Considerations for Device Selection xxxxx | Clinical Specialist Vascular Access Assessment Considerations for Device Selection From Schears presentation BAS/EDUC/0816/0050 xxxxx | Clinical Specialist Bard Access Systems

Why is Appropriate Selection So Important? Scrutiny on Hospital Acquired Conditions (HACs) More device choices Potential inappropriate use Consequences to patient

“A good beginning makes a good end.” Patient Impact “A good beginning makes a good end.” Venous Access is essential Establishing and maintaining reliable access is a priority1 EARLY access planning may help address some IV related complications and negative outcomes for patients and for the hospital2 The choice of which VAD to use is a collaborative process Bahl article page 1, Helm article reference page 190 Louis L'Amour. (n.d.). BrainyQuote.com. Retrieved January 26, 2017, from BrainyQuote.com Web site: https://www.brainyquote.com/quotes/quotes/l/louislamo162932.html Louis L’amour 1Bahl A, et al. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed intravenous placement in difficult access patien..., Am J Emerg Med , 1-5. 2Helm, Robert E., et al. (2015). "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3, 189-203

Vascular Access Continuum Not long ago, most of us had a limited selection of devices … MST Midline PICC CICC GW PIV AST Midline PLACEMENT TOOLS USG PIV PIV … but that is changing quickly POTENTIAL DWELL TIME

New device options create the potential to choose a device that: Is more readily available Has less risk of serious complications More closely matches patient needs Is less costly to place Shutterstock picture

New device options also create the potential to choose a device that may: Be inappropriate for required infusates Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

New device options also create the potential to choose a device that may: Be inappropriate for required infusates Be unable to fulfill all required functions Shutterstock image CVP Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

New device options also create the potential to choose a device that may: Be inappropriate for required infusates Be unable to fulfill all required functions Be unable to last the duration of therapy Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

New device options also create the potential to choose a device that may: Be inappropriate for required infusates Be unable to fulfill all required functions Be unable to last the duration of therapy Have risk of serious complications Helm, Robert E., et al. "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3 (2015): 189-203.

New device options also create the potential to choose a device that may: Be inappropriate for required infusates Be unable to fulfill all required functions Be unable to last the duration of therapy Have risk of serious complications Be more costly over course of therapy Helm, Robert E., et al. "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3 (2015): 189-203.

Critical Assessment is More Important Than Ever New device options also create the potential to choose a device that may: Be inappropriate for required infusates Be unable to fulfill all required functions Be unable to last the duration of therapy Have risk of serious complications Be more costly over course of therapy Critical Assessment is More Important Than Ever Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159. Helm, Robert E., et al. "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3 (2015): 189-203.

Key Drivers of Critical Assessment Type of therapy Duration of treatment Difficulty of insertion Patient factors Other Factors Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

Type of Therapy: Vesicants and Irritants Total Parenteral Nutrition (TPN) Many chemotherapeutics Many antibiotics Vasopressors Hypertonic saline Calcium Chloride/Calcium Glutonate Will your patient need these during the course of therapy? Chemotherapy and Biotherapy Guidelines and Recommendations for Practice ONS (2009) pg 105

New INS Publication “Extravasation Checklist: Prevention & Identification” “Preadministration assessment: Identify anticipated duration for administration of vesicants. Assess appropriateness of vascular access device (VAD) for vesicant administration Avoid peripheral infusion of vesicants when infusion time exceeds 30 to 60 minutes Advocate for early central vascular access device (CVAD) placement for continuous vesicant infusions, high-frequency intermittent vesicant drug infusions”1 INS Standards of Practice on Midline Devices: “Use caution with intermittent vesicant administration due to risk of undetected extravasation.” BAS/EDUC/1116/ NSM presentation This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. 1Gorski et al., 2016, Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society (emphasis added)

New INS Publication “Noncytotoxic Vesicant Medications & Solutions” This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. Bard Access Systems has not independently confirmed the information on this list. Gorski et al., 2016, Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society

Non-Vesicant Infusates New INS Publication “Noncytotoxic Vesicant Medications & Solutions” Cytotoxic Drugs (Chemotherapy, etc.) Use safe handling methods RED LIST Well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation YELLOW LIST Vesicants associated with fewer published reports of extravasation , published drug information, and infusate characteristics indicate caution and potential for tissue damage Non-Vesicant Infusates INS “It is important to recognize that large infiltrations of non-vesicant medications or solutions may also be associated with severe tissue damage.”1 This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems Bard Access Systems has not independently confirmed the information on this list.. Gorski et al., 2016, Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. Bard Access Systems has not independently confirmed the information on this list.

Type of Therapy: pH A more complete view on pH … situational questions are important PIV Midline Central line Continuous vs. intermittent? Length of therapy? Patient tolerance? Multiple infusates? Need to tread carefully—serious consequences if you push peripheral devices too far. Grosklags, A et al. “The PICC Book: A Guide for Clinicians.” Bard Access Systems, 2015.

Most are known in advance: Duration of Therapy Diagnostic categories known to typically require >5 days of IV therapy Abscess Cardiac dysrythmias Craniotomy Cystic fibrosis Epidermolysis bullosa Leukemia Liver disorders Lymphomas Metabolic disorders Neutropenia Nutrition disorders Pneumonia RSV pneumonia Spinal procedures Surgery of: esophagus, duodenum, kidney Syncope and collapse Transplants: heart, liver, lung, kidney Ventricular shunt procedures Most are known in advance: Should you start with a longer dwell device? http://lane.stanford.edu/portals/cvicu/HCP_Vascular_Access_Tools/Vascular_Access_Needs_Assessment.pdf accessed 8/30/2016

Difficulty of Insertion BAS/EDUC/1116/0055 Shutterstock images

Patient history which may contribute to difficult insertion Chronic diseases Diabetes End stage renal disease Cancer Cardiovascular diseases HIV/AIDS Sickle Cell Obesity Elderly Pediatric Drug abuser Sedentary Edema Vasculopathy Cystic fibrosis Rheumatoid Arthritis COPD Bowel disease Hypovolemia History of multiple venous cannulations Most are known in advance: When should you move to advanced placement technologies? Hadaway, L. (2005). InfraRed Imaging Systems, 1. Dychter, S., Gold, D., & Haller, M. (2012). Intravenous therapy: a review of complications and economic considerations of peripheral access. Journal of Infusion Nursing , 35 (2), 84-91.

Patient Considerations Co-Morbidities Medical condition(s) existing simultaneously but independently with another condition Perform a history for: Potential previous I.V. Therapy Potential previous hospitalization Potential previous venous complications – including thrombosis http://www.merriam-webster.com/dictionary/comorbid accessed 8/30/2016

Additional Factors # of lumens required- Multiple medications? Compatible vs Incompatible Required flow rates Need for blood draws Central venous pressure (CVP) monitoring Power injection

Peripheral vs. Central Summary Become a strong institutional voice in device selection Take advantage of newer peripheral developments for difficult sticks & intermediate dwell times Protect patients from inappropriate use of all devices

Algorithms Helps with problem-solving Difficulty following flow when there are multiple steps Technical difficulty representing complex decision making Helps with problem-solving Breaks down task into smaller steps making it more manageable Improves efficiency Assists in ensuring all variables are included in decision making process Provides clarity http://benefitof.net/benefits-of-algorithm/

Flow chart base for I-Consider An interactive tool for education related to vascular access device selection as prescribed by a physician Flow chart base for I-Consider

I-Consider

References Guidelines for the Prevention of Intravascular Catheter-Related Infections. (2011). Centers for Disease Control and Prevention. Phillips, L.D. Manual of I.V. Therapeutics. Third Edition. 2001. F.A. Davis Company Grosklags, A., et al. (2015) The PICC Book. PICC Manual. Bard Access Systems. Infusion Nurses Society. Infusion Nursing Standards of Practice. Journal of Infusion Nursing. Jan/Feb 2016. Vol 34 Number 35. Ciocson, M. A., Hernandez, M. G., Atallah, M., & Amer, Y. S. (2014). Central vascular access device: An adapted evidence-based clinical practice guideline. The Journal of the Association for Vascular Access , 19 (4), 221-237. Gorski, L., et al. (2016). "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1, S1-S159. Griffiths, V. (2007). Midline catheters: indications, complications, and maintenance. Nursing Standard , 21 (11), 48-58. Helm, Robert E., et al. (2015). "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3, 189-203. Infusion Nurses Society. (2016). Noncytotoxic Vesicant Medications and Solutions. Oncology Nursing Society. (2009). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, 105. Hadaway, L. (2005). InfraRed Imaging Systems, 1. Dychter, S., Gold, D., & Haller, M. (2012). Intravenous therapy: a review of complications and economic considerations of peripheral access. Journal of Infusion Nursing , 35 (2), 84-91. Bahl A, et al. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed intravenous placement in difficult access patien..., Am J Emerg Med , 1-5.

References Bard Access Systems. (2003, May). BardPort®, SlimPort®, and X-Port ™ Implanted Ports with Open-ended Catheters Instructions for Use. Salt Lake City, Utah. Bard Access Systems. (2007, March). Hickman®, Leonard® and Broviac® Central Venous Catheters Instructions for Use. Salt Lake City, Utah. Bard Access Systems. (2015, November). Powerglide Pro® Midline Catheter Instructions for Use. Salt Lake City, Utah. Bard Access Systems. (2011, September). PowerHohn® Central Venous Catheter Instructions for Use. Salt Lake City, Utah. Bard Access Systems. (2007, August). PowerPICC® Instructions for Use. Salt Lake City, Utah. Bard Access Systems. (2016, January). Accucath® Intravascular Catheter. Salt Lake City, Utah.

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