March/April 2018 Volume 1 Issue 2 INSider
March/April 2018INSiderVolume 1 Issue 2The official membership news publication of the Infusion Nurses SocietyThis issue of INSideris made possible byAnnualMeetingPreviewINS Boardof DirectorsElectionResultsA Conversationwith ElizabethSmart
We have science on ourside.and some reallydetermined nurses.No one is more passionate about protecting patients from vascularaccess complications than clinicians. That’s why 3M relies on thepartnership of healthcare professionals to create technologicallyadvanced I.V. care solutions. Our innovative products help reducethe risk of infection, skin injury and catheter movement so clinicianscan provide superior patient care.Learn more at 3M.com/IVCareINS 3M 2017. All rights reserved. 3M, “3M Science. Applied to Life.”, are trademarks of 3M Company.
In this Issue5INS Board ofDirectors News2018-19 Election Results6President’sMessageChange Is Inevitable forTomorrow’s Health Care13COVER STORYA conversation with INS 2018keynote speaker ElizabethSmart, plus a special previewof this year’s educationalsessions and events8Faculty File18Guest FeatureThe Positive ROI on CLABSIPrevention InterventionsMichael Passwater, a medicaltechnologist and specialist inblood banking, talks abouttransfusion therapy andautoimmune issues.20Risk ManagementFocusSexual Harassment by Patients:Do You Know What to Do?10Clinical ConceptsBlood Sampling From CentralVascular Access Devices24INSight into INSIV Nurse Day 2018photo galleryMarch/April 2018 3
INS BOARD OF DIRECTORS 2017-2018PresidentPublic MemberPamela Jacobs, MHA, BSN, RN, CRNI , OCN Donald J. Filibeck, PharmD, MBA, FASHPPresident-ElectINS Chief Executive OfficerFelicia Schaps, MSN-Ed, RN, CRNI , OCN , CNSC, IgCNMary Alexander, MA, RN, CRNI , CAE, FAANSecretary/TreasurerLisa Bruce, BSN, RN, CRNI , IgCNPresidential AdvisorRichelle Hamblin, MSN, RN, CRNI , RN-BCDirectors-at-LargeDawn Berndt, DNP, RN, CRNI Max Holder, BSN, RN, CRNI , CEN, VA-BCINS StaffChief Executive OfficerNurse EducatorsEditorMichelle Berreth, BSN, RN, CRNI , CPPMary Alexander,Nancy Delisio, RNSenior Certification & MemberServices AssociateMaureen FertittaMA, RN, CRNI *, CAE, FAANGraphic DesignerExecutive Vice PresidentChris HuntDirector of Operations andMember ServicesMaria ConnorsAbigail WestonMarketing SpecialistMember Services AssociatesAmy NickersonSusan RichbergJustin PelletierMarketing CoordinatorJames PriggeBookkeeperCheryl SylviaAssociate Managing EditorLeslie NikouPublications CoordinatorMargaret QuinlanMeetings ManagerMeghan Trupiano, CMPMeetings CoordinatorYvonne DrakeDirector of Nursing EducationConference CoordinatorMarlene Steinheiser, MSN, RN, CRNI Jill Cavanaugh*CRNI is a registered trademark ofthe Infusion Nurses CertificationCorporation.
2018-2019 INS BOARD OF DIRECTORS ELECTION RESULTSINS is pleased to welcome Roberta “Lynn” Deutsch,Angela Skelton, RN, CRNI , was elected as a newMSN, RN, CRNI , VA-BC, as our new president-electdirector-at-large. Ms. Skelton is currently managerMs. Deutsch is currently a vascular access nurseof outpatient chemotherapy/infusion services atat Dell Seton Medical Center/Seton HealthcareUnited Regional Health Care System in WichitaFamily in Austin, Texas.Falls, Texas.C O N G R AT U L AT I O N S !INS podcasts are on-demand audio recordings of infusion-related topics.VISIT WWW.LEARNINGCENTER.INS1.ORG/PODCASTS AND LISTEN TODAY!PODCASTSFUNDED THROUGHA GRANT BY
President’s MessageChange Is Inevitable for Tomorrow’s Health CarePamela Jacobs, MHA, BSN, RN, CRNI , OCN , INS President, 2017 – 2018A decision has been made to change again.But why?To understand that age-old question, lessonscan be learned from Hiatt and Creasey’s,“Change Management: The People Side ofChange.”1 First, there must be a reason forchange. Every change may have a differentreason, such as the need for growth, patientsatisfaction, cost control, improvementin service or quality, and many more. Butchanges that lie ahead must be different fromthe present and hopefully will lead to desiredoutcomes.1To succeed, change must be embraced byeveryone affected. For example, healthcare organizations that have implementedelectronic health record (EHR) systems haveexperienced massive change. Every individualwho used the new EHR was required to learnnew skills and embrace the new technology.1The process for changing individual behavioris best described by Prosci’s ADKAR Model.1ADKAR can be used as a communicationframework when individuals think a changeis a waste of time, believe what is currentlybeing done is perfectly fine, feel kept in thedark about change, and cling to old ways ofdoing things. People want to know when thechange is expected, how it will affect them inthe performance of their role, and if trainingwill be provided.Focusing on the ADKAR model helps theleader in conversations about change, forinstance: Do you understand and agree withthe reasons for this change? Do you want thischange to happen? What would cause you towant this change? Do you know how to makethe change? Are you capable of performing thenew skills, and are you receiving the necessarysupport and reinforcement to sustain thischange? Asking these simple questions mayhelp target an isolated gap in the changeprocess.1One of the greatest and best-known authorsof change management is John P. Kotter. Inhis book, “Leading Change,”2 he outlines 8reasons organizations fail to change:The 5 Components of ADKARA Awareness of the change and an understanding of why it’s neededD Desire to make a personal choice to accept and commit to the changeK Knowledge includes education and training to learn how to make the changeA Ability is demonstrated proficiency to achieve desired outcomesR Reinforcement is reward, recognition, and compensation that sustains the change6 INSider
1. Allowing complacency: This happens when there7. Declaring victory too soon: When this happens,is no sense of urgency. It’s often underestimated howhard it is to move employees from their comfortzones, and because of a leader’s own actions, orinactions, reinforcement of the status quo mayinadvertently occur.the urgency of the change is less intense, the guidingcoalition loses power, and the vision becomes unclear.Tradition takes over, and resisters of change are quickto spot the opportunity to undermine the effort.2. Lack of a powerful guiding coalition: Even themost dedicated individuals need guidance.3. No clear vision: Visions inspire, and as Kottersays, “Whenever you cannot describe the visiondriving a change initiative in 5 minutes or less andget a reaction that signifies both understanding andinterest, you are in for trouble.”2(p9)4. Under-communicating the vision in words anddeeds: Change is undermined if communication isinconsistent.5. Permitting obstacles that block the new vision:Even if the roadblocks are in the heads of people,there is a challenge to convince them otherwise.6. The failure of creating short-term wins:Change takes time. Short-term wins must be createdby the leader who is looking for clear improvement,reaching and achieving goals, and rewarding theemployees involved.8. Neglecting to anchor change: It’s often said,“that is just the way we do it around here,” and whenthe pressure of change is removed, new behaviors areapt to revert to what is comfortable.2Traditionally, management training has been focusedon preparing budgets, organizing, staffing, controlling,and problem-solving. Developing leaders who cancreate and communicate change is the future. Vision,communication, and empowerment are leaders’ keys tochange. Leaders must be given opportunities to learn,blossom, test themselves, and grow. Through trial anderror, coaching and encouragement, a leader can reachhis or her potential to lead change. Leaders recognizethat change is not to satisfy their own ego or a knee-jerkreaction to yesterday’s events. Change is meant to makeimprovements. Change is dynamic, never boring, andaccomplishing it is fun.2Nurses have experienced a lot of change over the pastyears and will continue to do so in the future. Nurseleaders who commit to getting out of their comfort zone,taking risks, assessing failure, listening to others, andremaining open to new ideas will be the ones who leadchange in tomorrow’s health care.References1. Haitt JM, Creasey TJ, Change Management: The People Side of Change. Loveland CO: Prosci Learning Center Publications; 2003.2. Kotter JP, Leading Change. Brighton, MA: Harvard Business Review Press; 2012.March/April 2018 7
Faculty File, DLM,er, MT(ASCP)SBBMichael PasswatCSSGB(ASQ)BIO:B, DLM,er, MT(ASCP)SBMichael PasswatAmericancertified by theCSSGB(ASQ), isedicalPathology as a malicinClofyetSocinking, andialist in blood baecspa,stgiloe hastechnomanagement. HrytorabolaineFora diplomates for 26 years.ritorabolaalicagerworked in clinhas been the manhes,arye12stthe paansplantn service and trof the transfusionter indant Medical Celaboratories at ViMedicalCarolina. VidantthorN,lleviennt Health,Grehospital of Vidaipshagflethislina.Centerstern North CaroEainestiuncoserving 29INS Nationalculty member atfaaaswlaeichMmainsCincinnati. He reAcademy 2016 inhemostasis,,eme systunmimethbyfascinatedd efficacioussafe, efficient, anginizmtiopdancare processes.INSider: What is transfusion therapy?MP: Transfusion therapy is the practice of collecting bloodelements—red blood cells, platelets, and plasma—to later infusethose elements to treat deficits in tissue oxygenation, hemostasis, andother circulatory disorders. Blood transfusion can be an importantsupportive therapy, allowing a person to withstand intensive primarytreatments, such as major surgery or myeloablative chemotherapy. Inother situations, such as hemolytic disease of the fetus and newborn,blood transfusions may serve as the primary treatment. In recentyears, the term patient blood management (PBM) has been growingin popularity throughout the world. The term PBM is an attemptto encourage focus on a comprehensive plan, including conserving8 INSidera patient’s own blood supply while optimizing his or her own bloodproduction and hemostasis status before, during, and after intensiveinterventions, in addition to any blood infusions that may benecessary during the intensive treatment.INSider: How many hours a week are you in alaboratory? And how do you introduce new researchinto practice?MP: My office is in the transfusion service and kidney transplantlaboratory area. As a manager, much of my time involvesadministrative duties—ensuring the incredible staff has the tools
they need to provide excellent care and service every day. I especiallyenjoy learning to operationalize the latest treatment strategies withthe laboratory staff and interdisciplinary teams. Their flexibility,creativity, and willingness to do the “impossible” is inspiring.Working in Eastern North Carolina where an airplane first flewsuccessfully, I am fond of aviation pioneer Orville Wright’s remark,“If we all worked on the assumption that what is accepted as true isreally true, there would be little hope for advance.” It’s fun to learnnew things and to learn that some “old things” are not as true as weonce thought.INSider: In your opinion, what are some steps thatcould improve transfusion safety?MP: On the supply side, continue improving storage solutions todecrease the “storage lesion” and increase the “physiologic bufferingcapacity” of blood products. This may include expanding the typesof blood products available to tailor products more specifically to theindication for transfusion.On the patient/treatment side, minimize the need for transfusion.Our health care system, like many, has safely reduced transfusions bymore then 20% in recent years. Better care with less blood is possible.Additionally, reliable electronic safety checks and the development ofcost-effective strategies to provide more complete antigen matchingfor red blood cell transfusions for chronically transfused patients mayimprove safety and reduce alloimmunization.INSider: What are some of the educational andtraining challenges related to alloimmunizationprevention?MP: In daily practice, attention to the mundane, but criticallyimportant, specimen- and patient-identification tasks, as well asunderstanding specimen volume, frequency, and time requirementsfor pretransfusion testing can be challenging.Personally, unlearning the over-simplified immunology of longago has been challenging for me. Immune cells are highly versatileand highly interactive with other cells and biochemicals in theirimmediate environment. New wrinkles in these interactions arediscovered every year.Clinically, individualizing care plans and recognizing when totransfuse and when to rely on other options is an ongoing learningexercise.INSider: Can you explain the differences betweeninflammation and antibody production?MP: Inflammation is a more immediate and more general responseto any tissue damage. When groups of cells are stressed, they leakdifferent chemicals and display different chemicals on the outside oftheir membranes—an internal “911 call” to attract both the policeto get rid of intruders and the rescue squad to repair and rebuildthe injured tissue. Initial antibody production, if it occurs, typicallyhappens later in the response. It is one of several tools the “bombsquad” or the “police” may employ after responding to the scene ofdistress. Inflammation often occurs without antibody production,but antibody production rarely, if ever, occurs in the absence ofinflammation. (In addition to the target antigen, vaccines containadjuvants and other immune-stimulating compounds to mimic a“danger signal” from tissue inflammation.) The severity, location,and cause of the inflammation, as well as genetic and environmentalhost factors, seem to influence the likelihood of antibody production.INSider: What trends are you seeing in theidentification of antibody formation and/or otherautoimmune issues?MP: The incidence of autoimmune issues appears to be increasingworldwide. Increased detection and recognition of these issues arelikely factors, but the possibility of increased exposures, as well asgenetic and other environmental changes influencing immune systemdevelopment and function, deserves further study. It’s estimated that23.5 to 50 million people in the United States suffer from any of 80to 100 autoimmune conditions. The National Institutes of Healthhas estimated that direct health care costs related to autoimmunediseases are in the range of 100 billion. Consequently, the study ofautoimmune diseases has become a priority for the National Instituteof Allergy and Infectious Diseases.INSider: What are your most challenging cases?MP: Sickle cell disease can be especially cruel. I hope to see the daywhen a reliable cure is readily available. In the meantime, determiningif and which alloimmunizations to red blood cells are present duringa hemolytic crisis is very challenging. I am grateful to have theprivilege of working with hematologists and pathologists who areadept at supporting people with hyperhemolysis syndrome and otherhemolytic crises with minimal use of red blood cell transfusions.It has also been gratifying to help implement processes that makeantifibrinolytics and blood products more readily available for traumapatients in the hospital and in the field.For more in-depth information, INS encourages members to readMichael’s article, “Antibody Formation inTransfusion Therapy,” in the March/April 2018 issueof the Journal of Infusion Nursing or online atjournals.lww.com/journalofinfusionnursing. You canalso listen to his podcast on the INS LEARNINGCENTER at ation-in-transfusion-therapy.March/April 2018 9
Clinical ConceptsBlood Sampling From Central Vascular Access DevicesMichelle Berreth, BSN, RN, CRNI , CPP, INS Nurse EducatorInformation obtained from laboratoryblood tests can be invaluable to treatmentdecisions; for some therapies, blood testsare essential. Vascular access devices, inparticular central vascular access devices(CVADs), initially seem to offer the bestmethod for obtaining blood samples, yetthey can place patients at risk of costlycomplications. This article discusses variousmethods of obtaining blood samples fromCVADs.The tip of a CVAD terminates “in the lowersegment of the superior vena cava at or nearthe cavoatrial junction for lower bodyinsertion sites, the CVAD tip should belocated in the inferior vena cava above thelevel of the diaphragm.”1(S46-S48) These majorblood vessels route all deoxygenated bloodfrom the body to the heart. Blood flow10 INSiderrates reach 2000 mL/min, ensuring rapiddilution of intravenous medications andsolutions administered through implantedports; peripherally inserted centralcatheters; tunneled, nontunneled, single, ormultilumen catheters.2The decision to use a CVAD as the sourcefor obtaining blood samples needs tobe considered carefully. It may seem anobvious choice, but there are risks associatedwith using a CVAD that can lead to seriouscomplications. Bloodstream infections,hospital-acquired anemia, or catheterdysfunction are all possible. Results ofmonitoring levels of certain medications canbe inaccurate if the sample is drawn from alumen being used to infuse the drug or if theCVAD is made of certain materials.1(S86-S91)Four methods to obtain blood samplesfrom CVADs have been identified. In aliterature review examining blood-drawmethodologies, it was noted, “the bestmethods for blood collection reduce therisk for infections, occlusions, thrombusformation, and blood loss that requiretherapeutic interventions.”3(para6) Anotherliterature review, however, noted “littleevidence exists to support any one methodfrom drawing blood samples from vasculardevices.”4(para6) Methods include thereinfusion, dead space, discard, and pushpull methods.The Reinfusion MethodThis method was thought to limit theamount of blood loss that might resultfrom frequent sampling. The amount of
blood required for discard was withdrawninto a syringe and set aside. After the bloodsample was obtained, the so-called discardblood was reinfused into the patient.5 Thismethod is not recommended because ofthe risk of discard contamination and clotformation.1(S86-S91)The Dead Space MethodThis method wastes only the amount ofblood needed to fill the volume of the CVADand any add-on devices. A waste syringe isattached and, without flushing, the CVAD isaspirated until blood just reaches the syringebarrel. This syringe is removed and discarded,and a sample is obtained.The Discard MethodThis method is more frequently used forblood sampling in adults.6 Typically, 5 to 10mL of blood is aspirated from the CVADand discarded before the sample is obtained(amounts vary from 3-25 mL).4,5 In onestudy, nearly 100 mL of blood was discardedas waste on average per patient per week.5,6 Inaddition to the volume of blood withdrawnfor the actual sample, patients were at risk foriatrogenic, or hospital-acquired anemia.The Push-Pull MethodAlso referred to as the mixing method,1(S86-S91)the push-pull method minimizes bloodloss related to blood sampling. A syringe isattached to the CVAD and blood is gentlyaspirated and then reinfused withoutdetaching the syringe. This push-pull cycleis repeated 3 to 5 times. Then the syringe isremoved and discarded and a new syringe isattached to obtain the blood sample.1(S86-S91),6No blood is wasted.Implications for Infusion NursesThe methods used to obtain blood samplesfrom CVADs vary from organization toorganization. Patient circumstances may alsoaffect how blood specimens are obtained. Aninfusion nurse competent to perform CVADblood sampling will assess the risk versus thebenefit to the patient, educate the patientregarding the procedure, and maintain strictinfection prevention practices in the bloodsampling procedure. Best practices andblood conservation strategies help ensuretest results will be accurate and that patientswon’t experience complic
Mar 04, 2021 · March/April 2018 Volume 1 Issue 2 INSider The official membership news publication of the Infusion Nurses Society This issue of INSider is made possible by Annual Meeting Preview INS Board of Directors Election Results A Conversation with Elizabeth Smart. No one i
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Volume 3, Issue 2, March – April 2014 ISSN 2278-6856 Volume 3, Issue 2 March – April 2014 Page 44 2.1.1 6T SRAM cell Figure 2 Six-transistor CMOS SRAM cell [5]. The SRAM cell should be sized as small as possible to achieve high memory densities. A 6T SRAM is shown in Fig.2
