive strategies. To minimize unnecessary CVAD placement.indd S52 05/01/16 11:30 PM . antineoplastic thera- 6. Implanted Ports) CVADs. hypercoagu- patients who are anticipated to require intermittent lability. Expected dwell of more than 5 days. trauma. tunneled CVAD for patients who medication including anti-infectives in patients are anticipated to require intermittent or continuous with a known or suspected infection). Patients with enhanced risk of infection (ie. tration due to risk of undetected extravasation. Use a PICC with caution in patients who have Therapy) cancer or are critically ill due to venous thrombo- 5. The device is not left in place. recommended (refer to Standard 62. antineoplastic thera- or end-stage renal disease requiring vein py). Episodic chemotherapy treatment anticipated for native site for patients in whom chest ports can- more than 3 months. blood or blood products). 6.22-23 (V) 1.6. when not enteral nutrition. parenteral nutrition). and analgesics with characteristics that are settings. A. 4. Use caution with intermittent vesicant adminis- 4. Recognize risks with peripherally inserted central power injection and know the pressure limits and catheters (PICCs). The implanted vascular access port.18. and an evidence-based list of indications for CVAD use burns.3.19. identify uncontrolled sepsis or positive blood culture. par. with an osmolarity greater than 900 mOsm/L 3. Measure the vein diameter using ultrasound (IV) before insertion and consider choosing a catheter with a catheter-to-vein ratio of 45% or less (refer to Standard 52. Consider infusate characteristics in conjunction strategy. 15 (IV) minocycline. Tunneled. Consider the need for a CVAD that is designed for C. Consider a cuffed. has the advantage of allowing for ease tions.20 (III) administration.1-3. medica. extension S52 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.25 (V) access.18 (I) well tolerated by peripheral veins.17 (V) tion include severe uncorrectable coagulopathy. an improved patient self-image. maximum number of power an increased risk for central line-associated blood. not be implanted. decreased venous flow to the extremities.17 (V) 5. accessed.6. Long-term intermittent infusion therapy (eg. Transfusion 1. Use CVADs to administer any type of infusion 1. continuous port access has infec- III. neu- (see Standard 61.3. or be safe in 1 study. CLABSI rate remains high even after employing cant therapy. G. of bathing and swimming and is associated with 4. Invasive hemodynamic monitoring. parenteral nutrition. fluid replace- decrease in colonization and/or CLABSI in some ment.16-17 (IV) incidence of catheter-related bloodstream infection (CR-BSI).1-3. 5. B. but not limited to18: (IV) wall placement. transplant. as anti-infective CVADs have shown a solutions such as antimicrobials.17.5 2. 3. any F. Midline Catheters [CVAD]-Associated Venous Thrombosis). cular access ports in the forearm may be an alter- 2. however.6. Radiologically guided insertion of implanted vas- ity of infusion regimen (multiple infusates). Do not use anti-infective CVADs in patients with The administration of vancomycin for less than allergies to the anti-infective substances. Avoid the use of a midline catheter when the E. Consider a midline catheter for medications and stances. Do not use midline catheters for continuous vesi- 2. including venous thrombosis and other limitations (eg. rifampin. long-term infusion therapy (eg. fluid and electrolytes. if use of ultrasound guidance has failed. Consider an implanted vascular access port for patient has a history of thrombosis. Use steel winged devices only for single-dose sis and infection risk.21-23 (IV) A. silver sulfadiazine. Collaborate with the interprofessional team to con- weeks). When used intermittently. 5. or neoplasm that preclude chest including.5. Prescribed continuous infusion therapy (eg. 2.24 (IV) 3. such as 6 days through a midline catheter was found to chlorhexidine. Do not use a PICC as an infection prevention 1. Contraindications to vascular access port inser- therapy.2.1-3. Central Vascular Access Device II. burn.11-14 (V) 1.5 (IV) sider anti-infective CVADs in the following circum- 2.1-3. ports have a lower preservation. Central Vascular Access Devices (CVADs) tion rates that are similar to other long-term (Nontunneled.11 tropenic. Risk of venous thromboem- Nursing: An Evidence-Based Approach. 3rd ed.S. Improving antibiotic treatment outcomes through the implementation of a midline: piloting a change in practice for cystic fibrosis patients. 2010:456-479. In: Alexander M. 2014.35(1):63-68. catheters is a 20-gauge catheter.48(1)(suppl 1):S248-S273. O’Grady NP. J Clin Res.html. MO: Saunders/Elsevier. eds. Alexander M. The risk of bloodstream www. Corrigan A. Radiol. 480-494. In: Alexander M. Ngo V. and complications. 2010: 3. J Hosp Infect.E. 18. St Louis. Mikell M. Caparas JV. Safe administration of vancomycin through a Note: All electronic references in this section were accessed August novel midline catheter: a randomized. Saint S. Hearse N. 2014. access port devices implanted at the forearm: a retrospective 10. Marschall J. Perucca.34(9):908-918. MO: practice guidelines and recommendations for vascular access. Perucca R. Plumer’s Principles and Practice of Infusion insertion. 2013.35(4):751-764. Infect Control Hosp Epidemiol. Borgmeyer S. Sacks G. LeGal G. compounding. Place a peripheral arterial or pulmonary arterial catheter for adult cystic fibrosis patients: a retrospective. Chopra V. Ann Intern Med. update. http:// 20. 2015. In: Alexander M. results from an international panel using the RAND/UCLA 21. prevention of intravascular catheter-related infections. Society for Healthcare Corrigan M. Therapy. 2012. order Incidence and risk factors of symptomatic venous thromboembo- review. Gorski L. 2006. Fabian B. 9th ed. Fakih M. O’Horo J. Hu JP. Alexander M. 2014. et al. Eur Radiol. Boullata JI. The most commonly used catheter gauge for radial care unit: a cost-effective proposal for timely central line removal. Esterman A. Williams & Wilkins. Carrier M. et al. 2014. et al. with chronic kidney disease (CKD) as a permanent 11. Perucca R.26-27 (V) catheters for catheter placement success. et al. 2011. Loveday H. Goday P. 2014. Rogers M. Gorski L. Ramjan L. a low rate of com. recommendations for practice. prospective clinical trial.5 (V) guided placement of midline catheters in the surgical intensive B. PA: Wolters Kluwer/ ciated bloodstream infections in acute care hospitals: 2014 Lippincott Williams & Wilkins. Lancet. Guidelines for the 311-325.51(5):694-702. Phillips L. Chopra V. S1-S70. Arterial Catheters 12. Bierman S. Gilbert K. J Assoc Vasc Access. In: Alexander M. Risk factors for peripheral 24. Pratt M.N. Wilson J. Hankins J. et al. Spencer T. Venous access ports: indications. St Louis. Gorski L. Deutsch GB.gov/hicpac/BSI/BSI-guidelines-2011. McDiarmid S. follow-up. Infusion therapy in the older adult. Alexandrou E. 4. Johnson P. Webster J. Cummings M. 15. Chopra V. Fishman E. 4th ed.N. 22.29(1):11-15.org/stable/10. 2011. 9. R. 2013. J Parenter Enteral lism related to implanted ports in cancer patients. McGrail M. systemic review and meta-analysis.25: with dual source 128-MDCT: a randomized controlled study 606-616. The Michigan review and meta-analysis. eds. 1. nique.16(1): 35-41. plications was documented in one large study. Strategies to prevent central line-asso- Infusion Nursing. Crill C. and complications. Gorski L. eds. J Kidney Dis. 3rd ed. epic3: National evidence- Appropriateness Method. Corrigan A. REFERENCES J Vasc Nurs. Anand S. Hemodialysis catheters in the adult acute care setting: clinical implications and Vascular Access Devices [VADs]). et al. Hankins J. Hankins J. 2014:1-85. Technical and clinical application. McCutcheon H. 17. eds. needleless connector) to avoid catheter rup.35(7):753-771. Philadelphia. Gorski L. Sharp R.133:30-33. J 31. compared with central venous catheters in adults: a systematic 6. Hickner A. infusion rate.1177/0148607114521833. The use of midline access for dialysis (refer to Standard 29. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S53 JIN-D-15-00057. doi:10. 2015. clinical guidelines: parenteral nutrition ordering. Infusion Nursing: An Evidence-Based Approach. Mermel LA. image H.38(1):27-46. Assoc Vasc Access. Burns LA. eds.1086/676533. Philadelphia. Bullock M. Petrcich W. 3rd ed. National Kidney Foundation Vascular Access Work Group. observa- catheter for short-term use for hemodynamic moni- tional study. and analyzing 13. Gorski L. Bullock-Corkhill M. Infusion Kidney Disease Outcomes Quality Initiative (KDOQI). obtaining blood samples. McCutcheon H. Earhart A. IV. 2010:571-582. PA: Wolters Kluwer/Lippincott Perucca R. Hagle M.P. toring. Appropriateness Guide for Intravenous Catheters (MAGIC): 2013. et al. Peripheral venous access devices. set. 2013. Piran S.) 23. Hagle ME. 2015. MO: bolism associated with peripherally inserted central catheters: a Saunders/Elsevier.jstor.163(suppl based guidelines for preventing healthcare-associated infections 6):S1-S39. A.P. The safety and efficacy of midlines compared to peripherally inserted central A.E. et al. cation and pH: reevaluating the evidence. J Infus Nurs. Infect Control Hosp Epidemiol. Intermittently delivered IV medi. Thromb Res. Am Saunders/Elsevier. Plan proactively for a fistula or graft for patients quality. comparing 18-gauge nonfenestrated and 20-gauge fenestrated ture. In: Weinstein SM. St Louis.S. Corrigan A. Core Curriculum for Epidemiology of America.28 (V) 14. 2014.202(6): 1166-1170. Labossiere RJ. Int J Nurs Stud. Walser E. Cardiovasc Intervent 8. implantation tech- 2015. Dickenson A. Short-term and long- intravenous catheter failure: a multivariate analysis of data from term outcome of radiological-guided insertion of central venous an RCT. 2014.191(1):1-5. Am J Roentgenol. Hearse N.382(9889): 5. in NHS hospitals in England. 16. Flanders SA. and dispensing. American Society for Parenteral and Enteral Nutrition (A.cdc. Central vascular access device access and Hagle ME. Haller B.indd S53 05/01/16 11:30 PM . Clinical Nursing: An Evidence-Based Approach. 2. Ultrasound blood gas in critically ill patients. http://www. Infusion 19. Nutr. IV contrast administration monocenter analysis in 1794 patients. Wallis MC. Singh N.86(suppl 1): 7. Peripheral venous access.15(4):251-256. Sathyanarayana SA. labeling. Wildgruber M. Deuter K. Corrigan A. Infect Control Hosp Epidemiol. Christensen G. Published infection associated with peripherally inserted central catheters April 2011. 2014:303-334. Nicastro J. phlebitic. and patient preference for lymphedema. Visualization). and catheter rupture. bruised. such as areas with (VAD) required for the prescribed therapy. power injectors.11. which has leg with the tip below the groin and in the scalp with a higher failure rate. and ulceration.16.18 (V) condition of skin at intended insertion site.12(5):809-812. unless an emergency length of the prescribed therapy. Catheters phlebitis. condition of the vasculature at the inser. corded. For patients with chronic kid- established in organizational policies. 2010. 1. For infants and toddlers. For neonates and pediatric veins in the hand. history of 4. et al. defects that may have decreased blood flow to 27.3 Assess the patient’s condition. the scalp. or the affected extremity from a cerebro- (CVADs) by clinicians competent in the procedure is vascular accident. eter. Consider veins with difficult venous access and/or after failed found on the dorsal and ventral surfaces of the venipuncture attempts (see Standard 22. For pediatric patients: the region of the antecubital fossa. Navuluri R. Select sites in the upper arm. Do not use veins of the lower extremities unless II.4. and upper arm below patients.7. decrease pain during 6. Moller T. catheter placement in adult and pediatric patients dental removal and occlusions.13. Use ultrasonography (US) for short peripheral dwell time. Use the venous site most likely to last the full cephalic. 4. Semin Intervent Radiol. and prevent acci. 25. and median veins.19-25 (V) Peripheral Catheters 5. infiltrated. used for sucking.11 (IV) A.7. Hemodialysis I. and brachial veins.5. sion with the patient and the licensed independ- ent practitioner (LIP) is needed to discuss the benefits and risks of using a vein in an affected Practice Criteria extremity (see Standard 29.17 (V) 2. 2008. the tip in the neck. procedures. promote self-care. Smith L. Cannulation of hemodialysis fistulas.26-31 (I) cephalic. A collaborative discus- or other licensing agency. Surgical and patient risk C. Kane HA. Nuttall G. including a recommendation to use sites in the nondominant arm. also consider veins of B. situation exists.7. Cancer Nurs. Peripheral Venous Access via Short Vascular Access Devices [VADs]). grafts.1-9 (IV) 2. For adult patients: catheters for infusion therapy requires the order 1. the subclavian artery. forearm. Avoid the ventral surface of the wrist due to pain 27. additional site selections include veins in the the axilla. thrombo. or secondarily B.7. Avoid veins in an upper extremity on the side of previous venipunctures and access devices. selecting a site for infusion therapy.7. median cubital. Use the venous site most likely to last the full of a nephrologist or LIP.2 Peripheral vein preservation is considered when infection.12-15 (V) 28. Burckhardt J.25 (V) arm to increase dwell time. areas of previous comorbidities. including the metacarpal. Standard 3. For all patients: factors for severe arterial line complications in adults.32-34 (V) 2. procedures. areas on an extremity with an S54 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. infiltration or extravasation. or with an arteriovenous fistula/ VAD site selection. Peripheral Venous Access via Midline necessary due to risk of tissue damage. SITE SELECTION on insertion and possible nerve damage (refer to Standard 47. with duration of infusion therapy.3. and if not walking. above the thorax. basilic.33(6):426-435. with the length of the prescribed therapy.6. Vascular upper extremities. or engorged). open wounds. Chest port fracture caused by power injec- dren after procedures treating congenital cardiac tion. 1. and areas of planned tion site and proximal to the intended insertion site.1 Select the vein or site that best accommodates the pation. avoid unnecessary venipuncture of or practice guidelines and in accordance with rules and peripheral veins in the upper extremity intended regulations promulgated by the state’s Board of Nursing for future vascular access. veins that are compromised (eg. graft. Avoid cannulation in areas with pain on palpation. using the fore. computed tomography. 2011. type and breast surgery with axillary node dissection. Avoid areas of flexion and areas of pain on pal- 27. considering basilic vein preferred. 3. Hematologic patients’ clinical and psycho. Clin J Oncol Nurs. [Epub ahead of print] VAD site selection.10. Slaby J. Implanted ports. after radiation therapy to that side of the 27. Nerve Injuries). and A. preferred. diagnosis. areas of open wounds.28(3):357-358. Avoid the antecubital area. areas of valves.4 Placement of central vascular access devices body.3. Avoid the hand or fingers.13. using the basilic. Discuss with the patient the arm preference for Anesthesiology. avoid compromised areas and sites distal outer diameter and length of the vascular access device to these compromised areas. Avoid veins in the right arm of infants and chil- 26.12. or the thumb/finger social experiences with implanted long-term central venous cath. Adamsen L.indd S54 05/01/16 11:30 PM . 2015 Dec 4. sclerosed. areas on an extremity with an 27. 27. and/ ney disease. age. the foot. (see Standard 29. For adults.23. for patients with chronic test. and the saphen- clavicular or medial inframammary sites in children ous and popliteal veins in the lower extremities.47-49 (I) D. Avoid veins in the right arm of infants and children the internal jugular vein or. corded. the radial artery is the most appropriate engorged). For pediatric patients. pulse oximetry.36.12 (V) 1. and obtaining blood Devices [VADs]. the Vascular Visualization).58 (III) Visualization). the subclavian vein is nation of hand circulation such as assessing favored in adult patients. A Central Vascular Access Devices and venous site in adults where the catheter-to-vein ratio Implanted Ports is equal to or less than 45% is recommended. trauma. and veins that are compromised (eg. Standard 48. Use ultrasound (US) to aid in vein identification and of infection. infiltrated.3.28. veins that are compromised (eg. For A. use the as well as resultant venous depletion preventing future radial. the after procedures treating specific congenital cardiac external jugular vein. fistula construction (see Standard 29. Avoid areas of pain on palpation or areas with ment the presence of a pulse and presence of distal wounds. these sites are preferred Vascular Access Devices [VADs]). The brachial artery is not used in pedi- selection for decreased adverse events and first.50-52 (I) A. nosis and venous occlusion when the subclavian vein C. or B. Vascular flow. although tip placement at removal was more frequently non. the temporal vein and tunneled catheters and implanted ports.11 (V) ficult intravenous access (see Standard 22. to Standard 43.22.43 (IV) over the femoral or axillary sites to reduce the risk D. Central Vascular samples. Vascular D.12 (V) C.56 (I A/P) bruised. or Doppler flow study (refer kidney disease. and bra- chial veins with sufficient size for peripherally V. circulation.46. However. assess the circulation to the hand. infiltrated. complications with a nontunneled CVAD.11. rather than the femoral vein. rather than the jugular or radial and ulnar pulses. posterior tibial.3. assess for the use A. cephalic. atric patients due to the absence of collateral blood attempt success (see Standard 22. sclerosed. Prior to puncture of the radial artery. Hemodialysis For adults and children.27. weigh the benefits and risks that accompany arteries via peripheral arterial catheters. and dorsalis pedis arteries. If the patient has chronic kidney disease.27. arterial puncture.39. Avoid PICCs in patients with chronic kidney disease chial artery followed by the dorsalis pedis as due to the risks of central vein stenosis and occlusion. VI.22 (V) subclavian artery. sclerosed. corded.42. infection. Peripheral Arterial Access central for PICCs in upper extremities.19. consider C. Avoid areas of wounds or infections catheters are used for hemodynamic monitoring. Use to reduce complications. consider the risks of central vein ste.44-46 (IV) 1. Central Venous Access via Nontunneled tory (eg.3. the risk of infection. Consider using vascular visualization technologies tunneled CVAD in infants and children to minimize that aid in vein identification and selection for dif. alternative sites.7.41. and performing the Allen femoral veins.indd S55 05/01/16 11:30 PM . secondarily. Use US in arterial identification and selection to B.11. Use ultrasound (US) in adult patients for vein iden- Visualization). Central Venous Access via Peripherally hemothorax (see Standard 22. Vascular Inserted Central Catheters Visualization). Review the medical his- IV.31 (I) tification and selection to decrease risks of cannula- tion failure. Select the median cubital. Include as selection criteria from physical assess- B. Do not administer infusion therapy in peripheral is used.19.35-40 (IV) A. hematoma. basilic. To minimize the risk of catheter-related infection of anticoagulants. To minimize the risk of catheter-related thrombotic increase first-attempt success (see Standard 22.41 (IV) access for percutaneous cannulation.60-62 (I) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S55 JIN-D-15-00057. and perform a physical exami- with a nontunneled CVAD. There is no preferred venous insertion site for a non- D. Hemodialysis Vascular Access blood gas analysis.57. bruised.53-55 (IV) the best available vein in neonates: upper and lower extremities have similar complication rates.47 (I) and areas of planned procedures. phlebitic. radial artery harvesting). phlebitic. Central Venous Access via Tunneled inserted central catheters (PICC) cannulation. and III. additional site selec- assessment and site selection for the placement of tions include the axillary vein.3. weighing benefits and risks defects that may have decreased blood flow to the for each access site. these each access site. with the bra- C. Use the sub- posterior auricular vein in the head. Collaborate with the health care team and patient in neonate and pediatric patients. subclavian vein is recommended in adult patients. previous radial artery cannula- Central Vascular Access Devices tion. Phlebotomy). or engorged).59 (V) Access Device [CVAD] Occlusion). PICCs using the external jugular vein in patients in 14. Alexander M. 3rd ed. Schon D. eds.26(6): ed to exceed 96 hours. 2008. Hagle ME.750 catheter-days. Braby JE. J Adv Nurs.cdc. Saad T. Vascular access for hemodialysis. Plumer’s Principles and Practice of Infusion peripheral venous catheter site and increases after 96 hours: a Therapy. Plumer’s Principles and Practice of Infusion method. Mikell M. Oncology Nursing Society. tive cohort study. Corrigan A. Guidelines for venous access in patients with chronic 6. MO: access (guidelines 2. Perucca R. 3rd ed.27(2):135-140. 2539-2549. Pediatr Emerg Care. El-Masri MM. Philadelphia.38(3):189-203. Burns LA. UK Renal Association. and Nursing: An Evidence-Based Approach.64 (V) 15. Beauman SS. 27. Heinrichs J. http://www. 2013. rates as determined by peripheral intravenous catheter sites. 8th ed. 2012. Duell DJ. Fox-Wasylyshyn SM. Vandermeer B. eds. American 5. 2006. Todman RW. O’Halloran L.pdf?sfvrsn=2. prevention of intravascular catheter-related infections. Crandall C.6(4):193-201. VII. Am J Emerg Med. from a randomized controlled trial. cannulation of children.199(2):447-452. 2010:139-177. Clinical Nursing Skills: Basic to Advanced eral intravenous catheter failure: a multivariate analysis of data Skills. Helm RE.org/docs/ 8. 2001. 2014. Aust J Adv Nurs. ed.63. 2015.1-2. 18.31(6):367-374.30(7): pdf. Phillips N. statement]. MO: Saunders/Elsevier. Perucca R.renal. Redfern WS. 3rd ed. 1134-1140. Healy D. Fritze Z. PA: In: Alexander M.27(6):626-631.org/ diameter. 2001. Follow-up of radiologi- possible. collaborate with the LIP for 602-608. Hoggard J. Swanson A. 19. Institute of Medicine. Association for Vascular Access [position Nurs. eds. Huang E. Cicolini G. Can 23. Dean AJ. et al. Semin Dial. Gorski L. Crossing the Quality Chasm: A New Health System for the 7. 22. In: Weinstein SM. Manzoli L. eds. America. Hadaway L. 2015. 9th ed. Curtis S. Egan G. 2012. Infusion short peripheral catheters. Hankins J.35(1):63-68. some risk factors. 22. In: Weinstein 1. other veins cannot be accessed. Clinical Accepted but unacceptable: peripheral IV catheter failure. Am J Roentgenol. et al. Perucca R. St Louis. Gerard J. Published 2015. Infect Control Hosp 26. Infusion Nursing: An Evidence-Based Approach. Schwartz Y.17:26-39. Pittsburgh. Marsigliese AM. and location on ultrasound-guided peripheral intrave. 2014.163(suppl 6): Therapy. Gorski L. External Jugular Vein Access 13. midline catheters. an international panel using the RAND/UCLA appropriateness Hagle ME. Newborn Infant Nurs 29. Herrmann J. Benaya A. 9th ed. access: systematic review and meta-analysis. Washington. PA: Wolters Kluwer/Lippincott S1-S39. Williams & Wilkins. Heinrichs J. St Louis. Eur J Clin Walsh SR. REFERENCES 17.21(2):186-191. lar access for haemodialysis. St 21. Published and meta-analysis of new interventions for peripheral intravenous April 2011. Salgueiro-Oliveira A. Saint S. Kory R. Am J Emerg Med. Home intra- venous therapy and the ability to perform self-care activities of Note: All electronic references in this section were accessed September daily living. 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Stolz U.40(8):2479-2485. patients. The effect of catheter to vein ratio on location matters. clavian insertion and nontunneled central venous catheter-associ- guided peripheral venous access: a meta-analysis and systematic ated infection risk reduction in critically ill adults. Nicastro J. 57. analysis. Paulin LM. Furuya RK. Ultrasound insertion. care unit: a cost-effective proposal for timely central line removal. de Carvalho Onofre P. doi:10. doi:10. Mora M. An emergency department nurse-driven ultrasound. 2012. Liu JC. The role of the regis- 2013. bloodstream infection with femoral venous catheters as compared mendations for practice. 2013. Ramjan L. Crit Care. Corrigan A. Central Ann Emerg Med. Schick G.CD004084. Blood sites. 47. New 41. Crit Care Med. Increased complication extremity venous thrombosis. Ultrasound J Surg Res. 49. Infusion Nurses Society [position paper]. 43.indd S57 05/01/16 11:30 PM . Am J Kidney Dis. Sathyanarayana SA. Pan L. Larimer EL.pub3. McGill RL. tral catheter usage patterns and associated symptomatic upper 53. MD: 39. Nursing: An Evidence-Based Approach. review of the literature and meta-analysis. O’Horo J. et al. 2012. Cochrane Database Syst Rev. Eur J 40. eds. Moore C.org/ ultrasound-guided radial artery catheterization: an updated meta- website/download. 2015. Fielder A. Ge X. Gao YB. 2015. tered nurse in the insertion of external jugular peripherally VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S57 JIN-D-15-00057. Gu WJ. Int J Nurs subclavian totally implantable access ports: catheter position. CD011447. 2014. MO: 44. Smith AF.140(1):48-53.(1): J Nurs. Pan SM. et al.1002/14651858. Dains JE. 2011(1). PICC zone insertion method (ZIM): a systematic 52. Chest. Anesthesiology. Brass P. The use of ultrasound guidance by registered nurses 60. Gonçalves N.13(5): 2014. 2015. Meta-analysis of sub- 31. Farrell IJ. Parienti JJ. 63. Radiol. Am J Emerg Med. In: Alexander M. Mahnken AH. source of bloodstream infection: a systematic review and meta- 42. Ultrasound. 48. Maki D. Evid Rep Technol Assess (Full Rep). 2012. Bullock-Corkhill M. Hadaway L. Krupp A. Rockville. Kolodziej L.CD006962.asp?id=279996. Plumhans C. Gorski L. 2015. Real-time approach to determine the ideal insertion site for PICCs in the two-dimensional ultrasound guidance for central venous upper arm. Arterial catheters as a atic review.61(4):444-454. 50. NY: Mosby. Making health eterization of the radial artery: a systematic review and meta-analysis care safer II: an updated critical analysis of the evidence for of randomized controlled trials. Bhardwaj R. Dawson R. Yanit KE. 2015. Ultrasound-guided cath- 46.1002/14651858.139(3):524-529. AHRQ Esterman A. Wrightson DD. Ultrasound. doi:10. Gwilliam NR.avainfo. optimal time for replacement of the noncoring needle when the implanted vascular access port is used for continuous infusions. Assess patient needs and preferences related to pain dressing or gauze dressing that covers the noncoring management during port access (refer to Standard needle and access site when the port is accessed. Care.7 (V) 28. Adhere to aseptic technique during implanted port the TSM dressing to support the wings of an access access. Allow skin antiseptic agent to fully dry prior 28.5 (V) Practice Criteria E. 2.4 A sterile dressing is maintained over the access site 3.2 (V) ter syringe barrel).4-7 (I) 28. 1.9 (IV) capable implanted vascular access ports have 2. the outflow channel where the catheter is attached ing needles designed for power injection are used with to the port body. IMPLANTED VASCULAR b.1 Placement and removal of an implanted vascular to port access. inserted central catheters and external jugular peripheral intrave. J Infus Nurs. an iodophor (povidone-iodine). or discomfort. catheter fragment emboli. Flushing and Locking). include presence of identification cards.31(4):226-227. When gauze is used under C.indd S58 05/01/16 11:30 PM .2 Implanted vascular access ports are accessed using 2.3 Only implanted vascular access ports and noncor. Do not use palpation of the port as the only iden. and the organizational policy. Exchange]). There is insufficient evidence to recommend the unique characteristics identifiable by palpation. procedures. lar access ports daily. including use of sterile gloves and mask. Committee Consensus) the TSM dressing every 5-7 days. Local Anesthesia for Vascular Access Device Change the TSM dressing every 5-7 days and gauze [VAD] Placement and Access).9% sodium chloride (USP) manufacturer.10-12 (V) need for port removal and replacement. Catheter Damage [Embolism. Flush accessed but noninfusing implanted vascu- tification method as not all power-injection. with validated competency operating within the state’s 1. a. use a noncoring needle of a length that according to organizational policies. Central drainage. dressings every 2 days. Repair. documentation. 64. Use a transparent semipermeable membrane (TSM) B. 1. During and after power injection be aware of the cular access port that is not accessed for infusion. Use at least 2 identification methods that may to Standard 40. taking note of any resistance (refer 1. In vitro testing demonstrates a power-injection equipment for radiologic imaging in greater amount of protein is removed when accordance with manufacturers’ directions for use. Assess vascular access device (VAD) functionality by A. 10-mL-diame- purpose. change (V. Suspect 3. for patients who have a history of catheter-relat- ized swelling or erythema or reports pain (refer to ed bloodstream infections (CR-BSIs) (refer to Standard 51. or key chains provided by the with preservative-free 0. Perform skin antisepsis prior to port access. and/or allows the needle to sit flush to the skin and practice guidelines.6 (V) venous access via external jugular vein in children. securely within the port.5% chlorhexidine in alcohol solution. tincture of iodine. or 70% alcohol may also Standard be used. If there is a contraindication to alcoholic ACCESS PORTS chlorhexidine.5 (I) c.5 (V) access port are considered surgical procedures and are D. Standard 40. Confirm that the implanted port has a labeled indi.5-8. Anticipate use of antimicrobial locking solutions catheter rupture if the patient shows signs of local.1. Consider orienting the bevel of an implanted noncoring safety needles. 2008. Losek J.13-16 (IV) S58 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.8 (IV) 28. Flushing and Locking).3. Cochran J.4 needle and does not obscure the access site. 32. port access needle in the opposite direction from 28. Perform hand hygiene before and after examin- nous catheters. Pediatr Emerg 2. G. erythema. There is insufficient evidence to recommend an if the implanted vascular access port remains accessed.26(8):554-557. 2010. Webb S. F. Tecklenburg F. review operative procedure or heparin lock solution (refer to Standard 40. ing the site to assess for swelling. which can lead to refer to manufacturers’ directions for use and extravasation.5. flushing with this bevel orientation. Access the implanted vascular access port with the to be performed by a licensed independent practitioner smallest-gauge noncoring needle to accommodate (LIP) or advanced practice registered nurse (APRN) the prescribed therapy. To reduce the risk of needle dislodgment during rules and regulations for professional practice and access. using a 10-mL syringe or a syringe specifically designed cation for power injection before using it for this to generate lower injection pressure (ie. venous patterns. Flush and lock the implanted vascular access port wristbands. potential for catheter rupture. Use the preferred skin antiseptic agent of >0. Flushing and Locking). Habib D. and palpate the port. optimal frequency for flushing an implanted vas- 3. Subhi A. routine care. Alexander M. Infect Drug Resistance. McCollom C. Totally implantable port noncoring needle. and complications. Clin J Oncol Nurs. H. 2012. St Louis. Tsang L. leaking. Implanted ports. Adv Lung Cancer. Baram A. Janssens C. J Pediatr Oncol Nurs. 29. Impact of decreased heparin dose for flush-lock of tations of aseptic technique during access. 29. et al. and impact of the policies. AV graft. expec- Auerbach A.1 The selection of the most appropriate type of vas- 4. and potential complications.28(3):357-358. and long-term VAD. Hankins J. Bustos C. immediately reporting any signs or 15. Smith L. Basic infection con. Bannon C. follow-up. MO: Saunders/Elsevier. In: Alexander M. Provide appropriate patient/caregiver education 11.24(7):1892-1899. Gorski L. Conway M. Losser MR. 2012. Clin J Oncol Nurs. Pozo J. Pittsburgh. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S59 JIN-D-15-00057. computed tomography. gical procedures and will be performed by a licensed eterization: current approaches in the diagnosis and treatment of independent practitioner (LIP) with validated compe- port-related infections.11(1):46-51. Hankins J. Patient Education). Moller T.3 Removal of a temporary nontunneled or nonim- Perucca R. and insertion of an AV graft are considered sur- 6. and recognizing the importance of stopping Nursing Society.4. 2015. implantation tech- wetness.35(4):751-764.12(5):809-812. Burns LA. 2011. 2014. Heparin versus saline including placement procedure. Semin Intervent Radiol. Access Device Guidelines: Recommendations symptoms of pain.gov/HAI/settings/outpatient/basic-infection-control.17 (V) Radiol. how to dress and undress to avoid pulling at the 14. Albert O. Gorski L. 29. 17. Ann Oncol. 2010. eds. Jerome M. Hunter M. number of lumens). et al. ACCESS DEVICES (VADs) 2. 10.2 Placement and removal of a tunneled or implanted prevention of intravascular catheter-related infections. power injectable. Determine the access method in advance of begin- flushing recommendations: a systematic evidence-based practice ning dialysis. management: impact of positive pressure during needle with- drawal on catheter tip occlusion (an experimental study). insertion. Note: All electronic references in this section were accessed August 26.cdc. Walser E. Durussel J.7:25-35. Goossens G. Abdullah H.61(5):855-858. Merckx J.16 (V) care. type of port placed solutions for locking of totally implantable venous access port (eg. plan. Flushing ports licensure rules and regulation and organizational of totally implantable venous access devices. Hematologic patients’ clinical and psycho- social experiences with implanted long-term central venous cath- REFERENCES eter. Chest port fracture caused by power injec.indd S59 05/01/16 11:30 PM .33(6):426-435. Corrigan A. 5. burning. and catheter rupture. Wilson S. Adamsen L.15(3):324-326. Huber point needle bevel orientation: experimental tests and 29. Vigier J. 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The general order for vascular access review. including checking the dressing daily. protecting the site during bathing. Provide appropriate patient/caregiver education for Corrigan A.html. 2011. 2008. the infusion pump and immediately reporting any 16. ed. Long-term cath. non. tency operating within the state’s rules and regulations 7. 8 (V) Standard I. Vascular access team collaboration to central catheters (PICCs).7. et al.aspx.8 (V) H. Assessment. Benedetto F. blood transfusions. Lincoln M. A review of hemodialysis vascular access devices. 2013. National Institute of Diabetes and Digestive and Kidney Diseases.6. Avoid using a hemodialysis catheter for routine www. et al.2. UMBILICAL CATHETERS return before use of a tunneled or nontunneled dialysis catheter. Preventing catheter-associated bloodstream infections dysfunction. In critically ill patients.kidney. Schinstock C. Wear sterile gloves and a mask when performing 30. Aspirate the locking solution and confirm a blood 30. Clinical indicators and preven- of fistula maturation.html.1. Albright R.org/2014/view/v2_03.gov/kudiseases/pubs/vascularaccess . according to the manufacturer’s directions 9. Monitor all access devices for signs or symptoms of 6.38(5):411-415. VA/va_guide2. et al. Patient Education).usrds. Because multiple lumens increase the risk of infec- tion.4(7):281-294.2. Outcomes of arterio- therapy needs.nih. Objectives and design of the sion medications.2. site when there is no interaction with the catheter J Infus Nurs. functional. and Dressing Changes). et al. NKF. dialysis VAD or create a means of long-term vascu. blood sampling.pdf. plications. din/polymixin ointment at the dialysis catheter exit 8. 2.org/professionals/KDOQI/guideline_upHD_ should collaborate on the decision to place a hemo. Mondello P. and severity of illness in an effort to Note: All electronic references in this section were accessed August decrease their unnecessary use and associated com- 26.1 Placement and removal of an umbilical arterial dressing changes for hemodialysis access devices. 2015.gov/hicpac/BSI/BSI-guidelines-2011. Dember L. E.11 (IV) tive care.6(8):1996-2002. are likely to need vascular access for hemodialysis. . Vascular access fact sheet. Robson J. Administer medications through the venous fistula creation after the Fistula First initiative. subclavian vein catheters and peripherally inserted 4. cuffed catheter with a medial infusion port may be 2014. Beck G.36(6):404-410. infection. or other complications at in hemodialysis centers: the facility perspective.2. operating present). http://www. Imrey B. Care. Do not routinely replace temporary catheters used 7.8 (V) 2011. Teach patients/caregivers/surrogates how to assessed on a daily basis and promptly removed when care for and protect the VAD and to report no longer indicated. 2014. Vascular Access Device [VAD] procedures. Whiteman K. and patho. any signs and symptoms of dysfunction. Use UACs for obtaining blood samples and con- Selection and placement of hemodialysis access. Vascular access for hemodialysis. 1. Mbamalu G. Variables Kotter’s change process. Nephrol Nurs J.2 The clinical need for the umbilical catheter is J. Williams A. B. Published April 2011.41(3): such as clinical.1-3 (IV) 1.1. United States Renal Data Center. Clean gloves can be worn for accessing a within the state’s rules and regulations for professional tunneled catheter with an established cuff (see practice in accordance with organizational policies and Standard 41. http://www. and venous catheter (UAC and UVC) are performed by including AV fistulas and grafts (when dressings are licensed clinicians with validated competency. Clin J Am medial infusion port and not the dialysis lumens. logical issues are under study to identify predictors 5. O’Grady NP.9 (I) prevention of intravascular catheter-related infections. 2006. anatomical. D. S60 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. American Nephrology Nurses’ Association. Burns LA.8 (V) Practice Criteria A.1-7 (III) vascularAccessFactSheet. KDOQI clinical practice guidelines.org/download/reference/practice/ lar access for the purpose of hemodialysis. placed for short-term vascular access for infusion 11. each dialysis session. such as temporary 2014. Alexander M. limit the duration that a dialysis catheter with a medial infusion port is used.7-9 (I) decrease catheter rates in patients on hemodialysis: utilization of C. Published 2013. Use povidone-iodine ointment or bacitracin/gramici. Int J Nephrol Renovascular F. tinuous blood pressure monitoring.kidney. a non- hemodialysis fistula maturation study.1. Am J Kidney Dis.htm. Dis. infection. National Kidney Foundation. Establish organizational guidelines for appropriate REFERENCES use of UACs and UVCs based on gestational age.63(1):104-112. Soc Nephrol. When feasible. or other complications pertaining to the access device in use (see Standard 8. Published May bosis and central venous stenosis. Nephrol Nurs J. The patient/caregiver and interprofessional team http://www2. or other infu- 10. 283-287. 2011. http://www.8 (V) 30. 2014.annanurse.10.9 (I) hemodialysis: current perspectives. Published 2014. Vascular access for for dialysis. use a matured AV fistula.indd S60 05/01/16 11:30 PM .niddk Avoid access devices that are associated with throm. Santoro D. birth weight.1. Guidelines for the for use.cdc. http:// G. material. Use vein preservation techniques for patients who 3. 5 (II) pathway. but not limited to.4 (I) est and most effective chlorhexidine solution in H.and by continuous infusion of heparin 0. low-birth. Standardizing guidance is safe. extravasation. Ultrasound imaging using parasternal long. high position) or eter (PICC) for continued infusion therapy is one below the renal arteries and above the aortic strategy to reduce central line-associated blood- bifurcation into the common iliac arteries (ie.2. Determine the length of catheter to be inserted by vascular constriction. Evaluation of arterial catheter vertebrae 6 and 10 for high position and between management in very preterm neonates: peripheral artery versus lumbar vertebrae 4 and 5 for low position.34. 2. 1 cm per minute to minimize arterial Use of the cardiac silhouette is reported to be spasm. There is a lack of life.31 (V) more accurate than positioning based on vertebral bodies. parenteral nutrition.26 (IV) Systemic absorption has been reported due to skin G. air embolism.25 (V) 2.17-19 (IV) 2. For UVC. roid gland. Pediatrics. Injection of normal per day). Consider limiting UVC dwell time to 7 to 14 1. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S61 JIN-D-15-00057. and antimicrobial resistance. For UAC. or ultrasonography before cath.18.12-16 (V) longer needed or if a complication occurs. obtain AP radiographic view of the chest 2014. Place the catheter tip for: 1. stump. UVCs in the inferior vena cava near the junction days.133(6):e1742-e1752. cardiac tamponade. Use both aqueous and alcohol-based chlorhex. and ease of use. evidence demonstrating the best method.6-11 (I) cardiac arrhythmias.35 (IV) echocardiography. dwell times.25 to 1 unit short-axis views for UVC tip location compares per mL (total dose of heparin 25-200 units per kg favorably to radiography. or with purposes.30. UACs in the thoracic portion of the descending insertion of a peripherally inserted central cath- aorta below the aortic arch (ie. birth-weight neonates. For removal of UACs. For difficult bedside UVC placement or patients 22. Confirm the catheter tip location by radiography. and abdomen for tip location between the thoracic 2.5% chlorhexidine in chest and abdominal radiography for identifying alcohol solution.32. Imamura T. stream infection. due to risks of chemical burns to the skin. based on promoting skin integrity. and peripheral C. pleural potential deleterious effect on the neonatal thy. Momoi N. Perform skin antisepsis prior to insertion: 5.20 (IV) Note: All electronic references in this section were accessed September 2. will not rule out loops or curls in the catheter ucts. UVC removal at 7 days followed by 2.58(1):1-8. Use all chlorhexidine antiseptic agents plications including. Consider limiting UAC dwell time to no more E. 2012. et al. 2015. a lateral or cross-table view may be needed. Do not use topical antibiotic ointment or creams on immaturity.24. Maintain patency and reduce risk of thrombosis 4. and blood prod. Go H.33 (III) low position). effusion. pericardial effusion. by equations based on body weight. Anticipate the use of ultra- anatomical measurement of shoulder to umbilicus sound or echocardiogram for diagnostic length.18. Shivananda S.4.23 (IV) B. Shahid S.4. Use povidone-iodine. than 5 days. from the umbilical stump. infection. thrombosis. however.4.12.17. 3. D. the final 5 cm of graphic view of the chest and abdomen for tip catheter length should be slowly withdrawn at location at or slightly cephalad to the diaphragm. and within the first 14 days of complications. However.indd S61 05/01/16 11:30 PM . Studies have not established the saf. Use UVCs for the infusion of medications and ing the exact tip location. >0. Symington A. hemor- 3. liver damage. saline through the catheter may assist in identify- 3. or aqueous chlorhexidine malpositioned catheters or in extremely low- solution. with congenital cardiac conditions. systemic effects are not umbilical sites due to the risk of fungal infections documented. Neonatal echocardiography may be superior to 1. Remove umbilical catheters slowly over several eter use. minutes after placing an umbilical tie around the 1.27-31 (IV) other research-based protocols to achieve successful I.22. Remove umbilical catheters promptly when no tip placement. Monitor for signs and symptoms of potential com- neonates.21 (V) umbilical catheter usage in preterm infants. obtain anteroposterior (AP) radio. Dutta S. decreasing weight neonates. F. 3.4. Fukushima J Med Sci. fluoroscopy 1.17 (V) umbilical artery. Choose a method for securing the UVC and UAC idine with caution in preterm neonates. Avoid the use of tincture of iodine due to the rhage. risks of infection are increased with longer with the right atrium. When an AP view is insufficient to identify REFERENCES the catheter pathway and tip location. ultrasound solutions. bleeding with caution in infants under 2 months of age. Gorski L. Pasquali R. 2012. Chapman A. Verheij GH. Umbilical venous catheter position: evalua- gov/hicpac/BSI/BSI-guidelines-2011. Simple measurements to place Saunders/Elsevier. Te Pas AB. Eur J Pediatr.7(1):13-19. review and meta-analysis of the clinical efficacy and perceived role 28.1 The selection of the most appropriate type of vas- 19. based catheter bundle alters central venous catheter strategy in Arch Dis Child Fetal Neonatal Ed. Vargas JH. Hankins J. tion by ultrasound. Dungen FA. neonatal intensive care unit: results from a national survey. Eur Radiol. 5. Infusion umbilical vein catheters.32(8):604-607. Ramasethu J. Guidelines for the preven.160(6):972-977. 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Chan ES. Min SR. PLoS One.32(1):4-9. 34. Pettit J. Umbilical arterial catheter insertion length: in quest of a uni. Baker A. Brevaut-Malaty V. J Pediatr. Comparison idine gluconate used for skin antisepsis prior to catheter insertion of complication rates between umbilical and peripherally inserted in preterm neonates. Radiographic assessment of umbilical venous and arterial catheter tip location.35(7):476-480. 12. 2013. Milstone A. St Louis. Published April 2011. APHERESIS CATHETERS 2014. Bar-Oz B. newborn infants. tion of intravascular catheter-related infections. Pediatr Neonatol. J Perinatol. Kieran EA. Butler G. 18. 2015. Bojanic K.50(8):649-652. 25. Chest. 3rd ed. How long should umbilical venous 11. Physicians evidence-based clinical practice guidelines. Hoey H. Consider the following when choosing the most genital heart disease. Maiwald M. Weissenbruch MM. 2014. factors for catheter-associated bloodstream infections in neonatal 14. J Perinatol. Aucott S. 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Ryan S. appropriate VAD for therapeutic apheresis: the type S62 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. An evidence- ment: a randomised trial [published online August 11. 2014. Donohue JE.5(7):476-489.13(6):426-429. 2014.32(12):933-940.html. 2012. cal venous catheter tip localization: accuracy of a clinician perfor- nate used for skin antisepsis in the preterm infant. 2014.10(4):317-325. Hoellering AB. 2013.141(suppl 2):e737S-e801S. Congenit Heart Dis. Rozovsky K. The forgotten role of alcohol: a systematic Nurs. 31. O’Grady N. length. Ergaz Z. Resuscitation. Advani S. James A. Goldenberg NA. 2014. Butler-O’Hara M. Perucca R. et al. 23. AJP Rep. Walther FJ. 2013. eter insertion depth in newborns using weight or body measure. the interprofessional team based on the projected 20. Using treatment plan. Gupta A. Arnts IJJ. (≥5-7 days) central venous access? J Paediatr Child Health. Trotter C. Milstone AM. Venkatalakshmi umbilical artery catheters may not be associated with increased A. of chlorhexidine in skin antisepsis. et al. the patient’s vascular anatomy. and complemen- commonly. intradermal lidocaine. Kalantari K. apheresis. Pain Res Manag.1 The clinician considers local anesthesia for vascu. 2014.59(1):72-73. and 32. J Clin Apher. B. Hsiu-Lin C. acuity.1-11 (I) 2. Xyrichis A. Golestaneh L. Semin Dial. J Clin Apher. 2011 ENA Emergency REFERENCES Nursing Resources Development Committee.130(5):e1391-e1405. Bueno M. 2012. 2011. Levas MN.29(5):367-376. 5. Consider local anesthetic agents for painful VAD dren (< 30 kg) due to small veins but may be placement or access including. Crowley M. J Clin Apher. agents. infants. Lidocaine/tetracaine patch efits. et al. Okafor C. J Trop Pediatr. to reduce pain and discomfort prior 4. J Emerg Nurs.1. Mayer L.25(2): neonates.12-17 (I) blood flow rates. of apheresis procedure (centrifugation-based or fil. Emergency nursing resource: difficult intravenous access.3 (IV) 5. 2012. J Perianesth Nurs. Use a nontunneled or tunneled cuffed central B. or inadvertent injection of the drug into ter-based systems). 9. A systematic review and 2.18(3):153-161. but not limited to. Mokrzycki MH. 2015. et al. 2012.28(1):36-47. 5. as well as adjunctive and less invasive 3. frequency and treatment duration. Medicine. 2013. the vascular system. cognitive. Peripherally inserted central catheters should not to each painful VAD puncture or procedure in chil- be used for therapeutic apheresis due to small dren. Ann Emerg Med. topical transdermal Peripheral veins are not appropriate for filter. Therapeutic apheresis in children: special consid. 1. Peripheral or central VADs are recommended for procedures. Br J Anaesth. topical vapocoolant sprays. erations. and/or practice guidelines. 2013. therapeutic apheresis as follows: 1. Zempsky WT. use double-blind. Pywell A. Sima B. Use the most effective and available local anesthetic VAD with a catheter size of at least 11. anxiety in pediatric patients in emergency medical systems.9. American Academy of Pediatrics. tissue damage. Relief of pain and 4. Peripheral vein access is not recommended in young chil. Use of 16. upon assessment of patient condition.1-4 (IV) tary therapies. 2014. 3. Hui-Chen F.2.25(2):165-170. VASCULAR ACCESS DEVICE 6.1-5 (IV) accelerated lidocaine. Oman KS. Pediatrics. et al.66(5):466-474. Drendel AL. 2012. Jain NG. and for large-bore vascular access internal diameters and inability to accommodate in the hand (eg. Hunt EAK.5 Fr for method and/or agent. Goldstein SL. assess the method of anesthetizing a peripheral IV site? J Perianesth Nurs.28(4):217-222.1-3 (IV) tiveness. A randomized clinical trial of jet-injected lidocaine to reduce venipuncture pain for 32. possible with older children and adolescents.28(1):64-72. et al. Brim C.1-3 (IV) placement are established in organizational policies. eutectic mixture of local anaesthetics (EMLA) cream? A system- lar access device (VAD) placement and access based atic review and meta-analysis of randomised controlled trials. (Rapydan) for topical anaesthesia before arterial access: a 32. Yamada J. et al. risks.1-3 (IV) 1. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S63 JIN-D-15-00057.32(9):733-737. and anticipated discomfort of the procedure.38(4):335-343.4 Protocols for the use of local anesthesia for VAD underlying disease state. LOCAL ANESTHESIA FOR young children. and pressure- based apheresis systems.to 18-gauge peripheral catheters Practice Criteria placed in antecubital veins for adults. 2013. ben- 8. Emerg Med J. 2.indd S63 05/01/16 11:30 PM . et al.109(5): the agent and method that is least invasive and carries 790-796. Kleiner C. Fink R. Shun-Line C. Implanted vascular access ports are used less anxiolytic. needs. The effect of EMLA an overview of key technical aspects and a review of experience cream on minimizing pain during venipuncture in premature in pediatric renal disease. Semin Dial. The choice of vascular access for therapeutic 2012.3 When administering a local anesthetic. Lunoe MM. Intradermal lidocaine or bac- (VAD) PLACEMENT AND teriostatic normal saline to decrease pain before intravenous ACCESS catheter insertion: a meta-analysis. 140-144. Arteriovenous (AV) fistulae and AV grafts may be REFERENCES placed for long-term treatment. Fein JA. A. Does topical amethocaine cream increase Standard first-time successful cannulation in children compared with a 32. Vascular access in therapeutic Emergency Medicine and Section on Anesthesiology and Pain apheresis: update 2013.2 When local anesthesia is ordered or necessary. Kalantarinia K. Vascular access considerations for meta-analyses of nonsucrose sweet solutions for pain relief in therapeutic apheresis procedures. Knicely C. patient and intervene for potential allergic reactions. considering time to peak effec- adults. Cravero JP. behavioral. 2013. What is the least painful 32. the least risk for adverse reactions. 7. Somers MJG. some adults.27(3):153-159. Harrison D. randomized trial. Winfield C. 16 gauge). Apheresis therapy in children: 4. Jensen C. Proehl J. Committee on Pediatric 3. Ruetzler K. 2013. for needle-related procedural pain and distress in children and Central Vascular Access Device [CVAD] adolescents. Kassab M. increase cost. clinical trial. Beyene J. sterile vascular access device (VAD) is used for each catheterization attempt. 16. Adams-Webber T. Wang VJ. Treatment options include open opera- doi:10.0000000000000257. and increase 33. pers. controlled.(5):CD008408. Dedicate a tourniquet to only a single patient. Vascular Visualization). Hillis D. 33. Pediatr Emerg Care. 2. Br J Anaesth.pub2. Hunsaker S. placebo-controlled trial [published online D. 33. et al. Consider implementation of specialized infusion 33. Cochrane Database Syst Rev. Vapocoolant spray vs subcutaneous lido- caine injection for reducing the pain of intravenous cannulation: patient-use scissors or disposable-head surgical clip- a randomized. Sweet-tasting solutions for reduction of needle-related patient reports paresthesias (numbness or tin- procedural pain in children aged one to 16 years. Foster JP. Immediately remove the VAD and promptly notify Effects of vapocoolant spray on skin sterility prior to intravenous the licensed independent practitioner (LIP) in the cannulation. 2013.indd S64 05/01/16 11:30 PM . General These include: A. 1. A. following situations: 13. cleanse the intended VAD needle-free powder lidocaine delivery system in adult patients insertion site prior to application of antiseptic undergoing venipuncture or peripheral venous cannulation: rand. Foureur M. Cryotherapeutic topical intravenous access per clinician. Consider use of visualization technologies to aid in 33. Psychological interventions endovascular management (see Standard 53. Ensure that the intended VAD site is visibly clean promised circulation. vention. ficult venous access (refer to Standard 22. Short Peripheral and Midline Catheters ment.1097/AJP. Ward P. while maintaining arterial circulation. VASCULAR ACCESS SITE the risk for complications.90(4):333-337. II. doi:10.1-3 (V) omized. Use of a blood pressure cuff or tourniquet (refer to Standard 8. Harrison D. Inadvertent arterial 15.(10):CD005179. Uman LS. Remove excess hair at the insertion site if needed to May 15. apply pres- 14.1002/14651858. puncture during CVAD placement is a life-threat- tions for needle-related procedural pain in infants one month to ening complication requiring immediate inter- one year of age. and limit total analgesics for pediatric intravenous catheter placement: ice versus attempts to no more than 4. Hurren F. 2015. Page DE. I. double-blind. facilitate application of VAD dressings. 2015. do not shave as this may increase the risk for 2010. Safety and efficacy of visible soil is present. such as when the Stevens B. F. sure to the peripheral site.1.4 (V) 12. limit future vascular access. applied in a manner to impede venous flow B.1002/14651858.CD008411. Taylor DM. Yeoh M. when veins.3 Aseptic technique is adhered to during all aspects teams to improve success rates with peripheral of VAD placement. Cochrane gling) related to VAD insertion (refer to Standard Database Syst Rev.5.6 (V) doi:10. C. Noel M. 2013. Malposition). 33. 2013. Sweet-tasting solu.8-10 Standard (III). Waterhouse MR.29(1):8-12. 2015]. Intraosseous vascular access for alert patients. Birnie KA.113(11):34-40. 47. Use an appropriate method to promote vascular Practice Criteria distention when placing short peripheral catheters.pub3. If nerve damage is suspected.pub3. J Hosp Infect.7 (IV) G. infection (although research is limited). intravenous (IV) insertion (refer to Standard 4. Clin J Pain. Ohlsson A. doi:10. Patients with difficult PREPARATION AND DEVICE vascular access require a careful assessment of VAD PLACEMENT needs and collaboration with the health care team to discuss appropriate options. and/or have fragile prior to application of an antiseptic solution. Yamada J. are at risk for bleeding. B. Am J Nurs.105(4):519-525. Liu DR. Cochrane Database Syst Rev. use single- 11. apply tourniquet or avoid its use in patients who Informed Consent). Meyer JM. Make no more than 2 attempts at short peripheral 17. directions for use. Nerve Injuries).7 (I A/P) S64 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.2 Skin antisepsis is performed prior to VAD place. E. CD008408.1 A new. 2012. Obtain informed consent according to organiza. Multiple unsuccessful vapocoolant spray. Provide patient education prior to inserting a VAD 1. 10. bruise easily.2. Patient Education). Schmitz ML. Loosely tional policy or procedure (refer to Standard 9.4 The VAD is not altered outside the manufacturer’s Infusion Team).1002/14651858. If an artery is inadvertently accessed. attempts cause patient pain. Taylor DM. Howden BP. Evans JG. Zempsky WT.5 Proper tip location for central vascular access vein identification and selection in patients with dif- devices (CVADs) is verified prior to use. tive approach and repair and.(12):CD008411. Fowler C. have com- C. solution(s). delay treatment.CD005179. more commonly. Use ultrasound technology when inserting CVADs E.11-14 (IV) of and completion of a standardized checklist com- D. Take this measurement 10 cm above the nique. within ing the Seldinger. edema. a peripherally III. which includes the following interventions: evaluated before and after CVAD insertion to VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S65 JIN-D-15-00057.5% chlo- than the heart for several minutes). contamination of nonster.20 and when clinically indicated to assess the pres- (V) ence of edema and possible deep vein thrombosis 2.32 (V) tralateral side is preferred for CVAD placement.33 (I) found to increase the likelihood of successful B. including strict attention to skin antisepsis antecubital fossa. wire loss. assess for the location and other and the use of sterile gloves. breaches in aseptic technique. G. 2. steps (eg. 2. Central H. Completion of a hexidine solution. modified Seldinger technique the lower one-third of the superior vena cava (SVC) (MST). Use the safest available insertion technique. nonsterile gloves in Visualization). an iodophor checklist should be done by someone other than the (povidone-iodine). Adults and older children: at the level of the Standard 53.32 (V) pacemaker in place for the most appropriate cathe- 3. maximal sterile barri- patient open and close her or his fist. or new techniques that eliminate multiple for BSI. Ensure adherence to proper technique through use peripheral catheter insertion. and lightly er precautions. Ensure appropriate midline catheter tip location: Vascular Access Device [CVAD] Tip Location. and bleeding. and avoidance of the femoral vein in stroking the vein downward. having the rhexidine in alcohol solution.24-26.16. guide- F. The use of dry heat has been and controlled conditions. Implement the central line bundle when placing choice.35 (V) dence comparing bloodstream infection (BSI) F.2. Committee CVAD placement to reduce the risk for insertion- Consensus) related complications such as air embolism.24-26 (V) tion. If there is a contraindication to alcoholic chlor. Consider the use of maximal sterile barrier precau. conjunction with a “no-touch” technique for E. inadvertent arterial cannula- tions with midline catheter insertion. Neonate/pediatric scalp vein placement: jugular H. infusion. Vascular 1. 1. Adhere to and maintain aseptic technique with short to increase success rates and decrease insertion- peripheral catheter insertion: related complications (refer to Standard 22. Perform skin antisepsis using the preferred skin anti. within the inferior vena cava (IVC) above the midline catheter placement. Pacemakers are usually placed ment (before walking age): in the leg with the tip on the left side of the chest or abdomen.15-19 (I) D. meaning that the inser.7 (I A/P) obese adult patients during placement under planned 3. It is important to have the pacemaker CVADs. such as pitting or nonpitting peripheral catheters.32 (V) [CVAD] Malposition). Allow the CVAD. Furthermore. ter and insertion site.indd S65 05/01/16 11:30 PM . Use of gravity (positioning the extremity lower hand hygiene. Measure upper-arm circumference before insertion peripheral IV insertion. guidewire loss. Use chlorhexidine with caution in premature C. Use a new pair of disposable.3. empower the clinician to stop the procedure for any tion. The con- below the inguinal crease. Central Vascular Access Device (CVAD) inserted central catheter (PICC) may be the safest A. inadvertent arterial reposition the CVAD and obtain a confirmation of cannulation.30. if placed via the femoral steps (eg. Neonate/pediatric lower extremity vein place. includ. or embolism. Use of warmth. Use the safest available insertion technique. alterations to the Seldinger technique) for vein. before use of the CVAD for insertion-related complications such as air embo. embolism. longer ing the Seldinger. when placing short characteristics. pleted by an educated health care clinician and septic agent of >5% chlorhexidine in alcohol solu.15. skin antisepsis using >0. If required.21-23 (V. or new techniques that eliminate multiple or cavoatrial junction or. and bleeding.3. Use a standardized supply cart or kit that contains infants and infants under 2 months of age due to all necessary components for the insertion of a risks of skin irritation and chemical burns. (DVT). of a peripherally inserted central catheter (PICC) tion site is not palpated after skin antisepsis. Consider increased attention to aseptic tech.34 used.26-31 (V) correct location (refer to Standard 23. the inserter should properly lism. While there is a lack of evi. but if the ipsilateral side is selected. Central Vascular Access Device axilla and distal to the shoulder. includ- rates with or without use of sterile gloves.36-39 (V) G.1. or 70% alcohol may also be CVAD inserter.3.15. Ensure proper placement of the CVAD tip.15 (IV) antiseptic agent to fully dry before insertion. modified Seldinger technique dwell times have raised concerns regarding risk (MST). alterations to the Seldinger technique) for ile gloves is documented. Carefully evaluate and assess patients who have a vein above the clavicle. to reduce the risk for level of the diaphragm. tincture of iodine. Turba UC.cdc. Hall H. http://www. Med J Aust. 2011. novel midline catheter: a randomized.15(4):251-256. Marschall J. Aucott SW. Australas Med J. Wear a cap. Absorption and REFERENCES tolerability of aqueous chlorhexidine gluconate used for skin antisepsis prior to catheter insertion in preterm neonates. rently no practice guidelines developed related to 11. http://www. Perform skin antisepsis using the preferred skin anti- oncology outpatient population. intensive care units. 20. et al. 25.guideline. Ann Vasc Surg.195(5):276-279. 26.325(7361):409-410. 2012. Williams & Wilkins. Milstone AM. Melen K.CD004122. Infusion preterm neonates.5% chlorhexidine in alcohol 2009. IV.36(4):E198-E204. 23. Directions for use in infants. mask. et al. J Perinatol. Lenhardt R. Pratt RJ. www. Hagle ME.86(suppl 1): S1-S70. Safety of chlorhexidine 1. phor (povidone-iodine). doi:10.35(4):230-240. Arterial Catheters aspx?id=36841. used.ncbi. Berland TL. 2014. et al. Houston PA. Rumbaugh K.fda. solution. for bacterial pathogens.2(5):3-10. Preoperative hair removal to reduce of bacterial glove contamination in medical. Cochrane Database Syst Rev. paedic ward. Saunders/Elsevier. In: Weinstein S. Safe administration of vancomycin through a 8. Clare C.3. Management of sub. eds. an iodo. 2012. 6th ed.org/stable/10. 194-197. Sala G. sterile fenestrated drape when placing a ciated bloodstream infections in acute care hospitals: 2014 peripheral arterial catheter. and Epidemiology of America. Tanner J. Obtaining vascular access in the obese patient artery identification and selection (refer to Standard population. 2001. 9th ed. Br J Nurs.pdf.jstor. nonsterile gloves in the critical care setting: a comparison 4. eds. Nursing 2014. Phillips LD. Vascular Visualization). during central venous catheter placement. In: Alexander M. Pinto AN. Oncol Nurs Forum. Kimberger O. Rowley S. Sessler DI. Hughes KA. Gottlieb T. 7. et al.96(suppl 1): 27. Gorski LA. Nicastro J. Infect Control Hosp Epidemiol. Spencer T. Emergency Nurses Association/Emergency Nursing Resources pacemakers and CVADs. Trivedi U.41-42 (II) in NHS hospitals in England. Lucas C. Guidelines for the updated practice framework for aseptic technique. Caparas JV. Sathyanarayana SA. Philadelphia. nlm. Arch Dis Child. J Note: All electronic references in this section were accessed August Perinatol. Dixon T. Ramjan LM. 26. Siarakas S. Burns LA. gluconate used for skin antisepsis prior to catheter insertion in Corrigan A. Published 2012. moist heat on peripheral IV catheter insertion in a hematology- B. Getz O. surgical and burn surgical site infection. and eyewear.6(6):331. Phlebotomy tourniquets: vectors access: a descriptive study. Loveday HP.41-42 (I) 15.20(3):396-402. Wenger B. J niquets in clinical practice. unused. J Infus Nurs 2013. Published 21. Local chlorhexidine solution. ANTT v2: an 3.3. tions. Abi-Jaoudeh N. Peripheral venous access devices. determine integrity of the pacemaker unit and leads. PA: FA ucm307251. Southwest Respir Crit Care Chron. Cayne NS. Postgrad Med J.40 (V) Development Committee. Manual of IV Therapeutics: Evidence.16(1):35-41. 2014.19(suppl 5):S5-S11. 2010:456-479. et al. Perucca R. or 70% alcohol may also be 2002. 16. Fink RM. 6. Watch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ Based Practice for Infusion Therapy. 18. Brooks HJ. Emergency nursing resource: difficult intravenous access. Cornwall J. The use of midline Hagle ME. 2014.44(10):60-66. 2014. disposable non-sterile gloves on a hospital ortho- artery injury.gov/content. Davis. Singh N. Ultrasound A47-A48. Stoiser B. et al. septic agent of >0. Alexandrou E. J Vasc Interv Radiol. and there are cur. Short peripheral intravenous catheters and infec- 2008.32(1):4-9.35(7):753-771. et al. warming and insertion of peripheral venous cannulas. Employ maximal sterile barrier precautions when http://www. PA: Wolters Kluwer/Lippincott recommendations for practice. Alexander M. Dissanaike S.36(1):52-56. US Food and Drug Administration. Theis J-C. Hjort E. http://www. O’Grady NP. Philadelphia.88(1038): Assoc Vasc Access. Aucott SW. 2013.33(10):768-771. 2014. Evaluation of midline vascular 9. 2012. Krischock L. epic3: national evidence- placing pulmonary artery and arterial catheters in based guidelines for preventing healthcare-associated infections the axillary or femoral artery.pub4. 2014. Chapman AK. Consider use of visualization technologies to aid in 12. Wilson JA. Dumont C. 3rd ed.1002/14651858.(11):CD004122. Mikell M. The impact of dry versus 22. 24. Hu JP. Bacterial contami- nique for the endovascular management of iatrogenic subclavian nation of unused. J Infus Nurs. Phan T. Kane L. Molyneux R.nih. Norrie P. 13.41-42 (II) update. Mermel LA. guided placement of midline catheters in the surgical intensive S66 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. prevention of intravascular catheter-related infections.3. Hankins J. Fakih M. 2011. Society for Healthcare C. A.gov/Safety/Med 2. 2010.gov/pmc/articles/PMC3702138/pdf/AMJ-06- clavian arterial injuries following inadvertent arterial puncture 331. J Hosp Infect. 5.html.indd S66 05/01/16 11:30 PM . BMJ. tincture of iodine. 17. Experience and tech. prospective clinical trial. Published 2011. 2013. 22. Cheong EY. There are no published reports of displaced leads Reusable venesection tourniquets: a potential source of hospital noted during CVAD insertion. Hadaway L. If there is a contraindication to alcoholic 14. Contamination of April 2011. Perucca R. Arslan B. Nursing: An Evidence-Based Approach.htm. sterile gloves.gov/hicpac/BSI/BSI-guidelines-2011. http:// 2010. Plumer’s Principles and Practice of Infusion catheters in the adult acute care setting: clinical implications and Therapy. Peripheral venous access. 2015. MRSA contaminated venepuncture tour. Seybold T.1086/676533. Rockman CB. Macqueen S. Gilmore MM. transmission of multiresistant organisms. MO: 19. S.24(1):44-47. Miller. St Louis. Chlorascrub swabsticks. Strategies to prevent central line-asso- use a large. Chapman AK. Gorski L. 2011. D. 10. 2014. et al. Deutsch GB. Elhassan HA. J Assoc Vasc Access. Modified Seldinger technique with ultra- real-time imaging modalities for peripherally inserted central sound for peripherally inserted central catheter (PICC) in the catheter and midline placements by clinicians. analysis. Central venous access devices: access and 29. Adherence for central line 42. 2014. 2014. 2010:480-494.19(1):29-34. Infusion Nursing: An Evidence-Based Approach. eds. Infusion therapy in children. Clemence BJ. St Louis. Pettit J. risk factors and preven- gov/nhsn/acute-care-hospital/clip/index. 2014. In: Alexander M. 2011. J Intensive Care Med . Shekelle PG. J Vasc Nurs.191(1):1-5. Deuter K. O’Horo JC. Bowdle TA. Association for Vascular Access [position paper]. Perucca R. n c b i . The risk of central venous placement ipsi- summary. J Infus Nurs. Seldinger or modified Seldinger technique. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S67 JIN-D-15-00057.asp?id=280292. Maki DG. Executive 40. et al. avainfo. St Louis. Hu JP. Gorski L. 2013. et al. O’Horo JC. McCutcheon H. Caparas JV. 2009. related upper extremity deep vein thrombosis in patients with 28. Frey AM. 30.14(2):93-99. Published 2011. Cummings M. 2014]. stream infection: incidence. Perucca R. eds.1177/0885066614541407. 2014. et al. Penoyer DA. In: Alexander M. Safdar N. 2010:550-570.14(1):28-30. 3rd ed. J Assoc midline: piloting a change in practice for cystic fibrosis patients. Krupp AE.44(5):65-67. mechanical complications of central venous catheterization using Corrigan A. MO: Saunders/Elsevier. 36.org/website/download. Warrington WG. insertion improve safety? Nursing 2014. Analysis of the Evidence for Patient Safety Practices. J Assoc Vasc Access. Arterial catheters as h t t p : / / w w w. Vasc Access. access. J Hosp Infect. Hung HW. Rodriguez MV. Kamps TA. 39. 33. 34. Bullock-Corkhill M. J Assoc Vasc Access.pdf. Risk factors associated with catheter- J Surg Res. Crit Care Med. pediatric patient: a precise advantage. 2013. Safdar N. g o v / b o o k s / N B K 1 3 3 3 6 3 / p d f / a source of bloodstream infection: a systematic review and meta- TOC. 2012.indd S67 05/01/16 11:30 PM . 2009. eds. Maneval RE. Hankins J. Infusion landmark technique: do not try more than 3 times [published Nursing: An Evidence-Based Approach. care unit: a cost-effective proposal for timely central line removal. in combination with 37. Van Hoeck EH. Wachter RM. n l m . Pronovost PJ. peripherally inserted central venous catheters: a prospective obser- Outcomes of using a modified Seldinger technique for long term vational cohort study—part 2. MO: online July 2. Corrigan A. Maki DG. 2015.html.37(4): intravenous therapy in hospitalized patients with difficult venous 260-268. n i h . Pacana C.cdc. http://www.29(1):11-15. doi:10. The use of 3rd ed. Nichols I. Incidence of 32. Arterial catheter related blood- insertion practices (CLIP) surveillance. 41. Hearse N. Rockville. Guidewires uninten- antibiotic treatment outcomes through the implementation of a tionally retained during central venous catheterization. In: Making Health Care Safer II: An Updated Critical lateral to the permanent pacemaker. National Healthcare Safety Network. pathogenesis. Gorski L.42(6):1334-1339. Durand JB. 35. Williams TL.85(3):189-195. tion. Doellman D. Hankins J. Trochez A. Saunders/Elsevier. Calvache JA. 31. March 2013. http://www. MD: Agency for Healthcare Research and Quality. Does a novel method of PICC insertion. Winters BD. Improving 38.17(1):24-31. flushing. Consider use of an extension set between the periph- vascular access device (VAD) management. placement. type of needleless connector to prevent or reduce VAD-related bloodstream infection. disinfection of the needleless connector prior to each mary purpose of needleless connectors is to pro. povidone-iodine). clamping. and reducing risk of complications. and/ require careful adherence to infection prevention or practice guidelines and according to manufacturers’ practices. VAD access and allow it to dry. NEEDLELESS CONNECTORS D. tect health care personnel by eliminating needles 1.3 Use aseptic no-touch technique to change the intraluminal thrombotic occlusion.4 (IV) I. procedures. Avoid using a needleless connector for rapid depends on the design of the needleless connector flow rates of crystalloid solutions and red blood and the properties of the disinfecting agent.5-8 (IV) 34.14. Needleless connectors have different internal mecha- nisms and fluid pathways.15 (V) the VAD hub and the administration set used for F. Recognize that needleless connectors are potential II. the clinician is competent in B.5% chlorhexidine in alcohol solution. ing administration sets and/or syringes to the VAD or >0. and VAD manage- catheter manipulation (refer to Standard 36. Perform a vigorous mechanical scrub for manual continuous fluid infusion is unknown. physiology.1-3 (II) (Regulatory) 2. Follow manufacturers’ directions for the appropri- cular access device (VAD) hub or access site. Add-on ment techniques aimed at maintaining vascular access Devices). into the VAD lumen and. The device design that Standard produces the least amount of thrombotic VAD lumen occlusion remains controversial and requires 34. thus. The pri.16 hub or injection site for intermittent infusion. The Art and Science of Infusion Nursing Section Six: Vascular Access Device (VAD) Management Section Standards cells. C. iodophors (ie. propyl alcohol. E.indd S68 05/01/16 11:30 PM .7. and disconnecting the syringe 34. The sequence for needleless connector.9-13 (IV) junction when attaching needleless connectors to a vas.3. Indications and protocols for VAD management are sites for intraluminal microbial contamination and established in organizational policies.2 Disinfect needleless connectors prior to each entry disconnection to reduce the amount of blood reflux into the device.1 Use a luer-locking mechanism to ensure a secure further study. Standardizing the type of needleless con- nector within the organization may reduce risk for Practice Criteria confusion about these steps and improve out- A.4 Access needleless connectors only with a sterile depends upon the internal mechanism for fluid dis- device. as their presence can greatly reduce flow rates. including eral catheter and needleless connector to reduce knowledge of anatomy. For S68 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Acceptable disinfecting agents include 70% iso- and subsequent needlestick injuries when attach. ate sequence of catheter clamping and final syringe 34. There is no consensus on the design or directions for use. the incidence of 34. Length of contact time for scrubbing and drying 1. To ensure patient safety. The need for a needleless connector placed between comes. Infection). McIsaac JH.indd S69 05/01/16 11:30 PM .17(2): quent time interval adds no benefit and has been 75-77. Needleless connectors: a primer on reduce the rates of central line-associated blood. Hadaway L. long-term acute care setting. Gipson KE. 2. 2011. reducing needleless connector. flush 5. More research is needed for manufacturer’s directions for use (see Standard other agents or combinations of agents due to 49. of central line-associated bloodstream infection rates when 3. Richardson D. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S69 JIN-D-15-00057. J Infus Nurs. After removal. and/or practice guidelines. Occupational Safety and Health Administration (OSHA). the needleless connector should be changing to a zero fluid displacement intravenous needleless con- changed in the following circumstances: if the nector in acute care settings. ing new technology. there are no studies on changing 13. p_table=STANDARDS&p_id=10051. Needleless connec- connector. 70% isopropyl alcohol. 2014. displacement connector reduces catheter-related bloodstream infections in a comprehensive cancer center. The effects of syringes and administration sets) and require needleless connectors on catheter-related bloodstream infections. Gross JB. 7. What is the predominant source of intravascular Scrubbing time. Lynch D. http://www. these used caps are discarded 753-771. Chernecky CC.35(7): 2. Btaiche IF. Protection of intraluminal pathway with zero fluid hours). Strategies to prevent depends upon product design. Khalidi N. Am J Infect Control. Neutral displacement intravenous connectors: evaluat- 1. and are never reattached to the needleless 4. 6. Eur J Oncol Nurs. s h o w _ document? should be considered. Replace the stopcock with a needle- needleless connectors on catheter-related thrombotic occlusions.120(4):801-804. of research. For peripheral catheters with dwell times longer 2012. g o v / p l s / o s h a w e b / o w a d i s p .1016/j.42(2): needleless connector is removed for any reason.25-30 (Committee Consensus) nique for needleless connector care on central venous access 4. if there is residual blood or debris within the 14. 2015]. cedures. Mermel LA.19-24 (IV) Note: All electronic references in this section were accessed August G. than 96 hours. primary administration set is changed (eg.3. into the VAD. Flynn JM. to contamination from personnel hands and the doi:10.14.3. terminology. 2015. J Assoc Vasc Access. Achieving zero central line-associated bloodstream H.33(1):22-33. 32-33. consult manufac. Comparison the attached needleless connector/extension set. The effects of environment. isopropyl alcohol) has been shown to reduce intraluminal microbial contamination and 1. Use a stopcock or manifold with an integrated devices in a bone marrow transplant population: a comparative needleless connector rather than a solid cap due study [published online June 6.52(2):211-212.2015. Consider using a vigorous 5.05.18 (V) tals: 2014 update. 28-30. Alexander M. J Assoc Vasc Access. J Assoc Vasc Access. depending upon the needleless 8.html. Once removed. Anesth Analg. less connector as soon as clinically indicated. 9. Use vigorous mechanical scrubbing methods needleless connector disinfection. upon range from 5 to 60 seconds with biocide activity contamination. Use of disinfection caps 2. Ensure that disinfecting supplies are readily avail- time. et al. Sterile v aseptic non-touch tech- connector design. When used within a continuous infusion system. Changing on a more fre. O’Grady N. multiple accesses of the VAD may during rapid infusion. additional disinfection before each entry. Hadaway L. Needleless connectors: improving practice. 2010. 2013. Papke LF. o s h a .36 (V) even when disinfecting needleless connectors with antimicrobial properties (eg. 200-202.34.7. Additionally.31-33 J Infus Nurs. 2015. 1. technique. be required to administer a medication (eg. Kovacevich DS. shown to increase the risk of CLABSI. Published April 15-second scrub time with each subsequent entry 2011. Use of passive disinfection caps containing disinfect- 27. Khalidi N.35 (IV) conflicting reports regarding the optimal scrub I. fection of the needleless connector between sub.ejon.003. reported scrub times for blood culture from the VAD.17(2):86-89. per organizational policies. J Assoc Vasc Access. Macklin D. Papke LF. stream infection (CLABSI). Jarvis WR. Guidelines for the pre- sequent connections are unknown due to a lack vention of intravascular catheter-related infections. silver REFERENCES coatings). 96 12. Keogh SJ. Logan R. Marschall J. Am J Infect Control. 2011. Fakih M.34(2):89-96. 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Clin Infect Dis. https:// on peripheral catheters has limited evidence but w w w.gov/hicpac/BSI/BSI-guidelines-2011. Reducing the risk of infection in drawn through valved catheter hub connectors carries a signifi- vascular access patients: an in vitro evaluation of an antimicro. 1. 33.36(3): 35. Autonomy and self- antibacterial activity of three silver-impregnated/coated mechani. Sherertz RJ. Karchmer TB. J Hosp Infect.30(12):1571-1577.1 2014. material. www. 2013. 34. Jacob JT. 31.86(suppl 1): luer access split septum system (Q-Syte®). Wilson J.com/journals/nrp/2015/7967621. Loveday H. et al. cant risk of contamination. Anesth Analg. S1-S70. Becker H. Blood 19.1.17(4):210-213. 35. Nightingale P. Chernetsky Tejedor S. Craig M. 25. Conway M. Dodson B. 2014. Linford L. 23. in-line or add-on filter appropriate to the prescribed 2012. Am J Infect Control. Mancos PS. Clin Nutr. 2014. Gensicke S. In vitro studies of a novel antimicrobial luer activated G. Dillon-Grant M. Preventing con. Comparison of a silver-coated needleless connector and a standard needleless connector for the prevention of central line-associated blood- stream infections. Am J Infect 2011. Brown A. Reduction of blood stream infections 32. Koff MD.1 (V) Assoc Vasc Access. 15. Am stream infection. glass. FILTRATION 294-301. et al. Williams M. Karpanen TJ. Risk of infection due to medical interventions via 16.52(3):823-831. Maki D. In vitro study assessing the 36. Stern J. rub- Access. A. and air-eliminating alcohol-based disinfecting cap. epic3: national evidence. J Clin Microbiol. Holzmann T. J Infect Control.34(3):193-200. et al. Am J Infect Control. Pohl F.42(12):1274-1277. solution. Hamadani M. Brown JR. Cook M. 2012. et al. 2011. Pichler J. Central venous catheter protective use and filtration requirements of the infusion ther- connector caps reduce intraluminal catheter-related infection.indd S70 05/01/16 11:30 PM . neutral pressure connectors on central line-associated blood- stream infections and contamination of blood cultures in an Practice Criteria inpatient oncology unit. Hautmann M. Sweet MA. Reducing bloodstream patient. Waller JL. Elliott TS. in NHS hospitals in England. latex) on capillary endothelium and S70 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 2014. Smith JS. Ramirez C. Stango C. Sandora TJ.3 Intraspinal infusion solutions are filtered using a tamination of central venous catheter valves with the use of an surfactant-free. Hosp Epidemiol.80(4):299-303.41(3):278-280. Hill S. Impact of needleless connector change fre- needleless connector for prevention of catheter related blood.114(6):1236-1248. Pratt R. Wright M-O. Nurs Res Pract. 35. 2012. 22. in-line or add-on filter appropriate to the type of 24. the volume of medication delivered to the 30. 2014. Macintosh C. Recognize that there is evolving evidence docu- data on passive intravenous connector disinfection.42(5):485-489. Flynn J. 2012. Lee AM. Use filters adhering to manufacturers’ directions for 27. Control. 2012. Hartmann W. J Infus volumes as drug retention may seriously decrease Nurs. J Hosp Infect. consult with pharmacy or published associated bloodstream infections. A successful 2. 2014. Dent Reyes M. J apy solution or medication. Clin Infect Dis.50(12):1580-1587. 2010. Kirksey KM. Jarvis WR. 2014. Am J Nurs. Briggs F.40(10): 931-934.4 Medications withdrawn from glass ampoules are Impact of alcohol-impregnated port protectors and needleless filtered using a filter needle or filter straw. 17. Needleless connectors for IV catheters. Sumner S. Valentine MJ.40(5):e179-e180. Disinfection of needleless connector hubs: tribute to intraoperative bacterial transmission. Jacob JT. 21. Edmiston CE Jr. Avoid filters when administering very small drug approach to reducing bloodstream infections based on a disinfec- tion device for intravenous needleless connector hubs. Soothill J. Perez E. Hadaway L.hindawi.35(9):1187-1189. Kölbl O. Margossian SP. 2014. central venous catheters or implantable venous access port based guidelines for preventing healthcare-associated infections systems at the middle port of a three-way cock: luer lock cap vs.19(2):87-93. ber. Filters are contraindicated for use with certain 28.112(11):32-44. Macri I. 26. Multiple reservoirs con- 18. DeVries M. Microbiological comparison of a silver-coated and a non-coated 35. Intraoperative stopcock and manifold colonization of in children following a change to chlorhexidine disinfection of newly inserted peripheral intravenous catheters. Taylor C. J Assoc Vasc menting the effect of particulate matter (eg. Moureau NL. efficacy as influencing factors in nurses’ behavioral intention to cal valve needleless connectors after blood exposure. BMC Infect Dis. Control. Tropp J. Casey AL. Cumpston A. component. Graham DA. Am J Infect disinfect needleless intravenous systems. Vacca M. Merrill KC. clinical evidence systematic review. Potter-Bynoe 20.37(6):462-465.14(1):41. Bischoff W.2 (V) infection risk in central and peripheral intravenous lines: initial 3. Palavecino E. 2015. 2015. Impact medications that would be retained on the filter of universal disinfectant cap implementation on central line. particulate-retentive. drug resources regarding filtration indications.1 Parenteral nutrition solutions are filtered using an acute care hospital.38(6):421-423. J Infus Nurs. 35. Eur J Clin Microbiol Infect Dis. Mermel L. Am J Infect Control.2 Blood and blood components are filtered using an needleless intravascular connector in clinical use. Infect Control parenteral nutrition catheter connectors. 2012. et al. http:// 2012. 2010. bial silver nanotechnology luer activated device. Infect Control Hosp Epidemiol. Markina V. quency on central line-associated bloodstream infection rate. (V) 29.33(1):85-89. Chernecky CC. Loftus RW. Microbial biofilms on Standard needleless connectors for central venous catheters: a comparison of standard and silver-coated devices collected from patients in an 35. Welch K. filter. Runyan D. Microbubbles: pathophysiology and clinical 1.110(6):1624-1629. 3rd ed. Unverdorben M. use a primary administration set REFERENCES with a preattached.2-micron filter for the dex.2-micron filter and lipid-containing emul- taminations of infusion solutions in a pediatric intensive care sions (3-in-1) using a 1. Brent BE.1 (V) Saunders/Elsevier. Circulation. Filter blood and blood components using a filter 8. E. cise review. connection. Brent BE. St Louis.2-micron filter (refer to Standard 54. the effect of microbubbles of air that may cause reduction in overall complications for patients in cerebral and pulmonary ischemia. Jack T. Williams RG. Gorski L. randomized cles. Parenteral Nutrition).to 260-micron filter. controlled trial. be used in peripheral intravenous catheters to prevent infusion- Transfusion Therapy). Compounding cated for a specific purpose and in accordance with and Preparation of Parenteral Solutions and manufacturers’ directions for use. 2013. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S71 JIN-D-15-00057.2 Add-on devices are of luer-lock or integrated I. 7. et al. recognize that glass fragments may enter the ampoule 36. trials. Analysis of particulate con- using a 0.1. D.7. Köditz H. Boehne M.2-micron filter was used for crys- (eg. including a significant late-retentive and air-eliminating filters can reduction in systemic inflammatory response syn- prevent potential damage from air/particulates drome (SIRS). Perucca R. consult manufacturers’ directions for use. Jack T. a 0. eds. Anesth Analg. 2010. Eur J Pharm Sci. randomized. Filter intraspinal infusion medications using a sur. use of particu. factant-free 0. and change unit. et al.3-5 (V) lipid-containing admixtures. Wilkins RG. F. Infusion therapy equipment. related phlebitis? A systematic review of randomized controlled G. 5. pediatric intensive care units. et al. Filter parenteral nutrition solutions without lipids 3. Intensive Care Med. Infusion and air-eliminating membrane filters as close to the Nursing: An Evidence-Based Approach. 2010.118(23):e714-e833. Medications).35(6):404-408. Use a filter needle or filter straw to withdraw any 36. in-line filter whenever possible to reduce tubing manipulation and risks of contami. 2010:418-421. 36. Hadaway L. In-line filtration minimizes designed to remove blood clots and harmful parti. ACC/AHA 2008 2. 2011.13:21. organ dysfunction: new aspects from a prospective. a prospective. during “piggyback”).1 (V) drug solutions with low concentration. et al. Bashore TM. There is insufficient evidence to support the routine adults with Eisenmenger’s syndrome (heart defect use of in-line intravenous particulate filters for non- that causes right-to-left shunting) as exclusion of blood/blood component therapy in peripheral intra- air bubbles in administration sets is recommend. and accidental disconnection/mis. required. 2005.com/1471-2431/13/21.6 (I A/P) infusion-related phlebitis. 2015. and filter after each unit or no 9. Consider fluid and medication filtration in critically design to ensure a secure junction. a 1. Barak M. 4. 2012. Locate add-on bacteria. When lipids are infused separately from dextrose/ implications.38(6):1008-1016.2-micron filter is used on the sepa. Boehne M. filter use was associated with a significant and minimize the risk of disconnection. Stijnen T. Latz Y. BMC Pediatr.9 (I) B. 2012. If disease. Note: All electronic references in this section were accessed August nation. van den Broek PJ. Separate lipid emulsions may not require filtra. reduce manipulation. ADD-ON DEVICES medication from glass ampoules and replace the fil- ter needle or filter straw with a new sterile needle Standard after the medication is withdrawn from the ampoule. Accidental infusion of air: a con- trose/amino acid solution and infuse the lipid emul. 28.36(4):707-711. filters every 24 hours. use a 0. 2008. Leopold CS. Change add-on filters to coincide with administra- tion set changes.128:2918-2932.1 Add-on devices are used only when clinically indi- when opened (refer to Standard 17. Hankins J. Warnes CA. http://www. Intraspinal Access Devices). guidelines for the management of adults with congenital heart tion. Drug retention by inline filters: does not exceed the pounds per square inch (psi) effect of positively charged polyethersulfone filter membranes on rating of the filter when an EID is used. Change the transfusion central.8 (III) 4. Use air-eliminating filters during treatment of J. standard blood administration sets include a controlled trial. J Infus Nurs. Ensure that electronic infusion device (EID) pressure 2. Jack T.2-micron filter.44 (1-2):49-56. venous catheters for the purpose of preventing ed as essential. 6. MO: vascular access device (VAD) hub as possible. Knoth H. Chest.biomed- 170.1 (V) 1. Niël-Weise BS. Boehne M. Intensive Care Med. H.2 filter (eg. C. administration set. amino acids. In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: rate lipid emulsion (refer to Standard 61. sion below the 0. misuse. cardiac anomalies with right-to-left talline solutions and a 1. Gasch J.indd S71 05/01/16 11:30 PM . ill patients. Should in-line filters less often than every 4 hours (refer to Standard 62. In: Alexander M.2-micron filter was used for shunting).and particulate-retentive Corrigan A. 5-6 (V) 753-771. Infusion fere with assessment and monitoring of the access site Nursing: An Evidence-Based Approach. Graham DA. 1. http://ismp. Bacterial con.pdf.11 (IV) J Infect Control. manifold sets.1 Stabilize and secure vascular access devices (VADs) Note: All electronic references in this section were accessed August to prevent VAD complications and unintentional loss of 28.2 Methods used to stabilize the VAD will not inter- Corrigan A. J Hosp Infect. Alexander M.2 (V) Documents/UCM313385. with each administration set more than your fingerprint on the intravenous line: a prospective replacement.gov/MedicalDevices/Safety/ Connectors). Conway M. Gravenstein NL. Preventing tubing and luer grated extension sets (see Standard 34. or enhancing gate the risks of misconnections with small-bore connectors function of the infusion system (ie. Institute for Safe Medication Practices (ISMP). Technical and clinical application. Arriba Vilela A. 13. Published February 11. Impact of needleless connector change fre- hands. In: Alexander M. Tamura N.1-9 (IV) Epidemiology of America. 6.aspx. extension intravenous catheters: a randomized study. Infect Control erative infection because of microorganism Hosp Epidemiol. http://www.15(4):257-263.35(9):1187-1189. 4th ed. quency on central line-associated bloodstream infection rate. eds. When indicated. Marschall J. US Food and Drug Administration. needleless connectors. Hankins J. Ensure that all add-on devices are compatible with ciated bloodstream infections in acute care hospitals: 2014 the administration system to prevent the risk of update. 2014.fda. 2015.1.86(2):117-126. Use a stopcock or manifold with an integrated needleless connection rather than a solid cap or replace the stopcock with a needleless connector 37.htm.13 (IV) (VAD) STABILIZATION Standard REFERENCES 37. Change the add-on device with new vascular access 10. 37. and the environment contribute to infec.org/tools/stayconnectedprogram. VASCULAR ACCESS DEVICE to reduce stopcock contamination. access. Strategies to prevent central line-asso- B. Phillips L. intravenous catheter replacements can be reduced using an inte- preferentially use systems that minimize manipula. Consider use of an engineered stabilization device Lippincott Williams & Wilkins.42(5):485-489. line filters. manual flow-control devices and stop. 2014. mised or suspected of being compromised. Brown J. 1. http://www. Potter-Bynoe tamination of the patient’s skin. Philadelphia. Infusion therapy equipment.fda. Benedicto Marti C. Mermel L. Needleless misconnections.120(4):816-867. et al. Unfavorable peripheral cocks) only for clinical indications. in. Cole D.35(7): leaks. Dickenson A. such as inte. 3rd ed. and 9. Multiple reservoirs contribute D.indd S72 05/01/16 11:30 PM . Gorski L. tamination. American Nurses Association [position paper]. Anesth Analg.nurs- ingworld.org/position/practice/tube. Herrera Portal P. In: Alexander M. tal disconnections or misconnections. Baslanti T. Infect Control Hosp Epidemiol. Safety considerations to miti- enabling filtration capabilities. Sandora TJ. Stay connected exists with all add-on devices. Abe S. Bullock M. C. US Food and Drug Administration. the provider’s G.and times. Earhart A. related to tubing and catheter misconnections. Anesth Analg. Gorski L.12. Gorski L. solid cannula caps. MO: and will not impede vascular circulation or delivery of Saunders/Elsevier. or as defined by the organization. St Louis. Intraoperative stopcock and manifold colonization of 1. Propofol anesthesia may increase risk for postop- newly inserted peripheral intravenous catheters. 12. Perucca R. J Vasc Access. 2. 2010:391-436. Gonzalez Lopez J. loops. grated closed intravenous catheter system. and study on propofol anesthesia and implications of stopcock con- whenever the integrity of the product is compro. Society for Healthcare costs. adding an intended for enteral applications. 2015. Olivares Corral J. eds. et al. growth in stopcock dead spaces. 5. tion and reduce multiple components. add-on devices whenever possible to decrease 8. Leaving device (VAD) insertion. Core Curriculum for Infusion Nursing. 2014. Limit the use of program. Margossian SP. et al. the prescribed therapy. Koff M. http://www.aspx.1.gov/downloads/ extension to decrease movement/manipulation at MedicalDevices/DeviceRegulationandGuidance/Guidance the short peripheral catheter hub). Safety issues the number of manipulation episodes. 2. Practice Criteria Corrigan A. Practice Criteria 3. Loftus R. Indwell A.114(6):1236-1248. Consider the use of add-on devices (eg. Consider that the potential for contamination 7. of infection. Corrigan A.2 (V) 11. Fakih M. 2012. 2. 2014. PA: Wolters Kluwer/ A. disconnections. complications and costs of open vs closed safety peripheral multilumen extension sets. Dodson B. Hagimoto K. (ESD) to stabilize and secure VADs as inadequate S72 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 2014. Avoid the use of stopcocks due to the increased risk to intraoperative bacterial transmission. Fernandez del Palacio E.10. or misconnections. Gravenstein N. Mermel LA. Am tion risk associated with stopcocks. acciden. single. 2015. Clinical indications may include adding length. Hadaway L.1-4 (IV) AlertsandNotices/TubingandLuerMisconnections/default. 2014:1-85. 4. Rolls of nonsterile tape can clamp designed for staple use demonstrated signifi- become contaminated with pathogenic bacteria. sutures. gauze and tape dressings) as a means for ence of skin disorders that contradict the use of VAD stabilization as there is insufficient evidence medical adhesives (ie. infection and catheter dislodgment and are 1. been studied in vitro.13 (III) (eg. F.24-26 (IV) stick injury. to secure any type of VAD because they bloodstream infection.27 (IV) traditional hub allowed more peripheral cathe. A system using a special catheter alternatives to an ESD. how- devices. cantly less time for securing the VAD in a variety of although its contribution to VAD infection has not insertion sites. Subcutaneous ESDs have been successful in stabiliz- 3. pared to use of tape with PICCs in pediatric patients 2. Regulatory) do not adequately secure the VAD. but additional VAD outcome data are been quantified. An ESD complication rates for both types were not greatly designed to remain in place for the life of the VAD reduced with either type of ESD. Be aware of the risk of medical adhesive-related skin ters to reach 72 hours of dwell time with fewer injury (MARSI) associated with the use of adhesive- needing to be restarted. Studies on central vascular access devices in a randomized. trials of peripheral venous and arterial catheters. and any type of drainage from the and shortens securement time but increases pain on insertion site. Patient outcomes and patient there is an absence of data for these combination and inserter satisfaction have been favorable. during the dressing change to allow for appropriate onstrated equivalent complication rates. in addition to supporting the growth of H. Both have dem.14 (V) 1. Sutures are associated with needle.3. considered to be safer than sutures. J. toxic epidermal necrolysis) may necessitate the D.18-20 (III) descriptive study design. although skin antisepsis and apply a new ESD. nonbor. with or without elastic biofilm and increasing the risk of catheter-related properties. signs and symptoms of complications. Use of a bordered polyurethane securement removed and replaced if appropriate stabilization is dressing alone on a peripheral catheter with a no longer being achieved. Avoid use of tape or sutures. use of tubular gauze mesh rather than adhesive eter stabilization: (1) an integrated stabilization ESD. and may decrease cost of care. subcutaneous ESD) may need to be 1. Cyanoacrylate tissue adhesives for securement have pate potential risk for skin injury due to age. antici- 2.7-10 (II.23. needed.22.indd S73 05/01/16 11:30 PM . adhesive dressing to reduce the risk of MARSI.11 (I) sa. stabilization and securement can cause unintentional ing. yet jugular vein of adults. more data are based ESDs. pediatric epidermolysis bullo- supporting their benefits as stabilization devices. Assess skin when the device is changed. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S73 JIN-D-15-00057. Apply barrier solutions to skin exposed to the Tissue adhesive plus a standard transparent dress. The effect of adhesive ESDs on peripheral cathe. and in small pilot joint movement. the use of staples as an alternative to age. however. associated with fewer complications when com- ited number and quality of randomized trials. can obscure C.12. reduce VAD motion that can E. Decisions about the most appropriate method for needed. Many devices merge the interventions of catheter ing PICCs and CVADs inserted through the internal stabilization with the dressing of the VAD.3. standard. The pres- dressings. ever. previous adhesive sutures reduces exposure to contaminated sharps skin injury. used due to increased risk of MARSI because it tion with a standard transparent membrane dress. reduce interruption of needed central catheters (PICCs) as they may reduce risk of infusion therapy. Remove adhesive ESDs combination with an adhesive ESD. larger trials are needed to confirm dislodgment and complications requiring premature these findings and identify patients for whom this VAD removal. may increase the bonding of adhesives to skin. additional studies with other CVADs are 4. and can dered transparent semipermeable membrane [TSM] impair circulation or the flow of infusion. and presence of edema. ing have shown a slight trend toward reduction in Compound tincture of benzoin should not be catheter failure with these adhesives in combina. For CVADs. in animals.1-6 (IV) application and removal and does not adequately B. however. Sutures were ter complication rates is unclear due to the lim. ESDs promote consistent practice might not be suitable. Do not use rolled bandages. controlled trial that excluded use (CVADs) are limited to small populations or of stabilization devices. as they are not effective secure the CVAD. 2. Do not rely on VAD dressings (ie.15-17 (III) among all clinicians.4 (V) feature on the peripheral catheter hub combined I.21-23 (V) VAD stabilization and securement include patient G. consider 2 options for cath. skin turgor and integrity. needed. For peripheral catheters. Assess the integrity of the ESD with each dressing with a bordered polyurethane securement dressing change and change the ESD according to the manu- or (2) a standard round hub peripheral catheter in facturer’s directions for use. Use adhesive-based ESDs with peripherally inserted lead to complications.5. 21(5): gov/hicpac/BSI/BSI-guidelines-2011. J Vasc Interv Radiol. Sutureless securement 3. A randomized controlled trial to compare the complications of 2 peripheral intravenous Standard catheter-stabilization systems.99(5):1436-1439. O’Riordan E. Solomon J. reinsertion at a new site. Soulen M.20(6):S32-S35. McNichol L. Anaesth Intensive Care.cdc. Emerg Med J. Delp J. et al. Brandon D. Burns L. Crit Care Resusc.16(3):237-244. intravenous securement devices. Hollenback C. Published April 2011. J Infus peripheral venous catheters to prevent failure: a randomised con- Nurs. 10. Hadaway L. Novel technolo- gies can provide effective dressing and securement for peripheral Note: All electronic references in this section were accessed October arterial catheters: a pilot randomised controlled trial in the oper- 5. Baliakas P. Rieder CJ. Helm RE. A prospective trial on a new suture- eters. MO: StatLock stuck? BMJ. Cordovani D. Washington. Docherty SL. present and future of cath- 9. Flint LM. Br J Nurs. Nurs. Never readvance a dislodged VAD into the vein. Br J Nurs. Hill EK. 2013. Central venous access devices: 2004:2. DC: OSHA. 2011. patient safety: state of the science: consensus statements for the Improving safety and efficiency during emergent central venous assessment.16(2):74-76. doi:10. Egan GM. Emerg Med injuries. Hughes ME. 2013. Taraporewalla K. Cochrane Database Syst Rev. 20.30(8):683-686. Reynolds H. device reduces complications of peripherally inserted central Evaluation of the use of a stabilization device to improve the venous catheters. http://www. Jefferson P. Perucca R. Schlichting A.1136/bmjopen-2012-002327. Jackson A. 365-380. McMillan D. 27. Tower M.60(5):504-505. Hulton 18. Cooke M. et al. 2015. tain device patency and are not considered restraints. prevention. J Infus Nurs. Walters S. 23. Ball D.40(4): J. Cyanoacrylate tissue adhesives: effective securement K. Huang E. 2012. Griswold S. such as an arm board or outcome for a community health system. 2002.pub2. or exchange could devices compared with standard polyurethane dressings for secur- be the most appropriate intervention. Rickard CM. tissue adhesive and sutureless removal. Fact Sheet: Securing Medical Catheters. Rapchuk I. 2015. splint. 2011. Retrospective comparative audit of two peripheral IV 38. 78-79.13(1):77-81. Gorski L. causing skin injury when the adhesive-based ESD 15. 2006. Outbreak of cutaneous 25. Securing pediatric 2013. eds. Anesth Analg. Saunders/Elsevier. Examining the role of secure- outcomes. Smyth DJ. 1. 13. Cooper RM.40(3): After assessment of the tip location. dered polyurethane dressings. 2015. Simonova G. J Pediatr Nurs.CD003827. 2015. Rickard CM. Inwood S. Franker C.2 A joint stabilization device is a single-patient-use securement dressings. Yang J.8 (I) Fraser JF.23(suppl 8):S26-S27. O’Grady N. Hetzler R.81(3):213-215. Klemperer JD. 2012. Byrne M.1 Joint stabilization devices. Guidelines for the pre- L. JOINT STABILIZATION 12. Edwards M. et al. A prospec- model. et al. Carpenter A. 19. 2014.23(suppl 2):S12-S18. Olson M. et al. Patel S. Rickard CM. Marsh N. Xochelli A. 2004.21(suppl 2):10-15.33(6):371-384. Lefaiver C. Gillies D. Securement methods for peripherally inserted central catheter stabilization system. 2014. 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A pilot trial of bor- could be stabilized at the current location. ion (eg. Haesler E. or nerve dam. Hockenberry M. In: Clinically Oriented Anatomy.15-17 (IV) Standard 39. Lander MJ. 2. procedures.4:7429. policies. NY: Wolters Kluwer/ Practice Criteria Lippincott Williams & Wilkins. B. maintain device patency. elbow. Phillips LD. In: Alexander M. Alves P. Hankins J.1-13 (V) Int Wound J.94(6):F394-F396.27(1):28-34. cognitive. 3.14-18 (V) Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury 2. arm. 4. Int Wound J. Misuse of the wooden tongue depressor. MO: Elsevier. Black J. 39. National Pressure Ulcer Advisory Panel. St Louis. skin impairment. 1.1 The use of site protection and/or physical immobi- REFERENCES lization devices to protect vascular access devices 1. Arch Dis Child Fetal Neonatal Ed. Schols JM. Specific patient populations including pediatric. and/or practice guidelines. J A. the joint is stabilized. removal of the VAD. 9th ed. tion and assessment of the vascular access site VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S75 JIN-D-15-00057. 2015: pressure ulcers. PA: FA Davis. 2014. Nurs. Dalal S. In: Manual of IV Therapeutics: Evidence-Based Practice for Infusion Therapy. Simandl G. Techniques for initiation and mainte- tain a functional position. Paul V. J Nurs Care Qual. 2008. Perth.348(9025):441-443. Singh J.19(1):80-89. 4th ed.1. 1996. Philadelphia. ment due to activities of daily living. Applied in a manner that permits visual inspec- ed. Padded as needed and supports the area of flex. and 1996. Risk and associated factors of pressure ulcers in hospitalized children over 1 year of age. Disorders of skin integrity and function. and if all other measures have 6. 2010:671-819.6-12 15. Lancet. Perucca R. are established in organizational controlled trial. and psychologi- 9.10. 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MO: risk of accidental VAD dislodgment or patient Saunders/Elsevier. Use site protection methods or immobilization Alliance.1. New York. Akl KF. NY: pressure as to cause circulatory constriction. Kaushik V. Morgan ME. Chawla D. Durbin GM. Lancet. Walko MA.7(5):358-365. 2010. Prevention and Treatment of Pressure Ulcers: Clinical devices in a manner that permits visual inspec- Practice Guideline. Wooden tongue depressors as joint stabilization devices should not be used in preterm infants or 39.2 (III) rates and risk factors. Use of wound dressings to protection from water. 2010. A. Taylor T. Didier LA. Apold J.14 (I A/P) C. MacDonald A. Holzel H. or move- enhance prevention of pressure ulcers caused by medical devices. is present. Leeming JG. and 11. et al. elderly.12(3):322-327. hand. Gray J. Macqueen S. Wolters Kluwer/Lippincott Williams & Wilkins. 3rd ed. European cal status. Deorari A. Considered when a short peripheral catheter is venience? J Hosp Infect. 13. 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Risk factors for periph- physical immobilization device should be removed eral intravenous catheter failure: a multivariate analysis of data as soon as the patient’s condition allows. Published December 8. Pediatric infusion therapy.19 prevention of intravascular catheter-related infections. Mitchell P. https://www. Restraint management: moving from outcome to Manuals. McGrail M. 2010:550-570. NY: Springer. 2013. 31. April 2011. and vascular pathway and does not exert such Therapy. transmittal 37. E-dition v. 4th ed. Hospital conditions of participation: patients’ rights. vider certification. or surrogate on the 13. Published October 17. Corrigan A.02.38(6):515-526. eds. Duell DJ. 20. Oakbrook Terrace.pdf.167(5):429-435. Perucca R. 2015.cms. Philadelphia. Restraints or alternatives: Regulations-and-Guidance/Guidance/Transmittals/downloads/ safety work in care of older persons. Document. Comprehensive Accreditation 1. In: Weinstein Care. Hospital-Provision of Care. Milstone AM. Philadelphia. 2014:687-742.03. Published September 10. Advani S. eds. 2015. Clinical Nursing Skills: Basic to Advanced Saunders/Elsevier. REFERENCES 2006. Webster J. Gorski LA.02.pdf . 2015. Capezuti E.23(3):227-232. The Joint Commission (TJC). In: Boltz M. Lane S. Infusion 19. The Joint Commission (TJC). Redfern WS. 8th ed. 21. J Nurs Care Qual. 2012. The Joint Commission (TJC).03. 2015. In: Alexander M. 2015. Martin BC. MO: devices: restraints. Gorski L. and Services: PC. eds. Manual of IV Therapeutics: Evidence.cms. Evidence-Based Geriatric Nursing patient’s response to the immobilization device. immobilization devices should be distal to the com/1741-7015/8/53. Patient 14. Routine resite of peripheral intravenous devices every 3 days did not reduce com- age under the device and in accordance with plications compared with clinically indicated resite: a randomised manufacturers’ directions for use. delivery TJC. Evidence-Based Geriatric Nursing Protocols physical immobilization device. ed immobilization device should not interfere Treatment. et al. Treatment. any rails in acute and critical care settings. Physical controlled trial. 6th ed. Frey AM.35(1):63-68. ability to assess the vascular access 9. Infusion therapy in children. JAMA Pediatr.18(3):321-326. device. type and location of for Best Practice. final rule. at a minimum. New York. http://www. pressure ulcers. Guidelines for the site. 18. zation devices (refer to Standard 8. Bradas CM. 2011.29(6):421-423.20-22 from a randomized controlled trial. Rigid site protection devices and all immobiliza. Antonelli MT. management of the critically ill. Hospital—Provision of Care. Hsieh C. or nerve dam.html. Dialysis line separation: for supervised range-of-motion activities. IL: with the prescribed infusion rate. State operations pro- tions in children. 6th ed. Hospital-Provision of process. 3rd ed. Published 3.February 1. Weingart S. Casey CM. Oakbrook Terrace. Protocols for Best Practice. NY: Springer. Manual of IV Therapeutics: Evidence- Based Practice for Infusion Therapy.15-19 maximizing patient safety through education and visibility of (I A/P) access site for patients on hemodialysis. 2014. Fulmer TT. 22. skin impairment. New York. SM. Gorski LA. 2014:462-539. reassessment of the need for the immobilization 2012. the rationale for the TT. S76 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Regularly assess patient safety without the physi. tion devices should be removed at established 10. Mion LC. and removal of the 16. McCann D.2. Jumani K. Davis. 4.07. Brany JE. or catheter stabilization/securement. Saibu R. Nephrol Nurs J. Skills.02. O’Grady NP. In: Boltz M. site and circulatory assessment. NY: Pearson. 8. Alexander M. Comprehensive assessment and Education). Smith SF. the immobilization device. and Services: PC.gov/ 4. Burns LA. Sandhu SK. Standard 53. [CVAD] Malposition). 10-mL-diameter syringe bar- Practice Criteria rel). Central Vascular Access B. use chloride (USP).13 (V) catheter-related bloodstream infection (CR-BSI).3. 23.10 (IV) Needleless Connectors).9% sodium chloride is used. drug precipitate.1-3 (IV) (refer to Standard 48. ency of whole blood. IL: the lumen. Differences in gradation markings.1 Vascular access devices (VADs) are flushed and effects of the preservative.11 (V) aspirated for a blood return prior to each infusion to 3.2 VADs are flushed after each infusion to clear the 4. Do not use intravenous (IV) solution containers 2. Device [CVAD]-Associated Venous Thrombosis. Oakbrook Terrace. Do not forcibly flush any VAD with any syringe (eg. Use single-dose systems (eg. bags or bottles) as a source for obtaining size. ride. Factors to consider when choosing TJC. including.12 (V) 40. Inform patients that disturbances in taste and clamps or kinked sets. slowly aspirate the VAD filled labeled syringes) for all VAD flushing and for blood return that is the color and consist- locking. If resistance is met and/or no blood return flush solutions. the flush volume include the type and size of 24. being injected.4 (V) Malposition). deposits. Do not use sterile water for flushing VADs. catheter. Central Vascular Access Device [CVAD] Infection). Use a minimum volume equal to twice the inter.3-6 (IV) noted. removing dressing. Perform disinfection of connection surfaces (ie. The Joint Commission (TJC). Do not transfer the medication to nal volume of the catheter system (eg. dedicate a Device [CVAD] Occlusion. diabetes. Use only preservative-free solutions for flushing assess catheter function and prevent complications. 10 mL for central vascular medications. benzyl alcohol. temic conditions (eg. syringes appropriately sized for the medication 1. If bacteriostatic 0. age of the patient. Oakbrook Terrace. catheter a larger syringe. to confirm tip location and mechanical causes Leaching of substances from the plastic syringe (eg. The Joint Commission (TJC). needleless connectors. FLUSHING AND LOCKING 2.9% sodium chloride (USP) when the reducing the risk of contact between incompatible medication is incompatible with sodium chlo- medications. taking note of any resistance. antineoplastics).) to odor may occur with prefilled flush syringes and locate an external cause of the obstruction. D. all VADs in neonates to prevent toxicity.7-9 (II) causes (see Standard 52. and type of infusion Treatment. pinch-off syndrome). and Services: PC. Infusion of blood compo- TJC. Use 5% dextrose in water followed by preserva- infused medication from the catheter lumen. Assess VAD functionality by using a 10-mL syringe or a syringe specifically designed to generate lower injection pressure (ie.14 (V) depending on the solution used. although it is sound.02. A. injection ports) before flush. etc. but not limited to. thereby tive-free 0.10 (IV) 40. color duplex ultra- into the saline has been reported. 1. Hospital—Record of Care. which is an important 1. and radiation. Standard 53. Do not allow dextrose to reside in the cath- 40. or fluoroscopy to identify thrombotic not thought to be harmful to health. Central Vascular Access 2. single-dose vials or pre. Flush all VADs with preservative-free 0.15 (V) plus add-on devices). 5. 5 mL 4. Commercially available prefilled syringes may component of assessing catheter function prior reduce the risk of CR-BSI and save staff time for to administration of medications and solutions syringe preparation. limit flush volume to no more than 30 mL in a Standard 24-hour period to reduce the possible toxic 40. Do not use prefilled flush syringes for dilution of for peripheral VAD.3 The VAD is locked after completion of the final eter lumen as it provides nutrients for biofilm flush to decrease the risk of intraluminal occlusion and growth. parenteral nutrition.05. After confirmation of patency by detecting no C. Internal causes may require diagnostic tests. and Services: RC. and other viscous solutions may require larger flush volumes. vial to a single patient (see Standard 49. Crohn’s disease). a chest radiograph medications (eg. Central Vascular Access Device ing and locking procedures (refer to Standard 34. contrast media. 2015. If multiple-dose vials must be used. Hospital—Provision of Care. During the initial flush. Larger volumes (eg. access devices [CVADs]) may remove more fibrin an unchangeable label on prefilled syringes. checking for closed 4. IL: therapy being given. 3.02. may be related to several causes including sys.indd S77 05/01/16 11:30 PM . take further steps (eg.03. nents. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S77 JIN-D-15-00057. 3.05. and other debris from Treatment.01. 2015.9% sodium resistance and the presence of a blood return. of 1% or less (see Standard 52.26 (II) sent. In adults. and obtain con- patient populations are controversial. and when there are compared to continuous low-flow techniques. consider orienting the bevel of an Heparin-induced thrombocytopenia (HIT) has implanted port access needle in the opposite been reported with the use of heparin lock solu- direction from the outflow channel where the tions.38 (II) ing demonstrates a greater amount of protein is 7.19 (IV) receiving only heparin in the form of a catheter G. Use heparin or preservative-free 0. 1.indd S78 05/01/16 11:30 PM . patient population.29 (V) tion errors with syringe-to-syringe drug 2. Randomized controlled trials have shown equiv- transfer. organization-wide. Lock apheresis CVADs with heparin 100 units/mL. Prevent syringe-induced blood reflux by leaving (II) a small amount (eg. There is insufficient evidence to recommend the lock solutions. Outcome data in these products (eg. inform to 10 units per mL or preservative-free 0.45 (IV) S78 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. and possible con.18 concentrations of heparin used in hemodialysis (IV) catheters could lead to systemic anticoagulation.5 units 8.9% patients when using heparin derived from animal sodium chloride (USP).9% sodium chloride 3. allow- connection determined by the type of needleless ing leakage of lock solution and ingress of blood connector being used (refer to Standard 34. into the catheter lumen when the CVAD tip loca- Needleless Connectors). High clarity on the true effect of this technique.20-24 (I) Thrombosis). 4. Flow characteristics during injection 2.9% sodium reflux into the VAD lumen. Prevent disconnection reflux by using the appro. Consider using pulsatile flushing technique. bovine).10.38 (II) 2.10. or needleless connector. intraluminal bacteria). internal volume of the VAD and add-on devices vent this type of reflux. flush the VAD lumen with preservative-free neled CVADs. spurious laboratory studies drawn from the Clinical studies are needed to provide more CVAD that has been locked with heparin.9% sodium Access Device [CVAD]-Associated Venous chloride (USP) for locking.39 (V) intermittent infusion. Following the administration of an IV push medica. Because of conflicts with religious beliefs.27 (III) tion 1000 units/mL.25. Lock CVADs with either heparin 10 units per mL or week as a strategy to reduce CR-BSI.30-33 (I) F. Lock hemodialysis CVADs with heparin lock solu- 24 hours. consider locking once every J. acid-citrate-dextrose Formula A. more effective at removing solid deposits (eg.9% sodium chloride (USP).10. Central Vascular 1. Establish a standardized lock solution for each tamination increase the risk of serious medica. peripherally inserted central cath- 0. chloride (USP) for locking CVADs in children. In neonates and pediatrics. 4% citrate.3 (V) solution over the other. use preservative-free 0. Consider using heparin 10 units per mL for lock- in a traditional syringe (ie.16 (V) alent outcomes with heparin and sodium chlo- E. In 6.9% sodium chloride (USP) at the same rate of eters (PICCs). ride lock solutions for multiple-lumen nontun- tion. although the exact rates are unknown (see catheter is attached to the port body. 0.29 1.11. not a prefilled syringe) ing PICCs in home care patients.34 (III) to avoid compression of the plunger rod gasket 5. mended in postoperative and medical patients tion. use heparin 0.17 (IV) plus 20%. according to the directions for use for the VAD and 4% citrate. tion is higher than the insertion site.40-42. when heparin-induced thrombocytopenia and fibrin. There is solution to adequately clear the medication from the insufficient evidence to recommend one lock lumen of the administration set and VAD. activator to lock hemodialysis catheters once per I.40-43 (I) preservative-free 0. other antimicrobial lock solutions. clamping. and implanted ports while accessed injection as the medication. Use preservative-free 0. thrombosis (HITT) develops. or antimicrobial H.28.3. K. In vitro test.44. Standard 43. will cause overspill into the bloodstream. and dis.5-1 mL) of flush solution 4. When feasible. Use positive-pressure techniques to minimize blood 3.10. For short peripheral catheters not being used for (USP) instead of heparin when possible. Use an amount of flush and when the access needle is removed.35-37 (IV) 3. partial loss of the drug dose. Lock short peripheral catheters immediately lock solution due to a very low incidence of HIT following each use. drug precipitate. porcine. Change to an alternative locking solution when vitro studies have shown that 10 short boluses the heparin lock solution is thought to be the of 1 mL interrupted by brief pauses may be cause of adverse drug reactions from heparin. solution density is less than whole blood. Use recombinant tissue plasminogen solution for locking midline catheters. Volume of the lock solution should equal the or by using a prefilled syringe designed to pre. Monitoring platelet counts for HIT is not recom- removed when flushing with this bevel orienta. Lock priate sequence for flushing. Phlebotomy). Infect Control. and hepatic toxicity.43 (I) maintain patency of arterial catheters used for 5. Nurs. Sharp D. for thrombotic lumen occlusion servative-free 0.46-48 (II) for all antimicrobial lock solutions to enhance M. jhin.36. 3. hemolysis. combined with heparin. Use standardized formulations and licensed inde- time the arterial catheter will be required. Bertoglio S. 1 unit per mL lation. A time and duration of use remains controversial. crobial effects. et al. Follow catheter manufacturers’ instructions for 4.9% sodium chloride [USP]) or preservative-free arrest.14(1):137-151. high-risk patient populations. despite to increase CLABSI rates. Use solution containing heparin (eg.42. Schaefer MK. Institute for Safe Medication Practices (ISMP). Use a continuous infusion of heparin 0. Merlo FD.37(2):96-101. basic infection control. 2015. the anticipated length of 6. Chatterjee S. 2014.37.02.59 (II) application of other methods of CLABSI reduc- tion. doi:10. citrate. an anticoagulant with 7.42.58. Irreversible precipitation of 6. Monitor for thrombotic lumen occlusion as investigations highlight the need for safe injection practices and ethanol has no anticoagulant activity. 4. Thompson ND.51 (I) 2015.51. patients with a history of multi.9% sodium chloride (USP) instead and protein precipitation.53 (II) with peripheral arterial catheters (see Standard 8. Marsh N. DC: Association for silicone.53. and ethylenedia. unclear.indd S79 05/01/16 11:30 PM .57 (I) risk of catheter occlusion. from gentamicin lock solution have been reported associated bloodstream infection (CLABSI). Changes in Position Paper: Safe Injection. Consult with pharmacy when and pediatrics. Practitioners in Infection Control.49-52 (I) REFERENCES 1. Use heparin 5 units per mL. Keogh S. and protein precipitate formation with 0. Davies K.29 (II) the CVAD lumen at the end of the locking peri- N. development of antibiotic resistance and other ple CR-BSIs.2013. L. and pendent practitioner (LIP)-approved protocols patient factors such as heparin sensitivities. Aspirate all antimicrobial locking solutions from 30. 26% sodium chloride. Outbreak of Tsukamurella plasma proteins that could add to CVAD lumen species bloodstream infection among patients at an oncology occlusion is associated with ethanol concentra. within 48 to 72 hours of diagnosis. hypocalcemia that could produce cardiac of 0. for systemic anticoagu. methylene blue.5 units planned so that correct information about com- per kg for all CVADs in neonates. as this could increase long-term CVADs. Anticipate the chosen antibiotic to be based on the specific infecting 1. Clin Liver Dis. Celetti SJ. and in adverse effects.008. Patrick M. Gentamicin-resistant bacteria facilities with unacceptably high rates of central line. Monitor sodium citrate. clinic. an amino acid with antimi- hemodynamic monitoring. Use antimicrobial locking solutions for therapeutic od. the 2. Cox T. Pre-filled normal saline organism or on prevalent organisms within the syringes to reduce totally implantable venous access device-asso- organization when prophylaxis is the goal.1016/j. combinations of antimicrobial solutions are 1. 2011-2012. Pascuet E.30. have led to catheter rupture and split. Antiseptic locking solutions include ethanol. Barnes S. PA: ISMP.53 (II) motion study of peripheral venous catheter flushing practice 2. which could cause of heparin infusion should be based on the clinical lumen occlusion. Monitor taurolidine. Antibiotic lock solutions contain supratherapeu- Note: All electronic references in this section were accessed September tic concentrations of antibiotics and may be 1. numerous combinations. Ward K. Infusion.58 (II) per mL (total dose of heparin 25-200 units per kg 7. Vaillancourt R. Higgins N. 2010. 2013]. Horsham. Use continuous infusion of heparin 0.35(3): tions greater than 28%. Perz JF. Do not flush the lock solution into the and prophylactic purposes. Rezzo R. 3. For ciated bloodstream infection: a single institution pilot study therapeutic use. fusidic acid. Use in patients with patient’s bloodstream. Safe Practice minetetra-acetic acid (EDTA) used alone or in Guidelines for Adult IV Push Medications.54-56 (I) 300-306. up to 12 hours per day may be required. Dolan S. The length of time that antimicrobial lock solu- per day) for umbilical arterial catheters in neo. APIC intraluminal locking with ethanol. The decision to use pre. however. See I. 2009. patibility and stability of the solution are 2. but not Practices in Healthcare. J Infus taurolidine. tions should reside inside the CVAD lumen is nates to prevent arterial thrombosis. Umbilical Catheters). Nguyen DB. et al. and Medication Vial CVADs made of polyurethane material. West Virginia. Patel PR. 5. disturbances in pediatric patients undergoing IV flush with VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S79 JIN-D-15-00057. Felizardo G. 1 mL per hour as a This will limit use in patients receiving continu- continuous infusion for neonates and children ous or frequent intermittent infusions. J Hosp Infect. US outbreak ting. Apply the following recommendations for neonates patient safety. Rickard C. start the antibiotic lock solutions [published online March 15. using manually prepared and prefilled flush syringes. Washington. 2014.9% sodium chloride (USP) as a continuous flow to concentrations greater than 12%. Taste and/or odour antimicrobial effects.25 to 1 unit addressed. 3. Flushing vention [published online February 19. Normal saline flushes per- 9.58(10):1327-1334. 2014. 2008. Allara E. Monagle P. tion of heparin-induced thrombocytopenia: antithrombotic ther- 22. 2007. 2015]. Conway MA. Goossens GA. 2014. prevention of thrombosis: American College of Chest Physicians 12. Goldenberg NA. systematic review. Peterson F.141(suppl 2):e495S-e530S.5(4):205-208. eds. the Huber point needle bevel orientation: experimental tests and 36.6(1):e81-e90. J Infus Nurs. Linkins LA. Chest. 2013. Lyons MG. Flushing the central safetyauthority. 23.5(2). Carbonell of culture media and nutrients on biofilm growth kinetics of Sanchis R. Rosenberg J. Schlagenhauf A. Pennsylvania Patient Safety Authority.” Penn Patient Saf Advis. Pediatrics. 13. 30th ed. 2007. NZ). Published June 2008. Vigier JP. flushing recommendations: a systematic evidence-based practice 2008. Bassler D. Goode C. In: Alexander M.100(7):700-703. McCollom C. St Louis. 29. 25. Infusion therapy equipment. J Evid Based Med. ized versus nonheparinized intravenous lines. NZ). Moores LK. MO: Mosby. Tsang L. et al. Analysis of the research about heparin. 28. solution in hemodialysis patients with central venous catheters.27(7):2953-2957. Ferroni A. Rakel B.9% sodium chloride injection to may conflict with religious patients’ beliefs. 2011. 20. Kumar M. Heparinized saline vs normal 42. Nurs Res Pract.indd S80 05/01/16 11:30 PM . et al. 2015. BMC Med Ethics. devices.65(5):368-372. protein precipitation: new safety issues for catheter locking tech- 21. et al. Am J Health Syst Pharm. Kwong TK. Cabello JB. Benner K. J Pharm a randomised controlled trial. sodium chloride for flushing and locking peripheral intravenous 41.31(4):185-190. López-Briz E. Seneviratne C. et al. Heparin versus 0. Am J Health Syst Pharm. Saunders/Elsevier. Gorski L. Arch Dis Child. Rev. Marschall J. Nazareno AR. Adv Neonatal Care. Durussel JJ.37(4):270-281. Gustatory dysfunction. Guiffant G. J Clin Exp Dent. Gaudin F. Sterile water should not be 2014. Med Devices (Auckland. 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ASHP therapeutic position statement 39. Bannon C. Dal Molin A. Kirchhoff K. 2013. Infect Control Hosp Epidemiol. 208-215. 2014. 14.org/ADVISORIES/AdvisoryLibrary/2008/ venous catheter: is heparin necessary? J Vasc Access. S80 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 2012. Maheswaran T. 9th ed: American College of maintaining peripheral intravenous lock in children. Allegaert K. Chang J. MO: implanted venous access ports in pediatric oncology patients.CD008462. Gahart BL. 3rd ed. Effect 30. Luo O. Flaud P. et al. Eriksson A. Jeelani S. 16. ports of totally implantable venous access devices. et al. 2013. review.6(suppl 1):S30. Treatment and preven- Res. J evidence and evidence deficit [published online May 14.1002/14651858. 2014. and impact of doi:10. 2012. 2012. Cook L.9% sodium chloride inter- laboratory and clinical strains of Enterococcus faecalis.9% 2008. Bellini S. Bioallied Sci. Mansoor N.40(6):324-330. 2):e737S-e801S. 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Vaidya CK. Lau J. Add-on Devices. tions: a systematic review and meta-analysis of randomized con. (eg. Assess VAD function by flushing and aspirating for treatment of catheter-related bloodstream infections.indd S81 05/01/16 11:30 PM . Zacharioudakis IM. Alexander P. 2010. Am J Health Syst Pharm. 2015. 2008. or 48. 2013. rounding area for redness. Cochrane sion intervention. 51. Cao L. cuffed catheters. dialysis patients receiving gentamicin lock catheter prophylaxis. Maceira EL. Visually inspect the entire infusion system from the 52. are performed at established intervals and saline in maintaining patency of arterial and central venous cath.54(3): 735-743. of America.(11):CD003295. tenderness. cedures. et al. Bouza E. peripherally inserted central 49. or visibly soiled. Teo HS. Ann a blood return prior to each intermittent VAD use Pharmacother.48(5):607-615. 2014. Lee HE. Clin Infect Dis. leakage. Tran MH. Liu Y. 1. Adverse effects associated with ethanol dates of the infusate and administration set. Wales PW. including skin antisepsis and dressing 47. Sweet SJ. Oliveira C. Proc Singapore Healthc. Inspect the infusion system for clarity of the infu- CD003295. intermittent medication) and as clinically indi- 56.69(10):2611-2619.2(1):13. Heparinized saline versus normal changes. Brindle M. Nesrallah G.3 A sterile dressing is applied and maintained on all solutions on the incidence of arterial catheter occlusion. Mermel LA. Standard 40. 2013. Justo JA. drainage.3-6 (V) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S81 JIN-D-15-00057. Burns L. infusate.2 Site care. 1. 43. van Woensel J. Halm MA. numbness. Sherertz RJ. Landry DL. care and dressing changes on VADs. http://www. C. Bookstaver PB. and tunneled for the diagnosis and management of intravascular catheter. Osby M. Lawrie TA. Tan M. nontunneled. integrity of the system (ie. Rokas K. or if moisture. 2014.1. drainage by visual inspection and palpation through Stability and compatibility of antimicrobial lock solutions. 41. science tell us? Am J Crit Care. midline catheters: assess at least daily. Novak C.2 catheter lock solutions: a systematic review. peripheral. Bhatnagar N. PLoS One. accessed implanted VADs. Ethanol locks in the prevention and B. Guidelines for the pre. Infect Drug Resist. Nasr A. Antimicrobial lock solutions as a method to prevent central line-associated bloodstream infections: Practice Criteria a meta-analysis of randomized controlled trials. Zhang A-Q. loosened. Mylonakis E.30(1):22-27. Braden GL. J Intensive Care Soc. 2014. dressing. Tully RP.129(2):318-329. Haessler SD. Zappone P. doi:10. Mermel LA. 2014. infusion accu- analysis. 2014. immediately if the dressing integrity becomes damp. luer con- 53. 2011. Naber tainer to the vascular access device (VAD) insertion site. Grudzinski A. and 58. Guglielmo BJ. Gobeille SL.pub3. Assess the VAD catheter-skin junction site and sur- trolled trials. 2009. Central vascular access devices (CVADs) and Clin J Am Soc Nephrol. Clin Infect Dis. J Clin Apher.59(12):1741-1749. Agarwal A. van de Wetering MD. the intact dressing and through patient reports 59. Goh LJ. Flushing solutions for the prevention of catheter-related bloodstream infec. Flushing hemodynamic catheters: what does the administration set. Edwards JM. Pediatrics.1 The entire infusion system. 2012. Observational study of the effect of heparin-containing flush 41. Norris LB.15(3):213-215. Recognize the risk of contamination with nutrition: a meta-analysis. Moore JA. Published April to be changed based on organizational policies and pro- 2011. A. vention of intravascular catheter-related infections. Alang N. swelling. Rigg J. from the solution con- 45. occlusion prevent catheter-related bloodstream infections in parenteral alarms). Database Syst Rev. 2014. and expiration dates of the infusate. eters.html. blood are present under the dressing. CARE.gov/hicpac/BSI/BSI-guidelines-2011. 55. McGrath BA.8(11):e79417. Benefits 41. VASCULAR ACCESS DEVICE and harms of citrate locking solutions for hemodialysis catheters: (VAD) ASSESSMENT. et al. correct nique and logistical challenges. Mermel LA.7:343-363. Ziakas PD. Transfusion . 41. AND DRESSING CHANGES 44. Allon M. accurate flow rate. racy. Prophylactic solution container. Masagoes M. nections secure) and of the dressing. progressing down the adminis- antibiotics for preventing gram positive infections associated with tration set to the VAD insertion site with each infu- long-term central venous catheters in oncology patients. Bookstaver PB. Passero BA.49(1):1-45.20(3):190-196. at least until the insertion site is well related infection: 2009 update by the Infectious Diseases Society healed. 2013. Barton P. J Antimicrob (V) Chemother. Zervou FN. a systematic review and meta-analysis. M. 41. Can J Kidney Health Dis.1002/14651858. 2015. about any discomfort including pain. paresthesias. Xia H-T. and 46. Antibiotic lock therapy: review of tech. each manipulation of the infusion system (refer to 57.70(24):2185-2198.5 Label the dressing with the date performed or date cdc. Acid-citrate-dextrose Formula A versus heparin as primary catheter lock solutions Standard for therapeutic apheresis. Ethanol locks to cated with continuous infusions (eg. Citrate versus heparin for apheresis catheter locks: an efficacy is regularly checked for system integrity. or tingling. Alexander M. Taurolidine lock Standard 36. 41. and Locking). Ma J-J. sate. Lam CN. J. hexidine solution. The preferred skin antiseptic agent is >0.5 to 2 minutes.5.11 (V) nal route is the primary source of infection. 2. or 70% alcohol may also be eters if the dressing becomes damp. every 1 to 2 hours for ciated with the use of adhesive-based engineered patients who are critically ill/sedated or have stabilization devices (ESDs). H. Perform skin antisepsis as part of the site care pro. Measure the external CVAD length and compare to gauze dressings at least every 2 days.2-5 (V) or nonpitting. Anticipate poten. Be aware of the risk of hexidine. peripheral catheter. as more frequent dressing changes sis.17 cedure: (III) 1.5 (I) visibly soiled and at least every 5 to 7 days. Take this mea. Standard 52. Perform dressing changes on CVADs and midline ing dislodgment immediately to their health care catheters at a frequency based on the type of provider. 2. 1. Patients receiving outpatient or home care: adhesives to skin. Documentation in the Medical Record. Secure dressings to reduce the risk of loosening/ detect possible catheter-associated venous thrombo.3 (V.9. Vascular Access Device [VAD] Stabilization). If gauze is used to support sible deep vein thrombosis (DVT). instruct to check the site 1.2. Do not use if any history of reactions to chlor- and presence of edema.3. loosened.3. note that a gauze dress- Standard 10.10 (I) facturers’ directions for use (refer to Standard 37. Even 4. ing underneath a TSM dressing is considered a Standard 53. Do not use com- patients. joint movement. plications and to report signs/symptoms or dress. 3. the wings of a noncoring needle in an implanted surement 10 cm above the antecubital fossa. Use chlorhexidine with care in premature infants when organizations show a low baseline central line- and infants under 2 months of age due to risks of associated bloodstream infection (CLABSI) rate. tion. skin irritation and chemical burns. Short peripheral catheters: assess minimally at medical adhesive-related skin injury (MARSI) asso- least every 4 hours.3-5.9% sodium chloride (USP) or sterile term CVAD use. it is the location and other characteristics. Change the adhesive-based ESD based on manu- chlorhexidine in alcohol solution. Central Vascular Access 4. for continuous infusions via a short dressing. for at least 30 seconds. Change the dressing immediately to closely Device [CVAD]-Associated Venous Thrombosis). been shown. or if dressing becomes loose/dislodges. research has the external CVAD length documented at insertion not supported the superiority of a TSM dressing when catheter dislodgment is suspected (refer to versus a gauze dressing. for iodo. cleanse. has not G. the catheter exit site. a 3-cm increase in arm circumference and edema due to dislodgment are associated with increased were associated with upper-arm DVT (see Standard risk for infection. Compare to baseline measurement to 3. The efficacy of chlorhexidine dressings in long- sterile 0.12-14 (IV) further reduction in CLABSI rate has been demon- 5.8 assess. site tenderness. causing skin injury when the instruct the patient or caregiver to check the adhesive-based ESD is removed (refer to Standard VAD site at least once per day for signs of com. Assess skin underneath dressing. other signs of infec- F. 37. Change transparent semipermeable membrane every 4 hours during waking hours.7 (V) (TSM) dressings at least every 5 to 7 days and D. Allow any skin antiseptic agent to fully dry prior Committee Consensus) to dressing placement. an iodophor I. identify port and does not obscure the insertion site. Measure upper-arm circumference when clinically 2. and disinfect the site in the event (IV) of drainage.3-5.3-5. Vascular Access Device [VAD] Stabilization).3-5.17 (III) Placement. Central Vascular Access Device gauze dressing and changed at least every [CVAD] Malposition). Use chlorhexidine-impregnated dressings over idine solutions.indd S82 05/01/16 11:30 PM . 2 days. beyond 14 days when intraluminal water. and more often for patients receiving pound tincture of benzoin due to increased risk of infusions of vesicant medications. Perform dressing changes on short peripheral cath- (povidone-iodine). and/or used. hourly for neonatal/pediatric tion to reduce the risk of MARSI. Documentation in the Medical Record. dislodgment. Vascular Access Site Preparation and Device than 3-fold increase in risk of infection. for at least 1. Use a skin barrier solu- cognitive deficits. CVADs to reduce infection risk when the extralumi- phors. remove dried povidone-iodine with ings. tincture of iodine.16 (II) E. For pediatric patients with compromised skin strated with use of chlorhexidine-impregnated dress- integrity. such as pitting not considered a gauze dressing.18 (I) tial risk for skin injury due to age. If there is a contraindication to alcoholic chlor. Standard for disruption were associated with a greater 33. Select a gauze dressing if there is drainage from indicated to assess the presence of edema and pos. with alcoholic chlorhex.5% 5.5 (V) S82 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.15 (V) sources of infection are the primary source. more than 2 dressing changes 10.7 (V) MARSI because it may increase the bonding of 3. Gorski LA. Chapman AK. Kimura H. Burns LA.35(5):290-292. 2010.30. et al. Gilmore MM. with or without elastic tolerability of aqueous chlorhexidine gluconate used for skin properties. Munoz-Price S. 18. 23. Crit Care Med. Am J Infect Control.fda.CD003827.cdc.jstor. Saunders/Elsevier. Miller S. et al. eds. REFERENCES 15.149(2):195-199. The use of midline nated central-line dressings and necrosis in complicated skin dis- catheters in the adult acute care setting: clinical implications and order patients. Dressing disruption is a major risk factor for Corrigan A. Consider the use of a hemostatic agent to reduce iodine for long-term central venous catheter care in hematology initial site bleeding if other methods (eg. Central line-associated bloodstream 2011. Cooke ML. Strategies to prevent central line-asso. a 2% chlorhexidine preparation on a daily basis if 2014.35(7):753-771. When the subcutaneous tunnel is well healed.33(10):768-771.1086/676533. Crit Care Med. 2014.31 (III) 13. Efficacy of 1. J Infus Nurs. cuffed CVAD.CD010367. et al. 14. Gorski L. http:// stream infection: a meta-analysis. 2014. Ramjan LM. Association for Vascular Access. impregnated central access catheter dressings as a cause of erosive based guidelines for preventing healthcare-associated infections contact dermatitis: a report of 7 cases. Consider bathing patients over 2 months of age with catheters in children on hemodialysis. St Louis. infection prevention. Chapman AK. 2011. ommendations for frequency of assessment of the short periph.29 (III) directions for use in infants. Buckner J. INS position paper: rec. 2. The efficacy of daily eral catheter. Gillies D. M. Doellman D. Published April 201l. Weiser JA.25(4): 7. 20. MO: tral venous catheters. 2012. Kuehn SC. doi:10. Sherriff KL. Mitchell M. Biasuzzi A. MedWatch/SafetyInformation/Safety-RelatedDrugLabeling sideration may be given to no dressing with a tun.37(4): pathologies. Aucott SW. et al.29(6):1130:e1-e4. Bronchard R. necrosis have occurred. Use chlorhexidine-impregnated dressings with 8. Consolo S. Wilson JA.5. Updated 2012. 2013. 2013. 412-422. J Perinatol. Vascular Access Device [VAD] J Perinatol. Weitz NA. http://www. 2014.gov/Safety/ N. et al. Hemodial Int. Standard 37. 1703-1713. Garrouste-Orgeas care. Maragakis L. Fakih M. et al. et al. Clemence BJ. Perucca R. Timsit JF.(9):CD010367. Pepe G. securement devices for central venous catheters (CVC). Milstone AM. Consider use of chlorhexidine-impregnated dress. 11. 3rd ed.18-20 (V) chlorhexidine for the exit-site care of tunneled central venous K. Divito SJ.pub2. http://www. 2015. Eur Rev Med Pharmacol Sci. Alexander M.org/stable/10. Marschall J. et al. Bouadma L. Perucca R. Frey AM. et al. Changes/ucm307251. O’Riordan E.5. US Food and Drug Administration. Chlorhexidine gluconate- 5. 10. Hankins J. Pettit J. Silva G. Panunzi S. to secure any type of VAD (refer to antisepsis prior to catheter insertion in preterm neonates.42(5):574-576. et al.18-20 (V) 9. In: Alexander M. in NHS hospitals in England. In: Alexander M. Guidelines for the impregnated dressing for prevention of catheter-related blood- prevention of intravascular catheter-related infections. S1-S70. Safety of chlorhexidine Stabilization). Catudal P. O’Grady NP. Webster J. pressure) departments: a prospective study. Chlorhexidine- 3.pub2. J Assoc Vasc Access. 2010:496-498. Talbot SG. Infusion catheter-related infections. Hankins J. Absorption and O. Alexandrou E. contact dermatitis and pressure 260-268. Rickard CM. PEDIVAN. O’Horo J. Misao H.16(1):35-41. J Infus Nurs. Chlorascrub swabsticks: reduction intervention. Corrigan A. 3rd ed. Safdar N. Infect Control Hosp Epidemiol.18(suppl 1):S13-S18.0% effective. Infusion Gauze and tape and transparent polyurethane dressings for cen- Nursing: An Evidence-Based Approach. neled.html.(11):CD003827. 2010:456-479. 16. J Crit Care. Lauren CT.1002/14651858. MO: 1707-1714. Magalini S. Observational study on changes after peripherally inserted central catheter preoperative surgical field disinfection: povidone-iodine and (PICC) insertion. 1. Dressings and Epidemiology of America. Perucca R. eds. Curr Opinion Infect Dis. doi: update. St Louis. Safdar N. 2014. Schwebel C. Gorski L.17. epic3: National evidence. Perucca R. Pratt RJ. Ghufran A. Aucott SW.4.32(1):4-9. Gorski L. Risk factors associated with catheter- caution in premature neonates and among related upper extremity deep vein thrombosis in patients with patients with fragile skin and/or complicated skin peripherally inserted central venous catheters: a prospective observational cohort study: part 2.indd S83 05/01/16 11:30 PM .28 (V) chlorhexidine-alcohol. con. Cochrane Database Syst Rev.htm.23-29 (I) chlorhexidine-gluconate ethanol compared with 10% povidone- L.5. Paglianlonga F. Monitor for erythema and dermatitis at the ter-related infections after switching from povidone-iodine to dressing site. Hallock D. Reduction in cathe- 3. bathing with chlorhexidine for reducing healthcare-associated VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S83 JIN-D-15-00057. Ruckly S. Burns D.3. Maneval RE.gov/hicpac/pubs. Mermel LA. Ullman AJ. ciated bloodstream infections in acute care hospitals: 2014 Cochrane Database Syst Rev. Spencer T. Hunter M. JAMA Dermatol.40(6): Nursing: An Evidence-Based Approach. other CLABSI prevention strategies have not been 10.3. 4. Wall JB. ings with peripheral arterial catheters as an infection 12. Loveday HP. J Hosp Infect. 2014. Best practice guidelines in the Note: All electronic references in this section were accessed September care and maintenance of pediatric central venous catheters. 22.86(suppl 1): 2013.42(7): www. 2015. Do not use rolled bandages. gluconate used for skin antisepsis prior to catheter insertion in preterm neonates. et al.17(24):3367-3375. Peripheral venous access devices. maintenance and potential complications. M. 2012. et al. Central venous access devices: 17. 2012. Yamamoto N. Saunders/Elsevier. Society for Healthcare 19.1002/14651858. 21. Chlorhexidine gluconate-impreg- 6. 2. 2012. 1. fail to reduce the need for unplanned dressing 2014. recommendations for practice. O’Horo JC. 10 (V.166-170.368(6):533-542. blood. Warren D. supplied in glass or semirigid containers. based on factors such as type of solution admin- Intermittent Infusions). Montecalvo M. when feasible use an Epidemiol. Change a secondary administration set that is Standard detached from the primary administration set every 24 hours as it is now a primary intermittent admin- 42. 505-511. bloodstream infections: a meta-analysis. et al. 2012.3.indd S84 05/01/16 11:30 PM . tration sets used to administer solutions other than lipid. administration set with devices as an integral part of 24. Noto MJ. risk for catheter-related bloodstream infection 42. there 42. Committee Consensus) B. Lancet. Daily chlorhexidine bath.125(5): Sensitivity or Allergy). Safdar N. the administration III. Add-on Devices). O’Horo JC. Olson K. ADMINISTRATION SET changing the administration sets more frequently CHANGE does not decrease the risk of infection. compatible cover- Practice Criteria ing device to the male luer end of the administration I. subcutaneous) to indicate the correct 28. Label administration sets for infusion via VADs with 2013. Rennie RP. sions.33(3):257-267. near the connection to the device. Do not attach the A.2 In addition to routine changes.3 (V) istered. General set after each intermittent use. Avoid disconnecting primary continuous adminis- intermittent). (V. ed. or when the integrity of the product or system has Committee Consensus) been compromised. Halm M. Hanson J. Arterial catheters as before connecting or reconnecting any infusion/ a source of bloodstream infection: a systematic review and meta. Hinson K. Chlorhexidine bathing the set (refer to Standard 36. Primary tinely. and place the label does it decrease hospital-acquired infections? Am J Crit Care. There is strong evidence that 42. Effect of daily chlorhexidine administration. and health care-associated infections: a randomized clinical trial. 2011. et al. device. Armola R. sterile. Elward A. Pittsburgh. service.1 Administration set changes are performed rou- istration set (see Practice Criteria III.4 Administration sets are attached to a vascular (CR-BSI). intraosseous. PA: Oncology II.1. frequency of the infusion (continuous versus C. There is an absence of studies addressing access device (VAD) hub or access site with a luer- administration set changes for intermittent infu- locking mechanism to ensure a secure junction. 2015. Camp-Sorrell D.313(4):369-378. Blough L. Milstone AM. Infusions 32.381(9872):1099. Evaluation of a no-dressing intervention for tunneled central catheter exit sites. and the male luer vented administration set is used for plastic solution end of the administration set. and as part of the handoff process. immediately upon suspected contamina- tration sets from the VAD hub or access site. Primary Intermittent Infusions set is changed whenever the peripheral catheter site is A. Yokoe D. Krupp AE. J Infus Nurs. Regulatory) bathing on hospital-acquired infection. Domenico HJ. and disconnection. 2011. or blood products no more frequently than every 96 hours.4 (V) 29.3 A vented administration set is used for solutions is increased risk of contamination at the spike end. at each care transition to a new setting or analysis. and a non- catheter hub. 1106. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream with a latex allergy (refer to Standard 14. and avoid use of a latex-containing set for patients 25. et al. Am J Med. Change intermittent administration sets every 24 changed or when a new central vascular access device hours. istration sets used for medications that are adminis- cluster-randomised. 2012. Check the packaging of administration sets for latex JAMA. Yarrish R. McKenna D. disconnected and reconnected for the infusion. Access Device Guidelines: Recommendations for Nursing Practice and Education. Climo M. When an intermittent infusion is repeatedly (CVAD) is placed. The science of a “seal” for PICC line E. C. potentially increasing containers. tion.42(6):1334-1339. D. intraspinal. Chlorhexidine gluconate bathing: administration route and device. tered via specialized access devices (ie. 42.2 (V. Maki DG. et al.8-11 (I) B.5-7 (IV) 31. needleless connector. Replace primary and secondary continuous adminis- 2004. the date of initiation or date of change based on 27. A. Song X. 2014.15(2):66-73.20(2). port on the same set (“looping”). 2010. Sievert D. Hen J. Attach the administration set and prime just prior to 26. Minimize the use of add-on devices for administration exposed male luer end of the administration set to a sets as each device is a potential source of contamination. Trace all catheters/administration sets/add-on devic- management. Label admin- ing to reduce bacteraemia in critically ill children: a multicentre. Byrne DW.27(1):37-44. Crit Care Med. N Engl J Med. Primary and Secondary Continuous Nursing Society. et al. es between the patient and the solution container 30. 2013. J Assoc Vasc Access. Infect Control Hosp misuse.12 (V) S84 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. B.3. organizational policies and procedures. Latex infection: impact and sustainability. crossover trial. Aseptically attach a new. gov/MedicalDevices/Safety/ C. Rockville. Fakih M. 2008. Infusion Nursing.15 (II) 43. A. Replace administration sets for parenteral nutrition injection. Dolan SA. MD: United States 43. Infusion hours. et al. MedWatch: the FDA safety containers. Replacement of administra- integrity of the product or system has been compro. 2014. PA: Wolters Kluwer/ tainer.ismp. Boullata J. PHLEBOTOMY REFERENCES Note: All electronic references in this section were accessed September Standard 30. General Chapter <797>: pharmaceuti. Failure to cap IV tubing to Standard 62. Hemodynamic and Arterial Pressure 13. Pharmacopeia/ lection and in the presence of the patient. In: Alexander M.2 Use blood conservation techniques for phlebotomy Pharmacopeial Convention Inc. Replace administration sets used for intravenous fat Earhart A.9-11 (IV) 4.S.CD003588. Published August 20.35(7):753-771. Perucca R.pdf.E. 4th ed.accessdata. of all blood sample containers at the time of sample col- cal compounding—sterile preparations.1 Perform patient identification and proper labeling 1. Published 2002. National Formulary. Alexander M. US Pharmacopeia (USP). immedi. US Food and Drug Administration. Preventing tubing and luer conducive to the growth of microorganisms. US Food and Drug Administration. 37/32 ed.jstor. J Clin Nurs. Sentinel event alert: managing risk during late (DEHP) to administer lipid-based infusates. 6. The Joint Commission. ies have demonstrated increased DEHP levels in fda. St Louis. Alexander M. and disconnect IV ports place patients at risk for infections. http://www.P. Felizaredo G. http:// www.htm.gov/drugsatfda_ namic pressure monitoring every 96 hours.pub3. eds. emulsions (IVFEs) infused separately every 12 hours. et al. Blood and Blood Components April 2011. et al. J Parenter Enteral Nutr. and long-term home care cular administration set replacement. https://www. used polyvinyl chloride administration sets and 7.S. A. In: U. Gorski L. http://www. Ayers P. and stud. near Lippincott Williams & Wilkins. information and adverse event reporting program. ISMP Med Saf Alert. Cooke M. DE: device. Gorski L. manufacturers’ recommendations or when the con. AlertsandNotices/TubingandLuerMisconnections/default. transition to new ISO tubing connector standards. Transfusion Therapy). infusion.38(3):296-333. or when the 15.htm. 2010:391-436. continuous flush 14.fda. Phillips L. Marschall J. and flush solution used for invasive hemody. parenteral nutrition after the completion of each unit or every 4 hours. 2015. IV. Gorski L.fda. Wilmington. Parenteral Nutrition). Burns LA. Replace the disposable or reusable transducer and/ fda. 9. more than 1 unit can be infused in 4 hours. 10. Standard 61. Corrigan A.indd S85 05/01/16 11:30 PM . Gillies D. propofol infusions every 6 or 12 hours per the http://www. Propofol Infusions Epidemiology of America. VII. Corrigan A.1086/676533. 2014. eds.13 (III) 2013. Barnes S. Cochrane Database Syst Rev. Parenteral Nutrition 2.org/assets/1/6/SEA_53_Connectors_8_19_14_ extracted into the lipid solution with commonly final. Guidelines for the tainer is changed. MO: administration set with each new PN container (see Saunders/Elsevier. doi:10.1002/14651858. such as IVFE or TNA. Published VI. Ullman AJ. Hadaway L. Use administration sets free of di-ethylhexyl-phtha. Diprivan injectable emulsion [package insert]. Institute for Safe Medication Practices. Published July 26.N. FDA public health notifica- Monitoring tion: PVC devices containing the plasticizer DEHP. Dickerson A. 2007.html. pediatric. entries into the system. US Food and Drug Administration. 2014:1-85. 3. Rickard C. PublicHealthNotifications/UCM062182. lipid solutions. transfusion set can be used for a 4-hour period (refer 12. DEHP is considered a toxin. http://www. 2010.asp. B. Adams S. patients. et al. Mermel LA. Minimize the number of manipulations and a systemic review. the characteristics of IVFE (iso-osmotic. Society for Healthcare V. 2012.pdf. DEHP is lipophilic and is jointcommission. Infect Control Hosp Epidemiol.cdc. In: Alexander M. ately upon suspected contamination. 3rd ed.14 (I) prevention of intravascular catheter-related infections. Hankins J.gov/hicpac/BSI/BSI-guidelines-2011. docs/label/2008/019627s046lbl. Strategies to prevent central line-asso- ciated bloodstream infections in acute care hospitals: 2014 A. the 2014. 2014. Cooke ML. If safety consensus recommendations. including the administration set. which is especially a risk with neo. tion sets (including transducers) for peripheral arterial catheters: mised. and containing glycerol) are 5.11 (V) misconnections. O’Grady NP. Philadelphia.22(3-4):303-317.org/stable/10. to reduce the risk of hospital-acquired anemia. Bullock M. Infusion therapy equipment. A. (PN) solutions (total nutrient admixtures [TNA] and Am J Infect Control. APIC position paper: safe A. Change the transfusion administration set and filter 11. Optimal timing for intravas- natal.(9):CD003588.org/ newsletters/acutecare/articles/20070726. Technical and clinical application. et al. Core Curriculum for Change the administration set with each new con. et al.gov/Safety/MedWatch/default. Daud A. 43. http://www. AstraZeneca. neutral-alkaline pH. 8. http://www.gov/MedicalDevices/Safety/AlertsandNotices/ or dome and other components of the system. there are also recommendations to change the Nursing: An Evidence-Based Approach.11. and medication vial practices in health care. amino acid/dextrose formulations) at least every 24 Corrigan A. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S85 JIN-D-15-00057. Replace administration sets used to administer update.38(3):167-172. bar-code or radio-frequency technology) for a vein below or distal to the site of infusion should patient identification and sample container labeling be used. root cause analy. (see Standard 33.1-4 (IV) (III) B. 2. paralysis. or winged needle on veins in the antecubital fossa accidental needlestick injury. and never remove the rubber stopper from C.5. Regulatory) to the lower rates of hemolysis associated with these G. appropriate use of gloves. Avoid venipuncture on upper extremities with E.10. Hemolysis causes spurious values D. >0. such as hemolysis and specimen labeling. transparency of data on mislabeled and unla.5. care. restrict venipuncture to the dorsum of the hand in and appropriate skin antisepsis (see Standard 16. Practice Criteria 1. A. Appropriate agents include 70% alcohol. use of safety-engineered devices.12-14 (III) has previously been thought to cause hemolysis. Standard 18. Perform venipuncture for phlebotomy with a straight the tubes as methods to decrease blood exposure. Regulatory) side of axillary node dissection comes from conflict- F. there remains a recommenda- to the manufacturer’s directions for use (eg. Blood con. If phlebotomy must be sis.4.11. Control blood sampling procedures to prevent 3.25-28 (II) of all ages.24 (II) to detect hemolysis. Contact the clinical labo. however. color of tion to avoid all venipuncture procedures on these the rubber stopper). Reducing the frequency of obtaining blood I.5. Eliminating unnecessary laboratory tests. Excessive alcohol on the skin that would cause a sample to be rejected. Use additional precautions for obtaining blood cul- for blood transfusion and its inherent risks.5-7 (V) erly store and control the temperature to reduce the D. performed on the extremity with infusing solutions. median cubital. tures to avoid false-negative and false-positive Collaborate with the laboratory about the minimum results and to reduce incorrect classification as volume of blood required for each test. Competent nursing staff should perform sample col- 7. These errors delay treatment 4. for many tests (eg. Site tents and blood.15-23 lections from vascular access devices (VADs). central line-associated bloodstream infection servation strategies include: (CLABSI).7-9 (V) B.5-7 (V) lytic errors and enhance patient safety. or hemiparesis patient tourniquets. discard the needle and tube holder Selection). Use vacuum tubes in the correct sequence according ing studies. Using closed loop systems for venous and arterial ized patients has been shown to reduce preanalytic VADs as these systems return the blood to the errors. General samples.13. Employ blood conservation strategies to reduce however. Perform all infection prevention practices including lymphedema. An electronic sys.5. S86 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. cephalic. tincture of iodine.5% markers.6 (V) tainer and dispatch to the laboratory immediately C.indd S86 05/01/16 11:30 PM . upper extremities (refer to Standard 27. A centralized phlebotomy service for hospital- 6. Using small-volume collection tubes (eg. Perform venipuncture for phlebotomy on the oppo- beled specimens. and error in sample (eg. with radiation therapy. Educate the patient about the purpose and process I. and accountability measures. or if delivery blood samples. Use multiple process improvement methods such as staff engage. This blood loss often results in the need E. and basilic veins) due analysis. appropriately mix the tube con. Assess the patient for fasting prior to collection of using an appropriate delivery method. Drawing blood samples based on clinical need errors in the preanalytic phase before the sample rather than a routine schedule. enhance the ing less than 2 mL of blood). single-use venipuncture and from a cerebrovascular accident.11 (V. which is a sig. if appropriate for the requested labo- must be delayed (eg. leakproof con- for blood sampling. Do not rely on visual inspection of the blood sample devices and sites. glucose. Use the same unique numbers for both patient iden- risk for inaccurate laboratory values and the poten- tification and specimen labeling to reduce preana- tial for hemolysis. Medical Waste and graft. single. Evidence for avoiding all venipuncture on the Sharps Safety). patients with an actual or planned dialysis fistula or Hand Hygiene. requir- decisions due to spurious lab values. prop- ratory values. site extremity of an infusion. electrolytes. sampling devices. Place all blood specimens in a closed. When possible. patient. and increase costs of 5. Vascular Access Site Preparation nificant cause of hospital-acquired anemia in patients and Device Placement). Blood Sampling via Direct Venipuncture ment. home-drawn specimens).10 (V. coagulation times). Using the push-pull or mixing method. potential for patient harm. H. cardiac bio. II. chlorhexidine in alcohol solution. as 1 unit. compromised circulation associated hand hygiene. ratory about parameters for the free hemoglobin level and povidone-iodine. 1 study has shown this to not be a cause phlebotomy-associated blood loss.14. process changes. tem (eg. A. Perform skin antisepsis prior to all venipunctures. reaches the laboratory. Using point-of-care testing methods.7 (V) has been shown to reduce these errors. 53 (III) container. checklist. 1. obtaining chemistry panels and niquet time to less than 1 minute to reduce the complete blood counts. waste 1 to 2 mL of blood before III. Obtain blood for culturing from a peripheral 2. infants and children).53. Infusing solutions should be stopped for at least 2 minutes prior to obtaining the blood sample. No studies of 6. mixing) methods ple for other tests. Disinfect the rubber stopper of the blood culture list combined with periodic direct observations for bottles using 70% alcohol. alterations in VAD clinically indicated for diagnosis of catheter. These studies do not provide consensus um from increased venous pressure and hypoxia.37-39 (IV) 1. eters and 9 mL from tunneled cuffed catheters kalemia. for obtaining a sample from CVADs. Consider obtaining a blood sample from an 5. do not discard the initial the discard specimen into the VAD after obtain- sample except when a winged needle with an ing the sample) due to risk of contamination and attached extension set is used. Sampling of blood from indwelling short periph- A. adults with difficult venous access. and vincristine. Do not dis. Apply these additional factors more than 1% of the total blood volume for based on patient age and type of CVAD. Blood Sampling via a Vascular obtaining the sample.54 (IV) sion set prevents the correct ratio of blood to D. Discard volumes of 6 mL from nontunneled cath- and closing the fist to prevent pseudohyper. patency.51 (IV) 1.40 (II) serial tests. Iodine products are adherence to the checklist to reduce CR-BSI. delivery of 4. Discard the initial blood sample (eg.44. B. blood clot formation. bleeding disorders. and erroneous lab values associated related bloodstream infection (CR-BSI). and the need for lance.12. catheters at insertion or during the dwell is not damage to skin and nearby nerves. Use a straight or winged needle instead of obtain. CVADs. although the discard volume for implanted ports ing the sample during the procedure to insert a could not be established. Draw blood for culture before drawing the sam.33 (II) 3. 2.41-48 (IV) ture collection kit to reduce sample contamination. the VAD.49. A 3-mL discard volume produces the same mea- 7. Draw a quantity of blood that is sufficient for these specific techniques are found for peripheral or isolating organisms (ie. Risks associated with use of a VAD include venipuncture. is no consensus on the exact contents of such a per material.55-58 (IV) Access Device 2. pres- due to the increased pain from the heel ence of bleeding disorders. For coagulation studies. 20-30 mL for adults.24.34-36 (IV) 4.4. Risks of venipuncture include anxiety.52. Use a dedicated phlebotomy team to reduce in patients receiving anticoagulants or with blood culture contamination. 1.51 (IV) short peripheral catheter.41. There not recommended as they can degrade the stop.27-29 (II) card volume is coagulation studies obtained from F. and hematoma recommended.59-61 (II) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S87 JIN-D-15-00057. The push-pull or mixing method produces good 3. Avoid use of a tourniquet or blood pressure cuff outcomes for measuring levels of actinomycin-D if possible. pain.29. Do not use the reinfusion method (ie. Obtaining blood cultures from short peripheral 1. including coagulation studies. Use a central vascular access device increased hub manipulation and the potential for (CVAD) for drawing blood cultures only when intraluminal contamination.50.32. samples.indd S87 05/01/16 11:30 PM .50. Carefully analyze risks versus benefits before eral catheters is reliable for many routine deciding to use a VAD for obtaining blood blood tests. with adsorption of medications infused through 3. To improve phlebotomy practice: a CVAD exposed to heparin. If a tourniquet is required. 5 cycles blood begins to flow into the collection is the most common. 5 mL) when surement outcomes when compared to a 5-mL drawing from a direct venipuncture. Air in the exten. however. no midline catheters. on the required number of push-pull cycles or the Immediately release the tourniquet when the volume of blood to be pulled. and therapeutic drug risk of hemolysis and inaccurate chemistry lab monitoring for gentamicin and doxorubicin from values caused by changes in vascular endotheli. Use the discard or push-pull (ie. 2. Consider use of a CVAD phlebotomy bundle check- 4. Perform venipuncture in neonates by a skilled indwelling short peripheral catheter for pediatric phlebotomist instead of heel lance methods patients. The exception to this dis- from any type of CVAD.31 (V) were sufficient to remove infused glucose. Avoid tight fist clenching or repetitively opening 2.30.50 (V) 5. discard volume in multiple types of CVADs in a card the first sample when the sample is obtained pediatric population. C. Consider use of a standardized sterile blood cul. limit tour.11. Short peripheral catheters anticoagulant additive in the tube. agulants.5 (V) small study. The effect of this process 6. requiring G. Standard 33. 8. Obtaining a blood sample during the insertion of blood sampling from a CVAD. Site Selection).46.13. and flush the lumen with pre.63 (IV) nutrition for blood sampling as this is a signifi- 2. via direct venipuncture may be necessary.47. Ensure that a standardized protocol is used con. pulse oximetry. short peripheral from the heart. possible overtreatment with insulin. However.76 (IV) S88 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Veins of the antecubital fossa produce the lowest from the lumen exiting at the point farthest away rates of hemolysis. Prior to puncture of the radial artery.48 (V) test results may be falsely elevated. assess presence of antico- els with blood sampling from CVADs while oth. assess cir- ent upon the accuracy of the test results. One study suggests larger vol- catheters inserted for infusion into veins of the umes (10-20 mL) of flush solution provide more antecubital fossa are not recommended due to accurate peak levels of antibiotics when com- higher catheter complication rates in areas of pared to smaller volumes (3 mL). flow or the amount of flush solution. 4. When a dedicated CVAD lumen cannot be used.69 (IV) joint flexion (see Standard 27.11. pulsation. discard the used needleless connector prior to F. cant risk factor for CR-BSI.9% sodium chloride [USP]) followed by an and Device Placement).46 (IV) attached extension set. Carefully assess coagulation values from a blood and place the syringe on ice for immediate trans- sample obtained from a heparinized CVAD.45. For CVADs with staggered (II) lumen exit sites. Ensure that the label on the solution 5.62 this purpose should be limited to the absence of (IV) peripheral venipuncture sites or when there is a E.75. For midline catheters. radi- Conflicting studies show elevated antibiotic lev. polyurethane. container is visible and not obscured by the pres- servative-free 0. Allen test. heparin.63.63-65 (III) 3. Stop all infusions. Because palpation is needed to feel the arterial 3. no evidence is available need for diagnosis of a CR-BSI. Research has not a short peripheral catheter is associated with established the length of time for stopping fluid higher rates of hemolysis and spurious lab val. Store discarded. Avoid using a CVAD for obtaining blood samples (II) for culturing as these samples are more likely to 5. Central vascular access devices drawing a blood sample to reduce risk of a false- 1. trauma. ulnar pulses. previous radial artery cannulation. Do not use solutions containing glucose when heparinized peripherally inserted central in adults as this results in falsely elevated glucose catheters (PICCs) were flushed with 10 mL of levels. adequate volume of wasted blood when using the 4. Retesting culation to the hand. damage to the radial artery. and 0. One study ues. Maintain patency of arterial catheters with 0. regardless of whether the sample was drawn suggests a wait time of 10 minutes after stopping directly from the catheter hub or from an the infusion before drawing the sample. Remove and regarding obtaining blood samples.73. Vascular Access Site Preparation free 0. Use the largest lumen for blood sampling from on the outcome of the catheter is unknown. or cyclosporin and tacrolimus) given through Doppler flow study. coagulation values correlated with 5. al artery harvesting).24 multilumen CVADs.4. and perform a physical examination of ers have shown no difference.9% values drawn from a separate venipuncture. In vitro and in vivo hand circulation such as assessing radial and studies of immunosuppressant medications (eg.74 (I A/P) CVADs constructed of silicone.indd S88 05/01/16 11:30 PM .44. For arterial blood gases. expel air from the discard method. Use a 20-gauge catheter or smaller to reduce and polyurethane with silver have shown exces.45. sodium chloride (USP) with or without added except international normalization ratio (INR). Arterial catheters careful evaluation if dosage adjustment is depend. the sample should be drawn 4. use sterile gloves for puncture and sistently by all staff including thorough flushing catheter insertion into any artery (refer to of the VAD lumen (eg.65 (IV) syringe immediately after obtaining the sample. Use of a CVAD for insertion can produce inaccurate lab values. draw the blood positive blood culture result.70-72 (IV) sample from a dedicated lumen not used for infu.14. 2. 10-20 mL preservative. Review medical history (eg.24 7. In 1 port to the lab. 3.73 (IV) sively high drug levels.9% sodium chloride and 6 mL of blood was dangerously low serum levels of glucose.66-68 (IV) infusion. For therapeutic drug monitoring. Lengthy tourniquet time and difficult catheter produce false-positive results. 1. Do not routinely use CVADs infusing parenteral sion of the drug being monitored.9% sodium chloride (USP) prior to ence of a pressurized device. Retesting via a direct venipuncture is solutions intended for arterial infusion in a loca- required when questionable results are tion different from solutions intended for venous obtained. 2. WHO guidelines on draw.nlm.3(2):70-71. Salvagno GL. BMJ Qual Saf. Spitzer ED. Manual of IV Therapeutics. 22. Esses D.32012. Published 2010. Hagle M. atic review and meta-analysis of the clinical efficacy and per- ry specimens at a large tertiary care hospital. Goonan EM. Preanalytical qual. Wyncoll D. In: Phillips LD. Gorski L.48(6):562-565. 2011. 24. Dunn EJ.133(6):870-877. Thurlow VR.43(11):1222-1237. 2013. tures to determine effective interventions for increasing the yield 11. 2013. doi:10. my: a quality improvement report.2014. Carroll PD. 2013. Clin Biochem. John Gallagher E. 32. Straszewski SM. 8. Occupational Safety and Health Administration. Reduction in 26. Is suboptimal phlebotomy technique terfly needles to draw blood is independently associated with impacting on potassium results for primary care? Ann Clin marked reduction in hemolysis compared to intravenous catheter.3(1):1-6. Nurses Association. McEvoy MT. Chadwick MA. Winges L. et al. and new strat. Diagnostic blood loss ity improvement: in quality we trust. Lippi G.14(2):216-221. phlebotomy in elderly patients. 2012. Use a closed loop system to reduce hospital-acquired 16. Bradford JY. risks. et al. Branco BC.ena. Intern Emerg Med.23(2):201- 2010. 6th ed. 2012. eds. J Multidiscip ing blood: best practices in phlebotomy. Shander A. Berg J. Ayling RM.pdf. 9th ed. and laboratory errors: an example of multidisciplinary manage- 5. Hemolysis of coagulation pseudohyperkalemia by avoiding making a fist during phleboto- specimens: a comparative study of intravenous draw methods. Burns L. et al. 205. Ranum A. Becan-McBride K.45(3):266-269. Disposal of 28. Anemia. 3rd ed. Hunter M.43(1):78-83. Biochem. Sherman B. Perucca R. research/CPG/Documents/BCCCPG. 2015. 3. Nonpharmacological. Leviner S. 2011. Clark SL. Diagnostic testing and values. 2010. 30. et al. Adv Aging Res. Plebani M. Phillips LD. 13. Morrison AP. Seferian EG. Injury. Reducing the incidence of 14. 2014. PA: Wolters Kluwer/Lippincott cdc. mens: a major challenge for emergency departments and clinical 23. Bailey IR. multi. to reduce blood sample hemolysis in EDs: a laboratory medicine Gorski L. Derzon JH. Lima-Oliveira G.indd S89 05/01/16 11:30 PM . Semin Perinatol. Tanasijevic MJ. Seimiya M. rate venipunctures for IV access and laboratory studies decreases egies. Plumer’s Principles and Practices of Infusion vention of intravascular catheter-related infections. Chan ES.org/practice-research/ 2009. ceived role of chlorhexidine in skin antisepsis. http://www.134(2):244-255. Alexander M. FA Davis. Perucca R. Variation in phlebotomy techniques in of true-positive bacteremias. et al.46(pt 3):244-246. Bijur PE. Clinical practice guide- prospective study of causes of haemolysis during venepuncture: line: prevention of blood culture contamination: Emergency tourniquet time should be kept to a minimum.23(8):690-697. Blood conservation devices in criti- cine: a qualitative analysis of 227 root cause analysis reports in cal care: a narrative review. and potential complications.nih. et al. Central venous access devices: phlebotomy in the development of anaemia and need for blood care. Tiwari D. Guidi GC. from phlebotomy and hospital-acquired anemia during acute myo- 51(1):229-241.20(11):1151-1155. bleeding. 15. PA: best practices systematic review and meta-analysis.gov/hicpac/BSI/BSI-guidelines-2011. Cunningham JL. Arch Pathol Lab Med. Hemolyzed speci.html.21 (II) tion techniques for preventing neonatal anemia: effective and promising strategies for reducing transfusion. Sanchez L. Maiwald M. 4. review of best practices for collection and handling of blood cul- my. Jamal S. Doughty R. 2014. Garcia RA.ncbi. Corrigan A. St Louis. Blood loss from labora- tory diagnostic tests in children.48(3):143-153. Healthc. Phlebotomy techniques. Use of but. et al. et al. Gorski L. et al. spurious hemolysis.6(4):357-359. Multidisciplinary team contaminated needles and blood tube holders used for phleboto. Berg J. and blood transfu. Moga PJ. 31. Vascotto F. Heyer NJ. O’Grady N. 2013. eds. The forgotten role of alcohol: a system- faceted improvement initiative to eliminate mislabelled laborato.html.45(13-14):1012-1032. 7(9):e44277. Lippi G. 7. Pugh L. Hematology point of care testing laboratories. Mani V. McGillicuddy D. Danese E. Beba J. Ann Intensive Care. Salisbury AC. 2008. 2012. Retter A. 2012. 2011.56(4): J Emerg Nurs. Visconti P. gov/books/NBK138665. Stauss M. Sawabe Y. Behúlová D. 2011. Am J Crit Care. tions. Rabinstein AA. Hagle ME. cardial infarction. 2014:108-141. 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Townsend K.40(1):20-26. 45. Secola R. Hasimi A. Gómez IA. 2012. J Emerg Nurs. Venipuncture versus 41. Am J Clin Pathol. 700-707. Baldwin KM. Rodgers GM. leukocyte activation and cancer. J Clin Nurs.21(3):279-282. Cochrane Database Syst Rev. Okamoto 66. Enc N. Med. previous data sets. 2013. MRSA contaminated venepuncture tourni. Paguina-Marcos M. Use of peripheral venous access devices for 42. et al. during phlebotomy and the influence on clinical chemistry test. Sánchez-Pérez I. and discussion. Watanabe M. Jamerson PA. 766-771. Lippi G. Nurse Spec. 2008. Fairholm L. Nutr Clin Pract. Chen J.18(5):474-478. 2012. 2014. Elhassan HA. 2008. 37. 2012. Therapeutic drug monitoring of methotrexate on the pediatric Monitoring parenteral nutrition in hospitalized patients: issues oncology ward: can blood sampling from central venous accesses related to spurious bloodwork. 40.indd S90 05/01/16 11:30 PM . J Nurs Care Qual. A R.1002/14651858. 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Nutr and peripheral vein samples of antibiotics in children with cystic Clin Pract. Zengin N. 51. Needleman J. Díaz-Bergara M. 2009.16(5):454-458. 2011.P. et al. Shova A. Albertioni F. Clin J Parenter Enteral Nutr. Baun M. Arch Pathol Lab 61. 2006.48(7):687-695. One poke or two: can intravenous catheters provide 50. Doering L. 58. Pai AB. Yeung M. Oncol Nurs Forum. 2013. 38. Wyant S. Salvador M. 2014. Determining the minimum discard volume an acceptable blood sample? A data set presentation. Sampling for interna- of the use of a reliable and valid central venous catheter blood tional normalized ratios in patients on hemodialysis with central draw bundle checklist. Menting CH.25(6): coagulation assays: necessity of a discard tube. Skolnik JM.29(4):447-451. Ther Drug Monit. Dunne A. Determining optimal waste volume from an intrave- sampling in term neonates. 39.47(6):769-776.14(1):23-27. 2014. 2011. Zhang AY. Bijur P.26(6):310-316. 46. Krischke M. Approaches to peripheral catheter: do infusions alter laboratory results? J Emerg clear residual chemotherapeutics from indwelling catheters in Nurs.134(5):851. Budde-Schwartzman B. Wilson K. Feasibility 67.33(6): intravenous catheters: best practice? Am J Crit Care. Berger-Achituv S. Blood Coagul Fibrinolysis. A study to determine the mini- 34.S. Boyd A. Chatfield S. Prue-Owens LKK. Examining the push-pull method of blood sampling 36. hematological parameters. Ortells-Abuye N. 48. Buchman AL. 2011. 2007. and central venous access. van der Graaf F. compare two blood collection methods: direct venous puncture Minimization of the preanalytical error in plasma samples for and peripheral venous catheter. 2014. Falsely elevated 63. Asheghan M. Venepuncture versus heel lance for blood Khoury J.26(6): substitute for capillary finger punctures? Ther Drug Monit. 2014. 575-578. 2013. parenteral nutrition 65. Ayers P. Gleaves M. Crist RA. 2010. A reliable and safe method of 2009. Brumley K. Hacker C. Crit Care Nurse. 57. McGraw CA. Steimer W. Cengiz M.E. Diamantidis TG.88(1038):194-197. Crickman R. Barrett JS. the incidence of nerve injury during phlebotomy. Opilla M. Smith S.36(2):92-96. Obtaining blood samples from peripheral doxorubicin as an example. Pediatrics. Favaloro EJ. BMJ Open. Clark KL. Parry A.25(4):200-207. Blood sampling through peripheral venous catheters is when drawing samples for hemostasis.18(1):33-41. Tonani M. Garbin LM. Silver M. Shenkman Z. Cosca P. pharmacokinetic analyses and therapeutic drug monitoring using 62. Butterfly needles reduce catheter. Lewis MA. 33. 55. Ellis MH. Clin Chem Lab Med. Ritzmo C. 2011. Eksborg S. Dixon T. J Clin Nurs.26(1):30-38. Adlard K. ters. Comparison of labo- Discard tubes are not necessary when drawing samples for spe. Clin J Nurs. nerve injury. J Spec Pediatr Nurs. 64. children with cancer. Boos J. 59. Holisaz MT. venous catheters. Kenar L. Atallah H. Watanabe T. Lawrence M. Paresthesia and forearm obtaining blood samples for measurement of activated partial pain after phlebotomy due to medial antebrachial cutaneous thromboplastin times.pub4. Ohnishi H. Discard tubes are sometimes necessary Erez I. 2011. fibrosis. ratory values obtained by phlebotomy versus saline lock devices. Khatibi A. 52. Ulker P. et al. et al. Cosic K.38(6):744-749. Corbo J.33(4):408-411. J Pediatr Oncol Nurs. collecting blood samples from implantable central venous cathe- 35. 2006.6(1): 60.29(3):277-282.32(6):741-748. 54. 1998. Fu L. 49. in anticoagulation therapy: venipuncture and peripheral venous 43. Kontny NE. Nanji M. Am J Clin Pathol. Price L.136(4):352. Halm MA. Saqui O. J Infus Nurs. et al. Raijmakers MT. quets in clinical practice.126(1):e179-e186. Serdar MA. Pediatr Blood Cancer. 2010. Ther Drug Monit. doi:10. Reinfusion of discard blood Collection of blood specimens by venipuncture for plasma-based from venous access devices. Andreu FAB. 2012. Hansen SJ. Vader HL. 2007. nous catheter. Soderhall S. review of for central venous catheter blood draws. Hempel G. from central venous access devices. Shah VS. Baskurt OK. Notify the LIP about signs and symptoms of sus- 76. any ed. Blood 4. Arterial administering the prescribed therapy (refer to line blood sampling: preventing hypoglycaemic brain injury Standard 26. Hadaway L. Clinical instability of the patient (eg. preferably within 24 to and treatment algorithm. Induration. Mogayzel PJ Jr. Cook T. E. Signs and symptoms of F. Dunning K. Corrigan A. 2013. par- longer included in the plan of care or has not been enteral nutrition.34(6):464-468. Mathew A. Remove the short peripheral catheter if it is no 2. Accidental hypoglycaemia caused by an arte- rial flush drug error: a case report and contributory causes analy- pected catheter-related infection and discuss the sis. St therapy is required. Hartle A. Déziel C. 2011. De Bortoli B.20(4):335-338. If unable to insert a new catheter in patients with In: Alexander M. Mills J. A. “emergent”). medica- used for 24 hours or more. Accuracy of tobramycin levels obtained from central venous access devices in patients out palpation. Palavecino E. Ying J. Nontunneled Central Vascular Access an unresolved complication. Short Peripheral and Midline Catheters vital signs.1 (IV) tions. VASCULAR ACCESS DEVICE F. 44. Central catheter blood puncture site. resistance when lection. 2008. drainage. Assess and discuss with the patient’s health care plan of care. but are not limited to. Pediatr Nurs. immediately contact the licensed Louis. presence of: 2008. Eur J Clin Microbiol Infect Dis. Troyanov S. 3. Infection). catheter include.3 VADs are not removed based solely on length of CVAD on a daily basis and remove when it is no dwell time because there is no known optimum dwell time. Gaslin T. B. fluid and electrolytes. 2010:139-177. 1. Any level of pain and/or tenderness with or with- 69. D. 3rd ed. VandeGraaf S. oxygen saturation). Halm M.2 Vascular access devices (VADs) are removed upon II. sampling: the impact of changing the needleless caps prior to col. or when deemed no longer necessary for the A. Leakage of fluid or purulent drainage from the 71. 44.indd S91 05/01/16 11:30 PM . 6. 2011. 7. alteration in I. pediatric and adult patients when clinically indicat. Vascular Access Device [VAD] 2014: the Association of Anaesthetists of Great Britain and Planning). J Infus Nurs. difficult venous access and continuation of infusion eds. Changes in color (erythema or blanching). Anaesthesia. Cannulation injury of the radial artery: diagnosis as soon as possible. Sherertz RJ. MO: Saunders/Elsevier. 44. Sprint WP. need for obtaining cultures (eg.5-7 (IV) 74. Anaesthesia. Quérin S. discontinuation of infusion Devices (CVADs) therapy. Prescribed continuous infusion therapy (eg.13(4):315-319. In the event of extravasation. flushing. independent practitioner (LIP) about delays in 75. (eg. Consider labeling catheters inserted under subopti- drawn through valved catheter hub connectors carries a signifi- mal aseptic conditions in any health care setting cant risk of contamination. with cystic fibrosis is technique dependent. longer needed for the plan of care. Changes in skin temperature (hot or cold). Blood C. Criteria for justi- fication of continued use of a CVAD include but are not limited to: Practice Criteria 1. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S91 JIN-D-15-00057.32(4):212-218. Hankins J.68(11):1179-1187.1 The clinical need for each peripheral and nontun. Measurement of the international normalized ratio (INR) in complications with or without infusion through the hemodialysis patients with heparin-locked central venous cathe. 2. Pierce E. Other types of dysfunction (eg. Rioux J-P. absence of a blood return). Gupta K. Prescribed intermittent infusion therapy (eg. Anatomy and physiology related to infusion therapy. Am J Crit Care. Gorski L. Wallach SG. Karchmer TB. Bischoff W. bloodstream infection). Woodcock T.2-4 (I) 72. Ireland. Hickson T. blood culture) before removing a peripheral catheter (refer to Standard 49. Perucca R. 4. Madore (eg. 48 hours. Stein D. the ters: evaluation of a novel blood sampling method. 2014. Am J Crit Care. Cook T. Remove and insert a new catheter 73. Infiltration and Extravasation).69(4):380-385. Infusion Nursing: An Evidence-Based Approach. cultures and central catheters: is the “easiest way” best practice? 5. et al.10(3):180-182. 2004. Remove short peripheral and midline catheters in 3. Gupta K. J Vasc Access. 2009. based on findings from site assessment and/or medication including anti-infectives in patients clinical signs and symptoms of systemic complications with a known or suspected infection). blood or blood products). Edema. neled central vascular access device (CVAD) is assessed on a daily basis. detach all administra- (VAD) REMOVAL tion sets and aspirate from the catheter hub prior to catheter removal to remove the vesicant medication Standard from the catheter lumen and as much as possible from the subcutaneous tissue (refer to Standard 46. team the continuing need for the nontunneled 44. Tanner M.30(12):1571-1577. 68. Hemodynamic monitoring. 70. 22 (I) 4. Leakage of fluid or purulent drainage from the 2. to Standard 46. and migration of the 2. Standard 49. PICC removal has not been found. The decision to remove or salvage a CVAD due catheter piece. Assess the clinical need for a tunneled cuffed cathe- able vascular access sites. For CVAD removal: the insertion site. Documented history of difficult peripheral catheter is correctly positioned at the cavoatrial venous access. avail. resistance when flush. Collaborate with the health care team members to possibly decreasing but not eliminating the risk plan removal and insertion of a new catheter to meet of air embolism on removal (see Standard 50. to. 3. Documentation of air embolism from removal of position changes (refer to Standard 47. Injuries. in the presence of an unresolved 3. and the continued considered for making the decision to remove the need for infusion therapy requiring a CVAD (eg. Infection. Standard 53. presence of contraindications 2. Assessment by designated unit-based nurse with. consider the S92 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. most likely be at or below the level of the heart. Central 3. D. ing diagnostic imaging studies and the appropri- 2. encountered. Forcible eter (PICC) or midline catheter has been sug. or upper abdomen. Infiltration and Extravasation).indd S92 05/01/16 11:30 PM . 8. Arrange for removal with the LIP when infusion Standard 49. CVAD. therapy is completed. Assess and report signs and symptoms of CVAD to Standard 53. Vascular removed with endovascular techniques to reduce the Access Device [VAD] Planning). Never forcibly remove a CVAD if resistance is therapy.19. interventions for successful removal. Nerve a femorally inserted CVAD has not been found.28 (V) to suspected or confirmed catheter-related blood- stream infection (CR-BSI) should be based on III. Changes in catheter function associated with arm 3. but not limited to: decision to remove the CVAD should also con- 1.8-13 (V) junction. Before removal. removal can result in catheter fracture and emboli- gested as a viable alternative upon removal of zation. Daily patient rounds by an interprofessional sider the severity of deep vein thrombosis (DVT)- team. patient’s current condition. unless contraindicated. any type of CVAD. position. could be at the same level as the patient’s heart.27. Venous Thrombosis). thrombosis. Pain and/or tenderness in unusual locations of CVAD. irritants) (see Standard 52.11. Standard 52. vesicants. Air vascular access needs in the presence of unresolved Embolism). although there is evidence of air entering the Central Vascular Access Device [CVAD]-Associated catheter during insertion and during other proce- Venous Thrombosis. Edema. A. is functioning correctly with a blood B. Unusual respiratory and neurological changes. Contact the LIP to discuss appropriate 1. Assessment by designated infusion/vascular Vascular Access Device [CVAD]-Associated access nursing staff. and LIP direction (refer to B.14-19 (IV) be repositioned to the cavoatrial junction (refer C. In the event of infiltration or extravasation from a 1. 6. Use of a standardized tool including factors to be for systemic anticoagulation. alteration in gravity infusion. Surgically Placed CVADs: Tunneled blood culture results. Insertion of a peripherally inserted central cath. specific cultured Cuffed/Implanted Ports organism(s). Remove a CVAD with a primary or secondary out other patient care responsibilities when other malpositioned catheter tip location that cannot strategies are unsuccessful. related symptoms. The exit site will Access Device [CVAD] Malposition). 4. Do not remove a CVAD in the presence of complication. Catheter pieces retained in the vein should be other types of CVADs (see Standard 26.23-26 (V) complication(s) and a continued need for infusion F. Infection). While documentation of air embolism during puncture site.20 (IV) risk of infection. Changes in color (erythema or blanching) at or ate medical management prior to removal (refer surrounding the insertion site. and when it is no longer needed for CVAD-associated vein thrombosis when the the plan of care. Catheter dysfunction (eg. The including. 1. but not limited [CVAD] Malposition).4. when removing 5. and has no evidence of any infection. Employ strategies to facilitate timely CVAD removal return. effectiveness of antimi.29 (II) crobial therapy.21. Central Vascular dures through the femoral vein. Place the patient in a supine flat or Trendelenburg 4. the presence of: 5. ter and implanted port on a regular basis. Central Vascular Access Device complications to the LIP including. consult with the health care team regard- neck. chest. absence of increasing the risk of air entering through an blood return). 5. the exit site 7. Changes in skin temperature at or surrounding E. intact skin-to-vein tract and fibrin sheath. ing. Sathyanarayana SA.indd S93 05/01/16 11:30 PM . et al. C. J Surg Res. Hospital-wide survey of the use sterile gauze pad until hemostasis is achieved by of central venous catheters.34 (V) 2012. Am J Infect Control. reduction of central line-associated bloodstream infections out- ing. Arora N. O’Grady N. Kearon C. Comerota AJ. 2012. Successful implementation of a unit-based quality nurse to reduce central line-associated blood- 1. Scott C. B. van Wijngaarden E. 2012.41(6): 22. et al. http://www. CLABSIs in neonates with PICCs: a multicenter cohort study. Flanders SA. replacement versus routine replacement of peripheral venous 20. practice guidelines for the treatment and prophylaxis of VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S93 JIN-D-15-00057. Malmvall B-E. resuture of incision). Published April 2011. Marsteller JA. necessary to verify cuff location and facilitate surgi- 2014. Consult with the health care team regarding the 7.38(2):149-153. Note: All electronic references in this section were accessed September 2014. Patel K. et al. Sustained to prevent subcutaneous abscess and delayed heal. Peripherally from a randomized controlled trial. A sterile dressing should be ment intervention. Chopra V. et al. Hanberger H.198(10):551-553. Saint S. Mestre G. A. 4. applied to the access site.132(6):e1609-e1615. Cochrane Database Syst Rev. Bryan-Nomides N. Medefindt J. Infection). or cancer diagnoses). intervention aimed to reduce short peripheral venous catheter. 2014. Peripheral intravenous decision to remove or salvage a CVAD due to sus- catheter-associated Staphylococcus aureus bacteraemia: more pected or confirmed CR-BSI (refer to Standard 49. 2014. Dumyati G. related adverse events: a quasiexperimental cohort study. Risk factors for periph. E. Catheter dwell time and designed to potentiate clot formation used in combi. 2013.(4):CD007798. Carey J. Beckers M. Squires M. Antithrombotic therapy multispecialty panel using the RAND/UCLA appropriateness for VTE disease: antithrombotic therapy and prevention of method. Rickard CM. Alexander M.34 (V) care.CD007798. Doan J. Osborne S. Day A.33 10. et al. Faruqi A. Influence of a multifaceted intervention on central line days in intensive care units: results of a national multisite study. 16. guided placement of midline catheters in the surgical intensive doi:10. The effect of interdisci- plinary team rounds on urinary catheter and central venous REFERENCES catheter days and rates of infection.35(1):63. Am J Infect IV. Rey JE. Tong D. venous catheter team. thrombosis. Yang T.163(suppl 6):S1-S39. Hemostatic pads 13. fibrosis. Engell CA. patients with sickle cell anemia.191(1):1-5.42(10):S197-S202. alternative to high-risk short-term central venous catheters. 2012. Farge D. Ann Intern Med.30. Hammarskjöld F.29(4):329-334.35. Berbel C. Weeks KR. McGrail M.31 (V) 2012. et al. et al. Guidelines for the pre- future (eg. possibility for infusion therapy to resume in the 6. Philip SA. Burdeu G. Reich NG. et al. Removing non- essential central venous catheters: evaluation of a quality improve- randomized trials. Infect Control. including “idle central venous catheter. Stein J. Assess the clinical need for the arterial catheter on a 11.gov/hicpac/BSI/BSI-guidelines-2011. Immediately report cuff or port body exposure to 8.42(7):723-730. 2010. Am J Infect Control. et al. J Hosp Infect. 2011. Hsu Y-J. Am J Infect Control. 30. marked improvements. Currey J. 2014. 17. LaRosa JA. 18. Jones K. et al. cal removal.59(12):1102-1110. Debourdeau P. Am J Sustained low incidence of central venous catheter-related infec- Infect Control. Inan C. Webster J. 2013. et al. catheter. Successful multifaceted stream infections. Assess and document the circulatory status distal to Effect of a multidisciplinary intervention on central line utiliza- the area of cannulation after removal of the arterial tion in an acute care hospital. Advani S. Deutsch GB. et al. Am J Infect Control.42(4):453-455. inserted central venous catheters in the acute care setting: a safe 68.36 (III) 15. care unit: a cost-effective proposal for timely central line removal. tions over six years in a Swedish hospital with an active central 2. 2014. Taxbro K. Am J 3.33(1):50-57. Wallis MC. Tompkins D. C. Custer M. eral intravenous catheter failure: a multivariate analysis of data 19. International clinical 531-536. Berg S. ness equal to or better than manual pressure in small 14. D. Webster J. ness guide for intravenous catheers (MAGIC): results from a 21. et al.1002/14651858. using manual compression.40(6):e211-e215. Peripheral venous catheter care evidence-based clinical practice guidelines. Burns L. Milstone AM. Dutta G. Ilan R.42(2):139-143. Thom KA. 2013. 2015.” Infect Control Hosp Epidemiol. Can J Anesth. Singh N.42(2):122-128. Al Raiy B.29 (II) cdc. Stuart RL. The Michigan appropriate.41(6):520-526. 2015. 2014. Fakih MG. Cameron DR. Idle central venous catheter-days daily basis and remove when it is no longer needed pose infection risk for patients after discharge from intensive for the plan of care. Li S. Fluoroscopy and ultrasound guidance may be side the intensive care unit with a multimodal intervention focus- ing on central line maintenance. Ultrasound- catheters.141 in the emergency department: education and feedback lead to (suppl 2):e419S-e494S. Pediatrics. 9th ed: American College of Chest Physicians 5. Am J Infect Control. Akl EA. Apply digital pressure to the insertion site using a 12. Cload B. Fakih MG. 2014. Temporary central venous cath- the health care team and anticipate appropriate eter utilization patterns in a large tertiary care center: tracking the interventions (eg. 2012. Tejedor S. Clinically-indicated Infect Control.pub3. nation with manual pressure have shown effective. Arterial Catheters Control. Chest. Am J Infect Control. CVAD removal. Nicastro J. Am J Med Qual. Med J Aust. New K.html. Pilcher D. Concannon C. Tortajada P. cystic vention of intravascular catheter-related infections. than 5 years of prospective data from two tertiary health services. Sawyer M. et al. Zingg W. Ensure complete removal of the subcutaneous cuff 9. Sandoz L.77(4):304-308.32. Iatrogenic venous air embolism from 33. Wei YD.15(3):183-188. Endoluminal dilation technique to remove “stuck” tun. Burris J. Technical report: use of ultrasound central femoral vein catheterisation. Walker TG. Med Surg. Central venous catheter 192-196. J Vasc 1357-1370.2(125):2. S94 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. A new hemostasis tool after percu- Oncology clinical practice guideline. Wade JC. J Thromb Haemost. PA: Wolters Kluwer/ 28. Zawacki WJ. of Infusion Therapy. et al. et al. Lee JD. central line removal. Reducing risk of air embolism associated with central 31. eds. Kim SM.1136/bcr-2013-008965. 2013.31(10): taneous angioplasty: the hemcon pad hemostasis device. 2014. Ryan SE. Barnacle AM.indd S94 05/01/16 11:30 PM . 2014. 2013. J Clin Oncol. Dermatol. Hadziomerovic A. J Vasc Interv Radiol. Heart tion due to a retained cuff from a central venous catheter. Xu DC. Clin J Oncol Nurs. Cho SH. Jain S.11(1):71-80. Akagi T. Kelly K.24(1):e14-e17. et al. BMJ Case Rep. Weis M. Jun HJ. Sano S. 2014. Aquino J. A neled hemodialysis catheters. DeVasher E. Jalota L. Lippincott Williams & Wilkins. Quaretti P. Hou L. Plaizier E. A refinement of Hong’s tech. 2011. 27. Hagle ME. doi:10. or failure to heal following venous access port placement in 23. J Neurosci Nurs. Plumer’s Priniciples and Practice to a complex problem. March 13. Greene MT.43(4):193-196. thrombosis associated with central venous catheters in patients 30. J Cardiovasc Nurs.18(4): 25. Cranney G. 34. Penn Patient Saf Advis. Galli F. Br J Radiol. dial coronary intervention. Giles R. 2009. Kim HS. Wound dehiscence with cancer. Rasuli P. J Vasc Intervent Radiol. Reduction of erosion risk in adult patients with venous access devices. implanted venous access ports. 2014:391-426. O’Kelly K.23(8):1089-1093. 26. Dai N. 2012. 2005. Fiorina I.20(5):624-627. Oozawa S. Arnott C.78(926):147-149. Ann Lung Circ.9(2):58-62.30(3): 29. Mangu PB. Wolfers D. Feil M. Schiffer CA.26(6):781-783. comparison of 2 devices for radial artery hemostasis after transra- 2012. 9th ed. Peng WH. J Vasc Access. Devastating cerebral air embolism after patients receiving bevacizumab therapy. Foreign body reac- lead extraction in a patient with a patent foramen ovale. guidance in the removal of tunnelled venous access catheter cuffs. 2013. 24. 2013. care for the patient with cancer: American Society of Clinical 36. Expanded approaches to access and monitoring. 35. Clark DK. Paradoxical 403-405. Xu YW. Cunningham I. In: nique for the removal of stuck dialysis catheters: an easy solution Weinstein SM. Aryal MR. 2014. 2015. Mitchell AW. Philadelphia. cardiac and cerebral arterial gas embolus during percutaneous 32. educates the patient and/or caregiver about phlebi- irritation.26. based on patient population. and stabi- A.11.16.23.24. and diabetes. secure catheter with sta- bilizing device.19-25 (IV) phlebitis. too large a catheter cations are established in organizational policies. and appropriately intervene. Bacterial phlebitis may be related to emergent sites of short peripheral catheters. Recognize risk factors that can be addressed: 1. Move catheter in a lower patient to report pain or discomfort at the vascular extremity to an upper extremity in adults. assessment.indd S95 05/01/16 11:30 PM . vascular access device (VAD) insertions and poor ters. Signs and symptoms of phlebitis include to a new proximal site or opposite side for pedi- pain/tenderness. and management of compli- particulates in the infusate. avoid areas of flexion. II. warmth. which can come from too large a cath- tis.11. and skin antiseptic solution that is not fully dried and pulled into the vein during catheter insertion. or palpable venous cord. purulence. cians and researchers (see Standard 41. the clinician is competent to with dextrose >10% or high osmolarity (>900 recognize signs and symptoms of vascular access device mOsm/L). atrics if possible. depending on length of infu- Standard sion time and anticipated duration of therapy. and any follow-up. Choose the smallest catheter for therapy. catheter movement. Consider a central vascular ration.27 (IV) VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S95 JIN-D-15-00057.1 The clinician assesses the vascular access site for antiseptic solution. Label a catheter inserted dur- (PICCs) for signs and symptoms of phlebitis using ing emergent conditions so it can be removed and a standardized tool or definition. manage- dosage and length of infusion).9-11. indu. and peripherally inserted central catheters aseptic technique.21. To ensure patient safety. and lower extremity except for infants. and/or practice guidelines. PHLEBITIS PICC for infusates listed above or identified as causing phlebitis. the vascular access 3. Assess regularly. certain medications (depending on (VAD)-related complications during insertion. The access device (CVAD) and/or consider alternative number or severity of signs and symptoms that route for medication.20. Care. and risk factors. Vascular immunodeficiency. swelling.27 (IV) of therapy.21 (IV) indicate phlebitis differs among published clini. Allow skin to thoroughly dry after application of 45. the intervention. tion. 4. determines the need for and type of interven- 2. proce- for the vasculature with inadequate hemodilu- dures.16. patient response to treatment. 20 Practice Criteria or 22 gauge if possible. um chloride. or catheter material and stiff- ness. midline cathe. Chemical phlebitis may be related to infusates I. and removal. Patient-related factors include current infection. insertion trauma. Mechanical phlebitis may be related to vein wall tion. type lize joint as needed. and age ≥ 60 Dressing Changes). Prevention. such as potassi- ment.20. move access site. insertion in a Access Device [VAD] Assessment. Consider using a midline catheter or 45. amiodarone. and assesses eter for the vasculature.1-18 (III) years. The Art and Science of Infusion Nursing Section Seven: Vascular Access Device (VAD)-Related Complications Section Standards B. and some antibiotics. Instruct the resited as needed.7. erythema.20. 5. Postinfusion phlebitis, although rare, occurs post TABLE 1 catheter removal through 48 hours due to any of the factors above.11,28 (IV) C. If phlebitis is present with short peripheral catheters, Phlebitis Scale Grade Clinical Criteria midline catheters, and PICCs, determine the possible etiology of the phlebitis, such as chemical, mechanical, 0 No symptoms bacterial, or postinfusion; apply warm compress; ele- 1 Erythema at access site with or without pain vate limb; provide analgesics as needed; consider other 2 Pain at access site with erythema and/or edema pharmacologic interventions such as anti-inflammato- 3 Pain at access site with erythema ry agents; and consider removal as necessary. Topical gels or ointments to treat phlebitis require further Streak formation study for efficacy) (see Standard 44, Vascular Access Palpable venous cord Device [VAD] Removal).11,20,23,29-34 (III) 4 Pain at access site with erythema 1. Chemical phlebitis: evaluate infusion therapy Streak formation and need for different vascular access, different Palpable venous cord > 1 inch in length medication, or slower rate of infusion; determine if catheter removal is needed. Provide interven- Purulent drainage tions as above.7,20 (IV) 2. Mechanical phlebitis: stabilize catheter, apply TABLE 2 heat, elevate limb, and monitor for 24 to 48 hours; if signs and symptoms persist past 48 Visual Infusion hours, consider removing catheter.23,33 (V) 3. Bacterial phlebitis: if suspected, remove catheter. Phlebitis Scale Consider the need to collaborate with the licensed Score Observation independent practitioner regarding the need for 0 IV site appears healthy continued or alternative vascular access when the 1 One of the following is evident: VAD is removed.10,11,35 (IV) slight pain near IV site OR Slight redness near IV site 4. Postinfusion phlebitis: if bacterial source, moni- 2 Two of the following are evident: tor for signs of systemic infection; if nonbacte- • Pain at IV site rial, apply warm compress; elevate limb; pro- • Erythema • Swelling vide analgesics as needed; and consider other pharmacologic interventions such as anti- 3 All of the following signs are evident: • Pain along path of cannula inflammatory agents or corticosteroids as • Induration necessary.28,33 (V) 4 All of the following signs are evident and extensive: D. When the short peripheral catheter, midline catheter, • Pain along path of cannula or PICC is removed, monitor the vascular access site • Erythema for 48 hours to detect postinfusion phlebitis or, • Induration upon discharge, give the patient and/or caregiver • Palpable venous cord written instructions about signs and symptoms of 5 All of the following signs are evident and extensive: phlebitis and the person to contact if this occurs.11 • Pain along path of cannula • Erythema (V) • Induration E. Use a standardized phlebitis scale or definition, • Palpable venous cord which is valid, reliable, and clinically feasible. The • Pyrexia population for which the scale is appropriate should Abbreviation: IV, intravenous. be identified as adult or pediatric. Jackson A. A battle in vein infusion: phlebitis. Nursing Times. 1998;28(94). Reprinted with permission. 1. Two phlebitis scales have demonstrated validity and reliability in some studies and have been used for adult patients. Recent evidence recom- mends further study for valid and reliable assess- F. Review phlebitis incidents causing harm or injury, ment tools.6,12,36-39 (I) using incident or occurrence reports or medical 2. The Phlebitis Scale (Table 1) has concurrent record reviews, for quality improvement opportuni- validity, interrater reliability, and is clinically ties (see Standard 6, Quality Improvement).41-43 (V) feasible.8 (IV) REFERENCES 3. Visual Infusion Phlebitis Scale (Table 2) has content validity, interrater reliability, and is Note: All electronic references in this section were accessed September clinically feasible.6,40 (IV) 30, 2015. S96 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.indd S96 05/01/16 11:30 PM 1. Anson L, Edmundson E, Teasley S. Implications of evidence- 20. Dychter S, Gold D, Carson D, Haller M. Intravenous therapy: a based venipuncture practice in a pediatric health care Magnet review of complications and economic considerations of periph- facility. J Contin Educ Nurs. 2010;41(4):179-185. eral access. J Infus Nurs. 2012;35(2):84-91. 2. Barría R, Lorca P, Muñoz S. Randomized controlled trial of vas- 21. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. cular access in newborns in the neonatal intensive care unit. J Accepted but unacceptable: peripheral IV catheter failure. J Infus Obstet Gynecol Neonatal Nurs . 2007;36(5): Nurs. 2015;38(3):189-203. 450-456. 22. Mowry JL, Hartman LS. Intravascular thrombophlebitis related 3. Dugan S, Le J, Jew R. Maximum tolerated osmolarity for periph- to the peripheral infusion of amiodarone and vancomycin. West eral administration of parenteral nutrition in pediatric patients. J J Nurs Res. 2011;33(3):457-471. Parenteral Enteral Nutr. 2014;38(7):847-851. 23. Phillips LD, Gorski L. Complications of infusion therapy: periph- 4. Dumont C, Getz O, Miller S. Evaluation of midline vascular eral and central vascular access devices. In: Phillips LD, Gorski L. access: a descriptive study. Nursing. 2014;44(10):60-66. Manual of IV Therapeutics: Evidence-Based Practice for Infusion 5. Foster L, Wallis M, Paterson B, James H. A descriptive study of Therapy. 6th ed. Philadelphia, PA: FA Davis; 2014:540-611. peripheral intravenous catheters in patients admitted to a pediat- 24. Salgueiro-Oliveira A, Parreira P. Incidence of phlebitis in patients ric unit in one Australian hospital. J Infus Nurs. 2002;25(3): with peripheral intravenous catheters: the influence of some risk 159-167. factors. Aust J Adv Nurs. 2012;30(2):32-39. 6. Gallant P, Schultz A. Evaluation of a visual infusion phlebitis 25. Spiering M. Peripheral amiodarone-related phlebitis: an institu- scale for determining appropriate discontinuation of peripheral tional nursing guideline to reduce patient harm. J Infus Nurs. intravenous catheters. J Infus Nurs. 2006;29(6):338-345. 2014;37(6):453-460. 7. Gorski LA, Hagle ME, Bierman S. Intermittently delivered IV 26. Cicolini G, Bonghi AP, Di Labio L, Di Mascio R. Position of medication and pH: reevaluating the evidence. J Infus Nurs. peripheral venous cannulae and the incidence of thrombophlebi- 2015;38(1):27-46. tis: an observational study. J Adv Nurs. 2009;65(6):1268-1273. 8. Groll D, Davies B, MacDonald J, Nelson S, Virani T. Evaluation 27. Rego Furtado LC. Incidence and predisposing factors of phlebitis of the psychometric properties of the phlebitis and infiltration in a surgery department. Br J Nurs. 2011;20(14):S16-S18, S20, scales for the assessment of complications of peripheral vascular S22-S25. access devices. J Infus Nurs. 2010;33(6):385-390. 28. Webster J, McGrail M, Marsh N, Wallis MC, Ray-Barruel G, 9. Maki DG, Ringer M. Risk factors for infusion-related phlebitis Rickard CM. Postinfusion phlebitis: incidence and risk factors with small peripheral venous catheters. Ann Intern Med. [published online May 14, 2015]. Nurs Res Pract. 1991;114(10):845-854. doi:10.1155/2015/691934. 10. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the 29. Di Giacomo M. Comparison of three peripherally-inserted cen- prevention of intravascular catheter-related infections. http:// tral catheters: pilot study. Br J Nurs. 2009;18(1):8-16. www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. Published 30. dos Reis P, Silveira R, Vasques C, de Carvalho E. Pharmacological April 2011. interventions to treat phlebitis: systematic review. J Infus Nurs. 11. Perucca R. Peripheral venous access devices. In: Alexander M, 2009;32(2):74-79. Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion 31. Eppert H, Goddard K. Administration of amiodarone during Nursing: An Evidence-Based Approach. 3rd ed. Philadelphia, PA: resuscitation of ventricular arrhythmias. J Emerg Nurs. Saunders/Elsevier; 2010:456-479. 2010;36(1):26-28. 12. Ray-Barruel G, Polit D, Murfield J, Rickard C. Infusion phlebitis 32. Leal A, Kadakia K, Loprinzi C, et al. Fosaprepitant-induced assessment measures: a systematic review. J Eval Clin Pract. phlebitis: a focus on patients receiving doxorubicin/ 2014;20(2):191-202. cyclophosphamide therapy. Support Care Cancer. 2014;22(5): 13. Salgueiro-Oliveira A, Parreira P. Incidence of phlebitis in patients 1313-1317. with peripheral intravenous catheters: the influence of some risk 33. Liu H, Han T, Zheng Y, Tong X, Piao M, Zhang H. Analysis of factors. Aus J Adv Nurs. 2012;30(2):32-39. complication rates and reasons for nonelective removal of PICCs 14. Tagalakis V, Kahn SR, Libman M, Blostein M. The epidemiology in neonatal intensive care unit preterm infants. J Infus Nurs. of peripheral vein infusion thrombophlebitis: a critical review. 2009;32(6):336-340. Am J Med. 2002;113(2):146-151. 34. Zheng G, Yang L, Chen H, Chu J, Mei L. Aloe vera for preven- 15. Vanhatalo T, Tammela O. Glucose infusions into peripheral veins tion and treatment of infusion phlebitis. Cochrane Database Syst in the management of neonatal hypoglycemia—20% instead of Rev. 2014;(6):CD009162. doi://10.1002/14651858.CD009162. 15%? Acta Paediatr. 2010;99(3):350-353. pub2. 16. Wallis M, McGrail M, Rickard C, et al. Risk factors for periph- 35. Joanna Briggs Institute. Management of peripheral intravascular eral intravenous catheter failure: a multivariate analysis of data devices. Aust Nurs J. 2008;16(3):25-28. from a randomized controlled trial. Infect Control Hosp 36. Powell J, Tarnow KG, Perucca R. The relationship between Epidemiol. 2014;35(1):63-68. peripheral intravenous catheter indwell time and the incidence of 17. Washington G, Barrett R. Peripheral phlebitis: a point-prevalence phlebitis. J Infus Nurs. 2008;3(1):39-45. study. J Infus Nurs. 2012;35(4):252-258. 37. Schultz AA, Gallant P. Evidence-based quality improvement pro- 18. Zingg W, Pittet D. Peripheral venous catheters: an under-evaluated ject for determining appropriate discontinuation of peripheral problem. Int J Antimicrob Agents. 2009;34(suppl 4):S38-S42. intravenous cannulas. Evid Based Nurs. 2005;8(1):8. 19. Biggar C. Comparison of postinfusion phlebitis in intravenous 38. Uslusoy E, Mete S. Predisposing factors to phlebitis in patients push versus intravenous piggyback cefazolin. J Infus Nurs. with peripheral intravenous catheters: a descriptive study. J Am 2012;35(6):384-388. Acad Nurse Pract. 2008;20(4):172-180. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S97 JIN-D-15-00057.indd S97 05/01/16 11:30 PM 39. Marsh N, Mihala G, Ray-Barruel G, Webster J, Wallis MC, 2. Infusion of antibiotics and corticosteroids Rickard CM. Inter-rater agreement on PIVC-associated phlebitis through a peripheral catheter. signs, symptoms and scales [published online July 17, 2015]. J 3. Current infection. Eval Clin Pract. doi:10.1111/jep.12396. 4. Subsequent peripheral catheters after the first 40. Bravery K, Dougherty L, Gabriel J, Kayley J, Malster M, Scales insertion. K. Audit of peripheral venous cannulae by members of an IV therapy forum. Br J Nurs. 2006;15(22):1244-1249. 5. Inability or difficulty with communicating pain, 41. Mestre G, Berbel C, Tortajada P, et al. Successful multifaceted tightness, or other discomfort. intervention aimed to reduce short peripheral venous catheter- 6. Altered mental status or cognition (eg, agitation, related adverse events: a quasiexperimental cohort study. Am J confusion, sedation). Infect Control. 2013;41(6):520-526. 7. Age-related changes to vasculature, skin, and 42. Tofani BF, Rineair SA, Gosdin CH, et al. Quality improvement subcutaneous tissue. project to reduce infiltration and extravasation events in a pedi- 8. Diseases that produce changes in vasculature or atric hospital. J Pediatr Nurs. 2012;27(6):682-689. impaired circulation (eg, diabetes, lymphedema, 43. Woody G, Davis BA. Increasing nurse competence in peripheral systemic lupus, Raynaud’s disease, peripheral intravenous therapy. J Infus Nurs. 2013;36(6):413-419. neuropathy, peripheral vascular disease). 9. Medications that alter pain sensation (eg, narcot- ics) or suppress the inflammatory response (eg, 46. INFILTRATION AND steroids). EXTRAVASATION 10. Difficulty with peripheral venous access related to obesity, history of multiple venipunctures, and Standard infusion therapy. 11. Peripheral catheters indwelling longer than 24 46.1 The clinician assesses the peripheral and central hours. vascular access device site for signs and/or symptoms of 12. Use of deep veins with insufficient catheter infiltration and extravasation before each infusion and length. on a regular basis and educates the patient and/or care- 13. Length of the injection or infusion time for vesi- giver about infiltration/extravasation, any interven- cant medications.1-9 (IV) tions, and any required follow-up. D. Recognize the differences between vesicant, nonvesi- 46.2 Appropriate intervention(s) are implemented as cant, and irritant solutions and medications. There determined by the characteristics of the solution or is no accepted scoring system for classification of medication escaping from the vein. medications as a vesicant or irritant, leaving clini- cians to rely upon specific drug information, case reports, and other published literature. Each facility Practice Criteria should reach a consensus on what medication is A. Select the most appropriate vascular access device considered to be a vesicant and irritant based on (VAD) and insertion site to reduce the risk for infil- their internal formularies. tration/extravasation. Do not use winged metal 1. Identify the vesicant nature of antineoplastic and needles for infusion as they are associated with an noncytotoxic medications prior to administra- increased risk of infiltration (refer to Standard 26, tion and be prepared to use the correct antidote Vascular Access Device [VAD] Planning; Standard treatment for each medication. 27, Site Selection). 2. Vesicant medications can produce varying B. Assess all VADs for patency and the absence of signs degrees of tissue damage, including blistering and symptoms of infiltration and extravasation and necrosis. Surgical washout procedure, prior to each intermittent infusion and on a regular debridement, and skin grafting may be indicated. basis for continuous infusions. Assessment includes 3. Nonvesicant solutions and medications may pro- observation, palpation, flushing to identify resis- duce tissue damage in neonates and infants. tance, aspiration for a blood return, and listening to 4. Vesicant and nonvesicant solutions and medica- the patient’s report of pain. Frequency of VAD site tions can produce compartment syndrome with assessment depends upon the specific patient popu- the possibility of arterial and nerve damage that lation and characteristics of the infusion therapy could lead to complex regional pain syndrome or (refer to Standard 40, Flushing and Locking; amputation of the extremity if not quickly Standard 41, Vascular Access Device [VAD] recognized. Assessment, Care, and Dressing Changes). 5. Tissue damage from irritant medications is asso- C. Recognize risk factors associated with infiltration ciated with a large volume of concentrated medi- and extravasation including: cation escaping into the tissue.2,3,10-15 (IV) 1. Insertion sites in the hand, antecubital fossa, and E. Identify causes of infiltration/extravasation that may upper arm when compared to sites in the forearm. indicate the need for more frequent monitoring or S98 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.indd S98 05/01/16 11:30 PM may appear with pas. contrast media) or may be delayed for days with respiratory and cardiac function). Peripheral sites most often associated with may vary from a few days to 1 to 2 weeks. bind DNA. subcutane- tion. catheter size. the medication’s ability to tional medication into the tissue. Immediately stop the infusion when the patient tion of deep veins of the upper arm is associ. which is pain intensity may increase over time. Obstructive issues. burning. Timing of CVAD sive stretching of the muscles in the extremity. infiltration/extravasation. injection of solution or medications. G. and aspirate from the catheter or hol or polyethylene glycol. removal and insertion of a new VAD. or entire sation when compared to other peripheral venous pathway. puncture site. Progression to ulceration a. outline the area with visible F. vesicants can produce progression. may be out 10. Disconnect the administration set from the cath- vascular dilatation. exacerbation of the tissue injury. based on the identified extravascular location of 2. Edema may appear as a raised area under the the catheter tip. Surgical intervention may be skin near the peripheral VAD site or as an needed as determined by the LIP.4. and rate of injection or infusion. sensation. removal depends on the plan of care. vascular access device (CVAD) tip location. 8. 4. Changes in color may include blanching from the clinical signs and symptoms and their nonvesicant solutions. Blister formation may appear within hours (eg. These symptoms and vessel depth are associated with higher require further assessment to determine the appro- rates of infiltration/extravasation (refer to priate intervention(s). the amount remaining Edema from a CVAD may appear as a raised area when stopped. and motor many anatomical locations and at any point in function. eral catheter tip could be inside the vein lumen. limiting blood flow and port access needle. eter hub. Signs and symptoms pro. enlarged and tense extremity due to fluid accu. and the clinical pre. infiltration/extravasation are the hand and depending upon the medication that wrist. Pharmacologic or physiochemical properties yet an additional puncture of the vein wall has associated with drug concentration and volume occurred. solution in the container. Using a skin marker. Assess the area distal (located below) to the VAD c. Remove the peripheral catheter or implanted site and tip location. Standard 22. extravasated. and/or cause 4. Central 2. Mechanical issues associated with VAD site selec. as this would inject addi- nonphysiological pH. although the periph- Vascular Access Device [CVAD] Malposition). antineoplastic agents. Anticipate use of radiographic tests to identify of proportion to the injury. Never apply pressure to the area. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S99 JIN-D-15-00057. 1. 1. securement.3. Aspirate for a blood return. Pain may be the initial symptom and may be sud. causing overflow of infusing solutions from the 6. sentation can be confused with phlebitis or flare 9. extravasation into deep tissue not limited to: may not produce visible color changes. including but redness. although a very small amount of fluid may be 3. or port pocket. however.6. on the neck or chest. foot and ankle. Short catheter length “normal” with any infusion. at ated with higher rates of infiltration/extrava. tion of some medications. into the tissue based on the original amount of Compare circumference of both extremities. such as alco.16 (IV) b. and normal body movement (eg. hyperosmolarity and 3. implanted port access needle with a small syringe. Limit the amount of solution that enters the tissue signs of infiltration/extravasation to allow for through early recognition of signs and symptoms of assessing changes. 11.16 (IV) 7. reports pain. the dwell time (refer to Standard 53. escaping into the tissue.indd S99 05/01/16 11:30 PM . such as vein thrombosis or retrieved. Extravascular CVAD tip location can occur in site for capillary refill. (LIP) about the event. 2. The need for surgical consultation is based on 3. Vascular Visualization). and activate the estab- 1.13. Fluid leakage from the puncture site. Ultrasound-guided peripheral catheter inser. kill replicating cells. and/or tightness.1. the catheter tip location. Notify the licensed independent practitioner reactions. central ous tunnel. Estimate the volume of solution that has escaped mulating in compartments of the extremity. Photograph the area to identify progression or gress from simple to complex. stenosis proximal to (located above) the insertion 5. insertion techniques. catheter tip. as this should not be considered catheter insertion sites. 5. and antecubital fossa. stinging.5. Do not flush the VAD. lished treatment protocol or the prescribed treat- den and severe when associated with a rapid ment. and excipients. used in the formula. or around the insertion site. 21 (IV) priate antidote. Neutralize the medication with the appropri. Follow the established treatment protocol or LIP iv. Phentolamine is preferred for vasopressor and symptoms to immediately report. Hyaluronidase is not considered to be an prescription as appropriate for the solution and antidote to the specific extravasated drug. 37°C. Automated power or pressure injectors produce should begin within 6 hours of the extravasa. extravasation. however. the manufacturer’s directions for dose and tion of vinca alkaloids and vasopressors and administration. Changes that should be reported to the LIP (eg.17. Repeated toms of infiltration/extravasation. Inject other antidotes into the subcutaneous ration and extravasation. osmolar solutions (eg. heat application. electronic order forms. Do not exceed 42°C (107.20. Terbutaline injection has been used for reabsorption of the solution/medication. a lower risk of allergic response. Subcutaneous injec- localize the medication in the tissue and reduce tion within 1 hour of the extravasation inflammation. Remove the cold compress 15 minutes before perse the extravasated drug.6. the infusion of dexrazoxane begins. to administration. parenteral nutrition plies. and other signs of infection).indd S100 05/01/16 11:30 PM . repeat every 8 hours as clinically indicated. sup. Use the appropriate method for clinical management is not derived from animals and may have of the infiltration/extravasation site. are not designed to detect the presence or absence of 4. it is an enzyme that increases exposure of subcutaneous tissue to the solution or absorption and dispersion of the drug in medication. Do not use cold compresses with extravasa. for anthracycline extravasation. S100 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. H. cold compresses when the goal is to inject by the IV route. they will exacerbate ane over 3 days is the recommended antidote the problem until the infusion is stopped. increase local blood flow. Medication with a high viscosity requires less small needle (eg. ate antidote. hyper- management protocols. Electronic infusion pumps do not cause infiltra- a. Elevate the extremity to encourage lymphatic iii. administration. and other materials needed to manage the and calcium salts). Use dry. 3. 12. postulated that this jet could induce vessel perfo- b. and disperse the medi. Follow the spe.17-19 (IV) trast media. strip to the site of vasopressor extravasation. Follow a. tissue surrounding the extravasated site. and radiographic con- event. J. 1. Administer the appropriate antidote for the solu. Educate the patient and caregivers about: mechlorethamine and has been suggested 1. Daily intravenous (IV) infusion of dexrazox. ele- extending to a greater area. a jet of fluid exiting the catheter tip. vated temperature. sation of acidic and alkaline medications as sub- a.2. Apply dry. Use a 3. Infusion 2. Do not rely on the alarm from an electronic infusion 3. sion is still present or if vasoconstriction is changes in extremity mobility and sensation. cold compresses for nonirritant and pump to identify infiltration/extravasation. surgical washout) for extrava- cation through the tissue. Apply topical nitroglycerin 2% as a 1-inch c.22-24 (IV) i Sodium thiosulfate is recommended for K. Apply dry. emphasizing the specific signs ii. infiltration/extravasation neoplastic and noncytotoxic drugs. cutaneous injections could cause gas formation b. Dilute the medication further with the appro.3. v. injection may be necessary if hypoperfu. 25 gauge or smaller) and force to cause fluid flow when it is warmed to change it for each injection. Use nonpharmacologic methods (eg.14. tions or medication in the tissue. tion/extravasation. It has been tion and be infused into the opposite extremity.6°F) in pediatrics. 2. Fluid warming may be associated with cific manufacturer’s directions for dose and lower rates of extravasation (see Standard 24.2. event produces the best response. Use of dry heat in con- in the presence of vaso-occlusive events (eg. gistically to increase blood flow and dis- b. Provide convenient access to the list of the tissue and its use is reported with anti- vesicants and irritants. Do NOT 1. junction with hyaluronidase works syner- sickle cell anemia). Recombinant hyaluronidase I. complications. warm compresses when the goal is to 5. and exacerbate the tissue injury.3. medication in the tissue with the goal of limiting the Instead. Flow-Control Devices). elevation. The risks of receiving a vesicant medication prior for large extravasates of cisplatin.17 vasopressor extravasation due to the inter- (IV) mittent shortages of phentolamine. alarms hyperosmolar fluids and medications. The possible progression of the signs and symp- area is seen within 10 minutes. Normal perfusion of the 2. 22.6. LC. feasible. Ducharme A. J Pediatr Nurs. Cervantes A. Almanric K. Jackson P. Polovich M. Northway T. observe and local tissue injury from administration of vasopressors skin integrity. Barbee MS. Compartment appropriate interventions to manage each level on syndrome of the forearm: a systematic review. Hanrahan KM.1.41(3):378- sen grading scale should also be accompanied by 385.19(1):49-58. management of extravasation injuries in the neonatal intensive Wheeler B. Wallis MC. Am J Roentgenol. Felberbauer F. 2011.262(2): 7. Monitor the site. Review infiltration/extravasation incidents causing 16. Implementation of a protocol for the prevention and 19.2. Russell JM. Vidall C. 2009. Media. Warren D. Fortier S. Boulanger J. 2015. Hacker S. A systematic review of extravasation area by measurement and/or photography.35(5):290-292. and be oriented 16-20. Quality Extravasations: Evidence-Based Practice Guideline. Pop RS. Bashir MR. the injection of iodinated contrast material. Risk factors for periph- L. Dufour A. Restieaux M. 12. Safe heat application for pediatric Support Care Cancer. 4. 28BF1D4E1B9A3A2918DA9E27A3. 2012. J Am Coll Radiol. Kuehn SC. Hyaluronidase for Treatment of Intravenous opportunities (refer to Standard 6. event and the venue of care. Neonatal extravasation injury: prevention and man- care patient. Owonikoko TK. 2015. Loubani OM. 24. 8. eds. Barker D.82(1):53-54. Use a standardized tool or definition for assessing eral intravenous catheter failure: a multivariate analysis of data and documenting infiltration/extravasation from all from a randomized controlled trial. Fish DN. Roberts CS. Weber P. O’Boyle C. using incident or occurrence reports ISRN Dermatol. Ebbinghaus S. Davenport MS. Taxanes: vesicants. Roila F. Dyer RB. DeZorzi P.2015. O. Singh A. Morris P.27(2):113-118.17 (IV) R. Mueller SW.16(5):528-534. doi:10.25(2):168-175. 2012.pdf. or just irritating? Ther Adv Med Oncol. Giannoudis PV. Nelson R. 2014. PA: Oncology Nursing Society. Harvey RD. Maw A.indd S101 05/01/16 11:30 PM .34(6):617. Pérez Fidalgo JA. and clinically 63-68. Maclaren R.014. Intravenous con. 2012. J Nurs Care Qual. 20. the tool. Acute compartment syndrome of the ongoing assessment and monitoring of the infiltra. Hallock D. Schindera S. Margulies A.17. irritants. Cefaratti M. 2012. Rice L.30(3):653. 6.109(4):32-33. Management of the extravasation of anti-neoplastic agents. Skala 475-484. American College of Radiology. 2014. 21. 2012. agement in Australia and New Zealand—a survey of current 2. Can J Hosp Pharm. Neville AM. Pharmacotherapy. however. CT contrast material to 37°C. A pediatric peripheral intravenous infiltration assessment peripheral catheter site. Green RS. http://www. This assessment should occur initially and 10. Pittsburgh. Describing intravenous extravasation in children (DIVE N. to the patient’s size and age. Saleem S. Al-Benna S. Howle L. Eur J Oncol Nurs. Extravasation injuries in adults. Coursey C. Haslik W. 2014.e9-17. 01. Gorski LA. ACR Manual on Contrast beep. tion/extravasation site and to document all factors 14. doi:10.35(4):243-248. Chemotherapy and Rate of contrast material extravasations and allergic-like Biotherapy Guidelines and Recommendations for Practice.25 (IV) 2011. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S101 JIN-D-15-00057.3. continue until resolution. McGrail M. Int J Evid Based Healthc. Eur J Surg Oncol. 3. Iowa City. Broadbent R. Nichols E. Carr involved with the event. Prasarn ML. 2015. M. 2011. 2015. 1. Kalyani BS. J Am Acad Orthop Surg. patients: a hot item. Several scales have been 11. 2010. harm or injury. noncytotoxic medications. tool. 2010. Improvement). Use a standardized format to document initial and 13.6 (IV) eters. Bulas D.acr. Kiser TH.193(4):970-979. J Infus Nurs.1016/jcrc. Huber C. practice.23(5):1459-1471.35(1): types of VADs that is valid. Dykes TM. Version 10. sensation. Standard 8. Patient Education). ed. 632. REFERENCES 18. LeFebvre K. results in favorable changes in fluid dynamic properties during trast extravasation during CT: a national data registry and prac. 2007. Kadom N. Protecting the site from sunlight. IA: University of Iowa College of Nursing. as needed based on severity of the study). BMC Pediatrics. doi:10. Shalaby- 5. 2013.64(5):340-345. 2014. et al. Paulson EK.1155/2013/856541. Assess changes of the 15.org/~/media/37D844 23. level of pain. 2013. Augustine A. tice quality improvement initiative. Olsen C. only 1 pediatric tool has been tion of vesicant cytotoxics: surgical options for a rare complica- tested for validity and interrater reliability. reliable. Modifying peripheral IV catheters with side holes and side slits 5. 4th reactions: effect of extrinsic warming of low-osmolality iodinated ed. 1. Olsen M. Management of chemotherapy extravasation: Note: All electronic references in this section were accessed October ESMO-EONS clinical practice guidelines.12(2):183-191. et al. 2015. Bhargavan-Chatfield M. Reynolds PM. J Infus Nurs. The frequency of follow-up visits to the LIP and/ Rana E. 2015. Hashim HD. Wang CL. Webster J. McGloin R. upper extremity. Limb amputation in hemoglobin SC disease Management of extravasation injuries: a focused evaluation of after application of ice and elevation.9(2):165-171. García Fabregat L. 2011. Ouellette EA. Infect Control. or medical record reviews for quality improvement 17.1186/1471-2431-13-34. Recommendations for frequency of assessment of the short 25. and motor through peripheral intravenous catheters and central venous cath- function of the extremity. J Crit Care.6 (IV) 9. Paquette V. Holley J. Kobayashi H. Port-a-Cath® extravasa- published. regularly based on organizational policies and pro. 2009. J Hand Surg Am.6(1): cedures. IV infusion alarms: don’t wait for the 4. The cho. Office for Nursing Research.36(3):535-543. Am J Hematol. Am J Nurs. Fisher BE. Nursing role model for computed tomography: contrast or other medical consultants as needed (see injection decreases extravasation rates. tion of cancer chemotherapy. Radiology. NERVE INJURIES symptoms of paresthesia.1 During peripheral venipuncture and catheter dwell Inform the licensed independent practitioner (LIP) time. reports of paresthesia-type pain require immediate of the patient’s report of symptoms as early recogni- removal of the vascular access device (VAD). arteries. Review the patient’s medication list for systemic ical. observe for respira- control bleeding at attempted and successful sites to tory difficulties or dyspnea and changes in the eye. 3.21-25 (V) tions of pain or discomfort. such as radiating electrical pain. however. common sites have a greater intensification of paresthesia (eg.22.indd S102 05/01/16 11:30 PM . 2. E. is not propor- ity.18-20 (V) and upper eyelid drooping. as fluid accumulating variations in these structures are common and can in the tissue can lead to nerve compression injuries. clinicians will maintain a high specialist) may be required. Median nerve on the volar aspects of the wrist. Recognize that anatomical dwell of a peripheral catheter. and autonomic changes. Details of the patient’s index of suspicion for nerve injuries when the patient report of symptoms should be documented in the complains of respiratory difficulty or unusual presenta. Neuroma. thermal. 2. burning or risk of nerve injury. Surgical removal is used to restore radial wrist.20. In the presence of any CVAD. 47. Use appropriate means to H. Median and anterior interosseous nerve at or pression resulting in lack of nerve tissue perfu- above the antecubital fossa. motor. Perform neurovascular assessment. D. It is characterized by ongoing neuro- As nerves cross a joint of the upper or lower extrem. sion. patient reports paresthesia-type pain during the eral or CVAD insertion. and chem- C. function. hematoma. Radial (median and radial nerve).19. be complex. Pallor and loss of peripheral pulse indicate antecubital fossa. sory. reduce the risk of hematoma that can lead to nerve such as pupil constriction with equal light reaction injury due to compression. (IV) ture in a vein or artery. there is an increase in neural tissue. thus increasing the risk of temporary or Fluid can originate from infiltrated intravenous permanent nerve injury during VAD insertion and solutions. producing nerve com- 4.30 anticoagulant medication(s) prior to making a punc. which is seen on a S102 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Immediately remove a peripheral catheter when a tions of veins. Standard Stop the procedure upon the patient’s request and/or when the patient’s actions indicate severe pain. Superficial radial nerve at the cephalic vein of the injury site. or numbness. Pain progresses from paresthesia to paral- 5. Selecting specific peripheral venous and arterial thrombophlebitis. Do not use subcutaneous probing techniques or multiple passes of the needle or catheter when per- Practice Criteria forming any puncture procedure as this increases the risk of nerve damage. Axillary (brachial plexus).14.23 (V) puncture sites for the purpose of avoiding nerves is G. debilitating condition that can result from veni- 3. tion of nerve damage produces a better prognosis.26 (V) 3.1-10 (I A/P) inflammatory process of phlebitis and B. medical record. and autonomic nerve injury is possible due to Frequently this syndrome spreads to nontrau- direct nerve puncture or nerve compression. include sensory. and edema associated with the dwell. or surgical sympathectomy. Venipuncture sites with the localized tingling. sen. Motor.22 (V) A. 47.9. Subclavian and jugular insertion sites can produce carefully remove the VAD if the patient reports damage to the phrenic nerve. prickly feeling.29. It requires lifelong manage- A/P) ment with medications. pathic pain over a regional area. pain.27.11-17 (I matized extremities. numbness) as these may indicate greatest risk include: advancing nerve damage including: 1.8. a mass of connective tissue and nerve nerves for sites in the dorsal hand. tingling. nerve blocks.14.9. Brachial plexus nerve for subclavian and jugular Surgical fasciotomy is required within a few sites. 47. Recognize normal and potential anatomical varia. Lateral and medial antebrachial nerves for the ysis. hours to prevent loss of the extremity. burning. 6.7. Compartment syndrome. Brachial (median nerve).9. increasing tional to the original injury. hand access devices (CVADs). Immediately stop the VAD insertion procedure and 1. and progresses to the risk of nerve injury in these areas. puncture. an advanced stage of compartment syndrome.28 Arterial sites with the greatest risk include: (IV) 1.9. Complex regional pain syndrome is a chronic. F. and nerves used for periph.21. fibers that prohibit regeneration of nerves at the 2. Distal sensory branches of the radial and ulnar 1. observing for not possible.2 During the insertion or dwell of central vascular Consultation with an appropriate surgeon (ie. review. 2001.21(1):38-45.44(12):653-655. venous catheters. REFERENCES 20. Stringer MD. Brachial plexus injury as a and jugular inserted catheters have been reported complication after nerve block or vessel puncture. this has been femoral vein puncture in a patient with severe coagulopathy. 33. Michel F. Puhaindran ME. Filshie J. and vein thrombosis. Clin Anat. A case of anterior interosseous nerve and infiltration/extravasation of infusing fluids. Singapore Med J. Merrot T. Huanmanop T. Oh EH. J Infus Nurs. J Child Orthop. 2011. Pediatr magnetic resonance imaging and anatomic correlation. nosis. nerve of forearm after venous cannulation: a case report and lit. “Just a sharp scratch”: permanent radial.52(9):831-833. Phrenic nerve injury can come from direct 15. Byun EJ. 2001. O’Donnell JM. Wongkerdsook W. Hughes P. Anatomy of the lateral antebrachial 24. Choi YS. Moss A. 2010. Lim H. Br J 2007. 2013. Jacobson JA. Med. Falk A. 13. the cubital fossa. Newman B. 2011. Edwards WD.1155/2014/613921. Ridolfini MP. 30. Hranchook A. Arterial cannulation: a critical diaphragm. 2012. Br J Anaesth. Chouliaras K. Agthong S. syndrome. Median nerve bisection: a morbid complica- trauma associated with multiple needle insertions. basilic vein and brachial artery. 2011. Casali C. 2013. Hemidiaphragmatic paralysis erature review. Cousins TR. Iatrogenic selective lesion of the 3. Takasaki Y. 2. which are suggestive of 2014.88(1):46-57. and arteries at venipuncture sites in els.14(3):203-204. 2007. Peripheral nerve injury from 2. chest radiograph as an elevated right hemi. Report of an unusual ture.31-38 (V) insertion. Ann Rehabil Med.33(8):1475-1483. Br J Hosp Med. Chentanez V. Villias C. Amarase C. Ho K. 2014.81(4):227-236. Transient right phrenic nerve palsy associated with 11. 1999. Aggarwal S. veins and nerves. intraventricular tip locations. median nerve at the elbow. J Assoc Vasc compression due to the presence of the catheter Access. Applied anatomy of the superficial 2014. Gunderson MA. Transfus Med Rev.66(4):409-416. 18. Zhang J. J Surg Educ. Tonosaki Y. AANA J. Medial ante. Manou V. Foukas A. 6. Wong HP. 16. Venipuncture-induced nerve injury.106(3):348-351. 35. Yotnuengnit P. Agthong S.14(3):337-338. 9. See M. Raikos A. Lopez A. Mehta S. Case Rep cial radial nerve and cephalic vein. clinical implication for subclavian vein catheterization. et al. syndrome: a case report and review of the literature. Chiavaras MM. 22.30(6):346-350.7(3): 2005. Lawton J. Nerve injuries related to vascular access insertion and cutaneous nerve in relation to the lateral epicondyle and cephalic assessment. tion of a peripherally inserted central catheter. Pathophysiology of nerve compression. Yamada K.indd S103 05/01/16 11:30 PM .40 (V) median and ulnar neuropathy following diagnostic venepuncture. Park SH. Bagga A. a rare complication arising from use of a central 12. 2014. Zlotolow D. Paraskevas G. Zhang J. dis. Kim HJ. Chiba S. Hand Clin. in preterm neonates: a rare complication of peripherally inserted VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S103 JIN-D-15-00057. Jones M. 2000. 5. Hari P. tended neck veins. Acta Neurol Belg.25(5):659-662. Topographical anatomy of super. 1997. Pierelli F.27(3):210-218. Boeson MB. Gourgiotis S.72(4):267-271. cutaneous nerves. Di Fabio R. Stevens R. 2000. Amarase C. Horowitz S. 225-233.89(3):672-673. venous and neural variations in a cadav.30(6):1226-1230. national no-fault compensation scheme: an observational cohort brachial cutaneous nerve: anatomical relationship with the study. 10.21(4):307-313. Int J Clin Pract. Ultrasonographic findings of superfi. Cubital fossa venipuncture sites intravenous cannulation: a case report. J Neuropathic Right phrenic nerve palsy as a complication of indwelling central Pain Symptom Palliation. Green M. syndrome after peripherally inserted central catheter (PICC) line CVAD removal is indicated. Katsuda I.26(5):540-543. Troupis TG. reported with trauma from insertion technique 19. Hiccups. 2014. Amrami KK. Iatrogenic nerve injury in a 4. J Brachial Plexus Peripheral Nerve Inj. Kanj WW. 23. Clin Anat. Pain. et al.87(3):510-511. itself. Sav T. Ultrasound Med. Clin Anat. Hida T. medial epicondyle. 32. Femoral nerve palsy: an unusual complication after Known as Horner’s syndrome. Michalinos A. 2012.7(3):129-131.94(3):225-229. and hiccups may also be pre. Rigg A. 2004. Tosello B. 2013. Hemodialysis Int.38(1):52-56. Int J Morphol. Damwan A. Ellis H. Anatomy 27. Shin HY. Iatrogenic upper limb nerve central venous catheterization. Agnes A. Peripherally inserted central catheters (PICCs) 17.68(3):160-161. 34. Kim KH.18(2):231-241. Clin Anat. Venipuncture-induced complex regional pain 7. 14. 2014. Variable 28. to produce eye changes. Anaesth. Moore AE. 2010. 2006. Horowitz S. Papaziogas B. Alomari A. Mikuni Y. with comparisons to experimental nerve injury mod- ficial veins.9(1):2. Acute of the lateral antebrachial cutaneous and superficial radial nerves compartment syndrome of the upper extremity in children: diag- in the forearm: a cadaveric and clinical study.27(1):44-49. 26. 25. Clin Anat. Korean J Pain. Stringer MD. branch of the radial nerve. Christie M. 21. 2003.110(1):97.39. ANZ J Surg. Mackinnon S.64(3):178-186.68(1): based on anatomical variations and relationships of cutaneous 53-57. Robson A. Spinner RJ. Hemorrhagic cystic lesion of the median nerve: an unusual complication of venipunc- 1. 31. Billone L. Mahadevan V. Dawson J. Arm complications after manual whole blood dona- eric upper limb. Moore AE. Masoorli S. hematoma. Elahi F. Anesth Analg. 2008. Cunningham D. inflammation of cervical sympathetic nerves. Stoller J. anatomical relationship of phrenic nerve and subclavian vein: Acute limb compartment syndrome: a review. Yotnuengnit P. 29. 2005. combination of arterial. Melone C. injuries: a systematic review. Injury to the lateral cutaneous venous catheter. Thorax. Arai T.32(2):481-487. Carrigan RB. 2008. vein. sent. Lawton JM. and outcomes. Germanos S.24(1):56-61. Phrenic nerve palsy: a rare Sonography of the lateral antebrachial cutaneous nerve with complication of indwelling subclavian vein catheter. management.1(1):109-114. doi:10. 2013. 2007. tion and their impact. Anat Sci Int. AANA J. 2002. Sankar WN. Reddy CG. J Hand Surg. Venipuncture-induced neuropathic pain: the clinical 8. Beldner S. J Nephrol. Right shoulder and neck pain. Shawyer A. Pediatr Reduce risk through adequate flushing with pre- Radiol. diazepam. J Parenter Enteral Nutr. Vaida SJ. Suspect thrombotic occlusions based on visible mented. Infiltration/extravasation or swelling/leaking at Standard infusion site. sluggish flow. Needleless Connectors). Korean J if available. Standard 53.1. lin. Phrenic nerve injury after image-guided insertion of a tun. Korhonen A-M. acidic drugs such as matic paralysis following subclavian venous catheterization: pos- vancomycin and parenteral nutrition solutions. A.2.1 (V) amount of blood reflux into the CVAD lumen E. CENTRAL VASCULAR ACCESS 4.7 (IV) restored and appropriate alternative actions are imple- 3. nytoin.1. Thrombosis. 48. Resolve external mechanical causes after checking (refer to Standard 34. return. Quyam S. Suspect precipitation based on the type(s) of tered based on an evaluation of potential causes of administered medications or solutions. Recognizing risk of lipid residue occlusion when 39.1. Horner’s syndrome after placement of a administering 3-in-1 parenteral nutrition solu- peripherally inserted central catheter.30(5):451-452. negative.indd S104 05/01/16 11:30 PM . history of infusion rate. Central Vascular 2. kinked/clamped cath- resistance and the ability to yield a blood return. Reduce the risk for CVAD occlusion by: Exchange]).6 (V) cist when unsure of compatibility. Jung YH. Ahn EJ.65(6):559-561.2. These include alkaline drugs such as phe- E17-E21. on the type of needleless connector (ie.1. central catheter extravasation. Suominen PK. Bae JS. Using the appropriate sequence of catheter Access Device [CVAD] Malposition). Checking for incompatibility when 2 or more down to the dressing (eg. Practice Criteria Catheter Damage [Embolism. and mineral case report. 2012. Identify signs of CVAD occlusion: 40.1.1-7 (IV) Anesth. 3. 2. inability to tip location or dye studies to evaluate catheter flow. do not leave an occluded CVAD lumen untreated positive. Repair. Central Vascular 1. observa- occlusion and on the order of a licensed independent tion of the catheter or infusion set for any visible practitioner (LIP) or an LIP-approved protocol. Korean J Anesth. Do not leave a CVAD with an occlusion untreated. nelled right internal jugular central venous catheter.3 The LIP is notified if catheter patency is not frequency. J Clin Anesth.2 (V) F Review the patient’s medication record and collabo- 4. Kang H. Standard 52. Check for external mechanical causes such as a defined by the ability to flush the catheter without tight suture at catheter site. and catheter-associated venous thrombosis (refer to Standard 51.9% sodium chloride (USP) 38. J Pediatr Surg. 2012. Baek CW. increased levels of calcium and phosphate. Links DJR.2. Identifying medications/solutions at high risk for rate with the pharmacist and the LIP regarding an precipitation if they come into contact with each appropriate intervention when the suspected cause S104 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Shin HY.46(7): other. acyclovir. Chippington S. B.20(4):304-306. and flushing 48. Horner’s 1. Hiller AS. Park TI.42(7):875-877. such as radiographic studies to identify catheter blood in catheter or add-on devices.63(2):183-184. servative-free 0. Schulze-Neick I. Frequent occlusion alarms on electronic infusion DEVICE (CVAD) OCCLUSION device. Inability to flush or infuse through the CVAD.4-6 (IV) 2006. imipenem. 5. et al. Internal mechanical causes may also cause CVAD management of CVAD occlusions. consult with pharma. aspirate blood. precipitate. Sluggish flow. Roebuck precipitate in parenteral nutrition solutions with D. Transient right hemidiaphrag. tions. Phrenic nerve between infusions or use separate catheter lumens palsy after internal jugular venous catheter placement. Crowe PJ. ter).3-5 (IV) Catheter salvage is preferred over catheter removal for 4.1 Central vascular access devices (CVADs) are regu- CVAD occlusion: larly assessed for patency and proper function as 1. and heparin.2.2 Thrombolytic agents and clearing agents used to (IV) clear occluding substances from a CVAD are adminis- 2. Yang CW.1-6 (IV) C. clogged filter or needleless connector. sible implications of anatomical variation of the phrenic nerve: a ceftriaxone and calcium gluconate. 2011. neutral displacement) to reduce the because another lumen is patent. 2013. clamped or kinked cathe- drugs are infused together. 2008. Using proper flushing and locking procedures Access Device [CVAD]-Associated Venous (refer to Standard 40. ampicil- 36. 37. occlusion including pinch-off syndrome. Inability to withdraw blood or sluggish blood syndrome secondary to internal jugular venous cannulation.5. eter. 5. Investigate and evaluate potential causes for a 48. second- ary CVAD malposition.1. the infusion system. clamping and final syringe disconnection based D.6 48. Flushing and Locking). ganciclovir. from the administration set 3. 1. Catheter Damage [Embolism. Collaborate with LIP to obtain orders and diagnos- should be equal to 110% of the catheter priming tic tests to verify suspected CVAD malposition or volume. treatment success or failure. Use ethanol with caution I.1. Repair. however. 2015. less than 6): investigation for treatment of CVAD occlusions 0. Use a syringe no smaller than 10 mL for administra- of occlusion is thrombosis.1. and facilitate maximum con. for pediatric patients. as above.1. include recombinant urokinase. there is limited research types of CVADs. and adult patients. Lipid residue: 70% ethanol in a sufficient volume tion and potentially infection. Avoid applying excessive force to an occluded with polyurethane CVADs as ethanol may dam. greater than Exchange]). Review the patient’s medication record and collabo. nal fluid so that the clearing agent has a better rate with the pharmacist and the LIP regarding an opportunity to reach the occluding substance. Infusion of low doses of alteplase to manage 1. Consider alternative actions such as a referral to repeated 1 time if necessary.1 (IV) policies and procedures and clinician education and 4.(suppl 1):3-34. Studies suggest that to fill the catheter lumen. if treating a training (see Standard 6. Monitor outcomes. Miller K. which is allowed to remain flushing the lumen. Instillation of tPA based on manufacturers’ direc.3-6.1 mmol/L. retaplase. Central Vascular Access 2 mL) for hemodialysis catheters have been Device [CVAD] Malposition).1N hydrochloric acid. Alkaline drug precipitate (pH greater than 7): tenectaplase. Alteplase infusion instilling an amount of a catheter-clearance agent has also been reported as safe and efficacious in based on the catheter lumen priming volume and critically ill pediatric patients.1 (V) in CVAD lumen for 30 minutes to 2 hours and L. Hill J. occlusion may be symptoms of pinch-off syndrome. K. the volume of tPA M. J Can Vasc Access over 30 minutes and up to 3 to 4 hours has been Assoc. reported in the literature and may be part of N. catheter neonatal. 1-4 mg) line for central vascular access devices (CVADs).2 (V) sodium bicarbonate 8. et al. the compression of the catheter between the clavicle rent guidelines. is recommended in cur.info/PUBLICATIONS/ reported in both adult and pediatric populations OcclusionManagementGuideline/tabid/229/Default. facilitate adhesion of bacteria.1 for suspected thrombotic occlusion: (IV) 1. Recognize that thrombi in and around the CVAD 0. and alfimeprase.12 (IV) allowing it to dwell for 20 to 60 minutes: 6. 2013.1 (V) multilumen CVAD to optimize thrombolysis dur- ing the dwell time.13.9-11 (I) menting CVAD occlusion prevention and interven- 3. Broadhurst D. a tPA use should heighten the awareness of risk for dose of 0.1.4% or sodium hydroxide H. Stop all infusions. Aspirate degradation products and discard prior to alteplase) 2 mg/2 mL. Occlusion management guide- occlusions in hemodialysis catheters (eg. Acidic drug precipitate (low pH. Instillation of tissue plasminogen activator (tPA. Other additional thrombolytic agents under 1. Consider use of tPA in community and long-term tions. While lower tPA doses. Identify barriers to imple- drugs for alternative dosing. and alteplase Standard 51.2. removal should be considered if catheter patency is atric patients weighing 30 kg or less. Use a thrombolytic agent tion of a thrombolytic or catheter clearance agent. aliquoting to increase volume (eg.8 (III) pinch-off syndrome. Intermittent or positional 2. Standard 53. including causes of occlusions in organizational protocols. Quality Improvement).55 mL/kg has been used with no more infection in these patients. 5. REFERENCES tact between the thrombolytic agent and the thrombus on the internal catheter lumen and Note: All electronic references in this section were accessed October external catheter surface at or near the tip. use of and first rib alongside the subclavian vein (refer to cryopreserved aliquots of alteplase.6 negative-pressure technique should be used to reduce (IV) the risk of catheter damage and to remove intralumi- G.1-4 (V) appropriate intervention when the suspected cause J.14 (V) than 3 mL maximum. of occlusion is medication precipitate or lipid when there is recurrent occlusion after multiple residue. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S105 JIN-D-15-00057.4. pediatric.indd S105 05/01/16 11:30 PM . tions for use. refer to vascular access instilled to reduce the risk of causing an intraluminal device (VAD) manufacturers’ directions for use level of pressure that could cause catheter damage. http://cvaa. is recommended as interventional radiology if the CVAD clearance pro- safe and effective in restoring catheter patency in cedure does not result in catheter patency.1 (IV) 2.1. A regarding exposure to any form of alcohol. and available to support the efficacy of thrombolytic other measures required. use the not restored.3 (V) same concentration. For pedi. Treatment of these occlusions includes direct alteplase instillations. leading to coloniza- 3.aspx. 2. when possible. CVAD when a thrombolytic or clearing agent is age the catheter material. and implement appropriate strategies including care settings. 39(9):741-747.42(4):417-420.1-3 (IV) catheter in hemodialysis patients: risk factors and efficacy of D. Reiss R. percutaneous versus surgi- cally inserted long-term catheter). vascular access device (CVAD). Silva TN. age. temperature elevation and the absence of confirma- 11. Willmas JA. Giordano P. 2015. 2012. Nonthrombotic complications related to central Practice Criteria vascular access devices. rather than the 1534-1540. Alteplase Selection). Difficulty with inserting a new CVAD. Anderson DM. blood cultures.14(3):306-309. jugular or femoral (refer to Standard 27.5-8 (IV) S106 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. The type of VAD (eg. Do not remove a functioning CVAD based solely on alteplase. 2015. 2014. Ramsey EZ. Evans MC. Factors to consider in the decision to salvage a catheter include: 49.1 (IV) venous catheter occlusions in neonatal and young pediatric B. but is not limited to. doi:10. Pediatric Hematology and Oncology (AIEOP). Artif Organs .indd S106 05/01/16 11:30 PM . the CVAD is required if there is clinical deteriora- 14. Collins M. Occluded tunneled venous derness associated with the catheter.and vas. Sulis C. and treatment of central interventions. dynamically stable outpatients with catheter-related The role of tissue plasminogen activator use and systemic hyper. determine if the CVAD can be salvaged. Haematologica. any presence of vascular or other hardware (eg. and implement planned 6. 49. et al. Ast D. Bolton D.18(11):539-540. indu- Syst Rev. Ponce D. necrosis of the overlying skin at the VAD lation defects working group of the Italian Association of insertion site. For hemo- 13. Removal of Am J Infect Control.38(5): removing the catheter if an infection is evidenced 399-403. Miller KE. Ponce D. 2010. Prevention. Doellman D.(4):CD007119.34(4):251-258. risks. egy to prevent infection. Cochrane Database extending at least 1 cm from the insertion site. Thakarar K. C. Baskin JL. severe sepsis. Ann Pharmacother. Beardsley AL. Korn C.1 The clinician implements infection prevention 4. Effective tory evidence of catheter-related infection. Interventions for restoring patency develops symptoms of infection (eg. Oliver MR. Consider site selection for VAD placement as a strat- patients. Bennett CL. endocarditis. Saracco P.2 The clinician assesses the patient with a VAD for including. Recommendations for the implanted intravascular device or subcutaneous tun- use of long-term central venous catheter (CVC) in children with nel for any tunneled catheter. 2014. 2014.54(4): is recommended in adult patients. et al. cular access device (VAD)-related infections. et al. 2013. Immediately notify the licensed independent practi- 5. Alteplase elsewhere or if a noninfectious cause of fever is sus- infusion versus dwell for clearance of partially occluded central pected.37(5): 349-358. fever with no other obvious source CD007119. any pain or tenderness or drain- 641-649. Evaluation of a catheter-related infection with a nontunneled central potential clinical interaction between ceftriaxone and calcium. central venous catheter occlusion. et al. Grassi M. Silva T. the subclavian vein Antimicrob Agents Chemother . et al. Rowan CM. 2012. or the patient and/or caregiver about infection. Mendes M. for the treatment of occlusion in pediatric patients. related infection are present. Ast T. may be a safe and appropriate strategy. Kwong L. Jill R. Site 8. Bhadelia N. 2. Mendes ML. of infection) or the patient reports any pain or ten- 10. bloodstream infection (CR-BSI).1002/14651858. Remove a peripheral venous catheter if the patient 9.94(11):1765-1776. 2014. Collaborate with the LIP and patient to collectively Care Med. but not limited to. 2013. Assess for signs and symptoms of a VAD-related 3. Pediatr Crit Care Med. The presence of other complicating conditions 49.15(6):253-260. Thompson AJ. To minimize the risk of 7. Barretti P. Ragsdale CE. sup- signs and/or symptoms of infection and educates the purative thrombophlebitis. and any required follow-up. and/or body temperature elevation. a interventions. benefits for each patient. 2. Pediatr Crit E. Casavant J. Presence of bleeding disorders. Pesaturo KA. Steadman E. The inser- malfunctioning central venous catheters correlates with catheter- tion of a new CVAD at a new site should be a col- associated bloodstream infections. INFECTION 1. Br J Comm Nurs. J Infus Nurs. 12. spontaneous rupture and occlusion and CVC-related thrombosis—on behalf of the coagu- drainage. Jones L.pub2. edema. Thrombolytic therapy for infection which may include. A. van Miert C. ration. Raisch DW. pacemaker).97(5): erythema. laborative decision based on the specific risks and 2013. Preventing occlusion and restoring patency to central tioner (LIP) when signs and symptoms of a VAD- venous catheters. Artif Organs.1. Alteplase use for tion or persisting or relapsing bacteremia.4 (IV) venous catheters in critically ill pediatric patients. 2011. assessment. Standard 3. catheter salvage coagulability in central-line associated bloodstream infections. erythema of occluded central venous catheter lumens. fluid in the subcutaneous pocket of a totally 4. The infecting organism(s) as confirmed by paired measures with the goal of preventing infusion.47(3):405-409. J Infus Nurs. induration at the exit hemato-oncological disorders: management of CVC-related site or over the pocket. exudate. Ann Hematol. Use clini- use of alteplase for occluded tunneled venous catheter in cal judgment regarding the appropriateness of hemodialysis patients. Castro JH.2. 5. http:// tive or gram-positive bacteria as ordered by an www. thus increasing the risk of international panel using the RAND/UCLA appropriateness emergence of antimicrobial resistance. Infections with Culture the introducer/sheath tip from a pulmonary Staphylococcus aureus. L. Collect a specimen of purulent exudates from a Infect Dis. Routine versus clini- cally indicated replacement of peripheral intravenous catheters: a al unless the patient has a suspected CR-BSI.1 (IV) Candida require immediate removal of the infected N Culture the reservoir contents of a port body of an CVAD and a defined course of systemic antibiotic implanted port and the catheter tip when it is therapy. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S107 JIN-D-15-00057. or infections due Standard 43. Phlebotomy). intravenous medications. that the catheter tip culture will identify microor. Catheter salvage in home infu- ganisms on the external catheter and not microor.1 (IV) Am J Infect Control.8 (V) and from separate percutaneous blood cultures. et al. Blood cultures from both the catheter Standard 40. The Michigan appropriate- This practice results in inappropriate use of anti. 2015.11 (IV) to S. Published LIP. endocarditis. has a history of multiple CR-BSIs despite optimal P. Flanders SA. randomised controlled equivalence trial. related infection: 2009 update by the Infectious Diseases Society minal surface for catheter exchange. or blood because of coagulase-negative Staphylococcus or products) as a source of infection. Lancet . for the diagnosis and management of intravascular catheter- impregnated catheter with an anti-infective intralu.1 (IV) of America. ganisms located on the intraluminal surface.2. Bouza E.1.1 (IV) native venous access is available. Consider a catheter exchange procedure when other 5. Patients with a O. 2014.cdc. ness guide for intravenous catheters (MAGIC): results from an infective medications. and venipuncture must be positive for the same H. vascular access sites are limited and/or bleeding dis- 1. Closely monitor and clinically tamination) or during its preparation or administra- evaluate pediatric patients treated without catheter tion in the patient care setting (extrinsic contamina- removal. Alexander M. Keller S. blood cultures or the differential period of central bloodstream infection that continues despite greater line culture versus peripheral blood culture positivi- than 72 hours of antimicrobial therapy to which the ty >2 hours for the diagnosis of CR-BSI (see infecting microbes are susceptible.indd S107 05/01/16 11:30 PM . but an infusate can become contaminated course of systemic antibiotics with the use of antibi. An infusate-related bloodstream infection is use of antibiotic lock therapy with systemic therapy the isolation of the same organism from the infusate for catheter salvage. Mermel LA.2 (V) Note: All electronic references in this section were accessed October J. Consider an antimicrobial.50(3):457. suppurative thrombophlebitis. 4. except in rare circumstances when no alter. indicate the presence of a bloodstream infection.49(1):1-45. prevention of intravascular catheter-related infections.7-9 solution in a patient with a long-term CVAD who (IV) (see Standard 43. Recognize method. Guidelines for the staining to determine the presence of gram-nega. Chopra V. Caroff D. organism with clinical signs and symptoms and no ated with any of the following conditions: severe other recognized source. Rickard CM. Anticipate the removal of a short-term CVAD (in M. Allon M. Erratum in: Clin K. P. Norris A. 5. Remove a CVAD from a patient with CR-BSI associ. Do not routinely culture the CVAD tip upon remov.html. peripheral or CVAD exit site for culture and gram 2. during the manufacturing process (intrinsic con- otic lock therapy.6. Ann Intern Med. Do not use a guidewire exchange to replace a non- tunneled catheter suspected of infection. aureus. Consider quantitative sepsis. et al. 2009. Aspirate all ples for culture.1 (IV) April 2011. Phlebotomy). et al. et al. Burns LA. or artery catheter when a CR-BSI is suspected. F. Wallis MC. including additional blood cultures and the tion). et al. Consider contamination of the infusate (such as par- long-term CVAD and an uncomplicated CR-BSI enteral solution. sion patients with central line-associated bloodstream infection. Consider the use a prophylactic antimicrobial lock with no other identifiable source of infection. fungi. O’Grady NP. aeruginosa. 2010. before the initiation of antimicro- lumen at the end of the locking period (refer to bial therapy. drawn from the catheter and a antimicrobial locking solutions from the CVAD peripheral vein. Clin Infect Dis. removed for suspected CR-BSI.380(9847):1066-1074. gram-negative bacilli.1.10. This is a rare Enterococcus may retain the CVAD and complete a event. Catheter colonization may be detected but does not 2012.50(7):1079. Culture the tip of short-term central vascular and situ less than or equal to 14 days) in a pediatric arterial catheters suspected of being the cause of a patient with an uncomplicated CR-BSI and treat CR-BSI using a semiquantitative (roll-plate) method with systemic antibiotics for at least 7 to 14 days or quantitative (sonication) method upon removal. Clinical practice guidelines orders are present. 3. 2010. G. Webster J.42(12):1331-1333. or mycobacteria following collaboration with the LIP. Saint S. 2015. Flushing and Locking). For a suspected CR-BSI. Clin Infect Dis. obtain paired blood sam- maximal adherence to aseptic technique.163(suppl 6):S1-S39.gov/hicpac/BSI/BSI-guidelines-2011.4 (IV) REFERENCES I. based on the pathogen. 8. reducing contamination. Catheter-related and infu- with air sensors. recent myo- cardial infarction. and peripherally inserted central safety features designed to detect or prevent air catheters: reappraising the evidence.html. Chopra V. numbness. Am J Infect Control. Place patient in a supine position during CVAD 10. a global perspective. Spitzer DE.8 (IV) 5. Suspect air embolism with the sudden onset of dysp- B. if able. Saint S. the exit tion sets or connectors from the catheter hub unless site could be at the same level as the patient’s they have been instructed in IV administration and heart.2. breathlessness.17 (IV) 2. 2. use a Trendelenburg or left lateral decu- administration sets are of a luer-lock design to ensure a bitus position. needleless connectors. Preventing central line-associated blood. tachyarrhythmias. Immediately take the necessary action to prevent procedures during removal. catheter (PICC) has not been reported. sion-related sepsis. Contraindications include. altered speech. Strategies for the preven- 4. wheezing. but are not limited to. lism during placement and removal of central vascu- stream infections: a global challenge.16. or paralysis as clinical 1. 6.7 nea. contraindicated because it increases intra-abdom- tions. http:// lar access devices (CVADs). the risk of air embolus. cdc. and any other add-on until hemostasis is achieved by using manual devices. 1. his breath as applicable. After removal of a CVAD.1.46(10):2000-2011. equipment with infection. including but not limit- www. For all vascular access devices (VADs). Darovic GO. changes in lowing techniques to prevent air embolism: facial appearance. D. 2015. Garcia RA. for 30 minutes after Practice Criteria removal. 2013. and retinopathy. Apply a sterile petroleum-based ointment with a therapy in non–acute care settings are instructed in how sterile dressing to the access site for at least 24 to prevent an air embolism and implement critical hours to seal the skin-to-vein tract. (IV) vention%20of%20central%20venous%20catheter.2 (V) with patients in the home care setting. Chenoweth C. Chen C.43(11):1222-1237. Clinician guide for collecting cultures. 3. Kethireddy S. and decrease actions if an air embolism is suspected. and neurological signs and symptoms. administra. Beaudry J. While documentation of air embolism A. 50. or Trendelenburg position if tolerated. Kumar A. Never use scissors or razors near the catheter. Crit Care Clin. http:// administration sets or needleless connectors. Published May ed to the following points1.10 anestesinorr. continued coughing. chest pain. When the Valsalva’s maneuver is contraindi- 50. Multidisciplinary team of the heart. http://www. apply digital pressure tion sets. Anand S. altered mental status. during removal of a peripherally inserted central nect or reconnect any intravenous (IV) administra.pdf. Instruct the patient and/or caregivers not to discon.11. Septimus E. Encourage the patient to remain in a flat or reclining position.12-15 Standard (I A/P) a. AIR EMBOLISM patients with cardiac dysfunction. needleless connectors. Instruct the patient to perform a Valsalva’s tures to determine effective interventions for increasing the yield maneuver at the appropriate point during cathe- of true-positive bacteremias. 2011. use the fol. The Joint Commission. so the CVAD insertion site is at or below the level 11. and cated. eliminating filters and electronic infusion devices 7. Implement special precautions to prevent air embo- 9. removal.indd S108 05/01/16 11:30 PM . Ensuring the VAD is clamped before changing systematic review. (IV) hypotension. J Pediatr Surg. The Valsalva’s maneuver may be nating false-positive central line-associated bloodstream infec.gov/getsmart/healthcare/implementation/clinicianguide. 2015. increasing the risk of air entering through evaluated as competent in the procedure. inal and intrathoracic pressure. nea. which reduces cardiac output and affects blood pressure. Huang EY.8 (IV) 50.6.1.125(8): embolism such as administration sets with air- 733-741. Priming and air purging of all administration events from air emboli produce cardiopulmonary sets. more air from entering the bloodstream by S108 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.8-11: (IV) 2012.3 Patients and/or caregivers managing infusion 4. Surgical Association Outcomes and Clinical Trials Committee 5. and elimi.2 Air is always purged from syringes.8 (IV) review of best practices for collection and handling of blood cul. 8. such as an intact skin-to-vein tract and fibrin sheath. 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J pressure.8 (V) Standard 51. medication being injected (refer to Standard 40. Bader AM. Cook LS. and no other signs/symptoms of complica- 2011. tions. Farber E.548.52(12):2516. Air embolism caused by a lac- eration to central venous catheter during shaving. Practice Criteria 5. Browell C. o r g / A D V I S O R I E S / 51. use syringes appropriately sized for the 8.231(1-3):e4-e10. Flushing and Locking). A novel risk of air embolism with intravenous B. cathe- H.1. 3. Chow CM. Published October 13. may be an indication of 10. Recognize that catheter dysfunction. Griffin J. 2013. 2014. 2012. Shimofusa R. Broadhurst D.66(3):229. MO: Saunders/Elsevier. J Strength Cond Res. ing. 2012. doi:10.1. 2014. Nussinovitch U. The mechanics of left ventricular has been removed.16 (IV) operating room: development and pilot testing. Corrigan A. March 2012. h t t p : / / p a t i e n t s a f e t y a u t h o r i t y. 2013. Medscape. c. ter-lumen occlusion. Care. leaking at the site https://psnet. catheter embolism. such as the paracetamol.17 (IV) filling during the strain phase of the Valsalva maneuver in healthy 2. 2.9(2)/Pages/58.9(2):58-64. Yanir Y. Gorski L. The unfamiliar catheter. A. Miller C. Gupta V. Iwase H. J Am Coll Surg. venous access devices.38(2):395. James A. http://emedicine.27(8):2338-2345.aspx. a. et al. 14. 2015. Ziewacz JE. 51. Assess vascular access device (VAD) function using a 3rd ed. closing. Catheter damage increases the risk for catheter frac- 13. or covering the exist. can indicate catheter rupture. Forensic Sci Int. J Infus Nurs. Campbell J. Hankins J. Implement additional actions: 2011. Trerotola SO. Pakalnis VA.23(suppl 14):S4-S8. bleeding. and bloodstream infection. the Trendelenburg position or in the left lateral 16. St Louis. folding. additionally. subcutaneous swelling. Death by air: how much is too much? Vasc Access.2. no resistance to flush- 7. Davies I.medscape. clamping. access catheter. air emboli.7(1):16-26.36(1):26-36. I. et al. Talavera F. 15. Pearson F. eds. 3. Mortlock N. Eur J Ophthalmol.26(3):366-371. Feil M. Allford M.gov/webmm/case/294/the-unfamiliar-catheter. BMJ Case Rep. Duggan J.8.1136/bcr. Ronen B.8.346(3):187-189. Charles S.213(2):212-217. evaluate catheter integri- cular access. Transfusion. or severe cardiac or res. eye surgery.3 Central vascular access device (CVAD) exchange is 2. Infusion Nursing: An Evidence-Based Approach. 51. licensed independent practitioner (LIP). 2015. mented prior to resumption of the prescribed therapy.5 After completion of the exchange procedure. Yuan LJ. The Valsalva maneuver: its effect on ing catheter or by covering the puncture site with intra-abdominal pressure and safety issues during resistance exer- an air-occlusive dressing or pad if the catheter cise. Makino Y. In the presence of 11. Anaesth Intensive venting catheter damage or rupture. piratory diseases. AHRQ Web MM. The goal is to trap the air in the 17. 1. Zhang XY. Recognising air embolism as a complication of vas- these signs and symptoms.ahrq. 10-mL syringe: 6.16(1):81-91. (EMBOLISM. Roy ture and embolization. Duszak RS. 2013. Hackett DA. Do not forcefully push against resistance. Deepak KK. inability to aspirate blood with localized pain and/or 01. Menon R. If VAD has blood return. General Perucca R. Arriaga AF.2 Catheter repair is initiated upon the order of a 1. Initiate code team if in acute care setting or call emergency medical services if in patient’s home or alternative care setting. Immediately place the patient on the left side in subjects. Pandey RM. Reducing risk of air embolism associated with central initiated upon the order of an LIP. In: Alexander M. Dada T. Intervention in a timely manner is recommended to VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S109 JIN-D-15-00057. Provide 100% oxygen if available and further EXCHANGE) support actions as needed. Br J Nurs. 2013.1-4 (IV) nism for angle closure. 51. 2010. C.1 Assessment of the patient’s risk-to-benefit ratio is REFERENCES performed prior to repair or exchange of the vascular Note: All references in this section were accessed September 3. Vasc Intervent Radiol. Cao TS. Air embolism during insertion and replace- decubitus position if not contraindicated by ment of tunneled dialysis catheters: a retrospective investigation other conditions such as increased intracranial of the effect of aerostatic sheaths and over-the-wire exchange. REPAIR. com/article/1228106-overview. pre- lowing central venous catheter laceration. Narrowing of the ante- rior chamber angle during Valsalva maneuver: a possible mecha- sampling. 2010:109-126. Brown LL. Notify licensed independent practitioner (LIP). To shave or not to shave: air embolism fol. Devastating air embolism.2012. Gorski L. Am J Med Sci. (MSB) precautions for the CVAD exchange procedure. Crisis checklists for the lower portion of the right ventricle. Swayze SC. Infusion therapy across the continuum. 9. Massive gas embolism 51. Penn Patient Saf Advis. 3. consider an antimicrobial chest radiograph assessments for this syndrome impregnated.4. consider regular infection (CR-BSI). or bonded catheter for and for catheter embolism.4.22 (V) arm or shoulder movement. tion.23.19 (V) 3.18. as the repaired catheter may not have A. If there is limited vascular access or unavailable 3. and resulting waiting for the repair procedure to be performed. dyspnea. Examine VAD catheter tip and length after removal.24 (IV) portion of an implanted port catheter. the clinician B. and identify any continu- II. therapy.8.3. In some cases there are no signs type of catheter. assesses the risk-benefit of the procedure for all tation are catheter pinch-off syndrome. If damage is 2. Recognize the early signs and symptoms of pinch-off B. Catheter Exchange not labeled for this purpose. C. con- patient report of pain.25-27 (IV) 1. For totally implanted CVADs via the subclavian sites in the presence of an actual or suspected vein with increased risk for catheter embolism infected catheter or catheter-related bloodstream due to pinch-off syndrome. or insertion of a new catheter at a differ. A. or fold the external segment and ent site. such as catheter exchange or tion site.28. coated.8.13 (IV) A. Perform regular assessments after repair to confirm the integrity of the repair. If no device-specific repair kit is available. Suspect catheter embolism when the patient 3.indd S110 05/01/16 11:30 PM . Factors to consider in making this decision secure) between the patient and the damaged area to include. prior to initiating or resuming prescribed eter damage when VAD removal is difficult. Prevent catheter embolism through the following the same strength as the original catheter.15 (V) therapies.20 changes in proper tip location with repair.5-12 (V) (V) D. and according to the manufacturer’s directions for ing difficulty aspirating.8 (IV) C. sider other alternatives. resistance to flushing. The most frequent mechanisms of catheter fragmen.2-4.17 (IV) catheter exchange. for damage and possible fragmentation. Catheter Embolism ing problems. a catheter is malpositioned or mal- or symptoms.8. Catheter Repair consider for managing a damaged or ruptured cath. eter include use of a repair procedure.4.34 (I) S110 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.6. cough.33 (IV) C. Do not withdraw the catheter or wire from the is unable to be repaired.8. but damage often occurs after functioning and venous access is limited. includ. close an existing clamp. prevent air embolism or bleeding from the device immune status. Nontunneled catheters may be exchanged if there junction or other external connections. an exchange add a clamp. 2. The clinician should carefully assess the patient for nologies to confirm correct CVAD tip location signs or symptoms of catheter embolism and for cath.9.2-4. Label the damaged catheter “Do Not Use” while osmolarity).14-17 (IV) sites are unavailable. 2. A catheter exchange with or without a guidewire not associated with the patient’s primary disease may be considered if there is a need for a different or comorbidities.4. characteristics of infusion therapy (eg. catheter patients.8. Use maximal sterile barrier (MSB) precautions.21.28-30 (IV) mias. dressing material. Neonates and infants. infection. 2.23. or other lengthy usage. arrhyth. but are not limited to. and a change in the clinical picture with insertion of a new catheter. Remove actions: the VAD if the repair was unsuccessful or the device 1. evaluation may be warranted. length of time remaining on infusion immediately upon discovery of catheter damage. and fracture of a 1.31. Catheter separation may occur at the lumen-hub 1. Prior to performing a CVAD exchange. possible swelling at the inser. During a CVAD exchange procedure: comparing the removed length to the inserted length 1. a chest radiograph or further embolism.8. reduce the risk of these complications.27. Obtain a radiograph or use other approved tech- D. Patients with burns or transplants. Gently tug 2. Do not use power injection with VADs that are IV.31 (I) resultant bleeding or exsanguination. Patients with an infection or suspected infec- exhibits symptoms such as palpitations. Use techniques to reduce the risk of air seen or suspected. all connections must be visible dur. use. Tunneled cuffed catheters may be exchanged on all connections after insertion to verify a while avoiding infected tunnel or local site secure hold. separation of the lations such as: catheter from an implanted port. Options to III. or thoracic pain that are B.14. external catheter length. cover the damaged area with adhesive procedure.25.21 (V) needle during insertion.10. Use a repair kit designed for the device being repaired syndrome in subclavian vein insertion sites.15 (IV) 3.32 (IV) ing hemodialysis. Clamp or seal catheter (eg. with particular attention to high-risk popu- damage during catheter exchange. the patient’s age.9. with is no evidence of infection. Plumer’s Principles and Practice of Infusion devices for chemotherapy. Jamal M.26(2): coagulase-negative staphylococcal bacteremia: remove or retain? 132-141. A national survey of neonatal aged connectors of tunneled cuffed catheters with a two-piece peripherally inserted central catheter (PICC) practices. et al. Central venous access devices: Usefulness of exchanging a tunneled central venous catheter using care. catheter using a topical skin adhesive. 2. maximizing patient safety through education and visibility of 1. Lal S. Am J Perinatol. Perucca R. November 21. Hearse N. J Vasc spective. 2015. McAfee N. Med Oncol. Ghannam D. Central venous catheter embolisation. Stavropoulos SW. 2013. Faraj W. Zhou C. et al. 14. Guttmann D. Mermel LA.13(1):55-74. The use of minocycline-rifampin coated central venous catheters Central venous catheter repair is associated with an increased risk for exchange of catheters in the setting of Staphylococcus aureus of bacteremia and central line-associated bloodstream infection in central line associated bloodstream infections. interval between changing centrally placed intravascular cathe- line complications. Adv adaptor for peritoneal dialysis.31(4):337-340. Ztot S. 2013. Int J Nurs Stud. C. stream infection. Bodenham A. Repair of dam.49(8):1187-1194. 2014:335-390. O’Mara MS. Ababou A. Cummings M. Dialysis line separation: 3. Shlansky-Goldberg RD. Cook AM. In: Weinstein SM. 15. Endres J. J Parenter Enteral Nutr. exchange versus catheter removal and replacement. Clin Infect Dis. Spontaneous rupture 32.indd S111 05/01/16 11:30 PM . ment initiative to determine the impact of increasing the time 6. Earhart A. Buerke M.27(2):e10-e11. Kim S. Hankins J. et al. Central venous access. 2011. Lin CH. Complete cath.38(6):515-526. urethane tunneled infusion catheters: a comparison of durability 23. Routine exchanges are not necessary for CVADs that system: analysis of 73 cases with fracture of catheter. Shanaah A. et al. J Pediatr Surg. Ann Vasc Surg. Raad I. 2004.23(6):677-685. Behrmann Williams & Wilkins. Hachem R. Nutrition. 2007. Saibu R. Kassar R. 25. Malone F. analysis of complications of totally implantable venous access Hagle ME. a subcutaneous fibrous sheath. Anaesthesia. features. observational study. Chaftari A.26(6):733-737. Philadelphia. El Zakhem A. Ismaili M. Clinical review and 20. 2013. Taguchi T. ters. PA: Wolters Kluwer/Lippincott 3. Plumer’s Principles and prevention of intravascular catheter-related infections. 2012. Mitchell P. Kim JT. Jeong YK. 2010:495-515. Sharpe E.68(6):645. 2009. 2011. Elhassani A. et al. Exchange of peripherally inserted Nursing: An Evidence-Based Approach. Dagli M. In: Weinstein SM. Zerr D. Greenhalgh DG. 694-702. Brier M. Chang WH.59(1):90-97. Wienke A. 2008. Zaghal A. e11-5. Pinch-off syndrome: case report and collective review of the literature. Idowu O. A durable repair of a broken silastic systematic review. Hsieh CB. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S111 JIN-D-15-00057. Philadelphia. Letachowicz K. April 2011. Hudman L. 27.22(5):642-646. 2010. 9th ed.51(5): Intervent Radiol. maintenance. Weinstein SM. Therapy.24(5):692. Oh TY. PA: Wolters www. The related infection: 2009 update by the Infectious Diseases Society mechanisms of failure of totally implantable central venous access of America. Pettit J. 11. Palmieri TL. 2013. Infusion 26. El-Beyrouthy O. clinical 21. 12. embolism.22(5):638-641. Schulmeister L. D. 2011. Salifu M. Practical aspects of long-term venous 33. eds. Huang MH. 2013. and management. Contin Educ Anaesth Crit Care Pain. Management of non-infectious central venous Management of the catheter in documented catheter-related access device complications.8(11):18-22. Stanelle E. Mirza B. Masumoto K. Surov A.35(2):143-147. and potential complications. 5. Lundgren I. Clin Infect Dis. Allon M. 24. Note: All electronic references in this section were accessed September 19. 8.46(4):784-785. Teshiba R. Wake A.49(1):1-45. Pediatr Infect Dis J. Cohen AB. Guidelines for the tions. St Louis. Chan DC. for the diagnosis and management of intravascular catheter- 16.29(2):1361-1364.28(6):419-424.27(5):526-529. McCutcheon H. 28. Hagle ME. Kagan R. Vanek VW. A performance improve- and breakage rates. Spielman R-P.31. J Vasc Interv Radiol.gov/hicpac/BSI/BSI-guidelines-2011. 2014. Intravenous port catheter embolization: mechanisms. Trerotola S. Carter JM. pediatric patients. McCoy M. and troubleshooting central. 2009. Gorski L. J Burn Care Res. Alexander M. doi:10. J Assoc Vasc Access. Gantt S. Case Rep. 2011. J Surg Res. 30. Central eter disconnection and migration of an implantable venous access venous catheter infections in burn patients with scheduled cathe- device: the disconnected cap sign. Ellsbury D. Intravascular embolization outcomes: part 1. Hunter M. preventing. of venous catheter: causes. Hwang FR. Chaftari A. Hagle ME. 2012. http:// Practice of Infusion Therapy. Gorski L. Jiang Y. 2012. J Vasc Intervent Radiol. Surov A. Kutoubi A. 2013. and management: a 22. 29. Central venous catheter failure. Silicone and poly. Eur J Surg are functioning and without evidence of local or Oncol. Complications and nursing interven. Stavropoulos SW Jr. Am Nurse Today. Angiology. Published Kluwer/Lippincott Williams & Wilkins. 2011.cdc. Am Surg. Tunneled infusion catheter breakage: frequency and repair kit 4. Noori S.34 (I) 17. 2010. et al. Hachem R. et al. Corrigan A. Nagata K. Burns LA. Harrison E. 2008. ter exchange and replacement. Patterson C. MO: central catheters is associated with an increased risk for blood- Saunders/Elsevier. 13. et al. O’Grady NP. Semin Dial. Malfunctioning The safety and efficacy of midlines compared to peripherally and infected tunneled infusion catheters: over-the-wire catheter inserted central catheters for adult cystic fibrosis patients: a retro. Esterman A. Neely A.19(2):201-206. Reed NL.142(2):341-350. Letachowicz W. Nephrol Nurs J. Yakuboff K. clinical signs. 2010. 31. Fibrin sheath and its relation to of subclavian intraport catheter with cardiac and pulmonary subsequent events after tunneled dialysis catheter exchange. 9. Yu JC. In: Alexander M. 2011. Bedwell S. Neonatal Care. 2014:203-244. et al. 2014. Perucca R. Clinical practice guidelines access.1186/1471-2334-14-518. Recognizing. systemic complications. 2014. BMJ access site for patients on hemodialysis. doi:10.13(1):6-11. Semin Oncol Nurs.1136/bcr-2012-007249. Raad I. 3rd ed. Klinger M. Bouza E. 2009.70(7):635-644. Stavropoulos S. Kosling S. eds.13(2):203-207.36(1):100-103. J Cardiothorac Vasc Anesth. Ying J. Dwyer A. 9th ed. BMC Infect Dis. Esumi G. 10. REFERENCES 18.html. eds. Hagle ME. 2012. 7. Sharp R. Kupensky DT. Wu HS. D. an increased rate of DVT (see Standard 23.1 The clinician assesses the patient for suspected 2. length can result in the largest diameter of a 2. shoulder. diameter PICCs (eg. signs and symptoms. Clinical signs and symptoms ficult or traumatic insertion and the presence of are related to obstruction of venous blood flow and other intravascular devices (eg.1086/676533. are associated with higher rates of deep vein shoulder. design. PICC insertion through Vascular Access Site Preparation and Device the internal jugular vein rather than veins of the Placement). Peripherally inserted central catheters (PICCs) 4. neck. Edema in the extremity. Risk factors include. Age extremes in young children and older adults. upper extremity is associated with lower rates of G.35(7):753-771.org/stable/10. diabetes. prothrombin Vascular Access Device [CVAD] Tip Location). rect tip location is not reported to be associated with 5. Measure upper-arm circumference before insertion greater movement in the upper extremity. 1 compari- Practice Criteria son study between tapered and nontapered PICCs A. Pregnancy or the use of oral contraceptives. Reverse taper on the hub end of the catheter. could not find a difference between the catheter bosis before CVAD insertion. Central malities (eg.14 (II) insertion into veins with smaller diameter and F. CENTRAL VASCULAR ACCESS sound before insertion. A study of 6Fr triple-lumen PICCs was stopped before completion due to an unacceptably high Standard rate of DVT. Trimming a PICC to a patient-specific 1. 34. Strategies to prevent central line-asso. Factor V Leiden.8 (II) C. 5Fr and 6Fr PICCs develop DVT more rapidly in central vascular access device (CVAD)-associated venous patients with cancer when compared to smaller- thrombosis.6.1. Pain in the extremity. Marschall J. VENOUS THROMBOSIS 1. hyperglycemia in nondia. Known presence of genetic coagulation abnor. Anticipate diagnosis of CVAD-associated DVT with DVT than arm veins.7. resulting in the largest outer diameter being inserted into the smallest vein diameter. is thought to be a contributing factor. 52. upper arm insertion sites. Choose a catheter with a DEVICE (CVAD)-ASSOCIATED catheter-to-vein ratio of 45% or less.indd S112 05/01/16 11:30 PM . Critical care patients. and 3. B. DVT rates than femoral sites.8. For PICCs. DVT is clinically silent and does not produce overt 8. third of the superior vena cava or cavoatrial junc- 3. 3. or end-stage renal failure. PICC insertion sites in the ante. Society for Healthcare 2. Difficulty with neck or extremity motion. jugular CVAD are comparable for long-term use ciated bloodstream infections in acute care hospitals: 2014 in patients with cancer. Assess the patient for risk factors for venous throm. History of multiple CVADs. Recognize that the majority of CVAD-associated 7.14-16 mutation).jstor. Adjustment of PICCs to achieve cor- of venous thromboembolism. 1. provides timely and appropriate informa. Surgical and trauma patients. although the rate for both catheters was but are not limited to: high. Infect Control Hosp Epidemiol. Take this greater risk of DVT with PICCs when compared measurement 10 cm above the antecubital fossa. or chest. E. Ensure that all CVAD tips are located in the lower ease. Erythema in the extremity. 4Fr). shoulder. Fakih M. For short-term use.1-5 include.7 (I) color-flow Doppler ultrasound in veins of the upper S112 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. (II) 6.6. However. assess for the location and other characteristics such cubital fossa have higher rates of DVT than mid.8 (II) update. Critical of a PICC and when clinically indicated to assess the care patients and those with cancer are at a presence of edema and possible DVT. pacemakers). Engorged peripheral veins on the extremity. Mermel LA. the superior vena cava are associated with greater betic children in critical care may be a predictor rates of DVT. 3.9-13 (I) irritable bowel syndrome. has been suggested as a factor in DVT. assesses patient response to treatment. Presence of chronic diseases associated with a reverse-tapered PICC inserted into the vein and hypercoagulable state such as cancer. but there is no significant difference between jugular and femo- ral sites. 2014. Thrombosis rates for subclavian and internal Epidemiology of America. neck. History of deep vein thrombosis. but are not limited to: (II) 1. thrombosis. et al. tion as tips located in the mid-to-upper portion of 4. or chest. neck or chest wall. measure the vein diameter using ultra- 52. Choose the type of CVAD with the least risk of 2. as pitting or nonpitting edema (refer to Standard 33. subclavian sites have lower http://www. especially with dif. thrombosis (DVT) than other CVADs due to 5. congenital heart dis. to other CVADs. tion to the licensed independent practitioner (LIP). Stavropoulos SW. although a meta-analysis in cancer 9. A more recent study inserted central catheter-related deep vein thrombosis: contempo- showed an increased risk of catheter-associated rary patterns and predictors. Pan SM. Chopra V.pub3.108(6):1097-1108. Infect 3. Triple- patients with tunneled cuffed catheters and implant. Petit L. Ge X. gentle limb exercise. con. CVAD flushing and locking procedures have no effect as a marker of venous thromboembolism in critically ill children. Cummings M. Peripherally inserted central cath- protect against DVT in patients with PICCs. Another retrospective analysis in can. Int J Nurs bosis and allowing for adherence of organisms. and thrombosis thrombosis. Subclavian central venous extremity DVT for at least 3 months after CVAD catheter-related thrombosis in trauma patients: incidence. J Infus Nurs.indd S113 05/01/16 11:30 PM . 2014. Access Device [VAD] Removal). technique and solutions used are directed to the inter. and symptomatic catheter-associated DVT may Esterman A. Wang YW. 5. Jumani K. Stavropoulos SW. Trerotola SO. Diagnosis and manage- sure to radiation. Faustino EV. Wypij D. Shuman EK.23-26 (IV) tematic review. Siperstein AE. tion. Risk botic syndrome are associated with upper extremity factors for peripherally inserted central venous catheter DVT. Cutting peripherally inserted central cath- opposed to home care patients as no correlation eters may lead to increased rates of catheter-related deep vein between infection. Risk factors for catheter- rectly with a blood return. Vidal E. Lee A. Do not remove a CVAD in the presence of DVT Surgical Quality Improvement Program data and a call to reassess when the catheter is correctly positioned at the prophylaxis strategies. Costello JM. 2014.167(5): 429-435. This Stud. Vascular (IPD) meta-analysis of clinical trials and prospective studies.20-22 (I) randomized controlled study. Hickner A. 2015.e1. 2013. The catheter to vein ratio and rates of symptomatic develop simultaneously and is probably caused by the venous thromboembolism in patients with a peripherally inserted fibrin sheath supporting the development of throm. Recognize that pulmonary emboli and postthrom. Milstone AM. et al. Mikocka-Walus A. Crit Care. Anzlovar N. Impact of postplacement adjustment of peripherally inserted central catheters on the risk of Note: All electronic references in this section were accessed September bloodstream infection and venous thrombus formation. extremity because it is noninvasive and avoids expo. M. and adequate venous access sites for the prevention of venous thrombosis.1 (IV) complications in children. was reported in a study of cancer patients receiving 13. including early mobilization of the catheter. Woller SC. Radiology.256(1):312-320. Line-associated thrombosis as the major cause of hospital- nal CVAD lumen rather than the vein lumen.17 (II) in children: recent advances. et al. Saber W. how. For CVADs with a longer dwell time. Scipione CA.14 (II) nosis and infection.(3):CD004084. Prophylaxis with anticoagulant therapy is not rec. Ratz D.37(6):466-472. cavoatrial junction. et al. 6. Stevens SM.52(3):677-685. Peripherally home parenteral nutrition. Fielder A.9(2):312-319. Kuhn L. Mondshein JI. Mondschein JI. eter thrombosis—reverse tapered versus nontapered catheters: a ever. lumen occlusion. Baxi SM. Steele D. Anticipate prescription of therapeutic doses of anti.31(4):241-248.18 (II) 4. may be a greater problem in critically ill patients as 12. Grant JD.12(6): 847-854. H. Yacopetti N. et al. with heparin and asymptomatic DVT is reduced 2010. 2014. Lancet. as the J Thromb Haemost. Gosey L. Am J Surg. J Infus Nurs. K. Pediatr Crit Care Med. 15. Grech C. Sharp R. Recognize that catheter-related bloodstream infection 11. Tala JA. 1. and there is no evidence related thrombosis (CRT) in cancer patients: a patient-level data of any infection (refer to Standard 44. Norris CM. Masson F. coagulant medication in the presence of upper 3. Central venous catheter-related thrombosis: a sys- treated with alteplase for malfunctioning. 10. 2012. Gentile A.CD004084. Pemira S. Trerotola SO. systematic review and meta-analysis. Central daily living. Encourage the patient to use nonpharmacologic 7. ste- hydration.12(6):891-896. 2013. the catheter is functioning cor. 2. Gutnick JR. Advani S.208(1):45-49. Chopra V. N. ment of upper extremity deep-vein thrombosis in adults. L. 2015. et al. factors and influence of polyurethane type.17(3):R103. J Thromb Haemost. Itkin M. Reich NG. J Thromb Haemost.14(3):273-283. Clapper TC. Blood glucose I. 8.25(1):85- 91. tinue the treatment for as long as the CVAD is in 2013. Mino JS.19 (V) acquired deep vein thromboses: an analysis from National J. Cavallazzi R. Control Hosp Epidemiol. computed tomography venography. risk removal. Krein S. 2014. Risk of venous thromboem- strategies for thrombosis prevention whenever pos. central catheter (PICC): a prospective cohort study. Williams EC. 2008. bolism associated with peripherally inserted central catheters: a sible. 2014. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S113 JIN-D-15-00057. situ. REFERENCES 16. 2013. Li C. additional study is needed.34(8):785-792. 2011. bloodstream infection in CVADs that had been 14. Wang FL. Moua T. 2012. Soulen MC. Anand S. Shlansky-Goldberg cer patients suggests that antiplatelet agents may RD. Venography with contrast injec. J Vasc Interv Radiol. lumen peripherally inserted central catheter in patients in the ed ports found that symptomatic DVT is reduced critical care unit: prospective evaluation. performance of normal activities of 311-325. doi:10. on catheter-associated venous thrombosis. with warfarin. 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Recognition and prevention of nosoco- mial vascular device and related bloodstream infections in the 2.1. Beardsley AL. in the pericardium pro- catheters: reappraising the evidence. common iliac veins. obesity. Ahn DH. and different Syst Rev.pub5.9(1):e8-e12. in the mediastinum producing infiltration/ 25. azygos vein. Extravascular malposition includes tip location intensive care unit. iliolumbar. Krein SL. Infectious and thrombotic complications of central mately 3 times more common than with other venous catheters. cal patients: antithrombotic therapy and prevention of thrombo- Femoral insertion sites may produce malposition sis. 2010:495-515.4.141(suppl 2):e351S-e418S.125(8): ducing pericardial effusion and cardiac tampon- 733-741. Chopra V. 17. Comerota AJ. CVADs. cardiac imaging studies are Practice Criteria needed to determine blood flow characteristics. Sherertz RJ. C. Chest. use of mechanical ventilation. thoracic vein. CENTRAL VASCULAR ACCESS ing the vein. MO: than 2 cm below cavoatrial junction).2. 2010. Perucca R. et al.141(suppl 2): e195S-e226S. Diagnosis of DVT: breast tissue are associated with a change in CVAD antithrombotic therapy and prevention of thrombosis. Ramly EP. Dunn AS. PLSVC is the most common form of 53. maintenance. Nakazawa N. et al. Wang DH. Jaeschke R. ade. and pulmo- nary veins. Critical care patients may erally inserted central venous catheters: a retrospective analysis of have a tendency for a higher rate of malposition risk factors.1 The clinician verifies the documented anatomic congenital anomaly and will probably be undi- location of the central vascular access device (CVAD) agnosed until placement of a CVAD is required. 2012.26(2):121-131. and a number of small tributary veins 20. on peripherally inserted central catheter (PICC) 22. 9th ed: tip position. Gorski L. variations cause CVAD malposition during 2013. St Louis. Akl EA. and peripherally inserted central rax or pleural effusion. Lim W. Anand S. kidney) and Descent of diaphragm and abdominal contents with may require repositioning the CVAD. eds. et al. and arm movement. 2012. Sharma A. intraperi. brain. Chest. Chenoweth C. Akl EA. 1. et al.14(3):306-309. CVAD tips move due cant risk for air or thrombotic emboli to a vari- to patient position. 3rd ed. venous thrombosis. Before using a CVAD in a PLSVC. respiration. Perucca R. Miller KE. A. ipsilateral or contralateral internal jugular veins 19. for VTE disease: antithrombotic therapy and prevention of thrombosis—American College of Chest Physicians evidence- 1.1002/14651858. insertion. tip upon insertion prior to initial infusion through the PLSVC may be present with or without other catheter.13. congenital cardiac anomalies. pericardiophrenic vein.3-9 (I A/P) 24. Recognize that acquired and congenital anatomical associated bloodstream infections. and (I A/P) S114 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Recognize that primary CVAD malposition may practice guidelines. 2):e419S-e494S. Chittick P. Kearon C. doi:10. throm- bosis. and potential complications. 2014. in the pleura producing hemotho- infection. the right Saunders/Elsevier. Bloodstream extravasation. Prevention of VTE in nonsurgi. Hunter M. DEVICE (CVAD) MALPOSITION 2. et al. Antithrombotic therapy intravascular or extravascular tip location. eter advancement. position with PICCs is reported to be approxi- 23.38(suppl 8):S363-S372. Dowell JE. 2013. Chest.14 position change from lying to standing. venous blood flow characteristics. of the innominate and superior vena cava (SVC). Alteplase use for abdominal bleeding. resulting in 18. 2012.2.2 (I A/P) American College of Chest Physicians evidence-based clinical B. Infusion mammary vein. Malpositions are reported 21. right or left internal care. and clinical practice guidelines. retract H.7. If arterial placement of a CVAD is suspected. No evidence artery (eg. Arterial versus venous waveform from an F.2.6. Vascular problem: Visualization). Manage malposition depending upon the location of sure space with the risk of bleeding into that the CVAD. is recommended to determine the current of these techniques. CT scan. Cardiac tamponade from a CVAD is required.17. Provide clavian. Edema in the neck or shoulder.16-18 (I A/P) and unpredictable nature of this type of malposition. Ultrasound is also useful to rule out cephalad complications before each CVAD infusion as tip orientation in the jugular vein prior to removal these factors will be the first indication of a of the sterile field (refer to Standard 22. sition based on clinical signs and symptoms and nal jugular. Paresthesia and neurological effects due to ret- known as tip migration and is related to spo. symptoms of catheter dysfunction and associated tion. Risk factors for implanted port to enhance their ability to identify the problem. carotid) with site compression increases for other types of CVAD malposition related to risk of brain ischemia from lack of blood flow. Invasive techniques include PICC tip location. walking. reliable indicators for arterial location. usually into a low-pres. and plan for 2. and positive py. 1. or emboli. Withdrawal of large catheters from an accessed postprocedure flush of sodium chloride. Complaints of hearing gurgling or flow stream occur at any time during the catheter dwell time.2. Reported effective I. puted tomography (CT) angiogram with contrast. trachea) is licensed independent practitioner (LIP) may be possible. Tip migration may be niques. D.21 (V) sive techniques are preferred. deep vein thrombosis.1. flushing the catheter. Shoulder. and the patient’s acuity. vomiting). tance on the chest radiograph. tip migration are reported to be an original tip Routine chest radiograph at specific intervals may positioned high in the SVC and presence of lung not identify tip migration because of the sporadic cancer.6. or topo.indd S115 05/01/16 11:30 PM . The most common locations nance imaging (MRI) to diagnose secondary malpo- for secondary CVAD malposition include inter. sub. E. axillary. Correlate growth to tip location. Central Vascular 3. Pulsatile flow and color of the blood are not always 8. a scout scan. Absence of blood return from all catheter lumens. rograde infusion into the intracranial venous radic changes in intrathoracic pressure (eg. waveforms using a pressure transducer. 4. Use tip location technology to enhance awareness of 2.18. 2.22-24 (IV) hematoma. Collaboration with the ies or veins and other structures (eg. noninva- CVAD changes as needed. 7. procedure (refer to Standard 23. sinuses.25 (IV) coughing. innominate (brachiocephalic). and related to a sudden change in viscosity between retraction and advancement under fluoroscopy.16. Consult with the LIP VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S115 JIN-D-15-00057. space.2. Anticipate diagnostic tests including chest radio- the SVC. Access Device [CVAD] Tip Location). Fistula formation between veins and arter. Atrial and ventricular dysrhythmias. or com. fluorosco- failure. G. power injection is available. Recognize that secondary CVAD malposition may 10.20 (I A/P) than 2 cm below the cavoatrial junction. Power injection is reported to partial PICC retraction with guidewire tech- cause PICC tip migration. Changes in respiration. Use dynamic ultrasound during the insertion proce. problems with functionality of the catheter. J. 6.26 (IV) through the vessel wall. and deep in the radiology department with clinical information the right atrium. the contrast agent in the catheter lumen and the 3. and azygos veins.15 (I A/P) 9. assess attached pressure transducer. CT contrast agent injection. Difficulty or inability to flush the CVAD. For PICCs with jugular vein location.13.19. Secondary extravascular CVAD malposition is Chest radiographs for diagnostic purposes should associated with erosion of the catheter tip include catheter tip location. Changes in blood color and pulsatility of the primary CVAD malposition during the insertion blood return from all catheter lumens.10. associated with fluid infusion and may be diag. blood gas 5.2. L. original tip located high in K. or a combination gram.14-17. echocardiogram. chest. Recognize that the growth of infants and children catheter based on electrocardiogram (ECG) results in suboptimal intravascular tip location when results. congestive heart graph with or without contrast injection. Before and after using a power-injectable PICC for methods include elevating the patient’s head. sounds on the ipsilateral side. 1. and/or magnetic reso- pressure ventilation. or back pain. catheter flushing while advancing. For PICCs with intracardiac location that is more nosed with echocardiogram. 1. the continued need for infusion therapy. Assess the patient and the CVAD for signs and dure to reduce the risk of inadvertent arterial inser. Secondary intravascular malposition is also 11. values for a sample taken from the CVAD. or from measurement of the specific dis- a CVAD is indwelling for extended periods of time. neck or arm movement. Changes in blood pressure and/or heart rate. EJVES Extra. Alwassia A. Therapy. Curtis O. PA: Wolters Kluwer/Lippincott bar vein: incidental detection by bone scintigraphy.14. before removal from arteries to determine if sur. 2012. Ibrahim GM. Measure the external CVAD length and compare mechanisms of intravenous port catheter migration. Perstoft I. Turi G. Hatakeyama Y. insertion: is increased PO2 a sign of arterial cannulation? A case ies have established an acceptable length of time report. 16. Rare but insertion. sult with the LIP regarding changing the infusion 12. and no stud. Hong Kong J Emerg Med. Pericardial effusion and cardiac therapy until the proper CVAD tip location can be tamponade associated with central venous catheters in children: reestablished. Withhold infusion through a malpositioned catheter ondary to tip position in the right atrium: an urban legend? A until proper tip position has been established. 2015.59(2):200-203. Davidson B. Wani M. azygos fistula. Rodan AR.29 (V) an uncommon but serious and treatable condition. Bishop S. Arm movement. Araimo F. Anterior mediastinal central line sible. Pittiruti M. J Comput Assist Tomogr. 2007.9(1):173. 15. Twiddler’s syndrome). Br J Anaesth. 2012. 2014:687-742. therapy. Kenney BD. Chen P-T. alteration of CVAD tip location. Hemodialysis catheter der skin or the catheter to be sterile. Consult with the LIP. Kawamura ally inserted central venous catheter lines frequently flip after K. 21. 22.15(1):127. tion of insertions in one unit. Martin L.51(1):44-48.40(2):182-183. Persistent left superior vena cava: review stabilization cause CVAD dislodgment (movement of the literature. Removal when an infiltration or extravasation spective cohort study in 1619 patients. Dislodgment could indicate the tip serious complications of central line insertion. 2012.45(8):1687-1692. J Cardiothorac Vasc Anesth. Pikwer A. Wu C-Y. Shinoda K. Chan K-H. Central venous catheter placement: where is the 5. Baath L. See T. An uncommon arteriovenous fistula resulting from haemodialysis catheterization despite applying ultrasound 1. may cause hematoma or pleural or peritoneal 8. Anaesth Intensive Care. Patel J. BMC Nephrol. Braby J. Lozano LAS. 2011. after insertion for such catheter manipulation. and inadequate catheter 13. increasing the risk for Surg. power injection of contrast. 2013.1136/bcr-2013-200313. Yoder K. Management may require catheter exchange or Wandering peripherally inserted central catheter tip: an under- removal and insertion at a new site. Aizaki T. Tsuda R. Acta Anaesthesiol Taiwan. Central venous catheter through a peripheral vein.110(3):333-346. 14. 2013. Lamperti M. Chaubey VK.29(2):491-495. Nazir O. Metcalfe M. Feng P-H. Chen C-Y. Chirinos JC. Plumer’s Principles and Practice of Infusion cannulation of a femoral central venous catheter into the iliolum. In: Weinstein S. N. Misra R. Mai CL. Chhabra L. Misplaced central venous catheters: into the azygos vein with subsequent development of a tracheo- applied anatomy and practical management. 2013. Ladd AP. to the external CVAD length documented at 17. 9th ed. Chu Y-C.44(1):82-87. Akeson J. 197. Marn C. Andrews MH. 2014. Tobe K. Assess systematic review of the literature. Complication of femoral vein CV port catheter malposition. Kang B. 3. Khabiri H. result- principles of central venous access device placement and venogra- ing in changes of the external catheter length and phy in cancer patients. Neyra JA. is suspected. et al. Chang W-K. Patibandla B. the infusion therapy being administered and. Managing complications of 4. The inci- effusions. Med.36(4):427-430.36(1):30-37. insertion site. Hounoki H. the nurse should assess malposition into intrapleural space. Weil BR. if pos- 10. 18. 2015. 2009. Removal from other extravascular tip locations tip? Am J Crit Care. Anesth Analg.43(1):74-78. Clin Nucl Williams & Wilkins. Semin Pediatr location is suboptimal. J Pediatr Surg. clinical implications.18(2):73-83. BMJ Case Rep. Defining guidance: malposition of catheter into right subclavian artery. Johnston A. Acute back pain and paresthesia after gical removal or use of a percutaneous closure femoral venous catheter placement. Povoski SP. Leissner KB. applied to skin or the external catheter will ren. Choi H. No antiseptic agent or technique 2013. patient manipulation 2010. 2014. 5. Philadelphia.6. J Cardiothorac Vasc Anesth. 3. peripherally inserted central catheter tip position and an evalua. body habitus. Takahara S. doi:10.30 (V) recognised intensivist challenge. Thompson M. eds. REFERENCES 19. has occurred will require a treatment plan for the 2008. 20. Bartley A. If the infusion therapy is not possible 11.indd S116 05/01/16 11:30 PM . insert a short peripheral catheter to continue malposition.21(2):317-318. J Med Imaging Radiat Oncol. dence and risk of central venous catheter malpositioning: a pro- 6.117(1):123-125. and relevance of alterations in thoracic central venous anatomy as pertaining to the general of the CVAD into or out of the insertion site). Redfern W.41(3): the potential risk for discontinuing therapy and con. Bodenham A. Kitasato Med J. Matsushima S. Eur J Vasc Endovasc Surg. device is most appropriate. Streater C. (eg. Risk factors and possible 2. Jain A. 2013. Accidental Hagle M. Fu J-Y. 6.29. Never advance any external portion of the Diagnosis and insertion of Hickman catheter for a patient with CVAD that has been in contact with skin into the persistent left superior vena cava. Anaesthesia. removal may be indicated if cardiac tamponade 2011.26-28 (IV) 9.2. Taki H. Caniano DA. 1. Spontaneous migration of a portacath 2. catheter-related thrombosis. Fluid aspiration through the CVAD before the misplaced central venous catheter. Pediatric infusion therapy. 2015.21(5):370-371. 2011.18(3):166. Goodman LR. Power injectable peripher- 4. Gibson F. J Sci Soc. 2013.22(1):e6-e8. World J Surg Oncol. Late cardiac tamponade in adults sec- M. S116 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Askegard-Giesmann JR. 7. Chisholm BD.68(5):484-491. specific medication involved. Tordiglione P. 3rd ed. Corrigan A. 2014.23(7):981-983. JAMA Surg. not return blood: two case reports of rare causes for misplaced Corrigan A. subclavian artery cannulation with a central venous catheter. 2014. Infusion central venous catheters. MO: 27.2014. 2015. McGoldrick M.148(11):1063-1066.163(suppl 6): caused by power contrast medium injection. 26. Management 30. multispecialty panel using the RAND/UCLA appropriateness Karimi A. Bechara CF. Vasconcelos P. Lin PH. et al. The role of saline flush successful retrieval using a minimally invasive technique. guide for intravenous catheters (MAGIC): results from a 24. Barshes NR. Gorski L. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S117 JIN-D-15-00057. Perucca R. Central venous access devices: 25. Morden P. Pinho C. Hankins J. In: Alexander M. Chopra V. Tadros A. Braz J Anesth (English ed). Brophy D. 2010:495-515.202(1):W13-W18. Goski L. 2012.107(9):292-293.02. In: Alexander of inadvertent carotid artery sheath insertion during central venous M. Nursing: An Evidence-Based Approach. Infusion catheter placement. inserted central catheter tip during power injection of contrast 28. Kougias P. Preto C. O’Donohoe R. Hankins J. 2014. and potential complications. 2013. Ann Intern Med . Redmond C.indd S117 05/01/16 11:30 PM . Inadvertent Saunders/Elsevier. St Louis. 2010:204-228. MO: 10. Pisimisis G. The Michigan appropriateness material. Breslin D. Pereira S. Flanders SA. 23. Perucca R. Goyal A.007. Asadoorian M. eds. Saint S. Lambeth L. maintenance. J Vasc Intervent S1-S39. Perucca R. Hunter M. Radiol. St Louis. Gorski L. Ir Med injection rate in displacement of CT-injectable peripherally J. doi: Nursing: An Evidence-Based Approach.1016/j-bjane. Roberts AC. 29. Am J Roentgenol. et al. Saunders/Elsevier. eds. 3rd ed. Miller L. When one port does care. Sokhandon F. Infection prevention and control. Peripherally inserted central catheter tip malposition method. and 54.3 Removal of a temporary intraspinal access clonidine. patient and caregiver education. when accordance with organizational policy. C.4. pharmacology. care and management. and management pain management (eg. proce. Competency Assessment and administration system and differentiated from other Validation). chronic malignant and non- risk of complications. the clinician is competent in A. but are not limited tered via the intraspinal route.1-9 access are established in organizational policies. Provide comprehensive education to clinicians who care for patients receiving intraspinal infusions to include the following content: related anatomy and 54. INTRASPINAL ACCESS physiology. and subcutaneous access and medi. use and troubleshooting of access devic- es. morphine. hydromorphone.indd S118 05/01/16 11:30 PM . D. Titrate medications carefully during medication ini- titioner (LIP) in accordance with rules and regulations tiation when converting from one route to another promulgated by the state’s Board of Nursing and in (eg. ing should start extremely low when converting from one medication to another. may include opioids alone. The Art and Science of Infusion Nursing Section Eight: Other Infusion Devices Section Standards Practice Criteria I. and subcutaneous administered via an intraventricular access device. Intraspinal. recognition and manage- ment of complications and emergency situations. and opioids in combi- a licensed independent practitioner (LIP). intraosseous (IO). these include. ziconotide. Administer only preservative-free medications via an 54.6 (V) by or upon the order of a licensed independent prac. and administration for patients in practice settings from subcutaneous devices. Removal of converting from one medication to another. nation with local anesthetics and clonidine. and dos- procedures.1. intraspinal route.2 (V) S118 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Anticipate intraspinal (epidural/intrathecal) infusion the management of intraspinal. IO. and 0. B. and/or practice guidelines.1 Intraspinal access devices and administration sets review of organizational policies and procedures are identified and labeled as a specialized infusion (see Standard 5. Dosing and opi- neled intraspinal devices are considered surgical oid conversion guidelines should be used. patient assessment and DEVICES monitoring. IO. and complication Antineoplastic agents and pain medications may be management for intraspinal.5 (V) infusion administration and access systems. Infusions II. fentanyl. Standard device removal. opioids in combination cation/solution infusion are initiated upon the order of with dilute local anesthetics. Insertion. acute care to outpatient and home care who require physiology. side effect management. malignant pain) and for spasticity control. intravenous to epidural to intrathecal). during/after a surgical proce- techniques aimed at maintaining access and reducing dure. 54. (IV) dures. III. baclofen. infusion administration. to.1. including knowledge of anatomy. women in labor.2 Only preservative-free medications are adminis. when adding adjuvant medications.9% sodium device (intrathecal and epidural) is performed either chloride (USP). and long-term implanted ports/reservoirs/pumps or tun. To ensure patient safety. bupivacaine. both at rest and with activity. Perform site care and dressing changes over a 4. Presence of any side effects: pruritis. in accordance with organizational policy. Recommendations include assessing tissue. or patients tak- dural infusions. Consider the use of chlorhexidine-impregnated over-the-counter. drainage. swelling.4.6 (V) G. agent to fully dry as all antiseptic agents have the 7. progressive numbness. clinical serous fluid is aspirated. mended due to risk for dislodgment.7 (V) of blood. Ensure availability of naloxone to treat inadvert. respiratory rate. notify the LIP.5 mL ing for changes in external catheter length. occur with every patient encounter. 0-10). Pain rating using a validated. taping. dislodges to epidural space) or an increase in side es prior to medication administration to ascer.2-micron filter. as concomitant medication use may increase device. Perform the access procedure and medication filling N. assessment of out- pump refill.6 (V) 1. Apply a sterile dressing.13 (III) F. M. Assess and monitor patients after initiating or H. E.4.11 (V) and staffed environment (eg. Committee 6. or motor (V) block. Be especially vigilant when infusion device with anti–free-flow protection. epidural placement dislodges to intrathe- tain the presence of spinal fluid and the absence cal space).6 (V) dural abscess.8 (V) J. Number of bolus doses. effects (eg. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S119 JIN-D-15-00057.6. there 5. Routine dressing changes for short-term epidural 2.4. A significant reduction in epidural skin the risk of complications of intraspinal therapy (see colonization and catheter tip colonization has Standard 13. if greater than 0. Ensure strict attention to needle placement to O.4. if used (eg.2. pulse. Maintain strict aseptic technique while wearing a 7. ask patients to report every tricular reservoir.8 (V) sion.7. nausea. fewer incidents of premature dislodgment of tration. Use a transparent semipermeable membrane erythema. Perform a medication reconciliation with every 5. tine site care and dressing changes. Identify catheter tip dislodgment by routinely assess- spinal fluid and blood. Blood pressure.11 (V) thoracic epidural catheters when compared to 1. 1.8 (V) been demonstrated with their use. tenderness. Confirm proper placement of the intraspinal access 8. Filter infusion medications using a surfactant-free restarting an intraspinal infusion in a fully equipped 0. hospital setting) for at I.6. such as those with Patient-controlled analgesia may be used with epi. such as back pain. allow any skin antiseptic block. decrease in pain control (eg. If site care is performed. 4.7.14 (III) tion administration to ascertain the absence of L. Signs of catheter insertion site infection or epi- potential to be neurotoxic. fever. Administer continuous infusions using an electronic least the first 24 hours. Aspirate intrathecal and ventricular access devic. appropriate pain K. intrathecal placement 2. ture.4. at the following time intervals: hourly for the first 2.11 (V) body. Level of sedation if opioid is being administered. orthostatic hypotension. for the patient in labor. psychiatric conditions.12. patients and patients receiving home care should 3. malaise. sleep apnea. motor 3.4 (V) medication that they take including prescription. Reduce the risk of accidental dislodgment by tap- mask and sterile gloves during any intraspinal access ing a tension loop of tubing to the patient’s or maintenance procedure. 2. 1. and complementary/herbal medi. Medication Verification). 6. dressings for patients with an epidural access cations. uri- Consensus) nary retention. leave the site open to air.5. Maintain peripheral intravenous access for at least of an implanted intraspinal delivery system with a 24 hours due to the potential need for naloxone medication reservoir at regular intervals in accordance administration for evidence of respiratory depres- with the manufacturer’s directions for use. patient-con- tunneled and accessed implanted epidural device trolled epidural analgesia).indd S119 05/01/16 11:30 PM . (V.10. After the first 24 hours postplacement of a ven- patient encounter.4. Subcutaneous tunneling and sutures resulted in device before any infusion or medication adminis.8 (V) ing concomitant medications. and do evidence of catheter tip dislodgment may include not administer the medication. (TSM) dressing to allow for site visualization. Observe patients for at least 30 minutes after a 24 hours and then every 4 hours. Fetal status and response to intraspinal infusion are no evidence-based recommendations for rou.4 (V) 3. monitoring higher-risk patients. tempera- and intrathecal access devices are not recom. Aspirate epidural access devices prior to medica. and stabilize the intraspinal scale based on the patient’s age and condition access site: (eg.6.6 neck stiffness.8 (V) ent overdoses. Assess the patient’s response to therapy at estab- avoid accidental injection into surrounding lished intervals. In: Alexander M. increased pain and Standard withdrawal symptoms may be indicative of 55. Fast fact #98: intrathecal drug therapy for pain. Published 2007. Cowley C. Deer T.4. Camp-Sorrell D (ed). isolation precautions: preventing transmission of infectious 11. Neuromodulation. Raffaeli W. Martin B. Stearns CK. euphoria.capc. advanced life support guidelines suggest the use of ence 2012: recommendations for the management of pain by the IO route as the initial vascular access route. urgent. Increase and improve appropriate IO use through 6. not available or cannot be obtained quickly. indicate an epidural hematoma. care is compromised without rapid vascular access. doi:10. INTRAOSSEOUS (IO) ACCESS caution with active repetitive bending or twisting DEVICES of spine as these may increase the risk for cathe- ter damage or dislodgment. sedation. Schroeder M. et al. major traumatic Perucca R. and/or when delay of 3rd ed. Address the following patient education topics1. REFERENCES and medically necessary situations. 8. 10.8-18 nurse management and monitoring of analgesia by catheter tech- (IV) niques: position statement. dislodgement. Andruccioli J. Guideline for dysfunction. Intraspinal access and medication admin. Siegel JD. 2008:47-51. Duell DJ. use and correct administration parameters. Wilson GR. Principles of Analgesic Use in the A. Levy R. Access Device Guidelines: Recommendations for Nursing Practice and education and competency programs as underuse of Education. 5. Catheter and administration set connections. Registered Use of IO infusion is also reported in anesthesia. 2007. Rhinehart E. Pasero C. eds.15(5):467-482. 14. Topics in Neuromodulation vascular access. leg pain. peripheral regional catheters. Polyanalgesic consensus confer. Dressing for intactness and absence of moisture/ 8.cdc. Schmitz A. J Antimicrob Chemother. of thoracic epidural catheters decrease the incidence of catheter 3. 9. PA: Oncology Nursing Society. Glenview. Sarti D. and motor block. 2012. Brant JM.1-7 intrathecal (intraspinal) drug delivery—reports of an interdiscipli- (II) nary expert panel. Sellmann T. Ezzone SA. ed. BioMed Res Int. Center to Advance Palliative Care. 2015. Electronic infusion device for history of analgesic 11. Eberhart L. Chiarello L. Treatment of Acute Pain and Cancer Pain. American Pain Society (APS).html. 2007isolationprecautions. 6th ed. Pittsburgh. 9. Bierfischer V. over- dressings reduce bacterial colonization rates in epidural and the-counter. C. injuries. including unex- 10. Chlorhexidine gluconate medications used including prescription.8: 12.org/fast-facts/85. Intrathecal drug B. Pain Manage Nurs. knowledge and skills through demonstration. http://www. and complementary medications. 3rd ed. Note: All electronic references in this section were accessed September 8. Hankins J. obtained. anxiety. Best practices for intrathecal drug leakage. Corrigan A. 2014. 2010:525-539. in pain perception.5772/1255. doi:10.1155/2014/610635. et al. the IO route in emergency departments is reported. seizures. The importance of reporting alcohol use and all a meta-analysis. In: Carrillo-Ruiz J. Center to Advance Palliative Care. 2015. Upper Saddle River. 3. Published 2007. P. Jackson M. Eksterowicz N. Gorski L. life-threatening or istration.indd S120 05/01/16 11:30 PM . extensive burns. status epilepticus. 2011. increased morbidity or mortality if access is not 4. Ho KM.17(4):354-372.8(2):48-54. et al. S120 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. delivery for pain. Kerwat M. initial and ongoing validation of safe insertion epidural-analgesia. new or worsening side effects.gov/hicpac/2007ip/ carbon dioxide levels as prescribed. Prager J. 4. 2.1 The clinician evaluates the patient and anticipates problems. and respir- atory depression. Tunneling and suture and fever. (II) 7. appropriate use of the intraosseous (IO) route in the event of difficult vascular access for emergent. Include the following in competency programs: fact #85: epidural analgesia. MO: Saunders/Elsevier. Patients with implanted infusion pump systems: 55. 13. 8th ed. and nonemergent use in patients with limited or no ic pain. The IO route may also be considered for emergent administration for the treatment of cancer and non-cancer chron. such as during shock. Magnani F. NJ: Prentice Hall. Primeau M. Healthcare plained back pain.capc. bowel or bladder Infection Control Practices Advisory Committee. Changes in sensory or motor function that may org/fast-facts/98-intrathecal-drug-therapy-pain.19 2011:75-80. when the patient may be at risk of Treatment. or severe dehydration. http://www. Use of chlorhexidine-impregnated dressing to (V) prevent vascular and epidural catheter colonization and infection: 1. Oxygen saturation levels via pulse oximeter and agents in healthcare settings. Pediatric 2. Neuromodulation. 2006. et al. Practice Criteria 1. including changes doi:10. 2014. Sci World J. Fast 1. Clinical Nursing Skills. Published 2007. Kerwat K. Levy R. et al. In the event of adult or pediatric cardiac arrest. Deer T. http://www. Clinical signs of overdose including dizziness. Signs and symptoms to report. Gordon D. Litten E. 12.1155/2015/1149785.58(2):281-287. IL: anticipate use of the IO route if intravenous access is APS. Smith S. St Louis. Infusion Nursing: An Evidence-Based Approach. Cope DG. Prager J. Reisfield GM. L.31 (IV) include the proximal and distal tibia and the 1. of resistance upon bone penetration.18. avoiding multiple attempts at IO access at the and the sternum in adults. superiority of the battery-powered IO drill over Vascular Access Device [VAD] Planning). organizational policies and procedures. Schexnayder SM. time of placement.to 10-mL ous versus central venous access in adults under resuscitation in (adults) or 2.26.18.12. guidelines for cardiopulmonary resuscitation and emergency car- tion. >0. 3 categories of devic.15. previous Infectious complications were more likely to orthopedic surgery/hardware.11. Bingham R. Reduce risk for infiltration/extravasation through proximal humerus. the distal femur for children. ongoing and frequent assessment of the IO F. et al.24. Apply a sterile dressing over the IO access site. ulna.11. Chameides L.27.24. and tions/known vesicants and large volume infu- clavicle.30-32 (IV) issues): compartment syndrome in target extrem. Resuscitation. 2.81:1305-1352. ensuring proper needle placement.to 5-mL (pediatric) preservative-free the emergency department with inaccessible peripheral veins. 2010. Comparison of intraosse- signs of infiltration upon flushing with 5. 2010: adult evidence addressing the optimal antiseptic advanced life support. Nolan JP.10. Absolute contraindications (related to anatomic less than 24 hours.122(suppl 3):S876-S908. Soar J. ers’ directions for use as each IO device has approval Infants and young children may be at greater risk for for particular sites.24. sensation of loss ric life support. ease of use. and was present during the time of local vascular compromise.23. 2010.27 (IV) sions. severe access (see Standard 5. Kirchoff C.20 (V) manual needles and other semiautomatic devic. Circulation.11. rechecking IO placement. Otto CW. solution.26. consider IO admin. absence of any 5. There is no 3. Part 14: Perform skin antisepsis using an appropriate pediatric advanced life support: 2010 American Heart Association solution (eg. Section 6: European I.23.18. and osteomyelitis.18.81:1364-1388. While relatively uncommon. infection. 2. osteopetrosis. Competency Assessment dehydration) and therefore is not an indication of and Validation).30. occur with prolonged infusion or if bacteremia tion or severe burns near the insertion site. and drill powered. Rarely reported complications include iatrogenic ity. user prefer.26-28 (V) diovascular care. 1. guidelines for cardiopulmonary resuscitation and emergency car- tion.10-12.24.27. et al.5% chlorhexidine in alcohol solu. Monitor for complications associated with IO es. 2010: pediat- assessment of the needle position. Select an appropriate IO site based on the clinical mon reported complication is infiltration/extravasa- situation and device specifics.9% sodium chloride (USP). Presence of bone diseases such as osteogenesis imperfecta. attempt. fractures at or above the site. 2. insertion.22-26 (IV) access. Consider the use of lidocaine as a local anesthetic Note: All electronic references in this section were accessed September during insertion (subcutaneously at the intended 8. presence of infec. Adhere to aseptic technique during IO access. Kleinman NE. including manual needles.18.14. Neumar RW. the most com- E. K. previously used IO site or recent failed IO fracture. 2010. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S121 JIN-D-15-00057.15. and limiting infusion time to 1. Eich C. Other sites less commonly reported in the securing IO device. 0. tion from dislodgment and compartment syndrome. fat emboli. and driven.23. demonstration of appropriate maintenance.18. impact J.20. pelvis. Bogner V. Limit dwell time of the IO device to no longer than ence) of different IO devices was evaluated with few 24 hours. Part 8: adult advanced istration of 2% preservative-free and epinephrine. Performance (success stabilize device.29 (V) 4. ment confirmation are present.18.14. cardiovascular life support: 2010 American Heart Association free lidocaine given slowly prior to infusion initia.122(suppl 3):S729-S767. Link MS.12. et al.11. Avoid IO access in the following sites/situations: site and extremity.21 (V) improper placement if other indications of place- D. et al.10-12. povidone-iodine. et al. Section 4: European Resuscitation Council guidelines for resuscitation. blood or bone marrow also assists in confirmation ity to recognize complications related to IO but may be difficult in certain patients (eg.12. Assess for an appropriate replacement comparative studies and weak evidence supporting vascular access device (VAD) (see Standard 26. and osteoporo.18.27 (V) es are available.13. Refer to manufactur.83:40-45. 2015. 70% alcohol) based on diovascular care.23. Use an appropriate IO device. H. Resuscitation.15. REFERENCES sis. same site.12.30-32 (IV) 2. Circulation. Deakin CD. For infusion-related pain. Biarent D. 2012.26.10.27. 2010. Insertion sites most commonly reported in the drome due to small bone size and too long needle literature for use in both adults and children length.27.29 (V) rates. The ability to aspirate Resuscitation.28 (IV) G. Leidel BA.27. extravasation and subsequent compartment syn- 1.15. abil. Confirm proper placement of the IO device by Resuscitation Council guidelines for resuscitation. site).15. literature and that may be off-label for IO access especially before infusing highly irritating solu- include the radius.indd S121 05/01/16 11:30 PM . 32(4):187-188. 2014. Hillis D. Pediatr Anesth. patients in the hospital setting. Compartment syndrome of the leg after tion paper]. drug delivery during cardiopulmonary resuscitation. Garside J. Tobias JD. settings: a consensus paper.guideline. Feb Kramer GC. doi:10. document to NAEMSP position statement].120(4):1015-1031.83:107-112. Studnek JR. J Infus Nurs. B. do Nascimento P Jr.127(3):e748-e757. Williams B. 15. 11. Resuscitation.27(1):63-67. Gallagher JV. Intraosseous vascular access subcutaneous access device (hypodermoclysis) for for in-hospital emergency use: a systematic clinical review of the literature and analysis. Hoffmann. 13. absorption of 1. Alexander M. Rouhani S.org/Documents/Position%20Papers/POSITION%20 subcutaneous access device. dextrose in water or 0. resource-limited care. Intraosseous vascular access is anesthesiologist with a focus on pediatric use.2.pdf . Anson JA. Vascular access in resuscitation: is there a role for the 56.5.58(6):509-516. Ross AK.14(3):216-224. 2011. terbutaline). Pediatrics. Weiser G. Dev SP. 2012. immu- 21. Prescott S.28(2):185-199. CONTINUOUS aspx?id=36841. Amputation and intraosseous access in 12.20(2):168-171. Trauma. et al. Weiss M. Lima RM. Prehosp Disaster Med. ness of the subcutaneous route in relation to the pre- 16.33(3):162-174. Intraosseous 25. C. 26. 2007. et al. Vizcarra C.indd S122 05/01/16 11:30 PM . Louis.1111/nicc. 27. Intraosseous access. Alternative infusion access devices. Use hyaluronidase to facilitate the dispersion and Published 2006.342:d2778.9% sodium chloride) via a 19. http://www. 29. 2010. Hunsaker S.27(10):928-932. Intraosseous access in the prehospital versus intravenous vascular access during out of hospital cardiac setting: literature review. Parker M. J Clin condition. J Emerg Med. 2008. Mull CC. Gorski L. The role of the regis.gov/content. 32. Statter MB. Emergency nursing resource: difficult intravenous access.39(4):468-475. Intraosseous vascular access: a review.12-20 (V) patients. Intraosseous route as alternative access for A. The dosage of subcutaneous solutions 2012. Intraosseous vascular access in 7. Olaussen A. N Engl J Med. Pediatr Emerg Care. Intraosseous infusions: a review for the 30. Paxton JH. Dolister M.naemsp.37(12):e198-e200. 2012. needle in adults. Anesth Analg. Newgard C. Shavit I. 2013. and Nonemergent Situations in Various Healthcare Settings [posi. Recommendations for the use of intraosseous access intraosseous infusion: guidelines for prevention. Ahn R. complications. 2014. eds. Miller S. http:// ister other medication on an intermittent basis via a www. and the presence of adequate subcutaneous Anesth. opioid (eg. 2011. Neuhaus D.12163. 2014. Borron S. morphine. Emergency Nurses Association/Emergency Nursing Resources Development Committee. Am J Nurs. National Association of EMS Physicians [position paper]. vascular access in the out-of-hospital environment [resource weight. The role of intraosseous administered is dependent upon the patient’s age. Vandeventer S. 23. Meloney L. Lottenberg L. Hankins J. Voigt J. 2010:516-524. administration should not exceed those employed 24. critically ill adults: a review of the literature. Garrett J. Galbraith R. Isaacs SM. Spiro D.27(5):468- arrest: a randomized controlled trial. Lee S. Meckler G. and laboratory values. Reades R. Engelhardt T.2. J Assoc Vasc Access. fentanyl) 2009. Infusion Nursing: An Evidence-Based Approach. Sinz EH. and other infusion therapies/medications (eg. 2010. 2010.24:e35. Taylor CC. Neuhaus D.110(2):391-401.113(11):34-39. Consider administration of isotonic solutions (5% infusion therapy. BMJ.3. Ann Emerg Med. Nurs Crit Care. Perucca R. Semi-elective intraosse. admin- Intraosseous vascular access in the out-of-the hospital setting. atric patients. Clarke NMP. The Consortium on Intraosseous Vascular Access for Emergent infants. Prehospital Emerg The rate and volume of subcutaneous fluid Care. In: 9. 2010. hydromorphone.33(6):346-351. Swick JT. for emergent and nonemergent situations in various healthcare and treatment. S122 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 2011.9-11 (V) IntraosseousVascularAccessintheoutofhospitalsetting. Insertion of an intraosseous Resuscitation. Stefan RA. 6. Atanda A Jr. safe. Published 2011. clinical condition. Shaw S.000 mL or more of subcutaneously 22. treatment of mild to moderate dehydration. Intraosseous line AND ACCESS DEVICES use. 2013. J Infus Nurs. Burke TF. ous infusion after failed intravenous access in pediatric anesthe. Hansen M. Corrigan A. 2012. Saun T. MO: Saunders/Elsevier. Pediatr Standard Emerg Care. Current advances in administered hydration solutions in adults and pedi- intraosseous infusion: a systematic review. rehydration methods: a systematic review and lessons for 2012. Alternative 28. Nelson B. and outcomes among a population-based cohort of children presenting to California hospitals.83:20-26. Infusion Nurses Society [position paper]. The versatility of intraosseous scribed medication or solution. Practice Criteria 18.1-8 (V) 20. St sia. 31. 56. Hoskins SL. Anson JA. Henderson K. Clum S. 3rd ed.5-7. the patient’s clinical vascular access in perioperative medicine: a case series. tissue. Consider the subcutaneous route for continuous tered nurse in the insertion of intraosseous devices. Espana-Tenorio JM. Intraosseous vascular success for alert for intravenous infusion. In addition. Am J Orthop.11(1):63-66. Luck RP.14(3):195-232. Intraosseous infusion in elective and emergency anes- thesia: when should we use it? Curr Opin Anesthesiol.27(3):282-287. 10. Fowler R.1 The clinician assesses the patient for appropriate- intraosseous route? Anesthesiology. 8. Waltzman M. early detection. SUBCUTANEOUS INFUSION 14. J Infus Nurs. effective and costs less than central venous catheters for 2010. 17. 2011. Pharmacokinetics of intraosseous and central venous 2015. 472. 2014. noglobulin therapy. Haines C. Humphrey P. Persistent reactions may Infusion Nursing: An Evidence-Based Approach. mines. Apply a transparent semipermeable membrane administering any drug with hyaluronidase. abscess. this M. the subcutaneous infusion device according to the 8. subclavicular chest wall. 2010:516-524.5.17(5):28-30. A stainless steel winged needle is not recom- persion and absorption of other injected drugs. Auerhahn C. pain. Ann Long Term Care.19 (V) (TSM) dressing over the subcutaneous access site to 3. In patients taking salicylates (eg.22 (V) settings.1. liters of solution has infused and as clinically indicat.6.7 (V) thetic solution increases its absorption.5.5-7. 2011. Hypodermoclysis: an alternative to IV infusion tion solutions every 24 to 48 hours or after 1. dressing is compromised. 3rd ed. The optimal subcutaneous infusion rate is unknown.1. bleeding. taneous access device using 70% isopropyl alcohol. globulin infusions. When hyaluronidase is added to a local anes.com/content/hypodermoclysis- site when there is erythema. decrease over time. Corrigan A. Hankins J.19 (V) as a continuous infusion via a subcutaneous access E.5 (IV) 1.44(12):66. Aspirate the subcutaneous infusion access device to sion and absorption of dopamine and/or alpha. require a slower infusion rate or decreased vol- 6.7.19. but the wider spread of the local anes. Assess the subcutaneous access site and rotate the http://www. Walsh G. Assess for adverse reactions of hyaluronidase of recommended subcutaneous administration rate/infu- mild local access site reactions such as redness. Hypodermoclysis with older adults. Hypodermoclysis: maintaining hydration in ed based on the access site assessment findings. 2009. thetic agent. Rotate the subcutaneous access site used for hydra- 2. site rotation but immediately if the integrity of the tration. Smith L.2. Perucca R.gov/content. as the drugs are incompatible. http://www.2. Do not use hyaluronidase to enhance the disper. and allergic N. Emergency Nurses Association/Emergency Nursing Resources manufacturer’s guidelines. cortisone or estrogens).5 to 2 therapy.6. or >0. D. swelling. anaphylactic-like reactions.19 (V) reported. abdomen (at least 2 O. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S123 JIN-D-15-00057. Use a small-gauge (ie.23(5):16-22. or pain. it hastens the onset of analgesia and Change the TSM dressing with each subcutaneous tends to reduce the swelling caused by local infil. leaking. Use with caution in a nursing mother as it is not mL over 24 hours are reported.19 (V) larger infusion volume. 3. Nursing. Scales K. indicated based on the access site assessment findings.2. MO: Saunders/Elsevier.6. Rotate the subcutaneous access site used for medica.19 (V) hol solution. 5. K. Older People.5. 2005. Use a subcutaneous Development Committee. Emergency nursing resource: difficult needle labeled for high flow rates when indicated by intravenous access.indd S123 05/01/16 11:30 PM . aspirin). Parker M. and hydration infusion rates of up to 1500 4. and pruritis are common and tend to Alexander M.guideline. Nursing. or site change. eds.10. Avoid areas that are scarred. Henderson K. J Infus Nurs. and access device using a manual flow regulator. Select a site for subcutaneous access to include areas device using an electronic infusion device that has with intact skin that are not near a joint and have the ability to titrate the rate up or down if required adequate subcutaneous tissue. 1. povidone-iodine. sion method for immunoglobulin infusions. longer needle. bruising. the drug manufacturer.10 (V) Consult the drug manufacturers’ references prior to L.9 (V) pain. More than 1 subcu- known if hyaluronidase is excreted in breast taneous infusion site may be used to accomplish a milk. Hypodermoclysis: an alternative method for rehydra- device to establish subcutaneous access.2. Gorski L. and insert tion in long-term care. burning. Hypodermoclysis in the home and long-term care ume per site.annalsoflongtermcare. or antihista. 2009. Lybarger E. Nurs 1. Mei A. upper back. Published December 15.5-7 (V) 4. 2014. J.28(2):123-129.4. I. Follow the manufacturer’s 5. such as the upper to improve tolerability. local maintaining-hydration-frail-older-adult. a larger dose of hyaluronidase for equiva.7 (V) the frail older adult.21 (V) aspx?id=36841.21 (V) arm.7 (V) thighs and/or as recommended by the drug manufac- turer. H. ster.5.5-7. Use of hypodermoclysis to manage dehydration. some swelling and site erythe.41(11):16-17. 2015. In: ma. St Louis. confirm the absence of a blood return prior to agonist drugs. Alternative infusion access devices. shortens its duration of action and tends to Medication infusion rates of 3 to 5 mL per hour are increase the incidence of systemic reaction.6. Perform skin antisepsis prior to inserting the subcu- oids (eg. 2011.32(1):40-44. 2011. G. Note: All electronic references in this section were accessed September tion administration every 7 days and as clinically 8. infected. 24.6 (V) 1. J Infus Nurs.23 (V) 2.21 (V) REFERENCES F. Consider the use of hyaluronidase to increase the dis.5% chlorhexidine in alco- lent dispersing effect may be required. allow for continuous observation and assessment. Infuse isotonic fluids for hydration via a subcutaneous inches away from the umbilicus). or acutely inflamed.to 27-gauge) infusion 7. For patients receiving subcutaneous immuno.20 (V) mended. Regulate the infusion of medications administered reactions. medication and fluid administration. Clin Ther. S124 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Bartz B. J Emerg Nurs. 2015. http://www. Younger ME.gov/downloads/Biologics a systematic observational study. St Louis. Printz MA. Perucca R. Blouin W. MO: technique. Clinical immunogenicity 12. UCM414440. O’Quinn L. Continuous subcutaneous infusion: an efficacious. versus intravenous rehydration in mild to moderately dehydrated 10. et al. 2015. 3rd ed.17(5):1144-1156. 2013. 2014. J Infus Nurs. Corrigan A.com/files/doc_downloads/ Is self-administration of subcutaneous immunoglobulin therapy June2015/Hylenex-Package-Insert-LBL301-02-Rev- safe in a home care setting? An evidence-based practice journey. Infusion 17. Lednik L. et al. Stiel S. Inc.34(11):2232-2245.27(3):230-236.36(1):58-68. Mace S. Mace S. 2013. 20. 22. D. J Infus nous fluid infusion in children. Comparing subcutaneous fluid infusion with intrave. 18. Turpin R. CA: Halozyme Therapeutics. administration of immunoglobulin replacement therapy. 11. HyQvia [package insert].22(suppl 3):S6-S12. Gorski L. Ostgathe C. Younger MEM. Murphy E. Spandorfer P. 9. BloodVaccines/BloodBloodProducts/ApprovedProducts/ 2014. The use of subcutaneous infusion in medication admin. Seifert A.38(3):179-187.pdf. Nursing guidelines for 15. J Pain Symptom Manage. Gabriel J. Subcutaneous immunoglobulin replacement therapy: ensuring 2012. Okada P. Nurs. Armstrong E. Friend K. Westlake Village. Herget I. 21.pdf. Hylenex [package insert]. a hyaluronidase enabling subcutaneous drug istration. Sedlak children in the emergency department. 2011. Saunders/Elsevier. Poynter M. Epland KB. LicensedProductsBLAs/FractionatedPlasmaProducts/ 14.indd S124 05/01/16 11:30 PM . Aro L. Br J Nurs. January-2015. of rHuPH20.fda. Justad M.31(6):928-934. 13. 19. Smith C. A randomized clinical trial cost-effective analgesia alternative at the end of life. Arthur A. Innovations in subcutaneous infusions. Infection prevention and control. Sullivan K. 2009. 2013. McGoldrick M. In: Alexander J Emerg Med. CA: Baxter Healthcare Subcutaneous administration of drugs in palliative care: results of Corporation.46(4):540-547. 2015. Pediatr Emerg Care. Subcutaneous rehydration updating a traditional Nursing: An Evidence-Based Approach. 2010:212. Harb H. Duff C. 2013. AAPS J.27(3):140-147. 2015. 16. administration. Baker M. Blouin W. Klein C.31(3):134-141. 2013. eds. San Diego.38(1):70-79. Dychter S. Hankins J.39(1):86-91.hylenex. Lebel F. J Infus Nurs. Spandorfer P. Rosengren S. Home of recombinant human hyaluronidase-facilitated subcutaneous Healthc Nurse. Home Healthc Nurse. M. Am 23. Kuensting L. success. http://www. et al. neonatal. tions and medications: dosing. and in the alter- expiration date. Practice Criteria including omissions. interactions. B. sterility (within generic). 57. integrity of 57. monitor- including indications. beyond-use or expiration date). infusion solution or medication for the patient’s age 3.1 The clinician reviews information regarding the D. when VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S125 JIN-D-15-00057. instructions. dosing errors. References and resources that include current infor- drug dosage and volume limitations. Administer solutions and medications prepared and IV. The Art and Science of Infusion Nursing Section Nine: Infusion Therapies Section Standards administration. fied by reviewing the label for the name (brand and open or damaged packaging). Perform a medication reconciliation at each care transition and when a new medication(s) is ordered to reduce the risk of medication error. no leakage/discoloration/precipi- fied. initiate administration within 1 hour after AND SOLUTION ADMINISTRATION the start of the preparation (refer to Standard 17. if compounded outside of the pharmacy (“immediate-use” compounded sterile 57. and adverse/side effects for appropriateness prior (name. rate. At least 2 patient identifiers are used to ensure accu- pregnant. duplications. Recognize physiologic characteristics and effects on II. pharmacologic mation about parenteral medications and solutions. orders of a licensed independent practitioner (LIP) in and/or risk management. PARENTERAL MEDICATION product). integrity of packaging (eg. concentration. pediatric. smart pump administration. Identify and verify medications and infusion solu- prescribed medication/solution including indications. follow the rights of medication with dose-error reduction software). compared against the medication order. A. prescribing I. medications and solutions. route. actions. dosage and concentration. special patient populations (eg. when administering solutions and medications to are readily available to the clinician at the point of care. Infusion therapy administration is initiated upon the licensed independent practioner (LIP). and adverse/side effects. Compounding and Preparation of Parenteral Standard Solutions and Medications). III. dosage. Special rate patient identification when administering infusion Patient Populations). compatibility data. Review the label for accuracy against the order data. solution (eg. dosing. Aseptic technique is adhered to during all aspects of dispensed from the pharmacy or as commercially parenteral medication and solution administration. Review the order for appropriateness of prescribed and drug interactions. and any other special refrigeration. dose. 2. and response to infusion therapy routes/rates. beyond-use date. Use technology according to organizational poli- and condition. bar code. rate and route of cies and procedures (eg. C. prepared solutions and medications in accordance with USP <797>. and veri. native care settings.indd S125 05/01/16 11:30 PM . address concerns about the appro- priateness of orders with the pharmacist. acceptable infusion routes/rates. side effects/toxicities.2 Medications and infusion solutions are identi. verify appropriate storage/ quency of administration. sterility state. access device. tate/gas formation). acceptable infusion ing parameters. supervisor. older adults) (refer to Standard 2. compatibility 1. infusion rate). frequency. route. administration to administration. and fre. or as defined in organiza- accordance with organizational policies and proce- tional policy.1-4 (V) dures. Flushing tive delivery of the prescribed therapy.5. but such G. flushing.11. Discontinuation of therapy and reason for dis- assistive personnel (UAP) to obtain assistance continuation. feeding tubes routed toward the feet). injection ports) before medi. independently administering infusion medica. 6. and achieving effec- tions and medications (refer to Standard 40. and locking proce. tic/anaphylactoid reaction. speed shock. be necessary. infusion administration and signs and an existing IV infusion to allow the medication symptoms to report. which F. Perform an independent double check by 2 clini. standing of. interventions. Label administration sets with the infusing solu. Instruct the patient. are replaced every 24 hours.8. Route tubing having different purposes in differ- tration. after infusion therapy. Replacing other IV solu- tion (eg. I. time. rate. Provide patient/caregiver education including. ent directions (eg. at each care transition to a new setting or catheter lumens are used. When multiple vascular access devices (VADs) or device. and clinician education and training. Document as follows: 1. priming) just tion containers less often than every 24 hours is prior to administration. Discard and do not use any medication syringes head. L. route. circula- dures (refer to Standard 34. drug. 3.1. documenting patient response. Parenteral Nutrition). anaphylac- cation administration.indd S126 05/01/16 11:30 PM . tainers (without postmanufacturer additives) with nections (refer to Standard 36. or adverse events and or infusions unless the patient or caregiver is laboratory tests as appropriate. communicating patency prior to administration of parenteral solu. Assess vascular access device (VAD) function and adverse events. and patient S126 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Standardization (ISO).13 (V) tions: Q. to verify medications prior to adminis. tion/medication near the patient connection and 3. Patient Education). and unlicensed 4. Discontinue infusion medications/solutions: J. Anticipate the implementation of new connector pared at the patient’s bedside and immediately standards from the International Organization for administered without a break in the process. Administer intravenous (IV) push medications and decisions are weighed against the risk of infection. Add-on Devices). IV catheters routed toward the 4. make it nearly impossible to connect from one deliv- cians according to organizational procedures for ery system to another (eg. enteral to IV) are being high-alert medications (refer to Standard 13. organizational prepa- E. each device or lumen.10 (V) to only those clinically indicated due to increased M. Upon LIP order. but needleless connector port closest to the patient in not limited to. document which solu- service. needleless connectors. Administer IV push medications through the N. tory overload).7 (V) of prescribed therapy. Patient/caregiver participation in. dose. and under- tions. the results of laboratory tests. and as part of the handoff process. P. New connectors that will 5. Do not add medications to infusing containers of IV O. any subsequent flush at the rate recommended by One study found no relationship between length of the manufacturer or in accordance with organiza. Patient’s response to infusion therapy including perceived need to connect or disconnect devices symptoms. available and LIP immediately. devices between the patient and the container and method of administration. In the event of a severe reaction (eg. There is insufficient evidence to recommend the fre- risk for contamination from manipulation and to quency of routine replacement of IV solution con- the risk for accidental disconnections and miscon. Trace all catheters/administration sets/add-on 1. side effects. Limit the use of add-on devices (eg. Standard 61. extension sets) ration. Perform disinfection of connection surfaces (ie. time used and likelihood of colonization and suggests tional procedures or guidelines.9 (IV) that are unlabeled unless the medication is pre.12 (III) 1. Reduce the risk for administration set misconnec. before connecting or reconnecting any infusion/ 2. tions and medications are being infused through 2. Evaluate and monitor response to and effectiveness solutions.13 (V) and Locking). Type of therapy.6 (V) to Standard 8. Condition and patency of VAD site prior to and near the solution container. caregivers. spiking infusion container. therapy. routine replacement at regular time intervals may not priate volume of flush solution to ensure administra. 2. 1. the exception of parenteral nutrition solutions.6 (V) considered in times of product shortages. and use an appro. tem. as in a home care setting. engineered and introduced into the health care sys- Medication Verification). including those that may occur to reach the circulatory system as soon as after the patient leaves the health care setting (refer possible. Prepare solutions and medications for administra. This requires awareness. H. Further research is recommended (see tion of the entire dose. notify rapid response team as K. and interventions. 4. from licensed staff whenever there is a real or 5. Needleless Connectors). available. closed system drug transfer jointcommission. working with antineoplastic drugs in the health care 5. Reising DL. Published 2015. Published August 20. Perry AG. Tubing and luer misconnec- double chemotherapy gloves.org/DocLibrary/Policy/ if inhalation potential. Nursing. eye protec- Utah Drug Information Service. Practice Criteria 3. Dolan S. Graves K. Ensure that only qualified clinicians administer anti- 13.com/Documents/Risk%20Education/individuals/ rnclaimstudy. the American Society of Health-System Pharmacists (ASHP). Perucca R. 8th ed. assessment of competency is recommended. Ensure that personal protective equipment (PPE) 4. Documentation antineoplastic agents are to be placed on hold or discon- in the Medical Record). 4. A. Barnes S [position paper]. reactions and extravasation injuries. tion if liquid could splash. Hankins J. http://www. Published March 20. MO: Saunders/ including treatment and management of anaphylactic Elsevier.18(2):3022-3028. http://www. J Clin Nurs.1. B. Sentinel event alert: managing risk during net (BSC) or compounding aseptic containment transition to new ISO tubing connector standards. Intravenous solution conserva. containers in all areas where hazardous drugs are tions: normalization of deviance. agent within the BSC or CACI. US Food and Drug Administration. Simmons D. Informed Consent). University of ing: double gloves. 3rd ed.org/ place (see Standard 15. and the right to accept or refuse treatment. guidelines. Symes L. isolator (CACI). procedures.pdf. dures to reduce risk for drug exposure should be in 6. MO: Mosby/Elsevier. 2011. protective gown. protective gown. an opportunity to ask questions.pdf. Phillips LD. Antineoplastic drugs are considered hazard- infusion. 2. Nutr Clin Pract. A. A variety Standard of approaches may be used to obtain informed con- 58. http://www. and treat- ment alternatives. Corrigan ing but not limited to General Chapter <797>.1 Antineoplastic agents are administered only upon sent (see Standard 9.pdf .ismp.1-6 (V) 286-293. and medication vial practices in healthcare. Tubing misconnec. and organizational policies and proce- Control. education (refer to Standard 10. Evidence-Based Approach. Seven legal tips for safe nursing practice. includ- 1. CNA/NSO. 3. Provide access to PPE. Rickard CM. 1. et al. Drug administration sets should be attached and 12. CNA HealthPro nurse claims study: an analysis of organizational policies. Published 2009. Hall A. Felizardo G.5 (V) written orders. spill kits. Guenter P.8 (V) C. Infusion Nursing: An 58. Philadelphia. Gorski L. Am J Infect ous drugs. Institute for Safe Medication Practices (ISMP). 2013:609. Pharmacology. Make your nursing care malpractice-proof.ashp. American Society of Health-System Pharmacists.2 (V) 2014.5.htm. In: Alexander M. containment bags. Manual of IV Therapeutics: Evidence. ANTINEOPLASTIC THERAPY include a description of risks. safety data sheets (SDSs. tinued. St Louis. Austin S. controls such as a class II biological safety cabi- 10.4.4.26(3): handled.6 (V. and designated waste disposal 8.hpso. http://www. including new orders or changes to D.3 Clinical management of potential adverse events. neoplastic therapy based on completion of a special- Based Practice for Infusion Therapy. PA: FA ized education and competency program. Vannapraseuth B. 2014.fda. Regulatory) final. Gorski LA.7 (V) 2009. 7. 2015.gov/ eye/respiratory protection. St Louis.1. Ensure that informed consent was obtained prior to initiation of antineoplastic therapy. setting.indd S127 05/01/16 11:30 PM . and/or practice claims with risk management recommendations. 1997-2007. is addressed in 2. 2010:263-298.38(3):34-39. 6th ed. benefits. McGrail MR. Hankins J. and a closed system drug Conservation-Strategies-for-IV-Fluids. Potter PA. The Joint Commission. eds. 58. Verbal orders are acceptable only if and provide patient/caregiver education related to VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S127 JIN-D-15-00057. Am Nurse Today.38(3):167-172. respiratory protection tion strategies. and engineering controls are in place for clinicians 2008. Fundamentals of formerly material safety data sheets). Stockert P. annual Davis. Waste). 2012. and the United States 9. Assess patient’s level of understanding of treatment existing orders.org/assets/1/6/SEA_53_Connectors_8_19_14_ device. ventilated engineering MedicalDevices/Safety/AlertsandNotices/TubingandLuer Misconnection s/default. Pharmacopoeia (USP)-National Formulary (NF). Safe injection. employ the follow- 11. A cross-sec- primed prior to the addition of the antineoplastic tional study investigating the relationship between intravenous infusate colonization and fluid container hang time. During compounding. During drug administration. 2014. which should 58. Safe practice guidelines for adult IV push medications.2 Compounding of antineoplastic agents is in accord- REFERENCES ance with state and federal regulations. employ the following: 9. Turner M. http://www. 2010. the Drug Note: All electronic references in this section were accessed September Quality and Security Act.7(1):24-28.pdf. Hazardous Drugs and Tools/guidelines/ivsummitpush/ivpushmedguidelines. Nursing. transfer device. tions: preventing dangerous medical errors. bar-code 9. Cincinnati. Use standardized orders. independently verify the H. Do not admin- tion errors with antineoplastic drugs. Infiltration and Extravasation). and day. Assess patient prior to each treatment cycle. Do not use scalp veins in the neonate and pediat. observe and report errors and adverse events. Prior to administration. 4. Infiltration and Extravasation). drug prior to vesicant administration.4. for IV push and every 5 to 10 minutes during an Medication Verification). infusion pump rate. should be proximal to the previous attempt or on tic tests. Central Vascular Access include drug name. wrist.10. counter and complementary and alternative thera. Discontinue infusion at first sign of extravasation 6. Consider involving patient and family members 4. the opposite arm. risk-reduction strategy.11 (V) contaminated with hazardous drugs (refer to G. near a joint. antineoplastic therapy. volume. and presence of new signs or or feeling of fluid on skin during the infusion. Confirm and document a positive blood return F. priate. Administer vesicant medications safely via a short Standard 15.10. S128 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 6. additional attempts ing a review of current laboratory data and diagnos. 3. istration. as appro. Limit to intravenous (IV) push or infusions last. 1.9 (IV) 6.10-13 (V) Standard 46. for Occupational Safety and Health (NIOSH). report/whom to call. NIOSH List of 4. 5. 2. OH: US Department of Health and Human where there is impaired circulation or lymphatic Services. Hazardous Drugs and Waste). Publication no. Device [CVAD]-Associated Venous Thrombosis). Standard 46. volume. Do not admin- names. 3. treatment cycle.10. flowing infusion of a compatible solution. Assess and verify blood return every 2 to 5 mL Strategies to involve patients in the process of for IV push and every 5 to 10 minutes during an medication verification should be considered a infusion.7. expiration date.11 (V) infusion. Implement safeguards to reduce the risk of medica. standardized dosage 8. Infiltration and Extravasation). 1. 2014-138. and adequately secure and appearance/physical integrity of the and stabilize the noncoring needle within drugs. If a new IV site is initiated. or signs of venous thrombosis present qualified in antineoplastic administration to (refer to Standard 52. If the IV E. signs and symptoms to tion.10 (V) 7. tions with each change in the patient’s medica. prior to vesicant administration. Confirm and document a positive blood return include confirmation of 2 patient identifiers. pretreatment vital signs and weight. to ensure that the drug is discontinued if 7. Assess and verify blood return every 2 to 5 mL technology. (see Standard 46. ized prescriber order entry (CPOE). 3.4 (V) (see Standard 46. Antineoplastic ister in the absence of a blood return (see drugs are high-alert medications. Administer vesicant medications safely via central antineoplastic order by 2 clinicians who are vascular access devices (CVADs). route. Ensure proper placement. and schedule of administration/treatment than 24 hours old. Do not administer if signs of inflammation. Antineoplastic and Other Hazardous Drugs in Healthcare antecubital fossa. 2014. Provide dilution by administering through a free- calculation. current medication list (including over-the. physical and psychological 5. Discontinue infusion at first sign of extravasation tion list. Connor TH. expected reporting any pain. et al.9 (V) use the smallest catheter possible. Consult with pharmacist to review drug interac. and in the limb Settings. sensation changes. antineoplastic order by 2 clinicians who are swelling. Provide dilution by administering through a free- in medication identification. dose. side effects of therapy. Do not use an established IV site that is greater effects. includ. dose. Monitor cumulative chemotherapy dose.4. potential side effects. established dosage limits. remaining with the patient during the 2.indd S128 05/01/16 11:30 PM .5. Safely dispose of hazardous drugs and materials the maximum lifetime dose is reached. and smart pumps (see Standard 13.14 (V) qualified in antineoplastic administration to 1. rate. burning. At the time of the order.5. plan. computer. DeBord DG. attempt is unsuccessful. including mechanism of drainage and/or history of lymph node dissec- action. patients often flowing infusion of a compatible solution. Do not use an infusion pump for peripheral vesi. calculation for ister in the absence of a blood return (see dosing. peripheral catheter5. 10. MacKenzie BA. 2015. independently verify the 2. 9. rate of admin.13 (V) implanted vascular access ports. Infiltration and Extravasation).11.10. Instruct patient in the importance of immediately pies).4.14: (V) 1. REFERENCES ing less than 30 to 60 minutes. Note: All electronic references in this section were accessed September cant administration. 5. entire infusion. National Institute ric patient. Avoid the following sites: dorsal hand. symptoms of toxicity. Standardize prescribing. therapies.2 9. Chemotherapy safety and safety as a primary factor when selecting the severe adverse events in cancer patients: strategies to efficiently treatment setting. 2013. Eur J Cancer Care. Access Device Guidelines: Recommendations biologic waste per state guidelines. PA: Oncology 1. Camp-Sorrell D. tion adverse reactions and errors with biologic Oncol Nurs Forum.org/advocacy-policy/positions/edu. Pittsburgh. Pittsburgh. 7. Published 2015. Implement safeguards to reduce the risk of medica- the safe administration and management of oral chemotherapy. Nurses’ protective measures during chemotherapy preparation and administration in Turkey.72(8):e6-e35. ing drugs to treat anaphylaxis.and outpatient treatment. Bruce S. 4. 2012. colony-stimulating factors. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S129 JIN-D-15-00057. National Institute for Occupational Safety and Health (NIOSH). Oncology Nursing Society position on safeguards. prepare. Vesicant administration and extravasation management. BIOLOGIC THERAPY (refer to Standard 17. Medication Verification). St Louis. Rizalar S. Store. PA: Oncology Nursing inflammatory agents may help prevent fevers Society. ASHP guidelines on 5. Polovich M. Olsen M. titioner (LIP) and pharmacy regarding special 8. Hankins J.3-8 (V) 11. Antineoplastic therapy. http://www. and administered perature before infusing. Corrigan A. Ensure that biologic products are at room tem- ance with state laws and regulations. ed. but are not product. Markert A. 2010. and immunoglobulins. 2011. fusion proteins. Oncology common to many biologics.1. et al. Neuss MN. Hoffman JM. LeFebvre K. 2008.5-9 (V) avoid chemotherapy errors in in. et al. Thierry V. In: Esparza DM. inhibitors. Published 2004. 2013. Gorski L. Examine solution for particulates. turbidity. dispensing. types. USP-NF General computerized prescriber order entry (CPOE). Polovich M. eds. et al. when interleukin-2 is administered. Check expiration dates. includ- Am J Health Syst Pharm. and dispose of errors. and administer biologic infusion prod- Cancer.3. tion strategies (REMS) may be required by the cation/rn. Reconstitute or prepare liquid products in a clean environment consistent with USP <797> 59. Compounding and Preparation of Parenteral Solutions and Medications). 2014. adverse reactions in the treatment setting. Nurs Pract. McNiff K.1 (V) Guidelines and Recommendations for Practice. been frozen. and involvement of patients in prevention— 4. in a setting in which the clinician is prepared to recog- NIOSH alert: preventing occupational exposures to antineoplas. Pittsburgh. Publication 59. risk evaluation and mitiga- biotherapy. Griffith NL. Infusion 2. Anticipate potential orders for premedications. 5. to the beginning of therapy and prior to each adminis- 3. Altay B. 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Before you press that button: a look at chemotherapy and in accordance with USP <797>. 2. and smart pumps using tions. or monoclonal antibodies. 3rd ed. 14. Medication errors in chemothera. limited to. and do not use if present.pdf. Dahlin C. Clin J Oncol Nurs. 1.19(3):285- such as acetaminophen and diphenhydramine. and PA: Oncology Nursing Society. Do not use immunoglobulin products that have Nursing Society. Schwappach DLB. MO: 3. due to serious risks associated with the education of the nurse who administers chemotherapy and some biologic agents. alert medications in community/ambulatory healthcare. and what to monitor or report during or infusion sites.com/ trough levels.org/communityRx/tools/ambulatoryhighalert. for autoimmune diseases: an update. REFERENCES 2. and the potential for side Approach. age. Studies 9.16 (V) tions. Infusion and Access Devices). Antineoplastic and biologic therapy. 10. Shoenfeld Y. dosing considerations. Published and quality of life. 2013. Murphy E. immune deficiency diseases. after the injection. Zandman-Goddard G. Vogel W.16-18 (II) March 3. Avoid switching immunoglobulin products as 3. Ostrowski R. Inform the patient and caregiver about all aspects of 4. but not limited to. 4th ed. and management doi:10. side and adverse effects. For any significant changes in health status prior Note: All electronic references in this section were accessed September to each infusion. USP-NF General 1. US Food and Drug Administration. pres. Consider nurse-administered home administration events. drug-drug interac. Zandman-Goddard G. Perucca R. and enhanced compliance releases/rheumatology/nursing/prweb12558929. such as infusion reactions. acuity. subcutaneous administration. J Infus Nurs. provision of patient/family education. Review of biologic hyaluronidase-facilitated SCIg. therapy prior to initiation and during subsequent cfm. Younger M. Rosman Z.5-7. Approved risk and mitigation 4. Sedlak D. a syringe pump is used. 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Check vital signs prior to infusion and as indi. cal effects. ration. 10. ability to establish venous tance of site rotation.fda.19 (IV) malignancies. medications. eds. 2015. such as changes in weight. history of any previous treatment with by infusion frequency and decreased cost per and reaction to biologicals. 3. 2. http://www. Ensure that the first SCIg dose is administered in a Chapter <797>: pharmaceutical compounding—sterile prepara- controlled setting under medical supervision. weight changes. 1. ment. infusions as indicated. comorbidities. fungal. ismp. or presence of 1.16 (V) http://www. Shoenfeld Y. Corrigan A. and benefits. Neuro-opthalmology. Tehrani R. In: the biologic therapy. Educate the patient/caregiver about drug prepa- cal implications. Data suggest that treatment outcomes were infections (viral. For 11. Vizcarra C. Hariman R. BMC Med. 2014:258-308. duration 7. pushing the SCIg is also an option for some C.(11):88. TB testing. Consider the option of self-administered subcutane. Eisenberg S. Core Curriculum for Infusion Nursing. Corrigan A.14(2):E10-E21. BMC Med. 6. E. Infusion reactions: diagnosis. S130 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. St Louis. Select the most appropriate flow-control method for 6. For risk factors before initiation of therapy. J Infus Nurs. Biologic therapy (see Standard 56. for patients who have obstructive sleep apnea or are dylitis: a literature review. but not limited to. 2010. If risk factors are present. Drugs.38(1):70-79. Monitoring for potential adverse effects includ- knowledge of the appropriate drugs used with PCA.32(6):1180-1192. but are 2012. Assess the patient for the appropriateness of PCA therapy and the patient’s comprehension of. Ash S. Duff C.20 (V) Rezaei N. and/or other clinically effective outcomes.15(5):445-454. Medication 18. E. Oakes LL. 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The benefits of authorized agent controlled with clinical practice recommendations.50(3):371-374.apsf. McCaffery M. Peters LM. Mahmoud M. Am J Obstet Gynecol. American Society for reveals frequent desaturation and bradypnea during patient-con- Pain Management Nursing guidelines on monitoring for opioid. practice guidelines: authorized agent controlled analgesia. J Pain Symptom Manage.38(4):278-283.pub2.jointcommission. Marinkovic A.pdf. MD: Agency for 29. 34. Shaik Z. (PCA) and their experience of postoperative pain relief: a review 8. Redford DT. Zambrano S. Quah CS. eds. Kleeman SD. Manworren R. 2014. Hainsworth K. nutri- 39. as they have been found to infusion pump implementation on intravenous patient-controlled prevent errors related to prescriptions for PN. Lynch T. Nurs Econ.38(3):112-119. 37. during “piggyback”). Bates A. Gentile DL. Pronovost PJ. the American Society of Health. If ited to. Filter PN solutions without lipids using a 61. of drug/component shortages. eds. Jahansouz F. standards. Use the enteral route in preference to the breathing patterns during patient-controlled opioid analgesia.1-9 (II) the PN solutions/emulsions before or during infusion 2. 4. Wachter RM. Mann J. Smart pumps and other protocols for infusion pumps: accordance with USP <797> standards. Tran M. Arvind D. additions to the PN solution should be limited in 61. St Marie B. the lipid emulsion must be infused below the System Pharmacists (ASHP). Security Act. 2011. Ginsberg B. (3-in-1) using a 1. West D. macy using a primary engineering control in 43. and the United States Pharmacopoeia Separate lipid emulsions may not require filtration. precipitate. ance coverage. required. Ciarkowski S. (Regulatory) eds. ing medications and other substances to PN solu- 44. 2013. or particulate con- device (EID) with anti–free-flow control and appropri.9(2):103-109.2-micron filter is 61.2-micron filter is used on the sepa- 61. For patients who will transition from an acute Odou P. 2012. et al. PCA oversedation: application Practice Criteria of healthcare failure mode effect analysis (HFMEA™).8. Chu F. consult manufacturers’ directions for use. Barthélémy C.1-6 (I) 38.9 analgesia medication errors. Characterization of 1. with fat emulsion added as a 3-in-1 formulation. 2014. Impact of infusion set characteristics on the accuracy of care to the home setting. Compound PN solutions/emulsions in the phar- and smart pump technology implementation. Prescribe PN safely and appropriately.10 (Regulatory) Agency for Healthcare Research and Quality. Debaene B. Jt Comm should be made to the PN solutions outside of J Qual Patient Saf. In: Shekelle PG. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S133 JIN-D-15-00057. Wagner D.2 PN is administered using filtration appropriate to 0.2-micron filter and lipid-containing emulsions the type of solution/emulsion. Prepare and compound PN properly. Drummond G. Prewitt J. 2013.36(8):359-364. In acute care settings. home safety. 2010.111(6):971-978. Jackson J.9 (V) 42. and psychological needs assessment.10 (Regulatory) and the interprofessional team based on the projected C. Stevenson JG. tamination. Do not exceed a hang time of 24 hours for PN without consultation with a pharmacist regarding com. (IV) 2013. New York. treatment plan.4. B. NY: Wolters Kluwer/Lippincott 3. J Patient Saf. Attach administration tubing to the PN container of the Evidence for Patient Safety Practices.29(2):79-87. Décaudin B. a 1. Impact of smart whenever feasible. PN administration. In: Weinstein SM. and and federal regulations. Assess for compatibility and stability before add- 48-54.2-micron filter (eg. Develop licensed independent practitioner (LIP)- 41. Making Health Care Safer II: An Updated Critical Analysis 2.10 (V. Use standardized order forms or templates and Williams & Wilkins. in home settings. Br parenteral route for nutrition support whenever J Anaesth. the Drug Quality and 0. PARENTERAL NUTRITION number and made as close as possible to infusion initiation. Cronrath P. Moss J.3 PN is administered using an electronic infusion risk of microbial.1 The decision to implement parenteral nutrition substances added to PN solutions/emulsions are (PN) occurs in collaboration with the patient/caregiver also documented on the label. Anaesthesia. Hammond J. Jt Comm J substitution or conservation methods in the event Qual Patient Saf. 1. 2014:651-683. MD: and prime the tubing just prior to use. a 0. Reducing errors during patient-controlled analgesia approved written protocols for PN component therapy through failure mode and effects analysis. tional. (USP) National Formulary (NF) including.indd S133 05/01/16 11:30 PM . Pain management. Schneider S. Medications and other 61.2-micron filter to reduce the 61. PCA safety data review after clinical decision support 1. March 2013: 3. computerized prescriber order entry (CPOE) 40. 36. et al. Reston J. no additions gesic pumps at a tertiary care academic medical center. Label PN solutions/emulsions in accordance with Standard USP <797> standards. Rafie S.5 Medications are not added to or coinfused with rate lipid emulsion. containing dextrose and amino acids alone or patibility and stability. 9th ed. 2. Calif J Health Syst Pharm.7 (V) Hagle ME.69(2):131-136. but not lim. Regulatory) 4. the compounding pharmacy. Plumer’s Principles and Practice of Infusion Therapy. Lebuffe G.25(5):145-150. from dextrose/amino acids. Horvath M. include the following patient-controlled morphine administration: a controlled in-vitro factors in the discharge planning process: insur- study. feasible.10 brief review. Rockville. A. Foinard A. General Chapter <797>. Atayee R. When lipids are infused separately ate alarms. and a physical.4 Compounding of PN is in accordance with state used for the dextrose/amino acid solution. Lamott J. A case study on tions/emulsions in compliance with USP <797> the safety impact of implementing smart patient-controlled anal. Winkler M. catheter to administer lipid-containing PN 5.37(5): to avoid oxidation of vitamins. Durfee S. sociological. Griggs K. and psycho- acid/dextrose formulations) at least every 24 logical aspects of response to therapy for patients hours. Consider patients to fit PN into their lifestyle (see Standard dextrose and other additives that affect osmolar. 3. A.N.N. Standards Task Force.18-20 (V) Central Vascular Access Device [CVAD] Tip 3. Clinical REFERENCES trials demonstrate that peripheral PN causes phle- bitis. et al. Containers and administration sets should body weight. Keep PN solutions refrigerated and protected from 7. A. J Parenter Enteral Nutr. Standards not required for adult patients but is recom.7. Administration Set Change).38(3):296-333. et al. techniques as possible (see Standard 26. A. In: Alexander M. MO: 8. tion safety consensus recommendations.P. There are also recommendations to change who are on long-term PN.28(2):262-276. Flow.5-7. Vascular Access Device initial cycling in the acute care or home setting. Vascular 1. Nutr Clin Pract. adverse drug events (refer to Standard 13. mended for children < 3 years of age. A. 3rd ed.29(4):542- pumps with dose-error reduction software as 555.4 (V) 2007. fluid and electrolyte balance.4 (IV) 389-395. Perucca R. Krzywda E.N. especially glucose control. and psychological final concentrations exceeding 10% dextrose or responses. J Infus Nurs. Gilbert K. parenteral nutri- Phlebotomy). Standard 24. they are associated with reduced risk for infu. standards for nutrition support: alarms for occlusion. Guenter P. PN when feasible (refer to Standard 43. signs and symptoms to report. organ to Standard 42.E. Ayers P. Long-term home parenteral nutrition: it light until shortly before the time of administration takes an interdisciplinary approach. 4. Medication Verification. Meyer D. St Louis. Parenteral nutrition. function. Standard 26.18-20 (II) the administration set with each new PN con. Patient Education).4 (V) 3. functional performance.18-22 (V) ity and do not exceed an osmolarity of 900 mOsm/L for peripheral PN solutions.17 (IV) Nursing: An Evidence-Based Approach. Consider the use of smart home and alternate site care. nutrition therapy-related complica- 4.4 (IV) of infusion. Monitor and provide patient education. Nutr Clin Pract. Do not attach administration sets until the time emulsions alone. American 7. and access device complications cular access device (CVAD) (see Standard 23.P. 2010. et al. Groh-Wargo S. (total nutrient admixtures [TNA] and amino 1. tion of PN. 2. Reserve the administration of PN solutions/emul. to report to the health care team. 9.P. ance.S. Adams S. Monitor blood glucose on and off PN during Location. American Society for Parenteral and Enteral Nutrition. 2014. Home and Alternate Site Care Access Device [VAD] Planning).1. infection. 2. Arthur E.S. Ukleja A. meta- be di-(2-ethylhexyl)phthalate (DEHP)-free (refer bolic tolerance.11-16 (III) (V) 5.N. ards for nutrition support: adult hospitalized patients. including error Standards for Nutrition Support: Pediatric Hospitalized Patients. Boullata J.5-7 [VAD] Planning).11-16 (IV). Corkins M. Administer PN solutions/emulsions containing tions. 2015. Include physiological. Educate the home patient/caregiver other additives that result in an osmolarity of about signs and symptoms of metabolic intoler- greater than 900 mOsm/L through a central vas.E. Reduce the risk of catheter-related bloodstream Society for Parenteral and Enteral Nutrition. interceptions (eg. Replace administration sets for PN solutions D. blood/urine midline catheter for situations in which a CVAD glucose monitoring.indd S134 05/01/16 11:30 PM .S. 2010:316-350. Nutr Clin a. Teach patients or family members of patients sions with a final concentration of 10% dextrose who receive home PN about access device care. Use EIDs with anti–free-flow protection and Enteral Nutrition. Corrigan A. or lower administered via a short peripheral or weight and hydration monitoring. American Society for Parenteral and 6. Avoid unplanned interruptions in the administra- Saunders/Elsevier. et al.E. of practice for nutrition support nurses. Adams S. 2014. for Nutrition Support: Adult Hospitalized Patients. eds. 2013.P. Monitoring of the patient receiving PN includes tainer. EID use and troubleshoot- is not currently feasible and delay of feeding ing. stand- infection (CR-BSI) when administering PN.25(4):403-414. Nutr Clin Pract.E. Consider use of a designated single-lumen 2014.1. Freeman K. Task Force on sion-related medication errors.S. Hankins J. The risk/benefit decision to use peripheral Note: All electronic references in this section were accessed September PN should include as many phlebitis-mitigating 14. Task Force on Standards Control Devices). Gorski L. American Society for Parenteral and Enteral Nutrition. Do not exceed a hang time of 12 hours for fat 10. Avoid blood sampling via the CVAD used for Pract.22(5):558-586. S134 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. 8. wrong rate) and reduced standards for nutrition support: pediatric hospitalized patients. Tapering the rate of administration is 6. 4. Infusion solutions. and assist would be detrimental to the patient. b. donor identification number.8. cryoprecipi- parenteral nutrition ordering. O’Callaghan TA. Rudman D. Gazitua R. heart failure. 8. current fever.8(4):179-180. Clin ter gauge is recommended (14-18 gauge). Baxter JP. US Pharmacopeia (USP). Pratt RJ. Factors deter. During an independent double check by 2 adults Standard in the presence of the patient (eg. MO: Elsevier/Mosby/Sanders. tions. Dugan S.indd S135 05/01/16 11:30 PM . an opportunity to ask ques- Pharmacopeial Convention Inc. Boullata J. A review of the quality of 3. Rh type.N. and risk of fluid volume excess). erally inserted central catheters. ease.30(4):552-559. based on vein size and patient preference. Int J Pharm Compd. recognize that with periph- based guidelines for preventing healthcare-associated infections in NHS hospitals in England. an appropriate and patent vascular access device ence with three-in-one admixtures administered peripherally. Loveday HP. from the transfusion service to include: recipi- 21. J Parenter Enteral Nutr.6(3):216-220. 62. J Parenter Enteral Nutr. Rockville.9 (V) Nutr Clin Pract. lung assessment. (VAD). Transfuse blood and blood components in 334-377.org. plasma. 1. Perform patient and blood product identification: and risk of self-harm in patients with central venous catheters. 2006. 2014. When 16. Jacyna N. Emery D. Sacks G. et al. 2. Blackburn GL. Review article: psychological atric patients. Arch may increase the risk of transfusion-related adverse Surg. 1989. Clinical experi. Hersh T. 37/32 ed.25(4):543-553. epic3: national evidence- able for transfusions.8 (V) peripheral administration of parenteral nutrition in pediatric C. accordance with evidence-based indications to 9.8. infusion may be 18.27(10):910-918. Jew RK. TRANSFUSION THERAPY time of issue.8. the presence of 14. tion and transfusion needs: Parenteral nutrition of adults with 900-milliosmolar solution via 1. Nazareno A. Maximum tolerated osmolarity for transfusion.oley. J Hosp Infect. platelet). including vital signs.2 Blood and blood components are filtered using an adult): in-line or add-on filter appropriate to the prescribed a. Hoffmann E. Lloyd DAJ. plasma and plasma performed. Joswiak BJ. ABO 22. 2002. and date/ 62. D.10 (IV) Nutr.P.12 (V) aspects of home parenteral nutrition. special transfusion requirements. J Parenter Enteral Nutr. 2015. 2014. reactions (eg. gauge) are commonly used in infants and/or pedi- 20. Wilson JA. label.1-6 (V) 10. Intravenous Medications: A Handbook ensure patient safety. 2012. size. abnormal illness behavior E. and dispensing. type of blood compo- nent (red blood cell. benefits. Gahart B. donation identification number. red blood cells. 1990. 12. Consent cal compounding—sterile preparations. Am J Clin Nutr. St Louis.38(4): 290-300. licensed independent practitioner’s (LIP’s) order for transfusion. Winkler MF. obtaining blood for transfusion. Wilson K. crossmatch test interpretation if performed.38(7):847-851. and for Nurses and Health Professionals. Stranz M. Central vascular access devices (CVADs): accept- 17. et al. A review of pH and osmolarity. A.8. optimal patient outcomes.114(8):897-900. Stern JM. General Chapter <797>: pharmaceuti. et al.38(3): ered. Corrigan M.10.13 (V) 2. Short peripheral catheters: use 20 to 24 gauge peripheral vein. The Oley Foundation Web site. Speerhas R. McKinley AW. hospital/outpa- tient setting: 2 persons trained in the identifica- 62.36(6):632-644.S. unit VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S135 JIN-D-15-00057. 2014. The impact of long-term home parenteral ent’s 2 independent identifiers. Millikan WJ. eliminate unnecessary transfusions. MD: United States treatment alternatives. Ensure that informed consent was obtained. Fayers PM. renal dis- 13. crossmatch test interpretation if (whole blood. Neonatal/pediatric patients: umbilical venous life of adult patients treated with long-term parenteral nutrition.S.7. Home parenteral slower based on catheter length and lumen nutrition tutorial. and current laboratory values. Stackhouse J.E. a larger-size cathe- peripheral intravenous nutrition in the postoperative period. 2014. 1977. Kirby D. patient Practice Criteria blood type compatibility with the unit to be A. tate) only after alternative therapy has been consid- ling. clinical standards: components. Hoheim DF. 31st ed. compounding. In: U. ABO group and nutrition on the patient and family. order review. identification of conditions that mining peripheral vein tolerance to amino acid infusions. expiration date/time. 1979. www.5(3):118-122.86(suppl 1):S1-S70. Kastango E. group and Rh type if required. Glibert K. platelets. Le J. and the right to accept or refuse the 11.7. Perform a baseline physical assessment prior to patients.11 (V) 19. Verify the blood component: review the therapy. At the time that the blood component is released Alimentary Pharmacol Ther. Isaacs JW. granulocytes. in uct is performed in the presence of the patient prior to home setting: registered nurse and responsible transfusion. Administer human blood and blood components transfused. 2008. Pharmacopeia/ should include a description of risks. Smith CE. catheters or small saphenous vein catheters (24 Clin Nutr. 2015. A randomized study of central venous versus rapid transfusion is required. B. and National Formulary. J Infus Nurs.8.1 Verification of the correct patient and blood prod- tion of the recipient and blood components. Choose an appropriate VAD based on patient condi- 15. Bistrian BR. administration set with blood or blood components according to manufacturers’ directions for use. standard blood administration Hg. presence of floccular material. Electronic infusion devices (EIDs) can be used to application). Consider asking reaction and importance of reporting.7.7. depending on patient condition.8 (V) transfusion. Stop the transfusion immediately if signs and (V) symptoms of a transfusion reaction are present.8. totally encase the blood bag. For rapid infusion. increase the transfusion kocyte-reduced blood products (red cells and rate if there are no signs of a reaction and to platelets) decreases the risk of febrile transfusion ensure the completion of the unit within 4 reactions. after the transfusion. have a labeled indication for blood transfusion miss events. A 1-person verification process may be used administered as quickly as tolerated by the patient with automated identification technology (eg.8.8 (V) tion.8 (V) sodium chloride. and any product modifi. 4. Administer blood or blood components with 0. are most often used for reinfusion of blood shed 1.8 (V) alloimmunization.18 (V) I. Monitor for adverse transfusion events. Consider the use of an externally applied compres- should be added to or infused through the same sion device or electronic rapid infusion device.13.to 260-micron filter. Leukoctye reduction filtration is generally pre. with a labeled and do not use if container is not intact or if the indication. Use of leu. The use of computerized bar deliver blood or blood components without signifi- code-based blood identification systems cant risk of hemolysis of red blood cells. when clinically necessary.13 (V) minutes to 4 hours.8 3. Do not use microaggregate filters routinely.7. unless they have been approved by the US Food and when rapid transfusion is required. Never use leukocyte filtration when transfusing notify the LIP and transfusion service. 2. No other solutions or medications M. Blood and Fluid Warming). exchange trans- significant color change in blood bag compared to fusions.8. with a pressure gauge.12. for transfusion set can be used for a 4-hour period (see patients not under direct observation after the Standard 42. Change the transfusion administration set and filter 4. Platelets should be administered over 30 (CMV) seronegative component. the reactions associated with the transfusion. pediatric patients or adult patients at risk for fluid cation such as irradiation or cytomegalovirus overload. and matic hypotension in some patients.13 (V) be more effective than a pressure device. Flow-Control (IV) Devices).indd S136 05/01/16 11:30 PM .7. turers’ directions for filter use. and as needed ferred “prestorage” or shortly after blood collec. tions. or over 15 to 60 minutes.8 (V) sion. If least 4 to 6 hours to detect febrile or pulmonary more than 1 unit can be infused in 4 hours. and apply uniform pressure against all parts of the 1. L. Externally Drug Administration (FDA) for this use. mL per minute for the first 15 minutes.8. Follow the manufacturers’ direc- radiofrequency identification devices.13 (I A/P) applied compression devices should be equipped H.8. Ensure safe transfusion practice if transfusing in an cells or whole blood into smaller aliquots when out-of-hospital setting including the following: doc- slower infusion of a unit is required. Bedside leukocyte reduction is a less effi. a larger-gauge catheter may sets include a 170.17 (IV) F. such as with appearance is not normal (eg. Emerging technology includes should be used.13 (V) scribed. Pressure should not exceed 300 mm harmful particles. provide patient education about J. Initiate the transfusion slowly at approximately 2 cient method and has been associated with dra. risk of human leukocyte antigen (HLA) hours. large-volume or rapid transfusions. Check the patient’s vital signs prior to transfu- and collected during surgery. Use a filter designed to remove blood clots and blood container.7.13 (V) bar code with appropriate logic/interface K. fusion.8. Inspect each blood component prior to transfusion.7. these N. such as with umentation showing no identified adverse events S136 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057.14-16 tions for use (see Standard 24. excessive hemolysis.8.8 (V) 2. Each unit of plasma should be b.8. and transmission of CMV. expiration date/time. The risk cloudy appearance) and return it to the transfusion for clinically important hypothermia is increased service.8. patients with clinically significant condi- administration set. Administer and complete each unit of blood or signs and symptoms of a delayed transfusion blood component within 4 hours. remain near the patient. Administration Set Change). within 5 to 15 minutes after initiating trans- 3. Monitor patients for transfusion reactions for at after the completion of each unit or every 4 hours. EIDs that resulted in a large increase in discovered near. and granulocyte or hematopoietic progenitor administer emergency medications as pre- cells.9% Standard 25. Filter all blood components and follow the manufac.7. and the neonate/pediatric population.18 (V) the transfusion service to divide a unit of red blood O.8.13 (V) when blood is transfused through a CVAD (see G. Use only a blood-warming device. 88(4):354-359. A.50(6):1227-1239. Administration of blood components. Carson JL. Ann Intern Med. National Healthcare Safety Network. Safety Network’s (NHSN’s) voluntary program to 17. Kemp JD. Phillips L. Mayo Clin Proc. Bethesda. McKeith J. Computerized bar code- patient identification and calling for medical assis- based identification systems and near-miss transfusion episodes tance if needed. 2014:682-765. Blood safety surveillance. cooling containers verified for correct temperature. AABB Technical ANALGESIA USING Manual. 29th mon complications and interventions. immediate access to 13.4(4):465-470. Published 2013. Grossman BJ. Hillyer CD. McGrane SP.40(3):209-213. 2012. Josephson CD. eds. Puca KE. Askeland RW. http://www. Circular of information for the use of human blood and the LIP by phone during the transfusion. Nuttal GA. through age-appropriate cardiac life support validation. Bethesda. Updated September 14. safe medication administration.162(3):205-213. Changing blood transfusion policy and practice. organizational policies and procedures. 2015. Ann Intern Med. Djulbegovic B. during previous transfusions. tration of moderate sedation/analgesia. In: skills when administering IV sedation/analgesia. Hagle ME. Healthc Q. can be used for interorganizational comparison and 2015. Hillyer CD.1 The registered nurse may administer moderate Medicine Committee of the AABB. Biologicals. Stahorsky K. Kaufman RM. Ensure competency and advanced knowledge and 11. Evidence-based prac. Grossman BJ. regarding transfusion reactions. Blood manage- ment: best practice transfusion strategies. Reyes MD.8 (V) Applying radiofrequency identification (RFID) technology in P. 2014. another blood components. eds. Neonatal and pediatric transfusion tered by the registered nurse: medications for mod- practice.indd S137 05/01/16 11:30 PM . Kleinman S. mechanisms. and management of Based Practice for Infusion Therapy. Standards for Blood Banks and Transfusion Services. Kolmer V. Davis R. 63. Hohberger C. J edge of preprocedure assessment. Reeves C. Caldwell SA. Roback JD. neuroleptic VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S137 JIN-D-15-00057. Grossman BJ. related to infusion pumps: a comparison of 3 different pump trol incidents related to blood transfusions. Bethesda. et al. Philadelphia. 2003.3 An emergency cart and reversal agents are imme- Grossman BJ.12(Sp):85-89. propofol.aabb. B. 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MODERATE SEDATION/ 1. ability to transport blood product in and transfusion errors. including knowl- 5. as well as airway man- fusion: a clinical practice guideline from the AABB. 18th ed. 2013. Roback J. 14. tice guidelines for plasma transfusion strategies. eds.35(1):187-190. Patient blood management. meperidine).2 The registered nurse is competent in the adminis- 2010. Smolarek S. PA: Wolters Kluwer/ Lippincott Williams & Wilkins. Crookston KP. 2014:480-529. diazepam). Westhoff CM. et al. Westhoff CM. Tolich DJ. Plumer’s Principles & Practice of (IV) Intravenous Therapy. 2015. Meyer E. 2014:545-559. advanced 9. agement. 18th ed. Am J Nurs. (fentanyl. Briggs L. 63. Transfusion reaction Participation provides organizations with data that identification and management at the bedside. and clinicians with expertise in air- Manual. 6th ed. INTRAVENOUS INFUSION 2. Magnan M. Reifert DR. 10. Philadelphia. Koenig JC. Consider participation in the National Healthcare transfusion medicine. 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An evalua- tion of instruments for scoring physiological and behavioral cues izational criteria to assess adequacy of sedation of pain.7.7. patient receiving moderate sedation should have no 10. Fry M. Updated 2011. and reinforcement after the procedure. and verification of NPO policy: essential elements and evidence-based considerations. parameters for laboratory val- 1.aana. and level management/standards-and-g uidelines/search?q=basic anesthetic of consciousness.1 All hazardous waste. restrictions. Published 1986. tranquilizers (droperidol). AORN J. Registered nurse-administered sedation for gastro- and for potential need for emergency resuscitative intestinal endoscopic procedure. The clinician who is monitoring the monitoring. allergies. Published 1996. 4. respiratory rate. about the Standard sedation/analgesia infusion. medications. 2014. Celis-Rodríguez E. (nothing by mouth) status. monitoring and manag- 1.23(3-4):374-384. Conway A.4. G. Establish the discharge plan prior to the procedure. Society of Gastroenterology Nurses and Associates (SGNA) giver/friend drive the patient home and observe the [position statement]. procedure and recovery for administration of medications 7. Australas Emerg Nurs J. Varndell W. Int J Nurs Stud.aspx.pdf.4.com/resources2/professionalpractice/Pages/ (see Standard 9. Worrall-Carter L. F.7 (IV) 48(8):1012-1023.2-4. 2014. Include the following in orders for therapeutic phle- Note: All of the electronic references in this section were accessed botomy: laboratory values to be assessed specific to September 14. medications. Sumamo Schellenberg E. 2015. oxygen. Urman RD. 1. Statement on the use of sedation and anal- patient post procedure. Initiate and maintain vascular access throughout the Clin Nurs. Provide patient and caregiver education prior to. Updated November 2005. 2014.7 (IV) izational policies and procedures. American Society of Anesthesiologists. (diphenhydramine). http://www. and drug sensitivities. the patient’s diagnosis. patient’s physical status. Perform a comprehensive preprocedural assessment org/Portals/0/Education/PDF/Position-Statements/Sedation_ to include medical history/current condition. and adequacy of analgesia and and analgesia and readiness for discharge home sedation in pediatric mechanically ventilated patients: a system- or transfer to a hospital unit. American Association of Nurse Anesthetists (AANA). Page K.4.asahq. airway issues. current 2013-FINAL. 3. non-pain related distress. and specific volume of blood to be management of patients receiving conscious sedation for short. Dorfman TL. Caperilli-White L.2. http://aamsn. Developing a moderate sedation drug/alcohol/tobacco use. THERAPEUTIC PHLEBOTOMY J. The role of the registered nurse in the of phlebotomy. de la Cal MÁ.7 (IV) org.indd S138 05/01/16 11:30 PM . moderate 2015. allergies. Standards for basic anes- procedure. et al. cardiac rate and rhythm. https://www.18(2):59-67.7. potential complications related to the infusion site 64. significant opioid use. and antihistamines term therapeutic. or surgical procedures. Elliott D. Birchenall C. Rolley JX. Consult with an anesthesia licensed independent ing continuous intravenous sedation for critically ill adult patients practitioner (LIP) based on any problematic and implications for emergency nursing practice: a systematic issues identified during the assessment. C. Med Intensiva. Conway A.4. I. Fulbrook P.37(8): adequacy of ventilation. including that from therapeu- and the procedure. 2013. Amornyotin S. will be disposed of according to organ- 24-hour contact phone number. 2011. such as literature review.4. and/or reversal agents. Issues and challenges moderate sedation. and tic phlebotomy. Clinical other responsibilities during the procedure. and-Analgesia. procedure. the catheter laboratory: an integrative review. 11.7 (IV) gesia in the gastrointestinal endoscopy setting. World J Gastrointest Endosc.1-3 (IV) S138 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Observe the patient for at least 90 minutes after the procedure if reversal agent administration is required. 2015. frequency [position statement]. E. previous sedation experience. emergency instructions. Published 1991.4. Practice Criteria REFERENCES A.7 (IV) 64. Rolley J.2-4. and associated with nurse-administered procedural sedation and anal- significant comorbidities. Nurse- administered procedural sedation and analgesia in the cardiac consciousness due to the types of agents used.8 (IV) practice guidelines for evidence-based management of sedoanal- H.sgna.7 (IV) gesia in the cardiac catheterisation laboratory: a qualitative study. according to organizational policy and procedure http://www. including blood pressure. Assessing.51(4):654-676. American Association of Moderate Sedation Nurses (AAMSN) ues guiding the indication for phlebotomy.7(8):769-776.org/quality-and-practice- oxygen saturation. Rempel GR. Assessment of donor 3. 2011. Cardiovascular E.51(6):1331-1338. The patient tion for syncope. manual pres. France C. 2010. Koek G. manage. and rate of Hagle ME. anticipated dromes. or patient instructions. Ball S. and effects.53(6):1373-1375. 2014:303-334.51(12):2727-2738. Kowdley K. treatment considerations. monitoring vital REFERENCES signs before and after the procedure. and recognize common side vital signs. Select the most appropriate vascular access device 3. 2. Central vascular access device (CVAD) if already 6. Cook LS. report. subjective distress. et al. then instructed to rise slowly. Short peripheral catheter using an 18. and other infusion 4. 2012. Powden S. Antle E. Davaine J. Hagle ME.53(2):337-343. encouraging oral hydration before and after the procedure. Transfusion. effects such as a hematoma. Kamel H. In: Weinstein SM.53(2):315-321. 1. 2011. Provide patient education. Philadelphia. Blood collection receptacles may include collection teer blood donors. nausea/vomiting. and administer. Ruiter R. After completion of the phlebotomy. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S139 JIN-D-15-00057.1. Plumer’s Principles and Practice of Infusion Therapy. Sloop G. F. et al. Apheresis catheter. 2014.indd S139 05/01/16 11:30 PM . then a dressing applied. Peripheral venous access. Cho Y. France CR. bags used for volunteer blood donation or bags spe. Rofail D. Cyr J. having blood drawn from your arm? A simple fear question pre- syringes may also be used based on the VAD.1 (V) rare adverse events.29(2):102-116.52(2):375-380. Perfusion. eds. van Dongen A.4 (V) 13. Aliment Pharmacol Ther. dressing applied or catheter locking. Rombout-Sestrienkova E. Instructions should include the type and of adverse reactions. G. ing parenteral solution replacement if prescribed. C. Prevent.4 (V) HFE hemochromatosis patients: results from a randomized trial.4-13 (IV) Williams & Wilkins. to risk of air embolism. and therapeutic phlebotomy will not pseudoaneurysm after phlebotomy for iron overload: first case compromise other infusion therapies. Blood-injection-injury phobia: preventative interven- ing has stopped. such as hypovolemia. 2013. Brissot P.to 20-gauge 5. Review article: the iron overload syn- (VAD) based on patient condition.2. Holsworth R. by using a reclining chair or exam table/bed for the procedure.1. Siddique A. 2010:33(2):81-88. 2013. 2014. Bardou-Jacquet E. Sebbag U. after removal of the peripheral catheter until bleed. and anxiety on retention amount of physical activity before and after the pro. Do not dicts vasovagal reactions without causing them among high use vacuum containers to facilitate blood flow due school donors. 7. Transfusion. The influence vomiting. cedure. Thijs R. treatment.1. and nausea/ 12.52(3):470-477. Kowalsky JM. Transfusion. J Infus Nurs. How afraid are you of cifically designed for therapeutic phlebotomy. indicating the type of solution.2. J Contin Educ Top Issues. syncope. including potential side Transfusion. 9th ed. Documentation should include total volume of Physiologic strategies to prevent fainting responses during or after blood withdrawn.16(2):52-54. France JL. Tomasulo P.35(8):876-893.1. amount. 11. et al. Wieling W. Therapeutic phlebotomy: a review of diagnoses and ing about fear of needles or blood. whole blood donation. Transfusion.1 (V) 9. van Dijk N. Brissot P. patient response to the procedure. Jin V. should remain in a reclining position for several Erythrocytapheresis versus phlebotomy in the initial treatment of minutes. Veldhuizen I. Nieman F. of first-time blood donors. 2013. Transfusion. Weidman J. Cannon H. PA: Wolters Kluwer/Lippincott infusion. France CR. Who needs a therapeutic phlebotomy? Clin J Oncol therapies: Nurs. Hereditary hemo- device and inserted before phlebotomy and chromatosis: patient experiences of the disease and phlebotomy removed upon completion. Mikell M. ask. 10. 2012. 2. 8. B. length of treatments needed. benefits of phlebotomy: relationship to changes in hemorheologi- sure should be maintained at the venipuncture site cal variables. France JL.14(6):694-696. Transfusion. 1.11 (V) fear enhances prediction of presyncopal symptoms among volun- D. Brachial artery placed. Abraham C. 2012. Menitove J. mentors. The Art and Science of Infusion Nursing Appendix A. S140 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. efficiency. The scope of services for the infusion team consists of a variety of activities related to the safe insertion. they provide the advanced knowledge for safe practices to support the primary care staff. While this team may not be directly providing each infusion. CRNI®s) and may contain a staff mix of registered nurses. blood and blood components. lower costs. Goals for this team include accuracy. and maintenance of all infusion and vascular access therapies including fluids and medications. Unlicensed team members work under the direction of the licensed professional infusion nursing staff. Infusion Team Definition This team is defined as a group of nursing personnel centrally structured within an acute health care facility charged with the shared mission of outcome accountability for the delivery of infusion therapy. licensed practical nurses. Mercanti-Erieg L. This team is led by infusion nurse specialists (eg. and better outcomes. patient populations and their specific needs and risks. and the complexity of the knowledge and skill(s) required to perform each nursing intervention. educators. J Infus Nurs. Infusion teams in acute care hospitals: call for a business approach: an Infusion Nurses Society white paper. Dalton L. The Centers for Disease Control and Prevention (CDC) and published research recognize that the use of teams in the health care setting reduces mistakes and enhances patient safety. greater patient satisfaction. Meeting this goal will reduce liability. and unlicensed assistive personnel. coordinators. The identified services of this team should be based on the fact that infusion therapy is needed in all areas of the organization and by all ages of patients/clients. coaches. and consistency for safe delivery of all infusion services. Responsibility for performing direct clinical practice should be divided between the infusion team and the primary nursing staff based on documented clinical outcomes.indd S140 05/01/16 11:30 PM . and decrease length of stay. Source: Hadaway L.36(5):356-360. and managers. advocates. the roles of the infusion team members include direct care providers. thereby indicating that the use of an infusion team is strongly recommended for all health care organizations. Thus. This team will provide guidance for establishing policy and practices according to the nationally recognized Infusion Therapy Standards of Practice. along with reduction and/or elimination of complications. 2013. consultants. delivery. and parenteral nutrition. while promoting vascular preservation. Used with permission. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S141 JIN-D-15-00057. 30th ed.indd S141 05/01/16 11:30 PM . 2003: 2014. Philadelphia. From Dorland’s Illustrated Medical Dictionary. PA: Saunders/Elsevier. The Art and Science of Infusion Nursing Appendix B. Illustrations Figure 1 Principal veins of the body. B. The arrows indicate where perforating veins penetrate the deep fascia. Philadelphia. Forearm. Used with permission. Dorsal surface of hand. PA: Wolters Kluwer/ Lippincott Williams & Wilkins. arm.indd S142 05/01/16 11:30 PM . Dalley AF. A. 13th ed. Palmar surface of hand. Grant’s Atlas of Anatomy. C. Blood is continuously shunted from these superficial veins in the subcutaneous tissue to deep veins via the perforating veins. and pectoral region. Figure 2 Superficial venous drainage of upper limb. From Agur AMR. 2013:498. S142 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Dalley AF. From Agur AMR. the axillary vein becomes the subclavian vein at the lateral border of the first rib. Grant’s Atlas of Anatomy. are shown. The basilic vein joins the brachial veins to become the axillary vein near the inferior border of teres major. The cephalic vein in this specimen bifurcates to end in the axillary and external jugular veins. Philadelphia. enlargements in the vein. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S143 JIN-D-15-00057. Used with permission. PA: Wolters Kluwer/ Lippincott Williams & Wilkins. Numerous valves. Figure 3 Veins of axilla.indd S143 05/01/16 11:30 PM . 13th ed. 2013:509. and the subclavian joins the internal jugular to become the brachiocephalic vein posterior to the sternal end of the clavicle. Figure 4 Cubital fossa: surface anatomy and superficial dissection—anterior view. Dalley AF. Used with permission. 2013:546. Philadelphia. Grant’s Atlas of Anatomy.indd S144 05/01/16 11:30 PM . PA: Wolters Kluwer/Lippincott Williams & Wilkins. 13th ed. Cutaneous nerves and superficial veins. From Agur AMR. S144 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Used with permission. Grant’s Atlas of Anatomy. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S145 JIN-D-15-00057. 2013:754. From Agur AMR.indd S145 05/01/16 11:30 PM . Philadelphia. The posterior division of the retromandibular vein unites with the posterior auricular vein to form the external jugular vein (EJV). PA: Wolters Kluwer/Lippincott Williams & Wilkins. The facial vein receives the anterior division of the retromandibular vein. Figure 5 Superficial veins of the neck—lateral view. The superficial temporal and maxillary veins merge to form the retromandibular vein. forming the common facial vein that empties into the internal jugular vein. 13th ed. Dalley AF. A theoretical frame- tain adequate arterial perfusion. Any unintended or untoward event that Apheresis. acute care hospital that includes. Aseptic Technique. ports. The presence of air in the vascular sys- Arterial Pressure Monitoring. red blood cells. and microbore tubing. Hermetically sealed glass medication con- cognitively impaired person). A type of isolation precaution to Arteriovenous (AV) Fistula. but is not limited to. A substance used to reduce the risk of infec- practitioner. or a administration set or vascular access device. tainer that must be broken at the neck to access the Authorized Agent-Controlled Analgesia. Infusion device specifi- plies. reinfusing the remaining components. Organic components of protein. growth. Adverse Event. proce- blood cells. Process of separating blood into 4 compo- occurs with a patient receiving medical treatment that nents: plasma. etc. Air Embolism. stopcock. Y-site. variety of antiseptic agents. equipment. long-term care and assisted living facility. development. to combine 2 or more medications. Assent. into the patient when the administration set is removed from the flow-control device. integrated filter. A health care setting outside of the be applied to all clinical procedures. Medication that prevents the include a Y-set. give legally valid informed consent (eg.indd S146 05/01/16 11:30 PM . manifold Antimicrobial Locking Solutions. Administration set technol- activate the analgesic dose when a patient is not able ogy that prevents intravenous solutions from flowing to do so. sion of airborne droplet nuclei that may remain sus- Arteriovenous (AV) Graft. removing 1 of the components and then dure. or nurse midwife. Monitoring of arterial tem that obstructs venous blood flow primarily to the pressure through an indwelling arterial catheter con- lungs or brain. patient mobility and independence. The Art and Science of Infusion Nursing Glossary A Anti-infective CVAD. extension set. from microorganisms (eg. ganisms. line filter. and a male luer-lock end. clinical nurse specialist. work for safe and effective aseptic practice that can Alternative Site. Advanced Practice Registered Nurse (APRN). A test performed on the radial and ulnar tured synthetic material. A competent medication. and absolute separation of sterile items cally designed to be worn on the body to promote from those that are not sterile). Airborne Precautions. a child or Ampoule. nurse anesthe- tion by killing or inhibiting the growth of microor- tist. that is added to the supratherapeutic concentrations of antibiotic. method to maintain objects and areas maximally free outpatient center/clinic. between an artery and a vein. Agreement by an individual not competent to Amino Acids. S146 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. Central vascular access device coated or impregnated with antiseptic or antimicro- Add-on Device. A tubing set composed of plastic lar access device (CVAD) lumen for a prescribed components that is used to deliver infusions and that period of time for prevention or treatment of cathe- typically includes a spike. usually of a manufac- Allen Test. injection ter-related bloodstream infection (CR-BSI). Surgical structure created pended in the air. artery of the hand prior to arterial puncture to ascer- Aseptic No-Touch Technique. or proliferation of malignant Admixture. Variations may Antineoplastic Agent. Surgical anastomosis reduce the risk of infection from airborne transmis- between an artery and vein. through use of sterile sup- Ambulatory Infusion Device. such as an in- bial agents. and/or needleless connector. product. Solutions using set. cells. and physician office. a drip chamber. barriers. A nurse Antiseptic. To mix. and white is related to a medication. Additional component. to lock the central vascu- Administration Set. person authorized and educated by the prescriber to Anti–Free-Flow Protection. platelets. nected to an electronic monitor. A primary infection prevention the home. and experience within a given spe- secondary vein thrombosis related to the presence of cialty. urethane. product may not be used. inserted into Certification/Board Certification. tion and many classes of drug dosages. ring during the insertion procedure. ages. Primary CVAD Malposition. clinical definition used when the catheter is identified exposed to ambient atmospheric conditions. A manufacturer’s original container has been opened. and determining radia- occurs as primary or secondary malposition. An electronic device with ade- Extravascular Malposition. The date added to a product vascular access device (CVAD) with a new CVAD label during the compounding process after which a using the same catheter tract. A hollow tube made of thermoplastic poly. thrombosis overlying the fibrin sheath. Used in calculating pediatric dos- suboptimal or aberrant position inside a vein. (normal flora) or pathogenic (disease causing). com- Catheter. B Catheter Dislodgment. Secondary CVAD Malposition. A laboratory-confirmed. CLABSI definition is used for surveillance purposes Examples of biologic therapies include immunoglob- and may overestimate the true incidence of catheter- ulins. BSI is not related to an infection at another site. and vaccines. Blood Return. CVAD tip located in a in square meters. down- Central Vascular Access Device (CVAD). Used during drug National Healthcare Safety Network (NHSN) for the compounding. after the individu- CVAD’s length.indd S147 05/01/16 11:30 PM . usually a resistant layer. The process to reestablish catheter tion or medication contacts an incompatible solution lumen patency using medications or chemicals or medication within the vascular access device (VAD) instilled into the lumen for a specific period of time. Concentrated medication and/or solution given in a suboptimal or unacceptable location occur- rapidly over a short period of time. Change in the molecular located in deep veins or superficial veins when structure or pharmacological properties of a substance placed for CVAD use. ment. or solution container. lumen. Catheter ward high-efficiency particulate air (HEPA)-filtered inserted into a peripheral or centrally located vein laminar flow to protect the product. and the tion in the organism and include the use of sera. Catheter Exchange. cava. awarded by a third-party. CVAD tip found to be in a suboptimal or unacceptable location at C any time during the catheter dwell time. Body Surface Area. or ture during administration. blood that is the color and consistency of CVAD tip located in an aberrant position and no longer whole blood upon aspiration. monly referred to as tip migration. and may through specific laboratory testing to be the source of not have the integrity of the original packaging. a ventilated cabinet that has an open current CLABSI surveillance criteria. CVAD tip positioned Bolus. credential that demonstrates the holder’s specialized Catheter-Associated Venous Thrombosis (CAVT). interferons. Centers for Disease Control and Prevention’s (CDC’s) Biological Safety Cabinet (BSC). Refer to the kins. located in the original vena cava or cavoatrial junction. stream infection in a patient with a central line in Biologic Therapy. The antitoxins. pleura. A thin coating. managing burn patients. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S147 JIN-D-15-00057. Treatments for disease by the admin- place for more than 2 calendar days before the devel- istration of substances that produce a biological reac- opment of the bloodstream infection (BSI). silicone elastomer. administration set. that may or may not be visually observed when a solu- Catheter Clearance. front with inward airflow to protect personnel. such as the Infusion Nurses fibrin sheath encompassing all or part of the Certification Corporation (INCC). cells. A knowledge. peritoneum. the bloodstream infection. pericardium. includes the presence of an extraluminal entity or association. and HEPA- with the tip residing in the superior or inferior vena filtered exhausted air to protect the environment. monoclonal antibodies. primary blood- an implanted or indwelling device. and organs. Surface area of the body expressed Intravascular Malposition. may be Chemical Incompatibility. CVAD tip located out- quate temperature controls that raises refrigerated side of the vein in nearby anatomical structures blood or parenteral solutions to a desired tempera- such as mediastinum. A component of VAD patency assess- Central Vascular Access Device (CVAD) Malposition. Biofilm. of Central Line-Associated Bloodstream Infection microorganisms that form on and coat the surfaces of (CLABSI). based on the fact that the Catheter-Related Bloodstream Infection (CR-BSI). or metal. skills. Microorganisms that may be nonpathogenic optimal position. tissues. with a mural or veno-occlusive al has met predetermined and standardized criteria. A voluntarily earned the body and used for injecting or evacuating fluids. vaccines. Blood/Fluid Warmer. Replacement of existing central Beyond-Use Date (BUD). interleu- related bloodstream infection (CR-BSI). Catheter movement into or out of the insertion site indicating tip movement to a sub- Bacteria. nongovernmental a CVAD. bling. and infection and sterilization procedures because inor. take. consciousness. The process of revealing to the patient and tem in which clinicians directly enter medication. S148 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. used in compounding and admin. techniques used are not intended to produce loss of ganic and organic materials that remain on the sur. the RN retains accountability for the outcome of the Compounding. this is medications by the use of a color system. Drug-induced depression of conscious- making. The process of reviewing and Delegation. withdrawal. specific tasks.indd S148 05/01/16 11:30 PM . critical thinking. Minimally depressed level of con. free needle or cannula through a designated closure or port to effect transfer. ously and to respond appropriately to physical stimu- Thorough cleaning is essential before performing dis. To add a diluent (eg. An integration of behaviors in the varied tory function may be diminished and support to circumstances of the work environment demonstrat. Multiple unsuccessful veni- device. drug delivery Difficult Vascular Access. intact through the entire transfer process. decision. sterile water) to a solution of medication in order to sirable levels of airborne drugs and to provide an make it less concentrated or to provide additional aseptic environment when compounding sterile prep. into which fluid can move. the need for special interventions to establish fessional agreement between the practitioner. venous cannulation based on a known history of dif- and pharmacist. compro. the capacity to preserve respira- Competency. and linguistic needs of patients and mised only by the penetration of a sterile. solution for ease of administration and titration. or to arations. A sys. painful stimulation. ficulty due to diseases. to another patient. Capability of the individual to apply or discard. Used during drug compounding to provide Dilution. Deep Sedation. vein. and/or frequent unsuc- Compounding Aseptic Containment Isolator cessful venipuncture attempts. Cleaning. The removal of visible soil (eg. their families served by the health care organization. which are spread by direct or indirect con- device that mechanically prohibits the transfer of tact between the patient and environment. knowledge. and labeling a drug. As applied to needleless connectors. puncture attempts (ie. System that identifies products and Dead Space. er. nificant complication from a medical error or mis- Conscious Sedation. 0.9% sodium chloride. role. the internal space outside the intended fluid pathway Compatibility. preserved. The movement of sterile prod. delegated tasks or activity. Introduction or transference of patho- escape of hazardous drugs or vapor concentrations gens or infectious material from one source to anoth- outside the system. The delivery of infusion services tainers. Cross Contamination. ganisms from objects so they are safe to handle. Disclosure. (CACI). test. closure system. D Color Coding. and transfer devices remain that are respectful of and responsive to the beliefs. Strategies implemented to prevent cesses. environmental contaminants into the system and the Contamination. Contact Precautions. Cardiovascular function is generally related activities and tasks. practices. use. or device according to a practitioner’s pre. the transmission of infectious agents such as wound Closed System Drug Transfer Device. maximum of 4) to cannulate a scription for an individual patient or based on a pro. The act of preparing. Competence. injury. assem. Competency Assessment. The drugs. may be required. The removal of pathogenic microor- or physical changes or loss of therapeutic action. maintain the airway and spontaneous respiration ing the individual’s ability to perform the desired job. Capable of being mixed and adminis. pyrogen. medica. packaging. information that is necessary for the patient’s sciousness in which the patient retains the ability to well-being or relevant to future treatment. patient. tered without undergoing undesirable chemical and/ Decontamination. A drug transfer drainage. or other patient activities not commonly performed by that person. interpersonal. lation and verbal commands. Cultural Competency. ucts from one container to another in which the con. or delivery. The indirect movement of path- ardous drugs. culture. mixing. and psychomotor skills to the performance ness. The process by which a registered nurse documenting the individual’s demonstrated ability to (RN) directs another person to perform tasks or perform a job. istering sterile doses of chemotherapy and other haz. Computerized Prescriber Order Entry (CPOE). ogens or other harmful substances from one patient Closed System Transfer. care activities. doses. family all the facts necessary to ensure understanding or procedure orders into a computer system. of what occurred when a patient experiences a sig- tion orders are transmitted directly to the pharmacy. health care worker protection from exposure to unde. the patient responds persistently to repeated or of infusion therapy. faces interfere with the effectiveness of these pro. organic and maintain a patent airway independently and continu- inorganic material) from objects and surfaces. decrease the tissue irritation of a medication. Flushing. and electronic infusion devic- through close respiratory or mucous membrane con. plies used to administer hazardous drugs). ered by electricity or battery to regulate infusion rate. A device or system Guidewire. EIDs designed to prevent errors in solution and Flow-Control Device. Mass of undissolved matter present in blood actual and required knowledge. level. results from vascular irritation or capillary conges. A type of isolation precaution to (eg.” sion flow rate. skill. specifically of tightly wound coiled wire in a variety of designs. slide. or trunk. Hazardous Drugs. tact with respiratory secretions. time. spinal arter. evaluate a process or device for the purposes of VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S149 JIN-D-15-00057. The date and time. mined hazardous by the above criteria. liquid. screw). Agent that eliminates all microorganisms Expiration Date. F Doppler Flow Study. designed and engineered to control movement at the contains safety mechanisms that allow it to be insert- catheter hub. mechanical infusion reduce the risk of infection from pathogens spread devices (see definition). such as sharps disposal containers. Engineering Controls. izational level. proactive method used to of patient preferences. blood. Combination of liquid. The act of moving fluids. Extrinsic Contamination. often called “smart pumps. able synthesis of research results in conjunction with Healthcare Failure Mode and Effect Analysis clinical expertise and with attention to and inclusion (HFMEA). opposite of proximal. es (see definition). A process that eliminates many or all product should be discarded beyond this date and pathogenic microorganisms. low doses. or from the point of attachment. Gap Analysis. and sharps with following 6 characteristics in humans or animals: engineered protections. Engineered Stabilization Device. reproductive toxicity. lipid. Instrument used to regulate infu- mediation delivery. standard tool. flexible metal structure. needleless systems. except bacterial spores. Redness of skin along a vein track that Hazardous Waste. hazardous waste is differentiated from medical waste tion in response to irritation. whichever is the shorter period. tem formulated for intravenous use. or organ- or gaseous. organ toxicity at its meninges. except bacterial spores. Plastic cap containing an antiseptic Extravasation. Space surrounding the spinal cord and tal toxicity. containers and intravenous sup- Evidence-Based Practice. considered a potential space that is profiles of new drugs that mimic existing drugs deter- not created until medication or air is injected. or performance. may be done on an individual. Contamination that occurs Distal. contains fatty tissue. or midline. ed into the vein or artery. Devices that isolate or remove H the blood-borne pathogens hazard from the work- place. rated by a needleless connector to disinfect the surface and pro. Erythema. Assessment of the difference(s) between Embolus. Electronic infusion Filter. A systematic. sage of air or other undesired substances. Farthest from the center. the Disinfection. design determines size of substances retained. self-sheath. In the context of this document. may be either a positive-pressure pump or controller G (gravity fed) used to regulate the flow rate of the infu- sion therapy. veins. Drugs exhibiting 1 or more of the ing needles. vide protection between intermittent uses. beyond which a product should not be used. teratogenicity or other developmen- Epidural Space. and structure and toxicity ies. composed placed subcutaneously or topically. hazardous drugs (eg. roller clamp. A form of ultrasound technology Fat Emulsion (Intravenous Fat Emulsion [IVFE]). when applicable. an embolus may be solid. product taining drug name and soft and hard infusion limits. and blood products out of the vascular access device E into the bloodstream. may be a precursor to and refers to that generated from administration of or indication of phlebitis. medications. and an emulsifying sys- istics of circulating blood. includes categories of manual devices Droplet Precautions.indd S149 05/01/16 11:30 PM . Dose-Error Reduction System. Inadvertent infiltration of vesicant solu- solution placed on top of the connection surface of a tion or medication into surrounding tissue. department. Device that is pow- medication incompatibility. or lymphatic vessel. of the body after the manufacturing process of a product. genotoxicity. carcinogenicity. assigned on the basis of both stability and risk on inanimate objects. and nerves. Disinfectant. Disinfection Cap. Application of the best avail. that produces audible sounds to determine character. used to assess and maintain patency and prevent precipitation due to solution/ Electronic Infusion Device (EID). A long. A special porous device used to prevent the pas- devices (EIDs) manufactured with drug libraries con. or organ attached to a subcutane- High-Alert Medication. cation. Hand hygiene per Centers for Disease Control results are used to identify and prioritize the most and Prevention (CDC) recommendations. Immediate-Use Compounded Sterile Preparations Infusate. Aseptic technique is followed. consultants. and understand basic 4. vessel. A catheter surgically placed into a arterial thrombosis. having a concentration less than the normal based upon adequate knowledge and understanding tonicity of plasma. agulable state with a strong association to venous and Implanted Pump. they Immediate-use CSPs do not need to be compounded provide the advanced knowledge for safe practices to in an ISO Class 5 environment. Heparin-Induced Thrombocytopenia (HIT). 1. name or initials of preparer. A group of nursing personnel centrally would add additional risk due to delays in patient structured within an acute health care facility charged care (eg. nal containers are involved in the compounding. A catheter surgically Hospital Disinfectant. coaches. as long as all of the follow. therapeutic. The treatment of dehydration by Infection. 5. when used in error. to participate in research or to undergo a diagnostic. beyond-use date (BUD) and time. Having an immune system with transient prothrombotic disorder caused by heparin. A process whereby 2 peo- solution. The degree to which individuals have 3. damage. While this team health care facilities. ponent of a work process. A general term for and no more than 2 entries into any 1 container determining the functional status of the cardiovascu. 2. and garbing and support the primary care staff. dental offices. such as in home infusion). reduced capability to react to pathogens or tissue dependent. lar system as it responds to acute stress such as myo. Hypodermoclysis. Medications that possess a ous reservoir that contains a pumping mechanism for heightened risk of causing significant patient harm continuous medication administration.indd S150 05/01/16 11:30 PM . Health Literacy. Solution of higher osmotic concentration changes or producing undesirable effects. body cavity. solutions are isotonic or Infiltration. An arrest of bleeding or of circulation. The preparation is labeled with patient identifi- blood cells resulting in the liberation of hemoglobin. having a concentration greater than the nor. coordinators. Hemolysis. 6. sion team members include direct care providers. A person’s voluntary agreement. which diffuses into the surrounding fluid. cant solution or medication into surrounding tissue. (No intervening steps between intracardiac pressure changes. or preventive I procedure. Immunocompromised. infusion. The presence and growth of a pathogenic infusing fluids into the subcutaneous tissues at rates microorganism(s) having a local or systematic effect. hospitals. or organ attached to Environmental Protection Agency (EPA) for use in a reservoir located under the skin. Inadvertent administration of a nonvesi- near-isotonic. needed process changes. advocates. and any other medi. and managers. medications with short stability that must be with the shared mission of outcome accountability prepared immediately before administration outside for the delivery of infusion therapy. and heart rate. Thus the roles of infu- gowning are not required. Solution of lower osmotic concentration rated by a standard tool. health care information and services needed to make nonhazardous drugs in the manufacturers’ origi- appropriate decisions. where adhering to low-risk compounding procedures Infusion Team. of relevant information. ple working apart from each other verify each com- mal tonicity of plasma. This team is led by infu- S150 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. may not be directly providing each infusion. clinics. blood compounding and administration should occur. process. platelet-activating antibodies. An acute. a hyperco. and exact 1-hour Hemostasis. than that of a reference solution or of an isotonic Informed Consent. No batching or storage of CSPs occurs. than that of a reference solution or of an isotonic Independent Double Check. Hypotonic. Parenteral solution administered into the vas- (CSPs). Only simple transfer of no more than 3 sterile. No more than 1 hour elapses from the time com- cardial infarction and cardiogenic or septic shock. Implanted Vascular Access Port. occur. solution. A pounding begins to the time of administration to pulmonary artery catheter is used to directly measure the patient begins. Destruction of the membrane of the red 7. mentors.) pressure. Hemodynamic Pressure Monitoring. identifying where and how a process might fail. Incapable of being mixed or used simul- cal-related facility. greater than 3 mL/hour. the capacity to obtain. A disinfectant registered by the placed into a vessel. and amounts of all ingredients. cardiac output. body cavity. ing criteria are met: educators. Incompatible. taneously without undergoing chemical or physical Hypertonic. No hazardous drugs are used. Used in emergent situations or in situations cular or nonvascular systems. names. ance on counting drops. A device that controls burning. A (“defects. and abilities processing”). Intraosseous (IO). the major arteries and veins of the central circulation. contaminated items that would VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S151 JIN-D-15-00057. Equipment and Joint Stabilization. stinging) or pain as a result of irritation in fluid flow rate by manual adjustment of components the internal lumen of the vein with or without imme- such as a roller clamp or flow regulator. thrombolytic medications. cap. full body drapes. The instillation of a solution into a vascular Intrathecal. are accountable for the systems they design and for examples include the elastomeric balloon device and how they respond to staff behaviors fairly and justly. or extruded rubber. permitted by law and by the organization to provide which are connected. without direction or supervision. Referring to vascular access devices placed catheter placed in a lateral ventricle of the brain. The interior space of a tubular structure.indd S151 05/01/16 11:30 PM . care and services. the fluid container and the device. tears. resources that do not create value are of each professional health team member. such deliver medications into the CSF. such as medi- medication into a vascular access device (VAD) cal vial stoppers and syringe plungers. motion. and unlicensed assistive personnel. inventory. the vessels of the IO space con. Locking. liquid or semiliquid blood or other potentially fumes in the work area. within the scope of the practitioner license and con- nal canals that contain an artery and a vein. waiting. CRNI®s) and may contain Latex Safe Environment. Maximal Sterile Barrier Protection. for aspiration of cerebrospinal fluid (CSF) or to Lumen. licensed practical all products containing natural rubber latex intended nurses. gloves. organizations strive to eliminate as “DOWNTIME” Interprofessional/Interprofessional Collaboration. includ- support and stabilize a joint when veins or arteries in ing sterile coverings for the clinicians and patient: or near that joint must be used for VAD placement. M Irritant. gic individuals or those at risk for developing aller- Instill/Instillation. examples include locking solutions to maintain dipping forms in liquid latex (eg. Manual Flow-Control Device. A contained workstation with following adhesive removal. between VAD use and/or reduce risk of catheter- Intraventricular Access Device. plasma). Dry. protective eyewear. and extra upon the overlapping knowledge. catheter patency. assists in preventing bacterial con. Contamination that occurs during the manufacturing process of a product. A model of shared accountability in Mechanical Infusion Device. the spring-coil piston syringe device. Refers to the 8 types of waste that medications/solutions used to dissolve precipitate. skills. the sistent with individually assigned clinical responsibili- Volkmann’s canals connect the IO vasculature with ties. or development of vesicles or bulla in an area exposed to L medical adhesive and lasting for 30 minutes or more Laminar Flow Hood. An access device con. gloves). infectious materials. is affected by factors such as Isotonic. Having the same osmotic concentration as the dislodgment of the components or distance between solution with which it is compared (eg. a just culture understands that individuals should not Medical Adhesive-Related Skin Injury be held responsible for system failure. and Lean Six Sigma. Used for anticipated need of greater than 1 month. A device that uses a non- health care based on the premise that organizations electronic method to regulate infusion flow rate. and therefore is the J least accurate. Within the brain or spinal canal in the access device (VAD) used to maintain patency in space under the arachnoid membrane. (MARSI). gown. A health care setting in which a staff mix of registered nurses. The practice of using a device to clothing used to avoid exposure to pathogens. large or should not be considered as a physical restraint. mask. overproduction. create less risk intended to fill the VAD rather than systemic infu. Medical Waste (Regulated). Administration of a solution or gies. requires reli- diate external signs of vein inflammation. Redness. Unlicensed for contact with mucosa or nonintact skin are team members work under the direction of the removed or covered. Intrinsic Contamination. The spongy. An agent capable of producing discomfort (eg. Includes contaminated tamination and collection of hazardous chemical sharps. related bloodstream infection (CR-BSI). filtered air flow. or erosion of the skin. A practitioner epiphysis and the medullary cavity of the diaphysis. The goal is to prevent contact licensed professional infusion nursing staff. sisting of a reservoir (or port) that is attached to a Long-term. Just Culture. (See between high-allergen and airborne latex with aller- Appendix A). sion nurse specialists (eg. transportation. of allergen exposure than those items formed by sion. cancellous bone of the Licensed Independent Practitioner (LIP). molded. nonutilized tal- cooperative approach to patient care that depends ent. and towels. wasteful and should be eliminated. nect to the central circulation by a series of longitudi. as a blood vessel or catheter. Anti-Reflux NC. Solutions and medications that do not N produce tissue damage when inadvertently delivered Near-Infrared Light Devices. negative. a subcutaneous tract. peripherally inserted central catheter (PICC) or mid. leukocytes. and the cardiorespiratory functions are taminated sharps. Drug-induced depression of con. Legislation that defines the practice on the electromagnetic spectrum. the center lumen without any internal mecha- osmotic pressure equal to 1 thousandth of the molec. A device that allows inter- materials during handling. A microor. positive. administration set or syringe without the use of nee- tious materials. over-the-counter. information for each patient. Nonpermeable.indd S152 05/01/16 11:30 PM . predominantly bacteria. Items that come in contact ganism. Pertaining to the first 4 weeks of life. Extremely small living body not per. or (3) any other procedure involving the respond to verbal commands or light tactile stimula. eg. potential for occupational exposure to blood-borne tion. and fibrin ponents that allow fluid flow in both directions. (2) the administration of medication or sciousness in which a patient is able to persistently solutions. Noncritical Equipment. upon set or Midline Catheter. The lowest Needleless Systems. One thousandth of an osmole. A vascu- Staphylococcus aureus (MRSA). and certain gram-negative directly through the skin and the intended location bacilli (GNB) that have important infection control without a portion of the device allowed to remain in implications. disconnection due to movement of valve mecha- Microorganism. infrared light. nism or removal of syringe/set. Microaggregate Blood Filter. Neonate. but are not limited to. Prevents passage of fluid or gases. Complex NC. sufficient and also usually preserved. S152 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. and herbals/ nal mechanism designed to prevent blood reflux nutritional supplements—that the patient is currently into the catheter lumen when the flow of infusion taking. or 1 thousandth of a millimeter. Filter that removes micro. a range of 700 to 1000 nanometers Nurse Practice Act. Measurement of upper arm at designed to prevent blood reflux into the catheter a predetermined distance above the insertion site of a lumen upon connection or disconnection. The process of collecting or complex) and function (ie. or and documenting complete and accurate medication neutral) upon set or syringe disconnection. into subcutaneous tissue. vancomycin-resist. including all medica. Neutral NC. cephalic. axilla and distal to the shoulder. A catheter inserted into the upper syringe disconnection. Contains a pressure-sensitive inter- tions—prescribed. Simple NC. example is a prepierced ular weight of a substance divided by the number of septum accessed with either a blunt cannula or ions that the substance forms in a liter of solution. more classes of antimicrobial agents. Allows blood reflux Micron (μ). Allows a small amount line catheter. A device that does not use needles concentration of a drug that will inhibit bacterial for (1) the collection of bodily fluids or withdrawal of growth. Has a variety of moving internal com- aggregates (includes platelets. Allows a straight fluid pathway through Milliosmoles (mOsm). mechanical valves. dles. male luer device. Negative Displacement NC. Multidrug-Resistant Organism (MDRO). established. nism to control flow. resistant to 1 or with intact skin but not mucous membranes. MDROs include. with through the catheter lumen to clear any blood the internal tip located level at or near the level of the that refluxed into the lumen. occurrence of nonhemolytic febrile reactions. Minimum Inhibitory Concentration (MIC). of fluid to be held in the device. body fluids after initial venous or arterial access is Moderate Sedation. infectious materials and are capable of releasing these Needleless Connector (NC). Positive Displacement NC. this fluid is pushed arm via the basilic. lar or nonvascular access device inserted by puncture ant enterococci (VRE). or brachial vein. and microbiological mittent access to a vascular access device with an wastes containing blood or other potentially infec. solution has stopped. Contains an internal mechanism Mid-arm Circumference. pathogens due to percutaneous injuries from con- ent airway. items the superficial veins and reflecting it to the skin that are caked with dried blood or other potentially surface. types are categorized by description (ie. works by either of registered nurses and licensed practical or voca- transilluminating the extremity and projecting the tional nurses within each state. release blood or other potentially infectious material vessel image to a screen or by capturing an image of in a liquid or semiliquid state if compressed. simple Medication Reconciliation. methicillin-resistant Nontunneled Central Venous Access Device. Nonvesicant. A unit of length equal to 1 millionth of a into vascular access device (VAD) lumen upon meter. interventions are not needed to maintain a pat. A device using near. split septum. ceptible to the naked eye. that are present in stored blood) and reduces the eg. may be accompanied by pain. Catheter compres- Parenteral Nutrition. outpatient. streak formation. A device (eg. mechanical. and/or per unit of solvent. Nursing Diagnosis. regardless of insertion site. skilled nursing facility. a purpose for which it has not been approved or Personal Protective Equipment (PPE). the patient and requires full knowledge of assessment and the home. and trace elements. and tions pressure used for radiology procedures. or shock-like sensations. situated away from a center or central evaluation. The state of being occluded. erythema. glass particles. problem identification. intervention. or head freely. The number of osmotically active particles Phlebotomy. Pain associated with nerve injury including patient care. Patient Care Setting. typical compression between the bones. Policy. vascular access device medication and solutions. Withdrawal of blood from a vein by in a solution. fingers to the surface of the body in order to detect Pinch-off Syndrome. Pounds per Square Inch (psi). Written.indd S153 05/01/16 11:30 PM . subcutane. Technique performed through the skin. Inflammation of a vein. can result in catheter components include carbohydrates. by the ionic concentration of the dissolved substances Phlebitis. the inability to infuse or inject solution into a catheter. fats. examples of PPE Older Adult. and planning stages of the nursing process. the step may include hospital. The intravenous provision of sion causes intermittent or permanent catheter occlu- total nutritional needs for a patient who is unable to sion and. vein in the narrow area bounded by the clavicle. eye protection. Nursing Intervention. A vein that is rigid and hard to the touch. The patient problem identified for Pathogen. prickling. The characteristic of a solution determined pH. first ous. 300 to 325 pounds per square inch (psi). (Note: the Nursing Process. or manual Palpable Cord. as well as additives such as electrolytes. intramuscular. Pertaining to or situated at or near the outcome identification. includes steps of assessment. preferably at its junction with the right approved drug in the treatment of a condition or for atrium. A cath- O eter inserted through veins of the upper extremity or neck in adults and children. or mucosal route. usually plastic pieces. including undissolved [VAD]. may be Occlusion. comparison to what is considered to be normal. proteins. Pediatric. In the nursing process. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S153 JIN-D-15-00057. Unwanted matter relating to or pressure. A measurement of Particulate Matter. nonnegotiable statement(s) that estab- mins. and periphery. logical approach to American Academy of Pediatrics states that pediatrics administering nursing care so that the patient’s needs is actually the fetal period to 21 years of age. Physical. 1 psi equals 50 mm Hg or 68 cm H20. for infants. catheter tip is located in the superior or inferior Off-Label Use (Extra-Label Use). Percutaneous. assisted living facility. extension set) capable of withstanding injec- drugs or precipitate. occurs when organs. device that immobilizes or decreases the ability of the Palpation. costoclavicular space medial to the subclavian vein Parenteral. Osmolality. ty. Newborn to 21 years of age. tingling. body. P Physical Restraint. The degree of acidity or alkalinity of a substance. A microorganism or substance capable of intervention by analysis of assessment findings in producing disease. measured in milliosmoles per liter. Peripherally Inserted Central Catheter (PICC). and costoclavicular ligament. An orderly. and/or tearing. because of the “scissoring” effect of catheter take appropriate amounts of food enterally. Where patient care is provided. by the American Geriatric Society. planning. gown. Osmolarity. and catheter embolism. rated by a standard scale. as defined include items such as gloves. The equipment cleared for use by the US Food and Drug worn to minimize exposure to a variety of hazards. structure. Administration (FDA). Peripheral. the inability inserted through veins of the scalp or lower extremi- to aspirate blood from a catheter or both. lish rules guiding the organization in the delivery of Paresthesia. Administered by any route other than the and is positioned outside the lumen of the subclavian alimentary canal. Examination by application of the hands or patient to move arms. or physician office after planning.) for such care are met comprehensively and effectively. rib. vita. and face mask. direct venipuncture or via a central vascular access device (CVAD). Greater than 65 years of age. legs. edema. involves aspects of actual caring for setting. also used to determine location of peripheral the central vascular access device (CVAD) enters the superficial veins and their condition. composed of fine particles found in intravenous Power Injectable. The use of an vena cava. including blood-borne pathogens. A relatively rare but significant evidence of disease or abnormalities in the various and often unrecognized complication. transection. such as the intravenous. rubber cores. palpable cord. library. performance. Objects in the health care setting that can be mary emphasis on the various degrees of physical reasonably anticipated to penetrate the skin and to skills and dexterity as they relate to the preceding result in an exposure incident.indd S154 05/01/16 11:30 PM . Practice Guidelines. a time frame of less than 1 month. promulgated by the profession by which the quality Risk Management. uncom- reported to the US Food and Drug Administration promised product suitable for intended use. and dressing. after Preanalytic Phase. Written statement of a series of steps infectious microorganisms or their toxins in the required to complete an action. with a built-in safety tive intended to extend the content. Containing or producing pus. Amount of fluid required to fill the after use. Proximal. (FDA) when the patient outcome is death. fluid pathway of the vascular access device (VAD). ous injuries and blood exposure before. or administering ble of inhibiting bacterial growth. nent damage. analysis. obtaining. insertion site. scalpels. or determines. analyzing. the event is serious and should be Product Integrity. ited to. When used in reference to a vascular access the purpose of creating turbulence within the vascular device. All blood and body fluids are treated as ing basic or causal factors that underlie variation in potentially infectious. Sentinel Event. not individual performance. emulsi- of an exposure incident. Method or product used to protect the Purulent. lancets. workers with occupational exposure to blood-borne Root Cause Analysis (RCA). and problem solving. A nonneedle caused by a change in pH. The process for identify. tion in a patient. S Precipitation. pathogens. Site Protection. Process that centers on identifica. labeling. that no such improvement opportunities fluid specimen reaches the laboratory. and education to objectively assess the performance of others. the oppo- talization. any add-on devices. Closest to the center or midline of the body life threatening. Smart Pump. short (eg. including the occurrence or possible Statistics. 1 mL) pushes followed by a brief pause for Short-term. systematic process tency in a specific skill who is qualified by training for monitoring. Impenetrable to x-rays or other forms of dosing errors through the presence and use of a drug radiation. or bacteriocides. See Serious Adverse Event. and evaluation of real and Standard Precautions. but not lim- thought process. includes exist. and transporting the specimen to the laboratory. Free from living organisms. An ongoing. Contains no added substance capa- fluids. and professional standards. during. broken glass. evaluating. focuses primarily on izing. Free of any addi- medications or other solutions. accessing a vein or artery. The act of adding diluent to a powder to Standard. access device (VAD) lumen. external vascular access device (VAD). organ- occurrence of a sentinel event. Characterizing behaviors that place pri- Sharps. Individual with documented compe- Quality Improvement. of such events in the future. stability. or education can be judged. Authoritative statement enunciated and create a solution. treatment. Any undesirable experience mance based on compliance with policies. such as antioxidants. Reconstitute. disability. The systematic science of collecting. of practice. Psychomotor. including. needle devices. nearer to the point of attachment. Process. The condition of an intact. service. Pulsatile Flushing Technique. Guidelines designed to protect potential hazards. or steril- feature or mechanism that effectively reduces the risk ity of active ingredients. The systemic response caused by the presence of Procedure. The period of time before a body analysis. tion. Electronic infusion device (EID) with an R imbedded computer software aimed at reducing drug Radiopaque. S154 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. proce- associated with the use of a medical product/medica- dures. detectable by radiographic examination. most commonly Engineered Sharps Injury Protections). and interpreting numerical data. Actual performance and observation of perfor- Serious Adverse Event. sharp or a needle device used for withdrawing body Preservative-Free. and administration set. Repetitive injection of or broken capillary tubes. systems and processes. Sterile. requires initial or prolonged hospi- or trunk. or Priming Volume. bloodstream. or requires intervention to prevent perma- site of distal. Sepsis. The act or process of a substance or drug Safety-Engineered Device (also known as Sharps with in solution to settle in solid particles. Provide direction in clinical care identifies potential improvements in processes or decisions based on the current state of knowledge systems that would tend to decrease the likelihood about a disease state or therapy. Used to prevent percutane- fiers. Q Skill Validator. States Pharmacopeia (USP) National Formulary (NF) Thrombolytic Agent. A device using sound waves at frequencies decision-making process. Transducer. including transfused blood cells or other components of the veins. indicates that the skin exit Subcutaneous Infusion. tubes. Complication of blood transfu. including both nursing and medical assistants. An unexpected occur- rence or event resulting in death. Unable to be altered. condition. or existence settings in which sterile preparations are compounded. An agent capable of causing tissue damage Transillumination. someone who acts on behalf of the U patient when the patient cannot participate in the Ultrasound. identification of blood vessels. ongoing observation of health care workers who work as assistants to and the occurrence and distribution of disease within a under the direction of licensed health care profession- population and of the events or conditions that als. A category of Surveillance. greater than the limit of human hearing. Vesicant. which are spectrum. when strategies beyond Standard Precautions are Visualization Technology. Active. tion of the skin surface beneath it. or the middle of the electromagnetic Droplet. An unusual occurrence also includes an Therapeutic Phlebotomy. Shining a light at a specific body when it escapes from the intended vascular pathway part (ie. or sion where there is an immune response against the devices inserted into the vascular system. Removal of a specific volume incident resulting in the abuse of a patient. VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S155 JIN-D-15-00057. of a blood clot within the vascular system. surrogates may be desig. A ster- peripheral catheter designed to facilitate venipuncture ile air-permeable dressing that allows visual inspec- and catheter insertion. Unlicensed Assistive Personnel (UAP). of sound or light waves to allow for the location and tious agents. 700 nanometers.indd S155 05/01/16 11:30 PM . A device using light from 400 to Transmission-Based Precautions. Inflammation of the vein in con- and compliance requirements for compounding sterile junction with formation of a blood clot (thrombus). arteries. to transilluminate an extremity to locate implemented in addition to Standard Precautions superficial veins. or T serious injury to a patient that is not related to a natural course of the patient’s illness or underlying Tamper-Proof. Unusual Occurrence (or Event). Transfusion Reaction. water resistant. increase or decrease the risk of such disease occurrence. sound waves nated by the patient and know the patient’s prefer. skin. Administration of medications site and vein entry site are separated by the subcuta- into the tissues beneath the skin. Vascular Access Device (VAD). Thrombophlebitis. A long wire guide inside the catheter lumen Tunneled Cuffed Catheter. The use of Airborne. Stylet Wire. procedures. Stylet. Umbilical Catheter. extremity) to identify structures beneath the into surrounding tissue. without such knowledge a surro. of blood from a patient as ordered by the licensed USP Chapter <797>. device (CVAD) with a segment of the catheter lying lar access device (VAD) into the vein. and/or Contact Precautions. Chapter 797 “Pharmaceutical independent practitioner (LIP) for the treatment of a compounding—sterile preparations. may be multiple in a subcutaneous tunnel with the presence of a cuff pieces welded together and is not intended for into which the subcutaneous tissue grows to offer advancement into the vein alone. Surrogate.” in the United specific condition or disease. Device that employs the use required to reduce the risk for transmission of infec. life-threatening. neous tunnel. The formation. security for the catheter. transfusion. A sharp rigid metal hollow-bore object within a Transparent Semipermeable Membrane (TSM). patient’s best interest. this knowledge. A pharmacological agent capable are enforceable sterile compounding standards issued of lysing blood clots. A catheter that is inserted into 1 of gate is required to make decisions that are in the the 2 arteries or vein of the umbilical cord. Visible Light Devices. development. and bone marrow. Catheters. A device that converts one form of energy V to another. preparations and set the standards that apply to all Thrombosis. directed into human tissue to identify and display ences or may be court appointed with or without physical structures on a screen. A central vascular access used to provide stiffness for advancement of a vascu. by the USP that describe the guidelines. systematic. Also referred to as legally authorized rep- resentative. S77 transfusion. S113 peripheral or pulmonary. S66 (CLABSI) site selection. S127 S91 Antiseptic agents. S42 disinfection caps and. S69 B needleless connectors and. S65 sterile glove. S57. S22. S55. S92 Blood sampling. See Local anesthesia parenteral nutrition and. S92 Catheter exchange. S135 planning. S79 S112 S156 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. S22 patient-controlled. S93 Central line-associated bloodstream infection site preparation and device placement. S21 Biologic therapy. S78 venous thrombosis and. S58. S46 C Central vascular access devices Catheter damage. S110 implanted ports. S137 monitoring rates of. S21 Central venous access device-associated thrombosis. S55. S59 Catheter embolism. S52. S58. S85 chlorhexidine-impregnated dressings and. aseptic technique and. S86. S34. S92 adverse events and. S52 changes and. S71 catheter exchange and. S52. S108 identifying. S79. S79 Arterial pressure monitoring: administration set central vascular access devices and. S131 nontunneled CVAD removal and. S78 umbilical catheters and. S109 hemodialysis vascular access. S85 site preparation and device placement. S106 Airborne Precautions. S82 Advanced Practice Registered Nurse (APRN). Antineoplastic therapy. S87 catheter damage and. S12. S129. S52 warming. S78. S65 tip location. S31 CVAD salvage and. S61 Arterial catheters vascular access devices and. S55 antimicrobial locking solutions and. S134 Antimicrobial locking solutions. S107 Adverse events. S52 intravenous infusion for. S110 removal. S68 central vascular access devices and. S128. antimicrobial locking solutions and. S86 Bar-code technology. S108 Add-on devices. S17 Analgesia. S110 nontunneled. S136 rate calculation.indd S156 05/01/16 11:30 PM . S47 Administration set changes. S82 Assent. S14 CVAD removal and. S69 Air embolism. S63 intermittent vascular access ports and. S58. S55. S62 sutures and. S55 administration set changes and. S65 Apheresis catheters. S110 needleless connectors. S85 flushing and locking. S49 removal. The Art and Science of Infusion Nursing Index A blood sampling and. S27 disinfection caps and. S91 Anesthesia. S73 flushing and locking. S107 short peripheral and midline catheter removal and. S129 tip location and. S91 Catheter-related bloodstream infection (CRBSI) peripherally inserted central catheters. S52. S53 Catheter repair. S77 flushing and locking. S84 chlorhexidine-impregnated dressings and. S84 tunneled. S47 Blood and blood components Central vascular access administration set changes. S69 phlebotomy and. S55 Compounding. S38 Color coding. S31 rate calculation. S69 vascular access device-related. S35 Engineered stabilization device. S118 Dressing changes. S98 infection. S43 Standard Precautions. S133 Infection Contact Precautions. S32 parenteral solutions and medications compound- Disinfection ing and preparation. S56 Locking. S63 External jugular vein access. S114 H Certification. S77 Extravasation. and defect reporting. S133 beyond-use date. S106 I infiltration. Central venous access device malposition. S18 Hemodialysis vascular access devices. S39 durable medical equipment. S70 Medical Assistants (MAs). Intraosseous access devices. S74 E Electronic infusion devices (EID). S129. S78 VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S157 JIN-D-15-00057. S34. S43 J Joint stabilization devices. S133 manual. S114 Implanted vascular access ports nerve injuries. S106 Documentation. S92 venous thrombosis. S21 in medical record. S27 product evaluation. S34 assent. S136 Medical waste. S58 occlusion. S120 S134 Intraspinal access devices. S127. S59 Complications flushing and locking. S14 blood and blood components. S127. S140 Dose-error reduction system. S14 Epidural access devices. S112 site selection. Infusion Nurse Specialist (CRNI®). S48 L flow control device. S98 malposition. S43. S72. S49 Latex sensitivity or allergy. S39. S77 flushing and locking. S109 changes and. S40 Defect reporting. S118 Droplet Precautions. S72 verification. S28 Informed consent. S34 Hazardous drugs and waste. S82 Licensed Practical/Vocational Nurse (LPN/LVN). S42 Disinfection caps. S131. S24 Local anesthesia. S42 prevention and control durable medical equipment disinfection. S14 Hand hygiene. S38 medical waste and sharps safety. S81 Intrathecal access devices. S14 S32 Infusion team. S108 Hemodynamic pressure monitoring: administration set catheter damage. S118 Light devices. S41 needleless connectors. S34 Fluid warming. S98 M F Medical adhesive-related skin injury. S43 D hand hygiene.indd S157 05/01/16 11:30 PM . S44 Evidence-based practice and research. S48 compounding. S78 extravasation. S85 catheter embolism. S49 Midline catheters Flushing. S98 adverse and serious adverse events. S42 Durable medical equipment disinfection. S12. S26 medication verification. S104 planning. S119 Medications parenteral nutrition. S110 Heparin-induced thrombocytopenia. S17. S73. S102 placement. S52 phlebitis. S95 removal. S39. S40 Flow-control devices. S78 air embolism. integrity. S40 intravenous infusions. S28 Infiltration. S68 Transmission-based Precautions. S36 Competency assessment and validation. S82 Filtration. S48. S91 Patient education. S54 therapeutic. S72 S158 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing JIN-D-15-00057. S41 P Transmission-based Precautions. S85 Sentinel events. S75 planning. S54 Peripheral arterial catheters. S26 infusion team structure. S64 blood sampling via vascular access devices. S134 site selection. S110. S32 Near-infrared light devices. S36 special populations. S68 Pulmonary arterial catheters. S133 Sedation. S102 Nontunneled central vascular access devices Quality improvement. S52 Phlebotomy. S39 flushing and locking. S34 Occlusion: central vascular access devices. S14 arterial catheters. S129. S78 Site protection. S85 Short peripheral catheters compounding and preparation. S125. S13 hazardous drugs and waste. S35 O medical waste and sharps. S40 administration set changes. S42. S131 removal. S23 Respiratory Care Practitioner. S65 Registered Nurse (RN). S51 Patient-controlled analgesia. S91 blood sampling via direct venipuncture. S40 medication verification. S41. S54 removal. S87 site selection. S11 site selection. S64 Pediatric patients. S52 Site selection. S25 adverse and serious adverse events. S91 Radiologic Technologist. intravenous infusion for. and defect Older adult patients. S17 S patient care. S78 planning. S34. S104-S105. integrity. S53 Site care and dressing changes. S95 joint. S93 Nursing practice standards nontunneled central vascular access devices. S55 Stabilization Phlebitis. S65 Smart pumps. S22 vascular access devices. S53 Neonatal patients. S31 administration. S11 Safety patient education. S48. S11 reporting. S28 surgically placed central vascular access devices. S55 Removal. S25 site preparation and device placement. S43 Practice setting. S137 Pinch-off syndrome. S11 N Product evaluation. S44 Propofol infusions: administration set changes. S21 durable medical equipment disinfection. S91 documentation in medical record. S81 flushing and locking. S32 Standard Precautions. S92 competency assessment and validation. S11 latex sensitivity or allergy. S13 site selection. S11 Pregnant patients. and defect reporting. S18 short peripheral and midline catheters. S15 Scope of practice. S31 quality improvement. S15 site preparation and device placement. S149 Multidrug-resistant organisms. S74 rate calculation. S11 Q Nerve injuries. S138 Moderate sedation/analgesia. S52 R removal. S31 Parenteral solutions and medications Serious adverse events. S86 site preparation and device placement. S104 product evaluation. S13 Parenteral nutrition. S85 removal. S85 Needleless connectors. S65 site preparation and device placement. S128. S92 evidence-based practice and research. S91 Skin antisepsis. planning. S42 Paramedics. integrity. S137 administration set changes. S77. vascular access device Nursing assistive personnel (NAP). S15 informed consent. S21 flushing and locking. S11 planning. S40 Patient care standards. S43 scope of practice. S125 Sharps safety.indd S158 05/01/16 11:30 PM . S84 Vascular access devices. S64 Venous thrombosis. General Chapter < 797 >. S77 site selection. S42 blood sampling via. S87 Tunneled central vascular access devices complications. S60 needleless connectors. See Central vascular access devices T add-on devices. S81 stabilization. S51 local anesthesia.indd S159 05/01/16 11:30 PM . S138 administration set changes. S54 assessment. S63 umbilical. S51 Vascular visualization. S72 administration set changes. S55 for hemodialysis. S44 removal. S86 site preparation and device placement. S41 site protection. S95 types. S84 Therapist/Technologist/Technician. S60 planning. S95 planning. site care. S84 site selection. direct: for blood sampling. S62 blood warming. S54 access devices. S72 complications. S15 anesthesia for placement and access. S52 Umbilical catheters. S63 Transfusion therapy. S14 removal. S92 flushing. S71 Therapeutic phlebotomy. S39 planning. S51 Unlicensed Assistive Personnel. S81 Transmission-based Precautions. S135 apheresis. Standard Precautions. S52 filters. S51 V site preparation and device placement. S45 midline catheters. S70 removal. S74 U locking. S75 Subcutaneous infusions site selection. S75 administration set changes. S68 United States Pharmacopeia (USP) National Formulary phlebotomy. S91 Venipuncture. S49 assessment. and dressing changes. S91 short peripheral catheters. S77 management. S112 VOLUME 39 | NUMBER 1S | JANUARY/FEBRUARY 2016 Copyright © 2016 Infusion Nurses Society S159 JIN-D-15-00057. S85 (NF). S64 Vascular access site protection. S122 stabilization. S68 Ultrasonography. S59 joint stabilization devices. com/INS2 today or call (888) 237-2762. 1-888-237-2762 © 2015 BD MSS0933 (12/15) www. You need a catheter that can do double duty. BD Logo and all other trademarks are property of Becton.com/INS2 NAN3901S-IBC.5 mL/sec)* with those patients that require a smaller catheter and may provide a lower cost alternative to more costly IV access options like PICCs.* BD Diffusics™ technology enables the use of a smaller IV catheter (22 gauge up to 6. To order or learn about all the ways BD is caring for you and your patients. Performance Under Pressure BD Nexiva™ Diffusics™ Closed IV Catheter System For high-pressure injection A simple solution when the pressure is on. BD Medical 9450 South State Street * Compared to a non-diffusion tip IV catheter. Let’s just say we thrive under pressure. visit bd.bd. Its unique catheter tip features multiple teardrop-shaped holes to diffuse flow and reduce forces that can cause catheter motion in the vein by up to 67%.indd 3 31/12/15 3:39 PM . Dickinson and Company. Utah 84070 BD. Accommodating CT power injection protocols can be challenging when it comes to selecting and using an IV catheter—especially when efficiency and safety are top priorities. Sandy. That’s why the BD Nexiva™ Diffusics™ Closed IV Catheter System was created. NANv39n1S-C4.indd 4 31/12/15 4:08 PM .