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Infusion Therapy: An International Perspective
slon
A n International
Perspective
Angela Alien, RN. CRNI - Vera Higa - Silvana Torres, RN Katia Teixeira - Tim Spencer, IC, Cert. Dip App Sci, BaN, MCN - Jim lacy, RN, CRNI Recent articles in the Journal ofVascular Access Devices have focused upon the evolution of infusion therapy practices in the United States. This evolution is a worldwide phenomenon that was illustrated by a panel presentation at the 2002 Annual Conference of the Nationol Association ofVoscular Access Networks (NAVAN) entided:"Vascular Access - An International Perspective." This article follows up on that presentation with a view of current infusion therapy practices in Australia, Brazil, and the People's Republic of China, and a discussion on the best practices to prevent neonatal death in developing countries.
The Medical ~ystem and Infusion Nursing in the Peop'le's Republic of China Angela Alien, RN, eRNI
ntil the early 1990s, health care in the People's Republic of China (PRC) was provided primarily through a socialized system of medical care. Almost all the hospitals were owned by the slate and the care coverage was territorial. Patients' medical costs were covered by their workplace, which also were all slateowned. Since the early 19805, China has opened her doors to the outside world. During the 19905, extensive economic reforms in China had a tremendous impact on its health care system. As people left their state jobs and went into private business, they lost their medical
U
coverage. On the other hand, people started to have more money in their pockets than ever before and private health care institutions began to appear. Most (98%) nurses in the PRC have completed three years of full-time study in a "very strenuous" educational program. One year of postgraduate residency training is required in order to practice nursing, but no special certification or additional training is required for RNs to perform IV therapy. All RNs are expected to perform venipuncture for IV therapy and blood sampling, as well as arterial puncture for ABGs. In recent years, the increasing complexities of infusion therapy and the vast technolog-
Summer
ical advances achieved by foreign medical equipment manufacturers have challenged the philosophy and practice of irtfusion therapy in China. Manufacturers spend a substantial amount of resources in order to provide education programs and technical support on their products such as IV catheters, blood collecting systems and peripherally inserted central catheters (PICCs). The concept of IV therapy is rapidly changing in the PRC. In the past decade, many Infusion Nursing Specialists were brought to China to present lectures, seminars, and special UN Skills Week" programs to promote IV therapy. Nurses in China are very anx-
2003
.JVAD
IS
ious to accept new technologies and to
costlbenefit analysis is not often easily
establish intravenous therapy as an officially recognized specialty in nursing. A seminar tided "The Concept of Infusion Therapy," conducted by Angela Alien, RN, CRNI, attracted more than 500 nurses. In December 2001, the first IV team in the PRC was established in Chao Yang Hospital, Beijing. In the same month, Infusion Nurses Society
proven to physicians and the health care system. Nurses are responsible for inser-
organizations were established in Bei-
jing and Shanghai. Today 30% of the urban hospitals have converted their peripheral IV access from stainless steel needles to
catheters. Approximately 5,000 to 6,000 PICCs are placed each year nationwide, and the number is on the rise. There is also a strong interest in implanted ports, tunneled central catheters, and even
computerized implanted devices.
tion and maintenance of these devices. For central venous access, healthcare
facilities often use over-the-needle catheters placed using the Seldinger technique for short-term therapy. For extended dwell therapies, tunneled catheters and implanted ports are the options. However, PICC lines are being implemented very rapidly in Brazil, and have shown the greatest increase in use
over the past four years. PICC lines are primarily used for oncology treatment, antimicrobial therapy, and in ICUs, especially NICUs, substituting for the traditional "cut down" procedure and umbilical catheters, which have short dwell times. The clinical advantages of PICCs have been proven, and the recent approval for nurses to place these lines have con-
Infusion Therapy in Brazil
tributed to their increase in use. The greatest challenge in increasing the use of PICCs in Brazil is the limited offering of courses for nurses at a reasonable cost. Education has been formally provided by SOBETI (Brazilian Critical Care Nursing Society) and soon INS Brazil will offer approved courses. Several manufacturers also have sup-
ported the market with clinical infor-
Vera S. Higa Silvana Torres. RN Katla Teixelra
mation and promotion of technique. Maintenance of intravenous devices
differs from facility to facility. Each entity has its own internal guideline but usually follows United States' Centers for Disease Control's guidelines
ealthcare in Brazil is provided through both public and private systems of care. The practice of infusion therapy is gaming recog- and recommendations. These are nition as a specialty, as illustrated widely promoted by local and regional by the founding of the Brazil Infusion infection control associations (a service Nursing Society in 2002. This has been all hospitals and regions must have, a cooperative effort among other nurs- according to Brazilian law). ing and healthcare organizations in Home care is just beginning in Brazil order to promote best practices in infu- and there are many questions to be answered before it is Widely accepted. sion therapy throughout Brazil. The common devices used for These questions include: Can a person peripheral IV therapy are winged needle from the family assist the patient instead sets and peripheral intravenous of a more capable professional? In catheters. There is still a need to change which cases? If a needlestick occurs to a from steel neeclles to peripheral intra- home care nurse, where should shelhe venous catheters; it is estimated that report and receive treatment? The polionly 33% of patients receiving periph- tics involved in implementing a eral infusion therapy receive peripheral widespread home care system versus intravenous catheters. However, change care in the hospital are affecting the is difficult in light of increased cost; a acceptance of this as a modality of care.
H
16
.JVAC
Sum mer
200 3
Infusion Therapy in Australia Tim Spencer, IC, Cert. Dip App Sd, BaH,MCN
ealthcare in Australia is provided by a mixture of public (70%) and private (30%) systems. Hospitals are accredited through a
H
government organization and
must adhere to specifically designed quality standards. The greatest challenge to the healthcare system is provision of care to a wide rural geographic area. This is accomplished through a system of clinics and aerial transport teams with more than 190,000 patients treated annually, and 23,000 patients evacuated to urban and suburban health care facilities annually. Infusion therapy practice differs from state to state, and from facility to facility. The scope of practice for registered nurses performing infusion practice is often governed institutionally. Insertion, care and maintenance of vascular access
devices are performed by registered nurses, medical officers (physicians), technicians, radiographers, and paramedics. While there are no established standards of practice for infusion therapy, the Intravenous Nurses Societies of New South Wales, Queensland, and Victoria are working cooperatively in their development with other organizations, such
as the Infection Control Association of Australia, Australian College of Critical Care Nurses, the National Nursing organization, and regional academic institu-
tions. Issues to be addressed in these standards include education and training in cannulation (practical), recommendation for the implementation of safer medical devices, dressings and secure-
ment, and accreditation and credentialing for infusion therapy services and practitioners. Key to the development of these standards is researcll, publication,
networking, and education and training in the area of infusion therapy. Australian nurses are taking an active role in research and publishing their findings. Peripheral intravenous catheters are most commonly used and are inserted by nurses. PICCs also are used widely and are placed predominately by nurses. In New South Wales, a vascular access service was started and staffed by nurses who place PICCs, and other central venouS access devices. This service has been able to document improved outcomes and a reduction in catheter-related complications. The practice of infusion therapy in Australia is evolving. There is a wide range of vascular access options and accessories available to patients, despite the diversity and challenges presented by Australia's geography.
A New Challenge in Infusion Therapy Jim Lacy. RN. eRNI
FACfS: • There are 5 million neonatal deaths annually, and 98"10 occur in developing countries. • More than 40% of neonatal deaths are caused by infectious diseases. • Many cases never reach health care facilities. • Case fatality rates in heath care facilities range from 13"10 to 69"10. Synopsis: Major causes of death in young infants (2000). Child Health Research Project (!SAID Retrieved February 20, 2OO],.from the World Wide Web:
eduction of neonatal mortality in developing countries is a primary focus of the World Health Organization (WHO). Cooperative efforts have led to the development and implementation of the Integrated Management of Childhood Illness (IMC!) initiatives focused on applied research, communitybased and healthcare provider education and training, and protocois to address children's health and disease management.
R
Major neonatal infections include: • Acute respiratory infections (2.5 tttillion cases annually, 750 thousand deaths);
• Neonatal tetanus (438 thousand cases annually, 372 thousand deaths), • Sepsis <750 thousand cases annually; 300 thousand deaths), • Diarrhea (25 million cases annually, 150 thousand deaths); and • Meningitis (J 26 thousand cases annually, 50 thousand deaths).
Conclusion Infusion therapy practices are so similar yet different worldwide. Faced with unique and differing challenges, nurses in Brazil, Australia, and the People's Republic of China are making a difference. As new challenges arise, research, and promotion of best practices will only serve to improve infusion therapy for the furure. •
The primary infectious agents are
treatable with cost-effective and available antibiotic therapy and, in the case
Angela Alien, RN, BSN, CRNJgraduated from nursing school in 1981. Sbepractiad of neonatal tetanus, irrununization. as a Pediatric Intensive Care nurse for 15 Intravenous antibiotic therapy is the year.5, and became an infusion nUr.5e in preferred method of delivery. intra- 1997. Currently, she practices infusion venous therapy is restricted to health- nurn"ng in both inpatient and outpatient care centers throughout the developing settings. She is the current president of the world. Multi-<:enter studies have demon- INS Northern California chaptelO strated that effective treatment can have Vem Higa is the produ£t managerfor ""'a great impact on infant survival. cular occess for BD Medical Systems, Brazil. Silvana TOrTes, RN, is an infection control A primary issue with intravenous therapy in the developing world is lack of nurse and member of the Intravenous Nurses available technology that can further Society. She has authored artkles and a te:xtdecrease intravenous therapy complica- !xJok on Infection Control in hospitals. She sen.es tions and provide reliable access in this . as dinical diroctor ofthe Bmzilian lntrr:uxmous frIable population. The use of sholt-term Newsletter, and Nursing Coordinator for BD intravenous catheters and intravenous Vascular Access Training Centre. needles (including winged-needle sets) Katia C. Tei»?ira is a market analyst with are inadequate for the delivery of medi- BD Medical Systems, Brazil cations to infants reliably and often result Tim Spencer is a Clinical Nurse Consulin serious complications, thus delaying or tant in Central Venous Acc~ and Parstopping treatment. Central venous and enteral Nutrition at Liverpool Hospital, other access points common in the devel- Australia. He has been one ofthe leading oping world often are accomplished by a nurses taking vascular access to the fonfront cut-down procedure (aiso known as vein in nursing and has had recognition for dissection). This puts the infant at greater making vascular access a specialty within risk for infection from catheter-related Australia. He is currently VICe President of nosocomial bloodstream infection. the New South Wales Infusion Nurses SociA focus for vascular access specialists, ety, and held theposition previously ofTreaindustry, and organizations is to facilitate surer for 3 yrs. He has published sewral safe and appropriate care and access to articles in local journals and has presented intravenous therapy, reduce infant mor- at local and international conferences, taliry, reduce nosocomial infections including attendances at INS and NAVAN related to vascular access, and promote over the last 8 years and was an expert infection control practices in developing panel member with Dr. Dermis Malzj in july, countries. Reducing neonatal sepsis is 2000. He was recently ocknowledged in the only one issue related to infusion ther- journal Nutrition for his involvement with apy and vascular access that exists in two publicationsfrom Turil£y. the developing world. The prirrtary jim wcy, RN, CRNJ, is a fOrrnRr NAVAN issue, access to quality care for all, can board member, author, and educator. He be addressed through initiatives such as has presented at regional and national conthis one and infusion therapy practition- ferences and rru;etings in the Us. and interers can make a difference by contribut- nationally. jim is currently Worldwide ing time, ideas, money, and supplies to Manager, Customer Support for the promote best practices and improve the Extended Dwell Catheter division of BD state of healthcare worldwide. Medical Systems based in Sandy, Utah.
Summer
2003
.JVAD
17
A n International
Perspective
Angela Alien, RN. CRNI - Vera Higa - Silvana Torres, RN Katia Teixeira - Tim Spencer, IC, Cert. Dip App Sci, BaN, MCN - Jim lacy, RN, CRNI Recent articles in the Journal ofVascular Access Devices have focused upon the evolution of infusion therapy practices in the United States. This evolution is a worldwide phenomenon that was illustrated by a panel presentation at the 2002 Annual Conference of the Nationol Association ofVoscular Access Networks (NAVAN) entided:"Vascular Access - An International Perspective." This article follows up on that presentation with a view of current infusion therapy practices in Australia, Brazil, and the People's Republic of China, and a discussion on the best practices to prevent neonatal death in developing countries.
The Medical ~ystem and Infusion Nursing in the Peop'le's Republic of China Angela Alien, RN, eRNI
ntil the early 1990s, health care in the People's Republic of China (PRC) was provided primarily through a socialized system of medical care. Almost all the hospitals were owned by the slate and the care coverage was territorial. Patients' medical costs were covered by their workplace, which also were all slateowned. Since the early 19805, China has opened her doors to the outside world. During the 19905, extensive economic reforms in China had a tremendous impact on its health care system. As people left their state jobs and went into private business, they lost their medical
U
coverage. On the other hand, people started to have more money in their pockets than ever before and private health care institutions began to appear. Most (98%) nurses in the PRC have completed three years of full-time study in a "very strenuous" educational program. One year of postgraduate residency training is required in order to practice nursing, but no special certification or additional training is required for RNs to perform IV therapy. All RNs are expected to perform venipuncture for IV therapy and blood sampling, as well as arterial puncture for ABGs. In recent years, the increasing complexities of infusion therapy and the vast technolog-
Summer
ical advances achieved by foreign medical equipment manufacturers have challenged the philosophy and practice of irtfusion therapy in China. Manufacturers spend a substantial amount of resources in order to provide education programs and technical support on their products such as IV catheters, blood collecting systems and peripherally inserted central catheters (PICCs). The concept of IV therapy is rapidly changing in the PRC. In the past decade, many Infusion Nursing Specialists were brought to China to present lectures, seminars, and special UN Skills Week" programs to promote IV therapy. Nurses in China are very anx-
2003
.JVAD
IS
ious to accept new technologies and to
costlbenefit analysis is not often easily
establish intravenous therapy as an officially recognized specialty in nursing. A seminar tided "The Concept of Infusion Therapy," conducted by Angela Alien, RN, CRNI, attracted more than 500 nurses. In December 2001, the first IV team in the PRC was established in Chao Yang Hospital, Beijing. In the same month, Infusion Nurses Society
proven to physicians and the health care system. Nurses are responsible for inser-
organizations were established in Bei-
jing and Shanghai. Today 30% of the urban hospitals have converted their peripheral IV access from stainless steel needles to
catheters. Approximately 5,000 to 6,000 PICCs are placed each year nationwide, and the number is on the rise. There is also a strong interest in implanted ports, tunneled central catheters, and even
computerized implanted devices.
tion and maintenance of these devices. For central venous access, healthcare
facilities often use over-the-needle catheters placed using the Seldinger technique for short-term therapy. For extended dwell therapies, tunneled catheters and implanted ports are the options. However, PICC lines are being implemented very rapidly in Brazil, and have shown the greatest increase in use
over the past four years. PICC lines are primarily used for oncology treatment, antimicrobial therapy, and in ICUs, especially NICUs, substituting for the traditional "cut down" procedure and umbilical catheters, which have short dwell times. The clinical advantages of PICCs have been proven, and the recent approval for nurses to place these lines have con-
Infusion Therapy in Brazil
tributed to their increase in use. The greatest challenge in increasing the use of PICCs in Brazil is the limited offering of courses for nurses at a reasonable cost. Education has been formally provided by SOBETI (Brazilian Critical Care Nursing Society) and soon INS Brazil will offer approved courses. Several manufacturers also have sup-
ported the market with clinical infor-
Vera S. Higa Silvana Torres. RN Katla Teixelra
mation and promotion of technique. Maintenance of intravenous devices
differs from facility to facility. Each entity has its own internal guideline but usually follows United States' Centers for Disease Control's guidelines
ealthcare in Brazil is provided through both public and private systems of care. The practice of infusion therapy is gaming recog- and recommendations. These are nition as a specialty, as illustrated widely promoted by local and regional by the founding of the Brazil Infusion infection control associations (a service Nursing Society in 2002. This has been all hospitals and regions must have, a cooperative effort among other nurs- according to Brazilian law). ing and healthcare organizations in Home care is just beginning in Brazil order to promote best practices in infu- and there are many questions to be answered before it is Widely accepted. sion therapy throughout Brazil. The common devices used for These questions include: Can a person peripheral IV therapy are winged needle from the family assist the patient instead sets and peripheral intravenous of a more capable professional? In catheters. There is still a need to change which cases? If a needlestick occurs to a from steel neeclles to peripheral intra- home care nurse, where should shelhe venous catheters; it is estimated that report and receive treatment? The polionly 33% of patients receiving periph- tics involved in implementing a eral infusion therapy receive peripheral widespread home care system versus intravenous catheters. However, change care in the hospital are affecting the is difficult in light of increased cost; a acceptance of this as a modality of care.
H
16
.JVAC
Sum mer
200 3
Infusion Therapy in Australia Tim Spencer, IC, Cert. Dip App Sd, BaH,MCN
ealthcare in Australia is provided by a mixture of public (70%) and private (30%) systems. Hospitals are accredited through a
H
government organization and
must adhere to specifically designed quality standards. The greatest challenge to the healthcare system is provision of care to a wide rural geographic area. This is accomplished through a system of clinics and aerial transport teams with more than 190,000 patients treated annually, and 23,000 patients evacuated to urban and suburban health care facilities annually. Infusion therapy practice differs from state to state, and from facility to facility. The scope of practice for registered nurses performing infusion practice is often governed institutionally. Insertion, care and maintenance of vascular access
devices are performed by registered nurses, medical officers (physicians), technicians, radiographers, and paramedics. While there are no established standards of practice for infusion therapy, the Intravenous Nurses Societies of New South Wales, Queensland, and Victoria are working cooperatively in their development with other organizations, such
as the Infection Control Association of Australia, Australian College of Critical Care Nurses, the National Nursing organization, and regional academic institu-
tions. Issues to be addressed in these standards include education and training in cannulation (practical), recommendation for the implementation of safer medical devices, dressings and secure-
ment, and accreditation and credentialing for infusion therapy services and practitioners. Key to the development of these standards is researcll, publication,
networking, and education and training in the area of infusion therapy. Australian nurses are taking an active role in research and publishing their findings. Peripheral intravenous catheters are most commonly used and are inserted by nurses. PICCs also are used widely and are placed predominately by nurses. In New South Wales, a vascular access service was started and staffed by nurses who place PICCs, and other central venouS access devices. This service has been able to document improved outcomes and a reduction in catheter-related complications. The practice of infusion therapy in Australia is evolving. There is a wide range of vascular access options and accessories available to patients, despite the diversity and challenges presented by Australia's geography.
A New Challenge in Infusion Therapy Jim Lacy. RN. eRNI
FACfS: • There are 5 million neonatal deaths annually, and 98"10 occur in developing countries. • More than 40% of neonatal deaths are caused by infectious diseases. • Many cases never reach health care facilities. • Case fatality rates in heath care facilities range from 13"10 to 69"10. Synopsis: Major causes of death in young infants (2000). Child Health Research Project (!SAID Retrieved February 20, 2OO],.from the World Wide Web:
eduction of neonatal mortality in developing countries is a primary focus of the World Health Organization (WHO). Cooperative efforts have led to the development and implementation of the Integrated Management of Childhood Illness (IMC!) initiatives focused on applied research, communitybased and healthcare provider education and training, and protocois to address children's health and disease management.
R
Major neonatal infections include: • Acute respiratory infections (2.5 tttillion cases annually, 750 thousand deaths);
• Neonatal tetanus (438 thousand cases annually, 372 thousand deaths), • Sepsis <750 thousand cases annually; 300 thousand deaths), • Diarrhea (25 million cases annually, 150 thousand deaths); and • Meningitis (J 26 thousand cases annually, 50 thousand deaths).
Conclusion Infusion therapy practices are so similar yet different worldwide. Faced with unique and differing challenges, nurses in Brazil, Australia, and the People's Republic of China are making a difference. As new challenges arise, research, and promotion of best practices will only serve to improve infusion therapy for the furure. •
The primary infectious agents are
treatable with cost-effective and available antibiotic therapy and, in the case
Angela Alien, RN, BSN, CRNJgraduated from nursing school in 1981. Sbepractiad of neonatal tetanus, irrununization. as a Pediatric Intensive Care nurse for 15 Intravenous antibiotic therapy is the year.5, and became an infusion nUr.5e in preferred method of delivery. intra- 1997. Currently, she practices infusion venous therapy is restricted to health- nurn"ng in both inpatient and outpatient care centers throughout the developing settings. She is the current president of the world. Multi-<:enter studies have demon- INS Northern California chaptelO strated that effective treatment can have Vem Higa is the produ£t managerfor ""'a great impact on infant survival. cular occess for BD Medical Systems, Brazil. Silvana TOrTes, RN, is an infection control A primary issue with intravenous therapy in the developing world is lack of nurse and member of the Intravenous Nurses available technology that can further Society. She has authored artkles and a te:xtdecrease intravenous therapy complica- !xJok on Infection Control in hospitals. She sen.es tions and provide reliable access in this . as dinical diroctor ofthe Bmzilian lntrr:uxmous frIable population. The use of sholt-term Newsletter, and Nursing Coordinator for BD intravenous catheters and intravenous Vascular Access Training Centre. needles (including winged-needle sets) Katia C. Tei»?ira is a market analyst with are inadequate for the delivery of medi- BD Medical Systems, Brazil cations to infants reliably and often result Tim Spencer is a Clinical Nurse Consulin serious complications, thus delaying or tant in Central Venous Acc~ and Parstopping treatment. Central venous and enteral Nutrition at Liverpool Hospital, other access points common in the devel- Australia. He has been one ofthe leading oping world often are accomplished by a nurses taking vascular access to the fonfront cut-down procedure (aiso known as vein in nursing and has had recognition for dissection). This puts the infant at greater making vascular access a specialty within risk for infection from catheter-related Australia. He is currently VICe President of nosocomial bloodstream infection. the New South Wales Infusion Nurses SociA focus for vascular access specialists, ety, and held theposition previously ofTreaindustry, and organizations is to facilitate surer for 3 yrs. He has published sewral safe and appropriate care and access to articles in local journals and has presented intravenous therapy, reduce infant mor- at local and international conferences, taliry, reduce nosocomial infections including attendances at INS and NAVAN related to vascular access, and promote over the last 8 years and was an expert infection control practices in developing panel member with Dr. Dermis Malzj in july, countries. Reducing neonatal sepsis is 2000. He was recently ocknowledged in the only one issue related to infusion ther- journal Nutrition for his involvement with apy and vascular access that exists in two publicationsfrom Turil£y. the developing world. The prirrtary jim wcy, RN, CRNJ, is a fOrrnRr NAVAN issue, access to quality care for all, can board member, author, and educator. He be addressed through initiatives such as has presented at regional and national conthis one and infusion therapy practition- ferences and rru;etings in the Us. and interers can make a difference by contribut- nationally. jim is currently Worldwide ing time, ideas, money, and supplies to Manager, Customer Support for the promote best practices and improve the Extended Dwell Catheter division of BD state of healthcare worldwide. Medical Systems based in Sandy, Utah.
Summer
2003
.JVAD
17