NURSES ’ KNOWLEDGE REGARDING THE HANDLING OF THE TOTALLY-IMPLANTED VENOUS ACCESS DEVICE

In the light of nurses’ questions regarding the handling of the totally-implanted venous access device, this study aimed to evaluate these professionals’ knowledge. This is a descriptive study with a qualitative approach, whose sample was made up of 28 nurses working on the Internal Medicine ward and in the Emergency Room. The study was undertaken in two stages: interviewing, to evaluate knowledge regarding the handling of the implanted port; and an integrative review to clarify the doubts identified. The results indicated that the nurses’ knowledge was inadequate regarding when to use the implanted port, its purpose, the puncture technique, maintenance and handling. It is concluded that the knowledge of the subjects evaluated is inadequate, and that it is necessary for these professionals’ clinical skills to be standardized and for them to receive theoretical-practical training.


INTRODUCTION
Patients who receive prolonged treatment and need constant use of the venous network are likely to present, at some point, peripheral vascular weakness.Cancer patients stand out among these, as chemotherapy treatment causes this condition.In these cases, it is necessary to select resources which viabilize safe, long term venous access, which can be obtained through use of the central venous catheter. 1n the area of Oncology, the totally implanted venous access device (TIVAD) (also known as the implanted port) is an option for adult patients, as it ensures safety in the long term administration of intravenous medications.This catheter is indicated for those patients who shall receive long-term chemotherapy (over six months) over multiple cycles, the infusion of vesicant chemotherapy agents, or agents which lead to severe medullary aplasia, chemotherapy in which the infusion time is over eight hours, patients who underwent bilateral mastectomy, and patients with intense lymphedema, as well as obese patients with difficult venous access.] The access to the device is made through pushing a non-coring needle through the skin and the silicon rubber membrane of the port chamber, and the main element of the care includes flushing with normal saline solution and heparinization. 6Although this is a safe route, some complications related to the use of the implanted port can appear, such as: infection, obstruction, infiltration or leakage, among others.8] Furthermore, continuous education actions must take place regularly, so as to keep the team up-to-date regarding the han-dling techniques and the main care steps relating to the handling of the catheter. 2he University Hospital of Brasilia (HUB) has a unit termed the High Complexity Center in Oncology (CACON), which is a center of excellence in cancer care in the Federal District, and which runs on an outpatient basis.Bearing in mind how it runs, when the patients monitored there need emergency or inpatient treatment, they are referred to the Emergency Room (ER) or to the Internal Medicine (IM) ward, respectively.Although the nurses who work in these departments deal with cancer patients on a daily basis, the majority do not have professional training for attending this clientele, which gives rise to innumerable doubts regarding undertaking the procedures specific to this area.The handling of the TIVAD is one of these procedures, as it is undertaken frequently in these areas, given that most of the patients have been fitted with this device.It is emphasized that this fact prompted the undertaking of this study.
As a result, knowing the principal doubts held by the professionals who deal directly with this clientele can guide continuous education actions, with the aim of improving the quality of the nursing care.Therefore, the present study aimed to evaluate the nurses' knowledge regarding the handling of the TIVAD.

MATERIALS AND METHODS
This is a cross-sectional study, with a descriptive character and a qualitative approach.The study was undertaken in September -October 2012, in the IM and ER departments of the HUB.The workforce of the areas mentioned was made up of 32 nurses.During the period of data collection, however, two were on leave and two declined to participate in the research.As a result, the sample was made up of 28 nurses, for whom the inclusion criteria were: to manage the TIVAD and to accept to participate in the study through signing the Terms of Free and Informed Consent (TFIC).Those with professional experience of less than one year were excluded.
The study was submitted for consideration by the Research Ethics Committee of the Faculty of Medicine of the University of Brasília (UnB), following the precepts established by Resolution CNS N. 196, of 10/10/96, which establishes ethical rules for regulating studies involving human beings. 9he study was protocolled under N. 047/2012, and was approved on 17 th August 2012.
Nurses' knowledge regarding the handling of the totally...The interviews were held in a room in the subjects' workplace and during their shift.Only the interviewer and the subject were present.The guiding question was as follows: what are your main doubts and/or difficulties when you face a patient with a TIVAD?Based on this central question, a number of topics related to the handling of the catheter were raised, should the interviewee not address them, so as to identify possible doubts which did not emerge in answering the main question.
The interviews were recorded, the subjects being identified as I1, I2, I3 etc, in accordance with the order in which the interviews were held, thus preserving the participants' privacy and the confidentiality of the data.The method used for analyzing the data obtained was the system of content analysis 10 .Content analysis is a set of techniques for analyzing communications, which uses systematic and objective procedures for describing the content of the messages, which allow the inference of knowledge relating to the conditions of production of and receiving of these messages.This method is composed of three stages, namely: pre-analysis, exploration of the material, and treatment of the results/interpretation. 10,11he interviews were then transcribed through repeated and interrogative reading of the material, which allowed the arrangement of the set of the information obtained and to grasp the principal doubts indicated by the participants, thus constructing the categories which emerged from the data.
The results obtained in this stage supported the development of the second stage, in which an integrative review of the literature was undertaken, so as to settle the doubts identified in the first stage, which could contribute to the appropriate management of the implanted port.
For this, it was sought to respond to the following guiding question: "What are the principal nursing care steps identified in the scientific literature which must be adopted in the managing of the TIVAD"?
The searches were undertaken in October -December 2012 in the online databases: the Cochrane Library, PubMed/MEDLINE, CINAHL and LILACS.The following search terms were combined: catheterization central venous and antisepsis, implanted catheter and nursing care, catheterization central venous and accessing, catheterization central venous and maintenance.It included studies addressing the managing of the TIVAD in adults, published in English, Portuguese and Spanish, there being no restriction regarding the methodological design of the study or the period of publication of the same.The following were excluded: articles addressing care with the Hickman catheter, the short-term catheter or the peripherally-inserted central catheter (PICC) and those which evaluated the use of catheters for other purposes, such as neonatology, cardiology, hemodialysis and parenteral nutrition.
After the articles selected had been read in full, a data collection instrument 12 was filled out, containing the identification of the article, the type of study, the content addressed, the results and the level of evidence.For determining the level of evidence, the hierarchical system of evidence was used, 13 which sets out seven levels: level 1 -systematic review or meta-analysis of the relevant randomized clinical trials; level 2 -evidence obtained from at least one well-designed randomized clinical trial; 3 -well-designed clinical trials without randomization; level 4 -case control studies and cohort studies; 5 -systematic reviews of descriptive studies and qualitative studies; 6 -single descriptive or qualitative studies; and 7-the opinion of authorities and/or a committee of specialists.

RESULTS AND DISCUSSION
Twenty eight nurses participated in the present study, of whom 10 worked in IM and 18 in ER.Only one of the subjects was male.The mean age was 30 years old and the mean length of professional experience was four years; eight had been qualified for over five years and two of the subjects were specialists in oncology nursing.
Based on the analysis of the interviews it was possible to identify five categories, namely: indications and purpose; the puncture technique; maintenance and handling of the totally implantable venous access device; and the need for standardizing the professional skills.
The categories which emerged from the interviews guided the searches in the databases.283 articles were identified, of which only 32 met the inclusion criteria.The 251 excluded articles were rejected for the following reasons: short-term central venous catheter (n=52), the semi-implanted catheter (n=12), PICC (n=15), related to parenteral nutrition (n=19), hemodialysis catheter (n=21), related to the implantation technique (n=20), repeated in the databases (n=18) and others (n=94).
The results found in the two stages are presented below, in accordance with the categories identified.

Indications and purpose of the Totally-Implanted Venous Access Device
During the interviews, questions were raised in the nurses' accounts, related to the indications and purpose of this device, as many associated the use of the catheter only with the infusion of the chemotherapy.
[...] I don't know specifically what it is indicated for, but I know that it is used for chemotherapy (I9).
[...] Like, is there is a problem taking a blood sample from the catheter, as it is there because the patient doesn't have any other type of access?Is there a problem in relation to this?And another thing, when the patient enters Emergency Room, can I puncture the port because this really is the access that the patient has, so there is the question: it is a gateway for infection, so should we really puncture this port when we are admitting somebody, or leave it restricted for chemotherapy?Can it be used for blood transfusions?(I1).
1 Furthermore, the use of this device offers a lower risk of infection, when compared with the short-term central venous catheter. 26,30

Puncture technique
One doubt indicated by the nurses (n=9) was related to the puncture procedure and they confirmed that they did not know how to carry out this technique.

Actually, I have many doubts, in the management at the time of the puncture. I have never undertaken the puncture, I have only watched a nurse doing the puncture in the health center (I14).
Other nurses stated that they know how to undertake the puncture technique; however, they did have specific doubts.Six nurses did not know which type of needle they should use for the puncture.Another doubt indicated was related to the preparation of the skin for the puncture, for which the majority of the interviewees reported using 70% alcohol.They could not confirm, however, if this is the appropriate solution for this purpose.Subjects also had doubts regarding the angle for introducing the needle when making the puncture (n=10), as well as the confirmation of the correct positioning of the needle after the puncture (n=8).
[...] And in relation to the blood withdraw, when you can't aspirate any, then I am not sure.I know that there might not be this blood withdraw, but I am concerned with whether the patient will feel anything and I remain unsure (I2). [

...] I don't know what the angle is for puncturing, because I have never done the puncture (I20). [...] But the doubt which I had, and still have, is in relation to the fact of drawing back on the needle or not. This is because sometimes the aspiration of blood is not possible during the puncture. I think it is safer to leave it punctured with a return of blood when you aspirate (I27).
9][40] It is important to emphasize that the antisepsis of the skin must be undertaken using spiral movements, from inside outwards, starting at the center of the port, and that these must be undertaken at least three times prior to the insertion of the needle. 8,31,33] The confirmation of the correct positioning is seen as an important step during the undertaking of the technique of puncturing and is done through carrying out the check for blood return, removing between 2 and 3 ml of blood from the catheter.Another means of confirmation is through the Nurses' knowledge regarding the handling of the totally... free, easy and painless infusion of the solution to be infused.In the event of absence of withdrawal occlusion resistance to the infusion and/or pain in the infusion, the professional must interrupt it and assess the appropriate positioning of the needle. 28,32

Maintenance of the implanted port
The maintenance of the patency of the implanted port is also an issue which, according to the subjects, causes doubts.Five nurses showed that they did not know the type of solution used for this purpose; others (n=15) reported doubts regarding the concentration of heparin and, further, in relation to the frequency of heparinization (n=23).
[...] One doubt is the right quantity of heparin which is put in...We have an idea, but we don't know the exact amount...The maintenance is monthly?I'm not sure, because we hardly do it here [...] (I11) The maintenance of the patency is obtained through flushing (using the push-pause technique), with 20 ml of 0.9% normal saline after the infusion of any solution and, finally, using a heparin solution to seal the catheter when the catheter is not to be used further on that occasion. 23,26,28,34,40,42he dose of heparin can vary from 10 to 1000 IU/ ml, with the concentration of 100 IU/ml, in a volume of 2ml, being the most commonly used. 8,15,28,38 relation to the heparinization interval, the manufacturers recommend that this should be undertaken every 30 days.Some retrospective studies, however, state that harm did not occur in the maintenance of patency in catheters which were heparinized at 30 days or 60 days. 21,24e subjects also questioned which clinical actions should be taken in the event of obstruction (n=15).[.

..] I don't know what solution must be used for clearing obstructions. (I14)
Upon identifying obstruction, one must check the blood return and, following that, attempt to infuse normal saline solution.Emphasis is also placed upon the importance of assessing possible mechanical occlusions, poor positioning of the catheter, kinks, and, even, poor positioning of the needle.In cases of obstruction caused by deposits of fibrin or thrombus, thrombolytic agents have been widely used for clearing obstructions: their administration, however, requires monitoring by a doctor, as there are risks of complications with the use of these drugs. 17,35

Handling of the implanted port
Five nurses confirmed that they did not know which substance could be used for undertaking antisepsis when changing the dressing.There were also doubts in relation to the frequency for changing the dressing and needle when there is continuous use of the device.
In Emergency Room, we puncture the port chamber, but a lot of people don't know what the protocols are for doing the dressing.For example: if the puncture is undertaken on a patient today, how long should it be before we change the dressing?[...] I don't know the time for changing the needle either, in the case of a hospitalized patient, I don't really know how long it should stay in.I think it is up to 72 hours.(I2).

I'm not sure about the solution used for the dressing or about changing it, I think it is daily. (I4)
4] This dressing must be changed whenever it becomes dirty, damp or loose; these cases excluded, changing is recommended every 48 hours, when sterile gauze is used, and, at the most, every seven days, when a transparent film is used. 8,30,33,40The recommended solution is alcoholic chlorhexidine, due to its greater residual effect on the skin. 15,36,39egarding when to change the needle, most studies recommend that the maximum period for a needle to remain in place should be seven days. 26,29,30,33One descriptive study assessed 70 patients who had received prolonged infusions of chemotherapy agents, among whom the changing of the needle varied between seven and 50 days.None of the cases presented complications due to the needle's remaining in place.It is concluded that the needle can be kept in for a mean of 28 days. 25owever, no other study was identified validating this result.Hence, it is suggested that the needle should be changed every seven days.
Upon being questioned regarding the identification of complications, such as infection in the implanted port, and the clinical action to be taken, one nurse stated that he did not know how to identify these or what clinical action to take.The other nurses reported that they would request a medical assessment after detecting inflammatory signs in the region of the catheter.
Identification is through the inflammatory signs which the tissue presents, if there was secretion… the patient has hyperemia.In relation to what to do, it is a medical procedure, to remove the catheter (I14).
The first clinical action, in the event of suspicion of infection of the implanted port, is to undertake a blood culture from the peripheral access and the central access, so as to identify the site of infection and the microorganism involved, guiding the choice of the antibiotic to be used or the removal of the catheter. 8,35,37t should be emphasized that the removal of the catheter is recommended in the event of the persistence of the infection following antibiotic therapy or in the case of detection of infection by Staphylococcus aureus or Candida spp. 15,37he use of the catheter after its implantation was also a doubt present in some accounts.
I have doubts about the puncture, whether you can puncture the device as soon as it is implanted, or whether you have to wait a little [...] (I8).
[...] I have doubts about the right time to puncture following the implantation (I24).
Pain is the only limiting factor for puncturing the device soon after its implantation.If the patient is feeling pain which makes the puncture impossible, one must wait for 24 to 72 hours to use it.Should the immediate use of the device be necessary, it must be punctured in the operating room. 2

The need for standardization of clinical skills
Although there was no question specifically on the standardization of routines, the need for professional training and for standardization of clinical skills was identified in the nurses' accounts.
[...] For doing the puncture, I don't have any doubts, but the only thing I know about the catheter is to puncture because we -here -have never had any training on the management of this device.(I20).
[...] Actually, we have never had any training on how to proceed with this type of device , we learnt it as we went along, in practice [...] (I12).
I have doubts, because I'm not a specialist in the area, I don't like the area much, and here, as we work in the health clinic, we end up having to deal with the device, but we don't receive any training here, and didn't at college either [...] (I16).
It is believed that the nurses' theoreticalpractical knowledge in relation to the handling of catheters in general is of extreme importance for qualified nursing care and the prevention of com-plications.Academics indicate that this knowledge should be acquired prior to finishing the undergraduate nursing course. 20,45Currently, in Brazil, the teaching of oncology and of the puncture technique with this device is not a common practice in the undergraduate courses, which can hinder the clinical practice of professionals integrated into this setting, without prior professional training. 46he standardization of clinical skills, based on evidence, through manuals and protocols, is one way of ensuring a qualified clinical practice, as it allows the professionals to settle doubts and guides the undertaking of their actions, offering the professionals greater safety during the undertaking of the procedure. 28,43hus, the development and validation of standard operational procedures are of extreme importance for the improvement of the nursing care, as they direct how to undertake the procedure and offer the nurses greater security.

FINAL CONSIDERATIONS
From the nurses' accounts it was noted that their knowledge regarding the implanted port is inadequate.This fact is worrying, given that the place where this research was undertaken is a center of excellence in oncology and assists innumerable patients fitted with this device.
The systematized review of the literature indicated a large number of studies classified as having a low level of evidence, which hinders the transposition of findings to clinical practice.It is believed, however, that these results must create -both in the academic community and among the nurses working in the area -interest in undertaking studies whose designs can produce strong evidence, with a view to strengthening the nursing care.
It is concluded, therefore, that there is an urgent need for professional training; and it is hoped that the results presented here may contribute to settling the doubts indicated, affording greater security in the handling of the device and preventing the appearance of complications -which will ensure qualified nursing care and, consequently, better quality of life for the patients attended.