Every day, you make clinical decisions about many aspects of patient care, but you face challenges for many situations. Your first choice for a resource is the facility policy and procedure book, or to check other valued textbooks. Another option is to ask a trusted colleague. But what happens when your questions remain unanswered, or you wonder if practice can be made safer through use of more recent evidence. The Institute of Medicine established a goal of having 90% of clinical decisions based on the latest evidence but we are far from that goal.
When do you have the time to go to a computer, sign on to a search engine, locate the needed papers and analyze them?
That is where we can help!
Our Evidence-Based Practice Reports asks a clinical question, then provides a concise report based on the latest published evidence. We include term definitions, analysis of studies, recommendations for practice and the complete list of references used.
We have just released a new EBP Report – Venipuncture and Lymphedema
The Clinical Questions are
Numerous guidelines have statements instructing patients to avoid all punctures on the ipsilateral arm after breast cancer surgery. This recommendation based on a theory dates back to 1921. Almost 100 years later we still do not have a complete scientific answer. We did find 4 systematic literature reviews on these questions, but the studies are not high-level evidence and are conflicting. What happens when all veins in the unaffected arm cannot be found or your patient has had bilateral breast cancer? Learn more about the evidence for these decisions by obtaining this paper here.
The first EBP Report is Continuous and Intermittent IV Sets
The Clinical Questions are:
We welcome your ideas for new EBP Reports. Please email your suggestions.
Finally, as a free service, we have compiled a paper on infusion therapy references. This list includes textbooks, journals, and standards and guidelines. Find a copy of Your Infusion Library here .
And we are not finished with free services! All customers purchasing an online course, EBP report, recorded presentation, or other consulting services are invited to join a closed discussion group on Facebook – STIC or Stop the Infusion Confusion, an online, private community. The group discussions are facilitated by Lynn with her unique point of view as an experienced infusion therapy educator. Post questions and obtain continued support through interactive discussions. Watch for your invitation by email after your purchase.
Intravenous (IV) therapy is increasing in skilled nursing facilities for several reasons. The number of IV medications is increasing and expanding to treat more diagnoses than ever before. The length of these IV medications may be a few doses, a few days, or the rest of the patient’s life. Medical diagnoses treated with a variety of IV fluids and medications include diabetes, heart failure, and many types of infections, which can be common among residents. Skilled nursing facilities (SNF) fill a great void when patients are not a candidate for home infusion services or when frequent travel to an ambulatory infusion clinic is not possible. Additionally, needs of current residents change and could easily include treatment with IV fluids and medications in your SNF.
Value-based purchasing is being applied to skilled nursing facilities, after 10 years of experience in acute care hospitals. The focus for the SNF is on potentially preventable readmissions (SNFPPR) to an acute-care hospital. A quick look at the list of PPR conditions includes many that require treatment with intravenous infusions. Additionally, inadequate management of vascular access devices is well document to cause bloodstream infection and vein thrombosis. Central line associated bloodstream infection (CLABSI) has been regarded as a preventable hospital-acquired condition for the past 10 years. Its occurrence in a hospital means significant reduction in Medicare payments to the hospital.
Is your nursing staff prepared to safely deliver IV fluids and medications? Can they safely insert a peripheral IV catheter and correctly administer the prescribed therapy while preventing serious complications like phlebitis, infiltration/extravasation, nerve injury, and infection?
We can help with a different approach...
We combine online delivery with a skills lab, reducing classroom time while providing a valuable learning experience. The online course material is based on the familiar nursing process – one chapter each on patient assessment, planning, intervention, and evaluation. The nurse chooses the time and place to access the course material online and has access to the material for a year. The goal is knowledge acquisition and critical thinking. After successful completion determined by passing an online exam, the skills lab offers a full day of practice in a structured simulation lab. Practice is guided by case studies and repetition is encouraged until the learner is comfortable. This is followed by a de-briefing session to discuss the specific skill and follow up on additional questions.
The next Peripheral IV Therapy Skills day is March 28th. This offers a great way for developing IV therapy skills in your nursing staff. Register your nurses now to immediately begin the online class as its completion is required to attend the Skills Lab.
Also atch for our next announcement about next blended learning offering - Central Venous Access Devices COMING SOON.
The 2016 Infusion Therapy Standards of Practice call for use of a large, sterile transparent membrane dressing over the probe for peripheral catheter insertion or a sterile probe cover along with sterile gel (page S45). Also, these standards support increased attention to strict aseptic technique by using sterile gloves when placing a peripheral IV catheter. (page S65).
There are several objections to these standards with some citing the cost of sterile probe covers. Others cite the possible conflict with the Use of Ultrasound to Guide Vascular Access Procedures, from the American Institute of Ultrasound in Medicine (AIUM). This document can be found at http://www.aium.org/resources/guidelines/usgva.pdf
This document states that maximum sterile barrier precautions are not needed for peripheral IV access, but goes on to state that a sterile probe cover or a transparent film dressing may be placed over the probe and that sterile gel is preferred.
The INS Standards consider one aspect of care not addressed by the AIUM guidelines. The standard for removal of a PIVC is now based on clinical indications and not removal by a certain number of days or hours of dwell time. Many clinicians automatically assume that this means these catheters can be allowed to dwell for extended periods of time. Research shows that the actual dwell time for PIVC is far less than 72 to 96 hours, with most failing less than 48 hours of dwell. Longer dwell times are possible but we must use every tool for strict aseptic technique to reduce the risk of PIV catheter associated infections. A sterile probe cover, or sterile transparent membrane dressing and sterile gel must be included in those tools.
Midline catheters are 3- to 8-inch-long catheters; are inserted into peripheral veins; and require the use of sterile probe covers for insertion. USGPIVCs are 2 or even 3 inches long. Why should there be a lower level of aseptic technique for one and not the other?
The studies referenced in the INS Standards are descriptive studies using sterile technique for insertion of USGPIVC, which makes this Level V evidence. To my knowledge there are no higher-level studies comparing sterile vs non-sterile technique with USGPIV insertions. The literature search for these standards was completed in early 2015, and there may be newer studies published since then.
Although the level of evidence is low at present, we know that PIVC associated infections do occur, yet they are not tracked and documented like CLABSI. Patients are often discharged before clinical signs and symptoms of infection are seen. PIVC associated infections are being seen in lawsuits now. I firmly believe that sterile technique is required for USGPIVC insertion. And all clinicians must focus on better aseptic techniques for insertion of all PIVCs!
When should a chest xray be repeated during the dwell time for any central vascular access devices (CVAD)? This is a frequent question for many nurses and facilities and it involves several different scenarios.
There is a risk of radiation exposure, albeit small, from a routine chest xray. Reducing their use will reduce this exposure along with decreasing costs. However, there will be clinical situations when the benefits outweigh these risks.
When a new patient with a PICC or implanted port is admitted to your facility or agency, the first option is to check documentation of the original tip location at the time of insertion. But there will be many times when this information is not available. Do you know about tip location practices in other facilities or agencies in your area? Some may still be using the old “midclavicular” tip location for PICCs with the inserted catheter length based exclusively on external measurement. Some practitioners may not understand or acknowledge the importance of tip location at the cavoatrial junction, leaving the tip high in the superior vena cava. This means the first reason would be a suboptimal tip location on insertion.
The second reason would be clinical signs and symptoms of a malfunction or malposition which can occur at any time for many reasons. Clinical assessment of all CVADs is on ongoing process while the patient is under your care. Signs and symptoms are outlined in an evidence-based list in the 2016 Infusion Therapy Standards of Practice and includes:
For many years, we have overlooked the infection risk associated with peripheral IV (PIV) catheters while focusing exclusively on infection risk associated with central vascular access devices. Our attention must include both! While there is no doubt that published rates of central line associated bloodstream infection (CLABSI) were far too high, we must take a closer look at the rates of BSI that are associated with PIV catheters as well.
Unfortunately, there is very little prospective data on actual PIV-BSI rates. There are 2 unique studies on Staphylococcus aureus BSI that used retrospective data to analyze the problem. These studies reported similar processes and outcomes. Both studies used medical records to identify patients with S. aureus BSI and correlated blood culture results with clinical data.
Trinh, et.al, reported 24 cases of S. aureus BSI related to PIV catheters. They reported these patients to be more likely to have the PIV inserted in the emergency department or outside the hospital and to have the PIV placed in the antecubital fossa. Of all S. aureus BSI, 12% were caused by PIV catheters. Using this data and data on all US hospital adult discharges, these researchers estimated that as many as 10,000 PIV-BSIs from S. aureus alone happen in US hospitals.
Austin, et.al, reported 34 of 445 (7.6%) of all S. aureus BSI were related to thrombophlebitis at a PIV catheter site. The length of the bacteremic period was longer in patients with PIV-BSI, primarily caused by methicillin-resistant S. aureus BSI. Most cases were caused by PIV catheters inserted in the proximal forearm and antecubital fossa. Also, most cases were due to thrombophlebitis at old PIV sites. No guidelines recommend frequent monitoring of previous PIV catheter sites for developing or worsening signs and symptoms of thrombophlebitis, however this study indicates the necessity for monitoring sites after PIV removal.
The bottom line is the need for careful aseptic technique with each PIV catheter insertion. Don’t use veins of the antecubital fossa. One or two swipes on the skin with an alcohol pad is not sufficient. Touching the prepped site with gloved fingers can only be done when wearing sterile gloves. All methods of infection prevention must be used. Hospitals are no longer reimbursed for treating infections associated with any type of vascular access device, including PIV-BSI. Strict attention to PIV catheter insertion and maintenance is just as important as the attention we now give to central VADs.
Short Peripheral Intravenous Catheters and Infections
Trinh, T. T., Chan, P. A., Edwards, O., Hollenbeck, B., Huang, B., Burdick, N., . . . Mermel, L. A. (2011). Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infection control and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America, 32(6), 579.
Austin, E. D., Sullivan, S. B., Whittier, S., Lowy, F. D., & Uhlemann, A.-C. (2016). Peripheral intravenous catheter placement is an underrecognized source of Staphylococcus aureus bloodstream infection. Paper presented at the Open forum infectious diseases.
Online Course Updated - Peripheral IV Therapy in Adults
One of our most popular courses has been updated with content that incorporates the 2016 Infusion Therapy Standards of Practice.
Start out on the right track with this basic course. If you are new to IV therapy, this course will provide the needed information about all steps in process of patient assessment, planning what is needed, performing the procedures and assessing the outcomes.
Click here to learn more!
Were you taught to use the axillary lines to determine the tip location for a midline catheter? If so, you need to learn a better method as these lines are nowhere near the appropriate location for the tip of a midline catheter.
According to the 2016 Infusion Therapy Standards of Practice, a midline catheter is defined as “a catheter inserted into the upper arm via the basilic, cephalic, or brachial vein, with the internal tip located at or near the level of the axilla and distal to the shoulder.” The axilla is the armpit and this tip location describes placement in the upper arm. A midline catheter must remain in the upper extremity for adults and should never go into the shoulder or chest area.
There are 3 axillary lines used for guidance on many procedures like thoracentesis and for placement of various ECG leads. Look at the drawing and notice that all axillary lines are on the chest and do not involve the arm. The anterior axillary line would be the closest to a midline tip location, however using this axillary line would put the midline tip location directly in the shoulder where joint motion will lead to catheter complications. The midclavicular line was the tip location of a midclavicular catheter, however studies in the late 1990’s showed that tip location to have a greater risk of vein thrombosis. For this reason, the INS Standards have never included the midclavicular tip location.
To achieve the midline tip location as defined by the INS Standards, place your index finger in the patient’s armpit and bring your thumb around the circumference of the upper arm at that level. This is the correct midline catheter tip location. Choose your insertion site and measure between these 2 points. Insert that length of catheter and you will have a correctly placed midline catheter meeting the definition in the national standards. For clinicians with a bad experience with midline catheters, could this be the reason for their failure?
Twas the night before Christmas, and all through the ward,
Not a patient was stirring, not a thing to record.
The charts were all placed in their slots with great care,
In hopes that the doctors would leave them right there.
I’d complete my rounds, all the meds and re-starts,
Hung three units of blood, and restocked all the charts.
When far down the hall, there arose such a clatter,
I sprang from the desk to see what was the matter.
Away down the hall, I flew like a flash,
Rounded the corner, and met with a crash
A jolly old man, all covered with snow
With a round little belly and cheeks all aglow.
“What are you doing here?”, I exclaimed in surprise,
As he twinkled at me with his fat little eyes.
“Visiting hours were over at eight.
It is now after twelve. You are much, much too late.”
“Nurse, don’t you know me?”, he said with a smile.
“And now that I’m here, can’t I stay for a while?”
“I’m afraid I don’t know you”, I exclaimed quite irate.
The confusion was such I’d forgotten the date.
“But nurse, I have come such a long way” he said
“And I couldn’t show up until all were in bed.”
“Your excuses are slim and this you must know.
Rules are made to be kept; I must ask you to go.”
For answer he lifted a sack from his back,
Put it down on the floor and began to unpack.
More RN’s and LPN’s with infusion experience,
I knew it would brighten the entire team’s spirits!
Other gifts followed. He had them right there.
All the things that were needed for the good patient care.
For each of the doctors, a smiling machine,
So each could look pleasant, although he felt mean.
For each of the nurses, A SALARY RAISE!!!!
Saying tell them for me dedication still pays.
The best of all gifts, he then pulled out with glee,
For each patient, the right VAD!
Then I saw that the man I had almost thrown out,
Looked very familiar, as he turned about.
And I asked him to stay, “Please don’t go!” I grew bolder.
But he finished his job, putting his bag on his shoulder.
He sprang to his sleigh waiting there on the roof.
With eight tiny reindeer, the ultimate proof,
Of just who he was and as he flew out of sight,
“Merry Christmas” he called, and “God Bless you this night.”
Feel Free to Download and use how you see fit!
We will be back in January with announcements about new online courses and video conferences!
- Lynn and Megan
Can the dressing on a tunneled PICC be eliminated after the tunnel is “healed”? The short answer is NO!
The practice of putting in a PICC using a subcutaneous tunnel seems to be growing. Separating the venipuncture site from the skin exit site may have benefits such as moving the exit site out of the area of neck motion and possible reduction in bloodstream infection from skin organisms, although the evidence supporting infection reduction is not strong.
A small size PICC inserted in the jugular vein offers the benefits of bypassing the subclavian vein, a site with higher risk of vein thrombosis. This may be beneficial in -renal failure patients where axillo-subclavian thrombosis can present significant concerns.
But don’t confuse a PICC inserted with a short subcutaneous tunnel with a tunneled cuffed catheter (e.g., Hickman®, Broviac®). The subcutaneous tunnel for a PICC is much shorter than the subcutaneous tunnel for a tunneled cuffed CVAD. A tunneled cuffed CVAD has a cuff made of a rough material encircling the outer lumen of the catheter. This cuff is positioned several centimeters away from the skin exit site usually in the middle of the chest. The subcutaneous tissue grows into this cuff causing a mechanical barrier to the migration of skin microorganisms into the bloodstream. It also adds a form of stabilization to prevent dislodgement of the CVAD. A tunneled PICC usually does NOT have this cuff encircling the catheter. Long-term hemodialysis catheters also have this subcutaneous cuff. I am not certain how many brands of PICCs are made with this subcutaneous cuff, however I don’t think there are many.
A question I recently received asked about no dressing on a tunneled PICC after it has “healed”, citing the statement in the INS Standard. The statement from the standard on dressing changes is, “When the subcutaneous tunnel is well-healed, consideration may be given to no dressing with a tunneled, cuffed CVAD.” (page S83) It specifically states a tunneled, cuffed CVAD, and this does not apply to PICCs. This statement applies to the time required for the subcutaneous tissue to grow into the cuff. That time varies with each person and depends upon many factors. Once again, most PICCs are not made with these cuffs and a stabilization device and a dressing is required for all PICCs. Skin irritation and inflammation should be prevented by using a skin barrier solution from the very first dressing. This solution (e.g., Skin-Prep®, Cavilon®) are solutions to prevent this irritation, but they are not designed to heal the skin after the irritation is present. Medical adhesive related skin injury (MARSI) is discussed in several standards and the use of this barrier solution is strongly recommended.
A common problem continues to be raised – the absence of information about the original tip location for a PICC when the patient is transferred to another venue of care, especially if multiple transfers are involved. For instance, the PICC is placed while the patient is in the hospital. He is then transferred to a rehabilitation or skilled nursing facility for a period of time and is then transferred home and admitted to a home care agency. No information is provided to the home care agency about the original tip location, or any change in the external measurements.
How should the PICC be used until the original documentation can be obtained? Will it be possible to obtain the original information? Should administration of vesicants and non-vesicants be managed the same way? Without the original documentation, should the PICC be removed with the patient in the home or should the patient be sent to the hospital or practitioner’s office for removal?
While a PICC may be the most common CVAD used in these situations, the standard of practice for tip location applies to all CVADs. As we all know, information about the original tip location should go with the patient with each transfer but we know that does not always happen. Additionally, a tunneled cuffed catheter or implanted port may have been inserted months or even years before admission to the current home care company. So there are many situations where the original tip location will not be known. But remember this documentation was only for the location of the CVAD tip at insertion.
Many factors can lead to CVAD tip migration during the dwell time, including physical activity, heaving lifting, ventilation, congestive heart failure, or anything that changes intrathoracic venous pressure. Although specific data on the frequency of malposition is not available, patients that have been receiving physical therapy in a rehabilitation program could easily have changes in the tip location. This may happen more frequently if the original tip location was sub-optimal in the mid to upper superior vena cava.
Tip migration means that only the CVAD tip is moving and the external segment of the catheter remains unchanged. The tip could migrate to the jugular vein, the opposite subclavian vein, or any number of small tributary veins. Tip migration is sporadic and unpredictable. Dislodgment is a change in the length of the external catheter, which also means that the tip location is retracted by that same distance. These are just 2 examples of malposition but this could also include the catheter tip eroding through the vein wall or cardiac wall, formation of a fistula between an artery and vein or other structures such as the trachea.
Before infusing through any CVAD, a complete assessment is necessary. This goes way beyond reliance on information about the original tip location. In addition to assessing for a blood return from each lumen, you should also include flushing to detect difficulty or resistance; changes in blood pressure, heart rate, and/or respiratory rate; any type of pain, discomfort, and/ or presence of edema in the back, neck, shoulder, or chest; complaints of hearing a running stream on the side of the CVAD insertion; and neurological problems like paresthesia. Any problem found during this assessment means the CVAD should not be used until a diagnostic test can be done to determine the cause of the problem. The presence of a blood return that is the color and consistency of whole blood and the absence of all other signs or symptoms of a complication indicates the CVAD can be used. I would apply the same assessment to vesicants and non-vesicants. Although a vesicant has the potential to cause tissue damage for a variety of reasons, a non-vesicant can also cause tissue damage due to compression from the volume infused. Also remember that a vesicant causes the damage OUTSIDE the vein but vein thrombosis is quite common with intravascular malposition.
Removal of a PICC or other percutaneous CVAD in the home is routinely done and the nurse may not know the exact location of the tip. If there is a change in how the catheter is functioning or some other complication, it might be wise to have the patient return to a clinic or practitioner office for removal. Each situation requires a thorough assessment and application of critical thinking skills.
While the original tip location information is important to have, it really provides no information about where the tip is located weeks or months into the dwell time and use of the catheter. You must rely on your assessment of the patient and the CVAD. When signs and symptoms of malposition are present, a diagnostic test such as a chest radiograph or ultrasound is needed.
Many questions still arise about the need for informed consent for a midline catheter. My answer is Yes and No! To ensure that all who read this understands my thoughts, I need to emphasize the definition of informed consent from the 2016 INS Standards of Practice:
“A person’s voluntary agreement, based upon adequate knowledge and understanding of relevant information, to participate in research or to undergo a diagnostic, therapeutic, or prentice procedure”
Standard #9 provides more details on informed consent, emphasizing this as an educational process based on shared decision-making. This standard does not provide a list of procedures that require informed consent.
If you are thinking of “informed consent” as the signature on a piece of paper, the answer is either yes or no for a midline catheter insertion based on the direction of your risk management department. They will know about any applicable state laws regarding informed consent. Risk management’s decision should be included in your policy and procedure for midline catheter insertion.
I would also encourage you to broaden your thinking about informed consent. This is an educational process that ends with a signature on a piece of paper but the patient’s adequate knowledge comes from what they are taught, preferably by the midline inserter who would have the most current and accurate knowledge about this procedure.
The educational component of the informed consent process is always required for all procedures and all patients in all situations. Even if your facility does not require a signature on that consent form, you should still be educating the patient about the catheter, why they need it, what the procedure will entail, risks, benefits, and complications. If a signed consent form is required, the education must also include alternatives to the proposed midline catheter.
So, the possible answers are
Both approaches still require patient education. The INS standard on informed consent includes 9 criteria for appropriate education for the patient’s age and level of health literacy. Please check out this standard for the details.
Author: Lynn Hadaway
Lynn Hadaway has more than 35 years experience in infusion nursing and adult education. Her experience comes from multiple acute care settings, healthcare manufacturing, continuing professional education.