By Pat Parks, MD, PhD, and Laura Rutledge, RN, MN, CRNI, CCRA
Earlier this year, one of the most widely used resources guiding clinical practice for the infusion specialty received a major upgrade. The Infusion Nurses Society (INS) issued a revised Infusion Therapy Standards of Practice, incorporating five years’ worth of new data to establish the most current, evidence-based best practices in vascular access.
The new Standards were revised after one of the most extensive literature reviews to date, including more than 350 additional references than the 2011 edition. The extensive resource focuses on ways to reduce the risk of patients acquiring a catheter-related bloodstream infection (CRBSI), having a device complication and enduring unnecessary discomfort.
The Standards got a noteworthy name change too. The resource changed from the Infusion Nursing Standards of Practice to the Infusion Therapy Standards of Practice, to highlight the growing breadth of cross-functional teams involved in vascular access care from a variety of practice settings.
When guidelines and clinical standards such as these are published, it’s a great time for infection prevention leaders to review them and collaborate on refinements to their facility’s policies and procedures. It’s important to identify new clinical data and innovative technology advancements that can help ensure your facility is compliant and put your teams in the best possible position to deliver exceptional patient care.
While the new Standards is an incredibly detailed guide that requires more attention than a simple summary can provide, we’ve highlighted five important changes.
1. Use the smallest gauge size – (VAD Planning; Standard 26, page S51)
There is a growing recognition that vessel health is critical to preserve function of the catheter and to avoid complications. Complications such as phlebitis have been related to subsequent bloodstream infections involving peripheral vascular catheters. The new Standards for central vascular catheters encourage choosing a gauge size that is no greater than 45 percent of the diameter of the chosen vessel to avoid complications.
2. Limit access attempts – (Inserting Catheters; Standard 33, page S64)
When inserting peripheral line (PIV) catheters, it’s recommended that there should be no more than two attempts per any one nurse and a limit on the total number of attempts to four.
3. Properly secure – (Catheter Stabilization; Standard 37, page S72)
Do not rely on vascular access device dressings (standard, non-bordered transparent semipermeable membrane (TSM) dressings, gauze and tape dressings) as a means of stabilization as there is insufficient evidence supporting their benefits as stabilization devices. Instead, the Standards suggest considering the use of an engineered stabilization device (ESD) to stabilize and secure vascular access devices (VADS). Inadequate stabilization and securement can result in an increased infection risk as has been demonstrated clearly in clinical studies of central venous catheters and other complications requiring premature VAD removal. ESDs promote consistent practice and reduce VAD motion. Addressed in this section for the first time was to apply barrier solutions to skin that is exposed to adhesive dressings to reduce the risk of medical adhesive related skin injuries (MARSI).
4. Use CHG-impregnated dressings over CVADs – (VAD Care and Dressing Changes; Standard 41, page S81)
Perform skin antisepsis with a preferred skin agent >0.5 percent chlorhexidine gluconate (CHG) in alcohol for all vascular access sites. The use of CHG-impregnated dressings are recommended over CVADs to reduce infection risk when the extraluminal route is the primary source of potential infection. Even when there is a low central line-associated bloodstream infection (CLABSI) baseline rate, further reduction in CLABSI has been demonstrated using this method.
5. Consider passive disinfecting caps – (Needleless Connectors; Standard 34, page S68)
The use of passive disinfecting caps containing disinfecting agents, e.g., isopropyl alcohol (IPA) have been shown to reduce intraluminal microbial contamination and reduce rates of CLABSIs. Though the use of disinfection caps on PIVs has limited evidence, they should be considered. It’s important to note in this section to ensure disinfecting supplies are readily available at the bedside to facilitate staff compliance with needleless connector disinfection.
These new Standards focus on achieving a balance between patient focused care and infection prevention. In her quote from the INS press release announcing the new Standards, INS CEO Mary Alexander, MA, RN, CRNI, CAE, FAAN, captured the essence of why implementing the new Standards is so important: As infusion therapy clinicians, we always keep in mind that our patients are the reason we do what we do. No doubt there will be a positive impact on care when clinicians integrate the Infusion Therapy Standards of Practice in their practice. Our patients deserve nothing less."
We couldn’t agree more and urge you to seek out a copy of the full Standards from INS, or register for free, CE-accredited courses detailing more of the important changes from one of the Standards authors at 3M’s Health Care Academy professional educational resource, 3M.com/LearningConnection.
Pat Parks, MD, PhD is the medical director for 3M Critical and Chronic Care Solutions Division whose passion and responsibilities include research and technologies related to catheter related bloodstream infections and wound healing. He is also an adjunct associate professor in the Department of Experimental and Clinical Pharmacology at the University of Minnesota.
Laura Rutledge, RN, MN, CRNI, CCRA, is a clinical research specialist for 3M Critical and Chronic Care Solutions Division with more than 30 years of experience in various nursing leadership roles. Rutledge has been an INS Standards reviewer since 2006.