Van Boxtel - The future of DAV in the world

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GAVeCeLT, December 2019

Ton van Boxtel, RN, MSc

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Venous Access in the World

Where do we come from?

Current situation

State of the Art

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History of Venous Access

1945 first plastic cannula

1950 Rochester cannula

1952 Subclavian approach was described

by Aubaniac

(5)

Innovations and ‘old’ techniques

Drum Catheter

Blind procedure

High complication rate

Spit needle

Blind procedure

Short needle

Pre ultrasound

High complication rate

Cath link

Surgical procedure

Increased learning curve

(6)

Venous Access Devices

PC

(mini) Midline

Ax/ Subcl/ jug. (CICC)

PICC (port)

Tunneled catheter (all CVC)

Implanted Venous Access Port

Long

Cannula

peripheral

CVC

(7)

Peripheral canulla

Long canulla

Midline

PICC

Subclavian / Axillary, Jugular

catheter

Femoral catheter

Tunneled CVC

Implanted Port

Arm Port, Thorax Port

• PIVC: Peripheral IV < 5cm

• Mini Midline

> 5 – < 12 cm

• Midline

> 12 – < 25 cm

• PICC: Peripherally Inserted Central

Catheter

• CICC: Centrally Inserted Central Catheter

• FICC: Femoral Inserted Central Catheter

• Hickmann, Broviac, PICC

• PICC Port, Vascular Access Port

(8)

Vascular Access Devices

PICC’s - in most countries inserted by nurses and doctors

Often not recognized as CVC

CICC’s – Mainly inserted by doctors

FICC’s - not regularly inserted by nurses

Implanted thorax ports - mainly doctors

(9)

Trends in PICC‘s

Some countries hardly do PICC’s

–

Unknown

–

Unwanted

• Do not want to see a PICC as a CVC

• Have not developed a structure for home infusion (yet)

(10)

Trends in VA: Ports

Large numbers in Italy, France, Belgium, Germany and Eastern

European countries

Differences are influenced by

(11)

Current Situation

Many different ideas about the importance of Venous Access

Patients are still suffering

Many differences in procedures

Many differences in skills

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Most Patients

Don’t have any idea about the best VA option

Let the doctor decide

Have no idea about the skills and knowledge of clinicians

Accept mal practice

Mention problems with VA to have big impact

Get the blame for problematic vein access

(13)

Hierarchy

Doctors decide

Not always based on the right knowledge and skills

Nurses follow

Are often not well informed about state of the art

Easily accept what the doctor says

(14)

See one, Do one, Teach one

Not based on research

No new knowledge

(15)

Result

Significant incidence of failures

Complications

Delays

Waste of material

(16)

Central position in medical staff

Independent decisions

Medical background

Trained with:

‘See one, Do One, Teach one

Expected to ‘Do’

• Part of the nursing team

• Under supervision

• Nursing background

• Often more reluctant and act

dependent from doctor

• Expected to ‘Care’

(17)

Insert PIVC’s in most countries

(PIVC)

Insert Midlines in many countries

(PIVC)

Insert PICC (CVC)

Insert other CVC’s in some

countries / Institutions

Often a difference between ICU and

other wards

• Use and care & Maintenance

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Nurse-Led PICC insertion: is it cost effective?

Nurses insert PICC at bed side

Less expensive

Patients satisfaction

Easier planning

Less patient transport

(19)

PIV’s - in most countries

PICC’s - in most countries

CICC’s - not regularly inserted by nurses

FICC’s - not regularly inserted by nurses

Implanted thorax ports - mainly doctors

Implanted Arm Ports (PICC – Ports) increasingly inserted by

nurses

(20)

Cost Ultrasound guided PICC insertion

(21)

National Differences

Hierarchy

Leadership

Rules and regulations

Resources

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Venous Access Worldwide

Most used invasive technique

The world is not the same everywhere

Often seen as a generic skill

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• Hygiene

• Patient safety

• Resources

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Recent Development

Improvement of insertion techniques

Consensus on use of ultrasound

No blind sticking (Ledonne)

Prevention of complications

Tip positioning

Choice of materials

Care and maintenance

Education

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Ultrasound changed position VA

Less complications

The ZIM, PICC insertion in the green zone

First time access

Vein catheter ratio

More stable position on the arm

Extended dwell time

Option to tunnel

Direct or two step

(29)

US is the standard in VA

Smaller

Portable

Easy to use

Wireless

The use of ultrasound for procedural guidance

has been demonstrated to further increase the

rate of success and reduce the risk of specific

mechanical complications, especially in

(30)

‘Recent’ Innovations

ECG tip positioning for all CVAD

Glue: to be used to seal CVC insertion site

and skin after Port insertion and extra

puncture site when tunneling

(31)

(32)

CVC tip location

1998

NAVAN

lower one-third of the SVC, close to the

junction of the SVC and the right atrium

2007

EPIC

SVC

2009

ESPEN

cavo-atrial region or right atrium

2010

RCN

lower third SVC or right atrium

SIR

cavo-atrial region or right atrium

ASPEN

SVC adjacent to the right atrium

(33)

(34)

Conclusion: NS is a safe and effective locking solution in implantable ports if

combined with a strict protocol for device insertion and maintenance.

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Global Vascular Access Network

WoCoVA & Events (IE, Special Event, Post WoCoVA)

Data & Research

Education & Training

Projects

IE Certification, Library

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Evidence-based consensus on the insertion of central

venous access devices: definition of minimal requirements

for training

N. Moureau

1

_{, M. Lamperti}

2

_{*, L. J. Kelly}

3

_{, R. Dawson}

4

_{, M. Elbarbary}

5

_{, A. J. H. van Boxtel}

6

_{and M. Pittiruti}

7

1_{PICC Excellence Inc., Greenville Hospital System University Medical Center, Hartwell, GA, USA} 2_{Department of Neuroanaesthesia, Neurological Institute Besta, Via Celoria, 11, 20136 Milan, Italy} 3_{Department of Health, University of the West of Scotland, Glasgow, UK}

4_{PICC Academy, University of the West of Scotland, Concord Hospital, Nashua, NH, USA}

5_{National and Gulf Center for Evidence Based Health Practice, King Saud University for Health Sciences, Riyadh, Saudi Arabia} 6_{Infusion Innovations, Vascular Access Team Utrecht, Utrecht, The Netherlands}

7_{Department of Surgery, Catholic University, Rome, Italy}

* Corresponding author. E-mail: doclampmd@gmail.com

Editor’s key points

† This review presents consensus on standard minimal requirements for training on central venous access devices. † An international task

force generated an evidence-based consensus.

† The task force proposed 16 recommendations. † Standardized education,

simulation practice, and supervised insertions are the key to ensuring safe and competent practice.

Summary. There is a lack of standard minimal requirements for the training of insertion techniques and maintenance of central venous access devices (CVADs). An international evidence-based consensus task force was established through the World Congress of Vascular Access (WoCoVA) to provide definitions and recommendations for training and insertion of CVADs. Medical literature published from February 1971 to April 2012 regarding ‘central vascular access’, ‘training’, ‘competency’, ‘simulation’, and ‘ultrasound’ was reviewed on Pubmed, BioMed Central, ScienceDirect, and Scopus databases. The GRADE and the GRADE-RAND methods were utilized to develop recommendations. Out of 156 papers initially identified, 83 papers described training for central vascular access placement. Sixteen recommendations are proposed by this task force, each with an evidence level, degree of consensus, and recommendation grade. These recommendations suggest central venous access education include didactic or web-based teaching with insertion procedure, infection prevention, complications, care, and maintenance of devices, along with laboratory models and tools for simulation practice incorporating ultrasound. Clinical competence should be determined by observation during clinical practice using a global rating scale rather than by the number of procedures performed. Ensuring safe insertion and management of central venous devices requires standardized education, simulation practice, and supervised insertions.

Keywords:catheter-related infections, prevention and control; catheterization; central venous access; central venous, standards; clinical competence; competency; complications; computer-assisted instruction; consensus; evidence-based medicine; education; GRADE; guideline; humans; infection; internship and residency; programme development; programme evaluation; RAND; supervision; simulation; subclavian vein; training; ultrasound guidance; ultrasonography; vascular access; vascular surgical procedures

Education surrounding the insertion of central venous access devices (CVADs) remains undefined. Training is defined as the acquisition of knowledge, skills, and competence related to a specific activity or procedure. Understanding and establish-ing the level of education required for safe insertion proce-dures and management of CVADs is the focus of this publication. There is variability of knowledge and compe-tency among inserters which is represented quantitatively by the number of complications that occur from patient to patient.1 _{It has been demonstrated that a systematic}

training process, including ultrasound instruction before

patient insertions, reduces mechanical and infectious com-plications.2–6

Current CVAD literature related to training, supervision, and competence acquisition does not define a fully standar-dized programme for trainees; nor does it establish guide-lines for supervisors. No standard didactic or simulation training is currently required before the insertion of CVADs by clinicians in training other than supervision of an unspeci-fied number of insertions. The supervision requirements do not specify the role, experience, or competence of the supervisor.

British Journal of Anaesthesia Page 1 of 10 doi:10.1093/bja/aes499

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Trends in Vascular Access

Vascular Access expert specialist

Only Skilled ‘certified’clinicians (should) insert*

Based on minimal requirements*

Doctors, nurses, other clinicians

Increased use of Near InfraRed (NIR) and UltraSound (US)

Availability of better materials

PUR, impregnated, more variety

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Education & Training

• Certification project

–

GloVANet certificate for courses and training programs

meeting State Of The Art criteria

• _{Courses offered by related organisations (Certified)}

–

In agenda / website

–

Promotion

• _Library

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Future of Vascular Access in the World

Patients are better informed

More online sources

Not always accurate (State of the Art)

Treatment for patients should not / is not different

Why differences in VA training for doctors and nurses?

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Conclusion

From steel needle to polyurethane

Less traumatic, strong, every size, etc.

From short to long peripheral canula

Less migration, dislocation and extravasation

From cut down and blind sticking to ultrasound guided insertion

Less invasive, less complications

From general practice to expert teams

(Should be) Only done by well trained clinicians

From patient suffering to high quality care

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