Rob Dawson, DNP, MSA, APRN, ACNP-BC, CPUI, VA-BC
Vascular access is the most common invasive experience of any hospitalized patient. However, it is one of the least planned for events. Often, the procedure of vascular access is seen as a task to be accomplished rather than an essential function of healthcare. A fundamental truth of modern healthcare is the need to deliver intravenous infusions, especially in the acute hospital stay. Given the significance of access device insertion to modern healthcare delivery, it stands to reason that we ought to understand the implications of this practice on the healthcare system. Suffice to say, there is a better way to approach vascular access care.
There is a distinct body of knowledge about how to practice vascular access. Most important to this field of practice is the concept of matching the access device type to the patient’s need for infusion delivery. There are risk profiles associated with different devices and methods of insertion. In addition, there are patient factors that need to be considered before settling on a device choice and or method of insertion. In my experience, the device chosen is often left to preference and the current availability of resources and expertise. Preferential care without appropriate knowledge leads to unnecessary variation in care. This approach can subject the patient to less than ideal procedures, repeated attempts at device insertion, raise complication rates, and even increase the costs of care.
The Institute of Medicine (IOM) made it clear in 1999 and again in 2001 with their landmark reports on healthcare quality and safety, that there are too many preventable errors in healthcare. The IOM recommends a major part of the solution to reducing errors be through a systematic approach to knowledge application. Errors are not usually from malice, but from lack of, or inappropriate application of knowledge. Whatever the results that are observed in vascular access care, they are directly related to system design. One must change the system in order to change the results.
My practice observations have led to the conclusions that significant roadblocks to central device insertion are related to both scope of practice and availability of resources. A vascular access nurse that applies evidence-based vascular assessment sometimes has a recommendation for a central access device, but scope of practice has limited the nurse’s option to the peripheral access route. Many patients, especially those with chronic renal insufficiency, are not viable candidates for peripherally inserted central catheters (PICCs). This roadblock leads to delays in care, and often times a less than ideal device for the prescribed treatment plan because the nurse has to try to convince a provider of the reason for the device and then find someone to place the device. Another concern is the skill and ability of the provider that will place the central device. Often times they don’t have as much experience with ultrasound guided access as the RN who places PICCs regularly.
I have taken the issue of quality improvement in vascular access as a high priority in all of my professional endeavors. A couple of years ago, as the President of the New Hampshire Association for Vascular Access (NHAVA), I spoke at a New Hampshire Board of Nursing (NHBON) meeting to address quality and competency in vascular access. This past spring, I again represented NHAVA to present to the NHBON on the question of Registered Nurse Scope of Practice in regards to ultrasound guided central venous catheter insertion. Jim Lacy RN, in conjunction with Teleflex Medical, Inc. put together a packet of supporting evidence and board decisions from other states on this issue of RN CVC insertion. I added my own thoughts in a letter of introduction. I hand delivered the packet to the Executive Director of the NHBON, and spent a little time explaining the importance of this change in scope of practice.
I was asked to attend another public NHBON meeting to address this scope of practice change and answer any questions from the board. My goal was to present the issue very simply, as a procedure that is being done in other states by RNs, and is not new in terms of clinical principle or skill. This procedure is about guiding a needle to a vein, and RNs proficient with ultrasound guided PICC insertion can apply this skill to other even larger veins. In fact, RNs skilled with ultrasound access are probably more qualified to access the vein than those doing the procedure without ultrasound or with minimal ultrasound experience. Important to this issue is the fact that many specialized vascular access RNs in any given hospital, especially community hospitals, possess the most current knowledge on how to safely and reliably provide patient centered vascular access.
I have learned through graduate education as a Nurse Practitioner, that in general, healthcare providers do not routinely consider matching the access device with an infusion plan. Many providers do not know the different methods of access, nor why one is chosen over another. The irony is that these very same providers have the scope of practice to do the procedures, but not the knowledge of current vascular access science to support the practice. On the other hand, those with the knowledge and skill do not have the scope of practice. This is a correctable issue and one that can benefit the entire healthcare system if fixed. Even the IOM, in its 2010 report, The Future of Nursing, clearly states that nurses are vital to health system redesign.
The IOM states:
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
- Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
The NHBON Published Ruling:
Question: Can RN, with training and competency, insert CVC under ultrasound?
Answer: Board opined that it is within RN scope of practice to insert CVC under
ultrasound with competencies, appropriate setting and facility policy. Refer to AZ BON
guidelines with interpretation.
The key to progress in health system redesign is to systematically apply best, current knowledge in a context specific setting. A setting that understands the patients’ needs and works collaboratively to accomplish optimal care. With respect to vascular access, it is clear that competent vascular access nurses can and should take on a much larger role in choosing and inserting all vascular access devices. Personally, I changed my scope of practice by becoming a board certified acute care nurse practitioner that specializes in vascular access. I want to be able to help others expand their scope as an RN or Advanced Practice RN (APRN) to benefit the healthcare system. There is a better way to provide vascular access, but the system needs to be redesigned.