Scope, Impact, and Development of the Standards
Home infusion therapy is a common practice and is safe overall, given attention to patient selection and education, educated nurses, sound clinical policies, and interprofessional communication. However, it is not without risk due to potential complications associated with intravascular devices and adverse events associated with infusion medications. Whether your agency has been providing infusion therapy for years or is just beginning to offer it, it is vital that your nursing staff be kept up to date with effective, evidence-based training and the latest standards of practice to ensure the safety of the patients who your agency serves.
Every five years, the Infusion Nurses Society (INS) publishes evidence-based practice Standards. The Standards are widely cited, have been previously translated into several languages, and are used to develop and support clinical procedures in published procedure manuals. For 2021, a volunteer committee of 11 nurses representing the US, Australia, Canada, and the United Kingdom worked for over two years compiling comprehensive literature reviews, analyzing the research literature, and developing evidence-based recommendations, which are rated as to the strength of the evidence. Upon a committee-developed draft, it was reviewed by 120 peer reviewers (nurses, physicians, pharmacists, and attorneys), including 30 from outside of the US. The committee spent two months making final revisions based on reviewer suggestions and updated the literature reviews in preparation for final publication.
The 2021 edition includes 66 Standards. There are over 2,500 references cited to support practice recommendations in all patient care settings for vascular, subcutaneous, intraosseous, and intraspinal access devices and infusion administration. Three Standards are briefly described.
Standard 5: Competency and Competency Assessment (249)
Assessment of competency is a critically important INS Standard. In accordance with the INS Standards, competency is assessed and documented before providing a task or skill without supervision. Ongoing competency assessment is a continuous process driven by patient and organizational outcomes. Competency is assessed using a variety of techniques, and competency to perform infusion therapy procedures should never be based upon a nurse’s verbal assertion of skill. For psychomotor skills (e.g. site care and dressing changes, PIV insertion, and implanted port access), competency is assessed in four consecutive phases: knowledge acquisition, observation, simulation (e.g. port needle insertion on a chest model), and clinical performance. Knowledge acquisition may be addressed through instructor-led presentations or electronic-based content delivery such as my MedBridge Infusion Therapy courses. Organizations should ask themselves:
Are nurses provided with education relative to home infusion that addresses evidence-based recommendations, rationale for clinical practices, products used and how to use them, and complication risk reduction?
Additional methods of competency validation include written tests to assess knowledge and clinical scenarios to assess critical thinking skills. Not to be ignored are the qualifications for the competency “assessor” often called the “preceptor.” Substandard practice may be passed on to newly hired nurses if the preceptor is not competent with infusion administration. Preceptors should be assessed for expertise, competence, and ability to observe and provide critique of nurses’ skills. Also important is that preceptors not only validate competent performance of the skill but also ensure that the nurse is knowledgeable and understands the rationale for any given step in the observed procedure.
New Standard 18: Aseptic Non Touch Technique® (199)
Ensuring aseptic technique with invasive procedures, such as infusion administration, and vascular access device insertion and management, is a critical aspect of infection prevention. Failure to adhere to aseptic technique during infusion procedures puts patients at risk for bloodstream infections. Adherence to aseptic technique is an important aspect of nursing competency assessment for procedures including infusion administration, site care, and implanted port access.
A complete description of ANTT® is beyond the scope of this article, but ANTT® is addressed in my MedBridge Home Infusion Therapy and Infection Prevention courses. ANTT® is a comprehensively defined type of aseptic technique based on the concepts of Key-Parts and Key-Sites (VAD insertion site). Key-Parts are those parts of the infusion system that if touched or contaminated could potentially lead to infection; Key-Parts include the unprotected syringe tip, disinfected needleless connector, and IV tubing tip. Key-Site and Key-Site protection are achieved by integrating Standard Precautions with appropriate aseptic field management (e.g, laying out all needed supplies on either a clean or sterile drape), non-touch technique and sterile supplies. An Appendix with further description of ANTT® is included in the Standards. ANTT® is followed during all invasive clinical procedures and management of invasive medical devices. The concepts of ANTT® are easily taught to patients and caregivers who provide infusion administration procedures.
New Standard 55: Catheter-Associated Skin Injury (165)
This new Standard provides guidance in preventing and managing reactions at or around the vascular access device (VAD) insertion site. The home care nurse may encounter patients who develop skin irritations or sensitivities to antiseptics, dressings, and adhesive products. The standards provide guidance in identifying the type and severity of skin damage, the potential source of the skin issue, and preventative interventions. For example, preventative interventions include:
- Always allow the skin antiseptic to fully dry before dressing placement
- Use a sterile alcohol-free skin barrier product to protect at-risk skin, and always if using an adhesive-based securement method; always allow to dry prior to dressing application
- Apply transparent dressings without tension, pulling, or stretching
- Smooth product in place to avoid gaps and wrinkles
- Remove dressings slowly while keeping adhesive product horizontal to skin and folded onto itself
An evidence-based algorithm located in the Appendix provides helpful guidance in interventions to employ for patients who develop skin problems during VAD dwell time.
The INS 2021 Standards of Practice can be purchased via the INS website store.
- Gorski, L. A., Hadaway, L., Hagle, M., Broadhurst, D., Clare, S., Kleidon, T., & Meyer, B., et al. (2021). Infusion therapy standards of practice. Journal of Infusion Nursing, 44(Suppl 1S), S1-S224.