Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation.

INTRODUCTION: Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS: Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS: The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION: NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

Guía de práctica clínica para el manejo de la vía subcutánea / Clinical practice guide for the management of the subcutaneous route

La elaboración de esta GPC, se enmarca dentro del Proyecto de Calidad "Elaboración de una Guía de Práctica Clínica para el Manejo de la Vía Subcutánea", seleccionado en la convocatoria del año 2016, del programa de apoyo a las iniciativas de mejora de la calidad en el Servicio Aragonés de Salud e incluido en el Acuerdo de Gestión Clínica de 2017 del Hospital Sagrado Corazón de Jesús. Este trabajo es aprobado por la Dirección Asistencial del Hospital. El objetivo general de esta Guía de Práctica Clínica es aportar un conjunto de recomendaciones basadas en la evidencia científica y cuando ésta no exista, basadas en la experiencia y el consenso, sobre el adecuado uso de la terapia a través de un catéter por vía subcutánea, para el tratamiento de los pacientes de manera segura y sin disminuir la eficacia de los fármacos que pueden ser administrados a través de esta vía, proporcionando recomendaciones a profesionales y pacientes, para ofrecer una atención sanitaria de calidad.

Development and Application of One Separation-Free Safety Tube on the Disposable Infusion Needle.

OBJECTIVE: To develop a new type infusion set and apply it to the clinic, as well as explore its effectiveness in the prevention from needle stick injuries. METHODS: A total of 200 inpatients who were in need of intravenous infusion with a disposable infusion needle were included and randomly divided into two groups: intervention group and control group. Disposable infusion needles with a separation-free safety tube were used in the intervention group, whereas conventional ones were used in the control group. Then, effects of the two types of infusion sets were observed and compared. RESULTS: As for the operation time for infusion, it was (82.19 ± 1.80) seconds in the intervention group and (83.02 ± 1.83) seconds in the control group, with the difference statistically significant (P < 0.05). Besides, the exposure time of the needles after infusion in the intervention group was (3.36 ± 0.17) seconds while (18.85 ± 1.18) seconds in the control group; the difference between which was statistically significant (P < 0.05). In terms of the time for needle disposal, (18.60 ± 0.84) seconds was required in the intervention group, while for the control group, it took (18.85 ± 1.18) seconds, and the difference between two groups was of statistical significance as well (P < 0.05). Nevertheless, there was no statistically significant difference in the accidental slip rate of the needles as that turned out 0% in both groups (P > 0.05). It was worth noting that the block rate of the disposed needles in the intervention group was 100%. CONCLUSION: The separation-free safety tube on the disposable infusion needle could instantly block the sharp needle after infusion, which reduces the needle exposure time and lowers the risk of needle stick injuries. In the meantime, the safety tube is convenient to use, and its application can shorten the time for infusion and needle disposal, consequently improving the working efficiency of nurses. As the new type safety tube has above advantages and would not raise the risk of needle slippage, it is worthy of clinical promotion.

Using FRAM to explore sources of performance variability in intravenous infusion administration in ICU: A non-normative approach to systems contradictions.

Systems contradictions present challenges that need to be effectively managed, e.g. due to conflicting rules and advice, goal conflicts, and mismatches between demand and capacity. We apply FRAM (Functional Resonance Analysis Method) to intravenous infusion practices in an intensive care unit (ICU) to explore how tensions and contradictions are managed by people. A multi-disciplinary team including individuals from nursing, medical, pharmacy, safety, IT and human factors backgrounds contributed to this analysis. A FRAM model investigation resulting in seven functional areas are described. A tabular analysis highlights significant areas of performance variability, e.g. administering medication before a prescription, prioritising drugs, different degrees of double checking and using sites showing early signs of infection for intravenous access. Our FRAM analysis has been non-normative: performance variability is not necessarily wanted or unwanted, it is merely necessary where system contradictions cannot be easily resolved and so adaptive capacity is required to cope.

Efficacy of Rapid Fluid Administration Using Various Setups and Devices.

OBJECTIVES: In clinical practice, there are various methods that can be used for the rapid administration of fluid in infants and children. The current study prospectively evaluates gravity, pressure-assisted, and hand-pump methods for the rapid administration of fluid using an in vitro model. METHODS: Thirty participants were asked to deliver 500 mL of fluid using 1 of 6 setups: (1) standard blood tubing with gravity administration, (2) standard blood tubing with pressure bag maintained at 300 mm Hg, (3) standard blood tubing with pressure bag inflated to 300 mm Hg and left to flow, (4) blood tubing with in-line bulb pump, (5) blood tubing with in-line bulb pump and pressure bag, and (6) standard blood tubing with 20-mL syringe attached to the stopcock for a push-and-pull technique using a 20-mL syringe. RESULTS: The blood tubing with an in-line bulb pump to allow manual acceleration of the administration of fluid along with a pressure bag on the intravenous fluid bag achieved the fastest flow rate, requiring an average of 98 seconds to deliver 500 mL of fluid. CONCLUSIONS: When considering factors that affect fluid administration, Poiseuille's law dictates that the most important variable is the radius of the intravenous cannula, whereas the length of the cannula and the viscosity of the fluid administered are of secondary importance. With these limitations in mind, other factors may be used to speed fluid administration. Our study demonstrates the advantage of using blood tubing with the in-line bulb pump combined with a pressure bag.

Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting.

OBJECTIVES: Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups. DESIGN: Experimental study with repeated measures design. SETTING: High fidelity simulated adult ICU. SUBJECTS: Forty critical care nurses. INTERVENTIONS: Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system. MEASUREMENTS AND MAIN RESULTS: Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001). CONCLUSIONS: The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.

Administering intravenous therapy in patients' homes.

Intravenous therapy in patients' homes is a relatively new procedure in the community nursing practice. This article looks at the practicalities of administering home IV therapy from the following aspects: hand hygiene; how to adjust IV therapy practices to the home environment; care of the IV access site including appropriate dressings; identifying and reacting to problems; maintaining a safe environment when performing IV therapy in a patient's home; anaphylaxis and how to identify and manage it; and the need for training to perform home IV therapy.

Paediatric nurses' adoption of aseptic non-touch technique.

BACKGROUND:: in 2015, NHS Wales introduced a national standardised approach to aseptic non-touch technique (ANTT). This approach aims to standardise practice and promote better clinical outcomes. AIM:: to provide insight into the challenges faced by clinical staff adopting ANTT during intravenous therapy. METHODS:: focused ethnography across two paediatric wards in NHS Wales. Data collection included participant observation, audit questionnaires and semi-structured interviews. Data were analysed according to Wolcott's (1994) process and emerging themes were reflected upon against the theoretical framework of Kirkpatrick's (1994) model of training evaluation. FINDINGS:: absence of feedback following training, individual preference, lack of opportunity to practise the ANTT technique, lack of clarity and standardisation and expectations of parents/medical staff are all challenges faced by registered nurses. IMPLICATIONS OF THE STUDY:: the findings may be used by NHS managers to support national initiatives within staff training and development programmes, and to improve infection prevention initiatives. Organisational culture is a modifier of healthcare worker behaviour and requires further attention locally and nationally. Quality assurance in the adoption of standardised best practice must take into account staff training and development needs, and workplace culture.

Challenges in Implementing an E-Learning Education Program for Syringe Pump Use.

To prevent the incidence of risks imputable to human error during the process of preparing the infusion pump, clarity in teaching and learning are required. Because traditional classroom training is difficult and time-consuming, the aim of the present study was to challenge the implementation of an e-learning education program for syringe pump use. The impact of the e-learning program was evaluated with 100 nurses between March and June 2016. The e-learning program significantly increased general baseline knowledge in syringe pump use; however, aspects of the program confused participants. The feedback from 98 % of nurses on the e-learning program was that it was effective in helping them with this skill. However, only 54 % opted for the e-learning program versus traditional training. The present study showed nurses preferred a blended learning format. Based on our hospital incident and error reports, this study shows local training requires a specific approach strategy for syringe pump education.

Patient safety in nursing care during medication administration.

OBJECTIVE: to evaluate the conformity of care practices of the nursing team during the administration of drugs through central vascular catheter. METHOD: a descriptive, prospective, observational study conducted in an Intensive Care Unit. The non-probabilistic intentional sample consisted of 3402 observations of drug administrations in patients with central vascular catheters. The previously validated collection instrument was constructed based on the Guideline for Prevention of Intravascular catheter-related infections. Data was collected through direct observations of nursing practices performed by the nursing team. The analysis used analytical, descriptive and inferential statistics (Chi-square test and Fisher's exact test). RESULTS: a total of 3402 procedures of drug administrations were observed. Female nursing technicians performed the highest number of actions. In none of the procedures did the professional perform all necessary actions. 0.2% of drug administrations were preceded by hand hygiene and 1.3% by disinfection of the multidose vial, ampoule or injectors. CONCLUSION: the practice evaluated was classified as undesirable. Failure to achieve the desired conformity was probably due to the low adherence of professionals to the practice of hand hygiene and disinfection of materials, injectors and connectors.

Non-flushing of IV administration sets: an under-recognised under-dosing risk.

BACKGROUND: intravenous (IV) drugs are administered widely and under-dosing can result in therapy failure. The aim of this study was to quantify frequency, volume and dose of drug discarded within administration sets in the clinical setting. METHODS: residual volume for 24 different administration sets was measured under controlled conditions in a laboratory. Clinical assessment of current practice regarding post-infusion flushing occurred in 6 departments of one teaching hospital in the UK over 7 days. Details of drug last infused, (concentration, diluent and volume) and type and brand of administration set were collected. RESULTS: 74% of administration sets were not flushed. Non-flushing exceeded 90% and 61% for gravity and pump infusions respectively (p<0.001) in all areas excluding oncology. Oncology was the only area where flushing was standard practice for all infusions (p<0.001). Mean residual volume of the administration sets was 13.1 ml and 16.7 ml for gravity and pump sets respectively. Antibiotics were commonly infused and up to 21% of antibiotic dose was frequently discarded. CONCLUSIONS: the findings suggest disposal of substantial volumes of drugs occurs frequently in general hospital areas. Without clear national and local policies this unrecognised under-dosing will continue.

Peripheral Infiltration and Extravasation Injury Methodology: A Retrospective Study.

Peripheral infiltration is defined as the inadvertent delivery of nonvesicant fluid or medication into surrounding tissue that has the potential to harm the patient. Vesicant fluid that has leaked into the tissue space is called extravasation. At present, there is no agreement in the literature on the best practice for managing these injuries in pediatric patients. The purpose of this study was to identify occurrences of peripheral infiltration injuries and examine treatment modalities used to treat pediatric patients who suffered such an injury.