Maximizing vessel health

EHM talks to Nancy Moureau about the current challenges in vascular access.

What are the different types of vascular access devices used in chronic and acute illness?

Nancy Moureau. Central venous catheters (CVC)are most commonly used for patients requiring treatment over fives days and extending into months and years. The CVCs include peripherally inserted central catheters (PICC), tunneled CVCs and implanted Ports, then hemodialysis catheters for renal failure.

Short peripheral catheters are used when a patient needs to have intravenous medications for less than five days. PICC lines are considered one of the lowest risk devices for insertion because they're peripheral, which is why they are one of the more common choices here in the US; we're replacing about three million PICCs a year.

Then there are tunneled central venous catheters and non-tunneled. With acute illness, non-tunneled triple lumen catheters are more common in the hospital setting. In the outpatient or alternate care with chronic illness, tunneled central venous catheters carry a lower risk of infection. PICC lines and tunneled central venous catheters are both used in alternate care.

What role do these devices play in the delivering appropriate therapy across the chronic disease spectrum?

NM.In this day and age, central venous catheters are needed for almost all treatment plans. Every patient that is receiving some sort of treatment for their illness almost always has an intravenous medication ordered - whether they're cancer patients, patients with infection, or various types of problems - it is most common to have intravenous medications ordered, at least in the beginning, for acute and for chronic illness.

Without reliable vascular access, patients are not able to receive their medications, experience delays, more trauma with multiple accesses and medication is wasted all contributing to greater cost. Choosing the right device, for the individual patient and treatment plan, is key to getting the treatment job done and using money efficiently in healthcare.

There are chronic illnesses like Crohn's disease that require infusions of nutritional substances over a long period of time and the type of device that's chosen for these patients is somewhat dependent on the patient's preference, but also on the level of risk that the device would carry. The choice is a balance between the device that will work for their treatment, the duration of time that it's needed, the preference of the patient and the level of risk that the device would carry, choosing the lowest risk, of course.

How can medical professionals choose which devices to use to meet the needs of specific chronically ill patients?

NM.Enhanced communication between healthcare workers, MDs, RNs and specialty professionals will provide the means to improve the selection process for vascular access, speed selection and delivery of the device and efficiently administer the treatment plan. I am involved with a group of vascular access specialists, and doctors that have joined together with the help of Teleflex Medical to create a Vessel Health and Preservation Program aimed at developing an intentional selection process that can be applied in all hospitals for all patients.

The Vessel Health and Preservation Program was an effort to make sense out of the selection process for all medical professionals to create a standardized process for selection, placement, assessment and then discontinuation of the device. The way that we approached these issues were to bring a group of experts together, work on the process, work on creating a program that is evidence based, develop the program and the tools that were necessary for the program, and then work with individual hospitals on customizing and implementing the program. That's what we're doing now.

The VHP protocol is not just for selection; it also applies best practices to selection, insertion, daily assessment, discontinuation of the device and even continued in alternate care if needed. This is the first time I have seen a group work together to create a standardized approach to vascular access and one where the company is making the process available to all in a way that they can customize it to fit their facility.

I have been working on clinical pathways for vascular access for quite some time and it is much more than just an algorithm or decision tree, taking into account the whole patient, individual risk factors, treatment plan and conditions.

Medical professionals should choose the right device with a selection process within 24 hours of patient admission to acute care, placement within 48 hours if a CVC is needed and assessment each and every day as to whether it is still the right device.

What are the issues involved in tracking patients with existing vascular access devices once they are back in the community?

NM. Vascular access devices have become so common place in the US for alternate care that I believe they are managed quite well, sometimes by home health nurses and sometimes by the patient or family members taught in management.

However, processes for tracking patients and their device is inconsistent due to variations in companies that do alternate care with home health and clinic facilities. I don't have a solution for that as yet. I think that a Vessel Health and Preservation Program could carry over into alternate care and allow for a means of management and tracking of devices in a way that we haven't done before.

What are the other current top-of-mind issues in vascular access?

NM.In terms of vascular access, one of the most important things is communication between healthcare professionals. Working together and recognizing particular areas of expertise with the vascular access specialists that are growing in the hospital and with the physicians to really determine the best way or the best device for the patient is most important. Applying best practices in the development of vascular access teams that work within acute care and help to manage the transition into alternate care is also very important.

We've seen from research that enhancing communication between medical professionals improves the outcomes for patients. That's what we're trying to focus on with Vessel Health and Preservation in addition to establishing a true process.

Biography

Nancy Moureau is President and CEO of PICC Excellence, Inc.

Diagnostic criteria for PICCS

Use of diagnostic criteria for PICCs can guide the way to early device selection and placement promoting vein preservation. Admission of patients with this short list of diagnoses should trigger a referral to the vascular access specialists for assessment of the best device.

• Burns of more than 30% of body
• Cellulitis
• Ulcerative Colitis/Malabsorption
• Complicated Pneumonia
• Crohn's Disease
• Infection/Septisemia
• Lyme Disease
• Bacterial Meningitis
• Osteomyelitis
• Pancreatitis

Source: Indications for inclusion and exclusion of PICCs and CVCs, PICC Excellence, Inc., March 1, 2010

Exclusion criteria for CVCs

Central venous catheters, both percutaneous and tunneled are used for situations where immediate access, high volume fluid delivery, or long term access is needed. While generally CVCs can provide a reliable form of vascular access, there are some contraindications and exclusion criteria for limiting their insertion. The list below includes some of the known exclusions and is not considered comprehensive.

Source: Indications for inclusion and exclusion of PICCs and CVCs, PICC Excellence, Inc., March 1, 2010