Robin - InS Outlook On Intravenous Therapy

10/26/2016
Infusion Nurses Society: Infusion

Therapy Standards of Practice 2016
Updates
Robin Huneke Rosenberg, MA, RN-BC, CRNI, VA-BC
3M Health Care Academy

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3M 2015. All Rights Reserved
Disclosure
Speaker is employed at 3M Health Care,

Critical & Chronic Care Division.
-2016 INS Standards of Practice Content
Reviewer
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Discuss the impact of the Infusion Nursing Standards of Practice as an

important part of research and evidenced-based practice on nursing
practice to guide policy, procedure and practice issues.
Describe specific recommendation of the INS Standards of Practice related
to peripheral IV site assessment, device selection, site care and
maintenance, administration set changes, needleless connectors, solution
bags, vascular access device removal and documentation.

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10/26/2016
Infusion Nurses Society (INS)

Norwood, Massachusetts
Headquarters
1973 Started as National Association of Intravenous Nurses (NITA)
1987 Name change to Intravenous Nurses Society
2001 Current name
2006, 2011, 2016- Publication dates
Started to address lack of consistency, education and standards for the practice
of I.V. therapy
Currently affiliated chapters exist in 9 countries:
Brazil, Canada, Columbia, Germany, India, New Zealand, Philippines, Russia,
Thailand.
INS active members are in 29 additional countries:
Argentina, Australia, Bermuda, China, Dominican Republic, France, Greece,
Guam, Hong Kong, Indonesia, Ireland, Italy, Jamaica, Japan, Korea, Malaysia,
Mexico, the Netherlands, Nepal, Peru, Puerto Rico, Qatar, Saudi Arabia,
Singapore, South Africa, Taiwan, Ukraine, United Arab Emirates, the United
Kingdom
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Infusion Nursing Standards of Practice

First published in 1981
Most recent upgrade 2016
New edition scheduled release 2021 (Any volunteers?)
Intent - to reflect current knowledge and practices of the clinical nursing specialty of infusion
therapy. Committee of 6 appointed by INS Board for 5 year term
Content Reviewer (67 of them) reviewed outlines & literature based on areas of expertise;
recommendations/revisions submitted and considered before final printing
Disclaimer
Because clinical practice continually evolves based on on-going research, users should make an independent assessment of
the appropriateness and applicability of a standard in any specific instance and should also consider the applicable federal
and state laws and regulations, as well as the standard of care in a particular jurisdiction as these take precedence .

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Under What Authority Does INS

Issue these Standards
The integration of the science of infusion nursing and the mastery of nursing allow these
standards to be recognized:
Nursing is scientific discipline as well as a profession

Nurses use critical thinking
Research generating new knowledge or validating old knowledge
Evidence based practices removes the bias of opinion and tradition when
making decisions
Nurses continually evaluate quality and effectiveness of nursing practice and seek to optimize
outcomes
ANA Scope & Standards of Practice, 2007, p 10
Evidence-Based Practice and Nursing Research:

Avoiding Confusion. Health Leaders Media.

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10/26/2016
2016
What changed and what does this mean for
vascular access clinicians?
What was deleted?
What do the recommendations
ask of the clinicians?
What about Vancomycin?
What other content is included

from regulatory bodies?
Does an art line need CHG?
Can I use a midline for vesicants?
Do I change my practice?
What does my
patient know?
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Title formerly known as Infusion Nursing

Standards of Practice

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Because the standards apply to all clinicians..
INS

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10/26/2016
Definitions:
Standard of Care
The level at which the average prudent provider in a given community

would practice.
MedicineNet.com
Standard of Practice
The use of research findings, improvement data and other forms of

evaluation data, and expert opinion to identify methods for improvement .
Evidence-Based Practice and Nursing Research:
Avoiding Confusion. Health Leaders Media.
An idea about morally correct and acceptable behavior

Example
www.Webster-Meriam.com/dictionary/standard
A standard of care is that nursing practice will reduce the risk of infection
while providing infusion therapy.
One standard of practice to achieve this goal is the use CHG for all
intravenous starts.
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How do the new standards impact my

clinical practice?
Know the scope of your licensure: each clinical body is different
Know the scope of your professional organization
Recognize that there can be overlap in professional groups and that no one group has
exclusive ownership of any skill, task or activity

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What is
Evidence Based Practice Criteria?
Defines the practice settings, scope of practice, ethics, competencies and quality
improvement related to infusion therapy.
Defines how the nurse will utilized evidence-based practice and research to guide
policies, procedures and practice issues.

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10/26/2016
What do the standards tell me about my practice?

Standards: the "have-to" or requirement of each infusion topic..
Practice Criteria: Based on the evidence found, practice statements are offered for the
clinicians practice.
Weighing of evidence

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Where evidence translates to practice
follows
Provides
additional
Guidelines
recommendations
Established proper steps to
take
Procedures
How do I do it?
Assigns quantifiable measures

(What is required? )
Identifies issue & scope

(Why do I need to do this?)
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Standard Title: Minimum practice criteria

that VA/infusion clinicians are held liable
and accountable
Standards
Policies
Anatomy
of a
standard
Practice Criteria=based
strength of evidence
Regulatory statement
included:
single use safety control
mechanisms
Word usage: based on evidence
Educate: call for specific

criteria for clinical
setting, level V. Facility
to weigh literature and
develop clinical policies
accordingly
Literature references found at the end of each standard

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10/26/2016
Global Infusion/Vascular Access

standards

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Current 2016 standards:

64 Standards of Nursing Practice with
supporting Evidence Based Practice Criteria
under 9 Section Headings
Infusion Therapy Practice

Patient and Clinician Safety
Infection Prevention and Control
Infusion Equipment
Vascular Access Device: Selection & Placement
Vascular Access Device: Management
Vascular Access Device: Complications
Other Infusion Devices
Infusion Therapies

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Sections One, Two, & Three

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10/26/2016
Section Four: Insertion Equipment

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Standard 23: Central Vascular Access Tip

Location
Standard 23.3:
The CVAD tip location with greatest safety profile in adults and children Is the Cavo-Atrial
Junction.
Position the tip of the CVAD in the lower segment of the SVC at or near the CAJ for
adults and children
Effective 2016, catheter tip documentation,
position and confirmation activities
are recommended in the practice criteria section.
IVERA

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Section Five & beyond.its about the plan

and the patient
3M

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10/26/2016
Vascular Access Planning: short peripherals

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Vascular Access Planning: midlines

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Vascular Access Planning:

central vascular devices

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10/26/2016
Vascular Access Planning: Arterial Lines

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Vascular Access Planning (sites)

Select vein that best accommodates the outer
diameter and length of vascular access device
required for therapy
Goal of peripheral access: vein preservation
Site assessment includes: patient age, diagnosis, comorbidities; condition proximal to/of insertion site,
past venipuncture history, type and duration of
therapy
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Vascular Access Panning (other device sites)

Central Access Site:
Hemodialysis Catheter

Aphresis Catheter

Umbilical Catheter
Peripheral Access Site:

Pediatric
Peripheral Access Site:

Pediatric
Peripheral Access Site:Permission from ddoellman

Adult
author

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10/26/2016
New topics also addressed:

Local anesthesic use
Site preparation
Access limit

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2016 Topic Updates

36
34
37
40
37
34
40
48
3
6
41
57
41
44
64

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New Topics introduced in 2016
Look whats new in 2016

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10/26/2016
Standard 34: Practice Criteria G:

Disinfecting Caps

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New topic: MARSI*
(*medical adhesive related skin injury)
skin
Vascular
Device
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MARSI: Definition
A medical adhesive-related skin injury is an occurrence in which erythema
and/or other manifestation of cutaneous abnormality (including, but not limited
to, vesicle, bulla, erosion, or tear) persists 30 minutes or more after removal of
the adhesive.

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10/26/2016

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Looking at the skin-adhesive connection

Many tape, dressing, securement
devices and other medical devices
have acrylate based adhesive that
allow the product to stick to the skin
when applied.
The other type of adhesive that is
strong enough to stick under skin
conditions is silicone.
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Acrylate Adhesive
Tape is taperight?
Silicone
What happens during

tape application?
What occurs to the skin

when tape is removed?

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10/26/2016
A dressing is a dressingright?
*Recommend use of water proof cover over

dressing and IV site when showering
The TSM (transparent semi-permeable membrane) provides

protection between the outside elements and skin
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Description: Transparent Semi-permeable

Membrane dressings (TSM)
Sterile
Allow for site visibility (i.e. you can see what is happening underneath)
Provide an external barrier
Have moisture vapor release
Have an adhesive layer

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Conditions that affect a TSM performance

Adhesive: Lack of firm, direct pressure to entire dressing surface
Moisture: Interferes with adhesive bond with skin
Channeling and edge lift: providing a direct route to insertion site
Presence of skin hair
Residue: from prior applications
Adhesion promoters a.k.a as tackifiers

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10/26/2016
And can cause..

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How to prevent adhesive skin injuries

Prepare Skin, Insertion Site
Remove hair either clipping or trimming. Do NOT shave hair unless
using a sterile, disposable razor. Clean and dry skin to remove soil
and residue.
Perform skin anti-sepsis per facility protocol. Allow product to
completely dry.
Apply skin barrier protection product. Allow to completely dry.

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What does a skin barrier do?

With skin barrier
protection
Example of skin barrier

protection

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ExWithout skin barrier

protection
Example of skin
barrier protection
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10/26/2016
Apply dressing..
If blood is still present or site continues to ooze, consider using gauze
dressing until bleeding has stopped.
Apply CHG impregnated product, if ordered
Identify adhesive free areas on dressing
Apply dressing to site. Do NOT stretch dressing onto skin; rather place
dressing over skin in the middle; then drop sides.
Use gentle firm pressure after applying to skin; stroking adhesive product or
tape into place
Standard 41: Recommendation to change securement device with dressing
change found (practice criteria H)

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Could these injuries been prevented?

Skin Irritation/Contact
Dermatitis: persists up to 30
minutes post dressing
removal.
Irritant Contact Dermatitis:

Not as distinct, can evolve
over days.
Skin injury due insufficient

Anti-septic dry time prior to
Dressing application
Tension blister caused

from epidermis
Being pulled away from
Dermal layers.

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Additional injuries
Skin stripping through top

Skin layers. Epidermis delaminates
And appears as shiny skin. All of
Epidermis detaches from dermis
causing red, weepy skin
Allergic contact dermatitis:

Caused by direct exposure to allergen.
Prolonged exposure to allergen increases
Response. Skin testing (patch testing)
or biopsy/culture can confirm
allergen.
Insufficient dry time prior to dressing

application. Dressing border visible, skin
Weepy (yeast appearance)
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10/26/2016
Skin Impairment Algorithm

(Broadhurst, Moureau, Ullman, 2016)
D. Broadhurst,
Used with permission,

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What we, as clinicians can do prevent MARSI?

Use skin barrier all the time, all locations, all conditions. No exceptions.
Remove excessive tape, tape residual from skin surrounding insertion sites. More tape
better adhesion
Use a slow-n-low method of dressing removal from skin. Do not rip
Use low n slow

for tape &
bordered films
Use gentle pull n release

for non-bordered film

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Adhesive Removers
Many of the products, practices to remove dressings are not evidenced based (i.e. using
hand foam) and are non-sterile.
Many removers contain acetone which is extremely flammable but do manage adhesive
sticky-ness
Water and normal saline are effective removal agents; however do not manage the
adhesive sticky-ness
Citrus based solvents contain d-limonene which disrupts skin lipids and can be a skin
irritant. The product also affects future product adhesiveness when applied over same
site.
To date, there is not an exclusive adhesive product for infusion therapy populations.
(Thayer, 2012)

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10/26/2016
Conclusion
The 2016 Standards of Practice highlight a more thoughtful, patient centric approach to
vascular access and infusion therapies.
Recognition of non-nursing, nursing, and medical providers becoming more involved in a

once traditional nurse/medical role calls for universal standards of care based on training
Research and the call for evidence based practices in Vascular Access and Infusion
Therapy continue to increase. Activities including line monitoring, data collection,
dressing changes, education/competency, insertion success rates all support the call for a
dedicated team driven to maintain quality and safe arenas for patients.

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Questions?

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References
Broadhurst, D., Moureau, N., Ullman, A. (2016). CVAD Associated Skin Impairment Tool. Author
(electronic communication dated July 15, 2016)
Kutzsche, L. (2012). Management of irritant contact dermatitis and peripherally inserted
central catheters. Clinical Journal of Oncology Nursing (16) 2: E48-58. doi:10.1188/12.CJON.E48-E55
Hadaway, L. (2016). Action Verbs in the Infusion Therapy Standards of Practice, Lynn HadawayBlog post accessed: 6/17/2016
Infusion Nurses Society (2016). Infusion Therapy Standards of Practice. Journal of Infusion
Nursing, (39): 1S
Matsumura, H., et al. (2012). A mode for quantitative evaluation of skin damage at adhesive
wound dressing removal. International Wound Journal, 291-294.
McNichol, L., Lund, C., Rosen, T., Gray, M. (2013). Medical Adhesive and Patient Safety:
Consensus statements for the assessment, prevention, and treatment of adhesive
related injuries. Journal of Wound, Ostomy and Continence Nurse Society,
July/August:1-15.
Thayer, D., (2012). Skin damage associated with intravenous therapy. Journal of Infusion Nursing
(35)6: 390-401.
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10/26/2016

Infusion Nurses Society: Infusion

3M Health Care Academy

3M 2015. All Rights Reserved

Speaker is employed at 3M Health Care,

3M 2015. All Rights Reserved

Discuss the impact of the Infusion Nursing Standards of Practice as an

3M Health Care Academy

3M 2015. All Rights Reserved

Infusion Nurses Society (INS)

3M 2015. All Rights Reserved

Infusion Nursing Standards of Practice

3M Health Care Academy

3M 2015. All Rights Reserved

Under What Authority Does INS

Nursing is scientific discipline as well as a profession

Evidence-Based Practice and Nursing Research:

3M Health Care Academy

3M 2015. All Rights Reserved

What about Vancomycin?

What other content is included

Does an art line need CHG?

Can I use a midline for vesicants?

3M 2015. All Rights Reserved

Title formerly known as Infusion Nursing

3M Health Care Academy

3M 2015. All Rights Reserved

Because the standards apply to all clinicians..

3M Health Care Academy

3M 2015. All Rights Reserved

The level at which the average prudent provider in a given community

The use of research findings, improvement data and other forms of

An idea about morally correct and acceptable behavior

3M 2015. All Rights Reserved

How do the new standards impact my

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

What do the standards tell me about my practice?

3M Health Care Academy

3M 2015. All Rights Reserved

Where evidence translates to practice

Assigns quantifiable measures

Identifies issue & scope

Standard Title: Minimum practice criteria

3M 2015. All Rights Reserved

Word usage: based on evidence

Educate: call for specific

Literature references found at the end of each standard

3M 2015. All Rights Reserved

Global Infusion/Vascular Access

3M Health Care Academy

3M 2015. All Rights Reserved

Current 2016 standards:

Infusion Therapy Practice

3M Health Care Academy

3M 2015. All Rights Reserved

Sections One, Two, & Three

3M Health Care Academy

3M 2015. All Rights Reserved

Section Four: Insertion Equipment

3M Health Care Academy