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WINTER 2010 VOLUME 22 ISSUE 1 SPECTRUM Inside This Issue By: Paul L. Blackburn The gold standard for verification of catheter tip location has long been a chest radiograph. In fact, if you look at many of the organizational guidelines or standards, radiographic tip confirmation is suggested. According to the INS Standards of Practice (2006): “42.5 Central catheter tip location shall be determined radiographically and documented prior to initiation of the prescribed therapy.” LITE: A national educational association for infusion therapy, vascular access, home care, oncology, acute care and extended care Letter from the President Golden Rules of IV Therapy LITE 2010 Annual Educational Conference Preview LITE 2010 Preview: Welcome to the Conference! LITE 2010 Preview: Blood Management Overview Business Networking Skills for Conventions and Meetings Thank You to Our Sponsors and Exhibitors THE CHEST RADIOGRAPH — THE GOLD STANDARD? But are chest radiographs really the gold standard or just a well accepted standard of practice? In reality, there is no law on the books in any U.S. state that requires a chest radiograph to be completed prior to the use of a centrally placed catheter. In many instances, other techniques for central catheter tip confirmation are frequently used, such as fluoroscopy at the time of catheter placement (okay so this is just a moving form of x-ray, but nonetheless a different modality), MRI, and transesophageal echocardiogram (TEE). Recently, several new modalities have entered or are entering the U.S. market in the form of Doppler and ECG catheter tip placement. Several studies report enhanced accuracy in optimal catheter tip positioning with the use of cardiac electrical signal detection (Alexander et al, 2010; Jeon et al, 2006). This method is facilitated by ECG electrode attachment to both the patient and catheter stylet. Catheter tip positioning information is then provided during the insertion procedure via observation of the shape and size of the P wave as the catheter tip is threaded along specific anatomical locations within the central vasculature (Jeon et al, 2006, p. 978-80). In a more recent study, Jeon et al (2006) affirmed that the tallest peaked P waves occurred with CVC tip location at the cavoatrial junction, whereas the normally shaped P waves occurred at the mid to upper SVC. Further observation CONTINUED ON PAGE 4

10 Golden Rules of IV Therapy

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Page 1: 10 Golden Rules of IV Therapy

W I N T E R 2 0 1 0 V O L U M E 2 2 I S S U E 1

S P E C T R U M

Inside This Issue

By: Paul L. Blackburn The gold standard for verification of catheter tip location has long been a chest radiograph. In fact, if you look at many of the

organizational guidelines or standards, radiographic tip confirmation is suggested. According to the INS Standards of Practice (2006):

“42.5 Central catheter tip location shall be determined radiographically and documented prior to initiation of the prescribed therapy.”

L I T E : A n a t i o n a l e d u c a t i o n a l a s s o c i a t i o n f o r i n f u s i o n t h e r a p y , v a s c u l a r a c c e s s , h o m e c a r e , o n c o l o g y , a c u t e c a r e a n d e x t e n d e d c a r e

• Letter from the President

• Golden Rules of IV Therapy

• LITE 2010 Annual Educational Conference Preview

• LITE 2010 Preview: Welcome to the Conference!

• LITE 2010 Preview: Blood Management Overview

• Business Networking Skills for Conventions and Meetings

• Thank You to Our Sponsors and Exhibitors

THE CHEST RADIOGRAPH — THE GOLD STANDARD?

But are chest radiographs really the gold standard or just a well accepted standard of practice? In reality, there is no law on the books in any U.S. state that requires a chest radiograph to be completed prior to the use of a centrally placed catheter. In many instances, other techniques for central catheter tip confirmation are frequently used, such as fluoroscopy at the time of catheter placement (okay so this is just a moving form of x-ray, but nonetheless a different modality), MRI, and transesophageal echocardiogram (TEE). Recently, several new modalities have entered or are entering the U.S. market in the form of Doppler and ECG catheter tip placement.

Several studies report enhanced accuracy in optimal

catheter tip positioning with the use of cardiac electrical signal detection (Alexander et al, 2010; Jeon et al, 2006). This method is facilitated by ECG electrode attachment to both the patient and catheter stylet. Catheter tip positioning information is then provided during the insertion procedure via observation of the shape and size of the P wave as the catheter tip is threaded along specific anatomical locations within the central vasculature (Jeon et al, 2006, p. 978-80). In a more recent study, Jeon et al (2006) affirmed that the tallest peaked P waves occurred with CVC tip location at the cavoatrial junction, whereas the normally shaped P waves occurred at the mid to upper SVC. Further observation

C O N T I N U E D O N P A G E 4

Page 2: 10 Golden Rules of IV Therapy

Patricia Luptak, RN, OCN, BSED, MS

President Jefferson Regional Medical Center

412-469-7129

[email protected]

Diane DeStefano, RN, OCN, BSN

Presidential Advisor Jefferson Regional Medical Center

412-469-5370

[email protected]

Mary Ferris, RN, BSN, OCN, CRNI

Vice President St. Clair Infusion Center

412-942-3559

[email protected]

Denise Haught, RN, CRNI

Treasurer Accredo Therapeutics

1-866-890-3395 ext. 82467

[email protected]

Nancy Hrebenach, RN

Advisory Council Jefferson Regional Medical Center (retired)

412-844-0525

[email protected]

Marjorie King, RN, BSN

Advisory Council Washington Hospital (retired)

724-225-1698

[email protected]

LITE EXECUTIVE COMMITTEE

Dear Colleagues, We are nearing the end of winter and looking forward to spring and the renewal of life and the warm weather. With that renewal of spirit in spring, let’s think about the renewal of our professional spirit and life. Education is such an important part of growing personally and professionally. Our mission at LITE is to enhance your knowledge and help to expand your horizons on many different aspects of education related to vascular access and the associated areas of healthcare. We embrace your ideas and encourage you to contact us to share what you need from us as an organization.

We would also encourage you to become involved with us personally! We know that many of you would like to become involved in our organization in planning our seminar or educational meetings, or perhaps would like to teach a PICC class but don’t know how to become involved. If that is the case, please e-mail [email protected] or call 412-244-4338. Remember, you do not have to live in the Pittsburgh area to participate: We have conference call-in capabilities for our meetings.

LITE hopes to re-energize in this season of renewal with new ideas and new members to carry our mission into the future. We look forward to hearing from you, our members, because this is YOUR organization. Take full advantage of your membership and the services we provide. Happy Spring! Sincerely,

Patty Luptak President

LETTER FROM THE PRESIDENT

“Nurses dispense comfort, compassion and caring without even a prescription.”

Val Saintsbury

Page 2 S P E C T R U M

Patricia Luptak, RN, OCN, BSED, MS President of LITE

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By: Sue Masoorli, RN President/CEO Perivascular Nurse Consultants

Vascular access devices and related infusion therapies are the second highest category for nursing malpractice lawsuits. This is probably due to the large number of patients receiving infusion therapy at the hands of nurses and doctors who have little or no training. The importance of nurses utilizing proper insertion techniques, proper infusion techniques and proper assessment techniques cannot be denied. Following these golden rules will significantly improve patient safety and promote patient satisfaction. Rule No. 1 Avoid areas of joint flexion. The antecubital fossa, the wrist area and the ankle area in neonates, should be avoided for the insertion of peripheral IV devices. Rationale: These are considered areas of joint flexion. Flexing the joint will increase the pistoning movement of the IV device within the vein. Movement of the catheter can cause the catheter to puncture the vein wall, resulting in the leakage of IV fluids into the surrounding tissue. The risk of IV complications such as infection, infiltration, extravasation, phlebitis, septic thrombophlebitis and nerve injury have been well documented in the nursing literature when IV devices are improperly inserted in these areas.

Rule No. 2 Avoid the three inch area of the wrist over the distal radial bone. The cephalic vein and radial nerve are very superficial in this area. Avoid the three inch area on the ventral side of the arm, just above the palm. The median nerve is very superficial in this area. Rationale: Radial nerve injury is a commonly reported complication when peripheral IV devices are inserted in these areas. When an IV device is inserted and the patient complains of an “electric shock” sensation or numbness and tingling, the nerve has been touched by the needle. Remove the IV device immediately. Complex Regional Pain Syndrome (CRPS) can be the result of a needlestick injury to the nerve. Eliminating these two areas, for the insertion of peripheral IV devices, will drastically reduce the incidence of venipuncture related injuries. Rule No. 3 All central venous catheter tips including PICC lines, implanted ports, tunneled and non tunneled catheters must have radiographic confirmation that the catheter tip is in the superior vena cava prior to use. All nurses, who infuse IV fluids or medications through any central venous catheter, are required to know the correct anatomical location of the catheter tip prior to use.

DON’T MISS OUT ON LITE: RENEW NOW! C O N T I N U E D O N P A G E 4

Golden Rules of

IV Therapy

Does your membership expire soon? If so, be sure to renew so you won’t miss

out on any of LITE’s conferences, e-blasts and more!

Visit www.lite.org to renew your membership online, or print off a membership

application to fill out and mail in. Renew today!

Page 4: 10 Golden Rules of IV Therapy

Page 4 S P E C T R U M

concluded that biphasic patterns of the P waves confirmed catheter tip location within the RA (Alexander et al, 2010, p. 490; Jeon et al, 2006, p. 982).

Who would have thought 10 years ago that an understanding of how to read ECG’s would help ensure proper placement of a vascular access device? Yet we now know that when an ECG is used to verify placement, the ability to verify location is improved. By utilizing placement with an ECG, the nurse can verify the catheter has moved in the correct direction; the catheter tip is placed at the correct depth; and the patient’s exposure to risk is minimized.

Technological developments over the past 10 years have changed the way clinicians place central catheters such as PICCs, improved accuracy, and decreased insertion time. The new ECG tip positioning technology will forever change the way clinicians are placing PICCs and other central lines. It is a technology that has been long awaited.

——————————————————————————————————————--- Paul L. Blackburn, RN, MNA, is the Director of Clinical Services at Bard Access Systems. He has more than 25 years of clinical practice in operating and recovery rooms, and he also has more than 20 years of service as the Chief Nursing Officer for the Utah Air National Guard, 151st Medical Group.

CONTINUED FROM PAGE 1

THE CHEST RADIOGRAPH — THE GOLDEN STANDARD?

Rationale: The superior vena cava is a large diameter straight vein with a tremendous blood flow rate. Many organizations, including LITE, AVA, ONS and INS have standards or guidelines stating that this is the most appropriate location for all CVC catheter tips. Complications such as thrombosis, catheter malposition and vein perforation are significantly reduced and when catheter tips are in the SVC. Confirmation of catheter tip placement can be accomplished by x-ray or fluoroscopy. Rule No. 4 Prior to using any central venous catheter, a 3 ml free flowing blood return should be obtained. Rationale: All CVCs will develop biofilm and fibrin sheaths which can divert IV fluid pathways. The catheter tip should be confirmed in the SVC which has a blood flow rate of 2000 mls per minute. The inability to obtain a 3 ml blood return is a clinical indication that the catheter is malfunctioning. Instillation of a fibrinolytic drug will dissolve the fibrin sheath resulting in a free flowing blood return and the ability to reuse the catheter safely. Catheter fibrin sheaths can cause retrograde drug flow around the outside surface of the catheter, resulting in tissue damage. Rule No. 5 Document the assessment of the vascular access site (peripheral or central) at least every four hours for non vesicant infusions. Rationale: Documentation every four hours is evidence that the site was assessed. “No signs of IV related complications observed” implies the site and patient were assessed for all potential IV complications and none were evident. A “check mark” can be interpreted as the site was checked but not assessed. Nursing clichés — such as “patient tolerated procedure well,” ‘IV infusing well,” and “dressing clean, dry and intact” — have no legal or clinical value.

Using these five rules, as part of routine nursing practice, will improve patient outcomes related to vascular access devices and related infusion therapies.

Suggested Reading “Infusion Nursing Standards of Practice” January/February 2006 Infusion Nurse Society (INS) 315 Norwood Park South, Norwood, MA 02062 Masoorli, S. (Nov/Dec 2007) “Nerve Injuries Related to Vascular Access Insertion and Assessment” Journal of Infusion Nursing Vol. 30 No. 6 Vesely, T. et al (2002) “The Diverse and Conflicting Standards and Practices in Infusion Therapy” Journal of Vascular Access Devices, Vol. 7 No. 3 ——————————————————————————————————————— Sue Masoorli, RN, President/CEO of Perivascular Nurse Consultants, Inc., has more than 30 years experience in the areas of infusion therapy and vascular access devices. She has presented nationally and internationally. She has served as an expert witness in nursing malpractice cases since 1990.

Are you an expert on an IV-related nursing topic?

Do you have a passion for sharing knowledge with

others? Then write an article

for Spectrum!

We’re currently accepting submission for articles on ALL IV

nursing topics. Send your articles or proposed ideas to

[email protected].

CONTINUED FROM PAGE 3

GOLDEN RULES OF IV THERAPY

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March 11-12, 2010 Holiday Inn Washington-Meadow Lands

Washington, PA

LITE 2010 Annual Educational Conference Preview

Therese Austin, MS, RD, LD, CNSD Coram Specialty Infusion John Costa, RN Bard Access Systems Margy Galloway, RN, BSN, OCN, CRNI Saint Luke’s Hospital

Colleen Littrell, RN, BSN Saint Luke’s Hospital Lynn Manly, RN, CRNI Navilyst Medical Julie May, RN, MSN, CNS, CRNI Bard Access Systems Brenda McKay, RN, BSN, CRNI

Dr. James McCann, D.O. Teredesai, McCann & Associates Jamie Santolucito, RN, CRNI Oregon Health & Science University Hospital Nancy Sims, RN, BSN, OCN UPMC Cancer Center

LITE 2010 PRESENTERS

Page 6: 10 Golden Rules of IV Therapy

Page 6 S P E C T R U M

LITE 2010 PREVIEW:

WELCOME TO THE CONFERENCE! By: Patricia Luptak, RN, BSEd, MS, OCN

Imagine a setting where you can learn the newest techniques and information about vascular access, network with colleagues, and have fun shopping or trying your luck at the slot machines! LITE’s 38th Annual Educational Conference will provide just that setting for you as we move our annual conference to the Holiday Inn Washington-Meadow Lands, just south of the City of Pittsburgh, located across from the Meadowlands Racetrack & Casino.

The Education Committee has again worked hard to provide some great speakers and themes covering a wide variety of topics. This conference has something for everyone, beginning with moving into a whole new dimension of catheter tip verification with ECG to transitioning patients from parenteral nutrition from acute care to home care. There will be a chance to visit with many different vendors and “play” with some of the newest tools and ideas in healthcare. The annual Anna McGrath Dinner will give you a chance to network and enjoy a wonderful dinner as we award one of our colleagues for their outstanding service, dedication, and promotion of LITE. And our facility will provide shuttles to the Meadows or to the Tanger Outlets for a wonderful shopping experience, the perfect mix of education and FUN!

For more information and details about the speakers and topics, check out the website at www.lite.org. We hope to see many new faces on March 11 and 12: We want YOUR feedback on how to make LITE great, and we want a chance to network with you and find out what goes on in your world of healthcare. See you in March!!

This year's LITE meeting once again will feature a poster area. This area is meant to be yet another forum for sharing ideas and engaging in discussion. Complex and extensive research projects are not necessary — just proven and practical solutions for challenges IV nurses face daily!

Call For Posters!

Go to www.lite.org for more information!

Special ThanksSpecial Thanks to Our LITE2010to Our LITE2010

Sponsors

BARD Access Systems

Coram Specialty Infusion

Interim Healthcare

Navilyst Medical

St. Clair Hospital

University of Pittsburgh Medical Center Cancer Center

Exhibitors

BARD Access Systems

BeautiControl

Centurion Medical Products

Clinical Technology Inc.

Eloquest Healthcare

Genentech USA

ICU Medical

Maximus Medical

Navilyst Medical

Professional Disposables International

SonoSite, Inc.

The Leukemia and Lymphoma Society

Page 7: 10 Golden Rules of IV Therapy

LITE 2010 PREVIEW:

BLOOD MANAGEMENT OVERVIEW

By: Debra Fine Do you dread networking events, open

houses and other business related social events? Does attending another open house make you want to run inside your own and lock the door? For business professionals, these occasions represent opportunities to develop business friendships and broaden networks. Here are a few techniques business people can use to improve their small talk skills:

Be the first to say “Hello!” and introduce yourself. Act as if you’re the host and introduce new arrivals to your conversational partner or partners.

Get somebody to talk about why they’re attending the event and you’re on your way to engaging them in conversation.

Listen carefully for information that can keep the conversation going.

Play the conversation “game”. When someone asks, “How’s business?” or “What’s going on?” Answer with more than “Not much”. Tell more about yourself so that others can learn more about you.

Be careful with business acquaintances. You wouldn't want to open

a conversation with: “How’s your job at (fill in the blank)?” What if that person just got fired or laid off? Be careful when you’re asking about an acquaintance’s spouse or special friend: you could regret it.

Don’t act like you’re an F.B.I. agent. Questions like: “What do you do?” “Are you married?” “Do you have children?” and “Where are you from?” lead to dead end conversations.

Show an interest in your conversational partner’s opinion, too. You’re not the only person who has opinions about interest rates and Alan Greenspan, imposing sales tax on Internet purchases, wearing white after Labor Day, the merits of the Atkins, South Beach and Weight Watcher’s diets.

Be prepared with exit lines. You do need to move around and meet others.

Every encounter involves risk. As long as you keep looking for new people to meet, and you show an interest in other people, you can develop business friendships and enjoy lively conversations.

Turn every conversation into an opportunity for success! —————————————————————————— Debra Fine is the author of The Fine Art of Small Talk (Hyperion). She presents keynotes and seminars on conversational skills and networking techniques internationally. Contact Debra at 303-721-8266 or visit her web site at www.DebraFine.com.

BUSINESS NETWORKING SKILLS FOR CONVENTIONS AND MEETINGS

By: Colleen Littrell, RN, BSN “There is no reason why anyone

would want to have a computer in their home.” “Heavier than air flying machines are impossible.” “Louis Pasteur’s theory of germs is ridiculous fiction.” We would accomplish many more things if we did not think of them as impossible.

I am pleased to present information regarding the principles of blood management at the LITE Annual Educational Conference in March 2010. Blood Management is the appropriate use of blood products and the utilization of strategies to reduce or avoid the patient’s exposure to blood products to improve patient outcomes. There are many ways to decrease blood usage. The most effective ones entail a multidisciplinary team approach and the use of a combination of interventions, which are often simple and at a low cost.

Blood management programs are an essential part of medical care and can benefit potentially all patients. There is a shrinking blood supply and a growing list of risks and unfavorable patient outcomes associated with blood transfusions. Nurses have always had a vital role in patient safety; this is especially true in dealing with blood products. Early identification of anemia is essential. Education is necessary to identify the cause of anemia and best treatment plans for these patients. Nurses also need education to recognize blood transfusion adverse reactions and knowledge of the reporting process if an adverse event occurs.

At the LITE conference, I will discuss the need for a blood management program, the risks of blood products and the nurse’s role in developing a plan for the patient with anemia.

—————————————————————————— Colleen Littrell is a RN coordinator in the Blood Management Program at Saint Luke's Hospital in Kansas City, MO. She interacts with inpatients, outpatients, nurses and physicians throughout the hospital, focusing on anemia prevention and education. She is currently involved in a process improvement project, screening inpatients to determine their risk for a blood transfusion. Colleen has more than 20 years of nursing experience at St Luke’s Hospital that includes Oncology/BMT, Float Pool, Medstar Program, Outpatient Infusion Center and her present position with the Blood Management Program. Find out more about Blood Management at Ms. Littrell’s educational session on March 11 at LITE2010.

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It is the mission of the League of Intravenous Therapy Education (LITE), a national educational association for infusion therapy, vascular access, home care, oncology, acute care, and extended care, to educate the health care community. LITE will accomplish this mission by: • Promoting and providing professional opportunities through

scholarly activity, networking and educational seminars. • Establishing guidelines that promote safe, efficient and cost-

effective intravenous therapy in a multitude of care settings.

CONTACT THE LITE OFFICE

1844 Ardmore Blvd. Pittsburgh, PA 15221

Phone: 412-244-4338 Fax: 412-243-5160 E-mail: [email protected]

Visit Us on the Web! www.lite.org

Like the new Spectrum? Let us know your thoughts about the new Spectrum!

Send your comments to the LITE Office at [email protected].