ADVANCING BEYOND THE STATUS QUO - Mayo Healthcare

ADVANCING BEYOND THE STATUS QUOAMY BARDIN, MS, RRT, VA-BC

DISCLOSURES• Respiratory Therapist specializing Critical Care withfocus in hemodynamic monitoring and vascular accessfor 18 years.• Consultant for Arrow International a division of Teleflexfor vascular access and respiratory care• Faculty member, Instructor and co-Author, Arrow CVCcourse• Respiratory Care Supervisor Banner Estrella MedicalCenter, Phoenix Az2

OBJECTIVES• Describe the Evolution of multidisciplinary scope ofpractice specific to non-tunneled central venous accessdevice insertion• Discuss the clinical benefits of a Vessel Health &Preservation model of practice for hospitalized patients• Discuss the relevance for the use of ultrasound• Discuss standardized training relevant to CVC insertionsand impact on both clinician autonomy and patientoutcome3

EVOLUTION RCP ACCESS MODEL• Assessment and insertion for appropriate device (PIV,MID,PICC, CVC or HD)• Aid in bundle compliance during insertion assist• Primary or secondary insertion team for all accessexcept implanted ports• Second surveillance for line necessity• Daily maintenance consistency on ALL dwellingcatheters• Agile and task oriented by nature• 24/7 availability4

CHALLENGES• PICC Team- Nontraditional model• CVC Team- ER buy in• Product• Education• Bedside patient advocate5

SUCCESSES• 2 Published practice models from Arizona• Patel , 2007 Journal of Patient Safety– Scottsdale, Az• Ramirez , 2010 JAVA– Phoenix, Az• True multidisciplinary approach to patient care• Practice applied to Code Sepsis and Rapid ResponseTeams• 1hr. Cycle time including ARF patients6• NO BLIND STICKS!!• Use of ultrasound for ALL insertions including PIV,Arterial and Central Venous Catheters

7TRADITIONAL LOOK OF VASCULAR ACCESS

THE NEW PARADIGM SHIFT• WHERE WE ARE AND WHERE WE ARE GOING8

VASCULAR ACCESS TEAM GOALS• Reduced order to insert time• Appropriate site and catheter selection every time• Bundle compliance by a uniformed approach• Practitioner autonomy with the ability to work atmaximum potential• Incorporation of best practice due to utilization of a smallgroup• Daily quality control through maintenance andsurveillance process• Bedside insertion with use of ultrasound• Decreased patient movement throughout facility,especially for ICU patients9

VASCULAR ACCESS TEAM GOALS• Having a facility expert group to set a performancestandard that aligns with CMS expectations andoutcomes• Enhanced relationships between inter hospital staffincluding nursing, nephrology and infection preventionphysicians• The ability to establish patient centered care• Reduction in use of fluoroscopy• Increasing interventional radiologist time to do moreextensive and less routine procedures10

BEDSIDE ULTRASOUNDPRO• Recommended practice• Advancement of scope through visual aide• Portable, light weight, easy to use• Advances assessment skills• C/V Ratio• Changes an OUTCOMECON• Resistance older clinicians/MD’s• Unit availability• PIV selection11

ELECTRONIC• Earlier intervention through admission assessment• Increased automation through the EMR• Quality data reporting• Patient vascular device history12

FUTURE OF VASCULAR ACCESS• Elimination of the standard PICC Team• Evolution of a Vascular Access Model• Autonomous workflow cycle from order sets: insertion,tip verification, discharge• Multidisciplinary team approach14

WHAT IS MULTIDISCIPLINARY• Collaborative• Patient centered• Evidence based• Outcome oriented• Reduces barriers• Maximizes an Organizations potential to deliver highquality care.***It’s the Clinical impact YOU make at the bedsidenot the title on your badge.15

VESSEL HEALTH AND PRESERVATION EVERY TIME!!• Insertion of an intravascular access catheter is the mostcommon invasive procedure performed on patients• How do you provide reliable access while preservingvasculature for future use?• Timely, intentional proactive device selection provides:– A selected device that is right for the patient– Consistent access– Reduced delays in treatment– Improved patient satisfaction22

HOW TO PRESERVE VESSEL HEALTH• Clinical pathways improve outcomes by:– Establishing process to evaluate and assess needs– Reducing variation in treatment– Providing standards for device selection• Vessel Health and Preservation (VHP) protocol providesa clinical pathway for prompt device selection based onpatient needs and risks• VHP focuses on patient safety and vessel preservation23

RIGHT LINE. RIGHT PATIENT. RIGHT TIME.The right line for the right patient at the right time!•Right Line•Choose the correct device, access site prior to any venous accessattempt and apply guidelines for best practice.•Right Patient•Perform an individualized assessment for each patient prior toaccess.•Right Time• Assess the line daily for necessity and vessel health.24

VHP PROTOCOL: SELECTING THE RIGHT DEVICE• The VHP Protocol is a dynamic process• Ideally, indicated device is selected and placed within24-48 hours of hospital admission• Referral through risk assessment is sent to IV/VascularAccess team to assist with patient evaluation asnecessary• Daily assessment reviews IV complications occurringover each 24 hour period, reassess patient’s conditionand need for same or different device• Evaluation at discharge27

THE RIGHT PERSON FOR THE RIGHT LINE AT THE RIGHT TIME• Is this you?– Experience placing PICC’s28– Ultrasound Guidance– Knowing limitations– Agile– Career not a Job– Stickler for details– Does not settle for okay....– Can think in Greyscale (not black and white)– Outcomes– Leadership, Inspiration, Motivation, Passion

EXCEPTIONAL TRAINING29

SIMULATION LAB30• Learning Objectives– Demonstrate/discuss the steps of the VHP Protocol– Identify via ultrasound anatomic landmarks for CVC insertion:• External jugular• Internal jugular• Axillary• Subclavian• Femoral– Differentiate anatomical structures & measure vessel size– Distinguish between a patent cannulable vein & obstructed vein– Explain the preparation steps of CVC insertion• Central line bundle; IHI checklist; Sterile Technique; Materials Needs)– Show how to perform various insertion techniques• Modified Seldinger, Raulerson Seldinger, Traditional Seldinger– Demonstrate/discuss insertion techniques for:• Internal jugular• Subclavian• Axillary– Discuss/Identify complications and their prevention/management

RESOURCES• eTextbook31– Ultrasound Guided Central Venous Catheter Insertion: Compliance withinPractice• Vessel Health and Preservation (VHP)Tools– Sample Standard Physician Order– VHP Right Line Decision Making Guide– Sample Daily Assessment• Principles of Vascular Access Insertion Poster• Catheter Insertion Badge Card• Catheter Care & Maintenance Badge Card• Pressure Injection Badge Card• NHSN CLIP & ARROW Insertion Checklists• Video Library Catalog• Link to Central Line Checklist• Central Line Insertion Protocol (CLIP

It takes an entire team…..32

THE WINDS ARE CHANGING• Climate for Change• Exceptional Product• Exceptional Training• Enables Exceptional Opportunities• Call for Action• Overall cost reductionNEVER SETTLE!!33

Thank you for your attention!