Peripheral Intravenous Therapy - Essay Example

Introduction This essay is about changing the management of peripheral intravenous therapy in an intermediate rehabilitation ward. The essay is focusing on the efforts of a specialist practitioner, who will work with the qualified nurses to 'unfreeze' them from the current position and induce a change in Peripheral Intravenous Therapy management area. The idea that cannulation is solely the responsibility of the medical staff needs to be changed. The nurses in the unit need to believe and accept that it is their responsibility to safely and effectively manage the patients on intravenous therapy (NMC, 2004). These nurses should be trained and educated to take over the role. As it is the responsibility of the management of the hospital including medical staff and nurses to undertake the basic principle that the patients have the right to receive a uniform standard of care, regardless of who they are and where they are treated (Department of Health document, 2000). In order to bring about the change as discussed above, the Lewin (1951) change management theory will be used as a guide. Peripheral Intravenous Therapy Peripheral Intravenous Therapy refers to the injection of liquid substances directly into a vein of arm, hand, leg, foot and scalp which can be intermittent or continuous. A peripheral IV line consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein. A peripheral vein is any vein that is not located in the chest or abdomen. Arm and hand veins are typically used although leg and foot veins are occasionally used. On infants the scalp veins are sometimes used. Part of the catheter remains outside the skin, with a hub that can be connected to a syringe or an intravenous infusion line, or capped with a bung between treatments (Intravenous-therapy, 2006). Today, hospitals use a much safer system in which the catheter is a flexible plastic tube that originally contains a needle to allow it to pierce the skin; the needle is then removed and discarded, while the soft catheter stays in the vein. The external portion of the catheter, which is usually taped in place or secured with a self-adhesive dressing, consists of an inch or so of flexible tubing and a locking hub. (Intravenous-therapy, 2006) A peripheral IV cannot be left in the vein indefinitely, because of the risk of insertion-site infection leading to cellulitis and bacteremia. Hospital policies usually dictate that every peripheral IV be replaced (at a different location) every three days to avoid this complication (Intravenous-therapy, 2006). The use of intravascular devices can be complicated by a variety of local or systemic infectious events. Catheter related infections, particularly catheter related blood stream infections, are associated with increased morbidity, mortality and prolonged hospitalization. (Management, 1998:pg 1) Risks associated with the peripheral IV route are summarized as follows: Bolus injection Anaphylaxis/anaphylactoid reactions Speedshock Infiltration or extravasations Phlebitis Intermittent infusion Anaphylaxis/anaphylactoid reactions Infiltration or extravasations Phlebitis Fluid overload Medicine error - rate too fast or slow Continuous infusion All of the above Incorrect rate - overdose Anaphylaxis Anaphylaxis is a systemic immediate hypersensitivity reaction caused by an immunoglobulin(Ig)-E-mediated immunological release of mediators from mast cells and basophils. Anaphylaxis can have life-threatening consequences (Henderson, 1998:pg 49-53). Speedshock An associated hazard with peripheral IV therapy is Speedshock, and as a systemic reaction that occurs when a substance that is foreign to the body is rapidly introduced (Plumer et al, 2001). Phlebitis Phlebitis is an acute inflammation of a vein directly linked to the presence of any vascular access device (Jackson, 1998:pg 68-71). Many clinical areas now consider it good practice to use a phlebitis scale. (Panadero et al, 2002:pg 921-925). Infiltration Infiltration refers to the inadvertent administration of a non-vesicant drug into the surrounding tissues (Plumer and Weinstein, 2001). Extravasation Extravasation is the leakage of IV drugs from the vein into the surrounding tissues (Jones et al, 1997:pg 292-296). It tends to relate to the leakage of vesicant drugs, meaning the potential for injury is increased (Moreno de Vega et al, 2002:pg 488-490). Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema levels (Peripheral, 2005:pg 58-59). Electrolyte imbalance Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of sodium, potassium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels (Peripheral, 2005:pg 58-59). Embolism A blood clot or other solid mass, or an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV (Peripheral-intravenous, 2006). Infections resulting from peripheral IV therapy can cover a wide spectrum of clinical symptoms, from minor irritation to increased morbidity and mortality. Infection control should be an integral part of patient care. All nurses involved in peripheral IV therapy have a role to play in the prevention and containment of infection. Infection can be divided into two groups: exogenous and endogenous. Exogenous infection occurs when microorganisms originate outside the patient's body. This is usually due to cross infection, for example, via the hands of healthcare professionals and equipment. Endogenous infection is due to organisms already present on or in the patient's body. Exogenous and endogenous infection can be due to intrinsic and extrinsic contamination. Intrinsic contamination refers to infection that is present in the apparatus or medicine before use, whereas extrinsic is introduced during use. The following table will show intrinsic and extrinsic infection in relation to the different types of apparatus (Peripheral, 2005:pg 58-59). Intrinsic and extrinsic sources of infection Intrinsic Extrinsic Cracks in glass containers Attachment of administration apparatus Punctures in plastic containers Additives to infusion fluid Infusion fluid Injections into the closed intravenous (IV) system, including flushes and specimen collection IV infusion set - damaged packaging Contaminated air Contaminated equipment, for example, drip stands, infusion devices Stopcocks, three-way taps and other devices Insertion and manipulation of the device, due to contaminated hands, the patient's normal flora or contaminated skin disinfectants Bottle or bag changes (Peripheral, 2005:pg 58-59) As a clinical specialist, the person has to focus on quality issues, recognizing poor nursing practice, working as a change agent, determining good practice and advising on how this can be achieved (NMC, 2002). The specialist will ensure that the nurses and patients are protected from the complications and hazards associated with intravenous therapy. The Department of Health and Social Security (1977) summarized three fundamental principles of care for intravenous therapy as asepsis, comfort and safety. As with any planned change, some preparatory work needs to be undertaken to predict the relative success of the change (Tiffany and Lutjens 1998). As a change agent, the specialist will need to be well informed of the driving forces for the need for change and the perceived barriers for change. Lewin's change model describes the change process in three stages (Higgins 2003). He identified the first stage as 'unfreezing' stage. This involves some form of confrontation meeting or education process with those involved. The problem to be solved is analysed and data presented to show that a serious problem exist. The next stage is to identify driving and restraining forces through the process called 'force field analysis and then the 'moving' stage is entered, where change is experienced. The third stage is when the change agent 'refreezes' the desired situation. Due to the financial constraints and lack of time allocated for learning at work place, the specialist will take the opportunity of the organized monthly ward meeting and carry out training need analysis with the trained nurses. She will draw the attention of the staff that there is practice theory gap in the management of peripheral intravenous therapy and she will formulate 'Training Strategy' for education and training at the workplace. The first step will be to examine the existing ward culture on the management of peripheral intravenous therapy through brainstorming. Drucker (2005) stated that the first policy in change is to abandon yesterday in order to create tomorrow. Change must be planned, focused and inclusive to succeed. For the change to succeed she will need support from her colleagues who believe in the cause for change. Despite this being a nurse led general practitioner admission ward, none of the nurses can cannulate or re-site an infiltrated vein flow. Cannulation is still a preserved practice of junior doctors yet there is no routine medical visit to the unit. Most of the time, the doctor is called in to re-site a cannula. It has happened several occasions the doctor not turning up in time to carry out the task, as the same doctor will be covering other wards. The need to develop nurses to extend their roles in the management of intravenous therapy has been over looked. Most of the nurses in the ward are not competent to administer intravenous drugs. On several occasion due to the unavailability of doctors on time, nurses have to be called from other wards to come and administer intravenous medication. This situation is becoming more critical, as the numbers of patients who require intravenous therapy are increasing day by day. According to Clayton (1999), over 50% of patients are likely to receive intravenous intervention during their stay in hospital. Due to the shortage of skilled nurses in intravenous therapy, many times the intravenous drugs are not given at the recommended time. Some medication doses have been omitted due to unavailability of skilled staff in cannulation, resulting in incomplete treatment. Many times medication doses have been wasted; the nurse would have prepared the drug in the clinical room, not knowing that the cannula is infiltrated. According to the NMC (2004b) any medicine prepared should be used immediately. Some of the nurse will agree that there have problems in setting and managing the pumps this leads them to avoid the pumps and give the intravenous fluids direct. Ineffective medication management has financial implications as can cause resistance and prolonged hospitalization (Rycroft-Malone, 2002). Also the nurses are only trained to use the prescribed medicine with the given concentration of different chemicals. Under this circumstance, in an adverse situation where the patient's condition is not at that level which might be predicted by the doctor, and the contents of the injection to be infused is not appropriate for the patient, then this might create a hazard. But since this is the ward culture so it is not considered as a drug error as the nurse might indicate that the cannula was not available or the doctor was not there to change the concentration or the contents of the injection. Hence a critical analysis is needed to make sure at what level the holistic needs of the patients on intravenous therapy are met, at what degree the intravenous drugs are given according to the prescription and the intravenous infusions are completed as prescribed and as agreed with the patient. Keeping in mind the fact that the nurses are the only profession that gives twenty-four hour direct patient care (Hurst, 1993); hence it is essential to develop their skills to meet the needs of their service users. Demands of acute hospital beds, changes in treatment regimes, changes in government policy and great patient participation in treatment decision are challenging traditional ideas that infusion therapy is confined to acute hospital environment (DoH, 2000b). Some researchers have identified that nurses who learn new skills improve the total care of the patient by performing the skills when the patients needs them (Inwood, 1996). The NMC (2004) indicates all staff has a professional obligation to maintain their knowledge and skills. It is the responsibility of the organization to support and provide staff with the training and education. The implementation of the NHS plan by the Department of Health (2000) identified ten key roles for nurses, and cannulation was one of the key roles. One of the agendas of the NHS plan was to reduce the number of working hours of the junior doctors. Intermediate care is one of the Government's main initiatives in improving the quality of care for older people (DoH, 2001). According to the NHS plan (DoH, 2000b), Intermediate care is meant to build a bridge between hospital and home. The service is normally limited to a maximum period of six weeks. This period can be elongated because of a number of reasons, which includes ineffective interventions. Although this unit is meant for patients who do not need input from medical practitioners for at least, 24 hours, for assessment, diagnosis and treatment (DoH, 2000b). But there is always the issue of patient's health predictability. The health status of the individuals can change at any time, especial the elderly people who are the most users of this facility. Some patients develop hospital-acquired infections. Hospital acquired infections usually develop after 72 hours post admission. Some researchers have estimated that 9 % of patients admitted patients develop hospital-acquired infections (Taylor et al, 2002). In this case they may need intensive treatment with antibiotics, requiring intravenous therapy. There is always a chance of infection or reaction when intravenous therapy is applied on the patient, but mostly in elderly patients as a result of reduced skin elasticity and larger interstitial spaces, the chances of different infection, reaction and nerve damage (as described above) increases. According to Lewin (1951), the second stage in the change of management is the consideration of driving and restraining forces. The specialist should identify the need for change in peripheral intravenous management. Maintaining quality of care, while eliminating risks that can lead to adverse events, is the major driving force of this work. She is intended to develop solutions to prevent patient safety incidents while receiving peripheral intravenous therapy. For doing so she has to keep the following aspects in mind before implementing any decision: Identify and analyze key risks associated with peripheral IV therapy and nurses' roles. Identify measures to reduce risks through scenarios and critical analysis. Robust policies and procedures should be in place to help support and assess staff in clinical practice. Staff must complete an approved competency based training program (RCN, 2003). Patient safety is currently an international priority in health care (Bird and Dennis, 2005). Denerek and Dykes (2001) recommend it will be of good practice to be proactive versus reactive. Professional development is one of the concepts of clinical government, which advocates for continuous improvement and maintenance of high standard of care (DOH, 2000). Some researchers have identified inconsistence in nursing knowledge and practice in relation to peripheral intravenous therapy (Clayton et al, 1999). The policies and guidelines are there to bring consistence in practice. Some view extending nurse's role to benefit the patient and make significant contribution to the delivery of quality care. The patients will be seen to receive the appropriate care at the appropriate time without having to wait for the doctor. An appropriate educated nurse could be the person to provide this level of care (Alderman, 1996). There are a number of contributing factors to restraining forces. As with any other change, it will involve staff taking time out of the clinical area to undertake extra training as required. This has impact on to the organization, straining the budget by paying the extra staff to cover the clinical area and to pay for the course. This will also necessitate job evaluation to concur with the agenda for change, knowledge and skills frame work. The staff will find it as an added responsibility, which will require more documentation. Resistance may come from other members of staff who may be concerned that vital aspect of nursing will be lost if nurses begin to undertake functions which were once considered as the domains of the doctors. Castledine (1996) stated that while breaking down the boundaries it is important that nurses must not loose their fundamental role of patient care. He stated that 'nurses must become maxi nurses, not mini doctors'. Lewin's model of change advocates that the best strategies in implementing change rests on reducing the restraining forces. The increase in driving forces will be equal to the increase of the restraining forces. However the specialist will need adequate evidence to demonstrate that the long-term benefits of the training will out-weigh the cost. The evidence may be in the form of: The minutes from the staff meeting Drug omission audit results from the pharmacy, and Clinical incident forms from the patient complaints. The evidence reflects the extent of the existing problems and that the identified solution is through staff education. She will need to present the cost-benefit analysis of the training. The course comprises of all aspects involved in administration of infusion therapy, care and management of vascular access devises (RCN, 2003). Having identified the driving and the restraining forces the next stage is to progress to the 'move on stage'. This is the implementation stage where the change is put into action. The specialist will act as a link between the level of higher authority and lower level in the unit. She will provide clear and precise well understood information either verbal or written in order to support the staff and overcome the resistance to change. All conflicts and values are aired and dealt with in order to allow the change to proceed. The staff will be encouraged to accept the responsibility and undergo the training. The code of professional conduct (NMC, 2004) states that nurses should only undertake task for which they are adequately trained and deemed competent. The level at which the individual functions increases as his or her knowledge and skills develop. Benner (1984) describes this as stages of professional development from novice to expert. The final approach in change of management, according to Lewin's (1951) model of change, is the refreezing stage. This is the evaluation phase in which the change agent reviews whether change has taken place. Review can be done through the use of clinical audits. Johnston (2000) describes one of the main benefits of audit as providing a measure to assess whether the care is given as per agreed protocol. Clinical audit is one of the concepts of clinical government, which is meant to monitor the practice and reduce the risk (DoH, 2000). The specialist will liaise with the pharmacist and carry out some audits to see whether the drugs are given according to the five rights as suggested by Clayton (1999). These five rights provide a framework for checking that the right dose of the right drug is administered to the right person, given at the right time through the right route. Nurse led cannulation allows timely management of infusion therapy and may reduce the clinical risk associated with missed medication and delayed hydration. This measure is meant to reduce medication incidents. Incident reports are an integral part of a risk management program and help those in staff development identify education and training needs. After getting the approval from our local research office the specialist will devise a patient questionnaire and carry out patient survey as to assess whether their services are met at the right time. The doctors will be consulted whether the nurses' involvement in cannulation gives them relief to attend to other agent needs. The specialist will also devise staff questionnaires to assess staff job satisfaction. The staff appraisal will be carried out to determine the future professional development needs of the individual nurses. Nurses need to be proactive and every individual nurse must be able to assess the appropriateness of the recommendations with regards to patient condition, overall treatment goal, resource availability, institutional policies, available treatment options and any recent research findings before adopting any recommendations in clinical practice (Tan, 2002:pg 12). The nurses might be facing the problems every day but they take it as a tradition that they have to deal with. To change their belief, they need to realize the impact of the situation. Due the cost associated with the post registration training, the nurses need to justify to the employers that the training is essential. Therefore, if the change of management of peripheral intravenous therapy and cannulation in the intermediate rehabilitation ward is to succeed, the staff concerned should be involved in the planning. The staff needs to understand the benefits not to view it as an added responsibility. The audit results should be used to reflect the impact of the problem to the management and to the staff. These audits results should be acted upon, not just to be considered as mere statistics. Appendix A General Recommendations for practice 1. Consider whether a cannula is necessary. This is because some cannulae can be inserted 'routinely' and this practice should be challenged (Waitt et al 2004:pg 1-6). 2. Use a polyurethane cannula where possible, as this is the best method of reducing phlebitis rates (Gaukroger et al 1988:pg 265-271). 3. Ensure appropriate cleaning products are used on the skin before insertion of the cannula: chlorhexidine 2% has been shown to reduce the rate of infection (Maki et al 1991:pg 339-343). 4. Cover the cannula with a transparent, semipermeable dressing. This allows the site to be viewed easily (Parker 1999:pg 1491-1498). 5. Change the cannula site every 48 hours. This has been shown to reduce infection rates at the cannula site (Panadero et al 2002:pg 921-925). 6. Use an aseptic technique for cannulation and all further manipulations of the IV system to reduce infection (Wilson 2001). 7. Avoid lower extremities, joints and nerves when siting the cannula. Lower extremities are more difficult to view. Cannulating over joints is uncomfortable, reduces patient mobility and, if nerves are damaged, may cause patient harm. 8. Try to reduce the number of attempts to cannulate, as increased puncture sites means increased entry sites for infection. 9. Identify patients at risk and take additional precautions, including those who are older or younger, those who already have an infection, are immunosuppressed, have poor nutrition, have a loss of skin integrity, are on antibiotic therapy and patients having multiple invasive procedures (Dougherty 2002:pg 45-52). 10. Record and report any signs of infection (NMC 2004). 11. Educate staff in the portals for entry of infection so that steps can be taken to reduce risks. 12. Clean infusion equipment before and after use. Check whether equipment is for single use only. Equipment such as drip stands and infusion equipment can be contaminated, therefore it needs to be cleaned regularly and between patients (Medical Devices Agency 1996). 13. Good hand washing techniques and precautions to protect staff should always be employed. Contaminated hands of staff are a major source of infection. Gloves, aprons and, if necessary, masks and goggles should be worn if staff administering peripheral IV therapy are at risk (RCN 2003). (Peripheral, 2005:pg 59-60) Appendix B Phlebitis Scale Description 0 No clinical symptoms 1+ Erythema with or without pain Oedema may or may not be present No streak formation No palpable cord 2+ Erythema with or without pain Oedema may or may not be present Streak formation No palpable cord 3+ Erythema with or without pain Oedema may or may not be present Streak formation Palpable cord (Tan, 2002:pg 26-27) Appendix C Policy Statement This policy statement describes the roles and responsibilities of registered nurse and Licensed Practical nurse. The RN and LPN must possess a knowledge of: 1. Anatomy and physiology of age-specific disease processes and recognition of normal and abnormal laboratory values. 2. Organizational policies and procedures pertaining to infusion therapy. 3. Specific signs and symptoms of infusion therapy complications and actions to be taken in the event of suspected adverse reaction or complication. 4. Interventions specific to the drugs and intravenous solutions, infusion access device, supplies and infusion equipment to achieve desired patient outcomes including: a. special patient specific considerations regarding delivery systems; b. treatment modalities; such as dosing, site selection; and c. psychological implications 5. Drugs which include, at a minimum, drug actions, potential complications, side-effects, untoward effects and storage instructions to ensure safe administration. 6. Proper function, care and maintenance of supplies and equipment used in the delivery of infusion therapy and action to be taken in the event of problems or adverse situations. The RN and LPN must be able to demonstrate: 1. Ability to correctly calculate flow rate. 2. Principles of asepsis and standard precautions in the management of infusion methods. 3. Techniques for prevention of infection, phlebitis, occlusion, and infiltration / extravasation The RN and LPN providing care must: 1. Validate the authorized prescriber's specific infusion therapy order including dosage, frequency, rate, mode of administration, and duration. 2. Identify and utilize resources available for acquiring information concerning patient/client specific medications, including knowledge of resources available for immediate consultation in adverse situations. 3. Assess and/or observe patient's physical and psychosocial status, with appropriate interventions including measures for the prevention of adverse reactions and complications. 4. Coordinate and communicate with healthcare providers. 5. Educate peers, patient/client and/or caregivers based on patient/client need relative to the prescribed infusion therapy and care plan and appropriate to the care setting. 6. Document in the medical record: a. patient assessment, b. prescribed therapy, c. initiation, ongoing monitoring and discontinuation of treatment d. patient response. With appropriate knowledge and demonstrated competency the following may be performed by a LPN or RN: 1. Maintaining an infusion via ambulatory infusion pump, including narcotics 2. Administering central line drugs and fluids 3. Accessing implanted port 4. Inserting/discontinuing a peripheral line 5. Maintaining total parenteral nutrition (TPN) 6. Maintaining non-obstetrical epidurals 7. Changing central line dressings 8. Administering narcotics by direct push The RN, with advanced knowledge and demonstrated competency, may administer and monitor the following therapies: 1. Medication via ambulatory infusion pump 2. Vesicant medications with knowledge of extravasation protocols 3. Antineoplastic medications 4. Vasoactive drugs 5. Antiarrhythmic therapy 6. Thrombolytic therapy The RN, with advanced knowledge and demonstrated competency, may perform the following procedures: 1. Exchange of existing CVC over a guidewire 2. X-ray identification of catheter tip location for PICC line placement. 3. Suturing of central venous catheters 4. Central venous catheter blood draw 5. Therapeutic phlebotomy 6. Autologous blood donor draw 7. Peripherally inserted central catheter (PICC)/midline placement and/or exchange 8. Catheter clearance a. nonthrombotic occlusion b. thrombotic occlusion. 9. Catheter repair, temporary or permanent 10. Access nonvascular sites. a. epidural, except antepartal care. b. Intraosseous c. Intrathecal 11. Discontinuation of peripheral - short, midline, midclavicular, and peripherally inserted central catheter (PICC). 12. Arterial and hemodynamic pressure monitoring. 13. Refill/reprogram implanted pumps (Oregon Policy) References Alderman C (1996), Heart to Heart. 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