vascular access devices_setting%0d%0a your organization up for success

Infusion

Safety solutions

36 December 2016 • Nursing Management www.nursingmanagement.com

By Lorelle Wuerz, MSN, BA, BS, RN, VA-BC

majority of the 35.1 million patients admit-

ted to the hospital each year require place-

ment of an intravascular device, with 90%

of patients receiving a peripheral I.V. and

25% receiving a central venous access

device.1,2 This equates to over 7 million

vascular access devices used per year in

the United States.3 Practices related to insertion,

care, and maintenance of vascular access devices

are critical to positive

outcomes. The current

status of quality-driven

and outcome-centered care

isn’t just a goal; it’s now

mandatory in the inpatient

setting. Nurses at all levels

need to be educated on

nurse-sensitive indicators

and aware of individual

unit performance to drive

best practices and better

outcomes for patients.4,5

More important, proactive

engagement in these initia-

tives is imperative.

One outcome measure

that has a significant impact on American hospi-

tals is central line-associated bloodstream infection

(clabsi), which carries a significant patient mortality

risk, as well as implications for the financial sustain-

ability and reputation of healthcare organizations.

Mortality for patients who develop a clabsi can be

up to 25%. Although the overall incidence of clabsi

occurring in the United States is decreasing, the

number still remains at approximately 18,000, with

an estimated cost of between $5,734 and $22,939 per

incident.6,7 According to the Centers for Medicare

and Medicaid Services, clabsi is considered a non-

reimbursable never event if the infection occurs after

the patient is admitted to the acute care setting.8 And

the government now requires public reporting of

institutional outcome data for transparency through

the Hospital Compare

website, tying outcomes

to reputation.9

There have been many

efforts in recent years to

improve clabsi outcomes.

The Institute for Health-

care Improvement has

developed evidence-based

intervention bundles to

structure central line inser-

tion and care.10 In addition,

preinsertion checklists

have been developed to

offer care consistency and

standardization. The CDC

has developed a compre-

hensive guideline for the prevention of intravascular

catheter-related infection.11 Other critical interventions

for the prevention of clabsi include empowering

nurses to take the right steps, engaging multidis-

ciplinary groups on a regular basis to discuss best

practices, and regularly sharing concurrent data and

outcomes for each desirable measure.7

Vascular access devices: Setting your organization up for success

A

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

www.nursingmanagement.com Nursing Management • December 2016 37

Organizations can set them-

selves up for success in terms of

safe, quality care related to central

venous access devices by taking a

simple four-step approach to evalu-

ate the care being provided in their

settings:

• assess current knowledge of those

caring for central venous access

devices

• evaluate current policies and

procedures

• implement appropriate educa-

tional models

• integrate ongoing monitoring.2

AssessmentThe first step to an improved

vascular access program at your

organization includes assessment

of your staff members’ knowl-

edge base as it relates to central

venous access device management.

Nurse leaders should round on

patient care units and speak with

staff members about their practice

habits. Ask questions and survey

nurses about their knowledge to

gain a better understanding of

gaps in maintaining central venous

access devices. (See Table 1.)In addition to gaining an

understanding of staff knowledge,

practices should be observed. Use

a monitoring tool to gather obser-

vational data to help understand

practice variations and opportuni-

ties for improvement. The sample

tool provided is divided into three

sections: 1) observation of practice,

2) a questionnaire, and 3) a review

of electronic documentation compli-

ance. (See Table 2.) Organizations

can modify the left-hand column of

the tool to define what best prac-

tices they want to monitor and do a

point-prevalence data collection.

Policies and proceduresThe second step to setting your

organization up for success is

evaluating the infrastructure that

guides practice through policies

and procedures. Often, there are

several organizational policies and

procedures that discuss or mention

central venous access devices. Poli-

cies and procedures are intended

to facilitate adherence with profes-

sional practices; promote alignment

with compliance and regulatory

requirements; reduce variations in

practice; serve as a resource, espe-

cially for new staff; and eliminate

the need for staff members to rely

on memory.12 Hospitals often strug-

gle with managing policies and

procedures because of the number

of challenges they pose.13 Put best

practices in place so that policies

and procedures are well-managed

and helpful for staff in terms of

improving practice and impacting

patient outcomes.

Best-in-class hospitals have a

collaborative approach to policy

and procedure creation and main-

tenance, with silo-free coordination

and alignment between departments.

Developing committees empow-

ered to streamline policies and

procedures, ensuring that all key

players weigh-in on and commu-

nicate regarding changes, defining

process owners for managing poli-

cies and procedures, and engaging

staff members in the workgroup

responsibilities of reviewing and

managing policies and procedures

are all best practices.13 Organizations

should consider using a system or

template to guide policy and proce-

dure creation to help streamline the

process. In addition, process own-

ers and/or staff members engaged

in the process need basic skills in

understanding how to review and

revise policies and procedures.

Lastly, defining a regular schedule

for reviewing and updating poli-

cies and procedures is a key to sus-

tained success.

Overall, investment in the devel-

opment and review of policies and

procedures can reduce possible

risks and variations in practice,

impacting patient care related to

central venous access devices.

When reviewing your organiza-

tion’s policies and procedures,

ensure that there are no duplica-

tions, inconsistent statements, or

outdated references. Also ensure

that staff practice is aligned with the

policy and the policy is aligned with

practice. Other considerations are

in the length of the policy: Policies

that are long and difficult to read

will be frustrating for staff members

who are looking for guidance. Use

pictures, algorithms, diagrams, and

links to approved videos to stream-

line policies. This basic, but impor-

tant, foundational step will lead to

success in improving your overall

vascular access program.

Table 1: Central venous access device nurse survey

1. How long do you scrub the hub of your central venous access device before accessing it?

2. How often do you change the tubing for your patient’s infusions?

3. How often are central venous access device dressings changed on this unit?

4. What’s your definition of patency?5. Would you use a central venous

access device if it had sluggish or no blood return?



Infusion

Safety solutions

Table 2: Central venous access device monitoring tool

Unit: _____________ Date: ___ /___ /___

#1 #2 #3 #4 #5 #6 #7 #8 #9 #10

Observation Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments

Did the RN perform hand hygiene before touching the patient/CVAD?

Did all hubs have a needleless endcap applied?

Did the RN scrub the hub before any and ALL connections?

Did the RN scrub the central line hub for 15 seconds with alcohol?

Was the tubing for all medications labeled with date, time, and initials?

Was all tubing not in use capped off with a red cap?

Did the central line dressing have the date, time, and initials?

Was the central line dressing intact?

Each lumen of the CVAD flushes without resistance?

Each lumen of the CVAD has brisk blood return (3 mL) free flowing?

For central lines not in use, was an end cap in place?

Questionnaire Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments

RN is able to identify all appropriate times to scrub the hub of the catheter (all connections).

RN is able to verbalize that central line catheters are scrubbed for 15 seconds with alcohol.

RN is able to verbalize that central lines not in use have an end cap applied and they’re changed every 7 days with the dressing.

RN is able to verbalize that tubing for ABX/fluids is changed every 96 hours.

RN is able ot verbalize that tubing for blood products is changed with each unit.

RN is able to verbalize that tubing for PN/lipids is changed every 24 hours.

RN is able to verbalize that tubing for PCA is changed every 96 hours.

RN is able to verbalize that needleless end caps are changed every 7 days, with each new administration set, each new cath-eter insertion, or when visibly soiled or dirty.

RN is able to verbalize that all patients with a central line receive a CHG bath daily and how.

Documentation Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments

Date of last CVAD dressing change in flow sheet?

Date of last CHG bath in flow sheet?

Flushing order sets active in chart?

Flushing documented in MAR?


www.nursingmanagement.com Nursing Management • December 2016 39

EducationThe third step is evaluating edu-

cational models and processes. Do

all nurses regardless of the unit on

which they work receive the same

training and education regarding

central venous access devices upon

hire at your organization? If not,

why? Another consideration is to

understand all of the disciplines

that care for and maintain central

venous access devices. If providers

are manipulating central venous

access devices, have they received

the same training? The standard

of care for a central venous access

device is the same whether a

patient is located on a medical

rehabilitation unit or the ICU. Edu-

cational models should be designed

to offer all staff members the same

knowledge.

Another critical aspect of training

is methodology. Many education

initiatives are delivered to staff via

electronic online formats. Although

these online training modules

pass along information and track

compliance, they aren’t effective at

evaluating hands-on technique or

practices related to central venous

access devices. Organizations

should implement creative ways for

nurses to practice and demonstrate

central venous access device care

and maintenance techniques during

skills days and/or unit-to-unit in-

services. A peer review program for

monitoring skills related to central

venous access device care and man-

agement is also best practice.1,14

MonitoringThe fourth step is deciding how

outcomes will be monitored on

an ongoing basis. One of the big-

gest pitfalls for an organization is

a lack of continuous performance

monitoring. Many organizations

spend time assessing gaps, revis-

ing policies and procedures, and

fully educating staff, and then they

assume that practices are improved.

However, if practices aren’t moni-

tored on an ongoing basis, there’s

no way to evaluate gaps or changes

in performance and make necessary

adjustments. Most important, staff

engagement and involvement with

data collection are pivotal for long-

term success.15 Utilization of staff

champions is a best practice that

can bolster ownership and drive

improved outcomes.16

Organizations should be thought-

ful in selecting staff champions,

providing them with additional

training on how to be engaged in

education, policy and procedure

monitoring, and ongoing data

collection. Ideally, units should have

a champion for each shift and moni-

tor unit performance on a regular

basis. For those units struggling

with performance, more frequent

observations may be needed at

first. Once performance improves,

less frequent observations may be

warranted. Champions gather infor-

mation on the monitoring tool and

bring themes back to their peers to

drive continued improvements. It’s

important to note that this is a non-

punitive, conversational feedback

opportunity for champions to build

relationships and accountability

within the unit.

Areas showing improvement

should be celebrated, whereas areas

that need improvement should be

focused on with discussion, educa-

tion, and monitoring. Staff cham-

pions can discuss central venous

access device topics at regular

meetings, allowing for immediate

adjustments to patient care through

a proactive approach. Champions

make this ongoing peer-to-peer

conversation about central venous

access devices part of the unit’s

culture rather than the flavor of the

month.

The monitoring tool can be

used as data collection or simply

as a guide to improving practice

Best-in-class hospitals have a collaborative approach to policy and

procedure creation and maintenance, with silo-free coordination and

alignment between departments.



Infusion

Safety solutions

through discussions, whichever

is most appropriate for the unit’s

needs. Nurse leaders from all

units can collect monitoring tools

monthly for more formal data,

which can be rolled up and used

for a global view of organization-

wide performance related to central

venous access devices. This can

offer the data elements necessary to

track improved performance or pos-

sibly highlight areas that may need

additional education and training.

Safe, quality careUltimately, safety and quality in

healthcare are a must. Nearly all

admitted patients in today’s acute

care hospital setting receive some

type of vascular access device.

Central venous access devices play

a critical role in patient safety, with

an increased risk of mortality for

those who develop a clabsi. There’s

also a financial and reputational

impact because clabsi outcomes

are publically reported and tied to

organizational reimbursement. Tak-

ing a four-step approach to evaluat-

ing central vascular access device

care and maintenance within your

organization can help you make

overall improvements in patient

outcomes. Assessing knowledge,

standardizing and streamlining

policies and procedures, offering

education to all staff members, and

continuously monitoring outcomes

can drive improvements. NM

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Lorelle Wuerz is the vascular access depart-ment patient care director at NewYork-Presbyterian Hospital in New York, N.Y.

The author has disclosed no financial relation-ships related to this article.

DOI-10.1097/01.NUMA.0000508272.73964.eb

Taking a four-step approach to evaluating central vascular access

device care and maintenance within your organization can help you

make overall improvements in patient outcomes.


vascular access devices_setting%0d%0a your organization up for success

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