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Comparing standards: is everything clear? Jackie Nicholson
Clinical Nurse Specialist in IV Therapy Royal Surrey County Hospital
Guildford, Surrey, UK
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Evidence based guidelines save lives
Hierarchy of evidence
Meta- analyses , systematic literature reviews or at least three well-designed, randomized controlled trials
At least two well designed randomized controlled trials or a systematic literature review of varied prospective study designs.
One well designed randomized controlled trial or several quasiexperimental designs focussed on the same question. Includes two or more well designed laboratory studies.
Case control or cohort studies, narrative literature reviews or systematic literature reviews based on descriptive or qualitative studies. Includes one well designed laboratory study.
Descriptive studies and information from clinical articles, textbooks or well designed quality improvement projects. Includes generally accepted standard of practice which does not have a research base.
V
Evidence from anatomy, physiology and pathophysiology
Categories of evidence
Regulations set forth by organizations with oversight for monitoring the standards’ adoption and practice.
Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice supported by limited evidence.
Required by state or federal regulations, rules, or standards.
Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.
EducaGon & training
Hand hygiene & asepGc technique
Barrier PrecauGons
SelecGon of devices & sites
Skin preparaGon, dressings and securement regimens
Replacement of devices and administraGon sets
Use of needlefree sets
ConsideraGon of anGbioGc catheters, prophylaxis and locks
Elements to consider
Educa0on & Training
RCN INS CDC
Nurses should have ‘validated competency’ ref
Nurses should undergo theoreGcal and pracGcal training in ………ref
Pa0ents/caregivers
demonstraGon, verbal and wriRen demonstrate understanding ref
Nurses should be competent in:……
Nurses should be knowledgeable about ……
Pa0ents/caregivers
hand hygiene (V) prevenGon of infecGon flow devices (V) immobilisaGon devices wriRen instrucGons (IV)
Designate trained and competent personnel (IA)
Educate healthcare personnel regarding: indicaGons of VAD use proper procedures inserGon and maintenance infecGon control measures (IA)
Periodically assess all involved personnel: Knowledge, adherence to guidelines (IA)
Hand hygiene and asep0c technique
RCN INS CDC
Hand washing Visibly soiled hands – soap and water Alcohol Hand rub
Asep0c technique AsepGc technique during infusion & VAD placement ref
Hand washing Visibly soiled or exposed to spore producing pathogens –soap and water, Alcohol based hand rub preferred (II)
Asep0c technique Standard precauGons or transmission -‐based precauGons
Hand washing Soap and water or alcohol based hand rub (IB)
Asep0c technique AsepGc technique for inserGon and care of VADs (IB)
Barrier Precau0ons
RCN INS CDC
General Single use aprons and gloves when performing infusion procedures
MBP
No evidence to suggest that wearing a face mask and cap during central venous catheter inserGon reduces the incidence of infecGon (2007 ref)
If risk of body fluid exposure – face mask, cap and eye protec0on ref
General Standard precauGons and personal protecGve equipment (PPE) during infusion procedures when risk of exposure to body fluids
MBP
MBP including cap, mask, sterile gown, sterile gloves, protec0ve eyewear, full body drape should be used for all CVAD inserGon, exchange and repair (II)
MBP
MBP including cap, mask, sterile gown, sterile gloves, full body drape should be used for all CVAD inserGon or guidewire exchange (IB)
Skin prepara0on, dressing and securement regimens
RCN INS CDC
Skin prepara0on 2% CHG & alcohol ref
FricGon rub 30 seconds, air dry 30 seconds ref
Skin (dressing) 2% CHG
Dressing TSM/gauze
TSM 7 days, gauze 24 hrs ref
Skin prepara0on CHG preferred, iodine/70% alcohol (I)
CHG X < 2 months (I)
Skin (dressing) CHG preferred, iodine/70% alcohol (I)
< 2 months, povidone iodine, remove with saline or sterile water (V)
Dressing No evidence to support TSM over gauze Gauze if site moist (II)
TSM 5-‐7 days, gauze 2 days
Skin prepara0on PVD – 70% alcohol/alcoholic iodine/alcoholic CHG (IB)
CVAD -‐ > 0.5% alcoholic CHG (IA)
Skin (dressing) CVAD -‐ > 0.5% alcoholic CHG (IA)
< 2 months no recommendaGon (unresolved)
Dressing TSM /gauze (IA) Gauze if site moist (II)
TSM 7 days, gauze 2 days (IB)
Skin prepara0on, dressing and securement regimens
RCN INS CDC
Securement
Sterile tape TSM Securement devices Avoid sutures ↑ risk infecGon Sutures 21 days tunnelled
cuffed line Sterile surgical strips ref
Consider CHG dressing > 2 months (prevent infecGon) (I)
Well healed tunnelled device may not need dressing (III)
Securement
TSM alone not supported (III) No bandages (V) Securement device preferred to tape or sutures (III)
Consider CHG dressing > 2 months (infecGon rate ↑) (IB)
Cuffed tunnelled devices, no recommendaGon (unresolved)
Securement
Use a sutureless device (II)
Selec0on of devices and sites
RCN INS CDC
General Type & length of therapy, paGent’s condiGon and preference ref
Smallest gauge and length for therapy ref
PVDs 3-‐5 days
Ideally a safety device ref
Winged device -‐ bolus or non-‐vesicants ref
Avoid lower extremiGes ref
Not suitable vesicants or ↑osmo
General Type and length of therapy, dwell Gme, vascular integrity, paGent preference, ability and resources available for akercare
Smallest gauge and length, fewest lumens, least invasive.
PVDs < 1 week (V)
Safety device (V)
Steel winged -‐ short term or single dose (V)
Avoid lower extremiGes (IA/P)
Not suitable vesicants or ↑osmo
General Purpose, duraGon, known complicaGons, experience of operator (IB)
PVDs
Avoid steel needles for vesicant medicaGon (IA)
Upper extremiGes (II)
Selec0on of devices and sites
RCN INS CDC
Midline
Cephalic, basilic, median cubital ref
X vesicants /↑osmo
PICC Ideally upper arm using US
Non-‐tunnelled, tunnelled, implantable device Balance risks ref Subclavian preferred for non-‐tunnelled
Midline 1 – 4 weeks (V)
Cephalic, basilic brachial (V)
X vesicants/↑osmo (V)
PICC Basilic, median cubital, cephalic (V)
Non-‐tunnelled device Balance risks Subclavian site preferrred (I)
Tunnelled & implanted devices
Collaborate with health care team and paGent for site selecGon (V)
Midline/PICC > 6 days therapy
Non-‐tunnelled device Balance risks (IA) Avoid femoral site (IA) Subclavian site preferred (IB)
Tunnelled device
No recommendaGon for site for tunnelled device (unresolved)
Replacement of devices and administra0on sets
RCN INS CDC
PVD 72 – 96 ref
Midlines PICCs Tunnelled devices Implanted ports ? dwell Gme exchange -‐ absence of infecGon ref
Administra0on sets
1°/2° 72 hours ref IntermiRent 24 hours ref Lipid PN 24 hours ref
PVD
Replace when clinically indicated (I)
Midlines > 4 weeks clinical judgement (V)
Non tunnelled, tunnelled devices and implanted ports Dwell Gme unknown (II) removal determined by complicaGons (V)
Administra0on sets
1°/2° 96 hours (II) IntermiRent 24 hours (V) PN / other lipid 24 hours (III)
PVD 72 – 96 hours (IB) Replacement when clinically indicated (unresolved)
Midlines Replace only when clinically indicated (II)
CVADs No rouGne replacement (IB) Do not remove on basis of fever alone (II) Guidewire exchanges only absence of infecGon (IB)
Administra0on sets
1°/2° 96 hours IA) IntermiRent (unresolved) Lipid within 24 hours (1B)
Replacement of devices and administra0on sets
RCN INS CDC
Blood – end of transfusion/12 hours whichever sooner ref
Add ons with administraGon set or when integrity compromised ref
Hub as above or blood in device ref
Propofol 12 hours (regulatory)
Blood 4 hours (IV)
Add ons with administraGon set or when integrity compromised (V)
Hub as above/residual blood/ prior to blood culture (IV)
Propofol 6 – 12 hours (IA)
Blood within 24 hours (IB)
Add ons With administraGon set, no benefit more frequently than 72 hours (II)
Use of needlefree sets
RCN INS CDC
Needlefree system preferred method of access ref
Disinfec0on
CHG & alcohol
FricGon, allow to dry
Needles shall not be used for access
Needleless connectors
Split septum/mechanical valve negaGve posiGve neutral (II)
Needleless connectors sites of microbial contaminaGon (II)
Disinfec0on
Alcohol/iodine/CHG & alcohol
OpGmal technique or Gme frame not idenGfied (III)
Needleless system to access IV tubing (IC)
Needleless connectors
split septum valve ? preferred (II)
(Discussion p 54-‐56)
Disinfec0on
CHG/ iodine /70% alcohol (IA)
Scrub the access port Time – 3-‐5 secs with 70% alcohol did not disinfect.
Considera0on of an0bio0c catheters, prophylaxis and locks
RCN INS CDC
An0microbial catheters
Consider in ↑ risk paGents ref
An0microbial catheters
Consider > 5 days /↑ risk paGents /CRBSI rates not ↓ aker other intervenGons (I)
Prophylaxis Not rouGne ? history of CRBSI/ ↑ risk (I)
An0microbial lock ? long term CVAD salvage (Absence tunnel/port infecGon) ? + systemic anGbioGcs (I)
An0microbial catheters
Consider if CRBSIs not ↓ aker other intervenGons. (IA) ? cost effecGve ICU burns neutropenia ↑ CRBSI rates
Prophylaxis Do not give to prevent infecGon (IB)
An0microbial lock Long term CVADs + history of mulGple CRBSI despite other intervenGons (II)
(Discussion p 41-‐43)
Consensus
EducaGon & training Competence
Hand hygiene & asepGc technique Soap and water/alcohol hand rub
AsepGc technique – VAD inserGon and care
Barrier PrecauGons MBP – all CVAD inserGons
SelecGon of devices & sites Based on type and length of therapy
PVDs upper extremiGes
Non-‐tunnelled CVAD – subclavian site preferred but balance risks
Skin preparaGon, dressings and securement regimens CHG preferred -‐ CVAD inserGon
TSM or gauze
Avoid sutures
Replacement of devices and administraGon sets Lipid PN – 24 hours
Change add ons with administraGon set
Use of needlefree sets Needlefree systems preferred
Disinfect hub with anGsepGc – Gme frame not idenGfied
ConsideraGon of anGbioGc catheters, prophylaxis and locks Not for rouGne use but consider for specific groups of paGents
Consensus
EducaGon & training EducaGon of paGents/carers
Hand hygiene & asepGc technique AsepGc technique v standard /transmission based precauGons
Barrier PrecauGons Elements of MBP
Skin preparaGon, dressings and securement regimens % CHG CHG dressing -‐ prevenGon v intervenGon
VariaGon
Replacement of devices and administraGon sets PVD dwell Gme -‐ 72-‐96 hours v only when clinically indicated 1°/2° conGnuous -‐ 72 v 96 hours
Blood – 4hours, 12 hours, within 24 hours
ConsideraGon of anGbioGc catheters, prophylaxis and locks AnGbioGc prophylaxis when ↑ risk factors v do not give to prevent infecGon AnGbioGc lock -‐ salvage infected long term line v history of repeated CRBSIs
VariaGon
Further clarificaGon/research required AsepGc technique
DefiniGon/standardisaGon Technique and Gme frame hub disinfecGon
Barrier precauGons Elements of MPB
SelecGon of devices and sites Dwell Gme all VADs
Site selecGon tunnelled devices
Skin preparaGon, dressings and securement regimens CHG% Skin preparaGon < 2 months
Replacement of devices and administraGon sets Primary and secondary conGnuous infusion sets Blood administraGon sets
March 17th 2012
2 weeks later
Home 16th April 2012
To summarise Evidence based guidelines save lives
Wealth of evidence RCN, INS, CDC guidelines
Areas of Consensus
VariaGon Further research and clarificaGon
The future?
