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:

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.


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 /
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