preventing pediatric intravenous extravasation injuries neil johnson, md barb tofani, rn, msn sylvia...

Preventing Pediatric Intravenous Extravasation

Injuries• Neil Johnson, MD

• Barb Tofani, RN, MSN

• Sylvia Rineair, RN, MSHA, VA-BC

• Mary Haygood, RN, BSN (Retired)

• Julie Stalf, RN, MSN, VA-BC

• Darcy Doellman, MSN, RN, CRNI, VA-BC

March, 2014

Objectives• High Level Overview:

– Cincinnati’s 4 Year Intra Venous Extravasation Harm Reduction Initiative

• Our 4 Components– Reliable Hourly Bedside PIV Checks– Evidence Based 3 Tier Medication Tissue Toxicity List– “No Grade” 2 Component Assessment / Documentation

Tool– Real Cross-Cultural Leadership

• Discussion - Questions

Basic Principles

• It takes a Team• Culture change is really hard work• “What would we do for our own

children” ?• No-one has all the answers

Basic Principles

• It takes a Team• Culture change is really hard work• “What would we do for our own

children” ?• No-one has all the answers

What would we do for our own children ?

CCHMC Safety Culture

CCHMC infusion and Vascular Access Governance (iVAG)

Cabinet Sponsors•Medical Members of Cabinet•Bob Carpenter J.D.

Devices Operations and Safety

Blood Stream Infections

Process Improvement

and Monitoring

Training

Education

Public Relations

Permanent Working Groups Ad-Hoc Working Groups

Example:

PIV Infusion

Working Group

R/Y/G List

6Weeks

Leadership Group Bi-Monthly

•Sylvia Rineair R.N•Mary Haygood R.N.•Tracey Blackwelder•Darcy Doellman R.N.

Research

•Derek Wheeler M.D.•Denise Adams M.D.•Vicki DeCastro, RN•John Hingl RPH•Ranjit Chima M.D.

•Steve Muething M.D.•Rich Falcone M.D.•Sam Kocoshis M.D.•Lauren Solan M.D.

•Barb Tofani R.N.•Neil Johnson M.D.

Doellman Tofani / Johnson Johnson

Tofani

Doellman / Rineair Johnson / Haygood / DDJohnson / TofaniRineair / Stalf

January 25, 2011

CCHMC infusion and Vascular Access Governance (iVAG)

Cabinet Sponsors•Medical Members of Cabinet•Bob Carpenter J.D.

Devices Operations and Safety

Blood Stream Infections

Process Improvement

and Monitoring

Training

Education

Public Relations

Permanent Working Groups Ad-Hoc Working Groups

Example:

PIV Infusion

Working Group

R/Y/G List

6Weeks

Leadership Group Bi-Monthly

•Sylvia Rineair R.N•Mary Haygood R.N.•Tracey Blackwelder•Darcy Doellman R.N.

Research

•Derek Wheeler M.D.•Denise Adams M.D.•Vicki DeCastro, RN•John Hingl RPH•Ranjit Chima M.D.

•Steve Muething M.D.•Rich Falcone M.D.•Sam Kocoshis M.D.•Lauren Solan M.D.

•Barb Tofani R.N.•Neil Johnson M.D.

Doellman Tofani / Johnson Johnson

Tofani

Doellman / Rineair Johnson / Haygood / DDJohnson / TofaniRineair / Stalf

January 25, 2011

Definition• HARM

– Institute for Healthcare Improvement (IHI)• “Unintended physical injury resulting from

….medical care…”

– Canadian Disclosure Guidelines (JAMA 2012 Vol 307 #20)

• “an outcome that negatively affects a patient’s health / quality of life…”

CCHMC I/V Extravasation HARM

OUTCOME orTREATMENT Based

“hVAG”

Definition

• SAFETY

Institute of Medicine (2000):“….no commonly accepted definition of the safety net exists…..”

Institute of Medicine,2000 America’s Health Care Safety Net: Intact but Endangered. National Academy Press p3-4

Definition (CCHMC Vascular Access Team )

•SAFETY: • The Processes, Policies, People and Systems

which seek to:

•MINIMIZE Necessary Risk•AVOID Unnecessary Risk

Definition• SAFETY: (CCHMC Vascular Access Team )

– The Processes, Policies, People and Systems which seek to:

• MINIMIZE Necessary Risk• AVOID Unnecessary Risk

“NOTHING in Life or Medical Practice is Risk Free”The ONLY way to achieve Zero Risk is to close the Hospital

“PIV” Peripheral Intravenous

• PIV– A “simple” device for administration of

medical fluids directly into a peripheral vein

– A simple procedure not worthy of the attention of an MD

• Common Medical Procedure– 70 – 80% of Hospital Inpatients

When A PIV Goes Wrong

• Extravasation:– Inadvertant Deposition of Intended

Intravenous Fluids Into Surrounding Tissues

Source: Google Image Search

Terminology: Extravasation (Vs Infiltration)

• Cincinnati Only Uses “EXTRAVASATION”

• EXTRA = “Out Of or Outside”• VASCULAR = “Vessel”

• EXTRAVASATION = “Out of the Vessel”

“Infiltration” Better used to describe purposeful subcutaneous injection of fluidsExample: “The skin was infiltrated with local anesthetic solution before incision”

PIV Extravasation• Basic Mechanisms of Injury

1. VOLUME• “Simple” PIV Fluids Leak into Subcutaneous Tissues• Pressure Compresses Local Veins and later, Arteries• Reduces then Blocks Blood Supply To The Limb

PIV Extravasation• Basic Mechanisms of Injury

1. VOLUME• Pressure Compresses Arteries and Veins Reducing Blood Supply To The Limb

2. LOCAL TISSUE TOXICITY• Chemical: Acid – Base (pH) • Osmolality [H2O]

• Biological Activity “Drugs doing what Drugs do”

– Vasoactive Drugs– Chemotherapy

• VOLUME (Pressure)

• TOXICITY – Chemical (pH – Acid/Base)– Osmolality– Biological Activity

• VOLUME– Massive Amounts of I/V Fluid in Tissues– Compartment Syndrome

• Fluid Pressure Occludes Veins• Venous Occlusion More Swelling• Progressive Swelling Arterial Compromise

• Dead Limb

Mechanisms of Extravasation Injury

Our WORST Extravasation Injury was caused by Normal Saline

Google Images

• VOLUME (Pressure)• TOXICITY (Local Tissue)

– Chemical (pH – Acid/Base– Osmolality– Biological Activity

• TOXICITY: Chemical (Acid / Base)

Mechanisms of Extravasation Injury

Google Images

• VOLUME (Pressure)

• TOXICITY (Local Tissue)

– Chemical (pH – Acid/Base– Osmolality– Biological Activity

• pH Acid – Base [H+]

– Blood pH = 7.4 – High or Low pH

•Damages Proteins and Kills Cells

pH = 2

pH = 12

pH = 11

• OSMOLALITY:

Mechanisms of Extravasation Injury

• VOLUME (Pressure)

• TOXICITY (Local Tissue)

– Chemical (pH – Acid/Base– Osmolality– Biological Activity

– Non-Isotonic Solutions Destroy Cells / Tissue

EXAMPLES: TPN, 8.4% Na Bicarbonate, 20% Dextrose

Source: Wikipedia

Blood

• BIOLOGICAL ACTIVITY:

Mechanisms of Extravasation Injury

• VOLUME (Pressure)

• TOXICITY (Local Tissue)

– Chemical (pH – Acid/Base– Osmolality– Biological Activity

– Vasopressors (Epinephrine / Dopamine)

• CONSTRICT Vessels

– Chemotherapy Drugs • KILL Cells • Other

Journal of Hand SurgeryVol 36, Issue 12, Dec 2011. pg: 2060-2065

“Drugs doing what they are supposed to do”

Preventing PIV Extravasation Injuries

• Two Simple Ideas– AVOID Unnecessary Risk

• Give Tissue Toxic Drugs Centrally

– MINIMIZE Necessary Risk• Catch Extravasations Early• Use Oral Medications When Indicated

Preventing PIV Extravasation Injuries

• Two Simple Ideas– AVOID Unnecessary Risk

• Give Tissue Toxic Drugs Centrally

– MINIMIZE Necessary Risk• Catch Extravasations Early• Use Oral Medications When Indicated

“It’s not that simple”

“Give Tissue Toxic Drugs Centrally”- But What Is A Tissue Toxic Drug ?

CCHMC Modified INS Extravasation

Grading

Where Do I Find The Official INS List Of “Vesicants”?

• There Isn’t One !– “Each Institution Develops Its Own”– Each CCHMC Nursing Subspecialty Had Its

Own– “We Know One When We See One”

• Cincinnati Medication Risk Stratification– 18 Month Project– Multi-Disciplinary

• Pharmacy• Nursing (VAT)• Physicians• Evidence Based PhD• Nutrition Service• NICU

“rVAG”

Medication Risk Stratification

• Literature Evidence Search• MEASUREMENT

– pH– Osmolarity

• Measurement of COMMON Pediatric Formulations

• Blood Products Excluded– Blood = Bruise– Not Tissue Toxic

RED Criteria• pH <5 or >9• Strong Published Evidence• >950 Mili Osmoles

Journal of Infusion Nursing Vol 36, Number 1. Jan/Feb 2013

Each Update has a Different Color Border

Available at every clinical workstation

Unexpected Positives

• Universal Availability R/Y/G– Hard To Avoid– At Every Clinical Workstation

• Nurses Strongly Influence Doctor Behavior– Trend Central Access for Red Drugs– Increased Awareness of IV Risks of Red Drugs– “Pseudo Policies” are Sometimes a Positive Phenomenon

Preventing PIV Extravasation Injuries

• Two Simple Ideas– AVOID Unnecessary Risk

• Give Tissue Toxic Drugs Centrally

– MINIMIZE Necessary Risk• Catch Extravasations Early• Use Oral Medications When Indicated

Journal Pediatric Nursing (2012) 27, 682-689)

Hourly PIV Checks

• Peripheral I/V (PIV) Policy Revision• Nursing Staff Education

– Significant Institution-Wide Effort– TLC Methodology for Hourly Checks

• Nursing Unit Hourly Checks AUDIT– If >90% Compliance (after 3 months) STOP Manual Audit– If <90% Compliance Continue Audit until >90% Achieved

• PROBLEMS: – Manual Data Collection – Variable Documentation– Two Electronic Data capture Systems

Reliable Hourly Checks

Result: Good But Not Sustained

Reliable Hourly Checks

New Efforts: Reliable Hourly Checks

• EPIC EMR Implemented • All I/V Documentation now in ONE place

• 18 month “CVAT” Project with I.T.All Vascular Access Data Abstraction Project (CVAT)

• >60% Extravasation = 1 Month Manual Audit– Unpopular!

• Immediate Feedback System• “Personal Interview” (>60%)

Immediate PIV Extravasation Feedback System

• > 30% volume or R drug extravasation charted in EPIC

• Automatic messaging to VAT and Med Director• VAT Team nurse visits bedside 24/7• Immediate Feedback Advice to bedside nurse• Treatment if appropriate• VAT follow-up in 1-2 weeks

– Personal interview (Nurse, supervisor, VAT leader)– Information Gathering for Analysis by VAT Improvement Team

Compare Is SO ImportantEPIC Feedback Strategy Identified “Compare” Not Done Reliably

Compare Is SO ImportantEPIC Feedback Strategy Identified “Compare” Not Done Reliably

PIV

“Compare” Not Done Reliably -Recent Change: Based On Interviews

So…. TLC Poster Revised

• VOLUME (Pressure)• TOXICITY (Local Tissue)

– Osmolality– pH (Acid – Base)– Biological Activity

Reliable Hourly Checks

The INS Grading System (Briefly)

• Mostly Descriptive– Grades 1-4

• Adult Based – Fixed Measurements regardless of Patient Size

• Poor Harm Correlation with “Grades”– All Bad Outcomes were Grade 4 (Sensitive)– BUT….Very Few Grade 4’s had Bad Outcome (NOT Specific)

• Combines TWO Separate Harm Components Into One “Grade”– VOLUME (“Edema”)– Medication TOXICITY

• No official “Vesicant” list• Blood products included Instant Grade 4

• “Vesicant” Extravasation = Instant / Automatic Grade 4– 1ml or 100 ml -

• Same Grade, Very Different Outcomes

The INS Grading System (Briefly)

Grade 4

The INS Grade 4 ProblemAssumption: Highest Grade = Highest Harm

??

• CCHMC Safety Leaders Assumed “GRADE 4” =“Serious Harm”– “It’s the HIGHEST Grade.. Why not ??”

• Grade 4 PIV “Harm” was >40% of “Total Hospital Harm”• Pressure on VAT to “Reduce Serious Harm” was Substantial

2008 2009

The CCHMC Extravasation Documentation Tool

• It’s ONLY a Tool• Does NOT Change Outcomes Itself• Requires Leadership and Accountability• Informs Change and Quality Processes• Separates The Two Major Harm Components• Used for ALL Extravasations, Not Only PIV• Compulsory at CCHMC - INS Grades Not Available

• EMR (EPIC) Very Helpful

CCHMC Extravasation Coding System

• Step 1 - VOLUME Measurement

• Step 2 - MEDICATION (If Any)

• Step 3 - DOCUMENTATION

Step 1: VOLUME

Step 1a: VOLUME

• Measure Max Dimension• Includes ANY

Extravasation– PIV– PICC– CVC– PORT– Scalp / Chest

Step 1b: VOLUME

• Measure ARM Length• “Y” is ARM length

– Surrogate for Patient Body Size– Easy To Measure– Allows Consistent Quantification

• Even If Extravasation is Scalp, Leg or Chest

– Never Measure Leg or Other Part for “Y”– No Arms? CCHMC VAT Master Policy #1

Step 1b: VOLUME

• Measure ARM Length• “Y” is ARM length

– Surrogate for Patient Body Size– Easy To Measure– Allows Consistent Quantification

• Even If Extravasation is Scalp, Leg or Chest

– Never Measure Leg or Other Part for “Y”– No Arms? CCHMC VAT Master Policy #1

CCHMC VAT Master Policy #1:“Common sense and good judgment will be used at all times”

Step 1c: Calculate

Step 1c: Calculate

An Extravasation can be > 100%

Step 2: MEDICATION

• Other Institutions

Step 3: DOCUMENT

• Other Institutions

Step 3: DOCUMENT

http://cincinnatichildrens.org/vascularaccess

Implementation

• BIG Education Effort– Julie Stalf, RN– Sylvia Rineair, RN – Mary Haygood, RN– Barb Tofani, RN

• CCHMC Education Team• Institution Wide Initiative

CCHMC System: Driving Treatment

TREAT unless very good reason not to

Probably TREATunless good reason not to

Probably NOT Treat unless good reason to do so

NO Treatment

Consult and TREAT

In Plain English

Result: Hyaluronidase Rx

• $350• 4-5 Needle Sticks• Previously Widely Recommended

• 75% DECREASED Use – No Serious Harm Events

CCHMC I/V Extravasation HARM

OUTCOME orTREATMENT Based

Results: Calendar 2012-13

• ZERO Severe Harm • Moderate Harm = 0.55/1000 Line

Days

• Red Drugs– Most Red Drugs Now Only Given PIV in

Code Situations – Even In A Code Early Intraosseous

Rx

Results: Calendar 2012-13

• ZERO Severe Harm • Moderate Harm = 0.55/1000 Line

Days

• Red Drugs– Most Red Drugs Now Only Given PIV in

Code Situations – Even In A Code Early Intraosseous

Rx

“No one has all the answers. Severe Harm is only one slip up away” (2013)

Results: 2014

• ZERO Severe Harm • Moderate Harm = 0.55/1000 Line

Days

• Red Drugs– Most PIV Red Drugs Now Only Given

PIV in Code Situations Early Intraosseous Rx

– BUT:

“No one has all the answers. Severe Harm is only one slip up away”

Recent Case:4.2% PIV Bicarbonate

Documents Available:

• http://cincinnatichildrens.org/vascularaccess

Did We Change Anything?

INS Grades 3-4 (2008 -2009) INS Grades 3-4 (2010 -2011)

2014

No R Drugs

Probably ………

Did We Change Anything?

INS Grades 3-4 (2008 -2009) INS Grades 3-4 (2010 -2011)

2014

No R Drugs

Probably ………

Only 1 Case of Serious PIV Harm In 5 Years

“Still Working On It………..”

• AVOID Unnecessary Risk • MINIMIZE Necessary Risk

Summary• Overview:

– 4 Year IV Extravasation Harm Reduction:• Most Effort is Culture Change / Leadership• Hard Work: MD / Nursing / Administration Silos are SOLID

• Our 4 Components– Reliable Hourly Bedside PIV Checks– Evidence Based 3 Tier Medication Tissue Toxicity List– “No Grade” 2 Component Assessment / Documentation

Tool– Real Cross-Cultural Leadership

Thanks

• iVAG (Our Governance Group)• The Whole Extraordinary CCHMC VAT Team• “rVAG”• Dallas Children’s Vascular Access Team• John Racadio MD

– “Why Don’t You Just Abolish Grading ???”

• Glen Minano – Graphics• Marshall Ashby Quality Improvement Consultant

• Steve Muething MD– Vice President of Safety, CCHMC

Manuscript In Preparation:

Thanks

• iVAG (Our Governance Group)• The Whole Extraordinary CCHMC VAT Team• Dallas Children’s Vascular Access Team• John Racadio MD

– “Why Don’t You Just Abolish Grading ???”

• Glen Minano – Graphics• Marshall Ashby Quality Improvement Consultant

• Steve Muething MD– Vice President of Safety, CCHMC

What would we do for our own children ?

• Questions – Discussion …….

Preventing Pediatric Intravenous Extravasation

Injuries