(a) provides an account of your observations on the management of peripheral intravascular devices from your clinical practicum in NMIH202;
Clinical practicum NM1H202 introduces nurses to the management of peripheral devices via scholarly inquiry and clinical practice. The practicum includes a thorough training in handling, inserting, replacing, and dressing peripheral intravascular devices including peripheral venous catheters. Because the primary risk associated with peripheral intravascular devices is infection, proper management of the devices is crucial. Bloodstream infections can cause patient casualties, leading not just to humanitarian disasters but also financial ones as well.
Hand washing vigilance is a primary part of the introduction to peripheral intravascular device management. While it may seem like an abundance of common sense, hand washing and aseptic techniques themselves depend on continued knowledge acquisition and training. Nurses must stay abreast of latest products and tools that promote hygiene in relation to the management of peripheral intravascular devices in order to prevent infection.
The practicum addressed the different types of catheters and their most useful application in clinical practice. Teflon, polyvinyl chloride, silicone elastometer, and polyurethane are among the more common materials used, but their selection may depend on duration of use. Nurses must be sure to remove the intravascular devices when they are no longer needed, otherwise necrosis and infection may result. Flushing of the devices may be necessary in some cases in which long-term catheter use is required, and the use of a transparent dressing or gauze to cover the site may also help prevent infection. With proper and attentive care, and knowledgeable evidence-based practice, health care workers can take care to avoid disasters related to improper handling of peripheral intravascular devices.
(b) identifies the strengths and weaknesses of the clinical practice you observed based upon information contained in lectures/tutorials/simulations for NMIH 201, local hospital or health service policy from your clinical practicum in NMIH 202 and the Best Practice Information Sheet on “Management of peripheral intravascular devices? By the Joanna Briggs Institute (2008)
Strengths: The strengths of the clinical practice observed are partly based upon information contained in the lectures, tutorials, and simulations for NMIH 201 coursework. All activities witnessed during the clinical practice were grounded in the research presented in tutorials, lectures, and simulations in NMIH 201. Similarly, the clinical practice covered all areas addressed in the tutorials, with the possible exception of not addressing the technical differences between the various materials used to manufacture the peripheral intravascular devices.
The strengths of the clinical practice observed are also based on information derived from local hospital and health service policy, as well as from the clinical practicum in NMIH 202. For example, the local hospital includes its own self-published information sheets that are similar to the Best Practice information sheet, “Management of peripheral intravascular devices,” published by the Joanna Briggs Institute (2008). The hospital publications, like the Joanna Briggs Institute (2008) information sheet, outlined aseptic washing of hands, proper catheter insertion, and proper dressing and removal techniques.
Weaknesses: The weaknesses of the clinical practice observed include a cursory treatment of the conditions under which peripheral intravascular devices may and may not be flushed. Because the nurse will be receiving instructions from supervisors regarding the removal of the peripheral intravascular device, the clinical practice did not cover this issue with sufficient depth. It would also have been preferable to have more direct hands-on experience with each of the steps involved in peripheral intravascular device handling and management.
(c) Critically review the Best Practice Information Sheet on “Management of peripheral intravascular devices? (Joanna Briggs Institute 2008) and make suggestions on ways in which this information could be improved to increase the usability of this information for staff in clinical practice;
The Best Practice (2008) information sheet “Management of Peripheral Intravascular Devices” has been revised several times since it was first published in 1998. New data and guidelines by the Centers for Disease Control, plus systematic peer reviews and an economic evaluation have been incorporated into the current Best Practice (2008) information sheet. The information sheet addresses the potential dangers of improper management of peripheral intravascular devices including catheters. Information sheets like the Best Practice (2008) “Management of Peripheral Intravascular Devices” have the potential to greatly reduce the risk of infections ranging from Staphylococcus aureus to phlebitis (Steinberg, Clark & Hackman 1996). Nearly all of the information contained in the Best Practice (2008) information sheet “Management of Peripheral Intravascular Devices” precisely reflects the knowledge disseminated through the highly experiential clinical practicum.
In fact, the first recommendation offered by Best Practice (2008) in the information sheet is for healthcare professionals to receive “ongoing education, training, and assessment regarding the insertion and management of peripheral intravascular devices.” The emphasis on training in the fact sheet corresponds with the emphasis on training and education in the practicum related to intravascular devices. Moreover, the importance of continued training and assessment is supported by empirical research. Lopez, Molassiotis, Chan, Ng & Wong (2004) evaluated nursing practices pre- and post-exposure to education related to flushing agents, documentation related to the peripheral intravascular devices, and site dressing. The researchers found that after exposure to training and education, nurses complied with proper handling and management of peripheral intravascular devices. “It was concluded that evidence-based practice is important for improving patient outcomes. Compliance with the guidelines served as an important measure for the prevention of intravascular device-related complications,” (Lopez et al. 2004, p. 322). Future research could include the determination of a special coefficient for the degree of test score improvement vs. The degree of knowledge acquisition (Oakes 2011).
Hand washing, but more importantly, maintaining an aseptic hand washing technique, is vital for “palpitating, inserting, replacing, or dressing an intravascular device,” according to the “Management of Peripheral Intravascular Devices” fact sheet (Joanna Briggs Institute 2008). The first day of practicum involved proper hand washing techniques and the maintenance of a sterile working environment. Research consistently underscores the preeminence of proper hand washing techniques, which is why the Joanna Briggs Institute (2008) fact sheet is highly effective and relevant to clinical practice.
The Joanna Briggs (2008) publication is sufficiently thorough and yet brief enough to be called a fact sheet. One issue that is not sufficiently borne out in the research is how long it takes for bloodstream infections to develop in relation to improper handling of the peripheral intravascular devices. The Joanna Briggs (2008) institute plays it safe, stating that 72-hour intervals would certainly curb risks. However, the Best Practices (2008) fact sheet does list the 72-hour mark as a suggestion and a Grade B. Recommendation. That means that there is “moderate support that warrants consideration of application,” (Joanna Briggs Institute 2008, p. 1).
Research is conflicting on how often the peripheral intravascular devices need to be changed. Maki, Kluger, & Crnich (2006) performed an analysis of research, assess risk and found that over the long-term, “expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk.” The study does not have a significant bearing on the efficacy of the Joanna Briggs (2008) fact sheet, which offers advice on best practices. Bregenzer, Conen, Sakmann & Widmer (1998) were likewise “unable to demonstrate an increased risk after 3 days of catheterization.” However, the Joanna Briggs Institute (2008) is correct to play it safe because there is little harm that is caused by more frequent changes other than wastefulness and some discomfort to the patient. Ranking frequent changes of catheters as a Grade B. recommendation is important because nurses know that in many cases, the frequent change might do more harm than good. Similarly, Maki & Ringer (1987) found that “it is not cost-effective to redress peripheral venous catheters at periodic intervals; for most patients, either sterile gauze or a transparent dressing can be used and left on until the catheter is removed,” (p. 2396).
The Joanna Briggs (2008) fact sheet does not address new technologies such as “chlorhexidine, a chlorhexidine-impregnated sponge dressing, CVCs with an anti-infective coating, anti-infective CVC hubs, and novel needleless connectors,” which Crnich & Maki (2002) address. However, future issues of the Joanna Briggs (2008) fact sheet might indeed incorporate such new technologies.
An issue that is thoroughly addressed by the Joanna Briggs (2008) Best Practices fact sheet is intravascular device-related bacteremia. Interestingly, Paya, Guerra, Marsh, Farnell, Washington, & Thompson, (1989) found “limited usefulness of quantitative culture of blood drawn through the device for diagnosis of intravascular-device-related bacteremia.” This study also has little bearing on the efficacy of the Joanna Briggs (2008) data sheet, which does reflect best practices that are rooted in empirical research.
One issue that is often left on the sidelines in studies related to peripheral intravascular devices is the best type of dressing in relation to the type of peripheral catheter. For instance, “four dressing regimens for peripheral venous catheters were studied in a prospective randomized clinical trial with 2088 Teflon catheters” in a study by Maki & Ringer (1987). The methods used by Maki & Ringer (1987) include “sterile gauze, replaced every other day, and three dressings left on for the lifetime of the catheter; gauze; a transparent polyurethane dressing; and an iodophor-transparent dressing.” The Joanna Briggs (2008) Best Practices fact sheet addresses each of these methods as well. Therefore, the fact sheet accurately reflects the thoroughness of research data.
Crnich & Maki (n.d.) note that sepsis is a major problem associated with improper management of peripheral intravascular devices. The Joanna Briggs (2008) fact sheet addresses the risk of sepsis too and like Crnich & Maki (n.d.) emphasize the preventability of sepsis and related complications. In fact, the Joanna Briggs (2008) fact sheet proves to be generally a highly effective report, one that is representative of prevailing literature. The fact sheet reflects the O’Grady, Alexander, Dellingerâ€¦Weinstein (2002) list of guidelines for managing peripheral intravascular devices.
Conclude with a summary of your learning about the management of peripheral intravenous devices from your reflections on clinical practicum and the completion of this assessment task.
The assessment task allowed for a thought-provoking and thorough review of literature related to the best practices of catheter management. The review of literature reveals where the Joanna Briggs Institute (2008) culls its data from for compilation in the Best Practices fact sheets. The fact sheets provide guidelines for practice that are properly grounded in research and empiricism. Because the Joanna Briggs (2008) fact sheet reflects the most current research in the field of peripheral intravascular devices, it can be considered useful in a hospital or clinical setting. The clinical practicum underscored the importance of easy access to information. Best practices change, and their definitions will change over time. This is why the Joanna Briggs Institute (2008) updates its Best Practices fact sheets. The current edition is up-to-date, and can be used in a clinical setting. A clinical practicum that includes more direct practice would be helpful, but it is more important that health care workers understand that many infections including sepsis are preventable. Armed with knowledge, healthcare workers can ensure the health and safety of patients and prevent unnecessary infections. Proper hand washing is even more important than frequent dressing and changing of the peripheral intravascular device.
Bregenzer, T., Conen, D., Sakmann, P., & Widmer, A.F. (1998). Is Routine Replacement of Peripheral Intravenous Catheters Necessary? Arch Intern Med. 1998;158:151-156.
Crnich, C.J . & Maki, D.G. (2002). The Promise of Novel Technology for the Prevention of Intravascular Device — Related Bloodstream Infection. I. Pathogenesis and Short-Term Devices. Clin Infect Dis. (2002) 34 (9): 1232-1242
Crnich, C.J. & Maki, D.G. (n.d.). The role of intravascular devices in sepsis. Current Infectious Disease Reports 3(6): 496-506.
Elliot, T.S.J. (1988). Intravascular device infections. Journal of Medical Microbiology 27(1988): 161-167.
Fry, D.E., Fry, R.V. & Borzotta, A.P. (1994). Nosocomial blood-borne infection secondary to intravascular devices. The American Journal of Surgery 167(2): 268-272.
Graham, D.R. Keldermans, M.M., Klemm, L.W., Semenza, N.J., & Shafer, M.L. (1991). Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. The American Journal of Medicine 91(3).
Joanna Briggs Institute 2008, “Management of peripheral intravascular devices?, Best Practice, vol. 12, iss. 5, pp. 1-4, viewed 14 December 2009, http://www.joannabriggs.edu.au/pdf/BP_Book_Vol12_5.pdf
Lopez, V., Molassiotis, A., Chan, W.K., Ng, F., & Wong, E. (2004). An Intervention Study to Evaluate Nursing Management of Peripheral Intravascular Devices. Journal of Infusion Nursing 27(5): 322-331.
Maki, D.G., Kluger, D.M., & Crnich, C.J. (2006). The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies. Mayo Clinic Proceedings Sept 2006 81(9): 1159-1171.
Maki, D.G. & Ringer, M. (1987). Evaluation of Dressing Regimens for Prevention of Infection With Peripheral Intravenous Catheters. JAMA 987;258(17):2396-2403
Oakes, J. (2011) Personal communication.
O’Grady N.P. Alexander, M., Dellinger, E.P. Gerberding, J.L., Heard, S.O. Maki, D.G., Masur, H, McCormick, R.D., Mermel, L.A., Pearson, M.L., Raad, I.I. Randolph, A. & Weinstein, R.A. (2002). Guidelines for the Prevention of Intravascular Catheter-Related Infections. Pediatrics 110(5).
Paya, C.V., Guerra, L., Marsh, H.M., Farnell, M.B., Washington, J. 2nd & Thompson, R.L. (1989). Limited usefulness of quantitative culture of blood drawn through the device for diagnosis of intravascular-device-related bacteremia. J Clin Microbiol. 1989 July; 27(7): 1431-1433
Randolph, A.G., Cook, D.J. & Andrew, M. (1997). Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials. BMJ 316: 969.
Safdar, N., Fine, J.P., & Maki, D.G. (2005). Meta-Analysis: Methods for Diagnosing Intravascular Device — Related Bloodstream Infection. Annals of Internal Medicine. March 15, 2005 vol. 142 no. 6 451-466.
Steinberg, J.P., Clark, C.C. & Hackman, B.O. (1996). Nosocomial and community-acquired Staphylococcus aureus Bacteremias from 1980 to 1993: Impact of intravascular devices and methicillin resistance. Clinical Infectious Diseases 1996:23, 255-9.
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