Post-pandemic, the UK National Infusion and Vascular Access Society (NIVAS) recognised that vascular access as a specialty had been invaluable in supporting the care and survival of hospitalised patients with COVID-19. At its national conference this year, NIVAS (Barton, 2022) launched a strategy to ensure that provision of vascular access is included in future NHS plans. The society has taken the first steps to help achieve this goal, with a white paper that advocates for standardised vascular access services teams (VAST) across the NHS.
The Benefits of a Nursing Led Vascular Access Service Team (Barton, 2022) acknowledges the current pressures of restarting the NHS following the pandemic and the roadmap to reducing the elective waiting lists, arguing that VASTs can be part of attaining this. The NIVAS paper outlines how integrating a standardised model of VAST in NHS systems will benefit patients and new integrated care systems (ICS), as well as the wider objectives of the NHS.
Many patients admitted to hospital or who are in receipt of health care in other settings will be recipients of one or more infusion therapies at some stage. The NHS spends an estimated £29 million of its annual acute sector budget on peripheral intravenous catheter (PIVC) procurement (Guerrero, 2019) and around 70% of all hospitalised patients require at least one PIVC during their stay. Yet, despite such extensive and routine use, reported line failure rates are high.
Having a VAST in place can ensure that patients get the vascular access device (VAD) that is right for them at the right time, whether this is a PIVC, peripherally inserted central catheter (PICC), midline or port catheter.
Up to 90% of inpatients require IV access for delivery of fluids, medication and/or blood sampling (Moore, 2021), yet 35–50% of peripheral vascular catheters (PVCs) do not meet their intended dwell time, largely due to complications, which can cause delays in treatment and discharge (Helm et al, 2015).
Through the NIVAS network and wider NHS, it is evident that there is significant variation in the provision of VADs. Nurses are usually responsible for inserting most PVCs alongside junior doctors, who are often referred the most difficult cannulations. Failure of PIVCs is common, resulting in premature removal and replacement. IV access can be difficult to obtain, especially in patients with a lack of visual or palpable apparent veins and in those with a known history of difficult access (Loon et al, 2016).
In organisations where no formal vascular access service team exists, such patients would need referral to more experienced clinicians. This can result in patients being passed between numerous ‘expert’ staff, and experiencing multiple attempts to access a vein, in some cases as many as 15 in 1 day. This can destroy a patient's peripheral veins, cause pain and discomfort and be a traumatic experience.
Such situations can easily be avoided if additional technology is used to assist peripheral access placement or a central VAD can be placed, if required. This can be achieved if a VAST is in place.
The insertion of more complex and invasive central vascular catheters is traditionally performed by surgeons, anaesthetists, interventional radiologists and other medical consultants, performed in addition to their workloads in theatres, intensive care and radiology. This can result in patients experiencing delays of hours or days before receiving either an emergency VAD or appropriate central vascular access, and can contribute to longer hospital stays.
Additional pressures due to the pandemic have highlighted further the difficulties with this traditional model. As the NHS recovers from the pandemic, demand for theatre and interventional radiology time grows, with the service working to clear the backlog of operations and procedures. There are also additional costs to the NHS. This information is included in the white paper to support IV specialists to write a business case for implementing a VAST in their trusts.
A specialist VAST is responsible not solely for the placement of devices but ‘to assess, insert, manage, perform surveillance, analyse their service data, solve clinical concerns and where possible remove VADs (Carr and Moureau, 2019). A specialist vascular access service can ensure fewer delays to starting treatment, ensure lower infection rates and other complications, improve the patient experience and reduce length of stay. The view of NIVAS is that such services would alleviate pressures in the NHS.
The argument for VAD insertion by a VAST is that best-practice care is supported by a consistent, knowledgeable and skilled approach. Specialist clinicians have a higher level of knowledge and confidence in inserting IV lines, built on experience and procedural competence, suggesting the VAST approach has positive insertion outcomes for patients (Harnage, 2012; Jackson, 2012).
The benefits of having a dedicated VAST include a reduction in central line-associated bloodstream infections and ensuing reduced costs, as well as increased efficiency, improved quality of care, patient satisfaction and patient outcomes. The key to reducing healthcare-associated infections related to VADs is to standardise care, use evidence-based care bundles and employ a VAST to ensure patients have the most appropriate and safest device in place for the duration of treatment. The VAST can also educate, audit and perform surveillance, maintaining staff adherence to care and implement bundles for VADs.
Early adopter
The first nurse-led hospital-wide vascular access service was set up in 1991 in Oxford. This service proved that the implementation of a VAST could lead to a radical reduction in infections and complications associated with VADs and IV therapy, including the development of a community-based IV team and provision of care in people's homes (Hamilton et al, 1995). Yet in 2022 there is still no standardisation in provision of vascular access across the NHS.
Although vascular access services have become established in some places, they provide variations of a PICC service, usually in oncology and, more recently, outpatient parenteral antimicrobial therapy services. To be successful and cost-effective, VAST should be multifunctional and offer access to all clinical areas and service users. The team should respond to all cases of difficult IV access, including in children. Access to a VAST in emergencies, as part of a response to patient deterioration or cardiac arrest, can also be valuable.
Best practice
Patient safety is bolstered as the patient is at the centre of the VAST model: best practice is focused on the patient, with the right device being selected at the right time, and inserted by the most appropriate staff member.
Having access to vascular access teams offers not only quantifiable savings, but also provides benefits in terms of improving patient safety and avoiding the need to undertake repeated attempts to insert a device.
Infection rates and other complications in patients with IV catheters – which can be costly to the NHS – can drop once an experienced VAST is in place. In summary, NIVAS is recommending that NHS England:
- Implements standardised vascular access provision across the NHS with ringfenced funding
- Conducts a national survey to understand fully vascular access provision within all trusts, collecting information on current practices and their impact on patients, staff, trusts and the ICS
- Supports NIVAS in creating a national standardised training programme
- Supports the creation of academically recognised professional qualifications for training in vascular access and establish a career pathway
- Acknowledges that vascular access is an essential specialist discipline with agreed national key performance indicators
- Makes the recording and reporting of all complications associated with vascular access mandatory.