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Development of a trust-wide vascular access team

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Abstract

Jackson, A. (2007) Development of a trust-wide vascular access team. This is an extended version of the article published in Nursing Times; 103: 44, 28-29.

This article explains how a dedicated organisation-wide vascular access team was developed at The Rotherham NHS Foundation Trust, a single-site district general hospital trust serving a population of just under 250,000. It outlines the aims of the project and improvements in clinical standards as a result of setting up the vascular access team. It also identifies areas for future improvements.

Keywords: Management, Vascular Access, Cannulation, IV therapy, intravenous

Author

Andrew Jackson, RGN, is consultant nurse, IV therapy and care, The Rotherham NHS Foundation Trust.

Background

Vascular access devices (VAD) are an essential element in the treatment of many conditions. They include short peripheral cannulas, midline catheters and peripherally inserted central catheters (PICC).

While it has real benefits in healthcare delivery, vascular access can also have a significant negative impact on both patients and healthcare organisations (Jackson, 2003). This is often seen in patients who have tolerated multiple attempts at cannula insertion as well as those who have suffered from chemical phlebitic injuries. On rare occasions more serious problems such as extravasation or cannula fracture occur. Everyone involved in the Aspects of IV therapy pathway should look at ways to reduce the negative impact of vascular access by ensuring care of VADs is monitored, reviewed and improved as required.

In recent years the number of healthcare professionals able to insert VADs has expanded, and the clinical skills laboratory setting has often been used as a safe environment within which skills such as peripheral intravenous cannulation can be developed. However, few trials have examined the issues of transferability to clinical practice and retention of clinical skills over time (Lynagh et al, 2007). One of the few studies completed identified that as few as 5% of nurses who attend cannulation study days actually go on to practise the skill (Nielsen, 2003). So how appropriate is a ‘cannulation skill development for all’ approach for the NHS if it is a specialised skill requiring training and a degree of continuous exposure to ensure competency?

An alternative approach to the management of intravenous (IV) therapy is the development of vascular access teams, which originated in the US. A recent review of such teams in nine hospitals (Hunter, 2003) suggested that their general day-to-day role would focus on PICC placement and the facilitation of routine peripheral, midline and central catheter management. Insertion of peripheral intravenous cannulas would remain the role of the ward nurse with the vascular access team assisting with difficult ‘sticks’ as required. Hunter concluded that vascular access teams are a ‘…highly valued resource, enhancing the quality of patient care while increasing patient satisfaction’.

Within the UK many healthcare providers have attempted to expand the cannulation services provided by nurses, and the nurse-led services associated with skills such as peripheral IV cannulation (Collins et al, 2006), PICC placement (Gabriel, 1995) and tunnelled central venous catheter placement (Hamilton, 2004) have proved effective. However, the provision of an organisation-wide vascular access team dedicated to the insertion of a range of VADs and associated training needs in a district general hospital remains in its infancy. This article explains how a dedicated organisation-wide vascular access team was developed at The Rotherham NHS Foundation Trust, a single-site district general hospital trust serving a population of just under 250,000.

The project

The aim of the vascular access team is to:

  • Provide an alternative to exclusive doctor cannulation, reducing medical staff workload;
  • Combat poor transferability of cannulation skills from the clinical skills room to clinical practice;
  • Insert a range of vascular access devices and adopt various methods of insertion to suit patient and treatment;
  • Improve clinical standards of infusion therapy and care.

Across the UK various models exist that are described as vascular access services. Models include the provision of PICC and tunnelled Silastic catheter placement for specific treatments such as chemotherapy or parenteral nutrition (Hamilton, 2004), and short peripheral cannulation placement for specific clinical areas by a team within that area. To date, few organisations appear to have responded to peripheral venous access issues with the introduction of a trust-wide vascular access team.

The Rotherham vascular access team does not mirror the typical team model described by Hunter (2003), although there are similarities in that it delivers a routine peripheral cannula, midline and PICC placement service across the majority of the organisation. The majority of the devices inserted consist of short peripheral cannulas, which is the focus of this article, but the team also provides midlines, PICCs and ultrasound-assisted vascular access.

Two registered nurses and four clinical support workers maintain the service, providing 12-hour cover from 8am, seven days a week. In addition to the direct clinical element the team also undertakes multi-profession education, audit and research.

Dutton (1924) described how the impact of vascular access need not have negative results; describing cannulation as the insertion of ‘…a needle directly into a vein… with perfect ease and safety under proper aseptic precautions, so that no scar or mark of any kind is left to indicate the site of injection…’ With the introduction of a vascular access team at Rotherham and an understanding of Dutton’s philosophy, we continue to strive to improve the initial impact and eventual outcome of vascular access.

Evaluation

A review of the project’s objectives illustrates the wide-ranging impact the team has had on service delivery, education and improved patient experience.

Providing an alternative to exclusive doctor cannulation

The team insert around 14,000 short peripheral cannulas, 400 midlines and 70 PICCs per year. This has both a direct and indirect impact on workload. Cannulation activity has an obvious direct impact on workload. However, the appropriate use of midlines and PICCs ensures that patients do not have to undergo repeated cannulation over lengthy periods. Furthermore, high clinical standards associated with VAD insertion have resulted in a low incidence of IV complications such as infection and phlebitis that may require further medical intervention. This has a further positive effect on workload.

Improving transference of skills

Like many other organisations we struggled to transfer the knowledge and skills taught in a clinical skills environment efficiently, effectively and safely into clinical practice. An internal audit in 2003 demonstrated that out of 50 individuals trained in cannulation, only 26% went on to gain clinical competency. However, following this review all cannulation trainees worked with the vascular access team to gain practical experience, which resulted in 84% achieving clinical competency. We have also seen a dramatic increase in the uptake of support from the vascular access team by medical students. For example, one student who had spent time with the team commented that they were grateful to have had the opportunity and would recommend it to any other student or professional wanting to improve their cannulation skill

Inserting a range of devices

It is important that vascular access teams are not seen simply as cannula inserters. They also influence and, at Rotherham, provide alternative VAD methods of placement including ultrasound-assisted PICC placement and midline placement. Midlines are 20cm vascular access catheters that can provide reliable vascular access for many weeks. While it is not the purpose of this article to examine in detail the benefits of midlines, in a review of 121 midlines (1,118 catheter days), with dwell times ranging from less than a week to 76 days, the following outcomes were noted:

  • Nil catheter related bloodstream infection;
  • One local site infection;
  • Two episodes of phlebitis;
  • Fourteen accidental removal/dislodgement;
  • Four occluded;
  • Six leaking.

Improving clinical standards

Before the introduction of the vascular access team very little data was collected on issues linked with cannulation such as number of attempts, site and size. However, the introduction of the team provided the opportunity to collect this data (Fig 1) [where is this?]. In an attempt to ensure the collection of comparative data and to provide benchmark standards, the vascular access team developed ‘The Rotherham Intravenous Cannulation Standards’ (TRICS) (Table 1), which are informed by the standards for infusion therapy developed by the RCN (2005):

  • Site selection: The RCN standards state that where possible cannulas will be sited in distal areas of upper extremities. This standard was expanded locally – it was agreed that 80% of cannulas would be sited in these areas. In a review of 1,073 cannula placements by the vascular access team (one month’s activity), 88.7% met this standard.
  • Attempts: It is generally agreed that each practitioner should not exceed two attempts at cannulation. This recommendation was further clarified, with the team setting a standard of 95% of all cannulas being placed within a maximum of two attempts. Local results illustrate that 87% of cannulas are inserted at the first attempt and 10% at the second attempt, demonstrating that the team exceeds the local standard by 2%, at 97%.
  • Waiting times: No national standards exist to ensure patients are cannulated in a timely manner. Following the introduction of the vascular access team, it was agreed that at the point of referral patients would be prioritised based on clinical need. Locally, it was agreed that 97% of those referred to the team would be seen within an allocated time, which ranged from immediate to a maximum wait of two hours. A review of one month’s vascular access team activity demonstrated that 149 (97%) of patients deemed as high priority were seen within 30 minutes of referral (four were seen after the 30-minute benchmark). Of those allocated the 60-minute benchmark, 237 (99%) achieved the standard (two seen after the benchmark). Of those patients described as low priority, 677 (99.5%) were seen within the two-hour standard.
  • Premature cannula failure: The Chief Medical Officer for England’s publication Winning Ways (CMO, 2003) stated 72 hours as the maximum cannula dwell time, however, evidence demonstrates that more than 70% of cannulas need to be restarted before the routine change limit is reached (Schears, 2006). Premature failure may be the result of various problems such as phlebitis, occlusion, infiltration and dislodgement. However, much of the literature simply looks at premature cannula failure rather than investigating the specific reasons. The benefit of this evaluation is that the team enquire about the actual reason for premature failure.
  • Phlebitis: The literature often describes examples of high infusion phlebitis rates, with rates described as high as 53% (Monreal et al, 1999). However, an 80% reduction in phlebitis rates may be seen when additional methods of stabilisation are employed (Schears, 2006) and four times lower in organisations with vascular access teams (Grune et al, 2004). The Rotherham standards concur with those of the RCN (2005), which state that phlebitis rates should not exceed 5%. Results from Rotherham show that following a review of 6,442 patient-cannula episodes phlebitis rates fell within the 5% standard. Initial signs of phlebitis as indicated by the Visual Infusion Phlebitis (VIP) Score (Jackson, 1998) demonstrated an early phlebitis rate of 4%. Within the same patient group, the incidence of severe phlebitis was 1% for VIP 3 and 0% for VIP 4 and 5.
  • Occlusion: Correct flushing practice is often overlooked (Ingram and Lavery, 2005); in addition, actual occlusion rates associated with peripheral cannulas are not well represented in the literature. Even so, the local acceptable occlusion rate was set at 5% or less. Unfortunately, a review of 6,442 patients found that the local occlusion rate was 11%.
  • Infiltration: Infiltration is the inadvertent administration of a fluid or drug into the tissue, which is not vesicant and unlikely to cause tissue damage (RCN, 2005). Various factors are described that contribute to infiltration – these include needle or catheter puncture of the vein wall, damaged VAD, impeded blood flow above catheter site, fibrin sheath occlusion of the catheter and inflammation of the vein (Hadaway, 2002). The literature does not identify actual infiltration rates, partly because it fails to distinguish between infiltration, extravasation and the other forms of premature cannula failure previously mentioned. The Rotherham standard was set at 10% or less for no other reason than anecdotal evidence suggested that infiltration rates are high. After the six-month review of 6,442 patients the Rotherham infiltration rate was found to be 6%.
  • Dislodgement: As with the reasons for premature cannula failure, the literature includes few dislodgement rates for peripheral cannulas. The team considered dislodgement to be preventable; however, the acceptable Rotherham dislodgement rate was set at 10% or less. It was thought this would allow for accidental dislodgement. In fact, a review of 6,442 Rotherham patients indicated an unfavourable dislodgement rate of 36%.

Table 1. Rotherham Intravenous Cannulation Standards

Topic

Standard

Results

Site

At least 80% of peripheral short cannulas will be sited in distal areas of upper extremities.

88.7%

Standard achieved

Attempts

At least 95% of peripheral short cannulas will be placed within a maximum of two attempts.

97%

Standard achieved

Waiting time

Patients must be prioritised to ensure vascular access is obtained in a timely manner. At least 97% of patients must be seen within their allocated time.

97–99.5%

Standard achieved

Phlebitis

Site monitoring, medication awareness and the appropriate use of PICCs are important elements and contribute to the reduction of infusion phlebitis. In addition, phlebitis rates will not exceed 5%.

1%

Standard achieved

Occlusion

Peripheral intravenous cannula occlusion rates will not exceed 5%.

11%

Standard not achieved

Infiltration

Infiltration rates associated with peripheral intravenous cannulas will not exceed 10%.

6%

Standard achieved

Dislodgement

No more than 10% of short peripheral cannulas will dislodge.

36%

Standard not achieved

 

Conclusion

Completion of the benchmark of vascular access standards sets the basis for an honest reflective exercise that should be completed by individual practitioners, organisations and the NHS as a whole.

Vascular access teams are efficient, effective and most importantly a measurable resource. Cannulas inserted by infusion nurses have been shown to have fewer complications and remain in place longer than cannulas inserted by generalist nurses (Palefski and Stoddard, 2001).

This review has demonstrated that vascular access team insertion standards associated with short peripheral cannulas are high. Unfortunately, it shows that post-insertion complications such as occlusion and accidental dislodgement remain high, which suggests it might be beneficial if the team were to develop post-insertion advice and support systems. This notion has recently been expanded to include the development of a post-insertion cannulation patient information leaflet (Fig 2). We await the impact of patient empowerment on complications such as occlusion and dislodgement.

Vascular access teams are an innovative opportunity for healthcare improvement. Some organisations within the NHS have grasped the opportunity and I eagerly anticipate further investment in this innovative team approach to vascular access.

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