Intravascular Quarterly | IQ | Special Edition 2022 (1) by Association for Vascular Access

I N T R AVA S C U L A R

QUARTERLY THE FROEDTERT HOSPITAL VASCULAR ACCESS TEAM:

20 YEARS AND COUNTING

THE GREAT RESIGNATION:

MITIGATE WITH CONTINUING EDUCATION AND COMMUNITY

PARTNERSHIPS DRIVE PATIENT SAFETY

EVEN IN THE MOST CHALLENGING TIMES

INTRAVASCULAR QUARTERLY

CONTENTS PRESIDENT'S MESSAGE 4 THE FROEDTERT HOSPITAL VASCULAR ACCESS TEAM: 20 YEARS AND COUNTING

VACC JUNE 2022 IMPORTANT DATES 8 PARTNERSHIPS DRIVE PATIENT SAFETY EVEN IN THE MOST CHALLENGING TIMES

THE GREAT RESIGNATION: MITIGATE WITH CONTINUING EDUCATION AND COMMUNITY

A CAUSAL-COMPARATIVE EXAMINATION OF CLABSI, VASCULAR ACCESS TEAMS AND HOSPITAL TYPES 15 STRESSING THE DRESSING: THE ROLE OF ANTIMICROBIAL DRESSINGS IN THE PREVENTION OF CRBSIs 2

WELCOME

TO THIS SPECIAL EDITION OF INTRAVASCULAR QUARTERLY

VASCULAR ACCESS TEAMS ARE CRUCIAL TO PATIENT EXPERIENCE AND POSITIVE CARE OUTCOMES We hope you will enjoy this special edition of Intravascular Quarterly, highlighting the importance of Vascular Access Teams. Vascular access procedures are the most common medical practice in healthcare; whether caring for patients at home, in clinics, or in hospital settings, Vascular Access professionals touch every step of the patient experience. Using professional, well-trained teams ensures a high level of care, rigorous infection prevention techniques, and use of best practices in managing procedures and maintaining devices. Let AVA be your first stop for vascular access training. We combine all of the necessary resources in one convenient location with staff to support you every step of the way. Through our combined events, AVA hosts opportunities for more than 30 hours of continuing education at our events each year, a diverse on-demand library of past webinars and conference sessions, discounts on the cutting-edge Resource Guide, and -- most importantly -- access to the shared knowledge of thousands of vascular access professionals. Join our mission today and share our mission of bringing the highest quality of vascular access care to every patient!

PRESIDENT'S MESSAGE

Tonja Stevens, RN, BSN, VA-BC™, President, Association for Vascular Access

Continuing professional development—or more informally, continuing education (CE)—is an important core competency and member benefit of the Association for Vascular Access (AVA). It is why so many of our 3200 members and 7000 guests have embraced our vast array of digital education over the past 2 years of COVID-19. Never before have the healthcare professions seen such a dramatic shift from the comfortable and familiar face-to-face seminars, conferences, and local events to the dynamic delivery of impactful webinars, podcasts, and online education. While I believe it is safe to say that we all miss the personal interaction with our peers, digi-tal continuing education has opened up AVA’s tremendous re-sources to so many more clinicians who want to improve their practice. The question is why, when we are all exhausted, does the demand for quality, innovative CE continue to increase? A recent article, “Lifelong Learning and Nurses’ Continuing Professional Development, a Metasynthesis of Literature,” provides a solid exploration of the why and indicates what more needs to be done.1 While the article focuses on nurses, I believe the core elements can be extended to physicians, advanced practice providers, and allied health providers. There are 5 overarching themes to continuing education, according to the article. I have condensed them to (1) organizational culture and a supportive environment, (2) personal motivation and attitudes toward CE, and (3) perceived impact on professionalism and desire to improve patient care standards. Numbers 2 and 3 are easy: Not only is continuing education required in the healthcare professions, but it is also part of our very fiber. Vascular specialists value lifelong learning; we are a curious and innovative cohort. Organizational culture and an environment supportive to learning is a little more problematic. The article notes that CE (and academic learning) is vital to improving our skills, acquiring new knowledge, and applying recent evidence to practice. There is sometimes a disconnect between what is offered by our institutions and what the individual healthcare professional wants and needs. This is especially important to the vascular access specialty. Our institutions simply cannot provide the cutting-edge, best practices education that will make the impact we want to deliver in patient safety and comfort. The last decade has seen employers continuing to cut employee professional development allowances. Many times, this results in employee dissatisfaction and, in turn, has had a detrimental effect on retention, according to a Becker’s Hospital article.2 In this time of the “great resignation,” I implore our employers to support our vascular specialists by increasing both staff and money so that we, both as a VA team and as individuals, can improve patient care and our professions. This is where AVA excels with its specialized CE offerings and the new ACE by AVA program, which offers education, skills development, and a competency verification method. Additionally, the pre-licensure Fundamentals of Peripheral IV Access curriculum (which will have a professional-level course in late 2022) supports the demand for new skills as outlined in the 2022 Health Care Talent Scan report by the American Hospital Association.3 So here’s your call to action: Support your professional development by taking this article to your chief nursing, chief medical, or professional development directors, to your department chair, or to whoever approves professional development programs so that they can better understand that AVA makes a difference to you and why they should support your AVA participation and membership. REFERENCES 1.

M. Mlambo, C. Silén, C. McGrath. Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature [published online ahead of print April 14, 2021]. BMC Nurs. 2021;20:62. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC8045269/. Accessed January 10, 2022. 2. Gonzalez, G. How healthcare leaders can keep their teams during the ‘Great Resignation’. Becker’s Hospital Review. 2021. https://www. beckershospitalreview.com/hospital-management-administration/how-healthcare-leaders-can-keep-their-teams-during-the-great-resignation.html. Accessed Month day, year. 3. American Hospital Association. 2022 AHA health care talent scan. https://www.aha.org/aha-talent-scan. Accessed December 15, 2021.

THE FROEDTERT HOSPITAL VASCULAR ACCESS TEAM:

20 YEARS AND COUNTING Jennifer Bartowitz1, BSN, RN, VA-BC™ Carolyn Maidl-Putz2, MSN, RN, NE-BC Sarah White3, MD, MS, FSIR

INTRAVASCULAR QUARTERLY

“YOU’RE DOING THIS IN MY ROOM?” IS A QUESTION THE VASCULAR ACCESS TEAM (VAT) IS OFTEN ASKED WHEN ARRIVING TO PLACE A PICC AT A BEDSIDE.

While some patients are familiar with bedside PICC placement, not all have enjoyed the luxury of a bedside procedure. When a patient discovers they will not be transported to a procedure suite and have the option to sleep through the PICC placement in their room, the sense of relief is often palpable. This is just one of the many advantages a Vascular Access Team brings to patients at the bedside: offering convenience for the patient and staff while maintaining high quality care. Bedside PICC placement has become increasingly important for several key reasons during the pandemic, such as the avoidance of unnecessary transport to procedural areas, potential exposure to infectious diseases, and faster service which translates into a decreased hospital length of stay (LOS). LOS has been critical with the high volumes of patients in hospitals across the country: bedside PICC placement with a 24/7 team decreases LOS by avoiding the unnecessary wait time of finding a time in a busy IR procedural suite, which is often not operating 24/7 and may also be dealing with more critical clinical situations. Our Vascular Access Team was established in 1999 seeking to enhance the specialized needs of patients requiring vascular access. We are part of Froedtert & the Medical College of Wisconsin Froedtert Hospital, located in Milwaukee, Wisconsin. Over 20 years later, the team has evolved from just three to 35 RNs, with nursing experience ranging from two to 40 years with 25% of our RNs being board certified in vascular access (VA-BC ™). The team is supported by a nursing director, a nurse manager, and a clinical nurse educator, as well as five health unit coordinators (HUCs) that perform administrative tasks (answer phone calls and pages sent to the VAT, disperse information to VAT RNs regarding high priority access needs, as well as perform manual entry of data). We provide 24/7 vascular access coverage 365 days a year. Froedtert Hospital is a 702bed academic medical center and adult Level I Trauma Center located on a sprawling campus, including ambulatory clinics and outpatient areas such as imaging departments (CT/MRI/ Ultrasound, etc.), an infusion clinic, a cancer center infusion area with a translational research unit, and several pre-procedural areas. Truly, no department or patient population is “off limits” to VAT services. Two other hospitals within the Froedtert & the Medical College of Wisconsin health network have been providing ultrasoundguided peripheral vascular access services since 2015 by utilizing STAT RNs (dual role RNs trained as rapid response RNs as well as vascular access specialists). In 2021, two STAT RNs received advanced vascular access training by Froedtert Hospital VAT RNs to place bedside PICCs at these hospitals with the goals of improving LOS and patient experience. The collaborative training partnership has helped align vascular access policies across the enterprise and allows the experienced VAT staff of Froedtert Hospital to be a resource 24/7 to our hospital partners. Our VAT also trained RNs from our local Veterans’ Hospital, which has also established a team based on our team at Froedtert Hospital. 6

In 2016, Sarah White, MD joined our team as the first medical director of the VAT. An attending physician in the Interventional Radiology (IR) department, Dr. White has been instrumental to our VAT growth and reputation within the organization. This has included developing and implementing medical staff policies regarding PICC placement based on the Michigan Appropriateness Guide to Intravenous Catheters (MAGIC) criteria, as well as process improvements, including creating guidelines for best practices for radiology reporting of malpositioned PICC tip locations to the VAT. Her support extends throughout the entire IR department, as the VAT is able to page an IR attending provider 24/7, if additional support is needed when bedside providers face difficult vascular access issues. This multidisciplinary care allows us to troubleshoot difficult patient situations, if the best type of vascular access is not straight forward. Overall, the addition of a medical director has provided invaluable support for the team’s growth, growing respect within the institution, and cost savings. As a four-time Magnet® designated hospital, our RNs are actively involved in shared governance. One of our VAT RNs is chair-elect of the hospital Practice Council, while another is the chair of the hospital Nursing Research Council. With active participation in hospital-level shared governance, the VAT has an established department Coordinating Council. The council meets monthly with VAT leadership to share information gathered from hospital meetings and works on department projects. Most recently, they created a VAT Skills Fair that offers hands-on learning and education of “low volume-high-risk” procedures and competencies. Additionally, the VAT influence is enterprise-wide. One of our VAT RNs co-chairs the Enterprise CVAD Committee; additional VAT RNs participate as members of the Enterprise CVAD Committee and Enterprise CLABSI Domain Team. To stay updated on research, evidence and best practices, two to four VAT RNs have attended the Association of Vascular Access Annual Scientific Meeting for the past several years. Because of the VAT’s extensive experience and knowledge, in 2019, the VAT transitioned from being technicians, placing lines when ordered, to a consult service offering value to patient care. Currently, a patient in need of vascular access is seen by a skilled VAT RN who completes a chart review and physical vasculature assessment, then aims to place “the right line at the right time” for each individual patient. The VAT RN has discretion and autonomy to place an IV, an ultrasound-guided extended IV, or a midline catheter pending the patient assessment and clinical situation. While placing difficult access and bedside PICCs are the majority of our practice, our VAT also performs a variety of specialty tasks, including but not limited to: power flushing malpositioned PICCs, removing tunneled PICCs, trouble-shooting skin conditions interfering with vascular access sites, assessing and photographing peripheral and central line extravasations, accessing dysfunctional tunneled dialysis catheters for tPA infusion and assessing effectiveness of flow rates, changing PICC/power midline dressings, discussing access difficulties and options with providers and bedside staff, providing nursing staff, provider, and patient education, accessing difficult ports such as dual lumen and thigh ports, and removing large bore lines outside

of the critical care setting. Having specialized staff perform these many tasks not only improves patient care and comfort, but also improves safety while decreasing patient anxiety, risk and complications. New VAT RNs are often surprised by our call volume, which is currently split between roughly 90% inpatient calls and

“THE VASCULAR ACCESS TEAM AT FROEDTERT HOSPITAL IS A TREMENDOUS ASSET TO PATIENTS AND OTHER STAFF,” CONFIRMS JESS THOMEY, DNP, RN, AND DIRECTOR OF NURSING FOR THE VAT. “THEIR ABILITY TO PROVIDE ACCESS TO PATIENTS IN AN EFFICIENT AND SAFE MANNER ENSURES OUR PATIENTS ARE RECEIVING THE CARE THEY NEED AT THE RIGHT TIME.” 10% outpatient calls. Outpatient calls, while not as frequent, are considered high priority. The focus is on expediting care for patients that have scheduled surgeries, imaging studies, chemotherapy infusion appointments, etc., so their care can be provided in a timely manner and improve throughout in our outpatient centers. By not delaying or cancelling their appointments due to access issues, cost savings occur as well. “The Vascular Access Team at Froedtert Hospital is a

tremendous asset to patients and other staff,” confirms Jess Thomey, DNP, RN, and Director of Nursing for the VAT.

“THEIR ABILITY TO PROVIDE ACCESS TO PATIENTS IN AN EFFICIENT AND SAFE MANNER ENSURES OUR PATIENTS ARE RECEIVING THE CARE THEY NEED AT THE RIGHT TIME.” Cost reduction for the hospital and patient is significant with utilization of a VAT. Internal data collection shows that we place an average of 110 PICCs per month at the bedside, with the vast majority of PICCs placed with electrocardiographic (ECG) technology confirmation of the PICC tip location. This not only decreases radiation exposure to the patient and expedites care, but also decreases patient cost by eliminating the charge of $307 for a chest x-ray. Annually this is $405,240 in patient cost savings. In 2017, we expanded the scope and skill of the existing STAT/VAT RN in two of our health network’s other hospitals to include bedside PICC placement. This would allow evening and weekend PICC placement at the bedside, instead of utilizing on-call IR providers, which demonstrated an estimated direct cost reduction of $21,000 for IR “call in” savings. An estimated direct cost savings of $167,000 was calculated by shifting PICC placement to the bedside from the IR suite, allowing the procedure suite to be utilized for other uses. Patient cost savings was found to be significant, as fluoroscopy and provider billing was eliminated, providing a savings of over $700,000 in charges to the patient.

Graph shows the trend of vascular access device types placed over the past four years on the Froedtert Hospital campus. Utilization of ultrasound for peripheral IV (USG PIV) placement in difficult access patients has significantly increased over this four year period. Also note reduction in PICC placement since 2019, when the VAT consult service began, which coincided with the development of PICC/midline policies that limit inappropriate PICC placement based on MAGIC criteria. 7

The total impact the VAT has on cost is difficult to measure, as bedside PICC placement allows IR to accommodate patients for other higher acuity procedures in a timely manner. The placement of a bedside PICC also has the potential to reduce inpatient LOS if awaiting IR availability for the PICC placement is avoided. Additionally, the cost savings in the outpatient setting is difficult to measure as VAT availability improves throughput in high volume areas (such as pre-operative or pre-procedural areas) to ensure timely procedures, as well as avoids unnecessary cancelations of appointments, such as diagnostic tests or infusion appointments, due to difficult access issues. At Froedtert Hospital, the VAT places an average of 4,000 outpatient IVs thus ensuring these 4,000 appointments do not need to be cancelled or rescheduled.

TOTAL VAT FTE RN FTE

HUC FTE

22.7

2.8

The most recent developments on our team include the approval of 3.1 additional FTE’s including adding two RNs to day shift Monday through Friday with staggered start times between 0600 and 0830, an additional evening RN Monday through Friday and an additional night shift RN. During the weekend, staffing is downgraded 2-3 RN staff as call volume generally is slightly lower due to clinics being closed. We also have a new centrally located office on the campus customized to our team’s needs with our clinical

nurse educator’s office being in close proximity to the rest of the staff, as well as a supply and equipment room designed for our unique needs. Additionally, because of an increase in volume and best practice guidelines, seven new ultrasound machines were purchased in 2021 for peripheral access, providing exceptional ultrasound image quality to decrease nerve injury risk and increase first-stick success rate. This upcoming year we anticipate the addition of hand-held electronic devices to assist in coordination of calls, uploading images to the electronic health record, documentation and chart review. Finally, several VAT RNs are working towards an IRB research proposal. The continued growth and support of our team from the highest levels in the organization is a testament to the quality of care, cost-savings, and value we continue to bring to the enterprise. We are proud of our past 20 years and look forward to the next 20 years of improving vascular access care for our patients.

REFERENCES 1 Jennifer Bartowitz, BSN, RN, VA-BC™ is a Vascular Access Nurse at Froedtert & the Medical College of Wisconsin Froedtert Hospital in Milwaukee, Wisconsin. 2 Carolyn Maidl-Putz, MSN, RN, NE-BC is the Nurse Manager of Critical Care Resource Pool & the Vascular Access Team at Froedtert & the Medical College of Wisconsin Froedtert Hospital in Milwaukee, Wisconsin. 3 Sarah White, MD, MS, FSIR is a Professor of Radiology and Surgical Oncology in the Vascular & Interventional Radiology Department at Froedtert & the Medical College of Wisconsin Froedtert Hospital, in Milwaukee, Wisconsin.

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PARTNERSHIPS DRIVE PATIENT SAFETY EVEN IN THE MOST CHALLENGING TIMES Michelle DeVries, MPH, CIC, VA-BC™

AS AN INFECTION PREVENTIONIST WITH A BACKGROUND IN HOSPITAL AND MOLECULAR EPIDEMIOLOGY AND A PASSION FOR VASCULAR ACCESS, I’VE ALWAYS SAID MY “HAPPY PLACE” IS AT THE INTERSECTION OF HOSPITAL EPIDEMIOLOGY Vascular access and patient safety. I have been extremely fortunate to align with the Association for Vascular Access (AVA), originally participating through contributions as part of the annual scientific meeting, then on individual projects and task forces and for the past years as a member of the board of directors nationally as well as with my local network. Several years ago, I was asked why AVA did not have a special interest group (SIG) for infection prevention; our leadership at the time had the very accurate response that infection control is an integral part of everything we do, not something that can or should be separated into something independent. Reducing complications across all vascular access devices is a unifying goal. Championing vascular access specialist teams and providing opportunities for disseminating the success (and challenges) of those teams through our peer reviewed journal (JAVA), our quarterly online newsletter (lntravascular Quarterly“IQ”) or sharing through presentations at local and national events and webinars to promote the best possible outcomes for our patients are all ways that AVA strives to serve our community. We are a diverse specialty made up of the whole breadth of stakeholders and many different disciplines including technicians, respiratory therapists, nurses, and providers but also those who support the practice as administrators, quality directors, infection preventionists, educators and the industry specialists who provide the tools we use daily. We are inclusive and global in our goals and anxious to partner with individuals and organizations that share this same vision.

THE LAST SEVERAL YEARS HAVE WITNESSED OUR ASSOCIATION DEVELOP NUMEROUS POSITION PAPERS TO SUPPORT CLINICIANS AND BOLSTER THEIR PRACTICE.

Most recently that included tackling the ongoing question of appropriate disinfection of ultrasound transducers used in vascular access procedures. AVA partnered with American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Association for Professionals in Infection Control and Epidemiology and Society for Healthcare Epidemiology of America to create an intersocietal position paper on the topic. PediNeoSIG drafted and published Minimum Education and Training for Pediatric and Neonatal IV Insertion for all Clinicians along with a companion competency checklist. Several additional position papers were developed addressing the use of ultrasound guidance for central line insertion, arterial insertion, and visualization technology for peripheral IVs. These were rounded out by adoption of the international standards of Aseptic Non-Touch Technique (ANTT).

WE CONTINUE TO STRIVE TO PROVIDE MEMBERS AND CLINICIANS WITH THE TOOLS THEY NEED TO BE SUCCESSFUL. The Vascular Access Resource Guide is in its final phases of editing for the second edition, which now includes formal consideration of practices outside of the acutecare setting. BacSIG (our Beyond Acute Care special interest group) is evaluating the feedback from their recent member survey and hosting a panel webinar this fall to represent this sometimes overlooked but crucial patient population. Also very exciting for us is the progress being made on AVM Clinical Practice Guidelines. We have a global group of contributors working together to review the literature and develop guidance focused on the “grey areas” of vascular access. We recognize the tremendous value of the existing standards and practice guidelines

from around the globe and hope that leaning on our diverse leaders and international volunteers can add another resource for clinicians looking for further guidance on these difficult questions. We are fortunate to have numerous other organizations partnering with us for this undertaking including American Society of Radiologic Technologists, Association for Professionals in Infection Control and Epidemiology, Canadian Vascular Access Association, Emergency Nurses Association, National Association of Clinical Nurse Specialists, National Home Infusion Association and Oncology Nursing Society. Blake Hotchkiss, BSN, RN, CCRN, CRNI, VA-BC, who is AVA’s clinical education specialist, is serving as the project manager for this undertaking with an interdisciplinary team of leaders from across the globe, investigating the key elements of vascular access including assessment and device planning, pre-insertion, insertion, complication management, device maintenance and removal and administrative. Andrea Raynak, RN, MPH(N), CVM(c), VA-B C, a vascular access clinical nurse specialist at Thunder Bay Regional Health Sciences Centre Thunder Bay, Ontario Canada, is team leader for the assessment group and notes what an honor it has been to work with and learn from experts from so many different areas around the globe. She shares that the expertise everyone has brought creates an incredibly rich learning environment which will be reflected in the document. This past year and a half has been a challenge for all of us, personally and professionally. Infection prevention has received a level of sustained attention that I believe we have not previously witnessed. Similarly, the impact of vascular access and the innovations that arose during the COVID-19 pandemic by our specialists who pioneered gaining and maintaining access in these often critical and incredibly complicated patients re-emphasized that vascular access truly is the gateway to almost all healthcare. The partnerships that we create between our departments in our facilities as well as through strong professional associations and increasing the collaboration between our specialty societies are what will continue to drive patient safety initiatives even in the most challenging of times. October 5th is Vascular Access Specialist Day. We wear many different hats but thank you to everyone who supports this incredible specialty!

Article reprinted from Healthcare Hygiene Magazine. Chellie DeVries has been involved in infection prevention and hospital epidemiology for more than 25 years, with a passion for vascular access. She is a frequent presenter at local AVA, APIC, and INS chapters and has contributed to numerous publications at the intersection of vascular access, hospital epidemiology and patient safety.

THE GREAT RESIGNATION: MITIGATE WITH CONTINUING EDUCATION AND COMMUNITY Cate Brennan, MBA, CAE, Chief Executive Officer of AVA

THE GREAT RESIGNATION, COUPLED WITH STAFFING DISRUPTIONS CAUSED BY COVID-19 SICK DAYS AND PRE-PANDEMIC SHORTAGES, Continue to surge through healthcare systems and every type of health care setting and profession. The impact on patients across the continuum of care is significant. According to the Bureau of Labor Statistics, the overall healthcare workforce is down 2.7 percent from February 2020.

The impact on patients across the Nursing homes and other “beyond acute care” settings have been hit the hardest. The hospital workforce is down 1.8 percent from February 2020. The current conditions in hospital systems could be called The Big Shift because lower-skilled healthcare workers are moving from traditionally low-wage jobs to new job categories that can offer better career growth and salaries. These transformations are good for the individuals but leave yet another gap to fill. Healthcare leaders also are contending with growing gaps for specialists, like vascular access specialists. It’s an understatement to say staff recruitment and retention is stressed. According to a 2021 Nursing Solutions Inc. National Health Care Retention & RN Staffing Report, the average cost of turnover for a bedside RN is $40,038. The turnover rate for staff RNs was 18.7 percent in 2020, a 2.8 percent increase from 2019. Also in 2020, the average turnover rate for an APRN was 8.9 percent, PA was 9.2 percent, respiratory therapist was 18.6 percent, radiologic technologist was 18.8 percent and certified nursing assistant was 27.5 percent. The Association for Vascular Access (AVA) is concerned with the turnover rates because it delivers specialty continuing education, and other member benefits, to all of these providers, in addition to physicians and infection prevention specialists. AVA is a non-profit multi-disciplinary professional society. So how do the chief administrators and leaders at hospitals, nursing homes and health systems combat these cemented trends to improve provider retention and satisfaction? There is no single answer because it all depends on local conditions. But experts agree that parts of the retention matrix are improved working conditions, higher wages, financial support for improving skills and knowledge, and a commitment to team-based and patientcentered care.

VASCULAR ACCESS IS THE MOST COMMON INVASIVE PROCEDURE PERFORMED IN HEALTHCARE, WITH MORE THAN 380 MILLION PLACEMENTS OF PERIPHERAL INTRAVENOUS CATHETERS (PIVCS) PLACED IN PATIENTS ANNUALLY IN THE US. But how many providers are learning vascular access and other procedures from non-experts? What is the cost to a new provider’s confidence and a patient’s safety and satisfaction? What is the cost to the healthcare system in staff retention and satisfaction?1 13

Like other professional societies, AVA can help chief administrators and clinical educators provide expert, research-based continuing education that will improve the skills and knowledge of providers. Effective, targeted CE can have an immediate impact on the staff retention matrix and hospital quality measures. But to do this, healthcare systems must reverse the decades-long steady decline of financial support for continuing education and professional memberships that benefit the staff provider. Most providers want choices in their continuing education, choices that directly benefit them and fill their knowledge gaps. Continuing education is more than an employer-provided online course or virtual webinar, though there is certainly a place for those platforms. CE is also the peer-based community that membership provides. This irreplaceable community provides needed context and ongoing support long after the CE is completed. In almost all cases, the cost of a professional membership more than pays for itself in free CEs. The benefit to the hospital or healthcare system includes improved provider satisfaction because they have a choice in their CE and a support system. This is true of AVA and our other non-profit colleagues like APIC, AANP, AARC, ASRT, AMT and NAHCA, to name a few. The retirement trend is impacting vascular access teams, and there is a growing gap of VA specialists in the workforce. To address this growing shortage, AVA developed and offers its Fundamentals of Peripheral Intravenous Vascular Access™, a free 3-course curriculum to pre-licensure nursing, medical and allied health academic programs. The goal of the curriculum is to prepare new providers and make them competent and confident at the start of their career. A shorter Fundamentals course for practicing providers will be released in late 2022. Provider competency in vascular access is critical, given its status as the most common invasive procedure healthcare. ACE by AVA is an innovative education, skills development and competency verification method. Its goal is to provide improved training and competency that may result in higher provider satisfaction and retention, and improved patient satisfaction and outcomes.

AVA Academy has more than 100 on-demand CE courses and holds monthly live CE events, which are free to members. The AVA Annual Scientific Meeting provides both face-to-face and virtual learning. While the Magnet Recognition Program® specifically pertains to nursing, the fourth component of New Knowledge, Innovation & Improvements applies to continuing education. It states, “Strong leadership, empowered professionals, and exemplary practice are essential building blocks for Magnet-recognized organizations, but they are not the final goals. Magnet organizations have an ethical and professional responsibility to contribute to patient care, the organization, and the profession in terms of new knowledge, innovations, and improvements. Our current systems and practices need to be redesigned and redefined if we are to be successful in the future. This Component includes new models of care, application of existing evidence, new evidence, and visible contributions to the science of nursing.” There are many areas for improvement and progress in the US healthcare system. When the system supports its providers’ desire for self-directed continuing education and a supportive peer community, the likely result will be improved provider satisfaction and retention. Cate Brennan joined AVA in January 2021 at its CEO. She has more than 20 years experience of successfully leading non-profit healthcare organizations and additional years with national and international professional and trade non-profit organizations. She specializes in developing strategies to deliver high-impact, results-driven member programs and services. Her interests include U.S. public policy and advocacy, strategic planning and execution, and delivering great results. 1 Tripathi S, Gladfelter T. Peripheral intravenous catheters in hospitalized patients: Practice, Dwell times, and factors impacting the dwell times: A single center retrospective study. J Vasc Access. 2021 Mar 30:11297298211000874. doi: 10.1177/11297298211000874. Epub ahead of print. PMID: 33784876.

A CAUSAL-COMPARATIVE EXAMINATION OF CLABSI, VASCULAR ACCESS TEAMS AND HOSPITAL TYPES BY AMY JO BARDIN-SPENCER CHAPTER 5 EXCERPT FROM THE PUBLISHED DISSERTATION BY THE SAME NAME 15

INTRODUCTION AND SUMMARY OF STUDY The purpose of this quantitative causal-comparative study was to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. Prior studies have examined how healthcare organizations have attempted to improve vascular access device related infection, yet there is little research regarding the difference a vascular access team model has on the healthcare organization (Krein et al., 2019). Krein et al. (2019) further highlighted the need to better understand the model, role, composition, and practice of vascular access/ PICC teams which may impact patient outcome. Rajaram et al. (2015) identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there a correlation as to what type, if any; vascular access team model was utilized. Healthcare leaders are struggling to incorporate processes that augment healthcare efficiency, reduce patient harm and optimize patient outcome (Marschall et al., 2014; PorterO’Grady & Malloch, 2016; Zingg et al., 2015). Vascular access device insertion and use are high volume, high risk, and problem prone, requiring skilled operators to ensure the highest level of procedural compliance to reduce patient harm (Davis et al., 2016). As healthcare organizations attempt to consolidate care costs, optimize workflow, and patient throughput, a better understanding of vascular access team models may aide healthcare leadership with developmental and implementation of multi-modal strategies 108 (Hessels & Larson, 2016; Lawson, 2015; Patel et al., 2019; Rosen et al., 2018; Young, 2017; Zingg et al., 2015). This study was guided by two research questions and corresponding hypotheses. The research questions addressed the difference in reported CLABSI rates based on hospital type (teaching and non-teaching) for hospitals with a vascular access team and if there was a difference in reported CLABSI rates based on a vascular access team present or absence. Both questions were answered by using a two-way analysis of variance (ANOVA) and a t-test was used to investigate the relationships. Both tests compare the means between groups and determine whether any of those means are statistically significantly different from each other. Clinical practice variations between hospital type and size demonstrate an increased risk of CLABSI therefore, understanding how a team may aide in clinical practice variations and promote a standardized procedural process might be beneficial (Rajaram et al., 2015). Knowing that adherence to evidence-based practices decreases variation in CVAD insertion, and maintenance practice, may significantly improve the overall quality of care (Akinwole, 2015; Stone et al., 2014; Valencia et al., 2016), the possible team present contribution for risk reduction was explored. The result of this study may aide hospital leadership regardless of hospital type to better understand the difference a vascular access team model has on HAI reduction. 16

The remainder of this chapter provides a comprehensive summary of the study. The study findings are discussed, and conclusions are presented. This chapter addresses the implications of the study from theoretical and practical perspectives. Future implications are also addressed. Finally, recommendations for future research are presented.

SUMMARY OF THE STUDY The purpose of this study was to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. To understand if there is a difference in reported CLABSI, the researcher investigated the background of the study topic. Previous studies have shown that various healthcare teams play a role in the improvement of patient outcomes (Alexandrou et al., 2014; Davies et al., 2018; Johnson et at., 2017; Krein et al., 2019; Ulrich & Crider, 2017). Marschall et al. (2014) recognized that IV therapy teams responsible for peripheral IV insertion and maintenance reduce the risk of infection, yet few studies identified the impact of such teams on CLABSI rates. Rajaram et al. (2015) identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there correlation as to what type, if any; vascular access team model was utilized. The researcher reviewed and synthesized theoretical foundations and models that provided the conceptual framework for this research. The structure-process-outcome theoretical model was used in this research to provide a framework for evaluating healthcare outcomes (Donabedian, 1969). The Donabedian model has been used to evaluate health care quality in a variety of health care settings (Chou et al., 2008; Holt et al., 2014; Issel & Bekemeier, 2010; Watkins et al., 2010; Wübker, 2007). Donabedian’s theory focused on three primary categories: structure, process, and outcome (Donabedian, 2003). The researcher extended Donabedian’s theory by applying the framework to healthcare outcomes as it relates to hospital types and the presence of a vascular access team within U.S. hospitals. Donabedian defines structure as the professional and organizational resources associated with the provision of health care, for this study Structure referred to the characteristics of the location in which healthcare is provided (Donabedian, 1969, 1988) and was referred to as characteristics of U.S. hospitals providing healthcare to Medicare beneficiaries. Process refers to the things done to and for the patient such as interactions between patient and clinician or team, which involves care delivery. Outcome will refer to the measured U.S. hospitals reported CLABSI rates. Outcome is the desired result of care provided by the health practitioner (Donabedian, 1969, 1988) or the effect of healthcare delivery (Donabedian, 1969, 1988). A review of the literature provided an in-depth investigation of empirical research focused on the impact of healthcare team models. This review also focused on empirical data regarding the impact of team models as it relates to the work environment

and patient outcomes. The literature review examined the background of the study, how the theoretical framework related to the variables of the study as well as a historical perspective of the evolution of infusion and vascular access teams and its impact on patient outcome, and the development of outcome reporting through the Centers for Medicare and Medicaid Services, and its impact on healthcare delivery. In addition, current literature regarding Donabedian’s (1969) structure-process-outcome (SPO) framework was reviewed. This study was conducted using the quantitative methodology with a causal comparative design to answer the two research questions. As Ingham-Broomfield (2014) explained, quantitative research is used when researchers want to use statistics to describe and summarize data. The causal-comparative design is used when the researcher wants to determine if the independent variable affected the dependent variable by comparing two or more groups of individuals (Salkind, 2010). To examine whether hospital type, or vascular access team presence made a difference in reported CLABSI rates, the following research questions and hypotheses were developed. RQ1: Is there a difference in reported CLABSI rates based on hospital type (teaching and non-teaching) for hospitals with a vascular access team? H01: There is no statistically significant difference in reported CLABSI rates based on hospital type (teaching and nonteaching) for hospitals with a vascular access team? H1a: There is a statistically significant difference in reported CLABSI rates based on hospital type (teaching and nonteaching) for hospitals with a vascular access team? RQ2: Is there a difference in reported CLABSI rates based on a vascular access team present or absence? H02: There is no statistically significant difference in reported CLABSI rates based on a vascular access team present or absent. H2a: There is a statistically significant difference in reported CLABSI rate based on a vascular access team present or absent. The researcher used a stratified random sampling technique. A stratified sampling technique aligned with the study design and research questions. The data analysis included both descriptive and inferential statistics. The descriptive analysis provided an understanding of the sample characteristics. A two-way ANOVA was utilized to answer both research questions. Both research questions rejected the null hypothesis. In Chapter 5, the researcher examined the results of the data analysis, explained the findings in alignment with the research questions, and outlines conclusions drawn from the findings. Theoretical, practical and future implications were also discussed. Lastly, the researcher provided recommendations for practice and future research based on the findings and conclusions.

SUMMARY OF FINDINGS AND CONCLUSION The final data sample for this study included 128 hospitals participating in mandatory HAI reporting. This included 64 teaching and 64 non-teaching hospitals. The data collection instruments for this causal-comparative research included the Hospital Compare open access database (CMS.gov) and a phone inquiry. Hospital Compare reports information on quality measures including HAIs and patient satisfaction for over 3000 hospitals nationwide (CMS.gov). Reported HAI scores from a random sample of hospitals from 2016-2017 was examined. Hospital specific vascular access team detail was collected using a phone inquiry. The researcher formulated two research questions to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. To address the two research questions, the researcher conducted a two-way ANOVA. A paired t-test was also conducted for research question two. The causal-comparative design used for this study determines whether the independent variable affected the dependent variable by comparing two or more groups of individuals (Salkind, 2010). The following shows how the findings aligned with each research question and hypothesis.

RESEARCH QUESTION 1 The first research question addressed the significant mean difference between reported CLABSI rates based on hospital type (teaching and nonteaching) for hospitals with a vascular access team. A two-way analysis of variance (ANOVA) was used to answer this question. The ANOVA was examined based on an alpha value of 0.05. The results of the ANOVA were significant, F(2, 125) = 16.54, p < .001, indicating there were significant differences in reported CLABSI among the levels of hospital type teaching or non-teaching and team present or absent (Table 3). The main effect, hospital type was significant, F(1, 125) = 24.54, p < .001, ηp 2 = 0.16, indicating there were significant differences in reported CLABSI by hospital type. The main effect, team present or absent was also significant, F(1, 125) = 8.54, p = .004, ηp 2 = 0.06, indicating there were significant differences in reported CLABSI by team present or absent. Thus, accepting the alternative hypothesis and rejecting the null hypothesis. In a study by Rajaram et al. (2015) the authors identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there correlation as to what type, if any; vascular access team model was utilized. The results of this research suggest that having a vascular access team regardless of hospital type does positively impact infection outcomes. These results should guide healthcare leaders seeking to implement evidence based guidelines and infection risk reductions strategies throughout healthcare organizations.

RESEARCH QUESTION 2 The second research question addressed the significant mean difference in reported CLABSI rates based on a vascular access 17

team present or absence. A two-way analysis of variance (ANOVA) and a paired t-test was used to answer this question. The results showed there was a significant mean difference between a team being present or absent determined by two-way ANOVA, F(1, 125) = 8.54, p = .004, ηp 2 = 0.06, in addition, the paired t-tests demonstrated the main effect of team absent (M = 21.23, SD = 14.44), was significantly larger than for team present (M = 13.88, SD = 17.38), p = .004 thus, accepting the alternative hypothesis and rejecting the null hypothesis. Previous studies have shown that various healthcare teams play a role in the improvement of patient outcomes (Alexandrou et al., 2014; Davies et al., 2018; Johnson et at., 2017; Krein et al., 2019; Ulrich & Crider, 2017). According to Chopra et al. (2017), vascular access and infusion nurses who generally receive additional training in inserting and maintaining a range of intravenous (IV) devices, serve a critical role in providing safe and reliable vascular access. Davis et al. (2016) identified vascular access as being a high-volume/high-risk invasive procedure requiring specialized training and expertise to ensure positive outcomes. Alexandrou et al. (2014) emphasized that a centralized vascular access service with a small number of specifically trained personnel may be more important to procedural success than clinician grade. Specialized training includes both peripheral and central venous access catheter insertion and care (Chopra et al., 2017). Krein et al. (2019) recommended that nurse peripherally inserted central catheter (PICC) teams play an integral role in PICC usage, and device selection suggesting that use of such teams may promote key practices to prevent reported CLABSI. As healthcare organizations attempt to consolidate care costs, optimize workflow, and patient throughput, a better understanding of vascular access team models may aide healthcare leadership with developmental and implementation of multi-modal strategies (Hessels & Larson, 2016; Lawson, 2015; Patel et al. 2019; Rosen et al. 2018; Young, 2017; Zingg et al. 2015). Employing structured practice and processes for vascular access procedures should include: (a) patient assessment, (b) device insertion, (c) maintenance, and removal may reduce hospital risk (Moureau, 2017; Moureau & Chopra, 2016; Savage et al., 2019). Furthermore, the significance of these study findings may aide health care leaders with a better understanding of the relationship between hospital type, the presence of a vascular access team and reported CLABSI rates. CLABSI accounts for approximately 15% of HAIs and are serious yet avoidable outcomes that directly impact patient satisfaction and can be avoided with strict adherence to current evidencebased guidelines (Gorski et al., 2021; Marschall et al., 2014; O’grady et al., 2011). Understanding if a relationship exists between hospital type, vascular access team, and reported CLABSI rates might better prepare leaders in healthcare organizations to reduce HAIs. The results of this study do substantiate the findings from Alexandrou et al. (2014), Krein et al. (2019), Davis et al. (2016), and Chopra et al. (2017) in regard to use of a dedicated vascular access team. These results should guide healthcare leaders seeking to standardize practice through implementation of evidence-based guidelines and infection risk reductions strategies throughout healthcare organizations. 18

IMPLICATIONS This quantitative, causal-comparative study aimed to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. The data analysis revealed a statistically significant difference in reported CLABSI rates based on both hospital type and the presence of a vascular access team. This section discusses what the research discovered, as well as how the finding could be interpreted based on the theoretical framework. Practical implication of a vascular access team model and future implications for new research are also discussed. Theoretical implications. The Donabedian theory has been used to identify the structural components and clinician-patient care processes that lead to patient outcomes. The researcher formulated two research questions and corresponding hypotheses to study if there was a difference in reported CLABSI rates based on hospital type (teaching and non-teaching) and vascular access team present or absent in U.S. hospitals. Donabedian’s theory. This conceptual framework has been used to evaluate health care quality in a variety of health care settings (Chou et al., 2008; Holt et al., 2014; Issel & Bekemeier, 2010; Watkins et al., 2010; Wübker, 2007). The structure of a healthcare organization is comprised of relatively stable characteristics, to include the resources available, and the physical and organizational settings in which they work. Structures in healthcare referred to the physical and structural features of care settings (e.g., hospitals, employees, operations, finance etc.). The structure affects processes and outcomes. For this research, the structural variables include; the vascular access team, teaching and non-teaching medical centers and U.S. hospitals and CLABSI rates reported into the Medicare and Medicaid pay-forperformance program.

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Care processes are interactions or activities that occur within and between health care clinicians and the target population they serve (Donabedian, 1980; Donabedian, 2003). Outcomes are the definitive validator of the effectiveness and quality of health care, which may include improvements in social, physical, and psychological function; patient attitudes and satisfaction; and health-related behavioral change (Donabedian, 2005). This study resulted in a statistical significance difference in hospital (structure) F(2, 125) = 16.54, p < .001, indicating there were significant differences in reported (outcome) CLABSI among the levels of hospital (structure) teaching and non-teaching and team (process) present was significantly smaller than for Absent (M = 21.23, SD = 14.44), p = .004.

The Donabedian theory has implications for healthcare optimization through care delivery model assessment regardless of hospital type, size or resources. Healthcare organizations continue to seek care processes that provide quality, efficient and standardized processes. This theory as demonstrated in this study continues to have real world implications outcome focused organizations seeking quality of care measures through acknowledgement and assessment of established structures and processes.

Furthermore, this study has helped reinforce the need for specialized vascular access teams. As healthcare organizations seek to reduce cost and standardize patient care, teams should be resourced to ensure timely, optimized patient care is achievable with the least amount of patient harm or risk. Additionally, future research should include a nationwide survey assessment of team resources, this quantitative research may demonstrate resource need to healthcare leaders who are required to rationalize resources and overall team design.

PRACTICAL IMPLICATIONS

Strengths and weaknesses of the study. The strengths of this study were the focus on factors that can affect reported CLABSI rates within the United States teaching and non-teaching hospitals. Rajaram et al. (2015) identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there correlation as to what type, if any; vascular access team model was utilized. This study reinforced the difference in reported CLABSI rates between hospitals types but also identified that the presence of a vascular access team has a significant impact on reported CLABSI rates regardless of hospital type. The study can aide healthcare organizations seeking resource options to reduce reported CLABSI rates.

A major practical implication drawn from this study is that healthcare leaders should consider the use of dedicated vascular access teams as a CLABSI improvement strategy regardless of hospital type. More specifically, they should consider teams as an essential strategy when seeking to standardize patient care related to vascular access device insertion and management. This practical application is supported by Alexandrou et al. (2014) and Johnson et al. (2017), who stipulated that vascular access/ infusion teams augment risk reduction efforts and improve patient safety. Teams with specialized training and expertise are required to ensure both patient safety and positive outcomes (Alexandrou et al., 2014; Chopra et al., 2017; Davis et al. 2016).

TEAMS SHOULD

Another practical application is the opportunity to standardize care delivery, patient assessment and reduce overall costs to both teaching and non-teaching healthcare organizations. The presence of a vascular access team supports standardization practices to include; device insertion, care and maintenance and prompt device removal. The finding of this study along with that of Gunderson et al. (2016) support the practical application of vascular access teams as they have been shown to reduce supply costs, decreased the number of attempts to gain intravenous access, and increased time to treatments for patient care, and these teams are found to be beneficial to both patients and staff. According to McDiarmid et al. (2017) the use of standardized care and maintenance protocols demonstrated considerable benefits to patients with a low risk of major complications.

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FUTURE IMPLICATIONS This study was instrumental by further filling in the gap of knowing the extent to which the presence of a vascular access team impacts reported CLABSI rates regardless of hospital type. More precisely, this study’s findings offer useful insight for healthcare leaders seeking strategies to further reduce reported CLABSI rates. Additional research is needed to further explore the team variables which may further impact patient outcomes (Legemaat et al., 2015).

The researcher identified two weaknesses of this study. First the study included the use of reported CLABSI rates from 2016-2017. In 2017, the NHSN system changed to SIR reporting to adjust for hospital characteristics and hospital designations. Second the study identified the presence or absence of a team at each randomly selected hospital. The research did not break down the type of team or team variables which may contribute to reported CLABSI rates. There were several limitations to this study. The first limitation was the use of secondary data collected from a large mandatory reporting database. As described by Dubois et al., 2013; Smith, 2014; Zhan & Miller, 2003 the use of secondary data poses a fundamental risk due to potential data entry errors. The second limitation was the inability to control the environment related to the use of a phone inquiry (Baxter & Chua, 2008). The researcher used a phone inquiry to determine the use of a vascular access team. The final limitation was the study design. A causal comparative design examines a relationship between and dependent variables and there are often variables other than the independent variables that may impact the dependent variable (Salkind, 2010). This limits the ability to develop sound judgements related to cause and effect because the researcher does not directly influence the independent variables.

RECOMMENDATIONS The results of this study provide insight into opportunities for future research and practice. This study examined if hospital type, or the presence of a vascular access team made a difference in reported CLABSI rates. By examining reported CLABSI rates, hospital type and the presence or absence of a vascular access team. Based on this study, the researcher offers the following recommendations for future research and practice. 19

RECOMMENDATIONS FOR FUTURE RESEARCH This study met its purpose by filling a research gap identified in the literature review. The finding reflected the weaknesses and limitations of this study. To further examine the difference a vascular access teams has on reported CLABSI, the researcher suggests the following approaches for future research.

ROLE OF THE TEAM Tasks of team members vary: these include (a) insertion and management of VADs (Cooley & Grady, 2009; Curry et al., 2009; Holzmann-Pazgal et al., 2012; King et al., 2010) (b) performance of daily assessment (Cooley & Grady, 2009; King et al., 2010), (c) holistic management of all central lines (Curry et al., 2009) and (d) maintenance (Cooley & Grady, 2009; Curry et al., 2009; Holzmann-Pazgal et al., 2012; King et al., 2010; Taylor et al., 2011) of CVADs. Not all teams perform the same level of care related to vascular access device insertion, care or maintenance. Understanding the role of the team may allow researchers to gain a better understanding of what team roles have the most impact on reported CLABSI rates.

TEAM MODEL VARIABLES A number of hospitals have incorporated vascular access teams to insert and maintain both peripheral and central catheters with positive outcomes (Alexandrou et al., 2012; Hawes, 2007; Johnson et al., 2017; McDiarmid et al., 2017). The Infusion Nursing Society (INS) described three infusion/vascular access service models (Hadaway et al., 2014). These models include; primary care, vascular access, and an infusion team. The primary care model is described as having no centralized process for infusion therapy or vascular access, where all related practice is provided and managed by all facility frontline registered nurses. Vascular access insertion team model represents a small group of highly skilled experts who focus on insertion of all VADs, this model includes advanced knowledge and skills in the assessment, insertion, care, and management of vascular access devices which include nurses, doctors, respiratory therapists, technicians, and physician assistants (Carr et al., 2018; Gorski et al., 2021). Studies of teams with well-defined outcomes and clearly defined roles and team compositions are needed (Legemaat et al., 2015). Understanding team variables may allow researchers to gain a better understanding of practice variations which have the most impact on reported CLABSI rates.

INFECTION PREVENTION STRATEGIES AND TEAMS Hospitals have implemented multiple strategies to reduce CLABSI rates. A major component of the quality improvement collaboratives included the CLABSI prevention bundle and the 20

Comprehensive Unitbased Safety Program (CUSP), designed to improve teamwork, communication and patient safety, and culture (Marsteller et al., 2014). This Comprehensive Program includes: (a) educating staff on the science of improving patient safety, (b) identifying patient safety defects, (c) partner with a senior executive to prioritize safety defects and provide resources, (d) learning from at least one defect per quarter using a structured tool, and (e) implementing teamwork and communication tools. Adherence to evidence-based practices has been shown to reduce inconsistencies in practice, significantly improving the overall quality of care, yet healthcare organizations still often find them difficult to implement (IHI, 2018; Stone et al., 2014; Valencia et al., 2016). Understanding the hospitals compliance with current evidence based bundle strategies in addition to the use of a team may allow researchers to gain a better understanding of bundle compliance and use of a dedicated teams impact on reported CLABSI rates.

PRACTICE AND POLICY Hospitals maintain polices to ensure the use of evidencebased practices. Healthcare administrators and front-line providers must collaborate with infection control prevention staff to establish and maintain evidence-based infection prevention policy (Vokes et al., 2018). To further prevent hospital-acquired infections, infection control policies should be updated regularly to reflect best practices, and proper change management techniques should be employed to mobilize and empower staff to increase their ability to prevent such hospital-acquired infections (Vokes et al., 2018). Understanding the hospitals use of current evidence-based polices in addition to the use of a team may allow researchers to gain a better understanding of policy compliance and use of a dedicated teams impact on reported CLABSI rates.

LEADERSHIP ENGAGEMENT Leadership plays a critical role in the implementation science of moving evidence and have an obligation to understand the impact they have on the healthcare organization (Knobloch et al., 2018). Leaders seek to include tools that increase engagement in frontline staff (Knobloch et al., 2018; Owings et al., 2018). Leader rounding allows for direct observation and conversation to find common solutions to clinical needs. Leader rounding has been shown to reduce HAIs such as CLABSI by engaging front line staff with checklists and prompting questions related to risk reduction options during patient engagements (Owings et al., 2018). Identification and removal of barriers is one role leader rounding includes in addition, to promotion of a shared vision of

patient safety (Owings et al., 2018). Empowering team members in the decision-making process has shown to increase morale, motivation and job satisfaction (Dromey, 2014). Today’s health care leaders are obligated to understand the impact they can have on both organizational and also unitbased safety climates (Knobloch et al., 2018). Each interaction between a leader and a frontline staff person has the opportunity to foster psychologic safety, which can lead to open problem-solving to reduce barriers and promote implementation (Knobloch et al., 2018). Understanding the level of leadership engagement in addition to the use of a vascular access team may allow researchers to gain a better understanding of leader behaviors that may impact reported CLABSI rates.

RECOMMENDATIONS FOR FUTURE PRACTICE This section outlines recommendations for future practice based on the results and findings of the study. The recommendations are directed to healthcare leaders, vascular access teams and those interested in the impact of team models on hospital acquired conditions.

HEALTHCARE LEADERS The first recommendation is directed to healthcare leaders tasked with improving patient outcomes. According to Marschall et al. (2014), healthcare leaders are accountable for identifying and implementing resources for hospital acquired infection (HAI) prevention. According to Porter-O’Grady and Malloch (2016), leadership must establish foundational team elements, to include purposeful information, effective deliberative processes, clearly defined roles of the team members, and terms of engagement. Leadership plays a critical role in the implementation science of moving evidence and have an obligation to understand the impact they have on the healthcare organization (Knobloch et al., 2018). Both teaching and non-teaching hospitals can benefit from the presence of a vascular access team.

VASCULAR ACCESS TEAMS The second recommendation is directed to vascular access teams. A number of hospitals have incorporated vascular access teams to insert and maintain both peripheral and central catheters with positive outcomes (Alexandrou et al., 2014; Hawes, 2007; Johnson et al., 2017; McDiarmid et al., 2017). Vascular access insertion team model represents a small group of highly skilled experts who focus on insertion of all VADs, this model includes advanced knowledge and skills in the assessment, insertion, care, and management of vascular access devices which include nurses, doctors, respiratory therapists, technicians, and physician assistants (Carr et al., 2018; Gorski et al., 2021). Implementation of a vascular access team positively impacts the hospital due to reduced supply costs, decreased the number of attempts to gain intravenous access, and increased time to treatments for patient care, and has been found to be beneficial to both patients and

STRESSING THE DRESSING:

THE ROLE OF ANTIMICROBIAL DRESSINGS IN THE PREVENTION OF CRBSIs PRESENTED AT AVA 2021 VIRTUAL ANNUAL SCIENTIFIC MEETING SEPTEMBER 16–19, 2021 Robert Garcia, BS, MT (ASCP), CIC, FAPIC, Infection Preventionist, Valley Stream, New York

BACKGROUND/INTRODUCTION Intravenous (IV) catheters—in numerous designs for insertion into diverse body sites—have been used in healthcare for decades to administer life-sustaining formulations. It is estimated that there are 8.5 million central venous catheters (CVCs), 10 million peripherally inserted central catheters (PICCs), 4 million midline catheters, and 350 million peripheral intravenous (PIV) devices sold each year in the United States (US) alone.1,2 This wide usage accounts for millions of insertions, maintenance, and access procedures—each one with inherent risk for infection or other complications. Data on the number of nationwide infections associated with all IV devices is lacking due to narrow surveillance mandates. Currently, there are no federal or state requirements for hospitals or other healthcare entities to report Catheter-Related Bloodstream Infections (CRBSIs). Central Line-Associated Bloodstream Infections (CLABSIs), a subset of CRBSI, are currently the only national reporting requirement related to an IV device with defined surveillance criteria data reported to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network.3 In response to findings of significantly high infection rates in hospitals associated with the CLABSI metric, quality and regulatory organizations issued evidence-based interventions or “bundles” (including appropriate hand hygiene, maximal sterile barriers used during insertion, chlorhexidine skin antisepsis and prompt removal of unnecessary catheters).7,8 As a result, infection rates among patients with CVCs have decreased by 28% over the last five years.9 Despite this success, there remains today an unknown and a likely significant number of infections occurring not only in patients with CVCs but with other IV catheters. This poster attempts to provide relevant information emphasizing the need to establish the prevention of Hospital-Onset Bacteremia (HOB), an evolving and broad prevention concept that addresses all IV catheters10 and that may be advanced with use of evolutionary antimicrobial dressings.

MORE ON HOB: WHY ALL LINES MATTER 2021 will mark 20 years since the inception of the Institute for Healthcare Improvement’s (IHI) program to reduce CRBSI in ICU patients with central lines. Although later expanded to include patients on non-ICU wards, the initiative did not include

catheters other than CVCs. The scientific literature, however, provides extensive information on blood stream infections (BSIs) associated with many other types of IV catheters that are currently standard medical devices used in a wide variety of healthcare settings. Assessment of processes and practices related to IV insertion and maintenance indicates the need for implementation of a national and comprehensive strategy called HOB.11 This includes expansion of infection surveillance that focuses on capturing all IV catheters in all settings and institutes a standard of care that comprises scientifically supported interventions and novel technologies, forming the next level in the evolution of BSI prevention. The evidence for instituting HOB is extensive. Studies have associated arterial, dialysis, and peripherally inserted, and midline catheters with significant rates of BSI.12-15 In particular, infections associated with peripheral IV (PIV) catheters are the most underreported. PIV usage far exceeds that of CVCs and therefore accounts for an absolute infection rate that approaches the rate for CVCs.16

EVIDENCE HIGHLIGHTS • Hemodialysis: Risk of CRBSI exceeded 50% within 6 months of treatment • Peripherally Inserted Central Catheters: Analysis of 200 published studies reported a pooled BSI rate of 2.4%, equal to rate of other CVCs • PIV Catheters: Study indicated that 20.4% of all non-CLABSI events were related to PIV alone The authors of one study15 conclude with an insightful statement which provides impetus for the need to establish HOB programs: “Since almost all the national effort and progress to date to reduce the risk of IV device-related infection have focused on short-term noncuffed CVCs used in Intensive Care Units, infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IV devices."

CRBSIS AND ANTISEPSIS Protecting the skin is a critical factor in preventing infections originating at IV puncture sites. The most common mechanism by which CRBSIs occur is via an extraluminal route, resulting from translocation of bacteria from the patient’s skin flora, as transient bacteria, via the hands of caregivers, or because of breaks in techniques during maintenance. This problem is compounded

THE IMPACT OF CLABSIs, WHICH REPRESENT ONLY A FRACTION OF CRBSIs, IS CONCERNING. THE CDC ESTIMATES THAT CLABSIs: • • • •

Develop in nearly 250,000 hospitalized patients per year in the US Increase mortality rates by 15%–25% Increase length of stay by 5 days, from 9.6 to 14.3 days4 Impose considerable economic impact for healthcare facilities, such as: - Annual attributable costs are estimated between $0.67 and $2.68 billion dollars5 - Current federal regulations specify no hospital reimbursement for these types of infections6 23

Figure 1. Free Base Chlorhexidine vs Chlorhexidine Salt Formulations

by rapid bacterial re-colonization that occurs within hours of application of a skin antiseptic at the time of catheter insertion. Microorganisms proceed to migrate from the catheter insertion point onto the catheter surface. Therefore, an important prevention strategy would be an intervention that enhances antisepsis at the catheter insertion area, including proper dressing of the insertion site. Ullman and colleagues described the principles of a central venous access device (CVAD) dressing to prevent associated complications as “…providing a barrier to microbial colonization and contamination ... [while] providing these functions using coating, adhesion, antimicrobial properties, absorbency, moisture vapor transmission…and maintaining visibility of the insertion site.”17

ANTIMICROBIAL POWER OF CHLORHEXIDINE One advancement in IV site protection was the introduction of antiseptic-impregnated coatings utilizing a chlorhexidine antimicrobial to protect the catheter site from bacterial proliferation. Chlorhexidine is a broadspectrum antiseptic effective against gram-positive and gram-negative bacteria, aerobic and anaerobic bacteria, and fungi.18 It is widely included in medical products that are used in procedures in health care settings for prevention of bacterial proliferation on the human body. The use of chlorhexidine on skin can prevent the transmission of organisms frequently associated with CRBSI, such as methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA).19 Chlorhexidine was introduced in recent years as an additive on the surface of IV dressings to curtail the growth and subsequent introduction of microorganisms into the bloodstream. Among the most common chlorhexidineimpregnated products on the market today are semiocclusive dressings designed with a coating or with an antiseptic containing gel component on the dressing surface. Between 1998 and 2018, multiple meta-analyses confirmed the efficacy of CHG-containing dressings in reducing the incidence of catheter colonization and CRBSI.20-23 The various authors reviewed 20 randomized controlled trials (RCTs) and 2 quasiexperimental (before/after) studies that compared chlorhexidine-impregnated dressings with conventional (i.e. non-antimicrobial dressings) or no dressing. Although the studies often differed in such factors as inserter specialty, skin antiseptic, type of CVAD, insertion site, dressing changes, and colonization and infection definitions, the four meta-analyses indicated that most studies demonstrated a significant protective effect when CHG-impregnated dressings were used: 1.2% CRBSI rate in CHG group versus 2.3% in control group,20 1.3% vs. 2.5%,21 15.2% vs, 26.3%,22 2.0% vs 3.2%.23 24

NOT ALL CHLORHEXIDINE FORMULATIONS ARE EQUAL However, not all formulations of chlorhexidine are the same. Early research showed that pure chlorhexidine (also known as free base chlorhexidine) had poor solubility characteristics, thus limiting its role as an antiseptic in health care products at the time. In response, industrial scientists developed various chlorhexidine salt formulations including chlorhexidine gluconate (CHG) and chlorhexidine acetate (CHA), compounds which improved antiseptic solubility. However, this salt formulation strategy reduced chemical availability of the chlorhexidine molecule itself. With the advent of new and emerging polymer materials and manufacturing techniques, it has recently become possible for industrial chemists and engineers to develop medical device materials which utilize the full antimicrobial power of chlorhexidine free base. This includes a novel free base chlorhexidine (CHX) IV dressing. A 2020 study published in the Journal of Wound Care examined the in vitro antimicrobial effects of a chlorhexidine diacetate (CHA) and silver salt-based antimicrobial dressing against a novel CHX dressing.24 Two findings in this study are significant. First, the CHX dressing demonstrated a superior in vitro antimicrobial effect at 67% of the experimental time points compared to the CHA dressing, with at least equivalent efficacy at all other testing time points. The antimicrobial effect of the CHX dressing was also determined to be more rapid than the CHA dressing, particularly at the 1-day time point. The CHX dressing achieved a >5.0 log10 reduction at the 7-day period against 11 of the 12 test organisms, whereas the CHA dressing demonstrated such reduction in only 7 test organisms. This finding suggests that a dressing using CHX technology may provide enhanced protection against microorganism over-growth over the recommended 7-day in vivo lifespan of IV dressings. This is supported by the finding that the CHX dressing demonstrated significant log10 reductions versus the CHA dressing across most time points among organisms noted to be frequent pathogens associated with CRBSI, namely Methicillin-

resistant Staphylococcus aureus (MRSA), Enterococcus faecium, and Candida species. Second, when it comes to chlorhexidine content, more does not necessarily translate to a higher level of microbial kill. Manufacturer information indicates that the CHX polymer film has a chlorhexidine concentration of 0.27mg/cm,2 while the CHA adhesive film contains 0.42mg/cm2 chlorhexidine salt; this corresponds to a 36% greater chlorhexidine mole content in the salt. Yet, the lower chlorhexidine concentration product achieved a higher antimicrobial activity due to the chemical availability of the antiseptic. The chlorhexidine molecules within the adhesive in the conventional CHA dressing are ionically bound to acetate anions which limits the available concentration of chemically unhindered chlorhexidine molecules at any given time. Furthermore, the CHA dressing also included silver salts as well as a cationic triarylmethane dye which may moderate chlorhexidine release and therefore affect the overall antimicrobial performance. In contrast, the adhesive in the CHX dressing does not contain any additional chemical components. For these reasons, the proportion of unbound and chemically available antimicrobial chlorhexidine molecules is generally expected to be significantly higher in a CHX-based dressing than in a CHAbased dressing of similar design.

CONCLUSION Despite the implementation of CLABSI bundles over the last 20 years, CRBSI prevention efforts require new approaches. Strong evidence supports the need to focus these efforts on the prevention of Hospital Onset Bacteremia in order to reduce infections associated with all IV catheters. The next generation of IV dressings may significantly contribute to a new standard in the evolution of CRBSI prevention. The emerging technology of CHX IV dressings provide edge-toedge broad-spectrum antimicrobial effectiveness over the recommended lifespan of all IV dressings and enable insertion site visualization with transparent film material—all while utilizing chlorhexidine at lower overall concentrations.

Figure 2. In Vitro Kill Time Comparison Data*

*Note: In vitro effectiveness does not predict clinical performance. (GLP Testing Conducted at Independent Third Party Laboratory, Data on File: entrotech life sciences inc., San Francisco CA.

REFERENCES 1. Centers for Disease Control and Prevention. Guideline for the prevention of intravascular catheter-related bloodstream infections, 2011. Available at: https://www.cdc.gov/infectioncontrol/pdf/ guidelines/bsi-guidelines-H.pdf. 2. Hadaway L. Short peripheral intravenous catheters and infections. J Infusion nursing 2012;35:230-40. 3. National Healthcare Safety Network. Surveillance reporting for enrolled facilities. Available at: https://www.cdc.gov/nhsn/enrolledfacilities/index.html. 4. Siempos II, Kopterides P, Tsangaris I, Dimopoulou I, Armaganidis AE. Impact of catheter-related bloodstream infections on the mortality of critically ill patients: a meta-analysis. Crit Care Med 2009:372283-9. 5. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion. CDC 2009. Available at https:// www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. 6. Centers for Medicaid and Medicare. Hospital-Acquired Condition (HAC) Reduction Program. Available at: https://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ Value-Based-Programs/HAC/Hospital-Acquired-Conditions. 7. Institute for Healthcare Improvement. How-to Guide: Prevent Central Line-Associated Bloodstream Infection. Available at: http://www.ihi. org/resources/Pages/Tools/ HowtoGuidePreventCentralLineAssociatedBloodstreamInfection. aspx. 8. The Society for Healthcare Epidemiology. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals 2008. Available at: https://www.cambridge.org/ core/journals/infection-control-and-hospital-epidemiology/ article/strategies-to-prevent-central-lineassociated-bloodstreaminfections-in-acute-care-hospitals/1C0BF449E20018CF480BA D419BEF0532. 9. Centers for Disease Control and Prevention. Current HAI Progress Report: 2019 National and State Healthcare-Associated Infections Progress Report. Available at: https://www.cdc.gov/hai/data/ portal/progress-report.html. 10. Dante RB, Abbo LM, Anderson D, et al. Hospital epidemiologist’s and infection preventionist’s opinions regarding hospital-onset bacteremia and fungemia as a potential healthcare-associated infection metric. Infect Control Hosp Epidemiol. 2019;40(5): 11. Rock C, Thom KA, Harris AD, et al. A multicenter longitudinal study of hospital-onset bacteremia: a time for a new quality outcome measure? Infect Control Hosp Epidemiol. 2016;37(2):143-48. 12. O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of bloodstream infection: a systematic review and metaanalysis. Crit Care Med 2014;42(6):1334-39. 13. Shingarev R, Barker-Finkel J, Allon M. Natural history of tunneled dialysis catheters placed for hemodialysis initiation. J Vasc Interv Radiol. 2013;24(9):1289-94. 14. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81(9):1159-71. 15. Chopra V, Kaatz S, Swaminathan L, et al. Variation in use and outcomes related to midline catheters: results from a multicentre pilot study. BMI Qual Saf. 2019;28(9):714-20. 16. Zhang L, Cao S, Marsh N, et al. Infection risks associated with peripheral vascular devices. J Infect Prev. 2016;17(5):207-13. 17. Ullman AJ, Cooke M, Rickard CM. Examining the role of securement and dressing products to prevent central venous access device failure: a narrative review. J Assoc Vasc Access. 2015;20(2):99-110. 18. Karpanen TJ, Casey AL, Conway BR, Lambert PA, Elliott TSJ. Antimicrobial activity of a chlorhexidine intravascular catheter site gel dressing. J Antimicrob Chemother. 2011;66(8):1777-84. 19. Climo MW, Yokoe , DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Eng J Med 2013;368(6): 533-42. 20. Safdar N, O’Horo JC, Ghufran A, et al. Chlorhexidineimpregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit care Med. 2014;42(7):1703-13. 21. Wang HX, Xie SY, Wang H, Chu HK. The effects of chlorhexidine dressing on health care-associated infection in hospitalized patients: a meta-analysis. Iran J Public Health. 2019;48(5):796-807. 22. Wei L, Li Y, Li X, Bian L, Wen Z, Li M. Chlorhexidine-impregnated dressing for the prophylaxis of central venous catheter-related complications: a systematic review and meta-analysis. BMC Infect Dis. 2019;19(1):429-54. 23. Puig-Asensio M, Marra AR, Childs CA, Kukla ME, Perencevich EN, Schweizer ML. Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol. 2020;41(12):1388-1395. 24. Holinga GJ, McGuire JE. In vitro antimicrobial effects of chlorhexidine diacetate versus chlorhexidine free base dressings. J Wound Care. 2020;29(Sup5a):S22-S28.

Intravascular Quarterly | IQ | Special Edition 2022 (1)

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VACC JUNE 2022 IMPORTANT DATES

A CAUSAL-COMPARATIVE EXAMINATION OF CLABSI, VASCULAR ACCESS TEAMS AND HOSPITAL TYPES

YEARS AND COUNTING

PRESIDENT'S MESSAGE

PARTNERSHIPS DRIVE PATIENT SAFETY EVEN IN THE MOST CHALLENGING TIMES

THE GREAT RESIGNATION: MITIGATE WITH CONTINUING EDUCATION AND COMMUNITY

THE FROEDTERT HOSPITAL VASCULAR ACCESS TEAM