Vascular Access

The Value of Research and Education: Impact on Patient Safety

By Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC

This column originally appeared in the December 2020 issue of Healthcare Hygiene magazine.

Research and education are essential components of any healthcare organization to provide clinical knowledge to healthcare workers that establish practices and procedures ensuring patient safety. Research is used to identify gaps in practice that indicate the need for improvement, to answer questions for the best practice procedures, and to validate practices and products used within healthcare settings. Investigation of clinical practices for incidence and causes of negative patient outcomes often yields solutions that can be applied in the clinical setting. In addition, many new products are available claiming to solve problems and reduce complications. Product evaluation must be performed to validate claims in the clinical setting. This product research provides additional value to other institutions, when results are published, assisting them in establishing a value basis for products.

Patient complications increase the cost of healthcare. Research provides valuable insights, based on the results of investigations, that often have a considerable impact on cost reduction, improving efficiency of care and other positive effects of improved patient satisfaction. Education, performed in conjunction with research, has been shown to have significant value in reducing complications and cost. Inconsistencies in procedures, failure to follow policies, lack of standardization all contribute to poor quality and negative outcomes which drive up cost. With the increase in technology and essential requirements for vascular access devices for most patients the cost of health care is rising and the impact of serious complications increasing.

Educational program initiatives have been shown to be necessary to outcome improvement and cost-effective components of high-quality healthcare. Nursing and medical professionals receive education in the academic setting and during orientation to a new healthcare facility. Whether initiated by the individual or the institution, frequency and type of education and training following graduation and completion of orientation is often sporadic without defined requirements. Provision of education and clinical training within healthcare facilities are dictated by policy changes and performance improvement initiatives. As noted by Bianco and associates and supported by Marschall, et al. guidelines on strategies to prevent infections, well organized educational programs to continually train and increase competence of clinicians, for those involved with insertion and care of vascular access devices, is critical to the success of infection prevention methods. As research is incorporated into guidelines and standards, education provides a means to disseminate the information to the working clinician promoting application at the bedside.

The infrastructure of healthcare facilities should include resources to provide consistent education, training and procedural simulation to all staff including programs on basic practices of asepsis, infection prevention, insertion, and maintenance of all intravenous and intra-arterial devices. More emphasis is needed to expand the role and responsibility of all clinicians to include research and increase the emphasis on education within their current job functions. Periodic re-training should be performed following gap analysis of deficiencies in procedures or practices. In addition, clinicians should be provided information on device indications and appropriateness to aid in selection of the lowest risk access device that will effectively deliver the therapy. Encouraging application of research and accountability for education, training, and competency with credentialing requirements initially, prior to independent insertions, and periodically as a means of evaluation will improve and increase patient safety with procedures.

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.

1. Bianco A, Coscarelli P, Nobile CG, Pileggi C, Pavia M. The reduction of risk in central line-associated bloodstream infections: knowledge, attitudes, and evidence-based practices in health care workers. American journal of infection control. 2013 Feb 1;41(2):107-12.
2. Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, Sona CS, Buchman TG, Boyle WA, Polish LB, Fraser VJ. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Critical care medicine. 2002 Jan 1;30(1):59-64.
3. Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. The Lancet. 2000 May 27;355(9218):1864-8.
4. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf FM, Davis D, Odgaard‐Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane database of systematic reviews. 2009(2).
5. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard‐Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane database of systematic reviews. 2012(6).
6. James BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Affairs. 2011 Jun 1;30(6):1185-91.
7. Lobo RD, Levin AS, Gomes LM, Cursino R, Park M, Figueiredo VB, Taniguchi L, Polido CG, Costa SF. Impact of an educational program and policy changes on decreasing catheter-associated bloodstream infections in a medical intensive care unit in Brazil. American journal of infection control. 2005 Mar 1;33(2):83-7.
8. Marschall J, Mermel LA, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V. Strategies to prevent central line–associated bloodstream infections in acute care hospitals. Infection Control & Hospital Epidemiology. 2008 Oct;29(S1):S22-30.
9. Mohapatra S, Kapil A, Suri A, Pandia MP, Bhatia R, Borkar S, Dube SK, Jagdevan A, George S, Varghese B, Dabral J. Impact of Continuous Education and Training in Reduction of Central Line-associated Bloodstream Infection in Neurointensive Care Unit. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine. 2020 Jun;24(6):414.
10. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard‐Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis D, Haynes RB. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of systematic reviews. 2007(4).
11. Rosenthal VD, Guzman S, Pezzotto SM. Effect of an infection control program using education and performance feedback on rates of intravascular device-associated bloodstream infections in intensive care units in Argentina. American journal of infection control. 2003 Nov 1;31(7):405-9.
12. Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, Flynn L, Hayes S, Strong S, Cruz J, Bowton DL. Education of physicians-in-training can decrease the risk for vascular catheter infection. Annals of internal medicine. 2000 Apr 18;132(8):641-8.
13. Warren DK, Zack JE, Mayfield JL, Chen A, Prentice D, Fraser VJ, Kollef MH. The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest. 2004 Nov 1;126(5):1612-8.


Patient-Focused Care with Vascular Access Bundles

By Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC

Editor's note: This column originally appeared in the November 2020 issue of Healthcare Hygiene magazine.

Most patients entering acute-care receive therapies via an intravenous access device. The success of therapy is, to some degree, contingent on the success of the device used to deliver the medications. Improving success and function of vascular access device is done through the application of research for key practices points by clinicians and administrators. Research can be effectively integrated into a bundle of patient care measures to establish, maintain, and insure the most positive outcomes. Best practice bundles for vascular access devices have resulted in infection reduction, minimized supply usage, improved through-put of patient care and reduced length of stay that puts the well-being of the patient first for a patient focused care approach.

A care bundle is a structured way of applying research and recommendations for improving the processes of care and patient outcomes. The care bundle is described as a small, straightforward set of evidence-based practices of generally three to five components that, when performed collectively and reliably, have been proven to improve patient outcomes according to the Institute for Healthcare Improvement (IHI) ( Most important to this issue is the concept that a bundle is a cohesive unit of steps must all be completed to succeed; the “all or none” feature is the source of the bundle’s power.2-4 Other bundle criteria include that only practices based on level 1 or A graded evidence should be included in a bundle.

Evidence is expanding in support of specialized vascular access assessment, selection, insertion of vascular access devices with practices and teams that reduce the number of unsuccessful insertion attempts, catheter failure, and minimize complications. A recent study “Reaching One Peripheral Intravenous Catheter (PIVC) Per Patient Visit With Lean Multimodal Strategy: the PIV5Rights Bundle” reported how a bundle of practices led to improved patient outcomes with PIVCs and significant financial savings.5 Elements of the bundle that contributed to their success included the right proficient nurse inserter, the right insertion method, the right vein and catheter selection, the right supplies and technology, and the right assessment for care and maintenance. Each of these right practices are supported by a body of A through D graded evidence.6 The evidence for each of the individual components of the care bundle must be considered separately, but ultimately the bundle is a combination of actions, that when all are applied, result in better outcomes for the patient and healthcare facility.

Integration of a skilled and proficient inserter to assess, select the best insertion site and method, choose the best catheter and length for the therapy and individual patient characteristics, organize the most appropriate supplies, and use ultrasound when needed, creates the best scenario for patient intravenous access. The results of the PIV5Rights study are consistent with these components and reflect a positive impact of the proficient ultrasound trained nurses for fewer number of attempts, longer dwell time for intravenous catheters, with meaningful differences in fewer complications or failed PIVCs when comparing the specialist to the generalist nurse.

Financially, this type of proficient nurse and care bundle makes sense. The impact of the use of the generalist model for peripheral catheter insertions represents lost revenue and waste in terms of high supply usage with multiple attempts and shorter dwell time. The global financial burden for premature PIVC failure is conservatively estimated to range from $9.8 to $17.5 billion annually by calculating the reported PIVC failure rates of 35%-50%, multiplied by the estimated 1- billion PIVCs inserted each year worldwide, and integration of the published uncomplicated PIVC procedure cost range of $28-$35.6.7,8 Hospitals are under intense pressure to improve the quality of patient care while reducing total cost of care. One of the primary strategies to accomplish this is to use evidence-based practices such as the care bundle to minimize the unnecessary clinical variation that regularly occurs with invasive procedures.

Application of these type of bundled patient focused approaches result in the overall improvement of the patient experience. The goal in provision of healthcare is to promote health. The best practices identified in the PIV5Rights care bundle demonstrate a process for improving patient satisfaction, while reducing complications and cost. The Alliance for Vascular Access Teaching and Research (AVATAR), a research group based in Australia, says it best with their ‘Making Complications History’ campaign. 9 This group performs randomized controlled trials and research designed to guide practices to improve patient safety with vascular access devices. Care bundles and education for clinicians on the results of this type of research contribute to healthcare improvement establishing a patient focused approach that may lead to the eradication of vascular access complications.

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.

1. Sacks G, Diggs B, Hadjizacharia P, Green D, Salim A, Malinoski D. Reducing the Rate of Catheter-associated Bloodstream Infections in a Surgical Intensive Care Unit Using the Institute for Healthcare Improvement Central Line Bundle. American Journal of Surgery. 2014;207(6):817-823.
2. Lavallée JF, Gray TA, Dumville J, Russell W, Cullum N. The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implementation Science. 2017;12(1):142.
3. Sayin Y. What is A Care Bundle? Florence Nightingale Hemşirelik Dergisi. 2017;25(2):145-151.
4. Fulbrook P, Mooney S. Care bundles in critical care: a practical approach to evidence-based practice. Nursing in critical care. 2003;8(6):249-255.
5. Steere L, Ficara C, Davis M, Moureau N. Reaching One Peripheral Intravenous Catheter (PIVC) Per Patient Visit with Lean Multimodal Strategy: the PIV5Rights™ Bundle. Journal of the Association for Vascular Access. 2019;24(3):31-43.
6. Moureau N, and Steere L. Theoretical Methodology and Systematic Evidence Review of the PIV5Rights Care Bundle. Association for Vascular Access at Your Fingertips Virtual Conference 2020. Poster Presentation.
7. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but Unacceptable: Peripheral IV Catheter Failure. Journal of Infusion Nursing. 2015;38(3):189-203.
8. Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. Journal of hospital medicine. 2018;13(5).
9. AVATAR. The High Five Campaign: Making Vascular Access Complications History.
2017; accessed 2020

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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2. Hawes M. A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs.. 2007;30(1):33-44.
3. Sato A, Nakamura I, Fujita H, et al. Peripheral venous catheter-related bloodstream infection is associated with severe complications and potential death: a retrospective observational study. BMC Infect Dis.2017;17(1):434.
4. Castro-Sanchez E, Charani E, Drumright L, Sevdalis N, Shah N, Holmes A. Fragmentation of care threatens patient safety in peripheral vascular catheter management in acute care--a qualitative study. PLoS One. 2014;9(1):e86167.
5. O'Grady N, Alexander M, Burns L, et al. Centers for Disease Control and Prevention: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infectious Diseases. 2011;52(9):e162-e193.
6. Carr P, Higgins N, Cooke M, Mihala G, Rickard C. Vascular Access Specialist Teams for
Device Insertion and Prevention of Failure. Cochrane Database of Systematic Reviews
2014. 2014(12).
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8. Kelly L. The experience of patients living with a vascular access device [Internet]: IVUPDATE; 2017. Podcast. Available from: living-with-a-vascular-audios-mp3_rf_20838415_1.html
9. Harpel J. Best practices for vascular resource teams. J Infus Nurs.2013;36(1):46-50.
10. da Silva GA, Priebe S, Dias FN. Benefits of Establishing an Intravenous Team and the
Standardization of Peripheral Intravenous Catheters. J Infus Nurs. 2010;33(3):156-160.
11. Fong N, Holtzman S, Bettmann M, Bettis S. Peripherally inserted central catheters:
outcome as a function of the operator. J Vasc Interv Radiol.2001;12(6):723-729.
12. McGee D, Gould M. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-1133.
13. Lennon M, Zaw N, Pöpping D, Wenk M. Procedural complications of central venous catheter insertion. Minerva Anestesiol.2012;78(11):1234-1240.
14. Mourad M, Kohlwes J, Maselli J, Auerbach A. Supervising the supervisors—procedural training and supervision in internal medicine residency. J Gen Intern Med.2010;25(4):351-356.
15. Gianino M, Brunt L, Eisenberg P. The impact of nutritional support team on the cost and management of multilumen central venous catheters. J Infus Nurs. 1992;15(6):327-332.
16. Scalley R, Van C, Cochran R. The impact of an IV team on the occurrence of intravenous- related phlebitis: a 30-month study. 1992;15(2):100-109.
17. Maki D, Ringer M. Risk Factors for infusion-related phlebitis with small peripheral venous catheters: a randomized controlled trial. Ann Intern Med.1991;114(10):845-854.
18. Soifer N, Borzak S, Edlin B, Weinstein R. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med.1998;158(5):473-477.
19. Coopersmith C, Rebmann T, Zack J, et al. Effect of an education program on decreasing catheter related bloodstream infections in the surgical intensive care unit. Crit Care
Med. 2002;30(1):59-64.
20. Eggiman P, Harbarth S, Constantin M, Touveneau S, Chevrolet J, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet. 2000;355(9218):1864-1868.
21. Eggiman P, Pittet D. Overview of catheter-related infections with special emphasis on prevention based on educational programs. Clin Microbiol Infect. 2002;8(5):295-309.
22. Alexandrou E, Murgo M, Calabria E, et al. Nurse-led central venous catheter insertion- procedural characteristics and outcomes of three intensive care placement services. Int J Nurs Stud.2012;49(2):162-168.
23. Alexandrou E, Spencer T, Frost S, Mifflin N, Davidson P, Hillman K. Central venous catheter placement by advanced practice nurses demonstrate low procedural complication and infection rates--a report from 13 years of service*. Crit Care Med.2014;42(3):536-543.
24. Cotogni P, Barbero C, Garrino C, et al. Peripherally inserted central catheters in non- hospitalized cancer patients: 5-year results of a prospective study. Support Care
Cancer. 2015;23(2):403-409.
25. Galloway M. Insertion and placement of central catheters in the oncology patient. Paper presented at: Seminars in Oncology Nursing2010.
26. Pittiruti M, Emoli A, Porta P. A new area of competence for the vascular access nurse:
the PICC port. J Assoc Vasc Access. 2013;18(4):217-218.
27. Curto-García N, García-Suárez J, Chavarria MC, et al. A team-based multidisciplinary approach to managing peripherally inserted central catheter complications in high-risk haematological patients: a prospective study. Support Care Cancer. 2016;24(1):93-101.
28. Steere L, Ficara C, Davis M, Moureau N. Reaching one peripheral intravenous catheter (PIVC) per patient visit with lean multimodal strategy: the PIV5Rights™ bundle. J Assoc Vasc Access. 2019;24(3):31-43.
29. Flodgren G, Rojas-Reyes MX, Cole N, Foxcroft DR. Effectiveness of organisational infrastructures to promote evidence-based nursing practice. Cochrane Database Syst Rev.2012;2:CD002212.
30. AVATAR. The High Five Campaign: Making Vascular Access Complications History.
2017; accessed 2020