How to Prepare for Advancement to Central Venous Access Device Insertion Beyond Peripherally Inserted Central Catheters: Socially Relevant

Abstract

In today’s health care landscape, vascular access teams (VATs) are often tapped to increase appropriate device utility or independently seek ways to insert various central venous access devices (CVADs) not limited to peripherally inserted central catheters (PICCs). This includes all models of VAT models (APRN, NPs, RN, RT, RRT) seeking to provide a dedicated resource when a PICC is not appropriate for the patient. This is especially important when an alternative CVAD is indicated based on medication characteristics, duration of therapies, or anatomical limitations.1 As a resource dedicated to vascular access, it is critical that you have the ability and autonomy to assess and select the most appropriate device every time.2 Equally as important is that CVAD insertion is performed by an expert, using ultrasound with appropriate training, competency, and procedural volume while utilizing best practices.1,3Many clinicians take to social media to ask how to get started and who to ask. Prior to that step, the team should have a well-documented need to justify this clinical advancement. With that, let us review the minimal required considerations. Initially, it is important to identify the gaps within your organization—there are 2 significant gaps to outline to ensure the possible advancement supports the overall organizational goals.First, identify if a gap currently exists in an underresourced care area, patient population, or delay in care. For teams that track clinical outcome data closely, this could be easily identified based on device appropriateness documentation. This requires that your organization utilizes a standardized methodology for device selection and honest recognition when an alternate CVAD is indicated. This tracking will help identify procedural volume, a significant element relevant to advancement as risk is minimized when appropriate as procedural volume supports clinician confidence and competency.Second, identify the gap related to both reported and nonreported organization quality measures. Each organization has quality metrics that drive financial reimbursement related to vascular access which include CRSBI, CLASBI, CABSI, and more recently, hospital-onset bacteremia (HOB). Quality and process improvement initiatives within health care organizations should utilize benchmarks to identify, measure, and guide the process.1,4 Below is a list of questions to get you started. Keep in mind that well-adopted and sustainable programs are guided by established process improvement efforts driven by a need to improve a desired outcome.What are the current reported infection rates?What are the types of bacteremia/pathogen and device sources?Do you have representation on the CLABSI or quality committee?What are the infection prevention goals of your organization?Much like a product change, when considering advancement, you need to fully understand the value this advancement could bring to the organization. Partnering with your infection prevention (IP) department and quality teams is critical. IP teams manage through complex strategies to ensure harm prevention strategies are measured and benchmarks are routinely analyzed. Quality and risk management teams seek opportunities to improve the quality of care provided within the organization and reduce overall risk. These 3 groups should be included as part of your assessment plan when advancing to the insertion of additional CVADs. Both reportable and nonreportable collected harm metrics should be unit specific and by device type. These 2 factors will allow advancement, deployment, and prioritization in the hospital area with the highest risk. Advancement is not a quick process, yet knowing this detail allows teams to develop aligned strategies to augment device care or surveillance to support risk reduction. Several established teams have initiated formalized care, maintenance, and surveillance programs during the gap assessment process. This consideration supports unit-specific awareness and relationships needed to fully understand dynamics and basic practice gaps in all areas of the hospital. For hospitals to get ahead of vascular-access-related harm events, device insertion, management, and removal need a dedicated, systematic, standardized, and reproducible model of care.4VAT design and responsibilities vary between a nonacademic and academic organization.3 Ensure that your team is fully supporting all aspects of CVAD care. This may include daily device follow up, education, unit training, care and maintenance, observation, and catheter occlusion management. Being a comprehensive team establishes your team as an organizational solution; therefore, advancement may have less barriers. Another consideration will be service hours. Teams with limited availability are limited to advance as the need for appropriate vascular access is not limited to 8:00 a.m. to 5:00 p.m. hours.In general, nonacademic hospitals adopt an advancement model at a higher rate due to resource limitations. Academic centers will always have required resident training, and this is not a reason not to have the VAT advance practice.3 Academic centers require a collaborative relationship to ensure the resident training is maintained and supported by evidence-based practice guidelines by experts.5 Your team’s ability to support resident training, mentor new inserters, and educate creates relationships of support and mutual interest. Keep in mind, for academic settings, the team seeking advancement desires the opportunity to insert the most appropriate device on patients already being referred to the VAT for either a peripheral catheter, midline, or PICC.5Assess the current team and team size. Not all individuals want to advance, and it is important that you have the stakeholders with the right attitude on the team. Change is not easy, and it is even harder if team members are not aligned or resourced to cover this advancement. Team size matters, as you do not want to take on additional responsibilities if you do not have enough team members to proactively provide comprehensive vascular access.Only once the need has been fully identified and internal relationships established should the process of advancement be approached. Each professional board has a scope-of-practice position, and these vary slightly by state. Prior to discussing with your professional board, you should have a draft hospital policy, training plan, scope of practice in the surrounding states, and the gap assessment.Finally, you are not alone. Your AVA networks are here to support questions, as there are many states that have successfully advanced practice.