Newsline
Coverage of Issues and Activities Related to the Infusion Nursing Specialty
www.ins1.org • Vol. 29, No. 6 • NOVEMBER/DECEMBER 2007
INS Joins New IVIG Therapy Alliance
INS has joined a new organization that is committed to
­working for better access to intravenous immune globulin
(IVIG) products. The Washington, DC-based Alliance for
Plasma Therapies was created to “provide a unified voice of
patient organizations, healthcare providers, and industries to
advocate for fair access to plasma therapies for patients who
benefit from their lifesaving and life-enhancing effects.”1
INS was invited to join the Alliance to represent infusion
nurses and the critical role they play in providing care to IVIG
patients. Said INS CEO Mary Alexander: “As direct ­caregivers
to patients receiving IVIG, infusion nurses witness the ­positive
results the product has on many patient conditions, as well
as the adverse impact when access to the drug is denied. It is
­rewarding to see a patient’s improvement after treatment, and
sobering when we see one’s condition dramatically decline
when the patient can no longer get the drug. In a complex
healthcare environment with a complicated reimbursement
system, it’s important that we be involved in activities that
advocate for the best interests of our patients.”
IVIG is a plasma product used to treat a number of ­immune
system disorders, such as acute and chronic idiopathic
­thrombocytopenia purpura, B cell chronic lymphocytic
­leukemia, Kawasaki disease, and pediatric HIV. IVIG also has
a number of off-label uses, such as treatment of autoimmune,
neurological, and systemic inflammatory conditions. Demand
for IVIG is growing, but a concomitant increase in supply has
not taken place.2
For several reasons, there is an
uneven supply and ­distribution
of IVIG. When Medicare
reimbursement levels for
IVIG providers were reduced
in 2005, fewer providers chose
to offer IVIG any longer,
leading to a shortage for some
patients. In addition, there are
only five IVIG manufacturers in the United States, and several
of their products have been or will soon be discontinued; the
supply will not increase.
The Alliance for Plasma Therapies was created to encourage
partnerships among the different stakeholders in IVIG therapy:
the US Department of Health and Human Services (HHS);
federal and state agencies; patient organizations; ­providers;
manufacturers; and professional and trade associations.3
­Alliance Executive Director Michelle Vogel said she started the
organization because she saw that the “sacred bond” between
infusion nurses and their patients was being broken because of
new Medicare regulations and reimbursement issues. Patients
who had been cared for by the same nurse, sometimes for
years, were forced to change sites—and their caregivers—for
their IVIG treatments. These changes sometimes led to
­inappropriate treatments for patients.
A congressional taskforce on IVIG access has been formed
to look at the process of working together with the Centers
for ­Medicare and Medicaid Services (CMS) and the Alliance
toward a solution that would restore access to IVIG. The
taskforce is chaired by Congressman Steve Israel (D-NY), and
finalization of its bipartisan membership is near completion.
As the global authority in
infusion therapy, INS was
asked to join the Alliance
to provide infusion
nurses’ perspectives on
a topic in which they
are highly skilled and
­knowledgeable. The
­Alliance sought out INS’
expertise because ­
­infusion nurses are on
the front lines of IVIG
care. They also serve as
Continued on page 12
In This Issue
President’s Message . . . . . . . . . . 2
Medication Safety . . . . . . . . . . . . 3
Frequently Asked Questions . . . 4
Risk Management Focus . . . . . . 5
Chapter Newsbites . . . . . . . . . . . 6
Membership Corner . . . . . . . . . . . 7
Infusion Nurses Certification
Corporation News . . . . . . . . . . 8
Clinical Concepts of
Infusion Therapy . . . . . . . . . . . 9
Classifieds . . . . . . . . . . . . . . . . . . 13
President’s Message
Lisa Gorski, MS, APRN,BC, CRNI®, FAAN
INS President, 2007 – 2008
Advancing the Science of Infusion Therapy:
Recognizing and Overcoming Barriers to Implementing
thought that lack of time would be the most ­important barrier
­Evidence-based
to use of research, the top five ­barriers ­actually ­identified by
Practice
the nurses included lack of value of ­research, lack of under-
In my position as a clinical nurse
specialist for a large home health
agency, an important aspect of
my role is identifying areas for
improvement in clinical practice
and assisting nurses, as well as
other clinical staff, in the implementation of evidence-based practice (EBP). Although many
of the nurses I encounter are concerned about EBP, they are
more apt to ask questions and less likely to access research
themselves.
The American Nurses Association Standards of ­Practice
­require that the nurse “integrate research findings into
­practice” and “utilize the best available evidence, including
research findings, to guide practice.”1 With many acute care
organizations striving to become Magnet® hospitals, the good
news is that nurses at all levels are not only recognizing the
importance of research but are also becoming involved in
research and using research. And we are making important
strides in advancing evidence-based practice and improving
patient outcomes. For example, it wasn’t so many years ago
that there was a certain level of acceptance of central catheterrelated infections, especially in critical care units. Now research
is demonstrating significant reductions in catheter-related
bloodstream infections with education and implementation
of the central catheter bundle—that group of evidence-based
interventions including hand hygiene, maximal sterile ­barrier
precautions during catheter placement, subclavian vein as the
preferred site, and prompt removal of unnecessary ­catheters.2,3
So now, instead of acceptance, we are developing a “zero
­tolerance” attitude towards catheter-related infections.
The “room for improvement” news is that significant ­barriers
to nurses’ implementation of EBP still exist. I encounter
­nurses who lack knowledge, time, or even a desire to understand research. I do understand that the challenges of just
getting the work done can become overwhelming; that we may
forget that research is more than just reading a journal article,
but a means to improving the care of the patients we serve.
Pravikoff, Tanner, and Pierce4 surveyed 760 nurses from across
the country about readiness for EBP and concluded that nurses
are not ready for evidence-based practice. While the researchers
NOVEMBER/DECEMBER 2007 • www.ins1.org
standing of the organization or structure of electronic databases, difficulty accessing research materials, lack of computer
skills, and difficulty understanding research articles. Also of
interest, 67% of nurses were more likely to ask a colleague for
needed information rather than use reference materials.
Pravikoff and colleagues make recommendations for nursing
education, nursing administrators, and for nurses themselves.
They recommend that nurses personally must take responsibility to recognize gaps in their knowledge, obtain continuing
education, demand access to information resources at work,
demonstrate commitment to using resources, and set goals for
integration of EBP. Think about these responsibilities in terms
of your own situation.
As INS members, you have taken the initiative to belong to
a nursing organization and are more likely to be certified. I
know that many of you are knowledgeable about research
and ­possess at least a basic knowledge of research-supported
­practices. By reading the Journal of Infusion Nursing and by
attending INS conferences, you can’t avoid infusion therapyrelated research! As role models, help and motivate your
colleagues by not only answering questions they may have but
also providing rationale for your answers and referring them
to appropriate research studies, practice guidelines, and/or the
Infusion Nursing Standards of Practice. Share pertinent knowledge
that you have read or heard about at conferences. Participate
in data collection in your setting to measure patient outcomes.
These are just a few ways that you can personally help to break
down the barriers to evidence-based practice. By doing so you
are “Advancing the Science of Infusion Therapy.”
References
1.American Nurses Association. Nursing: Scope and Standards of
­Practice. Washington, DC: ANA; 2004, 40.
2.Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating
­catheter-related bloodstream infections in the intensive care unit.
Crit Care Med. 2004; 32: 2014-2020.
3.Berriel-Cass D, Adkins FW, Jones P, et al Eliminating nosocomial
infections at Ascension Health. J Quality Patient Safety. 2006; 32 (11):
612-620.
4.Pravikoff DS, Tanner AB, Pierce ST. Readiness of US nurses for
evidence-based practice. Am J Nurs. 2005; 105(9): 40-50.
Medication Safety
Michael R. Cohen, RPh, MS, DSc
President, Institute for Safe Medication Practices
Adjunct Associate Professor, Temple University School of Pharmacy
Lack of Standard Dosing Methods Contributes to IV Errors
Problem: As the use of parenteral medications increases,
improvements in drug infusion technology have enhanced our
ability to dose these medications very precisely. However, a
variety of ­dosing ­methods, such as mcg/kg, mcg/kg/minute,
mcg/kg/hour, and many others exist, and few drug-specific
dosing norms have been established. It is common to find
multiple dosing methods used for a single.1 Unfortunately, the
lack of standardization makes ­selection of the proper dosing
method difficult, and errors are common. Some mix-ups have
involved using the wrong dosing method when prescribing
medications. For example, Lesar found that the ­dosing method
was wrong in 29.5% of 200 consecutive prescribing ­errors
with ­potentially adverse outcomes, particularly with pediatric
­patients.2 Other errors have involved the misprogramming
of pumps when selecting the dose, dosing method, or ­ infusion rate. A recent example of an error reported this month
­follows.
An 80-year-old comatose man (80 kg) from a long-term care
­facility was taken to an urgent care center for treatment of
urosepsis and septic shock. Among other intravenous fluids
and medications, dopamine (400 mg/500 mL) was ordered in
a mcg/kg/minute dose to treat persistent hypotension, with
increasing titration prescribed to maintain his blood pressure.
Over the next hour, the infusion was titrated upward two more
times in 5 mcg/kg increments with no response. A critical care
transport service was called to transport the patient to a nearby
hospital for admission to a critical care unit.
When the transport team arrived, one of the paramedics
reviewed the patient’s IV infusions and, per protocol, independently calculated the rate of infusion for each. While
reviewing the pump settings, the paramedic noticed that the
dopamine dose had been programmed in mcg/kg/HOUR, not
mcg/kg/MINUTE. Although a Baxter ­Colleague smart pump
had been used to program the initial ­infusion, the nurse had
elected to bypass the pump library and instead used the pump
in the dose calculator mode. On the screen to choose dosing
options, the nurse accidentally selected mcg/kg/hour, which
appeared on an alphabetical list before mcg/kg/minute, a potential error-promoting pump feature since mcg/kg/minute is
used more frequently than mcg/kg/hour. After the pump was
reprogrammed to deliver the correct dose, the patient’s blood
pressure increased and he became conscious. The patient was
subsequently transported to the nearby hospital and discharged
five days later.
When reporting this error to
the receiving hospital where the
patient had been transported, the
­paramedic learned that the same
type of error had been reported
previously in the past six months.
To cite another recent example—this one from the Pennsylvania Patient Safety ­Reporting
System—an order for ­propofol
80 mcg/kg/ HOUR for an elderly man was ­administered at
80 mcg/kg/MINUTE due to a pump programming error,
­resulting in oversedation but no additional harm. A similar type
of error involves mix-ups between mcg doses and mcg/kg
doses. In one case, a 3-kg infant received a 36-mcg bolus dose
(12 mcg/kg) of ­fentanyl instead of a 12-mcg dose (4 mcg/kg).
Using a Smiths ­Medical ­Medfusion 3500 Syringe Pump with
smart pump technology, the nurse did not notice that the
pump had prompted for a mcg/kg dose, not a total dose. She
subsequently entered “12” into the pump, which calculated a
dose of 36 mcg (12 mcg/kg) for the 3-kg infant. In this case,
a soft dose-limit alert had displayed on the pump, and another
nurse had double-checked the pump settings, but the alert was
overridden, and the drug was administered. Later that day, the
infant received a 1.8 mg bolus dose of midazolam instead of
the intended dose of 0.6 mg after the same programming error
was made.
Safe Practice Recommendations: Healthcare organizations
should consider the following suggestions to reduce the risk of
IV dosing errors:
Standardize dosing methods. Look for variable dosing
methods for the same medication in your facility, and select a
standard way to dose the drug for adults and a standard way to
dose the drug for pediatric patients. Also examine the different dosing methods used in the facility for all drugs, and to the
extent possible, standardize the dosing methods to promote
familiarity. Health systems comprising multiple hospitals will
also benefit from system-level standardization, as patients and
nurses may transfer among the facilities. List the standard dosing methods on preprinted or electronic order sets in which
applicable drugs appear.
Continued on page 11
NOVEMBER/DECEMBER 2007 • www.ins1.org Frequently Asked Questions from the
National Infusion Nursing Network
The questions below have been selected from those received by the National Infusion Nursing Network. Questions are answered by a panel of infusion
specialists and the members of the Education Department of INS. Members are encouraged to access the INS National Infusion Nursing Network for
their clinical and educational questions by calling (800) 694-0298 or e-mailing kathy.walther@ins1.org.
Look for more Frequently Asked Questions in subsequent Newsline issues and add to your expertise by sharing the concerns of your colleagues in the
specialty.
I am the clinician for the Emergency Department and ­working
on a proposal to allow specific RNs in our department to
start IVs in the external jugular vein. It is a skill that a RN
can ­perform in our state, and I am working on a competency
program for this procedure. Do you have any information in
regard to this matter? I’d prefer not to reinvent the wheel.
INS has an External Jugular (EJ) Cannulation task force that is
developing a position paper and an educational program on the
insertion of EJs by RNs. This practice issue will be ­presented
in a 5-hour FOCUS track at the INS Annual Meeting in
May 2008 in Phoenix. In the future, INS plans to develop
­educational programs for peripheral and central EJ placement
that will assist clinicians engaged in this practice.
Recently, I have noticed at a major medical center that
­radiology technicians are placing peripherally inserted
­central catheters (PICCs) into patients at the bedside. Are
there recent changes allowing radiology technicians to do
­invasive ­procedures outside the Radiology Department
­without the ­interventional radiologist present? It has been my
­understanding that only a specially trained and competent RN
can place the PICC at a patient’s bedside. Do you have any
documentation confirming this? Or has there been a change?
The Nurse Practice Acts regarding RNs delegating ­placement
of a vascular access device (VAD) have not changed in
most states. However, if the technician placing a PICC has
been ­delegated by the radiologist, you do not have legal
­responsibility for the insertion of the VAD. INS is not aware
of any State Board of Nursing or Nurse Practice Act that
­allows a technician to insert a PICC under the ­delegation of an
RN. As a patient advocate, however, you should be ­concerned
if the person placing the PICC has not had ­adequate
­education or does not demonstrate competency. Then the
hospital ­system, radiologist, and nurse would be liable if the
patient experienced complications. INS does not ­support
or ­endorse non–nursing staff inserting PICCs. This is an
­advanced ­practice and requires advanced assessment skills and
­knowledge of the potential complications of insertion. The
issue of who can place a PICC will be discussed at the INS
Annual Meeting in Phoenix, May 3-8, 2008.
NOVEMBER/DECEMBER 2007 • www.ins1.org
I looked through the Infusion Nursing Standards of Practice and
could not find any information regarding infusion rates for
keeping veins open. Does INS have any standards regarding
safe infusion rates (To Keep Open [TKO], or Keep Vein Open
[KVO]), or is it determined by the facility?
Infusion Nursing Standards of Practice, Standard #9: ­Physicians or
Authorized Prescribers Order and Initiation of Therapy does
address this. Standard 9.6 states “Prior to ­initiation of ­therapy,
a Keep Vein Open (KVO) order shall contain a specific
­infusion rate.”1 A standard rate cannot be determined without
examining patient age-groups, fluid and electrolyte imbalances,
and comorbidities. Many of the ­electronic infusion devices can
maintain patency at as little as 1 ml per hour.
We have recently changed the brand of end caps at our
­hospital. Our infection control practitioner has observed the
nursing staff not disinfecting the end caps prior to ­attaching
administration sets or inserting a syringe for ­flushing or
­administering medications. Has there been a change in
­practice? Do we still need to disinfect an end cap prior to use?
The answer is simply that the practice of disinfecting end caps
has not changed with the advances in technology. All end caps
require cleansing prior to use to reduce the risks of catheterrelated bloodstream infections (CR-BSIs). Infusion Nursing
Standards of Practice, Standard #35: Injection and Access Caps
addresses this. Practice Criteria A states: “To prevent the entry
of microorganisms into the vascular system, the injection or
access port should be aseptically cleansed with an approved
antiseptic solution immediately prior to use; antiseptic solution
containers in a single-use packet should be used.”2
Reference
1.Infusion Nurses Society. Infusion Nursing Standards of Practice.
J Infus Nurs. 2006; 29(1S): S18.
2.Infusion Nurses Society. Infusion Nursing Standards of Practice.
J Infus Nurs. 2006; 29(1S): S35-36.
Risk Management Focus
Nurses Service Organization
Questioning a Doctor’s Orders
How do you tell a physician that the dosage of a drug
he ordered falls outside the normal limits? Very tactfully.
­Approached without rancor, many physicians will alter the
­dosage. Others will confirm that the order is correct, ­believing
that’s all that’s necessary. And occasionally, a doctor may
angrily insist you follow the order as is. If you express further
doubts, a physician may go so far as to tell you he’ll vouch for
the patient’s safety: “I’m willing to take full responsibility for
this,” he might say. Then what? Don’t ever agree to such an
­arrangement. It may be the doctor’s order, but if you carry it
out despite serious doubts, your license is at risk.
It is your right—and your responsibility—to question any
­order you think is inappropriate. In looking out for your
­patients’ best interests, never shrug off a dubious order,
­trusting that “the physician knows best.” Staying quiet could
be viewed as negligence, leaving you, your colleagues, and the
facility vulnerable to a malpractice charge. There may be a time
when you question your own judgment, but following through
on any concerns you have can protect you against liability.
Unwise as it is to accept a doctor’s word without question, it’s
important to realize that there will likely be times when the
physician has a rationale for what strikes you as unacceptable.
The key is knowing when to yield. If the practitioner will not
change the order, ask for an explanation or solid documentation to support his or her decision. A vague explanation that
“a study I read” found the extremely high dose ordered to be
safe and effective is not necessarily good enough. But solid
evidence—for example, a detailed explanation and precise
reference to a journal report of a randomized clinical trial that
revealed the benefits of the massive dosage—should suffice.
Either way, always take the time to document your objections,
the person with whom you spoke about these objections, and
what ensued. Don’t forget to include your name, the date, and
the time when everything occurred.
The most crucial situation, of course, is when an order could
compromise patient safety, such as when a physician gives an
order that you know to be contraindicated because of a wrong
drug or a wrong dosage. It’s also wise to question any order
that is below the standard of care, or violates a hospital or
employer policy or procedure.
Nurses today face many challenges that can add strain to their
job and can ultimately put them at risk for a lawsuit. Nurses
Service Organization (NSO), the INS-endorsed program
for professional liability insurance coverage for over 650,000
nurses since 1976, appreciates that among those hurdles are
doctors’ orders and the effort that goes with questioning them.
A nurse should never follow an unsafe order. In protecting
your patient, you protect yourself as well, because carrying out
an order despite serious doubts can leave you liable to a charge
of malpractice and put your license at risk.
Also, never guess at an unclear or illegible order—always ask
the practitioner exactly what he or she meant. Doing otherwise
could compromise patient safety and leave you facing disciplinary action. Many facilities have prohibitions, based on state
practice acts or in-house policies, against dispensing or following ambiguous orders. Remember three simple words: “Appropriate. Complete. Legible.” Unless the order fulfills them all,
don’t administer treatment.
Note:
This risk management information was provided by Nurses Service ­Organization
(NSO), the nation’s largest provider of nurses’ professional liability ­insurance
coverage for over 650,000 nurses since 1976. INS endorses the ­individual
­professional liability insurance policy administered through NSO and
­underwritten by American Casualty Company of Reading, Pennsylvania, a
CNA company. Reproduction without permission of the publisher is prohibited.
For questions, send an e-mail to service@nso.com or call 800-247-1500. www.
nso.com.
You always have the option of bringing a concern about a
physicians’s orders to your manager for clarification and advice.
If that advice includes speaking directly to the practitioner, be
concise and provide specific reasons for your inquiry, such as a
drug label’s indication that the dosage ordered for your patient
is dangerous. It is important to be firm and professional, and
don’t back down until you are convinced the order is safe.
NOVEMBER/DECEMBER 2007 • www.ins1.org Chapter Newsbites
Erin Herzog
INS Membership Services Manager
INS chapters have been hard at work in 2007, planning programs and events for chapter members to interact and enjoy education
opportunities in their backyard. Here is a sampling of some of our chapter activities around the country:
On September 25, the Maryland Capital Chapter hosted
a session on “PICC Lines: Access, ­Education and Insertion
Training,” presented by Julie May, RN, MSN, CNS, CRNI®,
of Bard Access Systems. Interested in learning more about
­Maryland Capital Chapter events and chapter education
­sessions? Log on at http://www.mdins.net for the latest
news and programs.
The Spacecoast Chapter hosted an active ­summer/fall
­schedule of meetings and programs. In August, the ­chapter
met for a brief business and social ­meeting, and their
­September ­meeting included a session on “Procedure Related
Pain Management in Pediatrics.” On October 9, Hospira
presented a ­program entitled “Detect, Correct, and Prevent
Medication Errors with Intelligent Infusion Technology.”
For further information on chapter activities, contact chapter
president Bonnie Trottier Smith, CRNI®, at bonnie.smith@
health-first.org.
In August, the Longhorn Chapter held their meeting at the
Medical City Conference Center. The dinner session, hosted by
Sean Kirby with Cubist, included a program on “New Options
and ­Treatments for MRSA,” presented by Janet Adams, RN,
CCRN. For further information on chapter activities, contact
the chapter president, Gail Koloc, CRNI®, at gkoloc@ghsrx.
com.
NOVEMBER/DECEMBER 2007 • www.ins1.org
The Lower Columbia Chapter of INS had their annual fall
seminar in October in Lake Oswego, Oregon. The seminar
included over 20 vendors and some great presentations from
Jim Lacy, “Controversial Issues in IV Therapy”; Tim Royer,
“Reducing Short Peripheral IV Complications”; and Dr. Mark
Rupp, “Healthcare Associated Bloodstream Infections: Update
on Pathogenesis and Prevention,” to name a few. There was
also a small celebration in recognition of the chapter’s recent
past president and 2007 CRNI® of the Year, Marla Spadafora.
Watch for seminar information in 2008.
Baxter-Hylenex Division sponsored the Florida ­Gulfcoast
Chapter’s September meeting at Feather Sound Country
Club in Clearwater. Forty nurses enjoyed a relaxing dinner
followed by an excellent ­presentation by Stacy Baldridge, RN.
­Attendees learned about Hylenex recombinant as an ­alternative
to ­difficult vascular access. Six BSN nursing students from St.
­Petersburg College joined the meeting. They found out about
the chapter by searching the internet and found the INS Web
site, and from there they found the local web site. They were
quite impressed with the INS local and national ­organizations
and have requested more information about ­becoming
­members of both. Florida Gulfcoast INS is ­working hard to
raise the ­visibility of INS in the area. Since ­putting up their
Web site, they have increased their ­visibility in the ­community.
The site has also afforded them ­opportunities to educate
­others about the local ­chapter as well as National INS.
For information on ­future ­meetings, please e-mail
floridagulfcoastins@yahoo.com or visit
http://www.geocities.com/floridagulfcoastins/
classic_blue.html.
Membership Corner
Erin Herzog
INS Membership Services Manager
What Makes My INS Membership Valuable?
Value. Webster’s dictionary defines value as “a fair return
or equivalent in goods, services, or money for something
­exchanged.” To date, INS maintains more than 5,800 ­members
from all facets of the infusion nursing industry. Each of these
members—either active RNs, faculty, or industry ­affiliates—
joined INS because they found value in the offerings and
professional development opportunities that are exclusive to
our membership.
Studies indicate that people join professional organizations
for a number of reasons—networking, continuing ­education,
­certification, social benefits—and the list goes on. INS
­recognizes the needs of our members by sending ­customized
surveys and targeted mailings, as well as by responding to
phone calls and e-mails that arrive daily. We use this feedback
to develop new educational products and meeting topics and to
produce articles and website announcements.
Like our membership rolls, the value and benefits associated
with INS membership will continue to grow with the ­changing
needs of our society. The following list outlines the current
benefits associated with membership:
Journal of Infusion Nursing
All current INS members receive a complimentary ­subscription
to the Journal of Infusion Nursing. This official, bimonthly
­publication provides members with up-to-the-minute scientific
and clinical information on the latest technology, research, and
news that affect the infusion nurse specialist.
INS Newsline
This official INS membership newsletter brings members
closer to INS with columns on medication safety, frequently
asked clinical questions, insurance issues, entrepreneurship;
­announcements of INS national and local chapter events;
­feature articles relevant to all infusion professionals; and a
spotlight on the professional experiences of INS members.
The INS National Infusion Nursing Network
The INS National Infusion Nursing Network gives members
quick, informed responses to their toughest clinical questions.
This resource puts INS members in touch with colleagues
who can ­offer ­perspectives on difficult practice situations.
It ­connects ­volunteers who have demonstrated expertise
in ­specific areas of the specialty with INS members who
­encounter obstacles in their clinical practice. INS members
consistently rank the ­Network as one of the most valuable
benefits of INS ­membership.
National Education Programs
Members receive special reduced registration rates to attend
the INS Annual Meeting, National Academy of Infusion
Therapy, and all other special education programs. These
events are excellent occasions to earn continuing education
credit and recertification units. They also offer networking,
professional development, access to the newest technological
advances in infusion products and services, and presentations
by the world’s leading experts in the infusion specialty. The
2008 INS Annual Meeting will take place May 3-8, 2008 in
sunny ­Phoenix, AZ. Further details and registration forms can
be found online at www.ins1.org.
CRNI® Certification and Recertification Programs
The Infusion Nurses Certification Corporation (INCC) ­is the
standard of excellence that nurses will seek in order to provide
optimal infusion care that the public expects, demands, and
deserves. The CRNI® Certification ­Examination is offered
in March and September (starting in 2008) to all registered
nurses who have at least two years of experience in infusion
therapy. Those who pass the exam earn the CRNI® credential
and recognition in the healthcare industry. INS members enjoy
reduced fees for exams and recertification ­programs along with
special educational resources to prepare them for certification.
Career Center
This INS member service allows infusion specialists the
­opportunity to search for entry-level and management
­positions at hospitals and training facilities throughout the
United States and abroad. Members can register and submit
their resumes online at www.ins1.org/classifieds. Log on
today to post your company’s open infusion positions, or post
your own resume for career advancement.
Chapter Activities
INS local chapters hold regularly scheduled meetings to
­provide area infusion specialists the opportunity to participate
in valuable career growth activities such as professional development programs, onsite training, networking, and leadership
opportunities as a chapter officer. With more than 40 chapters
throughout the United States, you are sure to find a group of
local infusion specialists in your area. For your reference, a
complete list of local chapters can be found online at
www.ins1.org/about/chapters_list.html.
Continued on page 8
NOVEMBER/DECEMBER 2007 • www.ins1.org Infusion Nurses Certification Corporation News
2007 Recertification Reminder—Save $50!
If your CRNI credential expires December 31, 2007 and
you have your 40 recertification units, submit your ­application
today and avoid the $50 late fee charged to applications
­postmarked between December 31, 2007 and January 31, 2008.
Details about CRNI® recertification and application forms are
included in the CRNI® Recertification Handbook. Download a
copy at www.incc1.org or call (800) 434-INCC.
®
2007 CRNI Exam Results
®
At the time of going to press INCC has not received the final
report on the September 2007 CRNI® Examination. As soon
as it becomes available, it will be posted at www.incc1.org. An
honor roll of nurses who passed the examination will also be
featured.
Julie Smiley
INCC Certification Manager
Calling all CRNI®s
Learn how to effectively market your achievements as a
CRNI®—call INCC at (800) 434-INCC or e-mail julie.smiley@
ins1.org for your free copy of the Market Yourself brochure.
Containing tips and ideas to help you get the most out of your
CRNI® credential, INCC’s Market Yourself brochure is essential
reading for all CRNI®s.
CRNI® Poster
If you are looking to promote
infusion nursing at your ­facility, the
2008 CRNI® poster is available.
Call (800) 434-INCC or e-mail
julie.smiley@ins1.org to request
your free copy.
2008 March CRNI®Examination
The application deadline for INCC’s new March CRNI®
Examination is fast approaching. Applications received by the
early-bird deadline of December 10, 2007 benefit from a
$50 discount. INCC’s free comprehensive guide to the CRNI®
Examination, the CRNI® Bulletin, is available at www.incc1.
org or by calling 800-434-INCC. Be among the first to sit
for the new exam administration and submit your application
today.
2008 Exam Application Deadlines and Fees are
listed in the table below.
Application Deadlines
March Exam
September Exam
Early Bird
Includes $50 discount
Regular
December 10, 2007
January 10, 2008
June 10, 2008
July 10, 2008
Exam Fees
Certification
INS Member
$285
$335
Joining INS
(includes 1-year
$375
$425
Nonmember
$410
INS membership)
$460
Note: The March CRNI® exam administration is open to
initial certificants only. CRNI®s applying to recertify by exam
must apply for the September administration.
NOVEMBER/DECEMBER 2007 • www.ins1.org
Advertise Your Achievement
If you’ve just passed the CRNI®
­examination or recently recertified,
celebrate your achievement—order your
CRNI® pin or mug today. At only $5,
the CRNI® mug is great way to celebrate
your accomplishment or that of a newly
­certified ­colleague.
What Makes My INS Membership Valuable?
continued from page 7
Gardner Foundation Scholarships
With the continued support of INS members and industry
friends, the Gardner Foundation is expanding its scholarship
and grant opportunities to make funding available to more
infusion nurse specialists. Throughout the last 10 years, the
Gardner Foundation has awarded more than $100,000 in
grants to members.
We put value in the benefits and services that we are able to
provide our members and look forward to continued success
with future product ideas and meeting offerings. Should you
have any questions about your membership with INS, please
feel free to contact Erin Herzog, Membership Services Manager, at (781) 440-9408 ext. 316 or via e-mail at erin.herzog@
ins1.org. Good luck with your INS endeavors. We look forward
to continue serving your membership needs.
Clinical Concepts of Infusion Therapy
Kathy Walther, RN, BSN, CRNI®
Nurse Educator
Intraosseous Vascular Access
Intraosseous (IO) vascular access has it origins back in 1922,
with the first documented use in World War II. Since that
time, IO access has been used primarily as an alternative
access in children when a vascular access device cannot be
placed. With advances in IO devices, their use spread to the
adult ­population. In 2005, the American Heart Association for
Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care stated that intraosseous cannulation provides access to
noncollapsible vascular plexus, enabling drug delivery ­similar
to that achieved by central vascular access. The American
Heart Association Advanced Cardiac Life Support (ACLS)
Pulseless Arrest Algorithm now includes IO access along with
­intravenous (IV) administration of medications during cardiac
arrest.1 This Newsline article will review the various types of
intraosseous devices and how they have been used, primarily in
the prehospital and military settings.
Background
In 1922, Harvard University’s C.K. Drinker, MD, examined
the sternum and discovered that the intraosseous space could
be considered a noncollapsible vein.2,3 In 1940, Dr. Leandro
Tocantins and his colleague J.F. O’Neill confirmed the marrow
cavities of the long bones could be used for vascular access.
This team determined that red dye injected into rabbits reached
the heart within 10 seconds. In 1942, E.M. Papper, MD, PhD,
discovered that the circulation times for both intravenous
and intraosseous were nearly identical. Doctor Papper served
in Europe during World War II and eventually became the
chief of anesthesiology and operating rooms at Walter Reed
­Hospital.4
The first documentation of a life saved by IO ­administration
was a 19-year-old B-29 crew member who was critically
wounded while flying over Japan during World War II. There
are 4,000 documented cases of IO being used in WWII. After
the war, IO did not carry over from military to civilian use. It
remained in limited use for over 25 years, primarily because
trauma surgeons did not have the protocols and technology
from the military.
In 1984, James Orlowski, MD, of the Cleveland Clinic, ­visited
India during a cholera epidemic. He observed fluids being
­given to children using IO access. He subsequently ­published
an editorial titled “My Kingdom for an Intravenous Line”
in the American Journal for Diseased Children. This editorial was
the ­foundation for renewed interest in IO access and became
a standard of care in the Pediatric Advanced Life Support
(PALS) guidelines in the 1980s.5 The introduction of plastic IV
catheters also promoted the decreased use of IO access.
The National Association of EMS Physicians (NAEMSP) has
developed a position statement saying that “[i]ntraosseous
access may provide a significant time saving which may
benefit may critically ill patients, both by decreasing time to
achieve ­access and by decreasing the time to administration of
­indicated medications.”6
Intraosseous Anatomy and Physiology
The intraosseous space is referred to as a noncollapsible vein
because the bone surrounding the vein is directly connected to
the central circulation. The IO space contains tiny noncollapsible intertwined blood vessels that act like a sponge when fluid
comes into contact. Any infusates are then directly absorbed
into the central circulation. Blood flow is constant, even in
trauma and shock situations. The blood pressure in the IO
space is about 35/25 mmHg, or approximately one third the
systemic arterial pressure.7
The term intraosseous space refers to the spongy cancellous bone
of the epiphysis and the medullary cavity of the diaphysis,
which are connected. The vessels of the IO space connect to
the central circulation by a series of longitudinal canals that
contain an artery and a vein. The Volkmann’s canals connect
the intraosseous vasculature with the major arteries and veins
of the central circulation.
Types of Insertion Devices
There are three different methodologies of needle placement
for intraosseous access: manual, impact driven, and drill powered. Manually inserted needles have been available for some
time. Some brand names are Jamshidi™ (Baxter Healthcare
Corp, McGaw Park, IL) and Dieckmann™ (Cook ­Critical Care,
Bloomington, IN). These are hollow steel needles with removable trocars that prevent bone fragments from ­plugging the
needles during insertion. The estimated time for ­preparation
and insertion varies with the devices, the patient’s condition,
and skill of the inserter. Limitations of the steel needles are
difficulties accessing the adult bones due to the density and
hardness of the bone, the time to insert the device, and the
possibility of extravasation because of leakage at the
insertion site.
The second type of devices are impact driven. One type is
designed for sternal access (FAST1™ Intraosseous Infusion
System, Pyng Medical Corporation, BC, Canada). This device
has several needle probes to accurately locate the depth of
Continued on page 10
NOVEMBER/DECEMBER 2007 • www.ins1.org Clinical Concepts
continued from page 9
the sternum. Pressure is then applied and the central needle
extends into the sternal medullary cavity. Limitations would be
the inability to perform compressions and gain access to the
sternum in a trauma situation. Estimated time of preparation is
50 seconds.
The second impact-driven device (Bone Injection Gun,
B.I.G., WaisMed, Houston, TX) uses a spring-loaded injector
mechanism to fire the IO needle into the medullary space of
the tibia. Estimated time of preparation is 17 seconds. Both
impact-driven devices must be adequately stabilized to prevent
patient or operator injury.
The third type of device is drill based (EZ-IO, Vidacare Corp.,
San Antonio, TX). It is a hand-held battery-operated device to
drill the IO needle into the intraosseous space. The ­insertion
time is less than 10 seconds. This device has had minimal
­complications and leakage from the insertion site.
IO Considerations and Contraindications
IO access requires the healthcare worker to have adequate
training and knowledge of the specific device. Studies have
shown that higher success rates in prehospital and military
settings are achieved with teams having the most practice
and knowledge. Currently, IO devices are a standard of care
for military personnel in Afghanistan and Iraq. Many large
­emergency medical services groups are using IO in the field for
cardiac arrest and multiple traumas.
Contraindications to using IO include fractures above or below
the site, previous surgery involving the bone, infection at the
insertion site, and local vascular compromise.
Complications include osteomyelitis, fat embolism, fracture,
infection, extravasation, or compartment syndrome. In a study
of 4,200 cases of IO access in children, osteomyelitis occurred
in only 0.6%. The largest concern would be extravasation of
the medications that can be given via IO access.
Pain during insertion is a concern in the conscious patient.
The use of 1% lidocaine initially injected into the IO space has
proved effective in reducing the pain.
Flushing the tubing with 10 ml saline prior to infusing
­medications or fluids has also proved to increase the success
rates. Any medication can be given via the IO route. Fluids
have averaged between 20 ml to 1000 ml per hour with the
­average of 350 ml per hour. The dwell time is usually less
than 24 hours. IO is the emergency access when the IV route
­cannot be obtained.
10 NOVEMBER/DECEMBER 2007 • www.ins1.org
In a chemical warfare emergency, nerve agent antidotes have
had a higher success rate given IO as opposed to ­intramuscular
or intravenous administration. Since the physician has to have
full protective gear, the time frame between initiating ­vascular
access and IO access determined the IO access could be
achieved at a faster rate and medications given to the patient
more quickly.8,9
Summary
IO access has had a resurgence owing to updated technology
and methodology. With support from the American Heart
­Association, NAEMSP, and the military, IO has become the
standard for obtaining vascular access during the “golden
hour” and with multiple traumas and mass casualties. The Food
and Drug Administration is looking to approve ­additional sites
such as the humeral head, clavicle, and medial malleous. Since
a central vascular access device has a higher infection rate and
requires more time and skill to place, IO access may be the
choice for first access during an emergency.10
References
1.American Heart Association. Advanced cardiac life support
­guidelines: management of cardiac arrest. Circulation.
2005;112-IV, 57-66.
2.Miller L, Kramer GC, Bolleter S. Rescue access made easy. JEMS.
2005 suppl, 8-18.
3.Drinker CK, Drinker KR, Lund CC. The circulation in the
­mammalian bone marrow. Am J Physiol. 1922;62:1-92.
4.Papper ME. The bone marrow route for injecting fluids via the
bone marrow. Anesthesiology. 1942;3:307- 313.
5.Orlowski JP. My kingdom for an intravenous line. Am J Dis Child.
1984;138(9):803.
6. National Association of EMS Physicians. Position statement.
Prehospital Emergency Care. January/March 2007;11(1).
7. Davidoff J, Fowler R, Gordon D, Klein G, Kovar J, et al. Clinical
evaluation of a novel intraosseous device for adults: prospective,
250-patient, multi-center trial. JEMS. 2005;30(10):suppl 20-23.
8. Dubick MA, Holcomb JB. A review of intraosseous ­vascular
access: current status and military application. Mil Med.
2000;165(7):552-559.
9. Ben-Abraham R, Gur I, Vater Y, Weinbroum AA. Intraosseous
emergency access by physicians wearing full protective gear. Acad
Emerg Med. 2003;10(12):1407-1410.
10.Gillum L, Kovar J. Powered intraosseous access in the
out-of-hospital setting. JEMS. supp 2005;24-26.
Medication Safety
continued from page 3
Use fully functional smart pumps. Use of smart pumps that provide dosage error-reduction software will help avoid harmful
mix-ups among various dosing methods for the drugs in the pump’s library. Other safety features include ­unchangeable dosing
units once a drug is selected, weight limits, and clinical advisories. Smart pump alerts warn practitioners of impending ­medication
errors and should not be overridden. If an alert is activated, it is crucial for the practitioner to investigate the warning and act
­accordingly. Organizations should conduct regular compliance rounds to ensure that the dose-checking capabilities are fully
­functional, as well as review available data from the error-reduction software to monitor appropriate staff interaction with the
technology.
List dosing methods on MARs and labels. When possible, the dose of a medication should be displayed on the medication
administration record (MAR) and the drug container label the same way the information will be needed to program the pump.
List dosing methods on orders. Prescribers should list the dosing method used along with the calculated dose of drugs at risk
for error (e.g., pediatric drugs, chemotherapy).
Verify the dosing method. When applicable, pharmacists and nurses should verify both the dosing method used and the
­calculated dose before dispensing or administering a medication.
Verify pump settings during hand-offs. Verify all pump settings upon transfer of patients and at the ­beginning of each shift. Be
sure the dosing method and total dose make sense for the patient given his or her weight, age, and condition.
Suspect an error. If a patient is not exhibiting the physiologic changes that would be expected given the infusion, consider the
possibility of an error, and verify the pump settings.
Use simulation training. To heighten staff awareness about mix-ups with dosing methods, consider simulation training in which
participants investigate a hypothetical case with a dosing error, uncover the error, and take corrective action.
References:
1. B
ates DW, Vanderveen T, Seger DL, et al. Variability in intravenous medication practices: implications for medication safety.
Jt Comm J Qual Pat Saf. 2005;31:203-10.
2. Lesar TS. Errors in the use of medication dosage equations. Arch Pediatr Adolesc Med. 1998;152:340-44.
INS Board of Directors 2007-2008
President:
Lisa Gorski, MS, APRN,BC, CRNI®, FAAN
President-Elect:
Cora Vizcarra, MBA, RN, CRNI®
Secretary/Treasurer:
Michelle Berreth, CRNI®
Presidential Advisor:
Lynn Czaplewski, MS, RN, CRNI ®, OCN ®
Directors-at-Large:
Lynn Phillips, MSN, RN, CRNI ®
Mary Zugcic, RN, APRN,BC, CRNI ®
Public Member:
Christopher Hughes, PharmD
INS Chief Executive Officer:
Mary Alexander, MA, RN, CRNI®, CAE
INS Newsline encourages submission of articles, press releases, and
other materials for editorial consideration, which are subject to
editing and/or condensation. Such submission does not guarantee
publication. Photos become the property of Newsline; return requests
must be in writing. Next news deadline: November 16, 2007. Newsline
is an official bi-monthly publication of the Infusion Nurses Society.
Copyright 2007 by the Infusion Nurses Society, Inc. All rights
reserved.
For information, contact:
INS Publications Department
315 Norwood Park South
Norwood, MA 02062
(781) 440-9408 • (781) 440-9409 Fax
dorothy.lohmann@ins1.org
NOVEMBER/DECEMBER 2007 • www.ins1.org 11
NEW!
Cast Your INS Board of Directors Vote Online
INS is making it easy for you to participate in the election of your INS Board of Directors.
The election for the 2008-2009 board will take place in cyberspace! When you visit the INS
Web site, just a few clicks will take you to the candidates’ information. Make your choice, then
click to vote. Here’s how it will work:
Each valid voting member (you must be an INS member) will need a user name (your last
name) and password (your INS membership number). If you do not know your membership
number, you can find out by contacting INS Membership Services by phone (800-694-0298)
or e-mail (ins@ins1.org).
When you’re ready to vote, go to the INS Web site: www.ins1.org. You will find a “vote
­sticker” right on the home page. Click on it, and you can start the voting process.
Voting will take place between December 5, 2007 and January 5, 2008. Please watch the INS
Web site for future announcements about the voting process.
Remember, the Board of Directors is your voice at INS. If you care about the direction of
INS, take just a few minutes to vote for your representatives.
INS Joins New IVIG Therapy Alliance
continued from page 1
patient advocates and work in many different healthcare
­settings, from the home to infusion centers to hospitals.
Mary Alexander represented INS for the first time at a
­September meeting of the Alliance. The meeting was called
to introduce members of the Alliance to lead officials at
HHS, including CMS. The main topics of discussion were
­reimbursement issues, including the clarification on Medicare
Part D coverage of administration in the homecare setting.
­(Under new rules, Medicare will not pay for professional
­services, equipment, and supplies necessary to administer
treatment safely in the home.) The HHS representatives were
impressed with the work of the Alliance and showed a great
deal of interest in working together to restore access to IVIG
12 NOVEMBER/DECEMBER 2007 • www.ins1.org
for all patients who rely on this therapy in all care settings. You
will be hearing more about INS participation in the Alliance as
the organization moves toward this goal.
References
1.The Alliance for Plasma Therapies. Mission. Available at www.
plasmaalliance.org/Mission.htm. Accessed September 26, 2007.
2.Eastern Research Group. Analysis of supply, distribution, ­demand,
and access issues associated with immune globulin intravenous
(IGIV). Available at http://aspe.hhs.gov/sp/reports/2007/IGIV;
1-1. Accessed September 27, 2007.
3.The Alliance for Plasma Therapies. Membership. Available
at www.plasmaalliance.org/Membership.htm. Accessed
September 26, 2007.
NOVEMBER/DECEMBER 2007 • www.ins1.org 13
MEDSYNTRIX.com is an online continuing education and training company designed to meet the educational
needs of the medical healthcare professionals using the World Wide Web. Web based learning provides an
alternative to traditional classroom presentations for medical professionals with busy schedules and healthcare
organizations with limited travel and continuing education budgets.
We offer a series of web seminars and on line self study modules on various topics related to infusion therapy
to assist you in meeting your continuing education and training needs. Web seminars provide on line, real time
audio and video communications in the comfort of your home or workplace with no travel required. On line self
study modules allow you to learn at your own pace and time while earning contact hours.
Web Seminars offered in 2007
Best Practices for Biologic Infusions: Patient
Assessment
Best Practices for Biologic Infusions: Infusion
Techniques
Best Practices for Biologic Infusions: Pharmacologic
Management of Infusion Reactions
Alternate Access for Infusion Therapy: Subcutaneous
Route
Alternate Access for Infusion Therapy: Intraosseous
Access
Alternate Access for Infusion Therapy:
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For more information, visit www.medsyntrix.com or
email info@medsyntrix.com Phone: 317-616-3897
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This is a paid advertisement for a private commercial entity and is not affiliated with or endorsed by INS or INCC.
Any claims or statements regarding products or services are solely those of the advertiser and cannot be verified by INS or INCC.
2008 INS Annual Meeting
and Industrial ­Exhibition in
Fabulous Phoenix
Advancing the Science of
­Infusion Therapy
Register now for discounted rates!
Visit www.ins1.org to register for
the 2008 Annual Meeting
14 NOVEMBER/DECEMBER 2007 • www.ins1.org
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NOVEMBER/DECEMBER 2007 • www.ins1.org 15
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