Q&A: Long-Term Care Facilities Present Unique Challenges

July 31, 2020
Frank Diamond

Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BC: “We see the competency of a vascular access specialist or team validated by the outcomes, by the level of infection with their patients, with other complications that may be present.”

Most long-term care facilities (LTCFs) don’t have an infection preventionist on staff. Most also don’t have a vascular access specialist or team working for them either, according to Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BC, a vascular access specialist and a member of Infection Control Today®’s Editorial Advisory Board. Most LTCF’s have to subcontract out vascular access services and that raises some questions, says Moureau, such as who oversees the quality of the work. “The long-term care facilities are unlikely to monitor them,” Moureau tells ICT®. “They’re doing everything they can in order to provide for the patients.” Most vascular access businesses do a good job of policing themselves, she adds. “But yes, these outsource services can function very well or … not; not quite as high level as some.”

Infection Control Today®:What are the challenges involved in providing vascular access services to long-term care facilities?

Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BC: In my role as a clinician, as well as an educator and consultant, I’ve worked in a variety of capacities from contracted work with long-term care and home care, to hospital vascular access teams and PICC teams. And currently I’m working in home infusion that provides care to not only home, but other areas. And so, within our long-term care facilities, there are many needs. Patients are relegated to these areas and they don’t necessarily have the high-level resources that our acute care hospitals have. No, they don’t have vascular access specialists. However, many of these long-term care facilities do contract with services in order to provide PICC insertions, midline insertions, even lung peripheral catheter ultrasound guided insertions. By this mechanism, they can again partner with the specialist in order to provide the service without having to pay for a full employee and maintain that employee and the level of training that is necessary to keep them up to date and safe and competent with their insertion practices. And in fact, that’s challenging for hospitals, as well. We’re talking about a vascular access specialist who has years of experience, has had to incorporate maximum sterile barrier procedures, modified Seldinger procedures, ultrasound guided procedures. And all of these don’t come easy. They require supervised insertions. They require insertion experience and numbers in order to achieve a certain level of proficiency and competency. And we know from the Joint Commission that they need to have supervised insertions on an annual or biannual basis in order to just validate that competency. We see the competency of a vascular access specialist or team validated by the outcomes, by the level of infection with their patients, with other complications that may be present. And so, making sure that these specialists are functioning at a high level is very important and must be monitored. I do see this level of competency assessment in some of these contracted services that provide insertions within long-term care. It’s achievable not only in acute care, but also in long-term care.

ICT®:Does using a third-party vendor raise concerns about quality in your mind?

Moureau:Well, I think there’s a degree of professional responsibility that these contracted services require. The long-term care facilities are unlikely to monitor them. They’re doing everything they can in order to provide for the patients. But I know, for example, services out of Tennessee and out of Texas that are very high functioning. Operated by owners that I know personally. They run a very tight ship. They hire people with experience. They provide additional experience for them. And they keep track of their outcomes. They do data collection and analysis. They monitor the processes in order to make improvements. I don’t see that in all contracted services. Certainly, there’s variation from company to company. But yes, these outsource services can function very well or … not; not quite as high level as some.

ICT®:Who does vascular access the best? Can you name any healthcare institutions?

Moureau:There are publications that have addressed that issue of what is the optimal process or methods that we should be using for vascular access. Not necessarily in terms of a company or even a hospital. There are a lot of hospitals that do it very well. Vanderbilt University Medical Center has an excellent program. The hospital that I worked at, Prisma/Greenville Memorial Hospital out of Greenville, South Carolina. Excellent job with their vascular access team. But it’s more than just one location. And it’s hard for even one location to do it perfectly. So, what we did was put together—specialists, experts from all over the world—to contribute to a book called Vessel Health and Preservation: The Right Approach for Vascular Access. That is a free book. It’s available open access through Springer Publishing Company. You can simply do a search for Vessel Health and Preservation and find the PDF file of that entire book. There were more than 13 authors that contributed to this process of vessel health and preservation that shows best practice for a quadrant or a cycle that is used for vascular access. From selection through insertion, management, and evaluation. This cycle of care can be implemented at any facility, whether acute care or outpatient. And the information that’s included in this very comprehensive and lengthy book provides the structure and the information that they need in order to apply these guidelines, recommendations, and even best practices.

ICT®:Is there something that I neglected to ask you that you think might be pertinent for infection preventionists and vascular access specialists to know?

Moureau:One of the things that we’ve seen with COVID-19, especially as it applies to vascular access teams, is the expanded scope of practice. And not necessarily that this was a desirable effect, but that these vascular access specialists—because of their ultrasound training, because of their ability to perform these procedures—have had to step up and move from peripheral insertions through into central insertions. So not only are they doing lung peripheral catheters with ultrasound, midline catheters and PICC lines, but they’ve also moved into axillary, subclavian, internal jugular, and femoral catheter insertions; preferably mid-thigh femoral. The expansion of these options that are available to the patient through this vascular access team have definitely helped the patient to move faster into a level of treatment that was necessary in order to help them to save their lives. We see many physicians who have stepped up to the plate to try and help to bridge that gap of the need for vascular access insertions and central line insertions. Most notably surgeons and others who found themselves available with the lowered levels of elective surgeries and other things. But many of those surgeons had no experience with ultrasound. Some did, some didn’t. And they were doing central line insertions with what we call the landmark technique that we know is not as safe and has a higher incidence of complications because it’s a blind insertion. Working together with the vascular access teams, the surgeons could learn some of these newer procedures, working together in order to ensure safety. And so, these expanded levels of practice, scope of practice, for nurses that are primarily the people that populate these vascular access teams, or even a multidisciplinary team like those we see in Arizona and others that have respiratory therapists that have physicians. Scottsdale, Arizona, the Mayo Clinic; they have a multidisciplinary vascular access team that includes all levels of clinicians. And so those types of teams I see are the highest-level functioning. They work together and help to encourage and facilitate the development of the skills that are necessary in order to provide the services to these COVID-19 patients.

This interview has been edited for clarity and length.