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A New Area of Competence for the Vascular Access Nurse: The PICC Port
ORAL PRESENTATION WINNERS 1st Place Infusion Phlebitis Assessment Scales: A Systematic Review of Their Use and Psychometric Adequacy Gillian Ray-Barruel, RN, BSN, BA(Hons), Denise F. Polit, PhD, FAAN, Jenny Murfield, BSc(Hons), and Claire M. Rickard, RN, PhD Purpose/Design: We sought to identify the definitions and symptoms used in assessment of infusion phlebitis, scope the number of scales available to assess phlebitis incidence and severity, and evaluate evidence regarding their reliability, validity, responsiveness, and feasibility. Methods: We conducted a systematic literature review of the Cochrane Library, Ovid MEDLINE, and EBSCO CINAHL until November 2012. All English-language studies (RCTs, prospective cohort, and cross-sectional) that included phlebitis associated with peripheral intravenous cannulation in adults as a primary outcome measure, or that evaluated an infusion phlebitis scale, were retrieved. Studies that assessed infusion phlebitis using a provided definition or scoring tool were included in the review. Results: Phlebitis related to peripheral intravenous cannulation was the primary outcome measure in 316 studies; of these, 222 provided no definition of phlebitis. Of the 94 studies that reported measuring infusion phlebitis incidence and/or severity, 62 used an assessment scale and 32 used a definition only. We identified 57 different assessment scales, which differed in symptoms included, definitions of symptoms, and cutpoints for a phlebitis diagnosis. None of the studies reported comprehensive psychometric testing. Psychometric analyses were undertaken for four assessment tools, but these analyses had many limitations. Nevertheless, the evidence from these studies suggests that inter-rater reliability for these phlebitis assessment scales is modest. Limitations: We only reviewed articles published in English, and we did not contact any of the authors for further psychometric details. Conclusions: No phlebitis assessment measure reported in the literature met rigorous psychometric standards. Many phlebitis scales and tools have been developed, but none have been sufficiently validated for use in the clinical setting. Consequently, a lack of consensus on phlebitis assessment criteria has led to disparities in reported phlebitis incidence, precluding any meaningful comparison of reported phlebitis rates. You can go to http://www.avainfo.org/posters to view this poster.
2nd Place Investigating the Impact of Blood Culture Bundles on the Incidence of Blood Culture Contamination Rates Theresa Murphy, RN, BS, CRN, CRNI, VA-BC Abstract: The American Society for Microbiology recommends a standard of 3% or less for blood culture contamination rates. The purpose of this study was to evaluate blood culture bundles on the blood culture contamination rates when blood culture was obtained through a central venous access device (CVAD). The study utilizes a non-experimental pre/post audit intervention design. The pre audit rates were compared to post audit rates of contamination after introduction of blood culture bundle. Mean results from pre/post audits were compared using bivariate statistical t-test. The results of the study revealed a 61% decrease in the contamination rate when a blood culture bundle was utilized to obtain a sample for a CVAD. These results indicate a proportion p-value of 0.0404 The limitations of the study were as follows; illegible hand writing on specimen labels,variance in laboratory personell methods to “check in” blood samples, sample size and maintaining an easily accessible supply of blood culture bundles on the nursing units. At the conculsion of the study it was determined the utilization of a blood culture bundle to obtain a blood sample from a CVAD was significant to make it a standard of care. Shortly after a policy and procedure was created to ensure this standard of care is met. Implementation of the blood culture bundle can potentially decrease the; number of false positive results, cost of microbiological testing, delayed patient care, length of stay and improve utilization of antibiotic therapy.
3rd Place A New Area of Competence for the Vascular Access Nurse: The PICC Port Mauro Pittiruti, MD, Alessandro Emoli, RN, and Patrizia Porta, RN Background: Placement of a PICC-port (or brachial port, or arm-port) may be indicated in selected oncologic patients candidate for chemotherapy. It is less expensive and less invasive than a chest port. Also, it is a procedure ideally performed by a vascular access nurse. Project: In our hospital, we are currently introducing and implementing the use of PICC-ports in oncologic patients. Indications are the same as a chest port (i.e.: prolonged, episodic use of the central line, less than once a week) plus a specific contraindication to the use of the chest area (radiotherapy, radiodermitis, complicated tracheostomy, morbid obesity, strong preference of the patient due to cosmetic/ psychological reasons, etc.). Contraindications are the same of PICCs (small veins, venous thrombosis, AV fistula, arm paresis, major skin or orthopedic problems of the arm, axillary node dissection, etc.); also, we avoid PICC-ports when chemotherapy is scheduled for >12 hours (risk of needle dislodgement while sleeping). Our protocol of insertion includes
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adequate asepsis (dedicated ambient, hand washing, maximal barrier precautions, skin antisepsis with 2% chlorhexidine); ultrasound-guided cannulation of a deep vein at upper midarm; 4-6Fr polyurethane or silicon catheters; small reservoirs; verification of tip position by the intracavitary ECG method; minimal or no tunneling of the catheter, skin closure with cyanoacrylate glue. The procedure is performed by a vascular access nurse expert in PICC placement. Implications: In our institution, years ago, placement of an “arm port” or “brachial port” was an expensive, physician-
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driven procedure, performed in operating room or radiologic suite: veins were cannulated at the antecubital area, without ultrasound, and the reservoir was often placed in the forearm; this was associated with high costs, poor compliance of the patient and high risk of complications. Today, the “PICC port” is a inexpensive, minimally invasive, nurse-based procedure, performed by ultrasound guidance and ECG-guidance, associated with an optimal compliance and a very low rate of complications. You can go to http://www.avainfo.org/ posters to view this poster.
2013
2nd Place Investigating the Impact of Blood Culture Bundles on the Incidence of Blood Culture Contamination Rates Theresa Murphy, RN, BS, CRN, CRNI, VA-BC Abstract: The American Society for Microbiology recommends a standard of 3% or less for blood culture contamination rates. The purpose of this study was to evaluate blood culture bundles on the blood culture contamination rates when blood culture was obtained through a central venous access device (CVAD). The study utilizes a non-experimental pre/post audit intervention design. The pre audit rates were compared to post audit rates of contamination after introduction of blood culture bundle. Mean results from pre/post audits were compared using bivariate statistical t-test. The results of the study revealed a 61% decrease in the contamination rate when a blood culture bundle was utilized to obtain a sample for a CVAD. These results indicate a proportion p-value of 0.0404 The limitations of the study were as follows; illegible hand writing on specimen labels,variance in laboratory personell methods to “check in” blood samples, sample size and maintaining an easily accessible supply of blood culture bundles on the nursing units. At the conculsion of the study it was determined the utilization of a blood culture bundle to obtain a blood sample from a CVAD was significant to make it a standard of care. Shortly after a policy and procedure was created to ensure this standard of care is met. Implementation of the blood culture bundle can potentially decrease the; number of false positive results, cost of microbiological testing, delayed patient care, length of stay and improve utilization of antibiotic therapy.
3rd Place A New Area of Competence for the Vascular Access Nurse: The PICC Port Mauro Pittiruti, MD, Alessandro Emoli, RN, and Patrizia Porta, RN Background: Placement of a PICC-port (or brachial port, or arm-port) may be indicated in selected oncologic patients candidate for chemotherapy. It is less expensive and less invasive than a chest port. Also, it is a procedure ideally performed by a vascular access nurse. Project: In our hospital, we are currently introducing and implementing the use of PICC-ports in oncologic patients. Indications are the same as a chest port (i.e.: prolonged, episodic use of the central line, less than once a week) plus a specific contraindication to the use of the chest area (radiotherapy, radiodermitis, complicated tracheostomy, morbid obesity, strong preference of the patient due to cosmetic/ psychological reasons, etc.). Contraindications are the same of PICCs (small veins, venous thrombosis, AV fistula, arm paresis, major skin or orthopedic problems of the arm, axillary node dissection, etc.); also, we avoid PICC-ports when chemotherapy is scheduled for >12 hours (risk of needle dislodgement while sleeping). Our protocol of insertion includes
2013
j
Vol 18 No 4
j
JAVA
j
217
adequate asepsis (dedicated ambient, hand washing, maximal barrier precautions, skin antisepsis with 2% chlorhexidine); ultrasound-guided cannulation of a deep vein at upper midarm; 4-6Fr polyurethane or silicon catheters; small reservoirs; verification of tip position by the intracavitary ECG method; minimal or no tunneling of the catheter, skin closure with cyanoacrylate glue. The procedure is performed by a vascular access nurse expert in PICC placement. Implications: In our institution, years ago, placement of an “arm port” or “brachial port” was an expensive, physician-
218
j
JAVA
j
Vol 18 No 4
j
driven procedure, performed in operating room or radiologic suite: veins were cannulated at the antecubital area, without ultrasound, and the reservoir was often placed in the forearm; this was associated with high costs, poor compliance of the patient and high risk of complications. Today, the “PICC port” is a inexpensive, minimally invasive, nurse-based procedure, performed by ultrasound guidance and ECG-guidance, associated with an optimal compliance and a very low rate of complications. You can go to http://www.avainfo.org/ posters to view this poster.
2013