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Infusion Therapy: Solve These Clinical and Documentation Issues to Provide Better Care

Infusion therapy services are so inherently complex that the Centers for Medicare & Medicaid Services (CMS) identifies “intravenous or intramuscular injections and intravenous feeding” and “enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day” as two of the 10 examples of direct skilled nursing services listed in section 30.3, Direct Skilled Nursing Services to Patients, in chapter 8, “Coverage of Extended-Care (SNF) Services Under Hospital Insurance,” of the Medicare Benefit Policy Manual. In other words, infusion therapy services may count as the skilled service in a Medicare Part A skilled level of care. Note: CMS defines all four components of a skilled level of care in section 30, Skilled Nursing Facility Level of Care – General.

By taking the following steps to address key clinical and documentation issues associated with these complex services, the director of nursing services (DNS) can lead the nursing staff and the entire interdisciplinary team to provide high-quality infusion therapy care that is supported in the medical record, according to Pamela Jones McIntyre, MSN, RN, CRNI, OCN, Ig-CN, VA-BC, CEO of Expert Infusion Nurse Consulting in Celina, TX:

Ensure all IV orders are complete

“It’s important for IV orders to include all critical components, including resident name, medication name, strength of medication (if required), dosage, route, frequency, the reason for administration, valid signature, and lastly an expiration date—or, at the very least, the day that the medication needs to be reviewed,” says McIntyre. “For example, a physician orders an IV antibiotic when a resident has a fever. The order may state to reassess the need for antibiotics in 72 hours, and then you would need to ensure that you have the resident’s culture results available for review at that time. Or, if a prescriber orders hydration for a resident, there should be a set time listed on the order to assess the need to continue or not. To ensure the safest care is delivered, IV orders cannot be open-ended.”

In addition, the results of those assessments should be documented in the medical record, suggests McIntyre. “Whether you are documenting lab values, cultures, or symptoms (e.g., for hydration orders), your documentation should be able to justify whether the resident has a continued need for IV therapy.”

Practice Aseptic Non-Touch Technique for better infection prevention

In October 2022, new surveyor guidance went into effect for F-tag 694 (Parenteral/IV Fluids) in Appendix PP of the State Operations Manual. This guidance primarily derives from the Centers for Disease Control and Prevention’s (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections—meaning that it is not 100 percent current with the Infusion Nurses Society’s (INS) 2021 Infusion Therapy Standards of Practice.

One key difference between the CDC guidelines and the newer INS standards is that the CDC recommends using aseptic technique when inserting or caring for intravascular catheters, says McIntyre. “However, INS recommends using a specific, international standard approach to aseptic technique, Aseptic Non-Touch Technique (ANTT), for all infusion-related procedures (e.g., the administration of infusion solutions), and the care of all infusion related devices, including intravascular catheters.”

ANTT provides improved infection prevention, explains McIntyre. “The technique involves not touching what are defined as key parts. For example, after you disinfect, you never want to touch the end of your hub with anything other than the tip of the infusion tubing or syringe. The end of the hub, tubing, and the syringe are key parts, and you connect them without touching the tips to ensure that they remain aseptic.”

One common practice in acute-care facilities and nursing homes is to create a loop with the end of the IV tubing and put it into one of the y-site ports to conserve the tubing when not in use, points out McIntyre. “However, that doesn’t follow ANTT practices and is a source of contamination of a key part—the tip of the IV tubing.”

Pay attention to antiseptic choices and scrubbing technique

Infection prevention has always been a critical part of F694. The guidance already directed providers to have policies and procedures that cover the use of hand hygiene during all aspects of IV therapy, the use of aseptic technique when placing a venous access device, and the use of personal protective equipment (PPE) if there is potential exposure to blood, bodily fluids, and infectious agents. The latest revisions add information about antiseptics to policy and procedure requirements, as well as to the investigative procedures used by state surveyors (as indicated via italics below):

  • Use of appropriate antiseptic (e.g., chlorhexidine, povidone iodine, an iodophor, or 70 percent alcohol, which is recommended in CDC guidelines) to scrub IV ports, needleless connectors, and hubs prior to access or use.   

Investigative procedures:  

Observe staff accessing the port and changing the IV site, tubing, or bottle/bag, if possible. Determine if the central venous or peripheral access port, needleless connector, and hub was scrubbed with an appropriate antiseptic prior to access or use. Determine whether aseptic technique is maintained in accordance with current, professional standards of practice.

Editor’s note: While the F694 guidance does not make it clear, povidone iodine is actually a commonly used iodophor.

As noted in the updated F694 guidance, the current standard of practice is to scrub IV ports, needleless connectors, and hubs prior to access or use, says McIntyre. “The recommendation for scrubbing comes from the CDC guidance that has been in place since 2011.”

However, inadequate hub care continues to be a problem in many sites of service, including long-term care, stresses McIntyre. “Disinfecting the threads of the connector every time that the catheter is accessed is critical. Often, nurses will swipe the hub with an antiseptic (e.g., an alcohol-based or chlorhexidine swab pad) instead of scrubbing it. But, swiping is not the same as scrubbing.”

Scrubbing causes friction, mechanically removing debris and pathogens so that the disinfectant can work, explains McIntyre. “Bacteria are tenacious. Just like you must put some muscle into removing sticky substances when they dry on your countertop, you want to make sure that you scrub the hub and tip of the injection cap or catheter for between 5 and 15 seconds to remove organisms and debris.”

Take advantage of clinical tools for residents with infection prevention concerns

Some clinical advances have provided tools that can help nursing homes with infection prevention and control, says McIntyre. “For example, a passive disinfection cap—a cap containing alcohol or chlorhexidine that goes on the end of the IV hub when the IV access device is not in use—can lower rates of bloodstream infections. However, using these caps for residents who may not have the cleanest hands, are incontinent, or have a cognitive deficit and might manipulate the tubing or the line is especially important because they prevent contact with the end of the hub.”

It’s also worth noting that another hallmark of ANTT is not using single-use items, such as antiseptic-impregnated end caps, twice, adds McIntyre.

Get the catheter insertion report for PICCs and central lines

“If your nurses may have to remove a peripherally inserted central catheter (PICC), they must have the line insertion report and the tip confirmation in hand before removing the line,” stresses McIntyre. “This documentation can be difficult to obtain from the acute-care hospital, but it needs to be included in the resident’s discharge documentation to help you prevent complications with device removal. In addition, having this documentation for both PICC lines and central lines will confirm that the line is in a proper place for infusion, especially if you are going to administer a vesicant therapy or parenteral nutrition.”

Don’t ever leave in a compromised line

“Assessments should always discern whether the current line is compromised in any way,” says McIntyre. “Sometimes, nurses leave in catheters that are not appropriate—either they are not ideally placed, or the site is red, tender, or swollen—because they suspect that the resident might need their catheter again. However, leaving in a line that is compromised causes more issues than taking it out.”

McIntyre offers the following additional tips for IV insertion and management:

  • Don’t use any area where the hand will flex, and keep IVs in the hand for 24 hours or less when possible.

  • With a peripheral IV on the forearm, don’t let it cross the bend of the elbow (i.e., the antecubital fossa).

  • Avoid having a vesicant therapy running continuously through a peripheral IV whenever possible.  

Source: Pamela Jones McIntyre, MSN, RN, CRNI, OCN, Ig-CN, VA-BC, CEO of Expert Infusion Nurse Consulting in Celina, TX.

Use wraps that can be easily moved for assessment

With cognitively impaired residents, IVs are often covered with some type of wrap so that they are obscured, says McIntyre. “For example, the resident may have a heparin lock that is left in and covered for later use. The goal is to reduce the likelihood of the resident disturbing the site.”

However, the site needs to be uncovered and assessed frequently—at least every one to two hours for a cognitively impaired resident—when an IV medication is infusing, notes McIntyre. “Best practice is to use a protective wrap that is easily removed so nurses can assess the site. For peripheral IVs, discomfort, any redness, any sign of swelling, and tracking up the vein are critical findings that must be discovered as soon as possible, especially for residents who are cognitively impaired and may not be able to verbalize discomfort.”

Review nursing documentation for site condition, technique, and assessment timing

“Nursing staff must be sure to document the condition of the site—whether it is patent, the placement, and the technique that they use to care for the area,” says McIntyre. “If, for example, the resident develops a bloodstream infection, documentation needs to show that the dressing was intact and that staff used aseptic technique in all instances, supporting that proper care was delivered.”

Staff also should document the time of each assessment, says McIntyre. “Some facilities use a flow sheet with check boxes and initials, plus signature lines at the bottom of the form for ease of documentation.”

Beef up medication reconciliations

Medication errors at care transitions—whether it’s from the acute-care hospital to the nursing home or from the nursing home to home health—remain common, says McIntyre. “In situations where there is more than one ordering physician, sometimes one prescriber may not discontinue an antibiotic, but another practitioner will order a potential duplicate medication or fail to address a change in the original order upon discharge. Having a robust medication reconciliation at every care transition and whenever a new medication is ordered will help prevent duplication, dosing errors, and drug interactions related to IV therapies.”

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