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

“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. 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

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

“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.” “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.