By: Robert B Dawson DNP, MSA, APRN, ACNP-BC, CPUI, VA-BC
Vascular Access is indisputably the most common invasive experience of any hospitalized patients. Vascular Access is also the engine that drives the modern healthcare treatment plan. Given these facts, we should consider the stark reality that an organized, systematic, multidisciplinary approach to this vitally necessary procedure seems a dream in many facilities, and a constant struggle in others. Is the difficulty in improvement a nursing issue, the up hill battle in the hierarchy of healthcare plan delivery? Is it that vascular access at any consequence is not a concern to healthcare providers and administrators? Could it be that we as a profession have failed to make a value proposition clear within in our own community, and consequently to our healthcare system? The reality may be a combination of all these things. Therefore, where can we start to make the biggest strides to create a dedicated role for vascular access professionals, along with definitive pathways for patient focused vascular access care? This may be one person at a small facility that can place any type of device, or a team of people with variable skills that work together to provide the most appropriate device, early in the treatment plan. Either way, I believe that Accountable Care is a genuine opportunity to demonstrate the value of vascular access to our healthcare delivery system.
Value is the key to gain support for change in Vascular Access. Value in the quality improvement science model is always a function of Cost and Quality: V = C / Q. Value is the key to decision-making in healthcare delivery, the decisions on where to focus resources for change. The pressure for healthcare delivery systems to be accountable for patient focused, efficient, and effective care is a reality today and for the future. We have seen this for CLABSI’s and other hospital-acquired infections, but the future is to go beyond this and connect care activity across the entire healthcare system of a community. Given this reality it seems plausible that we can make a case for Accountable Vascular Access for a facility and the community of patients it serves. After all, veins are a limited resource and patients keep going back for treatment given that we are living longer with more chronic diseases today than ever before.
A central philosophy to quality vascular access has been to be able to: provide reliable infusion delivery through the most appropriate access device and procedure based on patient assessment. The ability to actually accomplish reliable infusion delivery and mitigate risk requires a change in culture directed toward application of knowledge and process for most healthcare organizations. The Institute for Healthcare Improvement’s (IHI) triple aim:
- Improve a defined population health
- Improve the patient care experience through quality, access, and coordination
- Reduce and or control costs
sets the priorities for Accountable Care. These aims can be accomplished through a systems perspective, allowing for collaboration and teamwork to evaluate vascular access care from a Knowledge, Process, and Resource framework.
Value is realized by applying the evidence that drives reliable infusion delivery early in the treatment plan. We need to limit the number of devises, the attempts, and associated complications. Meaningful change is accomplished through intentional patient population assessment for high-risk vascular access patients. Some high-risk targets have limited veins, irritating or vesicant infusions, and treatment plans greater than 3 days, or any combination of the three. The process needs to target these patients early and resources need to be used to get to the ideal state of one device and one attempt vascular access. This is when value is realized and a case can be made for dedicated professionals in vascular access.
Performance improvement science relies heavily on a systems based approach that assesses the context of care, how the work is done, and by whom. The purpose of this is not to duplicate vascular access models from one facility to another, but rather to achieve similar outcomes given the application and use of the same generalizable scientific knowledge.
Start making the case for change by assessing your context of care, the type and quantity of specific patient populations of high-risk vascular access. Establish baseline measures for devices per hospitalization, attempts, complications, and even satisfaction. Propose a system for early identification of high-risk patients, and mechanisms of process and resource utilization to drive early, most appropriate device insertion. Device insertion and assessment should be systematic and standardized using known standards and evidence to drive one-device hospitalizations. The goal is to reduce venous depletion and resource consumption. This is the Value Proposition.
Finally, consider a pitch to your colleagues, administrators, and health system that shines the light of Accountable Care on the importance of value focused Vascular Access. Do not try to do it alone, but simply state the importance of vascular access and the need to make it an accountable care priority. Then work with a collaborative team to assess the context of care and develop an evidence supported implementation plan. The plan does not need to be perfect; the key is to just start improving. Pick one patient population, and one clinical unit to work with at first. Demonstrate success in one group or unit, and then you can expand to others. This is a process and journey, not a definitive equation for a specific result. Make it intentional, meaningful, and measurable and the results will be valuable.
Accountable Care is here, and is a great opportunity for the Vascular Access Profession to make significant strides in advancement of our role and value in health care. However, we need to make our own case for change. Do not wait for the right moment, but start with opening a dialogue with potential collaborators today and start improving!