Vascular access devices (VADs) (peripheral and central) are vital for the administration of medication and other prescribed intravascular (IV) therapy. Although these devices are essential, they put patients at risks of complications. These include, but are not limited to:
CR-BSIs are associated with the insertion and maintenance of VADs and are among the most dangerous complications for patients (Loveday et al, 2014). HCAIs are reported to affect approximately 300 000 patients each year; they were responsible for over 5500 deaths from Gram-negative infections (such as Escherichia coli) in 2015 and were set to cost the NHS more than £2 billion by 2018 (Mackley et al, 2018). Studies have reported that between 5.1% and 11.6% of hospitalised patients will acquire at least one HCAI (World Health Organization (WHO), 2010), with the greatest risks in intensive care units (ICUs), where the prevalence is 23.4% (Health Foundation, 2015), and the proportion of infected patients can be as high as 51% (WHO, 2010). It is reported that bloodstream infections (BSIs) represents about 12% of all HCAIs, and occurrences in Europe have been estimated at over 4.5 million annually, with approximately 37 000 deaths as a direct consequence and an extra 16 million days of hospital stay (Zingg, 2015; Public Health England, 2016). HCAIs have a significant impact on morbidity and mortality; however, they are largely preventable. Consequently, reducing them has become the focus of infection prevention and control interventions and strategies.
In October 2013, a practice audit of VADs was carried out in the medical division of a 500-bed district general hospital. The aim of the audit was to examine the standards of post-insertion VAD care, and to assess compliance with the evidence-based guidelines available at the time (Royal College of Nursing (RCN), 2010; Loveday et al, 2011; O'Grady et al, 2011; Infusion Nurses Society (INS), 2011). Seven key care elements (Box 1) were audited, focusing on four main components:
The results demonstrated poor standards of care and low compliance with guidelines (McGuire, 2015). After the results were reviewed, it was clear that a change in practice was necessary. Based on the findings, a bundle strategy of training, education, and standardisation for IV devices, underpinned by the latest evidence-based guidelines was proposed, and introduced to transform practice by raising standards and improving compliance (Loveday et al, 2014; INS, 2016; RCN, 2016).
To evaluate the impact of the strategy, the audit was repeated across the same division (13 medical wards) in October 2018.
Method
Clinical audit is at the heart of clinical governance; it is necessary for reviewing the quality of care provided and to support continuous quality improvement (Health Quality Improvement Partnership (2016). Therefore, clinical audits are important in measuring patient care and outcome against explicit criteria to demonstrate improvement in practice, and maintain confidence in the quality of clinical care.
To maintain consistency in line with the 2013 audit, the Trust-approved audit form was used for data collection and the audit was carried out by two intravascular practitioners over 7 non-consecutive weekdays between 3 and 23 October 2018. Convenience sampling was used to capture all IV devices in situ on the audit days; the audit population was adult patients aged 18 years and above. The devices were physically examined and the visual infusion phlebitis (VIP) score (Jackson, 1998), and documentation recording checked on the electronic patient record system.
VIP is a tool used in practice to monitor VAD sites during every shift for signs of phlebitis and facilitate timely removal when complications arise. The tool has a score range from 0, which indicates no sign of phlebitis, to 5, indicating an advanced stage of thrombophlebitis. Peripheral venous catheters (PVCs) must be removed at the first sign of infusion phlebitis (stage 2 on the VIP scale), and all scores and actions taken documented (RCN, 2016).
Between 2017 and 2018 the Trust implemented:
Results
A total of 158 devices were audited, averaging 12.15 in each ward, with a range of 5–21 on each ward (Table 1). The results demonstrated a collective compliance rate of 87%, with a non-compliance rate of 13%. Of the 158 VADs audited, 99% (n=156) were PVCs and 1% (n=2) were peripherally inserted central catheters (PICCs). As in the 2013 audit, no short-term central venous catheters (CVCs) were observed with this latest audit. In total, 97% (n=154) of PVCs were in situ for 10 days or fewer, with 3% (n=2) in situ for longer; with a range of 1-15 days.
| Ward | Number of devices | Ward | Number of devices |
|---|---|---|---|
| 1 | 15 | 8 | 18 |
| 2 | 8 | 9 | 15 |
| 3 | 5 | 10 | 8 |
| 4 | 8 | 11 | 15 |
| 5 | 13 | 12 | 21 |
| 6 | 8 | 13 | 19 |
| 7 | 5 |
Total number: 158. Average: 12.15 devices per ward, with a range of 5 to 21
To validate the results the data was independently analysed by the Microbiology Senior Infection Surveillance Analyst. Analysis was carried out using STATAv12 software; 95% confidence intervals (CI) and two-tailed hypothesis tests for differences in proportions between the two audit periods were calculated (Table 2).
| Indicator | 2013 audit compliance (n=120) | 2018 audit compliance (n=158) | Difference in compliance | 95% CI difference | P |
|---|---|---|---|---|---|
| Intact, clean and dry | 77 (64.2%) | 126 (79.8%) | 15.6% | 5.0%-26.2% | 0.0037 |
| Site visible | 58 (48.3%) | 148 (93.7%) | 45.4% | 35.6%-55.1% | <0.0001 |
| Dated | 53 (44.2%) | 142 (89.9%) | 45.7% | 35.7%-55.8% | <0.0001 |
| Ongoing care and documented VIP* | 46 (38.3%) | 113 (71.5%) | 33.2% | 22.0%-44.4% | <0.0001 |
| Compliant with duration policy | 94 (78.3%) | 156 (98.7%) | 20.4% | 12.3%-28.5% | <0.0001 |
| Still needed | 82 (68.3%) | 130 (82.3%) | 14.0% | 3.7%-24.2% | 0.0066 |
Dressing
In the recent 2018 audit, compliance for the dressing being dry, clean and intact was 80% (n=126), displaying a 16% increase compared with 2013 (95% CI 5-26% P=0.0037). Appropriate application of the dressing was observed in 94% of cases (n=148), which is important for visual inspection of the VAD insertion site, an increase of 45% (95% CI 36%-55% P<0.0001) in compliance. Some 90% (n=142) of VADs in 2018 were dated, a 36% (95% CI 36%-56% P<0.0001) increase compared with findings of the 2013 audit.
Documentation
Ongoing documentation and recording of VIP score are vital elements in VAD care; 71% (n=113) had documentation for ongoing care, including VIP score. Compared with 2013, this was an increase of 33% (95% CI 22%-44% P<0.0001). It is worth noting from the 2018 audit that 93% (n=147) of VADs audited had a VIP score of 0; 3% (n=5) had a score of 1 and 4% (n=6) had a score of 2. VADs that had a score above 1 were removed and in cases that had a score of 1 staff were advised to monitor if still needed; all VADs that were not needed/unused were removed. In 2013, only 38% of VADs audited had ongoing documentation and VIP score recorded.
Duration
In 2013, the policy was for routine removal of PVCs at 72–96 hours. Since then, the Trust moved to a policy of clinically indicated removal (up to 10 days' dwell time) to align with recommendations based on best available evidence (Rickard et al, 2012; Webster et al, 2015). Of the 156 PVCs audited, 99% (n=154) were in situ for 10 days or fewer; only two were in situ for longer (1%). There was a 20% (95% CI 12%-24% P<0.0001) increase in compliance with the policy between the 2013 and 2018 audits.
Indication/need
Evidence-based guidelines recommend that IV devices should be removed when complications arise or as soon as they are no longer needed. A recent study by Guembe et al (2017) found that more than a quarter (25%) of the 70 PVC-BSI in their cohort was due to PVCs that were no longer needed. Therefore, daily assessment should consider risks and continued need for the device (Hallam et al, 2016). This audit identified that 82% (n=130) of devices audited were still needed. There was a 14% (95% CI 4-24% P=0.0066) increase compared with the 2013 audit. Although this is an improvement when compared with 2013, 18% (n=28) of devices audited had no clinical indication for use and should have been removed. It is worth noting that all the VADs audited were used at least once, none were found to be inserted ‘just in case’.
It is well established that PVCs are the most frequently used invasive devices and, while they are less frequently associated with BSIs, the incidence of PVC-BSI is estimated at 0.2–0.7 per 1000 device days (Zingg and Pittet, 2009). More recently, a systematic review by Mermel (2017) reported an incidence of 0.18% among 85 063 PVCs, with a range of 0–2.2%. A study by Mestre et al (2013) found that 30–50% of PVC-BSI were associated with peripheral vein phlebitis. It is worth noting that of the 11 PVCs that had a VIP score above 0, seven were in situ for 1-4 days (two with a score of 1 and five with a score of 2), and four were in situ for 5-11 days (three with a score of 1 and one with a score of 2). A score of 1 was for erythema alone and a score of 2 for erythema and tenderness/pain on palpation. Although a very small sample, it indicates that phlebitis does not increase with removal when clinically indicated compared with routine removal.
In 2010–2011 (at the Trust's larger hospital) 50% (n=4) of CR-BSIs were associated with PVCs and, more recently, 67% (n=2) were caused by PVCs. It is therefore in patients' best interests to ensure PVCs are treated with the same vigilance and ‘respect’ as CVCs with regards to infection prevention and control measures, surveillance and monitoring, regardless of whether they are removed routinely or when clinically indicated. According to Russo et al (2018), surveillance is a fundamental tool in successful infection prevention and control measures.
As can be seen, the results demonstrate improvement across all the care elements, which undoubtedly improved patient experiences, outcomes and reduced costs. Regular surveillance and spot checks with timely feedback, staff engagement and support, coupled with bi-monthly trust-wide audits to evaluate standards, put the spotlight on VAD care and gave it priority along with other patient safety and quality improvement initiatives. Although this is a good achievement and should be celebrated, there is no room for complacency. Therefore, the focus must be kept on training and education, driven by ownership and strong leadership to support continuous improvements.
Discussion
The 2013 audit demonstrated that change was needed to improve standards of IV device care and this was widely accepted. Having established this, the next step was to raise staff awareness and get engagement and buy-in from all stakeholders within the organisation (board to floor) to increase the likelihood of success. According to Loveday et al (2014), when values and beliefs are shared by all, implementation of evidence-based guidelines is more likely to succeed. The Trust strives for excellence, and embedded in its strategic vision is a commitment to consistently deliver high-quality effective patient care. Nevertheless, improving practice requires making changes, and introducing/implementing change (large or small) to support quality improvement in any organisation is challenging; probably more so in the NHS. Despite the challenges, change can be accomplished through small improvements over time—an aggregation of increments. Therefore, due to the known challenges (particularly with current financial pressures), it was necessary to establish that, in order to reduce costs and disruption, the planned change would use an established strategy that has produced significant improvement in the larger hospital in the author's Trust (Caguioa et al, 2012).
Introducing a ‘bundle’ strategy of staff training, education and standardised Epic guidelines (Loveday et al, 2014) emphasised education, training and assessment of knowledge for all clinical staff involved in VAD insertion, use and care. This is necessary to improve patient outcomes and reduce healthcare costs. Loveday et al (2014) further emphasised performance improvement through the implementation of bundle strategies as a benchmark for quality assurance. They noted that ‘educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit and feedback’. Other research has found that education and training for VAD insertion and care with frequent updates, audit and feedback improve care and reduce CR-BSI rates (Rosenthal et al, 2003; Yilmaz et al, 2007; Boyd et al, 2011; Fakih et al, 2013; Guembe et al, 2017). In addition, evidence demonstrates that the risk of infection declines following standardisation of VAD equipment and care (Loveday et al, 2014).
The results of the audit were shared with staff at all forums (including Grand Rounds, which are regular multidisciplinary meetings for education and discussion, other meetings and committees), and via other communication channels such as emails, the intranet and daily bulletins. Discussions then took place with senior managers to agree the form that training and education would take, the method of delivery and dates. This was followed by organising and advertising to ensure everyone was aware of the need for improvement and the plan to implement a change in practice. Consistent ‘gold standard’ VAD care based on best available evidence is necessary to improve patient safety. Accomplishing this is dependent on a combination of different strategies, initiatives and interventions implemented together to increase effectiveness.
This includes close working with the procurement team because it plays an important role in the standardisation process. The team is instrumental in ensuring the right equipment is sourced and in the right place and available when needed. Equipment suppliers also played an important role in providing information, training and education to clinical staff on new products to ensure that they are used safely and effectively.
The care bundle, which includes the training and education sessions with HANDS (hand hygiene, antisepsis, non-touching of key parts, documentation/daily inspection and sharps safety) (Caguioa et al, 2012) and aseptic non-touch technique (ANTT) (Rowley and Clare, 2009), was introduced as the central component in early 2014. A key approach of care bundles involve assembling evidence-based or logical actions into a group of tasks to be performed consistently. Research has shown that using care bundles as part of a varied approach is beneficial when this is done in conjunction with other strategies (Health Foundation, 2015). The training sessions (in 1-hour slots) were delivered by the IV team in a classroom setting and consisted of a video demonstration and a short questionnaire, followed by practical application of key standards to insert, access and manipulate VADs. This training is mandatory for doctors and nurses of all grades.
According to Zingg and Marschall (2018), a guiding principle of training and education should be that it is hands-on, at the bedside and/or in the skills lab. To achieve best results, strategies must be multimodal, including using technology such as e-learning, and following best practice (Hallam et al, 2016); this is also supported by Zingg and Marschall (2018).
Other initiatives
As part of a wider strategy and to strengthen the foundation embedded through training, education and standardisation to maintain continuous improvements, other initiatives were introduced. These include the following.
IV link nurse programme
An IV link nurse programme with clearly defined role and expectations and quarterly educational master classes was introduced. Sopirala et al (2014) found that link nurses with clearly defined goals and continuous education are effective in helping to reduce HAIs. The IV link nurses are supported by the IV team, practice development nurses and ward managers to become experts in their role in order to influence practice in their wards/units. They play a vital role in sharing/disseminating information, training their peers, and challenging poor practice through empowerment and ownership, to ensure patients consistently get the best care. Studies have shown that behaviour change interventions are effective in reducing infections, and the IV link nurses are best placed to influence behaviour change locally.
Practice development nurses
There has been an increase in the number of practice development nurses. In 2013, there was only one such nurse within the district general hospital; there are now a total of 13. Practice development nurses are instrumental in the improvements that have been achieved because they work closely with the IV team, IV link nurses and ward managers to ensure standards are maintained to aid continuous learning and improvements. They also deliver the HANDS/ANTT mandatory training sessions.
Healthcare assistant training
Selected healthcare assistants were trained in cannulation skills and to recognise deficits regarding PVCs such as a compromised dressing (wet, loose, soiled, not dated etc) and to report any such findings to senior staff and rectify as instructed. They are supported in their role by the practice development nurses, ward managers, matrons and staff nurses. Healthcare assistants are well placed to recognise, report and rectify deficits as they spend more time providing care and interacting with patients than other staff.
Patient and wider multidisciplinary team involvement
Patients should be involved in decisions about their own care. They have a unique role to play and should be actively encouraged to be partners in their care, and decisions about which IV devices are appropriate for them. Everyone (including patients and their carers) have a responsibility to be active participants, because passive support will not change anything. Maintaining ‘gold standards’ in VAD care is a multidisciplinary effort, and all individuals and teams (nursing and medical) are engaged and work together to ensure practice and standards are uniform. This includes working with the community nursing team to align standards of care to minimise complications that create a ‘revolving door’ effect.
Identifying key issues: ‘the Big 3’
Wards also introduced ‘key areas’ by identifying non-compliance and focusing attention on one, two or three issues. These issues are discussed at senior manager governance meetings and decisions made on priorities, eg VAD documentation, VIP score and timely removal when no longer needed. The ‘Big 3’ is part of daily handover, ‘huddle time’ and the focus for 2 to 4 weeks at a time. During this time, spot checks are carried out by a designated nurse in each ward and feedback provided to the team. All staff are involved in the process to promote engagement and ownership. At the end of the timeframe, the Big 3 issues are evaluated and overall feedback provided; this is an ongoing process. Ward managers noted that it takes ‘persistence and perseverance’ to ensure standards are maintained, but implementing small changes like the Big 3, increases engagement, motivation and improves patient care.
Recent developments
The following practices have been introduced.
Use of the Vessel Health and Preservation framework
The Vessel Health and Preservation framework has been followed to provide a proactive patient-focused approach by ensuring timely intentional VAD selection during the first 24 hours of a patient requiring access, followed by placement of a clinically appropriate device within 48 hours (Moureau et al, 2012; Hallam et al, 2016). This is very apt because other options for an appropriate VAD are usually considered only after peripheral veins have been exhausted. The framework also encourages the timely removal or replacement of VADs when clinically indicated or no longer needed.
Electronic patient records
Electronic patient records have been introduced to align with the other hospital sites to benefit patients, staff and the organisation as a whole through better patient care, satisfaction and outcome, a reduced workload, improved efficiency and risk reduction. Having records and patient information in one place with ease of access improves communication between teams, which invariably benefits patients. Electronic records also provide the facility to collect data for audit purposes.
Daily notification report of all VADs
A daily notification report of all the VADs is recorded on the electronic patient records within the hospital. The report is automatically generated from the electronic patient records and sent at 07:00 every morning to the IV team, IV link nurses, practice development nurses, ward managers and matrons to help in the monitoring and timely removal of VADs. This report indicates the status of each device by rating it green, amber or red:
Implementation issues
Success cannot be attributed to a single initiative. It takes a combination of initiatives, none of which is a ‘silver bullet’ but each adds a small increment that contribute to a positive impact on VAD care. Although the introduction of electronic patient records should make the process of recording/documenting of VADs easier, this was not the case because documentation was below the 95% target set by the Trust. One explanation provided for non-compliance was that some devices were inserted in another ward/unit and some staff did not know how to order or record the device on the system. Devices may have been inserted elsewhere; nevertheless, the onus is always on the staff caring for an individual patient to ensure each patient's device is recorded and monitored. This information is a core component of training and education sessions. For staff who did not know how to order/record a device, the opportunity was used to provide on-the-spot training on electronic patient records/electronic prescribing and medicines administration. Every opportunity should be used to engage and educate clinical staff, execute actions and evaluate results as a continuous process of quality improvement.
Other reasons identified for non-compliance with documentation are:
Implementing quality improvement initiatives to raise standards of care through training and education, underpinned by evidence-based guidelines, is the right thing to do for patients, other service users and staff. Change is triggered by a need to respond to events; nevertheless, implementing any kind of change to improve practice is never easy, but it is achievable through an aggregation of small gains. Staff are encouraged to take ownership, which is important but not sufficient in the pursuit of consistent high-quality care (Department of Health, 2008). This requires clinical leadership, which is pivotal in making change happen.
Since the implementation of evidence-based guidelines and the bundle strategy in 2014, there have been no VAD-associated meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections at the district general hospital. However, there has been one confirmed VAD-associated meticillin-susceptible S. aureus (MSSA) bloodstream infection. This, along with the improvement in standards that can be seen across the care elements, is testament to the hard work and vigilance of everyone involved in the care and monitoring of VADs.
As noted by Zingg and Marschall (2018), guidelines alone do not change practice and knowledge alone does not change behaviour. However, this is a process that requires a variation and combination of strategies/initiatives, multidisciplinary engagement and strong leadership over time, with a good helping of commitment, conviction and inspiration.
Conclusion
Prevention of CR-BSIs is everyone's responsibility, and implementing strategies to improve practice has been shown to be effective. The success that has been achieved is attributable to a combination of initiatives, including regular surveillance and monitoring with timely feedback, making problems visible and therefore actionable. These are important tools in the drive to maintain high standards in order to deliver consistently high-quality patient care. Ownership, strong leadership and resources (human and material) available in sufficient quantity are the main ingredients needed to make optimal VAD care the norm; built into routine and hard-wired into practice. In order to make this the yardstick by which excellence is measured, senior managers need to create the right conditions and support structure to maintain standards, sustain continuous improvements and excellence in VAD care.