the importance of proactive cvad care and maintenance€“ the ipps is a system under the social...

CVAD=central venous access device.

The Importance of Proactive CVAD Care and Maintenance

Disclosures This program is presented on behalf of Genentech and the information is consistent with FDA guidelines

I have been compensated by Genentech to serve as a speaker for this program

This program is intended to provide general information about catheter management and not medical advice for any particular patient

This program may be monitored by Genentech for adherence to program requirements

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Objectives1. Discuss why proactive CVAD care is so important

2. Review why nurses should routinely assess for CVAD patency

3. Explore a program that includes patency and competency checks to help improve proactive CVAD care and maintenance in your hospital

Slide 3Lecture notes Objectives1. Discuss why proactive CVAD care is so important

2. Review why nurses should routinely assess for CVAD patency

3. Explore a program that includes patency and competency checks to help improve proactive CVAD care and maintenance in your hospital

[Audience questions: What is currently top of mind for you with regard to CVAD care? How are you thinking of improving CVAD care this year?]


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Why is CVAD care and maintenance so important?

Slide 4Lecture notesWhy is CVAD care and maintenance so important?• Poor catheter management may lead to serious consequences that can impact hospital efficiency and quality

of patient care

• One serious consequence is thrombotic occlusion. If the proper steps are taken to proactively implement quality central venous access device (CVAD) care in your institution, you can help to avoid and detect occlusions before they lead to more serious consequences (Richardson 2007) (Wingerter 2003)

— From an expert in the field of catheter management: "Avoiding catheter occlusion can limit interruption of therapy, reduce risk of trauma to the patient, and decrease the risk

of complications and costs." (Hadaway 2005)

• This presentation will emphasize the importance of proper CVAD care and maintenance, focusing on patency checks—how to effectively check for patency according to the INS, and how to implement a patency protocol in your own institution

INS=Infusion Nurses Society.

Avoiding catheter occlusion can limit interruption of therapy, reduce risk of trauma to the patient, and decrease the risk of

complications and costs.

—Hadaway LC. Nursing. 2005;35(8):54-61.

“ “1


Reference: 1. Hadaway LC. Nursing. 2005;35(8):54-61.

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Catheter occlusion is the most common noninfectious complication

1 in 4 catheters may become occluded, having a serious impact on patient outcomes1

About 58% of catheter occlusions are thrombotic1

Catheter occlusions may occur soon after insertion of a device or develop during the course of IV therapy2

Clinical signs include any of the following: the inability to withdraw blood, inability to infuse fluids, pain, swelling, or leakage2

Slide 5Lecture notesCatheter occlusion is the most common noninfectious complication• Catheter occlusion is the most common noninfectious complication in the long-term use of central venous access devices

(CVADs) (McKnight 2004)

• 1 in 4 catheters may become occluded, having a serious impact on patient outcomes (INS)

• About 58% of catheter occlusions are thrombotic (Stephens 1995)

• Thrombotic occlusions result from the formation of a thrombus within, surrounding, or at the tip of the catheter (NIH 1999)

• Catheter occlusions may occur soon after insertion of a device or develop during the course of IV therapy (Stephens 1995)

• Clinical signs include any of the following: the inability to withdraw blood, inability to infuse fluids, pain, swelling, or leakage (Stephens 1995)

[Audience questions: Do you know the prevalence of occlusions in your organization? What impact do you think occlusions can have on patient outcomes?]

CVAD with fibrin tail and biofilm

Biofilm layer

Thrombus formation

References: 1. Stephens LC, et al. J Parenter Enteral Nutr. 1995;19(1):75-79. 2. National Institutes of Health. Pharm Update. 1999 Nov/Dec:1-4.

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Nurses need to proactively assess CVADs for patency “

“Ensure patency by flushing all lumens following institution policy. If lack of blood return or sluggish flow* is encountered, take measures to ensure patency.

—Association for Vascular Access (AVA) I SAVE That Line campaign

“

“

Slide 6Lecture notesNurses need to proactively assess CVADs for patency

• To ensure that a line is patent, the healthcare provider should always aspirate for a brisk, free-flowing blood return (INS 2011)

— This is the ability to withdraw blood at 3 mL in 3 seconds, as defined by the Oncology Nursing Advisory Board (Cummings-Winfield 2008)

• Beyond a lack of free-flowing blood return, the healthcare provider should also be aware of all signs of a blockage, including (McKnight 2004) (Hadaway 2005)

— Inability to infuse fluids

— Increased resistance when flushing

• It’s important to remember that flushing the line is not enough. The healthcare provider must be able to withdraw blood before ruling out a partial occlusion. With a partial occlusion, infusion is possible, but aspiration is not (INS 2011) (Camp-Sorrell 2004)


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*According to the Oncology Nursing Advisory Board, sluggish flow is defined as blood return of <3 mL in 3 seconds.2

The nurse should aspirate for a positive blood return from the vascularaccess device (VAD) to confirm device patency prior to administrationof parenteral medications and solutions.

—Infusion Nurses Society (INS) Standards of Practice, 2011

References: 1. Infusion Nurses Society. J Infus Nurs. 2011;34(suppl 1):S1-S110. 2. Cummings-Winfield C, et al. Clin J Oncol Nurs. 2008;12(6):925-934.

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Occluded catheters may have a serious impact on patientsComplications from catheter occlusions include:

Extravasation1,2

Infiltration1

Delayed administration of critical therapies3

Thrombophlebitis4

Venous thrombosis (rare)5

Potential loss of site and replacement of line6

Increased length of stay and delayed discharge7

Slide 7Lecture notesOccluded catheters may have a serious impact on patients

An undetected catheter occlusion may lead to serious, painful consequences that can worsen a patient’s condition. These include:

• Extravasation: the result of vesicant fluids leaking into the surrounding tissues; can lead to pain, swelling, and tissue necrosis (INS 2011) (Mayo 1995)

• Infiltration: the leaking of nonvesicant fluids into the surrounding tissues; can cause pain, discoloration, and swelling (INS 2011)

• Blocked or delayed administration of critical therapies to patients (Nakazawa 2010)

• Thrombophlebitis: vein inflammation that can occur from the development of a fibrin sheath (Herbst 1996)

• Venous thrombosis (rare): a rare yet potential complication, along with pulmonary embolism (Wingerter 2003)

• Potential loss of site and replacement of the line (Cummings-Winfield 2008)

• Increased length of stay and delayed discharge (Warye 2009)

Example of extravasation in shoulder area4

Used with permission, JVAD Spring 2003

Port location

References: 1. Infusion Nurses Society. J Infus Nurs. 2011;34(suppl 1):S1-S110. 2. Mayo DJ, et al. Oncol Nurs Forum. 1995;22(4):675-680. 3. Nakazawa N. Semin Oncol Nurs. 2010;26(2):121-131. 4. Herbst SL. J Infus Chemother. 1996;6(4):186-194. 5. Wingerter L. Clin J Oncol Nurs. 2003;7(3):345-348. 6. Cummings-Winfield C, et al. Clin J Oncol Nurs. 2008;12(6):925-934. 7. Warye K, et al. Healthc Financ Manage. 2009;63(1):86-91.

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The CDC estimates approximately 41,000 CLABSIs occur annually in the United States1

According to the Joint Commission, CLABSIs can result in up to a 3-week hospital stay2

Slide 8Lecture notesThe association between occlusion and infection

• Studies show an association between thrombotic catheter occlusion and catheter colonization or sepsis (Segreti 2011) (Raad 1994) (Timsit 1998)

— Raad et al found a 23% incidence of central line–associated bloodstream infections (CLABSIs) in postmortem patients (N=72) with thrombotically occluded catheters (Raad 1994)

– Patients without a thrombotic occlusion had zero CLABSIs

— Timsit et al reported that the presence of catheter-related thrombosis (N=208) increased the risk of catheter-related sepsis by 2.6-fold (Timsit 1998)

• How is thrombus formation associated with infection risk?

— It’s caused by the interaction of fibrin, blood components, and a biofilm layer that attracts, encloses, and protects bacteria and other microorganisms (Ryder 2001) (Hadaway 2005)

— Aggressive flushing may shear off part of the biofilm or thrombus, releasing microorganisms into the bloodstream (Ryder 2001) (Hadaway 2005)

• What is the potential impact of CLABSIs? (Joint Commission 2012)

— CLABSIs are one of the most deadly types of hospital-acquired infections, with a mortality rate of up to 25%

— The CDC estimates approximately 41,000 CLABSIs occur annually in the United States— According to the Joint Commission, CLABSIs can result in an up-to-3-week hospital stay

CDC=Centers for Disease Control and Prevention.

CDC=Centers for Disease Control and Prevention.

The association between occlusion and infectionCentral line–associated bloodstream infections (CLABSIs) are one of the most deadly types of hospital-acquired infections, with a mortality rate of up to 25%1

References: 1. Centers for Disease Control and Prevention. CDC Vital Signs. http://www.cdc.gov/vitalsigns/pdf/2011-03-vitalsigns.pdf. Published March 2011. Accessed November 11, 2014. 2. The Joint Commission. Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May 2012. http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf. Accessed November 11, 2014.

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Thrombotic occlusions may impact cost of care

Slide 9

•Replacing a line costs between $1,012 and $2,6821*

•Central line–associated bloodstream infections (CLABSIs)

may cost $16,155 per patient, according to a recent study2

•Hospitals do NOT receive higher payment rates for CLABSIs3

•Hospital value-based purchasing: CLABSIs will account for

30% of a total performance score4

Slide 9Lecture notesThrombotic occlusions may impact cost of care

• Replacing a line is invasive, posing clinical risk, and expensive. Depending on the type of central venous access device, replacement can be anywhere from $1,012 to $2,682 (CMS Final Hospital OPPS Addendum B 2015)

• Central line–associated bloodstream infections (CLABSIs) may cost $16,155 per patient, according to a recent study (Dick 2015)

— CLABSIs can result in up to an extra 3-week hospital stay, as reported by the Joint Commission (Joint Commission 2012)

• Implications with the Inpatient Prospective Payment System (IPPS)

— Under the IPPS, hospitals do not receive higher payment rates from the Centers for Medicare & Medicaid Services for hospital-acquired infections (including CLABSIs) (CMS 2014)

[Additional talking points if needed for IPPS:]

– The IPPS is a system under the Social Security Act that provides payment for acute care hospital stays, based on prospectively set rates

– Payments are categorized into diagnosis-specific groups, with a payment weight assigned based on the average resources used to treat Medicare patients in that group

– Since October 2008, hospitals do not receive higher payment rates when certain conditions are not present at admission and could have been prevented through evidence-based guidelines

• CLABSIs will be 1 of the 5 outcome measures included in value-based purchasing (CMS 2014)

— Starting in fiscal year 2015

— Collectively, these outcomes will represent 30% of a hospital’s total performance score

References: 1. Centers for Medicare & Medicaid Services. Addendum B. Final OPPS payment by HCPCS code for CY 2015. 2015. http://www.cms.gov/apps/ama/license.asp?file=/hospitaloutpatientpps/downloads/2015-Jan-Addendum-B-File.zip. Accessed January 15, 2015. 2. Dick AW, et al. Am J Infect Control. 2015;43(1);4-9. 3. Centers for Medicare & Medicaid Services Web site. Acute inpatient PPS. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Accessed November 10, 2014. 4. Centers for Medicare & Medicaid Services Web site. National provider call: hospital value-based purchasing. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing. Accessed November 11, 2014.

*CMS Final Hospital Outpatient Prospective Payment System (OPPS) payment plus minimum adjusted copayment.

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Central line–associated bloodstream infections (CLABSIs)—is your hospital’s reputation at stake?

CLABSI data can be easily accessed on Medicare.gov’s Hospital Compare website1

Most hospital-acquired infections—including CLABSIs—can be prevented through proper precautions and procedures1

Recreated from Hospital Compare website.

Slide 10Lecture notesCLABSIs—is your hospital’s reputation at stake?

Central line–associated bloodstream infection (CLABSI) data are compared against a national benchmark.

• Data can be easily accessed on Medicare.gov’s Hospital Compare website

• Healthcare-associated infections, including CLABSIs, are reported using a standardized infection ratio that compares the number of infections in a hospital to a national benchmark based on data from the National Healthcare Safety Network

— If the confidence interval is

– Below 1, hospital had fewer infections than similar hospitals

– At 1, hospital has a comparable number of infections to similar hospitals

– Above 1, hospital has more infections than similar hospitals

— Lower numbers are better, and zero CLABSIs is considered best

Proper procedure can pay off

• According to the Hospital Compare website, most hospital-acquired infections—including CLABSIs—can be prevented through proper precautions and procedures

• Studies also indicate that a hospital’s patient satisfaction scores are linked to the quality of satisfaction with infusion care (Harpel 2013)

— Skills of nurses are ranked as the fourth level of importance (ranking just behind friendliness), with a focus on the skill of the nurse who “started the IV”

• According to the CDC, “Research shows that when healthcare facilities, care teams, and individual doctors and nurses are aware of infection problems and take specific steps to prevent them, rates of some targeted HAIs (eg, CLABSI) can decrease by more than 70 percent.” (CDC 2015)

[Questions for audience: Are you familiar with how your hospital is performing in terms of CLABSI rates? Do you know where you stand against other organizations and the national benchmark? This particular institution’s CLABSI rates are worse than the national benchmark—do you have any thoughts on what could have caused this?]

0

AN EXAMPLE OF MEDICARE.GOV CLABSI DATA

Better than US National Benchmark

Worse than US National Benchmark

1.0 2.0 3.0 4.0 5.0+

A US MEDICAL CENTER

STATE BENCHMARK

0.5

1.7

US NationalBenchmark

Reference: 1. Centers for Medicare & Medicaid Services Web site. Hospital Compare. http://www.medicare.gov/hospitalcompare/ search.html. Accessed November 10, 2014.

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Take action: Implement a program for proactive CVAD care and maintenance

Assess needs and identify gaps

Slide 10

Create an education plan with competency checks

Review policies and procedures and standardize patency checks

Monitor metrics to evaluate effectiveness and share performance


Slide 11Lecture notesTake action: Implement a program for proactive CVAD care and maintenance

It’s time to take action with a plan for implementation.

• Assess needs and identify gaps

• Review policies and procedures throughout the hospital and standardize patency checks

• Create an education plan with competency checks

• Establish and monitor metrics to evaluate the effectiveness of the implemented plan and share performance


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Slide 12Lecture notesAssess needs and identify gaps• Establish baseline data and identify gaps in knowledge, competency, and processes as they relate to your staff’s protocol

on central venous access device (CVAD) care and checking for patency (McCarthy 2006) (Johns Hopkins Quality and Safety Research Group 2014)

— Assess needs by recording the steps taken for CVAD care and maintenance

— Trends can be realized through the accurate collection of audit data (Harpel 2013)

— Genentech’s CVAD Quality Tracker (see slide 23 in the Appendix) can provide you with an overall view on how your institution is performing in terms of properly maintaining the function of a central line

– Provides documentation that a healthcare provider has walked through the appropriate steps when performing care and maintenance of a patient’s CVAD, and can be used to evaluate improvement or any gaps in proper CVAD care

– Provides a necessary step in checking for patency, ensuring that the healthcare provider is assessing the line for a brisk blood return

— Genentech Nurse Surveys can help gauge the knowledge of nurses who manage central lines (see slide 24 in the Appendix)

Other expert recommendations to determine how your institution is performing:

• Assess the implications of catheter occlusions, including the overall costs of central line–associated bloodstream infections (CLABSIs) (Johns Hopkins Quality and Safety Research Group 2014)

• If possible, complete a root cause analysis of all infections to determine how many are related to CVAD care or thrombotic occlusion (Data on file 2009)

CVAD=central venous access device; PICC=peripherally inserted central catheter.

Establish baseline data and identify gaps in knowledge, competency, and processes as they relate to your staff’s protocol on central venous access device (CVAD) care and checking for patency1,2

References: 1. McCarthy D, et al. Committed to safety: ten case studies on reducing harm to patients.http://www.commonwealthfund.org/Publications/Fund-Reports/2006/Apr/Committed-to-Safety--Ten-Case-Studies-on-Reducing-Harm-to-Patients.aspx. Published April 27, 2006. Accessed November 14, 2014. 2. On the CUSP: stop BSI comprehensive unit-based safety programmanual. Johns Hopkins Quality and Safety Research Group. Michigan Health and Hospital Association Keystone Center for Patient Safety &Quality. http://onthecuspstophai.org/wp-content/uploads/2012/04/CUSP-Manual-with-Appendices-A-N.pdf. Accessed November 14, 2014.

Nurses Survey

Department Shift

1. According to the INS (Infusion Nurses Society) Standards of Practice, when should a central venous access device (CVAD) be assessed for patency?

A. At the beginning or end of a shift B. At least once daily C. Before infusing medications/fluids D. At dressing change

2. How do you define a patent catheter?

3. How do you define a dysfunctional catheter?

4. How often do you see a line/lumen passed off as “not working”?

A. Never B. Daily C. More than twice per week D. Other ___________

5. How do you communicate the condition of a patient’s CVAD to the nurse on the next shift? (Circle all that apply)

A. Electronic Medical Records (EMR) B. Written shift report C. Verbal report D. I don’t report the condition unless it’s not working

6. Is it necessary to have each/all lumen(s) functioning in a multilumen catheter?

A. Yes B. No

Nurses Survey

Department Shift










A. Yes B. No

CVAD/PICC Line—Care & Maintenance Checklist

Date: Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10

Hand hygiene performed with all CVAD/PICC care

Clean gloves donned prior to CVAD/PICC care

CVAD/PICC site without redness, swelling, or drainage (Y/N)

Change CVAD/PICC dressing every________daysDate of CVAD/PICC dressing change________

Scrub the hub for________seconds

Change needleless connector every________daysNeedleless connector changed on________

Change infusion tubing every________daysInfusion tubing changed on________

Re-access port every________daysDate of port access________

Each lumen of CVAD/PICC flushes without resistance (Y/N)

Each lumen of CVAD/PICC has brisk blood return (3-5 mL) (Y/N)

If no, follow hospital policy on restoring function to CVAD/PICC

Able to draw labs from CVAD (Y/N)

Was this documented? (Y/N)

Type of CVAD (eg, PICC, port)

Number of lumens

Comments:

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Review policies and procedures

Review your organization’s policies, procedures, and protocols. Are they aligned to evidence-based standards?

Example of evidence-based protocol from the Association for Vascular Access

Slide 13Lecture notesReview policies and proceduresStandardization is key to implementing hospital-wide improvement (INS 2011)

• Develop and integrate evidence-based, standardized policies and procedures— Is checking patency, as indicated by the Infusion Nurses Society and the Oncology Nursing Advisory Board,

part of your policies and procedures?

— Is your organization aligned with the National Institutes of Health when faced with an occlusion? When a catheter becomes occluded, the main goal is to restore function (NIH 1999)

— Use the CDC, IHI, and AVA as a guide for overall central venous access device (CVAD) care and maintenance. They offer specific, best practices for the care and maintenance of central lines, included in best practices bundles

• Integrate policies and procedures aimed at reducing the risk of thrombotic occlusions and central line–associated bloodstream infections (CLABSIs) in each unit (Joint Commission 2014)

— Develop a “patency pact” in your hospital: institutionalize hospital-wide patency checks to always keep patency top of mind

– Make sure that everyone in your hospital understands the value of patency. By doing this you can ensure that it is always a focus and an essential part of hospital-wide protocol, and is included on central line checklists and quality trackers

— Institutionalize central line bundles in your staff’s protocol (Joint Commission 2014) (IHI 2012) (O’Grady 2011)

– Care bundles are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement (IHI 2012) (O’Grady 2011)

– Use checklists for insertions with instructions to halt the procedure for breaks in sterile techniqueCDC=Centers for Disease Control and Prevention; IHI=Institute for Healthcare Improvement; AVA=Association for Vascular Access.

Follow these important principles when inserting,using, and maintaining any vascular access device.

CRUPULOUS HAND HYGIENEis necessary before and after contact with any vascularaccess device

MPLEMENT INSERTION, CARE, AND MAINTENANCE BUNDLES

to minimize the risk of intraluminal and extraluminalcontamination

LWAYS DISINFECT EVERY NEEDLELESS CONNECTORprior to each access for solution and medication administration, flushing, or tubing changes

EIN PRESERVATIONis achieved by assessing for best device and site selectionto reduce the risk for complications, such as thrombus formation and infection

NSURE PATENCYby flushing all lumens following institution policy. If lack of blood return or sluggish flow is encountered, take measuresto restore patency

"KEEP PATIENTS FREE OF INFECTION!" For more information, contact the Association for Vascular Access (AVA) at www.avainfo.org or call 1-801-792-9079 or 1-877-924-AVA1 (2821)

CAT0000557401

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Are your protocols aligned with evidence-based standards?

Five key components of essential CVAD care and maintenance:

1. Hand hygiene

2. Maximal barrier precautions

3. Chlorhexidine skin antisepsis

4. Optimal catheter site selection, avoiding the use of the femoral vein for central venous access in adult patients

5. Daily review of line necessity, with the prompt removal of unnecessary lines

Your protocol for CVAD insertion, care, and maintenanceThis central line insertion strategy should be the protocol for every drug that will be administered through a central venous access device (CVAD). Bundled strategies improve performance and act as benchmarks for performance improvement. They should be implemented together, rather than individually, for better outcomes1,2

Slide 14Lecture notesAre your protocols aligned with evidence-based standards?Bundled strategies improve performance and act as benchmarks for performance improvement. They should be implemented together, rather than individually, for better outcomes. These steps can be incorporated into a central venous access device (CVAD) checklist or quality tracker to ensure protocol is being followed.

The “central line bundle,” 5 key components for CVAD care and maintenance, comprises (IHI 2014)

1. Hand hygiene• Wash hands, or use an alcohol-based, waterless hand cleaner to help prevent infection

2. Maximal barrier precautions• Strict compliance with washing hands, wearing a cap and sterile gown, and gloves

3. Chlorhexidine skin antisepsis• A better skin antisepsis than other agents and proven in reducing infection

4. Optimal catheter site selection, avoiding the use of the femoral vein for central venous access in adult patients• Site of insertion is not a risk factor for infection when experienced physicians insert the catheters, strict sterile technique is

used, and trained intensive care unit nursing staff perform catheter care. In addition, some studies cite that the femoral site is a greater risk factor in patients

5. Daily review of line necessity, with the prompt removal of unnecessary lines• Risk of infection increases over time. Risk is reduced when an unnecessary line is removed

Other bodies, such as the CDC and the SHEA/IDSA, add 2 more recommendations:• Educate healthcare workers on indications and proper procedures for IV catheters• Use of checklists for insertions with instructions to halt the procedure for breaks in sterile technique

CDC=Centers for Disease Control and Prevention; SHEA=Society for Healthcare Epidemiology of America; IDSA=Infectious Diseases Society of America.

References: 1. O’Grady NP, et al; the Healthcare Infection Control Practices Advisory Committee (HICPAC). Clin Infect Dis. 2011;52(9):e162-e193.2. How-to guide: prevent central line-associated bloodstream infections (CLABSI). Cambridge, MA: Institute for Healthcare Improvement; 2012. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCentralLineAssociatedBloodstreamInfection.aspx. Accessed November 14, 2014.

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Assess patient for pain or discomfort

Palpate insertion site

Flush the line to determine resistance

Aspirate for positive blood return (3 mL in 3 seconds)

Prior to administration of medications or solutions:

Slide 13

*Based on standards from the INS and Oncology Nursing Advisory Board.1-3

Slide 15Lecture notesAre your protocols aligned with evidence-based standards?

A routine assessment for catheter functionality, based on standards from the INS and Oncology Nursing Advisory Board

Patency should be checked

• Prior to the administration of any medications or solutions

A complete assessment for patency should include the following:

• Aspiration for positive blood return— Defined by the Oncology Nursing Advisory Board as 3 mL in 3 seconds

– Indications of a blockage include (McKnight 2004) (Hadaway 2005):— Lack of blood return— Sluggish blood return— Inability to withdraw fluids

• Attempt to flush to determine resistance— When flushing a connector or CVAD, flush with an adequate volume of saline or appropriate flush solution

— Palpate insertion site

— Palpation is especially important with a peripheral catheter; it can help determine tenderness or other indications of a central line–associated bloodstream infection (CLABSI)

• Assess patient for pain or discomfort

[Question to audience: To what extent are your nurses aspirating for brisk blood return before administration of medications?]

INS=Infusion Nurses Society.

Prior to administration of medications or solutions:

References: 1. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(suppl 1):S1-S110. 2. Infusion Nurses Society Web site. http://www.ins1.org/files/public/QA_Session_1_Webinar.pdf. Accessed November 10, 2014. 3. Cummings-Winfield C, et al. Clin J Oncol Nurs. 2008;12(6):925-934.

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Your protocol for CVAD functionality1-3

Slide 16Lecture notesAre your protocols aligned with evidence-based standards?• Make sure you have an organization-wide protocol to manage occluded central venous access devices (CVADs)

— Clinicians need to ask questions – Is it a thrombotic occlusion or something else? – A mechanical obstruction should first be ruled out

• Nurses should be trained to assess the cause of a dysfunctional catheter

— Nonthrombotic causes that could result in no brisk blood return include (Nakazawa 2010) – Tip migration – Catheter damage (pinch-off syndrome), kinks in the catheter, catheter breakage – Disconnection of the catheter from the implanted port

Some questions to ask if you do not get a brisk blood return (INS 2011):

— Sudden occurrence or a slow reduction in blood?

— Is there discomfort, pain, or edema at the insertion site?

— Does the blood return change based on the position of the patient?

— What fluids and medications have recently been infused?

• If no external cause can be found, then the nurse can determine that this is a thrombotic occlusion

• When a catheter becomes occluded, the main goal is to restore function

Sluggish flow or inability to withdraw blood or infuse fluid through the catheterg

Check for presence of mechanical obstruction

Suspect thrombotic occlusion

Flow restored

Obstructionremains

References: 1. Infusion Nurses Society Web site. http://www.ins1.org/files/public/QA_Session_1_Webinar.pdf. Accessed November 10, 2014. 2. National Institutes of Health. Pharm Update. 1999 Nov/Dec:1-4. 3. McKnight S. Medsurg Nurs. 2004;13(6):377-382.

Adapted from McKnight S.

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Standardize patency checks and create a culture of accountability

Slide 17

Identify a champion to support initiative

Institute patency checks in electronic health records and/or nursing notes so that checking for patency is standardized and documented throughout the hospital

3 mL

Create incentives for adhering to protocol

Slide 17Lecture notesStandardize patency checks and create a culture of accountabilityOnce you’ve established your protocol, how can you create increased vigilance around patency checks in your hospital?

• Institute patency checks in electronic health records and/or nursing notes so that checking for patency is standardized and documented throughout the institution

— A custom field can be added into electronic health records to monitor for improvement and to encourage daily checks for patency (Harpel 2013)

— If electronic health records are not available, nurses can document patency checks in their notes or with a CVAD checklist, and include them with the patient chart

• Identify a champion to support initiative (Pronovost 2010) (On the CUSP 2014) — Hospital leaders will be responsible for monitoring infection rates and supporting/championing prevention initiatives

(Pronovost 2010)

• Assembling a vascular resource team can also help with educational initiatives and in initiating and guiding procedures (Harpel 2013)

• Clinicians inserting and maintaining catheters must be accountable for performance, complying with evidence-based practices (Pronovost 2010)

• Create incentives for adhering to protocol

— Competitions, awards, certificates—any program that keeps patency top of mind and helps staff strive toward following procedure

[Questions to audience: How can your hospital standardize patency checks? Are nurses expected to check for patency on every shift?]

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Create an education plan to support patency and CVAD care

Slide 18Lecture notesCreate an education plan to support patency and CVAD care An education plan may inspire confidence and encourage adherence to procedures

• Provide consistent education

— Aim for quarterly or annual education (Joint Commission 2015)

• Educate healthcare workers on indications and proper procedures for IV catheters (Nakazawa 2010)

• Ensure competency checks

— Ensure competency checks for proper CVAD insertion and maintenance (O’Grady 2011)


Educate staff … about central line–associated bloodstream infections and the importance of prevention.

—The Joint Commission, 2015 National Patient Safety Goals1

“ “

Slide 17

Evaluate knowledge

Provide consistent education

Ensure competency checks

Slide 17

Evaluate knowledge

Provide consistent education

Ensure competency checks

Ensure competency checks for proper CVAD insertion and maintenance.2

References: 1. The Joint Commission. National Patient Safety Goals Effective January 1, 2015. Hospital Accreditation Program. http://www.jointcommission.org/hap_2015_npsgs/. Accessed January 16, 2015. 2. O’Grady NP, et al; the Healthcare Infection Control Practices Advisory Committee (HICPAC). Clin Infect Dis. 2011;52(9):e162-e193.

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Slide 19Lecture notes3 key steps to monitoring progress

1. Identify key metrics and document central venous access device (CVAD) assessments

• Establish and monitor metrics to evaluate the effectiveness of the implemented plan (Data on file, Moureau) — According to the National Patient Safety Goals, compliance with evidence-based practices should be monitored, and the

effectiveness of infection prevention efforts should be evaluated (Joint Commission 2015)

2. Regularly gather and assess data• Identify a team member to gather, analyze, and periodically report data

— This could be a member of the vascular access team (Harpel 2013) (Data on file)• Assess quality improvement by frequently checking for patency

— Utilize a CVAD quality tracker (Harpel 2013)

• Conduct periodic risk assessments for central line–associated bloodstream infections (CLABSIs) (Joint Commission 2015)

• Document initial and ongoing CVAD assessments, nursing assessments, interventions, and patient responses (INS 2011)

• Monitor knowledge and competency related to procedures, including patency checks

3. Share results, identify corrective actions, and reevaluate your goals• Continuously share results with key stakeholders, and reevaluate new goals and targets

for improvement

Slide 16

1. Identify key metrics and document CVAD assessments

3. Share results, identify corrective actions, and reevaluate your goals

2. Regularly gather and assess data


3 steps to monitor progress

20

Slide 20Lecture notesHow Genentech can help

Genentech offers a variety of resources to help your institution with education and training.

In-person and peer-to-peer training• In-person training for small groups of nurses, helping to train staff with experts in vascular access using hands-on, peer-to-peer

education on the principles of good catheter management

Speaker’s bureau• Thought-leader education on a broad range of catheter-management topics• Speaker presentation on-site or via Web

CathMatters.com• A comprehensive resource for practical tools, support, and information designed to help enhance catheter management. Helps

to improve skills through interactive learning based on unique needs

CathEd™: Interactive Learning Management System• Teaches central line assessment and management in an engaging digital format—videos, illustrations, and animations are

available

HealthStream.com• Educates nurses on the importance of central line assessment and proactive management of catheters

How Genentech can helpGenentech offers a variety of resources to help your institution with education and training:

In-person peer-to-peer training

Speaker’s bureau

CathMatters.com

CathEd™: Interactive Learning Management System

HealthStream.com

21

Slide 21Lecture notesSummary: What have we learned?• Catheter occlusion is the most common noninfectious complication, with 1 in 4 catheters becoming occluded

• Infection due to thrombotic occlusion may have a serious impact on your patients and on the reputation of your hospital

• Patency checks should be standardized across the hospital

Slide 18

•Catheter occlusion is the most common noninfectious complication with 1 in 4 catheters becoming occluded

•Infection due to thrombotic occlusion may have a serious impact on your patients and on the reputation of your hospital

•Patency checks should be standardized across the hospital

Summary: What have we learned?

22

Slide 22

Appendix

23

• Determine how your organization is performing

• Evaluate improvements and identify gaps

• Ensure patency checks


Slide 23Lecture notesAssess needs and identify gaps• Genentech’s CVAD Quality Tracker can provide you with an overall view on how your organization is performing in terms

of properly maintaining the function of a central line

— Provides documentation that a healthcare provider has walked through the appropriate steps when performing care and maintenance of a patient’s CVAD, and can be used to evaluate improvement or any gaps in proper CVAD care

— Provides a necessary step in checking for patency, ensuring that the healthcare provider is assessing the line for a brisk blood return


CVAD=central venous access device;PICC=peripherally inserted central catheter.

CVAD/PICC Line—Care & Maintenance ChecklistDate: Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10

Hand hygiene performed with all CVAD/PICC care

Clean gloves donned prior to CVAD/PICC care

CVAD/PICC site without redness, swelling, or drainage (Y/N)

Change CVAD/PICC dressing every________daysDate of CVAD/PICC dressing change________

Scrub the hub for________seconds

Change needleless connector every________daysNeedleless connector changed on________

Change infusion tubing every________daysInfusion tubing changed on________

Re-access port every________daysDate of port access________

Each lumen of CVAD/PICC flushes without resistance (Y/N)

Each lumen of CVAD/PICC has brisk blood return (3-5 mL) (Y/N)

If no, follow hospital policy on restoring function to CVAD/PICC

Able to draw labs from CVAD (Y/N)

Was this documented? (Y/N)

Type of CVAD (eg, PICC, port)

Number of lumens

Comments:

24

• Help gauge the knowledge of nurse administrators and nurse educators

• Ask questions essential to quality CVAD care and maintenance, including adherence to proper procedure based on expert guidelines

Create an education plan to support patency and CVAD care

Slide 24Lecture notesCreate an education plan to support patency and CVAD care

Evaluate knowledge with Genentech Nurse Surveys• Help gauge the knowledge of nurse administrators and nurse educators • Ask questions essential to quality CVAD care and maintenance, including adherence to correct procedures

and expert guidelines


Nurses Survey

Department Shift










A. Yes B. No

25

ReferencesCamp-Sorrell D, ed. Access Device Guidelines: Recommendations for Nursing Practice and Education. 2nd ed. Pittsburgh, PA: Oncology Nursing Society; 2004.

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Centers for Disease Control and Prevention. Making health care safer: reducing bloodstream infections. CDC Vital Signs. http://www.cdc.gov/vitalsigns/pdf/2011-03-vitalsigns.pdf. Published March 2011. Accessed November 11, 2014.

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Centers for Medicare & Medicaid Services Web site. Acute inpatient PPS. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Accessed November 10, 2014.

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References (cont’d)Centers for Medicare & Medicaid Services Web site. Hospital-acquired conditions. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Accessed November 14, 2014.

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Data on file, Genentech Inc. Doellman D. Best practices in pediatric central venous catheter care: a case study from Children’s Medical Center of Dallas. Doc. Revised April 6, 2009. Accessed November 14, 2014.

Data on file, Genentech Inc. Moureau N, Macher G. Best practices in central venous catheter care: case study from UPMC Hamot. Accessed November 14, 2014.

Dick AW, Perencevich EN, Pogorzelska-Maziarrz M, Zwanziger J, Larson EL, Stone PW. A decade of investment in infection prevention: A cost-effectiveness analysis. Am J Infect Control. 2015;43(1):4-9.

Hadaway LC. Reopen the pipeline for IV therapy. Nursing. 2005;35(8):54-61.

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References (cont’d)Harpel J. Best practices for vascular resource teams. J Infus Nurs. 2013;36(1):46-50.

Herbst SL. Options for venous access in ambulatory care: issues in selection and management. J Infus Chemother. 1996;6(4):186-194.

How-to guide: prevent central line-associated bloodstream infections (CLABSI). Cambridge, MA: Institute for Healthcare Improvement; 2012. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCentralLineAssociatedBloodstreamInfection.aspx. Accessed November 14, 2014.

Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(suppl 1):S1-S110.

Infusion Nurses Society Web site. Aspirating a blood return from a catheter: Webinar Q&A session. http://www.ins1.org/files/public/QA_Session_1_Webinar.pdf. Accessed November 10, 2014.

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The Joint Commission. Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May 2012. http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf. Accessed November 11, 2014.

Mayo DJ, Pearson DC. Chemotherapy extravasation: a consequence of fibrin sheath formation around venous access devices. Oncol Nurs Forum. 1995;22(4):675-680.

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References (cont’d)McCarthy D, Blumenthal D. Committed to safety: ten case studies on reducing harm to patients.http://www.commonwealthfund.org/Publications/Fund-Reports/2006/Apr/Committed-to-Safety--Ten-Case-Studies-on-Reducing-Harm-to-Patients.aspx. Published April 27, 2006. Accessed November 14, 2014.

McKnight S. Nurse’s guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):377-382.

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