1. IV Therapy Policy Changes & Highlights 2013
Safety begins with me.
Smart
Alert
Focused
Educated
Be SAFE

2. Please note…
This educational program is designed to be viewed as a PowerPoint slide show. At this time, be sure you are viewing the program in the slide show format.

3. Program Objectives
Provide an overview of the following newly developed policies:
IV Peripheral – Insertion, Care, & Maintenance
IV Therapy, Administration of Solutions and Medications
Prepare nurses to participate in planned education sessions on IV therapy.

4. Why?
Patient ordered to start Propofol infusion at 20 mcg/kg/min (standard concentration 1000 mg/100 mL). DOSE Mode used, but concentration manually changed making actual patient dose of 200 mcg/kg/min. Patient developed symptomatic hypotension requiring Phenylephrine infusion before programming error was detected.
What is Propofol?
Propofol, also known as Diprivan®, is a drug in the sedative-hypnotic class.

5. Why?
Patient ordered to start Heparin infusion (standard concentration 25,000 units/250 mL) at 500 units/hour (5 mL/hour). DOSE Mode not used and pump inadvertently programmed to deliver 50 mL/hour (5000 units/hour). Entire bag infused before programming error was detected. Patient required Protamine Sulfate to correct critical high aPTT.

6. Why?
Patient entered the hospital with a peripheral IV started in the “field” in an emergent situation. IV site not changed within 24 hours per policy. 3 days after admission, the peripheral IV site is red, swollen, and warm with purulent drainage.  The IV was removed at that time and culture sent. Site culture positive for Staph aureus with positive blood cultures. Patient developed a hospital-acquired infection of soft tissue with a secondary blood stream infection related to the peripheral IV.

7. Do you think the previous scenarios happened at St. Luke’s?
Transparency…
Do you think the previous scenarios happened at St. Luke’s?
The answer is “yes.”
Transparency of patient safety events plays a significant role in reducing the likelihood of recurrence, especially when staff know “it happened here.” Awareness of this demonstrates the importance of knowing and understanding SLUHN policy and expected practice related to IV therapy…

8. Review of policy changes & highlights…
The information contained in the remainder of this program will provide valuable policy information and expectations to incorporate into your daily practice. You will have the opportunity to further discuss and apply this information when you attend one of the upcoming live, interactive education sessions.

9. The first policy…
IV, Peripheral – Insertion, Care, & Maintenance [D-19]

10. New Policy… IV, Peripheral – Insertion, Care, & Maintenance [D-19]
The questions on the following slides will test your knowledge and memory of current policy and practice… In addition, you will learn about new policy and practice expectations.

11. Check with your manager to determine availability.
Which of the following are options if you attempt 2 IV sticks and are unsuccessful?
Consult another qualified nurse
Consider using ultrasound guided or vein illuminator equipment where available (education/competency needed)
Notify physician for options such as PICC or central line placement
All of the above
What’s new?
There is an increased availability of ultrasound guided or vein illuminator equipment at SLUHN…
Check with your manager to determine availability.

12. IV Starts… Important Safety Reminders
The importance of hand
Hygiene cannot be emphasized enough!

13. IV Starts… Important Safety Reminders
NOT ACCEPTABLE

14. IV Starts… Important Safety Reminders
Always prepare the skin with a chlorhexidine solution before peripheral venous catheter insertion unless there is a contraindication.
If there is a contraindication to chlorhexidine, 70% alcohol or tincture of iodine can be used.
Antiseptics should be allowed to dry according to manufacturer’s recommendation prior to placing the catheter.

15. IV Starts… Important Safety Reminders
During insertion, do not re-advance the needle into the IV catheter once retracted. Re-advancing the needle into the catheter may cause catheter shearing and subsequent risk to the patient.
A peripheral IV securement device (i.e. StatLock®) is generally used on IVs expected to remain in place for greater than 24 hours.
What is needed before applying the StatLock®?
Skin prep!

16. IVs… Important Safety Reminder
“Scrub the Hub” Protocol for Needle-Free Valves
Hand Hygiene before & after catheter contact
Use aseptic technique when accessing the line
Scrub valve with alcohol pad: Vigorous scrub using twisting motion
ALLOW ALCOHOL TO DRY before each infusion access 3 5 1 2 4
So what is a “vigorous scrub”?
SLUHN recommends the practice of a minimum of
5 vigorous “twists” with alcohol around the hub of the needle-free valve(s) before use.

17. When are IV site assessments documented?
What’s new?
The SLUHN policy will be revised to state that IV site assessments normally occur at 2 hour intervals.
True or False
Policy…
When are IV site assessments documented?
IV site assessments are documented minimally upon first contact with patient (e.g. at the beginning of shift, receipt of transfer, etc.) and with any changes or complications noted.
IV site assessments should be conducted by the nurse at the beginning of his/her shift and upon receiving a patient from another unit/department.
Ongoing IV site assessments will take place at frequent intervals, normally not to exceed 2 hours.
True
True

18. IV Sites Current and New Policy Unchanged…
“Time” is a factor when it comes to IV site infections… Therefore, changing the site every 96 hours is critical... As a reminder, an important practice is to label the initial IV site dressing with the DATE and TIME of insertion as well as the INITIALS of the person inserting the IV.
In adult patients, IV sites can remain in place for no more than ___________ and therefore peripheral IV sites are changed every ____________.
96 hours
96 hours

19. True or False
IV sites initiated pre-hospital by paramedics in the field must be changed as soon as the patient’s condition stabilizes or within 24 hours. The ED staff will affix a “pre-hospital IV” sticker noting the date/time initiated on the dressing of all pre-hospital IVs.
This is not new to policy 0r practice. See picture of orange sticker above.
True

20. IV Tubing Current and New Policy Unchanged…
IV tubing is changed every ____________.
Exceptions exist including but not
limited to the following:
TPN tubing is changed every __________.
Primary or secondary tubing used in an intermittent fashion is changed every __________.
(intermittent = disconnection from needless valve on
j-loop/extension tubing or primary tubing)
96 hours
24 hours
24 hours

21. IV Tubing Practice Note…
When a continuous IV is infusing, do not disconnect the tubing from the patient to ambulate or to go off the unit… …all attempts should be made to minimize tubing disconnections to reduce the risk of contamination.

22. IV Site Complications… True or False
Guidelines for IV site complications such as infiltration, phlebitis, extravasation, and infection are not and will not be included in policy.
False
Additional note…
Computer documentation will be revised to match new policy including specific documentation regarding IV site complications.
What’s new?
The SLUHN policy will be revised to include guidelines for IV site complications including assessments and interventions.

23. True True or False After discontinuing an IV due to an infiltration:
If IV access is still required, start new IV in opposite extremity (preferred) or well above site of infiltration; all new tubing and attachments must be used when a new IV catheter is inserted no matter how long the existing catheter has been in place.
True

24. The picture below most likely shows which of the following IV complications?
Infiltration
Phlebitis
Extravasation
Infection

25. A little more about extravasation…
True or False
A little more about extravasation…
The best treatment for extravasation is prevention! Vesicant medications have the potential to cause severe or irreversible tissue injury and necrosis. At times, the original IV catheter is left in place for necessary interventions and therefore it is important to discuss this with the physician before removing the IV and obtain appropriate orders. Some examples of vesicant medications include chemotherapy, dopamine, levophed, epinephrine, phenergan, vasopressin, and dilantin (this is not an all inclusive list).
Extravasation is the infiltration of a vesicant medication or solution (e.g. Dopamine) that causes destruction by chemical injury and/or severe vasoconstriction. When an extravasation occurs, immediately notify the physician to obtain orders for appropriate interventions such as retain IV catheter for antidote administration and application of cold or warm compress. In addition, consult pharmacy for recommendations.
True
Extravasation
True

26. Appearance (e.g. diameter of edema and/or redness, drainage)
Which of the following assessments are appropriate to make & document if a peripheral IV site infection is suspected?
Pain, tenderness
Appearance (e.g. diameter of edema and/or redness, drainage)
Temperature of skin (i.e. warm)
Patient’s vital signs
All of the above
Interventions appropriate for a peripheral
IV site infection…
Stop infusion immediately
Notify physician for orders (including culture)
Discontinue IV
Consider notifying the Infection Preventionist
Document findings & interventions
Start new IV if needed

27. IV Starts Practice Notes…
Reminder…
An important practice is to label the initial IV site dressing with the DATE and TIME of insertion as well as the INITIALS of the person inserting the IV.
The antecubital vein/site is generally reserved for blood draws and is often an uncomfortable place for an IV (this site is also more prone to complications).
Tourniquets are single-patient use!
All IV sites are to be labeled using the label included with the transparent dressing.

28. On to the second policy…
IV Therapy, Administration of Solutions and Medications [D-18]

29. Newly revised policy… IV Therapy, Administration of Solutions and Medications [D-18]
The questions and information on the following slides will highlight policy and practice expectations.

30. What is a “Med Infusion Time-Out”?
A standardized process designed to ensure accuracy of continuous medication infusions in DOSE Mode.
“Med Infusion Time-Out” terminology is replacing “independent double check” terminology.

31. Med Infusion Time-Out
Process includes one RN and one qualified individual (RN, Pharmacist, Physician) independently checking the following in the presence of the patient:
Patient identity
Original order
IV bag label (i.e. patient name and fluid/med/concentration)
Infusion pump settings including:
Body weight (when applicable)
Concentration
Dose
Rate
Trace of infusion line back to its origin

32. Med Infusion Time-Out A Med Infusion Time-Out will be performed:
On all initial pump set-ups for continuous med infusions in DOSE Mode
Upon receiving a patient with a new medication infusion started in a procedural area (e.g. OR, IR, etc.)
With a change in drug concentration
With a physical change of pump (i.e. current pump is replaced with new pump)

33. Med Infusion Time-Out Additional notes...
For continuous IV medication infusions in DOSE Mode initiated in an emergency situation, the Med Infusion Time-Out will be performed as soon as reasonably practical.
The Med Infusion Time-Out will be documented in the medical record by both individuals.
For a continuous medication infusion new to St. Luke’s or not yet added to our drug library, a Med Infusion Time-Out is required.

34. Practice expectation…
The RN assigned to the patient will independently ensure accuracy of all IV infusions by verifying the following at the beginning of his/her shift, upon receiving a patient from another unit/department, and with any change to physician orders:
Patient identity
Original order
IV bag label, i.e. patient name and fluid/medication/concentration
Infusion pump setting including:
Body weight (when applicable)
Concentration
Dose
Rate
Trace infusion line back to its origin

35. “IV Medications by Location”
How do you clarify the usage and administration of intravenous medications for specific locations?
Dopamine
Levophed
Lidocaine
Cardizem
Heparin
Nipride
Nitroglycerin
Amiodarone
How/where do you find the answer to this
question if you are unsure?
“IV Medications by Location”
This will no longer be a separate policy but will be an attachment to the IV Therapy,
Administration of Solutions and Medications [D-18] policy.
*Please note upcoming changes to this document will be made
due to unit/department restructuring.

36. A note about PCA Pumps and Epidural Pumps….
The process and timing for PCA & Epidural pump checks will not change…
What will change is the terminology we use; new terminology will be…
PCA Time-Out
Epidural Time-Out

37. Additional reminders…
Safety begins with me.

38. Safety Rule… Knowledge for Nurses & Patients
Information on IV medications & solutions
can be found in the following…
Intravenous Medications by Gahart
Online (MyNET) references…
Policy & Procedure Manuals (
MicroMedex
Krames On-Demand

39. Documentation…
Documentation related to IV therapy generally includes the following: patient/family education, initiation, assessments, complications, and discontinuation. Documentation specifically related to IV solutions and medication therapy should include the location of infusion, rate of infusion, and volume infused.

40. Patient Safety Event Reporting
What events need to be reported?
Reminder…
When a patient safety event occurs an Event Report is required. Event Reports are submitted online via the Patient Safety Event Reporting System located on MyNET.
Generally speaking, reportable events include errors, adverse reactions, allergic reactions, near misses, complications of a procedure or treatment, etc. Some specific examples include IV site infection, infiltration, phlebitis, or extravasation; IV pump programming error; IV site not changed according to policy; etc.

41. Anticipated go-live date for all new policy & documentation changes
September 3, 2013

42. Be proud of the job you do!
The best safety device is a safe worker.
Smart
Alert
Focused
Educated
Be SAFE

43. Please exit this program and proceed to the posttest (“Take Test”).
Don’t
Forget!
Please exit this program and proceed to the posttest (“Take Test”).
Once you obtain 100% on the posttest be sure to print the certificate of completion for your records.
You will receive 0.5 CE hour for completion of this education.
You will need to bring a copy of your certificate of completion in order to attend one of the upcoming live, interactive education sessions when you will discuss and apply the information you learned in this PowerPoint program.
Thank you!