Ultrasound Guidance and Difficult Venous Access (DVA)

For this week’s blog entry we are choosing and evaluating a clinical practice guideline that applies to our area of interest.  I chose the Cincinnatti Children’s Hospital Medical Center (CCHMC) guideline –  Use of ultrasound guidance for peripheral intravenous access in the pediatric population (2012), which provides recommendations for ultrasound use in pediatric patients with difficult venous access (DVA). Stevens and Mitchell call for explicit identification of the evidence and rating of evidence and recommendations in the development of quality guidelines (2013). They also require a guideline to undergo specific development steps, including the identification of the type of supporting evidence (research or expert opinion) used to formulate each recommendation, as well as the use of a rating scale to reflect the strength of evidence used. This guideline clearly meets these criteria (see image below). Other factors which influenced my choice of guideline:

• Population – this guideline focuses on patients with peripheral venous access needs, while others were more broad, making extrapolation of recommendations challenging.

• Setting – the guideline was developed by a hospital, making translation of recommendations more applicable.

• Format – easy to read and interpret.

Guideline Modifications

Potential Harms The CCHMC’s guideline elaborates on potential benefits but does not state any potential harms. Weiner, Geldard and Mittnacht acknowlege the limitations of ultrasound guidance for vessel access, remarking on the steep learning curve required for successful use and the need for training and skill reinforcement to avoid complications such as the inadvertant cannulation of an artery (2013). This video demonstrates the process of using ultrasound technology to guide a needle into a vein.  You might notice the screen represents a total of 2.2cm depth.  The target vein is about 0.5cm in diameter – it’s easy to imagine the potential for error in such a small space! The CCHMC does reference the need for appropriate training and maintenance of competency within the Implementation Strategy section of the guideline, however I believe a description of potential harms, including inadvertant arterial perforation, nerve irritation or damage and possible increased risk of infiltration warrants some discussion in this section.

Defining Difficult Venous Access Within the CCHMC’s guideline, references are made to patients with difficult venous access (DVA) and the definition for this characterization is provided: In my last blog entry I discussed the challenge of translating expert assessment into data that may be extracted and imported to clinical decision making tools. In reflecting how I might adjust this guideline for use at my hospital, my mind returns again to the utility of quantifying the expert assessment of patient’s veins. Generating data like this will define what we mean by DVA at our organization. I was unable to discover any standardized nursing terminology while searching the NANDA Knowledge Base for terms relating to venous access.  Below are some of the existing elements and changes I would make to the Lines, Drains and Airways (LDA) nursing documentation: Fields included in existing LDA:

• Date of placement
• Time of placement
• Anatomical location and orientation
• Catheter length and size
• Method used for placement
• Number of attempts to place successfully
• Role of clinician who placed

Fields I would add:

• Techniques for vessel dilation
  • dry heat
  • moist heat
• VAT assessment of difficulty
  • 1 – tourniquet only
  • 2 – moist heat required for vein id
  • 3 – VAT attempt >1
  • 4 – ultrasound use required
  • 5 – ultrasound use employed with difficulty and/or >1 attempt w/ultrasound

The data generated from the addition of these fields will help determine whether patients should be identified as DVA and thereby qualify for application of the guideline.  It may also help bedside nurses understand which techniques may be useful in maximizing venipuncture success for each patient. Extracting this data from the EMR and using it in determining a patient’s classification as DVA will help further the goal of my Venous Access Early Assessment Program by addressing the access history factor that may qualify a patient as DVA.  Below I have updated my SEIPS chart to reflect this evolution: One thing that may be a stumbling block is the accuracy and completion of this documentation.  You can create fields for data entry, but that doesn’t mean it’s always entered, or entered accurately. I would expect that retrieval of this data will reveal only partial compliance with it’s entry. This challenge can be viewed in light of the larger context of electronic charting time commitments. McGonigle and Mastrian describe nurse’s perception that the time required to document has increased significantly (2015). With all of the demands placed on nurses at the bedside in this age of informatics, the temporary tradeoff for the rapidly expanding access to information may (ironically) be the sacrifice of compliance with accurate documentation. Some of the questions I need to consider at this point include:

• How will DVA be defined?  At this point, I think it’s probably adequate to define DVA as any patient who ranks a score of 4 or 5.
• If a patient is considered DVA during one hospitalization, does this classification always follow them in subsequent admissions?  If so, how will this data be communicated from one hospital episode to the next?

Data Mining

Cummins, Pepper, and Horn define Knowledge Discovery and Data Mining as “a process in which machine learning and statistical methods are applied to analyze large amounts of data” (2013, p. 56).  Data mining would not be useful in my problem, as I am not seeking to evaluate large data sets to draw conclusions or guide care for populations.  However, descriptive references to the plan of care in the progress notes may require the application of Natural Language Processing.  This is a method of data extraction from text (Cummins, Pepper, & Horn, 2013) that will help identify those patients whose plan of care may be for a duration of irritant or vesicant medication administration that would benefit from central access.  The use of the hospital’s HealthLink software report features will provide patient specific reports highlighting “red flags”, such as specific irritant or vesicant medications on their profile or diagnoses and co-morbidities such as cancer, cystic fibrosis or kidney failure which may indicate the need for early central access.

One challenge to obtaining data for the VEAP is the matter of the popularity of the informaticians.  At an academic medical center the size of mine, get in line!   With the rapid pace of evolution of  the EMR, the associated ongoing modifications, and high volume of requests for information, it can be months before requests for changes or reports are met.  So, one of the keys, I believe, to achieving success in generating informatics related change at your organization is …

PERSEVERANCE.

Stay tuned….

References

Cincinnati Children’s Hospital Medical Center. (2012). Use of ultrasound guidance for peripheral intravenous access in the pediatric population. Cincinnati, OH: Cincinnati Children’s Hospital Medical Center. Retrieved from http://www.guideline.gov/content.aspx?id=46457

Cummins, M. R., Pepper, G. A., & Horn, S. D. (2013). Knowledge discovery, data mining and practice-based evidence. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach (pp. 54-71). St. Louis, MO: Mosby.

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

Neurocritical Care Ultrasound (Producer). (2014). Ultrasound guided vascular access- out of plane (axial/transverse) view. Available from http://www.youtube.com/watch?v=JkToLAbW8u0

NANDA International Knowledge Base.  Accessed at

Stevens, K. R., & Mitchell, S. A. (2013). Evidenced-based practice and informatics. In Nelson, R. & Staggers, N. (Eds.), Health informatics: An interprofessional approach (pp. 40-53). St. Louis, MO:  Mosby.

Weiner, M. M., Geldard, P., & Mittnacht, A. J. (2013). Ultrasound-guided vascular access: a comprehensive review. Journal of cardiothoracic and vascular anesthesia, 27(2), 345-360.

Developing the Venous Access Early Assessment Program

The Infusion Nurses Society calls for the placement of the most appropriate intravenous access device in patients who require intravenous therapy (Infusion Nurses Society, 2011). Often patients admitted to the hospital receive a short peripheral intravenous catheter when a different catheter would have provided for more reliable, satisfying and safer access. In addition, too much time passes before patients receive appropriate access for irritant or vesicant therapy, resulting in unnecessary complications. The informatics challenge I am exploring is how to choose the most appropriate device early in a patient’s hospital stay.

Collecting, Analyzing and Organizing the Data

According to Connors, Warren & Popkess-Vawter (2013), health informatics is the analysis and dissemination of stored health data through the use of technology. In gathering data to determine the most appropriate venous access for each patient early in their hospital stay, one of the informatics challenges lies in the analysis and organization of the data from the electronic medical record (EMR) into reports that can be used to guide clinical decision-making. Diagnosis, current medication list and prior venous access devices, the number of needle sticks required to place a peripheral intravenous catheter (PIV), it’s dwell time, and reason for removal will need to be extracted from the EMR for each hospital visit. This data currently is only available by manually entering each encounter within the patient’s EMR and scrolling through flow sheet entries one encounter or admission at a time. While both the EMR and the electronic health record (EHR) contain an individual’s digital form of health related data, the EMR is specific to one institution while the EHR represents the collection of this data across various facilities and agencies (Connors, Warren & Popkess-Vawter, 2013). I’ll be accessing data strictly from my hospital’s EMR, although it’s easy to imagine the utility of expanding this program and integrating data across care environments.  The expansion of this program into the realm of the EHR would enable an even more thorough understanding of patient’s venous access history and support more seamless care.

Nursing Informatics, Knowledge and Wisdom

The sub-specialty of nursing informatics is defined as a clinical health care informatics that incorporates the application of computer science and information science and provides for the management and communication of nursing knowledge and wisdom (Connors, Warren, & Popkess-Vawter, 2013). I am intrigued by this concept. As a new nurse, I recall lamenting the lack of translation of knowledge from one generation of nurses to the next – the opportunity to learn key skills and benefit from the collective wisdom of nursing was haphazard at best. The challenge here: how to find a way to record and retrieve data that represents the expert nurse’s assessment and findings, thereby making it possible to characterize and share their knowledge and wisdom. For example, while it may be possible to place a PIV for a particular patient on the first attempt, the expert nurse may have had to employ advanced techniques. The EMR would reflect that the PIV was placed in one attempt, but no data reflects the degree of difficulty as assessed by the expert nurse. Employing a scale or rating system using standardized terminologies would be useful in this context. The degree of difficulty and advanced techniques employed are an important piece of information that reflects nursing knowledge and wisdom and adds value to the overall clinical picture.

SEIPS Framework

The SEIPS model of work system and patient safety expands on the Donabedian framework of structure-process-outcome to more specifically underscore the effects of the work system, or structure, on processes and outcomes. The SEIPS model defines the work system as and inter-related network of technology and tools, organizational, environment, tasks, and people factors. This model stresses the central role of the people in the work system and how one factor within the work system can significantly impact the others. This system allows for assessment of the impacts of a work system as a whole while minimizing the focus on one element in isolation (Carayon et al., 2006). Below is a concept map of the work system for development of the VEAP. In reflecting on the challenge of developing the VEAP, the interdependent nature of the relationship between the patient, the nurse, the pharmacist and the ordering provider, will need to be considered. See below for a visual reflecting this dynamic. All of these individuals will impact the functioning of the VEAP in different ways: the patient as the recipient of services will play a role through determining personal preference of device; the nurse’s expert knowledge in the character and quality of the patient’s veins and their amenability to various forms of access; the pharmacist’s understanding of the physical properties of prescribed medications; and the provider’s knowledge of the patient’s medical condition and authority to drive the plan of care.

Barriers

One of the barriers to developing the VEAP may include resistance from ordering providers related to their concern for loss of autonomy in clinical decision-making. It will be important to educate providers about the program and stress that it’s intent is to integrate individual patient information in order to ensure awareness of the risks and benefits of various forms of venous access for each patient. This will serve to provide reassurance that this program is not intended to bypass any clinical decision making or provider autonomy, but to provide support for clinical decisions.

Organizational characteristics may also serve as a barrier to the development of the VEAP program. Carayon et al. (2006) describe teamwork, culture, collaboration, communication, and coordination as contributing to the organizational characteristics that may impact a work system. While the organizational culture at my hospital supports evidence-based change, which acts as a facilitating element for this program, collaboration among and between disciplines is strained and may present a significant barrier. Recruiting representatives from provider groups, pharmacy, administration and nursing to form the VEAP committee will be a starting point to promote collaboration and teamwork among the disciplines.

References

Carayon, P., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care, 15(suppl 1), i50-i58.

Connors, H., Warren, J., and Popkess-Vawter, S. (2013). Technology and Informatics. In J. F. Giddens (Ed.), Concepts for Nursing Practice (pp. 443-452). Mosby.

Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice (2011) (Vol. 34). Untreed Reads.

Welcome to Jen’s n764 Informatics Intravenous Access Blog

This blog will be a space for exploration of informatics issues as they relate to intravenous access in the hospital setting.