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I really liked this – pertinent in vascular access clinicians lives when trying to change things for the better..

Often, we find ourselves or other clinicians come across barriers and obstructions to promoting and encouraging best clinical practices, especially in the vascular access realm. It may have even happened to us – trying to make important changes, based on strong clinical evidence, guidelines and recommendations – to be frequently informed that higher powers, not familiar with the best evidence, do not consider the change relevant or even important.. Often, this is purely a lack of exposure to issues at hand – despite clear evidence supporting potential required change.

It is often very frustrating, and the inevitable feeling of being unable to make change for the better is quite often the reason why people just give up. ‘I’m done’. ‘I’ve had enough of beating my head against the wall’. ‘No-one listens’. ‘I given them the evidence but it is not highly regarded’. We all can acknowledge this is frequently something we come across, at all levels, however, when the patient is the central focus in our world, it becomes a lot more pertinent. Patients lives are often at stake. Poor, or should I say LACK, of the patients specific needs and requirements put them on the backfoot, especially if an inappropriate device is considered, or even placed, increasing obvious risk of complication, increased morbidity and mortality and procedural risks with inexperienced practitioners.

Striving to improve clinical practices and patient outcomes is the underpinning role of all healthcare practitioners, but what if they just aren’t interested in the change? Do not give up the fight. Patients deserve optimal care and pushing this is something that all clinicians and hospital executive/administrators need to ensure is happening in healthcare institutions around the country (and the world).

This image, which was posted recently on LinkedIn really highlights the need to continue to fight to improve all aspects of healthcare. It can be taken in numerous contexts when read and applied to any situation, even from end educational perspective, but to me, this is why we strive for excellence in vascular access practices.. Never give up, continue to fight and push for best practices always – even if we have to change our pathway of change process.. Patients deserve it – because we will all be patients one day, I’m very sure of it!

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My view on why Blind Sticking for CVC placement is not good – for anyone…

I have been following this thread on a research site, which I will leave unnamed, but its a widely used and respected online community – and interestingly there has been a huge number of clinicians who advocate for a ‘blind insertion’ of a central venous catheter.. Actually, there has been over 225 comments about the topic discussed.
Now seriously? In todays technological world of healthcare, where safety of the patient is paramount – why the heck would you want to do do that?… Risk, risk, risk – to everyone!

So I ended up writing a reply to these “blind stickers” who think that its ok to just stick a 7cm 18G needle into someone neck, chest or groin, without know what they can see..

Would you let a surgeon perform an operation he was very familiar with, blindfolded? – I think not!

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This was my reply – I copied it as I wanted my reply to show how I felt about clinicians who continually go against the current levels of evidence that SUPPORT ultrasound guidance… and patient safety.

I have a few comments. If you utilize a blind (landmark) insertion technique, it signifies that you CANNOT see anything below the skin surface. When did you all get x-ray vision? What surprises me in todays current clinical environment is the fact that clinicians who willfully choose NOT to use US, put themselves, and their patients, as great risk. Whether you are a skilled inserter or not. You cannot see any of the surrounding structures (arteries,  organs/glands), you cannot see anatomical and structural variances, you cannot see thrombosis, you cannot see vessel stenosis, you cannot see translocation of the vessels, you cannot see the nerves, you cannot see the pleura, you cannot calculate the vessel to catheter ratio.. anything else you can’t see? You cannot see ANYTHING! What more do I need to really say? 
The lack of US uptake in skilled clinicians is unfathomable in my mind. I teach 1000’s of physician and non-physicians alike around the world on USG-CVC insertion – the look on their faces when they actually SEE where the pleura is and the major neuromuscular bundles are, is priceless – so many times I have heard, ‘wow, I never knew it was so close to the…..’. With the current levels of evidence supporting the use of US guidance for this invasive procedure, considerations of litigation are to be expected. Now, in the USA, if you cause a complication related to a vascular device insertion, AND there was an US machine available (not just in the room, but within the hospital), the inserter will be liable to potential litigation.
If you think US slows you down in an emergent situation, then you are evidently incorrect. A CVC should never really be placed in an emergent situation – it often takes time to perform, forces clinicians to frequently place in the femoral vein (especially when active resuscitation is happening or patient has philadelphia collar insitu – as well as other neck/chest related injuries ) and in many situations, the inserter often breaches sterile insertion techniques just to make the procedure faster – this cutting corners is not acceptable, as it increases the chance of CLABSI/infection/sepsis and opens the patients to an unscheduled device change once stabilized. A humoral intraosseous device is faster and more appropriate in this setting (especially in the shocked/hypovolemic) and can remain insitu for 24hrs.. It also has flow into the SVC in 3 seconds. If you need more flow/volume, place a second IO device – it takes 6 seconds to do and you have reliable access. Who can place a completely sterile CVC in 6 seconds – no-one! However, that is a debate for another day – there is also plenty of evidence that supports this also.

I learnt and practiced a blind insertion technique for 10 years, primarily because we didn’t have access to bedside POCUS in our ICU/hospital (until 2005). Once we had US, I never looked back – and I have never placed a device blindly since. It’s just not worth the risk in my opinion – to anyone. I advocate and teach USGCVC insertion every day, and the modern young physicians and non-physicians using it are ensuring good clinical practices and higher levels of patient safety for the future – with a blind stick, you CANNOT guarantee this. Sometimes growing up means growing apart from old habits. #vascularacess #FOAMva #FOAMcc #FOAMed #POCUS #FOAMus #Leadership

to blindly go

Ultrasound transducer standards of care and cleaning

Disinfection and cleaning of ultrasound probes and transducers is extremely important in light of current infection control practices. The Australasian Society for Ultrasound in Medicine (ASUM) and the Australasian College for Infection Prevention Control (ACIPC) have released their joint ‘Guidelines for Reprocessing of Ultrasound Transducers’. You can find the current guidelines available for download free from the links below. There is also a link to the use and storage of ultrasound gel.

Here are the resources;

Media Release Ultrasound Transducer Reprocessing Guidelines Set New Standard For Healthcare Industry
The safe use and storage for ultrasound gel

9 Rights of Medication Administration

This came across my desk the other day, and while I had known about this 5 step concept and used it throughout my career, I thought it was a great and concise reminder for us all who work with intravenous and infusion medication administration, regardless of our specialty areas. NB: I have slightly edited this from its original form.

What are the nine (9) rights of intravenous medication administration?

Well known five rights of medication administration are,

  1. Right patient
  2. Right medication
  3. Right dose
  4. Right route
  5. Right time.

Infusion therapy involves reconstitution of medications, infusing medications and solutions, insertion, maintenance and removal of vascular access devices, preventing catheter-related infection, and documentation.

Additional “rights” during infusion therapy include,

6. Right compatibility: Compatibility and chemical stability of medications / solutions are important to prevent possible drug to drug, and/or drug-solution interaction when multiple medications are administered through the same catheter or tubing. This is particularly in reference to a particular medication/solutions osmolality, osmolarity and pH.

7. Right duration: Appropriate infusion time or duration depends on the type of drug, patient’s age and condition.

8. Right vascular access device (VAD): Continuous infusion of vesicant medications and solutions with osmolarity higher than 900msOm/L requires a central vascular access device (INS SOP 2016). Clinicians require knowledge to select a central or peripheral VAD according to the chemical nature of the infusate, duration of treatment and condition of the patient.

9. Right patient assessment: High alert medications require vigilance and close monitoring.

Nevertheless, clinicians administering infusion therapies require knowledge and skills to insert and mange vascular access devices, ability to prevent, recognize and manage vascular access and infusion therapy-related complications.

References:

https://www.cdc.gov/hicpac/BSI/04-bsi-background-info-2011.html
FiveRightsofMedicationAdministration.aspx
http://www.ins1.org