1. Dallas, TX November 2–4, 2012 Risk Benefit Analysis of Central Venous Access Devices Julie D. Painter RN MSN OCN Clinical Nurse Specialist Community Health Network Indianapolis, IN jpainter@ecommunity.com

2. Dallas, TX November 2–4, 2012 Risk-Benefit Analysis of CVAD’s Session Code:102 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 List the steps in the process of risk- benefit analysis Describe risk-benefit analysis as it applies to various CVADs

4. Dallas, TX November 2–4, 2012 Retrospective View Until the late 1970’s CVAD’s were not common in our patients Peripheral IV’s were the mainstay of intravascular therapy –most were made of metal and not flexible Central lines were commonly temporary subclavian & femoral caths & dialysis shunts for patients with leukemia Broviac and Hickman developed devices to assist in long term infusion that would meet the needs of our patients(right atrial silastic catheters)-most had only been used in the world of pediatrics to this point Venous ports, peripherally inserted central catheters

5. Dallas, TX November 2–4, 2012 Current State of Practice In 2012 we are at a point in practice where CVAD’s are common place Commonplace and so that perhaps we have lost our respect and diligence of the CVAD 500,000 CLABSI’s per year in the United States Increased length of stay 11-23 days Cost to healthcare per episode $33,000-$55,000- New info from VHA states potentially >$100,000 Mortality 5-7%

6. Dallas, TX November 2–4, 2012 A solid venous access device program will result in the least amount of risk to institution & patient with the greatest benefit to the institution & patient

7. Dallas, TX November 2–4, 2012 So how does one go about analyzing the risk and benefit of central venous access devices and processes??

8. Dallas, TX November 2–4, 2012 Value = Cost/Quality Cost is More than Money!! Quality=Risk/Benefit ratio

9. Dallas, TX November 2–4, 2012 Definition of Risk 1.A possibility of loss or injury; peril 2.Someone or something that suggests hazard 3.The degree of probability of loss or potential of peril Meriam-Webster Dictionary, 2012

10. Dallas, TX November 2–4, 2012 Definition of Benefit 1.Something that promotes well-being 2.A good or helpful result or effects Meriam-Webster Dictionary, 2012

11. Dallas, TX November 2–4, 2012 Risk & Benefit Viewed as institutional/facility risk benefit OR Viewed as personal risk & benefit for the patient

12. Dallas, TX November 2–4, 2012 Weighing risk vs. benefit

13. Dallas, TX November 2–4, 2012 Institutional or Facility Risk Inability to meet CMS measures with CLABSI’s Increased hospital acquired infections(HAI’s) Increased length of stay Increased cost from HAI & length of stay Reduction in reimbursement Loss of insurance contracts due to CLABSI Public reporting influences consumer choice & marketing(e.g. HCAPHS

14. Dallas, TX November 2–4, 2012 Patient Risk Increased morbidity Complications upon insertion- pneumothorax, hemothorax Infection, thrombosis, & migration up to 30% Superior vena cava obstruction Pulmonary emboli

15. Dallas, TX November 2–4, 2012 Patient Risk with Central Venous Access Device Infection Phlebitis Thrombus/DVT Infiltration Breakage Dislodgement/disconnection Increases in morbidity & mortality(due to HAI) Unnecessary risk due to inappropriate selection of venous access device

16. Dallas, TX November 2–4, 2012 Infection Risk & Sources Intraluminal Skin Extraluminal More lumens greater risk Diameter Duration of placement

17. Dallas, TX November 2–4, 2012 Infection Risk-Sources of Infection-Intraluminal Intraluminal-the catheter hub; stopcocks; injection ports; needle free connectors; connecting and disconnecting IV tubing's-without proper technique & devices to reduce infection introduction the bacteria are directly injected into the lumen and directly into the blood stream As we introduce bacteria into the bloodstream

18. Dallas, TX November 2–4, 2012 Infection Risks Endocarditis Osteomyelitis Septic joints Septic emboli Abscesses in remote locations

19. Dallas, TX November 2–4, 2012 How do we break the cycle of introducing infection? #1 Look at the product and the design of your needleless access device-proper technique #2 Look at the process of disinfecting the access device-proper technique #3 Look at the frequency of access device exchange Ryder studies related to access devices and factors that influence greater risk of a blood stream infection; have looked at design such as split septum and the shape of the top of the cap and a)Access mechanism b)Flow path c)Fluid displacement

20. Dallas, TX November 2–4, 2012 Infection Prevention Hand washing Meticulous respect of all central lines Dressings-occlusive Dressing change and care procedure- chlorhexadine, masks, sterile technique Cleansing of injection caps Tubing changes Reduction of interruptions & opening of lines

21. Dallas, TX November 2–4, 2012 Thrombosis Research notes that position of catheter tip determines risk of thrombosis Incidence of proven thrombosis corelated due to tip placement: 2.6% Distal 5.3%Intermediate 41.7% Proximal(16 Xmore)

22. Dallas, TX November 2–4, 2012 Thrombosis Greater risk in females Greater risk when placed in left side vs. right side History of hypercoagulability or DVT’s

23. Dallas, TX November 2–4, 2012 Institutional Benefit Appropriate line selection & care results in best possible quality outcomes Best outcomes results in meeting CMS and other payer expectations(contracting & reimbursement) Enhanced patient satisfaction when appropriate line selected and best outcomes occur Reduced costs related to LOS; CLABSI

24. Dallas, TX November 2–4, 2012 Patient Benefit Satisfaction Quality, safe outcomes without compromise from the desired state of care & well-being The expectation of our patients is that the care we provide is competent and state of the knowledge

25. Dallas, TX November 2–4, 2012 Benefits of CVAD Reduction of peripheral IV sticks for labs, medications, etc Reduced discomfort & anxiety related to PIV sticks Enhanced patient satisfaction

26. Dallas, TX November 2–4, 2012 Types of Peripheral Access Peripheral IV line Midline-duration of placement can last up to 30 days

27. Dallas, TX November 2–4, 2012 Types of CVAD’s Temporary non-tunneled caths such as subclavian or femoral lines Right atrial silastic (groshong, hickman) Venous port Peripherally inserted central catheters (PICC)

28. Dallas, TX November 2–4, 2012 Is there a need for a CVAD? Every institution needs a systematic approach to determining appropriate venous access Determine tools/algorithms to use to evaluate patient needs

29. Dallas, TX November 2–4, 2012 Before we place CVAD’s in our patients we must know that we have done our due diligence & have the best interest of the patient at the forefront of every intervention in care!

30. Dallas, TX November 2–4, 2012 Unique Patient Characteristics for Consideratio n History of DVT Previous Central Venous Access Devices Risk of Infection-Immunosuppression Hypercoagulability Previous lymph node removal Pacemaker placement Work or lifestyle

31. Dallas, TX November 2–4, 2012 Evaluation of Patient for a CVAD Duration of therapy Exhausted peripheral options including Midline Type of medication & fluids Irritant vs. non-irritant vs. vesicant Lab draws Patient co-morbid conditions

32. Dallas, TX November 2–4, 2012 Patient Case Situation #1 65 year old male; admitted for osteomyelitis due to dog bite Teaches golf at the local country club and amateur golfs at least 3-4 times per week Will need 45 doses of intravenous antibiotics Has excellent peripheral IV status but antibiotic is considered an irritant

33. Dallas, TX November 2–4, 2012 Patient Case Situation #2 48 year old female admitted with newly diagnosed stage III breast cancer 6 weeks post right mastectomy with total lymph node dissection & reconstructive surgery Will need every 3 week chemotherapy treatments and lab draws, chemotherapy regimen includes 2 vesicant agents

34. Dallas, TX November 2–4, 2012 These were examples of individualized risk benefit analysis but let’s consider a broader facility view of risk benefit analysis

35. Dallas, TX November 2–4, 2012 Process for Risk Benefit Analysis 1.Understand the definition of risk & benefit 2.Be open to looking at everything & leave “no stone unturned” 3.Determine the processes and practices that are taking place within your facility 4.Know your data and measurements that reveal outcomes of quality, safety and satisfaction related to central venous access devices 5.Utilize structured mechanisms to compare & contrast your practice to evidence based practice and national standards

36. Dallas, TX November 2–4, 2012 Have we done due diligence? Evaluate the number of central line days in comparison (National Healthcare Safety Network benchmark) Are peripheral IV starts being utilized first Are vein enhancement devices used to assist in peripheral IV starts Are the central lines appropriate

37. Dallas, TX November 2–4, 2012 What components in central venous access devices must be considered in our analysis? Line selection-algorithm or process Process for ordering & requesting Practice-is it evidence based? Does it match national benchmarks? Does it adhere to national standards(e.g. CDC) Line data-what does it show? What is it telling you? Types of lines; # of line days ; Products Number of persons involved in process Validation of expertise & competency of those inserting lines Process for monitoring outcomes-what does the data show? Risk events/reports-trends Use of central line bundle for placement Use of central line bundle practices

38. Dallas, TX November 2–4, 2012 Pitfalls in Analysis Process As we analyze our processes we often want “the quick fix” We want to take the “broad brush” approach to just start changing and adjusting the process Making any change or variation in a process influences outcomes

39. Dallas, TX November 2–4, 2012 Analysis-Takes Time There is no quick fix yet the problems that you find may appear small, you must look at the entire process Look at the way the process is “supposed to be” to the “way that actually is occurring” This requires us to be out there and work with each person who touches the process

40. Dallas, TX November 2–4, 2012 The Team Clinical Leadership(example CNS) Infection Prevention Quality Risk Management Bedside Staff Nursing Education Epidemiology & Physician Expert in process improvement-if available

41. Dallas, TX November 2–4, 2012 Analysis-Review the Process Review the process from A to Z- from the assessment & decision point to place a central line in a specific patient to the point of removal or discharge of the patient Include a review of the processes utilized to determine type of line; process for placement scheduling; timing;etc. Process for all line care from cap changes; dressing changes; line accessing; tubing changes; fluids and discontinuation

42. Dallas, TX November 2–4, 2012 Analysis-Diagram & Audit Diagram the process(es) from the perspective of policy; then meet with the persons who do the process; those who select the lines; those who place the lines; those who care for the lines; and anyone who touches the lines Audit the process-often best to have a set of “fresh eyes” a person who is naïve to the process and without preconceived notions

43. Dallas, TX November 2–4, 2012 Analysis-Ask Questions Questions: How did the processes map out? Do the 2 processes match?-Reality meets perception! What are the areas of conflict or concern? Any breaks in the system or areas of risk? In the review were products consistent?

44. Dallas, TX November 2–4, 2012 Determination of Change Once items have been reviewed by the team & actual practice audited- determine the process for enhancing outcomes What items are not meeting best practice & need changed a.s.a.p. Take standards and evidence based practice to improve policy & competency

45. Dallas, TX November 2–4, 2012 Determination of Change Meet with unit staff & leadership to help make the change Education-multi-modalities Implement Audit Evaluate and continue the process to sustain the gain!

46. Dallas, TX November 2–4, 2012 Remember the care we mentor & teach today will be the care “we” as patients & our loved ones will receive today & in the future. If the care you see is not what you would want then be a part of making the CHANGE