Foundation for implementing a comprehensive vascular access excellence initiative organization-wide to improve vascular access device insertion and standardize care: best practice for an acute care hospital
In 2016, a 263-bed public district hospital in California trialed a peripheral intravenous catheter (PIVC) inserted using ultrasound, with the potential to increase first attempt success in difficult intravenous access (DIVA) patients. This led to the implementation of a hospital-wide initiative to improve nursing vascular access skills and expedite vascular access device (VAD) placement.
To trial a PIVC and ultrasound-guided (USG) insertion, a training program was developed and led to a doctoral Capstone project piloting an evidence-based nurse-driven protocol for the identification of DIVA patients. A Vascular Access Committee was established to achieve vascular access excellence throughout the hospital by increasing the number of nurses with advanced skills in VAD placement and by developing a central venous access device (CVAD) insertion and maintenance bundle to decrease the incidence of central line-associated bloodstream infections (CLABSI). With ongoing support of nursing leadership and achievement of ANCC Magnet Recognition® in 2021, the hospital developed a comprehensive initiative to provide patients with a consistent level of nursing expertise for VAD placement across all shifts.
Requests for USGPIVCs increased throughout the hospital, DIVA patients themselves requested ultrasound guidance be used for PIVC insertions, and there were fewer requests for Emergency Department (ED) physicians to insert CVADs. From the related Doctor of Nursing Practice (DNP) Capstone project, there were higher first-attempt cannulation successes, longer PIVC dwell times, and a reduction in devices and supplies utilized. The CVAD bundles resulted in the number of central line-associated bloodstream infections decreasing from four in 2019 to one in 2020. Since the initiative's inception, a total of 92 nurses completed the USGPIVC insertion training, and patient access to advanced-skilled clinicians is now available around the clock.
This manuscript discusses the initiative implemented to standardize patient care through a collaborative multidisciplinary approach and has potential generalizability to other acute care hospitals to reduce associated healthcare costs and to prevent poor patient outcomes by expediting the arrival of a vascular access nurse for DIVA patients.
The vascular access excellence initiative implemented provided an effective strategy to enhance the skills and confidence of nurses in VAD placement and improved efficiency in processes to expedite the arrival of an advanced skilled nurse to place VADs on DIVA. Targeted educational initiatives improved patient outcomes by reducing catheter-related bloodstream infections.
Most patients admitted to a hospital require a vascular access device (VAD) during their hospitalization (Helm et al., 2015; Keleekai et al., 2016; Plohal, 2021). This common procedure is often performed by nurses trained to place peripheral intravenous catheters (PIVCs) using traditional landmark techniques. Between 8%–23% of the population are referred to as having difficult intravenous access (DIVA) and present challenges due to a lack of adequate peripheral veins, often requiring multiple attempts to successfully place a VAD (Armenteros-Yeguas, 2017; Davis et al, 2021). Repeated venipunctures cause pain and anxiety for patients, decrease satisfaction with care, and increase costs for supplies and clinician time. With each unsuccessful attempt, availability of peripheral veins appropriate for PIVC insertion diminishes, which increases the likelihood of escalation to a central venous access device (CVAD) as a rescue access and poor patient outcomes (Adkihari et al, 2015; Au et al, 2012; Paje et al, 2018; Psaila et al, 2023).
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