Maya Gossman, RN, is a vascular access nurse at Stillwater Medical Center in Stillwater, Oklahoma.

Maya Gossman, RN

A vascular access consultation order is placed, and the process begins. What is the patient’s admission diagnosis? Ordered medications? Expected length of stay? What is their vascular access history and what might they need in the future? Are there any physical, psychological, or perceptual barriers in regard to the placement of a vascular access device (VAD)? What is the patient, nursing staff, and physician preference in VAD? All these questions are addressed by the vascular access specialist working in today’s healthcare environment.

As healthcare has evolved, so too has the role of those working in the vascular access specialty. At my 117-bed community hospital, I have been a part of much of this evolution. When I started placing peripherally inserted central catheters (PICC) 7 years ago, I knew very little about vascular access as a specialty. PICC placement was a skill I had wanted to learn since I witnessed my first placement while still in nursing school and, once I became part of the “PICC Team,” I worked hard to improve my skill.

I did not look at vascular access in a holistic way, and I did little in the way of assessment prior to placing an ordered PICC. As my knowledge grew, I joined national professional organizations, attended local chapter meetings, and read professional journals, and it became clear that the PICC nurse was evolving into the vascular access nurse. I realized the next step would be forming a vascular access team.

The vascular access team at my facility was created 2 years ago with the goal of improving patient outcomes and increasing staff and patient satisfaction. Although we have never had a large number of central line-associated bloodstream infections (CLABSIs), one of our biggest goals was to prevent CLABSI by ensuring that only the most skilled inserters place PICC and midlines and that daily rounding by specialists is performed on all central lines. Although our infection preventionist is not an official member of the vascular access team, we do work closely with her to update and create new policies and interventions pertaining to vascular access. We also work together to stay current on best practices and to trial any products we feel might benefit our patients in reducing infection rates.

Our close working relationship with the infection preventionist stems from the fact that we trust each other to keep what is best for patients at the center of everything we do. We also have great respect for each other’s expertise and recognize that our specialties intersect in many areas.

Although both vascular access and infection prevention have their own focus, our commonality is in ensuring patients get the care they need while minimizing their chances of nosocomial infections. Infection preventionists have a wide scope, as infections can be caused by many factors while in the hospital, from medical devices to the hands of the healthcare workers caring for them. Vascular access specialists focus on the devices placed into the bloodstream of patients in order to deliver needed medications, allow access for dialysis, or accurately monitor blood pressure. It is because we know that these devices can be a conduit for life-threatening infectious agents that infection preventionists are vital to our specialty.

Since we are a smaller facility with a team of 2 vascular access nurses, we only officially round on central lines; however, we are called daily to assess VADs of all types, intervene when necessary, and replace VADs when required. Our objective is to get the patient through their hospital stay with the least invasive vascular access device that is appropriate for their condition while experiencing as few needle sticks as possible. Not only do fewer vascular access devices and needle sticks decrease cost and increase patient satisfaction, but each time the skin is broken there is an increased risk for infection. As we continue to grow our team, our goal is to provide care for all VADs as they each provide an entry into the same circulatory system and are therefore capable of serving as a source of serious (even deadly) infection. We were working toward this goal when COVID hit and both delayed our plans and helped justify our team.

My community hospital of 117 licensed beds received our first possible case of coronavirus disease 2019 (COVID-19) on a Sunday afternoon in March. The patient was in a negative pressure room in our intensive care unit (ICU), and a vascular access consult was ordered. Due to the patient’s condition and multiple ordered medications, a PICC line was selected as the most appropriate device. I had personally never placed a vascular access device while wearing airborne precautions personal protective equipment (PPE), but I did remember our infection control nurse teaching me how to don the powered air-purifying respirators (PAPR), gown, gloves, and shoe covers in the correct order. As the ICU staff assisted me into the PPE, I wondered about the feasibility of performing a sterile procedure while covered almost head to toe in PPE, but I knew the patient needed vascular access.

Because of my experience as a vascular access specialist and my collaboration with infection preventionists both at my facility and through professional organizations and journals, I was able to place a PICC that successfully delivered the needed medications. That patient ended up being discharged home at the completion of their stay while only undergoing 1 needle stick for vascular access during their stay at my facility.

Less than 24 hours after placing that PICC line I met with our infection control nurse to discuss how the COVID-19 team was going to interact with the vascular access team. We collaborated to create a plan for best protecting our team of 2 from exposure while also ensuring that our patients were protected from further infection caused by a vascular access device. In addition, the infection control nurse and I met with the directors of the lab, the medical floor, and the intensive care unit to discuss ways to minimize exposure of their staff to the patients with confirmed COVID-19 infection.

We also spoke with the emergency department and the hospitalists to plan for the vascular access needs of these patients. When it became clear we would have to change some of our normal practice to work within the national PPE shortage while still protecting staff, we worked together with our materials department to ensure we would have the needed supplies.

One concern we had was maintaining ideal positioning of vascular access devices once they were placed; to this end, we ordered a subcutaneous securement device we had been trialing. Although there were many areas of the country where PPE shortages did negatively impact healthcare systems, the incident command center at our facility was able to maintain an adequate supply for our staff. Through teamwork we were all able to navigate the unknown waters of COVID-19 while providing the highest level of care for all of our patients and protecting our staff.

The healthcare team is composed of different specialists from widely varied backgrounds. Although we each have our own focus, we all work together to care for our patients in an effective and efficient manner. Collaboration between specialties is vital to maximizing patient outcomes while minimizing complications. Although complications with vascular access devices are sometimes dismissed as a necessary evil associated with hospitalization, through the collaboration of vascular access specialists and infection preventionists we can decrease complications, decrease costs, and increase positive outcomes for our patients.

Articles

Although both vascular access and infection prevention have their own focus, our commonality is in ensuring patients get the care they need while minimizing their chances of nosocomial infections.

Maya Gossman, RN

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How This Vascular Access Nurse Relies on an Infection Preventionist