Out on a limb

As more nurses are exposed to peripherally inserted lines, Neville Hearse looks at ways to improve the management of vascular access devices.

Over the last decade, nurses have been exposed to the increasing trend toward vascular access devices (VAD’s) for many types of patient therapies. The benefit for patient groups receiving long-term devices is enormous when taking into account the reduction in vascular access attempts resulting in patient comfort and the reduced cost of staff resources and equipment involved.

The management of these lines is therefore of paramount importance in reducing blood stream infections (BSI’s) and catheter-related complications associated with care and maintenance from a nursing perspective. Nursing practice with regards to insertion, care and maintenance of these devices remains stringently evidence based, a practice that ensures accountability and clinically justifiable.

Royal Adelaide Hospital’s department of radiology alone has seen a 400 per cent increase in VAD demand over the last eight years and currently sits at approximately 1400 peripheral VAD insertions annually. The nursing-led service, established as the first in South Australia, accounts for 95 per cent of all insertions undertaken within the institution, working from the department of radiology.

It is important to highlight that principles of care for other non-peripherally inserted devices, such as permacaths and infusaports remain the same.

Traditionally, radiologists were approached to insert peripheral lines, however the boundaries between nurses and radiologists have blurred significantly in recent years, with more and more nurses undertaking this role with strict credentialing parameters in place.

In line with this practice, infection rates at insertion have reduced (BSIs determined by infection symptom onset within 48 hours of insertion) within Royal Adelaide Hospital to below 1 per cent in comparison with past practices. It is therefore vital that correct care and maintenance be implemented to gain longevity from peripheral VADs, supporting best patient outcomes.

Practices governing correct care and maintenance are drawn from the International Centre for Disease Control (Guidelines for the Prevention of Intravascular Catheter-Related Infections) and The Journal of Hospital Infection.

How then, as nurses, can we ensure that VADs are cared for to gain longevity and therefore, best patient outcomes? Some simple rules are set down, to aid this plan.

• Asepsis is the number one rule when handling and maintaining these lines. Correct hand washing techniques and aseptic techniques must be employed when changing dressings and giving medications. Friction wiping of bungs and caps and when giving medications and when cleaning the insertion site on dressing change is of paramount importance in preventing infection. Quantitative research shows that a large percentage of post-insertion infections are attributed to common skin flora such as staphylococci, making post insertion care vital.

• Before medication and blood product administration. Line should be aspirated first before flushing, to ascertain line patency and exclude thrombus accumulation.

• Correct flushing regimes. The flushing solution is determined by the manufacturer, or through guidelines and protocols established by the individual institution. Decisions about correct solution should be evidence based. Currently, normal saline and heparinised saline are the two most common flushing solutions; however, ongoing debate revolves around whether heparinised saline offers any benefit over normal Saline flushes.

• Correct flushing technique. All flushing pre and post-medication administration should be in a pulsatile (push, pause) manner, to create a pulsatile flow, as opposed to a steady push. These pulsatile flushing blows accumulated debris out of the line, allowing the line to remain patent. This will in turn prevent occurrence of thrombus formation and catheter related infections.

• Correct pressurising of line on treatment completion. It is important that 1ml of flush solution remains in syringe prior to disconnecting syringe from line or bung, or before closing clips. This ensures that the line remains in positive or neutral pressure, preventing blood aspiration back into the line, which may cause occlusions. Never use a syringe that is less than 10cc. Comparative tools are available that demonstrate syringe volumes and deliverable pressures. If a too small syringe is used, possible catheter rupture and possible catheter embolus may result.

It is recommended that bungs or caps are changed every 72 hours or when dressing attended, or if removed for blood taking.

A semi-permeable membrane such as IV 3000 is recommended to use for VAD dressings to allow breathability. This reduces moisture collection at insertion site, reducing infection risk. Occlusive dressings increase moisture and are useful primarily for wound care; therefore semi permeable should be used for fixation for vascular access devices. As a demonstration of differing permeability between membranes, IV 3000 is up to 14 times more permeable than a commonly used wound dressing membrane.

As the nursing profession is more exposed to the increasing trend toward these vascular access devices, the onus is on every nurse to familiarise themselves with the management of these devices. Patient outcomes are dependent on professional, evidence based care of and individuals’ access device and correct aseptic techniques, flushing regimes and techniques will ensure longevity of these devices.

Neville Hearse is the clinical management facilitator and PVAD Inserter with the Department of Radiology, Royal Adelaide Hospital. This article was reviewed by Melita Cummings RN, clinical practice consultant – vascular access specialist, Department of Radiology, Royal Adelaide Hospital.

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