Manual of I.v. Therapeutics, Evidence-Based Practice for Infusion Therapy, Sixth Edition

MANUAL OF

I.V.

Therapeutics

Evidence-Based Practice

for Infusion Therapy

6

_{E D I T I O N}

Lynn Dianne Phillips,

Professor Emeritus Butte College

Butte Valley, California Nursing Education Consultant President

Infusion Nurses Society 2009–2010

Lisa Gorski,

Clinical Nurse Specialist

Wheaton Franciscan Home Health & Hospice Milwaukee, Wisconsin

President

1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2014 by F. A. Davis Company

Copyright © 2014 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Thomas A. Ciavarella

Director of Content Development: Darlene D. Pedersen Project Editor: Echo K. Gerhart

Electronic Project Editor: Sandra Glennie Cover Design: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recom-mended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Phillips, Lynn Dianne, 1947- author.

Manual of I.V. therapeutics : evidence-based practice for infusion therapy/Lynn Dianne Phillips, Lisa Gorski. — Sixth edition.

p. ; cm.

Manual of I.V. therapeutics Manual of intravenous therapeutics

Includes bibliographical references and index. ISBN 978-0-8036-3846-4

I. Gorski, Lisa A., author. II. Title. III. Title: Manual of I.V. therapeutics. IV. Title: Manual of intravenous therapeutics.

[DNLM: 1. Infusions, Intravenous—methods—Examination Questions. 2. Infusions, Intravenous— methods—Handbooks. 3. Infusions, Intravenous—nursing—Examination Questions. 4. Infusions, Intravenous—nursing—Handbooks. WB 39]

RM170 615’.6—dc23

2013045751 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 978-0-8036-3846-4/14 0 + $.25.

I want to dedicate this edition of the Manual to the supportive, loving friends I have had the good fortune to know through the Infusion Nurses

Society: Mary Alexander, Michelle Berreth, Ann Corrigan, Beth Fabian, Lisa Gorski, Roxanne Perucca, Ofelia Santiago, Marvin Siegel, and Mary Walsh. I am truly blessed. To Lisa, it has been a pleasure having you co-author this edition. You have been an excellent author, and this

edition is better than ever because of you!

Additionally, as always, to nursing students—you are our future!

Lynn Phillips

First of all, I want to thank Lynn for asking me to co-author this edition of the Manual—it was a joy to work together! I dedicate this book to my husband John, my parents John and Audrey Morrill, and

my children Ben and Amanda Gorski, who have loved me and have supported me in all my professional endeavors. And also to my colleagues in the Infusion Nurses Society, who make a difference every day by supporting our Standards of Practice to ensure that our

patients receive the best possible care.

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your SUPER DUO today

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Call 800.323.3555 (US)

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v

P

REFACE

Manual of I.V. Therapeutics: Evidence-Based Practice for Infusion Therapy, Sixth Edition,

provides comprehensive information on infusion therapy for the nursing student and practicing nurse. Continuing with this edition is the focus on evidence-based practice (EBP), defined as the conscientious use of current best evidence in making decisions about patient care. Evidence-based practice includes research evidence in the form of systematic reviews and clinical practice guidelines to a clinician’s knowledge, judgment, and experience and de-emphasizes practice based on tradi-tion and ritual. EBP is important to any nurse performing infusion therapy because of the rapidly expanding dimensions of the nurse’s role, the ongoing introduction of new infusion devices and techniques, and the evolving research supporting the importance of nursing interventions in improving patient safety and reducing the risk of infusion-related complications. The sixth edition continues to address pedi-atric and the older adult patients in a separate section in each chapter. This text-book incorporates the 2011 Infusion Nurses Society Standards of Practice and the 2011 Centers of Disease Control and Prevention (CDC) guidelines for prevention of intravascular catheter-related infections.

This self-paced, comprehensive text presents information ranging from a simple to a complex format, incorporating theory into clinical application. The skills of recall, nursing process, critical thinking, and patient education are covered, along with detailed summaries, providing the foundation one needs to become a knowledgeable practitioner. The psychomotor skills associated with infusion therapy are presented in step-by-step procedures with rationales based on standards of practice at the end of the chapters.

Each chapter includes accompanying objectives, defined glossary terms that are bolded within the text, a post-test, a summary of chapter highlights, and a crit-ical thinking case study. Icons and special boxes are used throughout each chapter to key the reader to websites, patient education, home care issues, cultural consid-erations, and standards of practice. Skill Checks, 100 test questions, PowerPoint presentations, and math calculations tests are included in the DavisPlus faculty ancillaries and can be used in the educational setting, as well as in agencies, for validating competencies of nurses in infusion skills. The icons used in this sixth

edition are as follows:

Identifies key points of theory content

Identifies Nursing Fast Facts, which are set in italics and shaded within the chapter for important nursing practice information

Identifies relevant studies in Evidence-Based Practice (EBP)

✐

>

Identifies Websites

Identifies Nursing Points of Care Identifies Home Care Issues

Identifies Patient Education information

Identifies a media link, which refers to DavisPlus, and is located in the critical thinking case study and post-test sections at the end of each chapter

Identifies Infusion Nurses Society (INS), Standards of Practice

The sixth edition of this textbook is organized from foundations of practice followed by basic practices for all nurses and concludes with specialty infusion practices. The first three foundations chapters are designed to provide information to the reader on nursing practice related to infusion therapy (nursing process ap-plied to infusion therapy, legal and ethical responsibilities, evidence-based practice background, and performance improvement), infection prevention and occupa-tional hazards, and fundamentals of fluid and electrolyte balance.

The subsequent seven chapters provide the essential solid foundation in infu-sion therapy practices, including parenteral solutions, infuinfu-sion equipment, periph-eral and central vascular access techniques and management, complications, medication infusion, and infusion calculations. This sixth edition has incorporated recurring displays for cultural and ethnic-related issues. Key concepts for nursing practice are identified as “Nursing Fast Facts,” and “Note>” identifies an important theory concept.

The last two chapters encompass the additional topics of transfusion therapy and parenteral nutrition. The DavisPlus website contains questions based on stan-dards of practice and follows the guidelines of the INS Core Curriculum for certi-fication. It includes guidelines for discussion and answers to the case studies, and additional math calculations problems and answers. It also provides the learner with web-based ancillaries, an additional 50 interactive flash cards for learning terminology, interactive case studies, and web links for further research.

We hope this new edition provides you, whether you are a practicing health-care professional or a student, with valuable insights into the safe practice of infusion therapy and a reference for this rapidly advancing field.

Lynn Phillips and Lisa Gorski

vii

C

ONSULTANTS

Michelle Gricar, MS, RN, RMA

Clinical Nurse Specialist–Wheaton Franciscan Healthcare St. Francis Milwaukee, Wisconsin

Mark Hunter, RN, CRNI®

Senior Product Manager Peripheral Vascular Access CareFusion

Vernon Hills, Illinois

Elizabeth Krzywda, MSN, APNP, NP-C

Nurse Practitioner–Medical College of Wisconsin

Milwaukee, Wisconsin

Mary McGoldrick, MS, RN, CRNI®

Home Care and Hospice Consultant– Home Health Systems, Inc. Saint Simons Island, Georgia

Heather Moore, RN, BSN

Manager, Maternal/Child Program Wheaton Franciscan Home Health & Hospice

Milwaukee, Wisconsin

Deb Richardson, RN, MS, CNS

Owner/President–Deb Richardson & Associates

ix

R

EVIEWERS

Faculty, Nursing Skills Lab Manager Hondros College Nursing Programs Fairborn, Ohio

Faith Chennette,

MSN, OCN, CNE, CPHN, RN-BC

Nursing Faculty

College of Western Idaho Nampa, Idaho

Susan M. Hampson,

MS, RN, APN, FNP-BC, CNE

Assistant Professor School of Nursing Saint Xavier University Chicago, Illinois

Diane Madsen, BSN, MA, PhD, RN

Nursing Faculty

Pueblo Community College–Fremont Campus

Canon City, Colorado

Judy Mahan, RN, MS

Director, Allied Health Feather River College Quincy, California

Rox Ann Sparks, RN, MSN, MICN, LNC

Professor, Assistant Director Vocational Nursing Merced College Merced, California

xi

A

CKNOWLEDGMENTS

The authors would like to acknowledge the following:

The nurses in the specialty practice of infusion therapy

At F. A. Davis:

Tom Ciavarella, Nursing Acquisitions Editor, who assisted in the final develop-ment of this manual.

Echo Gerhart, Project Editor, Nursing, who as project consultant helped bring this vision to reality.

Sam Rondinelli, Production Manager, for guiding this manuscript through the production process.

Robert G. Martone, Publisher, Nursing, whose foresight brought the project to F. A. Davis.

And. . . .

Cassie Carey, Senior Production Editor at Graphic World Inc

Appreciation is also expressed to the following companies who provided product information, pictures, and illustrations:

3M Medical Division, St. Paul, MN AngioDynamics, Marlborough, MA

Baxter Healthcare Corporation, Round Lake, IL B. Braun Medical Inc., Bethlehem, PA

BD Medical, Sandy, UT CareFusion, San Diego, CA

Catheter Connections, Salt Lake City, UT Cenorin, Kent, WA

Centurion, Williamston, MI Cook Medical, Bloomington, IN C. R. Bard Inc., Salt Lake City, UT Infusion Nurses Society, Norwood, MA Interrad Medical, Plymouth, MN I.V. House, Inc., Chesterfield, MO

Ivera Medical Corporation, San Diego, CA

J&J Wound Management, Division of Ethicon, Inc., Somerville, NJ Lippincott Williams & Wilkins, Philadelphia, PA

MediVisuals, Inc., Dallas, TX

Moog Medical Devices Corp., Salt Lake City, UT Norfolk Medical Products, Inc., Skokie, IL Pall Medical, Port Washington, NY RGB Medical Imagery, Delaware, OH

Smiths-Medical Critical Care, Inc., Carlsbad, CA Tangent Medical, Ann Arbor, MI

TransLite LLC, Sugar Land, TX Vidacare, San Antonio, TX VueTek Scientific, Gray, ME

xiii

T

ABLES

1-1 Assessing Competency____________________________________6 1-2 Sources of Evidence _____________________________________10 1-3 Two Examples of Evidence Rating Scales __________________11 1-4 Elements of Informed Consent____________________________26 1-5 Most Frequently Reviewed Sentinel Event Categories

in 2012________________________________________________28 2-1 Organs of the Immune System____________________________54 2-2 Types and Functions of White Blood Cells__________________57 2-3 Factors Associated with Increased Central

Line-Associated Bloodstream Infection (CLABSI) Risk _____67 2-4 Microorganisms Most Frequently Encountered ____________71 2-5 Common Tests for Evaluating the Presence or

Risk of Infusion-Related Infections_______________________90 2-6 Sharps Safety Devices and Recommendations______________92 3-1 Percentages of Total Body Fluid in Relation

to Age and Gender __________________________________117 3-2 Regulators of Fluid Balance______________________________128 3-3 Summary of Laboratory Evaluation for Fluid

and Electrolyte Imbalances____________________________133 3-4 Quick Assessment Guide for Fluid Imbalances_____________140 3-5 Comparison of Electrolyte Composition in Fluid

Compartments_______________________________________ 142 3-6 Critical Guidelines for Administration of Potassium________154 3-7 Critical Guidelines for Removal of Potassium______________157 3-8 Critical Guidelines for Administration of Magnesium______167 3-9 Clinical Problems Associated with Electrolyte

Imbalances___________________________________________173 3-10 Summary of Acute Acid–Base Imbalances ________________185 4-1 Contents of Available Intravenous Fluids_________________214 4-2 Quick-Glance Chart of Common I.V. Fluids________________216 4-3 Common Colloid Volume Expanders_____________________227 5-1 Smart Pump Features___________________________________294 5-2 Infusion Pump Risk Reduction Strategies for Clinicians_____297 6-1 Comparison of Artery and Vein__________________________315 6-2 Selecting an Insertion Site for Superficial

6-3 Phillips 16-Step Peripheral-Venipuncture Method_________320 6-4 Tips for Selecting Veins_________________________________327 6-5 Phillips Multiple Tourniquet Technique___________________330 6-6 Transillumination_______________________________________331 6-7 Techniques to Assist with Difficult Venous Access___________333 6-8 Recommended Gauges__________________________________337 6-9 Conversion Chart: Rate Calculation______________________351 6-10 Summary of Steps in Initiating Peripheral l.V. Therapy_____353 6-11 Components of the Pediatric Physical Assessment_________363 6-12 Pediatric Infusion Sites___________________________________364 6-13 Flushing Guidelines for Pediatric Patients_________________369 6-14 Tips for the Older Adult with Fragile Veins________________375 7-1 Duties of the Nurse or Phlebotomist_____________________409 7-2 Blood Collection Tray Contents__________________________411 7-3 Order of Draw for Multiple Tube Collections______________435 8-1 Measurements of Veins (Adult)__________________________468 8-2 Conditions Affecting Vascular Access Device Site

Placement____________________________________________471 8-3 Flushing Protocols______________________________________496 8-4 Comparison of Central Venous Catheters_________________498 8-5 Summary of Care and Maintenance of Central

Vascular Access Devices_______________________________510 8-6 Neonatal and Pediatric Flushing Protocols________________511 9-1 Types of Phlebitis_______________________________________546 9-2 Factors Increasing Risk for Phlebitis______________________547 9-3 Phlebitis Scale__________________________________________549 9-4 Infiltration Scale________________________________________557 9-5 Factors That Increase Risk for Extravasation Injury_________560 9-6 Local and Systemic Complications of Peripheral

Intravenous Therapy__________________________________567 9-7 Central Venous Catheter Bloodstream

Infection Prevention__________________________________572 9-8 Summary of Complications of Central Venous Access______599 10-1 Advantages and Disadvantages of Intravenous

Medication Administration____________________________619 10-2 Patient Risk Factors for Oversedation and Respiratory

Depression with Patient-Controlled Analgesia__________631 10-3 Epidural and Intrathecal Medications_____________________657 10-4 Monitoring Parameters for the Patient Receiving

an Intraspinal Infusion________________________________659 10-5 Eight Rights of Medication Administration________________663 11-1 ABO Blood Grouping Chart______________________________687 11-2 ABO Compatibilities for Red Blood Cell Components______687 11-3 ABO Compatibility for Fresh Frozen Plasma_______________687

11-4 Blood Types by Population______________________________688 11-5 Blood Conservation Methods____________________________701 11-6 Summary of Common Blood Components________________717 11-7 Steps in the Administration of a Blood Component_______723 11-8 Risks of Transfusion Therapy_____________________________735 11-9 Summary of Transfusion Reactions_______________________736 12-1 Components of a Nutritional Assessment_________________773 12-2 Physical Findings Associated with Deficiency States_______777 12-3 Dextrose Solutions for Parenteral Nutrition_______________780 12-4 Components of Parenteral Nutrition Order Form__________788 12-5 Complications Associated with PN_______________________801

xvii

C

ONTENTS IN

B

RIEF

1

Professional Practice Concepts for Infusion

Therapy

_________________________________________

1

2

Infection Prevention and Occupational Risks

_______

49

3

Fundamentals of Fluid and Electrolyte Balance

___

113

4

Parenteral Solutions

____________________________

198

5

Infusion Equipment

_____________________________

240

6

Techniques for Initiation and Maintenance

of Peripheral Infusion Therapy

__________________

309

7

Phlebotomy Techniques

_________________________

406

8

Techniques for Initiation and Maintenance

of Central Vascular Access

_______________________

462

9

Complications of Infusion Therapy: Peripheral

and Central Vascular Access Devices

_____________

540

10

Infusion Medication Safety, Methods,

and Routes

_____________________________________

612

11

Transfusion Therapy

____________________________

682

12

Parenteral Nutrition

___________________________

766

xix

C

ONTENTS

CHAPTER1

Professional Practice Concepts

for Infusion Therapy

_____________________

1

Introduction______________________________________4

Delivery of Quality Care__________________________5

Nursing Process Related to Infusion Therapy _____11

Quality Management___________________________15

Risk Management and Risk Assessment___________23

Legal and Ethical Issues in Infusion Therapy______33

CHAPTER2

Infection Prevention and Occupational

Risks

__________________________________

49

Introduction ___________________________________52

Immune System Function _______________________53

Basic Principles of Epidemiology_________________59

Health-Care–Associated Infections_______________64

Strategies for Preventing Infection_______________72

Occupational Hazards___________________________91

Nursing Process_______________________________100

CHAPTER3

Fundamentals of Fluid and

Electrolyte Balance

____________________

113

Body Fluid Composition________________________116

Fluid Distribution______________________________117

Fluid Function_________________________________119

Fluid and Electrolyte Homeostatic Mechanisms____124

Physical Assessment of Fluid and Electrolyte

Needs_______________________________________128

Disorders of Fluid Balance ______________________134

Basic Principles of Electrolyte Balance___________141

Acid–Base Balance_____________________________174

Major Acid–Base Imbalances ___________________177

CHAPTER4

Parenteral Solutions

___________________

198

Rationales and Objectives of Parenteral

Therapy_____________________________________200

Key Elements in Parenteral Solutions____________204

Osmolality and Osmolarity of Parenteral

Solutions_____________________________________206

Types of Parenteral Solutions___________________209

Nursing Process_______________________________234

CHAPTER5

Infusion Equipment

___________________

240

Infusion Therapy Equipment ___________________243

Solution Containers____________________________244

Administration Sets____________________________250

Add-On Devices_______________________________259

Catheter Stabilization Devices__________________269

Site Protection and Joint Stabilization Devices____271

Peripheral Intravenous Catheters_______________271

Central Vascular Access Devices_________________279

Flow-Control Devices__________________________285

Developing and Participating in Product

Evaluation___________________________________299

Nursing Process_______________________________302

CHAPTER6

Techniques for Initiation and

Maintenance of Peripheral Infusion

Therapy

______________________________

309

Anatomy and Physiology Related to I.V. Practice___312

Approaches to Venipuncture: Phillips 16-Step

Peripheral-Venipuncture Method______________319

Intermittent Infusion Therapy__________________352

Peripheral Infusion Site Care and Maintenance (Peripheral-Short and Midline Catheters)______356

Nursing Process ______________________________379

CHAPTER7

Phlebotomy Techniques

________________

406

Introduction to Phlebotomy____________________408

Equipment for Blood Collection_________________411

Blood Collection Procedure_____________________422

Complications__________________________________438

CHAPTER8

Techniques for Initiation and

Maintenance of Central Vascular

Access

_______________________________

462

General Overview of Central Vascular

Access Devices______________________________464

Anatomy of the Vascular System_______________466

Assessment and Device Selection______________468

Nontunneled Central Vascular Access Devices and Peripherally Inserted Central Catheters__479

Long-Term Central Vascular Access Devices_____488

Care and Maintenance________________________497

Nursing Process______________________________517

CHAPTER9

Complications of Infusion Therapy:

Peripheral and Central Vascular

Access Devices

________________________

540

Local Complications___________________________542

Systemic Complications_______________________571

Central Vascular Access Device Complications __585

Nursing Process______________________________604

CHAPTER10

Infusion Medication Safety, Methods,

and Routes

___________________________

612

Safe Delivery of Infusion Therapy______________615

Principles of Intravenous Medication

Administration______________________________618

Drug Stability and Compatibility ______________620

Intravenous Medication Administration________623

Other Infusion Medication Routes_____________636

Infusion Medication Delivery__________________662

CHAPTER11

Transfusion Therapy

__________________

682

Basic Immunohematology_____________________686

Blood Donor Collection Methods______________693

Blood Management___________________________699

Blood Component Therapy____________________701

Alternatives to Blood Transfusions_____________720

Administration of Blood Components__________722

Complications Associated with Blood

Component Therapy________________________734

Nursing Process______________________________755

CHAPTER12

Parenteral Nutrition

__________________

766

Nutritional Support___________________________768

Concepts of Nutrition_________________________769

Nutritional Screening_________________________772

Nutritional Requirements/Parenteral

Formulations: Adults________________________778

Delivery of Nutritional Support________________786

Parenteral Nutrition Administration____________796

Complications Associated with Parenteral

Nutrition___________________________________800

Discontinuation of Nutritional Support_________806

Nursing Process______________________________813

Chapter Contents

Learning Objectives Glossary

Introduction

Delivery of Quality Care Clinical Competency Value of Certification Evidence-Based Practice Nursing Process Related to

Infusion Therapy Assessment Diagnosis Outcomes Identification Planning Implementation of Interventions/Nursing Actions Evaluation Quality Management Quality Assessment/Quality Improvement Performance Improvement Total Quality Management

Standards

Standards as Domains of Organizational Structure Additional Strategies in

Quality Management Risk Management and Risk

Assessment Informed Consent

Unusual Occurrence Reports Sentinel Events

Documentation Infusion Medication

Safety

Legal and Ethical Issues in Infusion Therapy Sources of Law Legal Terms

Legal Causes of Action Related to Nursing Practice

The Infusion Nurse’s Role as Expert Witness

Chapter

1

Professional Practice Concepts

for Infusion Therapy

In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscella-neous information or curious facts, but for the sake of saving life and increasing

health and comfort. Florence Nightingale, 1873

>

>

GLOSSARY

Assessment The systematic and continuous collection, organization, validation, and documentation of data; the first step of the nursing process

Barcoding system System that encodes data electronically into a series of bars and spaces, which is scanned by lasers into a computer to identify the object being labeled

Reducing the Risk for Malpractice

Ethical Issues Related to Infusion Therapy Home Care Issues Patient Education

Chapter Highlights

Thinking Critically: Case Study Post-Test References LEARNING OBJECTIVES ■ ■

■ _{On completion of this chapter, the reader will be able to:}

1. Define the terminology related to infusion-related professional practice.

2. Identify the elements of infusion nurse competency.

3. Discuss the use of competency-based education programs in the practice of infusion therapy. 4. Discuss the value of nursing certification. 5. Discuss evidence-based practice.

6. Identify five steps used in developing an evidence-based protocol.

7. Identify the components of the nursing process and how they are applied to infusion practice. 8. Apply quality management strategies to infusion

practice.

9. Identify risk management and risk assessment strategies.

10. Differentiate between standards of care and standards of practice.

11. Identify the sources of laws.

12. Identify the areas of breach of duty for the specialty of infusion nursing.

13. Identify the role of the nurse as an expert witness. 14. Identify the principles used in ethical decision

Benchmarking Process of measuring and comparing the results of processes with those of the best performers

Civil law Laws that affect the legal rights of private persons or corporations

Competency Includes aspects of performance such as skills, knowledge, ability, and judgment

Criminal law Offense against the general public; affects welfare of society as a whole

Data collection Gathering information through interviewing, observing, and inspecting

Documentation A recording, in written or electronic form, containing original, official, or legal information

Evaluation Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement

Evidence-based practice (EBP) Conscientious use of current best evidence (e.g., research) in making decisions about patient care; it deemphasizes practice based on tradition and ritual.

Expert testimony Witness from the same professional specialty who examines evidence, reviews pertinent nursing literature, gives depositions, and potentially testifies in court. An expert nurse gives advice and consultation throughout the litigation process.

Goal Broad statement of a desired outcome

Implementation Carrying out planned nursing interventions; the fifth step of the nursing process

Liable Legally responsible for damages, answerable Malpractice Negligent conduct of a professional person Negligence Not acting in a reasonable or prudent manner Nursing diagnosis A clinical judgment about actual or potential

individual, family, or community experiences/responses to health problems; identification of nursing diagnoses is the second step of the nursing process

Nursing standard Specific statement about the quality of a facet of nursing care

Outcome Result of the performance (or nonperformance) of a function or process(es)

Performance improvement (PI) Continuous study and adaptation of functions and processes of a health-care organization to increase the probability of achieving desired outcomes and to better meet the needs of patients and other users of services

Planning Determining how to prevent, reduce, or resolve identified patient problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner; the fourth step of the nursing process

Process A goal-directed, interrelated series of actions, events, mechanisms, or steps

Quality assessment (QA) Process including data collection and data analysis in evaluating a problem

Quality improvement (QI) Builds on the data identified in quality assessment to identify action steps including monitoring, evaluating, and problem solving.

Quality management (QM) An organizational culture committed to achieving excellence

Risk management Process that centers on identification, analysis, treatment, and evaluation of real and potential hazards

Standard of care Focuses on the recipient of care consistent with minimum safe professional conduct and describes outcomes of care that patients can expect to receive

Standards of nursing practice Focuses on the provider and defines competent care along with the activities and behavior needed to achieve positive patient outcomes

Statutes Written laws enacted by the legislature

Structure Standard that refers to conditions and mechanisms that provide support for the delivery of care (e.g., policy and resources) Tort Private wrong, by act or omission, that can result in a civil action

by the harmed person

Total quality management (TQM) Management system fostering continuously improving performance at every level of every function by focusing on maximization of customer satisfaction; focuses on process

Introduction

Infusion nursing is a recognized nursing specialty. Infusion nursing includes placement of an access device such as peripheral I.V. catheter, administration of a wide variety of infusion solutions and medications, interventions aimed at prevention of complications, and assessment and monitoring for patient response. The intravenous (I.V.) route is the most commonly used infusion route; however, other infusion routes include intraosseous, subcutaneous, and intraspinal. Non-I.V. infusions may be appropriate for administration in certain situations and with selected fluids and medications. The practice of infusion nursing encompasses nursing management and coordination of care (Corrigan, 2010) to the patient in accordance with:

1. State statutes

2. Infusion Nurses Society (INS) Standards of Practice ■

■

3. Established institutional policy 4. Accreditation requirements

Infusion therapy is administered in all health-care settings, including hospitals, long-term care facilities, outpatient settings, physician offices, and patients’ homes. Most nurses at some point of, or throughout, their career will be involved in infusion care. The patient populations served by this specialty practice range from neonates to elderly patients. Because vascular access device (VAD) care and infusion administration have become such common areas of nursing practice, nurses may consider these practices very routine. However, there are risks, and some complications are serious and life threatening. Regardless of the setting, the nurse must have a thorough understanding and knowledge of the appropriate type of access device being utilized, the appropriateness of the selected device for the prescribed therapy, care and maintenance of the device, potential complications related to the device and infusion solutions, and safe infusion administration.

Delivery of Quality Care

Clinical Competency

Competency Standards

The American Nurses Association (ANA, 2010a) asserts that the public has a right to expect the registered nurse to demonstrate professional competence. In their recommendations about the future of nursing, the Institute of Medicine (2011) states that nurses must be engaged in lifelong learning to gain the competencies needed to provide care for diverse populations across their patients’ life spans. The ANA Standards of Professional Nursing Practice (2010a, p. 49) include the Standard of Education, which states that the registered nurse attain knowledge and competence reflective of current nursing practice.

Competence and competency are two frequently used terms that sound similar and may be used interchangeably; however, they do have different meanings. Nursing competence refers to the potential ability to perform at an expected level of practice, whereas competency focuses on actual performance. Competence is required before one can expect competency (National Board for Certification of Hospice and Palliative Nurses, 2011). Competency integrates the following aspects of perform-ance related to patient care:

1. Skills: Psychomotor, communication, interpersonal, diagnostic 2. Knowledge: Examples include thinking, understanding,

profes-sional standards of practice, insights from personal experience ■

■

3. Ability: Capacity to act effectively

4. Judgment: Critical thinking, problem solving, ethical reasoning, decision making (ANA, 2010a, pp. 12-13)

Health-care organizations identify and measure competence, based on the needs of the organization (INS, 2011). Competency may be reviewed through information obtained from past and current employers, peer rec-ommendations, validating specialty certifications, testing, ongoing per-formance data collection, and/or skills observation, either separately on in partnership with customers. Competency validation should occur on ori-entation to the organization, on an ongoing basis, with changes in scope of practice, and when new equipment, new technology, or a new practice is introduced (INS, 2011, p. S11). The need to validate competency may be identified through clinical outcome data (e.g., increase in infection rates), occurrence or sentinel event reports, implementation of new equipment or technology, evaluation of patient satisfaction (e.g., problems with periph-eral I.V. placement), or changes in patient populations. When the health-care organization chooses to measure or validate specific competencies, it should do so in a thorough and ongoing fashion, including looking at new, significant, and/or high-risk practices, interventions, or activities that are unfamiliar to staff members.

Competence is assessed using different methods, yet there is no single tool or method that “guarantees” competence (ANA, 2010a). A variety of methods are used, including written tests and direct observation of a skill, whether in the work setting, in a skills laboratory, or through use of simulation. Observing performance of a skill in the work environment is the preferred method for evaluating invasive infusion therapy skills (INS, 2011, p. S11) (Table 1-1). Competence assessment requires a checklist that includes objective, measureable assessment of the actual performance,

>

■ Direct observation by a supervisor, designated evaluator, instructor, or preceptor while the employee/student demonstrates the skill in the work setting

■ Observation by a supervisor, designated evaluator, instructor, or preceptor while the employee/student demonstrates the skills in simulated settings, such as skill laboratories and mock drills

■ Direct observation and return demonstration may be supplemented with other forms of assessment, such as tests. The testing should not be the primary means of assessment.

Documentation of Competency

Competency assessments should be documented. ■ Competency checklist

such as specific criteria or critical behaviors, and the criteria for achieving success in the performance.

Competency-Based Educational Programs

Competency-based educational programs establish specific goals, account-ability, individualization, and behaviors for practitioners by defining clear expectations for levels of performance. The health-care organization has the responsibility of ensuring a competent staff. A framework for developing staff competencies and ensuring that the institution is delivering safe care includes:

■ Development of standards

■ Development of criteria for performance of skills

■ Assessment of learning needs

■ Establishment of a plan of educational programs

■ Presentation of educational programs

■ Evaluation of learning outcomes Three-Part Competency Model

A three-part competency model includes:

1. Competency statement: Statement that reflects a measurable goal 2. Domains of learning criteria: Cognitive criteria (knowledge base)

and performance criteria (psychomotor skills: observed behaviors) 3. Evaluation and learning outcomes: Written tests, return

demon-strations, and clinical demonstration of skill to nurse preceptor All professional nurses are accountable and responsible for all parts of the tasks associated with infusion therapy and for tasks that are delegated to the licensed practical nurse or technician for care rendered to the patient while under care. The three-part competency model is an effective tool for ensuring competent practice.

INS Standard The nurse shall be competent in the safe delivery of infusion therapy within his/her scope of practice and shall be responsible and accountable for attaining and maintaining compe-tence with infusion therapy within her or his scope of practice (INS, 2011, p. S11).

Clinical Competency Validation Program

The INS provides a clinical competency validation program for infusion therapy; the latest version was published in 2012. The Clinical Compe-tency Validation Program (CCVP) is a helpful tool for organizations to use when validating infusion-related nursing skills. There are 33 specific nursing competencies in the program, which can be used for procedural validation skills.

Value of Certification

Professional nursing certification programs have long established their value and importance to health-care organizations and to patients and their families. The American Board of Nursing Specialties (ABNS) was formed in 1991 with a mission to “promote the value of specialty nursing certification to all stake holders” (ABNS, 2006). Certification, as defined by the ABNS (2006), is the formal recognition of specialized knowledge, skills, and experience demonstrated by achievement of standards identified by a nursing specialty to promote optimal health outcomes.

Basic nursing licensure indicates a minimal professional practice standard. Certification is a mark of excellence, validates nursing knowl-edge and skills, and protects the public (Altman, 2011). There is a grow-ing body of evidence supportgrow-ing the impact of nursgrow-ing certification on nursing knowledge, value to the organization, and patient outcomes (INS/Infusion Nursing Certification Corporation, 2009). The INS pro-vides certification specific to infusion therapy with the designation of CRNI® _{(certified registered nurse, infusion). Other certifications that}

include components of infusion therapy are as follows: 1. Oncology Nursing Certification Corporation (OCN®_):

www.oncc.org

2. Pediatric Nursing Certification Board (CPN®_{): www.pncb.org}

3. American Society for Parenteral and Enteral Nutrition (CNSC): www.nutritioncare.org

4. Association for Vascular Access (VA-BC): www.avainfo.org Increasingly, health-care organizations are placing a high value on nursing certification. Based on initiatives for certification from across the country, the American Association of Critical Care Nurses identified five themes of best practices in creating a culture for nursing certification: commitment to excellence, a supportive and encouraging environment, goal-directed evaluations, availability of educational resources, and cele-brations for rewarding excellence (Fleischman, Meyer, & Watson, 2011).

Evidence-Based Practice

Evidence-based practice (EBP)is an essential characteristic of an effective health-care system. It is expected that the nurse utilize evidence-based in-terventions and treatments (ANA, 2010a).

The ANA (2010a, p. 65) defines EBP as a scholarly and systematic problem-solving paradigm that results in the delivery of high-quality health care. A classic definition of EBP is the conscientious use of current best evidence in making decisions about patient care (Sackett et al., 2000).

It deemphasizes practice based on tradition and ritual. Components of EBP include the following (Hagle, 2010):

■ Evidence from research/evidence-based theories, and opinion leaders/expert panels

■ Evidence from assessment of the patient’s history and physical examination, and availability of health-care resources

■ Clinical expertise

■ Information about patient preferences and values

Consider the following simple example of EBP implementation: You

are a home care nurse who has been caring for a patient for several years. He has an implanted port that you access for a monthly infusion. You have used povi-done iodine (Betadine) for skin antisepsis prior to port access. This patient has never had a catheter-related infection. There is now strong evidence that chlorhexidine/alcohol solution is a superior agent and is preferred for skin anti-sepsis; you also know that povidone iodine is still considered an acceptable agent. This patient does not want to switch antiseptic agents because he has never had a problem. You understand the research supporting the use of chlorhexidine, but you also use your clinical judgment based on the patient’s history and take into account your patient’s preferences, and you do not change his protocol.

EBP is important to the infusion nurse because of the rapidly expand-ing dimensions of the nurse’s role, the ongoexpand-ing introduction of new infusion products and technology, and the growing base of research addressing complication prevention. Each time a new device or technique is introduced, new practices must be considered. Questions must be asked when new technology is introduced, such as:

■ Are there studies supporting the benefits of the technology?

■ In what health-care settings has the technology been evaluated? Between the ongoing safety initiatives being introduced into health-care settings and the increasing presence of practice guidelines, it is imperative that the infusion nurse use evidence to support infusion practice. The 2011 INS Standards for Infusion Nursing were developed as an evidence-based document. There are 68 Standards, which are broad statements that describe expectations of practice applicable to infusion therapy in all settings. The Standards address areas such as the need for organizational policies and nurse competency. The Practice Criteria provide specific guidance on the implementation of each Standard. New to the 2011 document, each Practice Criterion is rated as reflecting the strength of the body of evidence. Although evidence that is research based is preferred, evidence may come from a variety of sources (Table 1-2).

The following is an example of a Standard and a Practice Criterion from Standard 35: Vascular access site preparation and placement.

Standard: The nurse shall prepare the intended VAD insertion site with antiseptic solution using aseptic technique.

Practice Criterion: Chlorhexidine solutions is preferred for skin antisepsis. One percent to two percent tincture of iodine, iodophor, and 70% alcohol may also be used. Chlorhexidine is not recommended for infants under 2 months of age.

This Practice Criterion is rated as Level I evidence. According to the INS table of the Strength of the Body of Evidence, this is the highest level of evidence, based on meta-analysis, systematic literature review, guideline based on randomized controlled trials (RCTs), or at least three well-designed RCTs.

Using the 2011 INS Standards to develop changes in procedure or policy is one way to apply EBP to infusion practice. As with many areas of nursing practice, there are unanswered questions, there often is limited research, and there is a constant influx of newly published studies to read and review. Although nurses may apply EBP through application of evidence-based guidelines, policies, or protocols, nurses also may be actively involved in EBP when the answers are not so easily found. Numerous evidence-based models are available; however, all share certain steps as follows:

1. Select a topic or ask the question. 2. Search and critique the evidence.

3. Adapt the evidence for use in a specific practice environment. 4. Implement the EBP.

5. Evaluate the effect on patient care processes and outcomes (Titler, 2007).

There are a variety of scales used to rate the evidence. Table 1-3 lists the rating scale used by the Centers for Disease Control and Prevention (CDC, 2011) in their guidelines addressing infection prevention related to intravascular devices, as well as excerpts from the INS (2011) rating scale. Of note, INS does not rate the strength of the recommendation; rather, it only rates the strength of the evidence used to support each Practice Criterion.

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Published research

Published research utilization report Published quality improvement report Published meta-analysis

Published systematic or integrative literature review Published review of the literature

Policies, procedures, protocols Published guidelines

Practice exemplars, stories, opinions

General or background information/texts/reports

Unpublished research, reviews, poster presentations, similar materials Conference proceedings, abstracts, presentations

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From the Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (CDC, 2011)

Category IA:Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiological studies.

Category IB:Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.

Category IC:Required by state or federal regulations, rules, or standards.

Category II:Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale.

Unresolved issue:Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.

Excerpts from the Strength of the Body of Evidence Rating in the INS Standards of Infusion Nursing (INS, 2011)

Level 1:Evidence description: Meta-analysis, systematic literature review, guideline based on randomized controlled trials (RCTs), or at least three well-designed RCTs

Level I A/P:Includes evidence from anatomy, physiology, and pathophysiology as under-stood at the time of the writing

Level III:One well-designed RCT, several well-designed clinical trials without randomiza-tion, or several studies from quasi-experimental designs focused on the same question; includes two or more well-designed laboratory studies

Level V:Clinical article, clinical/professional book, consensus report, case report, guide-line based on consensus, descriptive study, well-designed QI project, theoretical basis, recommendations by accrediting bodies and professional organizations, or manufacturer recommendations for products or services

Infusion Nurses Society (2011). Reprinted with permission.

Websites

Center for Evidence-Based Nursing: www.york.ac.uk.healthsciences/ centres/evidence/celon.htm

Agency for Healthcare Research and Quality: www.ahrq.gov/downloads/ pub/advances/vol2

Additional websites on web-based Ancillary—Student/General

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Nursing Process Related to Infusion Therapy

The six steps of the nursing process are identified as the Standards of Pro-fessional Practice by the ANA (2010a). These Standards provide each nurse with a framework to utilize when working with a patient. For the

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patient who receives infusion therapy, the process begins with good basic assessment skills and continues until the patient no longer requires a VAD or infusions to meet health-care maintenance. The INS supports the ANA Standards and publishes its own specialty standards of practice approxi-mately every 5 years. Relevant INS Standards will be highlighted throughout this text.

Assessment

According to ANA Standards of Practice (2010a), assessment consists of the comprehensive collection of data, including and addressing physi-ological, functional, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual, and economic issues. Assessment includes both subjective and objective information. The following are examples of areas to assess in relation to infusion therapy:

Subjective

■ Patient’s related fears of infusion therapy

■ Patient’s experiences with prior infusion therapy

■ Patient’s needs and stated preferences for venipuncture site, if applicable

■ Patient’s best learning method, health literacy, language barriers, and readiness to learn

Objective

■ Review of patient’s past and present medical histories

■ Physical assessment

■ Review of laboratory data and radiographic studies

■ Assessment of level of growth and development for neonate and pediatric clients

■ Potential factors affecting readiness to learn, such as weakness, fatigue, anxiety, and/or functional limitations

■ Factors that guide decision making in placing the most appropriate VAD for the patient: characteristics of the prescribed infusate, anticipated duration of therapy, physical assessment, health history, support systems and resources, patient preference

■ Peripheral vein assessment and selection based on age, vein condition, activity level, and needs

Diagnosis

The nursing diagnosis is used to describe and label patient problems based on the assessment data. Defined by NANDA International (NANDA-I, n.d.), a nursing diagnosis is a clinical judgment about actual

or potential individual, family, or community experiences/responses to health problems/life processes. The nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnoses are validated with the patient, family, and other health-care providers.

The ANA recognizes 12 terminology sets that support nursing prac-tice. The following examples of terminologies include nursing diagnoses, interventions, and/or outcomes:

■ NANDA-I Nursing diagnoses: www.nanda.org

■ Nursing Interventions Classification (NIC):

www.nursing.uiowa.edu/excellence/nursing_knowledge/ clinical_effectiveness/index.htm

■ Nursing Outcomes Classification (NOC): Same as above

■ Omaha System: www.omahasystem.org

■ Clinical Care Classification System (CCC): www.sabacare.com

■ Perioperative Nursing Data Set: www.aorn.org

Use of a standard terminology or language in the electronic health record (EHR) allows for clear communication among members of the health-care team and for data collection that can be used in quality improvement. Standardized terminology is also critical in increasing visibility of nursing interventions and greater adherence to the standards of practice. In this textbook, nursing diagnoses developed by NANDA-I will be used. Nursing diagnoses related to infusion therapy are included in each chapter of this textbook. Some examples include:

1. Fluid volume deficit related to failure of regulatory mechanisms 2. Risk for infection related to compromised host defenses

3. Ineffective protection related to inadequate nutrition

Collaborative problems are physiological complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed as well as nursing-prescribed interventions (Ackley & Ladwig, 2011).

Outcomes Identification

The third step in the nursing process is the identification of expected outcomesfor a plan of care that is individualized to the patient (ANA, 2010a). It is important that time frames for attaining the outcomes be identified. It is also an essential step that the nurse collaborate with the patient, family, and other health-care providers (including the physi-cian and other health-care disciplines) in developing expected out-comes. Patient values and ethical and cultural considerations should be incorporated into the process of identifying expected outcomes. Out-comes can be developed in one of two ways: by using the standardized terminology of the NOC list or by developing an appropriate outcome

statement. General suggested outcome statements are provided in this textbook.

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Planning

Planninginvolves the prescription of strategies and alternative strategies to attain the identified expected outcomes (ANA, 2010a). Planning sets the stage for writing nursing actions by establishing the plan of care. Planning also includes development of strategies to attain the outcomes, validation of physician’s or authorized prescriber’s order(s), coordination and communication with the appropriate ancillary departments, and use of techniques to prevent complications.

Implementation of Interventions/Nursing Actions

Implementation is the “action plan” and the fifth step of the nursing process. The interventions are the concepts that link specific nursing activities and actions to expected outcomes. The nurse is expected to implement the plan in a safe and timely manner, utilize evidence-based interventions and treatments, coordinate the plan with all members of the health-care team, and use all appropriate resources (ANA, 2010a).

Nursing actions include both independent and collaborative activities. Independent activities are actions performed by the nurse, using his/her own discretionary judgment. Collaborative activities are actions that involve mutual decision making between two or more health-care practi-tioners. Implementation of infusion therapy includes administration of medications and solutions, care and maintenance of the VAD, and patient and family education. The care must be coordinated within and across all types of health-care settings for patients who transition to another setting (e.g., home care or long-term care). Specific examples of implementation of infusion therapy related nursing actions include:

1. Adherence to established infection prevention practices and maintenance of aseptic techniques

2. Preparation of infusate solutions with medication additives 3. Initiation of appropriate actions in the event of adverse reactions

4. Provision of infusion therapy-related education that is culture and age appropriate

5. Documentation of all care delivered

NIC is a comprehensive, standardized classification of treatments that nurses perform. A comprehensive list of NIC interventions is provided in an NIC text by Bulecheck, Butcher, Dochterman & Wagner (2013).

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Evaluation

The evaluation phase of the nursing process is often the most ignored phase of the nursing process. Outcomes must be evaluated in relation to the structures and processes of the plan of care and the timelines for at-tainment (ANA, 2010a). The evaluation phase is the feedback and control part of the nursing process. Evaluation loops back to assessment, which was begun in the initial phase. As new data are collected, a nursing judg-ment must be made as to whether diagnoses, outcomes, the plan, and/or implementation need to be revised. Three judgments are possible:

1. The evaluation data indicate that the health-care problem has been resolved.

2. The plan of care should be revised.

3. The plan of care should be continued based on the conclusion that the outcome has not been met at this time.

Quality Management

Quality managementis defined by an organizational culture committed to achieving excellence (Sierchio, 2010). It is not a single activity, and it does not occur only in the nursing department. An effective quality management program happens at all organizational levels. A quality management program seeks to improve the outcomes of care by focusing on processes and structures. There are a variety of quality models and approaches used in health care. “Quality assurance” is an old, outdated term that may still be used. Quality assurance focused mainly on docu-mentation of certain aspects of care. For example, medical records could be reviewed to determine if there was documentation that the peripheral I.V. catheter site was assessed every 4 hours. Documentation is being

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assessed rather than patient care. The reality is that quality “cannot be as-sured, it can only be assessed, managed, or improved” (Sierchio, 2010, p. 28).

Quality Assessment/Quality Improvement

Quality assessment(QA) and quality improvement (QI) are components of a two-step process. QA includes data collection and data analysis. It may include a retrospective and/or a concurrent review of care and may include review of medical records as well as other data or observation of care. Outcomes of care and patient satisfaction are monitored. Consider the following example:

On a hospital medical unit, the nurses identified what they believed were too many cases of phlebitis for their patients with peripheral I.V. catheters. Working with the QI director, the decision is made to collect data on the prevalence of phlebitis, to use a standardized tool in identifying phlebitis, and to define a time frame for data collection. Two certified infusion nurses on the unit both would evaluate the I.V. sites.

QI is the second step of the process. It builds on the data obtained in the QA process and identifies the action steps needed to improve the care. In the previous example, based on the literature, the prevalence of phlebitis on the medical unit was determined to be high. Potential causes of the high rate are discussed among the nursing team and the QI depart-ment, and plans to improve the rate are identified and implemented. To evaluate the effects of the changes, the QA process would be implemented again, using the same data collection strategy to assess whether changes in care lowered the phlebitis rate.

Performance Improvement

The term performance improvement (PI) was originally introduced by The Joint Commission (TJC) at the beginning of the millennium. It repre-sents another shift in quality management philosophy. Although it has been acknowledged that quality is difficult to define, “performance” is more easily defined, described, and measured. Performance is described by what is done and how well it is done in providing health care. The accountability measures required by TJC are examples of PI measures. The measures include evidence-based processes that can be associated with positive patient outcomes. Care measured since 2002 by TJC (2012a) includes heart attack, heart failure, and pneumonia. Examples of other added PI measures include surgical care, venous thromboembolism, and stroke care. Hospitals that are accredited by TJC must select four measure sets for reporting. For example, the core measures for pneumonia that are measured and reported are:

■ Pneumonia vaccine

■ Blood cultures in the intensive care unit (ICU)

■ Antibiotics in the ICU

■ Antibiotics in the non-ICU

These measures are calculated individually for each evidence-based process as well as a composite measure reflected as adherence to all the measures collectively.

Total Quality Management

Total quality management (TQM) is an outgrowth of several health-care organizations that adopted a management system fostering continuous improvement at all levels and for all functions by focusing on maximiz-ing customer satisfaction. This proactive approach emphasizes “domaximiz-ing the right thing” for customers.

Characteristics of what is done and how well it is done are called dimensions of performance.

Doing the right thing includes:

■ The efficacy of the procedure or treatment in relation to the client’s condition

■ The appropriateness of a specific test, procedure, or service in meeting the client’s need

Doing the right thing well includes:

■ The availability of a needed test, procedure, treatment, or service to the client who needs it

■ The timeliness with which a needed test, procedure, treatment, or service is provided to the client

■ The effectiveness with which tests, procedures, treatments, and services are provided

■ The continuity of the services provided to the client with respect to other services, practitioners, and providers over time

■ The safety of the client and others to whom the care and services are provided

■ The efficiency with which care and services are provided

■ The respect and caring with which care and services are provided Examples of TQM models are six sigma and lean manufacturing. Six sigma focuses on eliminating variations so that there are no defects. An example cited by Sierchio (2010) is the use of a written standard for an insertion tray for peripherally inserted central catheter (PICC) placement, which reduces the risk for breaks in aseptic technique during the procedure. Lean manufacturing focuses on reduction of waste of supplies, for example, ensuring that all items on the PICC tray are used and not wasted.

Standards

Effective quality management is based on defined statements of quality (Sierchio, 2010). Standards are statements of quality that integrate techni-cal features, behavioral aspects, and desired outcomes of health care.