November 21, 2011

Just something to think about…

This maybe old news to some…but others may have missed it…

Infiltration:

  • Checking for blood return or back flow of blood is good for patency but not a reliable method for assessing infiltration at IV site.
  • If infusion continues to run when you apply digital pressure 3 inches above peripheral IV site in front of catheter tip – suspect infiltration.

Flushing:

  • If you are wondering how much to flush an access device, use this formula to determine flush volume: Minimum volume of flush solution should be equal to at least 2x the volume capacity of catheter & add-on-devices.
  • If using 0.9% Sodium Chloride for flush, preservative free is preferred.
  • If using 0.9% Sodium Chloride with preservative for flush, volume should not exceed 30mL in a 24hr period for adults.
  • If using heparin to flush lines, use the lowest concentration to maintain patency and not cause systemic anticoagulation.

Local Anesthetic:

  • Bacteriostatic 0.9% Sodium Chloride can be used as intradermal anesthesia (numbing) prior to placement of peripheral IV lines. If you’re wondering how this works, read this blog entry.

Infection Control:

  • Nurses shall not wear artificial nails or nail products when performing infusion therapy procedures. This is not wishful thinking, it is a standard of practice. Read this blog entry.

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November 9, 2011

In case you missed it….

…some latest news and initiatives on infection prevention and safety…..

“Preventing Infections in Cancer Patients” - CDC is launching a new program called Preventing Infections in Cancer Patients, featuring tools to help both clinicians and patients prevent infections. CDC worked with partners to develop a Basic Infection Control and Prevention Plan for Outpatient Oncology Settings, which can be used by outpatient oncology facilities to standardize – and improve – infection prevention practices.  The Basic Infection Control and Prevention Plan for Outpatient Oncology Settings and a link to the Web site are available at Preventing Infections in Cancer Patients .

Improperly disposed sharps pose a public health risks -  this shouldn’t be a surprise to us nurses but the FDA launched a new website for patients and caregivers on the safe disposal of needles and other so-called “sharps” that are used at home, at work and while traveling. The website will help people understand the public health risks created by improperly disposing of used sharps and how users should safely dispose of them. Here’s what the FDA recommends.

For the safe disposal of needles and other sharps used outside of the health care setting, the FDA recommends the following:

DO:

  • Immediately place used sharps in an FDA-cleared sharps disposal container to reduce the risk of needle-sticks, cuts or punctures from loose sharps. (A list of products and companies with FDA-cleared sharps disposal containers is available on the FDA website. Although the products on the list have received FDA clearance, all products may not be currently available on the market.)
  • If an FDA-cleared container is not available, some associations and community guidelines recommend using a heavy-duty plastic household container as an alternative. The container should be leak-resistant, remain upright during use and have a tight fitting, puncture-resistant lid, such as a plastic laundry detergent container.
  • Keep sharps and sharps disposal containers out of reach of children and pets.
  • Call your local trash or public health department in your phone book to find out about sharps disposal programs in your area.
  • Follow your community guidelines for getting rid of your sharps disposal container.

DO NOT:

  • Throw loose sharps into the trash.
  • Flush sharps down the toilet.
  • Put sharps in a recycling bin; they are not recyclable.
  • Try to remove, bend, break or recap sharps used by another person.
  • Attempt to remove a needle without a needle clipper device.

Septicemia….caused by blood infections with bacteria such as E. coli and methicillin-resistant Staphylococcus aureus (MRSA), was the single most expensive condition treated in U.S. hospitals at nearly $15.4 billion in 2009, according to the latest News and Numbers from the Agency for Healthcare Research and Quality (AHRQ). Data include cases of septicemia acquired within the community and during hospital stays. For more information...click here

Photo from the FDA website..http://bit.ly/sZpIAf

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October 31, 2011

I see blood….

… as in blood return… which, to an infusion nurse is truly exhilarating!

When I am challenged to insert a 24g peripheral IV catheter in a tiny, invisible vein of a dehydrated infant, I jump for joy as I watch anxiously for the blood return and pray that blood continues to backflow as I advance the catheter into the vein. YES!! YES!!! YES!!!

When I aspirate for blood return from central venous catheters (CVC), it gives me the feeling of victory, knowing that the CVC is properly functioning and ready to use.  Positive blood return means a free flowing blood return easily obtained on aspiration, and the color of whole blood. In other words, bloody RED, not pink-tinged.

Seeing blood gives me the feeling of success as I watch the blood tubes fill up when I am drawing blood samples from a patient’s antecubital fossa.

Oh yes, it doesn’t take much to make an infusion nurse happy. :)   BUT in the world of infusion therapy, bloody may also indicate a serious problem.

  • Seeing blood at the peripheral IV site and/or CVC insertion/exit site can mean complications. Redness or blood at the site may indicate infiltration, phlebitis or infection.
  • Seeing a patient turn RED during an infusion is not a good thing -it may a sign of an infusion reaction. Stop whatever is infusing and manage the patient accordingly.

NOT able to obtain a blood return from CVCs makes an infusion nurse unhappy :( -  as this indicates a problem.

  • If the tip of the CVC is in the lower thirds of the superior vena cava at the junction of the SVC and RA, then you should get a blood return. If you can’t get a positive blood return, do not use and assess the cause.
  • It is not an expectation for patients to do arm and shoulder movements or what most nurses refer to as “central line aerobics” while you aspirate for a blood return.
  • If unable to obtain a positive blood return, then there is a problem with the central line. Consider possibly drug precipitate, fibrin sheath, thrombus formation at tip of catheter, and mechanical problems such pinch-off syndrome, malpositioning of catheter tip, or catheter dislocation.

Ok, so you’re thinking, but in practice if we call the physician and report the problem (inability to obtain blood return), we will be told to go ahead and use the CVC for infusion. It is a dilemma but don’t forget… Assessing for blood return is one of the key indications of a properly functioning CVC and  without a blood return, the use of the CVC can put the patient at risk of serious complications.

Today is Halloween and this is where my love affair with all things bloody ends. Honestly, I love Halloween but I’m a wimp. I’m  not in love with scary movies with splattered guts, blood, or gore . No offense to anyone, it’s just not for me… probably because  I’ve seen enough in real life!!

HAPPY HALLOWEEN!!!!

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October 22, 2011

Thou shalt not use scissors….

…”to remove vascular and nonvascular access device dressings, tape, or stabilization devices due to the potential of severing the catheter or administration set and patient injury”   Infusion Nursing Standards of Practice 2011

The use of scissors in the presence of  vascular and nonvascular access devices shall be limited to suture removal and during the procedure of catheter repair. There have been reports of  patient injuries and catheter damage related to the use of scissors near the vicinity of the catheter and dressing.

A recent one is an article about a court’s decision on a case where a nurse severely cut the left index finger of an infant when she was removing tape that was securing the infant’s intravenous tubing.  The infant’s finger was reattached and later, the parents sued the hospital. The hospital admitted liability and the jury decided on a $210,000 award for the family. See link below for details.

I’m guessing some of you didn’t even know that there’s a infusion nursing standard of practice on the use of scissors. I know some of you are thinking… it’s a bit silly to even have a standard. But, many nurses will admit they have actually used “their bandage scissors” for this purpose. After all, that’s why nurses carry these scissors, right?. Well…true but…learn from this case, don’t use to remove IV dressings or tape. There are better and safer ways to remove an IV dressing.

References:

1. Newsarticle on Court: $210,000 award against hospital not excessive.

2. Full Case description: St Joseph Mercy vs. Melissa and Josh Edwards

3. Infusion Nursing Standard of Practice S21 Scissors. Infusion Nurses Society 2011

Author’s Note: The case stated ‘cut” which implies the use of scissors but was not stated. The picture above is for the purpose of showing the bandage scissor commonly used by most nurses,  not necessarily the one used in this case.

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October 16, 2011

Guaranteed it works, if not, get $100,000..

We’ve all heard it before…in healthcare, anything can happen, hence there is no guarantee. Well, that is until the press release for a new needlefree catheter patency device called “Neutron” came out on Oct. 4, 2011. Click here for the press release.

Neutron, according to its manufacturer ICU Medical,  is the world’s first and only device with FDA 510k clearance to claim the ability to prevent fluid displacement during an IV bag run-dry, infusion pump stop, or patient vascular pressure changes caused by coughing, sneezing or movement — all of which have been associated with loss of catheter patency.

Blood reflux into a catheter is a common problem in IV therapy, and has been shown to contribute to numerous complications including biofilm formation, clotting, and intraluminal thrombotic occlusions that can lead to increased healthcare costs and potential delays in essential treatment. Because of an innovative design that maintains a constant neutral pressure at all times, the Neutron helps maintain catheter patency during times when traditional connectors have been shown to occlude most often.

This product release came with a $100,000.00 Performance Guarantee from the manufacturer to encourage early adoption of this new technology.  If a healthcare facility does not experience a reduction in catheter occlusion rates in the fist three months after converting all of its central IV lines to the Neutron technology, the manufacturer will pay that facility $100,000.00!!!  Not a bad deal….but of course, there are terms and conditions and a commitment to sharing the facility’s occlusion data before and after conversion.

Just in case you’re wondering what “neutral pressure” means – well its actually not generating pressure or force during fluid movement. The connectors are considered neutral because the device prevents blood reflux into the catheter upon connection and disconnection of IV sets or syringe.

Compared to a “positive fluid displacement” device- which are connectors with mechanical valves designed to produce a positive fluid displacement upon disconnection of the IV set or syringe. Upon disconnection, the fluid in the valve is pushed out to the catheter lumen to remove the blood that has refluxed. Blood can still move into the catheter tip but the displacement valve prevents blood from staying inside and causing occlusion.

And then there’s  “negative fluid displacement” – connectors have fluid inside the device either from an IV solution or flush solution. The connectors allow for negative fluid displacement, which means that blood will be pulled back into the catheter lumen and this occurs while the IV administration set is connected, when fluid container is empty and IV set remains connected, or when IV set or syringe is disconnected (blood reflux). When blood is allowed to stay inside the lumen of the catheter, this can lead to catheter occlusion.

Win-win?? Perhaps, if this product doesn’t get the clinician’s attention, their money guarantee will get “C” level attention!!!

References:

1. ICU Medical Press Release: October 4, 2011:

2. Neutron Product Information: 

Disclaimer: This blog entry is not an endorsement of this product. I have no relationship whatsoever with the manufacturer of this product and I would highly recommend evaluating the product yourselves.

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September 28, 2011

Drug Shortage…then and now

In September of 2010, I posted a blog about drug shortages, the good and the bad.  Then, according to ISMP, the drug shortage problem has risen to the level of a national public health crisis. Click here for this blog post.

Fast forward to September 2011…not only do we still have the same drug shortage problem, now there are 15 deaths reported resulting from this problem.According to this news report, the nine deaths and 10 patients harmed in Alabama due to bacterial contamination of a hand-mixed batch of liquid nutrition given via feeding tubes was because the sterile pre-mixed liquid wasn’t available.

The seriousness of the drug shortage was expressed by a patient who is on chemotherapy. She writes that she worries whether she would be the ‘”lucky one” to get the chemo drug on the shortage list. (click here for article) If she gets her chemo drug, that could mean some unlucky patients may not have received theirs. Many patients have express the same concerns about the shortage of their life saving drugs while their physicians are faced with difficult decisions.

The problem isn’t getting better this year….let’s just hope next year, there will be less drugs on the shortage list and better outcomes for our patients.

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September 14, 2011

Class I Recall: Synchromed Implantable Infusion Pumps

A Class I recall has been issued for the SynchroMed II Implantable Infusion Pump, models 8637-20 and 8637-40, distributed between May 2004 and July 8, 2011 manufactured by Medtronics Inc.  The SynchroMed II Pump is indicated when patient therapy requires the chronic infusion of the drugs or fluids. This infusion pump is indicated to deliver morphine sulfate, ziconotide and baclofen for the treatment of chronic pain, severe chronic pain and severe spasticity, respectively. It is also indicated for delivery of floxuridine and methotrexate for the treatment of primary or metastatic cancer.

There is a potential for reduced battery performance in the SynchroMed II infusion Pump. Medtronic’s analysis of the problem indicates it is related to the formation of a film within the pump battery. This problem can lead to the sudden loss of therapy and the return of underlying symptoms and/or therapy withdrawal symptoms. For example, patients receiving intrathecal baclofen therapy for severe spasticity are at risk for baclofen withdrawal syndrome, which can lead to a life-threatening condition if not treated quickly and effectively.

Medtronic encourages patients to carry their patient identification cards with them at all times and to contact their physicians immediately if they experience a return of symptoms or hear a device alarm.

Medtronic has a Device Identification web pagedisclaimer icon where customers can enter the serial number for any SynchroMed II infusion pump to determine if their pump is being recalled. Medtronic is not retrieving any implanted SynchroMed II pumps from the field. Medtronic does not recommend prophylactic replacement of SynchroMed II pumps because of the estimated low occurrence rates, the presence of pump alarms, and the risks associated with replacement surgery.

Class I recalls are the most serious type of recall and involve situations in which there is a reasonable probability that use of these products will cause serious adverse health consequences or death.

For more information on this recall, click here.

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September 11, 2011

9/11…we will always remember…

Today our nation marks the 10th year anniversary of the attacks on 9/11 in NYC, DC and Pennsylvania. That was a day no one would ever forget. We will always be grateful to the courageous firefighters, rescuers and first responders who risked their lives to save those in the rumbles of this dreadful day.  We will always remember those who died from this tragedy whose memories we celebrate today. But as we remember those who are no longer with us in this world, let us not forget those who survived or were left behind…those whose lives were forever changed.

Just like many of you, I vividly remember that sunny, cool September day..the day when our lives changed no matter where you were or what you were doing . I did not have any close friends or relatives affected that day but since then, I’ve met business colleagues who were there covered with dust and frozen in their tracks…survivors of 9/11. In the years that I have known them, they never spoke of their experience and no one even knew they survived this tragedy. They felt no one needed to know…they grieved and although they have moved on, they tell me their hearts have mended but not healed.

On this special day, as we remember those we lost…let us not forget those who are here with us carrying the burden of “why did I survive”?

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September 6, 2011

Tourniquets conceal superbugs……

This is the title of an article from the Medical Journal of Australia (MJA)  posted by my twitter colleague @chemosabe from Australia.

Design/Setting: A prospective study in a tertiary hospital to collect and analyse reusable venesection tourniquets for the presence of MROs —methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase and metallo-β- lactamase-producing Enterobacteriaceae — using a sensitive enrichment method. Tourniquets were collected and tested during a 10-week period between September and November 2010.

Results: The overall colonisation rate of 100 tourniquets randomly collected from general wards, ambulatory care areas and critical care areas was 78%. MROs were isolated from 25 tourniquets collected from a variety of hospital locations, including general wards, the intensive care unit, burns unit and anaesthetic bay. MRSA was isolated from 14 tourniquets and VRE from 19;
both MRSA and VRE were isolated from nine tourniquets. There were no microorganisms isolated from 22 tourniquets.

Conclusion: Reusable tourniquets can be colonised with MROs and may be a potential source of transmission of MROs to hospitalised patients.

This makes sense and should not be a total surprise, yet we see many nurses and lab technicians re-use tourniquets.I honestly have no idea why they would re-use tourniquets other than simply a practice carried on not knowing it’s not a good practice.

I would admit I was once guilty of re-using my “lucky” tourniquet when starting a peripheral IV. As a new IV nurse, I honestly believed that each time I used my lucky tourniquet, I would always get the vein on the first try.  I continued to use my lucky tourniquet and didn’t even think of cleaning it fearing the “luck” would be washed off. HAH!! What an idiot I was then..young and stupid!! My IV team nurse manager told me to throw my lucky toruniquet away and that we would start using IV start kits with “lucky tourniquets” in each kit designed to be discarded after use. Wasn’t she a doll?

Yes, tourniquets should be single patient use as stated in the 2011 INS Standards of Practice..S 31 Tourniquets…don’t let anyone tell you otherwise. There several other articles about MRSA and tourniquets reuse. This MJA article is the latest one I’ve seen on this topic.

For details on this article, click here…

Thanks to Glen (@chemosabe) for sharing this article.

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August 23, 2011

Two-wah……

Time flies when you’re having fun!!! This week, the Infusion Nurse Blog is celebrating its two year blog anniversary!!! *throws confetti*

As I said before and again this year, sometimes I still feel like I don’t have anything interesting to blog about. But I am very encouraged, grateful and honored because you have continued to visit, read, post comments, and subscribe to my blog posts. Thank you!!!  Thank you!! Thank you!!

As I always do each anniversary, here are  the top five most read posts this year:

1.  “Just Say No”: this continues to be the most read blog post for the past two years. It’s about avoiding the antecubital fossa when starting a PIV.

2. “Is there a difference? Osmolarity vs. Osmolality”: first time this year for this post to take second place so I’m thinking now you can tell the difference!!

3. “Nurses + Artificial Nails = Bacteria”:  Yes, please no artificial nails if doing patient care!

4. “Infusion by Gravity Drip”:  Yup, doesn’t hurt to know how to calculate drops!!

5. “The Phlebitis Scale does mean something” tied with “Wearing gloves is NOT optional” – a tie for fifth place!!! Never had that before. Obviously, one is about phlebitis and rating severity. The other is…well you know…wear gloves!!

To celebrate this big milestone, I am giving away “two” copies of the “2011 Infusion Nursing Standards of Practice” published by the Infusion Nurses Society.

The rules are simple.

  • To enter: Simply leave a comment (no spam please) below. Giveaway ends 11:59 ET August 31, 2011.
  • Valid comments with your name will be included in a raffle and two lucky winners will be notified by email and announced on this blog by Sept 1, 2011. If I don’t hear back from the winners within 48 hours of sending the winning email, I’ll pick another.
  • Oh sorry….this is open to US residents only!

Thanks again and here’s to another year of blogging!!!! Cheers!!!

Disclosure: I am personally providing the prizes for this giveaway and is no way connected to the Infusion Nurses Society.

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