Evidence-Based Practice
Carlton G. Brown, PhD, RN, AOCN®, FAAN— Associate Editor
Reduction of Erosion Risk in Adult Patients With Implanted Venous Access Ports Jennifer Burris, MA, RN, ACNS-BC, and Mary Weis, MSN, RN, ACNS-BC, CNOR, CRNFA
One of the most common venous access devices used in patients w ith cancer is the implanted venous access port. Although incidences of infection and thrombosis are the most commonly reported complications, erosion rates of venous access ports are estimated at almost 1%. This article describes how evidence-based interdisciplinary interventions decreased port erosions for a regional health center from 3.2% to less than 1%. Jennifer Burris, MA, RN, ACNS-BC, is an advanced practice nurse in the Medicine Care Center and Mary Weis, MSN, RN, ACNS-BC, CNOR, CRNFA, is an advanced practice nurse in the Coborn Cancer Center, both at St. Cloud Hospital in Minnesota. The authors take fu ll responsibility fo r the content o f the article. The authors did not receive honoraria fo r this w ork. No financial relationships relevant to the content o f this article have been disclosed by the authors or editorial staff. M ention o f specific products and opinions related to those products do n ot indicate or imply endorsement by the Clinical Journal o f Oncology Nursing or the Oncology Nursing Society. Burris can be reached at [email protected], w ith copy to editor at [email protected]. Key words: im planted venous access ports; p ort erosions; pow er port Digital Object Identifier: 10.1188/14.CJON.403-405
ed icatio n s (e.g., ch e m o th e ra peutic agents), IV fluids, blood products, and parenteral nutri tion solutions are administered via the use of implanted venous access ports (VAPs) in the care of patients w ith cancer (Silas, Perrich, Hoffer, & McNulty, 2010). VAPs are also used for the injection of contrast media and withdrawal of blood samples. From a p a tie n t’s perspective, a VAP is considered a lifeline w ith minimal impact on body image and interference w ith daily activities (D ougherty 2011). The m ost com m only d ocum ented com plications associated w ith VAPs include infection, venous thrombosis, and catheter occlusion (Zawacki et al., 2009). VAP erosion occurs w hen a portion or all of the port cham ber or indw elling venous tubing protrudes through the skin. VAP erosion through the skin is an infrequently reported complica tion (less than 1%) and has been associated w ith cachexia and suboptimal device se lection (i.e., high-profile ports in patients) (Zawacki et al., 2009). The authors sought to identify the actual organizational VAP erosion rate after the staff perceived an increase in device removal related to ero
M
Clinical Journal o f Oncology Nursing
sion. A review of 498 inpatient and outpa tient charts from a 20-month period at St. Cloud Hospital revealed a p ort erosion rate of 3.2%. Analysis of the literature showed erosion rates w ere uncommon, w ith rates of less than 1%, and w ere suspected to be underreported (Almhanna, Pelley, Thomas Budd, Davidson, & Moore, 2008; CampSorrell, 2004; Cil et al., 2006; Fong, Erinjeri, Suncion, Kemeny, & Solomon, 2009; Zawacki et al., 2009). Given higher rates at St. Cloud Hospital, the authors decided that a need existed for multidisciplinary practice change to reduce th e existing port erosion rates.
Review of the Evidence A lite ra tu re se arch w as p erfo rm ed searching MEDLINE® and CINAHL® to establish w hat the causes of erosion were. The key search term s included erosions, skin erosions, central venous ports, im p la n te d venous access devices, chem o therapy, w o u n d healing, corticosteroid therapy, and beva cizu m a b therapy. Arti cles w ere w ritten in the English language, dates ranged from January 2000 through
Volum e 18, Num ber 4
Evidence-Based Practice
March 2011, and populations of adults aged 18 and older w ere included. Fourteen articles w ere retained for evaluation, and 11 w ere used based on the level of evi dence (Armola et al., 2009). Protocols for VAPs must be established in accordance w ith m anufacturer’s directions for use (In fusion Nurses Society [INS], 2011). Two m a n u fa ctu re r reco m m en d atio n s w ere used as well as the INS, bringing the total references to 14. Many contributing factors are associated w ith erosions. Research suggests a correla tion betw een the timing of bevacizumab (a vascular endothelial g ro w th factorspecific angiogensis inhibitor) administra tion and the actual placement of the port (Almhanna et al., 2008; Erinjeriet al., 2011; Fong et al., 2009; G enetech, Inc., 2013; Grenader, Goldberg, Verstandig, & Shavit, 2010; Muslimani et al., 2010; Zawacki et al., 2009). A potential complication associated w ith the adm inistration of bevacizumab is delayed or incom plete w ound h eal ing (Genetech, Inc., 2013). Angiogensis likely plays a role in lack of w ound healing in repetitive traum a from pu n ctu re site wounds and surgical incisions. Long-term corticosteroid use is know n to cause thin skin and slower w ound healing (Vallerand & Sanoski, 2012). Erosions w ere correlated with repeated access at the same location (A lm hanna et al., 2008; Camp-Sorrell, 2004). VAP erosion has been associated w ith active patients w ho use repetitive movements (Almhanna et al., 2008; CampSorrell, 2004). According to m anufacturer recommendations, the depth of VAP place ment should be from 0.5-2 cm. If the port is placed too shallow or if the tissue layer over the VAP is too thin, it may lead to tis sue erosion (Bard Access Systems, 2014). In addition, the port pocket site selection should include an anatomic area that pro vides good port stability, does not create pressure points, and does not interfere 403
cizumab. All audited patients received corticosteroids, putting them at increased risk of inadequate wound healing. Direct observation by APRNs of current practice identified techniques that could contribute to VAP erosions. Variation in practice was demonstrated in securement of the VAP ac cess needles and tubing. Current practice did not provide adequate securement to prevent movement at the needle access. Evaluation of VAP sites indicated 12 of the erosions were occurring in the center of the septum. The VAP device was a power port with palpation bumps, and direct ob servation indicated that staff were repeat edly accessing the same area in the center of the three palpation bumps (set in a trian gular pattern) and not rotating the access site because of limited perceived surface area. Interventional radiology insertion technique practices, including depth and skin closure, were observed and indicated a need for practice review.
TABLE 1. R e tro sp ective C h art R e v ie w o f R ed u ctio n o f Erosion Risk in A d u lt Patients W ith Im p la n te d Ports (N = 15) Characteristic BMI a t placement BMI at removal
X
Range
27 25.4
20-34 21-36
Characteristic
n
G ender Female Male
12 3
S tage a t in s e rtio n II
4
III
4
IV
6
Not applicable
1
BMI— body mass index Note. Of 498 ports inserted in the charts re
viewed, 15 were eroded. The sample is based only on eroded ports. Note. Ports were in place from six weeks to
three years at erosion.
Practice Changes and Outcomes The multidisciplinary team made three evidence-based practice recommenda tions. First, to improve access surface area and prevent use of only one access area,
with clothing and mobility (Bard Access Systems, 2014).
Findings Advanced practice nurses (APRNs) conducted retro spective charts reviews of 15 patients with VAP erosion to identify trends specific to port erosions and poten tial contributing factors (see Table 1). Items evaluated included diagnosis, gender, length of time VAP was in place, BMI at placement and removal, and medications ad ministered through the VAP. Fourteen of the 15 patients had a malignancy diagnosis, and cancer staging was eval uated. Informal discussion with multidisciplinary team members revealed concerns related to superficial VAP placement and inappropri ate anatomic location. Eight of the patients who experi enced VAP erosion received bevacizumab therapy, indi cating a potential relation ship betw een VAP erosion and administration of beva 404
a decision was made to use a power VAP without palpation bumps. The palpation bumps and unique triangular shape were manufacturer features added to the VAP to make it readily recognizable as a power port (Bard Access Systems, 2014). Practice evaluation within the imaging department indicated that palpation bumps were not the only identifiers; use of a scout film, palpation for the triangular shape, and verification of an identification card were needed for accurate power port identifi cation. At least two unique identifiers are necessary at the time of access and prior to power injection, including presence of identification card or key chains provided by the manufacturer, review of the opera tive document, and palpation of the port (INS, 2011). Therefore, the product change would not change safe practice. Second, standardization of access needle device and size was incorporated into pol icy and practice after a successful pilot in the outpatient chemotherapy infusion de partment. Access needles were changed to only power access, and size was decreased from 19 to 20 gauge. The change in needle size was based on the INS (2011) recom mendation to select needle size based on type of infusion therapy'. Guidelines
4.5 4 o '-
"S ■*-» 1.5 DC
0.5
0 2010Sept. 2011a Jan.
ii ii Ji Ji i i Ji
Oct.
Dec.
20112011b
Jan.
2012- April 20122012C June 2012d
March
July
20122012
Sept.
Oct.
20122012
Dec.
Jan.
20132013
March
A pril
June
20132013
Tim e Reported data
Literary benchmark
aimplemented technique review, change o f access needle, best practice changes, and marking o f bra strap b Implemented change o f port access, change of access needle, change o f securement device, and mandatory educa tion 'Im plem ented m andatory organization-wide education d Implemented organization-wide use ofTegaderm ™ securement dressing
FIGURE 1. Port Erosion Complication Outcomes Note. Literary benchmark based on inform ation from Almhanna et al., 2008; Camp-Sorrell, 2004; Cil et al., 2006;
Fong et al., 2009; Zawacki et al., 2009.
A u g u st 2014
V o lu m e 18, N u m b e r 4
Clinical Journal o f O n co lo g y N ursing
suggest th at th e use o f a 20-gauge needle is ap p ro p riate for necessary th erap y and im aging services. T h ird , as reco m m e n d e d , se c u re m e n t dressings w ere upgraded to a n ew er gener ation o f Tegaderm™ . T he INS (2011) guide lines n o ted th at stabilization w ill m inim ize
Conclusion T h e m u ltid isc ip lin a ry te a m h a d tw o a ssu m p tio n s p rio r to th e investigation: VAPs w e re placed to o superficially, and p o r t e ro s io n s w e re o n ly o c c u rr in g in p atien ts w ith palp atio n b u m p devices. By
ca th e ter m ovem ent and dislodgem ent. The
investigating and evaluating th e evidence,
n ew tra n sp aren t dressing h a d im proved ability to consistently secu re th e access needle and tubing and to p rev en t tension
th e a u th o rs fo u n d th a t th e assu m p tio n s m ay b e c o n trib u tin g factors. A dditional p r a c tic e a n d e q u ip m e n t fa c to rs w e re
o n th e access site and surro u n d in g skin, p reventing skin breakdow n.
n o te d follow ing review o f th e literatu re and INS (2011) guid elin es. R ecognition
T h e in te rv e n tio n a l rad io lo g y d e p a rt m e n t evaluated and rev iew e d in se rtio n te c h n iq u e s to e n su re VAPs w e re placed
o f th e m ultiple co n trib u tin g factors led to ev id en ce-b ased p ra c tic e ch an g es ra th e r th a n un ifo rm o r reactive changes. Q uality
from 0.5-2 cm deep (B ard Access Systems,
m o nitoring o f p o rt erosions w as bu ilt into
2014). Pre-m arking th e p a tie n t’s b ra strap w a s in c o r p o ra te d in to th e VAP p la c e m en t p rep aratio n p hase; th e INS (2011) re c o m m e n d e d c o lla b o ra tio n w ith th e
th e p e rfo rm a n c e im p ro v em en t process. O ngoing Plan, Do, C heck, Act m o nitoring
healthcare team and p atient to d eterm in e site selection for placem ent o f im planted p o rts. P o stp lacem en t d isch a rg e p a tie n t
provides o p p o rtu n ity for early identifica tion o f in creased p o rt erosion and addi tional p ractice evaluation. The authors g ra te fu lly acknowledge
ed u catio n n o w includes th e im p o rtan ce o f p ro tectin g th e skin over th e p o rt, p a r ticularly from irritation related to seat belts o r clothing.
Roxanne Wilson, PhD, RN, fo r advising this project and Jean Beckel, DNP, RN, MPH, CNML, fo r providing editorial assistance.
T h e ev a lu a tio n o f VAP e ro sio n s w as p resen ted to th e m edical oncology d e p art m ent related to m edication regim en contri
References
bution to erosion rates. T he m an u factu rer o f bevacizum ab recom m end s suspending treatm en t for at least 28 days p rio r to elec tive surgery, and literature su p p o rts delay ing treatm en t w ith in 10-14 days of p o rt placem ent (Erinjeri et al., 2011; Zawacki et al., 2009). T he m edical oncologists at th e authors’ institution evaluate tim ing of VAP placem ent and bevacizum ab adm in istratio n b ased o n th e p a tie n t’s clinical p resen tatio n and prognosis. M ultidisciplinary p ractice changes took place from M arch 2011 th roug h April 2012. W ithin six m onths of im plem entation, VAP erosions w ere reduced from 3.2% to less th a n 1% (see Figure 1). W ith im plem enta tion o f m ultiple p ractice changes sim ul taneously, th e chan g e w ith th e g reatest im pact w as unable to be determ in ed .
A lm hanna, K., Pelley, R.J., Thom as Budd, G., Davidson, J., & Moore, H.C. (2008). S u b cu tan eo u s im p la n ta b le ven o u s ac cess d ev ice ero sio n th ro u g h th e skin in p a tie n ts tre a te d w ith an ti-v asc u lar endothelial grow th factor therapy: A case series. A nti-C ancer Drugs, 19, 217-219. Armola, R.R., Bourgoult, A.M., Halm, M.A., Bucher, L., H arrington, L., Heafey, C.A., .. . Medina, J. (2009). AACN levels of evi dence: W hat’s new? C ritical Care Nurse, 29(4), 70-73. Bard Access Systems. (2014). In stru ctio n s fo r use. R e trie v e d fro m h ttp ://b it.ly / lpW Ptpl Camp-Sorrell, D. (2004). Im planted ports: Skin erosion. C linical J o u rn a l o f Oncol ogy Nursing, 8, 309-310. Cil, B.E., C anyigit, M., P ey n ic iro g lu , B., H azirolan, T., Carkaci, S., Cekirge, S., & Balkanci, F. (2006). Subcutaneous venous p o rt im plantation in adult patients: A sin
gle c e n te r ex p erien ce. D ia g n o stic a n d In te rv e n tio n a l Radiology, 12, 93-98. Dougherty, L. (2011). Im planted ports: Ben efits, challen g es and g u id an ce for use. B ritish J o u r n a l o f N ursing, 20(Suppl.), S12-S19. E rin je ri, J.P., Fong, A.J., K em eny, N.E., B row n, K.T., G etrajdm an, G.I., & Solo mon, S.B. (2011). Tim ing of ad m inistra tio n o f b e v a c iz u m a b c h e m o th e ra p y affects w ounds healing after chest wall p o rt placement. Cancer, 117, 1296-1301. Fong, A.J., Erinjeri, J.P.. Suncion, V.Y., Keme ny, N.E., & Solomon, S.B. (2009). Abstract no. 140: W ound healing com plications following m ediport placem ent in patients tre a te d w ith bevacizum ab. J o u r n a l o f Vascular a n d In terven tio n a l Radiology, 20(Suppl.), S55. G enentech, Inc. (2013). Avastin* (b ev aci zumab) [Package in sert]. Retrieved from http://bit.ly/lrM q691 Grenader, T., Goldberg, A., Verstandig, A., & Shavit, L. (2010). Indw elling cen tral v e n o u s a c c e ss p o r t in s e rtio n d u rin g bevacizumab-based therapy. Anti-Cancer Drugs, 21, 704-707. Infusion N urses Society. (2011). In fu sio n n u r s in g s ta n d a r d s o f p r a c tic e . N or w ood, MA: Author. Muslimani, A., Reid, R., Daw, H., Wills, S.M., Wang, S.K., Jaiyesimi, I.A., & Decker, D. (2010). Incidence o f central p o rt failure among patients receiving bevacizum ab. J o u rn a l o f Clinical Oncology, 28(Suppl.), el9579. Silas, A.M., Perrich, K.D., Hoffer, E.K., & Mc Nulty, N.J. (2010). Complication rates and outcom es of 536 im planted su b cu tan e ous chest ports: Do rates differ based on the prim ary o p erato r’s level of training? A cadem ic Radiology, 17(4), 464-467. V allerand, A.H., & Sanoski, C.A. (2012). D a v is’s drug g u id e fo r nurses (13th ed.). Philadelphia, PA: F.A. Davis Company. Zawacki, W.J., Walker, T.G., DeVasher, E., Halpern, E.F., Waltman, A.C., Wicky, S.T., . . . Kalva, S.P. (2009). W ound dehiscence o r failure to h eal follow ing venous ac cess po rt placement in patients receiving bevacizumab therapy.J o u rn a l o f Vascu la r a n d In te rv e n tio n a l R adiology, 20, 624-627.
Implications for Practice VAP erosion, although rare, is a com pli cation th at can cause significant anxiety, fear, dissatisfaction, and u n n ecessary p ro cedures. A m ultidisciplinary team should assess th e contributing factors and evidence to m ake clinically sound p ractice changes. Clinical Journal o f Oncology Nursing
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Evidence-Based Practice offers inform a tion to help nurses integrate research-based fin ding s into practice. Length should be no m ore than 1 ,0 0 0 -1 ,5 0 0 words, exclusive o f tables, figures, insets, and references. If interested, contact Associate Editor Carlton G. Brown, PhD, RN, A0CN®, FAAN, a t cgenebrow n@ gm ail.com .
Volume 18, Number 4
Evidence-Based Practice
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Carlton G. Brown, PhD, RN, AOCN®, FAAN— Associate Editor
Reduction of Erosion Risk in Adult Patients With Implanted Venous Access Ports Jennifer Burris, MA, RN, ACNS-BC, and Mary Weis, MSN, RN, ACNS-BC, CNOR, CRNFA
One of the most common venous access devices used in patients w ith cancer is the implanted venous access port. Although incidences of infection and thrombosis are the most commonly reported complications, erosion rates of venous access ports are estimated at almost 1%. This article describes how evidence-based interdisciplinary interventions decreased port erosions for a regional health center from 3.2% to less than 1%. Jennifer Burris, MA, RN, ACNS-BC, is an advanced practice nurse in the Medicine Care Center and Mary Weis, MSN, RN, ACNS-BC, CNOR, CRNFA, is an advanced practice nurse in the Coborn Cancer Center, both at St. Cloud Hospital in Minnesota. The authors take fu ll responsibility fo r the content o f the article. The authors did not receive honoraria fo r this w ork. No financial relationships relevant to the content o f this article have been disclosed by the authors or editorial staff. M ention o f specific products and opinions related to those products do n ot indicate or imply endorsement by the Clinical Journal o f Oncology Nursing or the Oncology Nursing Society. Burris can be reached at [email protected], w ith copy to editor at [email protected]. Key words: im planted venous access ports; p ort erosions; pow er port Digital Object Identifier: 10.1188/14.CJON.403-405
ed icatio n s (e.g., ch e m o th e ra peutic agents), IV fluids, blood products, and parenteral nutri tion solutions are administered via the use of implanted venous access ports (VAPs) in the care of patients w ith cancer (Silas, Perrich, Hoffer, & McNulty, 2010). VAPs are also used for the injection of contrast media and withdrawal of blood samples. From a p a tie n t’s perspective, a VAP is considered a lifeline w ith minimal impact on body image and interference w ith daily activities (D ougherty 2011). The m ost com m only d ocum ented com plications associated w ith VAPs include infection, venous thrombosis, and catheter occlusion (Zawacki et al., 2009). VAP erosion occurs w hen a portion or all of the port cham ber or indw elling venous tubing protrudes through the skin. VAP erosion through the skin is an infrequently reported complica tion (less than 1%) and has been associated w ith cachexia and suboptimal device se lection (i.e., high-profile ports in patients) (Zawacki et al., 2009). The authors sought to identify the actual organizational VAP erosion rate after the staff perceived an increase in device removal related to ero
M
Clinical Journal o f Oncology Nursing
sion. A review of 498 inpatient and outpa tient charts from a 20-month period at St. Cloud Hospital revealed a p ort erosion rate of 3.2%. Analysis of the literature showed erosion rates w ere uncommon, w ith rates of less than 1%, and w ere suspected to be underreported (Almhanna, Pelley, Thomas Budd, Davidson, & Moore, 2008; CampSorrell, 2004; Cil et al., 2006; Fong, Erinjeri, Suncion, Kemeny, & Solomon, 2009; Zawacki et al., 2009). Given higher rates at St. Cloud Hospital, the authors decided that a need existed for multidisciplinary practice change to reduce th e existing port erosion rates.
Review of the Evidence A lite ra tu re se arch w as p erfo rm ed searching MEDLINE® and CINAHL® to establish w hat the causes of erosion were. The key search term s included erosions, skin erosions, central venous ports, im p la n te d venous access devices, chem o therapy, w o u n d healing, corticosteroid therapy, and beva cizu m a b therapy. Arti cles w ere w ritten in the English language, dates ranged from January 2000 through
Volum e 18, Num ber 4
Evidence-Based Practice
March 2011, and populations of adults aged 18 and older w ere included. Fourteen articles w ere retained for evaluation, and 11 w ere used based on the level of evi dence (Armola et al., 2009). Protocols for VAPs must be established in accordance w ith m anufacturer’s directions for use (In fusion Nurses Society [INS], 2011). Two m a n u fa ctu re r reco m m en d atio n s w ere used as well as the INS, bringing the total references to 14. Many contributing factors are associated w ith erosions. Research suggests a correla tion betw een the timing of bevacizumab (a vascular endothelial g ro w th factorspecific angiogensis inhibitor) administra tion and the actual placement of the port (Almhanna et al., 2008; Erinjeriet al., 2011; Fong et al., 2009; G enetech, Inc., 2013; Grenader, Goldberg, Verstandig, & Shavit, 2010; Muslimani et al., 2010; Zawacki et al., 2009). A potential complication associated w ith the adm inistration of bevacizumab is delayed or incom plete w ound h eal ing (Genetech, Inc., 2013). Angiogensis likely plays a role in lack of w ound healing in repetitive traum a from pu n ctu re site wounds and surgical incisions. Long-term corticosteroid use is know n to cause thin skin and slower w ound healing (Vallerand & Sanoski, 2012). Erosions w ere correlated with repeated access at the same location (A lm hanna et al., 2008; Camp-Sorrell, 2004). VAP erosion has been associated w ith active patients w ho use repetitive movements (Almhanna et al., 2008; CampSorrell, 2004). According to m anufacturer recommendations, the depth of VAP place ment should be from 0.5-2 cm. If the port is placed too shallow or if the tissue layer over the VAP is too thin, it may lead to tis sue erosion (Bard Access Systems, 2014). In addition, the port pocket site selection should include an anatomic area that pro vides good port stability, does not create pressure points, and does not interfere 403
cizumab. All audited patients received corticosteroids, putting them at increased risk of inadequate wound healing. Direct observation by APRNs of current practice identified techniques that could contribute to VAP erosions. Variation in practice was demonstrated in securement of the VAP ac cess needles and tubing. Current practice did not provide adequate securement to prevent movement at the needle access. Evaluation of VAP sites indicated 12 of the erosions were occurring in the center of the septum. The VAP device was a power port with palpation bumps, and direct ob servation indicated that staff were repeat edly accessing the same area in the center of the three palpation bumps (set in a trian gular pattern) and not rotating the access site because of limited perceived surface area. Interventional radiology insertion technique practices, including depth and skin closure, were observed and indicated a need for practice review.
TABLE 1. R e tro sp ective C h art R e v ie w o f R ed u ctio n o f Erosion Risk in A d u lt Patients W ith Im p la n te d Ports (N = 15) Characteristic BMI a t placement BMI at removal
X
Range
27 25.4
20-34 21-36
Characteristic
n
G ender Female Male
12 3
S tage a t in s e rtio n II
4
III
4
IV
6
Not applicable
1
BMI— body mass index Note. Of 498 ports inserted in the charts re
viewed, 15 were eroded. The sample is based only on eroded ports. Note. Ports were in place from six weeks to
three years at erosion.
Practice Changes and Outcomes The multidisciplinary team made three evidence-based practice recommenda tions. First, to improve access surface area and prevent use of only one access area,
with clothing and mobility (Bard Access Systems, 2014).
Findings Advanced practice nurses (APRNs) conducted retro spective charts reviews of 15 patients with VAP erosion to identify trends specific to port erosions and poten tial contributing factors (see Table 1). Items evaluated included diagnosis, gender, length of time VAP was in place, BMI at placement and removal, and medications ad ministered through the VAP. Fourteen of the 15 patients had a malignancy diagnosis, and cancer staging was eval uated. Informal discussion with multidisciplinary team members revealed concerns related to superficial VAP placement and inappropri ate anatomic location. Eight of the patients who experi enced VAP erosion received bevacizumab therapy, indi cating a potential relation ship betw een VAP erosion and administration of beva 404
a decision was made to use a power VAP without palpation bumps. The palpation bumps and unique triangular shape were manufacturer features added to the VAP to make it readily recognizable as a power port (Bard Access Systems, 2014). Practice evaluation within the imaging department indicated that palpation bumps were not the only identifiers; use of a scout film, palpation for the triangular shape, and verification of an identification card were needed for accurate power port identifi cation. At least two unique identifiers are necessary at the time of access and prior to power injection, including presence of identification card or key chains provided by the manufacturer, review of the opera tive document, and palpation of the port (INS, 2011). Therefore, the product change would not change safe practice. Second, standardization of access needle device and size was incorporated into pol icy and practice after a successful pilot in the outpatient chemotherapy infusion de partment. Access needles were changed to only power access, and size was decreased from 19 to 20 gauge. The change in needle size was based on the INS (2011) recom mendation to select needle size based on type of infusion therapy'. Guidelines
4.5 4 o '-
"S ■*-» 1.5 DC
0.5
0 2010Sept. 2011a Jan.
ii ii Ji Ji i i Ji
Oct.
Dec.
20112011b
Jan.
2012- April 20122012C June 2012d
March
July
20122012
Sept.
Oct.
20122012
Dec.
Jan.
20132013
March
A pril
June
20132013
Tim e Reported data
Literary benchmark
aimplemented technique review, change o f access needle, best practice changes, and marking o f bra strap b Implemented change o f port access, change of access needle, change o f securement device, and mandatory educa tion 'Im plem ented m andatory organization-wide education d Implemented organization-wide use ofTegaderm ™ securement dressing
FIGURE 1. Port Erosion Complication Outcomes Note. Literary benchmark based on inform ation from Almhanna et al., 2008; Camp-Sorrell, 2004; Cil et al., 2006;
Fong et al., 2009; Zawacki et al., 2009.
A u g u st 2014
V o lu m e 18, N u m b e r 4
Clinical Journal o f O n co lo g y N ursing
suggest th at th e use o f a 20-gauge needle is ap p ro p riate for necessary th erap y and im aging services. T h ird , as reco m m e n d e d , se c u re m e n t dressings w ere upgraded to a n ew er gener ation o f Tegaderm™ . T he INS (2011) guide lines n o ted th at stabilization w ill m inim ize
Conclusion T h e m u ltid isc ip lin a ry te a m h a d tw o a ssu m p tio n s p rio r to th e investigation: VAPs w e re placed to o superficially, and p o r t e ro s io n s w e re o n ly o c c u rr in g in p atien ts w ith palp atio n b u m p devices. By
ca th e ter m ovem ent and dislodgem ent. The
investigating and evaluating th e evidence,
n ew tra n sp aren t dressing h a d im proved ability to consistently secu re th e access needle and tubing and to p rev en t tension
th e a u th o rs fo u n d th a t th e assu m p tio n s m ay b e c o n trib u tin g factors. A dditional p r a c tic e a n d e q u ip m e n t fa c to rs w e re
o n th e access site and surro u n d in g skin, p reventing skin breakdow n.
n o te d follow ing review o f th e literatu re and INS (2011) guid elin es. R ecognition
T h e in te rv e n tio n a l rad io lo g y d e p a rt m e n t evaluated and rev iew e d in se rtio n te c h n iq u e s to e n su re VAPs w e re placed
o f th e m ultiple co n trib u tin g factors led to ev id en ce-b ased p ra c tic e ch an g es ra th e r th a n un ifo rm o r reactive changes. Q uality
from 0.5-2 cm deep (B ard Access Systems,
m o nitoring o f p o rt erosions w as bu ilt into
2014). Pre-m arking th e p a tie n t’s b ra strap w a s in c o r p o ra te d in to th e VAP p la c e m en t p rep aratio n p hase; th e INS (2011) re c o m m e n d e d c o lla b o ra tio n w ith th e
th e p e rfo rm a n c e im p ro v em en t process. O ngoing Plan, Do, C heck, Act m o nitoring
healthcare team and p atient to d eterm in e site selection for placem ent o f im planted p o rts. P o stp lacem en t d isch a rg e p a tie n t
provides o p p o rtu n ity for early identifica tion o f in creased p o rt erosion and addi tional p ractice evaluation. The authors g ra te fu lly acknowledge
ed u catio n n o w includes th e im p o rtan ce o f p ro tectin g th e skin over th e p o rt, p a r ticularly from irritation related to seat belts o r clothing.
Roxanne Wilson, PhD, RN, fo r advising this project and Jean Beckel, DNP, RN, MPH, CNML, fo r providing editorial assistance.
T h e ev a lu a tio n o f VAP e ro sio n s w as p resen ted to th e m edical oncology d e p art m ent related to m edication regim en contri
References
bution to erosion rates. T he m an u factu rer o f bevacizum ab recom m end s suspending treatm en t for at least 28 days p rio r to elec tive surgery, and literature su p p o rts delay ing treatm en t w ith in 10-14 days of p o rt placem ent (Erinjeri et al., 2011; Zawacki et al., 2009). T he m edical oncologists at th e authors’ institution evaluate tim ing of VAP placem ent and bevacizum ab adm in istratio n b ased o n th e p a tie n t’s clinical p resen tatio n and prognosis. M ultidisciplinary p ractice changes took place from M arch 2011 th roug h April 2012. W ithin six m onths of im plem entation, VAP erosions w ere reduced from 3.2% to less th a n 1% (see Figure 1). W ith im plem enta tion o f m ultiple p ractice changes sim ul taneously, th e chan g e w ith th e g reatest im pact w as unable to be determ in ed .
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gle c e n te r ex p erien ce. D ia g n o stic a n d In te rv e n tio n a l Radiology, 12, 93-98. Dougherty, L. (2011). Im planted ports: Ben efits, challen g es and g u id an ce for use. B ritish J o u r n a l o f N ursing, 20(Suppl.), S12-S19. E rin je ri, J.P., Fong, A.J., K em eny, N.E., B row n, K.T., G etrajdm an, G.I., & Solo mon, S.B. (2011). Tim ing of ad m inistra tio n o f b e v a c iz u m a b c h e m o th e ra p y affects w ounds healing after chest wall p o rt placement. Cancer, 117, 1296-1301. Fong, A.J., Erinjeri, J.P.. Suncion, V.Y., Keme ny, N.E., & Solomon, S.B. (2009). Abstract no. 140: W ound healing com plications following m ediport placem ent in patients tre a te d w ith bevacizum ab. J o u r n a l o f Vascular a n d In terven tio n a l Radiology, 20(Suppl.), S55. G enentech, Inc. (2013). Avastin* (b ev aci zumab) [Package in sert]. Retrieved from http://bit.ly/lrM q691 Grenader, T., Goldberg, A., Verstandig, A., & Shavit, L. (2010). Indw elling cen tral v e n o u s a c c e ss p o r t in s e rtio n d u rin g bevacizumab-based therapy. Anti-Cancer Drugs, 21, 704-707. Infusion N urses Society. (2011). In fu sio n n u r s in g s ta n d a r d s o f p r a c tic e . N or w ood, MA: Author. Muslimani, A., Reid, R., Daw, H., Wills, S.M., Wang, S.K., Jaiyesimi, I.A., & Decker, D. (2010). Incidence o f central p o rt failure among patients receiving bevacizum ab. J o u rn a l o f Clinical Oncology, 28(Suppl.), el9579. Silas, A.M., Perrich, K.D., Hoffer, E.K., & Mc Nulty, N.J. (2010). Complication rates and outcom es of 536 im planted su b cu tan e ous chest ports: Do rates differ based on the prim ary o p erato r’s level of training? A cadem ic Radiology, 17(4), 464-467. V allerand, A.H., & Sanoski, C.A. (2012). D a v is’s drug g u id e fo r nurses (13th ed.). Philadelphia, PA: F.A. Davis Company. Zawacki, W.J., Walker, T.G., DeVasher, E., Halpern, E.F., Waltman, A.C., Wicky, S.T., . . . Kalva, S.P. (2009). W ound dehiscence o r failure to h eal follow ing venous ac cess po rt placement in patients receiving bevacizumab therapy.J o u rn a l o f Vascu la r a n d In te rv e n tio n a l R adiology, 20, 624-627.
Implications for Practice VAP erosion, although rare, is a com pli cation th at can cause significant anxiety, fear, dissatisfaction, and u n n ecessary p ro cedures. A m ultidisciplinary team should assess th e contributing factors and evidence to m ake clinically sound p ractice changes. Clinical Journal o f Oncology Nursing
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