Global Disclaimer: The views and opinions expressed in the Intervascular Quarterly Newsletter are those of the authors and do not necessarily reflect the official policies or positions of the Association for Vascular Access (AVA) or any of its leaders, volunteers, employees, committees, networks or other groups associated with AVA. For information on this publication, please email
GulfVAN is thrilled to be advancing peripheral intravenous insertion practices by offering TWO courses in October. The first course is an Ultrasound Guided Peripheral IV Workshop sponsored by PICC Excellence and Parker Laboratories. The second course is a Peripheral IV Insertion Workshop sponsored by Infusion Knowledge. Both four-hour classes will be held simultaneously on Saturday, October 26th from 9am-1pm at St. Joseph’s Hospital in Tampa, Florida. Seating is limited and all are welcome. Join us!
For more information, please visit us at: https://gulfvan.wildapricot.org
CLINICAL EDUCATION SPECIALIST
AVA’s Clinical Practice Guidelines (CPG) are making significant progress. We would like to acknowledge and express our gratitude to Solventum for providing the AVA Foundation with a grant to assist in this process. This work would not be possible without the generous support of our benefactors.
The D-Team and AVA Staff are diligently working to deliver an exciting, engaging, and educational scientific meeting in September. If you have not registered yet, we encourage you not to delay. You will not want to miss this event. Meanwhile, please visit the AVA website to catch up on any educational events you may have missed. In July, the education department kept busy by organizing 2 IV League events, a patient perspective podcast, and a webinar on tissue adhesive
Make sure to check the AVA calendar for upcoming events that your local network leaders are working hard to bring to you.
Congratulations to all those who obtained their VA-BC certification in the June testing. We see and appreciate your hard work and dedication. For those who are planning to take the test in December, Infusion Knowledge and AVA have once again partnered to offer a VA-BC preparation bundle. Use discount code avaweb10 until August 31st to get a 10% discount.
MICHELLE L. HAWES, DNP, CRNI, VA-BC, ACRP-CP CPG EDITOR-IN-CHIEF & DEVELOPMENT LEAD
Since the last CPG update in May, the section members have been working hard to assess the full-text articles from the latest search and a few missing articles from the first search. The volunteers have assessed thousands of articles since the beginning of this process, and two sections, “Assessment” and “Administrative,” are preparing to write their guidelines based on the evidence discovered.
The goal is to have these first two sections publish their guidelines in the first quarter of 2025. “Pre-Insertion” and “Device” sections are scheduled to be published in the third quarter of 2025. The sections dealing with “Insertion” and “Complications” will aim for the first quarter of 2026. With luck, this may go faster than the plan, but this is what I know as of this issue of Intravascular Quarterly.
Thank you to all the CPG Leaders and Volunteers who have given their passion for the patient, time, and expertise to this important project.
As always, please email Mickey with any questions. javaeditor@avainfo.org
The Association for Vascular Access (AVA) is excited to announce that Nancy Trick, RN, CRNI, VA-BC™, has been awarded the Suzanne LaVere Herbst Award for Excellence in Vascular Access for 2024. This prestigious accolade is the highest honor awarded by AVA, recognizing exceptional achievements in the field of vascular access.
Nancy has been a passionate advocate for enhancing vascular access care and promoting the specialty of vascular access. Her extensive experience includes educational presentations for nurses, physicians, and other healthcare professionals, as well as contributions to peer-reviewed publications. Nancy’s efforts extend globally as she provides education, training, and mentorship through her roles with medical device manufacturers and her consulting business.
Nancy is a key figure in the development of the Vessel Health and Preservation (VHP) textbook. Her work on the first edition, published in 2019, and her contributions to the upcoming second edition, scheduled for release in October 2024, highlight her ongoing influence in the vascular access community. Her dedication to patient care and clinical education is evident in every aspect of her work.
In addition to her regional contributions to AVA, she has served on international committees such as the Nominations Committee and the Policy Committee, and currently serves on the Board Development Commission, exemplifying her dedication to AVA’s mission. As a board-certified specialist, Nancy has been active in numerous professional capacities. She has served as an item writer for the initial VACC exam and chaired the INS Standards of Practice committee in 2000.
In addition to her work with VHP, her unwavering commitment to patient care and clinical education is further demonstrated through her continuous involvement in AVA’s clinical review team. Nancy’s Global impact can be seen in vascular access education in her role as a key opinion leader as she provides guidance across the world. She has also developed a college-level course on nursing leadership in the medical device industry at Purdue Global University and recently presented on clinical marketing at an alternative high school career day. Please join us in congratulating Nancy Trick on this well-deserved honor and for her extraordinary contributions to advancing the field of vascular access.
Sincere Congratulations, Nancy!
Click here to learn more about this prestigious award and past recipients.
September
Pre-Meeting:
At an AVA Scientific Meeting (AVASM) many years ago I referred to the Expo Hall as “Disney World for IV Geeks”. One of the best parts of going to an AVASM is going to the Expo Hall to see all the options available to solve clinician and patient problems. It is my hope that IQ can offer a small part of the Expo Hall with each issue.
Expo Corner will make available a forum for manufacturers to tell their stories about their products. A clinician’s or patient’s experience in real life. How did your product help them? Branded pictures are acceptable. Early research results are welcome. There will be a disclaimer that AVA is not endorsing the claims. Your advertorial will be highlighted in the issue.
Expo Corner is a chance for readers to experience a small corner of the Expo Hall. Submissions should be 750-1500 words, first person, de-identified pictures, references (if needed) in AMA format, no more than 5 references. QR codes are acceptable for more information.
Let me know if I can help, Mickey javaeditor@avainfo.org
For advertorial information and cost contact: Melissa melissalmurphy@gmail.com
Peripheral intravenous access catheter failure is ubiquitous in bedside care. We have become numb to the fact that up to 50% of these catheters fail.1 Executive leadership, including nursing and finance, often do not recognize the burden of poor peripheral intravenous catheter (PIVC) care on the facility, nursing staff, and patients. In 2018, Dr. Randall Jones published cost modeling that considered a comprehensive list of failures and complications. It was estimated that for every 10,000 catheters used, nearly $500,000 was wasted on failed devices and complications.2 For every 100 hospital beds, approximately 30,000 catheters are used per year.3 Translating this to a small 100-bed hospital means that the facility generates about $1.5M in annual waste from preventable complications and failed devices. Something must change!
Many in vascular access suggest that vascular access teams are the solution. However, being on a vascular access team does not prevent one from making poor decisions at the time of insertion. Regardless of whether the inserter is on a vascular access team or a bedside generalist, the inserter who understands how to optimize vein selection, site selection, and device selection for PIVC insertion will achieve the best outcomes. I have worked on multiple vascular access teams, started several, and observed hundreds of vascular access clinicians at the bedside placing lines. The knowledge deficit is consistent across facilities—small, medium, or large; with or without vascular access teams; and from simple community hospitals to prestigious university hospitals. I took a job on a large, well-known vascular access team that covered 24 hours a day, seven days a week, and had over 60 clinicians. I was truly honored and excited about the opportunity. The team had recently formalized peripheral IV catheter insertion with ultrasound and required new employees to attend training before using ultrasound to place devices. I thought this was great. I had been placing PIVCs with ultrasound for around ten years and knew the struggles of learning this skill without formal training. I was instructed to call the ultrasound trainer if I encountered difficult venous access, and the trainer would bring an ultrasound to facilitate training.
I went to place a PIVC for an obese patient who had been there for two days and was expected to stay for another three days receiving multiple antibiotics. Upon assessing the patient for an appropriate site, I found no suitable veins—only a couple of tiny, superficial, non-palpable veins in her shoulder. The patient had two failed devices in the first two days of admission and was going to be on antibiotics for three more days. Normally, I would have used my ultrasound to find a nice cephalic forearm vein and place a long catheter. Unfortunately, the current policy at my new facility did not allow that. So, I called the ultrasound trainer.
Another nurse showed up without the ultrasound. I asked, “Where’s the ultrasound?” The backup nurse responded, “I can usually get the lines without ultrasound.” I observed, curious about where this inserter would place the device. After witnessing the clinician place the device in the non-palpable shoulder vein, I replied, “If I wanted to place a line that was going to fail tomorrow, I would have done it myself,” and walked away.
Just because your hospital has a vascular access team doesn’t mean your patients are receiving optimal vascular access. Too often, even when a clinician can recite the standards of practice (SOP) regarding the best vein and site for PIVC placement, the application of the SOP is lacking. I have heard clinicians say, “We just do not have time to place every PIVC with ultrasound.” I would agree since the inserters place PIVCs every day on the same patient. However, if the catheter was placed optimally the first time and remained in place until discharge, the workload would be a quarter of the current demand. We would have much more time to incorporate ultrasound into more procedures. In this situation, the clinicians are not aligned in the process of optimizing PIVC placement. To optimize outcomes, we must make the effort to optimize the insertion not just place a device suboptimal just to hurry and go to the next patient.
In another situation, I asked a well-educated vascular access specialist from a combination vascular access and rapid response team to participate in a simple exercise. I expressed that we consistently place PIVCs in veins that are too small. We have good evidence indicating that the vein should be approximately three times the size of the catheter.4,5 I asked the clinician to assess the vein with ultrasound before placing a 20-gauge PIVC for the next three insertions. The 20-gauge catheter, which is 1.1 mm in diameter, would need a vein slightly larger than 3 mm in diameter to optimize the insertion to decrease the risk of failure and complications.
Figure 1:
Three examples of veins used for 20-gauge PIVCs. Non-palpable veins depicted in white.
In Figure 1, we see a forearm vein with a faint blue shadow, which is difficult to see. When the clinician scanned the veins, the diameters were 1.5 mm, 1.2 mm, and 0.9 mm. These veins are nowhere close to being appropriate for the infusion workhorse, the 20-gauge PIVC. The craziest part is that the clinician had the skill to place a catheter that was larger than the vein in which it was placed.
The current SOP tells us to use the largest vein and the smallest catheter appropriate for the prescribed therapy. 6 This is vague and not prescriptive. However, by using the most recent evidence, we know we need a vein three times the catheter diameter. Applying this to day-to-day
bedside practice is difficult. A large majority of PIVCs are started by generalists, who have two ways to identify an appropriate vein: visibility and palpability. Relying on visibility often leads to choosing veins much too small for a hospitalized patient expected to stay four to five days. These are the vein whisperers—those clinicians who can place a device in a rock! Such inserters often use veins like those noted in Figure 1. While the immediate issue of no access is solved, it perpetuates failed devices, unnecessary complications and repeat insertions. Palpation is key for traditional PIVC insertions to obtain a vein of adequate size. If there is no bounce to the vein, it is likely less than three times the catheter size.
How do we break the cycle?
We must change the culture of PIVC insertions. The first call to action is to stop requiring each inserter to stick the patient twice before asking for help. The Infusion Nurses Society standards of practice state that each nurse has two opportunities to stick the patient before escalating.6 However, this is not a requirement. If the inserter is not confident in successfully placing a device, they should not attempt placement. Venous access varies greatly among patients, and inserter skill levels vary widely. It is difficult to train every inserter for the most challenging venous access cases. Inserters should be encouraged not to stick the patient when their confidence is low, and no palpable vein is found. Assuming that competency on a rubber arm in a lab translates to readiness for all patients is harmful, increases hospital costs, and exhausts staff with repeat PIVC insertions and managing complications.
Competency is an arbitrary status. Once taken through the education process, the inserter is considered competent whether their insertion success rate is say 50% or 98%. However, this vastly different experience impacts patients and workflow. For the patient, optimal care means a PIVC placed with one stick on admission that remains in place for the entire hospitalization. This is the true measure of competency. Mielke et al. published a study showing that using a standardized approach to optimize PIVC placement can achieve over a 91% first-stick success rate, with a 94% likelihood the catheter will remain in place for the entire hospitalization. 7 A key component of this approach is empowering inserters not to place suboptimal devices. If the device is in an area of flexion, such as the hand or wrist, or if the vein is not palpable, the inserter can escalate the procedure to a higher skill level. These stops repeated and unnecessary insertion attempts that historically end in failure.
Another component is that every inserter uses an algorithmic approach to placing the PIVC. Standardizing decisions at the time of insertion is crucial. Bahl et al. published a study showing a 92% likelihood that a PIVC placed in the ED for difficult venous access patients remained in place until discharge. 8 This approach can significantly reduce waste and enhance the patient’s experience.
When considering competency, shouldn’t we have a quantifiable way to determine if an inserter is competent? I do not consider someone with a 50% success rate truly competent, but this seems to be the trend. 9 We would not allow this for medication administration. Medication errors are reportable events and can harm patients much like PIVC failed insertions. Nurses who continue to make mistakes are likely to be terminated. To break the cycle of PIVC failure, we must approach education and training differently. The exception to the rule should be placing a suboptimal device, not the standard of care. Competency should be redefined, and the culture should shift from “Stick’em again” to “Let’s use one catheter!” If we are not achieving this, we must figure out why we are failing. As vascular access leaders in hospitals, vascular access teams have work to do within their own teams and with other hospital inserters. Who else has the knowledge and skill to support PIVC insertion in the hospital? While it is difficult for vascular access teams to place every PIVC, they can certainly advocate for change and education.
Watch for the next two articles focusing on site selection and catheter selection.
1. Helm RE, Klausner JD, Klemperer JD, et al. Accepted but unacceptable: peripheral IV catheter failure. Journal of Infusion Nursing. May-Jun 2015;38(3):189-203. doi:10.1097/NAN.0000000000000100
2. Jones RK. Short peripheral catheter quality and economics: the intravenous quotient. Journal of Infusion Nursing. 2018;41(6):365-371. doi:10.1097/NAN.0000000000000303
3. Unknown. PIV catheter manufacturer’s Implementation estimate.
4. Tanabe H, Takahashi T, Murayama R, et al. Using ultrasonography for vessel diameter assessment to prevent infiltration. Journal of Infusion Nursing. 2016;39(2):105-111. doi:10.1097/NAN.0000000000000159
5. Mielke N, Johnson S, Karabon P, et al. A prospective sonographic evaluation of peripheral intravenous catheter associated thrombophlebitis. The Journal of Vascular Access. 2021:1-10. doi:10.1177/1129729821100901
6. Nickel B, Gorski L, Kleidon T, et al. Infusion Therapy Standards of Practice. Journal of Infusion Nursing. 2024;47(1S):S1-S285. doi:10.1097/NAN.0000000000000532
7. Mielke N, Xing Y, Gibson SM, et al. Bridging the gap in traditional PIVC placement: an evaluation of operation STICK vascular access outcomes. Therapeutics and Clinical Risk Management. 2023;19:937-948. doi:10.2147/TCRM.S435628
8. Bahl A, Mielke N, Xing Y, et al. A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial. The Journal of Vascular Access. 2024:1-13. doi:10.1177/11297298231219776
9. Vadgaonkar A, Kothale N, Patil P, et al. Factors determining success and the cost of materials used in securing intravenous access in an emergency setting: A prospective observational study. International Emergency Nursing. 2023;71:1-5. doi:10.1016/j.ienj.2023.101338
We invite you to submit original manuscripts that may improve patient outcomes and our understanding of the vascular access specialists’ role in the healthcare system. Manuscripts could include:
• Clinical Practice
• Patient Education
• Clinician Education
• Promoting & Sustaining Change
• Vascular Access Research
• Legal perspectives
• Financial Considerations
• Anything to move AVA’s mission forward.
For complete instructions, go to Information for Authors at www.avajournal.com
If you would like some mentoring help, email AVAFoundation@avainfo.org. The AVA Foundation board can match you with free mentoring for AVA members on research and publication.
If you have general questions or don’t know where to start, contact the JAVA editor at: javaeditor@avainfo.org.
BY CRYSTAL KILLIAN OLEY FOUNDATION MEMBER
Why does a PIV make the central line access population cringe? While a PIVC is commonplace for the majority, for those living with a CVAD, it can increase fear and potentially increase the risk of infection. When determining care and administration of IV medications and therapy, it is important to explore the perspective of a patient living with a CVL to ensure the best possible outcomes.
In my personal experience, I encountered this type of scenario and would like to share how and why a PIVC can prompt fear for a CVAD patient. I was scheduled for a routine endoscopy without anesthesia. As per protocol, the anesthesiologist came in, and we reviewed the procedural plan and discussed any potential complications. Given my complex medical history, we also discussed emergency protocol in the event of a dystonic episode during the procedure. It is important to note that I also disclosed my CVAD-Port was accessed and available if there was an indication for intravenous (IV) medications, which it has been used for both at home and has been used for in that hospital.
After review, the anesthesiologist insisted a PIVC would need to be placed as she was not comfortable using my port. This plan immediately elicited concern…
Why the fear and concern? There are many factors that induce fear: outside of the fact that I am not the easiest stick, more times than not, the PIV infiltrates within minutes to hours.
In this case, it was my limited access concerns, coupled with the potential risk of infection and feeling as though I was not being heard when voicing my concerns.
Reluctantly, I prepared for the PIV placement as I needed the procedure. I watched as the anesthesiologist started with my right hand. She quickly decided she could not find a “good” vein, and she moved to my left hand. She chose a dorsal metacarpal vein, despite me telling her this often does not work unless you just want blood. She was dismissive and stated, “It looks good.” She proceeded to sanitize and insert the needle when “Oops, it is not working.” She then took the guide needle out, moved it up less than a centimeter, and inserted the same needle/catheter combination again.
Yes, I’ll repeat: She inserted the same needle in my hand two times and fed the catheter into my vein. I saw this and was speechless; it was already in before I could say a word. It flushed, so she was satisfied it was “okay,” and then she proceeded to put an occlusive dressing over it. Note: I have an adhesive allergy, and it is clearly noted in my chart. We reviewed my allergies prior to the PIV placement.
I questioned her as to why she did not get a new catheter after the first failed attempt; her response was, “Well, I did not insert it.”
At this point, I felt unheard and chose to wait until she was done, as I knew I was not going to be listened to. When the nurse came in, I asked what the hospital’s policy was for PIVC placement and if she could change the dressing to one I was not severely allergic to. The nurse was surprised by my request, and she asked me why there was a little blood close to my finger.
I explained that the anesthesiologist had failed at her first attempt, reused the same IV, and did not bother to wipe up the blood. The nurse could tell I was not happy and that I was knowledgeable that the hospital protocol was not followed. She asked me if I wanted a new PIV placed. I declined, and said I only wanted the dressing changed, please, as my veins need to be preserved, and we most likely will not need this one. I reiterated that even if we need IV access, my port is accessed. The potential for contamination has already been done; no need to damage my veins anymore. The nurse obliged and changed the dressing, being careful not to move the PIV.
When the nurse anesthetist and surgical resident came to get me, we confirmed the procedure, and no anesthesia was going to be used unless emergency/rescue medications were needed. I reviewed the standard of care for administering medication and reminded them, if it is needed, to scrub the needless connector with alcohol for at least 15 seconds and allow it to fully dry. They said that is protocol. Of course, we will.
I said, “Thank you.” I felt it was my due diligence to discuss protocol. All too often, the protocol is not followed, and corners or “seconds” are cut. The reality is my CVAD access is my lifeline. I live with the understanding that one misstep could leave me with life-threatening consequences.
Yet, in the hospital setting, I am met with resistance, dismissive actions, and a lack of empathy at times.
This is just one example of why a PIVC is something people living with central lines fear. It is because we fear further damage to our already limited access veins that protocols will not be followed and the incidence of possible increased risk of infection.
We fear not being heard and respected as the guardians of our line.
I am sharing this experience with you because PIVC is something that often leads to fear and anxiety for people. Not just people living with central line, but it is often something we dread more than most because we live with the knowledge of what multiple sticks are doing to our veins and the potential for contamination.
A PIV is usually not in place long enough for many people to even consider it an infection risk, or it is considered a very low risk. If there is any takeaway from reading this, I hope to start a conversation as a provider when you encounter a patient with a CVAD: Is the PIV necessary when someone already has vascular access?
BY EMILY HOOPES OLEY FOUNDATION MEMBER
When people ask me what I do, I tell them I’m a mom. My son was born with short bowel syndrome and dependent on parenteral nutrition for the first six years of his life. He later received an intestinal transplant. His early years gave me over 70,000 hours of hands-on experience with central and peripheral lines.
Vascular access is a topic I am passionate about. That is the reason my son needed a transplant. By age 5, he had lost so much access that we had a plan to withdraw care when the last line failed. I am grateful that, at age 15, he is still with us, but little has changed for him and others on nutrition support, so I share his story with those who will listen.
I know you are as passionate about this topic as I am and that if we can learn from each other, we can improve vascular access care.
I wish we could sit down together and talk about what it was like to raise a little boy who is dependent on parenteral nutrition. You don’t get to see our world, where TPN is hidden away in a backpack while we go about our lives. You don’t see us playing at the park, exploring new cities, hiking in the mountains, or riding roller coasters.
You see us in the hospital because things do go wrong when you attach a central line to an active little boy. There are dangers — like teething and itchy fingers at naptime, curious pets and distracted grandmas, seatbelt buckles and playground slides, and hundreds of other unexpected little threats. You see us when someone flushes too hard. You see us when short guts become leaky guts, and translocated bacteria cause infections. You see us when the locks that stop infections cause line clots. Most of the time, parenteral nutrition gave my son the chance to live his best life. The hospital saw him at his worst.
If we could sit down together, I would tell you how precarious things become when someone on TPN cannot use their central line. Our community calls these “lifelines.” That is because parenteral nutrition literally sustains life. Without it, my son would have starved. So when he didn’t have a line, establishing alternate access to maintain his blood sugar and hydration was critical.
Therefore, I’d want to help you understand that peripheral veins are not a limitless resource. We talk a lot about venous preservation with central access, but we don’t often discuss preserving peripheral access.
With approximately 60,000 miles of veins in the human body, it is easy to see a limitless resource. Like an earth covered in water where only 0.3% is drinkable, usable peripheral veins are few. Ideal veins are straight, non-branching, distal, large enough for a catheter, and usually found in hands and arms, legs and feet.
My son had even fewer of these preferred access points. Growing up with lines changed the shape of his veins. Some are corkscrews — others wind like rivers on a map.
If we were talking, I’d explain that this is why families like mine are picky about who we allow to attempt peripheral access. We can’t afford to spend veins on “just one try “ before calling in an expert. Every try costs veins, so we need to start with the person who’ll succeed on the first try. We need tools that improve the chances of success, too. Vascular visualization tools reveal tangled veins and help find the straight ones.
I’d share how my son could burn through veins in just days in the hospital. His nutrition needs would often require D10 and amino acids — vesicants. They’d tear through his veins and leak into surrounding tissues. It was a good day if he only lost one IV.
I’d describe how, after a few days, nurses struggled to find new veins. And how the need for labs and new IVs was relentless. I’d tell how I’d beg to conserve veins early by combining labs and IV placements or by collecting capillary blood samples, but hospital policies would stand in the way until veins became scarce, and then they’d relent — when it was already late.
I’d recount the night in the ICU during one longer stay when the peripheral veins did run out, how the nurse searched with ultrasound for half an hour before breaking the news with trembling voice.
I’d tell you that although my son has been off of nutrition support for nine years, he still has PTSD from being restrained over and over again — my teenage son has panic attacks at the mention of IVs.
I know because I’ve seen firsthand the compassion of nurses who place IVs. I know you hate to be the one causing this pain.
I wish I’d been more trauma-informed. Sometimes we’d hurry. We’d have other tasks to get. We’d want the fear to be quick. It helps to give time to prepare, understand, and allow even children autonomy over their bodies. Loss of control is at the root of trauma.
I’d like to communicate how it feels when, after living with a line at home, you aren’t allowed to help with IV care in the hospital. It’s like having a part of your body taken away from you — like being told you can’t care for your own mouth. Someone else will brush your teeth and feed you, except with higher stakes. We are trained and experienced perfectionists, so we see every shortcut and slip of aseptic technique.
I’d tell you how when I try to speak up, I am dismissed. I’m called mama bear, helicopter parent, overprotective, or high maintenance.
My voice is not enough. I cannot do this on my own.
This is why I am telling you. Nutrition support patients need vascular access to survive. We need you.
BY EMILY HOOPES OLEY FOUNDATION MEMBER
Have you ever driven during rush hour during a major freeway closure? Suddenly, every alternate route and surface street becomes backed up—not just the main roads, but every road. The side streets and alleys, too, become overwhelmed as rush hour traffic seeks other routes through the city.
For someone on parenteral nutrition support, losing a central line is like closing the freeway during rush hour. Alternate routes are needed, and because the need is so high, those alternate routes, in this case peripheral access, are overwhelmed.
My son was born with short gut syndrome. He couldn’t eat during the first six years of his life. All his nutrition and hydration came from parenteral nutrition, TPN. He had a central line, which my husband and I cared for. We carried his TPN and pumps in a backpack that stayed with him everywhere he went. That line kept him safe, fed, and at home.
We took TPN out into the wild with an active little boy. In the real world we encountered dangers like teething, and playground slides, and pets, and wagon wheels. We also discovered that leaky guts can cause sepsis, even when you do everything right. We learned that ethanol locks decreased these infections but also caused clots and brittle lines. Most of the time, my son’s central line was a miracle that offered him freedom and adventure. Every once in a while, things would fail, and we’d drop everything to run to the emergency department.
In the hospital, we were always acutely aware of my son’s peripheral veins. The need for IV nutrition support doesn’t disappear when a central line fails. If he couldn’t use his central line because it was infected, occluded, or broken, he’d need fluids through a peripheral IV to keep up his blood sugar and hydration. If he went more than a few days without a line, he’d need D10 and amino acids peripherally, but since these are vesicants that tore up his veins, leaking into surrounding tissues. Extravasation was a regular occurrence, and we’d sometimes lose several IVs in a single day.
Daily labs spent veins, too, especially if my requests for a vascular access specialist were dismissed, resulting in multiple failed sticks.
With approximately 60,000 miles of veins in the human body, peripheral veins can seem like a limitless resource. For the average person, the number of veins needed for labwork and PIVs in a hospital stay is nominal.
However, chronic vascular access needs strain this resource to its limits.
I will never forget one night when, after weeks of hospital admissions for recurring central line infections, I stood at my son’s bedside in the PICU as a vascular access nurse used ultrasound to search arms and legs covered with bruises from blown IVs for a vein. Her faltering voice as she told me she couldn’t place an IV that night is something I won’t forget.
Abundance sometimes leads to scarcity. When it seems you have money or time—or veins—to spare, it is easy to spend more carelessly. Vascular access doesn’t disappear overnight. It’s the result of many choices spread out across days or even weeks: a missed stick here, a lost IV there, a sample that didn’t have enough blood, and then one day, the veins are gone.
With IV nutrition support, every poke matters. Every vein matters. Running out of veins is cutting off food and water. It’s an unplanned fast—an instant personal famine.
Is it any wonder that our community is protective about access? I guard my son’s veins like a castaway guards his last book of matches.
It’s a problem of sustainability. When you want to keep a limited resource from running out, you plan for its conservation. Vascular access should begin with sustainability in mind.
Just like small things can cost access, I’ve found small things can save it. I no longer allow a nurse to “try just once” before calling in a specialist. We always start with the person most likely to succeed on the first try—even if it means driving out of our way, waiting for someone’s break to end, or hurting someone’s feelings.
Growing up with lines and IVs in your veins changes them. My son’s veins are a maze—they are corkscrews. They don’t run in straight lines. They are a mountain roadmap that you can’t navigate them blind. Vascular visualization tools—transilluminators, ultrasound — take the guesswork out of IV placement. Working without these tools is like working blindfolded. You might get lucky, but more often, the result is needless pain and a lot of misses and spent veins.
Conservation is planning ahead. It’s thinking to draw blood with IV placements. It’s knowing how much blood to draw the first time so you don’t redraw later. Conservation is changing routines. It’s saving non-critical tests until the next IV fails, using technology to draw from an existing PIV, or using capillary blood samples instead of venous ones. Conservation is prevention. It is meticulous care to avoid lost lines. It’s cleaning your hands, using proper aseptic technique, and scrubbing long enough every single time. Yes, I’m counting how long you scrub.
Nutrition support patients need advocates to protect and preserve vascular access.
I am not afraid to speak up to protect my son, but my voice can be dismissed. I am called a mama bear. Helicopter parent. Overprotective. High maintenance. Emotional.
Hospital policies treat me as unqualified. I am not licensed. However, I have over 70,000 hours of hands-on experience, and no one is more invested in standard-based, quality-of-life-focused care for my son than I am.
I need clinicians to hear me — to treat me as a partner and an equal. I need you to be as invested as I am in preserving vascular access from the moment we walk through your doors until we walk out of them.
We have a sustainability problem with nutrition support patients and peripheral access. Their veins are critical to survival. Peripheral access is not an infinite resource.
BY TONYA HENRY OLEY FOUNDATION MEMBER
How many of you have ever had an IV (intravenous) line? Do you know what someone says when they say, “we have to start an IV on you?” It just means they need an access to your veins, so medication can be given, or, blood drawn.
It should be fairly simple to do this. They clean the area, generally, somewhere on an arm. Next, a needle is inserted. The technician or nurse looks for the flash (blood) to know they have gotten it into the vein. The needle is removed, but the catheter part, stays. This allows for quick access for intravenous fluids, IV medications, and drawing blood.
If you are like most, you have had at least one or two, in your life. You might be that rare person who has not had any procedures/surgeries, or, never gets sick. In that case, you have not had the wonderful experience that I described above.
Good Veins Gone Bad
I used to be in the military. Back then, I had great veins. I even donated blood on multiple occasions. Hint: We did because we got the rest of the day off. It was easy, helped others, and as a bonus, I got to relax the rest of the day.
Nowadays, my veins are horrible. Being someone with chronic illness, has created multiple issues.
1. I lost lots of weight. My arms are tiny now and as such, it is hard for them to find a “good” vein.
2. I have a lot of scar tissue of the inside elbow from repetitive blood sticks/IVs. This is where they go to start most IVs/draw blood.
3. My veins also tend to roll. Technicians think they have a good vein. They stick, and…nothing.
4. Aside from rolling a lot, my veins blow easily. This leads to more bruising and sticks.
Recent Example
I was hospitalized for Staph bacteremia last year. I had a port due to my reliance on artificial intravenous nutrition (TPN), fluids and other IV medications. The first step was to get a peripheral IV started. Even though the port was there, they always start a secondary access point.
For me, that would be ok, but it is always so hard to get and keep one functioning. In this instance, I was being transferred from a stand-alone emergency room (ER) to a hospital for further work-up. We already knew I was being admitted. The stand-alone facility had an IV going, but it was removed for transport by ambulance, to the new facility.
I get to the admitting hospital’s ER and they attempt to start an IV. One nurse tried several times and failed to get one started. She calls for help. The next one does get a flash on the second attempt. It flushes well. Wohoo!!
A little while later, I am in my room upstairs. I am started on several IV antibiotics for suspected infection, but blood cultures are not back yet. It seems that all is well, until we run into a problem. The IV line is not doing well.
I notice that there is pain while medication is infusing. The nurse kept saying that some medications may burn and to see if it settles down. It does not. We remove the old, and try to restart a new IV. After several attempts, with the vein finder, two nurses on the floor did get another IV started.
The other, and most important, issue was that, every day after day 2, my IV lines would occlude (become blocked). There were two reasons for this: 1. I have a bleeding/clotting disorder. 2. One of the antibiotics was hard on IV lines (Daptomycin).
Because of the issues with the peripheral IV’s, they had to call in the PICC (Peripherally Inserted Central Catheter) team at least 2x every day for about 10 days!! The nurses could not get a line in. Even the PICC team had to use ultrasound guidance for an IV.
I did not like getting stuck multiple times a day. I truly felt like a guinea pig, or, a pin cushion. Even though we were using my port in the beginning, for some medications, they stopped that around day 4/5 as it was pointing to the source of infection. I needed good IV access, but the peripherals were not doing it.
The nurses could not effectively treat me because of this. The PICC team got tired of being called from ICU to my floor daily, to restart another IV. They finally got through to infectious disease. I was now getting a midline. That did the trick with the Daptomycin. No more occlusions!!! To top this off, I left for rehab, after 17 days, with a midline and a PICC line.
That whole ordeal left me saying things must change.
While hospitalized, I think the care team should have carefully checked the patient’s history: conditions, if they have a central line, problems with accessing IV’s in the past, etc. The care team should take what the patient says to heart. If told that you need ultrasound guidance, use it. Chronic illness patients know their bodies. Also, if there are issues with the peripheral intravenous lines, changing them out multiple times a day, may be doing more harm than good, for the patient. Pain of starting, and patient’s comfort need to be addressed. The Hippocratic Oath should be listened to here as well.
SUBMITTED BY: AMANDA COX
Situation Outpatient oncology infusion center with high rate of catheter declot procedures performed on infusaports.
Background The outpatient infusion center is in it’s own building and does not have easy access to the in house vascular access team located at the main campus. In the previous year, this unit averaged 57 ports accessed per day. Any nurse could administer a thrombolytic agent for line that does not have optimal blood return. Documentation was inconsistent, 151 administrations were recorded.
Assessment No protocol in place for assessment or alternate intervention of occluded lines. Patients at risk of unnecessary procedures, delay in treatment, and cost associated with declot intervention
Intervention
Outcomes
A “CVAD superuser” team was initiated and led by VA-BC nurse on the unit. This super user team includes eleven nurses who meet specific criteria and underwent training to ensure consistent and effective management of catheter-related issues. The team also implemented standardized documentation practices within EPIC to ensure consistent documentation was occurring for malfunctioning lines. While any RN on the unit can still access a port, if brisk blood return is not obtained, a CVAD superuser must assess the line following an algorithm created by team leader and CNS.
After 9 months, the efforts of the CVAD superuser team have already shown promising results, with 39 documented instances of successful intervention without the use of a thrombolytic agent. Of these, 17 lines were found to be malpositioned and 22 were able to be troubleshooted more thoroughly to secure patency.
Conclusions Based on the success of this team, my hospital has implemented CVAD superuser teams on several units throughout the hospital system. These teams help reduce calls to the Vascular Access Team, improve patient outcomes by minimizing treatment delays, reduce costs, and enhance staff efficiency and satisfaction.
These are short-format patient cases without the rigor of medical case studies. A Jot Form has been set up to allow you to fill in the blanks and submit easily. Case Stories follow a modified “SBAR” format. See the example below.
Action Include
Situation What are the basics?
Background What do we know about the situation? Objective information. Just the facts.
Assessment What is the problem? Subjective issues.
Intervention What did you do with the situation you were given? How did you collaborate with other healthcare professionals and the patient/caregivers?
Outcomes What happened?
Conclusions What now?
Example
48 yoa Male with a history of injectable drug use requires 6 weeks of intravenous antibiotics.
The patient was diagnosed with osteomyelitis after a right knee replacement. The order is to discharge the patient to an ambulatory infusion center for oncea-day infusions, inserting and removing the vascular access each day. Ultrasound of the patient’s peripheral vasculature reveals inadequate size and flow for repeated insertions. However, the patient’s upper arms have sufficient venous health for access.
The patient has been sober for 2 years and has good family support and mental health assistance. Punishing the patient with unrealistic and unethical repeated venipuncture will cause additional trauma and possible noncompliance.
A plan was developed after discussions with the patient, family, behavioral health, ambulatory care, and the physician ordering the antibiotic. A PICC was placed with tamper-evident technology applied. A contract delineating rights and responsibilities was signed. The patient was set up to report to ambulatory care once daily for the remainder of his infusion therapy.
The patient successfully finished his antibiotics with one PICC. There was no evidence of tampering with the device, and random urine drug screens were negative.
Based on the success of this case, my hospital is moving forward with developing a program to help other patients with a history of injectable drug use.
Your case story should follow the Jot Form. If needed, use no more than 5 references in AMA format. Include non-branded and de-identified information. You must include your name but do not mention your specific hospital. For example, you can say “a rural hospital in the Midwest” or “a teaching hospital in Canada.”
You may leave your contact email if it is NOT your hospital email.
For any questions or concerns, please contact Mickey at javaeditor@avainfo.org
BY MICHELLE DEVRIES, MPH, CIC, VA-BC, CPHQ, FAPIC
At the intersection of vascular access and infection prevention, we have watched over the last decade of publicly reported healthcare associated infections and had many questions. Without a doubt, the public awareness of outcomes including central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections, surgical site infections, Clostridiodes difficile and methicillin resistant staphylococcus aureus had positive impacts on increasing organizational focus on these significant patient safety issues. Combined with the financial ramifications in the federal reporting programs as well as private insurance structures hospital leadership aligned with making prevention of these outcomes a priority. As vascular access specialists (VAS) however, we have also witnessed some unintended consequences as facilities explored all the ways to reduce reporting of CLABSI, including less patient centric approaches that do not support vessel health and preservation but simply shift poor outcomes to devices that don’t “count” for public reporting.
Several years ago CDC began sharing information about a proposed forthcoming measure which would expand surveillance to include all hospital onset bacteremia and fungemia events, not just those associated with central venous catheters. This metric would capture bloodstream infections related to a much broader number of causes and extending far beyond just vascular access. Likely prevention efforts would need to explore relative contributions of urinary and respiratory sources, surgical and other wounds, transient bacteremias and vascular access devices beyond central venous catheters. While the timeline and adoption as a public reporting mandate remains undefined, CDC continues to share that the voluntary reporting system should be available for interested organizations toward the end of this year or early next year. Interested facilities can submit their contact information for infection prevention and information technology to NHSN to evaluate existing system readiness for this fully automated measure.
For vascular access, how does this proposed measure complement existing efforts? While it is not the same as mandating PIV and midline bloodstream infection reporting (in a manner parallel to CLABSI), those events will be captured within the data. In its current format (as a fully endorsed measure through Battelle), submission of the events will not include attribution of source (device, procedure or otherwise). Each organization’s patient population and device utilization practices will likely have a significant influence on what the biggest contributing factors are. It will take time to build the data and risk adjustment once reporting becomes available but even after that it will be up to the individual facility to identify the biggest risks and plan strategies to help reduce those risks. This is where vascular access specialists have an opportunity to help lead the discussion. Not all HOB events are going to be vascular access associated, but for those that are VAS can review opportunities regarding device selection, insertion, care/maintenance, complications and removal to reset focus on optimizing performance on all devices. Early work on HOB suggests that there are four times more non-CLABSI events compared to CLABSI but relative contributions of other vascular access devices appears significantly smaller than other sources of infection.1 Recent evaluation in NICU settings found that 52% of events occurred on a day that there was no CVC in situ, echoing opportunities for prevention beyond the current focus.2 Expanded VAS involvement into specimen collection and avoidance of blood culture contamination is another opportunity to impact reporting of HOB as well as CLABSI. Using a standardized framework for evaluating events is encouraged for enhance objectivity and consistency.3
So what, exactly, does this mean about PIVs? Is this our chance to elevate awareness and improve outcomes? From my foggy crystal ball I say absolutely yes but we need to be transparent. We
know from numerous earlier articles that Staphyloccous aureus is one of the most frequent pathogens associated with PIVs.4 An easy starting point for conversations is looking at the historic data already reported to CMS on LabID events with Methicillin resistant S. aureus. You can review the EMR to explore whether there may have been opportunities with the number or quality of peripheral IVs the patient experienced leading up to that event - looking at number of attempts, anatomical site, skin preparation, securement and site protection as well as any details on dwell time and repeated failures. Reviewing a subset (depending on the volume of cases) of CLABSI cases that have been reported can also be an entry into the discussion of elevating peripheral IV practices. The surveillance definitions required for CLABSI reporting specify that a central line must be present the day of or day before the infection, there is no specific causation or attribution to that device in the definition. Looking back at the pattern of vascular access in the days or week prior may divulge a pattern of PIV practices worth exploring. Once your organization has enrolled in and begun submitting the voluntary reports through NHSN, ask to get involved with the drill down. For patients in whom another clear source of infection, has not been identified (ie, CAUTI, pneumonia, etc) the vascular access specialists can assist with further reviewing the vascular access experience of the patients to identifying remaining opportunities for risk reduction. Because the protocols won’t be determining device or procedure association through their requirements, institutions can review their own practices to identify likely contributing factors based on internal assessments. Highlighting repeated insertion attempts, serial failures and replacements along with review of complications and escalation due to vessel depletion are important considerations for the VAS to bring forward on the potential contributions for the overall HOB numbers. Partnering with infection prevention and microbiology to understand the implicated organisms can help further with prevention to illustrate the most likely sources (ie, skin, water, environmental) to continuing refining targeted prevention.
In conclusion, while HOB measures are not soley focused on vascular access related infections and by default will not specify which infections are associated with specific devices, including peripheral IVs, the metric will capture these infections. Vascular access specialists have the unique opportunity to help assess the existing and forthcoming data to highlight the relative contributions of peripheral IV related practices and how enhancing all aspects of the insertion and care of these devices may help reduce the overall patient and organizational impact.
1. Yu KC, Jung M, Ai C. Characteristics, costs, and outcomes associated with central-line-associated bloodstream infection and hospital-onset bacteremia and fungemia in US hospitals. Infect Control Hosp Epidemiol. Jul 10 2023:1-7. doi:10.1017/ice.2023.132
2. Prochaska EC, Xiao S, Colantuoni E, et al. Hospital-Onset Bacteremia Among Neonatal Intensive Care Unit Patients. JAMA Pediatrics. 2024;doi:10.1001/jamapediatrics.2024.1840
3. Schrank GM, Snyder GM, Leekha S. Hospital-onset bacteremia and fungemia: examining healthcareassociated infections prevention through a wider lens. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e198. doi:10.1017/ash.2023.486
4. Mermel LA. Short-term peripheral venous catheter–related bloodstream infections: a systematic review. Clinical Infectious Diseases. 2017;65(10):1757-1762.
Call for news, product evaluations, quality improvement initiatives, and patient stories.
IQ is a quarterly AVA Newsletter that serves our membership in a way that a peer-reviewed publication can’t. In this publication, our members can tell us how a product performs in the real world, let patients tell us about their side of the line, and share what our AVA Networks are up to.
IQ is a way for new authors to get started with publishing less formally. Submissions will require disclosures for product evaluations, patient permission to tell their stories, and references to support your statements. All IQ manuscripts are subject to scrutiny by the JAVA editor, and mentoring will be offered to help you be successful.
If you have questions or don’t know where to start, contact the JAVA editor @ javaeditor@avainfo.org.
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• Issue 4 (September): SPECIAL CONFERENCE ISSUE
• Issue 5 (November): 11/11/2024
The theme for this IQ is Vascular Access Resolutions. How will we, as AVA members, approach this new year? What goals do we have for our organization, practice, and ourselves? My hope is that more of our membership will dive into research and publication. A simple way to start is to submit your case stories or personal stories to IQ. To help you focus your writing consider which IQ you may be interested in.
NOVEMBER ISSUE: CENTRAL VENOUS ACCESS DEVICES (DUE 11/1/24)
• Neonatal to Geriatric
• HOB
• Training & Education
• Scope of practice
• Tip termination verification
• Specialized Teams
• Interprofessional collaboration
• Dressings & Securement
• Patient stories!
• All things good & bad related to CVADs.
Intravascular QUARTERLY
The Association for Vascular Access (AVA), in collaboration with The Clinician Exchange (TCX), launched a new, best-in-class learning management system tailored to aspiring and established vascular access clinicians.
Providing cutting edge training, critically-acclaimed presentations from scientific meetings, journal review courses and much more, AVA Academy is a groundbreaking initiative that advances the heart of AVA’s mission – Protect the Patient | Educate the Clinician | Save the Line. Academy curriculum is now available to the public, and to active AVA members at a discount.
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