Implementing an Emergency Department Vascular Access Team

The Journal of JVA Vascular Access Original research article

The Journal of Vascular Access 1–9 Implementing an emergency department ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions vascular access team: A quality review DOI: 10.1177/1129729820924554 of training, competency, and outcomes journals.sagepub.com/home/jva

Jon A Bell1 and Timothy R Spencer2

Abstract Peripheral intravenous catheters are frequently used devices in emergency departments. Many patients now present with difficult anatomy and are labeled as difficult intravenous access patients. A common technology to address this challenge is ultrasound. While studies have examined the ability to train emergency staff, few have addressed how this should be done and the outcomes associated with such training. No studies were found with dedicated vascular access specialist teams in emergency departments. An emergency department vascular access specialist team was formed at a hospital in Bangor, Maine, United States to train, validate, and proctor clinicians with ultrasound-guided peripheral intravenous devices. A quality review of this process was compiled and determined that appropriate clinicians with dedicated training and guidance can achieve higher levels of procedural success. Furthermore, evidence substantiates that frequent practice is linked to a higher quality of care and that a significant need for such teams is present. This review examines how a team was implemented and its impact both department- and facility-wide. It is possible that hospitals benefit from the services of vascular access specialists to provide higher quality care. Successful implementation of such specialist teams requires foundational knowledge and skills in vascular access with ongoing quality measures to ensure competency and compliance with evidence-based practices.

Keywords Ultrasound-guided peripheral cannulation, vascular access, emergency department, quality care, system efficiencies, teams

Date received: 18 August 2019; accepted: 8 April 2020

Introduction VASTs have been widely used in hospitals, most emergency departments (EDs) use a generalist model. The term vascular access specialist team (VAST) often A recent systematic review demonstrated a two- to represents a group of personnel specifically affiliated with 64-fold greater risk of catheter-related bloodstream infec- vascular access device (VAD) insertion and care1 and is tion (CRBSI) from a central venous catheter (CVC) com- now synonymous with numerous team titles in todays’ pared to a PIVC.4 Considering the 330 million PIVCs that health care setting. Vascular access specialists (nurses, are used each year in the United States, excluding approx- doctors, respiratory therapists, radiology technicians, and imately one-fourth used in children and the 20% from physician assistants) individually identify as having failed insertion attempts,5 and the 0.18% incidence of advanced knowledge and skills when inserting or manag- ing VADs.1 The alternative is a generalist model, where larger non-specialist groups of health care professionals 1 St. Joseph Hospital, Bangor, ME, USA who have fewer skills are tasked with gaining vascular 2 Global Vascular Access, LLC, Scottsdale, AZ, USA access for patients. The use of a team approach for inserting peripheral intravenous catheters (PIVCs) increases Corresponding author: Timothy R Spencer, Global Vascular Access, LLC, Scottsdale, AZ, 85251, first-time insertion success, and historically is associated USA. 2,3 with decreased device-related complications. While Email: [email protected] 2 The Journal of Vascular Access peripheral venous catheter–related bloodstream infection4 documentation and reporting allowed for improved peer highlights great potential for device-related infections and andself-assessmentreviews,whichinturnprovided related complications. Rates of PIVC failure and unsched- greater monitoring and evaluation by leadership. This uled restarts remain unacceptably high ranging from 33% helped establish a greater understanding in the role of local to 69%.6 Many patient experiences of PIVC insertion are data quality and its importance to support and evaluate associated with significant pain, stress, and concern.7 current services, and for possible future advancement stra- One community hospital addressed this issue by the tegies within the facility. All data were collected, entered, implementation of a dedicated nurse-led team to train and and analyzed in Microsoft Excel for Mac® 2019 (Ver. validate clinicians for the provision of emergency room 16.28; Microsoft Corp., Redmond, WA) using the basic vascular access requirements. This work yielded quality statistics package, from April 2016 to August 2018. clinical data that provided robust feedback to the facility, The second stage was to establish a standardized edu- highlighting outcomes that helped improve vascular access cation program to enhance the skills for clinicians who quality for patients across the continuum of ER care. This wished to learn USGPIV. The educational program incor- article will be of interest to any health care professionals porated two components: one covering the sciences of seeking to provide better quality vascular access services to anatomy, vascular access and US, and second, an their patients. evidence-based review of practices from the Infusion Nurses Society Standards of Practice.9 The didactic reviews covering US and clinical evidence were 2 h in Aim length and were expected to be completed prior to hands- To examine the process and outcomes of successful imple- on training. The self-study module was distributed to can- mentation of an emergency department vascular access didates via email upon registration to the class. Assessment specialist team (EVAST) in a single-center, 90-bed com- of this required knowledge base was then conducted using munity hospital and provide a summary of the efficiencies, a 25-question multiple-choice tool. After the assessment, a patient impact, and device-related experiences to the 2-h class was scheduled with a 1:2 teacher-student ratio, facility. where clinicians were provided with an in-depth education to several US machines used within the facility. This class included learning a full US assessment of peripheral Method venous and arterial systems, including surrounding nerve This level 3, 18-bed ED is located within the St Joseph and musculoskeletal structures, both performed on each Hospital, a 112-bed community primary and specialty other and the instructor(s). The class also allocated time health care facility, located in Bangor, Maine, United for students to develop the dexterity and skills of success- States. It is a small urban, non-teaching hospital with fully guiding a needle through tissue to veins, while con- approximately 20,000 ED patient visits per year. The tinually maintaining visualization of the needle tip and/or EVAST was created in April 2016 with five nurses, vary- needle shaft on an US tissue simulator. These were all ing in levels of experience and training for performing deemed essential requirements to improve clinicians’ pro- ultrasound-guided peripheral intravenous (USGPIV) cedural successes. access. A Plan-Do-Study-Act quality improvement cycle8 The final stage saw all clinicians performing three suc- was employed to evaluate and guide the implementation cessful US-guided cannulation procedures on patients with process and to drive clinician education and competency the direct supervision from an EVAST clinician. Candi- (Figure 1). This study was evaluated by the Director of dates were routinely encouraged to seek individual mentor- Compliance and Risk Management and deemed as a qual- ing throughout the training process, and most utilized a ity review process and did not require the hospitals’ Inter- mentor for their first 10 device placements. Many of the nal Review Board/Ethics approval. clinicians articulated that it took 25–50 procedures to The first stage of the implementation process aimed to become fairly proficient with USGPIV placement, which develop a data collection process to establish and validate is consistent with currently published evidence evaluating the EVAST team nurses’ competency and compliance, USGPIV competency.10 Today’s clinical practice environ- aligning with the facility policy of performing a minimum ment requires ongoing training and evaluation, and of six USGPIV procedures per month. Initial data capture USGPIV skills are becoming more evident with increasing was performed using hand-written log sheets; however, it patient acuities and difficult vascular access issues.10 was noted by several clinicians to be time-consuming and Eight additional clinicians were successfully trained onerous to provide clear documentation on the procedural throughout 2016 and subsequently added to the existing elements and for the use of point of care ultrasound (US). team numbers. The first full year of EVAST service This relatively short-lived non-compliance was addressed (2017) provided early team growth, with three additionally and was repeatedly encouraged through regular team dis- trained clinicians, as well as providing further education cussions. Providing more depth and accuracy of clinical and support to those who had recently completed their Bell and Spencer 3

Figure 1. Plan-Do-Study-Act. Source: AHRQ Practice Facilitation Handbook—Module 4. Approaches to Quality Improvement (https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod4.html). training. The number of devices being placed by the were also placed outside the department, primarily due to EVAST members steadily increased, including the num- a lack of skilled clinicians available to perform the pro- ber of first-time device insertions successes, highlight- cedure or with appropriate training. On these occasions, ing greater clinician skill and proficiency with US an EVAST member from the ED would provide USGPIV insertions (see Figure 2). There was clear demonstration support to the ward areas, most often when workload time that the need for US-guided device placement for diffi- permitted throughout the evenings or weekends. The cult venous access was much greater than the facility majority (n ¼ 2973, 88%)wereplacedonthefirst had initially estimated. attempt. All clinicians achieved a first-time success (FTS) of at least 80% over time, with the most proficient at 90% or greater. There was a correlation between numbers of Results attempts and FTS. There were 85 failed attempts to can- A total of 3351 devices were attempted. The most fre- nulate by trainees. These devices were then successfully quently placed device was a 20 Ga (gauge) 1.7500 (inch) placed with FTS by experienced EVAST team members catheter (n ¼ 3063, 93%). There was similar distribution who were supervising the trainee and procedure. Distri- between the left (n ¼ 1783, 54.4%) and right (n ¼ 1497, bution by day was consistent except Saturdays, which 45.6%) extremities. The majority were placed in the fore- were routinely busier. arm (n ¼ 1456, 44.4%) or upper arm (n ¼ 653, 19.9%), Many patients (n ¼ 1898, 56.6%) needed an USGPIV away from areas of flexion (wrist, elbow). A moderate on multiple occasions of admission, with a smaller number number of devices were placed in the antecubital fossa (n ¼ 238, 7.1%) being seen by a vascular access specialist (ACF) (n ¼ 1161, 35.4%), often due to specific treatment more than 10 times across the same period. Most weekdays requests (e.g. contrast injection), or in the upper arm, often (n ¼ 592, 67%) had between one and five patients who had due to lack of lower extremity alternatives. Very few a required need for an US-placed intravenous (IV) device. devices were placed both in the hand and the lower extre- Approximately 25% (n ¼ 214) had between 6 and 17 calls mities (n ¼ 10, 0.4%), which were avoided as frequently as for the team, with less than 10% of days having no place- possible. ments. Over the course of this review, 17 clinicians were The majority of the devices were placed in the ED (n ¼ trained in total, with an average of 12–14 clinicians on the 2759, 82.3%), while a moderate number (n ¼ 592, 17.7%) team at any given time. 4 The Journal of Vascular Access

FTS (%) Failure (%)

100.0%

75.0%

50.0%

25.0%

0.0% Apr '16 Jul '16 Oct '16 Jan '17 Apr '17 Jul '17 Oct '17 Jan '18

Figure 2. First-time success (FTS) demonstrated over study time period.

Per Month Power (Per Month)

188

150

113

0 Jul '16 Jul '18 Jul '17 Jan '18 Jan '17 Oct '17 Oct '16 Apr '17 Apr '16 Apr '18

Figure 3. Breakdown of device placements per month.

Discussion clinician training. Some team members originally trained in other healthcare institutions, often to various levels of It is not immediately apparent that an 18-bed ED in a competency, or had initially been self-trained, highlighting community hospital requires the need for a dedicated vas- an inconsistent knowledge and skill base. This was cular access team (see Figure 3). However, with the addressed through additional supportive education to align increasing rate of patients with difficult intravenous access the clinicians with current evidence-based recommenda- (DIVA), and the high failure of nurse generalists to gain 11–14 tions and the expectations of the facility’s program. Sec- reliable IV access, it is probable that every facility, of ond, there was no clear or supporting documentation of any size, needs to develop specialist clinicians for the 15 previously performed procedures to monitor the compli- provision of quality vascular access. There have been a ance and success rates for each clinician. Finally, balancing number of recent publications supporting the use of non- each team member’s mandatory ED nursing workloads, physician practice for vascular access provision and have while providing IV vascular access services, provided a comparable (or better) outcomes than other reported med- number of logistical challenges. 16–22 ical systems. The initial team members faced several Although early placements outside of the ED (17.7%) hurdles, as there had been early inconsistencies among were not deemed that large in numbers, the process began Bell and Spencer 5

Table 1. Anatomic location, laterality, and catheter size.

Location n Left side Right side % 14 Ga 16 Ga 18 Ga 20 Ga 22 Ga 24 Ga Antecubital 512 284 228 34.1 0 0 25 472 11 1 Forearm 659 386 273 43.9 0 0 26 616 17 0 Hand 3 0 3 0.2 0 0 0 2 1 0 Leg 1 1 0 0.1 0 0 0 1 0 0 Upper arm 327 179 148 21.8 1 0 27 292 5 0 Total 1502 850 652 100.0 1 0 78 1383 34 1

ER IP

300

225

150

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Figure 4. 24-h service utilization for emergency department (ED) and inpatient (IP) services. to demonstrate the teams’ ability to provide timely services without excessive trauma or stress to both patient and par- for vascular access needs throughout the entire organiza- ent, while utilizing using ultrasound-guided (USG) tion. The number of unsuccessfully placed devices demon- technologies. strated that some newly trained clinicians were still consolidating their skills and competencies. Where needed, these patients had devices successfullyplacedbymore Team availabilities experienced EVAST members. The EVAST service provides 24-h patient care and support Many clinicians historically place an IV device in the throughout the organization, and this is quite evident with ACF likely for the ease of finding a large, and relatively increased utilization outside ED both after-hours and on 23 superficial vessel. This location however is sub-optimal, weekends (see Figure 4). Providing after-hours cover has primarily due to an area of high flexion, with higher been a constant challenge, often due to clinicians fre- reported rates of infiltration, phlebitis, dislodgment, and quently changing rosters when permanent day shifts 23–29 extravasation, and less comfort for the patient. This become available. The EVAST have continued to work review shows an overall improvement to patient care with on training selected night staff to assist in this coverage an FTS rate of device placement over 85% for the team in both for the ED and for the facility. training, with the most competent specialists around 92%– The increased benefits and improved device and patient 94%. This may be due to a detailed assessment of more outcomes reported by dedicated vascular access special- appropriate site locations. Using feedback from the team’s ists’ teams have shown that there is an escalating require- collected data, and providing a strengthening of assessment ment for these specialist clinician services.13,15,16 There on site selection, we drastically reduced the number of were only 8.6% (63/730) episodes reported over 2 years devices placed in the ACF. EVAST team members access where no USGPIV catheter placements were requested, the ACF region only when required (35.4%), and this was and this number has continued to reduce over time. The most often requested by the imaging department primarily first quarter of 2018 show only 6.7% (6/89) with no place- for power injection of contrast media (see Table 1). The ments. There were several months in which 11–17 devices EVAST additionally provides care to the pediatric popula- were placed within a 24-h period, including weekends. On tion, often with difficult venous access issues themselves, average, approximately 5–10 USGPIVs are placed within 6 The Journal of Vascular Access

Figure 5. Comprehensive–Difficult IV Access Tool. the ER. Most of these devices are placed under emergent were encouraged to begin utilizing the new skills upon conditions, quite often for the sickest patients, with an returning to the ED. All team members are alerted to newly immediate need for vascular access. Emergency colleagues trained clinicians and encouraged to provide mentorship, within the facility have expressed a high level of apprecia- coaching, and feedback. In addition, individual reports tion and satisfaction for the timely quality of work pro- enable EVAST team leaders, and the clinicians themselves, vided, with patients ready for urgent treatments and to monitor professional development and growth. This therapies without delays. feedback is provided using reports generated for each team member from the collective data pool. The reports demonstrate an example of good data management and collation Training and validating to improve clinical practices based upon outcomes-driven Studies have shown that training vascular access specialists data. Once data metrics are decided and the spreadsheet is increases FTS and decreases costs and delays.30–33 This created, very little effort is required to enter, update, pro- review demonstrates the importance of having a clear pol- duce, and distribute the individual reports, and all clini- icy regarding frequent use of advanced IV skills.34–37 The cians on the team find it extremely valuable to see their EVAST found there was a 78% correlation between the numbers and outcomes and know how they are performing number of attempts performed and FTS of the EVAST on key metrics. memberswhencomparedtomemberswhoonlymain- tained the minimum required USG cannulations (6) estab- lished by the facilities policy. The EVAST team members DIVA scoring tool have achieved >95% FTS when inserting more than 10 In February 2017, the ED implemented the Comprehen- devices per month (see Figure 2). sive–Difficult IV Access (C-DIVA) scoring tool (Figure This collaborative training program has been success- 5). The tool was modeled on the A-DIVA tool which was fully implemented with the engagement of all clinical team developed and validated in Europe38 with reference to members, including the ED staff and hospital leadership. other similar tools which are population-specific (i.e. Clinicians who complete the training class components pediatric, oncology, etc.).39–43 This tool allows generalist Bell and Spencer 7 clinicians to provide assessment for vascular access needs can successfully place USGPIVs and improve vascular and determine when a VAS is needed to prevent failed access outcomes across various patient populations. Fur- attempts.39,44 Using a dedicated tool has enabled the ED ther investigation is required to understand the clinical and to reduce cannulation attempts, in parallel with the current financial impact of dedicated vascular access teams on Emergency Nurses Association DIVA guidelines,45 aiming larger health care facilities. to reduce unwarranted complications and improve care and overall patient satisfaction. Tracking of C-DIVA scores Declaration of conflicting interests demonstrated that many patients are objectively difficult, The author(s) declared the following potential conflicts of interest with clinicians having multiple patient attempts for device with respect to the research, authorship, and/or publication of this placement (46.7%), which is reported in current litera- article: Jon A. Bell provides consultancy for Interrad Medical, ture.24 Recognizing the patients’ degree of venous access LLC; Medical Components, Inc.; The Clinician Exchange; Bec- difficulty, using US technology, has improved device ton Dickinson; Velano Vascular; and Teleflex. Timothy R. Spen- cer is the director of Global Vascular Access, LLC, and provides choice and first-attempt successes. It has also attained consultancy for Teleflex, Inc.; FUJIFILM Sonosite, Inc.; Ethicon, greater patient satisfaction, reduced opportunity for failed LLC; and Interrad Medical, Inc. attempts by lesser skilled clinicians, and reduce pain asso- 46,47 ciated with device insertion. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. Conclusion There is a clear need for the implementation of specialty ORCID iD vascular access teams throughout all hospitals. 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