A nurse-led service for patients needing long-term venous access has reduced waiting times and resulted in fewer complications
Linda J. Kelly, MSc, BA, RGN, is lead nurse; Esther Buchan, BA, Dip Higher Education, SPQ Cancer Nursing, EN, RGN; Ann Brown, RGN; Yvonne Tehrani, RGN; Debbie Cowan, RGN, are all specialist nurses at the vascular access service, Gartnaval General Hospital, Glasgow.
Kelly, L.J. et al (2009) Exploring how the development of a nurse-led vascular access service has benefited patients. Nursing Times; 105: 24, early online publication.
The management and care of patients in Greater Glasgow and Clyde needing long-term vascular access has changed markedly over the past six years. A nurse-led vascular access service has been introduced to reduce waiting times for patients requiring long-term venous access for treatments such as chemotherapy, long-term antibiotics, renal dialysis and feeding. Nurses in the service now insert tunnelled central venous catheters (TCVCs) and also educate and train other healthcare professionals. This service has led to a reduction in complications and provided a source of expert advice for both patients and healthcare professionals.
Keywords: Nurse-led service, vascular access, Tunnelled central venous catheters
- This article has been double-blind peer reviewed
- Identify a need before thinking about service development.
- Ensure you have the involvement, buy-in and support of all key practitioners.
- Develop a robust proposal detailing the aims and objectives of the service.
- Build a business case with the involvement of financial services to ensure adequate funding.
- When introducing an initiative, work to a project plan and have a five-year vision for the service.
- Ensure audit is initiated from the start.
- It was decided to set up a nurse-led vascular access service because waiting times for TCVC insertion averaged 6-7 weeks.
- The project also fitted in with initiatives to expand nurses’ skills and roles.
- Nurses had intense training from nurses already carrying out the procedure and an interventional radiologist, including supervised insertion of at least 20 TCVCs.
The nurse’s remit has expanded in recent years and nurses are now taking on tasks traditionally carried out by doctors. There are many potential benefits of developing the nurse’s role, such as improved patient care and increased job satisfaction.
In North Glasgow in 2000 there was increasing demand for tunnelled central venous catheters (TCVCs). Primarily, this growth was due to an ageing population, consumer expectations and technological advances, particularly in the field of interventional radiology (Jones, 2003). The increased demand resulted in a lack of available theatre and radiological space for TCVC insertion and, as a consequence, waiting times for the procedure increased dramatically. At times patients were waiting an average of 6-7 weeks for catheter insertion.
In 2002 the NMC produced The Code of Professional Conduct (NMC, 2002). This document encouraged nurses to expand practices as long as they had the skills and knowledge to do so. It stated that the responsibilities for actions and omissions would remain with the nurse. A revised code published two years later included standards for conduct and ethics (NMC, 2004), with the most recent code of conduct published last year (NMC, 2008).
In response to this and initiatives designed to reduce the number of hours worked by junior doctors and the Department of Health’s (1999) Making a Difference document, it was felt nurses working in new ways could perform TCVC insertion, which might help reduce waiting times.
The vascular access service started in September 2002 because it was recognised that a better service needed to be provided for patients who had either been on the waiting list, or who had had their procedure cancelled because of emergencies in the radiology suite. The charge nurse from interventional radiology took on the role of scoping the requirements for a nurse-led service. A proposal and business case were developed detailing the benefits that a nurse-led service could have for patients.
The business case identified that the aims of the nurse-led service were to:
- Eliminate or reduce waiting lists;
- Reduce catheter-related infection rates;
- Reduce procedural complications;
- Free up space in theatre and interventional radiology;
- Provide safe, holistic patient care;
- Provide a safe and seamless patient journey, without the need for patients to transfer from their base site, whenever possible;
- Act as a specialist resource for patients’ clinical management;
- Act in a collaborative and advisory role to senior management;
- Offer training and education to medical and nursing staff.
Following consultation with the medical director, director of nursing and the practice development team a bid was submitted. Funding was eventually secured from The NHS Cancer Plan (DH, 2000) to set up the nurse-led service. The charge nurse from interventional radiology was then tasked with the role of leading the new service, established in 2002.
Responsibilities of lead nurse
The first nurse into post was the specialist nurse who was responsible for:
- Coordinating, organising and developing the service;
- Clinical duties on each site;
- Developing insertion criteria and the criteria for managing high-risk patients;
- Devising competency programmes and education;
- Developing a clinical teaching package.
The first two months in post were spent devising documentation. This included consent forms, procedural checklists, referral forms, patient and staff information as well as procedural audit forms. Evidence-based guidelines were developed from information and evidence from Standards for Infusion Therapy (RCN, 2003) as well as EPIC guidelines for preventing healthcare-associated infections (Pratt et al, 2001). In addition to this, a group of professionals was set up to monitor the development of the service. This group consisted of the lead nurse, service manager, clinical nurse manager, radiologist and high users (oncologist, haematologists and so on).
A project plan was drawn up to keep the service development on track and monitor progress. Three specialist nurses were drawn from high-user areas, including oncology, haematology and interventional radiology, to provide a balance of knowledge, specialisms and skills which would be required of such a service. They also provided a ring-fenced commitment to the vascular access service.
A TCVC is a long, fine, hollow silicone tube with an opening at each end. A Hickman type catheter (Fig 1) is the most commonly used TCVC in the acute setting, whereas a dialysis catheter or Permcath (Fig 2) is used for renal dialysis. The entry site for insertion is usually the right or left jugular or subclavian vein. The tip of the catheter terminates within the superior vena cava or the right atrium. The catheter is tunnelled subcutaneously and a cuff made of fibrous Dacron is located at the exit site. This anchors itself under the skin, to provide stability and also to help prevent infection tracking along the catheter (Pratt et al, 2007).
There are many indications for tunnelled central venous access. They include: difficult venous access; chemotherapy; long-term antibiotics; treatments needing multiple punctures, such as daily blood withdrawals in patients with coagulopathy, renal dialysis and total parenteral nutrition (Dougherty, 2006).
In the vascular access service we use a left or right internal jugular approach to gain venous access, which is achieved with the aid of a small portable ultrasound machine. After cleaning and draping the skin, the internal jugular vein is punctured using a 19-gauge Seldinger needle. A fine wire is passed through the needle to maintain access. A tunnel is then created underneath the skin. This is fashioned back to the point of venous access. A peel-away sheath is then passed over the wire into the inferior vena cava. The catheter is cut to length and, following removal of the dilator and wire, the catheter is fed through the sheath into the superior vena cava. The sheath is then peeled away, with the catheter tip in the lower superior vena cava or the right atrium (Fig 3).
Each patient receives written information about the reasons for catheter insertion and the actual procedure. On the day of the procedure the specialist nurse explains the process in detail including potential complications. The patient is then given ample time to ask questions before being asked to sign the consent form. Incapacity procedures are followed where relevant (DH, 2001).
Box 1 shows the number of line insertions and removals the service has carried out since 2003. The complications rate is approximately 2%, and these are predominately arterial puncture, air embolism, misplacement. There has only been one major complication needing surgical intervention.
Box 1. Number of line insertions and removals
Hickman lines 2,942
Dialysis catheters 594
Apheresis catheters 21
Catheter removals 1,241
There are many complications associated with TCVC insertion (McGee and Gould, 2003). These include:
- Air embolism: the patient will experience respiratory distress, unequal breath sounds, weak pulse and decreased blood pressure. This complication can be prevented by clamping catheters when open to air and by placing the patient in a head-down position (Drewitt, 2000);
- Arterial puncture: as the carotid artery lies close to the internal jugular vein, to prevent arterial puncture, ultrasound should be used when locating the vein (Bodenham and Simcock, 2009);
- Infection: full aseptic technique should be adopted when inserting TCVCs (Pratt et al, 2007);
- Cardiac arrhythmia: if the guide wire enters the right atrium it can cause arrhythmias - the wire should be pulled back to return the patient to sinus rhythm (Vesely, 2003);
- Cardiac tamponade: the heart can be punctured during the insertion of stiff guide wires and dilators. Wires and dilators should never be forced (Russell and Greiff, 2003);
- Pneumothorax/haemothorax: the patient will complain of sudden onset of chest pain and dyspnoea. All patients have a chest X-ray performed to check for signs of a pneumothorax (Dougherty and Lister, 2008).
All these complications can be prevented and staff carrying out the procedure must be aware of preventative measures.
Training for TCVC insertion
As the procedure of TCVC insertion is a minimally invasive surgical procedure that carries risks of complication, the interventional radiologists’ support was paramount in ensuring the vascular access service was as safe as possible. The support of other specialist nurses was also important.
At the time there were few centres with nurse-led services for TCVC insertion; one was the John Radcliffe Hospital in Oxford. The lead nurse went to Oxford to spend time learning and gaining information and advice from the nurses carrying out the procedure there. This proved invaluable.
On return to Glasgow, the lead nurse went through a period of intense training with the interventional radiologist, including inserting TCVCs under direct supervision. Competencies and standard operating procedures were used to help learning and to provide a learning training log. It was also felt important that the service involved more than just having the skills to insert catheters. It was important to gain the respect and confidence of the referring doctors. This meant having a good knowledge of the range of available devices, pre- and post-procedure care and follow-up care, as well as being able to demonstrate knowledge of a range of patient conditions.
The following areas of training were identified as essential for safe TCVC insertion:
- Demonstrating competence in aseptic technique;
- Attendance at resuscitation courses at regular intervals defined by service protocol;
- Knowledge of the complications of TCVC insertion and fail-safe procedures to prevent them;
- Training in basic radiation protection principles;
- Ultrasound-guided jugular puncture competence and demonstrating the ability to differentiate between the various structures in the relevant area (particularly veins and arteries);
- Knowledge of normal anatomy to conduct appropriate clinical examinations and differentiate normal from abnormal;
- X-ray interpretation of tip position;
- Knowledge of adequate blood results before procedures;
- Demonstrating critical thinking, diagnostic reasoning skills and clinical decision-making (including the initiation of emergency procedures);
- Promoting the implementation of evidence-based practice throughout the assessment, diagnosis, treatment and discharge/referral process;
- Evaluating professional ability in treating patients with the inclusion criteria without medical staff being present.
Specialist nurses were supervised by the consultant or lead nurse for at least 20 TCVC placements, and informed when they were considered competent. If the lead nurse or interventional radiologist felt an individual was not competent the right to perform placements was withheld and further training provided.
Box 2. Vascular access service exclusion criteria
- Pleural effusion
- Consolidation of the lung
- Neutrophils lower than 0.7 X 109 /L
- Platelet counts lower than 40 X 109 /L
- International normalised ratio over 1.5
- Neck lyph nodes
- Supraventricular tachycardia
- Pacing wires in situ
- Fixed neck
- Uncontrollable cough
- Previous thrombosis
- Children under the age of 16
Box 3. Key results
- Reduced waiting times.
- Low complication rates.
- Increased job satisfaction.
- Retention of highly qualified staff in the clinical setting.
- Education and training is now available for health professionals.
The vascular access service now consists of a lead nurse and four clinical nurse specialists and two healthcare support workers. Referrals are received directly from medical staff or nurse practitioners. Any patients who fall within our exclusion criteria (Box 2) are discussed with medical staff who either make themselves available while nurses carry out the procedure, or add them to their own lists.
We have no waiting list at present for Hickman line insertion, but due to the fact that we have only six radiology slots per week for renal dialysis catheter insertion, patients needing these can wait 7-14 days. Urgent requests, however, will be dealt with on the same day if possible.
The nurses discuss the procedure and potential complications and aftercare of the catheters with patients, and obtain consent before the procedure. Each patient is given a detailed information leaflet, containing contact numbers and advice on dealing with any complications or queries. This scheme has proved very beneficial: waiting times have reduced and patient satisfaction questionnaires have suggested patients are very satisfied with the care they receive (see Box 3 for key results).
We would like to thank Mark Cooper, lecturer/practitioner at NHS Greater Glasgow and Clyde, for his help with devising the training package
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