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Rumination and Rumbling on Vascular Access...

Moving Vascular Access Forward: Thoughts from a Clinician in Rome

7/14/2016

8 Comments

 
VC: Prof. Antonio LaGreca is a surgeon at Catholic University in Rome. We recently held an Open Discussion regarding the MAGIC recommendations at WoCoVA. Our exchange led to a number of important points, many of which pertain not only to the contrarian point of view with respect to PICCs but also nuances regarding vascular access devices. I therefore invited him to consider submitting a blog for ImprovePICC.

Dr. LaGreca has indicated the following conflicts of interest with respect to this blog: "I am a member of the Italian Study Group on Vascular Access (GAVeCeLT). This a non-profit association aimed at deepening and spreading knowledge and practice on vascular access."
 
VC: Your views regarding the safety of PICCs differ from mine. Tell my why?
AG: I tried to underline that, from a conceptual point of view, PICCs are not something different from CICCs (centrally inserted central catheters) or FICCs (femoral inserted central catheters), as we like to classify central VADs. The difference lies in the approach, not in the vascular access device (VAD), and the approach makes a big difference. If we look back to the genesis of PICCs, they were born as second choice devices. When placed at the elbow, their clinical performance was so unsatisfying (early massive thrombophlebitis as high as 70% at 3 days, mechanical problems such as dislocation, rupture, occlusion, high failure rates at insertion) that they could not be considered a first line approach. After introducing the mid arm approach under ultrasound guidance, a revolution occurred: success rates improved, indications widened, and the ability to obtain a CENTRAL line without facing potentially life-threatening complications of a cervical or thoracic approach (e.g., pneumothorax, vessel injury, etc.) extended the range of operators that could feel (or try to feel) confident with the procedure.
 
VC: Interesting - how do you think this influenced the adoption of PICCs?
AG: The culture of patient safety in the field of vascular access has always grown with the introduction of new and enthusiastic operators involved in insertion and management of new devices. This was true for central venous catheters, and in todays era, we have to thank PICCs for this.
 
VC: So are there no problems, in your opinion, when it comes to PICCs?
AG: Well, PICCs have faced several technical and procedural problems in the recent past. Some of these problems have been overcome thanks to a huge cultural and technical effort by clinicians and companies.

Technical problems may be summarized as follows:

  • They are small bore and long lines, offering resistance to flow as compared to conventional CVCs. This has been overcome by the introduction of power-injectable devices and the widespread use of infusion pumps, leaving a relative contraindication to PICCs use in patients needing very high-volume infusions (emergency, trauma, septic shock) or a great number of lumens.

  • Primary malposition rates are reported to be as high as 30% (totally unacceptable) if lines are inserted without any intra-procedural control, because of their flexibility and the long track to the target position; this has been overcome by the introduction of a simple and cost-effective method for intraoperative tip location, the intracavitary ECG, leaving concerns only for malposition’s occurring secondarily after line insertion.

  • They are also inserted in small and delicate veins, which don't forgive the operator in case of mistakes in choice of the device (large bore as compared to the vein size = thrombosis), in puncture technique (inadequate needle control under ultrasound guidance and consequently more than one attempt at cannulating the vein = thrombosis). This has been partially overcome by emphasizing ultrasound use training and strict adherence to the principle of not occupying a great amount of the vessel lumen (the catheter-to-vein ratio concept), but we still need to diffuse these concepts.
 
 
Procedural problems include correct indications and choice of device for each patient, wise proactive vascular planning, standardization of safe and effective insertion techniques.
 
In this context, numbers without wisdom can make the difference. If operators dealing with a new procedure increase, numbers may increase irrespective of actual needs and benefits, safe insertion and care procedures and cost-effectiveness. This may harm patients and health systems as well. I use to present a brief paradoxical example of what can happen if we consider the same issue from two different points of view: I call it "the rule of the numerator”…
 
In 2010, the vascular team of a small hospital inserts 100 PICCs, with a global complication rate of 10%. In 2013, the same team is able to insert 1000 PICCs with a global complications rate of 5%. The absolute percentage of complications looks much better in 2013, but if we look at the actual numbers of patients harmed - we had 10 complications in 2010 as compared to 50 in 2013.  If the average complication costs 25,000 euros (as it happens for a single CR-BSI), we are facing a global cost of 1,250,000 Euros in 2013, as compared to 250,000 Euros in 2010. Is this balanced by an actual increase in patients outcomes and/or reduction in other expense sections such as procedural costs, operators’ workload etc.?


VC: I see - what about major problems like bloodstream infection?
AG: In the middle between technical and procedural problems, catheter related blood-stream infections are still a concern, related to numbers as well as correct indications, care protocols and use of supporting devices (dressings, sutureless devices, etc.). In this field we have good quality evidence and devices, but still need to better incorporate these data into practice. This is especially relevant in the case of PICCs given the wider adoption of these devices and the growing availability of dedicated operators and staff to maintain them.
 
VC: So how to move this forward so that everyone inserts and cares for PICCs safely, much like you do in in Rome?
AG: A huge cultural effort by clinicians and technological effort by companies could further improve results as follows:

  • Insisting on the use of ultrasound as a tool to guide the operator in choosing the right device in the right vein with the right approach for that specific patient and not only to guide the needle.

  • Adopting the “vessel health” concept (led by Nancy Moureau here and here) that may take advantage of continued technical training of operators, allowing them to adopt minimally invasive insertion techniques, as well as technology such as use of minimally invasive devices (microintroducers, small bore and soft guidewires, small gauge needles).

  • Taking a comprehensive view of patient safety, aimed at preventing the whole spectrum of complications in someway depending on the operator’s choices and behavior before and during insertion.

  • Developing a structured approach for use of IV devices that incorporate correct and appropriate indications and appropriate care, especially in patients at high risk of inappropriateness. Some examples include:

    • Inappropriate indications: repeated peripheral IV cannulas until complete superficial veins exhaustion, PICC line insertions for very short   planned therapies or difficult venous access, tunneled/cuffed or totally implanted catheters inserted for in-hospital patients are all areas of concern.

    • With respect to catheter use and care, unwarranted removal of central lines at the first unproven suspicion of catheter related-bloodstream infection (CR-BSI), unwarranted retention of IV devices because of "theoretical" difficulty in obtaining new access despite a   strong indication for removal, sub-optimal tip position are frequent behaviors at risk for patients’ and health systems’ harm.
 
These are all avoidable in my opinion, as follows: first we need to define and adopt an evidence-based, but comprehensive algorithm for choosing the right device in each patient. We are proposing our hospital algorithm throughout the country: it includes indications and contraindications, and provides a reasonable approach to the problem. Maybe an international approach, one that began with the MAGIC paper that can be further modified and integrated to the local context could work even better.

  • Encouraging use of intracavitary electrocardiogram (ECG) as a cost-effective tool to monitor the position of the tip during insertion (see papers here).

  • The discovery and implementation of better performing materials - aspects such as flexibility, lowered thrombogenicity, decreased protein adhesion, protection against sleeve and biofilm formation, power injectability to improve flow rates and patency, etc.

  • Continued innovations in a number of areas including locking solutions, neutral displacement needle-free connectors, port protectors.

  • Improve training, in order to reach the vast majority of operators and to grant continuing education and spreading of innovations.
 
VC: What do you see as the major challenges in the field today?
AG: There are several important issues that need resolution:

  • The field has focused on improving operator performance, but are we improving patient outcomes as well?

  • What would happen if the same cultural and market effort be applied to old “conventional” CVCs ? In this sub-field, operators and kits still look similar to those of the late 90s.

  • If a procedure needs maximal efforts to get its expected results, shouldn’t we consider this a concern?

  • What happens in the real world, far from the landmark centers like yours and mine? How do we diffuse best practice to all those that operate, insert and care for these devices?
 
 
VC: Your thoughts are very interesting. What final words of wisdom do you have for our readers?
 AG:  I told you in Lisbon that I see myself as a good clinician, not as a researcher: so tell me what do and I will do it the best I can. I haven’t got answers yet, but only some ideas. One of these is, if one of the major concerns is thrombosis, we need a big multicenter study with a very homogenous insertion protocol throughout the centers, including a strict indication for catheter-to-vein ratio. This is feasible and will give a definitive answer as concerns pathogenesis of catheter related thrombosis and related consequences on practice. Also, we need better cost-effectiveness studies and data regarding empiric outcomes. The field should work on a simple, but effective algorithm for indication and choice of vascular access devices to be spread all over the world of operators. I hope we can work together to provide answers and conduct these types of studies.
8 Comments
Marcia Cooke
7/20/2016 09:34:57 am

Thank you for the excellent thoughts. What I worry about is our systems are so dissimilar. Many of our operators do not have the physician support you provide. I would appreciate your thoughts on how we can move this type of teamwork forward?

Reply
Antonio La Greca
7/25/2016 12:14:20 am

Thank you for your comment. I cannot see which is your country of origin and I understand (but I’m not sure) that the problem you raise is related to the integration of physicians’ and nurses’ work in the field of vascular access. Of course, relationships between physicians and nurses are not homogeneous in our country as well. By the way, nurses responsabilty has increased thanks to the huge daily work of operators and to the huge effort of some working groups within the GAVeCeLT, expecially our group in Rome, aimed at spreading some concepts:
- proactive vascular planning (see the GAVeCeLT algorithm under “structured approach” hyperlink in blog text);
- targeting zero complications (see the GAVeCeLT bundles under “structured approach” hyperlink in blog text);
- evidence-based and not operator-based practice;
- standardization of procedures and wide use of bundles (see GAVeCeLT algorithm and bundles under “structured approach” hyperlink in blog text);
- importance of a vascular service with dedicated operators: in the attached ppt slide presentation (https://www.dropbox.com/s/ajjkohrl0xdj6vr/A%20Vascular%20Team%20in%20Rome%20-%20La%20Greca%20WoCoVA%20Lisbon%202016.pptx?dl=0) you can see the structure and working flow of our vascular team in Rome, that includes multiple professionals whose activity is regulated by a reasonable scheme saying who does what and when.
If you look at the structure of our vascular team, nurses have a fundamental role in planning, operating, managing, coordinating the whole activity; in the operational setting, physicians intervene secondarily in particular conditions, while long term strategies are planned and shared among all operators in a cooperational fashion (periodical meetings, sharing of events and ideas, etc.). This is not a dream or something irreproducible:
a) first, early UK experiences of nurse-led services gave us the feeling that we were on the right way (Kelly LJ, Buchan E, Brown A, Tehrani Y, Cowan D. Exploring how the development of a nurse-led vascular access service has benefited patients. Nurs Times 2009 Jun 23-29;105(24):16-8; Gopal K, Fitzsimmons L, Lawrance JA. Nurse-led central venous catheter service: Christie experience. Br J Radiol 2006 Sep;79(945):762-5. Epub 2006 Apr 26; Hamilton HC. Advantages of a nurse-led central venous vascular access service. J Vasc Access 2004 Jul-Sep;5(3):109-12);
b) second, this framework, sometimes simplified, have been activated in multiple centers in Italy thanks to a few strategic interventions:
o data collection showing the problem to solve (i.e.: complications or high lenght of stay or delay in administration of chemotherapy due to inadequate vascular access);
o presentation of the problems to potentially envolved operators and to clinical directors and administrative professionals in multiple (even obsessive) meetings, exerting a “strategic” pressure on the potential medical-legal effects of the unresolved problem and showing consistent international literature;
o identification of “sensible” operators within each professional category who could act as “best practice activators” by spreading perception of the problems (i.e.: catheter related bloodstream infections) and knowledge of recommended evidence-based interventions;
o the latter point have been crucial in obtaining widespread cooperation by all professionals and in identifing operators that could enter the leading vascular access team;
o repeated “refresher” meetings organized and coordinated by representatives of the different professionals categorie in order to envolve and motivate them.
So, communication and spreading of knowledge have been the main (and reproducible) factors that led to the constitution of a multidisciplinary group in the forms above depicted. I hope that this can answer your question. If not, please ask again, maybe I will understand …

Reply
Anon
7/22/2016 02:47:00 pm

I don't understand what you mean by structured approach.

Reply
Antonio La Greca
7/25/2016 12:16:09 am

Thank you for your comment, that gives me the chance to better clarify this point.

"Structured approach" means a way of working by proactive planning and acting under the guidance of standardized and evidence-based protocols that take into account:

1. all the aspects we have to consider in order to provide the best care in this field. Placing a VAD is not only a technical matter of punturing a vein and introducing a tube in it, but involves:
• indications: how to choose the best device for the specific needs of that specific patient (SEE THE "STRUCTURED" ALGORITHM FOR VAD CHOICE provided by GAVeCeLT under the hyperlink "structured approach" in the blog text) in terms of functional performances and safety. I have extensively underlined in the main text of the blog the importance of a correct decisional process in choosing the VAD, but this is not enough. Indeed, after choosing the best VAD for the specific patient, even insertion and care practices should be regulated by evidence-based procedural bundles including a few simple but effective recommendations in order to provide the best success and functionality rate and prevent insertion-related and care-related complications;
• insertion: which procedures and techniques are most safe and cost-effective (SEE THE "SAFE INSERTION OF PICCs" PROTOCOL provided by GAVeCeLT under the hyperlink "structured approach" in the blog text as an example);
• care: which behaviors and which devices reach the best results in providing optimal device performances and prevention of complications such as infection, device dislodgement or dysfunction, etc (see the bundles for preventing catheter related blood-stream infections and venous thrombosis provided by GAVeCeLT under the hyperlink "structured approach" in the blog text);
Further bundles for prevention of catheter occlusion or catheter rupture/dislocation and specific ones dedicated to the Safe Insertion of Long Term Accesses (SILTA) and the Safe Insertion of Centrally inserted Accesses (SICA) are available at www.gavecelt.info; they are written in italian, but I can provide an english-translated copy if you like.
All these bundles work in our local environment but we have proposed them as a basic national framework to be adapted to the different local realities in order to encourage operators working under standardized and evidence-based conditions. Of course they do not represent absolute truth, but might work even in working environments different from ours as a proposal to be adapted to local needs. The "structured approach" helps working without leaving choices and practices to the chaos of non homogeneous or even emotion-based decisions; this eases decisional processes, prevents errors and allows comparison of results in order to emprove practice.

2. all the operators that may contribute to the three above mentioned phases (indication, insertion, care) in the context of a “structured” multi-specialistic Vascular Team. For instance, infectious diseases specialists are extensively envolved in catheter care in our Institution by providing their specialty competence in catheter-related blood-stream infection. The decision to request their consultation and the roles of the different specialists in managing the complication is not left to occasional choices but is regulated by a (gosh, again) “structured” working flow stating who does what and when. Please find the characteristics of our vascular team in Rome as an example in the ppt presentation provided below.
https://www.dropbox.com/s/ow0nltaeenz3miu/A%20Vascular%20Team%20in%20Rome%20-%20La%20Greca%20WoCoVA%20Lisbon%202016.pptx?dl=0

One of the first lessons of “structured approach” was given by Kathy Kokotis in 2005 (Kokotis K. Cost containment and infusion services. J Infus Nurs. 2005 May-Jun;28(3 Suppl):S22-32). What I tried to depict here is the attempt (apparently successful) made by GAVeCeLT in Italy at introducing into practice the concepts of “proactive vascular planning” and “targeting zero complications”.

I hope this has answered your question.

Reply
Dave Anderson link
3/26/2019 03:29:18 pm

That is interesting that a vascular team is improving year after year. That would be nice to have if I needed vascular help. That is something I am sure a vascular surgeon would want for their team.

Reply
Dave Anderson link
4/5/2019 01:03:54 pm

That is nice that an ultrasound can be a guide when looking into veins. Maybe it would be good for me to get a vascular ultrasound sometime soon. Then I could see if there were anything wrong in my arms at all.

Reply
Rick Jones link
12/1/2021 04:30:13 pm

I didn't know that PICCs have had a ton of procedural problems in the past. But maybe I can find one that works properly. Possibly I can get help from a professional with this part.

Reply
John Carston link
4/8/2022 06:23:33 pm

It's great that you elaborated that success rates improved after introducing the mid-arm procedure under ultrasound guidance. My best friend, who is a doctor, told me last night that she was planning to buy a vascular ultrasound machine for additional services at her clinic, and she asked if I had any idea where would be the best option to consider. Thanks to this helpful article, I'll be sure to tell her that it will be much better if she consults a trusted ultrasound equipment store as they can provide more information about their ultrasound machines.

Reply



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