2016INS指南英文版解读
圣诞快乐的英语-圣诞节快乐英文怎么写
Lynn Hadaway,
., RN-BC,
CRNI
Lynn Hadaway
Associates, Inc.
Infusion Therapy Standards 2016 -
Focusing
on Vascular Access Devices
Disclosures
•Speaker andor consultant
for:
–
–<
br>–
–
–
–
–
–
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3M
Atrion Corporation
B Braun
Bard Access
Systems
Baxter
BD Medical
CovidienMedtronic
Fresinius Kabi
Gayco
Healthcare
–
–
–
–
–
LineGard Medical
Lippincott Williams
Wilkins
Terumo
VATA
Velano Vascular
Foreword
•“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.”
•Vineet Chopra, MD, MSC
Ann Arbor VA
Medical Center and
the University of Michigan
Health System
Learning Objectives
•Describe the methods for
revising the
2016 Infusion
Therapy Standards of Practice.
•Discuss the ranking of levels of
evidence.
•Identify new standards and
major changes applicable to
vascular
access devices.
Committee Members
•Chair - Lisa Gorski, MS, RN, HHCNS-BC, CRNI,
FAAN
–Home care, 3
rd
edition of the
standards
•Lynn Hadaway, Med, RN-BC, CRNI
–Acute care IV Teams, educator, consultant,
3
rd
edition of the standards
•Mary E.
Hagle, PhD, RN-BC, FAAN
–Nurse scientist,
2
nd
edition of the standards
•Mary
McGoldrick, MS, RN, CRNI
–Home care, hospice,
infection control & prevention
•Marsha Orr,
MS, RN
–Parenteral nutrition, educator,
2
nd
edition of the standards
•Darcy
Doellman, MSN, RN, CRNI, VA-BC
–Pediatrics
Revision Process
•Literature
searches
–Identified keywords, phrases
for
each standard
–
Search English language
publications, 2009 through July
2015
•Classic publications also used
–Other
resources
•United States Pharmacopeia
(USP)
•US Department of Health and
Human Services
–Agency for Healthcare
Research and Quality
–Centers for Disease
Control
and Prevention
–Databases used:
•
•
•
•
Cochrane Library
CINAHL
MEDLINE, PubMed
Web of Science
•US Food and Drug
Administration
•US
Department of Labor -
OSHA
Revision Process
•Interprofessional
External Review
–Draft sent to INS members,
nurses in other specialties, physicians,
pharmacists, lawyers, other types of
clinicians, industry partners
–~800 comments
received from 60 reviewers
–Committee read and
evaluated each comment
–Revised the applicable
standard, additional literature searches if
required
–Finalized content for internal
editors review
–Review by editors from
publisher, Wolters Kluwer
Review
Process
•Revised the Policies and
Procedures for Infusion Therapy
•Two
separate resources
–Policies and procedures
are NOT the
same as Standards
Strength of the Body of
Evidence
•I = Meta-analysis, systematic literature
review, guideline based on
randomized
controlled trials (RCTs), or at least 3 well-
designed
RCTs.
•I AP = Evidence from
anatomy, physiology, and pathophysiology
references as understood at the time of
writing.
•II = Two well-designed RCTs, 2
or more multicenter, well-designed
clinical
trials without randomization, or systematic
literature review
of varied prospective study
designs.
•III = One well-designed RCT,
several well-designed clinical trials
without
randomization, or several studies with quasi-
experimental
designs focused on the same
question. Includes 2 or more well-
designed
laboratory studies.
Strength of the
Body of
Evidence
•IV = well-designed
quasi-experimental study, case control study,
cohort study,
correlational study, time series
study, systematic literature review of descriptive
and qualitative studies, or narrative
literature review, psychometric study. Includes
1 well-designed laboratory study.
•V
= Clinical article, clinicalprofessional book,
consensus report, case report,
guideline based
on consensus, descriptive study, well-designed
quality
improvement project, theoretical
basis, recommendations by accrediting bodies
and professional organizations, or
manufacturer directions for use for products or
services. Includes standard of practice that
is generally accepted but does not
have a
research basis (for example, patient
identification). May also be noted as
Committee Consensus, although rarely used.
•Regulatory = Regulations and other
criteria set by agencies with the ability to
impose consequences, such as the AABB, Centers
for Medicare & Medicaid
Services (CMS),
Occupational Safety and Health Administration
(OSHA), and
state Boards of Nursing.
Strength of the Body of
Evidence
•Practice Criteria Language
–Large body of
robust evidence = higher ranking of I or II
•Begins with action verb, use, perform,
–Robust design, but inconclusive or
undetermined findings
•“Consider use of---”
•Use identified evidence plus experience and
clinical judgment
Level I evidence
Level V
evidence
2011
3.8%
67%
2016
5.8%
46%
Major Changes
•What are the 2 most prominent changes in the
2016
standards document?
•Title change
–2011 Infusion Nursing Standards of Practice
–2016 Infusion Therapy
Standards of
Practice
•Professional designation broadened
–2011 – “nurse”
–2016 – “clinician”
Table of Contents
64 Standards –
divided into 9 sections
1: Infusion Therapy
Practice
2: Patient & Clinician Safety
3:
Infection Prevention & Control
4: Infusion
Equipment
5: Vascular Access Device (VAD)
Selection & Placement
6: VAD Management
7:
VAD-Related Complications
8: Other Infusion
Devices
9: Infusion Therapies
Section Changes
•New Section
Standards for Section 4-9
–Standard
statements that apply to all standards in that
section
–Reduces redundancy of statements
•“The clinician is competent to ---”
•“established in organizational policies,
procedures, andor
practice guidelines”
–Don’t overlook this important section!
Standard 1 Patient Care
•Applies to
all settings where vascular access are placed,
managed, or infusion therapies are
administered
•Practices established in
organizational policies, procedures,
practice
guidelines, andor standardized written
protocolsorders
•Attention to patient
safety and quality
–Individualized,
collaborative, culturally sensitive, age
appropriate
•Ethical principles as foundation
for decision-making
•Decisions including
deviceproduct selection, are not
subject to
commercial or other conflicts of interest.
Standard 2 - Special Patient
Populations
•Includes
–Neonates
–Pediatrics
–Pregnant patients
–Older
adults
Standard 3 Scope of Practice
•Clinicians practice according to applicable
regulatory board,
clearly defined in
organizational policy
•Within boundaries of
their legal scope of practice
•Collaboration
of the healthcare team members
•Delegation by
RNs to unlicensed personnel
–RN and
organization are responsible and accountable for
all
delegated tasks
•“Recognize the
overlap between professional groups and
that
no single professional can claim exclusive
ownership of
any skill, activity, or task.”
Standard 3 Scope of Practice
•Nursing personnel
–
–
–
–
RN
LPNLVN
Infusion Nurse Specialist, CRNI®
Advanced Practice RN
•Unlicensed assistive
personnel (UAP)
–Nursing assistants
–Medical assistants
•TherapistsTechnologistsTechnicians
–Radiologic technologists
–Respiratory
care practitioner
–
Paramedic
Standard 4 Infusion Team
•Scope of
service to meet patient and organization needs
•VAD insertion and management assigned to
individualsteams with infusion therapy
education, training,
and validated competency
•Peripheral catheter insertion by team =
increased insertion
success, decreased
hospital acquired BSI, local infection,
occlusions, and accidental removals
•Team
managing VADs decrease BSI and related costs,
phlebitis and infiltration, and increase
patient satisfaction
Standard 5
Competency
Assessment and Validation
•Individual clinician responsible and
accountable for
attaining and maintaining
competence within legal scope of
practice
•Beyond psychomotor skills, includes
knowledge, critical
thinking, and decision-
making ability
•Competency assessment and
validation initially and on an
ongoing basis
–Initially
–Continuing competency
•Frequency determined by each organization;
known problems,
concerns and outcomes
•Standardized, transparent process for
assessing and
judging competency
–Imbalance of power when manager is the
validator
Standard 5 Competency
Assessment and Validation
•Use a variety
of evaluation methods to increase outcome
reliability
•Clear performance
expectations for contracted clinician
competencies
–Documentation, supervision
of contractors learning procedures,
monitoring
outcomes
•“Do NOT perform invasive procedures
(eg, venipuncture) on
peers due to health risk
and the physical and emotional
stress created
for the volunteer.”
•Qualifications for the
competency assessor
•Well-designed forms
–Objective, measureable assessment of actual
performance
Standard 9 Informed
Consent
•An educational process involving
patient in shared decision
making
•Process is voluntary without coercion or
persuasion
•Includes clinical procedures and
research
•Addresses photographs
–Ability
to identify patient falls under HIPAA rules
–Not able to identify patient may not require
informed consent under
HIPAA but organization
policies should address this issue
Standard 22 Vascular
Visualization
•Includes use of
–Visible light devices
for transillumination
•Cold light source
needed
–Near-infrared light devices
•More
informed decisions about peripheral veins,
bifurcation, tortuosity
–Ultrasound
•
•
•
•
Peripheral sites –
requires longer catheters
Addresses CVADs
Dynamic or “real-time” use is recommended
Sterile TSM dressing (peripheral sites),
sheath cover and gel
Standard 23
Central Vascular
Access Device Tip Location
•Determined prior to initiation of infusion
therapy and when clinical signs
and symptoms
suggest tip malposition
•Documented and made
available to all organizations involved in
patient’s care
•Location with the greatest
safety profile in adults and children is the
cavoatrial junction
•Anthropometric
measurements to determine desired catheter length
•Avoid suboptimal tip locations
–Many
venous tip location identified for CLABSI data
collection and reporting,
but these should be
used when anatomical or pathophysiological changes
prohibit CAJ location
•Post-procedure
chest xray or ECG
–Documented competency for
assessment of tip location on both
Standard 26 Vascular Access
Device
Planning
•Change of focus from selection to
planning
–Collaborative process among
interprofessional team,
patient and
caregiver(s)
–Smallest outer diameter, fewest
number of lumens, least
invasive device needed
for prescribed therapy
–Peripheral vein
preservation!
•Goal - choose least invasive
VAD that has the greatest
likelihood of
reaching end of planned infusion therapy with
fewest number of replacements and lowest rate
of
complications
Standard 26
Vascular Access
Device Planning
•Consider
infusate characteristics and duration of therapy
–Osmolarity, vesicant nature, pH, stability,
compatibility, etc
–Comprehensive literature
review found no evidence to support
limiting
infusate pH range to <5 to >9 for short peripheral
and midline
catheters
•Peripheral and
midline catheters NOT for continuous
vesicant
therapy, parenteral nutrition, or infusates with
osmolarity greater than 900 mOsmL
•Midlines – use caution with intermittent
vesicant
administration due to risk of
undetected extravasation
Standard
33 Vascular Access Site
Preparation and Device
Placement
•Short peripheral catheters
–Committee Consensus: Consider increased
attention to aseptic
technique, including
strict attention to skin antisepsis and use of
sterile gloves….lack of evidence comparing BSI
rates with or without
use of sterile gloves,
longer dwell times have raised concerns
regarding risk for BSI ..furthermore
contamination of nonsterile
gloves is
documented”
•Midline catheters
–Consider
use of maximal sterile barrier precautions with
midline
catheter insertion
•Short
peripheral and midline catheters
–Skin
antiseptic - > 0.5% CHG in alcohol preferred
Standard 33 Vascular Access Site
Preparation and Device Placement
•Central
line bundle for insertion
•Completion of
standardized checklist by someone other
than
inserter; empowered to stop procedure for
identified
breach
•Standardized supply
cart or kit with all needed supplies
•CVAD
insertion on opposite side if pacemaker present,
assess pacemaker function before and after
CVAD
insertion; no practice guidelines
available
Standard 34 Needleless
Connectors (NC)
•NC between the VAD hub
and administration set used for
continuous
infusions is unknown
•Avoid use of NCs with
rapid flow rates of crystalloid
solutions and
RBCs as their presence can greatly reduce
flow
rates
•No consensus on design or type to
prevent or reduce
bloodstream infection
•Device with lowest thrombotic occlusion in
VAD is
controversial, requires more study
•Disinfect prior to EACH entry
•Includes
manual and passive disinfection practices
Standard 34 Needleless
Connectors
(NC)
•Glossary definitions upon set or syringe
disconnection.
• Needleless Connector
–Anti-Reflux
(NC). A device that
allows intermittent access
–Complex
–Negative Displacement
to a vascular
access
–Neutral
device with an
–Positive Displacement
administration set
or
syringe without the use of
–Simple
needles; types are
categorized by
description and function
Standard
34 Needleless
Connectors (NC)
•Use
stopcock or manifold with integrated NC rather
than a solid cap (III)
•Change NC no more
frequently than 96-hour intervals
•Change when
–
–
–
–
–
–
NC is removed
for any reason
Residual blood or debris inside
Prior to drawing a blood culture from VAD
Upon contamination
Required by
organizational policy, procedure
Required by
manufacturer directions
Standard 35
Filtration
•Practice Criteria
–Contraindicated for certain medications due
to retention on
the filter, consult with
pharmacy or literature
–Avoid filters with
very small drug volumes
–Evolving evidence on
effect of
•particulate matter on capillary
endothelium
•microbubbles on cerebral and
pulmonary ischemia
–Use air-eliminating
filters in patients with right-to-left
cardiac
shunting
–
Consider filtration in
critically ill patients; reduction in
systemic
inflammatory response syndrome in pediatric ICU
patients
Standard 35
Filtration
•Practice Criteria
–0.2 micron
for parenteral nutrition without IVFE
–1.2
micron for 3-in-1 PN and ALL IVFE infused
separately – new manufacturer directions
since SOP published
•May require use of
both filters
–Intraspinal infusion requires
surfactant free 0.2 micron
filter
–Filter
needle or straw for glass ampules
Standard 36 Add-on Devices
•Includes single or multiple lumen extension
sets,
manifold sets, etc
•Avoid use of
stopcocks; reduce contamination by
using a
stopcock with integrated needleless
connector
•Change add-ons
–
–
–
–
With
new VAD insertion
With new administration set
Defined by policy and procedures
With
compromised integrity or suspected of
contamination
Standard 37 VAD
Stabilization
•Includes adhesive based and
subcutaneous devices
•Tape, sutures not
effective alternatives
•Standard, nonbordered
polyurethane and gauze and tape
dressings –
insufficient evidence as stabilization devices
•Bordered polyurethane securement dressing
alone = more
peripheral catheters reaching 72
hours dwell time, more
data needed
•Do NOT
use rolled bandages
•Medical adhesive related
skin injury (MARSI)
–Apply barrier solutions
•NEVER readvance a dislodged VAD into vein
Standard 38 Joint Stabilization
•Used to facilitate infusion delivery and
maintain
device patency
•Are NOT
considered to be restraints
•Supports area of
flexion
•Permits visual inspectionassessment
•Wooden tongue depressors should not be used
in
preterm infants and immunocompromised
patients
Standard 39 Site Protection
•At risk patients - Pediatrics, elderly,
cognitive
dysfunction
•Consider site
protection, ie, clear plastic domes
•Protect
from water, other contaminants
•Permits visual
inspection of site
Standard 40 Flushing
and
Locking
•Flush with normal saline,
aspirate for blood return, clear
medication
from lumen, prevent contact between
incompatible solutions
–Minimum volume =
twice internal volume of catheter system
–Larger volume may be needed
•Lock
solutions
–Peripheral catheters – normal
saline in adults; heparin 0.5 to 10 units
per
mL OR normal saline for neonates and pediatrics
–Midline catheters – insufficient evidence for
recommendation
–CVADs – heparin 10 units per
mL OR normal saline
–Volume = internal volume
of catheter system plus 20%
Standard 40
Flushing and
Locking
•Antimicrobial lock
solutions
–Therapeutic and prophylactic uses
–Use standardized formulations
•Supratherapeutic concentrations of
antibiotics
•Antiseptic solutions
–
–
–
–
–
Ethanol
Citrate
Taurolidine
Ethylenediaminetetra-acedic acid (EDTA)
Combinations
–ASPIRATE all solutions
Standard 41 VAD Assessment,
Care, &
Dressing Changes
•CVADs, midlines assess at
least daily
•Short peripheral catheters
assessed
–
–
–
–
Minimally every 4
hours
Critically ill, sedated, or cognitive
deficits – every 1-2 hours
Neonatal and
pediatrics – every hour
Vesicant infusion –
more often that every hour
•CHG dressing on
CVADs when primary source of infection
is
extraluminal route
•Perform dressing changes
on short peripheral catheters if
the dressing
becomes damp, loosened, andor visibly
soiled
and at least every 5 to 7 days.
•2% CHG
bathing for patients more than 2 months of age
with CVAD when other strategies not effective
Standard 42 Administration
Set
Change
•Practice Criteria
–General
•Labels
–Date of initiation or date of
change
–Sets attached to intraspinal,
intraosseous, or
subcutaneous devices labeled
with medication
inside near the connection to
the device
•Trace infusion system from patient
to solution
container before connecting or
reconnecting,
at each care transition, during
handoff
process.
Standard 42
Administration
Set Change
•Primary and
secondary continuous
infusions
–Replace no
more frequently than every 96
hours
–Detached secondary sets replace every 24
hours
–Avoid disconnecting primary
continuous sets
from VAD hub or access site.
–Backpriming now addressed in Policy and
Procedure Book
Standard 42
Administration
Set Change
•Primary
Intermittent Infusions
–Change sets every 24
hours
–Aseptically attach new, sterile,
compatible covering to male luer
after each
use. Do not attach to port on the same set
(looping).
•Parenteral Nutrition
–Replace
set at least every 24 hours; also recommendations
to
change with each PN container
–Replace
IV fat emulsion (IVFE) sets for separate infusion
every 12
hours and with each new container
–DEHP-free sets for all IVFE and 3-in-1 PN
solution
•Toxin found in lipids solutions
•Risk factor for neonates, pediatrics, and
long term home care
Standard 43
Phlebotomy
•Greatly expanded!
•Blood
conservation strategies to reduce blood loss
and hospital-acquired anemia
•Tourniquet
time less than 1 minute
–Insert peripheral
catheter, secure and dress, then draw
sample
after insertion, NOT during insertion
•Discard
and push-pull (mixing) method addressed
•No
routine sampling from CVAD infusing parenteral
nutrition
Standard 44 VAD Removal
•Peripheral and nontunneled CVAD assessed
daily
•Removed for unresolved complications,
discontinuation of
infusion therapy, no longer
necessary for plan of care
•Peripheral
catheter – remove if not used for 24 hours
•List of clinical indications for removal of
peripheral and
midline catheters
•List of
criteria for justification of continued use of
CVAD
•VAD inserted under suboptimal aseptic
conditions – label as
such for removal ASAP or
with 24 to 48 hr
•CVAD unresolved
complications and need for continued
infusion
therapy requires collaborative decision
Standard 47 Nerve Injuries
•Paresthesia during venipuncture – immediate
removal
•Respiratory difficulty, unusual
presentations of pain or
discomfort – high
index of suspicion for nerve injury
•Anatomically, veins and nerves are located
close together.
Sites with greatest risk
listed
•No subcutaneous probing or multiple
passes to enter vein
•Neurovascular assessment
–Neuroma
–Compartment syndrome
–Complex regional pain syndrome
Standard 48 CVAD Occlusion
•
•
•
•
Previously – Catheter
clearance
Regular patency assessment includes
blood return
Catheter salvage is preferred
over removal
Criteria to
–Reduce risk of
CVAD occlusion
–Identify signs
–Investigate potential causes
•Do NOT
leave a CVAD or lumen with occlusion untreated
•Collaboration with pharmacists and LIP for
appropriate
management
Standard 51 Catheter Damage
(Embolism, Repair, Exchange)
•Merger of 2
old standards
•Risk versus benefit assessment
for repair or exchange
•Catheter embolism
–Pinch-off syndrome for subclavian sites
•Catheter repair
–Only with manufacturer-
specific repair kit
–Regular assessments of
integrity of repair
•Catheter exchange
–Only if no evidence of infection
–Maximal
barrier precautions
–Confirm tip location
after exchange
Standard 52 CVAD-
Associated Thrombosis
•PICCs = greater
risk of DVT in critical care and oncology
patients
•Measure vein diameter for PICCs
–Catheter to vein ratio 45% or less
•Majority of CVAD thromboses are clinically
silent
•For PICC measure upper arm
circumference before
insertion and when
clinically indicated
–Measure 10 cm above
antecubital fossa
•For CVAD with DVT, do NOT
remove when catheter is
correctly positioned
at CAJ, is functioning with a blood
return,
and no evidence of infection.
Standard
53 CVAD Malposition
•4 types
–
–
–
–
Primary malposition –
during insertion
Secondary malposition –
during dwell
Intravascular malposition
Extravascular malposition
•Growth of
infants and children with CVAD results in
suboptimal tip locations over time
•Scout
scan for power-injectable PICC before contrast
injection
•Blood return is critical
component of assessment
•Management requires
collaborative plan before removal
based on
where tip is located