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

The cleaning and disinfecting of ultrasound transducers and probes would seem to be straightforward.However, with the Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA), Joint Commission, and others using differing guidelines and recommendations, clinicians can be confused on how to clean this vital equipment.

American Institute of Ultrasound in Medicine (AIUM)

 taskforce is trying to create a more unifying answer to clinicians’ questions. However, where is the process right now?

Moureau, PhD, RN, CRNI, CPUI, VA-BC, is an expert in the field of vascular access practice, owner and CEO of 

)’s editorial board, and she discusses with 

 and where the process is in solving the confusion. She also examines why clinicians jumped to high-level disinfection of ultrasound probes and transducers and whether that level is always necessary.

This is the fourth of 4 segments of This is the third of 4 segments of 

 interview with Moureau. The first segment is 

): Since Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA) haven’t officially adopted the point of view supported by the 

, what steps can health care practitioners take to ensure that they’re consistent in their use of supplies and the performance of point-of-care ultrasound procedures?

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

Clinicians need to be aware of the manufacturers’ instructions for use on how to clean and disinfect transducers or probes appropriately, and they need to provide training to all of the personnel who are using those devices. FDA expects clinicians to follow the instructions for use approved for the device, so practitioners should ensure that their disinfection practices are consistent with the manufacturer’s recommendations.

 taskforce is working with the pertinent regulatory agencies—CDC, FDA, and the Joint Commission—to establish better guidelines and recommendations for the types of disinfection acceptable for percutaneous ultrasound procedures. There is a movement to establish some consistency and standardization with regard to the policies and practices that should be adopted for disinfecting ultrasound devices within a hospital. But right now, this process is still in flux, as we’re trying to establish consistent recommendations from research so that each of the regulatory agencies is seeing the same evidence and promoting the same practices.

We don’t want to overstep the evidence and require high-level disinfection or sterilization when there’s not enough evidence to support that stance. But over the past few years, some organizations have done exactly that, jumping to require high-level disinfection when there wasn’t enough research or evidence to support such requirements.

Where we’re at now is that we’re rethinking the processes, looking closely at the research and evidence that supports certain practices, and being willing to make some adjustments in order to provide clinicians with the best information and guidance.

: Why do you think some organizations jumped to require high-level disinfection so quickly?

Clinicians inthe United States are often eager to adopt the newest and most-extensive notions being promoted among their peers. Even when there hasn’t been enough investigation into the evidence supporting such recommendations, or where there is no supporting literature at all, some clinicians are willing to accept hearsay and adopt someone else’s recommendations.

The initial concern was that there has been an increase in the rate of infections associated with peripheral catheter insertions. Some organizations formed taskforces to look into the issue, and their knee-jerk response was to recommend fully sterile insertions, guided by ultrasound transducers that also needed to be completely sterile. But those groups didn’t really consider the lack of evidence supporting sterilization or high-level disinfection in the case of percutaneous procedures, nor did they consider the increased cost, time, and other ramifications associated with such a recommendation. Now those facilities and organizations are rethinking their positions and aligning with the Intersocietal Position Statement, in favor of low-level disinfection effective against bloodborne pathogens.

In my opinion, it is not necessary for peripheral catheter insertion to be performed as a fully sterile procedure. It is certainly a good thing if IV start kits include components that are sterile—sterile gloves, sterile tape, sterile gauze, and so on. But my observation is that even when such supplies start out as sterile, clinicians very quickly contaminate them during the procedure, and they do not seek to maintain the sterility of their gloves or other supplies.

Aseptic non-touch technique (ANTT) is a new approach that we’re trying to teach across clinical specialties to help clinicians understand about touch contamination, and how to perform a procedure in a safe way, regardless of what kind of gloves they are using.

When performing a percutaneous procedure, practitioners should keep in their minds the various points of contact that can cause contamination and promote bloodstream infections. Everything that the clinician touches represents a potential point of risk—the patient’s skin, the hub of the catheter, a catheter flow valve, and so on. What items can be touched, and what key supplies must remain sterile with no touch, are factors that should influence how a procedure is performed.

Again, it all comes back to education and training. ANTT is a really valuable method that we should teach clinicians in all care settings in order to safeguard patients.

: What other approaches could be used to improve the safety of percutaneous procedures?

I would love to see our processes be subject to credentialing or certification, so that clinicians would need to verify that they’ve completed their education prior to performing insertions on patients. I would also like to see some accountability for the success rate and longevity of catheter insertions. When a clinician performs a procedure and the catheter fails in a few hours, that shows the insertion was not performed well. Performing the procedure again unnecessarily places the clinician and the patient at risk of needlestick injuries, venous depletion, and other types of complications.

It would be useful to establish some consistent access to education or consistent performance of education with supervised observation of competency as regular processes within all health care facilities. We need to incorporate these practices for all clinicians who are performing percutaneous procedures.

Articles

With the CDC, FDA, and Joint Commission all using different guidelines and recommendations for the types of disinfection acceptable for various ultrasound transducers, clinicians should follow manufacturers’ instructions, but a more unified answer is needed.

Ultrasound Transducer Disinfection: Better Guidelines/Recommendations Needed 

Ultrasound transducer with barrier dressing (Image courtesy PICC Excellence, Hartwell, GA)

Stopping contamination during the use of an ultrasound transducer is vital to preventing health care-acquired infections. Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC, is an expert in the field of vascular access practice, owner and CEO of 

)’s editorial board, and she discusses her suggestions to avoid contamination with 

She also examines the controversy of using high-, medium-, or low-level disinfection for ultrasound transducers, what the American Institute for Ultrasound in Medicine (AIUM) and the Infusion Nurses Society (INS) recommend, and how the suggestions differ for vascular access and percutaneous procedures.

): You mentioned that ultrasound coupling gel has been identified as a source of patient infections. What precautions can practitioners take to prevent the transmission of contamination via that gel?

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

Inmy opinion, the best practice for preventing the transmission of contaminants via gel is not to use gel at the insertion site. We need to have coupling gel that aids in visualization, because ultrasound cannot transmit sound waves through air. It requires some sort of fluid medium or gel in order to be able to visualize the body’s structures.

But the variability and inconsistency that we talked about earlier is widely present in the use of gel. I have walked through a single institution and seen 5 different types of gels used, all of which were nonsterile. That raises the possibility that practitioners are using a nonsterile gel on a sterile insertion site, and effectively pushing that gel into the bloodstream. While I have not found a lot of evidence or research on the impact of gel within the bloodstream, it can’t be a good thing. Gel embolizing in the bloodstream is very likely to create problems that we may or may not be aware of.

If we can eliminate gel from the insertion site by keeping the gel and transducer on the other side of a barrier that still permits visualization of vascular structures, then we may have a home run. That way, variability in gel usage wouldn’t matter. We could use any kind of gel behind the barrier without creating a risk of contamination.

The best way to reduce variability is to have a complete IV start kit or central line insertion kit that clinicians can grab and use at a moment’s notice. Kits should be optimized, efficient, and not very costly, providing everything that’s needed—and nothing that’s not needed. In the case of central line insertions, for instance, sterile gel packets are included in the kits. A well thought-through kit is more likely to have departments and department heads agree to stock it in their areas, and to encourage their clinicians to use it, thus promoting greater standardization.

But just like everything else, there’s a huge amount of variability in the use of kits. Even IV start kits are not consistently used throughout the hospital, where peripheral IVs are inserted just about every minute of every day.

We need to be consistent with our practices, and management needs to enforce the use of these safety supplies—including the use of sterile gel, if gel is used on the skin during insertion. We need to have people enforce best practices—or at least to monitor and encourage those practices—and establish some form of standardization within all hospital departments.

: What are the key elements of guidelines from the American Institute for Ultrasound in Medicine (AIUM) and the Infusion Nurses Society (INS) regarding the use of ultrasound-guided vascular access procedures?

Both of these organizations have excellent recommendations on the use of visualization technologies. However, the Infusion Nurses Society does not have specific recommendations for processing transducers, other than to say that disinfection should be performed before and after use, which is a very consistent requirement.

 to clarify the methods used to disinfect transducers in a way that is practical, efficient, and provides a level of safety for patients. The new Intersocietal Position Statement has been accepted by the 

 and more than 20 other organizations. It supports the evidence-based position that cleaning and low-level disinfection (LLD) effective against bloodborne pathogens are adequate and sufficient methods for processing transducers used in percutaneous procedures. By contrast, procedures that are invasive or involve contact with mucus membranes would require high-level disinfection.

By making it easy to perform disinfection—making it a process that is consistent, manageable, and efficient—we can ensure greater standardization from department to department. In turn, departments will be able to utilize these visualization technologies in ways that are helpful to patients while optimizing the availability of critical equipment.

Ultrasound guidance improves the success of intravenous or arterial device insertions by making it possible to perform better assessments of veins, and by visually guiding the needle into the vessel. There are a number of advantages associated with the use of ultrasound, so we certainly don’t want to inhibit its use.

: How should the different levels of cleaning and disinfection be applied to transducers used in percutaneous procedures?

Current practices for the cleaning and disinfection of medical devices are based on the Spaulding Classification System, which was first published in 1957. The Spaulding system calls for different levels of disinfection or sterilization to be used in accord with the clinical application of the device. But the rules of the Spaulding system need to be interpreted differently when dealing with modern devices and procedures, and that’s where the Intersocietal Position Statement comes in. Focusing exclusively on ultrasound-guided percutaneous procedures, the position statement makes the case that ultrasound transducers used in such procedures do not need to undergo the high-level disinfection that might be required for more-invasive procedures.

Moreover, it’s not necessary to use high-level disinfection for transducers that are used with a cover or separating barrier that prevents the bare transducer from ever coming into contact with the insertion site. According to the evidence reviewed by the position statement taskforce—and now endorsed by 22 health professional organizations—it is safe and sufficient to use low-level disinfecting agents or wipes for the disinfection of transducers used in percutaneous procedures, when permitted under the manufacturer’s instructions for use.

Ultrasound transducers or probes that come into contact with mucous membranes or are used in endocavitary procedures (anal, oral, or vaginal) must be processed using high-level disinfection. This level of processing is more costly and time consuming and should not be applied to all types of ultrasound use.

Novel disinfecting agents are becoming available for conveniently performing not only low-level disinfection but also intermediate-level disinfection. In the future, we will have wipes that easily perform the function of high-level disinfection for these types of ultrasound devices.

Having complete IV start kits or central line insertion kits to reduce gel type variability and, thus gel contamination and following AIUM and INS disinfection recommendations are 2 ways to prevent health care-acquired infections. 


Ultrasound Transducers: Avoiding Gel Contamination and Using Proper Level Disinfection 

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

 A Cochrane Review investigating vascular access specialist teams for device insertion and prevention of failure

 define these groups as any of the following: infusion teams, intravenous teams and individual specialists (nurse, doctor, respiratory therapist, radiological technologist, nurse practitioner, and physician assistant) who have knowledge and skills through formal training and who frequently insert or manage vascular access devices.

The Infusion Nurses Society infusion therapy 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 bloodstream infections, increase in patient satisfaction, data collection for reporting quality outcomes, and impact on patient safety.

 The purpose and function of a vascular access specialist team (VAST) or trained individual may include the initial assessment and insertion and management of peripheral intravenous catheters (PIVCs), midlines, peripherally inserted central catheters, arterial catheters, and external and/or internal jugular, femoral, and subclavian 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 vascular access device (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 a particular 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 suggests 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 requiring more than 1 attempt.

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

 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 central venous access device (CVAD)–associated infections.

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

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

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

Adverse vascular events are largely avoidable through specific practices of assessment and selection of the vascular access device with the lowest risk for the patient and their treatment. These practices are evidenced in a
variety of specific models, recommendations and guidelines such as the Society for Healthcare Epidemiology of America,

Vessel Health and Preservation: The Right Approach for Vascular Access

 MAGIC,26 Infusion Nurses Society Standards of Practice,

 the European Society for Clinical Nutrition and Metabolism,

 Evidence-based Guidelines for Preventing Healthcare-associated Infections,

 and the National Institute for Health and Care Excellence

 all recommending specific strategies to promote better clinical outcomes. Each of these organizations and publications focuses on the necessity of specialized training for inserters and those managing VADs that integrate infection prevention and practices that avoid complications. Despite these recommendations the majority of insertion attempts of VADs are performed by a diversity of clinical professional disciplines with little to no formalized education or current training on insertion, or the means to prevent complications. Emphasis is placed on the central line bundle and other practices that include device assessment for risk reduction as a key component.

Device selection and assessment are focused on indications specific to patient, treatment type, and duration factors that point to the type, size, and location of device insertion that best meets the need.

 Steps leading up to insertion of a VAD require the clinician to perform the initial patient assessment, which incorporates vein assessment, patient condition, and selection of the most appropriate site and device for the treatment, all leading to successful insertion, vein preservation, and positive patient outcomes throughout treatment. Performing a patient-individualized assessment provides valuable information necessary to select the most appropriate device with the lowest risk of infection, thrombosis, and overall complications that can most reliably allow the patient to complete therapy without interruption.

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

However, with respect to the quality and design of studies reporting that 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 provides a glaring lack of any published interventional study to support this concept.

This is surely a wake-up call for associations committed to defining and growing the VAST concept, and perhaps the ambiguity on what constitutes best evidence when it comes to VAST would perhaps be resolved with interventional studies or, at minimum, prospective registered data sets.

 This lack of high-quality evidence may threaten the uptake and expansion of VAST and the reduction of complications related to the specialist role despite the CDC statements supporting specialized teams.

The purpose for the people, processes, and functions of a specialized team are to assess the patient for the most suitable VAD while providing (eg, inserting, recommending, assisting, and managing) reliable peripheral and/or central venous catheter access. Results of a cross-functional team demonstrated effectiveness in postinsertional care with statistically significant central line–associated bloodstream infection reduction with major economic impact.

 Clinical guidelines and standards describe how teams and such processes can deliver successful patient outcomes.

 However, such idealistic endeavors are often compromised by the lack of adherence and variety of clinicians responsible for assessment, device selection, insertion, and postinsertion management. All of this results in fragmentation of a service delivery leading to poor patient and clinical outcomes. Providing a consistent VAD assessment, insertion, and management service to patients in the pursuit of risk minimization involves health care personnel who have received special training. Patients indicate that the inadequate skill level of those performing these types of procedures is a source of great dissatisfaction.

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

 Because of this, device and vein selection processes, qualified inserters, effective management and evaluation of practices, and clinical outcomes are 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 improvements through both insertion and postinsertion care of patients. Providing dependable vascular access assessment, insertion techniques, and postinsertion care and management are necessary patient requirements to support modern health care treatment plans.

The value of specialized teams for insertion and management of vascular access has been demonstrated through numerous publications and a variety of research designs. While there are currently no randomized, controlled clinical trials that support the benefits of VAST teams, the CDC continues to evaluate and recommend this practice as a method to reduce complications and infection associated with vascular access devices. Additionally, standards for infusion therapy call for establishing or maintaining a team for CVAD insertion, maintenance, and removal, and the practice criteria to adopt. The discussion and research represented in this article underscore the potential advantages of VAST for assessment, insertion, management, and education with VADs. Underpinned by the concepts of vessel health and preservation, the application of specialty teams for insertion and management of vascular access devices may significantly contribute to the pursuit of making VADs complications history.

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The purpose and function of a vascular access specialist team or trained individual may include the initial assessment and insertion and management of peripheral intravenous catheters, midlines, peripherally inserted central catheters, arterial catheters, and external and/or internal jugular, femoral, and subclavian catheters.

Value and Evidence for Vascular Access Specialist Teams

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.

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.

1.         Carr PJ, Rippey JC, Cooke ML, et al. Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol. 

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

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

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