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  • Truth and Consequences of Intravenous Drug Addiction

    Contains 3 Component(s), 1 credit offered Recorded On: 05/08/2017

    After the session, attendees will recognize comorbidities associated with ­intravenous drug abuse and interventions to mitigate the impact in health care.

    Despite efforts to increase awareness of the serious, even deadly, consequences of intravenous drug use, the numbers of those addicted continue to increase at an alarming rate. This session explores medical consequences associated with intravenous drug addiction, as well as its impact on society and the health care system.

    Learning Objectives

    After the session, attendees will recognize comorbidities associated with ­intravenous drug abuse and interventions to mitigate the impact in health care.

    Gavin Bart, MD, PhD

    Director Division of Addiction Medicine

    Hennepin County Medical Center

    CRNI® RUs: 2                                                                       
    This entire program has been approved for 2 CRNI® recertification units and meets the INS Meeting criteria.                                                                
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive CRNI® recertification units through this online program.

    Expiration date for receipt of contact hours: May 8, 2020

    Contact Hours: 1                                                              
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive contact hours through this online program.

    Expiration date for receipt of contact hours: May 8, 2020

  • IgNS Daybreak Symposium: Incorporating Evidence-based Best Practices Into Care of the Ig Patient

    Contains 2 Component(s) Recorded On: 05/08/2017

    After the session, attendees will understand the importance of patient ­assessments specific to Ig therapy; be able to list risk factors of Ig therapy and describe management of and emergency preparedness; be able to discuss Ig dosing, product differences, and administration practices, and how each ­impacts patient outcomes; and understand the importance of the ­procurement and reimbursement landscape, including the 21st Century Cures Act (HR 6) and the impact to the patient’s treatment plan and outcomes.

    The Ig nurse’s role is of critical importance in ensuring optimal patient outcomes are actualized for patients requiring immunoglobulin therapy. The use of evidence-based standards of practice, such as the IgNS Therapy Standards of Practice, is increasingly important in everyday practice across the care continuum. This session will provide information and strategies for the Ig nurse to become equipped to assess patients and develop a treatment plan, educate the patients on their disease and treatment options, and ensure they have optimal clinical outcomes and quality of care. When necessary, the Ig nurse needs to be an advocate for the patient, assisting him or her in areas of reimbursement, medical care, support services, etc. Today’s health care landscape provides unique challenges and dynamics, and a discussion on how this impacts Ig care will conclude the presentation.

    Learning Objectives

    After the session, attendees will understand the importance of patient ­assessments specific to Ig therapy; be able to list risk factors of Ig therapy and describe management of and emergency preparedness; be able to discuss Ig dosing, product differences, and administration practices, and how each ­impacts patient outcomes; and understand the importance of the ­procurement and reimbursement landscape, including the 21st Century Cures Act (HR 6) and the impact to the patient’s treatment plan and outcomes.

    CRNI Recert Units: 2                                                                    
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive CRNI® recertification units through this online program.

    Jane Kirmse, MS, APRN, CNS, IgCN

    IgNS Standards of Practice and Education Development Committee Member

    Mayo Clinic

    Stacey Ness, RPh, CSP, MSCS, AAHIVP

    IgNS Standards of Practice and Education Development Committee Member

    Managed Health Care Associates, Inc.

    Amy Clarke, RN, IgCN

    Director of Nursing Clinical Program Services

    Amy Clarke, RN, IgCN, is the director of nursing clinical program services for Diplomat Specialty Infusion Group. Involved in specialty and home infusion services since 1994, she has performed more than 2,000 intravenous and subcutaneous infusions. Ms. Clarke has delivered numerous presentations on immunoglobulin administration, including continuing education sessions for the National Home Infusion Association and the Immunoglobulin Nursing Society (IgNS). She is the immediate past president of IgNS. 

  • Qualification or Certification?

    Contains 3 Component(s), 1 credit offered Recorded On: 05/08/2017

    After the session, attendees will be able to identify the difference between ­qualification and certification and the value of each.

    Employers are fighting for employees and looking for ways to promote their organization. One way to promote quality for an organization is to recognize their nurses’ skills. Nurses are competing for their dream job and need to promote their skill sets to be considered. Both situations result in nurses ­highlighting specific special skill sets to others. Terms often used for this highlighted focus is qualification or certification. While these terms are frequently used interchangeably, they mean very different things. This session will delineate between qualification and certification and discuss the value each brings to the nurse when competing for positions.

    Learning Objectives

    After the session, attendees will be able to identify the difference between ­qualification and certification and the value of each.

    Laurie Ellefson, BSN, RN, CWOCN, CFCN

    Faculty, Western Technical College

    CRNI® RUs: 2                                                                       
    This entire program has been approved for 2 CRNI® recertification units and meets the INS Meeting criteria.                                                               
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive CRNI® recertification units through this online program.

    Contact Hours: 1                                                             
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive contact hours through this online program.

    Expiration date for receipt of contact hours: May 8, 2020

  • CDC Guidelines and Infusion Therapy Standards of Practice: Defining the Difference

    Contains 3 Component(s), 2 credits offered Recorded On: 05/07/2017

    After the session, attendees will be able to apply the 2016 Infusion Therapy ­Standards of Practice and the 2011 CDC BSI guidelines, and analyze the differences between the two.

    INS’ 2016 Infusion Therapy Standards of Practice provides the framework that guides clinical ­practice. The CDC bloodstream infection (BSI) guidelines were created to produce evidence-based recommendations to prevent ­catheter-related bloodstream infections. In this session, a panel of ­experts will compare and contrast the differences between the two sets of standards and guidelines.

    Learning Objectives

    After the session, attendees will be able to apply the 2016 Infusion Therapy ­Standards of Practice and the 2011 CDC BSI guidelines, and analyze the differences between  the two.

    Mary Alexander, MA, RN, CRNI®, CAE, FAAN

    Chief Executive Officer, INS

    Mary Alexander, MA, RN, CRNI®, CAE, FAAN, has served as CEO of the Infusion Nurses Society (INS) and Infusion Nurses Certification Corporation since 1997. She is also editor-in-chief of the Journal of Infusion Nursing, the Core Curriculum for Infusion Nursing, and INS’ textbook, Infusion Nursing: An Evidence-Based Approach. In addition, Mary represented INS on the panel that revised the Centers for Disease Control and Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections in 2011. She speaks globally on topics such as the benefits of the specialty practice of infusion nursing, the development of standards of practice, and improving patient safety.

    Mary Hagle, PhD, RN-BC, FAAN

    Nurse Scientist

    Mary Hagle, PhD, RN-BC, FAAN, has more than 30 years of clinical experience and works a consultant for evidence-based practice, clinically focused research, and infusion therapy. She has primarily practiced as an oncology clinical nurse specialist and researcher in a variety of settings in the midwestern United States. Mary is currently is a research scientist at the Milwaukee VA medical center where she facilitates and conducts research, translates best evidence into practice, and supervises patient safety and post-doctoral fellows. Mary is a co-author of the Infusion Nurses Society’s Standards of Practice for Infusion Therapy, 2011 and 2016 editions. She is also an author of several book chapters on evidence-based practice and infusion therapy, as well as editor of the latest edition of Plumer’s Principles and Practice of Infusion Therapy.  

      

    Barb Nickel, APRN-CNS, NP-C, CRNI®, CCRN

    Clinical Nurse Specialist

    Barb Nickel, APRN-CNS, NP-C, CRNI®, CCRN, has extensive experience in the application of evidence-based guidelines relevant to infusion therapy practice. As a clinical nurse specialist, she is actively involved in infusion-related process improvement at the facility and statewide level, regarding topics such as CLABSI prevention, new graduate training, and smart pump drug library standardization. From 2011 to 2016, Ms. Nickel was a member, then chair/lead nurse-planner for INS’ National Council on Education. She was also a reviewer for both the 2011 and the 2016 Infusion Nursing Standards of Practice.

    Mark Rupp, MD

    Professor

    University of Nebraska Medical Center


    CRNI® RUs: 4                                                                      
    This entire program has been approved for 4 CRNI® recertification units and meets the INS Meeting criteria.                                                                    
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive CRNI® recertification units through this online program.

    Contact Hours: 2                                                             
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive contact hours through this online program.

    Expiration date for receipt of contact hours: May 8, 2020

  • ASPEN Guidelines for Parenteral Nutrition: An Update

    Contains 2 Component(s), 1 credit offered Recorded On: 05/06/2017

    Infusion nurses give parenteral nutrition in every practice setting. Since 1975, the American Society for Parenteral and Enteral Nutrition (ASPEN) has led in the science and practice of clinical nutrition. ASPEN guidelines assist practitioners in providing best practices in specific circumstances, such as neonates at risk for necrotizing enterocolitis, pediatric patients with intestinal failure, and adult hyperglycemia or obesity. This session will review current ASPEN guidelines for the provision and ­assessment of nutritional therapy.

    Infusion nurses give parenteral nutrition in every practice setting. Since 1975, the American Society for Parenteral and Enteral Nutrition (ASPEN) has led in the science and practice of clinical nutrition. ASPEN guidelines assist  practitioners in providing best practices in specific circumstances, such as neonates at risk for necrotizing enterocolitis, pediatric patients with intestinal failure, and adult hyperglycemia or obesity. This session will review current ASPEN guidelines for the provision and ­assessment of nutritional therapy.

    Learning Objectives

    After the session, attendees will be able to identify a goal of ­parenteral ­nutrition therapy and an assessment tool for nutritional support.

    Contact Hours: 1                                                              
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive contact hours through this online program.

    CRNI Recert Units: 2                                                                     
    *Note: Participants who attended the live version of this program at INS 2017 in Minneapolis, MN are not eligible to receive CRNI® recertification units through this online program.

    Gordan Sacks, Pharm.D., BCNSP

    Professor and Department Head

    Auburn University Harrison School of Pharmacy

  • Pediatric Hemophilia Care and Treatment

    Contains 3 Component(s), 1 credit offered Recorded On: 01/24/2017

    Hemophilia is a congenital blood disorder that prevents the formation of fibrin, which allows for sustained clotting. People with hemophilia are missing or have reduced amounts of this important clotting factor, so bleeding continues until they receive treatment. Hemophilia is not a disorder that is often seen in a hospital setting, and because of the variety of factor deficits and classifications, the care of each patient differs. The care and nursing management of a pediatric patient with hemophilia is often intimidating for the family, as well as for the professional care giver.

    Hemophilia is a congenital blood disorder that prevents the formation of fibrin, which allows for sustained clotting. People with hemophilia are missing or have reduced amounts of this important clotting factor, so bleeding continues until they receive treatment.

    Hemophilia is not a disorder that is often seen in a hospital setting, and because of the variety of factor deficits and classifications, the care of each patient differs. The care and nursing management of a pediatric patient with hemophilia is often intimidating for the family, as well as for the professional care giver.

    Catherine J. Taggart, RN, CRNI®, IgCN, MBA

    President and CEO, Agility Infusion Services

    Catherine has worked within the Baxter/Baxalta organization as a Medical Affairs Nurse Specialist and as home infusion clinician for more than 25 years. She has extensive infusion knowledge in a variety of clinical settings employing cutting edge therapies and methods. She has participated in several clinical study trials targeting positive patient outcomes, bringing the results to publication. She is a seasoned infusion professional and has great passion for the patient.

    CRNI® RUs: This session has been approved for 1 CRNI® recertification unit and meets the non INS Meeting criteria.

    Contact Hours: This session has been approved for 1 contact hour

    Expiration date for receipt of contact hours: January 24, 2020

  • Virtual Conference: The Spectrum of Sepsis

    Contains 3 Component(s), 5 credits offered

    Early recognition and treatment of sepsis is critical to surviving this life-threatening syndrome. Each year in the United States, sepsis claims more lives than breast cancer, prostate cancer, and HIV combined. Those who survive face chronic physical, cognitive, and psychological challenges as a result of the damage caused by the body’s response to the simplest infections. The sessions presented provide an opportunity to learn about the battle against this life-threatening condition—from diagnosis to discharge and beyond. This entire program has been approved for 5 contact hours and 10 CRNI® RUs and meets the INS Meeting criteria.

    The Spectrum of Sepsis

    Early recognition and treatment of sepsis is critical to surviving this life-threatening syndrome. Each year in the United States, sepsis claims more lives than breast cancer, prostate cancer, and HIV combined. Those who survive face chronic physical, cognitive, and psychological challenges as a result of the damage caused by the body's response to the simplest infections. The sessions presented provide an opportunity to learn about the battle against this life-threatening condition—from diagnosis to discharge and beyond.

    The Virtual Conference is supported by a continuing nursing education grant from:

    B | Braun


    More Than an Infection

    9:00 - 10:00 AM EST
    • Primary focus in public health
    • The immune system and altered hemodynamics
    • Key components in sepsis treatment

    Sepsis 3.0: Revised Sepsis Guidelines and the Impact on Practice

    10:00 - 11:00 AM EST
    • Early recognition of sepsis and prompt intervention
    • Current definitions of systemic inflammatory response syndrome (SIRS)
    • Prevention and management of catheter-related bloodstream infections

    How EMRs Improve Sepsis Outcomes

    11:00 AM - 12:00 PM EST
    • Integrate technology, data and analytics to clinical practice
    • "Track and trigger" systems, and early warning system alerts
    • Center for Medicare and Medicaid Services (CMS) classified sepsis as a core measure

    Virtual Exhibit Hall

    12:00 - 1:30 PM EST
    • View latest innovations in the infusion field
    • Extend your education and connect with industry leaders
    • Enjoy this exhibit hall experience right from you PC

    First Contact: "Nurses Know Sepsis"

    1:30 - 2:30 PM EST
    • Third leading cause of death in the U.S
    • Nurse are front line in advocating for patients
    • Communicate early sepsis interventions

    Carry On: Life Beyond Sepsis

    2:30 - 3:30 PM EST
    • Case study on unmet medical needs
    • Post sepsis Syndrome (PSS) survival
    • Sepsis survivor sharing his journey

    Virtual Exhibit Hall

    3:30 - 5:30 PM EST


    More Than an Infection

    Thomas Ahrens, PhD, RN, FAAN
    9:00 - 10:00 AM EST

    In this program, recent improvements in the understanding and treatment of sepsis will be presented. A review of past therapies and the recent introduction of newer treatments for sepsis will be discussed. Updates from the Surviving Sepsis Campaign will be presented, as will recent studies that address the management of sepsis. Controversies in the treatment and identification of sepsis will be reviewed, as well as case studies using novel treatments in the care of the patient with sepsis. The emphasis on early identification and how to implement protocols in hospitals, from the emergency department and floor to the intensive care unit will be highlighted. The program emphasizes innovative learning strategies in an attempt to help the learner retain more information as well as make the program a more enjoyable event.

    Session Learning Objectives
    1. Identify the reasons sepsis is one of the most important public health issues.
    2. Understand the role of inflammation, endothelial cell dysfunction, and altered hemodynamics in severe sepsis.
    3. Identification of the role of the nurse in the identification and assessment of the patient in severe sepsis.
    4. Discuss how use of lactate, ScvO2, and potentially StO2 can aid in evaluation of the severity of sepsis.
    5. Discuss the key components of sepsis treatment.

    Sepsis 3.0: Revised Sepsis Guidelines and the Impact on Practice

    Michael Taylor, MD
    10:00 - 11:00 AM EST

    Sepsis is the most important under-recognized medical problem in the United States. It affects well over one million people each year and continues to carry a high mortality. Sepsis survivors remain at significant risk for additional morbidity and mortality. Early recognition and prompt intervention are the cornerstones of treatment for this time-sensitive problem. However, there is no definitive test for sepsis, and screening of patients is a formidable challenge. The difficulties in identifying the septic patient has led many to question the current definitions. In this session, we will review the current definitions of systemic inflammatory response syndrome, severe sepsis, and septic shock, and then consider the suggested changes proposed in a special communication published in the Journal of the American Medical Association earlier this year. We will also examine key elements of the Surviving Sepsis Guidelines with specific attention to the prevention and management of catheter-related bloodstream infections.

    Session Learning Objectives
    1. Recall current definition of SIRS.
    2. Incoporate sepsis guidlines into practice.

    How EMRs Improve Sepsis Outcomes

    Fiona Winterbottom, DNP, MSN, APRN, ACNS- BC, CCRN
    11:00 - 12:00 EST

    Efforts to raise awareness and recognition of sepsis is in the forefront of health care providers. Use of “track-and-trigger" systems, such as electronic medical records (EMRs) and early warning systems, have been identified as one mechanism to leverage technology in early identification and treatment of sepsis. Infusion nurses play an important role in understanding best practice alerts and the correlation to guiding antibiotic administration for prompt sepsis treatment and positive patient outcomes.

    Session Learning Objectives
    1. Outline the need to integrate technology, data, and analytics to daily clinical practice.
    2. Provide an example of an electronic workflow that was designed in partnership with the front line clinical interdisciplinary team.

    Virtual Exhibit Hall
    12:00 - 1:30 PM EST


    First Contact: “Nurses Know Sepsis"

    Laura Messineo, MHA, BS, RN
    1:30 - 2:30 PM EST

    Sepsis is a toxic response to infection that kills more than a quarter million Americans each year--more than breast, lung and prostate cancer combined. In fact, sepsis is the third-leading cause of death in the United States. Twenty percent of sepsis cases are hospital-acquired. Nurses are the front line clinicians suspecting sepsis and advocating for their patients. It is vital for nurses to know the early warning signs of sepsis and to implement evidence-based treatments to reduce sepsis complications and mortality. Sepsis is a medical emergency that requires prompt identification and treatment so that more patients survive.

    Session Learning Objectives
    1. Recognize the early warning signs of sepsis.
    2. Communicate the early sepsis interventions needed for patients.

    Carry On: Life Beyond Sepsis

    Carl Flatley, DDS, MD and Chris Kuchnicki
    2:30 - 3:30 PM EST

    Carl Flatley, MD, will discuss how nurses are the key to decreasing sepsis mortality and morbidity, with infusion nurses a critical component in recognition of post-sepsis syndrome. Though mountains have been moved in recognizing post-sepsis syndrome, more than 3.5 million people continue to perish or suffer from organ dysfunctions, amputations, and cognitive problems. Sepsis is in fact the number 1 unmet medical need in the United States. This presentation will include several case studies: one of the untimely death of a young woman and the second a sepsis survivor sharing his journey. Having survived a life-altering septic event, attendees will hear from a survivor, Chris Kuchnicki, as he shares his journey and life experiences. Post-sepsis syndrome is becoming widely recognized in the medical community, with nurses playing a role in advocating and preparing sepsis patients for discharge home and life beyond the diagnosis.

    Session Learning Objectives
    1. Recognize impact of post sepsis syndrome on surviors
    2. Recall nurses role in post sepsis education

    Virtual Exhibit Hall
    3:30 - 5:30 PM EST

    Contact Hours/CE Credit

    This entire program has been approved for 5 contact hours. Expiration date for receipt of contact hours: November 4, 2019

    CRNI Recertification Units

    This entire program has been approved for 10 CRNI® recertification unit and meets the INS Meeting criteria.

    *Note: Participants who attend the live version of this program at the 2016 National Academy in Cincinnati, OH are not eligible to receive contact hours or CRNI® recertification units through this online program.

    Thomas Ahrens, PhD, RN, FAAN

    Barnes Jewish

    Tom Ahrens, PhD, RN, FAAN, is a research scientist at Barnes Jewish Hospital. He is actively involved in sepsis education and technology application, particularly in terms of hemodynamic monitoring and capnography. His book, "Essentials of Oxygenation," was an American Journal of Nursing Book of the Year. In 2004, Tom was inducted into the American Academy of Nursing. From 2006 to 2008 he was the American Association of Critical-Care Nurses' representative to the Surviving Sepsis Campaign.

    Michael Taylor, MD

    Fairview Hospital

    On completing a general surgery residency and critical care fellowship, Dr. Taylor entered private practice as a trauma surgeon and intensivist, After 7 years, he joined the Cleveland Clinic. In his roles as intensivist as well as board member of the Sepsis Alliance, he frequently helps train teams in care of the septic patient.

    Fiona Winterbottom, DNP, MSN, APRN, ACNS- BC, CCRN

    Ochsner

    Dr. Winterbottom has worked as a nurse for 25 years with most of that time in critical care. She has worked in two countries and seven states in various types of intensive care units. She has been clinical nurse specialist since 2007, and has presented widely on sepsis, resuscitation, interdisciplinary teamwork, and advanced practice nursing.

    Laura Messineo, MHA, BS, RN

    Presence Health

    Laura Messineo has extensive clinical experience managing professionals in critical-care environments and has spent a decade educating clinicians on the early-warning signs of sepsis. Laura is a national speaker, a member of a number of professional organizations, and a Sepsis Alliance board member. One of her passions is raising community awareness of sepsis, so each year she spearheads the Illinois Sepsis Challenge 5K to increase sepsis awareness.

    Carl Flatley, DDS, MD

    Sepsis Alliance

    A retired physician and dentist, Dr. Flatley lost a healthy daughter to septic shock in 2002. He founded the Sepsis Alliance and has been involved in the issue of sepsis globally at all levels.

    Chris Kuchnicki

    Flight Attendant

    In 2014, Flight Attendant Chris Kuchnicki's life changed forever after being hospitalized for Asthma. A staph infection he contracted while hospitalized caused "the perfect storm" of events after he was released. Chris talks about how Sepsis changed his life, career, and what living with Post Sepsis Syndrome has been like. He uses his free time help to spread awareness to others.

  • Report Card on the Handling of Hazardous Drugs: Is Your Facility Ready for USP Chapter <800>?

    Contains 1 Component(s)

    ​Is your facility ready for the new chemotherapy handling requirements? A survey sponsored by BD shows that pharmacists and nurses may not be as ready as we think…

    Is your facility ready for the new chemotherapy handling requirements? A survey sponsored by BD shows that pharmacists and nurses may not be as ready as we think…

    The recently published United States Pharmacopeia (USP) Chapter <800> establishes requirements for the safe handling of chemotherapy and other hazardous drugs (HDs) in healthcare settings. However, research indicates a lack of awareness among many healthcare professionals about the dangers of HD exposure, attitudinal and behavioral differences among pharmacists and nurses who compound or administer HDs and gaps between USP <800> requirements and current practices.

  • Noncytotoxic Vesicant Medications and Solutions

    Contains 1 Component(s)

    INS established a vesicant task force with the goal of developing an evidence-based list of noncytotoxic vesicant medications/solutions. Outside of oncology practice, there is not a list of noncytotoxic vesicants as established by a ­professional­ organization. ­INS ­identified ­the ­need ­to ­­address ­this ­gap ­based on ­the­ following­ ­premise:­the­ first­ step ­in­ preventing ­extravasation ­is ­the ­identification ­and ­recognition ­of ­vesicant­ drugs and solutions. The scope of work was limited to creating an evidence-based list of noncytotoxic vesicant medications/solutions and developing an extravasation checklist that outlines risk reduction strategies including early recognition of signs and symptoms of extravasation.

    INS established a vesicant task force with the goal of developing an evidence-based list of noncytotoxic vesicant medications/solutions.

    Outside of oncology practice, there is not a list of noncytotoxic vesicants as established by a professional­ organization. ­INS ­identified ­the ­need ­to ­­address ­this ­gap ­based on ­the­ following­ premise:­the­ first­ step ­in­ preventing ­extravasation ­is ­the ­identification ­and ­recognition ­of ­vesicant­ drugs and solutions.

    The scope of work was limited to creating an evidence-based list of noncytotoxic vesicant medications/solutions and developing an extravasation checklist that outlines risk reduction strategies including early recognition of signs and symptoms of extravasation.

  • The Role of Unlicensed Assistive Personnel (UAP) in the Provision of Infusion Therapy

    Contains 1 Component(s)

    INS convened a task force of infusion therapy experts from various practice settings to review and update INS’ position on the use of unlicensed assistive personnel (UAP) in the provision of infusion therapy.

    INS convened a task force of infusion therapy experts from various practice settings to review and update INS' position on the use of unlicensed assistive personnel (UAP) in the provision of infusion therapy.