Preventing Pediatric Intravenous Extravasation Injuries

1. 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

2. 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

3. 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

4. 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 ?

5. CCHMC Safety Culture

8. CCHMC infusion and Vascular Access Governance (iVAG) Cabinet Sponsors • Medical Members of Cabinet • Bob Carpenter J.D. Leadership Group Bi-Monthly • Sylvia Rineair R.N • Mary Haygood R.N. • Tracey Blackwelder • Darcy Doellman R.N. • 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. Permanent Working Groups Ad-Hoc Working Groups Tofani Doellman / Rineair Johnson / Tofani Rineair / Stalf Doellman Johnson Johnson / Haygood / DD Tofani / Johnson Devices Operations and Safety Blood Stream Infections Process Improvement and Monitoring Training Education Public Relations Research Example: PIV Infusion Working Group R/Y/G List 6 Weeks January 25, 2011

9. CCHMC infusion and Vascular Access Governance (iVAG) Cabinet Sponsors • Medical Members of Cabinet • Bob Carpenter J.D. Leadership Group Bi-Monthly • Sylvia Rineair R.N • Mary Haygood R.N. • Tracey Blackwelder • Darcy Doellman R.N. • 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. Permanent Working Groups Ad-Hoc Working Groups Tofani Doellman / Rineair Johnson / Tofani Rineair / Stalf Doellman Johnson Johnson / Haygood / DD Tofani / Johnson Devices Operations and Safety Blood Stream Infections Process Improvement and Monitoring Training Education Public Relations Research Example: PIV Infusion Working Group R/Y/G List 6 Weeks January 25, 2011

10. 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…”

11. CCHMC I/V Extravasation HARM “hVAG” OUTCOME or TREATMENT Based

12. 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

13. Definition (CCHMC Vascular Access Team ) • SAFETY: • The Processes, Policies, People and Systems which seek to: • MINIMIZE Necessary Risk • AVOID Unnecessary Risk

14. 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

15. “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

16. When A PIV Goes Wrong • Extravasation: • Inadvertant Deposition of Intended Intravenous Fluids Into Surrounding Tissues Source: Google Image Search

17. Terminology: Extravasation (VsInfiltration) • 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 fluids Example: “The skin was infiltrated with local anesthetic solution before incision”

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

19. PIV Extravasation • Basic Mechanisms of Injury • VOLUME • Pressure Compresses Arteries and Veins Reducing Blood Supply To The Limb • 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

20. Mechanisms of Extravasation Injury • 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 Google Images Our WORST Extravasation Injury was caused by Normal Saline • VOLUME (Pressure) • TOXICITY (Local Tissue) • Chemical (pH – Acid/Base • Osmolality • Biological Activity

21. Mechanisms of Extravasation Injury • TOXICITY: Chemical (Acid / Base) • pH Acid – Base [H+] • Blood pH = 7.4 • High or Low pH • Damages Proteins and Kills Cells pH = 12 Google Images pH = 2 pH = 11 • VOLUME(Pressure) • TOXICITY(Local Tissue) • Chemical (pH – Acid/Base • Osmolality • Biological Activity

22. Mechanisms of Extravasation Injury • OSMOLALITY: • Non-Isotonic Solutions Destroy Cells / Tissue EXAMPLES: TPN, 8.4% Na Bicarbonate, 20% Dextrose Blood Source: Wikipedia • VOLUME (Pressure) • TOXICITY(Local Tissue) • Chemical (pH – Acid/Base • Osmolality • Biological Activity

23. Mechanisms of Extravasation Injury • BIOLOGICAL ACTIVITY: • Vasopressors(Epinephrine / Dopamine) • CONSTRICT Vessels • ChemotherapyDrugs • KILL Cells • Other “Drugs doing what they are supposed to do” Journal of Hand Surgery Vol 36, Issue 12, Dec 2011. pg: 2060-2065 • VOLUME (Pressure) • TOXICITY(Local Tissue) • Chemical (pH – Acid/Base • Osmolality • Biological Activity

24. 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

25. 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”

26. “Give Tissue Toxic Drugs Centrally”- But What Is A Tissue Toxic Drug ? CCHMC Modified INS Extravasation Grading

27. 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”

28. Cincinnati Medication Risk Stratification • 18 Month Project • Multi-Disciplinary • Pharmacy • Nursing (VAT) • Physicians • Evidence Based PhD • Nutrition Service • NICU “rVAG”

29. 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

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

31. Each Update has a Different Color Border Available at every clinical workstation

32. 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

33. 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

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

35. 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

36. Result: Good But Not Sustained Reliable Hourly Checks

37. 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! • ImmediateFeedback System • “Personal Interview” (>60%)

38. 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

39. Compare Is SO Important EPIC Feedback Strategy Identified “Compare” Not Done Reliably

40. Compare Is SO Important EPIC Feedback Strategy Identified “Compare” Not Done Reliably PIV

41. “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

42. 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 TWOSeparate Harm Components Into One “Grade” • VOLUME (“Edema”) • Medication TOXICITY • No official “Vesicant” list • Blood products included  Instant Grade 4

43. The INS Grading System (Briefly) • “Vesicant” Extravasation = Instant / Automatic Grade 4 • 1ml or 100 ml - • Same Grade, Very Different Outcomes Grade 4

44. 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

45. 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

46. CCHMC Extravasation Coding System • Step 1 - VOLUME Measurement • Step 2 - MEDICATION(If Any) • Step 3 - DOCUMENTATION

47. Step 1: VOLUME

48. Step 1a: VOLUME • Measure Max Dimension • Includes ANY Extravasation • PIV • PICC • CVC • PORT • Scalp / Chest

49. 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

50. 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”