Vascular Access Matters


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  • Introduction IV lines. What do we know about them, about the proper use and maintenance of IV lines, best practice to prevent patient events related to IV lines, and staying abreast of new technologies? New challenges?
  • This education session addresses these issues and more. Today we look at VASCULAR ACCESS DEVICES….. You will encounter pre-tests throughout the education session. At the conclusion of the session, you will complete the post-test. So let’s begin. Remember that: Saving lines, saves lives…… Then read or highlight the bullet points above.
  • While vascular access devices are patient lifelines, they also present serious risk every individual with one. Then read or highlight the bullet points above.
  • An embolus, or a plug, composed of a detached thrombus or vegetation, mass of bacteria, or other foreign body, may occlude an IV line. Some non-thrombotic emboli Air, Catheter and Wire. Insertion or changing of a central venous catheter over a guide wire potentially can cause an acute pulmonary embolism as shown here.
  • For severe, life-threatening pulmonary embolism, treatment may consist of dissolving the clot with thrombolytic therapy. Anticoagulant therapy prevents the formation of more clots and allows the body to re-absorb the existing clots faster. Clot-dissolving medication (thrombolytic therapy) t-PA is most commonly used. Clot-preventing medication (anticoagulation therapy) consists of heparin by IV infusion initially, then oral warfarin (Coumadin). Subcutaneous low-molecular weight heparin is substituted for intravenous heparin in many circumstances. Patients who have reactions to heparin or related medications may need other medications.
  • Asepsis is the first step in protecting patients from complications related to vascular access. The majority of blood stream infections related to central lines are caused by improper care and accessing, and are intraluminal (from inside the line). You are the gatekeeper between bacteria and a potentially life-threatening infection for each of your patients, EVERY time you use a vascular access device.
  • The majority of blood stream infections related to central lines are caused by improper care and accessing, and are intraluminal (from inside the line). You are the gatekeeper between bacteria and a potentially life-threatening infection for each of your patients, every time you use a vascular access device.
  • Principles of asepsis are the foundation for providing safe care during patient interventions, particularly if they are invasive. Medical asepsis is used during non-sterile interventions. Surgical aseptic technique is used for procedures that significantly interrupt the patient’s integumentary defense. The placement, and subsequent management of, central vascular access devices is one of those interruptions. Maximum barrier precautions must be used for placement of all central lines, for example. Question: after you disinfect a needleless connector – how sure are you that you haven’t recontaminated it with your non-sterile gloved finger, or by brushing it or the male luer end of the administration set against a contaminated object like the bed linen? This is probably the single most common manner that catheters become contaminated, other than insufficient disinfection of needleless connectors.
  • Biofilm – it’s in rivers and streams, known there as “Didymo - didymosphenia geminata”, or “rock snot”, AND - it’s all over any medical device that is inside a patient’s body. Nearly 100% of bacteria form communities that attach to surfaces like catheters as opposed to being free flowing in the bloodstream. While the study of it is relatively new, it clearly has major significance in relation to it’s impact upon patient safety.
  • Here are a few examples of where biofilm will reside. Biofilm is pernicious, and largely resistant to all known forms of antimicrobials.
  • Almost all micro-organisms are embedded in matrices of these complex biofilm communities, or colonies. The biofilm allows the micro-organisms to adhere to any surface, living or nonliving. The adaptive and genetic changes of the micro-organisms within the biofilm make them resistant to all known antimicrobial agents. Biofilm begins forming on vascular access devices almost immediately upon contact with the patient’s bloodstream. Microbial biofilms are responsible for 65% of infections treated in the developed world. Vascular catheter-related bloodstream infections are the most serious and costly healthcare-associated infections – and the most life threatening. 87% of bloodstream infections are associated with an intravascular device. 1 1 Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med. 1999;27:887-892 .
  • Read bullets
  • Zero infection rates for central line associated blood stream infections are attainable. Keeping patient vascular access functional and safe is attainable. It’s a team approach, and the bedside clinician is the captain.
  • Vascular Access Matters

    1. 1. Clinical strategies to improve patient outcomes Vascular Access Matters ...because one small act can save - or cost - a life.
    2. 2. Introduction <ul><li>Proper care: saves lines, saves lives . </li></ul><ul><li>Standardization of Care: </li></ul><ul><li>new technology, new challenges: how to stay current? </li></ul>
    3. 3. FMEA: Failure Mode Effects Analysis Leaders FMEA #1:2007 Central Lines <ul><li>Project Leader </li></ul><ul><ul><li>Joan Blondin, Institute for Quality </li></ul></ul><ul><li>Inpatient Leaders: </li></ul><ul><ul><li>Mari Cordes, RN, Nurse Educator, IV Team </li></ul></ul><ul><li>Outpatient Leaders: </li></ul><ul><ul><li>Karen McBride, RPh, Director of Pharmacy </li></ul></ul><ul><ul><li>Debra Gibbs RPh, Outpatient Infusion Coordinator Health Center Pharmacy </li></ul></ul><ul><li>Physician Leaders: </li></ul><ul><ul><li>Kemper Alston, MD, Infectious Disease </li></ul></ul><ul><ul><li>William Raszka. MD, Pediatric Infectious Disease </li></ul></ul>
    4. 4. TEAM MEMBERS Kathy Castello RN, Outpatient Infusion Nurse, HCP Debra Wildermuth, Outpatient Infusion Nurse, HCP John Ahern RPh, Inpatient Pharmacy Heidi Pentkowski, Clinical Case Manager Heidi Moore, RN, Children's Specialty Center Sally Hess, Infection Control Practitioner Joanne Barton, RN, Baird 5 Keven Eriksen, RN VNA Nicole Courtois, RN, Nurse Educator Outpatient Cindy Gebo, RN, PICU Educator Deb Kutzko, NP, Infectious Disease Donna Benway, RN, Value Analysis Coordinator, Purchasing Sue Goetschius, RN, Nursing Education Director Ellen Crook, RN, Hematology/Oncology ACC
    5. 5. Process Review <ul><li>Central Line Care </li></ul><ul><li>Process review for central line care revealed significant variation in: </li></ul><ul><ul><li>medication administration </li></ul></ul><ul><ul><li>dressing changes </li></ul></ul><ul><ul><li>flushing process </li></ul></ul><ul><ul><li>blood draw technique </li></ul></ul><ul><ul><li>The variation occurred from unit to unit and clinic to clinic. </li></ul></ul><ul><li>Education Material </li></ul><ul><li>Review of the education material at FAHC revealed process techniques that do not meet nationally acceptable best practice standards for central line care. </li></ul><ul><li>Supplies </li></ul><ul><li>Review of supplies used at FAHC revealed 7 types of needleless connectors that included positive, negative, and neutral displacement caps, all requiring different flushing techniques. </li></ul>
    6. 6. Statistics <ul><li>Catheter related bloodstream infections (CRBSI) are the most costly & life threatening of all healthcare infections. </li></ul><ul><li>Between 500-4000 US patients die annually due to blood stream infections. </li></ul><ul><li>25% of all CVC usage ends in occlusion. </li></ul><ul><li>~ $100,000 of TPA used for PICC catheter clearance @ FAHC 10/07-03/08. </li></ul><ul><li>(Does not include expenses of nursing time, supplies, delay of treatment, catheter replacement.) </li></ul>1 References: Hadaway L. Flushing vascular access catheters: risks for infection transmission. Infection Control Resource. 2 Deitcher S, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplace for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. 2003;20(1):317-324.
    7. 7. Statistics (cont’d) <ul><li>271 people die from HAI every 24 hours 2 </li></ul><ul><li>40,000/day ibid </li></ul><ul><li>271 people die from HAI every 24 hours 2 </li></ul><ul><li>Case fatality rate for CR-BSI approaches 20% 1 </li></ul><ul><li>1 accessed 4/29/2008 </li></ul><ul><li>2, accessed 4/29/2008 </li></ul>
    8. 8. Problem Solving Central Lines <ul><li>Occlusion </li></ul><ul><li>Emboli </li></ul><ul><li>Extravasation/Infiltration </li></ul><ul><li>Infection </li></ul>
    9. 9. Problem: Emboli <ul><li>Different types of emboli </li></ul><ul><ul><li>Air </li></ul></ul><ul><ul><li>Catheter </li></ul></ul><ul><ul><li>Wire </li></ul></ul><ul><ul><li>Thromboembolus </li></ul></ul>
    10. 10. Occlusion <ul><li>Infection risk </li></ul><ul><li>Appropriate line flushing – do not force </li></ul><ul><li>Know your VAD – heparin, or saline flush? </li></ul><ul><li>Avoid plunging syringe to bottom </li></ul><ul><li>Is line positional? </li></ul><ul><li>Should have blood return each time catheter is used. Nurse is liable for use of malfunctioning catheter. </li></ul><ul><li>tPA for catheter clearance </li></ul>
    11. 11. Problem: Emboli – Identification <ul><li>Medical Emergency </li></ul><ul><ul><li>Deep respirations </li></ul></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Gasping </li></ul></ul><ul><ul><li>Weak pulse </li></ul></ul><ul><ul><li>Low or absent BP </li></ul></ul>
    12. 12. Problem: Embolus -Treatment <ul><li>CATHETER embolus (catheter fragment in bloodstream): THIS IS CONSIDERED A MEDICAL EMERGENCY: </li></ul><ul><li>Immediate medical intervention is warranted. </li></ul><ul><li>Implement strict bed rest. </li></ul><ul><li>Immediately apply tourniquet PROXIMAL to the site to retain the fragment in the arm. Obstruct venous, not arterial flow. </li></ul><ul><li>Assess pulses distal to tourniquet every 15 minutes. </li></ul><ul><li>Initiate oxygen therapy. </li></ul><ul><li>Notify physician, contact Interventional Radiology to prepare for emergent procedure. </li></ul><ul><li>Monitor vital signs. </li></ul><ul><li>Ensure patient has adequate peripheral IV access. </li></ul><ul><li>Only MD should remove tourniquet. </li></ul><ul><li>AIR embolus </li></ul><ul><ul><li>Clamp or kink catheter. </li></ul></ul><ul><ul><li>Position patient on LEFT side in Trendelenburg. </li></ul></ul><ul><ul><li>Call MD immediately. </li></ul></ul><ul><ul><li>Administer oxygen, monitor vital signs, and setup for code 99. </li></ul></ul>
    13. 13. Care Giver Audit <ul><li>Is needleless connector disinfected for 15 sec. prior to flushing and prior to connecting infusions? </li></ul><ul><li>Are needleless connectors changed every 72 hours (central lines) and after blood draws? </li></ul><ul><li>Are needleless connector changes documented anywhere? </li></ul><ul><li>Are peripheral and central line dressings dated? </li></ul><ul><li>Is dressing change documented in HISS caredex? </li></ul><ul><li>Is dressing dated? </li></ul><ul><li>If dressing dated, is it current? </li></ul><ul><li>Is administration set labeled with date? </li></ul><ul><li>If administration set labeled with date, is it current? </li></ul><ul><li>Is flushing appropriate for line type? </li></ul><ul><li>Is flushing appropriate after blood draw? </li></ul>
    14. 14. Infection Control
    15. 15. Central Line Knowledge
    16. 16. <ul><li>Principles </li></ul><ul><li>Of </li></ul><ul><li>Asepsis </li></ul>
    17. 17. Problem: Infection pretest <ul><li>If the nurse touches any pt. object after she performed hand hygiene, she must repeat hand hygiene immediately prior to handling vascular access devices. </li></ul><ul><li>T F </li></ul>
    18. 18. Problem: Infection pretest <ul><li>Evidence based : A ____ second scrub of hub will provide adequate disinfection. </li></ul><ul><li>Catheter related infections related to inadequate disinfection can most likely be classified as </li></ul><ul><li>a. intraluminal b. extraluminal </li></ul>“ All models of needleless access ports were successfully disinfected..” with 15 second scrub with isopropyl alcohol (IPA). Wendy, MT, MPH, CIC and Chinn, Raymond, MD, FACP “Successful Disinfection of Needleless Access Ports: A Matter of Time and Friction”, JAVA (12; 3) 2006 pps 140-142
    19. 19. Principals of Asepsis <ul><li>Medical Asepsis </li></ul><ul><ul><li>clean: reduce and prevent spread of microorganisms </li></ul></ul><ul><li>Surgical Asepsis </li></ul><ul><ul><li>sterile: aim to eliminate microorganisms </li></ul></ul><ul><li>Contamination – caused by: </li></ul><ul><ul><li>prolonged exposure to air </li></ul></ul><ul><ul><li>wicking (capillary action) from wet areas </li></ul></ul><ul><ul><li>out of field of vision </li></ul></ul><ul><ul><li>objects below waist </li></ul></ul><ul><ul><li>touched by non-sterile objects </li></ul></ul><ul><ul><ul><li>bedsheets, skin, contaminated syringes/tubing </li></ul></ul></ul>
    20. 20. Biofilm <ul><li>Fibrin is not necessary to make biofilm </li></ul><ul><li>All indwelling devices have biofilm </li></ul><ul><li>Biofilm formation begins immediately </li></ul>“… Biofilm forms when bacteria adhere to surfaces in aqueous environments and begin to excrete a slimy,glue-like substance that can anchor them to all kinds of material…” Center for Biofilm Engineering, Montana State University permission P. Stoodly
    21. 22. Biofilm and Infection Biofilm clusters with streamers Showing flow in channel (e.g. blood vessel) Biofilm: slimy glue like matrix created by bacteria that cannot be eliminated and is resistant to antibiotics. 1 Planktonic intra or extraluminal ‘clumps’ can be released into the bloodstream. 1 Catheter-Related Infections: It's All About Biofilm, Marcia A. Ryder, PhD, MS, RN Topics in Advanced Practice Nursing eJournal.  2005;5(3) ©2005 Medscape, Posted 08/18/2005
    22. 23. Integration how you practice. Transform into what you know
    23. 24. Catheter Site Assessment <ul><li>Assess all VAD sites for: </li></ul><ul><ul><li>erythema, induration </li></ul></ul><ul><ul><li>edema (swelling) </li></ul></ul><ul><ul><li>pain </li></ul></ul><ul><ul><li>discharge </li></ul></ul><ul><ul><li>catheter migration (measure external length of central lines) </li></ul></ul>With permission J. Bowen-Santolucito
    24. 25. <ul><li>Perform hand hygiene EVERY time immediately prior to handling vascular access devices. </li></ul><ul><li>Chlorhexidine and isopropyl alcohol (e.g. Chloraprep) is FAHC preferred antiseptic for central line insertion and maintenance </li></ul><ul><li>MUST use sterile procedure and wear mask (for IVAD accessing as well). </li></ul><ul><li>Home patients must wear mask; highly recommended for inpatients as well. </li></ul>Infection: Managing catheters
    25. 26. <ul><li>FAHC IV Therapy 847-3647 </li></ul><ul><li>Intradoc </li></ul><ul><ul><ul><ul><ul><li>NGP0009 Central Venous Access Devices </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>INFC00003 Prevention of IV Device Related Infections </li></ul></ul></ul></ul></ul><ul><ul><li>NGP 119 De-Clotting Central Venous Catheters Using Thrombolytic Agent tPA </li></ul></ul><ul><ul><li>Renal policies </li></ul></ul><ul><ul><li>NKF, Safe Care Campaign, and IHI websites </li></ul></ul><ul><ul><li>Professional forums </li></ul></ul>Resources
    26. 27. Infection: The Impact <ul><li>A Mother’s Letter to a Hospital CEO </li></ul><ul><li>Our son died in your hospital 7 days ago. He died from a bacterial infection he caught there as a result of his medical care while being treated for something else. It created so much pressure around his brain that it caused part of it to be pushed into his spinal column, leaving him a helpless ventilator-dependent quadriplegic and ending his short but unforgettable life among us all……. </li></ul>
    27. 28. <ul><li>……… ..Dear CEO, I hope you read this letter to your team aloud. Tell your board that we do not want anything for the loss of our dear son but a dramatic and effective plan for change that will make a difference for others who trust healthcare in general and your hospital specifically. We look to you to partner with us as patients and caregivers so that we may all be safe and well, both now, and in the future. Sincerely, Victoria Nahum </li></ul>
    28. 29. Questions?