INSider January/February 2024 by InfusionNursesSociety

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JANUARY/FEBRUARY 2021

T H E O F F I C I A L M E M B E R S H I P N E W S P U B L I C AT I O N O F I N F U S I O N N U R S E S S O C I E T Y

Finding the Light: Healthcare Is Human

INS Overseas: Saudi Arabia

Challenges for Vascular Access in Patients with Subcutaneous Emphysema

JANUARY/FEBRUARY 2024

Message from Chris Hunt, CEO VOLUME 7 • ISSUE 1

INFUSION NURSES SOCIETY

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In this Issue 3

CEO Message: A Fresh Beginning

Cover Story: Finding the Light

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Chris Hunt, MBA

Renée K. Nicholson, MFA

Case Study: Challenges for Vascular Access in Patients with Subcutaneous Emphysema Britt Meyer, PhD, RN, CRNI®, VA-BC, NEA-BC, Chris Halpern, RN, PMD, Zachary Tulin, RN, David Walker, RN, BSN

INS Overseas Part 2: Saudi Arabia Marlene M. Steinheiser, PhD, RN, CRNI®

SOP Virtual: TAOOs

Intravenous (IV) Push Medications Bridging the Gap Between Education and Clinical Practice

Incident Reports: A Safety Tool Nurses Service Organization

INSide Scoop Keep informed on things happening within INS

Welcome New INS Members Domestic and International

INS Learning Center

C E O

M E S S AG E

A Fresh Beginning by Chris Hunt “Happy New Year. Out with the old, in with the new, may you be happy the whole year through.” This classic greeting card message that accompanies the start of a New Year symbolizes a fresh beginning as well as a glance back at what previously took place. As INS looks back at the successes enjoyed during our 50th anniversary in 2023 and looks ahead to the exciting activities we have planned for 2024, I can’t help but feeling that the greeting card message was developed with INS in mind.

membership recruitment and retention programs, a Journal of Infusion Nursing manuscript acquisition plan, and a brand awareness program through the LEARNING CENTER and you have an outstanding and jam-packed 2023. But that’s not all! The proverbial cherry on top was revising Infusion Therapy Standards of Practice along with the Policies and Procedures for Infusion Therapy family of resources on a 3-year schedule versus the Chris Hunt, MBA normal 5-year schedule. The time, effort, expertise, and dedication that A celebration of our 50th anniversary, highlighted went into these revisions have enabled us to publish by a tribute to INS past presidents during the these unique and indispensable educational opening session at INS 2024 in Boston, gave us the resources this month, in January 2024. opportunity to reflect on our accomplishments and how we have shaped the specialty practice of There is a sign that hangs in my office that says, infusion therapy. As has been the case throughout Don’t Look Back... You’re Not Going That Way. our history, our successes have materialized I glance at it from time to time to remind myself that because of the support we have received from you, although INS has accomplished much in its 50-year our members. Your passion and commitment to our history, there is always more to do. The most important specialty is a major motivation behind the work we aspect of reflecting on the past is doing so as a means do. Nowhere was this more evident than during our to plan for the future. The constant that has existed golden anniversary annual meeting. The buzz that throughout the history of INS is our commitment to emanated from the meeting rooms, exhibit hall, and change, flexibility, strategic planning, and growth. the corridors of the Sheraton Boston Hotel was We wouldn’t be where we are if we didn’t constantly palpable. It was exciting to see and feel the support look forward. you have for INS, your specialty, your colleagues, As INS rings in a New Year, we do so with a and your patients. commitment to accepting the challenges and hard While this celebration was the most visible, it was work that always lie ahead. We also offer a by no means the only activity taking place in 2023. commitment to never stop working on behalf of our The development and delivery of educational members and the infusion community. We have programming through webinars and virtual reached this point in our journey because we have offerings provided a steady stream of valuable never wavered from our focus to be THE voice for infusion education. Record numbers of clinicians infusion therapy and for you. It is a challenge we fully participated in these programs and provided embrace and hold dear. As we move into 2024 and valuable feedback for future programming. all that it holds, we invite you to continue to join us Combine that with strategic initiatives such as on our journey.

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Finding the Light: Healthcare Is Human by Renée K. Nicholson, MFA Over the past 18 months, I’ve become well acquainted with the oncology unit situated on the sixth floor of the Berkeley Medical Center (BMC) in Martinsburg, West Virginia. Once a month, I trail Ryan McCarthy, MD, and portrait photographer, Molly Humphreys, through the halls of the hospital. People do not seem to find it odd that Dr. McCarthy has a photographer and a writer in tow; in fact, they say hello, and seem genuinely happy to see the team from Healthcare Is Human, a project dedicated to authentic storytelling in health care. When we arrive at oncology, we sit with a young nurse, Rachel Mattherly. From Fairmont, West Virginia, about three hours southeast of Martinsburg, Rachel came to the Eastern Panhandle of her home state during the COVID-19 pandemic. When we spoke with her about what it was like to graduate during the pandemic, she described online clinicals and fear of the pandemic looming over the heads of her nursing class. “We didn’t even get a pinning ceremony or a graduation,” Mattherly said. For those students who graduated from nursing school in 2020, the pandemic was all they knew at the start of their careers. But Mattherly also spoke of how graduating into the COVID health crisis gave her a backbone, a sense of survival, and a perspective that has since served her well as an oncology nurse. It’s these conversations that make Dr. McCarthy’s Healthcare Is Human program so authentic. He gently prompts his colleagues at the BMC to unlock their own stories in their own words, then these recorded stories are paired with Molly Humphreys’s photographs, so that listener-viewers come to know the workers of the BMC in a relatable, community-oriented way.

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After nearly a decade spent collecting stories with cancer and HIV patients, I came to know Ryan McCarthy in 2021 through my work as the Humanities Center director at West Virginia University, where we incorporate a practice known as narrative medicine. “The care of the sick unfolds in stories,” says Dr. Rita Charon, who founded narrative medicine, a discipline in which health professionals, literary scholars, and artists collaborate in order to recognize, absorb, interpret, and act on the stories of illness as a means of treating the whole patient, not just their diseases. Rachel Mattherly attended nursing school in her hometown, at Fairmont State University, and when she came to the BMC, the small-town feel of Martinsburg made her feel at home in this new place. The BMC’s in-patient oncology unit is small—only 8 beds—and this has allowed her to form connections with her patients. “We want those connections,” Mattherly said. “It’s a big part of why I choose to work at the BMC.” A Shepherdstown native and a high school friend of Ryan McCarthy’s, Molly Humphreys supplies the “real-world” glimpse of health care workers like Rachel Mattherly in their typical surroundings. While the fluorescent lighting of the hospital can often cause challenges to her as a photographer, Humphreys’s skill allows her to work in conditions that are often not optimal, and enhance her goal to capture her subjects as authentically as possible. Often, Humphreys will converse with the subjects of her photos, similar to McCarthy’s gentle prompting, helping these professionals to forget the camera’s lens. Her methods put those photographed at ease and also allows Humphreys a special insight into the lives of these workers. The results help us to understand better the lived experiences of these people who work at the BMC, and those working in health care writ large.

RACHEL MATTHERLY

“Prior to the pandemic, I photographed in what I call ‘the bubble of happy,‘” Humphreys says to me. She photographed graduations, proms, weddings, and other joyous events. “But here, I’m trying to show the ‘realness’ of these situations.” In the early days of the COVID pandemic, McCarthy contacted Humphreys about photographing health care workers to document the story from a uniquely West Virginian perspective. He’d recently learned about podcasting from a local sound engineer, Kym Mattioli, who he knew from coaching her son in high school cross country. Mattioli, once a local radio DJ, coached McCarthy through how to collect stories using a portable microphone. McCarthy will often begin his stories with “Hi, Kym,” followed by a few notes about the person he’s speaking with and where he’s speaking from, before launching into the formal opening of the segment. Although these touches

Listen to Healthcare Is Human Stories Here!

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are edited out for the podcast, they remind me that this is a project about a community of health workers by professionals from the local community, a forging of connections that make the whole enterprise work so well. Because I spent 2 years collecting patient stories at the West Virginia University Cancer Institute in Morgantown, I find myself particularly drawn to the stories from BMC’s oncology nurses. Although BMC is a WVU Medicine–affiliated hospital, the scale is much smaller than the academic medicine hub in Morgantown. Still, there have been moments where these professionals have reminded me of the nurses I worked with, like when Rachel Mattherly said about oncology patients, “We keep a piece of our patients in our hearts.” In another episode, McCarthy talks with Adriana Palmer, now a nurse manager in telemetry, whose career was greatly influenced by the oncology service at BMC. In 2002, Palmer lost a friend to a rare form of brain cancer, which prompted her to volunteer in the oncology unit where her mother worked. “Before that, I thought I was going to do something in special ed,” Palmer said, but the experience with her friend and her volunteer efforts led her in the direction of health care. Palmer added that this work was a natural outlet for her love of her community. A Martinsburg native, Palmer’s life literally started at the BMC, where she was born, and where she has worked for the past 20 years. Adriana Palmer thinks that the virtues that make Martinsburg, West Virginia, compelling—the outdoorsy focus of many of its residents, the local apple orchards, the friendly and hardworking people who make up its ADRIANA PALMER population—spill over into the hospital’s approach to patient care, which she describes as “opening our arms to you.” There is a community spirit captured in the stories that make up Healthcare Is Human, a collage of voices that embody the community spirit of West Virginia’s Eastern Panhandle, and these voices build trust. Palmer’s story has some crossover with Ryan McCarthy’s. Like her, McCarthy lives and works in his hometown, having returned after attending West Virginia University as an undergrad and WVU School of Medicine to become a doctor. In many ways, Healthcare Is Human is a love-letter to his hometown and to the BMC. Still, he sees the project as something that could spread beyond the walls of the hospital and beyond the borders of this state. “I think these approaches are teachable and portable,” says McCarthy. He’s quick to add that different communities can adapt the approaches that he, Humphreys, Mattioli, and others have developed around the culture at the BMC.

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Beyond making “feel-good” stories, Healthcare Is Human has real-world health care impact. As many outlets have reported, burnout among health care workers is a significant problem, not only in West Virginia, but nationwide. What keeps someone happily employed in a health care position for 40 years, like Adriana Palmer’s mother, also a nurse? It’s partially the spirit of community captured in these stories, now collected and broadcast through the Healthcare Is Human initiative. The project helps to share the collective values of this health care community, such as when Palmer describes it simply as “get the job done and make people happy” or a younger nurse, Mattherly, spoke of the oncology unit as “my home.” While the Healthcare Is Human project started as a way for McCarthy to feel more connected to his coworkers during the dark days of COVID, the project itself continues to have staying-power. Perhaps we have an innate human need for stories to make sense of the world. This is especially true in health care, which can often feel like an impersonal system, both for patients and for providers. There are also many workers behind the scenes who aren’t always considered “health care workers” but who keep the BMC running effectively: janitors, cafeteria workers, security guards, and clerks, just to name a few. McCarthy has intentionally included these workers’ stories in the Healthcare Is Human project because their work is vital to the health of the organization as a whole. He will often explain that he didn’t interview another doctor for the first year of Healthcare Is Human because he wanted to shed light on these other undervalued roles, the hidden stories of the health world. Because the podcast captures a vast array of health NATALIE SMITH care workers through the context of their workdays, and because we listen to these stories in the workers’ own voices, the Healthcare Is Human project is authentic, meeting people where they are at, both literally and figuratively. McCarthy told me that many of the people he interviews will share the podcast with their families to help them better understand not only what they do for work but why they do the work. And Humphreys’s accompanying photographs not only convey deep emotion, but also provide context to the stories of Healthcare Is Human. While it might be easy to downplay one’s work as “just doing a job,” the artistic way Humphreys presents health workers at the BMC elevates them to subjects of art, which also elevates the worth of the work they do. In this way, portrait photography plays a key role in the narrative experience, inviting close attention and study, in line with the processes at the center of narrative medicine. Back on the 6th floor, McCarthy spoke to Natalie Smith, a nurse on the transplant service, a selfdescribed foodie and self-taught crafter (thanks to YouTube videos). You immediately encounter

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her playful nature through her badge clip, which says, “Hello, My Name is: Hey, Nurse!” A joy spilled out of their conversation, a shared discussion of the role of creativity in health care. The two met during COVID in the busy and stressful ICU. Both McCarthy and Smith agreed that creative pursuits were a kind of self-care. Humphreys photographed Smith in the break area, her glue gun in hand, a smile wide across her face. “It gives me something to look forward to,” Smith said. “You gotta have some fun and branch out. I have sparkly art supplies waiting.” McCarty playfully calls these “Natalie’s art buffet.” Smith has made items for coworkers and patients, and she has encouraged her coworkers throughout BMC to find their own creative outlets. Full of spunk when it comes to her crafts, she turns her “to-do” lists into “ta-da” lists. “I’m called to take care of people, but I’m a patient too,” she said. Smith then described nursing as requiring a “pouring out for patients.” With a grin that turned to laughter, she collapsed the idea of “pouring back into her” as “pour me!” She and McCarthy enjoy a good chuckle over that pun. And though the conversation is playful, its message carries a serious lesson about how feeding creative appetites helps providers stave off burnout and better serve patients. After another hearty laugh, Smith mused on the real benefits her crafting might have to her colleagues. “I think it adds a little light to their lives,” she said, and before he left, she pressed a pair of stick-on googly eyes to McCarthy’s nametag. Crafts aside, perhaps this duo has inadvertently found a way to describe the magic that is Healthcare Is Human. While the day-to-day work might test one’s resilience, these stories and the community they created sparks an inextinguishable light.

Listen to Healthcare Is Human Stories Here! Renée K. Nicholson is the author of Fierce and Delicate: Essays on Dance and Illness, coeditor of the award-winning Bodies of Truth: Personal Essays on Illness, Disability, and Medicine and the poetry collection Roundabout Directions to Lincoln Center. Winner of the Nassau Review’s Prize for Prose and past emerging writer-in-residence at Penn State–Altoona, she currently directs the Humanities Center at West Virginia University. 9

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Challenges for Vascular Access in Patients with Subcutaneous Emphysema Britt Meyer, PhD, RN, CRNI®, VA-BC, NEA-BC, Chris Halpern, RN, PMD, Zachary Tulin, RN, David Walker, RN, BSN

Introduction: Subcutaneous emphysema occurs when air or gas accumulates under the skin. The condition can be caused by trauma, infection, pneumomediastinum with mechanical ventilation, and other medical procedures. Subcutaneous air complicates vascular access by compressing and obscuring the vasculature. Complication risks such as pneumothorax or air embolism are increased when central venous catheter landmarks are obscured as well. Air accumulation under the skin presents as edema with crepitus. Attenuation is defined as energy that is lost as ultrasound passes through a medium. Acoustic impedance is the tendency of the medium to resist the passage of ultrasound. When air is present in the tissue, most of the ultrasound is reflected, creating artifact that makes underlying structures difficult to visualize and limits the utility of ultrasound for vascular access.1-4

Case: 71-year-old male admitted for thoracoscopy to remove a left upper lung pulmonary nodule. Pertinent history included hypertension, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, benign prostatic hypertrophy, cerebrovascular accident, and gastric reflux disease. The patient was hospitalized for 30 days after developing an air leak intraoperatively that was thought to have spontaneously resolved. A left apical pneumothorax was noted on post-op day (POD) 1 and a chest tube was placed in the ICU for subcutaneous emphysema. Subcutaneous emphysema worsened by POD 3 spreading to the face and eyes. Chest tube suction was increased and improvement was noted in chest area by POD 4. However, by POD 6 the patient’s subcutaneous emphysema had worsened to include the bilateral upper extremities. Increased oxygen demands and agitation necessitated a return to the ICU and lab samples were drawn from the patient’s foot. By POD 9, the patient remained in the ICU with slowly improving subcutaneous emphysema and the team continued to struggle with vascular access and lab sampling. On POD 10 an IV was placed in right wrist and the team considered using a traditional stick for PICC placement for lab sampling needs since there was limited ability to visualize vasculature on ultrasound. Figure 1 depicts ultrasound imaging of the superficial cephalic vein in the upper arm. Only small segments of the vessel were visible with manual manipulation of the skin to displace the air. Since the patient had no other need for central access, the team decided to defer PICC placement. By POD 11 the patient had worsening hypoxia and subcutaneous emphysema and 2 additional peripheral IVs were placed to facilitate lab sampling and infusions. On POD 22 the patient was returned to surgery to correct the air leak after conservative management failed. On POD 25, the chest tube was removed, and the patient was discharged on POD 30. Over the course of treatment, the patient had 12 separate peripheral IV insertions for infusion of fluids, electrolytes, amiodarone, and lab sampling.

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Procedural Challenges: • Inability to palpate or visualize peripheral vasculature leading to delays in lab sampling. • Higher risk of post insertion bleeding and air embolus particularly in tunneled catheters. • Higher risk of arterial inadvertent puncture. • Inability to obtain and maintain vascular access. • Need for additional help in gaining vascular access in the setting of agitation. • Inability to identify upper extremity vasculature on ultrasound (Figures 1-4).

Figure 1

Key Points and Recommendations for Future Research: • Choose the most appropriate site for vascular access in the setting of subcutaneous air. • Recognize that peripheral access may pose less of a risk of complications as compared to internal jugular or subclavian access depending on the amount of air and ability to visualize landmarks.

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• Utilize manual pressure with the ultrasound probe to move the air and optimize ultrasound imaging. • Use small gauge introducers for central venous catheter insertions. • Ensure appropriate vessel purchase for peripheral catheters, as air will move back into the space around the catheter after insertion. Longer catheters can prevent infiltration. • Vascular ultrasound probe frequency ranges from 6-15mHz. Our team would like to test lower frequency probes to determine if structure visualization would improve. • Development of a “pushing” type tool as an attachment to the front of the ultrasound probe may assist in moving the air and visualizing underlying structures.

Figure 3

References: 1. Kubodera T, Adachi YU, Hatano T, Ejima T, Numaguchi A, Matsuda N. Subcutaneous emphysema and ultrasound sonography. J Intensive Care. 2013;1(1):8. doi:10.1186/2052-0492-1. 2. Verniquet A, Kakel R. Subcutaneous emphysema: ultrasound barrier. Can J Anaesth. 2011;58(3):336-337. doi:10.1007/s12630-010-9435-98. 3. George M, Lane J, Vachharajani TJ. Challenges with tunneled dialysis catheter placement with subcutaneous emphysema [published online ahead of print, 2022 Mar 27]. J Vasc Access. 2022;11297298221085421. doi:10.1177/11297298221085421 4. Practice guidelines for central venous access 2020: An updated report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020; 132(1):8-43.

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Part 2: INS in Saudi Arabia

by Marlene Steinheiser, PhD, RN, CRNI®

It was an honor to be invited to represent the Infusion Nurses Society (INS) at the 10th International Nursing Conference organized by King Faisal Hospital and Research Centre (KFSHRC). The conference, in collaboration with Sigma Theta Tau International, was held November 27-29, 2023 in Jeddah, Saudi Arabia. After about 6 months of preparation, including many early-morning Zoom meetings, I joined 400 nurses from around the Gulf region—Oman, the Kingdom of Saudi Arabia (KSA), Qatar, and United Arab Emirates—and the world, including the United States, Canada, South Africa, and the United Kingdom.

Betty Bell AlBeladi and Dr. Marlene Steinheiser

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Leadership from KFSHRC, Jeddah opened day one of the conference: Ms. Alanoud Abualsaud, Chair, Scientific Committee; Dr. Nasser Mahdi, General Manager; Dr. John Sedgewick Chair, Organizing Committee; and Dr. Kathy Sienko, Executive Director, Nursing Affairs. Following our first keynote address, we were treated with a musical interlude by the Nurse Choir and Students of British School Jeddah. It was then time for my keynote address entitled “Transforming Your Infusion Therapy Practice to Improve the Patient Experience.” I described the evolution of infusion therapy practice; the significance of infusion therapy continuing education, certification, and the INS Infusion Therapy Standards of Practice; and how improving key performance indicators related specifically to peripheral intravenous catheters can produce positive outcomes and enhance the patient’s experience. This presentation generated

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the audience’s interest in infusion nurse certification, quality improvement across health systems, implementation of the Standards, and continuing education resources offered by INS. I was excited to hear how the INS Infusion Therapy Standards of Practice are being implemented in the Kingdom as well as regionally and internationally. Equally important was the opportunity to share the significance of the Standards with those who were unfamiliar. Immediately following the keynote session, I led a small group workshop focusing on 1) vascular access device (VAD) access and Aseptic Non Touch Technique (ANTT®), 2) VAD technology to improve first cannulation success, and 3) VAD care and management, applying ANTT® principles. I appreciated the hospital’s nurses, the CRNI®s, and the BD representatives who assisted me with the INS workshop aimed at advancing the attendees’ infusion therapy clinical skills. During my visit I met Mahasen Juaton, KFSHRS, Jeddah nurse educator, who is leading a program of study for 12 KFSHRC nurses signed up as CRNI® candidates for the September 2024 exam. It was exciting to see these nurses’ investment in advancing their expertise in infusion therapy.

Dr. Mohammed G. Alghamdi and Dr. Marlene Steinheiser

It was truly an amazing experience meeting and getting to know each of the other keynote speakers: Dr. Sandra Garmon-Bibb, President, Sigma Theta Tau International; Dr. Michelle Acorn, Chief Nurse,

Mosque in Old Town Balad

Hadeel Niaz, Dr. John Sedgewick, Maisa Salamah, Alanoud Abulsaud, Dr. Sandra Garmon Bibb, Dr. Kathy Sienko, and Dr. Marlene Steinheiser.

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Nursing and Health Policy for International Council of Nurses; Dr. Reynold R. Rivera, Director, Nursing Research and Innovation, New York Presbyterian; Dr. Shanina C. Knighton, Associate Professor, Frances Payne Bolton School of Nursing; Dr. Monir Almotairy, Director, College of Nursing Research Center and Assistant Professor, Nursing Administration and Education Department, King Saud University; Ms. Hera Tashjian, Chief Nursing Officer, Al-Moosa Hospital, Saudi Arabi; and Dr. Mohammed G. Alghamdi, Director General Nursing Affairs, Ministry of Health, and President, Saudi Nurses Association. We not only learned clinical pearls from each other but came to know one another during our 4 days together experiencing the area and learning about the culture of the KSA. Our evening in Al-Balad taught us about the history of Jeddah as we strolled the cobblestone streets, passing a historic mosque during evening prayer time. During our cultural gala dinner, we were all encouraged to learn customary dances of the KSA. The Thought Leadership workshop led by Ms. Nada Masoudi, Chief Nursing Officer, International Medical Centre, Jeddah, KSA, invited key nursing leaders to discuss current challenges in nursing. The workshop was conducted following a survey of local, regional, and international nursing leaders. The 123 responses provided themes for our discussion. We found that nursing challenges are universal across the globe: safe staffing, recruitment and retention, health care transformation, nursing health and well-being, and leadership development. During the conference, on-site interviews with 16 staff nurses validated the accuracy of the leadership group’s identified themes and challenges. The work of Ms. Masoudi will continue regionally as she works with key stakeholders to address these issues. It interested me that there is no scope of practice defined for the KSA, that Above: Plenary Session instead organizations determine the Below: Nurse Choir and Students of British School Jeddah level of practice for their nursing staff. In the United States, scope of practice varies between states, but there is a scope of practice in each state. I am excited to continue cultivating the connections made during this workshop: several nurses from Oman, KSA, and Qatar expressed interest in infusion nurse certification and implementation of the Standards as well as in the development of specialized infusion/vascular access teams. I look forward to our future global Zoom strategy meetings across the Gulf region.

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Finally, I would like to especially thank Dr. John Sedgewick and Dr. Kathy Sienko for the invitation to present as well as the entire KFSHRC scientific and social committees for hosting and guiding me during my stay. Words cannot describe the gratitude I have for everyone’s kindness and hospitality. We spent only 4 short days together, but Rawan Atequallah Alsolami, one of our social hosts and KFSHRC head nurse, summed up the feeling of our visit when she said, “We have broken bread together. We are now family.” It was truly an amazing conference and opportunity to experience the Bride of the Red Sea, Jeddah!

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Workshop Session

Mahasen Juaton, Dr. Marlene Steinheiser, Joy Barrios, and Tercilly Lim

Rawan Atequllah Alsolami, Dr. Marlene Steinheiser, and Wesel Jamal Assiri

January/February 2024

On February 8-9, join us for a deep dive into the 2024 INS Infusion Therapy Standards of Practice. This 2-day symposium will provide a comprehensive overview of the revisions introduced in the 9th edition. The sessions will be as follows:

Session 1 INS 2024 Standards and Application to Clinical Practice Speakers: Lisa Gorski and Barb Nickel Session Description: The Infusion Nurses Society Infusion Therapy Standards of Practice have provided evidence-based guidance to promote optimal patient outcomes for decades. Due to the growing body of evidence to support infusion therapy practice, the INS Standards transitioned from a 5-year cycle to a 3-year cycle and improved the methodology of this review. The 9th edition of the Standards includes hundreds of references in support of the 66 independent yet coordinated Standards. This presentation will describe the scope and methodology of Standards revisions and the process used to evaluate the evidence supporting a specific Standard, and will then demonstrate the use of the Standards to inform two areas of clinical practice: vascular access device (VAD) removal based on clinical indication and VAD site protection.

Learning Objectives:

At the conclusion of this session, learners will be able to: • Describe the scope and methodology used to revise the INS Infusion Therapy Standards of Practice. • Describe the process for evidence and content review and revision of a selected Standard. • Demonstrate application of the Standards to inform selected clinical practice questions.

Session 2 The 2024 INS Standards: Focus on Patient Safety Speakers: Michelle DeVries and Lisa Gorski Session Description: Patient safety is a fundamental concept covered throughout the 2024 edition of the INS Standards. This session will specifically focus on key points regarding safety in vascular access devicerelated infection, phlebitis, and pain management for venipuncture and vascular access procedures as well as briefly discuss standard precautions, transmission-based precautions, and Aseptic Non Touch Technique (ANTT®). In this session, the speakers will introduce and provide an overview of these Standards with a focus on the practice recommendations.

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Learning Objectives:

At the conclusion of this session, learners will be able to: • Describe strategies designed to reduce the transmission of infectious agents between health care workers, patients, and the environment. • Describe recommendations to reduce the risk for phlebitis. • Summarize recommendations for assessing and addressing pain management in adult as well as pediatric populations.

Session 3 The Three New 2024 INS Standards Speakers: Barb Nickel and Lisa Gorski Session Description: Three new Standards were added to the 2024 edition of the INS Infusion Therapy Standards of Practice: Drug Diversion in Infusion Therapy, Vasopressor Administration, and Home Infusion Therapy. The literature supporting the addition of these new Standards include increased reports of drug diversion and the need to employ practices to reduce this risk, an increase in peripheral vasopressor infusions, and the significant growth in home infusion therapy. In this session, the speakers will introduce and provide an overview of the new Standards with a focus on the practice recommendations.

Learning Objectives:

At the conclusion of this session, learners will be able to: • Describe strategies designed to prevent and/or detect drug diversion in infusion therapy. • Describe recommendations for safe administration of vasopressors when considering vascular access device planning and reducing the risk for infusion-related complications. • Summarize recommendations for safe practice when planning and providing home infusion therapy.

Session 4 Vascular Access Device Management and Infusion Administration Speakers: Tricia Kleidon, Samantha Keogh, Barb Nickel Session Description: The INS Infusion Therapy Standards of Practice provides important guidance on the maintenance of vascular access devices (VADs) to promote optimal VAD function. Once the VAD is placed, evidence-based strategies assist in safe and accurate delivery of infusates and prevention of complications such as phlebitis, catheter dislodgement, occlusion, and catheter-related bloodstream infection. This session will provide an overview of four important Standards addressing VAD management: VAD and arterial catheter securement, flushing and locking, needleless connectors, and administration of medications and solutions.

Learning Objectives:

At the conclusion of this session, learners will be able to: • Describe evidence-based strategies for arterial catheter, peripheral, and central VAD securement. • Discuss flushing and locking techniques to promote patency and reduce infection risk. • Describe the current evidence guiding management of needleless connectors. • Identify strategies to provide accurate dose delivery of infusion medications and solutions.

Session 5 Implement and Innovate the INS 2024 Standards Speakers: Lisa Gorski, Barb Nickel, Tricia Kleidon, Samantha Keogh, Chellie Devries Session Description: The INS 2024 Standards guide infusion therapy practice and apply to all clinicians, in all practice settings, and for all patient populations worldwide. In the other sessions, we learned from the Standards committee members about new evidence as well as about the revised and new Standards in this edition. How do we implement and innovate this new evidence? How do we advance our knowledge, skills, and competency within our scope of practice? In this session, the audience will have the opportunity to ask our panel of experts their clinical practice questions.

Learning Objectives:

At the conclusion of this session, learners will be able to: • Describe methods of INS Standards implementation. • Define scope of practice and clinical competency. • Discuss use of the Standards to inform clinical practice questions.

January/February 2024

Intravenous (IV) Push Medications – Bridging the Gap Between Education and Clinical Practice This article was first published on the Institute for Safe Medication Practices (ISMP) website on November 2, 2023. Reprinted with permission.

As the acuity of patients continues to rise, not only in inpatient settings, but also in ambulatory clinics, surgery centers, and infusion centers, ISMP is once again raising concerns about potential errors with the frequent use of intravenous (IV) push medications (often controlled substances or high-alert medications). These error types, which continue to be observed and received through the ISMP Medication Errors Reporting Program (ISMP MERP), are associated with unnecessary dilution, resulting in a potential for wrong concentrations, wrong doses, and/or the wrong rate of administration. Throughout the years, ISMP has conducted numerous surveys, as well as a national summit in 2014, that included interdisciplinary practitioners, academic faculty, regulators, and vendors, to address the risks of IV push medication use and labeling practices. The results of these endeavors painted a compelling picture of IV push workarounds and identified a general lack of knowledge about practices that placed practitioners and patients at risk. As a result, ISMP published the nation’s first IV push guidelines: ISMP Safe Practice Guidelines for Adult IV Push Medications as well as a tool to enhance safety: ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. These resources caught the attention of many practitioners, as well as two faculty members from Arizona. They recognized that they and their colleagues were not in alignment with these recommended guidelines that had the potential for a generational impact on our newest nurses. As a response, in 2019,1 they surveyed clinical nurse educators and bedside nurses to determine what clinicians were being taught and what the variations in IV push practices were

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across Arizona. The results demonstrated a lack of consistency in teaching IV push medication administration to Arizona pre-licensure nursing students. In 2019, these faculty members were awarded a Cheers Award in recognition of their work to advance a known medication safety issue. These researchers subsequently partnered with other interested faculty throughout the United States, the Infusion Nurses Society (INS), ISMP nurses, and a nurse from Fresenius Kabi to form a task force to conduct a repeat survey, expanding to nursing programs on the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) distribution lists. Similar to prior survey findings by the Arizona faculty, the task force identified a definitive lack of understanding concerning the risks associated with IV push medications, limited practice standardization, and the lack of a standard curriculum for instructing undergraduate students about safe IV push medication preparation and administration. Unsafe practices described included the withdrawal and subsequent administration of medications from prefilled syringes or cartridges, unnecessary dilution of IV push medications, and nurse preparation or manipulation of IV push medications at the bedside. In addition, it appeared to the researchers that some practices were learned either during pre-licensure education or during on-the-job orientation, thus perpetuating these unsafe practices. A key outcome of the task force’s work was the development of an IV push administration standardized practice checklist2 that addresses the noted areas of inconsistent education and clinical competency validation. The checklist was developed in accordance

INTRAVENOUS (IV) PUSH MEDICATIONS – BRIDGING THE GAP BETWEEN EDUCATION AND CLINICAL PRACTICE

with the ISMP Safe Practice Guidelines for Adult IV Push Medications and the Infusion Nurses Society 2021 Infusion Therapy Standards of Practice.3 The checklist is intended for use in all clinical practice settings with both student nurses during their clinical practicum and licensed nurses during orientation to the facility. Most importantly, it can be used to standardize practice between nursing programs and clinical practice sites. As a potential safety strategy, this checklist, and associated materials and resources, were submitted to the Quality and Safety Education for Nurses (QSEN), a group designed to set six core competencies in order to prepare future nurses with the knowledge, skills, and attitudes needed to improve the quality and safety of the healthcare system. The checklist was approved and adopted by QSEN and is also available on the INS website in the learning center. As a follow-up, and with interest to see if there had been adoption of these recommended guidelines, this past year the task force resurveyed nursing program faculty across the United States for implementation data on the use of these tools. Nearly 200 respondents, representing 37 states, completed the 2023 IV push education survey. While much emphasis has been placed on the improvement of IV infusion safety, there has been limited national advancement regarding standardized practices associated with IV push safety. Results of the latest survey follow.

restrictions. In programs where IV push competency is measured, students are allowed to push adult IV medications in the clinical setting, but only under faculty supervision (54%), or with a registered nurse (RN) preceptor employed by the facility (not the school) (18%). Other respondents indicated that it is never allowed (6%) at the facility or there were other circumstances (22%) that deterred it, or they did not know.

Learning to Dilute IV Push Medications Although diluting IV push medications is usually not recommended in product labeling, skills labs are often set up to simulate how to prepare and administer IV push medications, including with dilution. To practice adult IV push techniques, students often have access to vials (98%), glass ampules (72%), ready-to-administer syringes with simulated medications (60%), syringe-tosyringe transfer devices using prefilled syringes of 0.9% sodium chloride (42%), CARPUJECT cartridges (32%), and CARPUJECT holders (30%). While some commented that students are taught not to dilute IV push medications, others teach students to dilute adult IV push medications prior to administration for certain classes of medications and/or under certain circumstances, including the following:

• Opioids (45%) • Antibiotics (42%) • Small volume medications less than 1 mL (39%)

IV Push Competency Assessment

• Anxiolytics (27%)

Almost all respondents (95%) reported that within their nursing program, adult IV push medication preparation and administration are taught in the nursing skills laboratory (skills lab). A skills lab is a place where nursing students can practice nursing competencies and techniques in a safe environment under the guidance of their instructor. These labs help ensure that students are comfortable with the techniques and protocols for each task before they perform them with actual patients. Almost two-thirds (62%) reported that competency for IV push medications is determined using a combination of a skills lab evaluation checklist and an observational faculty evaluation in the clinical setting. For others, competency is assessed solely via a skills lab checklist (27%), or only by faculty in the clinical setting (5%). Unfortunately, some respondents (6%) reported that IV push competency is not assessed, or that students are not allowed to administer medications via IV push in the clinical setting due to facility

• Antiemetics (26%) • Cardiac medications (19%) • Reversal agents (e.g., flumazenil, naloxone) (5%) • Others (37%) (e.g., nitroglycerin, heparin, atropine, EPINEPHrine) Some respondents said they instruct students to only dilute if the medication requires a slow IV push, or to send it back to the pharmacy for preparation if further dilution is required. Students are taught to use a vial of 0.9% sodium chloride (38%), a prefilled syringe of 0.9% sodium chloride (28%), a vial of sterile water (11%), or other (23%) (e.g., solution indicated by drug reference, a combination of those previously listed). Fortunately, all respondents indicated that they do not teach students to withdraw fluid from an actively infusing IV bag of 0.9% sodium chloride. January/February 2024

INTRAVENOUS (IV) PUSH MEDICATIONS – BRIDGING THE GAP BETWEEN EDUCATION AND CLINICAL PRACTICE

Teaching Challenges When asked about challenges that impede teaching nursing students about safe practices for IV push medications, respondents frequently gave the following examples: • Lack of simulation capabilities • Inability to practice IV push techniques at clinical sites due to facility restrictions • Variation in safe practice techniques taught in the school compared to IV push techniques used by staff nurses at the clinical setting • Variation in technique to dilute IV push medications (e.g., use of vials during simulated learning but taught to use prefilled syringes of 0.9% sodium chloride in the clinical setting)

Use of Resources and Guidelines A survey question asked which resources students were expected to use when preparing and administering adult IV push medications. The following resources were identified: • Davis’s Drug Guide for Nurses (43%) • Lippincott's Nursing Drug Guide (10%) • Mosby’s Nursing Drug Reference (8%) • Micromedex (7%) • Lexicomp (4%) • Nursing 2023 Drug Handbook (3%) • Other (25%) (e.g., a combination of those above, hospital-specific formulary, Elsevier's 2023 Intravenous Medications Handbook for Nurses and Health Professionals) In a subsequent question, nearly two-thirds (63%) of respondents confirmed that they were familiar with the ISMP Safe Practice Guidelines for Adult IV Push Medications but did not mention if they used it as a resource. In addition, a question was asked if respondents had read the IV push administration standardized practice checklist2 found in QSEN and if they had incorporated it into the curriculum, or if barriers exist. Many respondents indicated that they

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would be adding the QSEN-approved checklist to their curriculum. However, other respondents shared several barriers such as inconsistency (turnover) among faculty and staff, lack of faculty who know and understand QSEN’s mission, and faculty who are hesitant to institute best practices into educational programs. Respondents also noted that some faculty are resistant to change and want to continue with the "this is how we have always done it" approach. Others responded that they were not aware that this checklist existed but would work on incorporating it or a curriculum revision was already underway.

Response to Survey Results The results of the 2023 IV push survey showed variations and gaps in the use of IV push evidencebased standards. In fact, results clearly demonstrate that the steps between understanding the evidence and actually implementing the best practices do not always take place. In response, the task force published IV push medications: An evidence-based practice guide4 in 2023 in the official journal of the American Nurses Association to foster greater awareness of this practice gap. The task force continues to disseminate the checklist among nursing programs and all healthcare organizations to promote adoption.

Conclusion While this survey queried nursing program educators about their IV push practices curriculum, healthcare organization educators and managers need to understand the background of what new licensees may or may not be learning and experiencing in regard to promoting safe IV push practices. If your organization provides clinical rotation sites for nursing programs, educators from each practice site should meet with the clinical instructors who will supervise the students to review the organization’s approach to IV push medication administration and the role of students. Clinical faculty should also review the organization’s medication administration policies and procedures, including IV push guidelines. In addition, instructors should be strongly encouraged to attend an orientation program (the same program that new hires attend) that covers the organization’s safety goals so they can reinforce safe practices during clinical rotations.

INTRAVENOUS (IV) PUSH MEDICATIONS – BRIDGING THE GAP BETWEEN EDUCATION AND CLINICAL PRACTICE

Staff educators within your organization should also: • Ensure that evidence-based guidelines and IV push practices are incorporated into policies and procedures. • Recognize that while new licensees may have had simulation experience with IV push medication use, the content may have been a far less significant portion of a new licensee’s experience in their undergraduate program. • Complete competency assessment and validation for IV push medications when hiring new staff. • Work with pharmacy and nursing leadership to purchase or have pharmacy prepare and dispense IV push medications in a ready-to-administer form as much as possible. • Instruct staff to: – Only dilute IV push medications when recommended by the manufacturer or in accordance with approved institutional guidelines. – Never dilute or reconstitute an IV push medication by drawing the contents into a commercially available prefilled flush syringe of 0.9% sodium chloride or any other prefilled, labeled syringe of diluent. – Never withdraw IV push medications from commercially available, cartridge-type (CARPUJECT) syringes or any other prefilled syringe into another syringe for administration. – Scan the barcode on the IV flush syringe prior to its use. While it may seem unnecessary to scan a saline flush syringe, given that it contains no active medication, there may be look-alike prefilled medication syringes that could be inadvertently administered as a flush solution and cause patient harm. – Administer all IV push medications and any subsequent flush solutions at the rate recommended by the manufacturer, supported by evidence in peer-reviewed literature, or in accordance with internal guidelines. – Provide practitioners who prepare, dispense, or administer IV push medications with ongoing information about associated risks and errors that have occurred in the facility and have been reported by external organizations, and strategies to minimize these risks. – Instruct staff to report errors, close calls, and hazardous conditions associated with IV push medications to external safety organizations such as ISMP for shared learning.

We thank Marlene M. Steinheiser, PhD, RN, CRNI®, Infusion Nurses Society; Candy Cross, MSN-Ed, RN, Chandler Gilbert Community College; and Denise Dion, MSN, RN, CNE, PCCN, Scottsdale Community College, for providing the survey results and for assisting with this article.

References 1. Cross C, Dion D, Hulsey M, Marks R. Evidenced based guidelines for intravenous push medications. Arizona Nurse. 2019;72(3):16. 2. Dorn LK, Campbell E, Dion D, et al. IV push evidence-based practice checklist. Quality and Safety Education for Nurses (QSEN). January 7, 2022. Accessed October 16, 2023. 3. Gorski LA, Hadaway L, Hagle ME, et al. Infusion Therapy Standards of Practice, 8th Edition. J Infus Nurs. 2021;44(1S Suppl 1):S1-S224. 4. Dorn LK, Steinheiser MM, Cross C, et al. IV push medications: An evidenced-based practice guide. Am Nurse J. 2023;18(4):27-30.

January/February 2024

INCIDENT RE PORTS:

A safety tool Nurses tend to cringe when they think about completing an incident report. Reasons for this reaction include the distress that occurs when something untoward has happened, anticipated loss of precious time to complete the report (particularly if the organization’s reporting system is cumbersome), and fear of being blamed for the incident or becoming embroiled in a court case. In this situation, it’s easy to forget that incident reports are a valuable resource for keeping patients safe. They also can keep employees safe by identifying system-wide problems such as insufficient staffing or equipment to move patients, which often contributes to staff injuries. So that patients and employees can benefit from an incident report, nurses need to understand their use. They also need to know how to complete and file a report correctly to protect themselves and their organization from the report being used as part of legal action in a lawsuit brought by a patient.

A safety tool

Incident reports provide a record of an unexpected occurrence, such as a fall or administration of a wrong medication dose, that involved a patient, a family member, or an employee. These reports can be used to identify areas of safety improvement and to educate others about how to avoid similar events in the future. Nurses should think of the incident report as a safety tool, not a method of assigning blame. Organizations should view these reports through the lens of a culture of safety, which The Joint Commission defines as “the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.” One tenet of a just culture is to take a nonpunitive approach to reporting and learning from adverse events.

When to file

Nurses should check their organization’s policy and procedure related to when to file an incident report. In general, a report should be filed when something unexpected occurs that results in harm. Sometimes nurses may be unsure whether an event warrants reporting. In this case, it’s best to go ahead and complete a report. Even if the event did not result in harm (for example, the patient did not suffer ill effects after receiving a wrong medication), it’s still important to have a record of the event so that the organization can learn from the event and the risk of a similar event can be reduced.

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Typically, a licensed professional, such as a nurse or nurse practitioner, who was part of or witnessed the event completes the form. However, nonlicensed clinicians should report events and provide information as needed for the report. If the event wasn’t witnessed (e.g., the patient fell out of bed when alone in the room), generally the first licensed person who becomes aware of the event should file the report. Reports should be completed as soon as possible after the event (and within 24 hours) and submitted to the designated person/department. Many organizations now allow employees to file reports online, with the risk management department and the appropriate manager receiving notification. Hospitals, clinics, and other healthcare organizations should make reporting as easy as possible to encourage staff participation. Traditionally, incident reports have focused on situations where harm occurred, but many organizations now also encourage employees to file reports about “near misses” or “close calls”—events that could have resulted in harm but did not because someone became aware of the problem. An example of a near miss is the nurse who misreads a label on a medication mixed by the pharmacy department and almost administers an incorrect dose. These reports can be reviewed by risk managers and clinicians to determine changes that can be made to avoid future harm. In the case of the medication label, for instance, it might mean making the print on the label larger, so it is easier to read. The Joint Commission calls on organizations to recognize employees for reporting both adverse events and close calls, so lessons can be learned and shared.

Incident reports and legal action

In general, incident reports, which should not be part of a patient’s health record, cannot be used in legal action. Support for this comes from the Patient Safety and Quality Improvement Act of 2005, which established a voluntary reporting system designed to encourage data sharing so that healthcare quality could be improved. The act “provides Federal privilege and confidentiality protections for patient safety information, called patient safety work product.” (To be eligible for these protections, hospitals establish a patient safety evaluation system that provides data to a patient safety organization.) However, if the report is not completed correctly, it may end up in court. For example, in a Michigan case, the hospital was arguing that it didn’t know the cause of the injury, but a report contained an opinion about how an

injury occurred (even though opinions should not be included in incident reports). The report was allowed to be included in the case, and the court issued sanctions against the hospital and its counsel for raising defenses “not wellgrounded in fact.” In addition, a few state rulings have noted that incident reports are not always exempt from use in legal action. For instance, an Illinois court ruled that a “quality-related event report” was not privileged and that a patient suing the hospital should have access to it. Nurses can lessen the likelihood of an incident report being part of a lawsuit by correctly completing it (see sidebar). If the report ends up in court, an accurate document can help provide evidence that the nurse and organization were not at fault for what occurred.

Completing the report

The report should include a detailed description of what happened. Most organizations have a standard form designed to capture key information such as date, time, and location of the event; name of the person who was affected; names of witnesses to the event; names of those who were notified (e.g., the patient’s physician); the condition of the person affected (e.g., any visible breaks in the skin after a fall); and actions taken in response (e.g., radiograph obtained, malfunctioning equipment sent to biomedical engineering). Objectivity is key. Any relevant statements made by the person affected by the event or witnesses should be recorded verbatim. It’s also important to note who assessed the patient and the results of that assessment. Although the incident report is not part of the patient’s health record, nurses should still objectively document the event, including what happened, assessment results, interventions, and follow-up (such as physician notification), in the record.

A helpful tool

Incident reports are often seen as something to be avoided. However, if completed properly, they can provide useful information that can help keep patients and staff safe. Article by: Cynthia Saver, MS, RN, is president of CLS Development, Inc., in Columbia, Md.

How to complete an incident report Here are some do’s and don’ts for completing an incident report:

Do… • complete the report as soon as

possible after the event (but after the safety of the person affected has been ensured and immediate necessary follow-up is completed). • state only the objective facts that

you witnessed or know for certain. For example: “The patient was found on the ﬂoor next to his bed.” (NOT “The patient fell out of bed.” This is an assumption.) • include a clear, detailed (but concise)

description of what happened. • include relevant direct quotes

(use quotation marks) from witnesses and those affected by the event. For example, a family member may have said, “He didn’t want to wear his non-skid slippers and slipped on the ﬂoor.” • note interventions done in response

to protect the person affected by the incident. • provide a timeline for the event

REFERENCES

and responses.

Albert Henry T. Court should respect privilege tied to quality-related event report. AMA. December 29, 2021. https://www.ama-assn.org/delivering-care/patient-support-advocacy/court-should-respect-privilege-tied-qualityrelated-event Engel EVM. Discoverability of workplace incident reports. American Bar Association. June 9, 2020. https://www.americanbar.org/groups/litigation/committees/products-liability/practice/2020/discoverability-of-workplaceincident-reports/ HHS. Patient Safety and Quality Improvement Act of 2005 statute and rule. HHS.gov. 2017. https://www.hhs.gov/hipaa/forprofessionals/patient-safety/statute-and-rule/index.html Kelly C, Gross S. Do hospitals have an adequate patient safety system. MedCity News. March 30, 2020. https://medcitynews.com/2020/03/do-hospitals-have-an-adequate-patient-safety-system/ Kelly C, Gross S. Pennsylvania court interprets scope of Patient Safety Act privileges protections. MedCity News. August 7, 2020. https://medcitynews.com/2020/08/pennsylvania-court-interprets-scope-of-patient-safety-act-privilege-protections/ Schub T, Woten M. Incident report: writing. Nursing practice & skill. Cinahl Information Systems. 2015. The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert. Revised June 18, 2021. Waranch L. What?! Incident reports can be discoverable? Waranch + Brown. January 25, 2017. https://waranchbrown.com/wait-incident-reports-can-discoverable/ Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.

Don’t… • include subjective information such

as assumptions, opinions, or suggestions for how similar events can be avoided in the future. • document in a patient’s health

record that an incident report was completed. • use abbreviations that aren’t readily

understood. For example, instead of COPD, spell out chronic obstructive pulmonary disease. 24

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