Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: an education evaluation

Hospitals had to create new practices and training due to the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) pandemic. During the second wave of the pandemic (at the end of 2020), there was an increase in patient acuity and the need for peripherally inserted central catheters (PICCs), a central vascular access device (CVAD), across Michael Garron Hospital (MGH). This required Clinical Resource Leaders (CRLs), who are similar to advanced practice nurse educators, to create a training program to support in-patient nurses in acute and complex care units to manage PICCs. Traditionally, these skills were performed by the specialized registered nurses (RNs) from the Vascular Access Team (VAT), Intensive Care Unit (ICU), Cardiac Integrated Units (CIU), and Emergency Room (ER) nurses. Rapid Response Nurses usually supported clinical units when VAT was not available, however, their focus shifted to supporting deteriorating patients during this pandemic.

Michael Garron Hospital provides services to 400,000 patients a year. This hospital is committed to improvement and to adapting to the needs of a diverse community. With an aging population and being in the middle of a pandemic, the complexity of the patients cared for by interprofessional teams is increasing.

Formed in 2019, the VAT is composed of RNs who are accountable for inserting, troubleshooting, caring for, and managing the care for PICCs in in-patient adults. Managing PICCs is comprised of dressing changes, needleless connector changes, blood draw, and troubleshooting. In addition, they are the resource for any difficult intravenous device insertions and any other vascular access concerns. There are three regular RNs who support the hospital every day from 0800 to 1600 hours. Since the creation of the team, the VAT has been accountable for all nursing procedures associated with PICCs across the organization: assessment, insertion, care and maintenance, administration, monitoring, complications, and removal (Canadian Vascular Access Association [CVAA], 2019) outside of the specialty areas. With the increasing complexity of the patient population and an increase in the number of PICCs in the organization, it was necessary to plan the transition of the care of PICCs from the VAT to the nurses who work on the units. This aligns with education and competency practice guidelines (CVAA, 2019;Gorski et al, 2021).

The PICC insertion data were collected since program inception and are shown in Figure 1. The VAT nurses had to insert and maintain anywhere from 15 when they started to more than 40 PlCC lines in the first two waves of the pandemic. The increase in the number of PICC sacrosstheuvits, outside of ICU and CIU, comes with significant risks to quality care if the hospital does not extend the skill and competency to other RNs and registered practical nurses (RPNs), for example, blood work; results that are; required for specific medications or planning for patient discharge/transition. Vascular access team worklnad issues caused delays to treatment, intervention and/or bed flow. Another risk to quarlity is in accessing and de-accessing c PICC. A nurse may be required to start or end an infusion or medication that requires a PICC and VAT nurses arc; only, available until 4 pm. Waiting for the VAT nurses to arrive maybe as long as 16 hours resulting in delayed patient care. Additionally, consistently relying on the VAT can delay timely discharges. Understanding how to de-access IV fluids and/or medication s safely is essentiel for nurses to decrease the risk of developing central line infections. Note that Figure 1 has peaks and valleys, which represent either training and vacation days of the three nurses trained in the program. Figure 1 also highlights the influenza season in January 2020, tıs anticipated “surge” time or a surge in patient numbers that exceed hospital bed capacity. All of these factors signalled the need to train more nurses to supporr complex and acute care patients with PICCs.

This paper highlights the education plan, impelementation, and evaluation of a hospital-wide training program for RNs and RPNs in the medicine, surgery, and complex continuing care units during a pandemic. Kirkpatrick's model was utilized to guide evaluation, as this model creates a chain of evidence demonstrating the effectiveness of an educational intervention.

The model is divided into four levels describing different aspects of learning evaluation: (1) learner reaction; (2) learning; (3) behavioural changes after the educational intervention; and (4) the impact of the educational intervention on the organization's perspective (Kirkpatrick and Kirkpatrick, 2021).

Overview of education program

Target learners

Periph erally inserted central catheter care for this hospital, ehen, i s a new expectation of RNs and RPNs working in the various in-patient units for our local urban community hospital. Several programs are affected:

• Inpatient medicine;
• Surgery Services that include inpatient surgery and the recovery room;
• Complex Continuing Care (also known as Transitional Care); and
• Nursing Resource Team.

Nurses from six inpatient medicine units, two inpatient surgery units, two complex continuing care units, and the ursing resource team (NRT) were the target learners.

The NRT nurses traditionally spans multiple units, which include d all the units listed above. In addition, this program was also open to untrained nurses from the emergency department, perianesthesia care unit, and cardiac integrated units. A PICC education program was essential to ensure that the care provided was safe and standardized across the hospital (CVAA, 2019;Gorski et al, 2021). The educational intervention of the inpatient unit nurses included instruction on the importance of PICC care, support of new knowledge, providing opportunity to learn and practice skills, and working with certified nurses to ensure safe practice. In addition, the many manufacturers and types of PICC led to nuances in training nurses.

Education program development

Policies, procedures, and education development were based on current best practices and evidence (CVAA, 2019;Gorski, 2017; Gorski et al, 2021). According to the CVAA (2019) best practice guidelines, various education strategies should be utilized to ensure knowledge transfer into practice. Training goals and objectives, as well as learner activities, covered various domains of learning, including cognitive, affective and psychomotor.

Training Goal #1:

To obtain the knowledge and competencies associated with nursing care and management of PICC lines in adult patients (CVAA, 2019).

Objectives:

Upon completion of the PICC education program, learners will be able to:

• Outline the components and anatomical placement of PICC lines, list the indications and contraindications for a PICC line, as well as describe the nursing care and management of PICC lines;
• Compare and contrast central and peripheral venous access catheters;
• Describe potential complications and safety considerations associated with PICC lines as well as nursing actions to prevent and treat these complications;
• Create individualized nursing care plans for patients with PICC lines; and
• Adhere to hospital policies on nursing responsibilities related to care and maintenance of PICC lines.

Training Goal 2:

To learn and apply the skills to perform nursing care and management of PICC lines in adult patients.

Objectives:

By the end of the PICC education program, learners will be able to:

• Perform procedures related to care and management of PICC lines, including dressing change, cap change, flushing, and blood withdrawal;
• Perform nursing assessment and documentation of PICC line care and management; and
• Consider and perform appropriate nursing interventions to address PICC line issues or complications.

PICC education

Clinical Resource Leaders created a modular approach to upskill existing nurses and train new hires. The PICC education was informed by Kirkpatrick's (2021) four-level evaluation model. Various education strategies were used to support learners (CVAA, 2019), such as:

• The development of a learning package, inclusive of learning resources and practice support materials;
• The use of competency assessments;
• In-person training using low-fidelity simulations and handson practice;
• The incorporation of specialists as a resource; and
• The development of videos to use for teaching as well as a resource.

The PICC education program was developed to meet the aforementioned goals and objectives using the following teaching-learning strategies: A learning package was implemented to meet the first goal and its objectives while low-fidelity simulations and hands-on practice was used to address the second goal and its objectives. These strategies were also utilized to ensure knowledge transfer, application, and guidance of evidence-informed clinical practices (CVAA, 2019;Gorski et al, 2021).

These strategies were informed by the philosophical framework of social constructivism, which posits that the learners cognitively and socially engage in the learning environment to gain new understandings (Handwerker, 2012). By becoming active in learning, learners are able to develop metacognition and are more prepared to transfer knowledge and skills to new situations (Handwerker, 2012). The literature has found that educational activities aligned with this philosophy, such as simulations, are effective in developing learners to be critical thinkers, gain clinical reasoning, and foster a sense of salience (Handwerker, 2012; Peters, 2000).

Learning package

Benefits of this approach were two-fold. For the organization, having a learning package was cost-effective and each staff member had the same education resources, resulting in standardization of the information (CVAA, 2019). The content also highlighted procedures found in the revised organizational policies. For a staff member, the learning package encouraged self-directed learning and allowed easy accessibility of resources.

The learning package covered the content discussed in the objectives outlined in the first goal: (1) components and anatomical placement of PICC lines; (2) the indications and contraindications for a PICC line; (3) the differences between central and peripheral venous access catheters; (4) potential complications and safety considerations associated with PICC lines, as well as nursing actions to prevent and treat these complications; (5) nursing responsibilities related to care and maintenance of PICC lines and skills checklists; and (6) nursing care plans related to PICC lines. Included in the learning package also were skills checklists, which were created to outline all the steps required in the skills and the learner was evaluated based on the checklist to ensure consistency (CVAA, 2019).

To align with level 2 of Kirkpatrick's Model (2021), staff were required to take a 20-question multiple-choice test at the end of completing the learning package to measure the degree of the learner's acquisition of the intended knowledge. Staff required 80% to pass and move to the next part of the curriculum. If staff did not receive 80%, each CRL had to follow up with the staff member to address knowledge gaps before moving forward to in-person training.

In-person training

The second goal and its objectives predominantly focused on the psychomotor domain and technical skills; thus, low fidelity simulations (Kiker et al, 2020; Kim et al, 2016) and hands-on practice opportunities were chosen.

Low-fidelity simulations.

Simulation allows the educator to evaluate, via direct observation, if the learners are able to apply concepts learned in the learning package. Growing research has shown that simulations have a variety of benefits, such as the ability to make errors in a safe environment; improve confidence, critical thinking, and decision-making skills; provide standardized patient situations; provide immediate feedback; and improve psychomotor and technical skills (Nehring and Lashley, 2009). As a constructivist-based strategy, simulations promote the construction of knowledge by learners, as educators create experiences that resemble the real healthcare setting (Handwerker, 2012).

Learners participated in a one-hour in-service where they practised nursing assessment and care hands-on with low fidelity manikin arms with a PICC line in place. The inservice was designed to mirror the experiential learning that would occur in the clinical setting when they perform the skill independently. Nurses who attended low-fidelity simulations

• Demonstrated safe techniques related to PICC care in adults, such as:
• Infection control
• Positive patient identification
• Aseptic non-touch techniques;
• Demonstrated PICC skills:
• Dressing changes
• Accessing
• Flushing and locking (without heparin)
• Blood procurement; and
• Received feedback from the educators.

Hands-on training and competency validation.

As the last part of the education program, learners were given the opportunity to perform the skills learned in the low-fidelity simulations on real patients under the supervision of the CRL or aVAT nurse. A learner completed all modules after they were able to perform the skills accurately and were “signed off “. This strategy further bridged the gap between theory and practice as clinical experiences in real-life settings are the best form of experiential learning (Handwerker, 2012). Additionally, this part of the curriculum is aligned with level 3 of Kirkpatrick's Model, wherein the hands-on training measures the degree to which learners apply learning from the education program.

Practice supports

Vascular access device policies were accessible through the policy repository used by the hospital. Learning resources were available on the intranet practice pages. In addition to the learning package, skills videos were created by the CRLs using the supplies and equipment utilized in the hospital. This job aid was available for nurses who may need a refresher on the skill and expectations. It serves to standardize the resources available within the hospital rather than performing an internet search.

Methods

Setting

Michael Garron Hospital had a steady increase in patients requiring PICC lines so training was prioritized (Figure 2). The training occurred in this urban community hospital. Initial training of existing nurses occurred in a phased approach and in between pandemic waves. With infection control in mind, small group activities were scheduled in February 2021 (Quarter 4, 2020) and the beginning of April 2021 (Quarter 1, 2021). As noted previously, inpatient nurses, both RNs and RPNs, were included. In addition, any nurses from specialty areas like ER and CIU were also included in this phased approach. This training was included in the new hire nurse orientation in March 2021. The training intervention started with the distribution of learning packages two to three weeks prior to a nurse's scheduled hands-on training session. Passing marks were required to confirm attendance. The hands-on training portion was facilitated by the CRLs. Competency validation occurred after this training event.

Data collection

Information to validate the performance gap was obtained through the daily documentation submitted by the VAT. These documents include

• PICC insertion data;
• Pages received from switchboard and documentation of tasks in which they called to perform; and
• Planned bloodwork schedules.

Data found in Figure 1, Figure 2, and Table 1 were derived from the data listed above.

Baseline data were collected in February 2020, prior to launching the training program. This table shows that there were 512 calls related to PICC care, maintenance, and troubleshooting.

Training completion rates were collected for each program to ensure that the goal of 80% of full-time and part-time nurses were trained to care for and manage PICC lines was obtained. Only nurses who successfully achieved the four modules were counted.

Results

Evaluation results

Table 2 lists training completion rates by program between February to August 2021, which shows the range of trained nurses across programs. The number of clinical units counted within a program is listed in parentheses. Minimum values represent the lowest training rate within a program and maximum values represent the unit with the highest completion rates.

Level 4 Evaluation (Kirkpatrick and Kirkpatrick, 2021) shows the impact of an educational intervention from the organization's perspective. At MGH, this was evident; as more nurses were trained to care for PICC lines over the months, there were less calls to the VAT nurses (see Fable 3). The significant drop in VAT requests for blood draws and resource calls (from 214 requests for blood draws from PICCs in February of 2021 for 44 inserted PICCs, compared to 16 requests for help to 41 PICCs in August 2022) showed the effectiveness of the training program. In addition, resource calls that include VAD assessments and weekly line flushing for dormant lines, decreased by 57% from February to August.

In addition to the educational effectiveness, there were minimal clinical complications associated to the upskilling of inpatient unit nurses out of 1,000 requests for bedside insertions between 2019 to October 2021. The tracked complications followed by the VAT were

• 1 site infection;
• 1 reverse migration;
• 3 thrombi;
• 1 septic/thrombophlebitis (transitioned from a different hospital); and
• PICC salvage — 31 counts from April to September 2021.

Fable 3 shows that PICC rescues were minimal when the training program started in February and March of 2021. As more nurses were trained, there was a fluctuating number of phone calls to VAT nurses when the patency of PICC lines were compromised. These lines were salvaged through proper assessment and interventions by the VAT nurses (CVAA, 2019;Gorski et al, 2021).

Despite the increase in salvaging PICCs, what can be commended is the decrease in resource calls, requests for blood work support, needleless access, and de-accessing PICCs.

Discussion

Design and implementation considerations

There were two key anticipated operational issues that included resources and staffing. Due to the pandemic, CRLs often had many competing priorities. Since it was an organization-wide rollout, working collaboratively across all programs helped ensure that in-services were standardized and consistent across the organization. Given massive staffing shortages and increased acuity of patients, it was difficult for staff to leave the unit to be trained. With this in mind, the in-services were split into manageable sessions that were one hour in length to reduce the length of time nurses would be off the unit and away from patient care tasks. The modular approach to learning decreased the risk of overwhelming staff with new information. Furthermore, policies, the learning package, and job aids were made accessible to staff whenever they were available to alleviate this potential issue.

Organization-wide approaches were implemented to promote sustainability. The education program was integrated into corporate orientation. This change also was incorporated into hospital policy (eg indicating that nurses who are certified can now perform these skills rather than relying on VAT nurses) and into the electronic health records (eg nurses will have access to document these new skills).

Conclusions

The goal of evaluation for training programs is to show that there is a shift from knowledge to practice. With this initial evaluation, results show a significant decrease in requests for PICC assistance from the VAT (more than 512 calls in one month down to 149) from implementation to six months postimplementation, as noted in Table 3. Clinical complications from increasing trained staff were also minimal. From our results, further evaluation or research may be completed to understand the root cause of the fluctuating PICC salvage incidences.