Vascular Access Team Research Articles

Teaming Up to Take Down Community-Acquired Bloodstream Infections: A Program Aimed at Educating and Training Nurses in the Community

BackgroundAdvances in medical technology have allowed pediatric patients to be discharged home with complex devices, including central venous catheters (CVCs). For these patients to be safely discharged, families require training to care for these catheters. At a large children's hospital, extensive family education and training for CVCs was already established. However, community caregivers were not receiving the same training. In an effort to target these caregivers, an education program was designed and implemented in 2011. MethodsThe program was originally designed and implemented by nurses on a gastroenterology unit and has expanded to include instructors from the vascular access team, hematology/oncology department, and pulmonary department. All community nurses providing care for pediatric patients in the region are welcome to attend the free class with education hours offered. The class is structured with lecture time and skills practice through simulation. ResultsSince the program began in 2011, 34 classes have been offered and 305 nurses have attended from multiple home health companies and school districts in the region. Community-acquired central line-associated bloodstream infection (CLABSI) rates for the pediatric gastroenterology and oncology patient populations have decreased significantly since the class began. ConclusionsAn education program targeting nurses in the community who care for complex patients with CVCs can decrease community-acquired infection rates and complications. This program can be designed and tailored for multiple patient populations with varying complexities and medical devices.

Alternative strategies to improve vascular access for dialysis patients

Although vascular access is a critical intervention for patients on dialysis, guidelines in this area are based on low-quality research that is mainly observational in nature. To improve patient outcomes, Nicholas Inston believes a patient-centred, multidisciplinary approach to care should become the gold standard. He outlines four alternative, evidence-based strategies for vascular access teams to consider.

Preventing intraluminal occlusion in peripherally inserted central catheters.

Peripherally inserted central catheters (PICCs) are used in a variety of specialties. Infective and thrombotic complications are widely reported but little has been written about the complications of persistent withdrawal occlusion (PWO) or complete luminal occlusion in PICCs. An audit was conducted of all patients who had a PICC in situ for a 6-week period, using a combination of reviewing clinical documentation and local departmental databases, physical review of inpatients and discussion with the relevant clinical nurse specialists in haematology, oncology, outpatient antibiotic therapy and the vascular access team, to determine the degree of PWO or occlusion but also to review possible financial implications in the introduction of a more expensive product. It was difficult to determine a rate for either PWO or complete occlusion owing to the diversity of the patient cohort and the tertiary nature of the organisation; the occlusion rate was estimated at 5%, but there was general agreement this was underestimating the problem. A needle-free connector was subsequently introduced for all PICCs in haematology, oncology and hepatobiliary services. Following the change in needle-free connector, 180 PICCs were inserted by the vascular access team on one of the organisation's sites over a 12-month period, with a total dwell time of 9702 catheter days (mean: 53.9 days, median: 35 days), a PWO rate of 1/1000 catheter days and total occlusion rate of 0.4/1000 catheter days. The time for insertion to complication of PWO or occlusion ranged from 9 to 144 days. Despite poor baseline data the results suggested the introduction of the bi-directional needle-less connector had a positive impact on the PWO and occlusion rates in PICCs.

ECG-based PICC tip verification system: an evaluation 5 years on.

In 2011, the vascular access team at East Kent Hospitals University NHS Foundation Trust safely and successfully incorporated the use of electrocardiogram (ECG) guidance technology for verification of peripherally inserted central catheters (PICC) tip placement into their practice. This study, 5 years on, compared the strengths and limitations of using this ECG method with the previous gold-standard of post-procedural chest X-ray. The study was undertaken using an embedded case study approach, and the cost, accuracy and efficiency of both systems were evaluated and compared. Using ECG to confirm PICC tip position was found to be cheaper, quicker and more accurate than post-procedural chest X-ray.

Comparison of Outcomes of Extended Dwell/Midline Peripheral Intravenous Catheters and Peripherally Inserted Central Catheters in Children

BackgroundInsertion of extended dwell/midline peripheral intravenous (EPIVs) catheters is not common practice in pediatric hospitals. An interdisciplinary team in 1 pediatric hospital developed a venous access decision tree based on current standards that included EPIVs. The purpose of this evaluation was to assess the process and pediatric patient outcomes associated with use of EPIVs and with peripherally inserted central catheters (PICCs). MethodsA retrospective record review over 22 months was conducted for 375 patients who received either a PICC (67.5%) or EPIV (32.5%). Data collected included patient demographic characteristics, diagnosis category, type and purpose of the line, insertion and removal dates, catheter size, placement location, and complications encountered. ResultsEPIVs were inserted with a 1.9F or 3F catheter, whereas PICCs generally used a 3F or 4F catheter. EPIVS were more commonly inserted in children younger than age 1 year, whereas children aged ≥ 11 years more often had a PICC inserted. EPIVs remained in place an average of 9 days compared with 20 days for PICC lines. Significantly more complications occurred during the placement of PICCs, whereas EPIVs had more complications during use such as leakage, dislodging, and infiltration. ConclusionsEPIVs were a successful alternative to PICC or peripherally inserted venous catheters for children in an inpatient acute-care facility who need 30 days or fewer of nonvesicant intravenous therapy. The venous access decision tree provided useful guidance in determining the appropriate venous access device for pediatric patients and the decision tree was adhered to by the vascular access team.

Antimicrobial Stewardship: The Role of Vascular Access Teams

Interventions that address the increasing threat of multidrug resistance are the responsibility of all health care disciplines. Vascular access teams ensure that vascular access needs are met, facilitating antimicrobial agent administration. Competent vascular access practice includes participation on interprofessional teams and provision of expert knowledge that enables medication administration and process monitoring.

The Prevalence and Success Rate of Ultrasound Guided Peripheral Intravenous Catheter (USGPIV) Placement By Vascular Access Team Nurses (VATNs) before and after an Educational Intervention: Table 1

The Prevalence and Success Rate of Ultrasound Guided Peripheral Intravenous Catheter (USGPIV) Placement By Vascular Access Team Nurses (VATNs) before and after an Educational Intervention: Table 1

Developing a vascular access team.

remit of the vascular access team at the Royal Devon and Exeter NHS Foundation Trust was to reduce the rates of intravenous (IV) access-associated complications and bacteraemia by improving patient assessment and care of IV access devices. The principle drivers of Winning Ways (Chief Medical Officer, 2003) and Saving lives (Department of Health (DH), 2005) were the need to reduce infection associated with invasive devices. With central venous catheter care one of the top five high-impact interventions, the challenge is to ensure the dissemination and application of best practice. The Health and Social Care Act 2008: Code of Practice (Department of Health, 2015) states that providers must audit compliance with key policies and procedures for infection prevention. The Care Quality Commission (CQC) assesses compliance to ensure the care people receive meets essential standards of quality and safety. In 2008, the key challenges facing the team were: patient safety, high bed occupancy, costly antibiotics, procurement and education. Today the vascular access team comprises registered nurses and allied health professionals who have developed extensive specialist knowledge, skills and competence in effective patient assessment, bedside device insertion, maintenance and care. The benefits of a vascular access team are well recognised both locally and nationally (Jackson, 2007; Meyer, 2012; Walker et al, 2013; Chopra et al, 2015). Such benefits can include: ■ A reduction in device-related complications, including catheter-related bloodstream infections Developing a vascular access team

BJN AWARD RUNNER UP.

career in surgery, day surgery and accident and emergency (A&E) nursing. It was during my time as an A&E sister that my love of IPC was fully ignited by undertaking the role of link IPC practioner for the unit. Since May 2006, I have been a senior IPC nurse in the Barking, Havering and Redbridge University Hospitals Trust and have always had a particular passion for how staff insert and care for vascular devices that have been inserted in vulnerable patients. My vision was to have a standard package for insertion and care of peripheral intravenous access to ensure that patients had the best care from insertion, maintenance of care and removal of lines to reduce the risk of acquiring catheter-related infections. To achieve this involved a phased approach to standardise products, review both nurse and medical staff education to ensure that staff were aware of products available, and look at care expectations to sustain good practice. This was achieved through benchmarking audits of all aspects of peripheral access and care, which informed us about the products within the trust e.g. six different dressings, three different companies providing peripheral cannulas and a variety of skin disinfectants. In addition, the number of peripheral line associated blood stream infections for the previous year was reviewed to provide another benchmark. Once the benchmarking had been completed, a three-stage implementation programme commenced following trialing of different products. Stage one was the standardisation of peripheral line dressings from one company, stage two was the introduction of 2% chlorhexidine/70% alcohol skin disinfectant and stage three was the introduction of a bespoke trust peripheral cannulation pack. Since the introduction of these measures, blood stream infections associated with peripheral lines have reduced by 73%, reducing costs to the trust both in monetary terms and in reduced length of stay, and ensuring that patients are receiving safer, evidence-based care. Aseptic non-touch technique is now mandatory for all healthcare staff who insert, care for or remove cannulas and is part of the induction programme for all new starters. My vision for the future is that all acute trusts have a vascular access team to improve patients’ outcomes. I was honoured to be nominated for a BJN award and delighted to receive second place. BJN

Arteriovenous Vascular Access Selection and Evaluation.

When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient.

The Vascular Access Team: Nursing Roles and Responsibilities inside the Gated Community.

The Vascular Access Team: Nursing Roles and Responsibilities inside the Gated Community.

Peripheral Blood Stem Cell(PBSC) Harvest Through an Acute Hemodialysis Catheter Placed in an Outpatient Setting by a Respiratory Therapist Based Vascular Access Team

The PowerFlow implantable apheresis intravenous port is a venous access device for therapeutic apheresis procedures. In this case review article, we identify key similarities and differences between apheresis PowerFlow ports and traditional ports. We also list strategies that emergency departments can implement to aid in correct port identification.Using a case review format, we describe the clinical presentation of a 33-year-old female with neuromyelitis optica who was evaluated in the emergency department for an acute exacerbation. She had a history of outpatient apheresis procedures that made use of bilateral PowerFlow ports. Mistaken for a conventional port, the right PowerFlow port was accessed with a Huber needle rather than the appropriate catheter-over-needle device. On infusion of intravenous fluids, the patient experienced pain and swelling. Ultimately, the port malfunctioned and was eventually replaced.A subsequent root cause analysis identified opportunities for education and aids to improve port identification. To this end, strategies were implemented to appropriately identify the PowerFlow port using at least 2 of the following methods: (1) look in the patient’s chart for record of an implantable apheresis intravenous port; (2) check the port identification card, bracelet, or keychain issued at insertion; (3) palpate the port to look for the rounded top and hollow concave entry point; and (4) use x-ray or fluoroscopy to identify radiopaque port markers.When a patient with a history of apheresis procedures presents with an implanted port, steps should be taken to ensure correct identification and access.

Dual Vector Biosensor Catheter Tip Positioning System: A 3-Year Retrospective Analysis

BackgroundVascular access is continually evolving in areas of clinical practice and new technology. Our vascular access team (VAT), like many others, has moved away from chest radiograph after peripherally inserted central catheter (PICC) insertion to a catheter tip positioning system or tip locating device (TLD). Our VAT collected data over a 3-year period to assess any changes that resulted from the TLD implementation. The intent was to drill down into the PICC data over the 3 years and quantify any changes gained or lost from the previous practice of post-PICC insertion chest radiograph. MethodsA share point database system that was already in place was updated to also incorporate key elements of the TLD. Initial time studies were also collected to validate average cycle time. The VAT was educated and validated on the TLD technology before implementation. Key stakeholders (ie, members of the radiology department, administration, hospitalist physicians, and the medical director) were communicated with and signed off on the project. ResultsRetrospective analysis from 2012-2014 revealed that 1079 PICCs had been inserted. Of those, 781 PICCs were placed successfully with the TLD with an accompanying reduction of 781 chest radiographs. Precycle time averaged 114 minutes compared with post-TLD, which averaged 37 minutes. No changes in deep vein thrombosis rate were identified. ConclusionsImplementing the dual vector biosensor TLD improved our insertion cycle time by a mean of 77 minutes. The new cycle time provided increased procedure capacity for the VAT. Chest radiograph reduction of 72% was also realized with the TLD over the 3-year period.

How to Establish an Effective Midline Program: A Case Study of 2 Hospitals

IntroductionEstablishing an effective midline program involves more than simply learning an insertion technique for a new product. Midline catheters provide a reliable vascular access option for those patients with difficult venous access who would otherwise require multiple venipunctures or the use of higher-risk central lines to maintain access. An effective midline program establishes a protocol for device selection and includes standing orders to facilitate speed to placement. MethodsOur retrospective descriptive review evaluated the successful integration of midline programs into existing vascular access bedside insertion programs in 2 acute care hospitals. The investigator reviewed a convenience sample of hospital patients. Participants in the study included vascular access team managers and team members from the sample sites. ResultsThe results of this 2-hospital study demonstrate successful integration of a midline program into a bedside insertion program with 0 midline-related infections since initiation. Documentation of overall central line-associated bloodstream infection rates for hospital 1 changed from 1.7/1000 catheter-days to 0.2/1000 catheter-days, reflecting a 78% reduction in infections and a projected cost avoidance of $531,570 annually. Both hospitals demonstrated reduced rates of infection following implementation of a midline program. ConclusionsMidlines have a history of lower risk for both infection and thrombosis compared with central venous devices. Although more research is needed on the more recently developed midline catheters, available evidence suggests that midlines provide a safe and reliable form of vascular access, reducing costs and the risk of infection associated with central venous catheters, especially those placed solely for patients with difficult venous access.

Paediatric vascular access

### Key points Obtaining reliable vascular access in small children is frequently made challenging by anatomical factors—in particular, small, mobile veins and an excess of subcutaneous fat which make visualization and palpation of veins difficult. Paediatric patients are often less co-operative, and the potential for psychological trauma, especially with repeated procedures in the conscious patient, further complicates matters. Short-term vascular access is frequently required in hospitalized children for the delivery of i.v. fluids, medication, and blood product administration. Longer-term vascular access devices are required for repeated medication delivery (e.g. enzyme replacement therapy in inherited metabolic diseases), chemotherapy, immunotherapy, total parenteral nutrition, and extracorporeal procedures such as plasmapheresis and haemodialysis. In addition, vascular access devices may be needed for repeated blood sampling and invasive haemodynamic monitoring. The choice of vascular access device depends upon the condition and preference of the patient or parent/guardian, the likely duration and frequency of treatment, and the properties of the infusate. Infusates with vesicant properties (drugs with the potential to cause blistering with tissue injury, e.g. calcium solutions and amphotericin B), hypertonic solutions, and those with pH 9 will necessitate central venous access. Vasopressors and inotropes are preferentially administered centrally as they require reliable access and extravasation may cause tissue necrosis. It is important to try to predict future needs for vascular access as poor prospective management …

A Vascular Access Team's Journey to Central Venous Catheter and Arterial Line Placement

BackgroundThe frequency with which vascular access specialists (VASs) are placing peripherally inserted central catheters (PICCS) has allowed for the improvement and expansion of the skill set by using advanced insertion techniques such as the modified Seldinger technique and ultrasound for real-time imaging. The use of real-time imaging has decreased complications such as arterial puncture and has improved success rates. Due to this positive influence on patient outcomes, many VASs are moving to the placement of central venous catheters (CVC). MethodWe describe the service improvement process of expanding a vascular access team (VAT) practice to include the placement of CVCs and arterial lines in a large community hospital in Illinois. We also outline the history of vascular access and the journey of a VAT. ResultsBy following a methodic approach toward implementation of practice expansion, our VAT has gone from solely placing PICCS to the placement of CVCs in the internal jugular, axillary/subclavian, and femoral veins and to the placement of arterial lines. ConclusionsVASs have the capacity to positively influence patient safety and outcomes even further by placing CVCs, rather than simply staying with the current scope of practice by placing intravenous lines, midlines, and PICCs. Patient outcomes will improve as VASs move to the placement of CVCs, and the costs associated with potential complications will improve also. Moving to the placement of CVCs is vital to the specialty of vascular access and will continue the breadth and depth of service provided by VASs.

Preoperative assessment and planning of haemodialysis vascular access.

Effective haemodialysis (HD) requires a reliable vascular access (VA). Clinical practice guidelines strongly recommend the arteriovenous fistula (AVF) as the preferred VA in HD patients. The creation of an AVF should be promoted in all eligible patients who choose HD, as it improves outcomes and reduces costs when compared with central venous catheters. Fistula eligibility is a ‘work in progress’. Three steps in order to increase the pool of eligible patients can be individualized: (i) process of care, which includes three fundamental items: the VA team, early VA education and timely VA surgery referral; (ii) preoperative evaluation; (iii) surgical strategy. Nephrologists should be able to play a leading and coordinating role of the VA team. They should design a plan that identifies a sequence of options that can be used to provide adequate renal replacement therapy throughout the life span of every end-stage renal disease patient. The main points of this strategy are (i) early vascular education, in which a ‘save the vein program’ should always be implemented; (ii) timely VA surgery referral and preoperative evaluation: careful examination of arterial and venous beds is mandatory before VA placement; physical examination in addition to colour Doppler ultrasound mapping improves AVF outcomes; (iii) surgical strategy: a successful VA strategy must take into account vascular anatomy, clinical factors and prognosis.

The patient's role in patient safety and the importance of a dedicated vascular access team.

The role of dialysis patients in ensuring their own safety throughout the process of vascular access construction should be far from negligible. Patients can make important contributions to their safety starting in the predialysis stage, via vascular access construction and through the experience of chronic hemodialysis. Currently, patients assume a passive role and their empowerment requires both patients and caregivers to overcome many personal and cultural barriers, thus encouraging safety-related behavior. There are many opportunities for end-stage renal failure patients to be involved in every stage of their disease. In this chapter, we discuss how hemodialysis patients can participate in patient safety, including some of the main opportunities for involvement along the care pathway from the point at which the decision is made that the patient requires vascular access surgery.

Proactive Planning for Vascular Access Therapy: One Hospital's Plan for Success

BackgroundVascular access is a critical component of care for patients in neonatal intensive care units (NICUs). Our NICU had only a small number of nurses cross-trained to perform peripherally inserted central catheter (PICC) insertions and was not able to provide coverage 24 hours a day, 7 days a week. We combined the vascular access team (VAT) and NICU PICC team to improve the timeliness of NICU PICC insertions, standardize care, and use ultrasound for all PICC placements. MethodsA paper guide tool was developed to prioritize PICC placements as emergent, same-day, or nonemergent. NICU nurses were trained to insert PICCs using ultrasound. Catheter insertion and care processes were standardized for the new centralized PICC team. NICU and VAT staff worked together to improve daily communication, hand-offs, and referrals. Criteria were developed to determine the appropriate hospital location for PICC insertions. Charge nurses began capturing information about patients with PICCs on daily planning sheets. ResultsFollowing implementation of the new combined VAT, the average wait time for emergent and same-day insertions decreased 10%. No adverse events were reported due to a delay in PICC placement or the PICC referral process. ConclusionsCombining the NICU PICC insertion nurses and the VAT into a new centralized PICC team provided an opportunity for growth in both areas. NICU PICCs are now placed efficiently based on patient acuity and referral prioritization throughout the hospital. NICU and VAT physicians and nurses have developed a strong partnership for the provision of PICC services for NICU patients.

Vascular access for hemodialysis: current perspectives.

A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft, and central venous catheter (CVC). AVF, described by Brescia and Cimino, remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries. Once autogenous options have been exhausted, prosthetic fistulae become the second option of maintenance HD access alternatives. CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins. The subclavian vein is considered the third choice because of the high risk of thrombosis. Complications associated with CVC insertion range from 5% to 19%. Since an increasing number of patients have implanted pacemakers and defibrillators, usually inserted via the subclavian vein and superior vena cava into the right heart, a careful assessment of risk and benefits should be taken. Infection is responsible for the removal of about 30%–60% of HD CVCs, and hospitalization rates are higher among patients with CVCs than among AVF ones. Proper VA maintenance requires integration of different professionals to create a VA team. This team should include a nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff. They should provide their experience in order to give the best options to uremic patients and the best care for their VA.