Just published are the new 2006 Infusion Nursing Standards of Practice, which direct nurses and other healthcare workers as to how infusion therapy should properly be administered in and out of the hospital. Since the last standards were published in 2000, significant additions and changes have been made which reflect current evidence and thinking. ICT sat down with Lynn Hadaway, MEd, RNC, CRNI, a member of the Infusion Nurses Society Standards Committee, to discuss what is new in the standards and to explain the rationale that drove the changes.
ICT: Lynn, thank you for agreeing to talk with us about the INS Standards of Practice. To begin, can you explain what these standards are and how they are intended to be used.
LH: The Infusion Nursing Standards of Practice represent the scope of practice and offer evidence- based criteria essential to the delivery of safe, competent, and quality infusion therapy.
The standards establish a frame-work for monitoring care given and products used; provide a structure of reference that distinguishes among malpractice, product failure, and negative patient outcomes; and assist in resolving ethical conflicts between the infusion nurse’s duties to the patient and employer. In essence, the standards are written on two levels. First are the standards themselves. These are “shall” statements and represent the strongest directives in the new document. With regard to the standards, a clinician either did or did not comply, so it is very simple. Second are the practice criteria; these are “should” statements that assist the clinician in meeting the standard statement.
ICT: Are there adverse consequences to not complying with the standards?
LH: One would hate to use the INS standards as a club. Rather they are intended to promote positive patient outcomes and reduce the risk of unnecessary trauma or complications, assist the nursing profession by reducing risk of malpractice claims, and assist manufacturers by reducing risk of product liability claims. Really, the standards are written for our protection and for the patient’s safety. That said, whenever I consult on IV-related malpractice cases, the INS standards are always — with no exception — the standards to which nurses and other healthcare professionals are held.
ICT: So what is new in the 2006 INS standards?
LH: Let’s begin with Standard 41: access site preparation. In the 2000 standards, maximal sterile barrier precautions were a practice criteria recommendation for placement of midlines, PICCs and other central catheters. The new standards (41.2) state, “Maximal barrier precautions ... shall be used.” This is no longer merely advised; it is the standard of practice. No one should be surprised, since maximal sterile barrier precautions received a Category IA recommendation in the 2002 Centers for Disease Control and Prevention (CDC) Guidelines for Prevention of Device-Related Infections.
ICT: Are there any other generally applicable, new standards for infusion therapy?
LH: Most of the standards are generally applicable. For example, we’ll talk today about hand hygiene, visualization technology, catheter stabilization, site care, documentation, and infection control. These are all generally applicable, meaning they pertain to peripheral IVs, PICCs, central lines, and even port-access needles.
Let’s begin with hand hygiene. The old 2000 standards used the outdated term “handwashing.” Since we now know that alcohol-based disinfectants can help practitioners to avoid breakdown of their own skin, with subsequent bacterial proliferation, alcohol-based hand hygiene is now a part of Standard 20. Additionally, since published reports have established artifi cial nails as a potential reservoir for bacteria, nurses administering infusion therapy are now prohibited from wearing artifi cial nails or nail products. The practice criteria in this standard speak directly to the use or non-use of a wide variety of product categories. I would strongly advise nurses to read the Practice Criteria and decide on the appropriate products and practices for their facility.
ICT: Maximal sterile barrier precautions and proper hand hygiene are prescribed by both the INS standards and, as you acknowledge, in the CDC guidelines. But “visualization technology” is not mentioned in the CDC’s guidance. Can you enlighten us on this?
LH: In recent years, both infrared light and ultrasound visualization technology has improved significantly. A nurse no longer needs to rely only on her eyes and hands to locate a suitable vessel for cannulation. Instead, the practice criteria in the site selection standard 37 recommend that the nurse “...consider using visualization technologies that aid in vein identification and selection.”
ICT: Also barely mentioned in the 2002 CDC guidelines is catheter stabilization. In fact, the CDC simply states, “Sutureless securement devices can be advantageous in preventing catheter-related bloodstream infections.” Yet, the INS standards take a fairly strong stand here and cite a large number of published studies.
LH: Remember, all standards and guidelines are subject to expansion and revision as more evidence is published. As to catheter stabilization, a great deal of data has been published since the CDC first looked at this topic. The new standard 43 reflects that data as does the new Occupational Safety and Health Administration (OSHA) mandate to review catheter securement annually as part of the facility’s exposure control plan. It should be noted that non-sterile tape, suture and site dressings are no longer considered adequate for catheter stabilization. In fact, the practice criteria now state, “Whenever feasible, using a manufactured catheter stabilization device is preferred.” It is now clear that, in general, better patient outcomes and greater healthcare worker safety can be achieved by using these manufactured devices to secure catheters. Moreover, the practice criteria state that if for some reason suture is initially used for stabilization, it should be replaced with a manufactured device when the sutures become loose or are no longer intact. Manufactured catheter stabilization devices are a part of the new evidence-based practice of infusion therapy. Both patients and healthcare workers benefit from employing this relatively new technology. Those who feel uncertain about the benefits of proper catheter stabilization should refer to the extensive bibliography that accompanies this standard. In this regard, I should note that the standards committee is committed to reflecting what the science/literature teaches, rather than merely what the predominant practice is. In this instance, catheter stabilization with non-sterile tape — which still predominates — has an average published failure rate (resulting in complications and subsequent unscheduled IV restarts) of 71 percent. This is based on data from 83 hospitals, encompassing more than 10,000 patients. Manufactured catheter stabilization devices are shown to reduce that rate to an average of 16 percent. Naturally, evidence-based practice dictates the “preferred” method encouraged by the practice criteria.
What about site care? You mentioned there were some changes in the standard here, too.
LH: Indeed, there are. The committee recognized that proper site care must accomplish two objectives: First, full and complete visualization and assessment of the access site. And second, complete removal of items that, if not removed, could compromise the integrity of the site. As to the first objective, the new Standard 51 instructs visualization of “the catheter-skin junction and surrounding tissue.” This means that overlying gauze or transparent membrane dressings as well as stabilization devices must be removed during routine site care. Only then can a full assessment be made and recorded. Thereafter, proper skin antisepsis is prescribed by the practice criteria, followed by application of a new stabilization device and sterile dressing. Remember, bacteria reside in the lower layers of the epidermis and cannot be completely removed with antiseptic solutions. Therefore, the practice criteria advise that the entire access area be cleared, cleansed and re-dressed.
ICT: So access-site care is, as we all know, an important and necessary part of infection control. Are there other new measures in the Standards that address infection control?
LH: There are. Here the committee drew not only from journal publications, but also from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and other regulatory bodies. Standard 19, infection control, aligns nicely with the CDC guidelines with respect to maximal sterile barrier protection and hand hygiene. In addition, this standard reflects the new literature attesting to the dangers of improper nurse staffing and inappropriate work loads. specifically, the standard states, “Staffi ng policies and nurse workloads shall allow for compliance with infection control practices.” In addition to the infection control standard, a new infection section has been added under the section called “complications.” In the previous standard, only such complications as phlebitis, infiltration, and extravasation, were addressed. The new standards address infection amply, providing strong directives, useful practice criteria and an extensive bibliography. Practice standard 56.C deserves note, as it reflects much of the new evidence-base since the last standards were written: “Technology to control infusion- and catheter-related infections including, but not limited to, antimicrobial-impregnated catheters and antiseptic-impregnated dressings, and stabilization devices, should be evaluated to determine effectiveness (see Standard 43, catheter stabilization).”
ICT: Of the other changes or additions to the INS standards of practice, which would you consider to be most important?
LH: I’ll refer your readers to two additional standards and the focus my closing comments on what some might argue is the very most important standard of all. Standard 21 addresses medication compounding. It is important in that it directs laminar flow environments for compounding of IV medications. This is a key section for anyone inside or outside of the hospital charged with this task. Standard 45 addresses the issue of gauze used to shim up or support Huber or port access needles. Previously, most interpreted this to mean that such gauze constituted a tape and-gauze dressing and was required to be changed every 48 hours. The new standard allows such gauze to be changed weekly. I want to close by emphasizing the documentation Standard 14. Nurses should know this is critical to their protection as well as to good patient care. I can’t tell you how many cases I’ve consulted on where it was literally impossible to tell from the documentation where the access site was, how many attempts were made, where the attempts were made, what drugs were administered through which of the established IVs, and so forth. Further, I cannot recall one case where either method of stabilization or use of an arm-board was recorded. This makes it very difficult to mount a defense if a defense is needed. All nurses involved in infusion therapy should obtain and read the documentation standard, with keen attention to the practice criteria — which are there to assist compliance.
Understood. If you had to summarize the key points to documentation, what would they be?
LH: There are two: First, document knowledge of the standards (as reflected in your policy and procedures). Second, document detailed adherence to the standards. For example, practice criteria number B.3 states: “Date and time of insertion, number and location of attempts, type of catheter stabilization and dressing, patient’s response to the insertion, and identification of the person inserting the device.” Simple as it seems, it is rarely done right.
ICT: How can we obtain the INS standards of practice?
LH: The best way is to contact the Infusion Nurses Society at www.ins1.org.