Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC

Vascular access devices (VAD) are used in almost all medical, surgical, and critical care specialties, pre-hospital, hospital, long-term care, and home-care settings.

The range of catheters and devices referred to as a VADs include: peripheral intravenous catheter (PIVC), midlines, peripherally inserted central catheter (PICC), central venous catheter (CVC), tunneled CVC, subcutaneous port, arterial catheter, intraosseous device, apheresis catheter, umbilical, and ECMO catheters. As a result of VADs being used daily in almost all inpatient settings a range of healthcare professional roles share the responsibility for insertion, management, and removal of VADs. The varied interdisciplinary members responsible for one such VAD, the PIVC, were researched in a qualitative study.

The research suggested the accepted practice of allowing multiple professional entities to insert and manage PIVCs jeopardizes patient safety. They called for consistent approaches for all interdisciplinary professionals to follow. This suggests there is an opportunity to improve the current fragmented process to achieve positive outcomes with vascular access ownership of (i) assessment, (ii) insertion, (iii) care maintenance, and (iv) education. 

According to the US Centers for Disease Control and Prevention (CDC) in 2011, “Specialized teams have demonstrated unequivocal effectiveness in reducing infections, complications and cost of infusion therapy.”

Although there are studies reporting that a vascular access services team (VAST) positively impacts patients’ vascular access outcomes, there are no randomized controlled trials to support or refute the role of the VAST. A Cochrane systematic review on VAST describes a lack of high quality research on teams.

The Cochrane review defines these groups as any of the following; infusion teams, intravenous teams, individual specialists (nurse, doctor, respiratory therapist, radiological technologist, nurse practitioner, and physician assistant) who have knowledge and skills, through formal training, and who frequently perform insertion or manage VADs.

The Infusion Nurses Society standards of practice present practice criteria for an infusion team and include benchmarks for peripheral and central catheters which include: first time insertion success; daily assessments; decrease in catheter related blood stream infections (CRBSI); increase in patient satisfaction; data collection for reporting quality outcomes; and impact on patient safety.

The purpose and function of a VAST or trained individual may include the initial assessment, insertion and management of PIVCs, midlines, PICCs, arterial catheters, external and/or internal jugular, femoral, and subclavian placed catheters.

Teams and individual specialist functions will vary and may exclude the insertion and maintenance of some of the devices and associated activities listed above. Other functions embraced by these specialists may include patient access for difficult blood draws, use of ultrasound guidance for any or all of the functions, dressing changes for central catheters, daily evaluation of catheter necessity, removal of unnecessary catheters, and monitoring of dressing and insertion site for complication identification. Additionally, they provide a professional point of care for education and resource of VAD queries for device maintenance and management of complications. However strong the evidence for specialized teams, professional application of empirical guidelines for teams within the acute care setting is limited.

Whether through lack of awareness of guidelines and recommendations, changing administrative priorities or perceived economic constraints, the hospital adoption and support of VAST has been erratic. Similar to specific services where a cardiologist is required for specific cardiac problem to provide the best evidence-based care, it is logical that seeking the services of a trained vascular access clinician to initiate and maintain the most appropriate intravenous device, is a worthy mandate. Given the growing complexity in patient needs, a unique specialist discipline, namely the VAST. is surely needed to provide for patient needs. Specialty teams are also seen as models that not only improve patient safety and outcomes but also can serve as a platform for clinical training of junior residents, medical students, and nursing clinicians. The evidence to date is suggestive that the highest achieving system of initiating and delivering treatment to patients in acute care is inexplicably tied to a purpose-driven group of skilled individuals and the processes that guide their practices.

Evidence supports the value of a specialized infusion team for improved success with access, reduced insertion attempts, and reduced complications associated with intravenous or arterial device insertion. According to da Silva in 2010, use of a specialized team increased first attempt success with only 16% of attempts resulting in more than 1 attempt.

Teams of specialized individuals performing insertion of PIVCs report increased first-time insertion success.

Complications associated with VADs relate to the skill and knowledge of the operator for insertion

and for post-insertion complications related to maintenance by clinicians and patient specific risk factors.

Specialized education has led to infection prevention practices that reduce complications.

Advanced practice nurses and those teams receiving specialized training to perform insertions of all CVADs that work in collaboration with medical providers offer valuable contributions to the clinical care by performing insertions with low incidence of complications.

Consistent across all VADs, peripheral and central, teams historically represented the lowest levels of device-related complications.

Adoption of a team approach for care and maintenance has resulted in reduction of CVAD-associated infections.

Adverse vascular events are largely avoidable through specific practices of assessment and selection of the vascular access device with the lowest infection risk for the patient and their treatment (

). Improving selection of the best device and inserter skill reduces unnecessary central venous catheter insertions.

These practices are evidenced in a variety of specific models, recommendations, and guidelines such as the Society of Healthcare Epidemiology of America (SHEA),

Infusion Nurses Society (INS) Standards of Practice,

European Society for Parenteral and Enteral Nutrition (ESPEN),

World Congress of Vascular Access (WoCoVA) consensus,

Evidence-based Guidelines for Preventing Healthcare-associated Infections (EPIC),

and National Institute for Clinical Excellence (NICE)

all recommend a focus on the necessity of specialized training for inserters and those managing VADs that integrate infection prevention and practices that avoid complications. Despite these recommendations, many insertion attempts of VADs are performed by clinical professionals with little to no formalized education or current training on insertion or the means to prevent complications with emphasis placed on the central line bundle and other practices that include device assessment for risk reduction as a key component.

Vascular access catheter insertion is accepted as an invasive clinical procedure that exposes patients to iatrogenic risks such as procedural pain, bruising, bleeding, vessel depletion, and inadvertent anatomical injury of adjacent structure, infection, and in extreme cases death.

When intravenous, peripheral, or central catheters are required, patients may undergo multiple attempts to successfully insert these devices. Moreover, initial device insertion can be associated with procedural complexity that involves repeated attempts following insertion failures leading to increased patient risk of complications. 

Such complications associated with VADs are increased as the number of attempts and time during the insertion procedure increases.

Insertion of peripheral catheters by a variety of skilled and unskilled clinicians result in failure rates of 1.9 vs 2.9 insertions

For these reasons alone hospitals with VASTs reported higher insertion success rates and greater patient satisfaction.

Results of unsuccessful peripheral catheter attempts lead to vein depletion,

bruising and pain at the insertion sites,

and multiple punctures of the skin predisposing microorganism entry into the bloodstream. 

Consistent with the VHP model for selecting the right device, right site, inserted by the right clinician (people) at the right time, the clinician performing the insertion must have training, qualification, and competence to perform the procedure in a safe manner.

Education and training of staff integrates technology that facilitates increased success. Ultrasound and visualization technology knowledge and training aid inserters in gaining access on the first pass and minimize number of attempts and complications associated with multiple attempts and traumatic insertions.

Complications increase in number when there is difficulty with insertion. Currently, most patients will experience insertion failure and post-insertion failure prior to definitive device placement during their course of treatment. In research by Eisen and associates (2006), there was a 54% increase in complications when 2 or more puncture attempts are performed.

Inserters with experience of fewer than 50 CVAD procedures have greater than 50% risk of a complication occurring and more difficulty achieving successful insertions.

The use of specialist teams has demonstrated more positive clinical outcomes for patients including greater first attempt success, reduced CLABSIs, and subsequent economic advantages.

Insertion of VADs is not without risk, but risk is also associated with management of these devices that comprises the largest time component of each patient’s treatment process. Management of VADs requires the performance of regular assessment of device function, insertion site, securement, dressing adherence, and observation for signs of other complications. Of greatest concern is catheter-associated bloodstream infection (CABSI), as in the case of peripheral or central venous catheters, and specifically central line-associated bloodstream infection (CLABSI).

In a study of maintenance bundles, CLABSI rates fell from a peak of 5.2/1000 catheter days to zero infections for 24 months by using a bundle incorporating antimicrobial sponge dressing, chlorhexidine body wash, and daily device assessment by a specialist nurse.

Results of a cross-functional team demonstrated effectiveness in post-insertional care with statistically significant CLABSI reduction with major economic impact.

Evidence has demonstrated that education and training for insertion and maintenance of VADs, which includes criteria for educational content, simulation of practice and supervision, results in improved staff compliance with safe practices.

Recommendations for education in the clinical setting are to provide consistent and varied staff education on infection prevention, best practices and consequences of poor technique.

Clinicians performing consistent insertions and maintaining current education with evidence-based practices are better equipped to provide safe patient care.

Application of evidence through education, while promoting peer to peer engagement, lead to high performance and consistency in safety practices.

Effective device and site selection necessitates a heightened awareness of infection prevention guidelines that aid in site selection and insertion and the ability to choose the number of lumens necessary to complete treatment to minimize risk.

A higher risk of infection and other complications is associated with CVAD insertion when performed by unskilled, inexperienced, or unqualified inserters.

Therefore, integration of education, simulation practice, ultrasound training, and knowledge of complication management for CVAD insertions are part of the procedural competency necessary for those clinicians inserting or managing VADs.

Patient-focused safety initiatives should apply evidence of improved outcomes such as those represented in establishing and maintaining effective vascular access teams. Providing a consistent VAD assessment, insertion, and management service to patients in the pursuit of risk minimization involves healthcare personnel who have received special training. VAST contribute to infection prevention efforts to reduce CLABSI, CRBSI, and CABSI. Patients indicate the inadequate skill level of those performing these types of procedures is a source of great dissatisfaction, while use of technology and increased skills of the VAST promotes higher satisfaction.

These occurrences were exposed in the qualitative study of patient and staff experience indicating a need for vascular access specialist as a quality initiative.

Device and vein selection and insertion processes, qualified inserters, effective management and evaluation of practices, clinical outcomes are all improved as reflected in the elimination or reduction of complications, prolonged dwell times, reduced length of stay and improvements in patient satisfaction.

Teams have the potential to effect significant improvements through both insertion and post-insertion care of patients. Providing dependable vascular access assessment, insertion techniques, and post-insertion care and management is a necessary patient requirement to support modern healthcare treatment plans, patient safety, and promote economic savings through efficiency of insertions.

The value of specialized teams for insertion and management of vascular access has been demonstrated through numerous publications in a variety of research designs. Although there are currently no randomized controlled clinical trials that support the benefits of teams, the recommendation of the CDC and others continues for specialists as a method to reduce complications and infection associated with vascular access devices. Additionally, standards for infusion therapy call for teams for CVAD insertion, maintenance, and removal to promote patient safety and better outcomes. The discussion and research underscore the potential advantages of VAST for assessment, insertion, management, complications reduction, and staff education. Supported by the concepts of vessel health and preservation, the application of specialty teams in every hospital for insertion and management of vascular access devices could significantly contribute to the pursuit of making VADs complications history.

Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC, is the chief executive officer at PICC Excellence, Inc., an associate researcher for the Alliance for Vascular Access Teaching and Research (AVATAR) Group, and an adjunct associate professor at Griffith University in Brisbane, Australia.

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Articles

The discussion and research underscore the potential advantages of vascular access services teams (VASTs) for assessment, insertion, management, complications reduction, and staff education.

Establishing Vascular Access Teams for Patient Safety

Insertion of a peripheral intravenous (PIV) catheter is the most commonly performed invasive medical procedure in acute care. It is estimated that more than 70 percent of hospitalized patients require peripheral IV access for the administration of medications, fluids, blood products, and/or nutrition.
	
	Unfortunately, nearly 60 percent of those patients are considered to have difficult intravenous access. These patients can make PIV insertions challenging for even the most skilled clinician. Difficult access is caused by a variety of factors including aging veins, repeated cannulations, irritating medications, as well as obesity, IV drug use, and chronic conditions like diabetes and cancer. The high number of patients with difficult access has increased the use of ultrasound guidance to achieve successful PIV placement. It is estimated that ultrasound-guided PIV (UGPIV) insertions are now performed 12 million times per year in North America.
	
	With the greater reliance on ultrasound to guide PIV insertions, organizations have published guidelines to promote safety by clarifying infection control practices for the procedure and disinfection of the ultrasound transducer, also commonly known as a probe. While there is agreement that the presence of both the probe and gel at the sterile insertion site pose a risk of infection, there is wide variation among the recommendations regarding standardization of the procedure, aseptic versus sterile technique, appropriate levels of probe disinfection, and specific infection control practices that should be followed.
	
	


	Initially adopted by vascular access teams and emergency departments, ultrasound guidance can be used in many care settings to overcome the challenges with gaining successful PIV insertion in patients with difficult access. According to the American Institute of Ultrasound in Medicine (AIUM), ultrasound guidance for PIV access can be an invaluable technique for patients who are difficult or seemingly impossible to access. Ultrasound guidance has been shown to improve IV success rates, decrease the number of percutaneous punctures and decrease the time required to achieve IV access. This can improve patient outcomes and lower costs associated with PIV insertions.
	
	Yet UGPIV is not without risks. Research shows both probes and gels are frequently contaminated with bacteria, posing a serious risk of transmission between the ultrasound equipment, patients’ skin and the bloodstream.
	
	In one study, environmental organisms were found in 65 percent of samples taken from ultrasound equipment, while nearly 8 percent of samples included microorganisms that commonly cause infection. Another study reported a probe contamination rate of 17.5% following baseline cleaning methods. This contamination includes the potential for transmission of life-threatening staphylococcus aureus to the patient’s skin from the ultrasound equipment. According to Ohara et al., 60 percent of samples that tested positive for staphylococcus aureus were methicillin-resistant (MRSA).
	
	No one can argue that mitigating cross contamination risks during UPGIV procedures is essential for protecting patients and reducing costs. Most guidelines recommend some type of barrier/cover or protection film for the ultrasound probe; many also recommend sterile gel. However, research shows that even sterile probe covers can fail; clinicians may inadvertently puncture covers with the access needles, causing site contamination. These contamination concerns have led to a greater focus on the level of disinfection a probe should undergo between procedures, which is precisely where many of the various guidelines differ.


	Most published guidelines rely on the use of the Spaulding Classification system, a widely accepted standard designed to determine the level of disinfection required for reusable medical devices based on the potential risk of infection posed to patients.
	
	The Spaulding system has three device classification categories: critical, semi-critical, and non-critical. Devices that may come into contact with sterile tissue of the bloodstream are classified as critical. Devices that come into contact with non-intact skin, mucous membranes, blood or other bodily fluids are classified as semi-critical. Devices that only contact intact skin are considered non-critical.
	
	Based on this system, critical and semi-critical devices require high-level disinfection (HLD), which is defined as the complete destruction of all microorganisms on or in a device. Devices used in non-critical procedures require low-level disinfection (LLD), typically achieved through the use of a germicidal spray or wipe to eliminate some viruses and bacteria. Differing interpretations of these categories, as well as data on the efficacy of various barrier methods, has led to different safety recommendations.
	
	For instance, both AIUM and the American College of Emergency Physicians (ACEP) require the use of sterile gel and a protective cover during PIV procedures. The organizations conclude that with these infection control methods, LLD is justified. Other groups have a different take, including the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the Association for Vascular Access (AVA) and the Association for Professionals in Infection Control and Epidemiology (APIC). These groups assert that even with the use of probe covers, UGPIV is classified as semi-critical and therefore, HLD should be required before and after any insertion.
	These differences may contribute to a lack of standardization with procedures and disinfection policies. A recent survey of U.S. infection preventionists revealed a high degree of non-compliance with infection control guidelines for UGPIV. According to author Ruth Carrico, only 22 percent of practitioners indicated using a probe that had undergone HLD before or after performing a UGPIV insertion, and only one percent indicated using a sterile probe cover.

Similarly, a poll of vascular access clinicians conducted by this author in March 2019 revealed a significant gap between awareness of the risks of infection transmission and existing UGPIV practices. While 86 percent of respondents said they understand the probe and gel are potential sources of contamination, less than one-third said inserters at their facility always use sterile probe covers or sterile gel to maintain proper aseptic technique. Nearly 60 percent said their facilities have not established a standardized set of steps and policies regarding UGPIV insertions.
	
	While hospital policies establish the management of probe disinfection, guidelines can help drive change based on the evidence. Currently, more organizations appear to be supportive of the greater safety controls of the Spaulding system by requiring HLD for ultrasound probes involved in any invasive procedure, including UGPIV insertions. APIC and AVA are currently working on revised guidelines to address these issues, which could provide much needed clarity for vascular access clinicians and infection control professionals.
	
	


	In addition to proper disinfection, some barrier methods have been shown to be effective in safeguarding procedures and preventing further insertion site contamination. Barriers like sterile probe covers and use of transparent film dressings may provide more assurance of asepsis within the procedure, providing an added level of protection from pathogens.

It’s important to note, however, that film dressings that are applied to the probe, such as Tegaderm, are not recommended by ultrasound manufacturers or organizations such as AVA. These dressings have great variability in application and may leave a film residue on the probe, resulting in deterioration of the vital transmission surface.
	
	As an alternative to traditional sterile probe covers, facilities might consider a combination sterile barrier and film dressing that prevents probe contact with blood or non-intact skin and uses layers of plastic over the dressing to reduce the risk of needle penetration. A sterile barrier and securement dressing like the UltraDrapeTM (Parker Laboratories), designed specifically for UGPIV procedures, currently meets this criteria by separating the probe and gel from the insertion site. With this sterile barrier dressing, ultrasound gel is applied to a removable film layer. This keeps the puncture area dry and free from gel, while still enabling visualization of the target vessel through the dressing with ultrasound.


	Even with proper disinfection, applying gel to the skin may contaminate the puncture site and leave behind gel residue, making dressing adherence difficult. A barrier and securement dressing that prevents gel from reaching the IV site enables clinicians to better maintain sterility of the needle, catheter, and prepped skin of the insertion area. This type of dressing also eliminates concerns about gel being accidentally injected into the bloodstream. The top layer where the gel is applied is discarded after use and the dressing slides over the IV catheter, effectively eliminating the time-consuming post-procedure skin clean up.


	There is a clear need for the vascular access community to establish a standardized protocol for ultrasound-guided peripheral IV insertions and probe disinfection. Ideally, guidelines will address issues including the use of probe covers, sterile gel, and barriers as well as appropriate probe disinfection procedures. We should look to the results of future studies to guide decisions for disinfection and aseptic management of UGPIV and other ultrasound-guided procedures.

Ensuring safety for patients is the ultimate goal, while also responsibly considering the time and cost required for UGPIV procedures. A standardized protocol, proper training for all staff members and teams involved in ultrasound-guided procedures, and the adoption of technology that promotes a more aseptic insertion technique may improve patient safety while increasing efficiency and lowering costs associated with UGPIV.

Author | Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC

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Better Barriers and Standardized Protocols: Improving UGPIV Safety