Taking the Lead in Vascular Access Improving Patient Outcomes

Transcription

1 Taking the Lead in Vascular Access Improving Patient Outcomes Tricia Kleidon Nurse Practitioner Lady Cilento Children s Hospital Alliance for Vascular Access Teaching and Research (AVATAR) Menzies Health Institute Queensland Schools of Nursing & Midwifery

2 This presentation will focus on: Vascular access as a nursing specialty Improving patient outcomes through nursing leadership Practice v- research Insertion Maintenance How they compliment each other Complication free CVAD s myth or reality? The important implications for catheter management best practice emerging from research Current and future research directions in intravascular access research

3 Who chooses to put needles into children for a job? What sort of person does that?

4 So How does one become a paediatric vascular access nurse specialist?

5 A little bit about me. Bachelor of Nursing QUT Transition Support Programme in Paediatrics RCH Brisbane 3 rotations Medical Surgical Specialty - Emergency Applied for a job on orthopaedic/neurosurgical ward 2 years Developed an inquiring mind into PIVC s during this time Why did some kids get PICCs v-others who had multiple failed PIVCs? Why did some kids have a TKVO v-those with intermittent flushes? Was one better than the other? 10 years on WE STILL DON T KNOW!!

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8 Shortage Occupation. Paediatric nurse Monday Friday 9-5 No shift work Free to travel on the weekend

9 Interventional Radiology Growing sub specialty of radiology The key hole surgery of the 21 st century Minimally invasive procedures Angiography/angioplasty +/- stenting Large interest in oncology US guided tumour biopsy +/- line insertion Chemoembolization Diagnostic procedures for catheter malfunction Provide vascular access through non-traditional route when traditional routes were exhausted Recanalization (dilation and stenting) BcV

10 Specialist nurse - Improving Patient Outcomes

11 Specialist nurse - Improving Patient Outcomes Timely Catheter Insertion PICC Tunnelled cuffed CVC s Totally implanted venous port devices Providing venous access for neurosurgeons inserting VA shunts Permanent haemodialysis catheters Temporary haemodialysis catheters Non-tunnelled CVC Procedures under local anaesthetic for older children Training radiology and surgical registrars and fellows US guidance Training consultant surgeons

12 Specialist nurse - Improving Patient Outcomes Timely and Successful Catheter Insertion 99.5% 95-96% 90-95% this series reported suggested threshold These rates are for adults and could be expected to be lower in children Lewis, C.A. (2003) JVIR; 14:S231-S235

13 Specialist nurse - Improving Patient Outcomes Timely and Safe Catheter Insertion Complication suggested threshold reported rates this series pneumothorax 3% 1-2% 0% hemothorax 2% 1% 0% haematoma 2% 1% 0.4% perforation 2% 0.5-1% 0% air embolism 2% 1% 0% Lewis, C.A. (2003) JVIR; 14:S231-S235

14 Specialist nurse - Improving Patient Outcomes Vessel Health Compared success and complication rates of puncture of central veins with ultrasound guided andtraditional landmark techniques Report concluded that ultrasound guided puncture is more cost-effective increases success rates of insertion decreases complications associated with insertion National Institute for Clinical Excellence NICE (2002)

15 US v Surgical Cutdown prospective study ( ) patients returning for IR procedures after catheter removal data required for eligibility technique used size of catheter date of insertion date and reason for removal Roebuck et al. SPR 2005

16 Methods IJV patency assessed by US normal appearance patent but abnormal thrombus narrow occluded

17 Methods IJV patency assessed by US normal appearance patent but abnormal thrombus narrow occluded

18 IJV patency assessed by US normal appearance patent but abnormal thrombus narrow occluded Methods

19 IJV patency assessed by US normal appearance patent but abnormal thrombus narrow occluded Methods

20 IJV patency assessed by US normal appearance patent but abnormal thrombus narrow occluded Methods

21 Results US-guided group surgical group number of veins vein occlusion 2% 33% OR thrombus (if patent) 3% 21% OR mean age (yr) n.s. catheter size (mm) p<0.05 duration of use (d) p<0.05

22 Discussion Can duration of use account for the increased risk of jugular occlusion in children in the surgical group? occluded veins: mean duration 99 d patent veins: mean duration 177 d NO

23 Discussion Can catheter size account for the increased risk of jugular occlusion in children in the surgical group? occluded veins: mean size 2.27 mm patent veins: mean size 2.22 mm NO

24 Conclusions US-guided percutaneous insertion allows a statisticallyand clinically-significant reduction in the risk of jugular occlusion US-guided access should be preferred to surgical access, especially when multiple catheters may be required

25 Fast forward. A baby A move to Qatar Another Baby

26 Vascular Access Nurse Specialist Improving Patient Outcome - Device Management Establish an intentional process for the Right Linefor the Right Patientat the Right Time

27 Guide to device selection Intravascular Access Device Decision Tree </= 1 week 1 week 3 months (use this option if length of treatment unclear) > 3 months Isotonic Non-vesicant ph 5-9 <600mOsm/L Difficult access having exhausted all other avenues stem cell harvest or short term dialysis Hypertonic Vesicant ph <5 or >9 >600mOsm/L Continuous or intermittent infusion and Infrequent blood sampling required Continuous or intermittent infusion and Frequent blood sampling required Continuous Access e.g. TPN and long term antibiotics Frequent Intermittent Access e.g. Heamophilia or Cystic Fibrosis Large bore Haemodialysis / Aphaeresis Peripheral Intravenous Cannula (PIV) or Midline Nontunnelled Central Venous Catheter Temporary nontunneled dialysis catheter (n.b. this should only be used for maximum 7-10 days) Peripherally inserted Central venous catheter (PICC) Tunnelled Cuffed Central Venous Catheter Totally Implanted Venous Port Device Tunnelled cuffed permanent dialysis catheter Decision for venous access device should be made using decision tree as a guide only. For complex cases device selection should be made in conjunction with all clinical teams involved in care and lines management CNC. When choosing the most appropriate device the following principles must be adhered to 1. Right device inserted first time 2. Smallest possible device for completion of treatment 3. Minimum number of lumens required for completion of treatment

28 Make the basics unforgettable Dedicated CVAD trolley!

29 Impact on Infection Rates 500+ days infection free 0

30 Impact on Bundles Compliance Wards 1 & 2 Wards 3 & 4

31 Pre-requisite to be an NP 1. Masters Nursing Science (Nurse Practitioner) I. 1 year FTE or II. 2 years PTE III. Various subjects depending on university a) Assessment and diagnosis b) Evidenced Based Practice c) Pharmacology x 2 units d) Research project e) Internship x 2 units f) viva 2. Endorsement AHPRA upon completion 3. Entry and Endorsement requirements I. Minimum 3 years senior nurse (CN equivalent or greater) a) Must be within your area of specialty and within last 6 years II. Post graduate qualification within last 10 years III. Currently working >/= 0.6FTE in your specialty area IV. Institutional support

32 Get it right from insertion Use Ultrasound to define all anatomy Choose a trajectory that will minimise future complications Arterial puncture Nerve injury Constant tip visualisation to ensure single wall puncture Ulna Nerve Brachial veins Brachial Artery Median Nerve Ulna Nerve Basilic vein

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34 LIMITATIONS small study n=136 Small number of thromboembolic events n=4 All patients who developed VTE had haematological cancer including patient with CTV ration of 30% Most patients in this study had a CTV ratio < 46%

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36 Potential complications of vascular access Thrombotic occlusive clot Fibrin Sheath Displaced catheter tip Collateral veins Fractured catheter Catheter separation CCA Thrombosed LIJV Extravasation

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38 Insertion & removal ANTT & Infection Control Patency & flushing Connectors & cleaning Securement & dressings IV lines & solutions

39 CASCADE jnr: CAtheter SeCrement And Dressing Effectiveness in kids 3 arm PICC and 4 arm tc-cvc RCT: Standard care Combination dressing and securement device Glue Standard care + retainer (tc-cvc only) Primary outcome: Catheter Failure (dislodgement, occlusion, infiltration, phlebitis, infection) Secondary outcomes: Device life; Costeffectiveness

40 The FliP trial: Flushing in PIVs Randomize patients to 4 flush groups: Low frequency, low volume High frequency, low volume Low frequency, high volume High frequency, high volume Volume is 3 or 10 mls; 1 or 4 times/day Primary outcome: Catheter Failure (occlusion, infiltration, phlebitis, infection) Secondary outcomes: Device life; Costeffectiveness; Dislodgement Investigator-initiated study. BD & Uni funding Pilot RCT in 2014, larger RCT for 2015->

41 The One Million Global PIVC Study Worldwide PIVC benchmarking study Gillian Ray- Barruel Prelim results Platinum Showcase AVA Dallas 2015 Dr Evan Alexandrou Final results WoCoVAPortugal 2016

42 Research SMILE RCT comparing various methods of PIVC securement Primary outcome: reduction in PIVC failure. PICCOMPARE RCT comparing current generation polyurethane PICC to new generation bioflo PICC Primary outcome: reduction in PICC complications (infection, occlusion, thrombosis, fracture, dislodgement)

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44 Intravascular Line Savers are Life Savers Hosted by the Australian Vascular Access Society you are invited to attend the 1 st Vascular Access Scientific Meeting April 2016 Brisbane Convention and Exhibition Centre Queensland, Australia Join the conference mail list: #AVAS16