Friday, 9 May 2014

SENDING A PATIENT HOME WITH A NON-TUNNELED CENTRAL VENOUS CATHETER

Patients with non-tunneled long-term central venous catheters (CVCs) have been managed in home infusion, outpatient clinics, long-term acute care hospitals (LTACHs), and skilled nursing facilities for many years. This paper (link, below) discusses specific considerations when planning discharge, sample policies and procedures for care and maintenance in the outpatient setting. Controversy exists today in some areas of the country and particularly in the acute care hospital setting about discharging patients with non-tunneled CVCs. Data shows that these catheters are well tolerated in the above care settings.

Overview of Long-Term CVCs

Long-term non-tunneled CVCs are placed via the Internal Jugular, Axillary and Subclavian veins. These catheters may be placed at the bedside, in Interventional Radiology, or in surgery. Today, these devices are placed by physicians, nurse practitioners, registered professional nurses, respiratory care professionals, and physician assistants.

The use of these catheters dates back to the late 1980s. At that time, non-tunneled catheters were manufactured by a number of companies. Perhaps the best known of these were the Cook® Hyperalimentation Catheter (Cook, Bloomington, IN) and the Hohn® Catheter (CR Bard, Murray Hill, NJ). Available in single, double and triple-lumen configurations and made of silicone, they are still in use today. In recent years, newer polyurethane and power injectable polyurethane long-term non-tunneled CVCs have been introduced.

Tunneled catheters with cuffs (Dacron) or other materials, including cuffs with antimicrobial properties) are often used for long-term therapies. These have long been a catheter of choice, by some physicians, for the pediatric population. These catheters are available in pressure injectable polyurethane and non-pressure injectable silicone versions.

Peripherally Inserted Central Catheters (PICCs) have been a popular long-term central catheter option for more than two decades. Commonly used in both inpatient and outpatient sites of care they are often thought to have a lower risk of complications than other central access devices.

Summary

With current recommendations to avoid peripherally placed venous catheters in patients with Stages 2-4 renal disease, and the fact that many other patients may not be candidates for peripheral access, an alternative is required. Careful assessment and evaluation of each patient to determine the most appropriate vascular device should be common practice.

When performing a vascular access assessment it is important to consider many factors. These factors include potential for discharge with a vascular access device, patient and primary care provider understanding of the risks, benefits and care/maintenance and availability of health services in case of complications. Long-term non-tunneled CVCs are an option for patients that are leaving the hospital with a vascular access device.

For a full copy of the White Paper on this Topic click here:

For more information on device selection and patient assessment return to homepage www.vesselhealth.org.


Jim Lacy, BSN, RN, CRNI is a Product Manager for Teleflex and  current President of the Board of Directors of AVA.

Posted by TopicsInVascularAccess at 2:28 PM in /

Friday, 4 April 2014

Should Arterial Line Placement be a Part of Vascular Access Services? Chris Naylor, RN, VA-BC


In today’s environment of cost savings and downsizing, it is important to expand your skills and make your Vascular Access (VA) team indispensable. In other words, enable your team to be invaluable by embracing high quality, consistent training and continuing to reach forward with new technologies and procedures that can enhance your worth and ensure better patient outcomes. As a community hospital VA team, we followed and embraced professional standards as they were developed, before they were demanded. Because of this, we had extremely good outcomes.

The team was extremely high functioning in that we demanded the highest quality of work from each other. They were taught to be consistent, to do everything exactly the same way. Everyone set their tray up the same and performed the procedure with the same steps. This made it easier to train new nurses, standardizing how the tray was set up and how the procedure was performed eliminated confusion. It also made it easier to help set up and assist each other. We treated our patients like our family, and if someone on the team made a breach of the sterile field, the procedure was started over. We never risked the patient. As a result, I am proud to say that this team never had an infection from an insertion
in 14 years.

The teams made sure not to focus on delivering quality care with the skills we already had. Instead, we stressed the importance of continued education to expand skill sets. The more you can do, the more valuable you will be. If we don’t continue to advance as nurses, we won’t be doing the best we can for our patients, so I personally felt the next steps were the insertion of Arterial Lines (A-lines) and Central Venous Catheters (CVCs).

Inserting A-lines is a way for nurses to grow in their profession and expand their scope of practice. Using ultrasound guidance for insertion into veins can naturally progress to insertion into arteries. Traditionally, physicians have inserted A-lines. Having a dedicated, consistent team that may be more readily available has lots of advantages. Vascular nurses have applicable skills. They have already been looking at veins with an ultrasound for years, and this skill is transferable to inserting A-lines. Some nurses on the VA team have already inserted A-lines in emergencies when they have been assisting physicians who are not as skilled with ultrasound. This was on an unofficial basis.

Most nurses don’t put in A-lines yet because it is a new skill that requires some special training. We need more avenues for this training. Teams also need champions who will advocate for this training and education. Someone needs to drive the incorporation of A-lines into the VA practice. It is a new avenue for nurses in its infancy stage, just like CVCs. A-lines are a safe progression for these nurses. I personally think we should get away from “PICC teams”, and VA teams should encompass all vasculature. It might take a while, but I think it will eventually happen.

The first step nurses can take to move toward the insertion of A-lines is to know their state regulations and scope of practice. It is also extremely important that VA nurses stay current with their education and become certified in their field. This is accomplished by attending conferences like AVA, and INS, attending local network meetings, staying up to date on current literature and by reaching out to companies like Teleflex that offer training courses.

Nurses are the future of vascular access, and they should be investigating all areas of it so that, where appropriate, they can advance their practice and provide the best care possible to their patients.


Chris Naylor, RN, VA-BC, recently retired after a 44-year career as a nurse with background in Critical Care, Emergency Medicine and Vascular Access. She developed a very successful PICC program in a community hospital in Santa Rosa, California and was the manager of Procedure and Resource Nurses and the PICC team. She was also a Clinical Educator for Bard Access, a member of Association for Vascular Access (AVA) since 2000 and was on the Board of Directors of Bay Area Vascular Access Network (BAVAN) for many years.
Posted by TopicsInVascularAccess at 2:59 PM in /

Wednesday, 26 March 2014

COMMENTS FUNCTION ISSUE

The Comments function on the Blog was not working properly and has been fixed as of today. - Editor
Posted by TopicsInVascularAccess at 9:45 AM in /

Monday, 24 March 2014

REDESIGN THE SYSTEM: Advancing the RN Scope of Practice in Vascular Access

Vascular access is the most common invasive experience for hospitalized patients. However, it is one of the least planned for events. Vascular access is often seen as merely a task rather than an essential function of healthcare that can significantly affect patient outcomes, especially in the acute hospital stay. Given the significance of access device insertion to modern healthcare delivery, we must understand the implications of this practice on the healthcare system. There is a better way to approach vascular access care.

There is a distinct body of knowledge about how to practice vascular access. Most important to this field of practice is the concept of matching the access device type to the patient’s need for infusion delivery. When choosing a device and insertion method, patient factors and the risk profiles associated with various devices and insertion methods should be considered. In my experience, choosing a device is often left to clinician preference, and the availability of resources and expertise rather than what is most appropriate for the patient. This approach can subject the patient to less-than-ideal procedures, lead to repeated attempts at device insertion, raise complication rates, and even increase the costs of care.

I have learned through my graduate education as a Nurse Practitioner that, in general, healthcare providers do not routinely consider matching the access device with an infusion plan. Many providers do not know the different methods of access or why one is chosen over another. The irony is that these very same providers have the scope of practice to do the procedures, but not the knowledge of current vascular access science to support the practice. On the other hand, many of those with the knowledge and skill do not have the scope of practice. This is a correctable issue and one that can benefit the entire healthcare system if fixed.

The Institute of Medicine (IOM) made it clear in 1999 and again in 2001 with their landmark reports on healthcare quality and safety, that there are too many preventable errors in healthcare. The IOM recommends a systematic approach to knowledge application as a major part of the solution to reduce errors. Errors typically stem from the lack of or inappropriate application of knowledge. One must change the system in order to change the results.

In my practice, I have seen significant roadblocks to central device insertion that are related to both scope of practice and availability of resources. A vascular access nurse who applies evidence-based vascular assessment sometimes has a recommendation for a central access device, but scope of practice limits the nurse’s option to the peripheral access route. Many patients, especially those with chronic renal insufficiency, are not viable candidates for peripherally inserted central catheters (PICCs). This roadblock leads to delays in care, inefficient use of resources, and often a less-than-ideal device for the prescribed treatment plan because the nurse has to convince a medical provider the reason for the suggested device and then find someone to place the device. Unfortunately, providers who have within their scope of practice to place the appropriate central access device often don’t have as much experience with ultrasound guided access as the RN who places PICCs regularly.

Advocating for quality improvement in vascular access is a high priority for me. As the President of the New Hampshire Association for Vascular Access, I have addressed the New Hampshire Board of Nursing (NHBON) on this issue. Two years ago, I spoke about quality and competency in vascular access. More recently, I presented on the question of Registered Nurse Scope of Practice with respect to ultrasound guided central venous catheter (CVC) insertion. Jim Lacy RN, in conjunction with Teleflex Medical, Inc. put together a packet of supporting evidence and board decisions from other states on the issue of RN CVC insertion. I added my own thoughts in a letter of introduction and hand delivered the packet to the Executive Director of the NHBON in order to explain the importance of this change in Scope of Practice.

At the March 21, 2013 NHBON meeting, I addressed the scope of practice change with the goal of presenting the issue in its simplest form: it is a procedure that is being done in other states by RNs and is not new in terms of clinical principle or skill. This procedure is about guiding a needle to a vein and RNs proficient with ultrasound guided PICC insertion can apply this skill to other, even larger, veins. In fact, RNs skilled with ultrasound access are probably more qualified to access the vein than those doing the procedure without ultrasound or with minimal ultrasound experience. Important to this issue is the fact that many specialized vascular access RNs possess the most current knowledge on how to safely and reliably provide patient centered vascular access.

The NHBON Published Ruling:


Question:
Can RNs, with training and competency, insert CVCs under ultrasound?

Answer: Board opined that it is within RN scope of practice to insert CVCs under ultrasound with competencies, appropriate setting and facility policy. Refer to AZ BON guidelines with interpretation.

The key to progress in health system redesign is to apply best practices and current knowledge in a context specific setting using a systematic methodology. Collaboration among disciplines to share knowledge and understand patient needs can provide optimal care. With respect to vascular access, it is clear that competent vascular access nurses can and should take on a much larger role in choosing and inserting all vascular access devices.

Personally, I changed my scope of practice by becoming a board certified acute care nurse practitioner specializing in vascular access. I want to be able to help others expand their scope as an RN or Advanced Practice RN (APRN) to benefit the healthcare system. There is a better way to provide vascular access, but the system needs to be redesigned.

Robert Dawson, DNP, MSA, APRN, ACNP-BC, CPUI, VA-BC TM

Rob is a leading clinical expert in peripheral vascular access procedures, and a lead consultant focusing on a systematic process improvement for vascular access services. He has published in several peer reviewed journals as well as presented nationally and internationally on vascular access training standards. He is the first person in the country to use his DNP degree program to specialize in vascular access both clinically and theoretically. He has been a Naval Nurse Corps Officer, Clinical Vascular Access Manager and Nurse Administrator. He holds a graduate degree in Health Services Administration, and currently owns his own consulting practice. He is the founder and president of the New Hampshire Vascular Access Association, has served on the AVA Nominations and Bylaws Committee. He is a Member of the Board of Directors of the AVA Foundation.  Rob is currently working as a Nurse Consultant and Clinician for PICC Academy, Concord Hospital in Nashua, New Hampshire.

Posted by TopicsInVascularAccess at 1:12 PM in /

Tuesday, 11 March 2014


Persevere to Expand Your Scope of Practice and Embrace Your Abilities as a Specialist

Guest Blogger: Connie Girgenti, BSNc, RN, VA-BC™

As a Vascular Access Specialist (VAS), I was taught by my mentor to do what is best for my patients. She asked me, and I continue to ask myself, “What is best for the patient, and on what evidence do I base this decisions?” Asking and answering these two key questions for many years has led me to expand my VAS role, through education and training in vascular access, to include CVC placements.

When assisting with CVC placement, I asked why most physicians don’t use ultrasound. The response I often got was: “This is how I was taught. I have always done it this way.” It was hard to watch them blind stick and stick more than once when I knew I could do better because I had been educated and trained on current technologies and techniques. This was my specialty—accessing veins!

When I started talking about expanding my practice to include the placement of CVCs, many in my local vascular access community did not agree. I was told it was outside my scope of practice, or I wasn’t an advanced practice nurse (APN). Years ago, PIVs and PICCs were only placed by physicians; now, nurses place them as a common practice. I could not help but think, “This was the same fight the thought leaders that came before me fought—for PICC placement!”

After researching Illinois state law and practice documents I learned that CVC placement was, in fact, within my scope of practice. I gathered the evidence to support CVC placements by a VAS, with the goal to gain approval from key medical staff departments at my facility. It wasn’t an easy or short journey. I faced challenges directly and overcame them, including multiple revisions of my proposal, when I met resistance from certain groups. My proposal was patient-centric and focused on the best possible care. As VASs, we know that needle sticks are the most remembered hospital experience. Vascular Access touches all patients and is best performed by dedicated clinicians.

My motivation was clear. Vascular Access Specialists collaborate across disciplines to improve patient outcomes and reduce the risks associated with central venous access device placement. Once I had gained physician support, I approached my chief nursing officer (CNO). When my CNO saw that I had gathered national comparative data on PICC insertions I had performed, she gave her approval for me to move forward. Having this data was critical to my fight. Saying you are ready and able to increase your scope of practice is one thing, but having the facts to back you up is another.

One of the steps that I took to become proficient in CVC placement was attending a Teleflex CVC insertion course, which I found empowering. I was collaborating with others that believed a VAS could and should be accessing vessels beyond the arm. I found the pre-study material to be valuable because we jumped immediately into the hands-on sessions and clinical scenarios led by expert physicians.

One lesson that I took away from my experience is to build relationships with physicians early! If a physician agrees to be a mentor, have a well-written plan. It should include the number of CVCs to be placed with the mentor, and specifically state how you will handle complications. Having a plan and executing on that plan will enable you to achieve your goals and expand your scope of practice.

Once you are ready to begin, choose your battles carefully. I wasn’t going to compromise patient care by giving up the use of ultrasound because some physicians still stick blindly. Our physicians wanted me to suture the CVCs. Instead of challenging them, I learned to suture. It was a learning opportunity that I embraced. Some patients may require sutures for securement, and now I have that skill.

As I reflect on this journey, I realize that each challenge only created a stronger desire to excel beyond PICCs. None of this would have been possible without comparative level data, the ongoing support from my organization and support from VASs throughout the country. The greatest satisfaction comes from knowing I can now place the right device for our patients.
______________________________________________________________________________________

Constance Girgenti, BSNc, RN, VA-BC™, is the Vascular Access Coordinator at Presence Saint Joseph Medical Center, where she has expanded her role to the placement of central venous catheters (CVCs) in the internal jugular, axillary/subclavian and femoral veins. In this role, she is also the system’s Vascular Access Collaborative Chair. She was a founding member of the Illinois Vascular Access Network and currently serves as a committee member for The Association for Vascular Access. Connie is also a published author, and will complete her BSN studies in 2014 and pursue her MSN degree.
Posted by TopicsInVascularAccess at 10:27 AM in /


A QUESTION FROM ONE OF OUR READERS (PLEASE ADD A COMMENT BELOW TO REPLY)

Hello

We have a patient with a single lumen 4Fr PICC inserted via right basilic vein and has been in situ about 4 weeks. Unfortuneately the PICC insertion details were not transferred with the patient from another facility so the date of insertion as well as the type of PICC and insertion details are not yet available.

 The PICC can be removed but it is stuck. After three different attempts to remove it failed (using heat to the PICC arm 20 minutes QID, having patient do active ROM, different patient positions, chest xray confirms no kinks or abnormality) an ultrasound was done and revealed a thrombus from insertion site to the junction of the right axillary vein and subclavian vein. Patient does not have any swelling distal to the PICC site.

A surgeon was consulted, the advice was to, basically, keep trying. Patient’s medical history includes Aplastic anemia with thrombocytopenia, which is curious as to how he got the clot in the first place.

 What else can we do?

Many thanks!

Renee Logan, RN, CVAA(c), CRNI
Parenteral Nurse
University Hospital of Northern BC

 

Posted by TopicsInVascularAccess at 10:09 AM in Questions from Readers

Thursday, 6 March 2014

Topics in Vascular Access is a blog for Vascular Access Specialists and is supported by Teleflex.

This forum is designed to be a purely informational and educational platform where experiences and information can be shared.
Topics by Guest Bloggers in coming weeks include:
  • Persevere to Expand Your Scope of Practice and Embrace Your Abilities as a Specialist Connie Girgenti, BSNc, RN, VA-BC™
  • Discharging patients with Internal Jugular or Axillo-subclavian Catheters-Myth versus reality Jim Lacy, BSN, RN, VA-BC™
  • Vascular Access Team Model - Personal experience with a full-service vascular access team  Julie Eddins, MSN, CRNI®
  • Should Arterial Line Placement be a part of Vascular Access Services? Chris Naylor, RN, VA-BC
  • Risk Reduction Strategies in Vascular Access: The importance of technology and best practices to improve patient outcomes  Michael Drafz, RN, CRNI®, VA-BC
  • And much much more....
Suggestions for topics are welcome and may be submitted by clicking <Mail to Topics in Vascular Access>. This resource has been created for anyone who is interested in vascular access. We encourage questions, replies/responses, insight, or advice or information to be shared with other Vascular Access Specialists.
Posted by TopicsInVascularAccess at 12:06 PM in /

A Guide to Expanding Your Practice: Placement of Central Venous Catheters

A hot topic at the 2013 AVA Annual Scientific Meeting was RN placement of central venous catheters (CVCs). Teleflex introduced a workbook entitled: A Guide to Expanding Your Practice: Placement of Central Venous Catheters. By popular demand, we are making this publication available to readers of this blog as a downloadable PDF.

This publication presents a five-phase process that may assist in developing or expanding vascular access services to include placement of CVCs. In each phase, specific tasks and questions are outlined that lead to the creation of a business plan. Spaces for notes specific to an individual program are included throughout the workbook. Samples of a business plan, policies and procedures and program tools are provided in the appendices. To save view and save a copy click on the link below:

<A Guide to Expanding Your Practice Placement of Central Venous Catheters>

Questions for our Readers

Are you currently inserting CVCs? What barriers to success did you face and overcome?

Are you interested in inserting CVCs? What information would be helpful to you?

Reply to the Blog editor here Topics In Vascular Access

Author: Jim Lacy, BSN, RN, VA-BC TM is employed by Teleflex as Product Manager - Central Venous Access and serves as the current President of the Board of Directors of the Association for Vascular Access (AVA).
Posted by TopicsInVascularAccess at 12:03 PM in /