As I reviewed each of the articles included in this issue of the Journal of Infusion Nursing, I was particularly impacted by the passion, persistence, and fortitude of each of the authors/researchers. This level of clinical expertise, coupled with the ability to conduct research and/or provide evidence-based guidance, comes only from those who are deeply immersed in their specialty. As such, it is my pleasure to highlight the authors and researchers selected for this publication.
This issue's lineup begins with an article from Daphne Broadhurst et al, who present "International Consensus Recommendation Guidelines for Subcutaneous Infusions of Hydration and Medication in Adults: An e-Delphi Consensus Study." The Delphi technique is a unique research methodology that utilizes an approach to answer a research question by attaining consensus from a group of subject-matter experts. The iterative process creates an environment in which experts can collectively and collaboratively achieve consensus on the issue being researched. Broadhurst's research group comprised "a panel of 11 international clinicians with expertise in subcutaneous infusion research and/or clinical practice." The study addressed a lack of clinical practice guidelines for subcutaneous therapy. The objectives of the study are as follows:
1. To reach consensus on practice recommendations in guideline domains of a) assessment and device placement; b) best practices in subcutaneous infusion management; and c) competency and quality assurance in subcutaneous infusion therapy.
2. To summarize the recommendations for subcutaneous hydration in an Adaptive Behavioral Components (ABC) guideline framework.
3. To validate the recommendation guidelines through consensus.
This e-Delphi study resulted in the development of 42 practice recommendations presented in Tables 2, 3, and 4 within the article. Please do not miss the Supplemental Table associated with this study, which is available at http://links.lww.com/JIN/A106.
Clinicians must manage aspects of infusion therapy in which supportive, clear-cut evidence to guide clinical practice is limited. In these situations, health care organizations must often define facility-specific protocols to best meet the needs of patients. In, "Effect of Peripherally Infused Norepinephrine on Reducing Central Venous Catheter Utilization," Andrew C. Faust et al sought to "evaluate the impact of peripherally administered norepinephrine on avoiding central venous catheter insertion while maintaining safety of the infusion." Some find this topic highly controversial because vasoactive agents like norepinephrine are characterized as vesicants and are traditionally infused via a central vascular access device (CVAD) to limit the risk of tissue damage due to extravasation. After the implementation of an organizational peripheral norepinephrine-specific guideline (see Figure 1 of the article), the authors designed a single-center, retrospective, observational study of adult patients who required norepinephrine. I encourage you to review the outcomes and findings of this study. At the conclusion of their research, the authors assert, "To achieve timely resuscitation goals, as well as to minimize costs and complications associated with CVADs, preferential initial administration via peripheral intravenous catheters (PIVCs) should be considered."
In his article, "Moving Beyond CLABSI: Enhancement of the Prevention Process," Robert Garcia proposes preventive strategies, including a new imperative called Hospital Onset Bacteremia, a model that requires surveillance and prevention of bloodstream infections associated with all types of vascular access devices; expansion of vascular access service teams (VASTs), their role and utilization; and continued or added use of chlorhexidine-based products. Garcia has a significant background as an infection preventionist/consultant with more than 40 years of experience. He was elected in 2016 as a fellow in APIC 2016, a designation for experienced infection preventionists who have had significant contributions to the field of infection prevention. His history includes being, 1) an infection preventionist/director at 9 hospitals in New York, most recently as a senior instructional support specialist at the Healthcare Epidemiology Department, Stony Brook University Hospital (Stony Brook, NY); 2) a principal national researcher on the effectiveness of silver-hydrogel urinary catheters, chlorhexidine skin antisepsis, and comprehensive oral care to prevent ventilator-associated pneumonia. Given his extensive and acclaimed career in this field, I invite you to consider his recommendations for enhancing the infection prevention process for vascular access and infusion therapy.
Shilpa A. Patel et al authored, "Pegloticase in Uncontrolled Gout: The Infusion Nurse Perspective." Written as an educational overview, this article is packed with information for the infusion nurse, including a pegloticase infusion checklist and two model patient case studies. The authors emphasize the significant role infusion nurses play in managing patients with uncontrolled gout: "Pegloticase is often the last line of therapy for patients with uncontrolled gout. Therefore, the infusion nurse's role in patient education, serum uric acid (sUA) monitoring, medication compliance, pegloticase administration, and observation during therapy are all essential for ensuring patient safety and maximizing the number of patients who benefit from a full treatment course."
Paving the way toward clinical practice that is evidence-based, founded in research, and informed by leading experts is a major goal in any scientific publication. Scientific research is dependent on professionals who are bold enough to address areas of practice where clinical guidance is truly deficient or where treatment protocols present both clinical risks and benefits, which can evoke controversy. Again, I commend the authors and researchers selected for this issue of the Journal of Infusion Nursing who have developed clinical guidance, addressed a clinical controversy, proposed new practice imperatives, and offered sound clinical instruction. I would like to acknowledge their exceptional work, their vast expertise, and their willingness to share their understanding with others.