Volume 25: Issue 3

The purpose of this President's Message is to introduce the Association for Vascular Access (AVA) governance transition that will take place soon. The transition actually started some time ago, but as the year begins to wind down, this is an opportunity to familiarize our members with the leadership changes expected for 2021.

Transitions and succession planning are part of all great organizations. This is my chance to encourage you to consider a leadership position within AVA. During my tenure with this organization, I have had the opportunity to serve in many volunteer roles, all of which prepared me to serve

Highlights

Ultrasound cannot replace chest radiography in confirming peripherally inserted central catheters (PICC) positioning.
Saline bubbles are an accurate way to verify PICC positioning.
A standard amount of time to confirm PICC location with saline bubbles is not established.
There is potential for expanded ultrasound protocols to confirm PICC positioning.

Abstract

Background: Real-time utilization of ultrasound to confirm peripherally inserted central catheter (PICC) placement improves efficacy and reduces patient radiation exposure. We evaluated if novice ultrasound users could accurately confirm appropriate PICC tip location via ultrasound assessment.

Methodology: A prospective data collection study was conducted in an academic center with an established PICC team. Novice ultrasonography users performed 2 echocardiographic views (subcostal and apical 4 chamber) and noted position of visible wire. The presence of central bubbles (visualized in the heart) after a saline infusion, as well as time to bubbles (push-to-bubbles) seen in all patients, was also recorded. Image quality and confidence in imaging acquisition was also recorded.

Results: Twenty-eight patients between ages 0 and 18 were enrolled over the study period with mean patient age of 10 years and median weight of 34 kg. The quality of image acquisition was rated as great only 34–44%. The wire was visualized only 25% of the time. The median push-to-bubble time when the PICC was later confirmed to be in appropriate positioning was 1.5 seconds with a delay of greater than 3 seconds 40% of the time when the line was malpositioned. The overall positive predictive value of ultrasound identifying malpositioned lines in this study was 43%.

Conclusions: With this PICC placement technique, ultrasound confirmation of PICC placement by novice ultrasound users was not superior to confirmation with chest radiograph. There may remain potential for future ultrasound protocols, with pediatric-specific technology or echogenic catheter tips, to reduce radiation exposure from chest radiograph during PICC line positioning verification.

Highlights

Ultrasound-guided peripheral and midline IV access decreased PICC insertion volume.
Ultrasound-guided peripheral and midline IV access decreased the CLABSI rate.
Ultrasound-guided peripheral and midline IV access decreased CLABSI treatment cost.
Modified PICC insertion hours improved the efficiency of nurses’ workflow.

Abstract

Background: The process for patients to receive a peripherally inserted central catheter (PICC) has been unclear, allowing for delays in care and discharge and increased costs. To address these problems, a vascular access team implemented the Lean process. The purpose was to evaluate the effect of an ultrasound initiative to insert peripheral intravenous lines (IVs) and midlines and modification of PICC insertion hours on the nurses’ workflow and patient outcomes.

Methods: This quality improvement project used retrospective data analysis. Patients’ data from fiscal year (FY) 2010 to FY 2019 was analyzed using descriptive statistics, independent t tests for continuous data, and a Poisson regression for count data.

Results: After the ultrasound initiative, the volume of PICC insertions decreased by 20%, which represents a significant reduction. The mean cost also decreased from $171,681 to $147,620. Although there was no substantial cost saving, the total cost was reduced by 14%. After implementation of ultrasound guidance for peripheral IV and midline access, the central line–associated bloodstream infection (CLABSI) rate dropped by 70%. The estimated treatment cost for CLABSI significantly decreased from $481,600 to $156,800. After implementation, the total estimated cost savings was $1,624,000. Modified PICC insertion hours resulted in significantly reduced mean hours from order time to insertion.

Conclusions: Standard work and process improvements using the Lean process were effective. The ultrasound initiative decreased unnecessary PICC insertions, reduced cost, and decreased the CLABSI rate. Modified PICC insertion hours enhanced the nurses’ work by reducing the average time from PICC order to placement.

Highlights

The survey confirms that UGPIV procedures are performed frequently with half of respondents reporting 5–20 procedures per day.
Results demonstrate a wide variety of supply usage practices and inconsistencies between departments with UGPIV insertions.
Sterile gel was used by 56% and more than 22% of survey respondents stated they sometimes used each of the gel categories of multi-use, single gel packet and sterile gel packet.
In 41% of vascular access specialists and 51% of ED clinicians reported inadequate gel removal caused securement and dressing adherence issues.
These results suggest the need for investigation of guideline application and policy development to ensure patient safety with UGPIV insertions.

Abstract

Background: The purpose of this study was to investigate ultrasound-guided peripheral intravenous (UGPIV) supply usage practices by clinicians working in vascular access, in emergency departments (EDs), or in other roles.

Methodology: In 2019, a voluntary cross-sectional descriptive survey was conducted via SurveyMonkey. Data collected included demographics, practice-oriented information, procedural activities, and supplies used for UGPIV insertions. Frequency distributions and results of Fisher’s exact test and one-way analysis of variance were reported using R v.3.5.2.

Results: A total of 26,649 surveys were distributed with a response rate of 5.5% (n = 1475). Forty-eight percent of respondents (n = 709) indicated that they worked in a vascular access role, 310 (21%) worked in an ED, and 455 (31%) categorized their role as other. Clinically meaningful differences existed in all variables for UGPIV procedures and supplies between departments (P < 0.0001) and in all care settings. Using an investigator-constructed overall metric of supplies used, important differences were demonstrated between personnel supply use in vascular access roles and other roles (P < 0.0001) and personnel in EDs and other roles (P < 0.0001).

Conclusions: Use of supplies for UGPIV insertions varies by department. The variability in supply usage for UGPIV insertions revealed by this survey suggests a need for clinical education on guideline application and evaluation of compliance with policies to promote standardization of supplies for UGPIV insertion.

Substance Use Risk Assessment: Assessing the Risk of Vascular Access Device Tampering in Patients With a History of Drug Use

Toni EastridgeMHA, BSN, RN, MEDSURG-BC,

Brandy NordBSN, RN,

Ann SteffeMSN, RN, PCCN, and

Kathleen Willegal-RussDNP, MSNEd, RN, NPD-BC, a-IPC

Full Issue PDF

Looking Beyond the Horizon: A Vision for Association for Vascular Access's Future

Editor's Message

Diagnostic Accuracy Among Trainees to Safely Confirm Peripherally Inserted Central Catheter (PICC) Placement Using Bedside Ultrasound ^CE

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Implementation of Lean Daily Management: A Vascular Access Team Quality Improvement Project to Enhance Nurses’ Workflow and Patient Outcomes

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Survey of Ultrasound-Guided Peripheral Intravenous Practices: A Report of Supply Usage and Variability Between Clinical Roles and Departments

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Criterion and Construct Validity and Reliability of the Pediatric IV Difficulty Score

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Catheter-Associated Deep Vein Thrombosis (CADVT) in a Pediatric ICU: A Retrospective Case-Control Study

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Buttonhole Cannulation on a Femoro-Femoral Fistula: A Successful Approach in a Patient with Difficult Vascular Access

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Substance Use Risk Assessment: Assessing the Risk of Vascular Access Device Tampering in Patients With a History of Drug Use

President’s Message

Don’t Get on My Nerves: A Deeper Dive

2024 Association for Vascular Access Scientific Meeting: People’s Choice Poster Winners: Poster Abstracts

Opportunities for Quality Improvement Through a Simulation-Based Mastery Learning Curriculum for Interprofessional Central Venous Care: Foundational Support