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 /



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
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