Proactive management of vessel health: a multidisciplinary model

With more than 3.8 million Central Venous Catheters (CVCs), 2 million Peripherally Inserted Central Catheters (PICCs) and 310 million Peripheral Intravenous Devices sold yearly in the United States, vascular access is clearly a high volume, high usage procedure for patients receiving medical treatments (iData Research, 2008). Getting the right intravenous device placed early in the hospital stay is necessary to speed treatment and patient discharge while minimizing expenditures (Barton, Danek, Johns, & Coons, 1998; K. Kokotis, 2005; N. L. Moureau, Bagnall-Trick, Nichols, & Moureau, 2007 )

Vessel health and preservation has become an important issue as patients now come to hospitals more acutely ill, living longer and frequently having chronic illness. According to the Centers for Disease Control (CDC), selection of the right device inserted into the right location is paramount to reducing complications, specifically infection (O'Grady, et al., 2002). Additionally, with new requirements being released from governing organizations like the Institute for Healthcare Improvement (IHI, 2009) and the National Patient Safety Board (NPSG, 2009), hospitals are being forced to make changes that focus on patient safety. Patient safety is no longer a matter of hopeful thinking; it is the driving force behind the hospital of the future. Planning intentional safety with vascular access selection and management is the new industry standard for acute care patients.

In order to consistently select the best device to safely deliver the required medications while continuing to preserve vessel health, clinical pathways are being established in acute care such as the Guidelines for Chronic Kidney Disease (Hoggard, Saad, Schon, Vesely, & Royer, 2008). Clinical pathways are management tools used by healthcare professionals to define the best process using the best procedures and timing to treat patients with specific diagnoses or conditions according to evidence based medicine (Panella, Marchisio, & Di Stanislao, 2002). As previously established with a variety of current protocols (stroke, diabetes, hip, heart, etc.), vessel health protocols are effective in reducing variations in treatment, preserving vessel health and increasing positive outcomes by taking evidence based medical practices and consistently applying them to the patient plan of care (Hawes, 2007; K. Kokotis, 1999; K. Kokotis, 2005; Rotter, et al., 2008).

Vessel Health and Preservation Conceptual Model

In 2008 a conceptual model defining a vessel health and preservation protocol was created by a multidisciplinary task force of vascular access experts (N. Moureau,  N. Trick, 2009). The protocol incorporates a systematic process driving selection and placement of the Right Line upon admission through end of care. The step-by-step process is defined in easy to follow forms/flowchart that lead the healthcare team to the correct device and evaluation of outcomes based on specific criteria. A multidisciplinary process, assessment is completed within the admission history and coordinated with nursing, medicine and pharmacy.

Steps for protocol implementation include:

1. Right Line selection within 24 hours

• Standing Order initiated
• Clinical Pathway Selects Device
  • Diagnosis
  • Therapy/Pharmaceuticals
  • Identification of Right Device
  • Patient education

2. Right Patient Assessment

• Perform Admission Risk Assessment
• Individual assessment includes:
  • Critical factors and acuity
  • Infusion needs
  • Vein assessment
• Multidisciplinary coordination for placement of device within 48 hours
• Apply Central Line Bundle to insertion using CLIP checklist with observer

3. Right Line/Right Time Daily Review

• Daily assessment of vascular access
• Multidisciplinary assessment/rounds to determine necessity
• Evaluate changes in acuity, medications
• Apply Central Line Bundle to Care and Maintenance

4. Outcome Evaluation

• Measure compliance/consistency of process and CLIP insertion checklist usage with evaluation of time implementation (i.e. 24/48 hours)
• Evaluate complications compared to retrospective analysis
• Consider multidisciplinary aspects of communication and coordination
• Provide education to staff

Selection Process

The Vessel Health and Preservation program is initiated through standing orders and patient assessment. The selection process incorporates multidisciplinary aspects through selection of the right device, placement and daily assessment by the physician, nurse and other team members. The goal is to proactively drive patient specific device placement within 24-48 hours of admission. Anticipated results of the protocol are fewer accesses, less complications, reduced hospital cost and increased patient satisfaction.

Integrating the Central Line Bundle and other Guidelines

National guidelines such as the CDC and Society for Healthcare Epidemiology of America (SHEA)/Infectious Disease Society of America (IDSA) 2008 Compendium Strategies are a part of the Vessel Health and Preservation program through insertion and daily assessment of the patient and devices chosen to effectively administer treatment (Marschall, et al., 2008). The Central Line Bundle in the insertion process is evaluated through the Central Line Insertion Prevention (CLIP) checklist, which measures compliance with the Bundle and other infection prevention practices (IHI, 2009). Education is on-going with the Vessel Health and Preservation Program providing preventative education in keeping with the Joint Commission National Patient Safety Goal 07.04.01 requirement for insertion, care and maintenance training, patient education and a process for implementing this education (NPSG, 2009).

Process Flow Improvement

Fast, well-directed and measureable treatment is the hallmark of efficiently managed hospital systems. Costs are controlled when each patient receives a vascular access plan that is immediately implemented, assessed daily and adapted as needed with evaluation at the end of the process. Using new technology in placement of safety CVCs such as the Accelerated Seldinger Technique may reduce delays in device access. Roadblocks occur when patients fail to receive a vascular access plan. When peripheral veins for intravenous access are exhausted or develop complications, precious time is lost identifying the right person and device for placement. Application of antimicrobial catheters further reduces the risk of delays associated with hospital acquired infections. Process flow is improved when a Vessel Health and Preservation program institutes an intentional selection and placement process with indicators of daily successful function which will speed the patient to better health and discharge.

Conclusion

A program built with a Vessel Health and Preservation clinical pathway will ensure the patients' right to safe and timely drug delivery reinforcing the core message: the Right Line for the Right Patient at the Right Time.

Author information:

Nancy Moureau is a Vascular Access Consultant, educator, and per diem clinician at Greenville Memorial Hospital in Greenville, SC. She is the founder and CEO of PICC Excellence, Inc., a corporation established for training, education and consulting of PICC Lines. A pioneer in multimedia education for PICCs, her company has developed many forms of training for vascular access including DVD self-study and online training programs. Having trained thousands of nurses and other medical professionals in PICC placement, Nancy speaks, performs research and publishes on various issues related to vascular access and central venous catheters. As a resource for PICC information, Nancy is happy to receive questions and can be reached through nancy@piccexcellence.com or www.piccexcellence.com.

References

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