van boxtel - management of the infusion line boxtel - management of...the management of the infusion...
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Themanagementoftheinfusionline:amissingissueinmany‘bundles’
Ton van Boxtel, RN, MSc, Trainer & consultant for Infusion Innovations President of the Dutch Society of Infusion Technology President of World Congress on Vascular Access (WoCoVA) Home Infusion Specialist
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MAGIC paper, Chopra et al, 2015
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Algorithm Intravenous Access for Non Acute Treatment in Adults UMC Utrecht, 2009
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Riskfactors
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environment
hands touch contamination
access sites
Catheterhubs
stopcockhubs
Injectionports
Needlelessconnectors
Marcia Ryder, WoCoVA 2016
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connector hub cath segment flush
6 5 4 3 2 1 0
leas
t squ
are
mea
n (lo
g(C
FU/fl
ush)
3.6
2.2
3.1
5.4
1.5
4.6
1.9
0.7
…..which component is the predictor of bacterial transfer ?
Marcia Ryder, WoCoVA 2016
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Bundles
• InsertionbundleCVC• InsertionbundlePIVC• CareandMaintenance‘bundle’
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CentrallineAssociatedBloodStreamInfections(CLABSI)
© The Joint Commission Preventing Central Line–Associated Bloodstream Infections: Useful Tools, An International Perspective, 2013
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WheredoesanIVcatheterend?
• Withtheendcap?
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End Cap • Use of passive disinfection caps containing
disinfecting agents (eg, isopropyl alcohol) has been shown to reduce intraluminal microbial contamination and reduce the rates of central line-associated blood- stream infection (CLABSI)
Infusion Therapy Standards of Practice, 2016, P.69
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CVCC&Mbundle
• ACVCdailymaintenancecarebundleincludesproceduralguidelinesforhygiene,dressingchanges,andaccessaswellasspecifictimeframes.Failuretocompleteoneofthecomponentsofthecarebundlepredisposesthepatienttoabloodstreaminfection.
Duffy et all, 2015, JPON
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Problem:Confusionandlackofeducation• Survey554Healtcareworkers• AssessedtheknowledgegapinpracticewithNFC• 25%didnotspecifictypeofNFCused• 47%didnotusecorrecttechnique
Haddaway, JAVA 2011
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RESULTS flushes: bacterial transfer
Marcia Ryder, WoCoVA 2016
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Whatcomesnext?
BBraun, Melsungen
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Multiple Infusion Systems
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healthcare workers hands
Marcia Ryder, WoCoVA 2016
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Purposeoftheinfusionline
• Safeadministrationofdrugsandfluids• Preventcomplicationsandsideeffects
– Infections– Occlusion– Interaction– Exposuretounwantedchemicals
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Whatcomesnext?
• Antisyphonvalve• Connections• Accesspoints• Tubingmaterials
– PVC– PEE– Largebore– Smalbore
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Whatcomesnext?
• Howispreparationofdrugsperformed?
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Drugmanufacturers
• Followstrictrulesinproduction• Lastcheckisavisualinspection• Arenotawareoftherisksafterdeliverytothepharmacy
• Onlydoa(thorough)visualinspection
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Costofdrugincompatilities
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Whatcomesnext?
• Howispreparationofdrugsperformed?• Whathappenswiththeadministrationset?
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Tubing
• DEHP(diethylhexylphthalate,plasticizer)exposure?• Until2010,(DEHP)wasthemostfrequentlyusedplasticizertosoftPVCmedicaldevices
• Theincreasingknowledgeoftheeffectsofphthalateexposure,whichcanbeteratogenic,carcinogenicorinducereproductivetoxicity,hasledtothedevelopmentofalternativeplasticizers.
• Phthalates– DIDP(di-isodecyl-phthalate)– DINP(di-isononyl-phthalate)– DBP(dibutylphthalate)– BBP(butylbenzylphthalate)
Source: BBraun http://www.safeinfusiontherapy.com/
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PVCandDEHPinmedicalproducts
• Flexibilityinavarietyofphysicalformsfromtubestomembranes
• Chemicalstabilityandpossibilitytosterilize• Lowcostandwideavailability• Lackofevidenceofsignificantadverseconsequencesinpatients
Source: BBraun http://www.safeinfusiontherapy.com/
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Guidelines / Protocols
• EPIC3 guideline (NHS, 2014) • Guidelines for the prevention of intravascular
Catheter Related Infections, (CDC, 2011) • Infusion Nursing Standards of Practice,(INS, 2016)
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Guidelines
• Minimizetheuseofadd-ondevicesforadministrationsetsaseachdeviceisapotentialsourceofcontamination,misuse,anddisconnection;whenfeasibleuseanadministrationsetwithdevicesasanintegralpartoftheset
• Avoiddisconnectingprimarycontinuousadminis-trationsetsfromtheVADhuboraccesssite.(V,CommitteeConsensus)
INS Standards of Practice, 2016
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Guidelines
• Whenanintermittentinfusionisrepeatedlydisconnectedandreconnectedfortheinfusion,thereisincreasedriskofcontaminationatthespikeend,catheterhub,needlelessconnector,andthemaleluerendoftheadministrationset,potentiallyincreasingriskforcatheter-relatedbloodstreaminfection(CR-BSI).Thereisanabsenceofstudiesaddressingadministrationsetchangesforintermittentinfusions(CommitteeConsensus)
INS Standards of Practice, 2016
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Guidelines• IVAD37Administrationsetsincontinuoususedonotneedto
bereplacedmorefrequentlythanevery96h,unlessdevice-specificrecommendationsfromthemanufacturerindicateotherwise,theybecomedisconnectedortheintravascularaccessdeviceisreplaced(ClassA)
• IVAD38Administrationsetsforbloodandbloodcomponentsshouldbechangedwhenthetransfusionepisodeiscompleteorevery12h(whicheverissooner)(ClassD)
• IVAD39Administrationsetsusedforlipid-containingparenteralnutritionshouldbechangedevery24h(ClassD)
EPIC 3, 2014
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Evidence
• 13RCTswith4783patientsconcludedthatthereisnoevidencethatchangingintravenousadministrationsetsmoreoftenthanevery96hreducestheincidenceofbloodstreaminfection.
• Therewerenodifferencesbetweenparticipantswithcentralvsperipheralcatheters,norbetweenparticipantswhodidanddidnotreceiveparenteralnutrition,orbetweenchildrenandadults.
Gillies et al. Cochrane Database, 2005
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Whatcomesnext?
• Howispreparationofdrugsperformed?• Whathappenswiththeadministrationset?• Howtocheckpatencywithanantisyphonvalve?
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Checkpatency
• Notneededeverytime• Clinicianneedstobesureandtakeresponsibilityforadministration
• Atleastcheckwithsetexchange
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strategiesforpreventionofbacterialtransfer
ELD 96 hr (0.22 micron)
lowbacterialtransferneedlelessconnector
bacteriaretentiveendotoxinretentiveaireliminatingparticilateretentive
accesssitedisinfection
catheterhubdisinfection
antimicrobialanticoagulantlockflush
Marcia Ryder, WoCoVA 2016
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Conclusion
• Furtherreductionofcomplicationsbyusingprotectivetechniquesbasedonacceptedguidelines
• Implementationofanexpertinfusionteam– Responsibleforvascularaccess,care&maintenanceincludingthewholerouteofadministration
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Infusion team
• Teamgoals:accuracy,efficiency,andconsistencyand/oreliminationofcomplications• Meetingthesegoalswill:reduceliability,lowercosts,anddecreaselengthofstay,whilepromotingvascularpreservation,greaterpatientsatisfaction,andbetteroutcomes
Infusion Therapy Standards of Practice, 2016
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