Right Line, Right Patient, Right Time by the Right Clinician

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Disclosures• Speaker Bio

• Amy Bardin-Spencer Director, Clinical Affairs – Vascular

• No off label topics will be discussed

3Course Description - Abbreviated

Objectives:• Discuss device selection criteria from peripheral access to acute

central venous access • Review patient criteria and limitations for device insertion• Discuss the time impact on device insertion and removal• Review the criteria for the right clinician as it relates to vascular

access

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Right Line

Course Description - Abbreviated

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Assessment Based Approach

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Right Line

• Staff education for right training and practices• Assessment with treatment considerations• Interdisciplinary application

MC-002316

• Educate and train all staff involved in vascular access practices1

• Selection of the device that is most appropriate for therapy and preserves vessel health

• Insert the smallest device with the least amount of lumens required for therapy1

• Insert the appropriate device using evidence based guidelines

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Education and Training • Didactic and simulation training required with written competency for

vascular access procedures1

• Annual retraining for vascular access procedures1,2

• Training and a trial of all new add on devices or when changes in practice or process occur2

• Employ multiple methods for delivering education2

• Identify procedures/skills/tasks for ongoing competency by using clinical outcome data2

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Basic Device SelectionDecision Tree

Patient Requires IV Therapy

Osmolarity of solution Less than 900mOsm/L

Not listed as irritant or vesicant

Peripheral Access (Three sites or more)

Osmolarity greater than 900 mOsm/L, irritant or vesicant

Needs maximum hemodilution

Central Access(Acute less that 29 days)

Duration less than five days

Maintain by peripheral cannula

Duration greater than five days

Two - Four weeksmidline

Duration less than one year

Consider PICC, Tunneled CVC or

Totally implanted vascular access device

MC-002195

Duration of greater than one year

Tunneled CVC or Totally implanted vascular access device

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Appropriateness Guidelines3

Peripherally Compatible Peripherally Incompatible

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Medication Considerations13

• Healthcare organizations responsibility• Preadmission assessment • Identify risk factors • Risk reduction for administration• Administration through a VAD• Stop when extravasation identified

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Insertion Bundle 5 key components9,10

1. Hand hygiene (waterless alcohol-based hand sanitizer or wash hands with soap and water)

2. Maximal barrier precautions

3. Chlorhexidine skin antisepsis (chlorhexidine >0.5% in alcohol solution)

4. Optimal catheter site selection• Femoral vein should be avoided for central venous access in adult patients (femoral lines may be used

in pediatric patents)

• Subclavian vein favored for non-tunneled catheters

5. Daily review of line necessity, with prompt removal of unnecessary lines

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Maintenance Bundle 4 key components

1. Daily review and documentation of line necessity, with prompt removal and documentation of removal of unnecessary CVCs7

• Establishing a process (such as performing the review during daily rounds) or alert system (for example, a computerized alert) is important in establishing this maintenance process

2. Hand hygiene before intravenous set manipulation7

3. Catheter injection port care (covering open lumens with injection ports, sterile end caps, or needleless connectors; scrubbing the hub for at least 5 seconds; sanitizing access ports before and after use; minimizing cap change frequency)7,8

4. Catheter site dressing monitoring or changes (unless dressing is soiled, damp, or loose, usually changed every 2 days for gauze dressings or every 7 days for clear dressings)7

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Right Patient

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Right Patient MC-002316

• Evaluation of patient risk factors and need • Acute

• Chronic

• Assessment of vascular anatomy• Laboratory values• Exit site considerations• Risk / Benefit• Unit outcomes2

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Patients with High Risk1

• Neutropenia (S52, D3)

• Transplant (S52, D3)

• Burn (S52, D3)

• Critically ill (S52, D3)

• Chemotherapy (S52, A2)

• Pregnancy (S52, A6)

• Trauma (S52, D3)

• History of DVT (S52, A1)

• Catheter exchange (S49, J)

• Previous CLABSI (S49, J)

• Unit CLABSI rate high (S52, D2)

• Emergent insertions (S52, D4)

• Age extremes (S52, A7)

• Patients with multiple intravascular devices (S52, A8)

• Greater than 5 days dwell (S52, D1)

MC-002195

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Device History1,2,5

• Current device assessment • History of insertion

• Review of insertion attempts

• Type and Location of last device • Chronic (tunneled, implanted)

• Acute

• Peripheral (IV, Arterial, Midline, PICC)

• History of implanted devices?• Pacemaker, port, filter etc.

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Patient Assessment12

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Laboratory Values Vascular access

BUN/ Creatinine PT/PTT INR Platelets WBC

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Exit Site Management • Extremity right or left • Neck or Chest• Femoral • Ante cubital region (area of flexion)• Hand

“The goal of device insertion is to potentiate an exit site that is manageable and not a contributing factor to device complications”

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Right Time

Course Description - Abbreviated

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Right Time6MC-002316

• Insertion of device in a timely manner to avoid delay in treatment• Daily assessment and goals for device necessity• Prompt removal of the device when no longer used

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Patient Satisfaction • Limit 2 insertion attempts1

• Use ultrasound technology1,3

• Engage patient in plan, provide options2

• Plan discharge on admission • Patient, clinician and organization

centered care

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Vessel Satisfaction • Site assessment1

• Outcome tracking and reporting1

• Collaborative approach1

• Pharmacy

• Quality/ Risk

• Purchasing

• Leadership

• Catheter to vessel ratio1

• Virchow’s triad • Venous depletion

Hypercoagulability

Vessel Damage Circulatory Stasis

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Organizational Responsibility • Identify the gap2

• Understand the risk2

• Develop a comprehensive multidisciplinary team1

• Provide dedicated resources• Stop silo quick fix strategies

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Right Clinician

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Right Clinician• Passionate about vascular access• Dedicated to outcomes and collaboration• Shares outcomes through data collection• Agile • Change agent• Has broad shoulders • Values certification • Engages in professional organizations • A patient advocate• Has the right attitude

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Right Approach11

• Increased clinically indicated device insertions • Decreased total device orders• Decreased wait times from order to insertion• Decreased infection rates

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“Vascular access is not a product that your team decides to purchase, but a program requiring assessment, data collection, follow-up,

collaboration, education, motivation and accountability to patients requiring timely device placement and removal” A. Bardin-Spencer 2017

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Any Questions?

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1. Gorski LA, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. Journal of Infusion Nursing. 2016;39(1 Supplement):S1–S159.

2. Marschall J, Mermel L, A, Fakih M, Hadaway L, Kallen A, O'Grady N., P., . . . Yokoe, D. S. (2014). Strategies to prevent central line--associated bloodstream

infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35 (7), 753-771. doi:10.1086/676533

3. Chopra, V., Flanders, S. A., Saint, S., Woller, S. C., O'grady, N. P., Safdar, N., ... & Pittiruti, M. (2015). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results

From a Multispecialty Panel Using the RAND/UCLA Appropriateness MethodMichigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of internal medicine,

163(6_Supplement), S1-S40.

4. CDC Centers for Disease Control. (2011) Guidelines for the prevention of intravascular catheter-related infections: Centers for Disease Control and Prevention.

5. Kovacs, C. S., Fatica, C., Butler, R., Gordon, S. M., & Fraser, T. G. (2016). Hospital-acquired Staphylococcus aureus primary bloodstream infection: A

comparison of events that do and do not meet the central line–associated bloodstream infection definition. American journal of infection control, 44(11), 1252-1255.

6. Moureau NL, Trick N, Nifong T, Perry C, Kelley C, Leavett M, Gordan SM, Wallace J, Harvill M, Biggar C, Doll M, Papke L, Benton L and Phelan DA. (2012)

Vessel health and preservation (Part 1): a new evidence-based approach to vascular access selection and management. Journal of Vascular Access 13: 351–356.

7. The Joint Commission. CVC Maintenance Bundles. 2013. http://www.jointcommission.org/assets/1/6/clabsi_toolkit_tool_3-22_cvc_maintenance_bundles.pdf. Accessed Aug 2017.

8. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably

preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011:32(2)101-114.

9. Institute for Healthcare Improvement. Getting Started Kit: Prevent Central Line Infections: How-to Guide. 2005. https://www2.aap.org/visit/IHI.CentralLinesHowtoGuideFINAL52505.pdf.

10. The Joint Commission. CVC Insertion Bundles. 2013. http://www.jointcommission.org/assets/1/6/clabsi_toolkit_tool_3-18_cvc_insertion_bundles.pdf.

11. Johnson, D., Snyder, T., Strader, D., & Zamora, A. (2017). Original Article: Positive Influence of a Dedicated Vascular Access Team in an Acute Care Hospital. Journal Of The Association

For Vascular Access, 2235-37. doi:10.1016/j.java.2016.12.002

12. Pittiruti, M. (2012). Ultrasound guided central vascular access in neonates, infants and children. Current drug targets, 13(7), 961-969.

13. Gorski, L. A., Stranz, M., Cook, L. S., Joseph, J. M., Kokotis, K., Sabatino-Holmes, P., & Van Gosen, L. (2017). Development of an Evidence-Based List of Noncytotoxic Vesicant

edications and Solutions. Journal of Infusion Nursing, 40(1), 26-40.

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References