2. Disclosure
CEO and FOUNDER for AccessRN
ASSOCIATION OF VASCULAR ACCESS
FOUNDATION BOARD MEMBER
CONSULTANT BARD MEDICAL
CONSULTANT GENETECH MEDICAL
CONSULTANT ARGON MEDICAL
CONSULTANT ANALOGIC MEDICAL
3. Why is this Important
To me?
I’m an administrator, why do I need to know
about IV’s and IV meds?
I work in dietary, why do I need to know….
I don’t even work with patients, why do I need
to know……
6. Objectives
1. To gain knowledge of vein anatomy, principles
of infusions, and vascular access devices.
2. To understand vessel health and preservation to
provide best outcomes for residents by
decreasing complications.
3. To gain knowledge on building a successful
infusion program decreasing complications and
increasing profits.
4. To understand new controversial research and
its impact on the care you provide
5. Understand new technology and its impact on
the PT
8. Principles of Infusion
1. Hemodilution-the more blood mixes the
less harmful medicines are to veins
2. Right line at the Right time
3. Site selection is imperative
4. One patient, one stick, one device
9. Hemodilution
1. Hand veins 30-40 ml per minute
2. Forearm veins 50-60 ml per minute
3. Axillary veins 200-300 ml per minute
4. Subclavian vein 700 -800 ml per minute
5. Lower third of SVC or Cavoatrial
Junction 2000-2500 ml per minute
10. Right line at the Right Time
1. What is the prescribed therapy?
2. What is the duration of therapy?
3. What vein options does the patient have?
4. What are the available devices?
5. What is the vascular access skill level of
the clinician that is available to place the
line?
6. What is the competency of the bedside
nurse that accepts responsibility for the
patient?
11. Chose a device!
1. Short peripheral intravenous catheter (PICV)
2. Long PICV
3. Short Midline
4. Long Midline
5. PICC
6. CVC
7. JACC
8. Tunneled catheter
9. Implantable port
10. Power injectable
11. Valve or non-valve
12. Positive pressure, neutral pressure, negative pressure- needleless connectors
13. Antibiotic impregnated
14. Antimicrobial coated
15. Do we use Ultrasound guidance, b mode, c mode, in-plane, out of plane,
sagittal, longitudinal
16. Modified seldingers, microintroducer, steal needle, angiocath, nitinol,
platinum or stainless steal,
17. Will we verify the tip with CXR or EKG?
21. Decreasing Patient and Facility Complications
1. Develop an infusion program with specially train
nurses and specific policies and procedures, IV
resource personnel
2. Resources
A. Infusion Nurse’s Society standards of practice,
policy and procedure manual and position
statements (ins1.org)
B. Association of Vascular Access position
statements (avainfo.org)
C. CDC Guidelines for the Prevention of
Intravascular Catheter-Related Infections
D. Pharmacies
E. Independent Vascular Access Teams
F. Nursing Competency
22. Managing Infusion Program
1. Assess Nurse’s ability
2. Educate where knowledge deficits exist
3. Annual competencies
4. Market services to referral sources
5. Discuss appropriate vascular access
device at admission to LTC from ACH
6. Promote your readmission rates
23. Why infusion programs fail?
1. Accessing veins is a Low volume
procedure in LTC
2. Many devices with many purposes
3. Care and maintenance Knowledge deficit
among nursing staff
4. Residents are becoming venous depleted
24. Financial Breakdown
Resident with Medicare Part A
Unable to establish access in house
1. Ambulance ranges from $1000 to $1600
one way.
2. Line insertion-$1200 to $2000
3. If patient stays at hospital $400-$600 per
day lost in revenue to LTC
4. Not to mention the Hospital’s major focus
on preventing 30 day readmission penalty
25. Average Cost of sending patient out for line
placement
Ambulance ride round trip $1100
Line placement $1200
Total cost average $2300
Add an over night stay (loss) $400
Total cost $2700
26. Combat Cost
1. Assuring your nurses can care for
residents with vascular access devices.
2. Planning for the appropriate device that
will carry the IV infusion for the entire
length of therapy.
3. Maintain control over your patients by
keeping your residents in your
building!!!!
28. Infusion Nurse’s Society
Standards of Practice
Site selection
1. Avoid areas of flexion
2. Largest vein and smallest catheter
3. Avoid 4-5 inches on lateral surface of wrist
4. Avoid lower extremities
5. Avoid upper extremities in CKD 3,4,5 and end
stage.
29.
30. Vascular Access Devices
And Blood Return
• SOP 61 B “The nurse should aspirate for a
positive blood return…to confirm
patency”
• SOP 45 E “…as a component of assessing
catheter function”
• SOP 45 G “…no blood return noted,
further steps should be taken to assess
patency”
31. Flushing
• Heparin vs Saline
• Evidence to support both
• SOP 45 J “short peripheral…preservative
free saline”
• SOP 45 O “…central devices heparin lock
10u/ml” recommended
32. Peripheral Site Rotation
• SOP 44 1 A “Replacement of short
peripheral catheter when clinically
indicated”
• CDC “no more frequent than 72-96
hours”
33. Occluded PICC’s
• Know your end cap
• Proper flushing techniques
• Monitor for early signs of occlusions
• Catheter clearance; Declotting
34. Migration of Catheter
• Resident pulls catheter out
• Dislodged with dressing change
• DONOT ATTEMPT TO REINSERT
35. PICC vs Midline
PICC Midline
Hemodilution 2000-2500ml/min 200-
300ml/min
Cost Needs x-ray No x-ray needed
Infusate Any *No
Vesicant/Irritants
Duration Up to a year 29 days per IFU
Occluded Can use Cathflo Not FDA
approved For Cathflo
Placement Ultrasound Ultrasound
*Further discussion needed
36. Irritants and Vesicants
Through Midlines?
• INS SOP 32 “Therapies not appropriate
for midline catheters….pH less than 5 and
greater than 9”
37. New study
Safe administration of vancomycin through a novel
midline catheter: a randomized, prospective clinical
trial
• Small sample size 30 catheters
• Less than 5 days
• Concentration of 4mg/ml
Conclusions: Short-term intravenous vancomycin can
be safely and cost-efficiently administered in the deep
vessels of the upper arm using the midline study device
J Vasc Access 2014;15 (4): 251-256
38. NEED MORE DATA!!!!!
• Multicenter
• Tracking outcomes for Midline infusions
• Matt Gibson 270-577-6159
• Kivan.ava@gmail.com
40. PICC Tip Location
• INS Lower third SVC/CAJ
• CDC Lower third SVC
• NKF Lower third SVC
• AVA Lower third SVC/CAJ
• SIR Lower third SVC
Malpositioned if tip other locations
A PICC catheter cut to a midline length is
not used correctly. IFU advises SVC.
41. DIVA’s
(Difficult IntraVenous Access)
• Chronic diseases
• Elderly vascular changes
• Genetics
• Frequent hospitalizations
• Anticoagulants
What is it like for the bedside nurse to deal
with the DIVA’s?
44. Summary
• One patient, One stick, One device
• Place the best device first
• Proper care and maintenance
• CATHETER SHALL BE SMALLEST GUAGE
AND LENGTH AND FEWEST LUMENS
• Keep device in patient
• Keep patient in facility
• Track outcomes
• Partner with experts
45.
46. LESS THAN 7 DAYS MORE THAN 7 DAYS
NO
YES
LENGTH
PLA
> 10% DEXTROSE
>5% PROTEIN
VESICANT OR KNOWN
IRRITANT
ANTINEOPLASTIC
CONSIDER IF
MEDICATION PH < 5 OR>9
OSMOLALITY >600
YES
PLACE
CVA/PI
CC
NO
YES
LENGTH OF
THERAPY 7-
28 DAY
PLACE
MIDLINE
LENGTH 7-
365 PLACE
PICC
CONSIDER MIDLINE OR
PIV ULTRASOUND FOR
PLACEMENT
(ULTRASOUND TRAINED
NURSE,PICC NURSE RN
OR CONTRACT HITECH
VASCULAR TEAM
CONTACT
NEXT LEVEL EXPERT FOR
LINE INITIATION
START PIV
IF UNSUCCESSFUL AFTER 2
ATTEMPTS (HX OF DIFFICULT
ACCESS , OBESITY, OR
EDEMA TO UPPER
EXTREMITY
47.
48.
49.
50.
51. IMPROVES PATIENT SAFETY
MALPOSITIONS AND REPOSITIONSOF PICC TIP
NO MORE GAMMA SCATTER RADIATION
REDUCE NEED TO TRANPORT PATIENT S
REDUCE TIME TO INITATE IV THERAPY
REDUCE REPEAT PROCEDURES
COST EFFECTIVE (NO XRAY NEEDED)
