May 2024 IQ

Intravascular QUARTERLY

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

NETWORK NEWS

President David Markle BSN, RN, VA-BC™

Treasurer Amanda Pierce BSN, RN, VA-BC™

Secretary Austin Green BSN, RN, VA-BC™

Presidential Advisor Meagan Capen, APRN, CPNP-AC, MSN, VABC™

FLAVAN began 2024 with a virtual presentation where we collaborated with GulfVAN, and CEPAVAN to offer Partnering with Patients: Promoting a Culture of Safety presented by Beth Gore, PhD and sponsored by The Oley Foundation.

FLAVAN hosted our 13th annual educational summit in Orlando, Florida at the Courtyard Orlando Lake Buena Vista in the Marriott Village, where we welcomed 67 attendees and 16 vendor partners.

Our day was filled with education, networking and learning about industry products. Educational topics included Making Vein Preservation a Priority presented by Paul Blackburn and sponsored by Avia Vascular, Vein vs Vein-The Best Practice Interactive Game Show presented by Maya Yearns and sponsored by our Silver Partner Access Vascular, Are Labeled PICC Sizes Sufficient for Accurate CVR Calculations presented by Skipper Irish and sponsored by our Silver partner Teleflex, The Quiet Epidemic of Venous Depletion and a Vision of a One-Stick Hospital Stay presented by Jon Bell and sponsored by our Gold partner BD, and Collaborative Approach to Increasing Throughput and Decreasing Length of Stay presented by Carla Dillard and sponsored by our Gold partner Dynamic Access.

Attendees enjoyed chair massages and had opportunities to win several door prizes including FLAVAN memberships and swag, many gift cards to local establishments and an AVA membership.

NETWORK NEWS

CENTEXVAN was proud to present our first full-day educational symposium since the pandemic on February 23, 2024 in San Marcos, Texas.

Approximately 60 members and guests joined us at the beautiful Holiday Inn conference center for this event with the theme: “What Lies Beneath.”

Featured speakers and topics included:

• ●Vance Clement on “An Ultrasonic Story: The Effect of External Forces on Peripheral Catheter Movement Inside the Vein.”

• ●Nyle Maissen, MD on “Eliminating Preventable Harm” with a pediatric focus.

• Amy Rissler on “Understanding, Preventing and Managing Catheter-Related Complications from the Inside Out.”

• Chris Cavanaugh on “Substance Use Disorder and Vascular Access.”

• Tim Spencer on “Special Ultrasound Techniques.”

Many thanks to our sponsors, who made the symposium possible!

• 3M

• Angiodynamics

• Avia Vascular

• BD

• ICU Medical

• Lineas Medical

• Rymed

• Sonosite

• Teleflex

WHO’S READY FOR A CONFERENCE???

TODD HESLEP, BSN, RN, PARAMEDIC, VA-BCTM D-TEAM CHAIR, AVA SCIENTIFIC MEETING 2024

Hello everyone, I am delighted to warmly welcome each of you as we eagerly anticipate the 38th Annual Scientific Meeting of the Association for Vascular Access in beautiful Denver, Colorado. This conference is a testament to our collective efforts, and I am honored to serve as the chair of the design team (D-Team). I want to express my gratitude to Kasey Wisemen (2023 D-Team Chair) for her invaluable mentorship. I also extend my thanks to the 12 other D-Team members and five staff members from AVA. Our committee, representing various areas within vascular access, has worked tirelessly to ensure a diverse and enriching conference experience.

Now for the exciting news! The AVA Leadership Team has shortened the conference to a three-day event. But don’t worry; this change comes with a silver lining. You will still have access to all the fantastic content at the in-person meeting and even catch up on the sessions you missed through the on-demand platform after the conference. As the chair of the team, I have carefully considered the feedback from the 2023 survey, and with the help of artificial intelligence, the D-Team is setting the course of this year’s conference to meet your expectations.

For the 2024 conference, we received over 150 submissions, each blinded and reviewed by three members of the D-Team. Then, on February 24, 2024, the team spent over eight hours on a Zoom call to begin filling in a fantastic conference schedule. With the conference shifting to a three-day format, our selection process was challenging, but we persevered and got it done.

As the chair, I have continued to refine the schedule to offer a balance of topics, hands-on experiences, workshops, and networking opportunities. All of this was done while trying to avoid placing competing topics/sessions in the same time slots. I often struggle to be able to attend multiple sessions in the same time slots. It will still happen this year but remember to highlight the MUST SEES and catch them on the on-demand platform.

I am thrilled to announce that we will offer a series of interactive, hands-on sessions during the conference. These sessions, included in your registration, will provide a unique opportunity for learning and networking. Please note that pre-selection is required as space is limited. Although the final plans are still being finalized, the sessions will likely cover various topics, including vascular access team development strategies, patient safety, and steps to starting a research project. These sessions will enhance your conference experience.

I cannot wait to attend the conference alongside you while taking in views of the Rocky Mountains from the Gaylord Rockies Resort & Convention Center. At the Gaylord Rockies Resort, you will have no reason to take an Uber, bus, train, taxi, or shuttle anywhere. Your needs will be met through their five restaurants, bars, an on-site world-class spa, and a state-of-the-art fitness center. However, if you stay an extra day or have some free time and decide to venture off, there is shopping at the Stanley Marketplace, Southlands, or 16th Street Mall, or you can follow your love of science to the Wings Over the Rockies Air & Space Museum or The Wild Animal Sanctuary.

Thank you to each attendee, as attendance at AVASM24 shows your dedication to this profession and, ultimately, your focus on achieving the best outcomes for the patients you serve. Also, with infinite words of appreciation, I thank the AVASM24 D-Team, members of AVA staff, and our industry partners. Without the countless paid and unpaid hours of all these individuals, this conference would not be the fantastic experience we all expected. Serving as this year’s D-Team Chair is a privilege and an honor. I will continue to work on providing ALL attendees with an excellent experience, and I cannot wait to see everyone in Denver. Please do not hesitate to stop and talk with me or any members of the D-Team during the conference. We will all wear D-Team ribbons on our name badges and a D-Team jacket. We offer countless hours of volunteerism for you, so please let us know if there is anything we can do to make your conference experience more enjoyable!

Thank you to each attendee for your unwavering dedication to the profession. As we count down the days to AVASM24, know that our collective efforts will undoubtedly contribute to an unforgettable experience. I look forward to seeing you all in Denver, ready to connect, learn, and make lasting memories.

EDUCATION UPDATE

TONI SOCHOR, BSN, RN, VA-BCTM AVA CLINICAL EDUCATION SPECIALIST

I would like to thank everyone for welcoming me into this amazing organization with open arms. I am so happy and grateful to be a part of the AVA education team. I have met so many brilliant hard-working people who want nothing but the best for the patient population. The education department is off to a great start this year. We welcome all suggestions on how we can better serve this community. Please don’t hesitate to reach out to us. Here is an overview of what we have done so far this year.

We have record numbers of enrollment in the VA-BC exam preparation study bundle from AVA and Infusion Knowledge Inc. We congratulate those sitting for the exam in June and wish you the best of luck.

This year, four additional schools have implemented the PIV curriculum for their nursing programs. This brings us to a total of 27. PIVs are the most common invasive procedure in healthcare and yet continue to be the most overlooked. Our goal is to get a comprehensive vascular access program into every nursing school to provide new nurses with evidence-based education. Please speak to any schools you have connections to about this free program. More information can be found here: https://www.avainfo.org/page/piveducation

Please visit AVA Academy for access to three fantastic new ISAVE that webinars that provide free CEs. Our next event will be on May 29th when Elena Nelson will be discussing Rapid Vascular Access. Registration will open on May 15th.

Join us on your favorite podcast platform for two new shows. In “The Cost of Coffee” we answer your most asked questions about the AVA annual scientific meeting. “Let’s talk TikTok” focuses on how we can use social media to better patient care and what our responsibilities are in that space.

We also have six new episodes of IV League learning available. These brief informal learning sessions continue to be every other Wednesday night at 7:30pm EST. Register at this link: https://www. avainfo.org/page/IVLeagueLearning.

REFLECTION: AVA FOUNDATION SCHOLARSHIP WINNER

JENNIFER BARTOWITZ, BSN, RN, VA-BCTM

My experience as an AVA Scholarship winner brought about many opportunities, but I’d love to highlight two for which I’m especially thankful.

The first was the invitation to serve as an Intern on the AVA Foundation Board, which has proven to be both eye-opening and awe-inspiring. My current focus in this role is to assist with the AVA Scholarship process this year. I hope to make the amazing scholarship experience even better for our future recipients.

The second opportunity was being inspired to begin a Quality Improvement project to improve pain management for IV insertions, which came about after attending an AVA presentation about this important topic. The QI project is now complete, and I am presenting the results at the INS Conference and submitting a poster for the AVA Conference, with the eventual hope of publishing the results formally.

The networking with other leaders during the AVA Conference, especially after AVA, has been priceless Thank you again to the AVA Foundation for the opportunity to be a scholarship recipient!

ANNUAL CANADIAN VASCULAR ACCESS ASSOCIATION CONFERENCE: PUTTING PATIENT-CENTRED CARE CENTRE STAGE

The 49th Annual CVAA Conference was held in Winnipeg, Manitoba, in the centre of Canada from April 24 – 26, 2024 and it was a great time to come together, share knowledge, learn from renowned speakers, experience cutting edge technology, and participate in hands-on Skills Labs. This year, CVAA was fortunate to have many Canadian and American experts in their field share with our delegates. Speakers included Jocelyn Hill, Karen Laforet, Mary Duncan, Mark Rowe, Nancy Moureau, Sarah Burns, Lori Kaczmarek, Karen Mueller, Christopher Picard, and many more.

Hot topics at this year’s conference included ultrasound guidance, considerations for home care settings, Aseptic Non-Touch Technique (ANTT®) and ports. One especially impactful session by Karen Mueller: Project Alena: Turning a Tragic Accident Into Passion For Change drove home the reason we all do this work: for the safety of our patients.

Our local CVAA Manitoba chapter welcomed the world to their province and shared local delicacies, including shmoo cake, and taught us all something about bison! The conference is always a valuable opportunity for far-flung members to reconnect and strengthen relationships and partnerships. Next year, CVAA is thrilled to host our 50th Annual CVAA Conference in beautiful Charlottetown, Prince Edward Island. This milestone event will be an incredible event, hosted by our vibrant CVAA PEI chapter. We encourage all to submit an abstract here in September 2024 and Save the Date for the conference: April 30 – May 2, 2025

NEW: IQ EXPO CORNER

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

THE STORM BEFORE DISCHARGE

LYNN DEUTSCH MSN, RN, CRNI, VA-BCTM

VASCULAR ACCESS

NURSE

Patients who are discharged with peripherally inserted central catheters (PICC) often are very stressed and anxious about how they are going to handle their infusions. The liaison from the infusion pharmacy was in the room when I knocked on the door to enter the patient’s room. A visitor in the room looked a little bewildered on the couch.

The patient was upset and overwhelmed with the information. The liaison had a colorful trifold with all the steps. She was trying to explain all the steps to disinfect the connector to his PICC. He had no idea what a PICC was and struggled with the information. He kept telling her he was overwhelmed and dyslexic. She ignored his plea about how he was overwhelmed and could not do his infusion at home by himself.

I politely interrupted and asked the liaison to let me insert the PICC. She agreed to leave and come back later. She left me a 12” extension to place on the PICC. The patient asked me to wait a minute as he needed to call his sister before I inserted the PICC. During the phone conversation, he told his sister, “I will pray, but I feel like I just can’t do this.”

The patient ended the phone conversation and looked at me, visibly upset. I asked him if he would like me to pray for him before I inserted the PICC, “Yes, please, I am just so overwhelmed with this whole thing.” I took his hand and prayed for him, asking God to heal his infection and to bless him. “Thank you so much, “he said.

Praying for him settled him down, and I was able to do the patient teaching about the procedure, showing him my arm and how the ultrasound machine would help me find his vein. He was afraid but seemed to trust me, so he calmed down.

I inserted the PICC, and after I cleaned up the procedure, he looked at me and said, “You are a blessing, but I don’t feel like I can handle this.” His visitor had stayed in the room and told him, “Well, between the two of us, we can.” “No, I can’t do this,” the patient retorted.

I told him I would be back after I charted the procedure.

I gathered the supplies he would need to administer his infusion and the hospital’s home care instruction sheet. I wrote the acronym SASH on the back, with the word behind each letter. I showed him how to disinfect his connector. I showed him how to flush with an extension set and a saline syringe. I let him demonstrate in front of me. He had to handle the parts so he could understand. He verbalized, “This is how I need to learn. I must see what I am doing visually.”

I told them I would check on him in the morning to answer any questions. When I went to his room in the morning, the home health nurse explained his homecare plan. He looked at me and said, “You were a Godsend to me yesterday. I think with my friend’s help, I can do it.”

I am lucky to work in a faith-based hospital. I look for God’s signs in the room, such as books, bibles, jewelry, or conversations with the patients and their families. Praying before an insertion shows you are aware of their spiritual need. It demonstrates you are connecting with the patient “in the moment.”

I saw this patient two weeks later when he returned for a revision surgery. He walked up to me at the nurse’s station and told me he was proud he could do his infusions at home. He thanked me for my care and concern, allaying any fears he had about his therapy. Hospital vascular access nurses or other disciplines who place lines for home infusion therapies have a significant role in preparing them mentally to go home. We must take the time to teach them more than just shower care and complications. Writing a simple handwritten chart with SASH and demonstrating the steps is what made a big difference for this patient and his successful transition home instead of a beautiful, busy, colorful trifold. The storm became calm!

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.

Visit our website: www.avainfo.org

@associationforvascularaccess www.facebook.com/associationforvascularaccess/

@ISaveThatLine: twitter.com/ISaveThatLine

@i-save-that-line: www.instagram.com/i-save-that-line/

Association For Vascular Access www.linkedin.com/company/association-for-vascularaccess/ Association For Vascular Access www.youtube.com/AssociationForVascularAccess

2024 SUBMISSION DATES ARE:

• Issue 3 (August): 8/1/2024

• Issue 4 (September): SPECIAL CONFERENCE ISSUE

• Issue 5 (November): 11/11/2024

2024 IQ THEMES & SUBMISSION OPTIONS

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.

AUGUST ISSUE: PERIPHERAL INTRAVASCULAR CATHETERS (PIVC) (DUE 8/1/24)

• Intravenous

• Arterial

• Skin Tone factors

• Pain control

• Vessel visualization options

• Neonatal to Geriatric

• All lengths 2cm – 20cm

• Dressings & Securement

• Hospital Onset Bacteremia (HOB)

• Assessment

• Patient stories!

• Training & Education

• Anything about PIVCs

Intravascular QUARTERLY

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.

WHAT IS MARSI?

LEE GORSCHBOTH RN, MHA, VA-BC

Scenario

Imagine yourself lying in a hospital bed. You feel tired, sick, and overwhelmed. Then, your healthcare provider comes in and tells you that you need a vascular access device (VAD) inserted to get better, and you will be going home with it. You then have a nurse come into your room with this big cart with a funny-looking television and a big pile of stuff in their arms. The nurse explained that they were the vascular access nurses and would be the people to place their VAD. The nurse continues to talk with you about your history and why you need the VAD, describes what a peripherally inserted central catheter (PICC) is, how it will be placed, and what is required from you. But all you hear is that it is a long tube that goes to your heart, and if something happens to it, you can die.

The PICC is successfully placed with no complications, and you now have a long tube hanging out of your upper arm with a pretty plastic tape, which they call a dressing, over it. Your shoulder is slightly sore, and the dressing and skin look good, but you want to go home. Before the nurse leaves the room, you are told that another nurse will meet you at home to show you how to use the VAD.

Finally, you are released to go home. Your family comes to the hospital and asks you what that thing is hanging out of your arm. You answer it is a PICC. Your family asks what you are supposed to do with it, and your answer is I don’t know, put medicine through it? You were told that some nurse is supposed to show up at the house when we get home.

You get a phone call from the home infusion nurse to schedule the visit as soon as you get home. You have a big box on your front porch from the home infusion pharmacy with a bunch of supplies and medicine. Your home infusion nurse shows up and describes to you and your family what all of the supplies are and what to do with the medicine. The nurse also tells the patient and family not to get it wet, not to tug on it, and gives them a long list of do’s and an even longer list of don’ts, then leave. You are on your own until the nurse returns in seven days.

It has been 4 weeks since the PICC was inserted, and everything has been going clockwork. Then, one day, you notice an itchy rash under your dressing. Tell your infusion nurse about it and make an appointment to see you in a few days. The nurse tells you to try a cold compress or antihistamines to control the itch. Nothing helps relieve the itching and burning. The rash is only under the dressing, but as soon as the dressing is removed, there are blisters, and the skin is broken in several places. Using cleaners on your skin hurts, and you don’t know what to do. You call your doctor, and their answer is to move the PICC to the other arm.

As a healthcare provider who inserts and supports patients who utilize VADs, I find the above scenario familiar. As a patient, being told you need a VAD placed can be very scary for patients and their families, and it becomes even more frightening to find out that they will be responsible for most of the care and maintenance of their VAD. Add in a complication, and having the VAD now becomes even more overwhelming. MARSI is an acronym that stands for Medical AdhesiveRelated Skin Injury. MARSI is one of the many complications that can occur, like in the scenario above. MARSI can happen to any patient who uses items requiring medical-grade skin adhesion. It can occur immediately upon contact or after an extended period of use.

BACSIG

BACSIG is AVA’s “Beyond Acute Care Special Interest Group,” we have been tasked with providing education and support to patients and caregivers who use and care for their VADs outside of the hospital setting. We also offer evidence-based information to the healthcare professionals who support patients and caregivers with VAD. These healthcare professionals can be in outpatient centers, long-term care facilities, sub-acute care facilities, skilled nursing care facilities, ambulatory care facilities, doctor’s offices, and patients’ homes.

This article will be the first in a series of articles published in the IQ Quarterly addressing the prevention and treatment of MARSI using the most up-to-date evidence-based research. There will be discussions of the different types of dressings available, skin care products and methods to promote healing, the various types of cleansing agents and how they play a role in MARSI, and others to come.

NAVIGATING SHOWERING WITH VASCULAR ACCESS DEVICES: ESSENTIAL TIPS FOR HOME CARE – A PATIENT PERSPECTIVE

EMILY LEVY, BA

The increasing use of vascular access devices (VADs), particularly PICCs, ports, and midlines, in patients transitioning to home care necessitates a renewed focus on proper showering techniques. Clear communication from clinicians is crucial for empowering both patients and caregivers to manage hygiene confidently at home while also ensuring the VAD remains dry and protected from water exposure.

Effective communication goes beyond simply providing instructions. It involves fostering open dialogue to address patient anxieties, delivering easy-to-understand showering instructions specific to VAD care, and sharing best practices gleaned from experience with other patients. This collaborative approach between clinicians, patients, and caregivers equips individuals with the knowledge to prevent complications, navigate daily routines confidently, and maintain a sense of normalcy and independence.

While shower protectors have come a long way, a 2022 survey by Mighty Well at their booth at the Association for Vascular Access Annual Scientific Meeting revealed a surprising trend: 9 out of 10 vascular access clinicians suggested DIY methods like trash bags or plastic wrap to patients with PICCs transitioning to home care1. This article aims to equip clinicians with better solutions to help these patients manage showering at home, ultimately reducing the risk of complications and infections.

The Association for Vascular Access (AVA) partnered with Mighty Well to create a valuable video series for patients as a part of the Ultimate Guide to PICCs series. In episode 3, “Ultimate Guide to PICCs, Ep. 3 - How to care for a PICC at home?”2 Maria Gomez, the video presenter, reminds patients of the importance of keeping their PICC dry while showering. She emphasizes this point with two key messages: “Never, ever submerge your PICC in water,” and “You can use a waterproof shower protector, like the H2O Shield from Mighty Well.” Maria also highlights the importance of properly covering any waterproof shower protector, stating, “Make sure to cover the entire PICC dressing when taking a shower or bath.”

Christina D., a patient diagnosed with Ehlers-Danlos syndrome (EDS), Chiari Malformation, Tethered Cord, and other conditions, has firsthand experience with vascular access devices (VADs), including having a PICC for 6 months. EDS comprises a range of genetic disorders affecting connective tissue, which serves as the body’s internal support system. This leads to hyperflexible joints and delicate, stretchy skin prone to injuries. Common EDS symptoms include joint pain, frequent dislocations, and slow wound healing due to skin fragility.3

Drawing from her personal journey, Christina shares valuable insights and practical tips for managing PICC lines, especially during showering. She emphasizes the importance of using PICC covers for daily protection and also discusses her own “overkill” method for showering, which has proven effective in safeguarding her PICC during showers.

While managing a PICC line at home, Christina discovered some valuable showering practices that weren’t initially communicated by her healthcare provider.

Here are her top 3 tips for minimizing water leakage and ensuring PICC safety:

1. Minimize Direct Water Contact: “Even if your arm is wrapped up and protected,” Christina says, “you don’t want to push your luck.” This means keeping your PICC line arm out of the direct stream of water whenever possible.

2. Utilize Shower Seating for Two-Handed Tasks: If a patient needs to use both hands while showering, such as while shampooing, Christina recommends sitting down. “A shower chair can be helpful,” she suggests. This allows you to keep your PICC out of the water flow while still performing necessary tasks.

3. Paper Towel Method (Optional): Christina describes a method that goes beyond standard PICC water protection. This involves using medical tape to secure folded paper towels above and below the waterproof shower protector on her arm. “By placing these paper towels,” she explains, “I use them as a final barrier but also give helpful feedback as to how effective or not a waterproof shower protector is! If water gets past the protector, it will dampen the paper towels, serving as a visual indicator of a potential leak.” While Christina’s paper towel method offers additional security, it’s important to discuss this technique with clinicians to ensure it’s suitable for a patient’s specific needs. Christina demonstrates the paper towel method she uses for added security while showering on her YouTube channel, “Christina Doherty, Living with EDS.” In the episode titled “Living with EDS: All About My PICC Line | FAQ. She also details other methods she employed, such as AquaGuard, plastic wrap, and paper tape.4

Christina’s experience underscores the importance of proper showering techniques for patients with vascular access devices (VADs) like PICC lines. VADs are susceptible to infection if they come into contact with moisture. To prevent this, patients have two main options for protecting their VADs during showering: disposable and reusable shower protectors.

Disposable protectors, typically made of thin sheets of plastic, offer a cost-effective solution per use. They are lightweight, portable, and require no post-shower cleaning – simply discard and replace. However, these benefits come with drawbacks. First, repeated disposal creates plastic waste, a concern for environmentally conscious patients and healthcare facilities. Second, disposable protectors often lack size variations, potentially leading to discomfort or an insecure fit that doesn’t fully cover the dressing, which Christina expressed has been her experience. This can be particularly problematic for patients who need to use a PICC line for a long period, as they may end up needing to replace ill-fitting protectors frequently, negating the initial cost savings. Disposable options tend to be easiest for patients with chest ports to apply themselves, and as Christina discusses, applying a disposable option on one’s own can be extremely cumbersome, and a caregiver is typically needed to help apply the product.

For a more durable and eco-friendly approach, reusable protectors are a viable option for patients and healthcare facilities. Additionally, reusable options tend to be easier for patients to put on themselves and, therefore, foster independence. They are typically constructed from latex-free PVC with a watertight gasket, ensuring multiple uses throughout a treatment cycle. Additionally, reusable protectors come in various sizes for a more comfortable and secure fit and can be applied independently by patients, fostering a sense of self-care. However, proper air drying is necessary after each use, and they have a higher upfront cost than disposables. Ultimately, the ideal protector depends on individual needs and preferences. Bill Meeker, a patient with a PICC in Goleta, California, exemplifies this point. He shared his experience with reusable protectors, stating, “The H2O Shield is the absolute best product for keeping my PICC Line dry while showering every day. It beats plastic wrap and sticky shield products by a mile. Also, it is very easy to slide on and off without interfering with the PICC Line.” Factors like budget, showering frequency, environmental concerns, comfort, and travel needs should all be considered when making this choice.

Once patients have chosen their preferred shower protector, ensuring proper showering technique is equally important. Here’s a shareable list for clinicians to provide to patients transitioning to home care with vascular access devices:

1. Clinician Guidance is Key: Always consult your healthcare providers before showering with a VAD, as they may have device-specific instructions. They may have specific instructions or preferences regarding showering techniques and products.

2. Gather Essential Supplies: Stock up on waterproof dressings or reusable shower protectors (per clinician recommendation), have clean towels readily available, and consider using a shower stool for added comfort and stability.

3. Mastering Dressing Application: Request a demonstration from your clinician on how to properly apply the waterproof dressing or reusable waterproof shower protector. Alternatively, follow the manufacturer’s instructions for a secure and complete seal.

4. Showering Technique: Use warm water and avoid directly spraying the area around the VAD dressing. Keep showers brief, ideally under 15 minutes. Some patients find sitting in a bath with a handheld shower head easier to manage.

5. Post-Shower Inspection: After drying off with a clean towel, gently pat the area around the dressing and inspect it for leaks or damage. Report any concerns regarding the dressing or VAD to your healthcare provider immediately.

By following these steps and encouraging open communication with patients, nurses can help ensure safe and comfortable showering routines for those transitioning to home care with VADs.

In conclusion, managing shower routines with vascular access devices (VADs) like PICC lines requires a delicate balance of practical solutions and patient education. Clear communication between clinicians and patients is paramount, ensuring that patients are equipped with the knowledge and tools needed to protect their VADs during daily activities like showering. Christina Doherty’s insights, coupled with Maria Gomez’s guidance from the AVA and Mighty Well collaboration, underscore the importance of proper care techniques. Whether opting for disposable or reusable shower protectors, patients and caregivers can navigate showering with VADs confidently, minimizing risks and maximizing comfort. By following the provided guide and fostering ongoing dialogue, nurses play a pivotal role in promoting safe and effective VAD management in home care settings.

References:

1. Association for Vascular Access Annual Scientific Meeting 2022. AVASM 2022 Mighty Well Clinician Survey. MightyWell.com. Published online October 2, 2022. Accessed May 3, 2024. https://mighty-well.com/ products/picc-line-waterproof-shower-protector?_pos=1&_sid=1eb61d873&_ss=r

2. Mighty Well. Ultimate Guide to PICCs, Ep. 3 - How to care for a PICC at home? Allen C, ed. YouTube. Published online 9AD. Accessed May 3, 2024. https://www.youtube.com/ watch?v=Yj8XwuMNSeo&list=PLJSK-ruW05qhP4HPCitFgOXKDp6KgLhIw&index=3

3. Mayo Clinic. Ehlers-Danlos syndrome - Symptoms and causes. Mayo Clinic. Published August 25, 2022. https://www.mayoclinic.org/diseases-conditions/ehlers-danlos-syndrome/symptoms-causes/syc20362125

4. Doherty C. Living with EDS: All About My PICC Line | FAQ. Doherty C, ed. YouTube. Published online December 29, 2016. Accessed May 3, 2024. https://www.youtube.com/watch?v=eItgTjXaiTs&t=4s

Permission

Christine D. gave permission to print her images in Intravascular Quarterly while working with the author.

AVA

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.

and

• Review course content, outlines and objectives

• Purchase courses

• Add courses to your personal Course List

• Available to Members, Non-members and all site visitors with a Guest Account

• If you're not an AVA member, consider Joining AVA or you may create a Guest Account at no charge

• Sign in to your personal AVA Academy Account

• Launch your courses

• Take quizzes

• Available to Members and Non-members with a Guest Account

• You will need to sign in to the AVA website prior to clicking Launch My Courses above

CLINICAL PRACTICE GUIDELINES (CPG)

MICHELLE L. HAWES, DNP, CRNI, VA-BC, ACRP-CP CPG EDITOR-IN-CHIEF & DEVELOPMENT LEAD

PROTOCOL, PROGRESS, AND PLANS - 2024

Protocol

The original protocol for the Clinical Practice Guidelines (CPG) was completed in October 2021. During the last three years, more specific information has been added to expand but not alter the original plan. The protocol will be published in the Fall 2024 Journal of the Association for Vascular Access (JAVA).

Following the original search strategies for all the sections, the research librarian finished a final sweep of articles from 2016 to the 1st quarter of 2024. This work will give our teams the most recent articles available when the guidelines are written.

Progress

All sections have been working on their full-text leveling and grading of the evidence until April when the new batch of Titles and Abstracts required them to assess for inclusion or exclusion. Once completed, more full-text articles will be added to their pile for leveling and grading. After all articles are assessed, they are grouped into each PICO question. The leveling and grading of the evidence for each question will be aggregated. Evidence levels of less than 3.25 will be moved to the Guideline Governance Group (G3) for expert opinion according to specific methodology.

Plans

Due to the number of articles in each group, progress is variable. Two of the sections are almost ready to start writing guidelines. The AVA Board of Directors has approved of the AVA Education Department’s plan to publish the guidelines in parts rather than waiting for all sections to be completed at the same time for this inaugural version of the AVA CPG.

The first two sections are anticipated to be published in JAVA in the first quarter of 2025, the next two in the third quarter of 2025, and the largest two sections will be published in the first quarter of 2026. This will allow the members of each section to be released once the document is submitted. Many have been working on CPG since 2021 or earlier.

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

TELL IQ YOUR CASE STORIES

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

EXPLORING THE ROLE OF VASCULAR ACCESS BEYOND ACUTE CARE: ENHANCING PATIENT OUTCOMES.

DIANA NEGRÓN-SANTIAGO, MSN, RN, PM-C, CDN, CNN, DPT(ASCP) CM, PBTCM

I. Exploring the Role of Vascular Access Beyond Acute Care: Enhancing Patient Outcomes Vascular access is a critical component of healthcare delivery, extending far beyond the confines of acute care settings. While traditionally associated with procedures such as central venous catheterization for intravenous therapy or hemodialysis access, the importance of vascular access transcends acute care and plays a vital role in various healthcare domains. In this article, we delve into the broader scope of vascular access and its implications for patient care and outcomes.

II. Chronic Disease Management: One of the most significant areas where vascular access extends beyond acute care is managing chronic diseases. Patients requiring long-term therapies, such as chemotherapy for cancer treatment or dialysis for end-stage renal disease, rely on vascular access for regular treatment delivery. Central venous access devices (CVADs) and arteriovenous fistulas (AVFs) are commonly utilized in these scenarios, providing durable and reliable access for repeated interventions over an extended period (Ciocson et al., 2014).

III. Home Healthcare: As the healthcare landscape evolves, there is a growing emphasis on delivering care in the comfort of patients’ homes. Vascular access plays a crucial role in enabling home-based therapies, such as peritoneal dialysis, home infusion therapy, or parenteral nutrition. Patients with well-established vascular access can receive necessary treatments without the need for frequent hospital visits, promoting autonomy and improving quality of life (Bergmann et al., 2024).

IV. Palliative and Hospice Care: In palliative and hospice care settings, maintaining vascular access becomes essential for symptom management and comfort measures. Subcutaneous ports or peripheral intravenous catheters allow for the administration of pain medications, hydration, and other supportive therapies, helping to alleviate distressing symptoms and improve patients’ end-oflife experiences (Armenteros-Yeguas et al., 2017).

V. Pediatric Care: Vascular access is particularly challenging in pediatric patients, where small veins and limited tolerance for invasive procedures pose unique challenges. Specialized techniques, such as ultrasound-guided cannulation and the use of pediatric-specific devices, are employed to ensure safe and effective vascular access in this population. From neonatal intensive care units to pediatric oncology wards, vascular access is integral to delivering specialized care to children with complex medical needs (Ciocson et al., 2014).

VI. Preventive Healthcare: Beyond disease management, vascular access also plays a role in preventive healthcare initiatives. For example, vascular access may be required for the administration of vaccinations, blood transfusions, or diagnostic imaging contrast agents. Ensuring optimal vascular access in preventive care settings helps facilitate timely interventions and promotes overall health and wellness (Infusion Nurses Society, 2016).

VII. Conclusion: Vascular access extends far beyond acute care settings, permeating various aspects of modern healthcare delivery. From chronic disease management to home healthcare, palliative care, pediatric medicine, and preventive healthcare, the role of vascular access is diverse and multifaceted. By recognizing the broader implications of vascular access and implementing best practices for its maintenance and utilization, healthcare providers can enhance patient outcomes, improve quality of life, and ensure continuity of care across diverse healthcare settings. As healthcare continues to evolve, the importance of vascular access as a cornerstone of patientcentered care cannot be overstated.

VIII. References:

• Alnahhal, Khaled, Rowse, Jarrad, & Kirksey, Lee. (2023). The challenging surgical vascular access creation. Cardiovascular Diagnosis and Therapy, 13. 10.21037/cdt-22-560.

• Armenteros-Yeguas, V., Garate-Echenique, L., Tomas-Lopez, M. A., et al. (2017). Prevalence of difficult venous access and associated risk factors in highly complex hospitalized patients. Journal of Clinical Nursing, 26(23-24), 4267-4275.

• Bergmann, Matthias, Fakhoury, Butros, Barroso, Tiago, Prushik, Scott, Jaber, Bertrand, & Balakrishnan, Vaidyanathapuram. (2024). Early access flow rate predicts vascular access patency-related intervention in the first year: A retrospective cohort study. Hemodialysis international. International Symposium on Home Hemodialysis. 10.1111/hdi.13148.

• Ciocson, Ma Ana Flor, Hernandez, Maranda, Atallah, Mohammad, & Amer, Yasser. (2014). Central Vascular Access Device: An Adapted Evidence-Based Clinical Practice Guideline. Journal of the Association for Vascular Access, 19. 10.1016/j.java.2014.09.002.

• Infusion Nurses Society. Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 39(1S), S1S159.

• Kavurmacı, Mehtap. (2023). Hemodialysis Vascular Access and Care. Yeni Üroloji Dergisi, 18, 268-274. 10.33719/yud.2023;18-3-1269349.

• Masià Plana, Afra, & Fontò, Massimo. (2024). Vascular Access Management and Care: CVC. 10.1007/978-3031-30320-3_11.

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.

MEDICAL ADHESIVES: THE UNASSUMING CHALLENGE IN VASCULAR ACCESS CARE

DEANNE AUGUST, BSN, RN, GRADUATE CERTIFICATE, PHD

As experts in health care our focus is often on prioritizing the big procedures and care moments. As an example, the start of my career was focused on nasal injuries related to ventilation or the smallest and sickest babies. Yet, a decade later; I spend a large majority of my time promoting adhesive choices to protect paediatric and neonatal skin integrity; including vascular access and other medical devices. There is little doubt that in the scheme of critical or new healthcare diagnosis, medical adhesive choice and practice is low priority. Similarly, the complexity of ideal vascular device insertion requires time, knowledge, skill, training and practice. Yet, have you ever considered that the simplest and most ordinary tasks should require the same respect for knowledge and skill? Poor adhesive choices and inadequately adhesive application/ removal practices may have wider ramifications for our patients and their treatment journey; and therefor their wider health. Within this article I hope to provide some practical tips, insights and considerations for vascular access adhesive care; promoting best practice of the least assuming procedural moment in vascular access.

Goals and objectives

• Identify patient populations at risk for skin injury

• Prompt awareness of adhesive types

• Promote key timepoint and considerations for medical adhesives (selection, application, dwell, removal, post-removal assessment for complication)

• Review the importance of help for removal (a second hand, a colleague, family member or removal agent/moisture)

• Description of an activity for adhesive removal speed and skills

Patient populations needing best-practice adhesive selection

Realistically every patient can be at risk for a medical adhesive related skin injury (MARSI);1 central line associate skin injury (CASI)2 or other adhesive associated iatrogenic complications. Attentive decision making to for at risk patient groups can improve chances of an injury-free vascular journey. These patient groups include but are not limited to: oncology, extreme age/aged care, diabetes, critical care, renal failure, cystic fibrosis, burns, inherited skin conditions (e.g. epidermis bullosa) and neonates (all ages and sizes).1,3 Usually these patient groups have specialised healthcare teams with with robust vascular access policies and procedures; and thus ideal vascular access and adhesives are somewhat protected. Yet, do patients or their supports (family or next of kin) appreciate their unique risks? Would they know how to suggest to an emergency room practitioner or clinicians to take extra care when applying or removing an emergency dressing? Communicating these risks to the family and patient is a vital element to protect integrity.

Adhesive types- not all the same

The choices for vascular access device primary and secondary securement for are abundant. Within modern health care the majority of vascular access securements are an industry specific dressing/securement device; with intent to cover and secure the device to the skin. Evidence for the best securement choices for each type of vascular device and patient populations are readily available.1,3 Additionally, contemporary vascular securements and dressings are mostly comprised of multiple adhesive types; regularly polyurethane and a fabric combination. Unit or population-based policies and procedures assist in best adhesive selection; but may contribute to a lack of understanding of the product specific application and removal tips. Can you identify a polyurethane adhesive or dressing from a fabric and acrylate adhesive? Would you remove a fabric adhesive/component with the same technique as a plastic acrylate? While industry/brand specific instructions are paramount to safe practice - a basic understanding of adhesive top and base types are important to safe practice especially when encountering unfamiliar securements. Consider that fabric adhesives have ability to soak in moisture/removal agent, allowing you to de-engage the adhesive component from the top or backing; as well as de-activating the adhesive from the skin layers itself.4 Comparatively, there will be little impact in soaking a plastic or polyurethane adhesive

from the top, and all moistening needs to be done at the site of adhesive lifting (adhesive skin interface) and continued throughout the removal process.1

Key timepoints and considerations for medical adhesives (selection, application, dwell, removal and post-removal assessment)

Over the past fifteen years clinicians, researchers and industry professionals have developed educational materials for adhesive removal attributed challenges. Practice guidelines for complications such as MARSI;1 CASI2 or dermatitis;5 support categorisation of effects of unideal removal events. It is paramount that selection, preparation of area and application are also considered in injury prevention. Is the vascular access site dry and free of remaining decontaminate or other solutions (previous removal agents)? Is the adhesive size the appropriate for the patient and anatomical region? Without the assessments of skin dryness and adhesive size at application, the removal practice has less effect on maintaining integrity.

Adhesives, dressing and barrier selection is especially paramount for the high-risk populations; and expert assessment post the first MARSI/CASI can help to minimise subsequent or repeated injury. For example, placing tension on polyurethane films during application can increase the risk of injury, or using alcohol-based skin preparations on aged or neonatal skin can irritate tissue layers whereas using careful tension free application with silicone-based preparations for at risk populations are ideal.1,4

The Dwell of the vascular device and related adhesives is the least appreciated moment; yet this is associated with tension and torsion on skin’s tissue layers as the limb or body moves. Infusion line drag and securement extensions are considered to maintain vascular device position, but not to minimize injury. Attached infusion lines can add weight and shear stress to the connected tissues; but damage or injury is unseen till the moment of removal or dressing change. While there is little evidence for prevention of forces during dwell contributing to injury; practical minimisation of drag and pull on the device lines and accessories will defiantly help.

Medical adhesive removal or replacements are clinicians’ most familiar adhesive moment; but the need to promote infection prevention and maintain vascular access take priority. Thus, another reason why injuries are at times unavoidable. Variety of dressing choices and vascular devices themselves may add to dissimilarity and tendency to rush through a procedure with an unfamiliar dressing or device. Yet, a basic underpinning of vascular device type (peripheral/central) and adhesive/dressing type (composite or singular); could help clinicians use appropriate removal techniques including: rolling an edge to start rather than picking, low and slow parallel removal, working around the dressing from the outside moving towards the centre of the device to maintain insertion site protection and using moisture to lossen.4,6 Each of these skills and techniques can be learned and have little effect on the removal event time.

Help for removal (a second hand, a colleague, family member or removal agent/moisture) While removing adhesive is a humble clinical task, experts encourage supporting the surrounding skin. This can be done by the clinician removing the adhesive1 (known as the two handed technique).4 The value of the related vascular device (essential to treatment delivery) would also support that a two person removal may minimise skin injury, prevent infection and maintain access for high risk patients. If appropriate adhesive removal agents or moisture assist in injury free removals.

Practical activity for self-testing adhesive removal speed and skills

Have you ever practiced removing adhesives? Are you aware of your removal practice speed and technique? In the busy clinical setting with the competing priorities, the angle of removal or speed is insignificant. Adhesive practice removal can be done on mannequins or education models. Another, low-cost method or a simple self-test will require adhesive(s) and a newspaper or magazine page. Simply apply some plastic or fabric tape to a page of newspaper or magazine, creating a folded edge and smoothing the top at application. Once complete use your nondominate hand to support the page, and peel the adhesive back on itself in a low angle without tearing or removing ink. Hint- this is not easy and often impossible to get perfect. However, it creates a memorable scenario for skills and the low-speed required for ideal adhesive removal. Reflecting on this activity in practice can help pace this practice at the moment of care provision.

While unassuming and humble; medical adhesives and dressings play an integral role in vascular access longevity and patient wellbeing worthy of our time. If considered as ‘equipment’ requiring knowledge and skills; medical adhesives will be less likely to contribute towards injury and more likely to function to protect and secure vascular devices.

References

1. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science: consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. J Wound Ostomy Continence Nurs. 2013;40(4):365-380; quiz E361-362.

2. Broadhurst D, Moureau N, Ullman AJ, World Congress of Vascular Access Skin Impairment Management Advisory P. Management of Central Venous Access Device-Associated Skin Impairment: An EvidenceBased Algorithm. J Wound Ostomy Continence Nurs. 2017;44(3):211-220.

3. Nickel B, Gorski L, Kleidon T, et al. Infusion therapy standards of practice. Journal of Infusion Nursing. 2024;47(1S):S1-S285.

4. August D, Chapple L, Flint A, Macey J, Ng L, New K. Facilitating neonatal MARSI evidence into practice: Investigating multimedia resources with Australian Neonatal Nurses – A participatory action research project. Journal of Neonatal Nursing. 2020;27(4).

5. Ullman AJ, Mihala G, O’Leary K, et al. Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices. Int J Nurs Stud. 2019;91:6-13.

6. Ullman AJ, Cooke ML, Mitchell M, et al. Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review. Int J Nurs Stud. 2016;59:177-196.

Copyright 2024 Association for Vascular Access. All rights reserved.

Disclaimer: AVA (Association for Vascular Access) is a professional organization of vascular access professionals dedicated to improving vascular access practice and patient outcomes through education and other means. AVA publishes this periodic electronic newsletter for our membership and other interested parties for information purposes only. AVA distributes this electronic newsletter with the understanding that AVA is not engaged in rendering medical or professional service through the distribution of the IQ publication. AVA is not giving advice and does not subscribe to guarantee the accuracy or efficacy of the information provided. Privacy Policy and Unsubscribe Information -AVA maintains strict rules of confidence with regards to your email address and all other personal contact information. We will not, under any circumstances, sell, transfer, or provide your email address to any third party for any reason. Email lists are compiled on an opt-in basis by AVA for the sole purpose of distributing the IQ newsletter. AVA does not condone or participate in the distribution of unsolicited email. If you feel that you have received an email transmission from AVA in error, please contact AVA at and ask to be removed from the list. All removal requests are addressed promptly.