We all know THAT nurse – the one that you call when the going gets tough. They are knowledgeable, confident in their craft, and composed in crisis situations. But that competence, confidence, and excellence aren’t bestowed when the diploma is handed to them. There is a giant learning curve between nursing school and becoming proficient in the care of patients, and infusion therapy is one of the most complex tasks that nurses perform.
Considering the Inherent Risks of the Procedure, Where Does the Foundation for the Delivery of Infusion Therapy Originate, and Who Makes These Rules?
Standards of infusion care are determined by organizations that glean research, compile references and recommendations, and review and revise these recommendations regularly to guide clinicians in the delivery of safe, effective, and evidence-based practice. The saying “you just don’t know what you don’t know” is both factual and cautionary regarding nursing practice.
Without the standards of practice steering the practice of infusion therapy, there is potential to cause great harm, and we have real-life instances to demonstrate how serious these risks can be.
Here are a few from my experience:
#1 Put Yourself in the Patient’s Shoes
Picture yourself as a patient in the 1990s and with an early-era PICC catheter placed for your cancer therapy. Your nurse is experienced, confident, and has come to your home to change the dressing on your PICC line.
The early-generation securement device is sticking to the catheter and, unfortunately, the line is dislodged by several centimeters during the procedure. Your nurse, though knowledgeable, manipulates the PICC line and advances it back into the vein (a forbidden move due to the risk of infection), not being familiar with the current Infusion Therapy Standards of Practice.
Your dressing change is completed without any incident, and everyone goes about their daily business without a second thought until, three days later, you wake in the night with severe chills and a high fever. A trip to the emergency room confirms that your white blood cell count is elevated, and they suspect that your PICC line is the source of a bloodstream infection. You spend a week in the hospital, your scheduled chemotherapy is delayed, and you need to have your PICC line replaced once the infection is under control.
Had your nurse been aware of the Infusion Nurses Society (INS) Infusion Therapy Standards of Practice, they would have known that reintroduction of a displaced venous access device into the vein is prohibited, your bloodstream infection and interruption in chemotherapy would likely not have occurred, and you would have been spared the insult on your immune system.
Mentoring nurses in an instance such as this can be a delicate task. It’s critical to express the gravity of their actions, but to also correct the practice and encourage them to adhere to safe practices going forward.
The nurse in this case was struck by the cascade of events they caused but went on to be a witness to other team members and undoubtedly prevented many other similar cases from occurring.
#2 You’re the Nurse in Charge
Your young patient has had difficulty with their immune globulin (Ig) infusions for their immune disorder. Though they have noticed improvement with fewer respiratory infections this spring and haven’t missed any of their college classes due to infections, they suffer from leg cramps after each Ig treatment, to the point they are unable to function and have missed work and class for several days following each infusion. The goal of their Ig therapy was to lessen the impact of their disease state on their life, but it instead resulted in several days of missed obligations due to the after-effects of their infusions.
You then turn to the guidance in Immune Globulin National Society (IgNS) Ig Therapy Standards of Practice, which advises to hydrate generously and to supplement with intravenous hydration, if needed, to minimize this adverse effect.
Once made aware of this recommendation, you instruct your patient to hydrate orally for several days prior to their infusion. After each treatment, you notice positive results. Your patient starts attending classes again, work-study obligations are being fulfilled, and they are even able to practice with the marching band. Several years later, your client has completed their undergraduate degree and is headed to medical school, intent on working toward a specialty in immune disorders, and continues their monthly Ig infusions.
#3 This One’s Personal
This next one stings a little because it’s personal, but I relay this example as a forewarning whenever the opportunity arises.
A vibrant and cheerful lady with chronic leukemia arrived at the infusion clinic with a smile on her face. Several weeks of treatment on a machine to filter out the excess of critically high white blood cells was successful, and the time to explant her apheresis catheter had arrived.
The removal was uneventful – proper positioning was used throughout the procedure, and pressure with sterile gauze was held for 30 minutes at the site due to her chronically low platelet count.
The recommendation to seal the catheter site with petrolatum gauze was followed and, despite abiding by all proper measures, our cheerful charge suffered an air embolism which was clearly audible upon careful replacement of the gauze pad with the air occlusive dressing. EMS was called to transport our terrified patient to the emergency room, her concerned husband following closely behind in their vehicle.
Thankfully, my patient survived this event, and I came away with a profound sense of the importance of being vigilant throughout every step of a procedure. And though this complication occurred despite our team operating with an abundance of caution, I also learned that, despite taking all precautions, complications can occur. The reassurance I felt knowing that I had taken all appropriate measures during the access removal did little to soothe my nerves, but I use this as an example for others who may face a similar situation, highlighting the validation of our practice that can come from adhering to the standards.
Standards of Practice and Infusion Operations go Hand-in-Hand
Standards of practice offer not only evidence-based guidelines for hands-on care, but are also the model that nurses are held to in a court of law should litigation be initiated for an adverse event. An extensive review of current research is gleaned by experts to compile the latest recommendations and is the benchmark for safe and evidence-based nursing practice. A certification validates a nurse’s knowledge of the standards of practice in their specialty and is a critical component of their expertise in the delivery of evidence-based care.
Certification deserves to be supported by organizational leadership, not only as support for nurses’ professional development but also in promoting patient care excellence. Certified nurses are mentors to other team members, can be a resource for referral sources, and are valued as competent, confident, essential team members. Their pursuit of current trends in healthcare and the most recent advances in nursing care are of benefit to the entire organization and to the patients entrusted to their care. Even nurses with decades of experience will attest that they gained knowledge when studying for their certification exam.
Ambulatory infusion centers can benefit greatly from promoting nurse certification in their ranks. Certifications for numerous nursing specialties are available, but those especially helpful to infusion centers are the Certified Registered Nurse Infusion (CRNI®) and Immunoglobulin Certified Nurse (IgCN®) designations.
The Infusion Nursing Certification Corporation (INCC) and Ig National Society (IgNS) organizations have educational programs geared toward exam preparation and have a wide array of study materials and testing sites that hold exams at various times throughout the year.
Sometimes the most difficult step for nurses is committing to take the exam by registering. Encourage your nurses to take the leap today! And please don’t hesitate to contact me if I can be of assistance with their journey.
Contact INS to learn more about CRNI® certification at: https://www.ins1.org/crni-certification/about-incc/
Contact IgNS to learn more about the IgCN® certification at: https://ig-ns.org/igcn/