IMPLEMENTATION OF A DIFFICULT VENOUS ACCESS (DiVa) PATHWAY Evan Alexandrou RN MPH PhD Clinical Nurse Consultant, Central Venous Access Service Liverpool Hospital Senior Lecturer Western Sydney University Disclosures AVATAR research is supported by competitive government, university, hospital and professional organisation research grants as well as industry unrestricted donations, investigator initiated research/educational grants and occasional consultancy payments from the following companies: 3M, Adhezion, Angiodynamics, Bard, Baxter, BBraun, BD, Carefusion, Centurion, Cook, Entrotech, Flomedical, Hospira, Mayo, Medtronic, ResQDevices, Smiths, Teleflex, Vygon This presentation is independently prepared and reflects no commercial entity nor promotes particular products unless these are supported by research data Sources of funding for each particular research study will be disclosed throughout this presentation • PRNewswire. (2014). Global Peripheral I.V. Catheter Market 2014-2018. from http://www.prnewswire.com/news-releases/global-peripheral-iv-catheter-market-2014-2018-257019061.html • Alexandrou, Evan, Ramjan, Lucie, Murphy, Jeff, Hunt, Leanne, Betihavas, Vasiliki, & Frost, Steven A. (2012). Training of Undergraduate Clinicians in Vascular Access: An Integrative Review. Journal of the Association for Vascular Access, 17(3), 146-158. Background • Over 80% of patients coming to hospital will require some form of vascular access • Nearly 60% will require a short PIVC. • Needed for hydration, blood products, antibiotics and other therapies • Typically the first invasive procedure attended when patients present to hospital • PRNewswire. (2014). Global Peripheral I.V. Catheter Market 2014-2018. from http://www.prnewswire.com/news-releases/global-peripheral-iv-catheter-market-2014-2018-257019061.html • Alexandrou, Evan, Ramjan, Lucie, Murphy, Jeff, Hunt, Leanne, Betihavas, Vasiliki, & Frost, Steven A. (2012). Training of Undergraduate Clinicians in Vascular Access: An Integrative Review. Journal of the Association for Vascular Access, 17(3), 146-158. Background • PIVCs have an under appreciated failure rate…. • Up to 90% of PIVCs are prematurely removed or dislodge before they are due for removal! • Complications include phlebitis (mechanical / chemical / infective), infiltration, occlusion and dislodgement • Helm,RobertE,Klausner,JeffreyD,Klemperer,JohnD,Flint,LoriM,&Huang,Emily.(2015).AcceptedbutUnacceptable:PeripheralIVCatheterFailure.JournalofInfusionNursing,38(3),189-203. • Zingg,Walter,&Pittet,Didier.(2009).Peripheralvenouscatheters:anunder-evaluatedproblem.Internationaljournalofantimicrobialagents,34,S38-S42. • Rickard,ClaireM,Webster,Joan,Wallis,MarianneC,Marsh,Nicole,McGrail,MatthewR,French,Venessa, Zhang,Li.(2012).Routineversusclinicallyindicatedreplacementofperipheralintravenouscatheters:a randomisedcontrolledequivalencetrial.TheLancet,380(9847),1066-1074 Background One third of patients present with difficult access… • Require multiple attempts at cannulation • Increased failure rates compared to patients with good access • May need escalation to CVAD • AhlqvistM, Berglund B, Nordstrom G, KlangB, WirénM, Johansson E. A new reliable tool (PVC assess) for assessment of peripheral venous catheters. Journal of Evaluation in Clinical Practice. 2010;16(6):1108-1115. • Webster J, Clarke S, Paterson D, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomisedcontrolled trial. BMJ: British Medical Journal. 2008;337:a339(7662). Background Main Reason: Increasing Chronicity and Acuity.. • Increased survival rates with chronic disease • Patients present sicker • Intensive care beds now a premium • Sick patients pushed out onto wards • Typically this cohort becomes harder to cannulate over time Background Consequences of difficult access: • Multiple painful attempts (sometimes severe pain) • Delay in treatment • Increased risk of phlebitis and thrombosis • Increased risk of infection • Increased length of stay • Bahl, A., Pandurangadu, A. V., Tucker, J., & Bagan, M. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients. The American Journal of Emergency Medicine, 34(10), 1950-1954. • Fields, J. M., Piela, N. E., & Ku, B. S. (2013). Association between multiple IV attempts and perceived pain levels in the emergency department. Thejournal of vascular access, 15(6), 514-518. Background Difficult access leads to premature failure of PIVC: • PIVC then requires re-siting • Further painful attempts • Increased anxiety of patient • Eventual venous depletion from multiple attempts • Needing CICC vs PICC • Moureau, N. L., Trick, N., Nifong, T., Perry, C., Kelley, C., Carrico, R., ... & Biggar, C. (2011). Vessel health and preservation (Part 1): a new evidence-based approach to vascular access selection and management. The journal of vascular access, 13(3), 351-356 Background In my hospital: • Increasing patients with difficult access • Medical / Nursing teams unable to cannulate • Anaesthetics unable to cannulate in a timely fashion due to competing work demands • Patients presenting for PICCs after multiple cannulation attempts - (20-30 attempts) • Unable to insert PICC due to extensive bruising / thrombosis – CVC inserted Background We Needed To Do Something Enter…. DiVA Difficult intraVenous Access Pathway