IMPLEMENTATION OF A DIFFICULT VENOUS ACCESS (DiVa) PATHWAY Evan Alexandrou RN MPH PhD Clinical Nurse Consultant, Central Venous Access Service Liverpool Hospital Senior Lecturer Western Sydney University
Disclosures AVATAR research is supported by competitive government, university, hospital and professional organisation research grants as well as industry unrestricted donations, investigator initiated research/educational grants and occasional consultancy payments from the following companies: 3M, Adhezion, Angiodynamics, Bard, Baxter, BBraun, BD, Carefusion, Centurion, Cook, Entrotech, Flomedical, Hospira, Mayo, Medtronic, ResQDevices, Smiths, Teleflex, Vygon This presentation is independently prepared and reflects no commercial entity nor promotes particular products unless these are supported by research data Sources of funding for each particular research study will be disclosed throughout this presentation PRNewswire. (2014). Global Peripheral I.V. Catheter Market 2014-2018. from http://www.prnewswire.com/news-releases/global-peripheral-iv-catheter-market- 2014-2018-257019061.html Alexandrou, Evan, Ramjan, Lucie, Murphy, Jeff, Hunt, Leanne, Betihavas, Vasiliki, & Frost, Steven A. (2012). Training of Undergraduate Clinicians in Vascular Access: An Integrative Review. Journal of the Association for Vascular Access, 17(3), 146-158.
Background Over 80% of patients coming to hospital will require some form of vascular access Nearly 60% will require a short PIVC. Needed for hydration, blood products, antibiotics and other therapies Typically the first invasive procedure attended when patients present to hospital PRNewswire. (2014). Global Peripheral I.V. Catheter Market 2014-2018. from http://www.prnewswire.com/news-releases/global-peripheral-iv-catheter-market- 2014-2018-257019061.html Alexandrou, Evan, Ramjan, Lucie, Murphy, Jeff, Hunt, Leanne, Betihavas, Vasiliki, & Frost, Steven A. (2012). Training of Undergraduate Clinicians in Vascular Access: An Integrative Review. Journal of the Association for Vascular Access, 17(3), 146-158.
Helm, Robert E, Klausner, Jeffrey D, Klemperer, John D, Flint, Lori M, & Huang, Emily. (2015). Accepted but Unacceptable: Peripheral IV Catheter Failure. Journal of Infusion Nursing, 38(3), 189-203. Zingg, Walter, & Pittet, Didier. (2009). Peripheral venous catheters: anunder-evaluatedproblem. International journal ofantimicrobial agents, 34, S38-S42. Rickard, Claire M, Webster, Joan, Wallis, Marianne C, Marsh, Nicole, McGrail, Matthew R, French, Venessa, Zhang, Li. (2012). Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. The Lancet, 380(9847), 1066-1074 Background PIVCs have an under appreciated failure rate. Up to 90% of PIVCs are prematurely removed or dislodge before they are due for removal! Complications include phlebitis (mechanical / chemical / infective), infiltration, occlusion and dislodgement
Background One third of patients present with difficult access Require multiple attempts at cannulation Increased failure rates compared to patients with good access May need escalation to CVAD Ahlqvist M, Berglund B, Nordstrom G, Klang B, Wirén M, Johansson E. A new reliable tool (PVC assess) for assessment of peripheral venous catheters. Journal of Evaluation in Clinical Practice. 2010;16(6):1108-1115. Webster J, Clarke S, Paterson D, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ: British Medical Journal. 2008;337:a339(7662).
Background Main Reason: Increasing Chronicity and Acuity.. Increased survival rates with chronic disease Patients present sicker Intensive care beds now a premium Sick patients pushed out onto wards Typically this cohort becomes harder to cannulate over time
Background Consequences of difficult access: Multiple painful attempts (sometimes severe pain) Delay in treatment Increased risk of phlebitis and thrombosis Increased risk of infection Increased length of stay Bahl, A., Pandurangadu, A. V., Tucker, J., & Bagan, M. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients. The American Journal of Emergency Medicine, 34(10), 1950-1954. Fields, J. M., Piela, N. E., & Ku, B. S. (2013). Association between multiple IV attempts and perceived pain levels in the emergency department. The journal of vascular access, 15(6), 514-518.
Background Difficult access leads to premature failure of PIVC: PIVC then requires re-siting Further painful attempts Increased anxiety of patient Eventual venous depletion from multiple attempts Needing CICC vs PICC Moureau, N. L., Trick, N., Nifong, T., Perry, C., Kelley, C., Carrico, R.,... & Biggar, C. (2011). Vessel health and preservation (Part 1): a new evidence-based approach to vascular access selection and management. The journal of vascular access, 13(3), 351-356
Background In my hospital: Increasing patients with difficult access Medical / Nursing teams unable to cannulate Anaesthetics unable to cannulate in a timely fashion due to competing work demands Patients presenting for PICCs after multiple cannulation attempts - (20-30 attempts) Unable to insert PICC due to extensive bruising / thrombosis CVC inserted
Background We Needed To Do Something Enter. DiVA Difficult intravenous Access Pathway
DiVA Pathway incorporated our 5 Rights The RIGHT trained clinician (credentialed, has procedural load) inserts The RIGHT device (length of dwell, infusate characteristics) into The RIGHT vessel (after vascular assessment) for. The RIGHT patient (clinical assessment, allergies, coags, GFR etc.) at The Right time (early intervention for timely treatment)
DiVA Development with Ultrasound Training Ultrasound Guidance: US has become standard practice for CVADs Can mitigate many risks (pneumothorax / arterial puncture / nerve damage) The use of US for PIVCs is emerging as an acceptable practice - machines getting cheaper / more accessible US guidance by an experienced user can have a 4 fold increase in cannulation success Wu, S. Y., Ling, Q., Cao, L. H., Wang, J., Xu, M. X., & Zeng, W. A. (2013). Real-time Two-dimensional Ultrasound Guidance for Central Venous CannulationA Meta-analysis. The Journal of the American Society of Anesthesiologists, 118(2), 361-375. Lamperti, M., Bodenham, A. R., Pittiruti, M., Blaivas, M., Augoustides, J. G., Elbarbary, M.,... & Scoppettuolo, G. (2012). International evidence-based recommendations on ultrasound-guided vascular access. Intensive care medicine, 38(7), 1105-1117. Brass, P., Hellmich, M., Kolodziej, L., Schick, G., & Smith, A. F. (2015). Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev, 1.
DiVA Development Executive buy in: Medical and Nursing executive were briefed on the problem and the solution to provide trained personnel 24hrs for difficult cannulation Training program was endorsed by ICU director and JMO training director who took on governance
DiVA Development After hours CNC s / select JMO training: Completed a theory component addressing vascular anatomy and assessment, aseptic technique and ultrasound principles Practical training and 5 supervised ultrasound guided procedures
DiVA Pathway 24hr cover Business Hours: 1. Admitting Team Registrar 2. Duty Anaesthetist 3. Central Venous Access CNC After Hours : 1. Ward Senior 2. After hours Clinical Nurse Consultant 3. Duty Anaesthetist 4. ICU Registrar for urgent Central Access
January 2016 DiVa pathway became formal hospital policy Nursing staff empowered in policy to initiate referrals for CVAD/Midline after identifying DiVA patient and discussing with treating team
IV Decision Tool Incorporating DiVa
DiVA Effect In the first year (2016) we inserted midlines or CVADs in over 200 patients where the primary reason was difficult access Direct referrals from DiVa protocol True number would be close to 400 (Primary reason antibiotics, secondary reason difficult access) In 2016 DiVa accounted for 25% of service workload
PIVCs inserted with ultrasound by AH CNCs
PIVCs inserted with ultrasound by AH CNCs
PIVCs inserted with ultrasound by AH CNCs 30% of patients had 4 or more attempts prior to USGPIVC referral
PIVCs inserted with ultrasound by AH CNCs 40% of patients experienced 8/10 pain or more with non USGPIVC attempts
DiVA Pathway In Summary: DiVa pathway provides clinical staff with a solution to obtain IV access in difficult patients Guides thinking towards the most appropriate device for DiVA patients Reduced multiple cannulation attempts Allows timely referral for Central Venous Access when required Incorporates the 5 Rights of vascular access for improved outcomes Thus far has been a successful initiative at Liverpool Hospital
Questions? DiVa Team at Liverpool Hospital: Vanno Sou AH CNC Craig McManus AH CNC Julie Ale AH CNC Nicholas Mifflin CNC Central venous Access service Evan Alexandrou CNC Central Venous Access Service Anaesthetic Department AH Junior Medical Officers