1. Dallas, TX November 2–4, 2012 Peripheral Infusion Complications Leading to Sentinel Events Presented by Pam Ohls, MSN, RN RN Director, Clinical Education Banner Health System Pam.ohls@bannerhealth.com

2. Dallas, TX November 2–4, 2012 Peripheral Infusion Complications Leading to Sentinel Events Session Code:101 Contact Hours: 0.8 CRNI Units: 2 Please use session code shown above when completing your speaker evaluation and CE form. Return the evaluation to the registration desk or receptacles located outside meeting rooms at the end of the day. Handouts for this session are available online at www.ins1.org.www.ins1.org Session recordings will also be available post-meeting courtesy of B.Braun Medical/Aesculap Academy. As a courtesy to both presenters and attendees, please turn off all cell phones and refrain from talking during the session. Tonight’s Event: Industrial Exhibition and Networking Reception 3:30-5:30pm

3. Dallas, TX November 2–4, 2012 Objectives Discuss complications associated with peripheral IV therapy Discuss strategies to improve outcomes for patients receiving peripheral IV therapy

4. Dallas, TX November 2–4, 2012 Case Presentation Geriatric-aged Caucasian female presented to ED-auto accident-back pain IV started, CT Head, pain meds, labs Pain meds, K+, procedure for back scheduled Monday. IV restarted on Friday on day 3. Old IV site continues to become more reddened over 2 days, wound consult.

5. Dallas, TX November 2–4, 2012 Case Presentation Procedure cancelled on Monday. Pt febrile, BP dropped. To ICU. Diagnosis-Sepsis Patient expired 24 hours after admit to ICU Final diagnosis-sepsis from infected IV site-per Infectious Disease Physician.

6. Dallas, TX November 2–4, 2012 Sentinel Event Defined by the Joint Commission (TJC) Unanticipated event Results in death, serious physical or psychological injury

7. Dallas, TX November 2–4, 2012 Root Cause Analysis Involves interdisciplinary experts from the departments associated with the event Involves those who are the most familiar with the situation Digs deeper by repeatedly asking why at each level of cause and effect. Identifies changes needed to be made to systems Be impartial as possible

8. Dallas, TX November 2–4, 2012 Goal of RCA What happened? Why did it happen? What do you do to prevent it from happening again?

9. Dallas, TX November 2–4, 2012 Effective & Thorough Determine human factors Analysis of related processes Analysis of underlying cause and effect systems through a series of why questions Identification of risks & their potential contributions Determination of potential improvement in processes or systems

10. Dallas, TX November 2–4, 2012 Cause & Effect Diagram Human Factors- Communication Barriers/SafeguardsEquipment and Environmental Factors Event (Septic IV Site) Human Factors- Training Human Factors- Fatigue / Scheduling Rules, Policies, Procedures, Leadership

11. Dallas, TX November 2–4, 2012 Define PIV Terms for Team Phlebitis-expected/anticipated? Infiltration-expected/anticipated? Infection source from PIV?

12. Dallas, TX November 2–4, 2012 Phlebitis Defined as erythema, pain, swelling and or venous cord along the PIV site. Classified as: –Chemical –Mechanical –Bacterial

13. Dallas, TX November 2–4, 2012 Phlebitis Rates range from 2-80% INS recommendation rate 5% or less Risk factors –Drug related –Patient related –Health care related

14. Dallas, TX November 2–4, 2012 Phlebitis Scale 0No clinical symptoms 1Erythema, with or without pain 2Erythema and pain, with or without edema 3Erythema, pain, and/or edema and palpable cord 4Erythema, pain And/or edema Palpable venous cord > 1 inch Streak formation Purulent drainage

15. Dallas, TX November 2–4, 2012 Chemical Phlebitis Typically associated with peripheral-short venous access devices, i.e., peripheral IV or Midlines.

16. Dallas, TX November 2–4, 2012 Infiltration/Extravasation Infiltration: inadvertent administration of a non vesicant into the surrounding tissue. Extravasation: an inadvertent delivery of a vesicant into the tissues. Vesicants cause blistering, severe tissue damage, and even necrosis if extravasated.

17. Dallas, TX November 2–4, 2012 GradeClinical Criteria 0No signs or symptoms 1Skin blanched Edema less than 1 inch 2Cool to touch With or without pain Skin blanched Edema 1-6 inches in any direction 3Cool to touch With or without pain Skin blanched Edema greater than 6 inches 4Cool to touch Mild-mod pain Possible numbness Skin discolored Gross edema greater than 6 inches Circulatory impairment Infiltration of any blood product, irritant, or vesicant Infiltration Scale

18. Dallas, TX November 2–4, 2012 Extreme pH IV Medications pH <5 Ciprofloxin 3.3-4.6 Dopamine 2.5-5.0 Doxycycline 1.8-3.3 Morphine 2.5 Potassium 4.0 Pentamidine 4.1-5.4 Phenergan 4.0 Taxol 4.4-5.6 Vancomycin 2.4 Zofran 3.0-4.0 pH >9 Acyclovir 10.5-11.6 Ampicillin 8.0-10 Bactrim 10 Cerebyx 8.6-9.0 5FU 9.2 Ganciclovir 9-11 Phenytoin 12 Protonix 9-10.5

19. Dallas, TX November 2–4, 2012 Classified Vesicant Infusates Acyclovir Amiordarone Ampho B Ampicillin Aramine Bactrim Calcium chloride Calcium Gluconate 10% Ciprofloxacin Cerebyx Contrast media Daptinomycin Dextrose >10% Digitoxin Dobutamine Dopamine Doxapram Doxycycline Epinephrine Erythromycin Gancyclovir Gentamycin

20. Dallas, TX November 2–4, 2012 Vesicant Infusates Levophed Lorazepram Magnesium sulfate Mannitol 10% and 20% Morphine Nafcillin Norepinephrine Phenergan Phenytoin Phenylephrine Pentamadine Phenytoin Piperacillin Potassium chloride Protonix Sodium Bicarbonate Taxol Thiopental Valium Vancomycin Vasopressin Zofran Zosyn

21. Dallas, TX November 2–4, 2012 Mechanical Phlebitis Associated with placement of device or extremity movement resulting in irritation of vein intima Early-stage mechanical phlebitis caused by mechanical irritation of vein endothelium –Signs and symptoms are tenderness, erythema, and edema

22. Dallas, TX November 2–4, 2012 Bacterial Phlebitis Inflammation of the vein intima associated with bacterial infection Less frequently seen but more serious because it predisposes patient to systemic complications

23. Dallas, TX November 2–4, 2012 Review of Literature 30-80% PIV during hospitalization 50% PIV placed in ED-routine procedure, but not used 150 million PIV placed annually –15x higher than central lines Most literature focuses phlebitis and infiltration IV site change or needed (ZIngg & Pittett, 2009)

24. Dallas, TX November 2–4, 2012 Maki, Kluger, Crnich (2006) Meta-analysis of 200 prospective studies PIV BSI rate: 0.5 per 1000 device days Over 330 million PIV in US each year

25. Dallas, TX November 2–4, 2012 Pujol, Hornero, Saballs et al. (2007). Prospective study-catheter related BSI 2001-2003 Non-ICU patients 147 patients –77 PIV (0.19/1000 patient days) –73 CVC (0.18/1000 patient days) PIV infections –Inserted in ED, Staph aureus, 27% mortality rate

26. Dallas, TX November 2–4, 2012 Zingg & Pittet, (2009) Current data report PIV incidence density rates of 0.2-0.7 episodes per 1000 device days. 5-25% PIV colonized with bacteria at time of removal. Rare event or serious health care problem?

27. Dallas, TX November 2–4, 2012 Trinh, Chan, Edwards, et al. (2011). Retrospective study-adult patients- 2005-2008 24 PIV, median duration 3 days Site-antecubital, placed in ED or outside facility (p=.005) Treatment-19 days antibiotics

28. Dallas, TX November 2–4, 2012 Replacement of PIV Current HICPAC Recommendations –No need to replace PIV more frequent to reduct risk of infection and phlebitis Category 1B –No recommendation of placement of PIV when clinically indicated Unresolved issue –Replace PIV in children when clinically indicated Category 1B

29. Dallas, TX November 2–4, 2012 Policies & Procedures Current Practice Change IV sites every three days, sooner if reddened Check for blood return for chemotherapy Check for blood return for vesicants Contrast Media is a vesicant?

30. Dallas, TX November 2–4, 2012 What Effect Did Contrast Have on the PIV? What is the practice of Medical Imaging? What is the policy? How old are the IV’s used for Contrast? Did the nurse change the IV site according to policy? Do we have a policy on Contrast Media and what do we know about Contrast?

31. Dallas, TX November 2–4, 2012 Contrast Media Osmolarity

32. Dallas, TX November 2–4, 2012 Equipment/Patient ;;;;; Contrast Injected 1-6mL per second

33. Dallas, TX November 2–4, 2012 CT Rates of Injection 1mL per second = 3600 mL/hour 2mL per second = 7200 mL/hour 3mL per second = 10,800 mL/hour 4mL per second = 14,400 mL/hour 5mL per second = 18,000 mL/hour 6mL per second = 21,600 mL/hour

34. Dallas, TX November 2–4, 2012 Contrast Extravasation

35. Dallas, TX November 2–4, 2012 Facts About Contrast Media Vesicant Continues to burn intima of veins for 48 hours after administration Administration of contrast via IV in place longer than 20 hours increases risk of extravasation and phlebitis Multiple attempts at IV access at same site increases risk of extravasation Patient Safety Advisory (2004), Extravasation of Radiologic Contrast

36. Dallas, TX November 2–4, 2012 National Guidelines for Vesicants Avoid using sites more than 24 hours Avoid areas of flexion –Radiology Guidelines recommend AC for administration of Contrast Media Flush with Saline before and after Check blood return before and after Infusion Nurses’ Society Oncology Nurses’ Society Standards of Care

37. Dallas, TX November 2–4, 2012 Question What affect did Contrast have with the other medications she was receiving –Morphine –Potassium –Zofran

38. Dallas, TX November 2–4, 2012 Ask Questions What is the practice of CT Techs? Check for blood return? Check for patency? Scrub hub? Flush with Saline before and after? How old the IV site?

39. Dallas, TX November 2–4, 2012 The questions CT check for blood return? Power injected? What other medications through IV site? How long do IV’s last after administration of Contrast Media

40. Dallas, TX November 2–4, 2012 Results Collected data on 60 patients for CT & MRI Magnevist MRI-1960milli/osmL Omnipaque 350-844milli/osmL 60 patients, 63% (n=38) no extravasation or phlebitis 69% no blood return prior to injection Kirschner, R. (2010).

41. Dallas, TX November 2–4, 2012 Results 60 patients, 31% (n=22) had concurrent vesicant therapies 100% (n=22) developed phlebitis within 24 hours contrast and another vesicant –(n=10) MRI contrast –(n=12) CT contrast All CT patients power injected No MRI patients power injected

42. Dallas, TX November 2–4, 2012 Which Medications? Zofran Potassium Morphine Protonix Vancomycin

43. Dallas, TX November 2–4, 2012 Action Plans All PIVs need to be started with 24 hours of contrast media All CT techs check for date of insertion before administration of contrast All CT techs check for blood return before administration of contrast If not within 24 hours and no blood return-restart PIV

44. Dallas, TX November 2–4, 2012 Post Administration Discern alert placed in electronic documementation for nurses, alerting them to administration of contrast and top 5 medication. Site may develop phlebitis and may need changed within 24 hours.

45. Dallas, TX November 2–4, 2012 Resource Team Assistance

46. Dallas, TX November 2–4, 2012 Literature 90% of patients require PIV for procedures/medications IV education and skills have removed from many nursing school curriculum after Hegstad and Zsohar (1986) study showed no difference in outcomes from simulation versus live practice for IV skills Mentoring with an expert has been shown to improves skills and confidence (McGee, 2001)

47. Dallas, TX November 2–4, 2012 Experience with IV’s 16 participants (n = 16) The mean age of participants was 30 years (range 23 – 44 years). The majority of participants were female (n = 15) Most staff nurses had one to five years of RN experience (n = 9) About half of the participants worked on a med/surg unit as a staff RN (n = 8), while the other half were staff nurses in PCU or ICU (n = 7). One participant was from WIS. Participants’ highest level of nursing education was equally divided ADN (n = 8) and BSN (n = 8). All but one participant had experience inserting IVs in nursing school. The majority of participants (n = 14) had experience inserting IVs on both patients and mannequins / IV arms. Practice with IV in nursing school varied never (n=1) one to two times (n=1) three and five times (n = 8) six to ten times (n = 4) more than ten times (n = 2)

48. Dallas, TX November 2–4, 2012 Human Factors-Training Ultrasound IV insertions Education Competency Outcomes

49. Dallas, TX November 2–4, 2012 IV Cannulation Outcomes Using 1 ¼” needles with US 622 IVs 242-41% failed in under 24 hours 531-90% failed in under 48 hours 62-10% made it to 72 hours After 24 hours Upper arm fails 78% Antecubital fails 41% Lower arm fails 28% Unpublished data, Royer, T. (2006).

50. Dallas, TX November 2–4, 2012 Length and Size of Needles The deeper the vein, the less needle in the vein. Use longer catheters: 1 ¾ inch No deeper than 1cm Site selection: –Lower arm –Upper arm-Cephalic veins –Antecubital

51. Dallas, TX November 2–4, 2012 Bacterial Phlebitis Inflammation of the vein intima associated with bacterial infection Less frequently seen but more serious because it predisposes patient to systemic complications Type of ultrasound gel for assessing and accessing the vein –Clean to assess –Sterile to access clean sterile

52. Dallas, TX November 2–4, 2012 Claims and Dollars for the System for Claims where Medication Error was the Primary Event Year No. Amount Incurred 2005 130 $ 2 million 2006 130 $ 5 million 2007 130 $ 7 million

53. Dallas, TX November 2–4, 2012 Common Problems Identified in Claims Infiltration of IV contrast 14 of 58 claims Poor charting of IV site assessment IV not changed when patient complains IV not changed per policy MRSA infections after IV removed

54. Dallas, TX November 2–4, 2012 Scope of Practice Anatomy and physiology limbs, to include vein, artery, and nerves Assessment of vessels Appropriate vessels and cannulation techniques Aseptic technique Appropriate length and size of needles Complications, management, and troubleshooting

55. Dallas, TX November 2–4, 2012 Strategies Assessment of nurses’ IV knowledge and skills on hire Precepting and mentorship IV skills and knowledge Education, skills, competencies for US IV insertion Assessment of IV practice in your facility for vesicants/contrast media

56. Dallas, TX November 2–4, 2012 Guidelines for PIV insertion

57. Dallas, TX November 2–4, 2012 Algorhythm for Right Line?

58. Dallas, TX November 2–4, 2012 Competencies

59. Dallas, TX November 2–4, 2012 Summary Assessment of knowledge, competencies, practices, and policies Policies and Procedures Documentation INS Standards of Practice All nurses who start IVs are Infusion Nurses, not just nurses who are on IV teams and insert PICC lines

60. Dallas, TX November 2–4, 2012 References ECRI (2004). Extravasation of Radiologic Contrast, Patient Safety Advisory, 1(3), 1-5. Infusion Nurses Society Standards of Practice, (2011). Kirschner, R. (2010). Contrast media-Phlebitis implications. US Radiology, 27-30. Maki, D., Kluger, D., Crnich, C. (2006). The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc, 81(9), 1159-1171 Pujol, M., Hornero, A., Saballs, M., et al. (2007). Clinical epidemiology and outcomes of PIV related blood stream infection at a university- affiliated hospital. Journal of Hospital Infection, 67(1), 22-29. Royer, T. (2006). Unpublished data for US IV Insertion. Trinh, T., Chan, P., Edwards, O, et al. (2011). Peripheral venous catheter-rated staphylococcus aureus bacteremia. Infection Control and Hospital Epidemiology, 32(6). Zingg, W. & Pittet, D. (2009). Peripheral venous catheters: An under- evaluated problem. International Journal of Antimicrobial Agents, 34S. S38-S42.