Comparing	  standards:	  is	  everything	  clear?	                                                                Jackie	 ...
Evidence	  based	  guidelines	  save	  lives	  
Hierarchy of evidence
 Categories	  of	  evidence	  Strongly recommended for                                      Meta- analyses , systematic   ...
Elements	  to	  consider	    EducaGon	  &	  training                 	        	  	    Hand	  hygiene	  &	  asepGc	  tech...
Educa0on	  &	  Training	                    RCN	                                          INS	                            ...
Hand	  hygiene	  and	  asep0c	  technique	                       RCN	                                               INS	  ...
Barrier	  Precau0ons	                         RCN	                                                 INS	                   ...
Skin	  prepara0on,	  dressing	  and	  securement	  regimens	                        RCN	                                  ...
Skin	  prepara0on,	  dressing	  and	  securement	  regimens	                                    RCN	                      ...
Selec0on	  of	  devices	  and	  sites	                           RCN	                                             INS	    ...
Selec0on	  of	  devices	  and	  sites	                      RCN	                                            INS	          ...
Replacement	  of	  devices	  and	  administra0on	  sets	                                                                  ...
Replacement	  of	  devices	  and	  administra0on	  sets	                        RCN	                                      ...
Use	  of	  needlefree	  sets	                       RCN	                                                                  ...
Considera0on	  of	  an0bio0c	  catheters,	  prophylaxis	  and	  locks	                      RCN	                          ...
Consensus	    EducaGon	  &	  training                          	             	  	         Competence	    Hand	  hygiene...
Consensus	    Skin	  preparaGon,	  dressings	  and	  securement	  regimens                                             	 ...
VariaGon	    EducaGon	  &	  training	         EducaGon	  of	  paGents/carers	    Hand	  hygiene	  &	  asepGc	  techniqu...
VariaGon	    Replacement	  of	  devices	  and	  administraGon	  sets	         PVD	  dwell	  Gme	  -­‐	  	  72-­‐96	  hou...
Further	  clarificaGon/research	  required	    AsepGc	  technique                 	  	         DefiniGon/standardisaGon	  ...
March	  17th	  2012	  
2	  weeks	  later	                            Home	  16th	  April	  2012	  
To	  summarise	    Evidence	  based	  guidelines	  save	  lives	    Wealth	  of	  evidence	  RCN,	  INS,	  CDC	  guideli...
The	  future?
10.30 11.00 jackie nicholson publiceren
10.30 11.00 jackie nicholson publiceren
10.30 11.00 jackie nicholson publiceren
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10.30 11.00 jackie nicholson publiceren


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10.30 11.00 jackie nicholson publiceren

  1. 1. Comparing  standards:  is  everything  clear?   Jackie  Nicholson   Clinical  Nurse  Specialist  in  IV  Therapy                                   Royal  Surrey  County  Hospital       Guildford,  Surrey,  UK  
  2. 2. ?
  3. 3. Evidence  based  guidelines  save  lives  
  4. 4. Hierarchy of evidence
  5. 5.  Categories  of  evidence  Strongly recommended for Meta- analyses , systematic Evidence fromimplementation and strongly supported literature reviews or at least anatomy,by well-designed experimental, clinical, three well-designed, physiology andor epidemiologic studies. randomized controlled trials pathophysiologyStrongly recommended forimplementation and supported by some At least two well designedexperimental, clinical, or epidemiologic randomized controlled trials or astudies and a strong theoretical rationale; systematic literature review of variedor an accepted practice supported by prospective study evidence. One well designed randomized controlled trial or severalRequired by state or federal regulations, quasiexperimental designs focussedrules, or standards. on the same question. Includes two or more well designed laboratory studies. Case control or cohort studies,Suggested for implementation and narrative literature reviews orsupported by suggestive clinical or systematic literature reviews basedepidemiologic studies or a theoretical on descriptive or qualitative studies.rationale. Includes one well designed laboratory study. Descriptive studies and informationRepresents an unresolved issue for from clinical articles, textbooks or well designed quality improvementwhich evidence is insufficient or noconsensus regarding efficacy exists. V projects. Includes generally accepted standard of practice which does not have a research base. Regulations set forth by organizations with oversight for monitoring the standards’ adoption and practice.
  6. 6. Elements  to  consider    EducaGon  &  training        Hand  hygiene  &  asepGc  technique    Barrier  PrecauGons    SelecGon  of  devices  &  sites        Skin  preparaGon,  dressings  and  securement  regimens      Replacement  of  devices  and  administraGon  sets    Use  of  needlefree  sets    ConsideraGon  of  anGbioGc  catheters,  prophylaxis  and  locks  
  7. 7. Educa0on  &  Training   RCN   INS   CDC  Nurses  should  have  ‘validated   Nurses  should  be  competent   Designate  trained  and  competency’  ref   in:……   competent  personnel  (IA)  Nurses     Nurses     Educate  healthcare  personnel  should  undergo  theoreGcal   should  be  knowledgeable   regarding:  and  pracGcal  training  in  ……… about  ……                indicaGons  of  VAD  use  ref                proper  procedures                inserGon  and  maintenance                infecGon  control  measures                                                                                                  (IA)  Pa0ents/caregivers   Pa0ents/caregivers  demonstraGon,  verbal  and   hand  hygiene  (V)   Periodically  assess  all  involved  wriRen  demonstrate   prevenGon  of  infecGon   personnel:  understanding  ref   flow  devices  (V)                  Knowledge,  adherence  to     immobilisaGon  devices                      guidelines  (IA)   wriRen  instrucGons  (IV)  
  8. 8. Hand  hygiene  and  asep0c  technique   RCN   INS   CDC  Hand  washing   Hand  washing       Hand    washing  Visibly  soiled  hands  –  soap  and   Visibly  soiled  or  exposed  to   Soap  and  water  or  alcohol  water   spore  producing  pathogens  – based  hand  rub  (IB)    Alcohol  Hand  rub   soap  and  water,     Alcohol  based  hand  rub   preferred  (II)  Asep0c  technique   Asep0c  technique   Asep0c  technique  AsepGc  technique  during   Standard  precauGons    or   AsepGc  technique  for  inserGon  infusion  &  VAD  placement   transmission  -­‐based   and  care  of  VADs  (IB)    ref   precauGons  
  9. 9. Barrier  Precau0ons   RCN   INS   CDC  General   General  Single  use  aprons  and  gloves   Standard  precauGons  and  when  performing  infusion   personal  protecGve  equipment  procedures   (PPE)  during  infusion   procedures  when  risk  of   exposure  to  body  fluids    MBP   MBP   MBP  No  evidence  to  suggest  that   MBP  including  cap,  mask,   MBP  including  cap,  mask,  wearing  a  face  mask  and  cap   sterile  gown,  sterile  gloves,   sterile  gown,  sterile  gloves,  during  central  venous  catheter   protec0ve  eyewear,  full  body   full  body  drape  should  be  inserGon  reduces  the   drape  should  be  used  for  all   used  for  all  CVAD  inserGon  or  incidence  of  infecGon  (2007   CVAD  inserGon,  exchange  and   guidewire  exchange  (IB)  ref)   repair  (II)  If  risk  of  body  fluid  exposure  –  face  mask,  cap  and  eye  protec0on    ref    
  10. 10. Skin  prepara0on,  dressing  and  securement  regimens   RCN   INS   CDC  Skin  prepara0on   Skin  prepara0on   Skin  prepara0on  2%  CHG  &  alcohol  ref     CHG  preferred,  iodine/70%   PVD  –  70%  alcohol/alcoholic   alcohol  (I)     iodine/alcoholic  CHG  (IB)  FricGon  rub  30  seconds,  air  dry   CHG  X  <  2  months  (I)   CVAD  -­‐  >  0.5%  alcoholic  CHG  30  seconds  ref   (IA)  Skin  (dressing)   Skin  (dressing)   Skin  (dressing)  2%  CHG   CHG  preferred,  iodine/70%   CVAD  -­‐  >  0.5%  alcoholic  CHG   alcohol  (I)     (IA)   <  2  months,  povidone  iodine,   <  2  months  no   remove  with  saline  or  sterile   recommendaGon  (unresolved)   water  (V)  Dressing   Dressing   Dressing  TSM/gauze   No  evidence  to  support  TSM   TSM  /gauze  (IA)   over  gauze   Gauze  if  site  moist  (II)   Gauze  if  site  moist  (II)  TSM  7  days,  gauze  24  hrs  ref   TSM  5-­‐7  days,  gauze  2  days   TSM  7  days,  gauze  2  days  (IB)  
  11. 11. Skin  prepara0on,  dressing  and  securement  regimens   RCN   INS   CDC   Consider  CHG  dressing    > 2   Consider  CHG  dressing  > 2   months  (prevent  infecGon)  (I)   months  (infecGon  rate  ↑)  (IB)   Well  healed  tunnelled  device   Cuffed  tunnelled  devices,  no   may  not  need  dressing  (III)   recommendaGon  (unresolved)  Securement   Securement   Securement                    Sterile  tape   TSM  alone  not  supported  (III)                    TSM   No  bandages  (V)                    Securement  devices   Securement  device  preferred   Use  a  sutureless  device  (II)                    Avoid  sutures  ↑  risk   to  tape  or  sutures  (III)                    infecGon                    Sutures  21  days  tunnelled   cuffed  line                    Sterile  surgical  strips  ref    
  12. 12. Selec0on  of  devices  and  sites   RCN   INS   CDC  General   General   General  Type  &  length  of  therapy,   Type  and  length  of  therapy,   Purpose,  duraGon,  known  paGent’s  condiGon  and   dwell  Gme,  vascular  integrity,   complicaGons,  experience  of  preference  ref     paGent  preference,  ability  and   operator  (IB)   resources  available  for   akercare    Smallest  gauge  and  length  for   Smallest  gauge  and  length,  therapy  ref     fewest  lumens,  least  invasive.  PVDs    3-­‐5  days   PVDs  <  1  week  (V)   PVDs    Ideally  a  safety  device  ref     Safety  device  (V)  Winged  device  -­‐  bolus  or  non-­‐ Steel  winged  -­‐  short  term  or   Avoid  steel  needles  for  vesicants  ref     single  dose  (V)   vesicant  medicaGon  (IA)  Avoid  lower  extremiGes  ref     Avoid  lower  extremiGes  (IA/P)   Upper  extremiGes  (II)  Not  suitable  vesicants  or   Not  suitable  vesicants  or  ↑osmo   ↑osmo  
  13. 13. Selec0on  of  devices  and  sites   RCN   INS   CDC  Midline   Midline  1  –  4  weeks  (V)   Midline/PICC  >  6  days  therapy  Cephalic,  basilic,  median   Cephalic,  basilic  brachial  (V)  cubital  ref    X  vesicants  /↑osmo   X  vesicants/↑osmo  (V)    PICC   PICC  Ideally  upper  arm  using  US   Basilic,  median  cubital,   cephalic  (V)  Non-­‐tunnelled,  tunnelled,   Non-­‐tunnelled  device   Non-­‐tunnelled  device  implantable  device   Balance  risks     Balance  risks  (IA)  Balance  risks  ref     Subclavian  site  preferrred  (I)   Avoid  femoral  site  (IA)  Subclavian  preferred  for  non-­‐ Subclavian  site  preferred  (IB)  tunnelled   Tunnelled  &  implanted   Tunnelled  device   devices   No  recommendaGon  for  site   Collaborate  with  health  care   for  tunnelled  device   team  and  paGent  for  site   (unresolved)   selecGon  (V)  
  14. 14. Replacement  of  devices  and  administra0on  sets   RCN   INS   CDC  PVD   PVD   PVD  72  –  96  ref   72  –  96  hours  (IB)   Replace  when  clinically   Replacement  when  clinically   indicated  (I)   indicated  (unresolved)  Midlines   Midlines   Midlines  PICCs                                                                                               > 4  weeks  clinical  judgement   Replace  only  when  clinically  Tunnelled  devices   (V)   indicated  (II)  Implanted  ports  ?  dwell  Gme   Non  tunnelled,  tunnelled   CVADs  exchange  -­‐  absence  of   devices  and  implanted  ports   No  rouGne  replacement  (IB)  infecGon  ref   Dwell  Gme  unknown  (II)   Do  not  remove  on  basis  of   removal  determined  by   fever  alone  (II)   complicaGons  (V)   Guidewire  exchanges  only   absence  of  infecGon  (IB)  Administra0on  sets   Administra0on  sets   Administra0on  sets  1°/2°  72  hours  ref   1°/2°  96  hours  (II)   1°/2°  96  hours  IA)  IntermiRent  24  hours  ref   IntermiRent  24  hours  (V)   IntermiRent  (unresolved)  Lipid  PN  24  hours                ref   PN  /  other  lipid  24  hours  (III)   Lipid  within  24  hours  (1B)  
  15. 15. Replacement  of  devices  and  administra0on  sets   RCN   INS   CDC   Propofol  12  hours  (regulatory)   Propofol  6  –  12  hours  (IA)  Blood  –  end  of  transfusion/12   Blood  4  hours  (IV)   Blood  within  24  hours  (IB)  hours  whichever  sooner  ref  Add  ons   Add  ons   Add  ons  with  administraGon  set  or   with  administraGon  set  or   With  administraGon  set,  no  when  integrity  compromised   when  integrity  compromised   benefit  more  frequently  than  ref   (V)   72  hours  (II)  Hub  as  above  or  blood  in   Hub  as  above/residual  blood/  device  ref   prior  to  blood  culture  (IV)  
  16. 16. Use  of  needlefree  sets   RCN   INS   CDC  Needlefree  system  preferred   Needles  shall  not  be  used  for   Needleless  system  to  access  IV  method  of  access  ref   access   tubing  (IC)   Needleless  connectors     Needleless  connectors     Split  septum/mechanical  valve          split  septum  valve  ?  preferred                    negaGve                                                                                                  (II)                  posiGve                  neutral                              (II)   (Discussion    p  54-­‐56)   Needleless  connectors  sites  of   microbial  contaminaGon  (II)  Disinfec0on   Disinfec0on   Disinfec0on  CHG  &  alcohol   Alcohol/iodine/CHG  &  alcohol   CHG/  iodine  /70%  alcohol  (IA)  FricGon,  allow  to  dry   OpGmal  technique  or  Gme   Scrub  the  access  port   frame  not  idenGfied  (III)   Time  –  3-­‐5  secs  with  70%   alcohol  did  not  disinfect.            
  17. 17. Considera0on  of  an0bio0c  catheters,  prophylaxis  and  locks   RCN   INS   CDC  An0microbial  catheters   An0microbial  catheters   An0microbial  catheters  Consider  in  ↑  risk  paGents   Consider  > 5 days  /↑  risk   Consider  if  CRBSIs  not  ↓  aker  ref   paGents  /CRBSI  rates  not  ↓   other  intervenGons.  (IA)   aker  other  intervenGons    (I)   ?  cost  effecGve                      ICU                    burns                    neutropenia                        ↑  CRBSI  rates   Prophylaxis   Prophylaxis   Not  rouGne   Do  not  give  to  prevent   ?  history  of  CRBSI/  ↑  risk    (I)   infecGon  (IB)   An0microbial  lock   An0microbial  lock   ?  long  term  CVAD  salvage   Long  term  CVADs  +  history  of   (Absence  tunnel/port   mulGple  CRBSI  despite  other   infecGon)   intervenGons  (II)   ?  +  systemic  anGbioGcs  (I)   (Discussion  p  41-­‐43)  
  18. 18. Consensus    EducaGon  &  training         Competence    Hand  hygiene  &  asepGc  technique     Soap  and  water/alcohol  hand  rub     AsepGc  technique  –  VAD  inserGon  and  care    Barrier  PrecauGons     MBP  –  all  CVAD  inserGons    SelecGon  of  devices  &  sites         Based  on  type  and  length  of  therapy     PVDs  upper  extremiGes     Non-­‐tunnelled  CVAD  –  subclavian  site  preferred  but  balance  risks  
  19. 19. Consensus    Skin  preparaGon,  dressings  and  securement  regimens       CHG  preferred  -­‐  CVAD  inserGon       TSM  or  gauze     Avoid  sutures    Replacement  of  devices  and  administraGon  sets     Lipid  PN  –  24  hours     Change  add  ons  with  administraGon  set    Use  of  needlefree  sets     Needlefree  systems  preferred     Disinfect  hub  with  anGsepGc  –  Gme  frame  not  idenGfied      ConsideraGon  of  anGbioGc  catheters,  prophylaxis  and  locks     Not  for  rouGne  use  but  consider  for  specific  groups  of  paGents  
  20. 20. VariaGon    EducaGon  &  training     EducaGon  of  paGents/carers    Hand  hygiene  &  asepGc  technique     AsepGc  technique  v  standard  /transmission  based  precauGons    Barrier  PrecauGons     Elements  of  MBP    Skin  preparaGon,  dressings  and  securement  regimens       %  CHG     CHG  dressing  -­‐  prevenGon  v  intervenGon  
  21. 21. VariaGon    Replacement  of  devices  and  administraGon  sets     PVD  dwell  Gme  -­‐    72-­‐96  hours  v  only  when  clinically  indicated     1°/2°  conGnuous  -­‐  72  v  96  hours     Blood  –  4hours,  12  hours,  within  24  hours    ConsideraGon  of  anGbioGc  catheters,  prophylaxis  and  locks     AnGbioGc  prophylaxis  when  ↑  risk  factors  v  do  not  give  to  prevent  infecGon     AnGbioGc  lock    -­‐  salvage  infected  long  term  line  v  history  of  repeated  CRBSIs  
  22. 22. Further  clarificaGon/research  required    AsepGc  technique       DefiniGon/standardisaGon     Technique  and  Gme  frame  hub  disinfecGon    Barrier  precauGons         Elements  of  MPB  SelecGon  of  devices  and  sites     Dwell  Gme  all  VADs     Site  selecGon  tunnelled  devices    Skin  preparaGon,  dressings  and  securement  regimens     CHG%     Skin  preparaGon  <  2  months    Replacement  of  devices  and  administraGon  sets     Primary  and  secondary  conGnuous  infusion  sets       Blood  administraGon  sets  
  23. 23. March  17th  2012  
  24. 24. 2  weeks  later   Home  16th  April  2012  
  25. 25. To  summarise    Evidence  based  guidelines  save  lives    Wealth  of  evidence  RCN,  INS,  CDC  guidelines    Areas  of     Consensus     VariaGon     Further  research  and  clarificaGon  
  26. 26. The  future?