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
Many vascular access devices are inserted without undertaking a formal assessment of their suitability for patients and prescribed treatment. This can result in repeated attempts to cannulate patients with poor veins and failure of devices during treatment. A vessel health preservation framework has been developed to help support decision making when patients require vascular access and aims to ensure patients receive appropriate and timely care.
Citation: Dunn H, Weston V (2015) A framework for selection of vascular access devices. Nursing Times; 112: 35/36, 16-19.
Author: Helen Dunn is lead nurse in infection control at Great Ormond Street Hospital Foundation Trust; Valya Weston is lead nurse in infection control at St Helens and Knowsley Teaching Hospitals Trust.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
When patients need intravenous (IV) medication, it is crucial that the venous access device (VAD) used to deliver medication is selected, inserted and managed appropriately. Failure to do so can result in complications such as:
- Catheter migration;
- Development of fibrin sheaths;
- Embolism (Gabriel, 2013).
A range of VADs is available, including peripheral vascular cannulas (PVC), midlines, central venous catheters (CVC), and less commonly used devices such as total implanted venous access devices and dialysis lines.
While the need for long-term devices, such as dialysis lines is carefully considered by medical teams and discussed with patients, many short-term devices are routinely inserted in emergency departments. The assessment prior to insertion is often informal, poorly documented and carried out by junior members of staff (Jackson et al, 2013). Lack of a formal assessment may result in failure of cannulas due to poor vein quality or the administration of inappropriate drugs into the vein, while cannulas may be inserted but never used.
Developing a vessel health preservation framework
In 2011, a working group was set up to develop a vessel health preservation (VHP) framework for use in the UK. The group comprised anaesthetists, infection control and vascular access nurses, members of specialist vascular access groups and a representative from the Royal College of Nursing.
The VHP framework was completed in December 2014. Its copyright is jointly held by the Infection Prevention Society, National Infusion and Vascular Access Society, and the Royal College of Nursing. It aims to provide health professionals with an evidence-based framework to help decision making about VADs. It contains four tools:
- Vein assessment;
- Drug assessment;
- Right line decision;
- Re-evaluation of vascular access devices.
Vein assessment tool
Peripheral vein assessment is a crucial part of the framework as patients with poor veins often require multiple PVCs to complete a course of treatment (Oliver, 2015). Repeated failure of PVCs and the need to recannulate increases pain and discomfort for patients and might delay treatment and result in missed doses of drugs. The working group also identified that words or phrases used to describe the health of patients’ veins were also open to interpretation and needed to be standardised. For example, an experienced health professional may describe a patient’s veins as good, but an inexperienced practitioner may still find the patient difficult to cannulate.
The group identified a lack of documentation in patients’ records about cannula insertion problems, the number of insertion attempts and how many devices patients required to complete their treatment. Therefore, the vein assessment tool was developed to address these issues (Table 1, attached).
The tool provides a grading system forstaff to assess the difficulty of cannulation before they attempt the procedure. This can help prevent multiple attempts at peripheral cannulation being undertaken before patients are referred for central lines. It also offers advice on different aids, such as infrared vein viewers that help health professionals decide whether a peripheral cannula is the right device.
The vein assessment tool was informally evaluated in 2015 by a group of nurses in one hospital ward; over 95% said it was useful and assisted them to make assessments in practice (Hallam et al, 2016). Drug assessment tool
Some drugs are not suitable for administration via a PVC as this can result in failure of the cannula and pain and discomfort for the patient, so drug assessment was an important part of the VHP framework. The group worked with pharmacists to review UK guidance on drugs that should be given via a central line; the most commonly used are listed in Table 2, attached, (University College Hospital, 2014; Royal College of Nursing, 2010), but the list can be adapted for local use.
Right line decision tool
The right line decision tool brings together information from the vein and drug assessment to help health professionals assess the type of VAD that a patient requires (Fig 1, attached).
The first step in the tool is to decide whether IV administration of drugs is required; it follows a step-by-step process of drug and vein assessment, after which the health professional is asked to consider the duration of IV therapy. The tool also requires the health professional to consider any factors that may be unique to the patient including:
- Patient preference, lifestyle issues, body image;
- Known abnormalities of the vascular anatomy that limit access to sites;
- Health of the patient and duration of therapy;
- Relevant past medical history, for example coagulopathy and poor cognitive function.
A device is recommended based on the outcome of these assessments. The tool uses dwell-time guidance based on evidence from the US Centers for Disease Control guidelines (O’Grady et al, 2011) and Epic 3 infection prevention guidance (Loveday et al, 2014).
Re-evaluation of VADs is a crucial part of the VHP framework; the re-evaluation tool (Fig 2, attached) guides staff to check the device is required and asks them to consider the patient’s condition and any new information 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 evaluation 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.
The VHP framework is designed to help health professionals make decisions about which VAD is appropriate for individual patients. It allows them to conduct vein and drug assessments and constantly re-evaluate the decision around the VAD as their patients’ condition changes. This feedback helps to ensure patients receive the best care possible.
The poster summarising the VHP framework is available for download here.
- Peripheral cannulas often fail due to poor vein quality or the administration of inappropriate drugs into the vein
- A vessel health preservation framework was designed to help health professionals make decisions about vascular access devices
- Vein and drug assessments are essential parts of the framework
- Health professionals should constantly re-evaluate decisions regarding vascular access devices
- Devices that are no longer required should be removed promptly
Gabriel J (2013) Venous access devices part 2: preventing and managing complications of CVADs. Nursing Times; 109: 40, 20-23.
Hallam C et al (2016) Development of the UK Vessel Health and Preservation (VHP) framework: a multi-organisational collaborative. Journal of Infection Prevention; 17: 2, 65-72.
Jackson T et al (2013) Right line, right patient, right time: every choice matters. British Journal of Nursing; 22: suppl 5, S22.
Loveday H et al (2014) Epic3. National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals. Journal of Hospital Infection; 86: Suppl 1, S1-S70.
O’Grady N et al (2011) Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Disease; 52: e162-e193.
Oliver G (2015) Whose line is it anyway? British Journal of Nursing; 24: 2, S3.
Royal College of Nursing (2010) Standards of Infusion Therapy.
University College Hospital London (2014) Injectable Medicines Administration Guide.