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By MarilynHanchett, RN, PhD
Intravenous or IV therapy is probablythe most common acute care invasive procedure. Statistics are difficult toconfirm, but at least 90 percent of all hospitalized patients are thought torequire some type of IV therapy during their course of treatment.1 In the past 20 years, as home healthcare has become aprominent extension or in some cases an alternative to hospital admission, anincreasing number of infusion therapies are now done outside the acute setting. The prevalence of IV procedures in home health is alsochallenging to verify, since national data are collected only for Medicarepatients. However, the National Home Infusion Association estimates annualrevenue for home infusion therapy at $ 4.5 billion and projects an annualincrease of 5 percent due to the increasing number of patients.2
The risk of IV-related infection, as in any invasiveprocedure, is a serious concern. Fortunately, the infection risks associatedwith IV therapy have been extensively documented. For example, the Centers forDisease Control and prevention (CDC) reports that infections related toperipherally placed venous access devices (VADs) are the lowest among all types of catheters.3
Centrally placed catheters, or those whose tips terminate in amajor vessel, have the highest risk of infection. In fact, current studiesindicate that these central VADs are often associated with significant hospitalmorbidity and mortality. There are a variety of types of centrally placed VADs;not all have the same infection risk potential. For example, tunneled centralcatheters have a lower incidence of infection risk than nontunneledcatheters.4 However, the human and economic costs of catheter-relatedinfections remain high. The additional cost burden of these nosocomial centralVAD infections has been reported at $25,000 or more per episode.5
Understanding the IV System
The supplies and equipment used in infusion procedures todayemphasize patient and clinician safety. Also integral to device development arepatient comfort, ease of device use and maintenance, and a balanced cost benefitratio for the purchasing institution. In spite of the proliferation of IVproducts, device design remains a dynamic and intensely competitive field.
Since the 1980s, this process has included a steadilyincreasing focus on safety. For clinicians, the emergence of both primary andsecondary prevention products has maximized user protection against needle andsharps-related injuries. For patients, the increasing use of centrally placedVADS and a growing awareness of their risks has lead to many productenhancements, as well as the introduction of new types of safety technology.
An important part of this evolution has been the awareness ofIV 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 interms of its total effect and clinical outcome. Analysis of specific types ofproducts, (e.g. catheters, valves, site dressings, fluid bags), continues tohave benefit. But the true value of a specific product is best recognized inrelation to all products that make up the patients IV system.
Visualization of the IV Fluid Path
The acknowledgement of transparent IV components is awell-established early feature of the IV system. Traditional transparent glassbottles were replaced with safer, pliable plastic bags. Improved plastics leadto the design of enhanced tubing and IV administration sets. Both types of products have held a dominant role both in IVsystems, as well as the infection control of those systems, for decades.
For both bags and sets, the need to visualize the interior wasbased, logically and empirically, on the need to quickly identify any obviousdiscoloration of fluids, precipitates, reflux or any other potential contaminantwithin the sterile fluid pathway. The ability to quickly see and respond to anyproblem has remained an essential step in a safety process that today includesmultiple checkpoints.
For many years, the concept of visualization remained withinthe bag and IV set product categories. Then in the 1980s, and almostsimultaneous with a new national focus on product safety, it began to appear ina new generation of IV products. In fact, its increased use, although not widely studied oracknowledged in the literature, now makes it possible for the clinician tovisualize the entire IV path from the point of VAD insertion up through thefluid 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 alevel of clarity, efficiency and cost effectiveness than has never existed atany previous point in the history of infusion therapy. An examination of current product leaders is the best methodof demonstrating how the concept of visualization is shaping this new generationof safety products.
IV Securement Devices
A variety of IV securement devices emerged in the 1990s as analternative to stabilizing the VAD with tape or suture. The product leader inthis category is the adhesive anchor, an adhesive retainer to which the VAD canbe attached and removed as needed without requiring additional taping. Adhesiveanchors are applied near or adjacent to the hub of the catheter. In thisexample, the Statlock Ultra (Venetec International) maximizes the unobstructedview of the IV system over the hub of the Introcan Safety IV Catheter (B BraunMedical).
Transparent dressings are not new in healthcare; however, thenewest designs are specific to IV therapy use and offer additional features notavailable in the earlier forms of the products. For example, current dressingsoffer better moisture vapor permeability to reduce potential bacterial growth atthe insertion site. Other features may include special designs or reinforced edgesto better stabilize the VAD, enhanced water resistance, improved conformabilityand patient comfort, and less irritating adhesives. A Tegaderm (3M Health Care)transparent dressing, when combined with an adhesive anchor such as the StatlockIV Plus (Venetec International) eliminates the need for traditional tape andgauze, permitting rapid and complete inspection of the VAD site.
IV shields provide over-the-top protection of the VAD and itsdressing. These devices are most often used in pediatrics but may also be usedwith adults where there is risk of catheter dislodgement. Without a dedicatedproduct, nurses in the past had to cut medicine or beverage cups to formmakeshift 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 sufficientlytransparent to promote rapid site inspection.
Luer Activated Valves
Luer activated valves evolved as safer, more effectivealternatives to traditional injection ports. Luer technology permits needle-free intermittent access to thefluid pathway without compromising the sterility or integrity of the infusion.It also provides positive fluid displacement or pressure to help preventocclusions. Today there are many needlefree valves commercially available, butonly one model is completely transparent. The housing of Clearlink (BaxterHealthcare Corp.) luer-activated valve permits visualization of the chamber. Theclinician can immediately tell if flushing has been successful or if anyprecipitates remain.
Advantages of Visualization in Infection Control
Infusion therapy presents many infection control challengesfor clinicians. For example, mishandling and inappropriate use of IV productsand supplies have been documented repeatedly in the literature as potentialsources of contamination. Clinicians typically receive minimal education andtraining in IV procedures, and the role of the IV specialist has been eliminatedas a cost-containment measure in many facilities. Infusion therapy that isinitiated in one setting may continue elsewhere. Caregivers, family members andsometimes patients themselves administer infusions. The level of true infectioncontrol in these highly diverse situations is unpredictable. Unfortunately, the resulting infections, whether localized orsystemic, prolong patient recovery, increase mortality rates, and escalatealready high medical costs.
Improvements in the technological aspects of infusion therapyplay a vital supportive role in infection risk reduction. The ability to clearlyvisualize the entire fluid pathway is now emerging as an essential productdesign concept supporting infection risk reduction within IV systems.
However, as in all design improvements, a sustainable benefitis achieved only if the modified design is fully and consistently implemented. Therefore, visualization must be included in a comprehensiveclinical management program that includes other device- specific infectioncontrol measures, end user education and training, as well as rigorousscientific studies that validate the impact of a clear view of the IV fluidpath. When added to existing surveillance and maintenance procedures,visualization of the infusion system becomes a powerful adjunct to acatheter-related infection control program.
Marilyn Hanchett, RN, PhD, is director of nursing at IgGAmerica, a national specialty infusion pharmacy. She has an extensive background in infusion therapy andinfection control, is a widely published author and a frequent presenter for theNational Alliance for the Primary Prevention of Sharps Injuries (NAPPSI). Shecan be reached at firstname.lastname@example.org.