Lisa Dougherty

Guidelines on the insertion and management of central venous access devices in adults

Central venous access devices are used in many branched of medicine where venous access is required for either long‐term or a short‐term care. These guidelines review the types of access devices available and make a number of major recommendations. Their respective advantages and disadvantages in various clinical settings are outlined. Patient care prior to, and immediately following insertion is discussed in the context of possible complications and how these are best avoided. There is a section addressing long‐term care of in‐dwelling devices. Techniques of insertion and removal are reviewed and management of the problems which are most likely to occur following insertion including infection, misplacement and thrombosis are discussed. Care of patients with coagulopathies is addressed and there is a section addressing catheter‐related problems.

Decision-making processes used by nurses during intravenous drug preparation and administration.

AIM   The aim of this study was to explore the decision-making processes that nurses use during intravenous drug administration and how this influences risk taking and errors. BACKGROUND   Intravenous drug errors have been estimated to be a third of all drug errors. Previous drug error research has focused on observation of nurses and errors they make but has not attempted to understand the decision-making processes used during the preparation and administration of intravenous drugs. METHOD   A three-phased ethnographic study was carried out in a specialist cancer hospital in 2007 using focus groups, observation and interviews. This article is concerned with the observation and interview phase. Observation took place on two wards, each over a week. Twenty nurses were observed preparing and administering intravenous drugs; then interviewed about their procedure. Data analysis was carried out using a five stage approach. FINDINGS   Major themes identified include: interruptions; identification and knowing the patient; routinized behaviour, prevention of errors. These represent the findings of the observation and interviews with the nurses. One key finding was the lack of checking of patient identity prior to IV drug administration, which appeared to be based on nurses feeling they knew the patient well enough, although this was in contrast to how they checked even familiar drugs. This article will focus on identification and knowing the patient. CONCLUSION Implications for practice included: exploring new and effective methods of education based on behavioural theories; involving staff in updating policies and procedures; formal assessment of staff during intravenous preparation and administration.

An audit to determine the time taken to administer intravenous bisphosphonate infusions in patients diagnosed with metastatic breast cancer to bone in a hospital setting

ABSTRACT Objective: Bone metastases can occur in many forms of cancer. More than two-thirds of women with metastatic breast cancer may be affected by bone metastasis during the course of their disease. Bisphosphonates, which inhibit osteoclast-mediated bone resorption, are an established standard of care for patients with bone metastases. For patients with cancer and bone metastases, bisphosphonates are associated with a significant reduction in skeletal-related events such as vertebral fractures, non-vertebral fractures as well as increasing the time to skeletal event. The purpose of this study was to quantify the current time involved in the administration of IV bisphosphonates and how this might impact on patient experience and cancer unit capacity. Research design and methods: A pilot audit was initially conducted at the Royal Marsden Hospital (RMH), London (both Chelsea and Sutton sites), and was followed by audits at a further two UK hospital sites: Velindre Hospital, Cardiff and the Royal Surrey County Hospital, Guildford. The study was conducted between December 2005 and September 2006. Results: Overall, 151 forms were completed. Of the total patients audited, approximately 71% had a diagnosis of breast cancer. Where data on the reason for attendance were collected (Velindre and the Royal Surrey County Hospital), over 77% of patients attended hospital for the sole reason of having an IV bisphosphonate administered. The majority of patients (94%) required cannulation prior to infusion and, at the sites where this information was recorded (Royal Surrey County Hospital and Velindre Hospital), almost one-third of patients required two or more attempts before they were successfully cannulated. The time that the patients spent on the unit where the IV bisphosphonates were administered was greater for patients receiving pamidronate compared to those receiving zoledronic acid (2 h 36 min and 1 h 38 min, respectively). The magnitude of the difference was not as great as would be expected considering zoledronic acid should take one-sixth of the time to administer (Royal Marsden Hospital, pamidronate 1 h 29 min, zoledronic acid 18 min: Royal Surrey County Hospital, zoledronic acid 21 min: Velindre Hospital, pamidronate 1 h 42 min, zoledronic acid 17 min). Conclusions: IV bisphosphonates are accepted as standard clinical practice for the management of metastatic bone disease. They are often prescribed for long periods of time, so tolerability and patient acceptability are important factors in therapy. The administration of IV bisphosphonates contributes a substantial time burden for patients travelling to the hospital, considering that in most cases the purpose is for this treatment only. It also places a significant burden on hospital resources, creating capacity planning challenges. Receiving an IV bisphosphonate also has other disadvantages associated with it, such as the need for patients to undergo repeated cannulation. Service redesign, such as home administration of IV bisphosphonates, could help to overcome issues highlighted in this audit. The use of oral alternatives to pamidronate and zoledronic acid which may be more convenient for patients, and perhaps also cost-effective, should also be of ongoing interest.

Influencing organisational culture: a leadership challenge

In the wake of the Francis report, the need for NHS trusts and hospitals to adopt a culture of learning, safety and transparency has been highlighted. This article considers different aspects of culture in health care, and hones in on the link between culture and safety for patients in putting the patient first, embedding the 6Cs and considering the options to measure and influence organisational culture. The article reflects more deeply on how leadership across all levels can influence and inspire change in organisational culture, ensuring that the patient remains the focus of any changes in care delivery.

Maintaining vascular access devices: the nurse's role

Abstract The role of the nurse in maintaining vascular access devices has altered dramatically with the advance in vascular access device technology and the greater involvment in selection of the device and its insertion, maintenance and removal. Up-to-date knowledge and the use of evidence-based practice underpinned by good scientific research is the key to vascular access device maintenance. The routine maintenance of vascular access devices is a shared responsibility between the nurse and the patient, so that the nurse has an important part to play in the adequate preparation and education of the patient. The nurse therefore has a responsibility to ensure the maintenance of vascular access devices in order to increase the benefits to the patient and decrease the risk of serious complications.

Intravenous therapy in older patients.

Intravenous therapy is available in a variety of settings and for patients of all ages. Therefore, it is essential that nurses have the clinical knowledge and technical expertise to carry out this procedure and care for patients, particularly those who are vulnerable, such as older people. This article provides an overview of the anatomy and physiology of the skin and veins. Considerations for improving venous access, selection and insertion of a peripheral cannula, and recognition, prevention and management of complications in older people are discussed. Alternative routes for the administration of fluids and medications are also explored.

Reducing the risk of complications in IV therapy: This paper reviews the types and causes of complications in intravenous therapy and discusses the role of the nurse in preventing them

For many patients the IV route may be the safest and most effective method of receiving treatment and in some specialties a large proportion of nursing time is spent preparing and administering IV therapy. Nurses, therefore, must ensure that the practice of IV therapy is safe and beneficial for patients by applying three principles - asepsis, safe administration and patient comfort.

Frequency, Diagnosis, and Management of Occlusive and Mechanical PICC Complications

Patency is defined as the ability to infuse through and aspirate blood from a VAD. It is important at all times for the patency of the PICC to be maintained. Occlusion predisposes the PICC to device damage, infection, disruption to medication delivery, and inconvenience to patients. PICCs may become occluded due to causes related to thrombotic complications, (a) blood clot within the lumen, (b) fibrin sheath/tail, and (c) thrombosis, and non-thrombotic complications, (a) precipitation of drugs or (b) mechanical causes. Two main types of solutions are used to maintain patency in VADs: heparin and 0.9 % sodium chloride. In the case of a blood clot or fibrin causing the occlusion, the solution of choice is a thrombolytic agent. Catheter damage can be the result of forceful flushing in the presence of distal obstruction, catheter shear from needles/sutures or surgical instruments during insertion, on removal using traction, or against excessive resistance and catheter pinch-off syndrome. The prevention and management will be covered within this chapter.

Managing dysfunctional central venous access devices: a practical approach to urokinase thrombolysis

Tunnelled central venous access devices (CVADs) are defined as any intravenous multipurpose catheters placed within the central veins for use in haemodialysis and administration of blood products or chemotherapy in oncology and haematological conditions. Frequent complications include thrombosis and catheter-related infection, which may lead to significant adverse patient outcomes. Once thrombosis is suspected correction should be attempted empirically with thrombolytic agents. Commonly available thrombolytic agents in the UK include urokinase (Syner-Kinase) and alteplase (Cathflo). It is well recognised that urokinase usage differs widely and concerns were raised by clinicians about the variation of dose regimens nationally. The objective of the CVAD Focus Group was to address this issue and offer guidance in the management of suspected thrombosis of CVAD with urokinase using two algorithms for renal and non-renal dysfunctional CVAD and to audit prospectively the outcomes of intervention.