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Dallas, TX • November 2–4, 2012
Risk Benefit Analysis of Central Venous Access Devices
Julie D. Painter RN MSN OCN
Clinical Nurse Specialist
Community Health Network
Indianapolis, IN
Dallas, TX • November 2–4, 2012
Risk-Benefit Analysis of CVAD’s
Session Code:102 Contact Hours: 0.8 CRNI Units: 2Please use session code shown above when completing
your speaker evaluation and CE form.
Return the evaluation to the registration desk or receptacles located outside meeting rooms at the end of the day.
Handouts for this session are available online at www.ins1.org. Session recordings will also be available post-meeting courtesy of
B.Braun Medical/Aesculap Academy.
As a courtesy to both presenters and attendees, please turn off all cell phones and refrain from talking during the session.
Tonight’s Event:Industrial Exhibition and Networking Reception
3:30-5:30pm
Dallas, TX • November 2–4, 2012
Objectives
• List the steps in the process of risk-benefit analysis
• Describe risk-benefit analysis as it applies to various CVADs
Dallas, TX • November 2–4, 2012
Retrospective View
• Until the late 1970’s CVAD’s were not common in our patients
• Peripheral IV’s were the mainstay of intravascular therapy –most were made of metal and not flexible
• Central lines were commonly temporary subclavian & femoral caths & dialysis shunts for patients with leukemia
• Broviac and Hickman developed devices to assist in long term infusion that would meet the needs of our patients(right atrial silastic catheters)-most had only been used in the world of pediatrics to this point
• Venous ports, peripherally inserted central catheters
Dallas, TX • November 2–4, 2012
Current State of Practice
• In 2012 we are at a point in practice where CVAD’s are common place
• Commonplace and so that perhaps we have lost our respect and diligence of the CVAD
• 500,000 CLABSI’s per year in the United States• Increased length of stay 11-23 days• Cost to healthcare per episode $33,000-$55,000-
New info from VHA states potentially >$100,000• Mortality 5-7%
Dallas, TX • November 2–4, 2012
A solid venous access device
program will result in the least amount of risk to institution &
patient with the greatest benefit to the institution &
patient
Dallas, TX • November 2–4, 2012
So how does one go about analyzing the risk and benefit of
central venous access devices and processes??
Dallas, TX • November 2–4, 2012
Value = Cost/QualityCost is More than
Money!!Quality=Risk/Benefit
ratio
Dallas, TX • November 2–4, 2012
Definition of Risk
1. A possibility of loss or injury; peril
2. Someone or something that suggests hazard
3. The degree of probability of loss or potential of peril
Meriam-Webster Dictionary, 2012
Dallas, TX • November 2–4, 2012
Definition of Benefit
1. Something that promotes well-being
2. A good or helpful result or effects
Meriam-Webster Dictionary, 2012
Dallas, TX • November 2–4, 2012
Risk & Benefit
• Viewed as institutional/facility risk benefit
OR
• Viewed as personal risk & benefit for the patient
Dallas, TX • November 2–4, 2012
Weighing risk vs. benefit
Dallas, TX • November 2–4, 2012
Institutional or Facility Risk
• Inability to meet CMS measures with CLABSI’s• Increased hospital acquired infections(HAI’s) • Increased length of stay• Increased cost from HAI & length of stay• Reduction in reimbursement • Loss of insurance contracts due to CLABSI • Public reporting influences consumer choice &
marketing(e.g. HCAPHS
Dallas, TX • November 2–4, 2012
Patient Risk
• Increased morbidity
• Complications upon insertion-pneumothorax, hemothorax
• Infection, thrombosis, & migration up to 30%
• Superior vena cava obstruction
• Pulmonary emboli
Dallas, TX • November 2–4, 2012
Patient Risk with Central Venous Access Device
• Infection• Phlebitis• Thrombus/DVT• Infiltration• Breakage• Dislodgement/disconnection• Increases in morbidity & mortality(due to HAI)• Unnecessary risk due to inappropriate selection of
venous access device
Dallas, TX • November 2–4, 2012
Infection Risk & Sources
• Intraluminal
• Skin
• Extraluminal
• More lumens greater risk
• Diameter
• Duration of placement
Dallas, TX • November 2–4, 2012
Infection Risk-Sources of Infection-Intraluminal
• Intraluminal-the catheter hub; stopcocks; injection ports; needle free connectors; connecting and disconnecting IV tubing's-without proper technique & devices to reduce infection introduction the bacteria are directly injected into the lumen and directly into the blood stream
• As we introduce bacteria into the bloodstream
Dallas, TX • November 2–4, 2012
Infection Risks
• Endocarditis
• Osteomyelitis
• Septic joints
• Septic emboli
• Abscesses in remote locations
Dallas, TX • November 2–4, 2012
How do we break the cycle of introducing infection?
#1 Look at the product and the design of your needleless access device-proper technique
#2 Look at the process of disinfecting the access device-proper technique
#3 Look at the frequency of access device exchange
Ryder studies related to access devices and factors that influence greater risk of a blood stream infection; have looked at design such as split septum and the shape of the top of the cap and
a)Access mechanism
b)Flow path
c)Fluid displacement
Dallas, TX • November 2–4, 2012
Infection Prevention
• Hand washing• Meticulous respect of all central lines• Dressings-occlusive• Dressing change and care procedure-
chlorhexadine, masks, sterile technique• Cleansing of injection caps• Tubing changes • Reduction of interruptions & opening of lines
Dallas, TX • November 2–4, 2012
Thrombosis
Research notes that position of catheter tip determines risk of thrombosis
Incidence of proven thrombosis corelated due to tip placement:
2.6% Distal
5.3% Intermediate
41.7% Proximal(16 Xmore)
Dallas, TX • November 2–4, 2012
Thrombosis
• Greater risk in females
• Greater risk when placed in left side vs. right side
• History of hypercoagulability or DVT’s
Dallas, TX • November 2–4, 2012
Institutional Benefit
• Appropriate line selection & care results in best possible quality outcomes
• Best outcomes results in meeting CMS and other payer expectations(contracting & reimbursement)
• Enhanced patient satisfaction when appropriate line selected and best outcomes occur
• Reduced costs related to LOS; CLABSI
Dallas, TX • November 2–4, 2012
Patient Benefit
• Satisfaction
• Quality, safe outcomes without compromise from the desired state of care & well-being
• The expectation of our patients is that the care we provide is competent and state of the knowledge
Dallas, TX • November 2–4, 2012
Benefits of CVAD
• Reduction of peripheral IV sticks for labs, medications, etc
• Reduced discomfort & anxiety related to PIV sticks
• Enhanced patient satisfaction
Dallas, TX • November 2–4, 2012
Types of Peripheral Access
• Peripheral IV line
• Midline-duration of placement can last up to 30 days
Dallas, TX • November 2–4, 2012
Types of CVAD’s
• Temporary non-tunneled caths such as subclavian or femoral lines
• Right atrial silastic (groshong, hickman)
• Venous port
• Peripherally inserted central catheters (PICC)
Dallas, TX • November 2–4, 2012
Is there a need for a CVAD?
Every institution needs a systematic approach to determining appropriate venous access
Determine tools/algorithms to use to evaluate patient needs
Dallas, TX • November 2–4, 2012
Before we place CVAD’s in our patients
we must know that we have done our due diligence & have the best interest of the
patient at the forefront of every
intervention in care!
Dallas, TX • November 2–4, 2012
Unique Patient Characteristics for
Consideration• History of DVT
• Previous Central Venous Access Devices
• Risk of Infection-Immunosuppression
• Hypercoagulability
• Previous lymph node removal
• Pacemaker placement
• Work or lifestyle
Dallas, TX • November 2–4, 2012
Evaluation of Patient for a CVAD
•Duration of therapy
•Exhausted peripheral options including Midline
•Type of medication & fluids
•Irritant vs. non-irritant vs. vesicant
•Lab draws
•Patient co-morbid conditions
Dallas, TX • November 2–4, 2012
Patient Case Situation #1
• 65 year old male; admitted for osteomyelitis due to dog bite
• Teaches golf at the local country club and amateur golfs at least 3-4 times per week
• Will need 45 doses of intravenous antibiotics
• Has excellent peripheral IV status but antibiotic is considered an irritant
Dallas, TX • November 2–4, 2012
Patient Case Situation #2
• 48 year old female admitted with newly diagnosed stage III breast cancer
• 6 weeks post right mastectomy with total lymph node dissection & reconstructive surgery
• Will need every 3 week chemotherapy treatments and lab draws, chemotherapy regimen includes 2 vesicant agents
Dallas, TX • November 2–4, 2012
These were examples of individualized risk benefit analysis but
let’s consider a broader facility view of risk
benefit analysis
Dallas, TX • November 2–4, 2012
Process for Risk Benefit Analysis
1. Understand the definition of risk & benefit
2. Be open to looking at everything & leave “no stone unturned”
3. Determine the processes and practices that are taking place within your facility
4. Know your data and measurements that reveal outcomes of quality, safety and satisfaction related to central venous access devices
5. Utilize structured mechanisms to compare & contrast your practice to evidence based practice and national standards
Dallas, TX • November 2–4, 2012
Have we done due diligence?
• Evaluate the number of central line days in comparison
(National Healthcare Safety Network benchmark)
• Are peripheral IV starts being utilized first
• Are vein enhancement devices used to assist in peripheral IV starts
• Are the central lines appropriate
Dallas, TX • November 2–4, 2012
What components in central venous access devices must be
considered in our analysis?• Line selection-algorithm or
process • Process for ordering &
requesting• Practice-is it evidence
based? Does it match national benchmarks? Does it adhere to national standards(e.g. CDC)
• Line data-what does it show? What is it telling you? Types of lines; # of line
days;
• Products• Number of persons involved
in process• Validation of expertise &
competency of those inserting lines
• Process for monitoring outcomes-what does the data show?
• Risk events/reports-trends• Use of central line bundle for
placement• Use of central line bundle
practices
Dallas, TX • November 2–4, 2012
Pitfalls in Analysis Process
• As we analyze our processes we often want “the quick fix”
• We want to take the “broad brush” approach to just start changing and adjusting the process
• Making any change or variation in a process influences outcomes
Dallas, TX • November 2–4, 2012
Analysis-Takes Time
• There is no quick fix yet the problems that you find may appear small, you must look at the entire process
• Look at the way the process is “supposed to be” to the “way that actually is occurring”
• This requires us to be out there and work with each person who touches the process
Dallas, TX • November 2–4, 2012
The Team
• Clinical Leadership(example CNS)
• Infection Prevention
• Quality Risk Management
• Bedside Staff
• Nursing Education
• Epidemiology & Physician
• Expert in process improvement-if available
Dallas, TX • November 2–4, 2012
Analysis-Review the Process
Review the process from A to Z- from the assessment & decision point to place a central line in a specific patient to the point of removal or discharge of the patient
Include a review of the processes utilized to determine type of line; process for placement scheduling; timing;etc.
Process for all line care from cap changes; dressing changes; line accessing; tubing changes; fluids and discontinuation
Dallas, TX • November 2–4, 2012
Analysis-Diagram & Audit
Diagram the process(es) from the perspective of policy; then meet with the persons who do the process; those who select the lines; those who place the lines; those who care for the lines; and anyone who touches the lines
Audit the process-often best to have a set of “fresh eyes” a person who is naïve to the process and without preconceived notions
Dallas, TX • November 2–4, 2012
Analysis-Ask Questions
Questions:•How did the processes map out?•Do the 2 processes match?-Reality meets perception!•What are the areas of conflict or concern?•Any breaks in the system or areas of risk?•In the review were products consistent?
Dallas, TX • November 2–4, 2012
Determination of Change
• Once items have been reviewed by the team & actual practice audited-determine the process for enhancing outcomes
• What items are not meeting best practice & need changed a.s.a.p.
• Take standards and evidence based practice to improve policy & competency
Dallas, TX • November 2–4, 2012
Determination of Change
• Meet with unit staff & leadership to help make the change
• Education-multi-modalities
• Implement
• Audit
• Evaluate and continue the process to sustain the gain!
Dallas, TX • November 2–4, 2012
Remember the care we mentor & teach today will
be the care “we” as patients & our loved ones will receive today & in the future. If the care you see is not what you would want
then be a part of making the CHANGE