“veins are like real estate – god isn’t making anymore of it.”- ken symington “if you want...
TRANSCRIPT
“Veins are like real estate – God isn’t making anymore of it.”- Ken Symington
“If you want to go fast-go alone, but if you want to go far-go together”- African proverb
Professional Realization via Collaboration
Why did I Submit this for a Presentation?
• My yearly anemic “show of hands” of belonging to a comprehensive VAS program is barely improving (BTW- time for a poll)
• You who do not are missing an important patient care and professional satisfaction “boat”
• It runs contrary to the mission of this annual meeting which is to enlighten and to network
• Because we are less of a patient advocate than we should be if we are not a member of a comprehensive team- we are less of a resource
• To get a comprehensive outcome you need a comprehensive input
• As a professional, it is our duty to function, to the best of our abilities, as part of a clinical care team- ex. Stroke, cancer, etc.., whenever it is in the best interest of the patient
What does “Comprehensive” Mean ?
• You recognize all the necessary elements of what constitutes modern complete vascular care- VAD device selection, patient needs/special circumstances, catheter dressing placement and surveillance, sonographic guidance, ecg guidance, vendor relations, educational certification and ce’s, your specific political milieu , service with a conscience, risks, risk reduction , complication recognition, complication treatment and if need be-referral and patient follow up.
• You vow to excel at all of them yourself or align yourself with those who can do what you for whatever reason can not.
• Put another way: group mastery of knowledge and process
What is Needed
• A team leader / figure head -analogous to a clinical coordinator, e.g., stroke program. Somebody has got to take the clinical and political heat, do the PR and be the face of your team
• Should be a small group directing the leader (s)
• Not just what device and who inserts it, but also:• Hospital staff education• VAD (nurse) assessment• VAD repeat (nurse) assessment• Purchasing cooperation• QA metrics
• Can be a model for your hospital for additional clinical improvement programs that are felt needed or linked to governmental payment incentives/ penalties
Vascular Access Planning- Solution Statement
“On admission, the patient will have a vascular access plan that meets his/her needs. The plan will be reevaluated at regular intervals or as patient condition changes” Implemented decision algorithm based on following FACTORS: Drug(s) Diagnosis(s Length of anticipated drug therapy Vein condition Individual, patient-specific considerations
Source: Barton & Danek. “Improving patient outcome thru CQI vascularAccess planning. J Nrsg Qual Care 1998 13(2) 77-85
How to become a VAD Champion-KNOWLEDGE and CONVICTION
• Know venous anatomy• Know venous pathology and how to treat it• Know the infusates• Know and use an algorithm(s)• Know assessment methods available• Attend courses• Teach courses• Know how to place any device in your algorithm
(or know someone who can)-and do it well• Use ultrasound every time• Know where the VAD tip belongs• Know your local politics• BE WILLING TO TAKE A CHANCE
6
Knowledge- there is a Great Deal to Know !
The Vascular Access Certification Corporation (VACC) is an independent non-profit organization dedicated to the validation, through certification, of a specialized body of knowledge for all professionals working in the field of vascular access.
Get credentialed!
Picking the Right (Best) VAD – Not Easy
Variables to consider:• Drug
• Ph <5 and >9• Osmolarity >600• mOsm/L• Vesicant
• Patient• Visible veins• Palpable veins
• Location of therapy
Source: Josephson: Intravenous Infusion Therapy for Nurses (2004) PG 290
• Activities• Lifestyle
• Therapy• Time length• Location
• Underlying medical conditions• Diagnosis
Don’t be like me at home!
You have got to have a VAD Algorithm
But never forget- any Algorithm however Good it may be, is still just a Tool
• Not just what device and who inserts it, but also:• Hospital staff education• VAD (nurse) assessment• VAD repeat (nurse) assessment• Purchasing dept. and vendor cooperation• QA metrics
*THE INSERTION PROCEDURE AMOUNTS TO LESS THAN 1% OF AN AVERAGE CATHETER’S LIFETIME
VAS Silos Come in All Shapes and Sizes
hospital
home care
any silo is still a silo !
The Consequences of Working in your own VAD Silo
• Self importance or paranoia- depending on who you are- both bad (xenophobia)
• Over or under- estimation of abilities
• Unlikely to be as current as you could(should)be
• Lonely
• Boring
• Limiting
• Depth without breadth
• Might be financially a bad move
• Psychological , emotional, professional and intellectual blunder
*Known team sport truism- you play to the level of ability you surround yourself with
Somebody has to be in Charge – Consider Nominating IR ( if they will accept). Why IR ?
• Makes sense- that is where most VA problems end up
• Can place every device necessary
• Can fix most problems
• They have not only all the VAD’s but lot’s of very cool and often expensive gadgets to salvage the access
• They are usually very nice people
• Usually have reasonable hospital clout
• If IR does not work out for you , find some other service/ person
Why should IR (anyone) be Motivated to be VA Director ?
• Allows them to manage there day better by minimizing problems/ on call cases! Nip it in the bud.
• Facilitates better patient care!
• It could be someone else in charge!
• There could be no one in charge!
• Hospital might pay them a stipend! ( If IR, and in private practice then group might agree !)
• Because it is necessary!
• Because it is clinically rewarding!
Why Join/Create a Comprehensive VAD Service?Is your Status Quo Acceptable?
• It is the right thing to do for the patient
• One day you might be the patient!
• It is fun and intellectually stimulating
• Protect your job
• Protect your turf
• You might have to some day anyways just to stay relevant- “if you do not like change you will like being irrelevant even less” -General Eric Shinseki and Lack LeDonne!
Hospital VAD Inserters: Is it really like trying to herd cats?
• NURSES
• PA’S
• NP’S
• PARAMEDICS
• STUDENTS
• MD’S-
MD’S that place VAD’s- yes these guys are like herding cats !
• IR
• Intensivists
• Hospitalists
• ER
• Nephrologists
• Surgeons- Vascular, General, Oncologic, Trauma
• Anesthesiologists
How do we get VAD Corporations who have both monetary incentive/benefit and fiscal reserves, to enlist/assist us in creating VAD teams?
• Tell them that we want it• Tell them we expect it- a patient responsibility• Tell them it shows their commitment to patient care as well as
profit• Tell them the are a key element in the advancement of vascular
access as a multi-disciplinary specialty• Tell them a greater team approach to VA results in more
appropriate placements of their devices• Convince them that those who do partner with us stand to be
the companies most apt to succeed in VA Industry
How might an ideal VAD team / service be constructed in a hospital setting?
• Find your champions• Understand your political situation – everyone’s is unique• Develop political savviness- you will need it• Bring all of the stakeholders with a vested interest in VAD placement,
purchasing and care together• Show how this is a best practice• Show how it can save money and improve outcomes- (we need lots of
work / data on this- Industry resources can really help with this as well as Government)
• Let everyone else think that it was their idea ! (works great with M.D.’s)
VAS Stake- Holders
• Patients
• Champions
• Inserters- paramedics (IO), nurses, mid-levels, physicians
• Hospital Administration
• Infectious Disease
• ICU especially– but really all nursing floors benefit
• Purchasing
• Risk Management
• Vendors
• Suggest a Mediator?
Annual Estimated Usage of VADs in U.S. vs. OUS
US data OUS Data
PIVs 375000000 836870000
Acute CVC 4208000 9600000
Tunneled 578000 794000
PICCs 3339000 1550000
Port 529500 490000
VAD’s are a Pyramid of use (and big business)
Source: Millennium Research Group 2014
8.7 million total central VAD’s
1.2 billion PIV’s
VAD total US Market $- Trends
Know your Vendors and Know their Products
In units sold- skewed in some respects
Know your Vendors and Know their Products
Market leaders VAD’s with market share by product line
Corporate Collaboration
Vendor Collaboration
• We need their devices
• We need their training
• We need their sponsorship
• We must accept the sales component- after all this is the USA!
• We must try and separate substance from hype
• We trust they want to help patients
• They need to sell their products/ services
• WE ARE INEXTRICABLY INTERTWINED IN A SYMBIOTIC RELATIONSHIP- SO EMBRACE IT
How can a VAD Inserter who works in a Non-Hospital Setting become Involved in an Idealized Virtual VAD Team/Service?
• Virtual VAD teams less costly and more easy to organize -fewer impediments• For you working in such a setting- Pick your "fantasy " VAD team• Know the elements of a complete VAS• Search out like-minded VA specialist with complimentary skill sets to
complete your team- you will not be successful with 11 QB’s• Be mindful of political & business impediments- develop needed strategies• AVA networks Ideal for this kind of “networking”- join one• Attend AVA meetings- meet specialists and test them as a potential network
partner• Consider loosely bound comprehensive local referral pathways- you can
control patient referral traffic – they can reciprocate- 2 way street
What are the Barricades to Developing an Ideal VAD Team?
• Denying its’ importance
• Being lazy or seemingly too much work
• Not being connected- AVA networks, meetings, social media
• Not knowing or agreeing to what are the essential elements of comp VAS
• Being afraid to show your weaknesses
• Not understanding that device companies can help communicate the clinical and economic value of a VAD team
• Thinking that the status quo will last
• Thinking someone will find you instead- be proactive, make the first move
Convincing the Hospital: the Economics of a Comprehensive VAS
• Needs a great deal of focused research/ data. We all feel intuitively that the answer is yes- need the evidence
• Draw hospitals into our world- CLABSI can be and should be leveraged (my hospital economics with CLABSI as ex,) – great opportunity in this silver lined cloud – *av. CLABSI cost is 15-45k $
• If comprehensive VAS can accomplish a value added recognition then it will likely thrive as a comprehensive service
• Have industry assist in compiling evidence and in education
* source: Multiple
Can the resultant improvements and decreased complications exceed the potential increased costs of admin and otherwise?
Will non -payment for “Never Events"– present and future, be a driving factor in creating comprehensive VAD teams ? A quick summary of NE
• Never Event Hx:
Despite the widespread usage of the term "never events," the National Quality Forum (NQF) refers to these events as "serious reportable events" in all of their definitions and references.
In this editorial, we use the popular - but likely improper - term "never events" as it further illustrates the public's perception of adverse occurrences. Although the preferred terminology reverts to "serious reportable events", this definition may be unlikely be given the prevalence of the viscerally moving term "never event.“ *
.Non- reimbursable by Medicare, Medicaid and 3rd party payers following suit• Presently # are 3 related to VA- PTX, AE and CLABSI, 1 = 15-45 k $• Yes- money talks, as does being called out in public (my experience with the 5
am. Spokane news)• My Belief: More NE’s on the way with ever greater financial implications-YES more
Need for teamwork
*source: NEhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814808/
“If you do not like change you will like being irrelevant even less” – General Eric Shinseki
You Need To Be In This Picture to stay Relevant!
My OWN VAS at HFH- Team Members Speak Out
•Heather Barfield•Jim Sissons
Heather Barfield
Jim Sissons
Collaborating with Industry
Ryan Lemon
Strategic Marketing Manager
Bard Access Systems
Financial Disclosures
Please include the following information:Disclosure of Relevant Financial RelationshipsI have the following financial relationships to disclose:Stockholder in: Abbott Laboratories, Boston Scientific, C.R. Bard and HospiraEmployee of: C.R. Bard (Bard Access Systems)
Disclosure of Off-Label and/or investigative UsesI will not discuss off label use and/or investigational use in my presentation.
Elements of Collaboration
Listen Act Do
The Med Device Development Process1
Design Ouptut (aka the product you
use)
Design Validation
Design Verificatio
n
Design Input
Manufacturing Process Validation
1FDA 21 CFR 820.30 Design Control Guidance for Medical Device Manufacturers
Understanding Your Problem(s)
I hear and forget.
I see and I remember.
I do and I understand.
- Confucius
Allow industry to view your procedures, listen to your administration concerns as often as you can and together we provide solutions.
Attributes of a Great Industry Partner
• Patient Centric• Safety 1st
• Satisfaction
• Consistently researching to understand the problem• Blind surveys, interviews, watching procedures “feeling the pain”• Empathetic that your job satisfaction is important too
• Providing support• Clinical education• Product training, re-training intervals• Assist with justification (e.g. a VAS team) and evidence• Explains the reason for the product solution & shows you how it works
Attributes of a Great Healthcare Provider Partner (aka-You)
• Patient Centric• Safety 1st
• Satisfaction
• Straightforward• What we NEED to hear vs want to hear
• Objective Minded• Data driven – show us the problem versus tell us • Collaborative – (unbiased to brand)• Provide the entire perspective (let’s not create unintended consequences)
Become a comprehensive team member
• Collaboration leadership works…for us and you
• Collaboration drives changes in improving healthcare
• Driven by deep understanding of needs, wants and preferences
• Fueled by curiosity
• Delivering value is timeless and global
• Medical device developers seek your input
We are listening and committed
2015
Thank you
MC-PP-887
CollaborationJudy Thompson MSN, RN, VA-BC
Financial Disclosures
Please include the following information:I have the following financial relationships to disclose:
Clinical Education Manager - Teleflex MedicalVascular Access Specialist – Sharp HealthcareEmployee - Kaiser Permanente
I will not discuss off label use and/or investigational use in my presentation.
Why Collaborate?
•No one person has all the answer•Common Goals
How has Collaboration effected my Practice?
• Enabled my advancement of practice• Opened Opportunities• Increased Patient Safety
How to use Collaboration in your Daily Practice?
• Leave your ego at the door• It’s not about ‘your’ point• It’s about ‘the’ point• Attention to Bias
How to use Collaboration in your Daily Practice?
• Focus on Listening• Be ‘In the Moment”• Computer• Phone• Text• Response
MC-PP-887
Jack LeDonne
Know your Vendors and Know their Products
• Pie Chart market leaders breadth of product lines