Central Vascular Access Devices: From Orders to Insertion

Resultant harm

Insertion of an inappropriate central vascular access device (CVAD) can result in additional procedures for placement of the correct CVAD. Also, delays in needed therapy can occur while waiting for the correct CVAD to be placed.  

An inappropriate CVAD choice may also result in increased risk of infection, vascular damage, delayed or missed treatments, unplanned hospital admissions, extended length of stay, increased costs and unnecessary stress for the patient and family. Concerns also exist for patients with compromised immune systems/blood disorders (e.g., sickle cell), as well as the possibility of a retained guidewire from multiple line attempts.

Fundamental issue

Appropriate CVAD selection is based upon the prescribed therapy, anticipated duration of therapy, vascular characteristics, comorbidities, patient’s age, and resources for CVAD care (Infusion Therapy Standards of Practice, 2016).

The complexity of CVAD selection can be challenging in part due to the various types of CVADs (e.g., Broviac/Hickman, port-a-cath, PICC, hemodialysis/apheresis) available and considerations regarding required therapies, such as chemotherapy, blood transfusions, antibiotics.

Patient harm can occur when:

Organizations lack:

• Consultation practices and a standardized handoff process between the ordering physician and the proceduralist.
• Processes that clearly communicate the CVAD placement request, including all pertinent information (from ordering to placement).

Clinicians lack:

• Information and understanding of specific patient needs for CVAD insertion.
• Knowledge or understanding of the CVAD selection process.
• Consistent practice for utilization of CVADs.

Actions to mitigate risk at your hospital

Establish CVAD standardized processes for: 

• Ordering: Include reason for treatment, specific CVAD device (such as tunneled versus non-tunneled) to meet therapy needs and number of lumens needed.
• Scheduling: Utilize electronic ordering [e.g., surgical request form (SRF).
• Consent: Institute detailed consent forms for each type of line available for placement.
• Timeouts: Ensure the use of timeouts throughout the procedure.

First timeout: Used for identification of correct patient, proceduralist, operative site(s), anticipated risks, special equipment including implants (e.g., product, technique, lumen, hemodialysis/apheresis capable, expiration date, imaging and laterality verification).

Second timeout: Could be used for patients who are having two or more procedures or if the person performing the procedure changes. Timeout should be performed before starting each procedure (The Joint Commission, The Universal Protocol).

Third timeout (case debriefing): Could be used to verify key issues associated with the procedure(s) (e.g., guidewire removal, flushing of all lumens with positive blood flow, CVAD placement under fluoroscopy or confirmed by x-ray).

Other considerations:

• Selection of the CVAD kit from the CVAD cart by the proceduralist to verify the correct type of CVAD to be used.
• Delay opening the CVAD kit until the timeout is complete.
• Standardize CVADs throughout the organization with the focus on narrowing selections.
• Develop a database that includes all CVADs with the correct identification in order to produce a secondary label for CVAD package, which can be used to confirm contents for validation with the consent.
• Develop specific value analysis processes that control CVADs entering the organization and guarantees validation and entry into the database.

Target audiences

• Clinical leaders, infection prevention, learning executives, legal/risk management, medical leaders, nursing leaders, organizational leaders, patient safety, quality improvement, radiology, specialty care services, supply chain management/value analysis, surgical leaders.

What can I do with this alert?

• Forward this alert to the recommended target audience for evaluation
• Include in your Daily Safety Brief
• Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm
• Let Child Health PSO® know what is working and what additional information you need
• Leverage your PSO membership: Learn from each other to reduce patient harm and serious safety events
• Contact: Emily Tooley, RN, MSN, CPPS, (913) 981-4130

Has a patient experienced an event at your organization that could happen in another hospital?

• Child Health PSO members should submit event details into the Child Health PSO portal.
• Contact Child Health PSO Staff to share risks, issues to assess, and mitigation strategies with member hospitals.
• Nearly 60 children’s hospitals are actively engaged with Child Health PSO. We currently are enrolling new members.

Resources

(Note: Some resources may require a subscription to access.)

• Infusion Therapy Standards of Practice (January/February 2016). Journal of Infusion Nursing. (Standard 26. Vascular Access Device Planning). 
• Speak Up Poster (2012). The Joint Commission. (The Universal Protocol).

Acknowledgments

Thank you to the Infusion Nurses Society for their review of this alert. This alert is approved for general distribution to improve pediatric safety and reduce patient harm. This alert meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO.

In accordance with our Terms of Use and Code of Conduct, this material cannot be used for any commercial transactions that are unrelated to the original intent of Child Health PSO Patient Safety Action Alerts.

For additional resources, contributors and sources, download the PDF.