www.nivas.org.uk NIVASNews Spring 2014 Letter from the Chair All good things must come to an end and so I write my last editorial as the Chair of NIVAS. Time has gone quickly since we, as the RCN IV Therapy Forum, made the decision to leave the Royal College of Nursing and form our own independent multiprofessional society (with the help and support of Succinct we achieved this in 2009). And the board truly is multiprofessional with five nurses, two doctors and a pharmacist, but one challenge we still have ahead of us is how to make the membership truly multiprofessional and get our medical and pharmacy colleagues to join us. I hope that my time as Chair has been a productive one—I certainly feel that we have provided some excellent conferences over the years and this year’s change to provide two symposia on peripheral and central venous access will hopefully present a different dimension of education to the annual conference and meet some of the needs expressed in our post-conference feedback. In the future I may not be Chair but I will continue to support NIVAS and the work of the board. I would like to take this opportunity to thank all the board members for their hard work and enthusiasm. Thanks also to you, the members, for all your support and I hope that you will help us to sustain the work we are doing by continuing to be members—there is still so much more to achieve. Lisa Dougherty Contents Letter from the Editor Letter from the Chair 1 Letter from the Editor 1 Vessel Health and Preservation (VHP) update 2 Oxford Conference Report 6 Review of the IPS IV Forum Annual Conference 6 OMG PIVC study 7 AVA Conference Report 8 National Infusion and Vascular Access Society Welcome to the latest edition of NIVAS News. Spring is definitely in the air, and here at NIVAS we are planning a series of symposia that will be offered this year instead of our usual annual conference. The first event will be on central venous access devices and will be held on 9 September at Leeds Trinity University, the second event will be on peripheral access and will be held in the Oxford Belfry Hotel on 27 November. Our AGM will take place at the November meeting and we hope to see lots of you there as we reshape our board in time for 2015. Lisa will soon step down as Chair and I’m sure you will join me in thanking her for her hard work and effective leadership. Jill Kayley will step down as Treasurer, a behind the scenes but none the less important job, which Jill has delivered impeccably, our thanks to Jill as well. I too will step down and so we will be looking for a new editor for the newsletter— who knows, it could be you! We hope there will be lots of nominations in the forthcoming elections and we look forward to announcing the results at the AGM. The National Institute for Health and Care Excellence (NICE) intravenous fluid therapy guideline was finally published in December 2013, and I hope that by now you have all managed to see a copy, it is available from www.nice.org.uk/ CG174. The next phase of the project has started and the NICE Quality Standards Advisory Committee is now developing the quality standards to accompany the guideline. The standards will be released for public consultation later in 2014. Please do consider standing for election to the NIVAS board, more information will be available from our website. I hope it’s a great summer and we look forward to seeing you at one of the symposia later this year. Katie Scales Vessel Health and Preservation (VHP) update As mentioned in last year’s newsletter, the VHP concept aims to provide a flexible framework to guide and support healthcare professionals involved in any form of intravenous (IV) therapy to be able to make pragmatic choices with their patients about the “right line for the right patient at the right time” and in doing so minimise the risks to patients with vascular access-related complications, but also promote the best chance of IV therapy success. IV therapy continues to be the most frequent modality of invasive treatment in acute hospital settings, and the responsibility for the practical procedure of cannulation is often delegated to the most inexperienced members of medical and nursing staff. There is often ignorance of the potential complications and therefore the correct choice of vascular access device (VAD) is often overlooked. The framework that has been developed so far aims to be adaptable for all healthcare environments. The attached version of the framework is merely a starting point for individual clinical teams to evaluate and mould to their specific requirements. Following initially positive trials of the framework in specific general and specialist areas, we are now in the process of widening the consultation process, and further versions of the framework tools have been developed from the original format. Positive feedback has been received at both the NIVAS conference and the Infection Prevention Society (IPS) IV Forum Conference. It remains, however, a working progress and we greatly value any further feedback in order to make this a truly successful project, improving the experience and outcomes for as many patients as possible in the UK. The IPS VHP Working Group hope to finalise the framework during 2014, and are thankful for the valuable support that has been received from NIVAS throughout this process. VHP Right Line Framework Vessel health The evidence-based VHP concept of vascular access management was introduced in the US. The essence of VHP is timely, intentional, proactive patient intervention for VAD selection during the first 24 hours of entry into the healthcare process, followed by placement of a clinically appropriate device within 48 hours. Once placed, the focus shifts to daily maintenance and care of the device using the central line bundle and daily assessment to determine the health of patient’s vessels as well as continued necessity of the device. Preservation of the vessels is required to minimise damage (thrombosis, stenosis and infection) and maintain the patency of the peripheral and central veins for as long as possible. This maintains good venous access for future treatments. Further such actions have the potential to save significant staff costs to organisations providing IV therapy.* Genuine need for IV therapy? Have viable alternative routes been considered & excluded? NO YES Continue medical therapy via alternative route See decision tool *IV therapy can be defined as any form of treatment where access to veins is necessary; this comprises of administration of any form of treatment and/or the removal of blood In the meantime, comments are welcome. If you feel you have a team who might like to trial this framework, or even a small part of it, we are very keen to hear from you. Tim Jackson Consultant Anaesthetist, NIVAS Board Member & IPS IV Forum VHP Working Group Medical Lead [email protected] 2 Vessel assessment Grade Vein quality Definition Management Treatment options 1 Excellent 4–5 palpable veins & suitable to cannulate Cannula may be inserted by a Up to 6 months intermittent trained/authorised healthcare therapy practitioner 2 Good 2–3 palpable veins & suitable to cannulate Cannula may be inserted by a Up to 4 months intermittent trained/authorised healthcare therapy practitioner 3 Fair 1–2 palpable veins & suitable to cannulate (veins may be small, scarred or difficult to palpate & require heat packs to aid vasodilation) May require infrared viewer/ ultrasound 4–6 weeks intermittent therapy 4 Poor Vein unable to be seen or palpated (requires ultrasound assistance/VeinViewer) Cannula to be inserted by an expert in venous cannulation (requires ultrasound assistance/ VeinViewer) One-off cannulation up to 2 weeks intermittent therapy 5 None palpable No visible (naked eye or aids) or palpable veins Not for peripheral cannulation Refer for central venous access device. Use right line tool Example drug list Definitely central Possibly central Amiodarone (except emergency in cardiac arrest) Vancomycin (especially when more than just a few days) Chemotherapy Labetalol Dobutamine Argipressin Dopamine Caffeine Epinephrine (adrenaline) infusion (except bolus dose in cardiac arrest) Glyceryl trinitrate Norepinephrine (noradrenaline) Co-trimoxazole Potassium >40 mmol/litre Dantrolene Total parenteral nutrition (unless only for first 1–2 days of therapy) Phenoxybenzamine Dopexamine Foscarnet Glucose >15% Nitroprusside Nimodipine Phenytoin Sodium bicarbonate 4.2% or 8.4% Ganciclovir Sodium chloride 1.8% + Pentamidine Please refer to the local drug list/guidance given by your hospital pharmacy 3 VHP Decision Tool What therapy is indicated? Refer to injectable medicines guide Therapy which MUST be administered directly via central vein <1 week Therapy which is appropriate to be administered via PVC Therapy which MAY be suitable for a PVC BUT CONSIDER: Duration of therapy anticipated? Duration of therapy anticipated? Availability & quality of peripheral veins: consider difficulty/ frequency of changes CVC Good PVC Poor Consider MID or CVC 1–4 weeks MID >4 weeks CVC <1 week Availability & quality of peripheral veins Good Consider PVC or MID Poor Consider MID or CVC >1 week Consider CVC CVC Decision Tool CVC indicated by Right Line Decision Tool Anticipated duration of IV therapy? <2 weeks Non-tunnelled CVC or PICC 2–8 weeks PICC >8 weeks PICC, implanted port or tunnelled CVC CVC, central venous catheter; MID, midline; PICC, peripherally inserted central catheter Secondary questions which may refine line choice in individual patients: 1. 2. 3. 4. 5. 6. 7. Patient preference/lifestyle issues Known abnormalities of vascular anatomy which limit access site Intensity of therapy—e.g. intermittent versus continuous, sickness of patient, extreme duration of therapy (months–years), specific indications (e.g. bone marrow transplant) Intended dialysis or apheresis treatment Local availability of vascular access competency Patient factors/patient cognitive function Known infection risks 4 Re-evaluation of access device Remove IV access and continue treatment via alternative routes as appropriate NO Does the patient still need IV therapy? YES Does the current VAD still provide the optimum solution to the patient’s needs? Evaluate the following: VIP score >0 YES NO CRBSI: suspected YES NO YES NO Occlusion YES NO Persistent withdrawal occlusion YES NO Thrombosis YES NO Leakage YES NO Missed/delayed doses YES NO YES NO proven Has any new clinical information evolved which might affect the choice of the right line for this patient? Is a suspected diagnosis confirmed? NO to all Has their condition changed? (due to device failure) Dislodgement NO YES to any Refer to specific policies on management of VAD-related complications, but consider whether this implies failure of this VAD and re-evaluate for escalation to an alternative type of VAD Re-apply VHP Right Line Decision Tool to re-evaluate current need for VAD incorporating patient views YES Continue to use indwelling VAD according to Trust policy. Continue surveillance for complications and continue to re-evaluate the ongoing need for this VAD regularly CRBSI, catheter-related bloodstream infection; VIP, visual infusion phlebitis 5 Oxford Conference Report The nurse-led Department of Vascular Access at Oxford University Hospitals NHS Trust held its 10th international bi-annual intravenous (IV) therapy conference on 17 October 2013. The theme of the conference was enhancing and promoting a positive IV therapy experience. The conference was well supported with over 80 delegates. The delegates attending were able to network with experts who could advise on best IV therapy practices and also discuss with peers who may have had similar challenges in this specialist field. The keynote speech was on the role of commissioning in NHS services. This presentation allowed an insight into the part the commissioners play in buying services from the NHS. Amongst the plenary sessions there was a presentation on IV therapy in an era of zero tolerance of infection. This endorsed the key interventions necessary to reduce vascular device-related bacteraemia, focusing on the Centers for Disease Control and Prevention, and epic2 recommendations. It was proposed that most central line-related bacteraemia are avoidable and urged a zero tolerance approach to these preventable infections. There was also an international speaker who gave a perspective on the transatlantic IV therapies, from development to current practice. This was a very entertaining talk that included an overview of the different technologies used in the USA for peripheral and central venous access, and looked at how they had impacted on patients and practitioners. The afternoon comprised of breakout sessions, one of which was given by a patient on their experience of living with a central venous access device in the community. There was a good response to the call for posters and these were displayed at the conference and generated good discussions and interest from the delegates. The exhibition room was packed with the latest vascular access products and allowed the delegates to be involved in hands-on product demonstrations. This year’s conference was evaluated as informative, stimulating and enjoyable. The conference committee are now looking forward and are committed to developing the 11th international IV therapy conference to be held in 2016. We look forward to all of you joining us there and sharing your expertise. Nicola York Clinical Nurse Manager Vascular Access and Nutrition, John Radcliffe Hospital, Oxford Review of the Infection Prevention Society IV Forum 3rd Annual Conference “Towards Safer IV Practice” 26 November 2013, Cutlers’ Hall, Sheffield As a first time attendee to this conference I was impressed with the programme content and the exhibition (and the spectacular venue). The speakers were all very knowledgeable and had time to chat during breaks if you weren’t able to ask your question within the allotted time. The sessions of particular interest to me were: Right line for the right patient at the right time—a two centre trial and Developing CVAD competencies, both presented by Dr Tim Jackson. Although I had heard both these presentations at the NIVAS conference I managed to gather much more information from them after a second hearing. It was also the perfect forum to spread the message to a wider audience, highlighting the importance of selecting and caring for the correct device. Steve Hill also reiterated this in his presentation which included a decision-making tool that simplifies and standardises vascular access, which in turn helps to empower staff to make the best choices for patients. The burden of line-related bacteraemias presented by Dr Mike Cooper put fear and dread into every one who places or cares for a device as we all like to think it doesn’t happen to us. What is reassuring is that in my particular Trust we already have in place many of the suggestions put forward such as standardising placement, monitoring and, of course, audit. Balancing the elements to business case development presented by Sharon Rourke was an excellent presentation on how to bring together all the elements needed for a successful business case—without all the jargon. Finally, whilst all the exhibitors were excellent, I must mention Elaine from Clinell who boldly took up the challenge given to me by ward staff of how to get the wipes out of the packet without contaminating them—57 wipes later we managed it! Thank you NIVAS for giving me the opportunity to attend this most informative and enjoyable conference, I will be recommending it to my colleagues. Hazel Saddington Clinical Nurse Specialist for Parenteral Nutrition and Central Venous Access Devices, Sheffield Teaching Hospitals NHS Foundation Trust Don’t forget to register for the OMG PIVC study! The One Million Global (OMG) peripheral intravenous catheters (PIVC) study is an international prevalence investigation specifically targeting assessment and management of PIVCs across many countries. This study will be the largest benchmarking exercise ever attempted in vascular access and will provide previously unavailable data on the prevalence and management of PIVCs including the average dwell of a PIVC and identifying risk factors contributing to PIVC failure. Such valuable information can potentially save millions of unnecessary PIVC reinsertions and reduce healthcare costs substantially, particularly in developing nations. The study will also provide valuable information on whether organisations utilise best practice guidelines for care and management of such devices. Overall, the evidence gained from this research will be easily translatable for informing clinical practice and healthcare policy, and to improve patient outcomes related to PIVC care and management. Countries represented so far: • Argentina • Australia • Brazil • Canada • Chile • China • England • France • Germany • Greece • India • Iran • Italy • • • • • • • • • • • • Malaysia Malta New Zealand Papua New Guinea Romania Saudi Arabia Scotland South Africa Spain Sweden Tanzania United States There are certainly benefits for your hospital: • Each hospital in the study will be de-identified and have a unique identifier. We will not share your data with other organisations. We will publish the results by country, not by hospital, so your own results will remain confidential. Any information you collect remains the property of your hospital • You can use this information to benchmark your results with other hospitals in your local area or country. With their approval, you will be able to compare performance, identify areas for further education, patient safety initiatives, quality control issues, use of consumables (dressings, IV cannulas), number of redundant cannulas etc • The study is designed to discover what is actually happening with PIVCs in clinical practice. Are we using research findings to improve healthcare? Are we doing the best we can for our patients? • We believe the study will help people to evaluate their own practice, compare it to the research, benchmark with other hospitals, and discover ways to improve patient safety and healthcare • After the main study has been completed and the results published in a peer-reviewed journal by the OMG PIVC study team, there will also be the opportunity to publish your site-specific findings, and we can help you with this So please consider registering your hospital and hospitals in your region to be part of this global study! It is a one day—one off contribution. Please don’t hesitate to contact us: [email protected] And visit our website: www.omgpivc.org/ Evan Alexandrou RN MPH Lecturer, School of Nursing and Midwifery, University of Western Sydney 7 AVA Conference Report The 27th Annual Scientific Meeting of the Association for Vascular Access (AVA) was held in Nashville, Tennessee from 20–23 September 2013. Lisa Dougherty and I set off and, after a rather late arrival involving delayed departures, diverted planes and an unscheduled overnight stay in Chicago, we reached our destination—the Gaylord Opryland Convention Center. The conference kicked off with an inspiring keynote speech from Michael Schlappi entitled ‘If you can’t stand up, stand out.’ Mike was paralysed from the waist down in a childhood accident yet has made some extraordinary achievements despite his disability. As a wheelchair basketball player he won two gold medals at the 2002 Olympic Games and has been honoured as one of the top 50 athletes of the century. General and breakout sessions covered a wide range of topics. Having recently taken on a role that includes renal vascular access, I took the opportunity to learn as much For me, at last, AVA had a focus on peripheral cannulation and evidence to support the practice, that we, at The Royal Marsden, have been doing for years i.e. removing the cannula based on the clinical site, not every 48/72/96 hours! Professor Claire Rickard was like a shining beacon when she presented her and her teams’ research work from the Australian Vascular Access Teaching and Research (AVATAR) group. She got me to really challenge my thinking about what we want from cannulae—if we want them to have a better dwell time and less chance of movement and resulting infiltration/ extravasation (then use a longer, larger gauge cannula) or to reduce the risk of phlebitis (then use a smaller, shorter cannula), and this is where cannulation using ultrasound comes into its own. She also discussed other studies that are coming up for publication including how often to change administration sets, the effects of infusion pH and osmolarity, flushing practices, changing dressings, device securement and if phlebitis scores have any benefit. about this speciality as I could. It was interesting to hear some of the experts in the field talk about the latest developments and the increasing prevalence of end-stage kidney disease. It also highlighted, for me, the importance of considering future dialysis plans when selecting a vascular access device. There were some useful sessions on ultrasound-guided peripheral cannulation, which is now becoming more commonplace and more experiences with ECG tip location technologies are being reported. Some newer innovations such as tunnelled peripherally inserted central catheters (PICCs), PICC ports and the use of surgical glue (skin closure and infection prevention) provided interesting discussion points at some of the smaller sessions. It was good to meet up with other colleagues at the conference and see good representation from the UK in both the posters and presentations. Jackie Nicholson Also impressive was the technology used during the conference. The programme and all of the presentations were available as an app for smartphones and iPads etc. So you could then add notes to the presentations as the speakers were on the stage, you could set reminders to let you know when and where your next chosen session was, and you could vote for the posters on your phone. Speakers could also do a poll of the audience by asking them to vote on their phone and it would then be screened immediately as part of the presentation. Gone are the days of raising your hand and counting. We in the UK have a long way to go with our conferences! There was of course time for fun and a chance to do some line dancing at the Wild Horse Saloon, eat fried chicken and listen to a bit of country music. Lisa Dougherty NIVAS SYMPOSIA IV Therapy Quarterly supplement covering all aspects of IV therapy in nursing from infusion therapy to vascular access and patient care The British Journal of Nursing (BJN) IV Therapy Supplement aims to promote evidence-based practice and the provision of high quality patient care. We welcome unsolicited articles including literature reviews, care studies and original research in all areas of IV therapy. To contribute to the supplement or to enquire about how to become a peer reviewer in this area, contact us at [email protected] or 0207 501 6345. DATE FOR YOUR DIARY Central Venous Access Devices 9 September Leeds Trinity University Peripheral Vascular Access 27 November Oxford Belfry Hotel 8
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