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A Framework for Selection of Vascular Access Devices

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A Framework for Selection of Vascular Access Devices Copyright EMAP Publishing 2016 This article is not for distribution Keywords: Intravenous therapy/ Nursing Practice Vascular access devices/Vessel health/ Review Drug administration ●This article has been double-blind Intravenous therapy peer reviewed A vessel health preservation framework has been launched in the UK to help health professionals select and manage vascular access devices and improve patient care A framework for selection of vascular access devices In this article... 5 key Why a vessel health framework is needed points Peripheral How to use the framework 1cannulas often Benefits for patients fail due to poor vein quality or the administration of Author Helen Dunn is lead nurse in While the need for long-term devices, inappropriate infection control at Great Ormond Street such as dialysis lines is carefully consid- drugs into the vein Hospital Foundation Trust; Valya Weston is ered by medical teams and discussed with A vessel health lead nurse in infection control at St Helens patients, many short-term devices are rou- 2preservation and Knowsley Teaching Hospitals Trust tinely inserted in emergency departments. framework was Abstract Dunn H, Weston V (2016) A The assessment prior to insertion is often designed to help framework for selection of vascular informal, poorly documented and carried health professionals access devices. Nursing Times; 112: out by junior members of staff (Jackson et make decisions 35/36, 16-19. al, 2013). Lack of a formal assessment may about vascular Many vascular access devices are result in failure of cannulas due to poor access devices inserted without undertaking a formal vein quality or the administration of inap- Vein and drug assessment of their suitability for propriate drugs into the vein, while 3assessments patients and prescribed treatment. This cannulas may be inserted but never used. are essential parts can result in repeated attempts to of the framework cannulate patients with poor veins and Developing a vessel health Health failure of devices during treatment. A preservation framework 4professionals vessel health preservation framework has In 2011, a working group was set up to should constantly been developed to help support decision develop a vessel health preservation (VHP) re-evaluate decisions making when patients require vascular framework for use in the UK. The group regarding vascular access and aims to ensure patients comprised anaesthetists, infection control access devices receive appropriate and timely care. and vascular access nurses, members of spe- Devices that cialist vascular access groups and a repre- 5are no longer hen patients need intrave- sentative from the Royal College of Nursing. required should be nous (IV) medication, it is The VHP framework was completed removed promptly crucial that the venous in December 2014. Its copyright is Waccess device (VAD) used jointly held by the Infection Prevention to deliver medication is selected, inserted Society, National Infusion and Vascular and managed appropriately. Failure to do Access Society, and the Royal College of so can result in complications such as: Nursing. It aims to provide health » Catheter migration; professionals with an evidence-based » Infection; framework to help decision making about » Thrombosis; VADs. It contains four tools: » Development of fibrin sheaths; » Vein assessment; » Occlusion; » Drug assessment; » Phlebitis; » Right line decision; » Embolism (Gabriel, 2013). » Re-evaluation of vascular access devices. A range of VADs is available, including peripheral vascular cannulas (PVC), mid- Vein assessment tool lines, central venous catheters (CVC), and Peripheral vein assessment is a crucial less commonly used devices such as total part of the framework as patients with implanted venous access devices and dial- poor veins often require multiple PVCs to ysis lines. complete a course of treatment (Oliver, www.nursingtimes.net / Vol 112 No 35/36 / Nursing Times 14.09.16 16 Copyright EMAP Publishing 2016 This article is not for distribution For more articles on intravenous therapy, Nursing go to nursingtimes.net/ivtherapy Times.net TABLE 1 PERIPHERAL VEIN ASSESSMENT TOOL Grade Vein quality Definition of vein quality Insertion management 1 Excellent 4-5 palpable/visible veins suitable to Cannula may be inserted by trained/authorised practitioners cannulate 2 Good 2-3 palpable/visible veins suitable Cannula may be inserted by trained/authorised practitioners to cannulate 3 Fair 1-2 palpable/visible veins suitable to Cannula may be inserted by trained/authorised practitioners cannulate. (Veins may be small, scarred or but infrared viewer or ultrasound may be required to help difficult to find and require heat packs to locate the vein aid vasodilation) Poor Veins not palpated/visible (requires Cannula may be inserted by practitioners experienced in 4 ultrasound assistance or infrared viewer) cannulation (to be determined locally) 5 None No visible (naked eye or aids) or Peripheral cannulation should not be performed identifiable palpable veins Note: The number of cannulation attempts permitted before escalation should be reflected in local policy TABLE 2 Drug assessment tool EXAMPLE DRUGS LIST Some drugs are not suitable for adminis- Definitely central venous access Consider central venous access tration via a PVC as this can result in failure of the cannula and pain and Amiodarone (except emergency in cardiac Vancomycin (especially when more discomfort for the patient, so drug assess- arrest) than 2-3 days) ment was an important part of the VHP Some cancer chemotherapy drugs Labetalol framework. The group worked with phar- Dobutamine Argipressin macists to review UK guidance on drugs that should be given via a central line; the Dopamine Caffeine most commonly used are listed in Table 2 Epinephrine infusion (except bolus dose in Glyceryl trinitrate (GTN) (University College Hospital, 2014; Royal cardiac arrest) College of Nursing, 2010), but the list can Norepinephrine Co-trimoxazole be adapted for local use. Potassium >40mmol/litre Dantrolene Right line decision tool Total parenteral nutrition (unless only for first Phenoxybenzamine The right line decision tool brings together 1-2 days of therapy) information from the vein and drug Dopexamine Foscarnet assessment to help health professionals assess the type of VAD that a patient Glucose >15% Nitroprusside requires (Fig 1, page 18). Nimodipine Phenytoin The first step in the tool is to Sodium bicarbonate 4.2% or 8.4% Ganciclovir decide whether IV administration of drugs is required; it follows a step-by-step Sodium chloride 1.8% or above Pentamidine process of drug and vein assessment, after which the health professional is asked to 2015). Repeated failure of PVCs and the their treatment. Therefore, the vein as- consider the duration of IV therapy. The need to recannulate increases pain and sessment tool was developed to address tool also requires the health professional discomfort for patients and might delay these issues (Table 1). to consider any factors that may be unique treatment and result in missed doses of The tool provides a grading system for- to the patient including: drugs. The working group also identified staff to assess the difficulty of cannulation » Patient preference, lifestyle issues, body that words or phrases used to describe before they attempt the procedure. This image; the health of patients’ veins were also can help prevent multiple attempts at pe- » Known abnormalities of the vascular open to interpretation and needed to be ripheral cannulation being undertaken anatomy that limit access to sites; standardised. For example, an experi- before patients are referred for central » Health of the patient and duration of enced health professional may describe a lines. It also offers advice on different therapy; patient’s veins as good, but an inexperi- aids, such as infrared vein viewers that » Relevant past medical history, for enced practitioner may still find the help health professionals decide whether a example coagulopathy and poor patient difficult to cannulate. peripheral cannula is the right device. cognitive function. The group identified a lack of docu- The vein assessment tool was informal- A device is recommended based on the mentation in patients’ records about ly evaluated in 2015 by a group of nurses in outcome of these assessments. The tool cannula insertion problems, the number one hospital ward; over 95% said it was uses dwell-time guidance based on evi- of insertion attempts and how many useful and assisted them to make assess- dence from the US Centers for Disease devices patients required to complete ments in practice (Hallam et al, 2016). Control guidelines (O’Grady et al, 2011) www.nursingtimes.net / Vol 112 No 35/36 / Nursing Times 14.09.16 17 Copyright EMAP Publishing 2016 This article is not for distribution Nursing Practice Review FIG 1. RIGHT LINE DECISION TOOL www.nursingtimes.net / Vol 112 No 35/36 / Nursing Times 14.09.16 18 Copyright EMAP Publishing 2016 This article is not for distribution Nursing Practice Review and Epic 3 infection prevention guidance FIG 2. (Loveday et al, 2014). RE-EvaLUatION OF accESS DEVICE Re-evaluation tool Re-evaluation of VADs is a crucial part of the VHP framework; the re-evaluation tool (Fig 2) guides staff to check the device is required and asks them to consider the patient’s condition and any new informa- tion that may have emerged. If the patient’s situation has changed, the tool prompts staff to use the framework to re-evaluate whether the right VAD is in place. Evaluation of the tool To date, the VHP framework is being piloted in a haematology ward at Aintree University Hospital, with both nurses and doctors providing evaluations on how it has informed their practice. Further evalu- ation is underway in cardiology wards at Aintree University Hospital Foundation Trust and St Helens and Knowsley Teaching Hospitals Trust. Early feedback has shown that the tool has empowered nurses and doctors to assess and recognise which device is needed for their patients in a more timely manner. Conclusion The VHP framework is designed to help health professionals make decisions about which VAD is appropriate for individual patients.
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