Shonda Morrow, JD, MS, RN, CENP; Rush University Medical Center, Chicago, Illinois

Kimberly Alsbrooks, BSN, RN, RT (R), VA-BC; BD, Franklin Lakes, NJ, USA

Guadalupe Ordaz-Nielsen, BSN, RN, VA-BC; Rush University Medical Center, Chicago, Illinois

Cathy Heinzinger, RN, RNC-NIC, VA-BC; Rush University Medical Center, Chicago, Illinois

Mary Zack, BSN, RN, VA-BC; Rush University Medical Center, Chicago, Illinois

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The Importance of Vascular Access

Vascular access (VA) is a critical component of patient care that allows clinicians to safely administer medications and fluids, obtain blood samples, and provide other necessary treatment¹. VA is achieved by providers through the insertion of a peripheral or central vascular access device (VAD) into a blood vessel². Over 90% of inpatients will require a VAD at some point during their hospital stay, and worldwide the annual number of VAD insertions is estimated to be in the billions³.

Given the increasing role of VADs in patient care, there is a demonstrated need for dedicated VA teams (VATs) to place and maintain VADs³. VATs are composed of specialized clinicians with responsibilities including VAD selection, placement, and management³. The implementation of VATs in clinical settings has been shown to improve multiple clinical metrics, including rates of thrombosis, infection, and device failure^3,4. Furthermore, a recent publication detailing in-depth interviews with VAT members/leaders from nine countries revealed that, when combined with advanced technologies (i.e., point-of-care ultrasound) and evidence-based practices, VATs can significantly improve clinical, economic, and patient satisfaction outcomes⁵.

Recognizing the Obstacles

The Rush University System for Health is an extensive network of hospitals and outpatient care facilities located in Illinois with a mission to improve the health of the greater Chicago community⁶. The flagship hospital of the health system, Rush University Medical Center, previously had an intravenous (IV) service team that specifically managed VAD placements, but it was dissolved in 2012 due to lack of utilization. Following the termination of the IV team, Rush’s interventional radiology (IR) department resumed responsibility for most VAD placements between 2012 and 2019.

Losing the dedicated IV team was not without consequences; the access to specialists who support and educate on VAD selection, placement, and management was significantly reduced. Furthermore, the elimination of the IV service team and resumption of services by the IR department increased the use of hospital resources. VAD insertions in IR require the use of IR suites, IR specialists, sedation medication, and an accompanying nurse, which utilized substantial resources for simple line placements. Additionally, in the absence of a dedicated VAT, nurses at Rush’s neonatal intensive care unit (NICU) placed peripheral IVs (PIVs) for their own patients, as well as patients in other departments. As a result, nurses experienced additional travel times when responding to VA requests in various units.

Planning a VAT Initiative

To address the VA-related challenges identified by administrators and clinicians, Rush’s Chief Nursing Officer (CNO) approached hospital leadership in 2018 regarding forming a dedicated, nurse-led VAT. To explore this opportunity, a task force consisting of clinicians with significant VA-related experience (including Leoford D. De Guzman and Guadalupe Ordaz-Nielsen) was created, who then made a comprehensive plan for the team formation, training program, responsibilities, and hours of coverage.

The IR department was included in the early stages of VAT formation to inform the planning process and determine the percentage of VA procedures that could be completed at the bedside. Initially, the IR physicians were concerned about the nursing department overseeing the VAT since IR specialists were considered experts in line placements. The VAT also needed to maintain a strong working partnership with IR since some insertions could not be at the bedside and would require coordination between departments. To address this challenge, the task force recruited an IR physician champion to assist in future VAT efforts and establish lines of communication between VAT specialists and the IR department. As a result, the team was able to utilize their expertise while collaborating with IR on complex VA cases.

Multiple Rush stakeholders, including nursing leadership and finance managers, were consulted to provide valuable input and guide the VAT’s integration into the hospital system. Various departments, including IT, infection control, and pharmacy, served as key contributors by offering support and advice during the planning stages. Physician champions from other units (e.g., infectious disease, nephrology) were enlisted to bolster the team’s expertise and validity. Hospital leadership also played a crucial role in VAT development by providing ample financial and institutional support. For instance, the Associate Vice President for IR offered valuable input by sharing the VAT-related experience they previously gained at another institution. Moreover, the funds made available enabled the purchase of additional equipment, including two new ultrasound machines to assist in VAD placements and reduce radiation exposure.

Rush leadership provided significant investment into training for the VAT and utilized the partnership with their primary VAD vendor (BD, Franklin Lakes, NJ, USA), which provided equipment, educational resources, and training protocols. The involvement of the VAD vendor in Rush’s orientation program further streamlined the VAT implementation process and contributed significantly to the team’s formation. Specifically, the vendor provided a comprehensive and proven approach to VA care that included clinical practice assessments and education programs, which was utilized by Rush to develop the VAT orientation process. The vendor also provided VA equipment, training supplies, and instructors for the orientation process, and referred an experienced VA nurse to the team who became the VAT’s only external hire at the time. The support from the vendor ultimately saved valuable time by eliminating the need for Rush clinicians to create their own educational modules and dedicate staff to manage VAT training.

Formation of Multiple VATs

The hospital initiated the recruitment for the VAT for adult patients in early 2019. The search was expedited by an abundance of nurses at the health system with ultrasound or IV insertion experience who were qualified to join the team. Four internal candidates with relevant skills and interests were chosen to reduce orientation time, and their six-week training began in May 2019. During the training, the cohort was divided into two groups which alternated practicing sterile techniques and gaining floor experience under the guidance of two experienced nurses. Post-orientation, all four nurses were hired for the team and fulfilled additional training and qualification steps (e.g., acquiring board certification within a year). The VAT went live on July 1^st, 2019, and immediately saw a significant number of consults due to the existing high demand for VA services at the hospital. The team then expanded into Saturday coverage that same month to meet increasing VA needs and improve patient discharge rates.

The team’s success motivated the hospital leadership to form a VAT dedicated to pediatric patients (pediatric VAT). Three nurses were recruited in January 2020 and were trained using similar processes as the adult team. Prospective pediatric VAT members also received additional training from an external instructor to educate the team on pediatric-specific ultrasound-guided peripherally inserted central catheter (PICC) insertions. The pediatric VAT went live in April 2020 and was initially responsible for two pediatric floors. Due to their success, the team expanded coverage to include the pediatric emergency department, outpatient clinic, and infusion center.

Overcoming Hurdles

Following the implementation of the adult and pediatric VATs, Rush identified and addressed issues facing their newly established clinical teams. First, the IR department, the central line-associated bloodstream infection (CLABSI) team, and several physicians expressed concerns about the VAT’s expertise in VAD selection and insertion. To address these concerns, physician champions engaged in peer-to-peer discussions to assure Rush stakeholders of the VAT’s proficiency in VA-related clinical practices. Through these efforts, providers began heavily consulting the VATs within a few months, which proved the strength and longevity of the initiative.

Second, as Rush is an academic hospital, the yearly turnover of interns and residents created an ongoing challenge to re-educate providers on the VAT’s role in VA-related decisions. To address this challenge, the team began circulating a one-page document multiple times a year to all clinicians, which increased awareness of VAT policies and improved the sustainability of the VAT-clinician partnership.

Finally, the global COVID-19 pandemic initially caused a dip in consults for both the adult and pediatric teams due to a low-capacity ICU that prioritized more acute CVC insertions and limited patient exposure. The adult team could fill the void in consults by assisting in PIV placements for the ICU and other departments. However, the pediatric VAT saw a more sizeable drop in consults as they did not have the flexibility to extend their coverage to other locations. Eventually, consults for both teams increased significantly and have been steady since the beginning of 2021.

Achieving Results

Enhanced Safety for Patients and Providers

Implementation of the adult and pediatric VATs resulted in significant advancements to patient and provider safety at Rush. Clinicians noticed reductions in treatment delays and an increase in line placements as the VAT had a greater capacity to fulfill VAD placement requests compared to the IR⁷. VAT members traveled to patients’ bedsides and completed same-day catheter placements, allowing timely administration of medications and a reduction in length-of-stay⁷. The enhancement in line placement efficiency allowed the adult VAT to perform about 1,000 insertions annually in the first two fiscal years⁷. Additionally, the pediatric team has completed 517 successful insertions in the last six months⁷.

Both adult and pediatric VATs observed significant reductions in catheter-related complications (i.e., infection and thrombus rates) across their patient populations. Since the teams’ inception, a significantly lower number of CLABSI and DVT cases have been reported within both adult and pediatric patient populations⁷.

Furthermore, the reduction in the use of IR services led to a decrease in radiation exposure to both patients and providers since fewer patients were sent to IR for line placements⁷. Radiation exposure to patients and providers should not be overlooked considering the increasing role of IR-based procedures in healthcare⁸. The individual risk may be minimal for a single, low dose exposure from a chest x-ray. However, repeated procedures combined with the significant volume of imaging exams performed each year in the United States make radiation exposure a public health issue⁹. Therefore, it may be beneficial for patients and providers to avoid radiation exposure, especially when alternatives are available.

Improved Clinical Practice and Efficiency

As a result of their enhanced education and expertise, the VATs effectively addressed multiple VAD-related concerns that providers had observed prior to the teams’ implementation. The adult VAT reduced VAD-related readmissions by providing patients with instructional videos that allowed them to address common device problems at home. Consequently, the team reduced the total number of VAD-related readmissions by 74% within one year⁷. Moreover, the pediatric team switched to new, longer catheters that increased dwell time and resulted in fewer complications, including extravasations, treatment interruptions, and line migrations⁷. Thanks to the additional available device choices and related training, Rush achieved an average pediatric dwell time of 4.6 days⁷, which surpassed the National cVAD Registry average of 2 days⁷. The adult and pediatric VATs also engaged in patient rounding, which allowed the teams to address VA-related challenges earlier and implement proper line maintenance techniques such as dressing changes and catheter monitoring.

Boosting Patient Experience and Provider Satisfaction

Patient and clinician satisfaction significantly increased at Rush due to improved first insertion rates, faster discharges, fewer treatment delays, and a decrease in VA-related complications. There were also improvements in venous preservation due to increased first-time success rates, patient education efforts, and longer catheter dwell times. The teams achieved 97.6% and 97% first-time insertion success rates for adult and pediatric patients, respectively⁷. The reduction in multiple insertion attempts promotes patient comfort and may have downstream impacts such as decreasing needle phobia, which was shown to be caused by repeated/painful needle sticks^10-12.

Patients often expressed gratitude towards the VAT and specifically requested the VAT’s services. The practice of VAT rounding also improved patient experience as patients appreciated having an advocate on their side to monitor lines and answer VA-related questions and concerns. Moreover, provider satisfaction was enhanced as the VATs managed complex cases and inserted lines when other clinicians faced challenges. Providers thus expressed gratitude for the advice, education, and support they received from the specialized teams.

Contributing to Financial Health

There was a noticeable economic impact as a result of decreased resource utilization. Fewer catheters and less equipment were used thanks to the increase in first-time insertion, overall success rates, and increased catheter dwell times. Adult VAT members worked in pairs to ensure the proper sterile techniques minimizing equipment waste. There were also savings in nursing resources since the staff was no longer required to transport patients to IR for line placements. As a result, nurses allocated more time to patient-related clinical tasks.

There was also a significant increase in hospital revenue due to VAT improvements, including a reduction in patient days and an improvement in discharge rates. The IR department could also focus on more revenue-generating procedures as they were no longer responsible for simple line placements. Moreover, the VATs could complete more VAD placement procedures, representing a significant return on investment for Rush.

Unique Aspects of Implementing a Pediatric VAT

Rush’s experience forming adult and pediatric VATs emphasizes the VA-related differences among these populations, including management of complications and VAD selection. Therefore, Rush used a tailored approach to pediatric VAT formation to address the unique needs of the pediatric patient population.

To avoid VAD-related complications such as sedation-related challenges, CLABSI, and needle-phobia, pediatric patients may require additional care from providers. Sedation during IR procedures may lead to more severe complications in younger children compared to adults, including cardiovascular or respiratory instability, pulmonary aspiration, and airway obstruction^13-15. In previous studies, young age and low body weight have been identified as risk factors for increased CLABSI rates¹⁶. Invasive, needle-related events may also cause lasting fear and anxiety in pediatric patients, which may lead to an increase in perceived pain during subsequent procedures¹⁷. Furthermore, younger patients have smaller vein sizes and require appropriately sized VADs for catheter insertions.

Placement, management, and removal of VADs in pediatric populations require close monitoring since they may not effectively communicate their medical needs. Pediatric patients with VADs require more immediate attention and the use of appropriate line maintenance and removal techniques, which may prove more complex. Since placing and managing catheters in younger patients is more complicated, providers who are more experienced in this area tend to do the majority of line placements. Therefore, it is vital to create opportunities for other practitioners to build and develop these VAD-related skills.

To overcome these obstacles, Rush ensured that the formation/training of the pediatric VAT included additional elements that addressed the unique nature of pediatric care and that VAT candidates had prior pediatric experience. Pediatric VAT members also received special instruction regarding line placements and education on the use of ultrasound to guide VAD insertions. Additionally, the pediatric team was provided with specialized equipment (e.g., different types of ultrasound machines, catheter lengths/sizes) to safely place VADs in younger children.

The pediatric VAT assisted Rush clinicians by providing VA-related instructional materials, engaging in evidence-based discussions, and serving as a resource to address pediatric-specific VA issues. The team provided nurses with a reference binder containing VA-related information, including instructions on catheter selection and management of complications in pediatric patients. As a result, the VAT increased awareness regarding the unique challenges of VA-related pediatric care and contributed to the long-term sustainability of the initiative. The pediatric VAT also created a difficult intravenous access (DIVA) system that scored patients based on specific criteria. Floor nurses were thus able to practice line insertions, and the team was only called if patients reached a certain score.

Overall, the pediatric VAT initiative successfully addressed the multiple VA-related obstacles that Rush previously faced. Implementation of the pediatric team resulted in improved clinical and patient safety outcomes, increased patient/provider satisfaction, and significant benefits to Rush’s financial health. This experience serves as an example for other institutions and highlights the importance of pediatric-specific considerations (i.e., formation, implementation, unique challenges) when forming VATs.

Final Remarks and Future Directions

VA is a critical component of patient care, and clinicians face multiple challenges when placing VADs in children and adults. This case study demonstrates that significant improvements in clinical, economic, and patient and provider satisfaction outcomes can be achieved through VAT implementation. Although there are unique challenges in their formation and implementation, establishing a pediatric-specific VAT is feasible and provides similar benefits to their adult counterparts. Currently, Rush is looking to expand the VAT initiative to its two sister hospitals and establish a local network of VAT professionals to share their knowledge and experience with hospitals in the Chicago/Illinois area.

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References

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6. About Our System. Accessed November 17, 2021. https://www.rush.edu/about-us/about-our-system
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12. Kour G, Masih U, Singh C, Srivastava M, Yadav P, Kushwah J. Insulin Syringe: A Gimmick in Pediatric Dentistry. Int J Clin Pediatr Dent. Oct-Dec 2017;10(4):319-323. doi:10.5005/jp-journals-10005-1458
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14. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. Mar 2009;108(3):795-804. doi:10.1213/ane.0b013e31818fc334
15. Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. Jun 2019;143(6)doi:10.1542/peds.2019-1000
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