A REVIEW OF BEST PRACTICES IN

VASCULAR ACCESS AND INFUSION THERAPY

PRESENTER

JOSEPH PETTEE RN BSN CRNI VA-BC

President/CEO AccessRN, Inc.

Disclosure

CEO and FOUNDER for AccessRNASSOCIATION OF VASCULAR ACCESS

FOUNDATION BOARD MEMBERCONSULTANT BARD MEDICAL

CONSULTANT GENETECH MEDICALCONSULTANT ARGON MEDICAL

CONSULTANT ANALOGIC MEDICAL

Why is this Important

To me?I’m an administrator, why do I need to

know about IV’s and IV meds?I work in dietary, why do I need to know….I don’t even work with patients, why do I

need to know……

One day……You may……

…be the patient!

Objectives1. To gain knowledge of vein anatomy,

principles of infusions, and vascular access devices.

2. To understand vessel health and preservation to provide best outcomes for residents by decreasing complications.

3. To gain knowledge on building a successful infusion program decreasing complications and increasing profits.

4. To understand new controversial research and its impact on the care you provide

5. Understand new technology and its impact on the PT

Vein Anatomy

1. Tunica Intima-inside, one cell layer thick, keeps vein “water tight”.2. Tunica Media-middle, muscles, connective tissue.3. Tunica Adventitia-outside, sympathetic and afferent nerve endings.

Principles of Infusion1. Hemodilution-the more blood mixes

the less harmful medicines are to veins

2. Right line at the Right time3. Site selection is imperative4. One patient, one stick, one device

Hemodilution1. Hand veins 30-40 ml per minute2. Forearm veins 50-60 ml per minute3. Axillary veins 200-300 ml per minute4. Subclavian vein 700 -800 ml per

minute5. Lower third of SVC or Cavoatrial

Junction 2000-2500 ml per minute

Right line at the Right Time1. What is the prescribed therapy?2. What is the duration of therapy?3. What vein options does the patient

have?4. What are the available devices?5. What is the vascular access skill level

of the clinician that is available to place the line?

6. What is the competency of the bedside nurse that accepts responsibility for the patient?

Chose a device!1. Short peripheral intravenous catheter (PICV)2. Long PICV3. Short Midline4. Long Midline5. PICC6. CVC7. JACC8. Tunneled catheter9. Implantable port10. Power injectable11. Valve or non-valve12. Positive pressure, neutral pressure, negative pressure- needleless

connectors13. Antibiotic impregnated14. Antimicrobial coated15. Do we use Ultrasound guidance, b mode, c mode, in-plane, out of plane,

sagittal, longitudinal16. Modified seldingers, microintroducer, steal needle, angiocath, nitinol,

platinum or stainless steal, 17. Will we verify the tip with CXR or EKG?

One Patient,

One Stick,

One Device!

How many times do we stick?

How many nurses get to try?

As many as it takes?

What’s your policy?

How about 22 times?

Complications1. Phlebitis2. Infiltration/Extravasation3. Infection4. Hematoma/Arterial Puncture5. Nerve damage6. Embolism7. Thrombosis8. Catheter malposition9. Catheter occlusion

Phlebitis

Venous Depletion

Extravasation

Extravasation

Catheter Malposition

Cavoatrial Junction: Optimal

Decreasing Patient and Facility Complications1. Develop an infusion program with specially train

nurses and specific policies and procedures, IV resource personnel

2. ResourcesA. Infusion Nurse’s Society standards of practice,policy and procedure manual and position

statements (ins1.org)B. Association of Vascular Access position

statements (avainfo.org)C. CDC Guidelines for the Prevention of

Intravascular Catheter-Related InfectionsD. Pharmacies

E. Independent Vascular Access TeamsF. Nursing Competency

Managing Infusion Program1. Assess Nurse’s ability2. Educate where knowledge deficits

exist3. Annual competencies4. Market services to referral sources5. Discuss appropriate vascular access

device at admission to LTC from ACH6. Promote your readmission rates

Why infusion programs fail?1. Accessing veins is a Low volume

procedure in LTC2. Many devices with many purposes3. Care and maintenance Knowledge

deficit among nursing staff4. Residents are becoming venous

depleted

Financial BreakdownResident with Medicare Part A

Unable to establish access in house

1. Ambulance ranges from $1000 to $1600 one way.2. Line insertion-$1200 to $20003. If patient stays at hospital $400-$600 per day lost in revenue to LTC 4. Not to mention the Hospital’s major focus on preventing 30 day readmission penalty

Average Cost of sending patient out for line placement

Ambulance ride round trip $1100Line placement$1200

Total cost average $2300

Add an over night stay (loss) $400

Total cost $2700

Combat Cost1. Assuring your nurses can care for

residents with vascular access devices.

2. Planning for the appropriate device that will carry the IV infusion for the entire length of therapy.

3. Maintain control over your patients by keeping your residents in your building!!!!

Bedside Nurses And

Vascular Access

Infusion Nurse’s Society Standards of Practice

Site selection 1. Avoid areas of flexion2. Largest vein and smallest catheter3. Avoid 4-5 inches on lateral surface of wrist4. Avoid lower extremities5. Avoid upper extremities in CKD 3,4,5 and

end stage.

LEGALLY SPEAKING!!IF NO BLOOD RETURN DO NOT USE THE LINE UNTIL

YOU HAVE FLUSHES EASILY AND GOOD BLOOD RETURN

AND BE SURE TO DOCUMENT IN YOUR PROGRESS NOTES

Vascular Access DevicesAnd Blood Return

• SOP 61 B “The nurse should aspirate for a positive blood return…to confirm patency”

• SOP 45 E “…as a component of assessing catheter function”

• SOP 45 G “…no blood return noted, further steps should be taken to assess patency”

Flushing• Heparin vs Saline• Evidence to support both• SOP 45 J “short peripheral…

preservative free saline”• SOP 45 O “…central devices heparin

lock 10u/ml” recommended

Peripheral Site Rotation• SOP 44 1 A “Replacement of short

peripheral catheter when clinically indicated”

• CDC “no more frequent than 72-96 hours”

Occluded PICC’s

• Know your end cap• Proper flushing techniques• Monitor for early signs of occlusions• Catheter clearance; Declotting

Migration of Catheter

• Resident pulls catheter out• Dislodged with dressing change• DONOT ATTEMPT TO REINSERT

PICC vs MidlinePICC Midline

Hemodilution 2000-2500ml/min200-300ml/minCost Needs x-ray No x-ray neededInfusate Any *No Vesicant/IrritantsDuration Up to a year 29 days per IFUOccluded Can use Cathflo Not FDA approved

For CathfloPlacement Ultrasound Ultrasound

*Further discussion needed

Irritants and VesicantsThrough Midlines?

• INS SOP 32 “Therapies not appropriate for midline catheters….pH less than 5 and greater than 9”

New studySafe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical

trial

• Small sample size 30 catheters• Less than 5 days• Concentration of 4mg/ml

Conclusions: Short-term intravenous vancomycin can be safely and cost-efficiently administered in

the deep vessels of the upper arm using the midline study device

J Vasc Access 2014;15 (4): 251-256

NEED MORE DATA!!!!!• Multicenter • Tracking outcomes for Midline

infusions• Matt Gibson 270-577-6159• Kivan.ava@gmail.com

PICC Tip Location

6cm4cm2cm

86%

31%

1.2%

14%16%

Petersen et al, Am J Surg 1999, 178: 38-41

PICC Tip Location

• INS Lower third SVC/CAJ• CDC Lower third SVC• NKF Lower third SVC• AVA Lower third SVC/CAJ• SIR Lower third SVC

Malpositioned if tip other locations A PICC catheter cut to a midline length is not used correctly. IFU advises SVC.

DIVA’s(Difficult IntraVenous Access)

• Chronic diseases• Elderly vascular changes• Genetics• Frequent hospitalizations• Anticoagulants

What is it like for the bedside nurse to deal with the DIVA’s?

• Multiple sticks• Frustration• Time consuming• Suboptimal sight

selection• Medication delays

Summary• One patient, One stick, One device• Place the best device first• Proper care and maintenance• CATHETER SHALL BE SMALLEST GUAGE

AND LENGTH AND FEWEST LUMENS • Keep device in patient• Keep patient in facility• Track outcomes• Partner with experts

SUMMARY (CONTINUED)MEDICATION PH ALONE IS NOT A

CONTRAINDICATION FOR A MIDLINE THERE IS A GROWING BODY OF EVIDENCE TO SUPPORT A MORE

COMPREHENSIVE ASSESSMENT IN DETERMINING ACCESS TYPE AND

TYPE AND NUMBER OF INFUSATES DURATION OF THERAPY,LOCATION OF CATHETER, CONDITION OF PT’S

VEINS

VASCULAR ACCESS DECISION TREEDETERMINE PT’S VENOUS ACCESS NEEDS EARLY

DETERMINE LENGTH AND TYPE OF THERAPY INDICATED

LESS THAN 7 DAYS MORE THAN 7 DAYS

NO YES

LENGTH PLA

> 10% DEXTROSE>5% PROTEINVESICANT OR KNOWN IRRITANTANTINEOPLASTICCONSIDER IF MEDICATION PH < 5 OR>9OSMOLALITY >600

YESPLACE CVA/PI

CC

NO YESLENGTH OF THERAPY 7-28 DAY

PLACE MIDLINE

LENGTH 7-365 PLACE

PICC

CONSIDER MIDLINE OR PIV ULTRASOUND FOR

PLACEMENT (ULTRASOUND TRAINED NURSE,PICC NURSE RN OR CONTRACT HITECH

VASCULAR TEAM

CONTACTNEXT LEVEL EXPERT FOR

LINE INITIATION

START PIVIF UNSUCCESSFUL AFTER 2 ATTEMPTS (HX OF DIFFICULT

ACCESS , OBESITY, OR EDEMA TO UPPER

EXTREMITY

OPTIMAL PATIENT OUTCOMES DURING PICC PLACEMENT USING BED SIDE

CATHETER NAVIGATION AND CATHETER FDA APPROVED TIP COMFIRMATION

IMPROVES PATIENT SAFETY

MALPOSITIONS AND REPOSITIONSOF PICC TIP NO MORE GAMMA SCATTER RADIATION

REDUCE NEED TO TRANPORT PATIENT S REDUCE TIME TO INITATE IV THERAPY REDUCE REPEAT PROCEDURES COST EFFECTIVE (NO XRAY NEEDED)