By Kelly M. Pyrek
Infusion teams -- whose members are highly skilled in the placement, maintenance and removal of all types of lines -- perform a critical service in the acute-care environment, yet as a cost center, they are being scrutinized in an era of cost-cutting. In its whitepaper, Infusion Teams in Acute Care Hospitals: Call for a Business Approach (Hadaway and Dalton, et al. 2014), the Infusion Nurses Society (INS) reminds us that demonstrating the value of these teams is essential for continued, long-term viability of such a program.
As INS explains, " Vascular access insertion teams are small groups of skilled experts who focus only on the insertion of PICCs and are now beginning to insert other types of CVADs. CVAD insertion is an important aspect of patient care and is now associated with improved outcomes related to ultrasound for venipuncture and electrocardiogram for tip locations. Nevertheless, the insertion procedure represents only a short time frame in the life of that VAD. Successful and safe completion of infusion therapy requires much more than a successful insertion procedure. Infusion teams, commonly known as IV teams or IV therapy teams, have a wider scope of service. These teams are involved with safe insertion of all types of VADs, as well as serving as the resource for other infusion-related services. The role of change agent is a prominent one for infusion nurses through staff development and performance improvement."
The benefits of an infusion team are weighed equally in the increased comfort and safety of patients, and the cost savings to the healthcare institution. As Hadaway and Dalton, et al. (2014) remind us, "Peripheral catheter insertion requires skills derived from experience to minimize patient discomfort and complications, decrease risk of needlestick injury and blood exposure, and enhance patient satisfaction. A recent literature review reported first venipuncture attempt success rates between 74 percent and 88 percent in the general population and 46 percent to 76 percent in pediatric patients. Unsuccessful or failed venipuncture attempts are caused by numerous factors. Venous depletion, vein wasting, and vein preservation are concepts gaining attention as a means to increase appropriate use of peripheral veins and reduce the need for central vascular access devices (CVADs). Excessive venipuncture attempts also increase the cost to the facility through delays in treatment; waste of peripheral catheters, insertion kits, individual supplies, and valuable nursing time; and the need for central venous access when peripheral access proves too difficult. The cost of inserting a short peripheral catheter on the first attempt using one catheter, kit, flush syringe, needleless connector, and 20 minutes of nursing time is reported to be $45. Multiple unsuccessful attempts only increase these non-reimbursed costs."The discouraging trend is that many hospitals have either disbanded infusion teams or downsized these teams to perform only insertions of peripherally inserted central catheters (PICCs); however, INS says there is no known method to quantify the actual number of infusion teams that have been lost: "The outcomes of disbanding or downsizing infusion teams are virtually unknown. A 1998 editorial used details of lawsuits to highlight the serious complications that can occur when nursing staff lack adequate knowledge and skills associated with infusion therapy. Another report provided details of how an infusion team transitioned from 11 nurses to two in a 200-bed acute care facility over a nine-month period using a methodical, planned approach. Positive and negative outcomes were discussed; however, no data were provided. Another study focusing on the quality improvement process reported an increase in infusion-related litigation, along with an increase in complaints and questions about infusion care at a four-hospital system. Numerous discussions with colleagues indicated infusion teams were being disbanded, leaving no personnel for data collection on complication rates or medication errors. Additionally, challenges associated with patient and clinician safety or patient satisfaction may not have been addressed. These changes are often made in the name of cost savings; however, those data are also not found in the published literature."
Lynn Hadaway, M.Ed., RN-BC, CRNI, president of Lynn Hadaway Associates, Inc. in Georgia, reports that she sees hospitals at both ends of the financial spectrum and that while infusion teams are being eliminated at some hospitals, other, larger healthcare systems with the resources, are moving the needle toward better outcomes thanks to these specialized teams.
"It's a mixed bag," Hadaway says. "Some hospitals are going broke and they can't see their way out of their financial mess to figure out ways to do things better; by disbanding infusion teams, or not having them at all, they are digging their hole deeper. I recently saw an article that said the number of hospitals reporting zero CLABSIs had been reduced by half, so there are not as many hospitals that are doing as well at decreasing their infection rates to zero. That suggests we are going in the wrong direction. But then in certain regions of the country, we do see an increase in the number of infusion teams. Some institutions have developed teams that are expanding their catheter-insertion services; for instance, instead of just putting in PICCs, nurses are now learning to put in other types of central venous catheters, so they are expanding their scope of practice."
The lack of standardization in hospitals, despite well-publicized and accessible guidelines and recommendations governing vascular access and infusion therapy, is a significant challenge that infusion teams can help address.
Hadaway sees the confusion daily in the online forum she monitors with colleagues for INS. "When I look at the questions that clinicians are posting, and the answers to those questions, I realize the great variance in practice that exists and we have a significant opportunity to educate them," Hadaway says. "Some clinicians are saying, 'We do XYZ," while others are saying "No, we are doing ABC," and there is a world of difference between them -- we can't have the same good outcomes from both processes that are so different, or can we? That's the problem, as sometimes we don't know whether one process is better than the other and sometimes it's a variety of practices within the same hospital. The other day I was discussing an order for flushing and locking a catheter; the question was, is a pre-filled manufacturer's saline syringe a device or a drug. Well, according to the FDA, it is regulated as a device, and so the question was, 'Well, can nurses use this without an order?' Well, that depends upon the policy and the procedure of your hospital. The person said, 'We don't have those.' Well, why not? The bottom line was at that facility, anyone who writes orders had to prescribe how they flushed and locked the catheter, and I think that could lead to nothing but chaos in the facility. With so many differences, and so many preferences among the doctors, physician assistants and nurse practitioners, how is the floor nurse to know what is to be done? That seems like a nightmare scenario."
Many floor nurses are at a disadvantage because they are not taught to any degree about infusion therapy and lack the critical-thinking skills necessary to make important clinical decisions. As Hadaway and Dalton, et al. (2014) observe, "Currently, there is a growing emphasis on patient safety and measurement of patient satisfaction, the urgent need to rein in costs by driving waste and inefficiencies from our delivery systems, and radically changing reimbursement structures for health care. At the same time, there is minimal prelicensure education on infusion therapy and vascular access for nurses, pharmacists, and physicians. Additionally, the technology of infusion therapy continues to expand without support from well-designed clinical trials to guide appropriate implementation of these devices."
"The knowledge level of the nurse depends on the nursing school, of course," says Hadaway. "Most nursing students don't learn about IV therapy in most nursing schools. The core essentials curriculum for a BSN program that is determined by the American Association of Colleges of Nursing is divided into nine topics and IV therapy is not included. Now, it depends upon the arrangement between the college and the hospital; when I went to school, the school of nursing and the hospital was the same legal entity -- we were a school within the hospital. But now, a college is separate from the hospital, so it depends upon the contract between the hospital and the school as to whether those nursing students can do invasive procedures. Without infusion teams to take these students under their wings and supervise them, they don't receive any proper instruction. The nursing school or hospital might have a simulation lab where nurses can perform a couple of venipunctures on an anatomical model, and they might get a chance to administer a dose of medication during some of their clinicals, but as far as receiving instruction in dressings, troubleshooting lines and equipment, working with difficult patients, they don't have the knowledge about how to prevent infections and ensure good outcomes."
Hadaway continues, "The Joint Commission says that hospitals must document competencies before the clinician is allowed to do the job; but it’s a conundrum -- how are they documenting these competencies? A nurse may have started a line on an anatomical model in a classroom, but that's about the extent of it. The use of ultrasound to start peripheral catheters is quite common, but many hospitals turn the equipment over to clinicians without teaching them how to use it. In the hands of someone with appropriate knowledge and skill, that ultrasound device will allow you to stick one time and only one time, and allow that patient go through his or her entire hospitalization with just one stick. But in the hands of someone without that knowledge and skillset, ultrasound is wasted. It requires a specific level of expertise."
Knowledge and implementation gaps in infusion therapy persist, and Hadaway says hospitals are opening themselves up to clinical and legal liability even as they shortsightedly slash budgets. "I think it would be relatively easy to prove the financial benefit of these highly skilled, specialized teams," she says. "But when hospitals are in survival mode, they are not focusing on that. Many hospitals that eliminate infusion teams are trying to cut cost centers and trim expenses. They are thinking very short term and justify their actions to eliminate infusion specialists by assuming that a nurse is a nurse is a nurse, and everybody can do this, when they don't realize the level of skill that proper infusion takes. Another thing adding to the challenge is patient acuity and the complexity of decisions about what is the best type of catheter to use in a patient. We have so many different types now within peripherals and centrals, with multiple insertion methods and designs. The standard of practice is to choose the type of catheter that has the greatest likelihood of reaching the end of therapy with the minimal number of devices used, and preserving peripheral vessels so that you don't have to go to a central venous catheter during the course of care. The more you can decrease central venous catheter usage, the better the patient will be. But hospitals still aren't taking that preventive, proactive approach; they are still reactionary and trying to get by the best they can. They are not conducting an upfront analysis because they do not have a team of people with those analytical skills. The nurses are not thinking about it because all they can see is an overload of work. Hospitals that are strapped for revenue usually have staff that are so overworked and so burdened, they are stretched to their breaking point and all they are trying to do is make it through to the end of their shift -- they are not really thinking about the outcomes that they are producing. Now, there's the other end of the spectrum where that problem does not exist; these hospitals have taken this proactive approach and are looking at the outcomes and then working backward to figure out how to replicate success."
Gaming the system is tempting when hospitals lack specialized teams or individuals, and seek to avoid identifying and reporting central line-associated bloodstream infections (CLABSIs).
"One thing that we do see is hospitals trying to reduce the number of central lines, with the thought being, if there are no central lines, there is no chance of a bloodstream infection that can be counted against them," Hadaway says. "We see hospitals that are now refusing to allow as many central lines as they had before, so they have reduced the number of PICCs that they are putting in, which is probably a good thing because there has been a lot of overuse and erroneous decisions to put in those central lines for no good clinical reason. There is also a movement toward using peripherals and midlines because hospitals want to get patients through to the end of their therapy with as few complications and infections as possible. So, these institutions are carefully applying the catheter decision-making process, with good criteria. Sadly, other facilities are still just reacting to the notion, 'Well, we can't tolerate CLABSIs so we are just not going to put in any central lines, regardless of whether patients need them or not.' If they don't get infected, they don't get counted, so a lot of hospitals use peripherals and midlines. Then there are the people who really want to know what their infection rates are with those types of catheters. We still see too many poor line placements and suboptimal maintenance, and a failure to recognize complications early enough. There is also the additional issue of peripheral catheters used before the central line was placed; they are actually the cause of the CLABSI but it gets blamed on the central line because no one is paying attention to the peripherals."
Hadaway continues, "There are so many things for the nurse to consider, that it often is beyond the scope of a med/surg or bedside staff nurse who is already overloaded and burdened. I think it's asking far too much of that staff nurse to make these critical decisions about what catheter the patient needs; these staff nurses just don't have time to think about the questions, much less look for the answers. Performing evidence-based practice is so important these days. We go to great lengths when we write the standards of practice for INS to ensure that we have the evidence to back up the recommendations that we put forth and the statements that we make. But when nurses are faced with the fact that not everything has an evidence-based answer and when you are faced with the questions in hurried clinical practice settings, you don't have time to go to the internet to conduct a literature search and read 15 papers and figure out the best approach. Nurse administrators are not allowing time to do evidence-based practice, so the value of infusion teams and specialists is underscored."
The institution's infection preventionist(s) can be the champion for good vascular access and infusion practices and the behavior change that is often needed to foster positive change. "The IP is seeing the clinical outcomes as well as the fiscal picture," says Hadaway, "so, this individual is well suited to championing proper vascular access practices and programs at healthcare facilities. They realize that their institution is losing revenue when a patient develops a CLABSI. They know the hospital gets penalized if it is in the lower 25th percentile of all hospitals in the country and how it impacts annual Medicare payments."
Making this business case for infusion teams and specialists is essential to revenue preservation, but as Hadaway and Dalton, et al. (2014) observe, "While infusion therapy is pervasive throughout the entire facility, the business of infusion services has received very little attention, including using appropriate models for infusion cost analysis; cost-effective distribution of infusion therapy responsibilities among professionals and departments; calculating cost avoidance for positive patient outcomes; cost savings on time, supplies, and equipment used; and return on investment from use of infusion teams."
Hadaway emphasizes, "I think the most successful hospitals are the ones that examine their outcomes and identify the approaches that produce better outcomes. They also know to study what went wrong as well as what went right. If they have an outcome that is not so good, they ask themselves, 'What did we miss? What could we have done differently or better?' Some facilities, instead of looking at outcomes, they look at productivity, such as the number of sticks or lines placed, but that won't tell them if they had CLABSIs that decreased their revenue. Many nurses don't understand the ways money comes into hospitals and how the business side of the operation works. They don't understand DRGs and cost-containment issues versus revenue-producing issues. They may not understand that a PICC will be cheaper in the long run because the short peripheral sticks will add up and consume a greater portion of that DRG. You may have more costs up front to put in that long-term catheter -- including the cost of more skilled personnel, ultrasound equipment, the sterile procedure, -- but when one catheter lasts the entire hospitalization, you are not repeating the costs associated with the smaller, shorter-term catheter over and over. The proactive approach to the longer-dwell catheter will consume less DRG in the long-term. Nurses are not taught the business side of things, and they should educate themselves about it as they would the clinical side."
In the INS whitepaper, Making the Business Case for Infusion Teams: The Purpose, People, and Process, Hadaway and Wise, et al. (2013) note, "Currently, the United States is in the early stages of restructuring many aspects of financing its healthcare system with the introduction of value-based payments and pay-for-performance programs. The impact of these changes on infusion teams is yet to be determined; however, the renewed emphasis on improving patient outcomes and safety, such as reduction of all vascular access device and infusion-related complications and implementation of recognized standards and guidelines, could be supportive of infusion teams. Clinical outcomes after an infusion team has been disbanded are unknown. Additionally, there are very little data comparing hospitals or nursing units with and without infusion teams. Anecdotally, many infusion nurse leaders perceive an increase in infusion-related complications, compromises in patient safety, and a corresponding decrease in patient satisfaction, yet lack the personnel and resources to validate these perceptions. Anecdotal evidence or perception of these issues falls short of the data needed to prompt decision-makers to financially support formation of a new infusion team, continue support for an existing team, or expand the services of an existing team. Currently, decisions in hospital management are made with a critical focus on business aspects; specifically, how the proposed action will affect costs and revenue. The business case is a common mechanism used to answer the difficult questions about allocation of limited resources. The business case takes time and effort to create, therefore it is typically employed when a proposed change is expected to have a significant impact on the hospital’s strategic plan."
INS urges hospitals to consider the business case for infusion teams and/or specialist. As Hadaway and Wise, et al. (2013) emphasize, "Given the current rates of complications, costs, waste, and inefficiencies in our current processes, there is little doubt that each hospital or medical center must devote attention to infusion therapy—an invasive therapy that touches virtually all patients entering the facility. We propose that each facility make an assessment of their current outcomes related to infusion services. This assessment should include peripheral and central catheter-associated infections; catheter-associated air emboli; and infiltration and extravasation and the resulting compartment syndrome, necrotic ulcers, and nerve injuries related to all VADs. Consider the fact that the first list of 10 hospital-acquired conditions included three, or 30 percent, that are infusion-related: vascular device-associated infection, air emboli, and blood incompatibility. Moreover, ECRI Institute’s 2012 list of health technology hazards includes 3 of 10 hazards that are infusion related—alarm hazards, medication administration errors using infusion pumps, and needlesticks and other sharps injuries. The current fiscal constraints of healthcare require a careful assessment of the current methods for delivery of these vital infusion services."
Hadaway and Wise, et al. (2013) continue, "Delivery methods for providing safe patient care with positive, lower-cost outcomes may vary between facilities. For some, it may mean continuation of a primary-care model, although improving outcomes will need to be facilitated by a heavy investment in staff development. For others, the most cost-effective method may be to invest in the development or expansion of an infusion team. Regardless of the chosen approach, it is clear that a lack of attention to this invasive and potentially dangerous therapy increases problems, complications, patient dissatisfaction, and costs. A focus on the business aspects of infusion delivery in acute care hospitals is required. INS believes that this attention will serve to concurrently improve clinical outcomes as well."
Hadaway L, Wise M, Orr M, Bayless A, Dalton L and Guerin G. Making the Business Case for Infusion Teams: The Purpose, People, and Process. 2013.
Hadaway L, Dalton L and Mercanti-Erieg L. Infusion Teams in Acute Care Hospitals: Call for a Business Approach. An Infusion Nurses Society White Paper. 2014.