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Taking the Lead in Vascular Access Improving Patient Outcomes
Tricia Kleidon
Nurse Practitioner
Lady Cilento Children’s Hospital
Alliance for Vascular Access Teaching and Research (AVATAR)
Menzies Health Institute Queensland
Schools of Nursing & Midwifery
This presentation will focus on:
•Vascular access as a nursing specialty
•Improving patient outcomes through nursing leadership
•Practice –v- research
• Insertion
• Maintenance
• How they compliment each other
•Complication free CVAD’s – myth or reality?
•The important implications for catheter management best practice emerging from research
•Current and future research directions in intravascular access research
Who chooses to put
needles into children
for a job? What sort of
person does that?
So How does one become a paediatric vascular access nurse specialist?
A little bit about me ….
Bachelor of Nursing – QUT
Transition Support Programme in Paediatrics – RCH Brisbane
•3 rotations
• Medical
• Surgical
• Specialty - Emergency
•Applied for a job on orthopaedic/neurosurgical ward
• 2 years
• Developed an inquiring mind into PIVC’s during this time
• Why did some kids get PICCs –v- others who had multiple failed
PIVCs?
• Why did some kids have a TKVO –v- those with intermittent
flushes?
• Was one better than the other?
10 years on ……… WE STILL DON’T KNOW!!
Shortage Occupation ….
Paediatric nurse …
Monday – Friday
9-5
No shift work
Free to travel on the weekend
InterventionalRadiology
• Growing sub specialty of radiology
• The key hole surgery of the 21st century
• Minimally invasive procedures
• Angiography/angioplasty +/- stenting
• Large interest in oncology
• US guided tumour biopsy +/- line insertion
• Chemoembolization
• Diagnostic procedures for catheter malfunction
• Provide vascular access through non-traditional route when traditional routes were exhausted
• Recanalization (dilation and stenting)
• BcV
• Intrahepatic
Specialist nurse - Improving Patient Outcomes
Specialist nurse - Improving Patient OutcomesTimely Catheter Insertion
• PICC
• Tunnelled cuffed CVC’s
• Totally implanted venous port devices
• Providing venous access for neurosurgeons inserting VA shunts
• Permanent haemodialysis catheters
• Temporary haemodialysis catheters
• Non-tunnelled CVC
• Procedures under local anaesthetic for older children
• Training radiology and surgical registrars and fellows US guidance
• Training consultant surgeons
Specialist nurse - Improving Patient Outcomes
Timely and Successful Catheter Insertion
Lewis, C.A. (2003) JVIR; 14:S231-S235
• 99.5% this series
• 95-96% reported
• 90-95% suggested threshold
“These rates are for adults and could be expected to be lower in children”
Lewis, C.A. (2003) JVIR; 14:S231-S235
Specialist nurse - Improving Patient Outcomes
Timely and Safe Catheter Insertion
Complication suggested
threshold
reported
rates
this
series
pneumothorax 3% 1-2% 0%
hemothorax 2% 1% 0%
haematoma 2% 1% 0.4%
perforation 2% 0.5-1% 0%
air embolism 2% 1% 0%
Specialist nurse - Improving Patient Outcomes
Vessel Health• Compared success and complication rates of puncture
of central veins with ultrasound guided and traditional landmark techniques
• Report concluded that ultrasound guided puncture
• is more cost-effective
• increases success rates of insertion
• decreases complications associated with insertion
National Institute for Clinical Excellence
NICE (2002)
US v Surgical Cutdown
• prospective study (2001-2004)
• patients returning for IR procedures after catheter removal
• data required for eligibility
• technique used
• size of catheter
• date of insertion
• date and reason for removal
Roebuck et al. SPR 2005
Methods• IJV patency assessed by US
• normal appearance
• patent but abnormal
• thrombus
• narrow
• occluded
Methods
• IJV patency assessed by US
• normal appearance
• patent but abnormal
• thrombus
• narrow
• occluded
Methods
• IJV patency assessed by US
• normal appearance
• patent but abnormal
• thrombus
• narrow
• occluded
Methods
• IJV patency assessed by US
• normal appearance
• patent but abnormal
• thrombus
• narrow
• occluded
Methods
• IJV patency assessed by US
• normal appearance
• patent but abnormal
• thrombus
• narrow
• occluded
ResultsUS-guided
group
surgical
group
number of veins 158 63
vein occlusion 2% 33% OR 7.4-91
thrombus (if patent) 3% 21% OR 2.6-26
mean age (yr) 3.2 2.8 n.s.
catheter size (mm) 2.2 2.4 p<0.05
duration of use (d) 132 258 p<0.05
Discussion
Can duration of use account for the increased risk of jugular occlusion in children in the surgical group?
occluded veins: mean duration 99 dpatent veins: mean duration 177 d
NO
Can catheter size account for the increased risk of jugular occlusion in children in the surgical group?
Discussion
occluded veins: mean size 2.27 mmpatent veins: mean size 2.22 mm
NO
Conclusions
• US-guided percutaneous insertion allows a statistically-and clinically-significant reduction in the risk of jugular occlusion
• US-guided access should be preferred to surgical access, especially when multiple catheters may be required
Fast forward…….A baby A move to Qatar Another Baby
Vascular Access Nurse Specialist Improving Patient Outcome - Device Management
Establish an intentional process for the
Right Line for the
Right Patient at the
Right Time
Intravascular Access Device Decision Tree
</= 1 week 1 week – 3 months
(use this option if length of treatment unclear) > 3 months
Isotonic Non-vesicant
pH 5-9 <600mOsm/L
Difficult access having exhausted all other avenues
Hypertonic Vesicant
pH <5 or >9 >600mOsm/L
Continuous or intermittent
infusion and Infrequent blood
sampling required
Continuous or intermittent infusion and
Frequent blood sampling required
Continuous Access e.g. TPN and long
term antibiotics
Large bore Haemodialysis /
Aphaeresis
Frequent Intermittent Access e.g. Heamophilia or
Cystic Fibrosis
Peripheral Intravenous Cannula
(PIV) or Midline
Non-tunnelled Central Venous Catheter
Peripherally inserted Central venous catheter (PICC)
Tunnelled Cuffed Central Venous
Catheter
Totally Implanted Venous Port Device
Tunnelled cuffed permanent dialysis
catheter
Temporary non-
tunneled dialysis catheter (n.b. this
should only be used for maximum 7-10 days)
stem cell
harvest or
short term
dialysis
Decision for venous access device should be made using decision tree as a guide only. For complex cases device selection should be made in conjunction with all clinical teams involved in care and lines management CNC. When choosing the most appropriate device the following principles must be adhered to
1. Right device inserted first time 2. Smallest possible device for completion of treatment 3. Minimum number of lumens required for completion of
treatment
Guide to device selection
Make the basics unforgettable
Dedicated CVAD trolley!
0
Impact on Infection Rates
500+ days
infection free
Impact on Bundles Compliance
Wards 1 & 2 Wards 3 & 4
Pre-requisite to be an NP1. Masters Nursing Science (Nurse Practitioner)
I. 1 year FTE or
II. 2 years PTE
III. Various subjects depending on university
a) Assessment and diagnosis
b) Evidenced Based Practice
c) Pharmacology x 2 units
d) Research project
e) Internship x 2 units
f) viva
2. Endorsement AHPRA upon completion
3. Entry and Endorsement requirements
I. Minimum 3 years senior nurse (CN equivalent or greater)
a) Must be within your area of specialty and within last 6 years
II. Post graduate qualification within last 10 years
III. Currently working >/= 0.6FTE in your specialty area
IV. Institutional support
Get it right from insertion
Ulna Nerve
Brachial veins
Basilic vein
Median Nerve
Brachial Artery
• Use Ultrasound to
define all anatomy
• Choose a trajectory
that will minimise
future complications
• Arterial puncture
• Nerve injury
• Constant tip
visualisation to
ensure single wall
puncture
Ulna Nerve
LIMITATIONS
• small study n=136
• Small number of thromboembolic events n=4
• All patients who developed VTE had haematological cancer
including patient with CTV ration of 30%
• Most patients in this study had a CTV ratio < 46%
Collateral veins
CCA
Thrombosed
LIJV
Thrombotic occlusive clotFibrin Sheath
Fractured catheterCatheter separation
Displaced catheter tip
Extravasation
Potential complications of vascular access
ANTT &
Infection Control
Insertion &
removal
Patency & flushing
Securement &
dressings IV lines & solutions
Connectors &
cleaning
CASCADE jnr: CAtheter SeCrementAnd Dressing Effectiveness in kids
• Primary outcome: Catheter Failure (dislodgement, occlusion, infiltration, phlebitis, infection)
• Secondary outcomes: Device life; Cost-effectiveness
• 3 arm PICC and 4 arm tc-CVC RCT:
�Standard care
�Combination dressing and securement device
�Glue
�Standard care + retainer (tc-cvc only)
The FliP trial: Flushing in PIVs
• Volume is 3 or 10 mls; 1 or 4 times/day
• Primary outcome: Catheter Failure (occlusion, infiltration, phlebitis, infection)
• Secondary outcomes: Device life; Cost-effectiveness; Dislodgement
• Investigator-initiated study. BD & Uni funding
• Pilot RCT in 2014, larger RCT for 2015->
• Randomize patients to 4 flush groups:
�Low frequency, low volume
�High frequency, low volume
�Low frequency, high volume
�High frequency, high volume
Worldwide PIVC benchmarking study
www.omgpivc.org, Twitter: @OMGstudy1
Prelim results Platinum Showcase AVA Dallas 2015
Final results WoCoVA Portugal 2016
The One Million Global PIVC Study
Dr Evan
Alexandrou
Gillian
Ray-
Barruel
ResearchSMILERCT comparing various methods of PIVC securement
Primary outcome: reduction in PIVC failure .
PICCOMPARERCT comparing current generation polyurethane PICC to
new generation bioflo PICC
Primary outcome: reduction in PICC complications
(infection, occlusion, thrombosis, fracture, dislodgement)
Intravascular Line Savers are Life Savers
Hosted by the Australian Vascular Access Society
you are invited to attend the
1st Vascular Access Scientific Meeting
29 – 30 April 2016
Brisbane Convention and Exhibition Centre
Queensland, Australia
Join the conference mail list:
http://goo.gl/forms/vEnwFwq7Ro
#AVAS16@AVASociety
