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A holistic approach to vascular access services

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A holistic approach to the insertion and maintenance of all aspects of central venous access devices (CVADs) at Addenbrooke’s Hospital in Cambridge has led to greatly reduced infections and complications, and has even shortened some patients’ stay in hospital, explains specialist nurse manager Carmel Streater

The multidisciplinary team offers a holistic approach to the insertion and maintenance of all aspects of central venous access devices (CVADs). This has resulted in reductions in infection and complication rates, shortened length of stay and a day-case facility which prevents admission - all benefiting the patient experience.

It has standardised and optimised best practice and has advanced improvements through:

• Education
• Research
• Innovation
• Audit across the trust

A scoping exercise in 2005, gathering the views of patients, clinicians, nurses and managers demonstrated that expectations were not being met. Before then, it was essentially an ad hoc service with no central approach to standards and techniques.

Complications

Complication rates were high and continuity of care a challenge. No centralised service also meant inadequate auditing, little support or advice for staff or patients and no drive to implement new techniques or innovations to benefit patient care, such as the use of more discrete lines like port-a-caths.

Why redesign the service?

The central principle for the redesign of the service was to establish a central, multidisciplinary team with the knowledge and expertise to establish and communicate practice against the gold standards set out in national guidance (EPIC 2, Winning Ways and Saving Lives).

Despite the Vascular Access Team having a central base it is very much a 'service without walls'.

It was the ambition of the team to enable colleagues to become more competent and confident in managing the different devices after insertion. It was also imperative that lines which were inserted by the medical team out of hours conformed to best practice.

This was vital in reducing infection rates and other complication rates and thus reducing the number of lines that have to be removed and replaced prematurely. This means that patients don't have to have their lines removed before the end of their treatment.

Since the dedicated unit was set up, we have been instrumental in helping to reduce MRSA bacteria.

There were several problems to overcome initially:

• Ensuring that all members of the multidisciplinary teams across the trust adhere to best practice when inserting lines and maintaining lines in accordance to policy

• Ensuring that each directorate orders the recommended equipment and solutions to standardise insertion and maintenance of all lines

• Encouraging nurses on the wards to complete care records

• Expanding our work into the community and offering increased help and support to patients with long term vascular access devices and the staff caring for them.

This enables patients to be discharged into the community with the support of the GP's and community nurses


Lessons learned

• The most important aspect of the service is that by having a dedicated team inserting all CVADs and troubleshooting problems as they arise, we have seen a significant reduction in central venous access devices associated infections and a large reduction of complications

• By having a group of expert practitioners inserting a high percentage of the lines across the trust on a daily basis, all members of the multidisciplinary teams know that they can refer patients for insertion

• 99% of insertions are undertaken on day of referral and 100% inserted within 24 hours. This is paramount to ensure patients receive they treatment in a timely manner

• In-house training and education is paramount at all levels within the multidisciplinary teams across the trust and needs to be ongoing due to staff turnover

• It was also important to continue to develop the service to meet the needs of the service

• It was essential to ensure that policy and procedures were updated and were easily accessible for clinicians on the wards and in departments. For example, these policies and procedures now appear on the trust’s intranet so that all staff can access them.

• We now have written comprehensive consent forms and patient information leaflets that patients have found extremely valuable

• All our referrals and line insertions are fully audited and we have created computer databases that record all our activity and help to reform future developments

• This also allows comprehensive data to be made available to the Executive Trust Board in relating to infection control.

The main principles of setting up a similar service are:

• Make sure you have the backing of senior personnel within the trust

• Know what your vision for the future is, even if it changes at a later date

• Ensure that you have all your competences signed by your lead consultant your manager and your chief nurse.

• Do your homework with the procurement department so that you know what equipment is being purchased by your trust and whether it conforms to DH guidelines.

• Know when and where lines are being put in and who is carrying out this procedure at present.


Specialist nurse manager Carmel Streater is an expert practitioner and manager of a dedicated unit, the Vascular Access Service, which works across Cambridge University Hospitals NHS Foundation Trust

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