1. Do you know what you are really infusing into your patients’ veins? Why not? Sara Fort, RN, VA-BC Objectives 1.To increase awareness of the risk of peripheral complications from infusions that really belong in central vascular devices. 2.To prevent patient harm by educating nurses, physicians, pharmacists, and the patients by making correct choices in vascular access devices. Abstract It is well known that specific infusions may cause harm when delivered through peripheral vascular devices. Clinicians who prescribe or infuse these specific infusions may be unaware and may place patients at risk of harm. Whose job is it to say, “No, not that vascular device?” Risk factors such as thrombosis, infiltrations, phlebitis, and extravasations may occur when these infusions are delivered through a peripheral vein. With the drive to reduce central lines, we have put our patients at risk of vascular injury from infusions delivered through peripheral vascular devices. Much research has focused on the prevention of infections, complications, and vascular access devices, and less on matching infusions with proper vascular devices to prevent patient complications. Concern for patient care plus the rise in lawsuits from patient complications, means this issue demands the attention of health professionals. Blood is a Buffer What we add to the blood changes and affects the vessels health. The rate, flow, and frequency of these infusions over time may cause harm. Methods to Make Change Happen Relationship with hospital pharmacists, physicians, and nursing to discuss patient safety regarding infusions. Investigate the patient’s medical record and see the length of expected stay. Speak directly to physicians ordering infusions and make them aware of the risks involved when giving certain infusions via the peripheral veins. Suggest the correct access. Educate primary nurses about the increased risk of certain infusions helping them to better understand the rationale to check peripheral vascular access sites frequently. Results No change will happen, unless the nurse speaks up. Change of process, such as using the correct vascular device, depends on either the primary or vascular access nurse speaking up in the situation, preventing patient harm. Physicians who answer, “We have always done it this way,” do not have the right answer based upon possible risk to patient outcomes. No change will happen, unless the physician listens. Conclusion Providing safer outcomes for patients through the education of health professionals on vascular infusions and correct vascular devices is the right thing to do. Lawsuits averaging $100,000 are on the rise from patients receiving harm from peripheral vascular devices or complications from infusions. It is up to every health care professional to know and question: Is this infusion safe to go into a peripheral device? It is up to every healthcare individual develop an index or resources of known infusions that place the patient at risk of potential harm and be proactive in placing correct devices. Where to Find Available Infusion Information Who is checking the pH, osmolarity, and viscosity of these infusions? Infusion package inserts Pharmacological books FDA Websites REFERENCES Dolan SA, Felizardo G, Barnes S, Cox TR, Patrick M, Ward KS, Arias KM. APIC position paper: safe injection, infusion, and medication vial practices in health care. American Journal of Infection Control. 2010 Apr;38(3):167-72. FDA, Vancomycin infusion development, pages 1 to 15 http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/050671s014lbl.pdf Gahart BL, Nazareno AR. Vancomycin Hydrochloride. In Gahart BL, Nazareno AR. (editors) 2013 Intravenous Medications. 29 th Edition, pages 1162-1166. Elsevier, Mosby: St. Louis, Missouri. 2013. Hadaway LC. Anatomy and Physiology Related to Infusion Therapy. In Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. (editors) Infusion Nursing: An Evidence-Based Approach. 3 rd Edition, Chapter 10, pages 139-175. Elsevier, Saunders: St. Louis, Missouri. 2010. Perucca R. Peripheral Venous Access Devices. In Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. (editors) Infusion Nursing: An Evidence-Based Approach. 3 rd Edition, Chapter 23, pages 456-479. Elsevier, Saunders: St. Louis, Missouri. 2010. Stranz M. Adjusting pH and Osmolarity Levels to Fit Standards and Practices. JVAD Fall 2002 Stranz M. Understanding pH and Osmolarity of Infusion Solutions: What is Reasonable? Presented at the 15 th Annual National Association of Vascular Access Networks Conference. January 19, 2002. Alexandria, Virginia Stranz M. Kastango ES. A Review of pH and Osmolarity. International Journal of Pharmaceutical Compounding. 2002 May-June;6(3):216-220. Trissel LA. Vancomycin Hydrocloride. In Trissel LA. (author) Handbook of Injectable Drugs. 15 th Edition, pages 1548-1562. ASHP: Bethesda, Maryland. 2009. Turner MS, Hankins J. Pharmacology. In Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. (editors) Infusion Nursing: An Evidence-Based Approach. 3 rd Edition, Chapter 15, pages 263- 298. Elsevier, Saunders: St. Louis, Missouri. 2010. Special thank you to Kim Carmel for designing this ePoster.http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/050671s014lbl.pdf Chemical Injury Mast cells found in all connective tissues are granular cells whose actions include being released with inflammation; such as when chemical injury occurs from infusions,. Our patients place trust in us that we are infusing medication to get them well and not cause harm. Current Interdisciplinary Approach to Correct Vascular Access Choices The patient requires antibiotics, fluids or nutritional replacement, chemotherapy, etc… The physician orders the infusion. The pharmacist checks the order and sends the infusion to the patient’s unit. The vascular access is previously or newly obtained by IV team or staff nurse. Primary nurse hangs the infusion. After the infusion is hung the decisions are made as to the correct vascular device closer to discharge or after complications have decreased available access. Infusions that May Cause Harm Suggested Interdisciplinary Approach to Correct Vascular Access Choices Patient requires specific infusion. The patient might receive one or two peripheral doses before team can meet. Physician, nurse, and pharmacists discuss the need and length of time for the specific infusion as close to admission as possible. As soon as possible a better vascular device is placed for the specific infusion based upon the expected length of admission, pH, osomolarity, and vascular condition of the patient. Improved outcomes and benefits from evaluating vascular access early is less delay of infusions, less complications, improved patient satisfaction, and possible earlier discharge. Hold a Hot Pot Imagine that your hands and the pot holder are your vein. How long could you hold a very hot cast iron pot until you had to put it down or risk burning your hands? Flow of Potential Harm How many infusions before the vein says, “too much?” Blood Vessel Structure 3 layers of vessel walls: Tunica intima Tunica media Tunica advenitia Size counts in variation in blood flow rate Small vessels/capillaries 1ml/minute Medium vessels 16 ml/minute Large vessels 256 ml/minute Flow is dependent upon gravitational pressure, venous pressure and the health of the vessels. InfusionpHInfusionpH Amiodarone4.1Gentamicin3 – 5.5 Ampicillin8 – 10Levofloxacin3.8 – 5.8 Ciprofloxacin3.3 – 4.6Phenytoin12 Dobutamine HCL3.5 Sulfamethoxazole/Trimethoprim 10 Dopamine HCL3.3Tobramycin3 – 6.5 Doxycycline1.8 – 3.3Vancomycin2.5 – 4.5