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

MAGIC paper, Chopra et al, 2015

Algorithm Intravenous Access for Non Acute Treatment in Adults UMC Utrecht, 2009

Riskfactors

environment

hands touch contamination

access sites

Catheterhubs

stopcockhubs

Injectionports

Needlelessconnectors

Marcia Ryder, WoCoVA 2016

connector hub cath segment flush

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ush)

3.6

2.2

3.1

5.4

1.5

4.6

1.9

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…..which component is the predictor of bacterial transfer ?

Marcia Ryder, WoCoVA 2016

Bundles

•  InsertionbundleCVC•  InsertionbundlePIVC•  CareandMaintenance‘bundle’

CentrallineAssociatedBloodStreamInfections(CLABSI)

© The Joint Commission Preventing Central Line–Associated Bloodstream Infections: Useful Tools, An International Perspective, 2013

WheredoesanIVcatheterend?

•  Withtheendcap?

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

CVCC&Mbundle

•  ACVCdailymaintenancecarebundleincludesproceduralguidelinesforhygiene,dressingchanges,andaccessaswellasspecifictimeframes.Failuretocompleteoneofthecomponentsofthecarebundlepredisposesthepatienttoabloodstreaminfection.

Duffy et all, 2015, JPON

Problem:Confusionandlackofeducation•  Survey554Healtcareworkers•  AssessedtheknowledgegapinpracticewithNFC•  25%didnotspecifictypeofNFCused•  47%didnotusecorrecttechnique

Haddaway, JAVA 2011

RESULTS flushes: bacterial transfer

Marcia Ryder, WoCoVA 2016

Whatcomesnext?

BBraun, Melsungen

Multiple Infusion Systems

healthcare workers hands

Marcia Ryder, WoCoVA 2016

Purposeoftheinfusionline

•  Safeadministrationofdrugsandfluids•  Preventcomplicationsandsideeffects

–  Infections– Occlusion–  Interaction– Exposuretounwantedchemicals

Whatcomesnext?

•  Antisyphonvalve•  Connections•  Accesspoints•  Tubingmaterials

– PVC– PEE– Largebore– Smalbore

Whatcomesnext?

•  Howispreparationofdrugsperformed?

Drugmanufacturers

•  Followstrictrulesinproduction•  Lastcheckisavisualinspection•  Arenotawareoftherisksafterdeliverytothepharmacy

•  Onlydoa(thorough)visualinspection

Costofdrugincompatilities

Whatcomesnext?

•  Howispreparationofdrugsperformed?•  Whathappenswiththeadministrationset?

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/

PVCandDEHPinmedicalproducts

•  Flexibilityinavarietyofphysicalformsfromtubestomembranes

•  Chemicalstabilityandpossibilitytosterilize•  Lowcostandwideavailability•  Lackofevidenceofsignificantadverseconsequencesinpatients

Source: BBraun http://www.safeinfusiontherapy.com/

Guidelines / Protocols

•  EPIC3 guideline (NHS, 2014) •  Guidelines for the prevention of intravascular

Catheter Related Infections, (CDC, 2011) •  Infusion Nursing Standards of Practice,(INS, 2016)

Guidelines

•  Minimizetheuseofadd-ondevicesforadministrationsetsaseachdeviceisapotentialsourceofcontamination,misuse,anddisconnection;whenfeasibleuseanadministrationsetwithdevicesasanintegralpartoftheset

•  Avoiddisconnectingprimarycontinuousadminis-trationsetsfromtheVADhuboraccesssite.(V,CommitteeConsensus)

INS Standards of Practice, 2016

Guidelines

•  Whenanintermittentinfusionisrepeatedlydisconnectedandreconnectedfortheinfusion,thereisincreasedriskofcontaminationatthespikeend,catheterhub,needlelessconnector,andthemaleluerendoftheadministrationset,potentiallyincreasingriskforcatheter-relatedbloodstreaminfection(CR-BSI).Thereisanabsenceofstudiesaddressingadministrationsetchangesforintermittentinfusions(CommitteeConsensus)

INS Standards of Practice, 2016

Guidelines•  IVAD37Administrationsetsincontinuoususedonotneedto

bereplacedmorefrequentlythanevery96h,unlessdevice-specificrecommendationsfromthemanufacturerindicateotherwise,theybecomedisconnectedortheintravascularaccessdeviceisreplaced(ClassA)

•  IVAD38Administrationsetsforbloodandbloodcomponentsshouldbechangedwhenthetransfusionepisodeiscompleteorevery12h(whicheverissooner)(ClassD)

•  IVAD39Administrationsetsusedforlipid-containingparenteralnutritionshouldbechangedevery24h(ClassD)

EPIC 3, 2014

Evidence

•  13RCTswith4783patientsconcludedthatthereisnoevidencethatchangingintravenousadministrationsetsmoreoftenthanevery96hreducestheincidenceofbloodstreaminfection.

•  Therewerenodifferencesbetweenparticipantswithcentralvsperipheralcatheters,norbetweenparticipantswhodidanddidnotreceiveparenteralnutrition,orbetweenchildrenandadults.

Gillies et al. Cochrane Database, 2005

Whatcomesnext?

•  Howispreparationofdrugsperformed?•  Whathappenswiththeadministrationset?•  Howtocheckpatencywithanantisyphonvalve?

Checkpatency

•  Notneededeverytime•  Clinicianneedstobesureandtakeresponsibilityforadministration

•  Atleastcheckwithsetexchange

strategiesforpreventionofbacterialtransfer

ELD 96 hr (0.22 micron)

lowbacterialtransferneedlelessconnector

bacteriaretentiveendotoxinretentiveaireliminatingparticilateretentive

accesssitedisinfection

catheterhubdisinfection

antimicrobialanticoagulantlockflush

Marcia Ryder, WoCoVA 2016

Conclusion

•  Furtherreductionofcomplicationsbyusingprotectivetechniquesbasedonacceptedguidelines

•  Implementationofanexpertinfusionteam– Responsibleforvascularaccess,care&maintenanceincludingthewholerouteofadministration

Infusion team

•  Teamgoals:accuracy,efficiency,andconsistencyand/oreliminationofcomplications•  Meetingthesegoalswill:reduceliability,lowercosts,anddecreaselengthofstay,whilepromotingvascularpreservation,greaterpatientsatisfaction,andbetteroutcomes

Infusion Therapy Standards of Practice, 2016