Contextual Barriers to Communication Between Physicians and Nurses About Appropriate Catheter Use

BACKGROUND

Indwelling urinary and vascular catheters are a common cause of health care-associated infections. Interventions designed to reduce catheter use can be ineffective if they are not integrated into the workflow and communication streams of busy clinicians.

OBJECTIVES

To characterize communication barriers between physicians and nurses and to understand how these barriers affect appropriate use and removal of indwelling urinary and vascular catheters.

METHODS

Individual and small-group semistructured interviews were conducted with physicians and nurses in a progressive care unit of an academic hospital. Common themes were identified, analyzed, and then organized using a conceptual framework of contextual barriers to communication: organizational, cognitive, and social complexity.

RESULTS

Several barriers to communication between physicians and nurses contributed to inappropriate use and delayed removal of catheters. Workflow misalignment between clinicians was a barrier associated with organizational complexity, issues with electronic medical records and pagers were associated with cognitive complexity, and strained relationships between clinicians and rigid hierarchies were associated with social complexity.

CONCLUSIONS

Communication is contextual, and improving physician-nurse communication about appropriate catheter use may require innovations that address the identified contextual barriers.

[Improve the extravasation assessment of peripheral venous catheter by nurses, with the establishment of a standardized instrument and suitable for children]

In pediatric and neonatal intensive care units, severity assessment of extravasation is difficult, considering the specificity of this population. The purpose of this study was to demonstrate the ability to improve the measurement of extravasation by nurses with the establishment of a standardized instrument and suitable for children. 66 nurses, randomly assigned to two groups, assessed the severity of extravasations using 15 clinical vignettes.The intervention group with the Pediatric Peripheral Intravenous Infiltration Scale (PIV Scale) (n=33) and the control group based on clinical judgment only (n=33). The reference were obtained from a group of experts. For both groups, concordance and sensitivity were calculated. Concordance and sensitivity were improved by the use of the PIV scale κ=0,62 (IC 95% ; 0,57-0,67) vs κ=0,51 (IC 95 % ; 0,45-0,57), and (69 %) vs (60 %) (p<0,001), respectively. Severity assessment of extravasation on peripheral venous accesses by nurses was improved with the use of the PIV scale, compared to clinical judgment. As this study was based on clinical vignettes, further studies are needed to confirm these results in clinical setting.

Reduced Silent Occlusions with a Novel Catheter Infusion Set (BD FlowSmart): Results from Two Open-Label Comparative Studies

BACKGROUND

Insulin pump users experience periods of unexplained hyperglycemia. In some cases these may be due to insulin flow interruptions termed "silent occlusions," which occur without activating the pump alarm and may require set replacement.

MATERIALS AND METHODS

In-line pressure profiles of a novel infusion set with a 6-mm, 28-gauge polymer, dual-ported catheter (BD FlowSmart™; Becton Dickinson and Co., Franklin Lakes, NJ) were compared with those of an existing infusion set (Quick-set®; Medtronic MiniMed, Northridge, CA) in two separate studies involving insulin diluent infusions over 2.5-4.5-h periods in healthy adults without diabetes. Study 1, a pilot study (n = 25), compared the occurrence of flow interruption events (silent occlusions and/or occlusion alarms) between the two infusion sets and between manual or device-assisted insertion methods. Study 2 (n = 60) was designed to show ≥50% reduction in flow interruption events with the BD set after manual insertions. (Silent occlusions were defined by a continuous pressure rise for ≥30 min.)

RESULTS

In Study 1, significantly fewer silent occlusions were seen with BD FlowSmart versus Quick-set infusion sets for both manual (three of 22 [13.6%] vs. 12 of 24 [50%]; P = 0.012) and mechanical (two of 24 [8.3%] vs. nine of 25 [36%]; P = 0.037) insertions, yielding risk reductions of 73% (95% confidence interval [CI], 25-91%) and 77% (95% CI, 17-94%), respectively. In Study 2, flow interruption events occurred in three of 117 (2.6%) and 12 of 118 (10.2%) BD FlowSmart and Quick-set infusion sets, respectively, yielding a 75% risk reduction (95% CI, 20-92%; P = 0.030). Percentage of time with flow interruption was significantly lower with BD sets in both studies (P < 0.02). Leakage (>0.5 IU or 5 μL) occurred infrequently and did not differ between sets.

CONCLUSIONS

A novel side-ported insulin infusion set demonstrated significant reductions in flow interruptions, including silent occlusions, versus a leading marketed set, which may improve insulin delivery.

[Placement of a portacath under hypnosis]

The portacath reflects the cancer and its future treatments. Its insertion causes high levels of anxiety for patient. Thanks to medical hypnosis, he can use its internal resources to help them manage the situation and the symptoms he feels.

Comparison of technology-based cooperative learning with technology-based individual learning in enhancing fundamental nursing proficiency

BACKGROUND

The aim of nursing education is to prepare students with critical thinking, high interests in profession and high proficiency in patient care. Cooperative learning promotes team work and encourages knowledge building upon discussion. It has been viewed as one of the most powerful learning methods. Technology has been considered an influential tool in teaching and learning. It assists students in gathering more information to solve the problems and master skills better.

PURPOSE

The purpose of this study was to compare the effect of technology-based cooperative learning with technology-based individual learning in nursing students' critical thinking in catheterization knowledge gaining, error discovering, skill acquisitions, and overall scores.

METHODS

This study used a pretest-posttest experimental design. Ninety-eight students were assigned randomly to one of two groups. Questionnaires and tests were collected at baseline and after completion of intervention.

RESULTS

The results of this study showed that there was no significant difference in related catheterization skill performance. However, the remaining variables differed greatly between the two groups. CONCLUSIONS AND APPLICATIONS: This study's findings guide the researchers and instructors to use technology-based cooperative learning more appropriately. Future research should address the design of the course module and the availability of mobile devices to reach student-centered and learn on the move goals.

Moving beyond the "perpetual novice": understanding the experiences of novice hemodialysis nurses and cannulation of the arteriovenous fistula

Cannulation of the arteriovenous fistula (AVF) is an essential skill for hemodialysis (HD) nurses. With declining rates of AVFs, opportunities to develop expert cannulation skills have become limited. This study explored the concept of perpetual novice and AVF cannulation from the perspective of the novice cannulator. Nine hemodialysis nurses were interviewed using ethnographic methodology. The study identified the interplay between personal and environmental/contextual factors that hindered skill acquisition. Personal attributes identified by participants included HD nurses' approach to learning and previous experience, emotional reaction to stress, and interpersonal relationships with colleagues. Environmental/contextual factors identified as impediments to cannulation skill development included limited learning opportunities, attitudes and demands from patients, unit flow and time pressures, and limitations imposed by the current model of nursing care. This study will be helpful in directing future educational, operational, and supportive interventions for novice HD nurses around cannulation skill development.

Intravenous therapy: guidance on devices, management and care

This article aims to provide guidance for practitioners on intravenous therapy devices, their management and care. It explains the indications for their use and considerations when selecting devices for intravenous therapy and treatment. Both PVADs and CVADs are discussed in detail to provide the practitioner with a clear understanding for each. Infection control and how to reduce infection risks are also addressed with recommendations for best practice guidance on flushing devices, minimising complications and documentation. This article addresses the importance of safe practice and aims to help practitioners to improve their knowledge and clinical decision-making for patients undergoing intravenous therapy.

Does the direct application of povidone-lodine hasten hemostasis of the cannulation site after the removal of hemodialysis needles?

Historically, povidone-iodine has had multiple uses in the care of patients receiving hemodialysis and peritoneal dialysis due to its broad antimicrobial properties. Anecdotally, nephrology nurses and technicians have used preparation pads impregnated with povidone-iodine at hemodialysis cannulation sites after removing the needle post-treatment to hasten the clotting time at the site. This article explores the literature related to the use of povidone-iodine in the process of hemostasis after the removal of hemodialysis cannulation needles and also discusses the potential risks of using povidone-iodine in the patient population with renal failure.

BED-SIDE BLIND INSERTION OF PERITONEAL DIALYSIS CATHETERS

Access to the peritoneal cavity is an essential factor for successful peritoneal dialysis. The technique of catheter insertion can influence technique success and patient satisfaction. As compared to conventional surgical laparotomy, a bedside blind insertion technique under local anaesthesia has logistical advantages for the patient, the hospital and the community. This study compares outcomes of both methods in a single centre. A retrograde analysis of a prospectively collected database on all catheters implanted at the University hospital Ghent between 1/1/1998 and 31/5/2002 was carried out. During this period, catheters were implanted either by conventional laparotomy (CL) or by a bedside blind insertion technique (BI) under local anaesthesia.

Faecal incontinence in critical illness

Diarrhoea is a common problem in ICUs, occurring in as many as half of patients who are critically ill. There is a lack of specific guidance on the management of faecal incontinence in these patients. A literature review was used to identify best practice of faecal incontinence in patients in critical care and draw up local guidelines. A specific focus was put on the management of faecal incontinence to protect and heal damaged skin. Nurses are ideally placed to support patients with this condition.

Entrapped Foley catheter: a case study

Obstruction of the urethra can cause necrosis of the urethra. Without prompt intervention, this obstruction may lead to intrinsic renal failure. A unique nursing situation occurred with a patient's entrapped Foley catheter, requiring timely intervention. This case study reinforces that a nurse's ability to assess and describe clinical assessment findings to a physician via the telephone can be critical to patient outcomes.

[Hematology-oncology port-A: improving nursing care quality]

BACKGROUND

Hospitalized hematology-oncology patients undergoing chemotherapy face a significant risk of port-A related bloodstream infections. Nurses are uniquely positioned to help adjust clinical practices necessary to prevent port-A related bloodstream infections and improve patient outcomes. Between July 1st, 2008 and June 30th, 2009, twelve patients in our ward were stricken with port-A related bloodstream infections (an infection rate of .318%). Data analysis indicated inadequate nursing competency in all aspects of port-A care. Nurses did not have adequate knowledge of port-A modified standard care protocols and did not provide dressings suited to hematology-oncology patient needs. Also, both patients and caregivers lacked adequate skin care knowledge. Our team developed a project to address and minimize port-A related bloodstream infection issues in our hospital.

OBJECTS

The authors designed this project to enhance integration of both the central line insertion care and maintenance practice bundles in order to reduce port-A related bloodstream infection incidence.

RESOLUTION

The plan was implemented from August 15, 2009 to December 20, 2009. It included establishing a standardization port-A care protocol, implementing a more appropriate dressing type, performing an irregular audit of port-A care techniques, holding educational training, and establishing skin care instructions for patients and their families.

RESULTS

Hematology-oncology patient port-A related bloodstream infections fell from .318% pre-implementation to .099% post-implementation. The effective rate of improvement was 68.87%.

CONCLUSION

Standardization of Port-A care under this project achieved infection reduction results that achieved our anticipated goals. This project furthermore enhanced the delivery and quality of patient nursing services. This experience can serve as a reference to medical organizations involved in hematology-oncology patient care.

Buttonhole cannulation in hemodialysis: improved outcomes and increased expense--is it worth it?

BACKGROUND

Access to an adequate blood flow is a requirement for successful hemodialysis (HD). This often means repeated cannulation of an arteriovenous fistula (AVF), which can lead to damage that needs repair and revision. The Buttonhole (BH) method offers a successful cannulation with minimal damage.

DESIGN

A prospective cohort research study was initiated in two HD units in St. John's, Newfoundland and Labrador, to assess the effects of cannulating AVFs using the BH technique from the patient and nurse perspective.

METHODS

Twenty-five nurses and 29 patients completed questionnaires at four times throughout the three-month study period, rating their confidence levels about BH cannulation issues. Patients also provided information on the pain of the cannulation and the frequency of cannulation complications. Nurses documented data on arterial and venous pressures, and hemostasis times. Patient charts were also reviewed for complications requiring extensive interventions such as AVF repair or Central Line Catheter (CVC) placement. The cost of providing the BH cannulation was also examined.

RESULTS

At the end of the study, it was noted that cannulation pain was statistically reduced with both the arterial (p = .002) and venous (p = .010) needles, and vessel pressures and hemostasis times were decreased slightly or stayed the same throughout the study. The frequency of access infections, however, increased, although not significantly. Using a 10-point Likert scale in which a score of > or = 8 indicates a high level of confidence, 77.5% of nurses and 73.9% of patients reported a high level of confidence in the nurses' abilities to use the BH technique effectively. In terms of expense, no significant changes were noted in frequency of procedures required for AVF repair with the BH cannulation, although an increase of approximately $358.80 per patient per year for BH supplies was noted.

CONCLUSION

BH cannulation did provide significant improvements. However, the increase in infection rate was an issue of concern. The additional cost of the BH procedure should be weighed against the positive outcomes realized.

Ileoanal pouch dysfunction and the use of a Medena catheter following hospital discharge

With the advent of new surgical techniques to manage colorectal disease, the number of ileoanal pouch operations has amplified and therefore increased numbers of pouch patients are being discharged into the community setting. Community nurses will now encounter the ileoanal pouch patient and may be required to manage related complications. Restorative proctocolectomy with ileoanal pouch anastomosis (RPC) has become established as the gold standard operation for patients with ulcerative colitis (UC) and selected patients with familial adenomatous polyposis (FAP). Using a reservoir constructed from small bowel as a substitute rectum is a medical triumph which in the majority of cases improves the quality of life for patients, not only by eradicating disease and preserving anal sphincter function but also by avoiding a permanent ileostomy. Recent investigation into the use of Medena catheterization for pouch dysfunction has found that it is tolerated in the long-term and is associated with satisfactory quality of life in pouch patients with outflow obstruction.

Nurse cannulation: introducing an advanced clinical skill

Many patients admitted to emergency departments (EDs) require therapy delivered by cannula. Mid-Western Regional Hospital, Tipperary, used to run a system in which many patients had to endure two invasive procedures: on arrival their blood was taken by nurses and later they were cannulated by doctors. To reduce the number of procedures, ED nurses initiated a project to extend their skills to include cannulation. The new system of nurse cannulation at triage has also helped reduce waiting times.

Crossing professional boundaries: nurse-led catheter insertion

The steady expansion of nursing roles is enabling staff to perform tasks traditionally undertaken by doctors. This change is perceived as being in the interests of patients, particularly because it can reduce waiting times, but it can also increase job satisfaction and enhance opportunities for the recruitment and retention of staff. This article describes the establishment of a nurse-led service for tunnelled central venous catheter insertion for renal dialysis. The result of a retrospective audit describes what impact this service has had.

Nursing student medication errors involving tubing and catheters: a descriptive study

This retrospective case study examined reports (N=27) of medication errors made by nursing students involving tubing and catheter misconnections. Characteristics of misconnection errors included attributes of events recorded on MEDMARX error reports of the United States Pharmacopeia. Two near miss errors or Category B errors (medication error occurred, did not reach patient) were identified, with 21 Category C medication errors (occurred, with no resulting patient harm), and four Category D errors (need for increased patient monitoring, no patient harm) reported. Reported intravenous tubing errors were more frequent than other type of tubing errors and problems with clamps were present in 12 error reports. Registered nurses discovered most of the errors; some were implicated in the mistakes along with the students.

Management of traumatic brain injury: nursing practice guidelines for cerebral perfusion and brain tissue oxygenation (PbtO2) systems

Traditional modes of preventing brain cell death in traumatic brain injury (TBI) focus on the enhancement of cerebral perfusion pressure and control of intracranial pressure. Brain tissue oxygenation (PbtO2) monitoring systems are currently available to provide early detection of diminished cerebral oxygenation, and ultimately, ischemia. Research has demonstrated that early detection in PbtO2 is a more delicate measurement of cerebral blood flow and oxygenation. Monitoring PbtO2, in conjunction with cerebral perfusion pressure and intracranial pressure, has been shown to be a better guide to the prevention and treatment of secondary cerebral ischemia. This article reviews TBI, a PbtO2 monitor system description and indications for use, and the importance of nursing practice guidelines and education. With proper guidelines and education, this new technology can be used effectively by bedside clinicians and educators in adult and pediatric intensive care units.

Continuing Controversy of Midclavicular Catheters

A review of 50 years of research on catheter tip placement indicates an overwhelming preference for the lower third of the superior vena cava as the appropriate tip location. Despite this evidence, there are still practitioners, physicians, and nurses who advocate tip placement within the axillo-subclavian-innominate vein (also referred to as the midclavicular). This article looks at the arguments presented by practitioners who support midclavicular tip placement. It also reviews some of the research from which the recommendations for superior vena cava placement are derived.

Registered nurse management and monitoring of analgesia by catheter techniques: position statement

The American Society for Pain Management Nursing believes that the administration of analgesia and the management of the associated effects are fundamental nursing responsibilities. This position statement will address the registered nurse's responsibilities for the management and monitoring of analgesia by catheter techniques in all patients of all ages and in all care settings. It will provide recommendations for the health care institution, licensed independent practitioner, and registered nurse to ensure the safe and effective implementation of these pain control methods. The position statement reinforces the American Society for Pain Management Nursing's belief that the administration of analgesia by catheter techniques is within the registered nurse scope of practice.

Uso da solução salina para manutenção de acessos venosos em adultos: uma revisão

Trata-se de uma revisão bibliográfica sobre a prática da salinização em cateteres venosos periféricos. O estudo objetivou analisar os artigos científicos sobre o uso de solução salina na manutenção da permeabilidade de cateteres venosos periféricos em adultos, indexados no MedLine e LILACS no período de 1995 a 2005. A amostra consistiu de 5 artigos os quais foram analisados quanto à procedência e periódico de publicação, ao delineamento do estudo, a amostragem, e ao efeito da solução salina. Dois estudos indicam evidências da salinização, outros dois o oposto e um não é conclusivo. Há pequena produção acerca da temática exigindo-se novas pesquisas para validação do método.

Nurses' guide to early detection of umbilical arterial catheter complications in infants

Umbilical arterial catheters (UAC) are routinely used in the care of critically ill newborns. Complications related to UACs include vascular compromise, hemorrhage, complications related to malposition, severance of the catheter itself, and infection. This article is Part II in a series dedicated to assessing infants with an umbilical catheter. Part I focused on infants with umbilical venous catheters; this article will focus on the physical assessment relevant to infants with an UAC. Complications related to UACs can occur during any phase of treatment: insertion, while indwelling, or after discontinuing the catheter. Review of clinical signs of complications along with clinical photographs, will assist caregivers in promptly recognizing UAC-related complications.

A structured learning programme for venepuncture and cannulation

This article discusses a structured learning programme that offers a standardised assessment for all healthcare staff to learn venepuncture and/or cannulation. Nurses from four NHS trusts in London and the south east, with a special interest and expertise in cannulation and venepuncture, devised the programme to reduce the need for repeated training and assessment when staff take up new posts within these trusts. The authors in their respective trusts have used the tool over a four-year period and findings from a study in Chelsea and Westminster Healthcare NHS Trust are presented to demonstrate its use by staff. The tool has recently been reviewed by its authors and is being disseminated to organisations across the United Kingdom (UK). These organisations will evaluate it, with a long-term objective to standardise the training and assessment of venepuncture and cannulation across the UK.

Minimum nurse staffing ratios for nursing homes

The authors explored minimum nurse staffing ratios for nursing homes using production function simulations. Minimum levels of registered nurse hours per resident day were 0.31, 1.83, and 3.3 at 50%, 75%, and 90% levels of quality respectively. These results suggest that efficiency-oriented minimum nurse staffing points exist, and could be used to inform policymakers and nursing home administrators on better resource allocation and health care delivery.

New standards to improve catheter stabilization and patient and worker safety

The 2006 version of the Infusion Nursing Society (INS) Standards of Practice contains important changes to the society's recommendations for catheter stabilization. Some previously recommended stabilization methods are no longer endorsed, and one method -- manufactured catheter stabilization devices -- has emerged as the preferred method over all others. The literature cited in the document suggests that implementation of the revised standards should be an effective risk management strategy where catheter stabilization is concerned.

Improving arteriovenous fistula cannulation skills

Cannulation of arteriovenous fistulae is technically more challenging than cannulation of arteriovenous grafts. With the advent of the National Vascular Improvement Initiative, Fistula First, the United States has seen an increase in the number of arteriovenous fistulae. The problem we now face is how to refocus and reeducate nurses to the intricacies of arteriovenous fistula cannulation. Through evidenced-based practice and current best-demonstrated practices, this article will provide the tools needed to improve arteriovenous fistulae cannulation skills.

Management and effects of parenteral nutrition

Despite nutrition being a basic human need, malnutrition in hospitals remains surprisingly common, with the effects clearly documented (Taylor and Goodison-McLaren, 1992). Malnourished patients are more likely to suffer from complications; are at increased risk of developing infections; have poor or delayed wound healing, increased mortality rates and longer hospital stays. This article focuses on the basics of parenteral nutrition in the adult, addressing a small selection of potential complications.

Suprapubic catheterization: challenges in changing catheters

Suprapubic catheterization of the bladder is used as a short- or long-term alternative to urethral catheterization. As with any indwelling urinary catheter, correct insertion, care and removal are vitally important to minimize problems. A particular problem that affects suprapubic catheters is 'cuffing', which on its own or combined with encrustation can potentially cause a great deal of difficulty on removal or discomfort for the patient. This article discusses the causes of cuffing, and suggests using catheters with integral balloons to reduce the incidence of the problem.