Visualizing the IV Fluid Path as an Emerging Concept in Infection Control
By Marilyn Hanchett, RN, PhD
Intravenous or IV therapy is probably the most common acute care invasive procedure. Statistics are difficult to confirm, but at least 90 percent of all hospitalized patients are thought to require some type of IV therapy during their course of treatment.1 In the past 20 years, as home healthcare has become a prominent extension or in some cases an alternative to hospital admission, an increasing number of infusion therapies are now done outside the acute setting. The prevalence of IV procedures in home health is also challenging to verify, since national data are collected only for Medicare patients. However, the National Home Infusion Association estimates annual revenue for home infusion therapy at $ 4.5 billion and projects an annual increase of 5 percent due to the increasing number of patients.2
The risk of IV-related infection, as in any invasive procedure, is a serious concern. Fortunately, the infection risks associated with IV therapy have been extensively documented. For example, the Centers for Disease Control and prevention (CDC) reports that infections related to peripherally placed venous access devices (VADs) are the lowest among all types of catheters.3
Centrally placed catheters, or those whose tips terminate in a major vessel, have the highest risk of infection. In fact, current studies indicate that these central VADs are often associated with significant hospital morbidity and mortality. There are a variety of types of centrally placed VADs; not all have the same infection risk potential. For example, tunneled central catheters have a lower incidence of infection risk than nontunneled catheters.4 However, the human and economic costs of catheter-related infections remain high. The additional cost burden of these nosocomial central VAD infections has been reported at $25,000 or more per episode.5
Understanding the IV System
The supplies and equipment used in infusion procedures today emphasize patient and clinician safety. Also integral to device development are patient comfort, ease of device use and maintenance, and a balanced cost benefit ratio for the purchasing institution. In spite of the proliferation of IV products, device design remains a dynamic and intensely competitive field.
Since the 1980s, this process has included a steadily increasing focus on safety. For clinicians, the emergence of both primary and secondary prevention products has maximized user protection against needle and sharps-related injuries. For patients, the increasing use of centrally placed VADS and a growing awareness of their risks has lead to many product enhancements, as well as the introduction of new types of safety technology.
An important part of this evolution has been the awareness of IV therapy as a system, rather than merely individual components. Clinicians now approach infusion therapy as a complex process, rather than a simple task, and understand that the process must be managed in terms of its total effect and clinical outcome. Analysis of specific types of products, (e.g. catheters, valves, site dressings, fluid bags), continues to have benefit. But the true value of a specific product is best recognized in relation to all products that make up the patients IV system.
Visualization of the IV Fluid Path
The acknowledgement of transparent IV components is a well-established early feature of the IV system. Traditional transparent glass bottles were replaced with safer, pliable plastic bags. Improved plastics lead to the design of enhanced tubing and IV administration sets. Both types of products have held a dominant role both in IV systems, as well as the infection control of those systems, for decades.
For both bags and sets, the need to visualize the interior was based, logically and empirically, on the need to quickly identify any obvious discoloration of fluids, precipitates, reflux or any other potential contaminant within the sterile fluid pathway. The ability to quickly see and respond to any problem has remained an essential step in a safety process that today includes multiple checkpoints.
For many years, the concept of visualization remained within the bag and IV set product categories. Then in the 1980s, and almost simultaneous with a new national focus on product safety, it began to appear in a new generation of IV products. In fact, its increased use, although not widely studied or acknowledged in the literature, now makes it possible for the clinician to visualize the entire IV path from the point of VAD insertion up through the fluid bag, including all accessories used in support of the system.
Safety Products That Support Visualization
Today the ability to visualize the IV fluid path exists with a level of clarity, efficiency and cost effectiveness than has never existed at any previous point in the history of infusion therapy. An examination of current product leaders is the best method of demonstrating how the concept of visualization is shaping this new generation of safety products.
IV Securement Devices
A variety of IV securement devices emerged in the 1990s as an alternative to stabilizing the VAD with tape or suture. The product leader in this category is the adhesive anchor, an adhesive retainer to which the VAD can be attached and removed as needed without requiring additional taping. Adhesive anchors are applied near or adjacent to the hub of the catheter. In this example, the Statlock Ultra (Venetec International) maximizes the unobstructed view of the IV system over the hub of the Introcan Safety IV Catheter (B Braun Medical).
Transparent dressings are not new in healthcare; however, the newest designs are specific to IV therapy use and offer additional features not available in the earlier forms of the products. For example, current dressings offer better moisture vapor permeability to reduce potential bacterial growth at the insertion site. Other features may include special designs or reinforced edges to better stabilize the VAD, enhanced water resistance, improved conformability and patient comfort, and less irritating adhesives. A Tegaderm (3M Health Care) transparent dressing, when combined with an adhesive anchor such as the Statlock IV Plus (Venetec International) eliminates the need for traditional tape and gauze, permitting rapid and complete inspection of the VAD site.
IV shields provide over-the-top protection of the VAD and its dressing. These devices are most often used in pediatrics but may also be used with adults where there is risk of catheter dislodgement. Without a dedicated product, nurses in the past had to cut medicine or beverage cups to form makeshift site protectors. Today, the I.V. House shield (I.V. House Inc.), can be used. It is easy to apply, vented to prevent moisture accumulation and sufficiently transparent to promote rapid site inspection.
Luer Activated Valves
Luer activated valves evolved as safer, more effective alternatives to traditional injection ports. Luer technology permits needle-free intermittent access to the fluid pathway without compromising the sterility or integrity of the infusion. It also provides positive fluid displacement or pressure to help prevent occlusions. Today there are many needlefree valves commercially available, but only one model is completely transparent. The housing of Clearlink (Baxter Healthcare Corp.) luer-activated valve permits visualization of the chamber. The clinician can immediately tell if flushing has been successful or if any precipitates remain.
Advantages of Visualization in Infection Control
Infusion therapy presents many infection control challenges for clinicians. For example, mishandling and inappropriate use of IV products and supplies have been documented repeatedly in the literature as potential sources of contamination. Clinicians typically receive minimal education and training in IV procedures, and the role of the IV specialist has been eliminated as a cost-containment measure in many facilities. Infusion therapy that is initiated in one setting may continue elsewhere. Caregivers, family members and sometimes patients themselves administer infusions. The level of true infection control in these highly diverse situations is unpredictable. Unfortunately, the resulting infections, whether localized or systemic, prolong patient recovery, increase mortality rates, and escalate already high medical costs.
Improvements in the technological aspects of infusion therapy play a vital supportive role in infection risk reduction. The ability to clearly visualize the entire fluid pathway is now emerging as an essential product design concept supporting infection risk reduction within IV systems.
However, as in all design improvements, a sustainable benefit is achieved only if the modified design is fully and consistently implemented. Therefore, visualization must be included in a comprehensive clinical management program that includes other device- specific infection control measures, end user education and training, as well as rigorous scientific studies that validate the impact of a clear view of the IV fluid path. When added to existing surveillance and maintenance procedures, visualization of the infusion system becomes a powerful adjunct to a catheter-related infection control program.
Marilyn Hanchett, RN, PhD, is director of nursing at IgG America, a national specialty infusion pharmacy. She has an extensive background in infusion therapy and infection control, is a widely published author and a frequent presenter for the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI). She can be reached at [email protected].