(From the Spring 2013 issue of Everything Matters: In Patient Care)
Ginger Radcliff, RN, BSN, VA-BC, Vascular Access Team Clinical Leader
Winifred Payne, RN, MSN, NEA-BC, Director Clinical Support Services
In 2004, a Peripheral Intravascular (IV) Team was formed at Nationwide Children’s. Initially developed to provide temporary IV access to patients with vasculature or co-morbidities that made vascular access achievement difficult, the team’s services have expanded to starting numerous Peripheral IVs (PIVs) in the institution as well as performing venipuncture for blood sampling and culturing, assessing patients for vascular access needs and assessing and treating infiltrates and phlebitis. The Nutrition Support Services (NSS) Nurse Clinician, a parallel position to the IV team, serves to meet the central vascular access needs of Nationwide Children's. The NSS Nurse Clinician provides education to new and existing staff and educates families and patients prior to discharge with a central venous catheter (CVC). In addition, the central line nurse clinician serves as a clinical resource for implanted port access and de-access, CVC dressing changes, labs draws from CVCs, catheter occlusion clearance, catheter repair and assessment and treatment of any and all CVC complications.
In an effort to streamline our team and the services we provide to our patient population, the nurse clinicians merged to form the Vascular Access Team in January 2012. Our team members are trained to meet not only the peripheral placements and lab collection needs but also central venous catheter needs. Many of our team members are now board-certified in vascular access (VA-BC) with a goal that all the team will be certified by end of 2013. With more than 12,500 procedures performed in 2012, this team of nurse clinicians is recognized by staff and by patients alike as experts in the field of peripheral and central vascular access, serving as mentors and educators to our nursing and physician groups.
One of the goals of the Vascular Access Team is prompt assessment and treatment of adverse events related to vascular access and infusion therapy. Infiltration and extravasation are reported with all types of peripheral and central vascular access devices. The Infusion Nursing Standards of Practice define an IV infiltration as the unplanned administration of a non-vesicant solution or medication into the surrounding tissue. An extravasation is the unplanned administration of a vesicant solution or medication into the surrounding tissue.
A vesicant medication/solution is known to cause tissue damage when it infuses into the tissue and requires intervention and treatment based on the medication that is extravasated. The most common treatment is hyaluronidase which breaks down the hyaluronic acid in the cell wall allowing the fluid to be more rapidly absorbed for the next 24 to 48 hours. A list of medications and their required treatments is found in Appendix A of Policy XI-110:120 Prevention and Treatment of Phlebitis and Infiltrations. A non-vesicant medication/solution does not usually cause tissue damage and will reabsorb without a problem. It is important to know that all infusates can cause tissue damage.
Accurate hourly assessment is the key to reducing the risk of infiltration and extravasation. Observe the site from insertion up the path of the vein; it should be uncovered, dry and visible. Listen to the patient; any complaints of pain indicate that there is a problem occurring with the vein even if you cannot see the evidence. Compare the site to the other side. It should be without swelling and the same size. Touch the site to assess if it is soft, warm, pain-free and dry. Classify and document the grade of infiltration using the infiltration scale, then initiate the appropriate interventions. Flush the IV as needed to further assess patency and possible complication.
Early recognition of infiltration and extravasation signs/symptoms with timely intervention will effectively limit tissue damage. Always call the Vascular Access Team to assess the infiltration grade three and higher or with signs of tissue compromise present and extravasation of any vesicant. Finally, accurate documentation of the event is vital to facilitate patient care and treatment.
We can never eliminate all infiltrates and extravasation; however, vigilant monitoring of the PIV site and calling the Vascular Access Team for interventions/treatment can minimize the harm. The team is excited about future contributions and providing the very best outcomes for our patients.
TPN extravasation, untreated.
Infiltrate with nectrotic burn and tissue damage.