- Email: [email protected]
A Chronicle of Experience-Past, Present & Future
nerson ancer en er • nUSlon era earn
• •
AChronicle of Experience-Past, Present &Future Deborah Richardson,
RN, MS
and Brenda Caillouet,
RN, MPH
Abstract Infusion Therapy and vascular access devices have had a profound impact on nursing practice over the years. The domain of nursing practice lends itself to providing an open window of opportunity for the nurse to enter different arenas of nursing practice and to develop expertise in a chosen field. That is what happened at the M.D. Anderson Cancer Center, Houston, TX, in the 1970s. This article provides an overview of the history of the Infusion Therapy Team along with current and future practice.
nfusion Therapy and vascular access devices have had a profound impact on nursing practice over the years. As nurses, daily practice dictates a need for knowledge and experience to consistently maintain and improve the quality of patient care. The domain of nursing practice lends itself to providing an open window of opportunity for the nurse to enter different arenas of nursing practice and to develop expertise in a chosen field. That is what happened at the M.D. Anderson Cancer Center (MDACC) in the 1970s.
I
Past In the mid 1970s, chemotherapeutic agents were being infused by intravenous drip or by large infusion pumps through peripheral intravenous devices (PN's). The toxicity exacerbated by the method of delivery of the drugs caused patients to have severe side effects, such as nausea and vomiting. In addition, the medications were very caustic to the smaller peripheral vasculature. Patient needs, new and innovative
technology related to treatment, protocols, and delivery systems provided the impetus in the development of central line placement and use, along with the development of Infusion Therapy Teams. These same driving forces assisted the formulation of the Infusion Therapy Team at MDACC. The teams history dates back to 1976 when the team founder, Millie Lawson, RN, worked as a research nurse in Developmental Therapeutics at MDACC. Between 1976 and 1978, Ms. Lawson was part of a research study, through a grant by the Alza Corporation, evaluating the use of an ambulatory pump with various methods of intravenous access. It was during this time period that Ms. Lawson inserted
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the first peripheral silicone central venous catheter (CVC) at MDACC. Millie Lawson was also the first registered nurse in the United States to insert a peripheral central venous catheter. At the time, and for many years afterward, this catheter was called a "longline". The original longline product used at MDACC was the Intrasil, manufactured by Baxterffravenol (Figure 1). It was a 14 gauge slotted needle with a spool threading device (Figure 2). These central lines were inserted, maintained and monitored to determine whether they were safe, efficacious and reliable venous access methods. Through this process, the Infusion Therapy Team OTD at MDACC was "born". The team was officially established in January
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1978 with one RN, Millie Lawson, and one physician, ]oe Bottino, M.D. Initially, this team of two covered just four inpatient floors, but within a very short period of time progressed to cover all the inpatient and outpatient areas. Ms. Lawson designed and opened the Infusion Therapy Team clinic at MDACe. This was the second nurse-run clinic to be opened at the institution. Coverage was eight to five p.m., Monday through Friday, with 24-hour a day on call. This clinic still exists today. As responsibilities were expanded, staffing was increased to meet those needs and 24-hour coverage began in April 1978. During its first year, the team was expanded to include eight RNs. In September 1978, the Infusion Therapy Technician role was developed and seven technicians were hired and oriented. Team member roles, responsibilities and procedures were defined by the position description, patient needs and advancing technology (Tables 1 & 2). Each of these assumed responsibilities required the development of policies and procedures, orientation guidelines, design of monthly reports, product selection, the expansion and approval of nursing practice and other basic operational components. The original "on the job" training was the selected mode of orientation for staff. This training period varied from 2-3 weeks depending upon the ability of the new staff member in
104
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training. Present day orientation lasts an average of 6 weeks, and is still considered "on the job" training. Early on (March 1978) a format was established to collect data on a monthly basis to monitor staff utilization and team responsibilities. These were handwritten reports, which kept track of the number of dressing changes, PIVs, insertions, phlebitis, removals, infections, etc. In 1978, the team performed the follOWing number of procedures: Insertions:
Subclavian . . . . . . . . . . . . 208/yr Longline 4oo/yr CVC Dressings: . . . .. 4000 - 48oo/yr PIVs: 1500 - 1560/yr The complication rates for pWebitis (l8-2001o), thrombosis (2%), and infection (2-3.4%) were monitored on a monthly basis allowing for ongoing assessment and tracking of these issues. During this "start-up" period, eve insertion, maintenance, and problem management were identified as the primary responsibilities of the team. However, with the placement of a evc and the increased awareness for long-term dwell catheters, patient education soon became a primary focus. Initially, the staff utilized a 1:1 teaching modality to facilitate catheter care education. An educational program was developed for patients and caregivers to enable their participation in the care of their CVe. This class was held once a week, but
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quickly progressed to daily evc classes. The didactic portion of the class covered flushing, injection cap change and dressing changes (Figure 3). Each patient and caregiver was required to perform a return demonstration of those skills. If the patientlcaregiver was unable to perform or had no support system to help with evc care, a referral was made to the appropriate home care agency or facility. In 1981, a catheter care video was developed and implemented to assist in the teaching process and provide more efficient utilization of the nursing staff. Catheter care class consisted of the following modalities: video, lecture, instructional booklet, demonstration and practicum (Figure 4). Revision and updates of the catheter care video have been performed as procedures, equipment and/or patient needs warranted. In addition to the daily responsibilities, the team participated in multiple groundbreaking original research studies. The studies included: • Urokinase vs. Streptokinase to Restore Catheter Patency • Use of Transparent Dressings • Small Volume Portable Infusion Pumps • Use of Implanted Ports-PACs
Table I RN Roles & Responsibilities • • • • • • • • • • •
Longline insertion Assist subclavian insertion Blood drawing thru eve PIV insertion eve removals eve declots Problem management Maintenance care IV Tubing changes Daily rounds Patient/Staff education
Table 2 ITT Technician Roles & Responsibilities • • • • • •
Blood drawing thru eve Maintenance care of eVc/Plv Asst. surgeons with insertions Asst. RNs with longline insertions IV tubing changes Return demonstrations
class. In the 1990s, the program was revised to reflect student needs and recommendations from the evaluations. The didactic portion was changed to include PICC insertion technique, suturing, venous anatomy, chest x-ray verification, complications, repair, and legal issues. The program is still offered five times a year but is now a 4-day program. To date, approximately 400 nurses have been trained. The vision, purpose and practice standards established by the original members of the team provided the impetus for the continued high standards of nursing practice and the ability to "reach beyond the norm" on the Infusion Therapy Team.
Obviously, even at a very early stage, research became a part of the team's focus and functions and still remains so today. In 1983, a computer-based documentation system was designed and developed for the team. The system was implemented in 1988. This lIT documentation system provided a pilot program for the institution's plan to have all documentation become computer-based. The institution is now in the process of establishing an electronic medical record (EMR) to be used house-wide. It is a complex task that has and will take a number of years to implement. Also in 1983, the team was trained on reading chest radiographs for verification of tip position for PICCs and nurse performed overwire exchanges. The Texas State Board of Nurse Examiners allows delegation of Medical acts to registered nurses with appropriate training and education; competency assessment and documentation of that skill.' In addition, there must be written nursing policies and procedures and appropriate medical and nursing backup.2 Per policy, the nurses check for tip placement of PICCs and nurse exchanges only. However, through training many other catheter placement problems can be visualized, such as malpositions, kinks, embedment of the tip into the vessel wall, embolized catheter tips, and separated ports. If
additional problems are seen, the staff notifies the attending physician for verification and follow up orders. The policy states that a posterior-anterior (PA) and lateral of the chest is done to verify tip placement. 2 The posterior-anterior view is used to verify tip placement and the lateral is utilized to rule out malpositions. 2 Catheter tips in the azygous vein on a posterior-anterior view appears to be in place in the SVC, however, on inspection of the lateral, it will be quite evident the tip is pointing toward the spine. It has been very beneficial to the patients to have the nurses on the Team skilled in this area. It was found to expedite care by allowing them to receive treatment quicker, or be discharged to home, and decreased their wait time. Early in the 1980s, it became apparent from many outside requests that there was a growing need to instruct nurses outside MDACC in the art and skill of PICC insertions. The Infusion Therapy Team and MDACC Nursing Outreach Departments developed a program to meet this need. The program included both clinical and didactic instruction. The classes originally encompassed instructions in suturing, complications, repairs, viewing chest x-rays for placement, overview of catheter types, dressing procedures, PICC placement technique. The 5-day program was offered 4 to 5 times a year with a maximum of 4 students per
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Present The roles, responsibilities and the staffing mix of the team has evolved, grown and changed throughout the team's 26 years of existence. Today's team is believed to be the oldest, largest and most durable IV team in the country. In 1995, as downsizing hit the healthcare arena, the IV team lost only a few positions, much to the credit of the insight of hospital administration, continued presence of patient needs and high level of staff performance. However, one role was deleted, the lIT technician position. Previous to the deletion of the technician role, Licensed Vocational Nurses (LVN) had been added to the staffing mix, which helped the team through the transition. At its peak, the team staffing level was 59 members including: RNs, LVNs, hospital aide, clerical staff and technicians. Currently there are 54 staff members with a breakdown as follows: RNs (42), LVNs (4), Nurse Manager (1), Assistant Nurse Manager (1), Clinical
Figur 4
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Table 3 LVN Role & Responsibilities • Assist RN with PICC insertions • Assist RN/MD with subclavian insertions • Assist RN/MD with PortrTunneled Catheter removal • Prep for PI CC/Subclavian insertions • PIVs • Removals • Port Access/De-access • Maintenance care • Teach CVC class • Preceptors • Research • Product evaluations • Return demos
Table 4 RN Roles & Responsibilities 2004 • • • • • • • • • • • • • • • • • • • • • • •
PICC insertion CXR verification of tip placement Midline insertion Assist subclavian, jugular, femoral insertions Asst. PortrTunneled catheter Removal Perform overwire exchanges PIVs CVC removals Declots Problem management Resutures Maintenance care Asst. Chest tube placement! removal Port access/De-access Research Product evaluations Repair CVCs Pre-insertion interviews Patient education: CVC/ambulatory pumps Faculty for Education Programs Ultrasound for CVC Placement Teach CVC class Return demos
Nurse Specialist (1), Hospital Aide (1), and Administrative Support Staff (4). The staff is responsible for all patients with central lines. Today, there are over 13,642 active central lines. In terms of catheter equipment, we are currently using the Cook PICC silicone single lumen, Cook Antibiotic-impregnated Double Lumen/Triple Lumen, Quinton Apheresis, MedComp Hemocath Silicone apheresis, Bard double lumen PICC, Bard Hohn Silicone single
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lumen and double lumen catheters, and Deltec midline devices. The RN and LVN nursing staff responsibilities have expanded throughout the years (Tables 3 & 4). Recently, the Texas Board of Nursing added a number of practice statements related to LVNs and central venous catheters. I This has allowed an expansion in the LVN role on the team (Table 3). The team has been involved in approximately 40 research studies and over 300 product evaluations during it's 26-year tenure. IV therapy is a very dynamic field with the opportunity for continued growth and development of practice, products and technology. We have inserted over 100,000 CVCs with an average monthly insertion rate of about 450. Of the 450, approximately 150 of those insertions are PICCs. Statistically, the procedures break down as follows (Table 5). As stated before, the team has been involved in numerous research studies in which the results have been used to support practice changes. Some of those studies include, but are not limited to the following: • 1991-Maximal Sterile Barriers during the Insertion of cves for the Prevention of Infections Complications (Categol]' lA CDC recommendation) (#3) • 1995-The Optimal Frequency of Changing IV Site: 3 days vs. 7 days • 1996-Efficacy of CVC Impregnated with Minocycline and Rifampin vs. Catheter Bonded with Chlorahexidine and Silver Sulfadiazine in Reduction of Catheter Infection (categol]' lA CDC recommendation), (#3) • 1999-2ooo-A randomized, doubleblind-controlled study for Alteplase for the Restoration of Patency to CVAD (Cool 1 Trial) • 1999-2ooo-Efficacy of Long-term Silicone CVC Impregnated with Minocycline/Rifampin for Preventing Catheter-related Infection • 2QOO-2001-An Open Label Single Arm Clinical Trial of the Safety and Efficacy of Recombinant Tissue Plasminogen Activator for Restoration of Function to CVAD (Cool 2 Trial) Each of these studies has either had
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or will have an effect on practice standards and recommendations. The patient education component of our practice has evolved over the years. The catheter care class format and schedule have changed to accommodate time schedules and adult learning needs. Today, the class is held twice a day Monday, Wednesday and Friday; three times a day on Tuesdays and Thursdays, and once daily on Saturdays and Sundays. The implementation of the CVC care video as a teaching tool decreased actual nursing time required for class instruction by 6 hours a week. It also provides consistency of information and decreases the problems with instruction for patients with a language barrier. The M.D. Anderson Cancer Center multicultural patient population requires that patient education materials be written in multiple languages. Thus, some of the CVC teaching materials are written in Spanish, Arabic, Turkish, Vietnamese and Thai. 4 Currently, the video is in English and Spanish only (Figure 5).
ps
~igUre
5
Future Toward the end of 2004, the team will be expanding as MDACC continues to grow to meet the needs of our patients. A second outpatient lIT clinic will open in October 2004, in the new Ambulatol]' Clinic Building. This clinic will be open for operations Monday through Friday, providing the same services as the primary lIT clinic. Adding two more clerical staff, one nurse assistant, and six RNs will increase team staffing. Also, new to the plan is to add two additional Advanced Practice Nurse (APN) positions. The goal of the APN role is to reduce reliance on the surgical fellows for advanced procedures, especially
Table 6
Table 5 - Procedure 1978
2004
CPT Codes
Procedures Insertion of non-tunneled CVC > 5yrs. old, (Pediatric) Insertion of PICC (Pediatric)
Subclavian insertions
N/A
3,600
36555 (36556)
PICC insertions
400
1,800
36568 (36569)
PIVs
130
36,000
36575
Repair of a CVC without Port Overwire Exchange of CVC
Dressing change
450
14,400
36580
Exchanges
N/A N/A N/A
1,800
36584
Overwire Exchange of PICC
1,800
36589
Removal ofTunneled CVC
Declots Removals CVC Classes Return Demos Port Removals
6,000
36590
Removal ofTunneled CVC with Port
48
480
76942
Ultrasound guidance for Placement of CVC
N/A N/A
4,200
32020
Chest Tube Placement
420
36430
Transfusion Blood Components
36550
Declot by Thrombolytic Agent
subclavian insertions. With recent changes in the laws governing medical residences work hours, more responsibilities have fallen to the surgical staff fellow. By adding APNs, this will relieve the surgeon for more urgent and emergent care. In addition, the belief is that the failure rate and complication rates will decrease by using specialty trained advanced practice nurses with expert skills. Since APNs are able to bill for procedures in the same way as a surgeon, the revenue to the institution should not change. Financially, supporting a team of this magnitude requires continual review of current coding and charges. Current procedural terminology (Cm codes are reviewed annually to make sure proper coding and capturing of all procedures occurs. s By having a separate outpatient clinic, the team is able to bill for both procedures and clinic visits. A clinic visit charge is attached to those procedures that do not have a corresponding CPT code. By having APNs perform the more complicated procedures, the APN can bill a professional fee, as a surgeon would, without having the surgeons salary. The APNs are required to have a supervising surgeon in the State of Texas and the medical director for the ITT stands in this role, just as he does for the surgical fellows. By implementing a recent review of acceptable charges, the ITT has been turned into a revenue center for the hospital. Revisions that took place in 2003 increased revenue billing by 25% over 2002. Revisions in 2004 have
12001
Resuture
90784
IV Injection of medication
increased revenue billing by 55% over 2002. These numbers include clinic and procedure charges only, not professional fees. By adding the professional fees for the APNs, the numbers would be dramatically improved for any N team. The billing procedures and their corresponding CPT codes utilized at MDACC are displayed in Table 6. 5 Having a highly-skilled staff with excellent success rates has delayed the team in moving to ultrasonic placement of PICC insertions. However, due to reports showing increased patient satisfaction and decreased phlebitis rates with use of ultrasound, training has begun in the use of ultrasound for PICC placement and the assurance of vein patency. The goal is to expand the use of the ultrasound for not only PICC insertions, but also for subclavian/jugular or femoral catheter insertions to increase success rates and decrease complications. Another goal is to use ultrasound technology to diagnose catheter malpositions and to reposition errant CVC tips. The intent is to design future research projects with these goals in mind. Another anticipated project is evaluation of a new high-pressure polymer PICC. The design of this catheter makes it acceptable for use on high pressure infusion pumps (i.e. Medrad) such as those used for CATSCAN procedures. If this catheter is successful, the hope is to move the technology into subclavian
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catheter development as well. Insuring patient comfort goes handin-hand with every form of N Therapy practice. In an effort to improve patient comfort the team intends to look at several advanced approaches. These include: 1. Prophylactic improvement of phlebitis rates through (a) Using the upper arm for PICC insertions and (b) Evaluating the use of moist or dry heat or cold compresses during and post insertions. 2. Administering anxiolysis medication pre-procedure. Currently the team is working on a project to evaluate insertion success rate, decreased complication rates and compare the effectiveness of various drugs. MDACC has a unique patient population with unique infusion therapy needs. Few N Teams have as broad a scope of practice as the IV Team at MDACC. The ongoing success of this team can be observed in the consistent high evaluation of the team's services as made by the patients at MDACC. This team of dedicated nurses and support staff continually seeks to improve practice and results.
In Conclusion The Infusion Therapy Team of the M.D. Anderson Cancer Center has undergone significant changes since its
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inception over twenty-five years ago. The ongoing and constant changes occurring within the healthcare arena require each of us to remain flexible and willing to change to best meet the needs of the client. The need for intravenous specialty teams will continue to be evaluated. The future deSign of the team may change, but we as nurses and patient advocates must strive to be innovative risk takers, much like Millie Lawson, to continue to obtain and maintain quality patient care. It is important for the nursing staff,
administrators and clinical leaders of today to remain proactive in support of specially trained nurses to develop progressive concepts and approaches to devise and revise roles and responsibilities for tomorrow. Today, we are making history. • Deborah Richardson, RN, BS, BSN, MS is the Clinical Nurse Specialist for the InfUSion Therapy Team at MD. Anderson Cancer Center, Houston, IX. She has 23 years ofIV Therapy experience and has presented at numerous
national and international conferences and co-authored mUltiple articles related to IV Therapy. Brenda Caillouet, RN, BSN, MPH is the Patient Care Nurse Managerfor the InfUSion Therapy Team at MD. Anderson Cancer Center, Houston, IX. She has 22 years of IV Therapy experience in multiple care settings with the past three years on the Infusion Therapy Team at MDACC. The authors would like to thanklane Nelson, RN, BSNfor editing and reviewing this manuscript.
REFERENCES 1. Annotated Guide to the Texas Nursing
Practice Act 5th Edition, 2002 Austin, TX: Texas Nurses Association Publisher. 2. Central Venous Catheters- Verification of Placement 2003. MDACC Nursing Practice Policy and Procedures, Chapter 10
PC/lnfusion Therapy, Section 13.0. 3. Centers for Disease Control and Prevention, 2003. "Guide for the Prevention of Intravenous Catheter-Related Infections," Morbidity and Mortality Weekly Report, 51 (RR-lO).
4. Patient Education Tools, Infusion Therapy Team, M. D. Anderson Cancer Center, Houston, TX. 5. Current Procedure Terminology, 2004. Standard Edition. Chicago, 11.: American Medical Association Press.
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• •
AChronicle of Experience-Past, Present &Future Deborah Richardson,
RN, MS
and Brenda Caillouet,
RN, MPH
Abstract Infusion Therapy and vascular access devices have had a profound impact on nursing practice over the years. The domain of nursing practice lends itself to providing an open window of opportunity for the nurse to enter different arenas of nursing practice and to develop expertise in a chosen field. That is what happened at the M.D. Anderson Cancer Center, Houston, TX, in the 1970s. This article provides an overview of the history of the Infusion Therapy Team along with current and future practice.
nfusion Therapy and vascular access devices have had a profound impact on nursing practice over the years. As nurses, daily practice dictates a need for knowledge and experience to consistently maintain and improve the quality of patient care. The domain of nursing practice lends itself to providing an open window of opportunity for the nurse to enter different arenas of nursing practice and to develop expertise in a chosen field. That is what happened at the M.D. Anderson Cancer Center (MDACC) in the 1970s.
I
Past In the mid 1970s, chemotherapeutic agents were being infused by intravenous drip or by large infusion pumps through peripheral intravenous devices (PN's). The toxicity exacerbated by the method of delivery of the drugs caused patients to have severe side effects, such as nausea and vomiting. In addition, the medications were very caustic to the smaller peripheral vasculature. Patient needs, new and innovative
technology related to treatment, protocols, and delivery systems provided the impetus in the development of central line placement and use, along with the development of Infusion Therapy Teams. These same driving forces assisted the formulation of the Infusion Therapy Team at MDACC. The teams history dates back to 1976 when the team founder, Millie Lawson, RN, worked as a research nurse in Developmental Therapeutics at MDACC. Between 1976 and 1978, Ms. Lawson was part of a research study, through a grant by the Alza Corporation, evaluating the use of an ambulatory pump with various methods of intravenous access. It was during this time period that Ms. Lawson inserted
2 0 0 4
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9
the first peripheral silicone central venous catheter (CVC) at MDACC. Millie Lawson was also the first registered nurse in the United States to insert a peripheral central venous catheter. At the time, and for many years afterward, this catheter was called a "longline". The original longline product used at MDACC was the Intrasil, manufactured by Baxterffravenol (Figure 1). It was a 14 gauge slotted needle with a spool threading device (Figure 2). These central lines were inserted, maintained and monitored to determine whether they were safe, efficacious and reliable venous access methods. Through this process, the Infusion Therapy Team OTD at MDACC was "born". The team was officially established in January
No
2
..JAVA
103
1978 with one RN, Millie Lawson, and one physician, ]oe Bottino, M.D. Initially, this team of two covered just four inpatient floors, but within a very short period of time progressed to cover all the inpatient and outpatient areas. Ms. Lawson designed and opened the Infusion Therapy Team clinic at MDACe. This was the second nurse-run clinic to be opened at the institution. Coverage was eight to five p.m., Monday through Friday, with 24-hour a day on call. This clinic still exists today. As responsibilities were expanded, staffing was increased to meet those needs and 24-hour coverage began in April 1978. During its first year, the team was expanded to include eight RNs. In September 1978, the Infusion Therapy Technician role was developed and seven technicians were hired and oriented. Team member roles, responsibilities and procedures were defined by the position description, patient needs and advancing technology (Tables 1 & 2). Each of these assumed responsibilities required the development of policies and procedures, orientation guidelines, design of monthly reports, product selection, the expansion and approval of nursing practice and other basic operational components. The original "on the job" training was the selected mode of orientation for staff. This training period varied from 2-3 weeks depending upon the ability of the new staff member in
104
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9
training. Present day orientation lasts an average of 6 weeks, and is still considered "on the job" training. Early on (March 1978) a format was established to collect data on a monthly basis to monitor staff utilization and team responsibilities. These were handwritten reports, which kept track of the number of dressing changes, PIVs, insertions, phlebitis, removals, infections, etc. In 1978, the team performed the follOWing number of procedures: Insertions:
Subclavian . . . . . . . . . . . . 208/yr Longline 4oo/yr CVC Dressings: . . . .. 4000 - 48oo/yr PIVs: 1500 - 1560/yr The complication rates for pWebitis (l8-2001o), thrombosis (2%), and infection (2-3.4%) were monitored on a monthly basis allowing for ongoing assessment and tracking of these issues. During this "start-up" period, eve insertion, maintenance, and problem management were identified as the primary responsibilities of the team. However, with the placement of a evc and the increased awareness for long-term dwell catheters, patient education soon became a primary focus. Initially, the staff utilized a 1:1 teaching modality to facilitate catheter care education. An educational program was developed for patients and caregivers to enable their participation in the care of their CVe. This class was held once a week, but
No
2
20 0 4
quickly progressed to daily evc classes. The didactic portion of the class covered flushing, injection cap change and dressing changes (Figure 3). Each patient and caregiver was required to perform a return demonstration of those skills. If the patientlcaregiver was unable to perform or had no support system to help with evc care, a referral was made to the appropriate home care agency or facility. In 1981, a catheter care video was developed and implemented to assist in the teaching process and provide more efficient utilization of the nursing staff. Catheter care class consisted of the following modalities: video, lecture, instructional booklet, demonstration and practicum (Figure 4). Revision and updates of the catheter care video have been performed as procedures, equipment and/or patient needs warranted. In addition to the daily responsibilities, the team participated in multiple groundbreaking original research studies. The studies included: • Urokinase vs. Streptokinase to Restore Catheter Patency • Use of Transparent Dressings • Small Volume Portable Infusion Pumps • Use of Implanted Ports-PACs
Table I RN Roles & Responsibilities • • • • • • • • • • •
Longline insertion Assist subclavian insertion Blood drawing thru eve PIV insertion eve removals eve declots Problem management Maintenance care IV Tubing changes Daily rounds Patient/Staff education
Table 2 ITT Technician Roles & Responsibilities • • • • • •
Blood drawing thru eve Maintenance care of eVc/Plv Asst. surgeons with insertions Asst. RNs with longline insertions IV tubing changes Return demonstrations
class. In the 1990s, the program was revised to reflect student needs and recommendations from the evaluations. The didactic portion was changed to include PICC insertion technique, suturing, venous anatomy, chest x-ray verification, complications, repair, and legal issues. The program is still offered five times a year but is now a 4-day program. To date, approximately 400 nurses have been trained. The vision, purpose and practice standards established by the original members of the team provided the impetus for the continued high standards of nursing practice and the ability to "reach beyond the norm" on the Infusion Therapy Team.
Obviously, even at a very early stage, research became a part of the team's focus and functions and still remains so today. In 1983, a computer-based documentation system was designed and developed for the team. The system was implemented in 1988. This lIT documentation system provided a pilot program for the institution's plan to have all documentation become computer-based. The institution is now in the process of establishing an electronic medical record (EMR) to be used house-wide. It is a complex task that has and will take a number of years to implement. Also in 1983, the team was trained on reading chest radiographs for verification of tip position for PICCs and nurse performed overwire exchanges. The Texas State Board of Nurse Examiners allows delegation of Medical acts to registered nurses with appropriate training and education; competency assessment and documentation of that skill.' In addition, there must be written nursing policies and procedures and appropriate medical and nursing backup.2 Per policy, the nurses check for tip placement of PICCs and nurse exchanges only. However, through training many other catheter placement problems can be visualized, such as malpositions, kinks, embedment of the tip into the vessel wall, embolized catheter tips, and separated ports. If
additional problems are seen, the staff notifies the attending physician for verification and follow up orders. The policy states that a posterior-anterior (PA) and lateral of the chest is done to verify tip placement. 2 The posterior-anterior view is used to verify tip placement and the lateral is utilized to rule out malpositions. 2 Catheter tips in the azygous vein on a posterior-anterior view appears to be in place in the SVC, however, on inspection of the lateral, it will be quite evident the tip is pointing toward the spine. It has been very beneficial to the patients to have the nurses on the Team skilled in this area. It was found to expedite care by allowing them to receive treatment quicker, or be discharged to home, and decreased their wait time. Early in the 1980s, it became apparent from many outside requests that there was a growing need to instruct nurses outside MDACC in the art and skill of PICC insertions. The Infusion Therapy Team and MDACC Nursing Outreach Departments developed a program to meet this need. The program included both clinical and didactic instruction. The classes originally encompassed instructions in suturing, complications, repairs, viewing chest x-rays for placement, overview of catheter types, dressing procedures, PICC placement technique. The 5-day program was offered 4 to 5 times a year with a maximum of 4 students per
2 0 0 4
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Present The roles, responsibilities and the staffing mix of the team has evolved, grown and changed throughout the team's 26 years of existence. Today's team is believed to be the oldest, largest and most durable IV team in the country. In 1995, as downsizing hit the healthcare arena, the IV team lost only a few positions, much to the credit of the insight of hospital administration, continued presence of patient needs and high level of staff performance. However, one role was deleted, the lIT technician position. Previous to the deletion of the technician role, Licensed Vocational Nurses (LVN) had been added to the staffing mix, which helped the team through the transition. At its peak, the team staffing level was 59 members including: RNs, LVNs, hospital aide, clerical staff and technicians. Currently there are 54 staff members with a breakdown as follows: RNs (42), LVNs (4), Nurse Manager (1), Assistant Nurse Manager (1), Clinical
Figur 4
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Table 3 LVN Role & Responsibilities • Assist RN with PICC insertions • Assist RN/MD with subclavian insertions • Assist RN/MD with PortrTunneled Catheter removal • Prep for PI CC/Subclavian insertions • PIVs • Removals • Port Access/De-access • Maintenance care • Teach CVC class • Preceptors • Research • Product evaluations • Return demos
Table 4 RN Roles & Responsibilities 2004 • • • • • • • • • • • • • • • • • • • • • • •
PICC insertion CXR verification of tip placement Midline insertion Assist subclavian, jugular, femoral insertions Asst. PortrTunneled catheter Removal Perform overwire exchanges PIVs CVC removals Declots Problem management Resutures Maintenance care Asst. Chest tube placement! removal Port access/De-access Research Product evaluations Repair CVCs Pre-insertion interviews Patient education: CVC/ambulatory pumps Faculty for Education Programs Ultrasound for CVC Placement Teach CVC class Return demos
Nurse Specialist (1), Hospital Aide (1), and Administrative Support Staff (4). The staff is responsible for all patients with central lines. Today, there are over 13,642 active central lines. In terms of catheter equipment, we are currently using the Cook PICC silicone single lumen, Cook Antibiotic-impregnated Double Lumen/Triple Lumen, Quinton Apheresis, MedComp Hemocath Silicone apheresis, Bard double lumen PICC, Bard Hohn Silicone single
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lumen and double lumen catheters, and Deltec midline devices. The RN and LVN nursing staff responsibilities have expanded throughout the years (Tables 3 & 4). Recently, the Texas Board of Nursing added a number of practice statements related to LVNs and central venous catheters. I This has allowed an expansion in the LVN role on the team (Table 3). The team has been involved in approximately 40 research studies and over 300 product evaluations during it's 26-year tenure. IV therapy is a very dynamic field with the opportunity for continued growth and development of practice, products and technology. We have inserted over 100,000 CVCs with an average monthly insertion rate of about 450. Of the 450, approximately 150 of those insertions are PICCs. Statistically, the procedures break down as follows (Table 5). As stated before, the team has been involved in numerous research studies in which the results have been used to support practice changes. Some of those studies include, but are not limited to the following: • 1991-Maximal Sterile Barriers during the Insertion of cves for the Prevention of Infections Complications (Categol]' lA CDC recommendation) (#3) • 1995-The Optimal Frequency of Changing IV Site: 3 days vs. 7 days • 1996-Efficacy of CVC Impregnated with Minocycline and Rifampin vs. Catheter Bonded with Chlorahexidine and Silver Sulfadiazine in Reduction of Catheter Infection (categol]' lA CDC recommendation), (#3) • 1999-2ooo-A randomized, doubleblind-controlled study for Alteplase for the Restoration of Patency to CVAD (Cool 1 Trial) • 1999-2ooo-Efficacy of Long-term Silicone CVC Impregnated with Minocycline/Rifampin for Preventing Catheter-related Infection • 2QOO-2001-An Open Label Single Arm Clinical Trial of the Safety and Efficacy of Recombinant Tissue Plasminogen Activator for Restoration of Function to CVAD (Cool 2 Trial) Each of these studies has either had
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or will have an effect on practice standards and recommendations. The patient education component of our practice has evolved over the years. The catheter care class format and schedule have changed to accommodate time schedules and adult learning needs. Today, the class is held twice a day Monday, Wednesday and Friday; three times a day on Tuesdays and Thursdays, and once daily on Saturdays and Sundays. The implementation of the CVC care video as a teaching tool decreased actual nursing time required for class instruction by 6 hours a week. It also provides consistency of information and decreases the problems with instruction for patients with a language barrier. The M.D. Anderson Cancer Center multicultural patient population requires that patient education materials be written in multiple languages. Thus, some of the CVC teaching materials are written in Spanish, Arabic, Turkish, Vietnamese and Thai. 4 Currently, the video is in English and Spanish only (Figure 5).
ps
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5
Future Toward the end of 2004, the team will be expanding as MDACC continues to grow to meet the needs of our patients. A second outpatient lIT clinic will open in October 2004, in the new Ambulatol]' Clinic Building. This clinic will be open for operations Monday through Friday, providing the same services as the primary lIT clinic. Adding two more clerical staff, one nurse assistant, and six RNs will increase team staffing. Also, new to the plan is to add two additional Advanced Practice Nurse (APN) positions. The goal of the APN role is to reduce reliance on the surgical fellows for advanced procedures, especially
Table 6
Table 5 - Procedure 1978
2004
CPT Codes
Procedures Insertion of non-tunneled CVC > 5yrs. old, (Pediatric) Insertion of PICC (Pediatric)
Subclavian insertions
N/A
3,600
36555 (36556)
PICC insertions
400
1,800
36568 (36569)
PIVs
130
36,000
36575
Repair of a CVC without Port Overwire Exchange of CVC
Dressing change
450
14,400
36580
Exchanges
N/A N/A N/A
1,800
36584
Overwire Exchange of PICC
1,800
36589
Removal ofTunneled CVC
Declots Removals CVC Classes Return Demos Port Removals
6,000
36590
Removal ofTunneled CVC with Port
48
480
76942
Ultrasound guidance for Placement of CVC
N/A N/A
4,200
32020
Chest Tube Placement
420
36430
Transfusion Blood Components
36550
Declot by Thrombolytic Agent
subclavian insertions. With recent changes in the laws governing medical residences work hours, more responsibilities have fallen to the surgical staff fellow. By adding APNs, this will relieve the surgeon for more urgent and emergent care. In addition, the belief is that the failure rate and complication rates will decrease by using specialty trained advanced practice nurses with expert skills. Since APNs are able to bill for procedures in the same way as a surgeon, the revenue to the institution should not change. Financially, supporting a team of this magnitude requires continual review of current coding and charges. Current procedural terminology (Cm codes are reviewed annually to make sure proper coding and capturing of all procedures occurs. s By having a separate outpatient clinic, the team is able to bill for both procedures and clinic visits. A clinic visit charge is attached to those procedures that do not have a corresponding CPT code. By having APNs perform the more complicated procedures, the APN can bill a professional fee, as a surgeon would, without having the surgeons salary. The APNs are required to have a supervising surgeon in the State of Texas and the medical director for the ITT stands in this role, just as he does for the surgical fellows. By implementing a recent review of acceptable charges, the ITT has been turned into a revenue center for the hospital. Revisions that took place in 2003 increased revenue billing by 25% over 2002. Revisions in 2004 have
12001
Resuture
90784
IV Injection of medication
increased revenue billing by 55% over 2002. These numbers include clinic and procedure charges only, not professional fees. By adding the professional fees for the APNs, the numbers would be dramatically improved for any N team. The billing procedures and their corresponding CPT codes utilized at MDACC are displayed in Table 6. 5 Having a highly-skilled staff with excellent success rates has delayed the team in moving to ultrasonic placement of PICC insertions. However, due to reports showing increased patient satisfaction and decreased phlebitis rates with use of ultrasound, training has begun in the use of ultrasound for PICC placement and the assurance of vein patency. The goal is to expand the use of the ultrasound for not only PICC insertions, but also for subclavian/jugular or femoral catheter insertions to increase success rates and decrease complications. Another goal is to use ultrasound technology to diagnose catheter malpositions and to reposition errant CVC tips. The intent is to design future research projects with these goals in mind. Another anticipated project is evaluation of a new high-pressure polymer PICC. The design of this catheter makes it acceptable for use on high pressure infusion pumps (i.e. Medrad) such as those used for CATSCAN procedures. If this catheter is successful, the hope is to move the technology into subclavian
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catheter development as well. Insuring patient comfort goes handin-hand with every form of N Therapy practice. In an effort to improve patient comfort the team intends to look at several advanced approaches. These include: 1. Prophylactic improvement of phlebitis rates through (a) Using the upper arm for PICC insertions and (b) Evaluating the use of moist or dry heat or cold compresses during and post insertions. 2. Administering anxiolysis medication pre-procedure. Currently the team is working on a project to evaluate insertion success rate, decreased complication rates and compare the effectiveness of various drugs. MDACC has a unique patient population with unique infusion therapy needs. Few N Teams have as broad a scope of practice as the IV Team at MDACC. The ongoing success of this team can be observed in the consistent high evaluation of the team's services as made by the patients at MDACC. This team of dedicated nurses and support staff continually seeks to improve practice and results.
In Conclusion The Infusion Therapy Team of the M.D. Anderson Cancer Center has undergone significant changes since its
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inception over twenty-five years ago. The ongoing and constant changes occurring within the healthcare arena require each of us to remain flexible and willing to change to best meet the needs of the client. The need for intravenous specialty teams will continue to be evaluated. The future deSign of the team may change, but we as nurses and patient advocates must strive to be innovative risk takers, much like Millie Lawson, to continue to obtain and maintain quality patient care. It is important for the nursing staff,
administrators and clinical leaders of today to remain proactive in support of specially trained nurses to develop progressive concepts and approaches to devise and revise roles and responsibilities for tomorrow. Today, we are making history. • Deborah Richardson, RN, BS, BSN, MS is the Clinical Nurse Specialist for the InfUSion Therapy Team at MD. Anderson Cancer Center, Houston, IX. She has 23 years ofIV Therapy experience and has presented at numerous
national and international conferences and co-authored mUltiple articles related to IV Therapy. Brenda Caillouet, RN, BSN, MPH is the Patient Care Nurse Managerfor the InfUSion Therapy Team at MD. Anderson Cancer Center, Houston, IX. She has 22 years of IV Therapy experience in multiple care settings with the past three years on the Infusion Therapy Team at MDACC. The authors would like to thanklane Nelson, RN, BSNfor editing and reviewing this manuscript.
REFERENCES 1. Annotated Guide to the Texas Nursing
Practice Act 5th Edition, 2002 Austin, TX: Texas Nurses Association Publisher. 2. Central Venous Catheters- Verification of Placement 2003. MDACC Nursing Practice Policy and Procedures, Chapter 10
PC/lnfusion Therapy, Section 13.0. 3. Centers for Disease Control and Prevention, 2003. "Guide for the Prevention of Intravenous Catheter-Related Infections," Morbidity and Mortality Weekly Report, 51 (RR-lO).
4. Patient Education Tools, Infusion Therapy Team, M. D. Anderson Cancer Center, Houston, TX. 5. Current Procedure Terminology, 2004. Standard Edition. Chicago, 11.: American Medical Association Press.
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