Jo Kuehn, RN, MSN, CPHQ Jenell Westhoven, RN, BSN

Jo Kuehn, RN, MSN, CPHQ Jenell Westhoven, RN, BSN

Disclosure Information Intravenous Therapy and Parenteral Nutrition Administration: Nursing In- Focus Jo Kuehn, RN, MSN, CPHQ and Jenell Westhoven, RN, BSN We have no financial relationship to disclose. AND We will not discuss off label use and/or investigational use in our presentation.

Learning Objectives At the completion of this activity, you will be able to: Explain appropriate line selection for Parenteral Nutrition Discuss strategies to reduce related Healthcare Associated Infections (HAI) and device complications Describe general line safety Understand set up, administration and monitoring of Parenteral Nutrition

PN Considerations Patient First Multi-disciplinary relationships PN a complex prescription with safety risks

Line Selection for PN Vascular site considerations: Length of Treatment/Osmolality/Care Environment Peripheral Parenteral Nutrition (PPN) Peripheral IV & Midlines < 6 days <10% dextrose: less than 850 900 mosm/l Hospital Setting Central Vascular Access Device (CVAD) (TPN) Short Term: non-tunneled, PICC Medium Term: PICC, tunneled, implantable Prolonged Use/Home PN: tunneled, implantable Femoral and high Internal Jugular

Line Set up Set up tubing Dedicated line / port Limiting number of ports Diethylhexyl-pithalate (DEHP) free tubing Line changing timeframe Continuous IVPN without Lipids Intermittent infusions and fat emulsions with amino acids Fat emulsions infused separately Needleless Connector Devices (CVAD) Know your displacement type and facility protocol Flush routines Visibility of debris and blood Thoroughly disinfect and allow to air dry prior to any access

From Lipid Emulsion 0.2 micron filter Connect To Patient

Filters Single patient use Attached to the distal end of the tubing set up Line and filter not primed in advance Change filter with line changes Filter below tubing Non-fat emulsion PN: 0.2 micron filter Fat emulsion (Lipids) PN: 1.2 micron filter (INS S91) Y-ing considerations Co-infusion of medications require review with Pharmacist for compatibility and stability Occluded filter management

Prevention of Central Line Associated Bloodstream Infection (CLABSI) Patient Safety Goal reduce the risk of HAI Hand Hygiene CVC insertion bundle Standardized insertion kits CVC insertion checklist Strict aseptic technique CLABSI prevention through line maintenance Standardized maintenance kits: dressing change Aseptic Non-Touch Technique Scrub the hub Blood return / Push - Pause flushing of lines Alcohol impregnated protective caps for needleless connectors / ports Assess for line necessity / signs of infection Patient education chlorhexidene bathing

Preventing Tubing Misconnections

General Line Safety Human Factors System design factors Forcing functions Colored lines Lines with no ports Dedicated pumps Line labeling Policies Education

PN Administration Standardize nursing practice Multidisciplinary input / standardized order set Follow medication administration policy / procedures Refrigeration PN until 1 hour pre admin / Protection from light Same time of day admin Check solution integrity Infuse within 1 hour of inserting IV tubing in to container High Alert Med: Independent Double Check / dual sign off Primary infusion Standardized Smart Pump Guard rails Drug library / VTBI Maintain ordered infusion rate Bar Code Medication Administration (BCMA) Documentation

Monitoring Consistent order set to guide practice: Weight check Blood glucose Labs: Fluid and electrolytes Observe for signs of Infection Air embolism Phlebitis and extravasation

Phlebitis Frequent complication of Peripheral PN Prevention Heparin & steroids Fat emulsion Osmolality Re-site catheter every 24-48 hours Treatment and Management Apply heat Discuss PN components being used peripherally Re-site vein Limiting the duration of peripheral use before switching to Central Peripheral Nutrition (INS S92).

Extravasation Peripheral Lines / Vascular Access Devices Factors influence extent of tissue damage and treatment Consensus based recommendations: STOP infusion Aspirate residual fluid Elevate limb and apply cold dry compresses Consult with pharmacist Treat with Hyaluronidase Remove line and document

Lab Draws and Parenteral Nutrition Considerations Lab Draws Preferably always drawn peripherally Avoid the extremity of PPN Do not draw blood from dedicated PN ports Pause PN for 2-3 minutes prior to drawing labs from other ports Flush with a minimum of 20mL with Push Pause method after lab draws from CVAD s

References Agency for HealthCare Research and Quality. (2014) Patient Safety Primer: Checklists. Patient Safety Net. Retrieved November 14, 2015 from https://psnet.ahrq.gov/primers/primer/14 A.S.P.E.N. (2014). Parenteral Nutrition Safety Consensus Recommendations. College of Pharmacy and Health Sciences. Retrieved September 20, 2015 from http://digitalcommons.butler.edu/cophs_papers/1 Institute for Safe Medication Practices. (2013). Side tracks on the safety express: Interruptions lead to errors and unfinished...wait, what was I doing? Nurse Advise-Err, 11(2), 1 4. (Level VII) Nursing Guide, Bard Access Systems. Retrieved September 21, 2015 from https://www.bardaccess.com/assets/literature/mc-0180-01_powerpicc_solo_nursing_guide_web.pdf Ramirez, C. Lee. A.M.and Welch, K., (2012) Central Venous Catheter Protective Connector Caps Reduce Intraluminal; Catheter- Related Infection, Journal of the Association for Vascular Access 17(4) 210-213. Standard 27. Needleless Connectors. Infusion nursing standards of practice. (2011). Journal of Infusion Nursing, 34, S32-33. Standard 28. Filters. Infusion nursing standards of practice. (2011). Journal of Infusion Nursing, 34, S33-34. Standard 32. Vascular access device selection. Infusion nursing standards of practice. (2011). Journal of Infusion Nursing, 34, S37 S40. (Level VII) Standard 43. Administration set change. Infusion nursing standards of practice. (2011). Journal of Infusion Nursing, 34, S55 S57. (Level VII) Standard 45. Flushing and Locking. Infusion nursing standards of practice. (2011). Journal of Infusion Nursing, 34, S59 S63. (Level VII) Standard 65. Parenteral Nutrition. Infusion nursing standards of practice. (2011). Journal of Infusion Nursing, 34, S91 S92. (Level VII) The Joint Commission (2006) Sentinel Event Alert, Issue 36: Tubing misconnections a persistent and potentially deadly occurrence, retrieved November 15, 2015 from http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections%e2%80%94a_persistent_and_potentially_deadly_occurren ce/ The Joint Commission (2014) Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards, retrieved November 15, 2015 from http://www.jointcommission.org/sea_issue_53/

Test your knowledge 1. Internal Jugular and Femoral placed central venous catheters are contraindicated for PN administration due to increased risk of infection and difficulty in ease of access for Caregivers. True or False? ANSWER: True

Test your knowledge 2. Which is the correct treatment of PPN extravasation: a) Stop infusion, aspirate residual fluid, elevate limb and apply cold dry compresses, Consult with pharmacist, Treat with Hyaluronidase if indicated b) Stop infusion, flush line, apply warm compress, give Hyaluronidase c) Flush line, consult pharmacist, infuse hyaluronidase d) Flush line, elevate limb and apply cold compresses, consult pharmacist, treat with hyaluronidase ANSWER: a)

Test your knowledge 3. It is acceptable to draw blood from a dedicated PN port so long as it is flushed with 20mL preservative free Normal Saline? True or False? ANSWER: False

Test your knowledge 4. Peripheral PN is appropriate for a) Treatment anticipated less than 6 day b) Dextrose concentration less than 10% c) Osmolality less than 600-850 d) Patients in the hospital setting e) All of the above ANSWER: e)