Ten years ago, I was tasked with setting up an intravenous (IV) team within my trust to improve standards and help reduce the incidence of IV-related meticillin-resistant Staphyloccocus aureas (MRSA) bacteraemia. Hence, my dream was born out of bringing about change and ensuring evidence-based IV practice was implemented. Reflecting on the past decade, as our team evolved with a shift from education and training to a more active role in vascular access, I wanted to share the strategies that have been key to our success. At the outset, the team had 3 members but has today expanded to a staff of 8.
In 2009, a trust-wide point prevalence audit of all IV devices identified three themes that needed to be addressed. I tackled each of these with three strategies that came to be known as Project HANDS (Table 1) (Caguioa, et al, 2012).
| Evidence-based component | The interventions | |
|---|---|---|
| H | Hand hygiene |
|
| A | Antisepsis with 2% chlorhexidine |
|
| N | Non-touch technique |
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| D |
|
|
| S | Scrub the hub |
|
* The mnemonic HANDS has been amended since it was originally defined (see Figure 1), and it is now based on updated infection prevention standards (Infection Prevention Society, 2017)
Several practitioners have visited our organisation to see what we do as a team and how we have developed the service and implemented change. I also started visiting and networking with other nurses who had already established IV access teams. Their experience and knowledge has been invaluable. What I found from undertaking a case study as part of my MSc was that, as clinical nurse specialists in the field of IV therapy, we have to be strategic leaders and we have to be able to demonstrate our impact and value to the organisation. I do not claim to be an expert at getting everything right when setting up an IV service and gaining all the skills for this specialised field, but I have learnt some useful lessons. I'd like to share our strategies and the outcomes from implementing them.
Strategy 1: standardisation of IV practice and equipment
When I first started as lead IV practitioner, there were limited policies and guidelines for the trust in place. There was only a peripheral cannula guideline for insertion and a poster on how to insert central lines. Investigation into trust practice revealed many variations in practice, much of which could be linked to the variety of equipment available for staff to use across the organisation. It was clear that standardisation of policy, process and product would be a key target to implement.
Standardisation of practice
The next task was to firm up the policies and procedures, so that we could standardise IV practice and align this with national and international guidance such as that of the Infusion Nurses Society (2016), Royal College of Nursing (RCN) (2016), Centers for Disease Control and Prevention (CDC) (2017) and Epic (Loveday et al, 2014). As a result, we introduced HANDS© as a care bundle for IV device insertion and maintenance (Caguioa, et al 2012). (We have since amended the HANDS mnemonic to better reflect our point prevalence audited standards and to continue to remind staff of the care bundle.)
We followed this up with a simple IV audit tool that identifies basic standards of care to indicate that procedures are performed consistently. Figure 1 provides a snapshot of the updated tool, which is based on the latest Saving Lives (Infection Prevention Society, 2017) standards—and uses our amended HANDS definitions. Using a care bundle approach to evidence-based prevention measures, selecting specific compliance measures and having a data collection form that is simple and concise helps to improve quality and reinforces best practice (Harpel, 2013).
Conducting the IV audits provided the IV practitioners with an opportunity to deliver ‘just-in-time’ education and the ability to disseminate current or new updates to clinical staff and became a driver to standardising IV practice. Initially, the audits were carried out every month, but since 2017 they have been undertaken every other month.
Standardisation of equipment
One key factor to getting procedures right is finding the best evidence-based and cost-effective IV products and consumables. When innovative products come on to the market, there is value in reviewing and trialling these within an organisation, so that their appropriateness can be evaluated in a particular clinical context.
Once a decision has been made to standardise to a product, it is important to work closely with suppliers and industry to ensure that the new products that arrive in the clinical area are used effectively by clinical staff. In this job, I learnt that staff will use only what is readily available to them and, hence, the availability of evidence-based equipment is essential. It means constantly communicating and working with the procurement department to get the right codes ordered so that these reach the store rooms and that all clinical staff are using the same product appropriately and cost effectively throughout the trust.
Strategy 2: staff training and education
One of the key recommendations of Epic 3 (Loveday et al, 2014) was the education of healthcare workers and patients. We educate clinical staff in aseptic non-touch technique (ANTT) (Rowley, 2001; 2010) and HANDS. This involves taught sessions that stipulate protocol when performing an aseptic procedure and competency assessments of frontline staff performing an IV procedure using ANTT. This is then followed by reinforcing the key ‘D’ standards, such as documentation, daily inspections and questioning daily the need for the IV device.
Recently, we managed to put our training slide sets on the organisation's e-learning platform. This was made a part of mandatory training to ensure that we can reach other clinical staff who do not perform IV procedures, but who would still need to know about the basic standards for IV device management. They are asked to complete an e-assessment at the end of the e-learning session, reinforcing the HANDS care bundle.
Another Epic 3 recommendation was that staff should be aware of manufacturers’ advice relating to catheters and other products. Utilising the help and support of company representatives in training frontline staff on the use of their products appropriately supports this recommendation.
In January 2010, the IV team collaborated with the IT team to develop methods for electronic documentation and monitoring of IV lines with a view to reducing line-related infections. We devised the ongoing IV insertion and IV care documentation as an educational tool for new doctors and nurses to help familiarise them with the standards.
A strong link with an IT analyst is recommended to help to ensure that electronic IV documentation can be implemented. This initiative will assist in remotely monitoring the duration and state of the IV device, while at the same time overseeing what happens to a patient's IV access on a virtual basis. This is instead of relying on paper documentation on the wards to inform staff of a patient's IV access history—one click will do the job and this provides oversight of IV devices across the organisation.
Strategy 3: sustaining engagement and improvements
Finding the right people within the organisation (from top-level management down to frontline clinical staff) who can champion the project and have the same passion for caring about patients’ IV access is key when trying to implement change in an organisation.
Engaging the stakeholders and managers
Over the years, I have developed good connections with anaesthetists, intensivists, service managers, senior nursing management, procurement and clinical directors who will try to put IV on their meeting agendas and make things happen for the cause. It is important to consider what part of a project will particularly appeal to each individual or department. That might be better governance, fewer central venous line (CVC) infections, better IV kits and consumables, cost savings or a better experience and pathways for patients.
All clinical groups have their own specific interests and it is identifying these that can get things moving in the right direction. I was fortunate to have the support of senior management when implementing the IV service. Describing compelling patient stories was a powerful tool in persuading colleagues to listen to what I was trying to achieve.
Recruiting IV link nurses
In 2011, we formed a network of IV link nurses across departments and specialties that had an IV skill development pathway. The IV link nurse role was established to work with the IV team and to be a champion in their respective areas, promoting and providing evidence-based practice and maintaining standards throughout the trust. The idea was for them to be able to pass on the skills that they learn in quarterly IV masterclasses. Achieving competency in these skills equips them to provide uniform and consistent IV device care that will enhance the patient's experience and sustain improvement in IV standards.
These three strategies have helped in sustaining best practice and in ensuring that for the past 5 years we have been recognised as a centre of excellence for central line care by an independent industry supplier, who does our annual point prevalence audits on basic central line standards. This demonstrated that against 32 other trusts, our trust has the highest standards for ongoing CVC care.
In 2012, I had only one IV practitioner trained in the insertion of peripherally inserted central catheters (PICC) under fluoroscopy. At that time, I had only the basic skill of cannulation myself. Since then, standardisation of IV practice has led to a fall in the rates of IV-related MRSA infections and IV practice becoming safe and evidence based. Our team then needed to respond to the evolving needs of the organisation. We moved to improving patient flow and experience. At that time, there was a 3-4 week wait for a PICC line. Hence, a plan was put in place to upskill the whole IV team and to explore ECG-guided technologies to insert PICCs outside radiology.
This meant lobbying managers who could help provide what an IV access service needs, ie a dedicated procedure room, ultrasound and IV consumables. These do not come easily when the resources of the organisation are limited, but timely meetings with key decision-makers helped realise our plan: a nurse-led PICC insertion service outside radiology. With the additional resources, we were able to reduce PICC waiting times to 1-2 days. This has had a big impact on the patient's hospital journey and experience.
Strategy 4: save the vein, save the line
In January 2018, the IV team started to implement the Vessel Health and Preservation approach (Moureau et al, 2012) to ensure the right patient gets the right line at the right time. The following initiatives are currently employed to achieve this strategy:
This was supported by a poster campaign, which states: ‘Even if it is 3 days old, it is not the end of the line as long as it meets the ‘PVC’ criteria: Patent, VIP score of 0 and Clinically needed.’
Conclusion
‘Strategic leaders dream and do something about their dreams. They are a synergistic combination of managerial leaders who never stop to dream and visionary leaders who only dream.’
I had the privilege of starting an IV service based on the context and needs of my organisation and forming a team of IV practitioners from different specialties who have a common goal. Based on the feedback of key stakeholders, the strategies have been effective and the IV service has had a positive impact on patient care, on standards and on the organisation. The IV service is valued by stakeholders and my leadership is recognised as ‘gentle’, strategic and collaborative. The current IV team model is effective, but it is vital that it responds to the changing needs of the organisation in the future.