Establishing a Vascular Access Team Overseas

Over the years, INS has expanded its reach and influence across the globe. In this issue, we are featuring an interview with Maciej Latos, who utilized the Standards while establishing a vascular access team in Warsaw, Poland.

What is the name and size of your organization?

The University Clinical Centre of the Medical University of Warsaw is made up of three academic hospitals: 2 for adults and 1 for children. The complex was established at the Central Clinical Hospital (for adults) and has approximately 1,000 patient beds. There are 16 clinics and 6 departments.

Why did you decide that your hospital needed a vascular access and infusion team?

I think the reasons are the same as everywhere: we have numerous cannulations and numerous hospitalizations and difficult intravenous access. Working in a large hospital, we observed that everyone was playing their own game, that there was a problem with implementing strategies and thinking about the patient and their future in terms of vascular access. It's sad to admit, but the quality of vascular access care wasn't the best either. This, of course, stems from general problems in Poland—infusion nursing is not an official specialty in Poland. We don't have a certification similar to yours. It is usually dealt with by anesthesia nurses and anesthesiologists. There are times when, as clinicians, we place another PIVC and eventually, when there is no other option left: you have to insert a central venous catheter (CVC). We decided to change that. At the same time, it's hard to ask people to think about strategy when they don't have real support in access selection and infusion management. There was a strong need for a team, and we started to be aware of the possibilities.

What were the steps you took to set up this team? Please share with our readers your timeline.

It all started in the COVID-19 pandemic. It was 2020, and we were running an intensive care unit for COVID-19 patients in an atmosphere of great stress. Many patients only had respiratory failure and therefore rarely required a central line. Their condition on the ward deteriorated suddenly and reliable intravenous access was needed by everyone, but not always a CVC. My colleagues, Bartosz Sadownik (a doctor) and Marceli Solecki (a nurse), and I wondered what could be done. How was the world dealing with these problems, which the pandemic had amplified? Our colleague Dr. Robert Becler, who works not only with us but also in Sweden, told us about midline catheters. There was basically no widespread distribution of them in Poland, but we managed to import a few samples. I remember like it was yesterday when two of my colleagues—Dr. Mateusz Zawadka and Dr. Maciej Michałowski—told me, come on, you're going to insert a midline, it's a peripheral insertion, we should be able to do it. It worked, and new possibilities opened up for me. We started reading, looking for protocols, and observing patients and staff.

In 2020, we introduced 5 midline catheters. In Poland, nursing competencies are very unstructured and we were faced with the dilemma of whether midline placement could be carried out by nursing staff. We wrote to national consultants and scientific societies, and got the green light. We created a procedure, and started proposing midline catheters as an alternative to CVCs when the only indication was difficult intravenous access. Insertion was handled by the emergency team, which until then had been helping patients and nurses when there were difficulties with cannulation. Thanks to our head nurse, Elżbieta Żurawska, and chief physicians, Piotrowski Nowakowski and Paweł Andruszkiewicz, we began to implement midline catheters into routine practice, not only based on difficult intravenous access, but also on the expected duration of therapy. This has been successful.

By 2021, we already had an additional person on shift to do insertions and staff training, and we inserted 150 midline catheters. In 2022, we started to talk seriously about the need for systemic change in our hospital, and after training staff more effectively, we inserted 261 midline catheters. In February 2023, a team was officially established, and we inserted more than 100 in the first quarter of 2023.

What's more, through training, webinars, and social media, we started a debate on the need to develop the specialty of infusion nursing in Poland. It turned out that clinicians saw this problem, but hadn’t made any progress. Now more teams are being formed in our country, which makes us very happy. Remember, we are talking about a country where still many clinicians do not know what midline catheters are, and where inserting ultrasound-guided peripheral cannulas is not known.

Tell us about the process of introducing midline catheters and ultrasound-guided PIVCs. What was that process like for you? Who is performing these procedures?

This is a difficult question. To answer it you have to start with the fact that in Poland the nurse does everything, from typically caring activities to highly specialized ones. A lot of activity is based on the enthusiasm and activity of the nurses themselves. So, together with the emergency nursing team, we started to observe doctors who insert not only CVCs with ultrasound guidance (USG), but also PIVCs. I asked myself: is using USG for cannulation so difficult? We started looking for courses dedicated to nurses, but there were none. With the help of doctors, I started using ultrasound for cannulation, although we had and still have problems with the availability of ultrasound devices dedicated to nurses, for example. Nevertheless, I gained experience and passed it on to the rest of the team. This has been successful. Within two years, we ourselves had trained more than 500 nurses and doctors in Poland to guide the needle with ultrasound as well as midline catheter placement. They all saw the sense in delegating these competencies to the nurses who are closest to the patient, who most often have to solve problems in obtaining peripheral access. At the same time, we realized that these skills needed to be possessed by a small group of people who would specialize in it and do it effectively. This has been successful: nurses and doctors from the wards qualify patients, and the nurses from our IV team obtain vascular access. However, we knew that the work of such a team had to be interdisciplinary, so the team also has doctors who provide support, and also perform CVC-type procedures when a patient presenting for midline or ultrasound PIVC should have a central line inserted instead. This works. In 2018, due to difficult intravenous access, central catheters were inserted in 77 patients, but in 2022, only 19 were utilized.

What have you learned from that implementation and/or what new concerns have arisen?

I have learned determination and consistency. I realized that without those traits, unfortunately, nothing will be done. In a country where a lot of things have to be done from the bottom up, determination and consistency are very important. If we had given up at any stage, we wouldn't be where we are today. Teamwork is always the key to success, but there also has to be someone who sets the rhythm of the group and shows that we won't give up, that we will do it! There is a lot ahead of us. As we gain experience, we see how many more things there are to do. What we have achieved makes us constantly feel that we can do better, that we can do more. What I fear is losing energy. If you do something with the hope that you can make a difference, then you move forward. But this state cannot last forever. If stabilization doesn't come then there may not be enough energy to keep refueling.

What challenges have you had with either of those procedures and/or setting up the team?

The greatest challenge is people not understanding. I want them to understand that our work is important, that it doesn't have to be the way it is now, that everyone can be safer both for patients and staff. The most difficult part is convincing staff that what we do is important. Constant staff shortages, equipment shortages, and lack of money in hospitals makes it very difficult to introduce new things. People try to survive from shift to shift, and there are always new responsibilities.

Another issue is the formation of the team itself. How do you choose people? How do you form relationships? It is clear that not everyone has the disposition, skills, and knowledge to be in such a team. How do you demand the highest quality from people, and at the same time not lessen their enthusiasm for development? How do you explain to those who are not in the team that we are doing new things in a structured way? That we are breaking stereotypes because that is what modern nursing requires?

To be honest I think we had more interpersonal problems than administrative ones. In nursing, in a country with a communist background (although it's been a long time, since 1989), in my opinion, there is still a belief that everyone should do the same thing, keep their head down, know their place. Passionate people are looked upon as strange. Because how can you enjoy your day job? People don’t understand that.

How did the Infusion Therapy Standards of Practice influence your process?

They were a signpost. When I started looking through the literature, I came across the INS Standards. My first thought was: these guidelines are like resuscitation guidelines for cannulation. There are answers to most of the questions we didn't know the answers to. I called my friend Natalia Sak-Dankosky, a nurse who has earned a PhD over a span of 7 years, gaining her professional experience abroad including in the United States at the University of Pittsburgh. She described more or less how it is done in your country, and I felt inspired. At that time, the Standards were daily reading for me. Of course, there were problems of differences in competence and availability of equipment, but we managed to put it all together and adapt it to Polish realities. We wrote a book on vascular access. It turned out to be a bestseller. A book about venflons [cannulas] you might ask. Yes, because there was no publication in Poland dissecting cannulations and infusions. When building the team, we had no guidelines. I read a bit about our neighbors, and listened to lectures given by K. Lisova from the Czech Republic. But we based the team building on the Standards. Most of our guidelines and our protocols that we wrote so far are based on INS guidelines.

What would you do differently if you started from the beginning now?

There was a pandemic. There was no time to think much about it. As I mentioned—first we were looking for a way to help the patient, then the team-building initiative came out of it. If I had the opportunity, I would have started it from the other side. I would have planned the formation of such a team, started with education (which we did simultaneously), chose people in a quiet recruitment process, and started working with patients after such a team was established. Although it was possible to add more team members on a mentoring basis, it could have been more structured. But opportunities were what they were. The pandemic required a lot of quick decisions, especially as we didn't know how it would unfold.

What are the current benefits of having this team?

Patients, nurses, and doctors receive real support. This ranges from choosing the right vascular access to infusion dilemmas and infusion education. Every day, Monday through Friday, one person is on call at all times. A member of the team helps choose the right vascular access, inserts midlines and PIVCs, and helps solve dilemmas and trains staff. Patients know us, especially those coming back for treatment, and often suggest contacting us because they know if they have a difficulty, with us they will get real help.

What are some changes that you’d like to make to this team in the future?

In our team we have 10 nurses and 3 doctors and a lot of people around us who support us, who give us a solid background. People who work hard in the team are constantly gaining knowledge and skills. I hope that in the future we will be able to expand the team so that it is available 24/7 and always has the equipment it needs, such as a mobile ultrasound. I think that system changes in Poland’s hospitals and universities and the creation of infusion nursing in the public consciousness would make everyone's work easier, both for us and for every team that is created in our country.

Is there anything else you’d like to share?

I would like to thank everyone who is with me on this journey, who understands that we need to make changes step by step, sensibly and responsibly: the people who have a management role in the hospital and those who work at the bedside, the nurses and doctors. I would like to mention my team members, because for all of us, an interview with INS is a very big reward for what we do. Special thanks to: Bartosz Sadownik, Piotr Nowakowski, Paweł Andruszkiewicz, Elżbieta Żurawska, Halina Sęk, Robert Becler, Marcin Łasiński, Marceli Solecki, Artur Szymczak, Dorota Dąbrowska, Tatiana Radomska, Konrad Sopiński, Kamil Meyka, Marta Jurkiewicz, Klaudia Smyrek, Jakub Dzięciołowski, Natalia Sak-Dankosky, Łukasz Wróblewski, Mateusz Zawadka, Aleksandra Święch-Zarzycka, Konrad Baumgart, and Dariusz Kosson and others.

Maciej Latos, who has his master's degree in nursing, specializes in anaesthesia and intensive care. He is a paramedic, a historian, and an assistant at the Department of Anaesthesiology and Intensive Care Division of Teaching at the Medical University of Warsaw (MUW), where he teaches courses in the Centre for Medical Simulation and Innovation MUW. He works as the head of the vascular access and infusion team in the University Clinical Centre (Central Clinical Hospital of the MUW) and as a nurse practitioner in the postoperative unit and emergency team. He promotes the implementation of best practices in medicine by hosting podcasts and writing on professional topics. He is the editor of Polish Nurse and Midwife Magazine, the coauthor of the Polish book Vascular Access in Clinical Practice, and the author of several scientific articles. A member of the Polish Association of Anaesthesia and Intensive Care Nurses and the Infusion Nurses Society, he is also the father of two daughters and a fan of cycling.