Volume 1 Issue 2

INTRODUCTION
THE VASCULAR ACCESS NURSE
Nurse-led central venous access device (CVAD) services have slowly emerged globally over the last 20 years, responding to organisational shortages of skilled CVAD practitioners^1,2,15. Historically, insertion outcomes mirrored medico-led teams; however, a reduction of intra-procedural and post-insertion complications was subsequently achieved through the continued surveillance of the CVADs by the vascular access service^1,4,9. The vascular access nurse thus became a cost-effective means to improve patient CVAD management, leading to longer term placements of lines, fewer needle punctures, fewer complications, and an increase in patient satisfaction²⁰. In searching for data regarding the paediatric speciality, CVAD studies have been determined as generally only suitable for the group the study observed, thus adult statistics are not feasible in determining paediatric CVAD management, due to the incomparability between age groups, underlying conditions, size/location of veins, catheter dimensions/properties, and patient immunocompetence²⁰.

In addition, small veins, poor visualisation, and risk of psychological trauma make accessing a paediatric vein a unique challenge¹². With peripherally inserted central catheter (PICC) insertion, even with the use of sedation/anaesthesia and ultrasonography, intra-procedural complications are relatively frequent due to the amalgamation of juvenile vasculature and vessel damage, often in combination with sclerosed vessels from previously repeated cannulation attempts^3,13. Current literature, detailing the reduction of infection rates and procedural complications, has led to a global increase in PICC usage and its promotion as a safe, long-term access option^8,15. However, this literature does not specify details such as time of placement, attempts made to insert the line, and post-procedural complications⁷.

Due to the success in adult practice, paediatrics has progressively adopted the scheme over the last 5–10 years outside of Australia; Sydney Children’s Hospital (SCH) had commenced its own nurse-led service in April 2013, with the aim of improving provision of CVADs and reducing complication rates. This service, run by the author, focuses on ongoing clinical support (particularly dealing with PICCs), education and the commencement of a paediatric-specific CVAD database detailing insertion, complication and removal data of all CVADs inserted in SCH. This service, championed by the SCH anaesthetics and general medical departments, was developed as a means of preventing and/or reducing complications which had historically impacted patient safety within the hospital, combating the increased costs in relation to additional operating theatre procedural time and complication treatments. The service sits under the nursing banner and is funded by the paediatric recovery unit, but is supported by the anaesthetics department, acting as the intermediary between nursing staff, medical/surgical staff, and the anaesthetics department.

CLINICAL SUPPORT

The service required a permanent 1FTE position at CNS2 level (currently filled by the author) experienced in paediatric critical care and advanced skills in paediatric cannulation, nitrous oxide administration, critical assessment skills, and advanced paediatric life support training. Whilst originally broad, the role of the vascular access nurse was developed through research and hospital requirements to meet three main needs of SCH: improved clinical support for staff and paediatric patients with a CVAD; enhanced staff/patient/family CVAD education; and the creation of a centralised CVAD database which could be utilised in the upgrading of current practices through statistical analysis of trends. In addition, the service was to act as an intermediary between those requiring the vascular device (the patient and medical teams), and those inserting the devices, ensuring that the right patient received the right device, for the right treatment and time frame, at the right time.

As intermediary between the patient and multidisciplinary teams involved in their collective care, the vascular access service not only acts as a source of surveillance and education, but aids in the assessment of correct access selection. Trained in assessing and attending to difficult cannulation, the service reviews and determines the patient’s need for peripheral or central access; by either attending to cannulation (PIVC only, due to current hospital policy), or referring the patient to anaesthetic/surgical services for an alternate long-term device. Presently, over 300 patients have been referred to the anaesthetic department for PICC and CVC insertion in the 18 months since the inception of the vascular access service. This has already prevented many unnecessary needle punctures and avoidable escalations to more invasive vascular devices in paediatric patients (estimated at between 1 and 5 cases per day). This intervention has shown to avert complications related to vascular access in adulthood and minimise complications relating to vascular damage^7,10,20. As the service remains relatively new to SCH, it is safe to note that conflicts do arise in relation to the vascular access service recommendations and the medical teams requesting assessment and assistance with management. In an attempt to diplomatically and positively address these issues, and variance in agreement of management are referred back to the department who inserted the vascular access device (anaesthetics for all non-tunnelled devices, and surgical for all tunnelled devices).

The commencement of ‘ward rounds’ has aided in the capturing of data, prevention and management of CVAD complications within SCH. These daily ‘rounds’ allow for the assessment and review of all SCH inpatients in non-haematology/oncology/intensive-care environment. (Note: SCH haematology/oncology/intensive-care services manage their own CVADs and collaborate with the vascular access service.) An average of 14–20 inpatients are being assessed daily within SCH by the service, a combination of over 300 CVADs inserted in SCH in 2014 and the large paediatric outpatient CVAD population. Patient reviews include physical observation of the patient and their device; chart reviews; and discussion with the patient’s teams regarding treatment length and CVAD-related goals. The service also provides support to nursing staff by attending to line access, maintenance and dressing changes. Understanding and assessment of potential complications is paramount in effective management of CVADs^5,8,12,13,20, and whilst current quality assurance data does not detail trends in which to modify practice thus far, many adverse events (such as line migration and traumatic removal) have been prevented through early detection by the SCH vascular access service since its formation.

FOCUS ON PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCS)

Coupled with the anecdotal SCH complication rates and saturation of literature on surgical CVADs (ports and tunnelled catheters)^13,15,20, the vascular access service has chosen to focus on paediatric PICC lines over less complicated vascular access devices. Adopting early pre-insertion assessment has aided the service in expediting PICC line insertion in inpatients, preventing unnecessary cannulation attempts, and reducing trauma to the patient; whilst continued post-insertion surveillance has aided in pre-empting the management of complications. The PICC device is inserted by the anaesthetics department in an operating theatre environment, with the vast majority of these devices being inserted under general anaesthetic due to concerns over patient safety and difficulty in inserting these lines. Basilic and cephalic sites are more often utilised, and accessed using ultrasonography as the primary means of vein visualisation in the most part. Image Intensifiers are utilised to visualise PICC tip placement during insertion, but X-ray is mandated in paediatric recovery for formal baseline observation for official determination of tip placement. This allows for management to occur swiftly and with minimal trauma to the patient if actions such as catheter withdrawal is required if catheter placement is not on target. Complications such as migration and mechanical occlusions have been identified early, allowing for swift treatment to occur, improving patient safety and PICC dwell time. While current SCH statistics are insufficient to determine if the service has been effective in managing PICCs at present, the current findings, including increased monitoring/assessment of indwelling PICC devices aids in the swift capture and management of PICC-related complications, leading to improved patient outcomes and longer dwell times, do correlate with existing paediatric studies into PICC management^3,11,13,15. Furthermore, patient/family satisfaction has reportedly improved since the services inception which further highlights existing study findings^3,11,13,15.

EDUCATION

Lack of education regarding CVADs promotes distrust, clinical-resistance and misuse¹⁹. Thus, a primary goal was to provide a constant, structured approach to education for CVADs in staff, patients and families. Management of CVADs requires a high level of educational support, and successful CVAD services in the past showing that tailor-made education programs have had a positive effect in identification of complications and long-term management of CVADs^12,15,16,18. At service inception, a new CVAD guideline was introduced to SCH, and in conjunction with ward educators this policy was integrated into current practice via in-services and one-on-one tutorials. Resistance was observed at this time, primarily due to confusion over jurisdiction over staff education (between the vascular access service and ward educators), and minor practice changes (such as heparin lock dosage/administration) which concerned practitioners whose specialities included patients with long-term vascular access devices (such as haematology/oncology, and gastroenterology). Since that period, the service has acted as an active resource for staff, often running informal, hands-on in-services and practical sessions to assist in developing staff clinical skills in areas such as dressing changes, line access and device locking/flushing. The focus is equally split with patient/family education, as evidence outlines that early collaboration and education at the pre-insertion stage can have a positive effect on the prevention of post-insertion complications, as well as improving communication and psychological support during a time where feelings of loss of control and fear are common^6,7,16,19. The vascular access service has created parent fact-sheets, available for each CVAD type, for families to keep, and are used in conjunction with interactive education sessions that use a ‘hands-on’ kit containing examples of each line available to SCH patients. No statistical evidence is available at present to support the service’s current success with patient/family/staff education, but unofficial reports from families and staff hint at positive improvements to subjective experiences with CVADs and moderate improvement in patient quality of life. Unfortunately, the effect of this is not well covered in the literature¹⁶.

QUALITY ASSURANCE

The SCH vascular access service determined a chief priority would be the commencement of a paediatric-specific CVAD database detailing insertion, complication and removal data of all CVADs inserted at SCH. While much literature details a high incidence of underreporting of CVAD complications⁸, the active presence of the service has meant unreported/ignored complications are often identified, managed and included in the database to later aid in the development and standardisation of hospital policy and procedure⁵. While less than two years’ worth of inconsistent data has been collected to date, trends are beginning to become evident, which will eventually assist in the modification of practice via the Quality Assurance Framework⁴ and a favourable shift in organisational attitude towards the CVAD service^1,2. CRBSI data is currently the responsibility of and collected by the infection control CNC, and at current collaboration between infection control and vascular access is being discussed to share information relating to CRBSI in the inpatient arena, to include in the CVAD database.

DISCUSSION
SERVICE ACCEPTANCE AND FUTURE POSSIBILITIES

Creation of new teams within the hospital system is often fraught with scepticism, with acceptance often slow and hard fought^1,2. Little by little the SCH vascular access service is building support via improved patient care, complication prevention, staff assistance availability and expedited access to line insertion. The increased responsibility that comes with acceptance does dictate that the service members require further skills development to meet the growing expectations of the service by SCH. To build on his own skills, the author has sought membership and support from national and international vascular access bodies, including the Australian Vascular Access Society (AVAS) and the Infusion Nurses Society (INS). In accessing these bodies, the author has had the opportunity to attend and present at national and international conferences, in-services and seminars. In attending these occasions for practice development, the author has met and learned from the top authorities in the field of vascular access, developing professional relationships with colleagues from clinical and industry arenas. The author also seeks to be recognised as a vascular access clinician and thus will be attempting the CRNI examination in early 2015. Current literature champions the use of ultrasonography in the placement of vascular access^14,17. Therefore, the service aims to become accredited in the use of ultrasound to aid with difficult peripheral cannulation. In turn, this should assist with the service’s ultimate goal of inserting paediatric CVADs, though this is largely dependent on facility support, funding, statistical and clinical evidence, and the need for extensive education and accreditation. With the combined development of the CVAD database and slow emergence of trends, the presentation of quality paediatric-specific findings should not be far off, and the continued success of the SCH service aims to act as a beacon for other paediatric facilities considering nurse-led vascular access services. To date, many peripheral paediatric wards have contacted the SCH-based service for consultation regarding management of difficult CVADs in the greater paediatric community.

CONCLUSION

Paediatric vascular access has long been an area of need in terms of development and maintenance, largely due in part to the difficulty in generating data to support practices and policy. The increase in nurse-led vascular access teams globally has aided in the recognition that appropriate management of CVADs by such a service improves patient outcomes significantly. This paper has briefly outlined the formation and early stages of a paediatric-specific vascular access service at SCH. This service provides clinical support, assessment, education, and data collection, which combined aim to improve the landscape of paediatric vascular access not only at the SCH, but present data which may one day improve the outcomes of all paediatric patients requiring a vascular access device worldwide. While this service is only in its infancy, it is quickly evolving and developing, based on the needs of the environment in which it is based.

ACKNOWLEDGEMENTS

I would like to thank Fionnuala Torrisi, Dr Donald Hannah, Anita Johnson and Donna Sumner for the assistance and support they have provided.
 

Author(s)

Joel Mason CNS2 Vascular Access, The Sydney Children’s Hospital, New South Wales, Australia

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