Trauma treatment award

The US Army have won an invention award for trauma treatment steps that has saved lives and is to be transferred to civilian hospitals. Defense Industry Daily reports…

“Damage Control Resuscitation of Severely Injured Soldiers (Army Institute of Surgical Research). This is a new set of treatment steps for the soldiers, who require massive transfusions. Limiting the amount of intravenous saline solution (normally 3x blood volume), and transferring an even mix of plasma and blood (rather than the usual 4 plasma : 1 blood unit ratio) stabilizes the patient’s blood pressure, lowers the likelihood of fatal shock, and minimizes renewed bleeding. Early use of a clotting factor called rFVIIa has also been beneficial, and other blood products, such as platelets and cryoprecipitate are used as needed.

The treatment works especially well for non-compressible injuries – which comprise 70% of lethal combat injuries. The Army says that the technique has reduced the mortality rate for severely injured soldiers in the field from 65% – 17%. Civilian medical centers have taken notice, and are expected to begin using these techniques themselves. Dr. Michael Dubick, senior research pharmacologist for the Army ISR:

“The American Association for Trauma Surgeons calls this one of the biggest improvements to trauma care in the last 10 years… We’ve met with over 26 civilian centers and are working with 16 of them.”

 

IPS conference 2008

The inaugural Infection Prevention Society (incorporating the ICNA) Conference & Exhibition will take place from the 22nd-24th September 2008 at the Harrogate International Centre. This key Infection Prevention and Control Conference is an essential event for anyone who has the challenge of preventing and controlling infections that occur through the provision of care or in the wider community.

Eminent plenary speakers confirmed include::

• Prof. Stephan Harbarth (Attending Physician, Infectious Diseases, University of Geneva Hospitals)
• Prof. Dinah Gould (Professor of Healthcare Research, City University, London)
• Dr. Stephanie Dancer (Consultant Microbiologist, NHS Lanarkshire)
• Professor Robert Haley (Director, Division of Epidemiology, UT Southwestern Medical Center)

The themes for each day are: 

• Monday 22nd September – Informing infection prevention practice 
• Tuesday 23rd September – Promoting patient and public safety through control of infection 
• Wednesday 24th September – Sustaining quality improvement for infection prevention

Click here to view the full programme.

Booking form.

Addenbrooke’s IV conference

Addenbrooke’s Hospital, UK are holding an International IV Conference ‘Vascular Access – Enhancing Best Practice’

This international conference is aimed at all multi-disciplinary teams who are involved in intravenous therapy and central venous access. The conference runs for two days starting on the 25th September 2008.

Key themes include:

• insertion, care and complications of intravenous devices, both in hospital and in the community
• legal issues surrounding IV therapy and how to deal with them
• setting up a team
• procedure guidelines
• future directions and new technology.

Draft agenda

Wristbands reduce errors

Three companies have been contracted to supply wristbands to NHS hospitals in England and Wales. The contract is designed to address research findings by the National Patient Safety Agency’s (NPSA) that 72% of more than 24,000 annual errors in UK hospitals resulted from instances where patients did not wear wristbands.

The wristbands, to be supplied by Laserband from the USA, Japan’s Sato and Brenmoor from the UK, will employ technology that allows for clear printing of patient information as well as barcodes and even patient photos to ensure proper patient identification.

Click here for the full story.

NPSA wristband report.

Peripheral IV

Wikipedia is a free online encyclopedia that is reliant upon contribution from its readers. Wikipedia is a source that is often utilized by  students learning about new topics. Those learning about intravenous therapy are no different. For this reason here at IVTEAM we feel that the Wikipedia IV pages could benefit from review by the IVTEAM readership.

For example the ‘Intravenous Therapy’ page introduces the reader to many IV topics. The peripheral IV section begins:

“This is the most common intravenous access method in both hospitals and pre-hospital services. A peripheral IV line consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein, any vein that is not in the chest or abdomen. Arm and hand veins are typically used although leg and foot veins are occasionally used. Veins in the arm are the common site in emergency settings, commonly performed by paramedics and emergency physicians”.

Click here to view the Wikipedia page on Intravenous Therapy. Please contribute to the content if you can.

 

Incidence of PICC DVT

Loupus et al (2008) conduct a study to determine if there is a statistically significant increase in the incidence PICC related DVT  in quadriplegic patients.

Loupus, D., Schuetrumpf, S. and Vazquez, L.F. (2008) A Retrospective Review of Peripherally Inserted Central Catheters and Upper Extremity Deep Venous Thrombosis in Persons with Cervical Spinal Cord Injuries.  Journal of the Association for Vascular Access. 13(2), p.82-87.

Abstract:

Introduction: Peripherally Inserted Central Catheters (PICCs) are a proven and cost effective alternative to traditional short term central venous catheters inserted via subclavian or jugular vein routes. It has been theorized that persons with cervical spinal cord injury (SCI) are more prone to upper extremity deep venous thrombosis (DVT) post PICC insertion. Purpose: This study was conducted to determine if there is a statistically significant increase in the incidence of PICC-related upper extremity thrombosis in persons with quadriplegia as compared to other patient populations. Methods: A retrospective chart review of 56 PICC insertions, performed on 44 patients, was conducted to identify risk factors associated with symptomatic upper extremity DVTs. Results: The overall incidence of symptomatic DVTs was 7.1% per PICC line insertion (95% CI 2.8% – 17.0%) and 9.1% per patient (95% CI 3.6% – 21.2%) and the number of DVTs per 1,000 catheter days was 3.14. DVT diagnosis was not significantly associated with any of the patient or PICC-related characteristics examined. The incidence of symptomatic DVTs per PICC line insertion was not significantly different than the lowest incidence of thrombosis reported in the scientific literature among all patients receiving PICCs. Conclusions: Results from this study do not suggest that persons with cervical spinal cord injuries are at increased risk for developing upper-extremity DVTs related to PICC insertion. Due to the retrospective nature of the present study and small sample size, prospective studies are recommended to further examine DVTs in patients’ with spinal cord injuries. Estimates from the present study can be used in planning prospective studies.

Vascular haemodialysis access

Kawecka et al (2008) analyse the choice and appropriateness of haemodialysis vascular access devices in elderly patients.

Kawecka, A., Przekwas, M., Debska-Ślizień, A. and Rutkowski, B. (2008) Elder Patients – What is the Best Vascular Hemodialysis Access?  Journal of the Association for Vascular Access. 13(2), p.75-80.

Abstract:

Background: The incidence of end stage renal disease (ESRD) has increased in recent years. Elderly patients constitute the most rapidly growing group who need renal replacement therapy. In 2003, persons over 65 comprised 35% of all hemodialysed patients in Poland, and by the end of 2005 more than 44%.

Methods: From January 1984 through July 2004, patients 65 or older (n=133) starting hemodialysis (HD), were considered. The study group consisted of 80 men and 53 women (mean age 71.8±4.9years). Patients’ survival probability, primary, primary-assisted, and secondary patency of the vascular access (VA) were calculated using Kaplan-Mayer curves and log-rank analysis. Cox’s proportional-hazards model was used to assess the influence of risk factors on VA patency.

Results: A total of 196 VAs were created. Of the 108 native arteriovenous fistulas (AVF) created, 24 were radiocephalic (RCAVF), 15 were brachiobasilic (BBAVF), and 64 were brachiocephalic (BCAVF). Arteriovenous grafts (AVG) were used in 35 patients and permanent tunneled cuffed catheters (PTCC) in 53. Secondary patency at 1-year was: 49% for native AVF, 62% for AVG, and 19% for PTCC. The survival rate of the 133 elderly patients was 63% at 1-year, 50% at 2 years, and 26% at 5 years.

Conclusion: People 65 and older are a predominant population in whom HD can preserve life. In elderly patients AVG had the best secondary patency. When limited life expectancy was taken into consideration AVGs were a good alternative for vascular access in hemodialysis.

IV occlusion and vitamin E

Chernecky et al (2008) published a study in which patients felt that taking vitamin E, 400 -800 IU per day orally, avoided the problems of occlusion or inability to withdraw blood from their current VAD.

Chernecky, C., Macklin, D., Nugent, K. and Waller, J. (2008) Potential Value of Vitamin E in Cancer Patients with Venous Access Devices.  Journal of the Association for Vascular Access. 13(2), p. 71-73.

Abstract:

Background: Vitamin E has antiplatelet, fibrinolytic and endotoxin properties that may help avoid the problems of occlusion or inability to withdraw blood from port VADs.

Purpose: Disseminate information about the non-traditional therapeutic use of vitamin E associated with care of Venous Access Devices (VAD) in patients with cancer.

Methodology: In-person focus groups. Sample of 22 cancer patients who had port Venous Access Devices (VAD).

Findings: Fourteen percent (N = 3) of patients felt that taking vitamin E, 400 -800 IU per day orally, in capsule form, avoided the problems of occlusion or inability to withdraw blood from their current VAD.

Practice Implications: The effects of vitamin E on occlusion and inability to withdraw blood in caring for patients who have port VADs, requires further investigation.

 

Medication error prevention

The National Academies (2006) note that medication errors injure 1.5 people annually. This study by Rosenkoetter et al (2008) reports on the impact of “smart pump” technology on medication error prevention.

Rosenkoetter, M.M., Bowcutt, M., Khasanshina, E.V., Chernecky, C.C. and Wall, J. (2008) Perceptions of the Impact of “Smart Pumps” on Nurses and Nursing Care Provided. Journal of the Association for Vascular Access, 13(2), p.60-69.

Abstract:

Medication errors occur frequently in hospital settings, creating harmful consequences for patients and families, as well as tremendous financial losses. “Smart pump” technology is one means by which these errors can be reduced. The study reported here is a part of a three phase study and focused on the perceptions of nurses (n=512) in a tertiary care hospital regarding the impact of the implementation of “smart pump” technology and its impact on nursing care provided, medication errors, and job satisfaction. Sociotechnical System Theory and the Life Patterns Model were used to frame the study. The Infusion System Perception Scale was used to assess demographic information, and perceptions of nurses on a 30-item five-point Likert scale. Results indicate that nurses perceived the “pump” increased safe medication administration, did not decrease the perception of the punitive nature of reporting medication errors and did not increase the nurse’s workload, but did make routines easier. The “pump” was perceived to increase self-confidence but had no effect on use of the pharmacy staff. Findings suggest that the “pump” could be implemented in a variety of settings, regardless of the age, gender, and educational background of the nurses. The “pump” offers an effective approach to the reduction of intravenous medication errors.

 

Failure to monitor fluid balance

NHS Tayside has agreed to apologise to the family of a 79-year-old man who died in Ninewells Hospital after knee-replacement surgery.

Scottish Public Services Ombudsman Professor Alice Brown said the man — referred to as Mr A — was admitted to Ninewells on April 20, 2006, and had his operation the following day. He later suffered episodes of diarrhoea and vomiting and then a cardiac arrest and subsequently died on April 26.

The man’s sister — Ms C — complained first to NHS Tayside and then took her case to the Ombudsman, who found there had been a failure to properly monitor Mr A’s fluid levels on April 25 and to accurately control the flow of intravenous fluid as detailed on the prescription chart for April 26.

Click here for the full story.

Urokinase meta-analysis

The authors completed a meta-analysis of prospective randomized trials that examine the use of Urokinase lock or flush solution for prevention of bloodstream infections associated with central venous catheters for chemotherapy.

Kethireddy, S. and Safdar, N. (2008) Urokinase lock or flush solution for prevention of bloodstream infections associated with central venous catheters for chemotherapy: a meta-analysis of prospective randomized trials. Journal of Vascular Access. 9(1), p.51-57.

Abstract:

Background: Intravascular devices (IVDs) carry significant risk of device-associated bloodstream infection (BSI). Catheter thrombosis increases the likelihood of microbial colonization of the catheter and BSI. Urokinase has been studied for the prevention of BSI associated with IVDs. We undertook a systematic review to determine the efficacy of urokinase-heparin lock or flush solution compared with heparin alone in preventing IVD-associated BSI. Methods: Computerized databases were searched for relevant publications in English from January 1966 to 1 January 2007. We identified randomized controlled trials comparing a urokinase-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term IVDs. Summary effect sizes were calculated with assessment of heterogeneity. Results: Five randomized, controlled trials involving a total of 991 patients being treated with IVDs met the inclusion criteria; all five studies were conducted among patients with cancer; three of these studies were undertaken in children and two in adults. The summary risk ratio with a urokinase-heparin lock solution for IVD-associated BSI was 0.77 (95% confidence interval [CI], 0.60–0.98; p=0.01). Results of the test for heterogeneity were not statistically significant (p=0.53). Conclusions: Use of a urokinase lock solution in high-risk patient populations being treated with long-term central IVDs may reduce the risk of BSI. However, there are few randomized trials and methodologic limitations of these preclude more robust recommendations regarding the use of urokinase to prevent BSI. Further adequately powered studies should seek to evaluate the efficacy of urokinase and optimize dosage and instillation regimen.

 

Heparin update New Zealand

Stewart Jessamine, Group Manager, Medsafe in conjunction with the Ministry of Health (NZ)  are continuing to monitor the situation with respect to the global problem of heparin contaminated with over-sulphated chondroitin sulphate (OSCS) entering the market.

Medicines regulators around the world have taken a number of different approaches to managing this issue.  In New Zealand, Medsafe requires all manufacturers of heparin-based products to test for the presence of OSCS in products supplied to the market. To date all of the manufacturers of heparin and low molecular weight heparin products supplied to New Zealand have reported that OSCS has not been detected in the products used by patients.

Click here for the full update.

Barcode medication system

Actor Dennis Quaid, whose twins were given an overdose of a blood thinner as newborns at a California hospital, toured a Dallas hospital on Tuesday to learn about a system to prevent such errors.

Officials at Children’s Medical Center Dallas showed Quaid and his wife, Kimberly, the hospital’s system of bar-coding medications to allow the drugs to be tracked electronically from the point of dispensing until being administered to the patient.

“This system here at Children’s Medical Center, I’m really amazed … it’s beyond cutting edge,” Quaid said at a news conference after the tour.

Click here to view the full story.

 

MedPro and Greiner

MedPro Safety Products, has entered into two medical supply manufacturing agreements with Greiner Bio-One International. The two agreements grant Greiner the right to manufacture, market and distribute MedPro’s tube-activated and skin-activated blood collection systems and its winged ‘butterfly’ safety needle system.

MedPro’s Chairman and Chief Executive Officer, Craig Turner, stated: “Greiner is a world-class company, specifically known for its dedication to providing superior product quality and services. We are particularly pleased to expand our relationship with Greiner, which we believe will accelerate global market access for our product, and global exposure for our Company”.

Click here for the full story.

 

Venepuncture practice

Irene Lavery and Emma Smith from the Western General Hospital, Edinburgh contrast and compare the skill of venepuncture against the 2008 Nursing and Midwifery Council Code.

Lavery, I. and Smith, E. (2008) Venepuncture practice and the 2008 nursing and Midwifery Council Code. British Journal of Nursing. 17(13), p.824-828.

Abstract:

This article explores the new Nursing and Midwifery Council Code (2008) in relation to venepuncture and, through analysing each clause, will present key considerations for good practice. The skill of venepuncture is discussed and, using a scenario, will review the technique and the impact of the Code on the practitioner. Any clinical skill requires safe and competent practice; it is hoped that this article will aid practitioners involved in undertaking venepuncture to reflect on their skills and knowledge, and to review best practice.

Safe transfusion

The authors examine issues that impact upon the successful implementation of national guidance such as the NHS better blood transfusion programme and the NPSA safer practice notice 14, right patient, right blood.

Gray, A., Hart, M., Dalrymple, K. and Davies, T. (2008) Promoting safe transfusion practice: right blood, right patient, right time. British Journal of Nursing. 17(13), p.812-817.

Abstract:

Despite an array of initiatives designed to support the delivery of safe and appropriate transfusion practice, incidences of patients receiving the wrong blood continue to be reported. Nurses play a key role in delivering safe and appropriate transfusion care and have a responsibility to support national initiatives, such as the NHS Better Blood Transfusion programme of action and the National Patient Safety Agency Safer Practice Notice 14, Right Patient, Right Blood. This article examines factors, which impact on the successful implementation of a programme aimed at promoting best transfusion practice, such as organizational support, leadership, education and competency assessment, and the role of audit and feedback. By championing the  systematic assessment of transfusion procedures, the implementation of education and guidelines and the use of innovative approaches, such as care bundles, we can ensure that nurses have the appropriate knowledge, skills and understanding to provide the highest standards of transfusion care to our patients.

 

Systematic review anti-infective CVC

These two recently published systematic reviews consider the impact of anti-infective-treated central venous access devices on the incidence of catheter-related blood stream infections.

The first is…

Niël-Weise, B.S., Stijnen, T. and van den Broek, P.J. (2008) Anti-infective-treated central venous catheters for total parenteral nutrition or chemotherapy: a systematic review. The Journal of Hospital Infection. 69(2), p.114-23.

Abstract:

This systematic review assesses the effect of anti-infective-treated central venous catheters (CVCs) on catheter-related bloodstream infection (CRBSI) in patients who received a CVC for total parenteral nutrition (TPN) or chemotherapy. Randomised controlled trials were retrieved from Medline and the Cochrane Library up to 14 October 2007. Two reviewers independently assessed trial quality and extracted data. Data for CRBSI were combined where appropriate, using a random effects model, and subgroup meta-analysis was carried out where applicable. The impact of the risk for CRBSI in the control group on the effect of anti-infective CVCs was studied by using meta-regression based on the bivariate meta-analysis model. Nine trials were included in the review. One trial showed that antibiotic-treated CVCs reduced the risk for CRBSI in outpatients with chemotherapy and a CVC in-situ during a period of about nine weeks. Eight trials did not find an overall significant benefit in favour of antiseptic-treated CVCs in patients who had a CVC during a mean of about two weeks. No relationship could be established between the effect of anti-infective-treated CVCs and the underlying risk for CRBSI, although nearly all trials had serious methodological shortcomings. Thus, available scientific evidence to prevent CRBSI by the use of anti-infective-treated CVCs in patients receiving chemotherapy or TPN is not sufficient as a basis to recommend their use. The recommendation of the Centers for Disease Control and Prevention to use antibiotic- or antiseptic-impregnated CVCs, when the risk for CRBSI remains high despite good hygienic practice, should therefore be limited to patients in the intensive care/perioperative setting.

The second…

Hockenhull, J.C., Dwan, K., Boland, A., Smith, G., Bagust, A., Dündar, Y., Gamble, C., McLeod, C., Walley, T. and Dickson, R. (2008) The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation. Health Technology Assessment. 12(12), p.1-154.

Abstract:

OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of central venous catheters (CVCs) treated with anti-infective agents in preventing catheter-related bloodstream infection (CRBSI). DATA SOURCES: Major electronic databases were searched from 1985 to August 2005. REVIEW METHODS: The systematic clinical and economic reviews were conducted according to accepted procedures. Only full economic evaluations (synthesis of costs and benefits) comparing the use of anti-infective central venous catheters (AI-CVCs) with untreated CVCs or other treated catheters were selected for inclusion in the economic review. RESULTS: A total of 32 trials met the clinical inclusion criteria. Seven different types of AI-CVC were identified, with the most frequently tested being chlorhexidine and silver sulfadiazine (CHSS) (externally treated), CHSS (externally and internally treated) and minocycline rifampicin (internally and externally treated). In general, the trials were of a poor quality in terms of reported methodology, microbiological relevance and control of confounding variables. The pooled result suggests a statistically significant advantage for AI-CVCs in comparison to standard catheters in reducing CRBSI [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.34 to 0.60, 24 studies, I-squared = 0%, fixed effects]. Analysis by subgroups of catheters demonstrates that antibiotic-treated catheters and catheters treated internally and externally decrease CRBSI rates significantly (OR 0.26, 95% CI 0.15 to 0.46, six studies, I-squared = 0%, fixed effects, and OR 0.43, 95% CI 0.26 to 0.70, nine studies, I-squared = 0%, fixed effects, respectively). Catheters treated only externally demonstrate a wider CI and non-significant effect (OR 0.67, 95% CI 0.43 to 1.06, nine studies, I-squared = 0%, fixed effects). A treatment effect was also found for trials with an average duration of between 5 and 12 days, and for the one study with a mean duration of over 20 days. There was a statistically significant treatment effect for both femoral and jugular insertion sites and for those studies reporting a mix of insertion sites. The treatment effect was not observed in trials using exclusively subclavian insertion sites. Of the four trials that compared treated catheters, one reported a benefit of antibiotic-treated catheters over catheters treated externally with CHSS. All three sensitivity analyses testing for study design differences reported a statistically significant treatment effect. The review was limited owing to the quality of the trials included, marked differences in the definitions and methods of diagnosis of CRBSI, and inconsistent reporting of risk factors and patient population factors. Furthermore, two-thirds of trials were commercially funded. The economic performance (cost-effectiveness and potential cost-savings) of using AI-CVCs to reduce the number of CRBSIs in patients requiring a CVC was also reviewed. Results show that the use of AI-CVCs instead of standard CVCs can lead to a reduction in CRBSIs and decreased medical costs. To complement the reviews, a basic decision-analytic model was constructed to explore a range of possible scenarios for the NHS in England and Wales. Results show that for every patient who receives an AI-CVC there is an estimated cost-saving of 138.20 pounds. The multivariate sensitivity analyses estimate potentially large cost-savings, depending on the size of the population, under a wide range of cost and clinical assumptions. However, those considering the purchase of AI-CVCs should ensure that their patient populations and the important characteristics of local clinical practice are indeed similar to those described in this economic evaluation. CONCLUSIONS: Overall, AI-CVCs are clinically effective and relatively inexpensive and therefore their integration into clinical practice can be justified. However, the use of these anti-infective catheters without the appropriate use of other practical care initiatives will have only a limited success on the prevention of CRBSIs. Comparative trials are required to determine which, if any, of the treated catheters is the most effective. Pragmatic research related to the effectiveness of bundles of care that may reduce rates of CRBSI is also warranted.

 

Medical Device Alert MDA/2008/051

The MHRA have issued  a medical device alert (MDA/2008/051) which concerns the Kimal safety fistula needle. Kimal is aware of the potential for the unintentional retraction of the cannula into the protection sheath, which can result in exsanguination.  As a result, Kimal is recalling all lots of the device. 

 Click here to view the alert. 

 

Intraosseous access in children

This article reviews the safety of powered intraosseous devices in pediatric patients. The authors state that ”the rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients” (Horton and Beamer 2008).

Horton, M.A. and Beamer, C. (2008) Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatric Emergency Care. 24(6), p.347-350.

Abstract:

OBJECTIVE: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.

METHODS: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.

RESULTS: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 +/- 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 +/- 2.8, and mean infusion pain score was 3.2 +/- 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.

CONCLUSIONS: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.

Fist clenching during phlebotomy

The authors describe the potential impact of fist clenching during blood sampling upon the incidence of pseudohyperkalaemia.

Bailey, I.R. and  and Thurlow, V.R. (2008) Is suboptimal phlebotomy technique impacting on potassium results for primary care? Annals of Clinical Biochemistry. 45(3), p.266-269.

Abstract:

Background: Pre-analytical problems causing pseudohyperkalaemia have been highlighted previously. These include transit time and temperature effects when sample collection points are geographically widely spread. Similarly, inappropriate phlebotomy technique (in particular, requesting patients to fist clench to facilitate venesection) is a documented cause of pseudohyperkalaemia, but its incidence may be impossible to establish. This study illustrates how primary care population serum potassium data altered when local phlebotomy clinics optimized their technique.

Methods: The effect of improving phlebotomy was studied by plotting average monthly primary care population serum potassium data and average percentage of samples with hyperkalaemia (5.2 mmol/L or higher) against mean monthly temperature before and after changes in phlebotomy practice. Only samples from primary care were included between 2002 and 2005 inclusive.

Results: Primary care population serum potassium was inversely related to ambient temperature. Following the change in phlebotomy practice, the annual percentage of results above reference range (5.2 mmol/L or higher) was reduced from 9% to 6% and the number of results breaching the upper telephoning threshold (5.8 mmol/L or higher) fell from 0.9% to 0.5%.

Conclusions: Ensuring that phlebotomists were trained to avoid facilitating venesection by requesting patients to hand grip (fist clench), was associated with lower mean serum potassium results for the primary care patient population and a reduced incidence of hyperkalaemia. It is likely that the contribution of patient fist clenching during phlebotomy to pseudohyperkalaemia has been underestimated.

Epidural and IV confusion

In 2006 Jasmine Gant, 16, died following a mistake by nurse Julie Thao. Jasmine died following an inadvertent disconnection of her epidural during childbirth. Thao mistakenly attached the epidural to the IV device.

The Wisconsin State Journal state that progress has been made to increase the safety associated with tubing connections, but obstacles continue.

“It’s inching along,” said Rod Hicks, a professor at Texas Tech University and former research manager at U.S. Pharmacopeia, a nonprofit organization that sets standards for the drug industry. “But these errors can still occur. We have not made the world a safer place yet.”

This article calls for industry to provide the solution to safer tubing connections in healthcare.

Click here to read the full story.

Revised EU monographs for heparin

The MHRA have reported a revision of European Pharmacopoeia monographs for heparin.

“Following increased reports of adverse events associated with heparin preparations in the United States of America and some European countries, the European Pharmacopoeia monographs for Heparin Calcium (0332) and Heparin Sodium (0333) have undergone rapid revision and implementation in order to strengthen the level of testing required for quality control.

The revised monographs were adopted by the European Pharmacopoeia Commission on 25 June 2008 and are expected to come into effect on 1 August 2008, pending a decision by the European Committee on Pharmaceuticals and Pharmaceutical Care (CD-P-PH).

The revised monographs will be published in European Pharmacopoeia Supplement 6.4 and supersede the relevant monographs published in the British Pharmacopoeia 2008 and 2009 editions.

Further information and copies of the monographs can be obtained from the EDQM (European Directorate for Quality of Medicines & HealthCare) website“.

Redesigned peripheral IV catheter

The launch of the VantageCath has seen a radical redesign of the traditional peripheral IV catheter. Designed to not only prevent unexpected needlestick injuries, but also to eliminate the spillage of blood during the IV placement. The device is a product of a firm called Advantage Medical Devices from Solana Beach, CA.

Advantage Medical Devices state:

“The VantageCath is an innovative peripheral Intravenous (IV) Catheter Safety System designed to significantly reduce blood borne pathogen exposure without compromising the “pop and glide” that users want and need. Utilizing a patented “closed hub” design, blood is contained during the entire cannulation and needle retraction process. This eliminates the need to tamponade above the site of the IV catheter and allows the provider to have both hands free to secure the IV and attach tubing using sterile technique”.

Click here to view product animation.

Click here to view product page.

Needle and syringe redesigned

Christopher Holden has won an award redesigning the traditional needle and syringe. The ‘MediDome’ aims to eliminate needlestick injuries, simplify the process and speed up patient treatment.

Christopher has won a National Patient Safety Award of £3000 and NCR Internship worth £4000 for a duration of four weeks.

Christopher explains how the product works:

“A sterile cover is removed to expose adhesive wings that stick the MediDome to the required area for injection. The person administering the injection removes the blister cap and presses down on the top of MediDome until a little resistance is felt. A bubble on one of the wings is checked for blood – if it fills up the injection is halted. If all is well, they then give a small firm press until a click is heard, then softly compress and hold the dome. On release, MediDome returns to its original shape (but cannot be compressed again), is removed from the arm and disposed of for incineration. It is a fail safe single use design – once used it can never be used again, so syringes cannot be shared, and viruses such as HIV or blood born diseases cannot be passed on”.

Click here for more information.

 

Pediatric CVAD blood sampling

Kathleen Adlard examines the issues of central venous access device blood sampling from pediatric cancer patients.

Adlard, K. (2008) Examining the Push—Pull Method of Blood Sampling From Central Venous Access Devices. Journal of Pediatric Oncology Nursing. 25(4), p.200-207.

Abstract:

“The placement of a central venous access device (CVAD) has revolutionized supportive care for pediatric cancer patients. The CVAD is used to administer chemotherapy/biotherapy, blood products, total parenteral nutrition, antibiotics, and many other supportive medications. CVADs also provide the ability to obtain blood samples without the trauma associated with venipuncture. Frequent blood sampling is often needed to monitor the side effects and response of the cancer treatment. Unfortunately, the most common method requires discarding blood (0.5-10 mL, depending on the institution’s protocol) with each lab draws, for various reasons. For pediatric oncology patients, this can result in a large volume of blood being discarded and subsequently increase the need for blood transfusions. Repeated exposure to allogeneic (donor) blood products can put this patient population at additional risk for alloimmunization and febrile reactions. The purpose of this study is to test the limits of agreement between laboratory values (chemistry panel 18 and complete blood count) obtained using the push—pull and standard methods of blood sampling from CVADs in pediatric oncology patients” (Adlard 2008).

AVA conference brochure

The Association for Vascular Access (AVA) have published the brochure for the 22nd Annual Scientific Meeting.

The Association for Vascular Access will stress the value of a multidisciplinary approach as AVA demonstrates its leadership role in all aspects of vascular access. This conference incorporates multiple venues for vascular access education and networking. Through general sessions outlining cutting-edge technology along with research and scientific-based information, exhibitor theaters, breakout sessions, mini-breakout sessions, poster presentations, and product exhibits, each participant will be introduced to the latest technology in vascular access. 

Click here for conference brochure.

Cannula insertion documentation

Our recent IVTEAM poll has just finished. We asked the question “Should you record lot/batch numbers following cannula insertion”? 87% of IVTEAM visitors felt that it was important to record lot/batch numbers. Thank you to all who voted.

Our new poll has just been launched. IVTEAM are now asking “When securing a peripheral cannula do you use strips for additional fixation”?

Please visit our poll at the bottom of the page and cast your vote now.

Fatal injection of ranitidine

This case study describes the case of a 51-year-old man with negative anamnesis for allergic events, who died suddenly after the intravenous administration of one phial of Zantac(R) 50mg prescribed as a routine post-surgical prophylaxis for stress ulcer.

Oliva, A. et al (2008) Fatal injection of ranitidine: a case report. Journal of Medical Case Reports. 2, p.232.

Abstract:

Introduction: Ranitidine hydrochloride (Zantac®), a histamine-2-receptor antagonist, is a widely used medication with an excellent safety record. Anaphylactic reaction to ranitidine is an extremely rare event and a related death has never been described in the literature.

Case presentation: We present the clinical history, histological and toxicological data of a 51-year-old man with negative anamnesis for allergic events, who died suddenly after the intravenous administration of one phial of Zantac® 50mg prescribed as a routine post-surgical prophylaxis for stress ulcer. 

Conclusions: Although the incidence of anaphylactic reactions related to ranitidine is low, caution needs to be exercised on administration of this drug. In addition, further study is needed to define strategies for the prevention of adverse drug reactions in hospitalized patients. 

Click here to view the article.

Wristband warnings

IVTEAM have reported before on the use of wristbands in healthcare (click here). Well, its back in the press and yes we still have a problem with the ‘Do Not Resuscitate’ wristband!

BroMenn Healthcare and St. Joseph announced Monday that the two health care organizations have collaborated on color-coded wristbands to immediately alert doctors and hospital staff to critical information about patients. Eureka Community is part of BroMenn Healthcare.

“It’s an exterior red flag to (staff) that there’s something to be aware of,” explained Mary Anne Kirchner, a registered nurse and BroMenn clinical education specialist.

A red band indicates a patient allergy, yellow identifies a patient at risk of falling, purple is a sign that the patient has a do-not-resuscitate order on file, and pink is for patients with an arm or leg that shouldn’t be used for procedures such as blood pressure checks, intravenous infusions and blood draws.

Click here for the full story.

Vascular access in court

Four condemned prisoners are attempting to stop executions in Mississippi. They say the state’s method of lethal injection is unconstitutional because it might cause pain.

The inmates have issues with numerous parts of the process. One particular issue that they highlight is that they believe the insertion of the intravenous needle could also be a painful because the execution staff in Mississippi are not properly trained.

State officials dismiss the allegations, saying in court papers that the staff “is a highly trained team of paramedics” and that a state pathologist is on hand.

Click here for the full story.

Update: Cutdowns are not to be used in executions. An autopsy conducted on on an executed inmate found 10 puncture marks where the execution team tried inserting IV lines. The report also shows executioners likely used a cut-down procedure on part of the skin from his right arm to find a vein for the IV line. Click here for the full story.

14th August 2008 – Interesting update looking deeper into the role of the healthcare staff inserting vascular access devices and administering medication.

ASHP’s IV Safety Summit

ASHP and its partners will gather healthcare practitioners, thought leaders and medication-safety experts from around the nation to achieve consensus on actions that bring about real and lasting improvements in the use of IV medications, protecting patients from harm and death due to errors.

Summit Goals

• Achieve consensus on an initial set of broadly applicable standard practices and methods that are effective in preventing patient harm or death associated with the use of intravenous medications.
• Identify barriers to adoption or implementation of the practices and recommend specific actions to overcome them. Practices will be prioritized into an essential core group for immediate implementation and those requiring a phased-in approach.
• Identify areas for future research and issues that are specific to and should be resolved by various stakeholder groups.

The summit will take place on July 14 & 15, Rockville, Maryland. The organizers request that you check the ASHP website for summary materials and updates.

 

ANTT conference

The Aseptic Non Touch Implementation team have announced the 1st National Conference on Aseptic Non Touch Technique (ANTT) on the 29th September 2008 – London, UK. This National Conference for ANTT will present important latest evidence and developments from leading NHS hospitals.

Speakers include; Dr Carole Pellowe will update on EPIC2 progress and explain how ANTT is the vehicle for hospitals to successfully deliver best aseptic practice guidance from EPIC2, DOH and the ICP in the workplace. Renowned experts in the field; Stephen Rowley, Dr Peter Wilson, Annette Jeanes and Andrew Jackson will provide practical insight and the context of aseptic management in health care settings.

Click here for further information.

 

Neonatal IV dressing

Neonatal IV dressing technique is under represented in the literature. This article attempts to redress the balance.

Sharpe, E.L. (2008) Tiny Patients, Tiny Dressings: A Guide to the Neonatal PICC Dressing Change. Advances in neonatal care. 8(3), p.150-62.

Abstract:

Advances in neonatology now support the survival of the tiniest of infants. The peripherally inserted central catheter (PICC) has now become an integral part of routine practice in neonatal intensive care units around the world. Keen attention to safe maintenance of these devices is essential. A properly applied and maintained PICC dressing is the first line of defense to minimize the risk of complications such as dislodgement, migration, and infection. This article describes a neonatal PICC dressing change and discusses the frequently encountered quandaries surrounding this important procedure, including dressing materials, frequency, site preparation, barrier precautions, and other relevant concerns.

 

External jugular Groshong catheter

This article attempts to demonstrate the efficacy and safety of insertion of a Groshong catheter via the external jugular vein (EJV) for central vein access.

Ishizuka, M., Nagata, H., Takagi, K., Horie, T., Furihata, M.., Nakagawa, A. and Kubota, K. (2008) External jugular Groshong catheter is associated with fewer complications than a subclavian Argyle catheter. European surgical research. 40(2), p. 197-202.

Abstract:

BACKGROUND: To demonstrate the efficacy and safety of insertion of a Groshong catheter via the external jugular vein (EJV) for central vein access. METHODS: Central venous access was done by either insertion of a Groshong catheter via the EJV or an Argyle catheter via the subclavian vein with single puncture. RESULTS: Eighty patients (group 1) were treated with 146 subclavian venous catheters for 2,770 catheter-days, and 98 patients (group 2) were treated with 147 external jugular venous catheters for 2,381 catheter-days. Fever appeared in 36.3% (53/146) and 16.3% (24/147) of the patients in groups 1 and 2, respectively (p < 0.01). The malposition and pneumothorax rates were 17.1% (25/146) and 2.0% (3/147; p < 0.01), and 2.7% (4/146) and 0% (0/147; p < 0.05) in the two groups, respectively. CONCLUSIONS: Insertion of a Groshong catheter via the EJV is more acceptable for central venous access than insertion of a conventional subclavian venous catheter.

 

PICC’s for children with cancer

This article describes PICC’s as a convenient, reliable vascular access device for children with cancer.

Abedin, S. and Kapoor, G. (2008) Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer. Pediatric Blood & Cancer. 51(2), p. 251-5.

Abstract:

BACKGROUND: A long term venous access device is essential in children with malignancies for the safe administration of medication and to avoid repeated painful venipunctures. The advantage of peripherally inserted central venous catheters (PICC) over conventional central venous catheter (CVC) is easy bedside insertion without need for general anesthesia and theatre time. The purpose of this study was to evaluate our experience with PICCs particularly with regard to catheter life, reason for removal and complications in children suffering from various malignancies. PROCEDURE: A retrospective analysis of all PICCs inserted in children with cancer was done with regard to the demographic data, catheter life, reason for removal, and complications. The latter two were evaluated in association with patient age, catheter days, and year of insertion. RESULTS: Of 127 catheters inserted in 127 children, median catheter life was 161 days with a total of 18,955 catheter days (for 124 patients, 3 lost to follow-up). Elective removal occurred in 63/101 (62.4%) PICCs and removal due to complications resulted in a complication rate of 2.41 per 1,000 catheter days. The common reasons for catheter removal were suspected infection, breakage/leakage, dislodgement, phlebitis, and occlusion with rates of 1.27, 0.57, 0.31, 0.06, and 0.06 per 1,000 catheter days, respectively. CONCLUSION: We found PICC to be a convenient, cheap, safe, and reliable device for long term intravenous access in children with malignancies. This was possible with the help of dedicated catheter care nurses.

 

VisIV container reduces IV waste

Kennedy Health System recently announced that it has implemented the VisIV flexible intravenous container. Read more

Extravasation injury baby

Baby Lai Yok Shan, who lost her left arm soon after birth when it turned gangrenous, turned one year old on Read more

Baby died following extravasation

A coroner has ruled doctors at a Plymouth hospital were not to blame for the death of a two-week-old premature baby who died after the contents of her feeding tube leaked.

A paediatric expert at the inquest, Professor Peter Fleming, agreed with the doctors who treated Brooke, that the feeding fluid had led to a chemical erosion of the blood vessel it was in, causing it to leak into her liver and abdomen.

The coroner’s narrative verdict acknowledged the leakage contributed to Brooke’s death, but said her feeding tube had been inserted correctly by doctors.

The photograph shows Brooke Herridge who was born prematurely at 27 weeks.

Click here for the full story.

 

Marines learn IV access

Marines of 9th Engineer Support Battalion, 3rd Marine Logistics Group, practiced saving lives during the Combat Lifesavers Course.

With a limited number of corpsmen in the field, Marines often have to rely on fellow Marines to provide initial care. That’s one reason why deploying units must be 100 percent combat lifesaver certified, according to Petty Officer 2nd Class Prayot Bunmeema.

“Typically there is only one corpsman per squad of 15 Marines, and the corpsman can’t always be where he is needed,” he said. “That’s where the combat lifesaver Marines come in.”

Students learned how to assist victims who have lost too much blood by learning to insert and manage intravenous therapy to replenish bodily fluids, which is also a treatment for shock.

“The best part of the training is definitely the IVs,” said Pfc. Michael Schumacker, a bulk fuel specialist with 9th ESB.

Click here to view the full story.

 

Child cannulation competencies

The RCN have available an education and training competency framework for peripheral venous cannulation in children and young people.

The framework identifies the competencies,learning outcomes and the indicative content necessary for education and training programmes to meet the needs of children and young people.It aims to support consistent curriculum and practice development so that practitioners can develop and,maintain the ability to carry out this task, regardless of where they work.

Click here to view the document.

Syringe disconnection alert

The MHRA have issued an alert warning of inadvertent syringe disconnection.

The issue is with procedure packs from various manufacturers which contain BD Medical Surgical Systems 2ml, 5ml and 10ml Plastipak Luer slip syringes.

The warning points to potential for the BD Luer slip syringes supplied in procedure packs to spontaneously disconnect or fail to maintain a secure connection to Luer fittings of other devices.

Click here for further information.

Potential infusion error

The MHRA have  issued an alert warning of potential infusion device drug error when using the Smiths Medical Graseby Omnifuse and Omnifuse PCA syringe pumps.

The MHRA have warned of the possibility of patients being given an additional/unnecessary infusion when syringes are changed or infusions restarted when using DrugPro software. If the user selects – but does not confirm – a drug protocol from the drug protocol library and then resets/stops the pump, the previously infused volume will not be added to the ‘total volume infused’ display.

Click here for further information.

Fatal intrathecal drug error

The Times of India reports that a 37-year-old engineer died on Wednesday morning, allegedly because of intravenous chemotherapy mistakenly given via the intrathecal route. 

The Times of India writes “On June 18, an anaesthetist — in the absence of a doctor — pushed a chemotherapy injection into Kuntal Chowdhury’s spinal cord. The injection was supposed to be an intravenous one. Paralysis set in soon and Kuntal slowly slipped away”.

Click here for the full story.

Central catheter infection rates

New York city and New York state hospitals report catheter related blood stream infection rates.

In New York City, 2.8 out of 1,000 central lines at medical intensive care units resulted in infections, compared to 3.6 upstate. In the city, another 2.7 out of 1,000 central lines in surgical ICUs resulted in infections, compared to 4.8 in upstate facilities.

Officials credited a collaborative among 60 hospitals in the New York metropolitan area aimed at reducing hospital-acquired infections. According to the most recent data provided by the collaborative, which was established in 2005 by the United Hospital Fund and the Greater New York Hospital Association, the rate of central line infections was 2.33 infections for each 1,000 central line days as of December 2007, down from 4.98 infections for each 1,000 central line days in June 2005.

Click here for the full story.

High tech clean rooms

Hamad Medical Corporation has established the first pharmacy manufacturing  clean rooms in the Middle East. The clean rooms are being established in a bid to improve pharmaceutical activities within the corporation. Fully automated chemotheraphy machines have been installed in these rooms, which ensure sterile products, reduce human error and infections to patients.

Opening three such rooms yesterday at the hospital’s pharmacy department were Mohamed al-Nama, assistant executive director; Abdul-Rasak al-Kubaisi, assitant managing director Operations; Manal Borhan al-Zaidan, Al-Amal Cancer Centre director of Pharmacy; as well as corporation’s director of Marketing and Public Relations Mohamed al-Noaimi.

Al-Zaidan said that the decisions by the corporation to set up the additional clean rooms were to reiterate its commitment to excellence in patient care.

“These clean rooms are first of its kind in the Middle East and it is also very rare to find in the world as well with its high standard installations,” she said.

Click here to view the full story.

Click here for another story.

Heparin overdose

A Corpus Christi hospital says 14 babies in its neonatal intensive care unit received overdoses of the Heparin. 

Christus Spohn Hospital South CEO Bruce Holstein says the error in the dosage of the medicine – used to flush intravenous lines to prevent blood clots from forming – was discovered Sunday night by hospital nurses. He says the nurses noticed abnormalities in lab tests. 

Pharmacy operations were halted temporarily Monday. He said the error was believed to have happened in the pharmacy when the medicine was mixed.

Click the following links for the full story – Fox News – KRISTV – CBS News

UPDATE: The error was unrelated to product labeling or packaging of pediatric heparin, according to the statement by Dr. Richard Davis, chief medical officer of Christus Spohn Health System. 

IVTEAM beat nursing shortage

Dan Ast is a member of the IV therapy team at Via Christi Regional Medical Center-St. Joseph Campus.

As the nursing shortage worsens, Via Christi has adopted new ideas to make up for vacancies, things like the specialization of nurse tasks like those carried out by Ast and his team.

His bosses say these ideas have saved nurse time and improved care in spite of the shortage.

“It’s pretty simple how we can help,” Ast said, leaning back in his chair in his blue scrubs. “We’re nothing special compared with any other nurses, but we specialize in placing IVs, so we get really good at it. It’s not easy to place an IV, so a nurse on rounds might take 30 minutes to find and gather all the materials, then find the vein, then place it.

“I can do it all in 10 minutes or less.”

Saad Ehtisham, the senior vice president and chief nursing officer for Via Christi Wichita Health Network, said the IV team and other specialist teams created at Via Christi have become invaluable at a time when the vacancies have left hospitals 8.8 percent short of the registered nurses they need.

Click here for the full story.

Fresenius acquire APP

Fresenius will acquire APP Pharmaceuticals, the US manufacturer of intravenous drugs, for $3.7 billion (£1.9 billion) in a deal that will help the German dialysis specialist break into the American market.

APP, the second-largest maker of intravenous generic drugs in the United States, will complement Fresenius’ Kabi unit, a global supplier of infusions and gastric tube feeding equipment, which so far has lacked a U.S. presence.

APP shareholders will receive $23 a share in cash, a 29 per cent premium to the last closing share price.

Follow the link for the full story in the Times or here for Forbes.

FDA update on heparin

The FDA have recently released a video update on the contaminated heparin issue.

Over the past several months, FDA has been alerting healthcare professionals and the public about medical products that may contain contaminated heparin, which has been associated with a number of serious adverse events. Here is an update and recommendations on this continuing issue.

If the video does not show click here.

FDA update page here.

 

 

Vascular access infection control

This article highlights the importance of education in infection prevention. The authors illustrate that procedures may be common place, however they discover that the delivery of education related to vascular access and infection prevention is limited.

Higgins, M. and Evans, D.S. (2008) Nurses’ knowledge and practice of vascular access infection control in haemodialysis patients in the republic of ireland. Journal of Renal Care. 34920, p.48-53.

Abstract:

“Vascular access hygiene is an integral component of haemodialysis care. Ensuring nurses possess sufficient knowledge and utilise recommended guidelines on infection control is essential for safe practice and patient safety. The study aimed to investigate nurses’ knowledge and practice of vascular access infection control among adult haemodialysis patients in the Republic of Ireland. A confidential self-completion questionnaire was sent to all 190 qualified nurses employed in nine haemodialysis units in the Republic of Ireland, which assessed knowledge and behaviour in infection control. Although 92% of respondents reported that policies had been developed by their units and 47% had received infection control education in the previous year, knowledge and adherence to best practice demonstrated significant scope for improvement. The study recommended the development of standard guidelines and regular reviews and updates of policies. Systems should also be developed to ensure a high level of compliance” (Higgins and Evans 2008).

Neonatal procedure pain

A paper in JAMA examines painful and stressful procedures in neonates cared for in Parisian intensive care units, and comes to the conclusion that on average, each baby undergoes about 10 painful procedures a day, the majority with no analgesia at all. Many of these are repeated failures of common procedures such as insertions of intravenous cannulas or central catheters. The authors acknowledge the difficulties of effective analgesia in neonates, but suggest that the evidence that early pain can have lasting consequences means ICU staff need to think carefully about the risks and benefits of ‘routine’ practices

Carbajal et al (2008) Epidemiology and Treatment of Painful Procedures in Neonates in Intensive Care Units. JAMA. 300, p.60-70.