Vous êtes sur la page 1sur 17

10/26/2016

Infusion Nurses Society: Infusion


Therapy Standards of Practice 2016
Updates
Robin Huneke Rosenberg, MA, RN-BC, CRNI, VA-BC

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Disclosure

Speaker is employed at 3M Health Care,


Critical & Chronic Care Division.
-2016 INS Standards of Practice Content
Reviewer
3M Health Care Academy
SM

3M 2015. All Rights Reserved

Discuss the impact of the Infusion Nursing Standards of Practice as an


important part of research and evidenced-based practice on nursing
practice to guide policy, procedure and practice issues.
Describe specific recommendation of the INS Standards of Practice related
to peripheral IV site assessment, device selection, site care and
maintenance, administration set changes, needleless connectors, solution
bags, vascular access device removal and documentation.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

Infusion Nurses Society (INS)


Norwood, Massachusetts
Headquarters
1973 Started as National Association of Intravenous Nurses (NITA)
1987 Name change to Intravenous Nurses Society
2001 Current name
2006, 2011, 2016- Publication dates

Started to address lack of consistency, education and standards for the practice
of I.V. therapy
Currently affiliated chapters exist in 9 countries:
Brazil, Canada, Columbia, Germany, India, New Zealand, Philippines, Russia,
Thailand.
INS active members are in 29 additional countries:
Argentina, Australia, Bermuda, China, Dominican Republic, France, Greece,
Guam, Hong Kong, Indonesia, Ireland, Italy, Jamaica, Japan, Korea, Malaysia,
Mexico, the Netherlands, Nepal, Peru, Puerto Rico, Qatar, Saudi Arabia,
Singapore, South Africa, Taiwan, Ukraine, United Arab Emirates, the United
Kingdom
3M Health Care Academy
SM

3M 2015. All Rights Reserved

Infusion Nursing Standards of Practice


First published in 1981
Most recent upgrade 2016
New edition scheduled release 2021 (Any volunteers?)
Intent - to reflect current knowledge and practices of the clinical nursing specialty of infusion
therapy. Committee of 6 appointed by INS Board for 5 year term
Content Reviewer (67 of them) reviewed outlines & literature based on areas of expertise;
recommendations/revisions submitted and considered before final printing
Disclaimer

Because clinical practice continually evolves based on on-going research, users should make an independent assessment of
the appropriateness and applicability of a standard in any specific instance and should also consider the applicable federal
and state laws and regulations, as well as the standard of care in a particular jurisdiction as these take precedence .

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Under What Authority Does INS


Issue these Standards
The integration of the science of infusion nursing and the mastery of nursing allow these
standards to be recognized:

Nursing is scientific discipline as well as a profession


Nurses use critical thinking
Research generating new knowledge or validating old knowledge
Evidence based practices removes the bias of opinion and tradition when
making decisions

Nurses continually evaluate quality and effectiveness of nursing practice and seek to optimize
outcomes
ANA Scope & Standards of Practice, 2007, p 10

Evidence-Based Practice and Nursing Research:


Avoiding Confusion. Health Leaders Media.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

2016
What changed and what does this mean for
vascular access clinicians?
What was deleted?
What do the recommendations
ask of the clinicians?

What about Vancomycin?

What other content is included


from regulatory bodies?

Does an art line need CHG?

Can I use a midline for vesicants?

Do I change my practice?
What does my
patient know?
3M Health Care Academy
SM

3M 2015. All Rights Reserved

Title formerly known as Infusion Nursing


Standards of Practice

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Because the standards apply to all clinicians..

INS

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

Definitions:
Standard of Care

The level at which the average prudent provider in a given community


would practice.
MedicineNet.com
Standard of Practice

The use of research findings, improvement data and other forms of


evaluation data, and expert opinion to identify methods for improvement .
Evidence-Based Practice and Nursing Research:
Avoiding Confusion. Health Leaders Media.

An idea about morally correct and acceptable behavior


Example

www.Webster-Meriam.com/dictionary/standard

A standard of care is that nursing practice will reduce the risk of infection
while providing infusion therapy.
One standard of practice to achieve this goal is the use CHG for all
intravenous starts.
3M Health Care Academy
SM

3M 2015. All Rights Reserved

How do the new standards impact my


clinical practice?
Know the scope of your licensure: each clinical body is different
Know the scope of your professional organization
Recognize that there can be overlap in professional groups and that no one group has
exclusive ownership of any skill, task or activity

3M Health Care Academy


SM

3M 2015. All Rights Reserved

What is
Evidence Based Practice Criteria?
Defines the practice settings, scope of practice, ethics, competencies and quality
improvement related to infusion therapy.

Defines how the nurse will utilized evidence-based practice and research to guide
policies, procedures and practice issues.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

What do the standards tell me about my practice?


Standards: the "have-to" or requirement of each infusion topic..
Practice Criteria: Based on the evidence found, practice statements are offered for the
clinicians practice.
Weighing of evidence

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Where evidence translates to practice

follows

Provides
additional
Guidelines
recommendations
Established proper steps to
take
Procedures
How do I do it?

Assigns quantifiable measures


(What is required? )

Identifies issue & scope


(Why do I need to do this?)
3M Health Care Academy
SM

Standard Title: Minimum practice criteria


that VA/infusion clinicians are held liable
and accountable

Standards
Policies

3M 2015. All Rights Reserved

Anatomy
of a
standard

Practice Criteria=based
strength of evidence

Regulatory statement
included:
single use safety control
mechanisms

Word usage: based on evidence

Educate: call for specific


criteria for clinical
setting, level V. Facility
to weigh literature and
develop clinical policies
accordingly

Literature references found at the end of each standard


3M Health Care Academy
SM

3M 2015. All Rights Reserved

10/26/2016

Global Infusion/Vascular Access


standards

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Current 2016 standards:


64 Standards of Nursing Practice with
supporting Evidence Based Practice Criteria
under 9 Section Headings

Infusion Therapy Practice


Patient and Clinician Safety
Infection Prevention and Control
Infusion Equipment
Vascular Access Device: Selection & Placement
Vascular Access Device: Management
Vascular Access Device: Complications
Other Infusion Devices
Infusion Therapies

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Sections One, Two, & Three

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

Section Four: Insertion Equipment

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Standard 23: Central Vascular Access Tip


Location
Standard 23.3:
The CVAD tip location with greatest safety profile in adults and children Is the Cavo-Atrial
Junction.
Position the tip of the CVAD in the lower segment of the SVC at or near the CAJ for
adults and children
Effective 2016, catheter tip documentation,
position and confirmation activities
are recommended in the practice criteria section.

IVERA

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Section Five & beyond.its about the plan


and the patient

3M

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

Vascular Access Planning: short peripherals

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Vascular Access Planning: midlines

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Vascular Access Planning:


central vascular devices

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

Vascular Access Planning: Arterial Lines

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Vascular Access Planning (sites)


Select vein that best accommodates the outer
diameter and length of vascular access device
required for therapy
Goal of peripheral access: vein preservation
Site assessment includes: patient age, diagnosis, comorbidities; condition proximal to/of insertion site,
past venipuncture history, type and duration of
therapy
3M Health Care Academy
SM

3M 2015. All Rights Reserved

Vascular Access Panning (other device sites)


Central Access Site:
Hemodialysis Catheter

Central Access Site:


Aphresis Catheter

Central Access Site:


Umbilical Catheter

Peripheral Access Site:


Pediatric

Peripheral Access Site:


Pediatric

Peripheral Access Site:Permission from ddoellman


Adult

author

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10/26/2016

New topics also addressed:


Local anesthesic use
Site preparation
Access limit

3M Health Care Academy


SM

3M 2015. All Rights Reserved

2016 Topic Updates


36

34

37

40

37
34

40

48

3
6
41

57

41
44

64

3M Health Care Academy


SM

3M 2015. All Rights Reserved

New Topics introduced in 2016

Look whats new in 2016

3M Health Care Academy


SM

3M 2015. All Rights Reserved

10

10/26/2016

Standard 34: Practice Criteria G:


Disinfecting Caps

3M Health Care Academy


SM

3M 2015. All Rights Reserved

New topic: MARSI*

(*medical adhesive related skin injury)

skin

Vascular
Device
3M Health Care Academy
SM

3M 2015. All Rights Reserved

MARSI: Definition
A medical adhesive-related skin injury is an occurrence in which erythema
and/or other manifestation of cutaneous abnormality (including, but not limited
to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of
the adhesive.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

11

10/26/2016

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Looking at the skin-adhesive connection


Many tape, dressing, securement
devices and other medical devices
have acrylate based adhesive that
allow the product to stick to the skin
when applied.
The other type of adhesive that is
strong enough to stick under skin
conditions is silicone.
3M Health Care Academy
SM

Acrylate Adhesive

3M 2015. All Rights Reserved

Tape is taperight?
Silicone

What happens during


tape application?

What occurs to the skin


when tape is removed?

3M Health Care Academy


SM

3M 2015. All Rights Reserved

12

10/26/2016

A dressing is a dressingright?

*Recommend use of water proof cover over


dressing and IV site when showering

The TSM (transparent semi-permeable membrane) provides


protection between the outside elements and skin
3M Health Care Academy
SM

3M 2015. All Rights Reserved

Description: Transparent Semi-permeable


Membrane dressings (TSM)
Sterile
Allow for site visibility (i.e. you can see what is happening underneath)
Provide an external barrier
Have moisture vapor release
Have an adhesive layer

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Conditions that affect a TSM performance


Adhesive: Lack of firm, direct pressure to entire dressing surface
Moisture: Interferes with adhesive bond with skin
Channeling and edge lift: providing a direct route to insertion site
Presence of skin hair
Residue: from prior applications
Adhesion promoters a.k.a as tackifiers

3M Health Care Academy


SM

3M 2015. All Rights Reserved

13

10/26/2016

And can cause..

3M Health Care Academy


SM

3M 2015. All Rights Reserved

How to prevent adhesive skin injuries


Prepare Skin, Insertion Site
Remove hair either clipping or trimming. Do NOT shave hair unless
using a sterile, disposable razor. Clean and dry skin to remove soil
and residue.
Perform skin anti-sepsis per facility protocol. Allow product to
completely dry.
Apply skin barrier protection product. Allow to completely dry.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

What does a skin barrier do?


With skin barrier
protection

Example of skin barrier


protection

3M Health Care Academy


SM

ExWithout skin barrier


protection

Example of skin
barrier protection

3M 2015. All Rights Reserved

14

10/26/2016

Apply dressing..
If blood is still present or site continues to ooze, consider using gauze
dressing until bleeding has stopped.
Apply CHG impregnated product, if ordered
Identify adhesive free areas on dressing
Apply dressing to site. Do NOT stretch dressing onto skin; rather place
dressing over skin in the middle; then drop sides.
Use gentle firm pressure after applying to skin; stroking adhesive product or
tape into place
Standard 41: Recommendation to change securement device with dressing
change found (practice criteria H)

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Could these injuries been prevented?


Skin Irritation/Contact
Dermatitis: persists up to 30
minutes post dressing
removal.

Irritant Contact Dermatitis:


Not as distinct, can evolve
over days.

Skin injury due insufficient


Anti-septic dry time prior to
Dressing application

Tension blister caused


from epidermis
Being pulled away from
Dermal layers.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Additional injuries

Skin stripping through top


Skin layers. Epidermis delaminates
And appears as shiny skin. All of
Epidermis detaches from dermis
causing red, weepy skin

Allergic contact dermatitis:


Caused by direct exposure to allergen.
Prolonged exposure to allergen increases
Response. Skin testing (patch testing)
or biopsy/culture can confirm
allergen.

Insufficient dry time prior to dressing


application. Dressing border visible, skin
Weepy (yeast appearance)
3M Health Care Academy
SM

3M 2015. All Rights Reserved

15

10/26/2016

Skin Impairment Algorithm


(Broadhurst, Moureau, Ullman, 2016)

D. Broadhurst,
Used with permission,

3M Health Care Academy


SM

3M 2015. All Rights Reserved

What we, as clinicians can do prevent MARSI?


Use skin barrier all the time, all locations, all conditions. No exceptions.
Remove excessive tape, tape residual from skin surrounding insertion sites. More tape
better adhesion
Use a slow-n-low method of dressing removal from skin. Do not rip

Use low n slow


for tape &
bordered films

Use gentle pull n release


for non-bordered film

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Adhesive Removers
Many of the products, practices to remove dressings are not evidenced based (i.e. using
hand foam) and are non-sterile.
Many removers contain acetone which is extremely flammable but do manage adhesive
sticky-ness
Water and normal saline are effective removal agents; however do not manage the
adhesive sticky-ness
Citrus based solvents contain d-limonene which disrupts skin lipids and can be a skin
irritant. The product also affects future product adhesiveness when applied over same
site.
To date, there is not an exclusive adhesive product for infusion therapy populations.
(Thayer, 2012)

3M Health Care Academy


SM

3M 2015. All Rights Reserved

16

10/26/2016

Conclusion
The 2016 Standards of Practice highlight a more thoughtful, patient centric approach to
vascular access and infusion therapies.

Recognition of non-nursing, nursing, and medical providers becoming more involved in a


once traditional nurse/medical role calls for universal standards of care based on training
Research and the call for evidence based practices in Vascular Access and Infusion
Therapy continue to increase. Activities including line monitoring, data collection,
dressing changes, education/competency, insertion success rates all support the call for a
dedicated team driven to maintain quality and safe arenas for patients.

3M Health Care Academy


SM

3M 2015. All Rights Reserved

Questions?

3M Health Care Academy


SM

3M 2015. All Rights Reserved

References
Broadhurst, D., Moureau, N., Ullman, A. (2016). CVAD Associated Skin Impairment Tool. Author
(electronic communication dated July 15, 2016)
Kutzsche, L. (2012). Management of irritant contact dermatitis and peripherally inserted
central catheters. Clinical Journal of Oncology Nursing (16) 2: E48-58. doi:10.1188/12.CJON.E48-E55
Hadaway, L. (2016). Action Verbs in the Infusion Therapy Standards of Practice, Lynn HadawayBlog post accessed: 6/17/2016
Infusion Nurses Society (2016). Infusion Therapy Standards of Practice. Journal of Infusion
Nursing, (39): 1S
Matsumura, H., et al. (2012). A mode for quantitative evaluation of skin damage at adhesive
wound dressing removal. International Wound Journal, 291-294.
McNichol, L., Lund, C., Rosen, T., Gray, M. (2013). Medical Adhesive and Patient Safety:
Consensus statements for the assessment, prevention, and treatment of adhesive
related injuries. Journal of Wound, Ostomy and Continence Nurse Society,
July/August:1-15.
Thayer, D., (2012). Skin damage associated with intravenous therapy. Journal of Infusion Nursing
(35)6: 390-401.
3M Health Care Academy
SM

3M 2015. All Rights Reserved

17