Professional Practice Concepts
for Infusion Therapy
Infusion Related Infection
Control and Occupational Risks
Infusion Nursing
Infusion nursing is defined as the nursing
process relating to technical and clinical
application of fluids, electrolytes, infection
control, oncology pediatrics,
pharmacology, quality assurance,
technology and clinical application,
parenteral nutrition, and transfusion
therapy
Evidenced Based Nursing Practice
Evidence-based nursing practice (EBNP)
Conscientious use of current best evidence
in making decisions about patient care
(Source: Sackett, Straus, & Richardson,
2000)
Components of
Evidence-based Practice
Evidence from research/evidence-based
theories and opinion of leaders/expert
panels
Evidence from assessment of patient’s
history, physical exam, and availability of
health-care resources
Clinical expertise
Information about patient preferences
and values
Nursing Process Related to
Infusion Therapy
A study by NCSBN found that newly
licensed RNs indicated their time is spent
as follows
30% on assessments
12% on analysis
14% on planning
30% on implementing client care
14% on evaluation
(Source: NCSBN, 2003)
Assessment
Assessment includes
Collection of data
Critical laboratory values
Allergies
Environmental issues
Presence of adverse reactions or complications
Assessment Prior to Infusion Therapy
 Subjective Information
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Patient’s related fears of infusion
Patient’s experiences with prior infusion therapy
Patient’s needs and stated preferences
Disclosure of indications, including anticoagulants
 Objective information
 Review of patient’s past and present medical history
 Physical assessment, including evaluation of periphery for poor vascular
return
 Review of laboratory data and radiographic studies
 Assessment of level of growth and development for neonate and
pediatric clients
Diagnosis
 Problem list is based on assessment data
 NANDA-I (2007) provides a clear distinction
between nursing diagnosis and medical
diagnosis
Examples of infusion-related problems
 Fluid volume deficit related to failure of regulatory
mechanism
 Infection, risk for related to compromised host defenses
NOTE: Nursing diagnosis provides a basis for selection of
nursing interventions (nursing actions)
Planning
Planning involves three components
Setting priorities
Writing expected outcomes
Establishing appropriate interventions
Implementation of Interventions
 Nursing actions
Interventions are the concepts that link specific nursing
activities and actions to expected outcomes
Independent activities are those actions that the nurse
performs using his or her own discretionary judgment
Collaborative activities are those actions that involve
mutual decision making between two or more healthcare practitioners
Evaluation
Evaluation loops back to assessment
Once new data is collected a nursing judgment
is made on what modification in the plan of care
is needed
Three judgments can be made
• The evaluation data indicates that the health-care problem
has been resolved
• Revise the plan of care; outcomes have not been met
• Continue the plan of care based on progress toward goal
Note …..
If an act of malpractice does not create
harm, legal action cannot be initiated
However: Coercion of a rational adult
patient to place an intravenous catheter
constitutes assault and battery
Legal Terms
 CRIMINAL LAW: an offense against the general
public caused by the potential harmful effect to
society as a whole
 CIVIL LAW: effect the legal rights of private
persons and corporations. Contract Law and Tort
law are most applicable to nursing practice
 NEGLIGENCE: Failure to do something that a
reasonable person would do
 MALPRACTICE; Subset of negligence,
committed by a person in a professional
capacity. (nonadherence to the accepted
standard of care)
Legal Practice
Breach of duty
Legal perils related to infusion therapy
practice
Failure to monitor and assess clinical status
Failure to prevent infection
Failure to use equipment properly
Failure to protect the patient from avoidable
injury
Legal Terms
Four components needed to prove
liability for malpractice
It must be established that the nurse had a
duty to the patient
A breach of standards of care or failure to
carry out that duty must be proven
The patient must suffer actual harm or injury
There must be a causal relationship between
the breach of duty and the injury suffered
(O’Keefe, 2000)
Rule of Personal Libility
The rule of personal liability is “every person
is liable for his own tortuous conduct” (his
own wrong doing.)
Legal Action
Two most common causes for legal action in
nursing
Unprofessional practice: conduct that is a
departure from or failure to conform to the
minimal standards of care
Professional malpractice: professional
misconduct or unreasonable lack of skill that
results in harm
Legal Issues
Breach of duty:
 Failure to observe, failure to intervene, and
verbal rather than written orders are potential
risks for all nursing areas
A breach of application of standards of care can
be the basis for negligence. Always ask what a
reasonable and prudent nurse would do.
Legal Perils of IV Therapy
 Not enough IV experience to become
comfortable or proficient
 Entering the blood stream with a foreign object
 Litigation for nurses can result from
Infiltration and phlebitis
Fractured central venous catheters
Nerve injury, infiltration and Extravasation
Administering the wrong drug
Failure to document appropriately
Ethics
A code of ethics acknowledges the
acceptance by a profession of the
responsibilities and trust that society has
conferred and recognizes the duties and
obligations in that trust.
Infusion Nursing Code of Ethics
Autonomy (right to self determination,
independence
Beneficence (doing good for patients)
Nonmaleficence (doing no harm to
patients)
Veracity (truthfulness)
Fidelity (obligation to be faithful)
Justice (obligation to be fair to all people)
Risk Management
Standards of Practice for Infusion Therapy
come from the Infusion Nursing Society
New standards published in 2006
Association of Vascular Access
Oncology Nursing Forum
Standards of Care
Standards of care describe the results or
outcomes of care and focus on the patient
Standards of care are developed within
organizations to measure quality based on
expectations
Standards of care can be voluntary or
mandated by legislation
Standards of Practice
Focus on the provider of care
Represent acceptable levels of practice in
patient care delivery
Define nursing accountability
Provide a framework for evaluating
professional competency
Risk Management
The Revised Infusion Nursing Standards of
Practice define Risk Management as
“a process that centers on identification,
analysis, treatment, and evaluation of real
and potential hazards”
It is the process of collecting and analyzing
scientific data “to describe the form,
dimension, and characteristics of risk”
Medication Safety
NOTE
Medication error is the most common type of
error affecting patient safety. Preventable
adverse drug events (ADEs) are associated with
one of every five injuries or deaths occurring in
the health-care health care system
(Source: Rozich, et al, 2004)
Medication Errors
Lack of awareness:
Between 44,000 and 98,000 deaths annually
Approximately 2.5 million nurses and 900,000
Physicians practicing in 7500 Hospitals across
the United States
Complex environment: making clear
communication even more important.
Risk Management
Risk Management involves all medical and
facility staff.
It provides for the review and analysis of
risk and liability sources involving patients,
visitors, staff and facility property
Risk Management Components
Identification and management of clinical
areas of actual and high risk
Identification and management of
nonclinical (e.g. visitor, staff areas of
actual and high risk)
Identification and management of probable
claims events
Management of property loss occurrences
Risk Management Components (cont)
Review and analysis of customer surveys
and patient complaints
Review and analysis of risk assessment
surveys
Operational linkages with hospital Quality
management, safety, and performance
improvement programs
Risk Management Components (cont)
Provision of risk management education
Compliance with state risk management
and applicable federal statutes, including
the Safe Medical Devices Act
Clinician and Patient Safety
Barriers to Improvement
Two types of errors as identified by James
Reason
Active errors: “errors at the sharp end of
healthcare” Occur at the point of interaction
between the person (nurse) and a larger system
(medication cart)
Latent errors: “errors at the blunt end of health
care” error that gives rise to the active error and
is not necessarily apparent when it happens.
Clinician and Patient Safety
Barriers to Improvement
Culture of Blame
Clinician and Patient Safety
Pathophysiology of error
 Reliance on weak aspects of cognition
 Interruptions
 Fatigue
 Time Pressure
 Hand-offs
 Medication terminology
 Standardization
 Knowledge Base
 Paradigm Shifts
Risk Management Strategies
Informed consent
Unusual occurrence reports
Sentinel events
Documentation
Professional Liability insurance
Patient relations
Quality Management
Risk Management Strategies
Informed consent
To provide patients with enough information to
enable them to make a rational decision
regarding whether to undergo treatment
Unusual occurrence reports
Should be filed every time there is a deviation
from the standard. Record of the event
Unusual occurrence reports are meant to be
nonjudgmental, factual reports of the problem
and its consequences.
Risk Management Strategies
Documentation
Accurate, timely, and complete written account
of the care rendered to the patient.
Professional liability insurance
Patient relations
Quality management
Dimensions of Performance
Doing the right things includes:
The efficacy of the procedure or treatment in
relation to the client’s condition
The appropriateness of a specific test,
procedure, or service to meet the client’s need
Dimensions of Performance
Doing the right thing well includes:
The availability of a needed test, procedure,
treatment, or service to the client who needs it
The timeliness with which a needed test,
procedure, treatment or service is provided to
the client
The effectiveness with which tests, procedures,
treatments, and services are provided
Quality Patient Management
Quality management is the systematic
process to ensure desired patient
outcomes
 Continuous quality improvement (CQI)
Goal to create outcome monitoring and
evaluation processes to assist organization in
improving the quality of care.
Is continuous; outcomes are never optimized
but may be constantly improved.
INFECTION CONTROL
Basic Principles of Epidemiology
 Colonization: the presence of a microorganism
in or on a host, with growth and multiplication of
the microorganisms with no clinical symptoms or
detected immune response
 Dissemination: the shedding of microorganisms
into the immediate environment from a person
carrying them.
 Nosocomial Infections: developed within a
hospital of are produced by organisms acquired
during hospitalization. Now call HAC
Chain of Infection
First Link: Causative Agent
The ability of an organism to induce disease is
called its virulence.
Second Link: Reservoir
The source of microorganisms.
Other humans
Clients own microorganisms, plants, animals, or the
general environment
The place where the organism maintains the
presence, metabolizes and replicates.
Chain of Infection
 Third Link: Portal of Exit from Reservoir
Major portals of exit: respiratory tract, GI tract, skin,
blood.
 Fourth Link: Method of Transmission
Direct transmission
 From person to person, touching, kissing, biting, sexual
intercourse
Indirect transmission
 Vehicle-born: toys, handkerchiefs, soiled linens, clothes
 Vector-born: animal or flying or crawling insect
Chain of Infection
Fifth Link: Portal of Entry to the
Susceptible Host
Microorganisms often enter the body of the host
by the same route they use to leave the source
Sixth Link: Susceptible Host
Any person who is at risk for infection
Chain of Infection
Breaking the Chain of Infection
New microbiologic methods
Advancement of Epidemiologic Methods
Continuous Quality Improvement
Programs
Risk Management
Antibiotic Use
Pharmacoepidemiology
Emporiatrics (study of disease in travelers)
Infusion-Relate Infections
150 million intravascular devices are
purchased each year.
7-8 million central venous catheters placed
each year
More that 200,000 noscomial bloodstream
infections occur each year, 90% are
related to CVAD
Catheter Related Blood Steam Infections
CRBSI
Microorganisms that colonize the skin of
hospitalized patients cause the majority of
CRBSI
Biofilm “Slime” : extracellular
polysaccharide which helps bacteria to
adhere to surfaces
Organizations That Set Standards of
Practice for Infection Control
 APIC: Association of Practitioners in Infection Control
and Epidemiology
 CDC: Centers for Disease Control and Prevention
 CMS: Centers for Medicare and Medicaid Services
 INS: Infusion Nurses Society
 TJC: The Joint Commission
 OSHA: U.S. Occupational Safety and Health
Administration
BIOFILM
THE STUFF YOU SEE IN YOUR DOGS
WATER,
Catheter Related Blood Steam Infections
CRBSI
Primary risk factors include
Duration of catheterization (number of
catheter days)
Multiple lines
Colonization of catheter insertion site by skin
organisms
Location of catheter; Subclavin vein, groin
Aseptic dressing change
Aseptic insertion technique: Total Barrier
Precautions
CRBSI
Secondary Risk Factors:
Secondary bacteremia
Host defense status
Contaminated infusate,
Number of catheter lumens
CRBSI
Predisposing factors
Duration of placement
Multiple lumens
Catheters made of polyvinyl chloride
Catheters that develop fibrin sheaths
Port systems that develop sludge in reservoir
Compromised immune status
Phlebitis
Strategies for Preventing/Treating
Infections
 Follow CDC Standard Precautions Guidelines
 Tier One: Standard Precautions: universal precautions
and body substance isolation
 Tier Two: Transmission-Based Precautions
 Airborn precautions
 Droplet precautions
 Contact precautions
Notes
Nursing Fast Fact: Implementation of
standard precautions has implications for
infusion therapy nurses: Use of I.V.
therapy carts and trays may be limited for
patients who are on contact transmission
precautions.
Strategies for Prevention/Treatment
 Follow Hand Hygiene Procedure
 Nursing Fast Fact: Studies have documented
contamination of HCW’s hands with potential
healthcare-associated pathogens. Serial
cultures revealed that 100 % of HCW’s carried
gram-negative bacilli at least once, and 64%
carried S. aureus at least once.
 60% of Infections come from the patient, 35%
from other sources, and 5% from our hands
Strategies for Prevention/Treatment
Use Appropriate Skin Antisepsis
Use Catheter Site Dressing Regimens
Transparent, semi permeable polyurethane
dressing
Use Catheter Securement Devices
Use Anticoagulants
Use Antibiotic Locks
Sources of Infection
SAVE THAT LINE
Scrupulous Hand Hygiene
Aseptic Technique
Vigorous Friction to Hubs
Ensure Patency
Association of Vascular Access