New publication for those interested in maintaining catheter patency in the adult CVAD population..
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I just got off the phone with a colleague from North Carolina. I always enjoy his phone conversations. We had a robust discussion about many issues relating to vascular access, but one of the common threads of our conversation was the lack of self-education and keeping up to date in our specialty field. Despite having large professional bodies specifically educating to vascular access and infusion therapy, with organization such as AVA and INS, we still see clinicians who are unaware of the current evidence, and the standards of practice, within their specialty field.
Really? How can this be? I have seen for a fact that this is commonplace; I was speaking at a local chapter in Colorado last month and asked the room ‘who has read the new (2016) standards of practice (SOP)’. Probably 6-8 hands that went up in a room of ~25-30 people. So I prompted them again with another question; ‘of those who have read the SOP, how many had aligned their hospital policies with the new SOP to ensure they were practicing within the recommendations of the standards?’ Maybe 1 or 2 put their hands up. Wow! I was a little taken aback, as these clinicians are the forefront of vascular access and infusion therapy practice, many with credentialing letters after their names, and yet they are unaware or not reading the developing evidence that guides their clinical practices within their facilities and institutions.
Guidelines, recommendations and standards of practice all have differing cause and effects; and meaning. Car companies can make a recommendation that you use oil in your car, but if you chose not to do so, then your car will eventually stop functioning for a number of obvious reasons. Guidelines are similar; they guide clinicians in clinical practice through evidence and assisting them to make appropriate decisions based upon a certain level of evidence. Standards of practice is what we practice to that is also guided by regulation and peer-reviewed evidence. A standard is also something we held accountable for in a court of law. This is where this such a differing between the 3. Not to say a guideline isn’t peer-reviewed, but it’s looked upon in a slightly different manner. But the SOP, which is the go-to reference for those working in infusion therapy or vascular access, rely on this document to make appropriate clinical recommendations and decision-making process based upon the various levels of evidence and be held accountable in our actions for following these standards.
Standards are also put in place to reduce harm to patients. With todays ever increasing scrutiny of adverse events, patient satisfaction and quality improvement, we have to ensure that our clinicians are made aware and educated on changes that effect them while they are performing their roles and providing healthcare.
Why do we care about this? Because what we do has significant impact on our patient outcomes and we are judged on what and how we perform. Pleading ignorance to the evidence and standards will not support you in a court of law, even if you are deemed a competent clinician.
So, what is the importance of EBM and EBP? How does this relate to my clinical practices? Effective performance is a requirement to provide a standard of care. It will NOT stop you from getting sued… BUT should improve the quality of care clinicians provide and should decrease the chance of litigation (however, not guaranteed).
Read folks – this is the reason why we need to maintain our ongoing learning; to improve ourselves, and others, in our professional working world. We need it, our patients need it, our institutions need it. Better knowledge is better decision-making and performance, which in turn has better outcomes – for everyone.
And here is a great article from Harvard Business Review on mentoring;
Thanks to a team of creative colleagues from Cochrane Consumers and Communication, I want to share a video resource which answers this question clearly and simply for people who may not be familiar with the concept of systematic reviews: what they are, how researchers prepare them, and why they’re an important part of making informed decisions about health – for everyone. #vascularaccess #FOAMva
If you like this, then you will also enjoy this article on stakeholder involvement in systematic reviews..
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!
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!
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