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The sky is the limit...

Intravenous Nursing New Zealand's 15th conference at the Air Force Museum of New Zealand in Wigram Christchurch was appropriately titled "The sky is the limit for collaborative care in infusion therapy. " As always this conference offered a range of inspiring local and international speakers with both a broad and narrow focus on infusion therapy and collaborative practice. This report shares some of those presentations.

New Zealand Health Strategy

Dr Jane O'Malley, Chief Nursing Officer with the Ministry of Health, offered insight into the refreshed New Zealand Health Strategy to be released later this year. The strategy is the result of widespread consultation and offers both a health and social focus with better integration of services to empower people to manage their own health and 'live well, stay well and get well'. Nursing is key to addressing health priorities, especially at primary care level, and Dr O'Malley also discussed strategies to strengthen the New Zealand nursing workforce including the trialling of the new nurse practitioner training programme and the growth in the number and employment of new graduate nurses.

Collaborative practice

Dr Maggie Meek is a neonatal consultant and Clinical Education Advisor at the University of Otago, with a particular interest in collaborative practice and the use of simulation as a training tool. Dr Meeks emphasised that collaborative practice takes practice and a realisation that even the most highly trained and conscientious of us will still make a mistake at some stage. The performance characteristics of humans are such that it is part of our makeup.

The types of error and the circumstances under which they are more likely to occur can be predicted and as a collaborative healthcare team, including the patient and their family in the team, we need to be vigilant on behalf of each other--not to prove our own worth but in a humble way to value the worth of our colleagues. As well as the 'human' propensity for error it is also important to recognise our own specific risk pattern. Communication is a significant factor when things go wrong and the language used has features specific to personalities, professions and departments. We must ensure that the message we intended is the message that was received--which also takes practice. Dr Meeks vividly illustrated her points with personal anecdotes from her home and clinical practice.

Keynote address

Key note speaker Dr Lisa Dougherty is The Clinical Nurse Specialist / Manager of IV services at the Royal Marsden Hospital National Health magazine (the conference programme).

Service Trust, London. Lisa emphasised the importance of research and evidence to inform our standards and guidelines.

Medication administration errors represent one of the major concerns in patient safety and Lisa's doctoral research looked at decision making during IV drug administration. For every medication administration error detected, 100 go undetected. Errors can occur at any stage of the preparation and administration but the most common and basic fault observed was failure to check the patient identity and the impact of interruptions and distractions. Lisa noted that pilots come to work knowing if they make an error they may crash. Nurses come to work assuming that they will not make a mistake. Equally importantly there needs to be a no-blame culture to encourage reporting.

Recommended Strategies for Reducing Errors

* Engaging with patients

* Use of technology such as smart pumps and drug error software

* Reducing interruptions and distractions

* Assessing and auditing competency

* Acting as role models

* Changing nurses attitude to patient identification and the bedside check

Research results

Professor Claire Rickard the Founder and Head of the Alliance for Vascular Access Teaching and Research (AVATAR) Group at Griffith University in Brisbane, Australia and her colleague Gillian Ray-Barruel presented the preliminary results from a number of their studies. Research confirms that peripheral intravenous cannula should only be changed when clinically indicated but the following SITED acronym should be used:

Is the cannula:

S Still needed?

I Infected?

T Tolerated but with pain with pain being the number one indicator of failure

E Effective or still working?

D Dressing clean dry and well secured?

Claire recommended practice guidelines be changed to reflect the use of clinical indicators. More education is needed, along with use of standardised phlebitis scales.

Their research evidence also confirms the use of 20 gauge 30mm IV cannula with placement in the forearm ideal in the hospital ward setting. A cannula placed in the antecubital fossa, followed by the hand has a much higher level of failure.

IV therapy

Five speakers from the Christchurch region presented a range of topics related to IV therapy which reflected an enviable level of collaboration across their various services.

Rachel Haldane from Nurse Maude District Nursing Service talked about the establishment of the New Zealand's first community-based infusion centre. A change of approach was required to manage the increasing numbers of diverse patient referrals, often with complex needs, reduced hospital stays, but a static nursing resource. In the aftermath of the Christchurch earthquakes, patients often had marginal living conditions and travel and home visiting for the nurses was difficult with road closures and conditions. The infusion centre has enabled safer more efficient treatment for many patients within their existing nursing resource.

The inspirational Elizabeth Culverwell is the IV nurse educator for the Canterbury District Health Board (CDHB) with portfolio responsibilities covering all aspects of Central Venous Access Device (CVAD) and peripheral IV cannulation. In addition she has developed in collaboration with the radiology nurses vascular access team a Central Venous Catheter Insertion Training Manual for Registered Nurses who insert Peripherally Inserted Central Catheter (PICC), Tunnelled PICC and Tunnelled Chest Inserted Central Catheters (CICC). She has also facilitated the credentialing process for nurses involved in the insertion of PICC and tunnelled catheters. Elizabeth looked at the challenges around effective securement of PICC to prevent movement and migration of the catheter during therapy. The team trialled the use of a PICC subcutaneous securement system in a busy surgical ward, which had experienced frequent issues with catheter migration in the past. A robust education plan was provided for the radiology nurses placing the PICC and ward staff involved in the dressing, care and use of the lines. None-the-less Elizabeth indicated 'that change is painful' and it is essential to factor in the learning curve as not surprisingly all device-related issues occurred in the first month of trial. Consistency for insertion, management and removal is critical.

Steve Cotterell is a nurse in the Christchurch Hospital Radiology Department and has been inserting PICC catheters for the last 17 years. He is one of the nursing team specialising in paediatric PICC insertions. Steve discussed his experience to date in placing Chest Inserted Central Catheters (CICC). This technique of placing long term tunnelled catheters in the subclavian or internal jugular vein followed his attendance at the latest World Congress of Vascular Access (WoCoVA) conference held in May 2015 in Hong Kong where this technique was common.

While tunnelled central catheter insertion carries additional challenges for the inserter and increased risk of trauma for the patient, it does offer an alternative option for patients with anatomically small vessels, previous vessel stenosis or thrombus development, and for trauma such as burns where long term access is required. By introducing this new method into their practice the Christchurch team hope to offer their patients an individualised approach to selecting the right vascular access device the first time.

Wendy Jar is a Clinical Nurse Specialist in the Bone Marrow Transplant Unit at Christchurch District Health Board (CDHB) and is also involved in the on-going evolution of Central Venous Access Device (CVAD) management. This latter role includes collecting data on all the PICC inserted into haematology patients and reviewing what happens to these lines.

At the beginning of 2013 a new double lumen power injectable PICC was introduced to the hospital and PICC lines also began to be inserted into patients undergoing stem cell rescue instead of Hickman catheters. In the first few months following these changes a number of patients were developing an upper arm clot or thrombus and it was initially unclear if this was the result of the new PICC or increased use of these lines.

Through a process of research and auditing it was noted that while the new PICC do carry a higher risk of thrombosis, the incidence decreased as the radiology nurses gained experience inserting the lines. It was also determined that patients with blood disorders carry 4-8 per cent higher risk of thrombus formation because of their underlying conditions and that deep vein thrombus occurring within the first week of PICC insertion relate to the insertion process. Research also found that there was no evidence to support the immediate removal of the PICC if thrombus formed, as had been done in the past. Collaboration across the hospital services has been critical in investigating and overcoming these sorts of issues.

Standardised IV administration

Neil Hellewell, is a nurse educator at the CDHB Professional Development Unit and a specialist in developing on-line education resources. Neil's presentation entitled "It's like herding cats" described the challenges, but ultimate benefits, of developing a standardised South Island wide competency assessment approach to IV administration which met the needs of staff from any clinical area. This involved finding a way to work collaboratively across a large geographical area and range of specialties.

A series of on-line modules are being developed which will ultimately cover all aspects and routes of medication administration. Specific areas can select and combine modules to suit the required competencies of their staff. It also allows nurses to move seamlessly between hospitals without having to repeat training unnecessarily. This approach not only standardised assessment processes and reduced duplication but has helped build relationships and develop systems for future educational opportunities.

IVNNZ once again provided a fascinating, thought-provoking programme with the South Island DHB very much leading the way in terms of team work and collaborative practice.

Shona Matthews RN, BN, MHsc (Hons)
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Title Annotation:conference on collaborative care in infusion therapy
Author:Matthews, Shona
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Geographic Code:8NEWZ
Date:Jun 1, 2016
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