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Running head: TEACHING PROJECT

Teaching Project: Education Related to Accessing and Using Ports in the Emergency Department

Corinne H. Flora

Old Dominion University

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TEACHING PROJECT

Teaching Project: Education Related to Accessing and Using Ports in the Emergency Department

In the Emergency Department at Sentara Rockingham Memorial Hospital (SRMH) where

I work full time as a registered nurse (RN), we occasionally have to access, draw blood from and

administer medications and fluids via a port. Each RN spends their workweek divided between

triage, acute care, focused care, fast track and emergent psychiatric care. Currently, new

graduate nurses are assigned a master preceptor who mentors 3 orientees during their shifts.

Because the of the multiple areas in which to orient each RN may only work in each section

once every week or two. It is simply “luck of the draw” how frequently the new graduate RN is

assigned to care for patients with a port which requires accessing; then each port patient only

provides a 1 in 3 opportunity due to the master preceptor approach. This makes for an

unpredictable distribution of opportunity for new graduate RN’s to obtain competency and

confidence at accessing ports during the orientation process; I’ve chosen to address this

inconsistency as the focus of my teaching project.

A port should provide easy access to the patient’s venous circulation and is accessed by

inserting a needle into the bubble-like portal that is surgically implanted underneath the skin

(Hamstra, 2018). From the silicone portal there is a single lumen flexible catheter that is

threaded into a central vein (Hamstra, 2018). The large majority of ports seen at our facility are

power ports. On average, the self-sealing silicone can be punctured 2,000 times before it loses

its integrity and should last several years for the patient to receive intravenous treatment

(Hamtra, 2018). Due to the fact that this vascular access device is inserted into a central vein,

sterility is of utmost importance to prevent this device from being a mode for bacteria to enter

the blood stream (Hamstra, 2018). The Emergency Nurses Association takes a stance on
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infection control, stating that the Emergency nurse provides a pivotal role in infection

prevention (ENA, 2017). The ENA’s standard of practice related to infection control states that

ED RNs will: advocate for immunizations, adhere to appropriate hand hygiene, use indicated

PPE, clean equipment with the appropriate disinfecting solution, participate in antimicrobial

stewardship, use appropriate isolation precautions, assess patient’s potential for exposure,

participate in nurse driven removal of urinary catheters, appropriately dispose of soiled

materials and educate patient on infection prevention (ENA, 2017). Central line associated

blood stream infections (CLABSIs) are one of the top 3 hospital acquired infections, therefore

accessing ports with appropriate sterility and maintaining a sterile line while using the port are

important skills for the ED RN to possess and to be proficient at (Beardsley, Bogue, Nitu & Cox,

2014). Improving the consistency in our current training process is imperative.

Assessment of Learner

The target audience of this teaching session was be new graduate nurses orienting to

the emergency department at SRMH and recent new graduate RNs whom are released off of

orientation but elect to learn more about ports. This will include both male and female RNs

between the ages of 22-26-year olds.

In order to assess the need for this education department wide I sent out an electronic

survey to all of the new graduate RNs who had oriented to our department within the last 12

months, refer to appendix A for a sample of this survey. I learned that the majority of these

RNs did not feel that they had adequate exposure to accessing ports while on orientation.

Nearly none of the nurses surveyed had completed and returned the current sign off sheet to

the ED educator. Almost all of the nurses surveyed were interested in more consistent port
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training and practice and a large majority of these nurses felt that hands on learning was the

best modality to learn new skills. I also informally spoke with nurses who had oriented to the

ED more than 5 years ago; learning that the orientation process used to include more

consistent training on accessing ports. Then the ED policy changed to only authorize unit

coordinators to access ports, this was trialed and determined that it was not feasible to pull the

unit coordinator into a room to access each and every port that entered the department.

When all ED nurses were allowed to access ports again the consistent training and practice was

never re-established. It seems that those RNs who oriented 5 years or more ago were much

more competent and confident at accessing ports.

Development of Teaching Plan

The purpose of this teaching session was to establish more consistency in the

orientation process for new graduate nurses when considering competency and confidence

accessing ports and administering medications via a port. The goal of this teaching plan was

that new graduate RNs would obtain competency at accessing, using and de-accessing ports.

Following a 15-minute verbal presentation, 5-minute explanation of a port kit’s contents and

10-minute demonstration and return demonstration of accessing a port on a mannequin the

following objectives were set: Knowledge objective, the new graduate RN will be able to

accurately identify the equipment and tools necessary to access a port; Psychomotor objective,

the new graduate RN will be able to successfully demonstrate the ability to access a port with

appropriate sterile technique; and affective objective was for the new graduate RN to share any

apprehension surrounding accessing, using and deaccessing ports in the ED with their fellow

new graduate RNs.

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The content of the 15-minute verbal presentation guided by a power point consisted

first of defining a port and differentiating power ports from other ports. Secondly, how to

identify the power port was reviewed and the importance of verifying by at least 3 means was

stressed. Next, the basics of aseptic technique when accessing a port was reviewed. Then, how

to appropriately chart accessing and deaccessing ports in our electronic charting system, Epic,

was discussed. Also, the correct order for a heparin lock was reviewed which we place

independently as a protocol order in the ED. Next, the group was educated on possible reasons

for difficult access or inability to obtain labs such as spontaneous migration of the catheter tip

into the ipsilateral jugular vein (Houston & Yan, 2016). Then, possible solutions for these

problems were considered such as repositioning the patient, having them cough, etc. Lastly,

the importance of CLABSI prevention was considered and our CLABSI prevention bundle was

reviewed. It has been verified that improved education increases compliance with CLABSI-

prevention bundle to 85% and when the bundle is appropriately used, associated infections

were negligible (Beardsley, et. al., 2014). Please refer to appendix B to view the power point

content in more depth. The group then took 5 minutes to review together and physically

explore the contents of a port accessing kit and any additional materials that are needed to

access a port in the ED. The group was then given an opportunity to watch me demonstrate

accessing a port on a mannequin while talking through the steps and rationale as well as the

opportunity to practice themselves. After practice and remediation, the new graduate RNs

were asked one by one to demonstrate accessing a port on the mannequin and a skills check off

form was signed for each of them, reference appendix C to see the skills check off.

Implementation of Teaching Plan

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I sent out an email to all RNs in the ED with a date, time and location in which the

teaching would take place. A small group of nurses participated and the 3 new graduate RNs

were required to attend and complete a skill check off sheet at the end of the teaching session.

The self-efficacy theory is based on “a person’s expectations relative to a specific course of

action […] it deals with the belief that one is competent and capable of accomplishing a specific

behavior” (Bastable, 2019). Since the main goal of this teaching session is to obtain

competency in a task this learning theory is the most relevant.

Evaluation

The most effective portion of this teaching session was the demonstration and return

demonstration, especially for the subject of this particular teaching session because “the

learner establishes competency at performing a skill” (Bastable, 2019). After the teaching

session each of the 3 new graduate RNs completed, with 100% accuracy, a skills check off sheet;

refer to appendix C to review the skills check off sheet which evaluated the psychomotor

objective. The affective objective was evaluated by open discussion and the cognitive objective

was evaluated by each new graduate RN verbally listing the equipment needed to access a port.

The overall effectiveness of this instruction was good, 100% of the RNs were successful at listing

the materials needed to access a port, demonstrating the ability to access a port with

appropriate sterile technique and expressed improved confidence during the discussion at the

end of the teaching session. An obstacle to filming the teaching session was the shape of the

room in which the teaching occurred, there was not way to film myself as the instructor, the

power point material and the students. The students were also aware of the fact that they

were being videotaped which made them feel more self-conscious of asking questions, much
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more open dialogue occurred after the videotaping ended and was one of the reasons that the

demonstration and return demonstration did not occur on camera.

Summary

Effectiveness could have been improved if this presentation was completed at a

monthly staff meeting or annual skills day to reach more of the RNs in the department. The 2

week window for this project did not coincide with either of these options however.  I believe

this presentation and education will be presented during the next annual skills day and included

annually if the reception from staff continues to be positive.

This experience has given me empathy for all nurse educators and course instructors.  It

is so incredibly nerve wracking to get up in front of everyone and present on these topics.  It

has increased the respect I have for the time and effort that they put in to ensuring we as floor

nurses have the knowledge and resources to safely and effectively care for our patients while

also protecting our licenses.  This was definitely a learning opportunity for me and pushed me

out of my comfort zone.  I hope each time I am asked to complete any type of teaching I feel

less nervous and more confident and comfortable doing it!

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References

Bastable, S. B. (2019). Nurse as educator: Principles of teaching and learning for nursing

practice(5th ed.). Syracuse, NY: Jones & Bartlett Learning.

Beardsley, A., Bogue, T., Nitu, M., & Cox, E. (2014). High compliance with a CLABSI-prevention

bundle is associated with a zero rate of CLABSI. Critical Care Medicine,42(12), 785th ser.,

1549. doi:10.1097/01.ccm.0000458282.84462.12

ENA. (2017). Infection Prevention and Control. Retrieved August 2, 2019, from

https://www.ena.org/docs/default-source/resource-library/practice-resources/infographics/chain-

of-infection-infographic.pdf?sfvrsn=53fa8c3c_12

Hamstra, B. (2018, March 12). Port-A-Cath: How to access the port. Retrieved from

https://nurse.org/articles/what-is-a-port-a-cath/

Houston, B. L., & Yan, M. (2016). Spontaneous migration of an implanted central venous access

device into the ipsilateral jugular vein. Canadian Medical Association Journal,188(10), 752.

doi:https://dx-doi-org.proxy.lib.odu.edu/10.1503/cmaj.150872

Honor Code:

I pledge to support the Honor System of Old Dominion University. I will refrain from any form of

academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member

of the academic community it is my responsibility to turn in all suspected violations of the

Honor Code. I will report to a hearing if summoned

Signature Corinne H. Flora

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Appendix A
Nursing 402: Educational Needs Assessment Survey
How many times were you able to access a port while on orientation?
o 0-2 times
o 3-5 times
o 6 or more times

I feel as though the orientation process enabled me to feel confident and competent in my port
accessing skills.
o Strongly disagree
o Disagree
o Neutral
o Agree
o Strongly agree

My sign off sheet for accessing ports has been completed and turned back into my educator.
o True
o False

When administering medications through a port I am familiar with which medications need a
micron filter and which do not.
o Strongly agree
o Agree
o Neutral
o Disagree
o Strongly disagree

If false, I know where to look in order to verify if a micron filter is necessary or not.
o True
o False

I feel that more practice at accessing ports would have been beneficial during my orientation.
o Strongly agree
o Agree
o Neutral
o Disagree
o Strongly disagree

What time of day for training works best for your schedule?
o Morning (7am-11am)
o Afternoon (12pm-4pm)
o Evening (4pm-8pm)
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o Overnight (after 8pm)

What modality of learning is most effective for you in learning a new skill?
o Lecture/Powerpoint
o Computer based training
o Hands on learning/practice
o Observing others completing the task

How interested would you be in participating in more consistent training and practice at
accessing ports?
o Very interest
o Interested
o Neutral
o Uninterested
o Very uninterested

Appendix B
Powerpoint

Appendix C
IMPLANTED PORT SILLS CHECK OFF
Dat
Name Preceptor
e

Please rate your level of familiarity or experience with each procedure/skill/role responsibility with the following code:
0: no familiarity with task. 2: clinical practice with supervision or performed competently in past; need review
1: class or learning lab experience only 3: performed competently without supervision at least 1-2 times

Self
ACCESSING THE IMPLANTED PORT Evaluation
Met Not Met Preceptor

1. Explains procedure to patient

2. Washes hands and obtains necessary equipment
3. Chooses appropriate size and length noncoring needle for therapy planned
4. Applies gloves and mask
5. Removes dressing if appropriate
6. Palpates port and locates center of septum to be accessed
7. Observes site for edema, erythema, tenderness, condition of the catheter tunnel or swelling of ipsilateral
chest or neck veins or extremity
8. Discards used gloves and reapplies new gloves; applies topical anesthetic cream if ordered
9. Cleanses the area over the septum with chloroprep using vigorous strokes for 30 seconds
10. Grasps the edges of the portal body firmly through the skin to stabilize, pushing the noncoring needle
firmly through the skin and diaphragm, stopping when the bottom of the reservoir is reached
11. Flushes saline into port and checks for blood return
12. Applies dressing per institutional policy
13. Attaches IV tubing directly to catheter hub with clave if continuous infusion
14. Attaches injection cap if intermittent infusion is planned
15. If continuous infusion is planned, verbalizes that noncoring needle needs to be changed every 7days
FLUSHING AN IMPLANTED PORT
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1. Explains procedure to patient

2. Washes hands and assembles necessary equipment
3. If port is not accessed, accesses per above procedure
4. Flushes catheter with 10 – 20 ml normal saline for valved catheters and 5 ml 100 units/ml heparin lock
flush for open-ended catheters
5. If port does not need to be used, deaccesses per procedure below
6. Verbalizes that ports are accessed and flushed every 4 to 6 weeks when not in use
DEACCESSING AN IMPLANTED PORT
1. Explains procedure to patient
2. Washes hands and assembles necessary equipment
3. Applies gloves, mask and removes dressing if present
4. Discards used gloves and reapplies new gloves
5. While instilling the final 1 ml of flushing solution, maintains pressure on the syringe plunger while
clamping the tubing
6. Stabilizing port through skin with one hand, grasps noncoring needle wings or hub with the other hand
7. Pulls needle from the port septum, pushing down on the port edges to prevent tugging the port upward
8. Applies pressure over the needle exit site, then applies adhesive bandage if needed
BLOOD DRAWING FROM AN IMPLANTED PORT
1. Explains procedure to patient
2. Washes hands and assembles necessary equipment
3. Accesses port per above procedure if not accessed
4. Removes at least 5 ml of blood and discards. Exception: For blood cultures remove the clave, if
present, DO NOT DISCARD ANY BLOOD
5. Removes necessary blood for testing using additional syringes or Vacutainer system
6. Flushes catheter per above procedure and either continues infusion, recaps, or deaccesses
DOCUMENTATION / PATIENT EDUCATION
1. Documents all procedures, assessments, and patient response
2. Teaches patient and/or significant others implanted port care and observation