"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!

Mr. Carr has disclosed that he has served on speakers bureaus CareFusion in 2013 and Becton Dickinson in 2014 providing lectures on vascular access. He received a grant from CareFusion to attend a scientific meeting and a part-funded Scholarship from Becton Dickinson to support research activities.

VC: Tell me a bit about yourself and your background/calling to vascular access.
PC: I'm Irish which by default means I come from the most beautiful country in the world. However, I live in Perth, WA - the second most beautiful part of the world. If I want, I can cycle to work almost every day as the weather is super. I can even wear shorts in winter so what’s not to like!?
 
My professional interest in vascular access began in 2006 when I joined a European Working Time Directive initiative “IV Team”. A team of nurses and staff from the phlebotomy department provided peripheral intravenous cannulation to inpatients in Galway University Hospital; a teaching hospital in Ireland. While the service was disbanded due to the economic downturn, I had become motivated to research vascular access. My wife and I wanted a new adventure, a new challenge, to up skill clinically and academically so we departed the Emerald Isle taking a career leave from the Irish health service.
 
At that time the intention was to return and bring new knowledge/clinical methods back home. We have now been living “down under” for over 5 years and it looks like Australia is now our home and we appreciate the opportunity WA health have given us.
 
As a way of giving back to Australia, I am the current vice-president for the Australian Vascular Access Society and Scientific Chair for our 2nd Scientific Meeting. I am the Australian Global representative for World Congress on Vascular Access (WoCoVA) and lead the Western Australian Chapter of the AVATAR group. I won't be in these roles forever and the baton will be passed on in due course as change is a good thing (except for PIVCs!!).
 
VC: Tell me about your ongoing research work, interests and collaborators.
PC: I'm currently researching a clinical prediction model for first-time insertion success. This is focussed on appropriate insertion of peripheral cannulae on the first attempt in an anatomical location that will have greater dwell (and therefore reduce subsequent attempts ) by a clinician who is confident to do so.
 
It is part of my PhD and is co-supervised by a leading ultrasound expert and Emergency physician James Rippey. If clinicians/health care service providers are unable to succeed with traditional attempts then the appropriate use of ultrasound will be a superior method. For my research it is important to be with a clinical and academic expert in this area as James is. 
 
I found the world leading researcher in vascular access in Prof Claire Rickard of Griffith University. Claire had the only vascular access research group that I could find in the world. There is nothing like working and learning from the best. Myself James, Prof Marie Cooke, Dr Niall Higgins and Gabor Mihala are a great team. I contribute to the AVATAR group with some of the most passionate scientific minds who focus on making positive vascular access experiences for patients and eliminating complications using scientific methods. In a word, AVATAR is an inspiration. I am so lucky to be involved with it. I am busy with a Cochrane systematic review title and would love for a few RCT’s on specialist teams for successful device insertion and prevention of failure. So if any of your readers have a clinical trial registration, protocol and RCT on this subject, please feel free to send it my way. 

 VC: You have always believed that insertion skills matter most? Why so? 
 PC: Well, insertion skill matters to the patient who receives the cannula, no? As clinicians we can be so focussed on trying not to miss and undertake repeated attempts without considering the feelings of the patient who is on the receiving end of the PIVC. Nothing beats genuine empathy. It is important for our colleagues to also understand that while insertion skill is critical, using the least appropriate device could result in a high failure rate on the first attempt or lead to a high post insertion failure. This requires us to be skilled in the assessment phase of the procedure and skilled in selecting the right devices suited to the patient.
 
I have seen and heard many comments such as “I can cannulate the small vein on your baby finger”. Well, find me a compos mentis adult who wants the PIVC in their pinky? 
 
VC: So why has this issue not received more attention?
PC: Because PIVC is so frequently performed by a range of professionals, no one owns the insertion skill and this results in fragmentation in expertise. Some get protected proctoring by the worst possible mentors and very few get the best. It’s the classic bystander effect in clinical care, someone else will teach it, someone else will sort out the infection, the difficult patient and so on.
 
Inserting invasive devices into patient's anatomy is a unique relationship between provider and patient and we need to accept that we can always do better. People who we are privileged to look after are not getting good enough outcomes; at best 70-86% (note, not a 100%) first-time insertion success; is this acceptable in 2016? What about the other 30%.
 
Even with the use of ultrasound, you won't get a first pass success publication over 85%. This is what the scientific literature is telling us. Last week I gave a local presentation about PIVC evidence for an ultrasound PIVC workshop. When I told the audience the effectiveness of USG PIVC (based on randomised trials) was no better than traditional attempts it was like I stole the goose that laid the golden egg. But it's not a personal opinion but what the evidence is telling us! The latest systematic review (one of 5) on USG PIVC by Shannon Parker and colleagues from Canada sheds some perspectives on this.
 
The fact is after insertion 25%-50% (note, not 0%) can fail because of avoidable complications. I love the “getting to zero literature for CLASBI OR CRBSI” and applaud the clinical champions involved in this work but wonder why can't we get to down to 1 attempt? Behind each percent, each number, is our core business; human life; people in need of help. Imagine you are in a hospital bed, tired from chemo on your 5th PIVC insertion in 6 days (bear in mind you’ve had 8 attempts between the last two) and your thinking about your life, your kids, dog and you are finally getting some clarity before you hear the occlusion alarm on your infusion pump indicating another failure. This means another attempt and possibly more unsuccessful ones at that.
 
This is happening 24/7 around the world and it is going unnoticed as it is unrecognised or deemed to be of less importance amongst the array of competing healthcare issues. My hope is for our research to contribute to improving the insertion skills of clinicians today and in the future.
 

VC: So how do you propose to measure the skill of the inserter?
PC:We are working on a possible concept that we hope will attract funding (if you are a philanthropic reader, drop me a Tweet!). We (read as a generic term for Healthcare) poorly use data and poorly understand the relationship between data and vascular access regarding outcomes. One of those is the clinician's skill.
 
Let's say you had two medical/nursing inserters in the ED or Surgical ward, and on this occasion had to send 1 for mandatory PIVC training. Who would you send? (of course, some of your readers know this is a highly unlikely scenario… mandatory vascular access training that is)  How would you pick the 1? The skill of the inserter is important, but they should want to be measured as a hospital mandate. Otherwise, we will continue with the keep trying until you get it approach; let's all have 2 attempts; call the anaesthetic to insert the PIVC or the local vein whisperer when all else fails.
 
Some clinicians reading this think they know how good they are, some might know how good they think they are, but what is their actual, factual data… if one of the aforementioned could say ”I put 50 PIVCs in this month; 44 traditional on the first needle puncture; 6 USG PIVCs on the first attempt. My outcomes are: 1 failed by accidental dislodgment, 29 remain insitu and 20 no longer needed and 0 infection/occlusion/thrombus. The category of patient was well spread between easy to difficult ones."
 
These data can help the manager allocate who they want to send for training. It's frustrating when people think they have data on the issue when they really don't. Because they have done the 2-4 hours mannequin venipuncture and cannulation training day and got someone to sign off on 20 insertions (if they got 20), they are ready for cannulation.
 
Do you think the patient should know what the success of the inserter is before he/she attempts one? Would you like your mother, father, brother sister, wife, husband, son, daughter to be the human simulator? We know (or at least I know) having observed 1,400 insertions in 2 large tertiary EDs with a variety of clinicians inserting that practice varies; training varies and success varies.

VC: Your research focuses a lot on the emergency department. Why did you choose this site as a venue for your study?
 PC: It is the front door of the hospital and the first exposure that most patients (notwithstanding pre-hospital attempts) have with invasive devices. In Australia, we have a national target to get patient assessed, admitted, transferred or discharged within 4 hours.  PIVC insertion is ever present in ED admitted patients.
 
My clinical background is also in ED and my experience in vascular access have contributed to the concepts my research seeks to evaluate. ED is where vessel health and preservation should commence. In my opinion (but biased by my studies!) insertion practice is no different on the ward when compared to ED. Clinical practice should be no different, it should be as per policy. 
 
Insertion skill is the final act in a long process of critical clinical decision making; this can happen in seconds or much longer. Not to get too deep into cognitive psychology, but this is where Type 1 and 2 of thinking is evident. It could happen very quickly with some and be influenced by their Gestalt or others may take time with a procedure.
 
We are about to finish analysis on a data set that looks at which provider we could resource to certain veins based on their confidence. My clinical academic colleague James Rippey is fascinated by the influence of clinician gestalt on first-time insertion success. We have a paper in press in Emergency Medicine Australia.
 
Simply put, we hope to test an application of rules in future to resource the least experienced with the best veins so they amass consistent insertion success, increase their confidence and continue to develop successful procedural consistency and experience with patients with the fewest visible veins.

 
VC: How can one get better at inserting peripheral IVs? Is there a course or training you would recommend?
PC: It is a skill, an art and practice one can make permanent. You must know your product "intima"tely (pardon the pun) well. Your product target is a vein.
 
Jack LeDonne is a great friend and mentor, and he has a great saying “Feel is our fluoro” (this is the best advice he has told me). He’s right, though. The evidence to date is a visible palpable vessel is a strong predictor of insertion success. Don't set yourself up to fail; assessment is key. Once you can see and feel that vessel you approach it text book like (Aseptic-Sterile). You must be confident. Patient rapport and trust is important. Make them feel safe in your presence.  Simple, really.
 
However, clinicians need to follow their outcomes. Imagine you’re the clinician who was at the pin of their collar so to speak, and got the PIVC in only for the device to fail by occlusion on the ward 6hrs later? Now the patient has the duty anaesthetist who has to make an extra attempt at an extra cost. These are modifiable and avoidable outcomes.
 
There are many courses one can take locally, online and many scientific meetings have pre-conference workshops. Seek out the local health care professionals whose paid role is to provide such training and mentorship. Ensure they actually perform clinical PIVC insertion themselves; I know may vascular access educators who insert vascular access devices in mannequins but not patients. That's a concern. Find the person who you think is the go-to person in your hospital, ask for mentorship/proctoring. Reflect on your performance. 
 

VC: A lot of this comes back to having a dedicated group of providers to insert peripheral IVs? Is that your recommendation?
PC: You ask an excellent question Vineet. Yes it most certainly does, and in my opinion  not just for PIVCs but for all peripheral and central vascular access devices. I have been grounded into defending my answers where possible with an evidence base. We just don't have the evidence for dedicated groups though; by evidence I mean many RCTs- followed by Systematic appraisal and meta–analysis of the data proving this is the case.
 
By dedicated groups, we don't know if nursing vascular access team exclusively are better than a mixed healthcare professional model (nurses, doctors, RTs, PA’s) versus the general inserters. We have a Cochrane review coming out soon, and there is not one published RCT that randomises the patient (or indeed a registered protocol for one at the time of typing this) that suggests a dedicated group of providers is superior when compared to the current combination of medical, nursing, technician provision. There is an obvious evidence gap. 
 
Of course, there is evidence that local single centre initiatives prove teams are associated with good outcomes, but no causal data. This comes back to clinical confidence and procedural competency not defaulting to a technology. If you were to run against Usain Bolt in the morning who would win the 100m sprint? If you were to compare a vascular access team member with an HCP who focuses on less frequent insertion, who may you think will have better outcomes? We can’t all get the gold medal, but I’m willing to take a bet that we can have improved and sustained insertion success and a huge reduction in failure and waste with a process that uses a dedicated group of providers. Then patients will have a gold standard.  
  

VC: What types of policies need to be enacted in Australia to ensure consistent practice on a local/regional/national scale?
PC: That is a tough one. As someone who has contributed to policy and guideline development, I respect the efforts that are made in writing them. However, based on current evidence I read daily, Australia needs an exclusive national vascular access device standard to include:

1. Better evidence-based assessment tools so we promote appropriate placement by appropriately trained professionals;
2. Device registries in hospitals and better use of technology to capture data and report all outcomes, not just infection related. For example, alerts on previous line history, whether it was difficult or not.  Some great work is being done with renal patients in this area in Australia;
3. But the answer is in one word - consistent. Right now our first-time insertion success is “consistent” with 70-80% and post insertion failure is “consistent” 45%. Australia needs to continue to improve toward maintaining acceptable clinical outcomes for patients and aim for: “Consistent Practice” that reflects 100% first-time insertion success, 0% bloodstream infections, 0% complications through device failure.

In my opinion, the team approach to vascular access science is the biggest priority, and large metropolitan hospitals should have the professional entity that is “consistent” with practice approach. Otherwise, clinical decision-making will be underpinned by authority; let everyone have a go, rather than evidence.  
 
Finally, with the development of our national society “AVAS”, we have ignited a flame for vascular access device practice and research to be promoted. That flame will continue to burn brightly next May in Perth with what we hope will be a cracking scientific meeting that will engage clinical practice with science, supported by the patient narrative. Toward better patient and hospital outcomes for Australia and afar.   ​

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.

I just returned from WoCoVa 2016 in Lisbon. What a meeting! Representatives from over 60 countries, 1000 participants and so much interest in improving all aspects of device safety - from selection, insertion, care and maintenance. My heartiest congratulations to the organizers for arranging such a fantastic scientific session.

On a personal note - it was also nice to finally meet many of the people I have corresponded with via email, putting faces to names and shaking hands after all these years. I also appreciated the many different aspects of vascular access in the world. It's fascinating to me how the same device is often inserted by different people, cared for in different ways, and viewed upon variably based upon these and other factors. For those of you that have never been to WoCoVa, I highly encourage it -- it is refreshing and opens your eyes to important differences in our practice.

One of the highlights of the meeting for me was debates with key leaders regarding the evidence. At many sessions that I attended, there was  a palpable anxiety regarding the evidence base and whether or not it applies to current practice. Most notably, I heard the revered Drs. Pittiruti and Lamberti (both of whom I have tremendous respect for), speak about systematic reviews and meta-analysis and the limitations of current data. While I understood their concerns, I also was vexed regarding their interpretation of these studies that have been published in top-tier journals. In particular, they discussed our recent meta-analysis regarding PICC DVT published in the Lancet. I had the opportunity to challenge some of their assertions in an unscripted mini-debate. Here, in summary, are the key issues brought forward and my responses:

1. Meta-analyses of observational data is not appropriate or valid.
Response: This is simply not accurate. There is a robust science regarding how to use data from observational studies in meta-analyses, including guidelines and a checklist of best practices. Meta-analyses of observational data are responsible for key learnings, including those of global climate change and it's effect on species, the association between tobacco use and cancer, as well as the recent and Zika virus outbreak by the World Health Organization. These analyses are also extremely hard to do - much harder than analyses of randomized trials. And it's not as if RCTs are the silver bullet to solve all of our problems -- in fact, quite the opposite, as so nicely outlined by this author. They are therefore KEY to understanding and improving our knowledge about key scientific questions. Top tier journals, including the Lancet, understand this and have very stringent requirements to ensure such studies are well done and adhere to the highest standards of practice. In fact, our review was independently reviewed and met stringent scientific criteria to be included by DARE, an organization that reviews the quality of systematic reviews.

2. The studies put together are extremely heterogeneous,  do not reflect current practice.
Response: It is true that the studies included in our analysis span over 50 years and practice with PICCs has changed considerably. For instance, Drs. Pittiruti and Lamberti cite use of ultrasound as a key advancement that influences safety. While I  understand these concerns, there are important caveats. First, the key to a well-done systematic review is the use of an explicit protocol that includes all, not some of the evidence. Including only a few studies or focusing on those that (in the readers assertion) are the most representative (which is what they chose to do) is the key to introducing selection bias, the very thing systematic reviews were designed to counteract. Second, it is important to remember that systematic reviews cannot, by definition, improve upon the quality of the evidence. They are a representation of what is out there - and well done reviews are an important clue to a "signal" as to what current evidence suggests. Finally, it is always important to look at evidence holistically, not just from a single studies point of view. In this context, it is worth noting that the signal that PICCs might be more thrombogenic than other devices was not simply suggested by our review - but also by those of Saber and colleagues, Pikwer and colleagues, and also by Johanssen and colleagues. Is it possible that all of these are flawed. Possibly. But I doubt it. 

3. The data do not support greater risk of thrombosis associated with PICCs than central venous catheters.
Response: This assertion, unfortunately, occurred with some misrepresentation of the data from our studies and those of others. First, only certain studies from our analysis of 62 were picked and chosen to fit the bill for this argument based on ultrasound use, a modern era of PICC placement, etc. Asides from the huge concerns regarding selection bias here, I think it is wrong to pick studies only because insertion practices were better. I realize this is very important when it comes to thrombosis, but ultrasound represents but a fraction of  time for a PICC. What about the rest of the life of the device? We know that PICCs are more likely to develop malposition than other devices (this was conceded by the speakers as well), and since tip malposition is a key factor for thrombosis - how does an ultrasound at insertion at the time prevent this in the future? Second,  none of the numbers presented had confidence intervals around them. Confidence intervals are the key to understanding effect sizes -- in fact, in meta-analysis, they are FAR more important than the actual point estimate. When you actually look at the confidence intervals of the data points used by the speakers, they completely overlap those of the conclusion of the study. Third, concerns regarding including asymptomatic and symptomatic thrombosis and inclusion of both of these data were not correct -- we understood these are separate entities and did separate them in subgroup analysis, only to come up with the same conclusion. I will add that there are several new studies that suggest PICCs might be more thrombogenic, including a recently published RCT, a large study of DVT in medical patients, and a study from Italy by Dr. Bertoglio who also spoke at the conference. Again, remembering the totality of the evidence -- is it possible that these are all wrong? Maybe, but again - I doubt it. 

Take Aways:
1. Please note that I am obviously conflicted being the writer of this document and of the Lancet paper.  I am also an empiricist, not a rationalist (more on this topic here). I believe good science requires data and that all decisions must be made taking this data into consideration. This was not what was happening at this session, prompting me to take on two leaders in our field whom I have learned much from.  I think it is important to respect the evidence we have. In a field that struggles to find any type of evidence, we simply cannot afford to throw out the baby with the bathwater. There are patients in all of these studies that might have been hurt by the choices we providers made when placing PICCs. It is simply not right to assume all of the data is inaccurate given this important pretext. Absence of evidence is not evidence of absence. 

2. I do not want you to walk away from this seeing this post as more rhetoric and verbal jousting. Rather, regardless of our differences,  I share with Drs. Pittiruti and Lamperti the need for better data in helping make this assertion. Given the effect sizes and numbers involved, only a large, likely international, multi-site trial can give us the answers we need when it comes to thrombosis risk between these devices.  I see our role in leading just such a study, not arguing over the data. I was happy that we agreed on this -- and that we will work towards such a study in the years to come.

3. In the end, we agreed to disagree. But everyone reading this should know that this was a huge win for our field. This type of debate - by people who are passionate, knowledgeable and able to communicate in a non-defensive, conflict-free way - is precisely what vascular access needs. At the end of the day - the specialty won. And that, my friends, is what is most important. 

I look forward to your thoughts regarding the session (if you were there) or this post.

Dr. Claire Rickard is a PhD nurse investigator affiliated with Griffith University in Brisbane, Australia. An accomplished researcher who has published in top-tier journals and is internationally recognized as a leader in vascular access, she also oversees the Alliance for Vascular Alliance Teaching and Research Group (known widely as AVATAR). AVATAR and it's members have conducted some of the most influential trials in vascular access, including the recent routine vs. clinically warranted replacement of peripheral IVs (PIV) published in the Lancet.

Dr. Rickard was kind enough to sit down with us and answers some questions about vascular access and her research in this field. She has filled the ICJME form and has disclosed the following conflicts of interest:  grants and other from 3M, grants and other from BBRAUN, grants and other from BD, grants from CAREFUSION, grants from COOK, grants from ENTROTECH, grants from BAXTER, grants from HOSPIRA, other from BARD, grants and other from TELEFLEX,  outside the submitted work.

VC: Please tell us a bit about yourself and how you got interested in vascular access?
CR: I’m a Registered Nurse from Brisbane, Australia. I worked in medical and cardiac surgical wards (floors) and then in ICU for many years. I was always intrigued about all the variation in how we cared for vascular access devices between different hospitals. So, later I did (was almost forced to!) complete a research methods subject as I completed an ICU Graduate Diploma. It wasn' too longer afterwards that I could see how research just might be a good tool to sort out some of that care variation. And the rest, as they say, is history
 
VC: Your research group, AVATAR, is well-known for producing high quality research. How did the group come to be and tell us a bit about your focus?
CR: AVATAR came about quite organically over 20 years. When I say organically, I mean that it just sort of happened from the ground up - there was never some type of "master plan" to develop a research group focused on vascular access. At first it was just me and a couple of colleagues who shared this passion and interest. But then, as we were able to win larger research grants we met other researchers passionate about vascular access and just enjoyed learning from and spurring each other on. And so -AVATAR was born. Now keep in mind, AVATAR is a voluntary group -  we don’t receive any ongoing funding from any of the hospitals or universities. But somehow we have managed to survive and thrive - speaking to the power of passionate individuals coming together to advance science that they truly care about.
 
VC: Tell us about some of your ongoing research projects, especially those that relate to PICCs?
CR: We have about 70 research projects active right at this minute. Our bigger PICC projects at the moment are the RSVP Trial which is randomising patients to have 4 day or 7 day routine replacement of their IV tubing, and the PISCES Trial which is another multi-centre randomised trial comparing methods of dressing and securement that prevent infection, dislodgment and thrombosis.

VC: Is much of AVATARs research has focused on peripheral IVs? If so, can you share with us why you chose this device in particular?
CR: Well actually this is a common misconception. As a former ICU nurse (in Australia we rarely see PIVs in ICU) I was initially far more focussed on central and arterial device issues. Later on, I could see the commonality of the problems across all vascular access devices, and realised that although there were pockets of research activity in central lines in particular, the poor old PIVs were almost totally ignored. Looking at the bigger picture made me realise that improving PIV care was actually going to benefit a huge majority of the population, due to the numbers used.
 
VC: What have some of the surprises been in your research journey? 
CR: Well in Australia until recently we had no vascular access society (now we have avas.org.au),  and IV/PICC teams continue to be rare, although brilliant when we have them. So I was actually unaware that there was this whole specialty out there called vascular access or infusion nursing until many years after I started research in the area. Now I’m so happy and energised to be connected with this international community of practitioners and researchers. The other thing that surprises me constantly is how content healthcare professionals can be with using and implementing new devices and care procedures, that have little to zero evidence that they actually work. That’s very frustrating.
 
VC: Your team focuses on systematic reviews and trials? Why these two types of research methods?
CR: Well we only have so many hours in this life! and we know that we need ‘Level 1 Evidence’, like Cochrane systematic reviews, and randomised clinical trials, if we want to understand ‘cause and effect’ relationships and identify those policies and products that really do prevent complications. It’s hard yakka (that's Australian for hard work btw) to do research so we think we should focus our limited time and money on providing the most valid and reliable research results for implementing in practice.
 
VC:  What advice do you have for vascular access nurses interested in starting a research project?
CR: I would say go for it! But in reality you’re going to need some friends in the form of supportive clinical colleagues, and some experienced researchers who you can go to for advice. They don’t need to be vascular access researchers necessarily, you might have clinical trial nurses attached to the cancer or renal service for example, who would have heaps of knowledge about all the processes and paperwork. It would also help to find a mentor, either an academic nurse or doctor, but check they have published clinically focussed research themselves. I’d always suggest doing a randomised trial, not a pre and post study. It is actually no harder and your results will have so much more power. Even if you study a small number of patients, it’s very valuable data and can also then be included by authors of systematic reviews on the topic.

VC: You’ve discussed creating a “Center of Excellence” for vascular access. Tell us a bit more about this.
CR: We’d like to formalise what we have been doing in AVATAR for some time now. We are seeking government and philanthropic funds that would give us 5 years surety of funding. This money allows us to hire clinical nurses or doctors as researchers, so they can get that experience, and similarly fund Masters and PhD research scholarships so we can grow the global capacity for research. We plan to focus these research programs in three areas: (i) Insertion (assessment, procedure, devices), (ii) the Function phase (dressings and securement, flushing and blood sampling, connectors), and (iii) Removal (this one is a no-brainer - ongoing assessment and getting devices out when no longer needed). Some of this work will be clinical research but a whole other arm will focus on the Implementation/uptake of knowledge from research results.

VC:  In your opinion, what are the three most important questions remaining to be answered in vascular access? How can we go about getting these addressed? What barriers, if any, remain in effectively answering these issues?
CR: Wow, ok. Here we go:
#1:  We know 25-50% of vascular access devices have complications that lead to the device becoming non-functional, but how do we set up public benchmarking, so that hospitals take this seriously, and practitioners are more aware of this? We plan to set up a Vascular Access Registry to help with this, but that will still need to find ways to be championed throughout the Quality, Nursing and Hospitalist worlds in particular, to make this successful.
#2: In recent years, our research has shown that PIVs do not need to be routinely removed every 72-96 ours. They are licensed for up to 30 days use and with continued policies of clinical monitoring, can be safely used until there is a clinical reason for removal. We also know thanks to Dr Chopra and colleagues that PICCs have complications more similar to CVCs, so we are now taking that decision to place a PICC more seriously. So there is now this huge ‘middle ground’ – which patients/treatments can we use PIVs for (including new longer PIVs and mid-lines), and avoid the need for a PICC?
#3. Occlusion is the big ticket item, it’s the number one complication across most device types, not phlebitis or infection as many people think. In terms of picking the ‘low hanging fruit’ – what can we do with better care practices ?flushing ?dressings ?connectors etc to help there. If we could even bring occlusion down by 10% in PIV and central lines, that would be a massive cost saving and patient benefit across the system.

The barriers are simple: lack of funded research nurse positions within the health services, and lack of awareness across the broader health system about the catastrophe of vascular access complications occurring every day. 
 
VC: If there were one thing you wish you could have done differently in your research journey, who would it have been and why?
CR: I would have perhaps done less individual research studies and spent more time on promoting implementation of results. It’s a tough call though, as I always have a lot of exciting new ideas I want to pursue. A decade ago, we thought once we’d published, as researchers our job was done and we could move on to the next topic. Now, we know it takes a lot of effort to get the health system to change and take on new policies. I’m not saying it’s necessarily the researcher’s job to do this, but they can help a lot as the various societies update their guidelines for example.

Dr. Hugo Sax (front, right) is the Head of Infection Control,  Hospital Epidemiology and a Consultant in Infectious Diseases at the University Hospital of Zurich in Switzerland. A human-factors engineering and implementation scientist, Dr. Sax is perhaps most well known for creating the "Five Moments of Hand Hygiene" which has been adopted by the World Health Organization as the prototypical way of improving hand hygiene.

Dr. Sax recently visited Ann Arbor and our research team (picture). He was kind enough to sit down with me and share his wisdom  regarding hand hygiene for the vascular access community. Of note, Dr. Sax completed the ICJME form and disclosed research support from Ecolab for the evaluation of an alcohol-based hand sanitizer product in a previously published study.

VC:  Why did you choose hand hygiene as your area of research?
HS: I really didn’t' choose it: rather, it chose me. I had the opportunity to organize a nationwide hand hygiene promotion campaign in Switzerland in 2005 and after this I was hooked. Plus, it exemplifies THE challenge in infection prevention, no? Germs are invisible and infection always happen later. This makes hand hygiene operate in a system that basically never gives feedback to your behavior. Such systems are bad teachers: how do we keep doing hand hygiene when nothing perceivable happens when we don’t? So we need to better rely on mental models, as we discuss in this paper.

VC: Why is hand hygiene so important? What data suggests that it helps prevent infection?
HS: This is indeed a crucial question! Rather than go into all the data, I wonder if we could do a little survey here? Here is my email: hugo.sax@usz.ch. If you don’t mind, please send me a few words on the exact mechanism by which you think hand hygiene prevents a patient from getting any of the big 4 healthcare-associated infections (primary bloodstream infection, urinary tract infection, pneumonia, or surgical site infection). For example, you may think about how central line infections are thought to come about and in what step exactly hand hygiene would intervene to prevent them.  Plus, if you feel comfortable, tell me what went on in your head while you were thinking about this. In return for participating, not only will I answer each email personally, I will also send you the overall result of the survey and a signed reprint of our ‘Five Moments’ paper. We know very little about vascular access providers and hand hygiene so this will be a new and important project I think. Please note: I will treat your answers as absolutely confidential.

VC: Can you tell us a bit about the WHO "My 5 moments of hand hygiene" campaign?
HS: When organizing the Swiss Hand Hygiene campaign in 2005, we decided to measure hand hygiene performance before and after the campaign in over 100 hospitals at the same time. That needed a robust concept, one easy to understand, train, and monitor hand hygiene in a broad range of healthcare settings. So we tried a lot of different approaches, did a lot of videotaping and drawing, showed it to various people to tap into what I call their mental models -- that is, how they picture the world around them. Finally, we came up with the idea of five fingers, five moments: thus, making it ‘sticky’ with respect to memory and translation of the concept. But actually, the central piece of the concept is the patient zone, comprising the patient skin and immediate environment, which is colonized with the patient’s microbiome. The goal of this step is simple: no germs in, no germs out.

VC: When inserting vascular catheters,  variation in how we perform hand hygiene exists. Some use alcohol-based rubs, other chlorhexidine scrubs or antimicrobial soap with water, etc. Which is best?
HS: Alcohol-based handrub is certainly the quickest and most effective way to get rid of the transient hand flora, if the hands are visibly clean. If the hands are soiled, then best to use soap and water. 

VC: In your opinion, what are the greatest problems or barriers in performing hand hygiene?
HS: I think the biggest problem is cognitive overload - that is, clinicians are often busy doing all sorts of things in the day from thinking about patients to delivering treatments and interventions. Given all of this, its not hard to see how hand hygiene can "slip" out of focus - especially when approaching a patient. The other problem is lack of feedback that occurs if/when you skip hand hygiene. If you don't know you made a mistake, how can you fix it?

One way of solving this problem is to develop what I call "muscle memory" and "cues to action." For example, in Europe, we drive mostly stick shift cars and when we pull up to a red traffic light our hand automatically grabs the stick and shifts it into 1st gear, otherwise we feel uneasy. This happens unconsciously while watching people cross the street or listening to a radio program. Hand hygiene should be the same - an unconscious act that actually puts us at ease.

VC: How has  human factors research influenced your approach to studying hand hygiene?
HS: I believe that everyone takes genuine pleasure in organized, streamlined work flow. This translates well into my studies of hand hygiene. For instance, it is always a good idea to place dispensers conveniently where they are visible, accessible and can be used. It also makes sense to make sure that people fall in love with the experience of using them – a bit like car makers purposefully design the sound and feel of a shutting door of an expansive sports vehicle to be an addictive experience. I view hand hygiene much the same way - a safety component that can be designed such that it is easy, accessible and enjoyable for all those that useit.

VC: If there was one thing you hoped people would know about hand hygiene, what would that be?
HS: That our hands are meant to heal! 

​Please do take the time to email Dr. Sax regarding his hand hygiene survey by emailing him here. Dr. Sax will keep all replies confidential and will reply to your emails individually.

Sheila Inwood is a  vascular access specialist who was among one of the first nurses to place central catheters in the UK and the first to surgically place an implantable port. She has worked with industry, academia and clinicians to improve the care of patients that need vascular access in her NHS hospital. Ms. Inwood has served as Keynote Speaker at a number of international meetings including WoCoVa and the Association of Vascular Access. 

Ms. Inwood has completed the ICMJE disclosure form and has indicated no current conflicts of interest. She has served as the Director of International Medical Affairs and Clinical Affairs for CareFusion and has been a CVC faculty member for Teleflex Inc. in the past. 

VC: Tell us a bit about yourself, where you work, what you do and how you came to be where you are?
SI: I work in an 800-bed general hospital. My background in nursing is in the critical care, cardiothoracic area. I established the first IV nutrition nurse post at the hospital in 1987. The primary objective of the position was to enable IV nutrition to be administered around the general hospital, not just in ICU. A huge amount of my time was spent finding someone / anyone to insert a cuffed tunnelled central catheter. This was the only way intravenous nutrition was given (such a long time ago!)
 
Needless to say the variety of expertise, and knowledge that I encountered during those years as a nutrition nurse was extremely broad. There was no standardised method, level of expertise or equipment for inserting catheters. The supposed level of expertise was firmly in the hands of the anaesthesia department. Failing their support, it was very common to have patients waiting for a catheter to be surgically inserted by a surgeon.
 
Hand in hand with a visionary anaesthetist, we established a comprehensive vascular access service (VAS) in 1993 providing this to all areas of the hospital. I should clarify when I say that ours was a service that could insert all types of vascular catheters: Traditional, cuffed tunnelled, acute CVC, PICC, dialysis. It truly brought vascular access to the patient in a way that didn't happen before.
 
VC: I sense the passion in your response, but tell me why you chose the field of vascular access nursing as a career choice? What is it that excites you the most about this work?
SI: I found I could really make a difference. Part of the service delivery was that catheters were placed at the bedside -- when the patient required it. Rather than the patient being moved around the hospital to suit the location of the inserter, the service was delivered to the patient wherever they might be which I found very powerful
 
I also think vascular access may seem quite simple and straightforward to some, but it has a breadth and depth that never seems to end. It may appear at first glance to be a repetitive process but the one variable that constantly changes are the patients that require your service and expertise. Add to this changes in the accompanying technology (the female version of boys with their toys) and expertise that only grows with time.
 
VC:  What are some of the biggest problems you face on a daily basis as a vascular access specialist?
SI: One problem is that everything thinks they are an “expert” when it comes to vascular access, from peripheral to central lines. I believe this is because in many settings no one particular group “owns” this field. Subsequently, I often get referrals for a PICC, not a vascular access assessment or evaluation to determine what a patient may need. My way of dealing with this problem is to always accept the referral, but explain that I will review the patient and make a decision as to what would be the most appropriate access for their needs. This is a long-term education / culture change process that never ends. I would add that this philosophy only functions if a vascular access specialist such as myself can offer all the choices of vascular access. Meaning if I assess a patient and determine they require a CVC and not a PICC, I need to be able to place it for the patient and the referring provider. If you hold the title of vascular access specialist, you need to have the experience and skill set that justify the title across all devices.
 
VC: So given this issue, what do you think are the biggest challenges facing the field of vascular access access today and how do we move the field forward?
SI: I think one of the biggest challenges is on our end. For instance, I am not 100% certain that PICC teams are vascular access specialists. Rather, they need to understand their limitations and push to be able to place all types of devices - so that the patient gets what is best for them, not what is available.
 
Another challenge and area for innovation is a manufacturer’s / industry’s ability to keep up with the appropriate / safest products, technology. There is a real illusion that industry works hand in hand with practitioners; in my opinion, this is not always true. Rather, practice, technology is driven (sadly) by marketing. There needs to be a lot more collaborative cooperation particularly at the R&D stage. Industry needs to work in sync with clinicians so that the needs identified by us can be met by emerging technology.
 
VC: If there were one vascular access policy change you could make, what may it be and why?
SI: That's easy. All patients should be referred to a vascular access specialist, who is an expert and competent in all areas of vascular access. Just as a patient that may need surgery is referred for a surgical consult, vascular access should be a speciality in its own right. Last I checked we didn’t ask the surgeon to come down to the ER and do an appendectomy now, did we?