The Michigan Risk Score validation project in Brazil is heating up! Since the last time we spoke with Prof. Eneida Rejane Rabelo da Silva, the PICC-Brazil Research Group has been hard at work. Here is what has happened since our last update.
Dr. Naomi O'Grady is a Senior Staff Physician at NIH and first author of the CDC Guidelines. She recently wrote a thought piece for Annals of Internal Medicine. We sat down with her to have a discussion about her article, central line-associated bloodstream infection (CLABSI) and measurement of this infection. Here are some of our excerpts:
VC: CLABSI has become such a volatile HAI. Given all the penalties and public reporting, no wants to have one. And hospitals that do have one now have to report these data publicly - leading to all kinds of problems. What are your views on the policy for CLABSI reporting in the US? What impact has this had?
NG: The precise impact of public policy on CLABSI is unclear. In 2008, the Centers for Medicare and Medicaid Services (CMS) instituted financial penalties for hospitals with higher-than-expected CLABSI rates. At least two studies have reviewed the effects of such penalties on CLABSI rates: one suggested no effect, while the other reported a decline in infection. Whats important is to understand whether financial penalties have actually changed practice at the bedside. One fear is that such policies may dissuade clinicians from ordering blood cultures in patients with central venous catheters (CVCs). Less testing for CLABSI, in turn, could result in lower detection of CLABSI—improving hospital performance without changing patient outcomes.
In addition to the non-reimbursement policies instituted in 2008, several states instituted public reporting of hospital-acquired infection rates for hospitals. In 2004, only 4 states had such a requirement, but in 2016, 38 states and the District of Columbia required public reporting. Again, it is difficult to ascertain how these policies impact care at the bedside. But, by design, they pressure hospitals to reduce CLABSI to zero. It is well known that economic incentives to influence practice can lead to unintended consequences. In the case of CLABSI , financial pressure could lead to changes in the way that CLABSI is defined or detected.
VC: Lets talk a bit about measurement - there are challenges there, right?
NG: Well, determination of CLABSI rates is inherently dependent on the definition of CLABSI and methods used for case-finding. Changes in either of these influence the interpretation of CLABSI data over time. The National Healthcare Safety Network (NHSN) definition of CLABSI includes three components: 1) The presence of a laboratory confirmed bloodstream infection; 2) in a patient with a CVC; 3) with no alternative source of bacteremia identified. The last of these components is especially subjective. Policies tying public reporting to non-payment could influence hospitals to adopt an intense explanation for “alternate sources” of bacteremia. Of note, such relentless searches did not occur when financial consequences were not present. Thus, while CLABSI rates over the past 2 decades may have been over-estimates of the actual rates, it is plausible that current accounting strategies may be underestimating CLABSI, especially if some are attributed to other sources of bacteremia. Even with rigorous application of the NHSN definition, inter-rater reliability can be less than optimal.
VC: What about the new mucosal barrier injury (MBI) addition? Has that helped in getting closer to truth?
NG: The new mucosal barrier injury (MBI) category is intended to improve comparability of CLABSI rates by specifically classifying infections caused by certain pathogens as non-CLABSIs. The addition of MBI to CLABSI was a welcome change, especially for institutions caring for large numbers of cancer patients. But, as expected, retrospective studies showed an overall decrease in CLABSI rates when MBI cases were considered separately. Thus, whether lower CLABSI rates after 2013 reflect actual improvement in patient safety or artifact related to changes in classification remains unclear.
VC: CLABSI rates have gone down over the past few years. Your comments make me wonder: is the decline real, or "fake news?"
NG: Many factors have contributed to changes in CLABSI rates over time. Some changes have made a real impact on patient care. Conversely, others may have altered the numbers without improving patient outcomes.
VC: So what should clinicians and hospitals do?
NG: Facing this uncertainty, I think our focus should continue to remain on ensuring CVCs are used for appropriate indications, removed when no longer necessary and bundled strategies for CLABSI prevention are rigorously implemented. In addition, hospitals should internally monitor CLABSI rates over time. In this way, internally consistent data rather than comparisons with other institutions employing alternative definitions or measurement strategies may be used to assess progress.
VC: Any closing thoughts?
NG: Perhaps we will never know how much of the recent improvement in CLABSI rates is real versus how much is “fake news.” Regardless, we must continue to refine our definitions and data. After all, we should be zeroing in on zero when it comes to CLABSI. Our patients count on it.
Validation of the Michigan Risk Score for use in Brazil - A Multicenter Study
We are delighted to conduct this multi-center study in Brazil with the partnership of Prof. Dr. Vineet Chopra, from the University of Michigan, who was responsible for the development of the Michigan Risk Score (MRS). The MRS aims to estimate and predict risk of Peripherally Inserted Central Catheter (PICC)-related thrombosis. Although the score was developed and internally validated, it has not yet been externally validated. In fact, in Brazil, no tool to estimate the risk of PICC thrombosis currently exists. Therefore, in this study, we propose to externally validate the MRS and evaluate its applicability to the population in Brazil.
We will conduct this study in 23 institutions in Brazil, with representation from all of the 5 major regions of the country (Figure). All participating center have agreed to developing a dedicated team to this project, members of whom will be responsible for data collection. All researchers will use a standard protocol for data collection and will be trained by the coordinating center prior to starting the study. In order to ensure ongoing collaboration of this group to continue to study more vascular access questions. All of the principal investigators (PI) are registered in a PICC-BRAZILIAN RESEARCH GROUP
This group will not only collaborate for this project, but can now engage in other projects moving forward. The researcher responsible for this project in Brazil is Prof. Eneida Rejane Rabelo da Silva, RN, ScD
(CV: http://buscatextual.cnpq.br/buscatextual/visualizacv.do?id=K4701295A6) with her research group from the Hospital de Clínicas de Porto Alegre and the Universidade Federal do Rio Grande do Sul. We estimate that we will be able to accrue a sample size of 24,150 patients (including 5% of losses) in order to validate the MRS score. We propose to collect these data for analysis over an 18-month window.
I hear it everywhere I go.
"I wish I could have known that patient would have had a DVT..." "If only I could have done something different before ordering or placing the PICC..." "I had this feeling they were high risk, but I wasn't sure and it seemed like a reasonable choice..."
All of these are aphorisms of the sinking feeling when you get the call: the ultrasound is positive, and the patient has a PICC-DVT.
We know there are evidence-based ways to prevent this:
But even if you follow all of the above recommendations - some patients will still have a PICC-related DVT.
Is there a way to know?
I'm referring specifically to a crystal ball here - a way to be able to predict who will have a DVT and who won't, if you follow best practice.
That is what the Michigan Risk Score (MRS) does....
We looked at over 20,000 patients and separated those that had a PICC DVT from those that did not. Then - we went back in time to before the PICC was placed. What was it about those that had a DVT that different substantially enough from those that did not? Was there a signal?
We certainly found one - and published this for others to see/use. Here are the risk factors:
1. Presence of another CVC when the PICC was placed.
2. WBC count > 12, 000 at the time of PICC insertion
3. Number of PICC lumens
4. History of Venous Thromboembolism
5. Active cancer
Selecting each of these displays a final score and risk class (I-IV, IV being highest) that can then be used to determine whether the PICC is the best choice for the patient. This is particularly true for those with cancer or patients who have had prior VTE - since avoidance can be the best treatment in this subset as shown in the picture below.
There are a number of resources that can make this easier for you to apply on a day-to-day basis - before the PICC is ordered or placed (see below for links).
The MRS is now being validated through the leadership of a number of brilliant investigators and committed hospitals in Brazil. The project will likely take 18-24 months but will provide invaluable information about how the MRS performs and whether it can be improved. It's through tools like this - the proverbial crystal ball - that our patients will be best served.
See more information about the MRS and find a handy calculator here.
The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) is an evidence-based series of recommendations that provide guidance on how best to use, manage and care for vascular access devices. MAGIC is now being used in hundreds of hospitals across the nation, and many hospitals overseas.
But the question remains: does MAGIC work to improve patient safety?
Until recently, we all wanted to believe that it did. And belief was all we had...
But thanks to work by an inspirational physician and her team in a Michigan Hospital - now we know.
Dr. Lakshmi Swaminathan and her Vascular Access team led a real world "validation" study of MAGIC. Validation is a scientific process where a method or idea is removed from it's origin (or derivation) and makers and placed into a brand new environment to see if it "works" as designed. Often used for statistical models for prediction, validation serves to affirm that the method or research described does what is intended - while providing valuable insights about what worked and what didn't and why.
In an article published in this months British Medical Journal - Quality and Safety (BMJQS), Dr. Swaminathan and her team report findings following an interrupted time series implementation of MAGIC in their hospital. To ensure findings were rigorous, they compared their results to ten other hospitals involved in the Michigan Hospital Medicine Safety collaborative - members of which are all focused on PICC use and outcomes. Thus, this study answers a specific and important question: among hospitals all working to improve safety and use of PICCs, does adding MAGIC make a difference compared to baseline?
The results: absolute rates of inappropriate PICC use dropped 26% more than other sites. Even after adjusting (or taking into account) patient complexity, hospital characteristics and other improvements - MAGIC improved PICC appropriateness by 13.8%. Importantly, PICC complications also decreased at a substantial rate (34%) compared to other hospitals (26%).
In short - MAGIC worked to improve PICC use and patient safety, and does so in ways more than other quality improvement work might suggest.
But (as with all real world research) there are some important caveats. First, although the authors used a robust study method, this was not a randomized trial. Thus, unmeasured factors might explain the difference across the study hospital vs. other control sites. Second, multiple components of MAGIC (an electronic tool, algorithm, educational roll out and nurse-based checklist, etc.) were used; which component was the most critical (or was the "active ingredient") is not known. And finally, although the reduction in complications was great and outpaced that of other hospitals - it wasn't good enough to achieve statistical significance for CLABSI and DVT. A larger study with more patients is needed to better understand this aspect.
So what does this study add? A few key things: first, we know from this work that implementation of MAGIC leads to improved PICC appropriateness and outcomes at a hospital other than where it was created. This is good news, as other hospitals (particularly community hospitals where this work was performed) that use MAGIC are likely to see similar benefits. Second, we know that MAGIC reduces complications from PICCs more than hospitals using other QI approaches: thus, hospitals struggling with occlusion, CLABSI and DVT might particularly benefit from using MAGIC. And finally - this study tells us that a vascular access team driven initiative can have huge payoffs to a hospitals bottom line. The implementation study in this facility was driven largely by the vascular access team - and saved hundreds of thousands of dollars for this facility in terms of reduced complications and device appropriateness. That's the bottom line for many C-suite level leaders - and that helps answer why we need more vascular access teams in the country! If you're interested in learning more, check out our CLABSI and DVT Cost Calculator for a savings estimate!
But perhaps the best part of this work is that it lives beyond a paper in a journal. The team at this hospital continues to experience great reductions in inappropriate PICC use (including in ICU patients) and outcomes (all VTE in the hospital) as shown in the slideshow below! And the patients are simply better for it! That, perhaps, is the greatest reward of them all!
You'll find some key components of the MAGIC study in the links below, and you'll find a copy of the published article there as well. Please do share widely and post your comments and feedback. And remember - the easiest way to use MAGIC is through the app - which is available for free here!
Get your MAGIC On!
We all know that central line-associated bloodstream infections (CLABSI) are common, costly, morbid and lethal. While many interventions such as the checklist, bundle, and chlorhexidine-based products have been introduced to prevent CLABSI, the struggle continues for hospitals across the country. And for many – the battle is not being won.
One reason why CLABSIs are so hard to tackle is because the root causes of these infections are multifactorial. For example, not having the right team members or expertise to examine CLABSI cases represents a key gap in preventing future infections. Similarly, lack of support from leadership to implement change or trial new products can also be a barrier to infection prevention. In short – hospitals need a tool to diagnose their approach to CLABSI to understand what they can do better and where limited precious resources might be best directed.
Until recently, such a tool did not exist. However, we at the Patient Safety Enhancement Program at Michigan Medicine have developed a first-of-a-kind tool to help hospitals “diagnose” their CLABSI prevention efforts. Called the CLABSI Guide to Patient Safety (or, CLABSI GPS) this tool allows hospitals to understand what they are doing well – and what they are not. Developing following years of research, site visits and data analyses, we hope many members of the patient safety team – vascular access teams, infection preventionists, hospitalists, infectious disease physicians and various subspecialists – will use the team to help inform their CLABSI prevention efforts.
Tell us what you think about the CLABSI GPS by dropping us an email here. And thank you for working hard to keep your patients safe!
The recommendations found in the Michigan Appropriateness Guide for Intravenous Catheters, can now be found in an easy to use mobile application available on the iTunes App Store and on the Google Play Store.
The application is free and available for download by anyone with a mobile device running iOS / Android.
Based on user feedback, the Michigan Magic App will present the user with an easy to use set of recommendations on the appropriateness or inappropriateness of intravenous catheters as well as further information derived directly from the MAGIC publication.
Future iterations of the app will be expanded to include recommendations for patients as well as other types of providers so be sure to keep an eye out for updates!
For additional information on how to use the Michigan MAGIC app, please feel free to watch the short demonstration below narrated by Dr. Vineet Chopra.
"We have to keep moving forward" says a patient who helps shape research in vascular access
You might think that someone who spends nearly two months of every year in a University of Michigan hospital room would want to stay as far from the place as possible the rest of the time.
But not Georgiann Ziegler.
In fact, she says, it’s what she’s experienced as a “frequent flyer” at U-M over the last 12 years that keeps her coming back. Not just as a patient, but as a key member of several research and health care improvement teams.
“I’m a firm believer that what they [physicians] learn today from me could help somebody else, who won’t have to deal with what I’m dealing with,” she says “It may not help me today or tomorrow – but it definitely will help the next generation and maybe even me down the road.”
A patient behind the scenes
Georgiann has chronic pancreatitis, a disease that causes flare-ups of painful pancreas inflammation throughout the year.
She also has a port – a device implanted just under the skin of her chest that lets her U-M care team deliver pain medicine, nutrition and more without having to find new veins to put needles in every time she comes to the hospital.
Ports and their "cousins" called PICCs are known as vascular access devices because they provide a direct gateway to the bloodstream. They make life a little better for many patients every year – and for their caregivers.
But they also carry serious risks, since they can act as highways for germs to enter the body, or for dangerous blood clots to form. Georgiann experienced such a clot – called a DVT for deep vein thrombosis – herself.
U-M doctors who specialize in caring for hospitalized patients have studied the risks and benefits of devices such as PICCs and ports for years. They wanted to take that research to the next level, by making a guide to help doctors and nurses around the world understand which device to use, in which patients, and when, to get the best and safest result.
That’s where Georgiann came in.
Three years ago, the doctor who first suggested she get a port asked her to join the team that would write the guide. Vineet Chopra, M.D., M.Sc., was gathering experts in vascular access devices from U-M and around the world. But he wanted a patient’s perspective. And who better than Georgiann?
Even though she’s not a shy person, she remembers feeling in awe when she sat down at the table with the doctors, nurses and safety experts.
But then came a pivotal moment -- when the experts were debating a point about how to numb the skin of a patient who’s getting a new device. The only one in the room who knew just what that felt like was Georgiann. She helped them understand the issue from a patient’s perspective.
“As a patient or family member, we do not realize the work, time and dedication that goes into implementing the things out there that make us better,” she reflects. “Now that I’ve been able to sit in in on these efforts, I see it’s not just someone saying ‘I think we should do it this way.’ I have a greater appreciation for the things that are being done for me, and other patients, day by day in health research.”
The team of experts published their guide, called MAGIC for Michigan Appropriateness Guide for Intravenous Catheters, in 2015. Since that time, Georgiann has helped spread the word about them, bringing the patient’s perspective to gatherings of health care providers learning about the new guide.
“Having Georgiann as part of our MAGIC development team was invaluable,” says Chopra. “She provided an important perspective on selection of vascular access devices, including what types of information patients need, and how best to share decision-making with patients. Without her input, I am certain that the final product would not have had this important viewpoint for providers and stakeholders."
Above and beyond
But Georgiann’s role as the patient voice in improving care didn’t end with MAGIC. She now serves, with Chopra and a range of other patients and providers from around the country, on the steering committee of an effort called i-HOPE funded by a grant to the Society of Hospital Medicine.
Short for Improving Hospital Outcomes through Patient Engagement, it’s an effort funded by the federal Patient Centered Outcomes and Research Institute to better understand how patients, families, and others view the most important gaps in hospital care.
“Most patients and family members don’t have an understanding of how hard it is to get things implemented and to have it done right,” she says. “They don’t understand the behind-the-scenes work. As a patient it excites me to see that nobody’s giving up, especially when you have a condition like I have.”
Georgiann also serves on Michigan Medicine’s Patient, Family, Staff and Faculty Advisory Council, and in the U-M Medical School’s education program for medical students to learn from patients. She’s agreed to let her blood be used for laboratory research on pancreatitis, and allows student nurses to practice their port-related skills on her. She crochets blankets for hospitalized patients. And she even posed for a photo shoot to remind hospital laundry workers how much patients appreciate the clean sheets and gowns they deliver around the clock.
She’s also seen how care at U-M has changed over the years, because of new research on the best way to treat patients like her or prevent things like infections and DVTs.
That kind of research – aimed at improving health care delivery – may not get as much attention as the latest drugs for cancer or kidney disease, she says. But she hopes that funding for health care research stays strong.
“We can learn a lot from what’s already been done, but everything evolves and we have to keep moving forward, and figure out best practices that work,” she says. “I hope that the passion I saw around the MAGIC table continues – and that I can say to the researchers, ‘Thanks for doing this, because the things you find are helping me and other patients.’”
To learn how you can take part in research at U-M, as a healthy volunteer or in studies that need people with certain medical conditions, visit https://umhealthresearch.org/
As the CEO of the Infusion Nurses Society (INS), Mary Alexander is responsible for managing an international, nonprofit specialty nursing organization by assuring the consistent delivery of professional services to its more than 7,000 members. As the Editor of the Journal of Infusion Nursing, a scientific, research-based, peer-reviewed publication, Ms. Alexander writes bimonthly columns for the journal. She also handles editorial responsibilities for a bimonthly membership newsletter, INS Newsline. She is the Editor-in-Chief of the Core Curriculum for Infusion Nursing, 4th edition and Infusion Nursing: An Evidence-Based Approach. She is also responsible for the credentialing program of the Infusion Nurses Certification Corporation. We asked her to share her views and experiences with us this month.
VC: Tell us a bit about yourself and the Infusion Nurses Society?
MA: I began my career as a registered nurse at Massachusetts General Hospital (MGH) in Boston, MA, on a surgical floor, and after 3 years joined the IV team. In fact, MGH was the first to allow a nurse, Ada Plumer, one of the founders of INS, to be responsible for IV therapy administration. She eventually developed the first IV team. My clinical experience as an infusion nurse spans a variety of practice settings, including home care, alternative sites, and acute care settings.
In 1997 I was appointed as CEO of INS and INCC (Infusion Nurses Certification Corporation), where I serve as the editor of the Journal of Infusion Nursing (JIN), Core Curriculum for Infusion Nursing, and Infusion Nursing: An Evidenced-Based Approach. I’ve served the organization in a wide variety of roles at the local and national levels, including terms on the INS Board of Directors. My position has also taken me around the globe delivering infusion education programs to clinicians in Armenia, Brazil, China, Colombia, India, Japan, Mexico, and New Zealand, to name a few. I’ve maintained my certification in infusion nursing (CRNI®) since 1985, achieved the Certified Association Executive (CAE) designation in 2005, and was inducted as a Fellow in the American Academy of Nursing in 2008.
INS was established in 1973 and currently has over 7,000 members worldwide including 40 countries and territories and 3,500 CRNI®s. There is approximately a 50-50 split with INS members practicing in the hospital/acute care settings versus home care and alternative sites. Our mission is to set the standard of excellence in infusion nursing by developing and disseminating standards of practice, providing quality education, supporting research and certification, and advocating for the public, our patients. In order to meet our members’ needs and address nonmember queries, we provide numerous infusion-related resources—from face-to-face meetings, webinars, books, online offerings, position statements, JIN, and more, that can be found on the INS LEARNING Center.
VC: In 2016, INS released an updated version of the Infusion Therapy Standards of Practice with a subtle change to both its title and content. What’s new with this version?
MA: The 1st edition of the Infusion Nursing Standards of Practice was published in 1980. With the ever changing healthcare environment, advances in science, and increasingly more complex technology, INS is committed to revising the Standards every 5 years. This reference provides the framework to guide safe infusion practice to ensure the best patient outcomes.
While the title change for the 2016 Standards is subtle, there is a significant distinction. INS recognizes that not one discipline “owns” infusion therapy, but is the responsibility of all clinicians involved with infusion practice. Since infusion care goes beyond nursing, the title was changed to Infusion Therapy Standards of Practice. This change also aligns with today’s interprofessional approach to healthcare.
In this 7th edition, 4 new standards have been added (infusion team, vascular visualization, CVAD tip location, and nerve injuries) and other sections have been expanded to offer more guidance to clinicians. Explanations were added for clarity around the methodology for developing the Standards, including rating the strength of the body of evidence and determining practice criteria recommendations. Of note, the Standards Committee added rating V, “Committee Consensus”. It was applied when there was a lack of literature or very low levels of evidence with conflicting findings. Less than 2% of the practice criteria have this rating.
The 2016 Standards cites 350 more references than the 2011 Standards, a testament to the advancing science and research of infusion therapy. There was also a shift in the rankings of the strength of the evidence, with a 2% increase in Level I rankings (highest rating) and a 21% decrease in Level V (lowest rating) compared to the 2011 Standards. The distribution of rankings has changed thanks to the nature and robustness of the research.
VC: One big difference in the Standards is the recommendation regarding pH and route of therapy. Take us inside the conversations regarding this topic. Tell us more about this update and why it was made.
MA: Since 1998, the Standards has viewed pH as a critical factor in vascular access device (VAD) selection. It stated that infusates with a pH less than 5 or greater than 9 are not appropriate for short peripheral or midline catheters. The belief was that infusing those solutions peripherally would increase the incidence of phlebitis and infiltration, therefore implying that a CVAD should be selected in those situations. Recent evidence has shown that there are significant risks associated with CVADs, such as central line-associated bloodstream infection (CLABSI), deep vein thrombosis (DVT), and an increased utilization of unnecessary peripherally inserted central catheters (PICCs).
Committed to evidence-based practice and promulgating standards based on the strongest research available, the Standards Committee reviewed the evidence which was supporting the abandonment of using pH as the sole factor in device selection. As a result, the decision was made to revise the previous statement related to pH and device selection to reflect the current evidence.
VAD planning and selection requires critical thinking, and analysis and decisions should not rely on one factor only. In addition to the pH, the prescribed treatment, duration of therapy, vascular characteristics, and the patient’s age, comorbidities and history of infusion therapy should also be considered.
VC: Many people ask us whether the term infusion nurse and vascular access (VA) nurse are interchangeable? What do you think?
MA: There is confusion as to the definition of each role, in particular with patients, families, and caregivers, who may view them as one in the same. However, in my estimation, the terms infusion nurse and VA nurse, are not interchangeable.
A VA nurse is primarily focused on the pre-insertion assessment and the actual VAD insertion procedure. Post-insertion care and management may be limited based on the care setting. For instance, those in a radiology department may only be placing lines, not managing them after insertion.
The specialty practice of infusion nursing has a broader scope. In addition to preinsertion decision making, VAD insertion, and care and management, infusion nurses include additional aspects of care such as medication administration, fluid and electrolyte management, and nutritional and blood component therapy – the infusions going through the VAD. They address VAD complications and the relationships with the sciences of pharmacology, immunology, nutrition, to name a few. Preventing and managing complications from the therapies, along with those from the VAD, are fundamental elements of the specialty. Also, infusion nurses are employed in a wider variety of venues. Often VA nurses are performing procedures in a facility-based setting, while infusion nurses are practicing in all venues—acute care, home care, ambulatory care, and long-term care.
VC: We recently released the MAGIC document to guide vascular access device choice and care. How do you see this influencing infusion and vascular access practice? Did it influence the Standards?
MA: The conclusions from the MAGIC document offer constructive guidance for infusion and vascular access practice. It demonstrates that it’s not easy to apply a one-size-fits-all position when dealing with patient care issues. Patient assessment is key, an important aspect of infusion care that INS has long endorsed. The paper also provides a foundation to support practice, not just for the indication of PICC use, but the need to standardize care and maintenance practices based on evidence and research. With an array of different devices and equipment (e.g., visualization devices, ultrasound) to best meet our patients’ needs, clinicians must be vigilant in selecting devices best suited for the patient.
The MAGIC paper was cited as a reference in several Standards, VAD planning, site selection, VAD removal, infection, and CVAD malposition, to name a few.
VC: What are the three biggest challenges you see for infusion and vascular access nursing?
MA: First, a major issue is the lack of standardization in clinical practice. Many nurses get little to no infusion education in nursing school, and are expected to be skilled once they’re in practice. Lack of knowledge of the Standards, on-the-job training, and perpetuating traditions not supported by current evidence are factors that jeopardize the ability to prevent risk and provide safe infusion care. Providing curriculum in nursing (and medical) schools to better prepare graduates and increasing awareness of the Standards for application in clinical practice are steps to address this issue.
Second, despite the ubiquitous nature of the specialty, many clinicians don’t recognize the risks associated with infusion therapy. While complications may be local, such as a grade 1 phlebitis, others can be life-threatening. Infusion nurses need to be recognized as key members of the health care team and part of the discussion as it applies to strategic initiatives that impact patient outcomes. In particular, the C-suite needs to recognize the value infusion teams bring to an organization. The business case can be made to support infusion teams and their ability to impact an organization’s fiscal bottom line. Experienced, skilled infusion nurses impact costs—use fewer supplies, less labor, identify complications early and promptly implement treatments.
Third, establishing competencies and maintaining continued competence is a challenge. Clinicians need to stay abreast of the latest research and its impact on practice as well as the introduction of new technology that can enhance care delivery. Patients are living longer, more chronic diseases are being treated, and care is transitioning out of the hospital at a rapid pace. Clinicians must be prepared to competently and safely care for these patients. Standardized education and specialty certification will be vital in addressing these and related issues.
VC: We are a very research-oriented group. What are some of the major questions you see in the field that you think must be addressed by investigators such as us?
MA: Based on this “short” list of research questions, your team won’t be at a loss for potential projects!
How do we translate the research and/or accept the evidence-based principles, especially the Standards, into clinical practice? For example, while removal of a VAD is not based on dwell time and is performed when “clinically indicated”, uptake of this practice is still not widely accepted.
With the prevalence of short peripheral and midline catheter use, in lieu of CVADs to prevent CLABSIs, what’s the infection rate with these devices? With limited data on outcomes with midline catheters, what’s the incidence of venous thrombosis? Should we use of a higher level of aseptic technique (sterile gloves, draping) compared to standard practice? Outside of the hospital setting, what are the complication rates of both peripheral and central devices?
Is there a significant risk associated with ultrasound-guided peripheral catheter placement in deeper veins related to vein damage, infiltration and future vascular access?
More studies are needed on maintaining patency of long-term devices, not just the type of locking solution, but how often the device should be locked.
What’s the impact on patient outcomes and safety related to nurse/patient ratios?
The data, evidence, and research are the basis for our practice, validates what we do, and impacts patient care. Adding to the science of infusion therapy can only lead to best practices in infusion care—our patients deserve nothing less!
Its been a little over a year since we published MAGIC in Annals of Internal Medicine. Today, at the Annual Association for Vascular Access Annual Scientific Meeting, I shared just why and exactly how we developed this tool. I also provided some early insights into how it has started to influence practice. The journey, thus far has been amazing. Here are but a few highlights:
1. Many recommendations from MAGIC were widely incorporated in the latest Infusion Nursing Standards of Practice 2016;
2. MAGIC recommendations are being actively implemented in an ongoing project aimed at preventing CLABSI in over 500 US Hospitals;
3. Working with the AVATAR Group, discussion on creating MAGIC-Australia have begun. In this project, MAGIC recommendations will be adapted to the Australian context with respect to devices, operators, and practice standards;
4. In partnership with the Michigan Hospital Medicine Safety Consortium, we have started to move towards interventions that use MAGIC to improve PICC use and outcomes across 51 Michigan hospitals.
5. A recent market report from iData finds that use of midlines has increased in recent years - and credits MAGIC and the new INS Standards as being key forces in this change within the device market.
From a professional perspective, I cannot be happier. A tool is only as good as its user and I am delighted that MAGIC met with a warm reception today at AVA. I hope my talk today has inspired more people to take a closer look at MAGIC as a way to measure, evaluate and improve their performance. It has been heartwarming to see smaller hospitals with scarce resources turn to MAGIC to tackle CLABSI and VTE. I visited just one such hospital in Michigan that is making fantastic strides in midline and US peripheral IV catheter use in using MAGIC. It's inspiring to see the hard work of vascular access professionals in this way. I said it today and I will say it again: You are the secret....
This being said, I am wary of the future. Why? Because much more work needs to be done. Many changes need to be made. And these changes will not be easy.
If there is one thing that MAGIC makes perfectly clear, it's that choosing a vascular access device is not and should not be a reflexive process. We shouldn't knee-jerk to a PICC from a peripheral IV when faced with a patient with difficult IV access. Similarly, we shouldn't stick people two or three times blindly before we pull out the ultrasound machine to have a look. And yet, I know full well that this type of practice continues today...
There is a science to choosing devices that is based not just on indication on use and nature of infusion, but also on patient-, provider- and device-characteristics. Throughout our research - we have shown that these factors have to be carefully considered when selecting a vascular access device as they are most often associated with complications. And yet, I remain surprised at the overall lack of awareness of these issues - especially among my medical colleagues who order these devices. In fact, many aren't just blissfully unaware of catheters, they are also unaware of the risk of complications associated with these devices as we've shown here, here and here...
Why might this be the case? There are myriad reasons: lack of knowledge, awareness, ownership. But I want to discuss one more subtle one from our lexicon: use of the term "PICC nurse."
Think about it: what goes through your head when you hear PICC nurse? Do you think of a person empowered to help you make the right choice for what vascular device is best for a patient? Or do you think of someone who can place one device, and one device only? In fact, is it a verb or a noun?
In his best-selling book Blink, Malcolm Gladwell talks about how impressions and decisions about people and objects are made within milliseconds in our brains. He calls this the "unconscious adaptive," and the process - thin slicing. In my work and conversations with hundreds of providers to date, I am convinced that thin-slicing is a fundamental, dark part of the problem when it comes to vascular access. We are anchored to old ways of thinking about vascular teams and their roles.
We must move away from this euphemistic and naive approach and emphasize three linked components:
1. Vascular access professionals are consultants, not a procedure delivery service;
2. To attain #1, respect for the art and science of vascular access (and those that practice it) must rise;
3. In order to attain #2, vascular access specialists must work to define their value and role within the healthcare enterprise.
I heard someone at AVA say that, "we as a specialty should not be defined by the devices we place." And yet, vascular access specialists remain trapped in exactly this silo.
It is time for us to be the change we want to see.
No longer should the term PICC nurse or PICC team be used to characterize those involved in the placement of IV devices. Rather, vascular access consultant should be the new norm. Each of us in partnership with leading organizations such as AVA must take this charge so as to legitimize the specialty that we all know and love. MAGIC is one way to bring forward this legitimization -- a tool that harnesses evidence-based recommendations to inform and change practice. A tool that can measure, evaluate and benchmark your performance in ways that none other can.
So what's in a name? A lot. And I hope it changes with MAGIC.
If you were at the presentation and have thoughts about MAGIC, I would love to hear from you. Leave a comment below!
Blogs written and edited by Vineet Chopra unless otherwise stated in the header. Guest blogs are identified accordingly.