THE CVAA
Newsletter of the Canadian Vascular Access Association
Fall 2018
New Member Spotlights Get to know some of the 150+ new CVAA members who have joined this year so far!
Tracy Bohme
research and products that directly affect patient care. I am also interested in learning opportunities that will benefit my interactions with patients and other medical personal. What features of membership are you looking forward to utilizing: I am excited to have access to another research tool. I believe knowledge is power and I am passionate about expanding my knowledge base.
What is your current role/ institution: My current role is with Alberta Health Services for the Advanced Venous Access Service for the Foothills Medical Centre in Calgary, AB. Why did you join CVAA: I joined CVAA because I feel that is important for my practice to be aware of current
Are you considering writing the CVAA(c) certification exam: I am registered to write the exam on March 14—wish me luck! Why are you passionate about vascular access/infusion therapy: So many patients require vascular access and receive infusion therapy with each hospitalization, and with the focus being more orientated to outpatient care, this
requirement is also seen in the community more and more. I have found that not a lot of time is spent on education regarding vascular access and infusion therapy and most do not know what the best practice is. In my current role, I get the awesome opportunity to specialize in Central Vascular Access implementation, care, and maintenance and initiating peripheral vascular access with ultrasound assistance; this gives me the chance to provide guidance to many bedside nurses, which fulfills my passion for education and expanding the tools that are available for all who provide primary patient care. What are you most looking forward to this summer: I am looking forward to enjoying the summer with my amazing three-year-old and introducing her to more camping, fishing, and gardening. continued on page 3‌
Michelle Pothier
What is your current role/ institution: I am a Clinical Consultant with ParaMed Home Care Services. I live in beautiful Prince Edward County, Ontario—home to the best beaches and some fantastic wineries! Why did you join CVAA: With the upcoming retirement of one of my colleagues, I was given to opportunity to become more knowledgeable in this area as a clinical consultant. I am really looking forward to the new best practice guidelines coming out.
What features of membership are you looking forward to utilizing: As a new member, I am just discovering what is available for me. So far, I really like the CVAA Link e-newsletters, especially the QTip section! Why are you passionate about vascular access/infusion therapy: In homecare, we do a lot of infusion therapy! Nurses are on their own in peoples’ homes— it is my job to support and educate our nurses; keeping up to date with best practices, with an emphasis on what is realistic in the home (I was a homecare nurse for nearly 25 years in the county. It is amazing how we can improvise for an IV pole, or be darn sure we would do everything in our skill-set to get that IV started, as there just wasn’t another nurse available to be called in). What are you most looking forward to this summer: I really enjoy competing in triathlons, as well as cycling and running. I have signed up for a few triathlons this summer, as well as couple running races (including my hometown Prince Edward County Marathon) and a century bike ride—as my kids are grown, I have time to play.
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Alicia Monnet
What is your current role/ institution? I am the new Clinical Education Supervisor at Paramed Home Health in London, ON. Why did you join CVAA? I joined CVAA because my new role involves training of community nurses on IV initiation and care and maintenance of venous access devices. I have a goal to significantly increase the number of nurses with the skills of IV initiation and venous access care and management within our organization in order to meet the needs of our community clients. I want to ensure that I have access to the most current information and resources when I am providing
education and training and I am confident that being a member of CVAA will provide that support. I am planning to write the certification exam soon. What features of membership are you looking forward to utilizing? I am excited for the release of the Canadian practice guidelines also, so that I can share them with my organization and ensure that current best practices are adopted by the nurses. I am also excited to incorporate the educational resources and videos available on the website into the education material we currently use for teaching. Why are you passionate about vascular access/infusion therapy? I have attended CVAA education events in the past as a visiting nurse in the community, and I found them to be very educational and well presented. I am passionate about vascular access/infusion therapy because our clients often require this care in the community. In order to ensure clients remain safe and can successfully receive their therapy and treatments at home, they require care that is evidence based and nurses who are knowledgeable to provide that care.
How did you spend your summer? This summer I enjoyed the warm weather and spending time with my two boys, Chase and Kai, doing some family camping and longweekend getaways, as well as spending time at our cottage in Port Franks.
Julia Dean
Why did you join CVAA? I joined CVAA because I wanted to increase and improve my knowledge with best practices with CVADs, as I access them quite frequently in the community for IV therapy and flushing of devices. Healthcare and best practices are constantly changing and I feel that being a member of the CVAA will help me stay current and safe and maybe help other nurses as well!
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What features of membership are you looking forward to utilizing? I am looking forward to utilizing the modules and articles and looking forward to using the best practice guidelines. I love having access to resources so relevant to care I provide! Are you considering writing the CVAA(C) certification exam? I am considering writing the CVAA exam within the next couple of years, as I feel this would strongly benefit my current nursing role. Why are you passionate about vascular access/infusion therapy? I am passionate about vascular access and infusion therapy because I use it consistently! As we see clients in their homes, if a vascular access device becomes blocked it really interferes with their care and they may have to go to the hospital. I want to be able to do what is needed to prevent blocked CVADs or have patient care interrupted and keep patients safe! What are you most looking forward to this year? This summer I got married!
Watch Plenary Session Videos We are pleased to offer encore conference plenary presentations from the 2018 CVAA Conference in Toronto this past April.
Session 1: For Better or For Worse? Harm Reduction, Ethics and Patients Who Use Substances with Vascular Access/Infusion Therapy Challenges Jocelyn Hill, RN, MN, CVAA(C), VA-BC™ View the videotaped plenary session here and follow along with the slide show presentation as well.
Session 2: IV Push Medications: Increasing Safety, Choosing Best Practice Karen Laforet, MClSc, RN, VA-BC™, CVAA(C), IIWCC, and Maureen Burger View the videotaped plenary session here and follow along with the slide show presentation as well.
Coming soon! The Current State of Central Venous Access Device Knowledge Among Nurses Andrea Raynak, RN, MPH(N), CVAA(C), France Paquet, RN, MSc, CVAA(C), VA-BCTM
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Q
Welcome to Q-tip: Quality Tips for Improving Practice
TIP
What is a Q-Tip? Quality tips are drawn from the most available evidence and this information is summarized to support your clinical practice. In each newsletter, the authors will address a burning question from the CVAA community. Q: I have always been taught that we should always look at starting peripheral IVs in the back of the hand before using the arm. At a recent conference I heard a speaker say that this may not be the best option….why? Answer: A peripheral IV (PIV) is started on approximately 80% of patients entering the health care system (1) making it the most common invasive procedure performed. When assessing the best site to place the PIV, “distal to proximal” is the mantra we all learned, but what does “distal” really mean? Most, if not ALL, clinicians are taught that distal means the back of the hand and, while many organizations such as the Canadian Association of Nephrology Nurses and Technicians (CANNT) still recommend this practice, I would like to challenge our thinking on this and consider that perhaps the back of the hand may not be the best distal location to start the PIV. Why is this? The vessels of the vascular system are comprised of 3 layers: Tunica Intima, Tunica Media and
Tunica Adventitia/Externa. For the purpose of this discussion, we will look at the Intima lining of the vein: a single layer of endothelial cells folded at intervals to form valves. These cells derive their food and oxygen from the blood that passes through the vein. Nerves do not exist in this layer of the vessel, but are found in both the Media and the Adventitia layers. A study of 90 adult cadavers showed that the average internal diameter of the subcutaneous metacarpal vein is 0.9 +/- 0.2mm (2) while the external diameter of a 22G PIV cannula is 0.9mm, a 20G is 1.1mm and an 18G is 1.3mm.(3) The insertion of any of these cannulas would take up the entire volume of the vein thus blocking the flow of blood through the vein around the cannula. This can create 3 potential complications: i) Stopping the blood flow around the cannula cuts off oxygen and nutrients to the endothelial cells of the Tunica Intima, resulting in tissue death ii) Pooling blood in the vein at the insertion site can result in thrombus formation iii) Irritation (phlebitis), caused by Infusate exiting the end of the cannula and not being able to mix with blood flow. Vesicants such as Dopomine, Phenobarbital, Vancomycin, and many anti-neoplastic drugs, can destroy the tissue layers of the vein resulting in an extravasation.
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continued on page 10…
The length of the PIV cannula also offers challenges. The back of the hand on the average adult is not a large area and the length of the PIV cannula averages 3.2-3.5cm in length (3). Simply hold one of these to the back of your hand and note that the tip of the device sits at the bend in the wrist. Now put an extension set on the end of the cannula and think about the challenges your patient will have using the toilet, washing their hands, eating, or using an assistive device. The Infusion Therapy Standards of Practice state in Standard 27.2 that “Peripheral vein preservation is considered when selecting a site for infusion therapy.” (4) Peripheral vein preservation is very difficult in the back of the hand when considering the anatomy and physiology of the vein, in combination with the size of the device versus the internal diameter of the metacarpal veins. Standard 27, Practice Criteria C.3 states: “Avoid areas of flexion”(4). The device should not sit at or on a joint. This would also mean that the antecubital fossa (ACF) is not a good choice (understanding that there are exceptions in cases of trauma and emergency) for PIV placement. If you find a PIV already inserted at the ACF it should be moved to a more appropriate site. The vessels in the ACF should be preserved for phlebotomy.
The intent of this discussion is to give food for thought regarding PIV placement based on best available evidence, standards of practice, anatomy & physiology specific to vessel size as well as the device being placed. Vein preservation, future vascular access and patient comfort are all important considerations for the clinician. Placing a PIV for anything other than a single dose requires the same considerations as CVAD placement. CVAA revised guidelines are recommending “distal” references to help support your clinical practice, but in the meantime perhaps consider 2.5–3.5 cm above the wrist in the cephalic or basilic veins as a good starting point.
References 1. Clinical Procedures for Safer Patient Care. Chapter 8: Intravenous Therapy: https:// opentextbc.ca 2. Zhang SX, Schmidt HM. Clinical anatomy of the subcutaneous veins in the dorsum of the hand. Annals of Anatomy; Vol 175(issue 4). August 1993:381-384 3. Peripheral IV catheter chart. Online Continuing Education: www.pedagogyeducation.com 4. Gorski l, Hadaway L, Hagle ME, McGoldrick M, Orr M, Dellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;(suppl 1):S54
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NEOCVAA CLE September 24th, 2018 Competent Caring Hands 7th Annual CVAA Learning Event This all-day event held at the Steelworker’s Hall in Sudbury, ON, brought together healthcare professionals from 10 different communities across North Eastern Ontario. A total of 90 people (industry reps included) attended the day, which saw opening remarks by HSN CEO Dominic Giroux support peer learning for professional development. Our theme of “Competent Caring Hands” was encompassed by the presenters. Throughout the day each participant was reminded,
NEOCVAA Chapter Executive
Speaker and patient advocate Emily Levy
Speaker Pat Carlson
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regardless of background, of our requirement to be competent when caring for others. Each topic provided insight into the necessity of considering that the patient/client is affected by our actions. The patient perspective session by Emily Levy (an AVA patient advocate) continues to resonate with members. A selection of skills labs was offered in the afternoon: IV Etiquette, Peripheral IV Best Practice, Best Practice for Obtaining Blood Cultures, Hands on Port Access, (No touch) PICC dressing technique and CVAD Troubleshooting. This year, the planning committee divided the attendees into small groups, ensuring that everyone could rotate through each station in an organised fashion. This arrangement helped keep everyone on schedule and worked very well.
Karen Mallet and Pat Carlson
Eleven industry sponsors participated with booth presence providing a venue for knowledge exchange and product exploration. This is always a valuable addition to the event that is welcomed by all members. The NEOCVAA executive wishes to thank all who contributed to yet another successful event— from the volunteers behind the scenes to the staff at the Steelworker’s Hall, from the presenters to the skills workshop facilitators. The NEOCVAA CLE could not have happened without your “Competent Caring Hands.”
Pat Carlson, Emily Levy and Karen Mallet
See you in September 2019!
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Join the 2019–2020 Board of Directors This is an extraordinary opportunity for individuals who are passionate about CVAA’s mission and are interested in leadership, affecting change and furthering the association. There several positions available at this time and all CVAA members are invited to apply. Board of Directors’ positions each carry a two- (2) year term. The available positions for 2019–2020 are: • 3 Directors-At-Large (2019 & 2020) • 1 Industry Representative (2019 & 2020) Expectations for ALL Directors are in the Governance Manual here. Ideal candidates will have the following qualifications: • Understand and demonstrate a commitment to CVAA, our mission and our programs • Keep up to date with issues and trends that affect the organization • Prepare for meetings by reading agendas, minutes, reports and other documentation required to actively participate • Contribute skills and knowledge by participating actively in meetings and committee work • Work collaboratively as a team • Personal qualities of integrity, credibility, and a passion for improving the practice of vascular access/infusion therapy
Directors-At-Large (See the full role description here) Some key points and expectations for DirectorsAt-Large for the 2019–2020 term: • CVAA(c) certified or obtaining the certification within first year of their term • Participate in monthly Board meetings by teleconference • Participate in other meetings and activities called by the President for various issues, as required • Attend the CVAA national conference, April 23–26, 2019, in Quebec City, QC • Attend an in-person meeting in Toronto, ON (weekend in early 2019 – exact dates to be confirmed)
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Industry Representative (See the full role description here) Some key points and expectations for the Industry Representative for the 2019–2020 term: • Industry representatives are not required to be CVAA(C) certified, however, are welcome and encouraged to do so • Participate in monthly Board meetings by teleconference • Participate in other meetings and activities called by the President for various issues, as required • Attend the CVAA national conference, April 23–26, 2019 in Quebec City, QC • Attend an in-person meeting in Toronto, ON (weekend in early 2019 – exact dates to be confirmed)
Please contact cvaa@cvaa.info with any questions. We hope you will consider submitting your application to be a part of the CVAA National Board of Directors!
Service on the CVAA Board of Directors is without remuneration, except for administrative support, travel, and accommodation costs in relation to duties. For industry reps, all costs of participation as Board member shall be covered by your employer. Applications are due by November 9, 2018, at 4:00pm EST and must be submitted through the CVAA website here. Voting by electronic vote will be open to all members during the month of November 2018.
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Imagine trying to start an IV in the arm of an infant who weighs less than 4 pounds, or an adult patient weighing more than 500, or placing a PICC line in a small, squirming child. When you’re working with some of the smallest, most vulnerable patients, every single needle stick, and every single minute spent, truly matters. Accessing Difficult Vascular Anatomy with Ultrasound “Drawing blood on a kid is sometimes really very difficult,” says William Copeck, Nurse Manager at The Valerie Fund Children’s Center for Pediatric Cancer & Blood Disorders (part of St. Joseph’s Healthcare System), discussing his center’s ultrasound-‐guided vascular access program. “Before we had the vascular access program, we would often have to have multiple nurses in the room sometimes to hold the child down, to hold them still enough, so that we could get a line in them. It’s traumatic for the kids, it’s traumatic for the parents, and sometimes it’s traumatic for us.” Whether injecting medicine or drawing blood, the Valerie Fund Children’s Center team recognized that anything that could make their patients more comfortable would be worth investigating. Ultrasound-‐Guided Vascular Access Reduces Time, Pain St. Joseph’s Regional Medical Center, located in Paterson, New Jersey, houses the second-‐busiest emergency department in the nation, serving over 175K patients in 2016. Seeking new ways to offer patients a better overall experience is top-‐of-‐mind for executives and practitioners alike. When St. Joseph’s first introduced their ultrasound-‐guided vascular access program https://www.stjosephshealth.org/newsroom/press-‐releases/item/1858-‐vascular-‐access , which trained nurses in using ultrasound visualization to locate and access hard-‐to-‐see vasculature, they didn’t realize what a huge difference the technology would make. “Before we had the SonoSite ultrasound technology, we had a lot of patients with multiple sticks, bruises…” says Judy Padula, Vice President of Patient Care Services and Chief Nursing Officer at St. Joseph’s Healthcare System. “As minor as that may sound to some people, getting the IV in can be the make or break to their treatment.” Ultrasound allows the specialists at St. Joseph’s to clearly visualize the vascular structures that they need to access in real-‐time. This promotes more accurate needle placement, which can lead to many fewer attempts needed. “With the ultrasound,” says Matthew Ostroff, head o f the Vascular Access Program, “we assess the vein before we stick it; we can see our needle going into the vein.” Before St. Joseph’s began their specialized vascular access program, point-‐of-‐care ultrasound wasn’t something most care providers considered essential to their work with sick children. “It wasn’t even on my radar,” says Copeck. And now? “I would tell people, you’re crazy not to have it. I can’t even tell you how important it’s been to us.” “It takes roughly 40-‐45 minutes at the bedside to do a PICC line,” explains Ostroff. “When we’re able to substitute an ultrasound-‐guided peripheral [IV], it’s a 5-‐10 minute procedure. We’ve essentially changed the entire landscape of IV-‐insertion.” A Savings of $3.5 Million with POCUS. The drive to provide a better patient experience propelled the adoption of the Vascular Access program, but the phenomenal savings that the program introduced was a pleasant surprise. Since the advent of the Vascular Access program in February 2014 and December 2016, St. Joseph’s has seen a remarkable and unexpected level of cost-‐savings; nearly $3.5 million in total. To learn more, read Becker's article here https://www.sonosite.com/blog/ultrasound-‐guided-‐vascular-‐access-‐program-‐saves-‐st-‐josephs-‐35-‐million. Reduced Referrals to Radiology + Shorter stays in the ED = $2.5 million savings Patients cannot be admitted to the hospital (outside of the Emergency Department) until vascular access is obtained. For both children and “difficult stick” adults, the ability to quickly and efficiently insert a peripheral IV can shorten the stay in the ER, and the cost of an overall stay in the hospital, significantly. When nurse practitioners can use ultrasound to guide needle placement, radiology referrals are reduced, which lessens the cost of care per patient. Choosing PIV over PICC = $1 million savings Moving from a preference for PICC lines to ultrasound-‐guided peripheral IVs saved roughly $250 in catheter costs per insertion. Interested in Learning About the SonoSite Solution for Difficult Peripheral IV Insertion? Download this Program Overview to read about the clinical pathway that improves success rates associated with difficult Peripheral IV insertions. Want access to the SonoSite Solution website? Click here https://www.sonosite.com/sales/contact?id=soln to request an account today.