Patient Safety Enhanced Through Vascular Access Specialist Care
By Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC
Editor's note: This column originally appeared in the October 2020 issue of Healthcare Hygiene magazine.
Vascular access devices (VAD) are used daily in almost all inpatient settings with a range of healthcare professionals sharing the responsibility for insertion, management, and removal of VADs. Vascular access catheter insertions are accepted as common invasive clinical procedures that expose patients to risks such as procedural pain, bruising, bleeding, vessel depletion, nerve injury, or infection, and, in extreme cases, death.(1,2,3) There is much variation and fragmentation in practices suggestive of opportunities to reduce risk and improve patient care.(4) One action to achieve positive outcomes is by shifting vascular access ownership to specially trained clinicians for (i) assessment, (ii) insertion, (iii) care maintenance, and (iv) education as is seen with vascular access or infusion teams. We have seen in the COVID-19 crisis an increased urgency for VAD placement and innovation in maintaining infusions outside patient rooms. Ensuring the placement of a reliable intravenous device in an optimal location designed to perform without complications was a high priority during this time of crisis.
We know the Centers for Disease Control and Prevention (CDC) has emphasized specialized teams as a method to reduce infections, complications, and cost of infusion therapy.(5) A Cochrane systematic review defines vascular access specialists and teams (i.e., VAS or VAST) as any of the following; infusion teams, intravenous teams, individual specialists (nurse, doctor, respiratory therapist, radiological technologist, nurse practitioner, and physician assistant) who have knowledge and skills, formal training, and who frequently perform insertion or manage VADs.(6) Teams and individual specialist functions will vary, but commonly include the insertion and maintenance of some or all vascular access devices. Given the growing complexity in patient needs, a unique specialist discipline, namely the vascular access specialist (VAS), is needed to deliver efficiently and safely the prescribed intravenous treatment plan.
The No. 1 fear of patients entering a hospital is fear of pain associated with needles. The evidence to date is suggestive that the highest achieving system of initiating and delivering treatment to patients in acute care is tied to a purpose-driven group of skilled individuals and the processes that guide their practices.(7) Starting an intravenous device is often associated with repeated attempts following insertion failures leading to increased patient risk of complications. Evidence supports the value of specially trained individuals that have greater first-time success with fewer insertion attempts, and lower infection rate associated with intravenous or arterial device insertion.(11) Patients indicate that inadequate skill level of those performing these types of procedures is a source of great dissatisfaction, while use of technology and increased skills of the VAS promotes higher satisfaction.(8,9) According to da Silva in 2010, use of a specialized team increased first attempt success achieving 84 percent with one peripheral intravenous catheter (PIV) attempt and lower complications.(10) Complications associated with VADs relate to the skill and knowledge of the operator for insertion(11-14) and for post-insertion complications relate to maintenance by knowledgeable clinicians and patient specific risk factors.(15-18) Specialized education has led to infection prevention practices that reduce complications.(19-21) Advanced practice nurses and those teams receiving specialized training to perform insertions of all CVADs, working in collaboration with medical providers, offer valuable contributions to patient safety by performing ultrasound guided insertions with low incidence of complications.(22-27)
Standards for infusion therapy call for an increase of teams to perform CVAD insertion, ultrasound guided peripheral insertions for difficult access patients, maintenance, and removal of devices when no longer needed to promote patient safety and better outcomes. Other functions embraced by these specialists may include patient access for difficult blood draws, use of ultrasound guidance for any or all of the insertion and assessment functions, dressing changes for central catheters, careful daily assessment and monitoring of dressing and insertion site for complication identification, and daily evaluation of catheter necessity with removal of unnecessary catheters. Additionally, they provide a professional point of care for education and resource of VAD queries for device maintenance and management.
Patient-focused safety initiatives should apply evidence of improved outcomes such as those represented in establishing and maintaining effective vascular access teams. (28) The value of specialized teams for insertion and management of vascular access is demonstrated through numerous publications in a variety of research designs. (6,10,15,16) Although there are currently no randomized controlled clinical trials that support the benefits of teams, the recommendation of the CDC and others worldwide guidelines continue to support specialists as a method to reduce infections and complications associated with vascular access devices.(29) Supported by the concepts of vessel health and preservation, the application of vascular access individuals or teams as a consultative specialists in every hospital for insertion and management of vascular access devices could significantly aid the pursuit of making Central Line Associated Bloodstream Infections (CLABSIs) and VADs complications history.(30)
Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC, is the chief executive officer at PICC Excellence, Inc., a research member of the Alliance for Vascular Access Teaching and Research (AVATAR) Group, and an adjunct associate professor at Griffith University in Brisbane, Australia.
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