Value and Evidence for Vascular Access Specialist Teams

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According to the Centers for Disease Control and Prevention (CDC) in 2011, “Specialized teams have demonstrated unequivocal effectiveness in reducing infections, complications and cost of infusion therapy.”¹ A Cochrane Review investigating vascular access specialist teams for device insertion and prevention of failure² define these groups as any of the following: infusion teams, intravenous teams and individual specialists (nurse, doctor, respiratory therapist, radiological technologist, nurse practitioner, and physician assistant) who have knowledge and skills through formal training and who frequently insert or manage vascular access devices.²

The Infusion Nurses Society infusion therapy standards of practice present practice criteria for an infusion team and include benchmarks for peripheral and central catheters, which include first-time insertion success, daily assessments, decrease in catheter-related bloodstream infections, increase in patient satisfaction, data collection for reporting quality outcomes, and impact on patient safety.³ The purpose and function of a vascular access specialist team (VAST) or trained individual may include the initial assessment and insertion and management of peripheral intravenous catheters (PIVCs), midlines, peripherally inserted central catheters, arterial catheters, and external and/or internal jugular, femoral, and subclavian catheters.⁴ Teams and individual specialist functions will vary and may exclude the insertion and maintenance of some of the devices and associated activities listed above. Other functions embraced by these specialists may include patient access for difficult blood draws, use of ultrasound guidance for any or all of the functions, dressing changes for central catheters, daily evaluation of catheter necessity, removal of unnecessary catheters, and monitoring of dressing and insertion site for complication identification. Additionally, they provide a professional point of care for education and resource of vascular access device (VAD) queries for device maintenance and management of complications.

However strong the evidence for specialized teams, professional application of empirical guidelines for teams within the acute care setting is limited.⁵ Whether through lack of awareness of guidelines and recommendations, changing administrative priorities, or perceived economic constraints, the hospital adoption and support of VAST has been erratic. Similar to specific services where a cardiologist is required for a particular cardiac problem to provide the best evidence-based care, it is logical that seeking the services of a trained vascular access clinician to initiate and maintain the most appropriate intravenous device is a worthy mandate. Given the growing complexity in patient needs, a unique specialist discipline, namely, the VAST, is surely needed to provide for patient needs. Specialty teams are also seen as models that not only improve patient safety and outcomes, but also can serve as a platform for clinical training of junior residents, medical students, and nursing clinicians. The evidence to date suggests that the highest-achieving system of initiating and delivering treatment to patients in acute care is inexplicably tied to a purpose-driven group of skilled individuals and the processes that guide their practices.⁶

Value of a Specialized Team

Evidence supports the value of a specialized infusion team for improved success with access, reduced insertion attempts, and reduced complications associated with intravenous or arterial device insertion. According to da Silva in 2010, use of a specialized team increased first-attempt success with only 16% of attempts requiring more than 1 attempt.⁷ Teams of specialized individuals performing insertion of PIVCs report increased first-time insertion success.⁸ Consistent across all VADs, peripheral and central, teams
historically represented the lowest levels of device-related complications.^9-12 Adoption of a team approach for care and maintenance has resulted in reduction of central venous access device (CVAD)–associated infections.¹³

Complications associated with VADs relate to the skill and knowledge of the operator for insertion^14-17 and for postinsertion complications related to maintenance by clinicians and patient-specific risk factors.^{9, 18-20} Specialized education has led to infection prevention practices that reduce complications.^21-23

Adverse vascular events are largely avoidable through specific practices of assessment and selection of the vascular access device with the lowest risk for the patient and their treatment. These practices are evidenced in a
variety of specific models, recommendations and guidelines such as the Society for Healthcare Epidemiology of America,²⁴ Vessel Health and Preservation: The Right Approach for Vascular Access,²⁵ MAGIC,26 Infusion Nurses Society Standards of Practice,³ the European Society for Clinical Nutrition and Metabolism,²⁷ World Congress of Vascular Access,²⁸ Evidence-based Guidelines for Preventing Healthcare-associated Infections,²⁹ and the National Institute for Health and Care Excellence³⁰ all recommending specific strategies to promote better clinical outcomes. Each of these organizations and publications focuses on the necessity of specialized training for inserters and those managing VADs that integrate infection prevention and practices that avoid complications. Despite these recommendations the majority of insertion attempts of VADs are performed by a diversity of clinical professional disciplines with little to no formalized education or current training on insertion, or the means to prevent complications. Emphasis is placed on the central line bundle and other practices that include device assessment for risk reduction as a key component.^1,31

Device selection and assessment are focused on indications specific to patient, treatment type, and duration factors that point to the type, size, and location of device insertion that best meets the need.²¹ Steps leading up to insertion of a VAD require the clinician to perform the initial patient assessment, which incorporates vein assessment, patient condition, and selection of the most appropriate site and device for the treatment, all leading to successful insertion, vein preservation, and positive patient outcomes throughout treatment. Performing a patient-individualized assessment provides valuable information necessary to select the most appropriate device with the lowest risk of infection, thrombosis, and overall complications that can most reliably allow the patient to complete therapy without interruption.

Advanced practice nurses and those receiving specialized training to perform insertions of all CVADs who work in collaboration with medical providers offer valuable contributions to the clinical care of acute and chronically ill patients in by performing insertions with low incidence of complications.^32-37

However, with respect to the quality and design of studies reporting that VAST positively impacts patients’ vascular access outcomes, there are no randomized, controlled trials to support or refute the role of the VAST. A Cochrane systematic review on VAST provides a glaring lack of any published interventional study to support this concept.³⁸ This is surely a wake-up call for associations committed to defining and growing the VAST concept, and perhaps the ambiguity on what constitutes best evidence when it comes to VAST would perhaps be resolved with interventional studies or, at minimum, prospective registered data sets.⁴ This lack of high-quality evidence may threaten the uptake and expansion of VAST and the reduction of complications related to the specialist role despite the CDC statements supporting specialized teams.¹

The purpose for the people, processes, and functions of a specialized team are to assess the patient for the most suitable VAD while providing (eg, inserting, recommending, assisting, and managing) reliable peripheral and/or central venous catheter access. Results of a cross-functional team demonstrated effectiveness in postinsertional care with statistically significant central line–associated bloodstream infection reduction with major economic impact.³⁹ Clinical guidelines and standards describe how teams and such processes can deliver successful patient outcomes.^3,1 However, such idealistic endeavors are often compromised by the lack of adherence and variety of clinicians responsible for assessment, device selection, insertion, and postinsertion management. All of this results in fragmentation of a service delivery leading to poor patient and clinical outcomes. Providing a consistent VAD assessment, insertion, and management service to patients in the pursuit of risk minimization involves health care personnel who have received special training. Patients indicate that the inadequate skill level of those performing these types of procedures is a source of great dissatisfaction.⁴⁰ These occurrences were exposed in the qualitative study of patient and staff experience, indicating a need for vascular access specialist as a quality initiative.⁵ Because of this, device and vein selection processes, qualified inserters, effective management and evaluation of practices, and clinical outcomes are improved as reflected in the elimination or reduction of complications, prolonged dwell times, reduced length of stay, and improvements in patient satisfaction.^41,42 Teams have the potential to effect improvements through both insertion and postinsertion care of patients. Providing dependable vascular access assessment, insertion techniques, and postinsertion care and management are necessary patient requirements to support modern health care treatment plans.

Conclusion

The value of specialized teams for insertion and management of vascular access has been demonstrated through numerous publications and a variety of research designs. While there are currently no randomized, controlled clinical trials that support the benefits of VAST teams, the CDC continues to evaluate and recommend this practice as a method to reduce complications and infection associated with vascular access devices. Additionally, standards for infusion therapy call for establishing or maintaining a team for CVAD insertion, maintenance, and removal, and the practice criteria to adopt. The discussion and research represented in this article underscore the potential advantages of VAST for assessment, insertion, management, and education with VADs. Underpinned by the concepts of vessel health and preservation, the application of specialty teams for insertion and management of vascular access devices may significantly contribute to the pursuit of making VADs complications history.⁴³

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