On the other hand, research has validated the concern of increased risk of intraluminal contamination when using stopcocks and their contribution to catheter-related bloodstream infection (CR-BSI). Some institutions have gone as far as recommending not to use stopcocks. In The 2011 Infusion Nursing Standards of Practice this recommendation is followed by a call to give attention to the addition of sterile caps to ensure a closed system (pS31). In The 2016 Infusion Therapy Standards repeats a similar recommendation but adds that a stopcock with integral needleless connector (NC) should be chosen to reduce stopcock contamination (Ps72).

Improved stopcock design based on research
The predominant themes in stopcock research are stopcock contamination and its impact on CR-BSI and fluid flow dynamics through multiple stopcock systems.  In the last 20 years many studies have compared open and closed stopcock lumens and looked at infection during operations. Despite studies that demonstrated a significant trend toward reduced intraluminal contamination when the stopcock is closed with an NC, using a bonded NC on the stopcock is not yet common practice. Contamination is not only caused by stopcocks use, other sources of contamination found in studies in OR settings include bad hygiene habits as a major culprit.

Stopcocks are devices used to direct the flow of fluid through an infusion system, while allowing multiple fluids and even multiple unit (manifold) to be connected. Therefore watching flow rate and direction is important when researching the efficacy and safety of these devices. Flow rate is especially critical with drug administration. It is influenced by factors such as system volume, and carrier fluid flow dynamics. Researchers recommend that the drug be connected with a stopcock at the closest point to the patient.

The technology of stopcocks is improving to reduce the identified risks of contamination and flow issues. Stopcocks must meet many healthcare industry regulations, on topics such as flow rate, high- or low-pressure resistance, and chemical resistance to lipid-based solutions, as well as sterilization, dead space, and handle-rotating torque. Stopcocks are also offered in a manifold design, connecting a few stopcocks in a straight line. Stopcock design can be adjusted in accordance with habits of use in diverse locations worldwide. Stopcocks are branded and available in many colors and materials, depending on their targeted use.

Recently, this variety of devices and stopcock usage were expansively reviewed in a published article in The Art and Science of Infusion Nursing magazine. The article, called Stopcocks for Infusion Therapy – Evidence and Experience, was written by Lynn Hadaway, MEd, RN-BC, CRNI® and includes a comprehensive report regarding stopcock technology and characteristics, literature review results (published clinical stopcock uses, clinical and laboratory studies, open vs. closed stopcocks, stopcock contamination in the OR, flow rate concerns, blood sampling systems, miscellaneous studies), a survey and discussion of stopcock use. This publication elaborated on stopcock use in all patient ages and in virtually all health care settings, including inpatient, outpatient, and alternative sites.

Lynn Hadaway, the IV therapy expert discusses how the benefits of a closed stopcock design that allows for continual flushing of residual medications such as the MarvelousTM can reduce the risk of contamination.
Lynn Hadaway Med, RN-BC, CRNI is a published infusion expert with 40 years practical expertise. She knows all the risks and all the devices. In her report she discusses how the innovative design of a stopcock such as Marvelous^TM – with its minimized dead space can help reduce the problem of intraluminal contamination.

In her integrative literature review and clinician practice survey analysis of published evidence and reports of actual practices with stopcocks, Hadaway writes that “Dead space is an issue with stopcocks…A new stopcock design that has eliminated this problem allows fluid from the primary flow pathway to flow into and out of this space in a U-shaped pattern, flushing out trapped air bubbles or residual medication”. She then continues to present a figure of constant flushing of the side port.

She summarizes her review and closes it with the following remark: “Because of the extreme importance of infection prevention, ensuring standardization of stopcock practices throughout the entire facility is necessary. Further reduction of stopcock contamination could be achieved with the use of a stopcock design that allows for continual flushing of residual medications. Finally, maintaining a closed system by using a stopcock with bonded NCs would reduce the significant risk of intraluminal contamination that leads to CR-BSI.”

The article by Lynn Hadaway, MEd, RN-BC, CRNI, provides a combination of literature review and clinician practice survey in a complete report of stopcock use in addition to suggested practice changes for reducing the risks associated with stopcocks usage. She mentions the advantages of a reduced “dead space” and “continuous flushing” – features Elcam is proud to have integrated into the design of Marvelous^TM  from the day it was developed.

Read the full publication by Lynn Hadaway, free curtesy of Elcam Medical. Click here.

Watch how Marvelous works

For more information please contact our representive

Blood Loss and Infections due to Blood Sampling Impair Patient safety in the ICU

A specific concern for patient safety in the ICU is related to blood loss and infections associated with blood sampling. These issues are a major concern in the ICU because taking blood samples is a standard and often procedure in ICU treatment. Blood loss and catheter related infections can aggravate the ill health of patients and can complicate their overall condition, which in turn can delay their recovery.

Almost all the patients admitted to ICU have a lower than normal hemoglobin level after a week of admission. Only 5% of patients are an exception to this rule [2]. If the blood sample is taken from the patient’s indwelling catheter, 5 to 10ml of blood is wasted every time before a sample is taken. This can lead to the development of anemia.

A study conducted by Silver et al, compared the blood loss in patients with or without the usage of a conservative device. In a seven-day period, 340ml of blood was saved per patient averaging to 49ml per day when a conservative device is used. [4] Another study conducted by Peruzzi showed a reduction of almost 80 to 90 ml of blood loss per day when a conservative device is used for a four-day trial period. [5]

Infection to the already critically ill patients of the ICU can prove fatal. Many studies show that hospital-acquired infections in intensive care patients are commonly due to an indwelling catheter [6]. Blood draws involve catheter manipulation which can cause catheter-associated infections [7].

Minimizing the frequency of blood draws or using a closed system can reduce consequential blood loss and catheter-related infections and hence can have a positive effect on improvement of the patient.

Elcam’s Clear-IT^TM increases patient safety at an affordable price

Closed blood sampling systems help a lot in the reduction of incidence of iatrogenic anemia and catheter-related infections. This equipment is usually expensive.

Few closed systems enable the blood volume to be reinfused into a patient in a safe manner which helps to minimize contamination and also contribute to preventing blood loss. Elcam’s Clear-IT closed blood sampling system combines an In-Line Reservoir for waste collection and a Marvelous stopcock.

The new Clear-IT^TM product form Elcam is a relatively low-cost closed system used for blood sampling taken from the blood pressure monitoring line. Safety is enhanced via reduction of blood loss as the clearing volume is reinfused back to the patient after sampling is completed. With the Marvelous^TM stopcock, continuous-flushing ensures minimal blood residues.

The reservoir can be connected to a standard mount piece. It is easy to use and doesn’t require much training. It minimizes the blood waste, thus decreasing the risk of anemia. Continuous line, closed in-line design and syringe clearing all help in reducing microbial contamination.

As Patient Safety Day 2016 is approaching, Elcam is presenting yet another product with the ever continued agenda of enhancing patients and staff safety. As the international medical and healthcare community gets together to raise awareness for patient safety, we are happy to take even a small part in the progress achieved in this field.

References:
1. http://www.nhp.gov.in/World-Patient-Safety-Day_pg
2. Anemia in the ICU (Review) Cardiovascular Disease, Critical Care, Review Articles . Sept  2012 PulmCCM
3. World Patient Safety Day | National Health Portal of India. Nhpgovin. 2016. Available at: http://www.nhp.gov.in/World-Patient-Safety-Day_pg. Accessed October 11, 2016.
4. Silver M, Li Y, Gragg L, Jubran F, Stoller J. Reduction of Blood Loss From Diagnostic Sampling in Critically III Patients Using a Blood-Conserving Arterial Line System. Chest. 1993;104(6):1711-1715. doi:10.1378/chest.104.6.1711.
5. PERUZZI W, PARKER M, LICHTENTHAL P, COCHRAN-ZULL C, TOTH B, BLAKE M. A clinical evaluation of a blood conservation device in medical intensive care unit patients. Critical Care Medicine. 1993;21(4):501-506. doi:10.1097/00003246-199304000-00007.
6. Valles JLeon C. Nosocomial Bacteremia in Critically Ill Patients: A Multicenter Study Evaluating Epidemiology and Prognosis. Clinical Infectious Diseases. 1997;24(3):387-395. doi:10.1093/clinids/24.3.387.
7. Tinmouth A, McIntyre L, Fowler R. Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients. Canadian Medical Association Journal. 2008;178(1):49-57. doi:10.1503/cmaj.071298.

Central line-associated bloodstream infections (CLABSIs) are a major safety concern for both clinicians and patients. Majority of CLABSIs are related with the use of central venous catheters (CVC) and are in fact one of the most important complication in critical care.

It is estimated that as many as 250,000 blood stream infections occur annually, most of which are associated with the presence of intravascular devices. The CLABSI rate in American intensive care units (ICU) is projected to be 0.8 per 1000 central line days, while the International Nosocomial Infection Control Consortium (INICC) reported a CLABSI rate of 4.1 per 1000 central line days, following data surveillance of 703 intensive care units in 50 countries between January 2010 and December 2015. Of all healthcare associated infections (HAIs), CLABSIs are the most costly, accounting for an estimated $46,000 per case.

Considering the high rates of morbidity, mortality, lengthened hospital stay as well as the costs associated with these infections, CLABSI prevention guidelines provided to the healthcare community for the insertion and maintenance of central lines should be strictly adhered to, in an effort to curtail these incidences.

However, despite the fact that evidence based clinical practice guidelines for the prevention of CLASBI have recommended multiple strategies to lower CLABSI rates, it is evident that these infections remain a major cause of mortality and morbidity among patients with a central line in situ worldwide.

Poor adherence to prevention guidelines – a major cause for CLABSI prevalence

In order to assess compliance with CLABSI prevention guidelines, researchers documented attitudes and practices in intensive care units (ICUs) between June and October 2015. Medical doctors and nurses working in ICUs worldwide completed an online questionnaire designed to investigate central line insertion and maintenance practices as well as measurement of CLABSI.

Responses from 14 middle income and 27 high income countries were analyzed and revealed that the availability of written clinical guidelines for CLABSI prevention was up to 80 percent for middle income countries while it was 81 percent for high income countries. It was further found that the rate of compliance with a bundle of recommended central line insertion practices was at 23 percent of middle income countries and 60 percent of high income countries. The survey revealed that 60 percent of middle income countries and 73 percent of high income countries had a daily assessment of central line necessity.

Researchers concluded from this study that although there is clear awareness and interest in the ICU community for CLABSI prevention in high and middle income countries, implementation and adherence to those existing guidelines during insertion and maintenance of central lines need to be reinforced. The researchers have further identified areas for improvement in clinical and measurement practices related to CLABSI prevention in ICUs.

Factors contributing to poor adherence of CLABSI prevention guidelines

Lack of time or resource constraints, lack of proper information or necessary skill sets are critical factors that contribute to the compromised adherence to full prevention procedures. In a study published in the American Journal of Infection Control in 2014, comparing perspectives of infection control professionals and frontline staff, it was noted that some of the main challenges in CLABSI prevention guideline adherence in ICU settings was a lack of adequate time and a difficulty in the acquisition of education and skills to enable frontline staff to effectively apply and adhere to the CLABSI prevention guidelines as set out by the relevant bodies. 

As per the study, both infection control professionals (ICPs) and frontline ICU clinicians, especially nurses, unanimously contend that competing priorities often make it difficult to ensure that all recommended prevention procedures are adhered to.

Catheter maintenance procedures contributing to CLABSIs 

Flushing a catheter is strongly recommended to ensure it remains well-functioning. Flushing techniques, fluid dynamics, and ample flushing volumes are vital aspects in adequate flushing in all types of catheters. Adequate flushing of catheters may also wash out all possible nesting material for microorganisms, thereby reducing the risks of catheter-related bloodstream infections.

The catheter site and the hub are the main sources of bacteria (and fungi) that lead to catheter colonization and resulting CLABSIs. These microorganisms may be introduced when the catheter is manipulated, and when poor flushing techniques are used.

A larger port reservoir, or “dead space” typically creates an environment for the accumulation of debris and fibrin deposits, which in turn, create an environment for microbial colonization. This phenomenon is yet another great potential for the development of a CLABSI. An ample flush volume is necessary to enable the effective removal of debris and fibrin deposits within the catheter and the port reservoir.  Taking into account the fact that time and skills are evidently already lacking for clinicians in ICU settings, it may become difficult to adhere to and effectively carry out those procedures involving flushing and maintenance of catheters correctly and in accordance with CLABSI prevention guidelines.

How can Marvelous^TM stopcocks help prevent CLABSIs

The Marvelous^TM stopcock was designed with optimal convenience and safety for both patients and clinicians in mind.  The innovative Marvelous^TM stopcock can help prevent CLABSI because it comes with a continuous-flush feature, minimal “dead space” and a luer-activated valve (LAV) that serves as a bacterial barrier, allowing access to the line without opening it.

The continuous-flush feature of Marvelous^TM stopcocks means that not only is a clean catheter maintained at all times, but that catheter manipulation is greatly decreased and thus, the chances of microbial transfer is reduced and therewith, the chances of CLABSI contraction.

Minimal “dead space” in a CVC is ideal due to the fact that it leaves less environment for residual accumulation. Given the fact that “dead space” residue is a CLABSI hazard, the Marvelous^TM stopcock, with optimal safety as a priority, is designed with minimal “dead space” that ensures minimal residual accumulation.

These features of Marvelous^TM stopcocks may not only help in the prevention of CLABSIs directly, but also indirectly by compensating for the time and skills needed to maintain CVC lines in the ICU in good accordance with the recommended CLABSI prevention guidelines. Check out how much you can save with Marvelous^TM 

The benefits of preventing CLABSIs

Taking active measures towards Zero-CLABSI rates is highly beneficial.  Zero-CLABSI rates ensure a much shorter and safer hospital stay for patients as well as much speedier recovery. Furthermore, a Zero-CLABSI rate ensures that the pressure for clinicians working in critical care setting is reduced.

References
Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections (CLABSI) [Updated 2017 Mar 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2017 Jun-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430891/
https://www.ncbi.nlm.nih.gov/pubmed/25239713
https://www.ncbi.nlm.nih.gov/pubmed/23182523
https://insights.ovid.com/pubmed?pmid=22561118
https://insights.ovid.com/pubmed?pmid=27895904&isFromRelatedArticle=Y
https://insights.ovid.com/pubmed?pmid=27152193&isFromRelatedArticle=Y
https://insights.ovid.com/pubmed?pmid=27031355&isFromRelatedArticle=Y
https://www.cdc.gov/hai/bsi/bsi.html
https://www.beckershospitalreview.com/quality/cdc-investments-in-clabsi-prevention-produce-substantial-benefits.html

The Healthcare Infection Control Practices Advisory Committee (HICPAC) operates in addition to resources from CDC guidelines, especially in the prevention of intravascular catheter related infections [2].

Regularly checking for updates and / or changes  to guidelines provided by the CDC and HICPAC aids in maintaining compliance, allows for accumulating knowledge and information about recent advancements in technologies, as well as continuing development of processes and equipment that provide for the optimal safety and well-being of patients.

Infection Control Responsibility of ICU Staff

It is estimated that roughly 90% of catheter- related bloodstream infections – which are defined as BSIs – occur with central venous catheters [2]. Even more alarming is the fact that hundreds (and even potentially thousands) of patients die every year due to such infections. Nosocomial bloodstream infections extend hospital stays by approximately seven days at the outlay of $4,000 and up to $30,000 in treatment costs [2].

This is why familiarity of current CDC guidelines regarding standards for infection control in environments such as the ICU and OR is essential in providing high quality care for patients.

According to the recommendations, replacement of peripheral venous catheters within 72 to 96 hours is important in order to reduce risk of infection [1]. Replacement of administration sets no more frequently than 72 hours is deemed appropriate as well as cost-effective by the CDC. 

A number of standards in recent guidelines proposed by the CDC, suggest to cap stopcocks when they’re not in use and using closed catheter access systems to decrease the potential of catheter-related bloodstream infections (CSBRIs) [1].

In some situations, the “piggyback” method is used as an alternative to stopcocks, but this method continues to pose contamination risks. (‘piggybacking’ implies secondary IV medical infusions used for delivery of one or intermittent doses over time.) The CDC notes that “modified” piggyback systems can prevent contamination [1].
Additional recommendations by the CDC and HICPAC include minimizing contamination risk of needleless intravascular devices by wiping access ports with an appropriate antiseptic as well as changing needleless components as often as changing out the administration set [1].

Awareness and Education is Key

According to the Institute for Safe Medication Practices (ISMP), risk management as well as challenges to improvement of the quality of care are continually challenged by failure to follow standardized infection control recommendations in regard to IV injections, preparations, and administration.

Continuing education regarding the dangers of colonization in catheter hubs and lumens (which contribute to up to 50% of catheter related infections [3]) and staying up-to-date with the latest advancements, protocols, and safety guidelines for optimal patient care is therefore essential.

Luer-Activated Devices (LAD) Help Control Infection, while Increasing ROI.

Fewer infections may be facilitated by adhering to aseptic techniques, newer designs and variations in needleless connectors. Staff must continually focus on decreasing intravascular catheter-related infections by following disinfection process protocols: using luer-activated devices with disinfection sponges; adopting single-use solutions on unused needleless connectors on catheters following placement of catheter or in between catheter changes; disinfecting ports reduces risk of contamination of needleless connectors as well as male luer devices [4].

Attention to detail when it comes to poor flushing, as well as minimizing manipulations and/or access to pressure monitoring systems is also important. Continued advancement in technological development of devices that reduce negative pressure and neutral IV displacement connectors are helpful.

According to the CDC, luer-activated devices (LAD) can be beneficial in eliminating negative pressure, thus reducing the risk for fluid outflow in connectors. Second generation systems (needleless) have attempted to reduce this issue by creating either positive or neutral fluid displacement environments. Neutral displacement IV connectors were implemented in 2011, designed to reduce the risk for catheter-related bloodstream infections. [5]

Using unique continuous flushing LAD stopcocks, such as Elcam’s Marvelous^TM  allows staff to improve infection control and save time while creating considerable cost savings. The Marvelous^TM continuous-flushing feature provides greater protection against blood clotting and bacterial colonization. The injection site remains needle free and closed – consistent with the CDC recommendations. In addition to reducing the risk for fluid outflow from the connectors, with Marvelous^TM the fluid flow around the handle creates a unique “circumferential channel” that reaches the entire internal volume of the valve, assuring minimal residual volume.

Calculate your unit’s ROI

Elcam is happy to present a web based ROI calculation tool. We invite you to calculate annual savings per department and per bed depending on:

• Daily access
• Number of stopcocks per patient and number of LADs used per stopcock
• Amount of caps and syringes used per access for every stopcock

You will be surprised how much you can save in the long run by using Marvelous^TM continuous flushing LAD stopcocks.

The human factor

It is important for ICU staff to acknowledge and remember that even with advancements in technology, needleless systems, and even though luer-activated devices, stopcocks and luer-activated valves may reduce the risk of infection, their use does not guarantee absolute protection against infection or contamination.

Human attention to detail, adherence to infection control guidelines and protocols, and common sense do prevail.

Resources:
1. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
2. www.safecarecampaign.org/crbsi.html
3. https://www.hindawi.com/journals/nrp/2015/796762/
4. https://www.Beckers Hospital review.com/infection-control-products-to-know-list.html 
5. www.sciencedirect.com/science/article/pii/S1552885512001821

Drug administration errors in anesthesia care settings can range from misreading a drug label, administering incorrect doses and errors made during syringe drug swaps. [2]

Patient safety is vital in all medical care scenarios, but pre-operative, anesthesia delivery, and post-op scenarios are among those that pose the greatest and most significant risks to patients. No one involved in drug administration wants to experience an adverse drug event. 

The efforts in reducing errors in drug administration during anesthesia and throughout post-op care and recovery environments can be divided into three components:

• Enhanced communication goals among staff members
• Improved drug administration management processes
• Innovative, easy to use medical devices

Dealing with the Aspect of Human Error Caused by Overwork

CNRAs and anesthesia teams are among the most overburdened in many care environments and scenarios. Unfortunately, fatigue caused by overwork continues to be one of the primary contributors to human errors in medication administration. Reducing risk factors and errors in drug administration is vital – for the safety of both the healthcare provider and the patient.
 

A study recording fatigue events for anesthesiologists determined that following nine hours of consecutive work, risk for unintentional errors/accidents increased exponentially with every subsequent hour. [3]

A first-year resident is five times more likely to make a prescribing drug error, most likely due to extreme overwork and fatigue and clinical inexperience.[4]

Concerns of fatigue are not limited to the anesthesiologists. CNRAs participate in over 34 million anesthesia procedures in the US alone, with a continued increase of complexity and the number of procedures requiring their support 24/7. This high demand on the CNRA has contributed to sleep deprivation and fatigue, which can have a negative influence on not only performance, but outcomes for the patient. A nurse working longer than a 12.5-hour shift is three times more likely to make some type of error. [5]

Coaching for better communication

Better communication on patient status and any changes in drug administration can be facilitated by efficient updates to charts and databases. Increased collaboration between surgeons, anesthesiologists, and CNRA staff not only influences the ability to enhance anesthesia plan management, but also effects how surgical procedures are managed. The same applies to the anesthesiologists and CNRA’s comprehension of the surgical plan.

Suggestions for enhanced communication: [6]

• Brief “huddles” that aid all-around understanding of both surgical and anesthesia plans with regards to patient care.
• Increased transparency between anesthesia teams and ICU staff.
• Benchmarking CRNA performance (not only regarding patient satisfaction, but also referring to communication with surgeons, OR staff, Post-Op and ICU care teams).
• Attention to detail during an anesthesia hand off. Detailed information in a handoff report should include patient name, surgical procedure, medications given, fluid status, as well as past medical history and allergies. This applies to peri-operative as well as post-operative handoffs. [7]

Improved Procedures for Reducing Risk

A number of protocols and technologies have also aided in the reduction of risks in the field of anesthesia. Among them:

• Color-coded labels – easier identification of drugs. [8] 
• Drug bar code scanning systems – confirmation the right drug is being given.[8] [9]
• Electronic dispensing carts – automated functions and tracking of medications.
• Eliminating the removal of medications from packaging, as well as the discarding of inserts prior to use, and improved protocols in regard to the storage, preparation, documentation, and administration of medications.[9]
• Utilization of controlled “smart” devices – infusions facilitating use of electronic devices that also display a medication library. [9]
• Development of ready-to-use infusions and syringes – along with RFID codes, can be used with automated dispensing cabinets, clear expiration dates, and easier identification. [10]
• Automated information systems – providing up-to-date status and updates to charting. [11]

Some mistakes can be prevented by simply anticipating what can go wrong and then taking steps to prevent those things from happening. Processes and check lists help here.

Attention to detail, enhanced communication, knowledge, and careful planning reduces risks, adverse effects, and enhances patient safety.

Newer Devices Reduce Risk of Error in Drug Administration

One of the major contributors utilized today in reducing drug administration errors is the development of modern devices that provide enhanced usability and comfort for medical stuff already under pressure when conducting IV procedures. For example, more user-friendly designs in manifolds and stopcocks can contribute in efforts to reduce risks in this field, as formerly confusing equipment and devices are exchanges for easy to use options.

Reducing risks and errors in fluid regulation has been the focus of developers, resulting in increasingly advanced devices including Elcam’s SafePort manifold, designed specifically for use in ICU and OR environments, that will be demonstrated at Anesthesiology 2017.

The SafePort manifold is specifically designed for ease of use, offering safe and convenient facilitation in anesthesia and ICU scenarios. The device makes the job of the anesthetists and CRNA easier and safer, with benefits such as:

• Single-handed, simple and comfortable use.
• Dual flow option side port valves, controlled by a simplified 90° turn of the handle.
• Access to multiple IV lines and syringes, as well as delivery by pump. 
• Minimizing risk of inadvertent injections or drug mixtures.
• Assuring zero backflow.
• Eliminating risk of blood loss or gas embolism during disconnection of syringes.
• Facilitating visible control over flow direction and fluid path.

Reducing Complications in Drug Administration

Among the most prevalent hazards in drug administration in pre-operative, operative, post-operative and ICU environments include regulation of intravenous fluids and anesthetic residues found in IV lines. Anesthesia teams are aware that accuracy of flow rates and fluid regulation are essential for patient safety.

Reducing the risk of unintentional administration of residual anesthetics by continuous flushing of the internal valve volume is one of the several benefits of Elcam’s Marvelous^TM stopcock . 

The elimination of post-medication flushing with a syringe also reduces risk of medication interactions and errors.

Reducing the risk of fluid overloads is another risk that can be facilitated by using the Marvelous, via reduction of stopcock manipulations.

CNRAs, anesthetists, ICU staff, and nursing support staff are dedicated to reducing the risk of drug administration errors in dose aspects of patient care. Newer developments in IV, stopcocks, and manifold design are providing positive direction in the reduction of such errors.

Elcam invites you to learn more about SafePort and Marvelous^TM at Anesthsiology 2017. Meeting participants are also welcome to join the raffle  for a pair of SPECTACLES by SNAP Inc. at our booth #3729.

Resources:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933474
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3824420/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2447555/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713658/
5. www.aana.com/newsandjournal/20102019/04call-shift-fatigue-15.pdf
6. https://www.beckersasc.com/anesthesia/5-strategies-to-improve-surgeon-or-communication-with-anesthesiologists.html
7. The Effectiveness of an Anesthesia Handoff Tool: An Electronic Health Record Application to Enhance Patient Safety: Anesthesia eJournal. Vol 4- Issue 1 2016 
8. http://monitor.pubs.asahq.org/article.aspx?articleid=2431681&_ga=2.265776591.1168637975.1507133795-497424936.1507133795
9.  https://www.ppmrrg.com/risk-management/anesthesia-law
10. https://www.pharmedium.com/compounded-services/operating-room-anesthesia/
11. http://drugtopics.modernmedicine.com/drug-topics/news/clinical/hospitalhealth-system-pharmacy/new-technology-enhances-safety-anesthesia-p

Fluid Management
Medicine should be evidence-based, and the discipline of Anesthesia is no exception. While experience and intuition certainly play a role in any practitioner’s decisions, empirical evidence alone cannot be relied upon when making potentially life-threatening or life-saving decisions.
This assertion is at the heart of the argument against “traditional” fluid management, or calculations using the “4/2/1 rule.”¹ Firstly, it is argued that this method relies all too much on estimations and assumptions. For example, preoperative fluid loss is calculated by the anesthesia provider based on an estimation of the time since last oral intake.

Furthermore, estimations of fluid loss during the procedure are made according to the severity of tissue trauma associated with the procedure. Actual fluid loss varies widely from procedure to procedure based upon several factors like patient body habitus, surgical history, and surgical technique. While the traditional method may allow for adjustments with the standard guide of “3 mL of crystalloid for every 1 mL of blood loss,” this is an estimation albeit an educated one.¹ Each estimation made introduces additional room for error.

Evidence pointing out the dangers of this approach can be found in the FEAST trial by Maitland et al. A total of 3141 febrile African children with perfusion impairment were studied in the trial. A 48-hour mortality rate of 10.6% was seen in the patients who received a 20-40 mL/kg bolus of normal saline upon admission, versus a 7.3% 48-hour mortality rate in the control group of patients who received no bolus.²

While the hazards of overly-restrictive fluid management are well-known and understood, giving too much fluid can be equally hazardous. Fluid management should be precise and must be backed by clinical evidence. As a paper in Clinics in Colon and Rectal Surgery stated, “Traditional methods of perioperative fluid management have emphasized a liberal approach to administration of fluids. Those traditional methods have now been called into question.“ This paper looked at a total of seven randomized trials that examined the effects of perioperative fluid restriction on patient outcomes. Although there were conflicting results, the majority of the trials found that restrictive fluid strategies were associated with better results.³

So what does this all mean for today’s anesthetist and CRNA? Modern fluid management equipment can actually make the job easier and less stressful as the contemporary methods of fluid maintenance do not rely on estimation.

In fact, one accurate tool for fluid management decisions endorsed by the National Health Service of the UK, esophageal Doppler monitoring (EDM), has shown promising results. Kuper et al. compared 658 major surgical procedures without EDM to 649 major procedures using EDM at three large English hospitals. They found “a 3.7 day reduction in total length of stay. Length of stay was reduced at each site, and in most specialities.”⁴

In summary, providing fluids in the anesthetic setting based on estimations or even general rules is proving to be less reliable. Rather, fluids should be given based on physiologic need and in pursuit of a specific improvement in patient condition, using up-to-date equipment. This does not mean that patients undergoing major procedures or in critical condition should not be monitored closely, it basically takes the practice of assumptions out of fluid management and relieves some stress from anesthesia personnel.

Infection Prevention
It is the responsibility of all operating room personnel, from surgeons to anesthetists, from CRNAs to surgical technologists, to make every effort to prevent infection opportunities. Unfortunately, it would appear that a potential source of contamination is often neglected – the ventilator.

According to a 2012 paper by Zingg et al., in one randomized trial the ventilator was the second most common infection origin. The most likely explanation was that the ventilator was contaminated by the gloved hands of anesthesia personnel and the contamination was then transferred to the next patient.⁵

The authors acknowledge that anesthesia providers already frequently wash their hands and almost constantly wear gloves in patient interactions.⁵ However, an additional infection-prevention measure can be adopted by the use of modern stopcocks, like the Marvelous . The Luer-activated valve in this stopcock acts as a barrier to bacteria, eliminating the need to open the line to access it. The constant flushing of the side port with (main line) carrier fluid that minimizes dead space and prevents stagnation, can further reduce the risk of bacterial colonization.  The Marvelous further improves patient safety by the constant flushing of the internal valve volume. This feature assures complete rinsing of drugs from the system thereby reducing the chance of drug interactions and unintentional administration of residual drugs.

References
1. Stoelting, R.K. et al. Basics of Anesthesia, 5th ed. Elsevier, 2007; p. 349.
2. Maitland, K. et al. “Mortality after Fluid Bolus in African Children with Severe Infection.” NEJM. June 2011, 364(26);p.2483-2495. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1101549
3. Bamboat, Z.M. et al. “Perioperative Fluid Management.” Clin Colon Rectal Surg. Feb 2009, 22(1);p.28-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780230/
4. Kuper, M. et al. “Intraoperative fluid management guided by oesophageal Doppler monitoring.” BMJ. May 2011, 342;d3016. http://www.bmj.com/content/342/bmj.d3016.short
5. Zingg, W. et al. “Stopcock Contamination: The Source Does Not Explain It All.” Anesthesia & Analgesia. June 2012, 114(6);p.1151-1152. http://journals.lww.com/anesthesia-analgesia/Fulltext/2012/06000/Stopcock_Contamination___The_Source_Does_Not.3.aspx

The following CDC statistics illustrate how this problem is growing:

• More than one-third (36.5%) of US adults have obesity
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death
• The estimated annual medical cost of obesity in the U.S. was $147 billion U.S. dollars in 2008 (Incenta health published a figure of $190.2 billion in 2015); the medical costs for people who are obese were $1,429 higher than those of normal weight, (according to Incenta Health this is 36% higher)

Nurses and doctors are making adjustments to procedures to accommodate obese individuals, but it is increasingly clear that the standard tools and techniques might not be enough. In anesthesia there are specific challenges when the patient due to undergo surgery is obese.

The Known Risks of Administering Anesthesia to Obese Patients

Being overweight, and especially obese, puts an individual at a higher risk when undergoing surgery – with one of the primary concerns being the administration of anesthesia.

The known risks include:

• Difficulty in locating veins for intravenous medication
• Determining a proper medication dose relative to body size
• Ensuring proper oxygen and airflow before, during, and after surgery
• Taking more time to regain consciousness
• Intubation

Anesthesia Options for Obese Patients

During the preoperative assessment, health practitioners will create a tailored plan for each patient regarding anesthetic management. At this point, it may be determined that additional measures are required to safely and effectively administer anesthesia to the patient.

The preoperative assessment includes:

• Airway assessment
• Mallampati score
• Thyromental distance (TMD)
• Respiratory and oxygenation status
• Snoring, tiredness, observed apnea, and high blood pressure with BMI, age, and neck circumference (STOP-BANG)
• Cardiovascular system assessments
• Patient transportation planning

The chances of multiple measures being determined upon is higher when the patient is obese.

Multimodal Approach

It is recommended to take a multimodal approach to improving patient outcome, and perioperative epidural anesthesia (EDA) is often essential to prevent from relying exclusively on opioid administration for anesthesia. While the subject is still up for debate, one recent study found that EDA improved postoperative vital capacity, lung volumes, and other spirometric values quicker than patients who were treated with opioids.

Due to the lack of palpable bony landmarks and the depth of space in the fatty tissue of an obese patient, a multimodal analgesic approach is often more practical. This might include the use of opioids, acetaminophen, NSAIDs, and local anesthetic.

Postoperative Considerations for Obese Patients

Unless the patient has any ongoing medical conditions other than obesity, or underwent major surgery, they are usually nursed on the surgical floors following a complication-free surgery. However, extra precautions might still be necessary. For example, obese individuals who use a CPAP machine at home will benefit from a postoperative CPAP.

Maintaining safe IV connections can be a challenge in obese patients. Also, these patients may require more intravenous medication because intramuscular injections often are not a viable option in morbidly obese individuals.

This is where the Marvelous Stopcock and Safe2 Rotator acan ve useful. They can prevent disconnections and ensure medication is properly flushed – plus they keep nurses safer by preventing needle sticks.
 

Learn more about Marvelous Stopcock.

Source:
https://www.cdc.gov/obesity/data/adult.html
https://www.asahq.org/whensecondscount/patients%20home/preparing%20for%20surgery/surgery%20risks/obesity%20and%20anesthesia
http://ceaccp.oxfordjournals.org/content/8/5/151.full

Before Intubation Challenge – Airway (and Patient) Resistance

One of the most common intubation challenges for CRNAs is intubating a patient that is obese. Excess body mass, and especially additional soft tissue in the upper airway, increases airway resistance.

In many cases, the CRNA will need to position the patient slightly upright to shift the abdominal contents away from the diaphragm. This will reduce the pressure around the airway, making it easier to insert the tube, as well as ensuring proper ventilation while the patient is intubated.

A similar situation arises when patients simply have a narrow airway. In this case, CRNAs sometimes struggle to see if the tube is inserted correctly. Whenever this happens, the CRNA is usually required to ask for a second opinion to verify that the tube is placed properly, and in special circumstances, an X-ray can be performed to confirm proper placement.

Intubation Innovations

The ideal situation would be to have a small, lighted camera on the end of the Laryngoscope. This would improve accuracy and save the need for an X-ray to confirm the placement. The companies Infinium and Covidien (Medtronic) are only two of the companies that offer such a product. Verathon’s Glidoscope is even available on Ebay. Video Laryngoscopy and fiberoptics were documented as assisting tracheal intubation. You can read more about this case in the Medscape website.

As tracheal intubations are always a challenge, various developments of intubating devices are emerging in an effort to resolve the issue or at least make intubation a bit easier for medical staff. The MK intubating Airway claims that while standard procedure is maintained the new rigid, non-crushable conduit and bite guard improved on long standing airways that provide limited functionality by permitting removal of the airway without disturbing a placed bronchoscope. Another device still under development, the Esophocclude can be used to prevent pulmonary aspiration (yet another challenge of intubation). The Esophocclude is an encapsulated self-expanding stent that resembles a pill,  which is intended to be swallowed by patients before intubation. It expands and prevents the flow of gastric acids into the lungs.

New in Intubation Training

Swansea innovations have developed a unique training device for CRNAs as a means of improving the psychomotor skills involved in the manipulation of a fibreoptic endoscope, which today is considered a necessary skill in the anesthesia arsenal. The C-MAC Tip system from Karl Storz Endoscopy-America, Inc. is a great teaching tool, allowing learners to perform direct laryngoscopy while providing reassuring visualization to the instructor of the intubation on the screen.

Code Blue

The most common situation for ICU nurses that makes intubation challenging is during a Code Blue when a patient is thrashing around. It’s virtually impossible to insert the tube alone and this scenario requires collaboration between the team of nurses to restrain the patient before intubating. It would be great if nurses had some type of vest they could quickly toss over a patient and attach to the bed to restrain their upper body so they could start intubation with less people. Innovative spirit is demonstrated once more as a team led by Spectrum Health Innovations created a device to prevent self-extubation. The new approach led to the design of a retaining block to keep the tube in place. The block is held in place by headgear modeled after a scuba mask.

During Intubation – Monitoring is Key

While the patient is intubated, the vast majority of problems are easily prevented by an attentive CRNA who is monitoring their patient. The CRNA performs regular vital signs’ monitoring during anesthesia to ensure the patient remains in a healthy, stable state at all times. They also ensure proper airway management and anesthesia management throughout the procedure.

After Intubation Challenge – Sedative Weening and Patient Awakening

Following a procedure, a CRNA or ICU nurse will start the process of weening the patient off of their sedative. During this time, it’s critical to monitor sedation levels so a patient doesn’t wake up on their own and start choking on the tube.

Once the sedative has mostly worn off, the CRNA or ICU nurse removes the tube and briefly wake the patient to confirm that the patient can breathe on their own. If the patient needs to remain intubated because they won’t be able to breathe on their own, a nurse will be there when the patient wakes up to explain why they are intubated and how important it is for them to remain intubated.

A common problem in the ICU is when the floor is understaffed and all of the nurses get so busy that they don’t notice a patient is waking up from their sedative. This is an example of where telemedicine can help. Having an extra set of eyes on patients increases the level of care patients receive without requiring more nurses on duty.

It’s imperative for ICU nurses to continually monitor sedation levels, vital signs, and to be in the room when the patient wakes up to explain where they are and why they are intubated. If the patient isn’t restrained, they will often panic and remove the tube.

Even in scenarios where patients are restrained, they still find ways to get past restraints and remove their tube. This is a nightmare for ICU nurses because, during their state of panic, patients often end up disconnecting IVs and other tubing.

This is when innovative medical devices like the Safe2 Rotator are especially useful. The Safe2 Rotator has a luer lock connection that prevents disconnections when a patient pulls at tubing or moves around erratically.

If for whatever reason a patient does wake up while intubated, the Safe2 Rotator can help ensure they are still receiving the medications they need until a nurse can get to them and get them properly intubated again.

Daily challenges continue to be faced by ICU nurses and CRNAs, but technology and innovations are not far behind, assisting medical staff in giving enhanced patient care, while keeping staff and patients safe.

Sources:

• https://www.ukessays.com/essays/ nursing/assisting-in- endotracheal -intubation-nursing-essay.php
• https://ccforum.biomedcentral.com /articles/10.1186/cc13776
• https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3375171/
• https://www.ems1.com/ems-products/ medical-equipment/airway-management/articles/ 1957214-How-to-improve-airway-control-for-obese-patients/
• http://emedicine.medscape.com/ article/110880-overview
• http://www.medtronic.com/covidien/ products/intubation/ mcgrath-mac-enhanced -direct-laryngoscope
• http://www.infiniummedical.com/ camera-laryngoscope
• http://www.rehabmart.com/ category/ patient_restraints.htm
• http://innovations.clevelandclinic.org/ Technology/Invention-Catalog/ Medical-Devices/ Inventions/ MK-Intubating-Airway.aspx
• http://healthbeat.spectrumhealth.org/% E2%80% A2intubation-innovations/
• http://www.innovation.pitt.edu/ innovations/ esophocclude/
• http://www.mdedge.com/ emed-journal/article/ 100638/imaging/ tech-tools-innovative-devices-ed

What is Telemedicine?

According to the American Telemedicine Association, telemedicine is “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.” The first documented study of telemedicine in the ICU was conducted 25 years ago where telemedicine consultations were used to assist with the care of 395 patients in the ICU of a 100-bed hospital. The study found that telemedicine improved patient care and television consultations had a greater clinical impact than telephone consultations.

The way this works is that a tele-ICU system staffed with critical care nurses, nurse practitioners, physician assistants, and additional support staff operates 24/7 on-call. Each tele-ICU registered nurse (eRN) is typically responsible for 30 to 40 patients. There are currently around 45 tele-ICUs in the U.S. that connect over 200 hospitals with more than 6,000 beds.

How Nurses Are Responding to the Rise of Telemedicine in the ICU

According to an online survey of over 1,200 nurses from the American Journal of Critical Care, around 79% of nurses believe that tele-ICU systems improve patient care and about 75% believe it improves job performance. The feedback from nurses overall has been very supportive and encouraging, which demonstrates a clear need for telemedicine in the ICU.

Feedback on telemedicine from ICU nurses:

• 66% found improvements in collaboration
• 63% saw increased speed in work performance
• 60% noted improvements in communication
• 60% saw improvement in nursing assessments

However, not all of the survey findings were positive. The most significant barriers for telemedicine include staff attitudes towards telemedicine, technical difficulties with audio and video, and a lingering belief among some nurses that telemedicine actually interferes with patient care.

While there are still issues that need addressing, telemedicine is here to stay and we expect it to continue to improve patient care and provide greater opportunities for nurses with diverse skill sets.

The Biggest Benefit: Applying Multiple Specialties and Skills at Once

Nurses have always had a critical role in hospitals – assessing vital signs, administering medication, providing emotional support, and being the go-to person patients count on for virtually everything during their hospital stay. Today, hospitals want nurses to expand their skills and expertise even more.

The biggest benefit of telemedicine in the ICU is the ability to have so many nurses with different specialties and backgrounds on-call at all times. Tele-ICU systems provide a second set of eyes with a possibly different point of view, allowing patients to get better care without having to wait on the schedules of multiple specialists to line up perfectly.

As a nurse with specialized skills, telemedicine also expands your career opportunities. Many nurses love helping patients and find it too rewarding to walk away from, but they cannot always stay in the hospital environment for one reason or another. Telemedicine gives nurses the chance to do the work they love without having to deal with some of the things they don’t enjoy when working inside a hospital.

Source:
http://ccn.aacnjournals.org/content/30/4/46
http://journals.lww.com/ccmjournal/abstract/1982/07000/telemedicine_in_critical_care__problems_in_design,.14.aspx
http://ajcc.aacnjournals.org/content/25/1/e14.full
http://www.healthcareitnews.com/news/telemedicine-improves-patient-care-outcomes-icu-nurses-say

International Nurses Day is here again and we want to take the time to shed light on what makes nurses so valuable to hospitals and their communities.

The Role of Nurses in the Hospital

Nurses affect human lives by the very nature of their profession, nurses are the backbone of hospitals.

One of the most important role of the nurse in a hospital is that of a patient advocate. Nurses spend more time with patients than their doctors do. Often nurses might have to step in and advise the doctor to take a different approach due to the unique circumstances of their patient. Without nurses, patients would not be able to receive the quality of care at the scale that is necessary for hospitals to care for large groups of people at once.

Many nurses dedicate their careers to specializing in specific practice areas or skill sets (e.g. ICU, CRNA) that make them an invaluable asset to any medical team. These nurses comprise multidisciplinary teams that care for patients with complex disorders that require a wide breadth of specialized knowledge and experience.

Nurses are also the eyes and ears of the hospital. They know which healthcare products work best, they refine the processes for patient care, and they identify excessive waste and other inefficiencies.

In fact, all Elcam Safety products are inspired by nurses who want to improve the healthcare environment for patients and staff. For example, the Marvelous Stopcock,  which is designed to improve the safety of the patients by reducing risks of bloodstream infections and drug residues, and the staff safety concerning blood and drug spills and needle stick injuries.

How Nurses Can Positively Impact Their Communities

Nurses take on challenges that extend beyond the hospital doors. According to the International Council of Nurses, there are 17 sustainable development goals of modern nurses, for example:

• No poverty, no hunger
• Improved nutrition, clean water and sanitation
• Good health and well-being
• Quality education
• Gender equality and reduced inequalities
• Decent work and sustainable economic growth

(See the complete list here )

That might sound idealistic, but there are very practical ways nurses do impact their communities and work towards achieving these goals.

Here are 5 examples of how nurses improve their communities:

• Providing the same quality of care to rich and poor patients
• Treating male and female patients equally
• Educating patients on proper hygiene, optimal nutrition, and overall health practices
• Providing birth control education to young women
• Collaborating within hospital systems and the legislative system to improve the nursing profession

Great nurses love people and have the ability to influence others in a way that sticks with them long after they leave the hospital.

How Nurses Can Become Better Leaders

It has become apparent that nurses must understand the true value they provide and to make their voices heard. Part of spreading their message more effectively is becoming a better leader.

The first step to becoming a better leader as a nurse is advancing your education and growing your expertise. The more knowledge and skill you possess, the more you can contribute. Certifications and other advanced learning courses are great options for registered nurses.

The other crucial step is getting more involved in leadership roles in hospitals and other medical organizations. Nurses have an incredible point of view that other healthcare leaders need to hear and learn from. To create change, nurses must be proactive and challenge the current standards.

At Elcam, we aim to improve healthcare by equipping nurses and other staff members with safe, more effective medical devices. However, it would not be possible for us to supply so many hospitals without the approval and recommendation of the nurses who use our products .

Nurses affect human lives by the very nature of their profession. In the ICU and as CRNAs this is even more so due to the high pressured nature of these departments and the complex conditions of the patients. Nurses have an impact, wherever they go, inside and outside the hospital. On May 12th, we should all celebrate nurses and their dedication to people.

Source:

• http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet
• http://www.nursetogether.com/6-roles-nurses-play-truly-make-them-heart-healthcare
• http://www.icn.ch/images/stories/ documents/ publications/ind/ ICN AVoice ToLead guidancePack EN Lowres.pdf
• https://www.theatlantic.com/health/archive /2016/02/ nursing-shortage/459741/
• https://www.nursingtimes.net/roles/nurse-managers/nhs-to-face-chronic nurse shortage by-2016/5059871.article
• http://www.telegraph.co.uk/news/2017/01/ 19/96-per-cent-hospitals-have nurse shortages-official-figures/
• http://www.toprntobsn.com/countries-most-in-need-of-nurses/