Access Device Guidelines: Recommendations for Nursing Practice and Education (3rd ed.)

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Introduction

More than four decades ago, IV drugs could be administered only through short-term peripheral or subclavian access devices. Administration of drugs to other parts of the body such as the epidural or peritoneal spaces was only theorized. After years of improving upon catheters and ports, short-term as well as long-term devices are available to access the venous, intrathecal, arterial, peritoneal, and intraventricular body systems. As a result, complex treatment plans are being developed to increase the patient’s overall survival as well as to palliate symptoms, thus improving quality of life.

Evolving technology continuously leads to the frequent introduction of newer access devices and products used with these devices. This technology continues to improve on existing devices to decrease the occurrence of occlusion and infection and increase patient safety. Although basic routine care is common to all devices, each device has specific care requirements. Managing complications of access devices is similar among the different devices, with variations noted. The literature provides numerous studies on caring for and managing complications (see Appendix 1 for Internet resources available). However, evidence on which to base nursing care from these studies is lacking, and controversies still exist concerning the optimal management.

In preparing this revision, an extensive literature search was performed to identify studies published since the 2004 edition of the guidelines. Following is a summary of the search criteria.

Only human, not animal, studies were included in this search. Databases used to search the literature included PubMed, MEDLINE, CINAHL, and the National Guideline Clearinghouse. Subject headings for the searches included access devices, venous access devices, peripheral IV, subcutaneous devices, hypodermoclysis, apheresis catheters, hemodialysis catheters, nontunneled catheters, central venous lines, temporary venous lines, short-term catheters, long-term catheters, midline catheters, peripherally inserted catheters, tunneled catheters, complications of catheters, infection of catheters, occlusion of catheters, arterial catheters, peritoneal catheters, epidural, intrathecal, Ommaya reservoir, intraventricular catheters, educational needs, staff education, patient education, immunosuppression, myelosuppression, implantable pumps, ambulatory pumps, cost of catheters, maintenance of catheters, indwelling catheters, implantable ports, and controversial issues of access devices. Some of the older references from the previous edition of these guidelines were retained because of their importance to the subject matter.

Few randomized, controlled trials have been conducted on access devices; subsequently, little evidence-based information is available to guide nursing care. Thus, the guidelines developed from this synthesis of literature focus on strict hand washing, strict aseptic technique, and consistent maintenance care. Ongoing surveillance of infection and occlusion rates will help any institution to evaluate its policies and determine whether revisions are necessary.

The Oncology Nursing Society initially developed these guidelines in 1989 to provide recommendations for the application of access device technology within nursing practice. Over the years, these guidelines continue to be updated according to the evidence in practice. For the clinician, the guidelines serve as a basis for providing care to the patient with an access device and in developing policies and procedures in all patient care settings. Nurse educators can use the guidelines in developing access device educational programs. Administrators can use the clinical practicums for competency-based evaluations. The extensive list of controversial issues will be a stimulus to nurse researchers to begin conducting studies to answer these questions. Nursing research is essential to establish scientifically based methods for access device care and the management of complications.

Guidelines for the use of access devices are indispensable in the management of patients with cancer. Modern technology has enhanced the safety and efficacy of administration methods for cancer treatment and supportive care agents. Developing the expertise needed to manage access devices is a continual challenge to healthcare professionals. The intent of these guidelines is to provide the foundation for evidence-based practice that practitioners can use to guide their practice.

It is clear that, despite the lack of evidence-based practice for care of access devices, the patient’s quality of life has greatly improved over the past four decades with the advances in access device technology. This edition of Access Device Guidelines: Recommendations for Nursing Practice and Education explores the latest technologies, management procedures, and controversies that still exist. Recommendations for management and care are consistent with the literature and are deemed reasonable in the absence of definitive studies.