1. Infusion
Safetysolutions
36 December 2016 • Nursing Management www.nursingmanagement.com
By Lorelle Wuerz, MSN, BA, BS, RN, VA-BC
majority of the 35.1 million patients admit-
ted to the hospital each year require place-
ment of an intravascular device, with 90%
of patients receiving a peripheral I.V. and
25% receiving a central venous access
device.1,2
This equates to over 7 million
vascular access devices used per year in
the United States.3
Practices related to insertion,
care, and maintenance of vascular access devices
are critical to positive
outcomes. The current
status of quality-driven
and outcome-centered care
isn’t just a goal; it’s now
mandatory in the inpatient
setting. Nurses at all levels
need to be educated on
nurse-sensitive indicators
and aware of individual
unit performance to drive
best practices and better
outcomes for patients.4,5
More important, proactive
engagement in these initia-
tives is imperative.
One outcome measure
that has a significant impact on American hospi-
tals is central line-associated bloodstream infection
(clabsi), which carries a significant patient mortality
risk, as well as implications for the financial sustain-
ability and reputation of healthcare organizations.
Mortality for patients who develop a clabsi can be
up to 25%. Although the overall incidence of clabsi
occurring in the United States is decreasing, the
number still remains at approximately 18,000, with
an estimated cost of between $5,734 and $22,939 per
incident.6,7
According to the Centers for Medicare
and Medicaid Services, clabsi is considered a non-
reimbursable never event if the infection occurs after
the patient is admitted to the acute care setting.8
And
the government now requires public reporting of
institutional outcome data for transparency through
the Hospital Compare
website, tying outcomes
to reputation.9
There have been many
efforts in recent years to
improve clabsi outcomes.
The Institute for Health-
care Improvement has
developed evidence-based
intervention bundles to
structure central line inser-
tion and care.10
In addition,
preinsertion checklists
have been developed to
offer care consistency and
standardization. The CDC
has developed a compre-
hensive guideline for the prevention of intravascular
catheter-related infection.11
Other critical interventions
for the prevention of clabsi include empowering
nurses to take the right steps, engaging multidis-
ciplinary groups on a regular basis to discuss best
practices, and regularly sharing concurrent data and
outcomes for each desirable measure.7
Vascularaccessdevices:Setting
yourorganizationupforsuccess
A
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2. www.nursingmanagement.com Nursing Management • December 2016 37
Organizations can set them-
selves up for success in terms of
safe, quality care related to central
venous access devices by taking a
simple four-step approach to evalu-
ate the care being provided in their
settings:
• assess current knowledge of those
caring for central venous access
devices
• evaluate current policies and
procedures
• implement appropriate educa-
tional models
• integrate ongoing monitoring.2
Assessment
The first step to an improved
vascular access program at your
organization includes assessment
of your staff members’ knowl-
edge base as it relates to central
venous access device management.
Nurse leaders should round on
patient care units and speak with
staff members about their practice
habits. Ask questions and survey
nurses about their knowledge to
gain a better understanding of
gaps in maintaining central venous
access devices. (See Table 1.)
In addition to gaining an
understanding of staff knowledge,
practices should be observed. Use
a monitoring tool to gather obser-
vational data to help understand
practice variations and opportuni-
ties for improvement. The sample
tool provided is divided into three
sections: 1) observation of practice,
2) a questionnaire, and 3) a review
of electronic documentation compli-
ance. (See Table 2.) Organizations
can modify the left-hand column of
the tool to define what best prac-
tices they want to monitor and do a
point-prevalence data collection.
Policies and procedures
The second step to setting your
organization up for success is
evaluating the infrastructure that
guides practice through policies
and procedures. Often, there are
several organizational policies and
procedures that discuss or mention
central venous access devices. Poli-
cies and procedures are intended
to facilitate adherence with profes-
sional practices; promote alignment
with compliance and regulatory
requirements; reduce variations in
practice; serve as a resource, espe-
cially for new staff; and eliminate
the need for staff members to rely
on memory.12
Hospitals often strug-
gle with managing policies and
procedures because of the number
of challenges they pose.13
Put best
practices in place so that policies
and procedures are well-managed
and helpful for staff in terms of
improving practice and impacting
patient outcomes.
Best-in-class hospitals have a
collaborative approach to policy
and procedure creation and main-
tenance, with silo-free coordination
and alignment between departments.
Developing committees empow-
ered to streamline policies and
procedures, ensuring that all key
players weigh-in on and commu-
nicate regarding changes, defining
process owners for managing poli-
cies and procedures, and engaging
staff members in the workgroup
responsibilities of reviewing and
managing policies and procedures
are all best practices.13
Organizations
should consider using a system or
template to guide policy and proce-
dure creation to help streamline the
process. In addition, process own-
ers and/or staff members engaged
in the process need basic skills in
understanding how to review and
revise policies and procedures.
Lastly, defining a regular schedule
for reviewing and updating poli-
cies and procedures is a key to sus-
tained success.
Overall, investment in the devel-
opment and review of policies and
procedures can reduce possible
risks and variations in practice,
impacting patient care related to
central venous access devices.
When reviewing your organiza-
tion’s policies and procedures,
ensure that there are no duplica-
tions, inconsistent statements, or
outdated references. Also ensure
that staff practice is aligned with the
policy and the policy is aligned with
practice. Other considerations are
in the length of the policy: Policies
that are long and difficult to read
will be frustrating for staff members
who are looking for guidance. Use
pictures, algorithms, diagrams, and
links to approved videos to stream-
line policies. This basic, but impor-
tant, foundational step will lead to
success in improving your overall
vascular access program.
Table 1: Central venous access
device nurse survey
1. How long do you scrub the hub
of your central venous access
device before accessing it?
2. How often do you change
the tubing for your patient’s
infusions?
3. How often are central venous
access device dressings changed
on this unit?
4. What’s your definition of patency?
5. Would you use a central venous
access device if it had sluggish
or no blood return?
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3. 38 December 2016 • Nursing Management www.nursingmanagement.com
Infusion
Safetysolutions
Table 2: Central venous access device monitoring tool
Unit: _____________ Date: ___ /___ /___
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10
Observation Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments
Did the RN perform hand hygiene before touching the patient/CVAD?
Did all hubs have a needleless endcap applied?
Did the RN scrub the hub before any and ALL connections?
Did the RN scrub the central line hub for 15 seconds with alcohol?
Was the tubing for all medications labeled with date, time, and initials?
Was all tubing not in use capped off with a red cap?
Did the central line dressing have the date, time, and initials?
Was the central line dressing intact?
Each lumen of the CVAD flushes without resistance?
Each lumen of the CVAD has brisk blood return (3 mL) free flowing?
For central lines not in use, was an end cap in place?
Questionnaire Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments
RN is able to identify all appropriate times to scrub the hub
of the catheter (all connections).
RN is able to verbalize that central line catheters are scrubbed
for 15 seconds with alcohol.
RN is able to verbalize that central lines not in use have an end
cap applied and they’re changed every 7 days with the dressing.
RN is able to verbalize that tubing for ABX/fluids is changed every
96 hours.
RN is able ot verbalize that tubing for blood products is changed
with each unit.
RN is able to verbalize that tubing for PN/lipids is changed every
24 hours.
RN is able to verbalize that tubing for PCA is changed every 96 hours.
RN is able to verbalize that needleless end caps are changed
every 7 days, with each new administration set, each new cath-
eter insertion, or when visibly soiled or dirty.
RN is able to verbalize that all patients with a central line receive
a CHG bath daily and how.
Documentation Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments
Date of last CVAD dressing change in flow sheet?
Date of last CHG bath in flow sheet?
Flushing order sets active in chart?
Flushing documented in MAR?
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4. www.nursingmanagement.com Nursing Management • December 2016 39
Education
The third step is evaluating edu-
cational models and processes. Do
all nurses regardless of the unit on
which they work receive the same
training and education regarding
central venous access devices upon
hire at your organization? If not,
why? Another consideration is to
understand all of the disciplines
that care for and maintain central
venous access devices. If providers
are manipulating central venous
access devices, have they received
the same training? The standard
of care for a central venous access
device is the same whether a
patient is located on a medical
rehabilitation unit or the ICU. Edu-
cational models should be designed
to offer all staff members the same
knowledge.
Another critical aspect of training
is methodology. Many education
initiatives are delivered to staff via
electronic online formats. Although
these online training modules
pass along information and track
compliance, they aren’t effective at
evaluating hands-on technique or
practices related to central venous
access devices. Organizations
should implement creative ways for
nurses to practice and demonstrate
central venous access device care
and maintenance techniques during
skills days and/or unit-to-unit in-
services. A peer review program for
monitoring skills related to central
venous access device care and man-
agement is also best practice.1,14
Monitoring
The fourth step is deciding how
outcomes will be monitored on
an ongoing basis. One of the big-
gest pitfalls for an organization is
a lack of continuous performance
monitoring. Many organizations
spend time assessing gaps, revis-
ing policies and procedures, and
fully educating staff, and then they
assume that practices are improved.
However, if practices aren’t moni-
tored on an ongoing basis, there’s
no way to evaluate gaps or changes
in performance and make necessary
adjustments. Most important, staff
engagement and involvement with
data collection are pivotal for long-
term success.15
Utilization of staff
champions is a best practice that
can bolster ownership and drive
improved outcomes.16
Organizations should be thought-
ful in selecting staff champions,
providing them with additional
training on how to be engaged in
education, policy and procedure
monitoring, and ongoing data
collection. Ideally, units should have
a champion for each shift and moni-
tor unit performance on a regular
basis. For those units struggling
with performance, more frequent
observations may be needed at
first. Once performance improves,
less frequent observations may be
warranted. Champions gather infor-
mation on the monitoring tool and
bring themes back to their peers to
drive continued improvements. It’s
important to note that this is a non-
punitive, conversational feedback
opportunity for champions to build
relationships and accountability
within the unit.
Areas showing improvement
should be celebrated, whereas areas
that need improvement should be
focused on with discussion, educa-
tion, and monitoring. Staff cham-
pions can discuss central venous
access device topics at regular
meetings, allowing for immediate
adjustments to patient care through
a proactive approach. Champions
make this ongoing peer-to-peer
conversation about central venous
access devices part of the unit’s
culture rather than the flavor of the
month.
The monitoring tool can be
used as data collection or simply
as a guide to improving practice
Best-in-class hospitals have a collaborative approach to policy and
procedure creation and maintenance, with silo-free coordination and
alignment between departments.
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5. 40 December 2016 • Nursing Management www.nursingmanagement.com
Infusion
Safetysolutions
through discussions, whichever
is most appropriate for the unit’s
needs. Nurse leaders from all
units can collect monitoring tools
monthly for more formal data,
which can be rolled up and used
for a global view of organization-
wide performance related to central
venous access devices. This can
offer the data elements necessary to
track improved performance or pos-
sibly highlight areas that may need
additional education and training.
Safe, quality care
Ultimately, safety and quality in
healthcare are a must. Nearly all
admitted patients in today’s acute
care hospital setting receive some
type of vascular access device.
Central venous access devices play
a critical role in patient safety, with
an increased risk of mortality for
those who develop a clabsi. There’s
also a financial and reputational
impact because clabsi outcomes
are publically reported and tied to
organizational reimbursement. Tak-
ing a four-step approach to evaluat-
ing central vascular access device
care and maintenance within your
organization can help you make
overall improvements in patient
outcomes. Assessing knowledge,
standardizing and streamlining
policies and procedures, offering
education to all staff members, and
continuously monitoring outcomes
can drive improvements. NM
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Lorelle Wuerz is the vascular access depart-
ment patient care director at NewYork-
Presbyterian Hospital in New York, N.Y.
The author has disclosed no financial relation-
ships related to this article.
DOI-10.1097/01.NUMA.0000508272.73964.eb
Taking a four-step approach to evaluating central vascular access
device care and maintenance within your organization can help you
make overall improvements in patient outcomes.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.