VAD Guidelines for Home Infusion:

Creating a Resource to gAddress Our Unique Site

of Care for Adult andof Care for Adult and Pediatric Patients

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Disclosures• Each member of the panel of speakers including

Debbie Cain, Darcy Doellman, Melissa Leone, Nita Meaux Kevin Ross and Felicia SchapsNita Meaux, Kevin Ross, and Felicia Schaps, declares no conflicts of interest or financial interest in any service or product mentioned ininterest in any service or product mentioned in this program.

• Clinical trials and off-label uses may be discussed in this presentation, and will be p ,handled in a fair and unbiased manner.

IntroductionIntroduction

Melissa Leone, RN, BSN

V l A D i (VAD)Vascular Access Device (VAD) Guideline ResourcesGuideline Resources

• AvailableCDC Guidelines (2002)– CDC Guidelines (2002)

– INS Standards (2011)– Published research– Published research

• Why not accept them at face value?Guidelines and Standards are based on the– Guidelines and Standards are based on the available research

– Most research is performed in acute care psettings

P bli h d R h Li i iPublished Research Limitations• Acute care catheter types differ greatly fromAcute care catheter types differ greatly from

home infusion– 50% of HIT catheters are PICCs, non-tunneled

CVCs average 5-6%CVCs average 5-6%– Non-tunneled CVCs are the most common in acute

careCatheter infection rates vary widely between• Catheter infection rates vary widely between hospitals and home infusion– HIT: 0.24-0.45/1,000 catheter days – Hosp: 2.2-10.8/1,000 catheter days

• Acute care is provided by trained medical professionals while home infusion is primarilyprofessionals, while home infusion is primarily self-administered

F IFor Instance….• INS Standard 35 states that a nurse shall• INS Standard 35 states that a nurse shall

not make more than 2 attempts to insert a PIVPIV– This does not consider the impact on a home

infusion patient who would miss their dose orinfusion patient who would miss their dose or have a significant delay due to the lack of another nurse in their homeanother nurse in their home

• Many home infusion providers allow 3 attempts with patient permission

Importance of VAD Care in Home InfusionInfusion

• Vascular access is critical to the successful provision of home infusion therapyprovision of home infusion therapy

• CRBSI costs and mortality rates differ– Mortality rates higher with sepsis in ICU settingsMortality rates higher with sepsis in ICU settings,

complicating an already acute condition– Revenue loss with hospitalization days– Outcomes impact when reporting to payers/referral

sourcesI t i i ll l CRBSI t d d• Intrinsically lower CRBSI rates demand a modified/specialized approach to care

D fi i iDefinitions• Evidence based practice defined as:• Evidence-based practice, defined as:

The conscientious, explicit, and judicious use f th t b t id i kiof the current best evidence in making

decisions about the care of individual ti tpatients.

• CRBSI:– Clinical component– Laboratory componenty p

VAD Guideline for HIT• Why do we need a guideline for our

industry?– Account for differences in

• catheter types• risk factors• type of caregiver

Utilize research based in the HIT setting– Utilize research based in the HIT setting– Ensure cost-effective approach to best

possible catheter outcomesp– Standardization amongst providers

NHIA 2010 Provider Survey

Source: National Home Infusion Association, 2010

Th S f O D i HITThe State of Outcomes Data in HIT

Source: National Home Infusion Association, 2010

VAD G id liVAD Guideline

• Dressing Change• Injection CapsInjection Caps• Tubing Change

Bl d S li• Blood Sampling• Flushing• Special Considerations

A i i S l iAntiseptic Selection• There is no prospective home infusion• There is no prospective home infusion

research on the selection of a skin antiseptic for VAD careantiseptic for VAD care– 2002 CDC Guidelines recommended CHG

based on a single study showing that 2%based on a single study showing that 2% CHG was superior to 70% isopropyl alcohol (IPA) OR 10% povidone Iodine (PVP-I)(IPA) OR 10% povidone Iodine (PVP I)

– Acute care studies evaluate VAD types that are not standard for home infusion

INS S d d U dINS Standards Update• 2006: (Standards 41 & 51): “Formulations containing2006: (Standards 41 & 51): Formulations containing

a combination of alcohol (ethyl or isopropyl) and either chlorhexidine gluconate or povidone-iodine are preferred” for access site preparation (Standard 41)preferred for access site preparation (Standard 41) and catheter site care (Standard 51).

• 2011: (Standard 46, Practice Criteria C, page S63)“Chlorhexidine solution is preferred for skin antisepsisChlorhexidine solution is preferred for skin antisepsis as part of VAD site care. One percent to two percent tincture of iodine, iodophor (povidone-iodine), and 70% alcohol may also be used Chlorhexidine is notalcohol may also be used. Chlorhexidine is not recommended for infants under 2 months of age.

• INS Standards advise home infusion providers to use their own evidence and experience when applying the standards to the home setting

A i i S l iAntiseptic Selection• How do you apply ever-changing

recommendations?• How do you translate acute care-based

studies?• How do you justify the additional cost of

CHG products if you already boast veryCHG products if you already boast very low VAD infection rates?

H I f i G idHome Infusion Guidance• Read the studies of in vitro comparisons of• Read the studies of in vitro comparisons of

antiseptic action• Follow manufacturer directions for use• Follow manufacturer directions for use• Consider INS Guidelines for frequency,

application standards and other aspects ofapplication standards and other aspects of VAD care.

• Consider CDC Recommendations• Consider CDC Recommendations• Assess your own outcomes and compare

to your peersto your peers

A i i E l iAntiseptic Evolution• “ the safety and efficacy of PVP-I+IPA…the safety and efficacy of PVP I+IPA

was found to be less irritating and faster acting than CHG+IPA; both PVP-I+IPA and CHG IPA d t t d i t f 7CHG+IPA demonstrated persistence for 7 days.”

• This publication by Greg Art highlighted• This publication by Greg Art highlighted the preponderance of studies comparing CHG+IPA to IPA alone.– IPA has great immediate efficacy, but lacks

persistence.

Source: Art GR. JAVA, 2007; 12(3):156-163

A i i O iAntiseptic Options• Chlorhexidine Gluconate 2% with IPA• Chlorhexidine Gluconate 2% with IPA• Chlorhexidine Gluconate 3.15% with IPA• PVP-I+IPA Combinations• PVP-I+IPA in sequenceq• PVP alone when alcohol is not indicated• Sterility is critical (FDA indicated)• Sterility is critical (FDA-indicated)

VAD G id liVAD Guideline• Combination products are preferred• Combination products are preferred

– Shorter application time– Single application drying time– Single application drying time– Less confusion for self-care patients

• Be prepared to demonstrate that your• Be prepared to demonstrate that your antiseptic choice provides equal or improved catheter infection rates overimproved catheter infection rates over peer settings– Supported by INS and TJCpp y

VAD Dressing GuidelinesVAD Dressing Guidelines

Felicia Schaps RN, CRNI®, OCN, CNSC p , , ,

VAD Dressing Guidelines• Change dressing when damp loosened or soiled; andChange dressing when damp, loosened or soiled; and

when site inspection is necessary but cannot be performed through the dressing. INS46,PC:E,p.S63

• Allow all antiseptics (and skin protectants if used) to dry• Allow all antiseptics (and skin protectants, if used) to dry completely and naturally before applying dressing

• Transparent Semi-Permeable Membrane (TSM) p ( )dressing: INS46,p.S63-64– Change every 7 days & PRN– Gauze beneath transparent dressing = gauze dressing (unlessGauze beneath transparent dressing gauze dressing (unless

used to support wings of Huber needle in an implanted port)

• Gauze dressing: INS46,p.S63-64S ll d ith t h 48 h 3 / k– Secure all edges with tape, change every 48 hours or 3x/week (gauze dressing = gauze under a transparent dressing, unless used to support wings of Huber needle in an implanted port)

H li I it t d Ski B thHealing Irritated Skin Beneath a VAD Dressingg

• Avoid adhesives on the irritated skin until healed– Consider applying a skin protectant solution safe

for irritated skin if adhesive use cannot be avoided in the area

• Avoid alcohol on irritated skin (may be in the ti ti ki t t t l ti ) itantiseptic or skin protectant solution)-it can

further delay healingA l d i til ki h h l d• Apply a gauze dressing until skin has healed

P ti I it t d Ski B thPreventing Irritated Skin Beneath a VAD Dressingg

• Let it dry– naturallyLet it dry naturally– Antiseptics– Skin protectant– Skin protectant

• Remove adhesives carefully, slowly“L d l t h i ”– “Low and slow technique”

• Persistent irritation– try a different adhesive

TSM Dressings

• Wide variety-how do they differ?M i t V T i i R t (MVTR)– Moisture Vapor Transmission Rate (MVTR)

• Impact on CR-BSI rates not statistically significant in clinical evidencein clinical evidence

– “HP” dressings: highly permeable?• “Holding Power”Holding Power• Adhesive designed to hold a dressing in place in

the presence of excessive moisture

Needleless Injection Caps/Connectors Guidelines

Debbie Cain RN,CRNI

N dl l CNeedleless Connectors• Controversy continues– are we

protecting healthcare workers with a product that harms patients?– CDC Draft Guidelines

• Recommended split-septum connectors – INS Standards- a more moderate approach– FDA Letter to ICP

• http://www.fda.gov/MedicalDevices/Safep gty/AlertsandNotices/ucm220459.htm

Types of Connectors• Fluid Displacement Upon Syringe/Tubing

Disconnect– Positive– Neutral – NegativeNegative

• Internal fluid path– Dead spacep– Twists and turns

• Ease of cleaning

IV Connector Table, p. 1

IV Connector Table, p. 2

Changing Needleless Connectors• Frequency of Change• Frequency of Change

– Infusion providers must determineF t t id– Factors to consider:

• OutcomesMfg recommendations• Mfg recommendations

• Fluid being infused

• Must needleless connectors be “primed”?• Must needleless connectors be primed ?

Cleaning Needleless ConnectorsConnectors

• “Scrub the Hub”(Kahler et al)– (Kahler, et al)

– Vigorously scrub injection cap with 70% alcohol prep for at least 15 seconds andalcohol prep for at least 15 seconds and allow to dry before every use

– Cleanse “like juicing an orange”– Cleanse like juicing an orangeCap

“Save That Line” Program

• S - Scrupulous Hand Hygiene• A - Aseptic Technique during catheter

insertion and care• V - Vigorous friction to catheter hub prior

to entryy• E - Ensuring patency of device

Administration Set and Add-on Device Guidelines

Nita Meaux RN,CRNI®

Ad i i i SAdministration SetsC ti I f i I t itt t I f i• A set that is left in

place continuously• A set that is connected

to the VAD for short

Continuous Infusion Intermittent Infusion

place, continuously connected to the VAD without interruptionCh t

to the VAD for short periods to administer a therapy, then disconnected between• Change set no more

often than every 96 hours• Set can be changed

disconnected between doses

• Change set every 24 h

gevery 7 days if:– VAD is antimicrobial in

composition

hours

– Fluid being administered does not encourage microbial growth

Administration Sets• Therapy based rules• Therapy-based rules

– Blood, blood products: change tubing/set every 4 hoursevery 4 hours

– Lipids, lipid-based drugs: change tubing/set every 24 hoursevery 24 hours

– Parenteral nutrition: change tubing/set every 24 hours24 hours

Add D iAdd-on DevicesAdd d t VAD Add d t T bi

• Extension SetAdded to VAD Added to Tubing

• Extension tubing• Back-check valves• Stop cock

• Filter• Manual flow-control

• Needleless system components

device

General Rule:All t dd d t VAD t bi / t t• All components added to VAD or tubing/set must luer-lock in place

Ch i Add D iChanging Add-on DevicesAdd d t VAD Add d t T biChange every 7days

OR

Added to VAD Added to TubingChange with tubing/set change

ORORIn accordance with manufacturer’s

recommendationsOR

ORIn accordance with manufacturer’s

recommendationsOROR

In accordance with organizational standard operating procedures

(SOPs)

ORIn accordance with organizational

standard operating procedures (SOPs)( ) ( )

General Rule:All t dd d t VAD t bi / t t• All components added to VAD or tubing/set must luer-lock in place

C id ti Wh Ch iConsiderations When Changing Add-on Devices

• Priming the add-on deviceAdding on to CVAD during dressing change– Adding on to CVAD during dressing change

• Sterile field considerations• Externally sterile saline syringes vs. one-handed y y g

sterile technique/vial of saline– Priming a filter: which direction should it be

held?held?• Disinfecting CVAD hub during needleless

connector or extension tubing changeconnector or extension tubing change

Flush GuidelinesFlush Guidelines

Kevin Ross RN,BSN

Catheter Flushing- why is it needed?

• Verify patency and function of catheter• Clear medications from the catheter toClear medications from the catheter to

prevent medication incompatibilities• Decrease risk of catheter occlusion• Decrease risk of catheter occlusion• May decrease risk for catheter related

infectioninfection

2011 INS Standard of Practice 45• Vascular access device shall be• Vascular access device shall be

– Flushed prior to each infusionAft h i f i– After each infusion

• Vascular access device shall be locked after completion of final flush

• Flushing and locking should be addressed g gin policies and procedures

2011 INS Standard of Practice 45• Flush with preservative free 0.9% sodium

chloride (USP)– If medication in catheter not compatible with p

saline, flush with 5% dextrose in water to clear catheter, followed by saline

• Flush volume – at least twice the internal volume of catheter– 3-5 mL for most central catheters– Larger volumes (e.g. 10 – 20 mL) after bloodLarger volumes (e.g. 10 20 mL) after blood

draw• Flush and/or lock solution should not contain

the preservative benzyl alcoholthe preservative benzyl alcohol

S i SiSyringe SizeSh ld b i d ith• Should be in accordance with catheter manufacturer’s

d tirecommendations• Assess catheter patency with a

minimum 10 mL syringe• Some pre-drawn flush syringes p y g

engineered to generate lower amounts of pressurep

S i SiSyringe Size

• Administration of very small volume medications should be given with appropriate sized syringe– Assess catheter patency first using 10 mL or

larger syringe

H i L kHeparin Lock10 it / L 100 it / L• 10 units/mL – 100 units/mL – 100 units/mL historically used in home

i f iinfusion• 100 units/mL preferred for implanted ports

prior to de-accessing• Hemodialysis catheters and apheresis y p

catheters flushed with 1000 units/mL• Monitor patients for signs/symptoms ofMonitor patients for signs/symptoms of

heparin induced thrombocytopenia (HIT)

Valved Catheters (e.g. Groshong®, PASV®)(e.g. Groshong PASV )

• Manufacturer’s recommendation for flush with preservative free salinewith preservative free saline– Heparin not necessary

H i l k b id d• Heparin lock may be considered– Per physician order– Protocol from referring institution– Catheter with repeated occlusions

Why does flush technique matter?matter?

Plunger rebound

H i Al iHeparin Alternatives• Sodium citrateSodium citrate

– Not available in single use container– Sodium citrate 4%, 250 mL bag is FDA approved

for pheresis and plasma exchangefor pheresis and plasma exchange• EDTA

– Chelates ionized calcium in blood and blocks l i d d t l tti thcalcium dependant clotting pathway

– Lack of specific trials as anticoagulant in catheters

• Tissue Plasminogen Activator– Expensive– More labor intensive– More labor intensive

A ibi i L k (ABL)Antibiotic Lock (ABL)• Antibiotic lock may be used for salvage of• Antibiotic lock may be used for salvage of

infected long term catheterV i ft idi f li– Vancomycin, ceftazidime, cefazolin, ciprofloxin, gentamicin, and ampicillin reported effectivereported effective

– Use of ABL is not recommended as a routine prophylactic measure due to development ofprophylactic measure due to development of resistant micro-organisms

E h l L kEthanol Lock• Involves sterilization of the

intraluminal space (inside the catheter)

• Ethanol is bactericidal• Ethanol lock has been used to

help keep long term TPNhelp keep long term TPN catheters infection-free From Opilla et al. JPEN July-Aug 2007

Pediatric CVAD GuidelinesPediatric CVAD Guidelines

Darcy Doellman RN, BSN, CRNI®

Challenge of Pediatric Vascular AccessVascular Access

• Variation in age/size of patients• Variation in age/size of patients • Insertion of appropriate catheter size to meet

i f i d f th ti tinfusion needs of the young patient• Longer survival of chronically-ill children

often leads to repeated need for venous access

P di t i ti t t “littl d lt ”

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Pediatric patients are not “little adults”

P di i CVADPediatric CVADs

• Common pediatric sizes:• Many CVADs come in SL and DL• PICCs: 3Fr and 4 Fr • Tunneled CVADs: 2 7 7 Fr• Tunneled CVADs: 2.7 - 7 Fr• Ports: 5.5 - 10 Fr

• Device selection dependent on:• Device selection dependent on:• Vessel size• Type and length of therapy• Type and length of therapy• Developmental and activity level of patient

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CVAD Tip Placement• Optimal tip placment:• Optimal tip placment:

• Superior Vena Cava for upper extremity CVADs• Inferior Vena Cava for lower extemity CVADs• Inferior Vena Cava for lower extemity CVADs

Pediatric Central NoncentralPICCsn=1266

Centraln=1096

Noncentraln=170

Complications 3 8% 28 8%55

Complications 3.8% 28.8%

P di i CVAD P iPediatric CVAD Practice

• 2011: (Standard 2.1, page S6) Nurse providing infusion therapy for pediatricproviding infusion therapy for pediatric patients shall have clinical knowledge and technical expertise in this populationtechnical expertise in this population

Skill C iSkill Competencies• Anatomic characteristics and• Anatomic characteristics and

their effect on:• Device selectionDevice selection• Care and maintenance• CVAD complicationsp

• Growth and developmental stages

• Promotion of comfort and reducing pain and anxiety with procedureswith procedures

• Safe and appropriate settings

Ski A i iSkin Antisepsis• 2011: (Standard 352011: (Standard 35,

Practice Criteria, page S44) Chlorhexidine is preferredChlorhexidine is preferred agent although not recommended for infants < 2recommended for infants < 2 months of age, although there is evolving evidencethere is evolving evidence supporting safety and efficacyefficacy

Effect of Chlorhexidine Gluconate (CHG) on the Skin Integrity at PICC Line Sites

NN=40

Gestational age at birth (weeks) 23 - 39 (mean 32.1 ± 4.7 weeks)

Weight at birth (g) 590–4215 (mean 2009 ± 954)Weight at birth (g) 590 4215 (mean 2009 ± 954)

Age at start (weeks) 25 – 58 (mean 34.8 ± 5.5)

Weight at start (g) 780 – 4510 (mean 2246 ± 951)

Male 22

Female 18

iPICC site: arm 32

leg 8Results: CHG does not compromise the skin integrity on neonatal patients. This study does highlight the contribution of

59

neonatal patients. This study does highlight the contribution of tapes and dressings to the skin compromise observed in the clinical setting.

Ski I i iSkin Irritation• For skin irritation, sensitivity, or allergy , y, gy

with the use of chlorhexidine, use povidone-iodinep

• Upon resolution of skin irritation, re-attempt use of chlorhexidine as a skin antisepsic

• If irritation persists, continue use of povidone-iodine

2011: (Standard 46 Practice Criteria• 2011: (Standard 46, Practice Criteria, page S63)

R d i d id i di ith l– Remove dried povidone-iodine with normal saline wipes or sterile water 60

A ti i bi l P d t tAntimicrobial Product at Insertion SiteInsertion Site

• Consider use of antimicrobial patch or dressing at CVADpatch or dressing at CVAD insertion siteR d i d t ll d t i l i• Randomized controlled trial in a pediatric CCU (n=145) with CHG i t d d iCHG-impregnated dressings,

• Decreased colonizationCLABSI t did t diff (CG 3• CLABSI rate did not differ (CG 3, SG 4)

Levy et al, 2005

Silver Dressings

• Pilot-randomized controlled trial in Low Birth Weight (LBW) infants (n 25)Birth Weight (LBW) infants (n= 25)

• Serum silver concentrations were ( )measurable (below toxic level)

• Nonstatistically significant CLABSI reduction

62Khattak et al, 2010

Ski Adh iSkin Adhesive

• Acts as a barrier to protect the skin• Promotes skin integrity and minimizes skinPromotes skin integrity and minimizes skin

breakdown• Do not apply at insertion site or under• Do not apply at insertion site or under

antimicrobial patch or dressing

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Hub Antisepsis

64

CVAD S bili iCVAD Stabilization• 2011: (Standard 36 Practice Criteria• 2011: (Standard 36, Practice Criteria,

page S46) Catheter stabilization is considered the preferred alternative toconsidered the preferred alternative to tape or suturesM f t d t bili ti d i• Manufactured stabilization devices promote catheter securement

• Very commonly used in the pediatric world

65

Si P iSite Protection• Prevents excessive• Prevents excessive

forces on catheterT b l d i f• Tubular dressing for PICCs, comes in a

i t f ivariety of sizes• Ideal for infants and

toddlers

D i ChDressing Change• “Two man procedure” for PICC dressing• Two-man procedure for PICC dressing

changes2011 (St d d 53 P ti C it i• 2011: (Standard 53, Practice Criteria, page S73)

• Measure the external CVAD length and compare to the external CVAD length documented at insertion

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G h d D lGrowth and Development

• Assess for safety concerns• In long-term patients > 1 yr• In long-term patients > 1 yr

of age, an implanted port is a preferred devicea preferred device

• Offer choices when appropriate for CVADappropriate for CVAD procedures

• Parental presence for• Parental presence for venipuncture procedures

Fl hiFlushing• Normal salineNormal saline• Heparinized saline

(10u/mL)(10u/mL)• Volume of flush is based

on:• Type of CVAD

Si f CVAD• Size of CVAD• Age• Type of infusion therapy

Heparin is the preferred lock solution with• Type of infusion therapy

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solution with intermittent use

Pediatric CVADFlushing GuidelinesFlushing Guidelines

• 2FR PICC: 1mL q 6 hoursq• 2.6Fr PICC or greater: 2-3mL q 12 hours

(10u/mL heparinized saline)• Tunneled or non-tunneled CVAD: 2mL (10 -

100u/mL heparinized saline)• Implanted port:

– Daily: 3 - 5mL (10u/mL)– Monthly: 3 - 5mL (100u/mL)

70

C h PCatheter Patency• (Standard 61) Aspirate catheter for blood• (Standard 61) Aspirate catheter for blood

return prior to administering medications and solutionsand solutions

• Never forcefully flush catheter• Use a 10ml syringe on all pediatric CVADs

A l f l iAssess lumen for occlusion:Complete occlusionPartial occlusion

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Sluggish lumen

Bl d S liBlood Sampling• Blood sampling is safe and effective in 3• Blood sampling is safe and effective in 3

Fr PICCs and larger2011 (St d d 57 P ti C it i II• 2011: (Standard 57, Practice Criteria II, page S79)

• If a patient has a CVAD, it should be the first consideration for blood sampling

72Knue, 2005

Central Line Maintenance CareCentral Line Maintenance Care:Bundled Approachpp

• Hand hygieneMi i i th t t i• Minimize catheter entries

• Disinfect hub or needleless connector with alcohol or CHG

• Use prepackaged kits• Dressing change kitDressing change kit• Cap change kit

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B i CVAD CBasic CVAD Care

74

Sh i Th h C ll b iSharing Through CollaborationCooperation among agencies

CHG useCooperation among agencies

MaintenanceChecklistsChecklists

Data collection and analysis

I T k TIt Takes a Team• One of the best predictors of the safety• One of the best predictors of the safety

climateP t “b t ti ”• Promotes “best practices”

• Reduces complications• Reduces cost• Reduces painReduces pain

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Addi i l RAdditional Resources• INS• INS• CDC• Pedivan• NACHRI• NANN

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Panel Question and Answer SessionSession