talkBAC: Best Expectations, Worse Outcomes (Part III

talk BAC

BEST EXPECTATIONS, WORSE OUTCOMES (PART III)

Erik Samarpan, RN, VA-BC™, LNC | Board Certified in Vascular Access; Legal Nurse Consultant; Oncology Credentialed; Infusion Specialist; BACSIG (Beyond Acute Care SIG) Director-at-Large

Continued from the November 2020 and February 2021 IQ - Names changed for privacy

I spoke directly with Jose’s neurologist, let’s call him Dr. Noble, who works at a large metropolitan children’s hospital. His specialty is Duchenne Muscular Dystrophy. Thanks to my training, learned knowledge from certification and hands-on participation in pre-conference skills workshops, I was able to explain my concerns regarding Jose’s malfunctioning port. This experience gave me the tools to justify why I felt Jose required a dye study to confirm location of the catheter tip termination, device patency, and the possibility of a vessel stricture near the lumen of the catheter. Dr. Noble quickly expressed his lack of knowledge when it came to implanted ports and problem solving when one is not functioning correctly. I assured him that I was knowledgeable.

This brought up an issue that deserves discussion: the physician had never met me and had no knowledge of the VA-BC™ certification and what it means. When I explained my clinical expertise and steps I had taken to ascertain what I felt was the problem, the physician could only defer to the interventional radiologist as the only expert he had experience with… not a nurse or respiratory therapist! As part of leadership in our newly renamed BACSIG (Beyond Acute Care Special Interest Group), this encounter shows the need to educate physician-partners in the specialized certifications and continuing education provided by both the AVA and the INS. We need to educate other healthcare professionals on the skills of VA specialists and how we assist them in caring for patients.

Back to the story: Dr. Noble agreed to the dye study but results were inconclusive. There was no indication of fibrin buildup either intraluminally or externally on the catheter tip. He spoke with a thoracic surgeon who convinced him that a port exchange was warranted. Upon removal of the old port, we saw a large section of the septum seal was missing and, therefore, the answer to many malfunctions was now explained.

Thanks to AVA’s continuing education over the years, I had a seat at the table with problem identification, intervention and on-going monitoring of Jose’s new adult port. As a note of importance: the surgeon listened to my suggestions as to incision location and other techniques, including use of cyanoacrylates rather than sutures.

MOM’S IMPRESSIONS

During this process, Jose’s vague symptoms surrounding a defective port were ignored as were those of his mother, Marie. Epigastric discomfort requiring intermittent calcium carbonate and slow infusion became unnecessary with his new port. Access difficulty was resolved by the surgeon with CONTINUED ON NEXT PAGE

selection of a port with suture-base stabilization, placed at my request.

The neurologist now listens to Marie’s feedback and impressions with more credibility. In addition, the process has given Marie better understanding of correct procedures and some best practices, allowing her to be an even more effective caregiver for her son; she is now asking more questions before procedures are performed.

Jose has also become a better advocate for himself, asking more questions about his port and the procedures being performed, whether in-hospital or at home.

DR. NOBLE’S IMPRESSIONS

Dr. Noble reports he is seeing a disturbing trend occurring in home infusion, one which he feels has direct impact on patient care. He has no idea why or what the justifications are for the change but, as a stakeholder, he is concerned.

In what he terms “the traditional model,” nurses worked for home infusion companies providing patient care, medication, and supplies. The field nurse communicated directly with the physician or their designated representative. If a patient had questions, they could put a request in for the field nurse to call back. Now, things appear to have changed.

The current model now seems focused on specialty pharmacies contracting with nationwide staffing or pool agencies as designated by the Joint Commission. These companies provide nursing services only. All supplies, medications, and pumps, if applicable, come from the pharmacy and NOT the staffing agency, representing a significant deviation from the conventional pharmacy model practiced throughout the United States.

Dr. Noble has seen large pharmaceutical companies contract with these staffing-only agencies and, apparently, they have policies in place that prohibit field nurses from initiating phone calls or having any communication with the provider directly. The “field nurses” must call their office, relay the information to a clinical coordinator, who then relays information to the pharmacy representative (who could be a pharmacist or pharmacy technician) who is not providing direct patient care. Dr. Noble stated that even if he requests a call from the field nurse some agencies must go through the pharmacy staff first. This can delay notification of patient changes and affects the care his patients receive.

CONCLUSIONS

Jose is doing well and his new port is working perfectly. He no longer has any GI issues related to his infusions and he remembers “scrub the hub” every time - with the correct scrub times! The issues brought up by this case show the wide gaps in vascular access care across the country which hinders the application of consistently high standards of practice throughout the continuum of care.

If you work in post-acute care and are interested in sharing your passion for vascular access and wish to make positive change happen, please contact us at BAGSIG@avainfo.org to become part of the BACSIG family.

We welcome your feedback and thoughts regarding this series. Our dedicated section of IQ, titled talkBAC, is your place to bring up ideas, questions, suggestions, and tips on the practice and application of vascular access best practices.

JOIN THE BACSIG

Joining BACSIG is your pathway to knowledge. No matter what your specialty within the continuum of care, vascular access is a part of that specialty. Enhance your knowledge and stay current in practice by multidisciplinary participation and engagement at all levels from novice to expert.