INFUSION NURSES SOCIETY Policies and Procedures for Infusion Therapy: Ambulatory Infusion Centers 1st edition Policies and Policies and Procedures Procedures for for Infusion Therapy: Infusion Therapy: the Ambulatory Ambulatory Infusion Infusion Patient Centers INFUSION NURSES SOCIETY SETTING THE STANDARD FOR INFUSION CARE® Copyright© 2019 by the Infusion Nurses Society, Inc. All rights reserved. No part of this book may be reproduced without written permission from the Infusion Nurses Society. CONTENTS PREFACE .......................................................................................................................... 6 Infusion Therapy in the Ambulatory Infusion Setting ........................................ 7 1. GENERAL ORGANIZATIONAL POLICIES Infusion Team ...............................................................................................................12 Competence and Competency Validation ............................................................14 Product Evaluation, Integrity, and Defect Reporting ....................................... 17 Informed Consent ....................................................................................................... 19 First Dose Administration ....................................................................................... 23 Latex Sensitivity or Allergy..................................................................................... 25 Adverse and Serious Adverse Events .................................................................... 27 2. INFECTION PREVENTION AND SAFETY COMPLIANCE Hand Hygiene .............................................................................................................. 31 Sharps Management ................................................................................................. 34 Medical Waste Disposal........................................................................................... 36 Durable Medical Equipment Disinfection ............................................................ 37 Standard Precautions ............................................................................................... 39 Transmission-Based Precautions .......................................................................... 42 3. VASCULAR ACCESS DEVICE PLACEMENT Vascular Access Device (VAD) Planning ............................................................. 46 Local Anesthesia ........................................................................................................ 52 Short Peripheral Catheter (SPC) Placement ..................................................... 56 Ultrasound-Guided Short Peripheral Catheter (SPC) Placement ................ 63 Ultrasound-Guided Midline Catheter Insertion ................................................ 68 Ultrasound-Guided Peripherally Inserted Central Catheter (PICC) Insertion Using Modified Seldinger Technique (MST) ...................................... 77 4. SITE CARE AND MAINTENANCE Administration Set Change..................................................................................... 88 Maintaining Vascular Access Device (VAD) Patency: Flushing and Locking ................................................................................................. 91 Vascular Access Devices (VADs): Ongoing Assessment, Site Care, and Dressing Change ................................... 96 Vascular Access Device (VAD) Removal ............................................................ 102 5. INFUSION-RELATED COMPLICATIONS: IDENTIFICATION & INTERVENTION Air Embolism ..............................................................................................................108 Allergic Reaction and Anaphylactic/Anaphylactoid Reactions .................... 111 Catheter Damage ......................................................................................................114 Central Vascular Access Device (CVAD) Malposition .....................................118 Central Vascular Access Device (CVAD) Occlusion .........................................122 Central Vascular Access Device (CVAD)-Associated Venous Thrombosis ................................................................................................................ 129 Circulatory Overload .............................................................................................. 133 Infiltration/Extravasation ...................................................................................... 135 Nerve Injuries ........................................................................................................... 145 Phlebitis ..................................................................................................................... 148 Vascular Access Device (VAD)-Associated Infection .................................... 152 6. OTHER INFUSION-RELATED PROCEDURES Preparing Parenteral Medications ...................................................................... 157 Implanted Vascular Access Port: Accessing and Deaccessing................... 160 Phlebotomy: Blood Sampling from a Vascular Access Device (VAD) ....... 166 7. OTHER INFUSION ACCESS Intraspinal Access Device: Care and Management ......................................... 175 Subcutaneous Access Device: Placement and Infusion Administration .. 183 Intraosseous Access Device: Placement, Care, and Management ............ 188 8. INFUSION THERAPIES IV (Intravenous) Administration: Continuous Infusion, IV Push, Intermittent Infusion .............................................................................................. 194 Transfusion Therapy ............................................................................................... 205 Parenteral Nutrition ............................................................................................... 212 Antineoplastic Therapy .......................................................................................... 216 Biologic Therapy ...................................................................................................... 223 Patient-Controlled Analgesia (PCA) ................................................................... 227 Moderate Sedation/Analgesia ............................................................................. 231 Therapeutic Phlebotomy ....................................................................................... 234 Illustrations Vein Anatomy .............................................................................................................239 Policies and Procedures for Infusion Therapy: Ambulatory Infusion Centers is intended to reflect current knowledge and practices of the clinical specialty of infusion therapy. Because clinical practice continuously evolves based on ongoing research, clinicians should make an independent assessment of the appropriateness and applicability of a policy or procedures in any specific instance. Applicable federal and state laws and regulations should also be considered, as well as the standard of care in a particular jurisdiction, as these may take precedence. INS is not responsible for injury to persons or property, or other harm, arising from exercising guidelines outlined in this publication. Suggested citation for this publication: Infusion Nurses Society. Policies and Procedures for Infusion Therapy: Ambulatory Infusion Centers. Norwood, MA: Infusion Nurses Society; 2019. ............................... Policies and Procedures for Infusion Therapy: Ambulatory Infusion Centers Preface While a patient’s plan of care for infusion therapy often begins in the hospital, that care may transition to other practice settings. Ambulatory infusion centers offer an environment where patients who don’t need to be hospitalized can safely, efficiently, and cost-effectively receive their therapies. In our effort to ensure safe, quality infusion patient care, the Infusion Nurses Society (INS) develops resources to guide clinicians in their practice. We recognize the invasive nature and risks associated with infusion care—not only to our patients, but to clinicians as well. Therefore, it’s imperative the resources are supported by the most current research and best available evidence. Better patient outcomes result when there is consistency in practice among health care professionals. Incorporating practices from the Policies and Procedures for Infusion Therapy: Ambulatory Infusion Centersprovides the framework to do just that. As the basis for professional practice, clinicians are accountable within the boundaries of their scope of practice. With variations among health care organizations, knowledge of the policies, procedures, and practice guidelines of one’s organization is essential, as well as any directives from federal, state, or regulatory bodies. While the policies and procedures are written in general terms, there may be device-specific features or specifications that need to be followed for proper function, so clinicians need to adhere to the manufacturers’ directions for use. The format for the Policies and Procedures for Infusion Therapy: Ambulatory Infusion Centers includes the policy, which defines a course and purpose of an action, and the procedure, which lists the steps needed to comply with the policy. Sections on key points, assessment, and patient education have also been added. While there are areas of care, such as infusion-related complications and infusion therapies that don’t fit the typical policy and procedure format,