There is no doubt that 2020 has brought immeasurable change to health care across the world as the response to the COVID-19 pandemic has made us all think about how we provide every aspect of medicine. As IV access practitioners, we have had to very quickly consider how we could continue to provide safe IV therapy and device care, particularly for patients with long-term central venous access devices (CVADs).
Patients who have a long-term CVADs are by their very nature among the most vulnerable groups. Continuing to safely manage these patients and their IV access devices throughout the pandemic has been challenging. Patients were initially told to stay out of hospital for all but emergencies, and there was a lot of fear about attending hospital because it was often depicted in the media as a war zone-type of environment.
By the nature of their condition, the vast majority of patients with a CVAD would also have been told to completely shield, with hospital appointments eliminated or carried out virtually for anything but absolutely essential visits. However, managing a CVAD is a practical task requiring hands-on regular intervention, so individual plans for looking after each patient had to quickly be established.
Various strategies had to be considered. These included:
However, as practitioners, we also had to consider which elements of practice were absolutely essential to continue and what could safely be reviewed.
Our national and international IV guidelines provide us with the evidence base to consistently care for all IV access devices, but they were not written with a pandemic in mind. We found ourselves in an unprecedented situation where we had to weigh up the risk of bringing in vulnerable patients to the hospital environment versus the risk not following the recommended guidelines and time frames we are all so familiar with. What was going to be the higher risk? For example, if a patient had a hospital appointment 2 days after the weekly peripherally inserted central catheter care, was it safer to flush the line 2 days late or to attend the hospital twice, increasing the risk of COVID-19 transmission? This risk could only really be reviewed on a case-by-case basis and required constant critical thinking and flexibility of services.
Some long-held assumptions in the guidance have also been challenged. A recent meta-analysis of flushing regimens for totally implantable venous access devices, such as a Port-a-Cath (Wu et al, 2020), challenged the previous policy (Cullinane, 2019) of a monthly flushing regimen when not in use. The research suggested that it was safe (and may actually be beneficial) to extend the flushing intervals to 8 weeks. This was supported by Bertoglio (2020) who successfully took the flushing interval to 3 months for 200 patients during the pandemic with no negative effects and minimised the number of patients accessing hospitals. Bertoglio concluded that the pandemic had been an excellent opportunity to confirm the assumption that prolonging the flushing interval of ports can be an optimal clinical strategy without negative outcomes.
Now that we are entering the latter part of 2020, it is clear that healthcare delivery has changed significantly but, as well as all of the difficulties that the pandemic has bought, it has presented us with opportunities. As we continue to try to establish our new normal, we may have to accept that it may not always be possible to do things the way they have always been done previously. That may not necessarily be a bad thing. Being committed to finding the best outcomes for our patients with IV access devices is paramount at this time and remains a continuing goal for us all.