Please click on this link to view the NIVAS News Summer 2015

National Infusion and
Vascular Access Society
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Letter from
the Editor
and the Chair
The 5th NIVAS
Conference
A day in
the life
London
Nurse Show
NIVAS
News
Summer 2015
Letter from
the Chair
Letter from
the Editor
Welcome to the summer edition of the NIVAS newsletter. It’s
been an exciting year so far for vascular access and NIVAS. NIVAS
continues to keep intravenous (IV) therapy and vascular access at
the forefront of clinical practice through representation at national
organisational conferences and healthcare events and will
continue to do so for the coming months; we will be represented
at the upcoming Infection Prevention Society Conference and will
be holding a peripheral cannulation event in collaboration with
Vein Train.
This year seems to be dominated by advances in technology. You
will have already seen plenty of literature surrounding the use of
electrocardiogram for peripherally inserted central catheter (PICC)
line insertion and tip confirmation. There is now National Institute
for Health Care and Excellence (NICE) guidance on the use of
Sherlock 3CG catheter tip navigation technology and more evidence
is being published all the time to support the benefits of its use. We
have seen developments in infrared technology for peripheral vein
location which we showcased at this year’s conference in Bristol.
More versatile catheters are now available such as short-term
power midlines that can be used for computerised tomography
contrast. New fixation devices for PICC lines which enable us
to choose the best fixation device to meet the patient’s needs,
and new dressings to try and reduce the risk of catheter related
infections are being reviewed by NICE presently.
Time has flown since our highly successful 5th NIVAS
Conference ‘The challenges and future of IV therapy’.
The full report of the conference is available on the website
at http://www.nivas.org.uk/images/uploads/misc/NIVAS_
Conference_Report_Final_Version_20.07.15.pdf and there are
photos available for all to view. In the members’ section you
will find the Annual General Meeting report and talks from the
conference available to view. We have received really good
feedback from the conference which some are saying was the
best ever—always good to hear. As always we will take note of the
feedback and use it when planning our next conference. I don’t
know about you but I always find our conferences inspiring—an
opportunity to step away from the workplace, to see what others
are doing, be enthused and challenged, and sometimes to realise
that actually what you are doing is not so bad after all. It was good
to hear what is happening in Australia and across the globe but
also good to hear of local initiatives in Bristol. For me, being part
of NIVAS is about having a voice and about making a difference.
As always I make a plea to you to encourage your colleagues to
join NIVAS. Together we can have a say in the challenges and
future of intravenous therapy and together we can have a louder
voice and make a bigger difference.
Jackie Nicholson
Andrew Barton
www.nivas.org.uk
@NIVAS_tweet
The 5th NIVAS Conference:
The challenges and future of IV therapy
NIVAS Chair, Jackie Nicholson, opened the biggest yet NIVAS
Conference by paying tribute to the founding Board members
for setting up a truly multiprofessional society and thanked the
current Board members for their expertise and commitment to
the society. Reflecting the need for a co-ordinated approach to
practice, this year’s conference examined the common challenges
to delivering safe vascular therapy in the acute and community
settings, focussing on what the future holds by organising a range
of stimulating presentations, major study updates, case studies,
latest guidance updates and interactive workshops.
Cancer and Venous Access (CAVA) trial – implantable
venous access ports vs tunnelled central lines vs
peripheral inserted central catheters (PICCs)
Jon Moss provided the latest on the CAVA study, which aims to
determine which venous access device is safest, most effective
and affordable since data so far is generally lacking. All patients
enrolled in the trial receive either a venous access port, a tunnelled
central line (Hickman-type device) or a PICC to determine which
of these offers the best outcome from safety, clinical effectiveness
and cost effectiveness perspectives. Eleven sites are currently
active and recruitment is still ongoing; however, the cumulative
recruitment for PICC vs Hickman-type device arm is currently
slower than predicted. CAVA is the largest randomised control trial
with centrally placed venous access devices and the results are
eagerly awaited.
Challenges of long-term access for red cell exchange
in sickle cell patients
Vascular access – a global and UK perspective
Gillian Ray-Barruel presented on the global perspective of vascular
access and on the results of the One Million Global Peripheral
Intravenous Catheters (OMGPIVC) study. She gave an overview
of the well-known complications that occur with peripheral
intravenous cannulas (PIVCs), honed in on the high prevalence
of phlebitis and critiqued the current measures for phlebitis
assessment highlighting a lack of accuracy and consistency. Gillian
then put the OMGPIVC study in context for the delegates and
explained that it aims to bring to light the contributing factors for
PIVC failure in the clinical setting. A pilot OMGPIVC study, in which
14 sites in 12 countries participated, showed that most PIVCs were
used for intravenous (IV) medication rather than IV fluids, that all
sites had a proportion of idle PIVCs and that the overall phlebitis
rate was 10%. More than 30,000 PIVCs, in more than 50 countries,
have entered the main OMGPIVC study so far and results are
expected to be released at the World Congress on Vascular Access
(WoCoVa) 2016 in Lisbon.
Gillian’s talk was followed by Lisa Dougherty’s presentation, where
she shared her own experience at The Royal Marsden of participating
in the OMGPIVC study. For Lisa, this project was a “no-brainer” and
very similar to an internal audit. She advised that choosing a quieter
time at the Trust, such as December, was beneficial and that the least
compliant aspect at The Royal Marsden was the documentation.
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Patients with sickle cell disease are not a very common sight for
vascular access healthcare professionals (HCPs) and therefore
Daniel Putensen elucidated which vascular access options are most
appropriate for these patients. Delegates learned that peripheral
access should always be the first option in patients with sickle cell
disease and, within the options available, peripheral cannulation
is the most commonly used approach. If central access is needed
non-tunnelled central venous catheter is the most common
option. The pros and cons of each method were highlighted and
experiences from the apheresis centre at the University College
London Hospital, who conducted over 1,400 procedures in 2014,
were shared. The main take-home message was to always retry
peripheral cannulation, even if it has not worked in the past
because based on experience it may start to work again following
a break.
Community IV—practical, safe solutions to
delivering IV medication at home
Fritz Mühlschlegel and Gemma Oliver gave an impressive
presentation on the experience with the Hospital at Home (H@H)
service of East Kent Hospitals University NHS Foundation Trust
which delivers outpatient parenteral antimicrobial therapy. Set
up as a virtual ward, the outpatients in this service are treated
the same as inpatients in terms of speed of tests or images. All
treatment is delivered at the home of the patient and an audit
showed that just over 3,000 patients have now been through
the H@H service, with each patient representing a cost saving of
approximately £182 per night. Patient satisfaction was impressive
with 100% of patients feeling that the treatment was administered
safely and reporting they would recommend it to a friend.
Fritz and Gemma both acknowledged the importance of a strong,
knowledgeable, capable team for the success of this service.
Vessel Health and Preservation (VHP)
Challenges of the anatomical vein site
Steve Hill set the tone for this session by advising HCPs to “get the
right device, in the right patient, at the right time” to ensure the best
clinical outcome and help to minimise complications. Steve showed
the audience the beneficial impact that vascular assessment tools
can have on the success of vascular access devices and encouraged
delegates to spend time on assessments to avoid complications.
Challenges of rolling out a programme
The VHP programme aims to address issues currently present in the
vascular access arena by becoming proactive rather than reactive. Val
Weston shared with the conference delegates the hurdles that have to
be overcome to increase the odds of success for programmes such as this
and also reported the outcomes of the programme so far. A framework
that takes HCPs through the stages they need to consider when selecting
an intravascular device has been developed. Data so far show that the
tool improves patient experience, prevents delays in treatment, and
reduces the risk of infection by selecting the right line and re-evaluating
in case removal is necessary. The evaluation phase of the project is now
underway and will measure the benefits of the programme fully.
Case studies
In response to feedback from the last conference, three case studies
were presented and discussed this year. It proved to be a valuable,
engaging session that resonated with the audience on more than one
level. Beverley Carter, Esther Buchan and Tim Jackson presented case
studies that overviewed key challenges experienced in practice, such
as a the management of potentially life-threatening complications
and considerations to avoid potential harm. Cases presented
included the loss of peripherally inserted central catheter into the
central circulation, cardiac tamponade following and attempted
tunnelled central venous catheter insertion and extravasation
following cannulation of a vein in the foot. This session proved to an
excellent form of education for learned and learning HCPs alike.
Writing for publication
Tracy Cowan, Associate Publisher for the British Journal of Nursing
gave delegates advice on the practical steps of writing a good
publication and in ensuring an uncomplicated and streamlined
process. She recommended that delegates wanting to improve their
publication skills should begin with a smaller piece such as a letter to
an Editor, a book review or an opinion piece.
Dee Waterhouse described her experience in setting up a communitybased vascular access service and placing PICCs in a community
setting. Dee took delegates through the organisational stages of the
service and showed that, although numbers are small, none of the
PICCs inserted showed malpositioning, infection or clotting of the
line, which should offer confidence in this approach.
Jan Hitchcock presented on skin impairment associated with
vascular access devices and semi-permeable transparent dressings. A
collaborative approach began when Jan and her colleagues noticed
that skin integrity was treated as a secondary consideration and the
team have now developed resources that support clinical decision
making when selecting dressings and medical adhesives.
Peter Taylor spoke around his experience with establishing a nurseled PICC insertion service as an alternative approach to lines placed
in the interventional radiology setting. Peter stressed the importance
of preparation, support and careful deliberation from the outset. He
advised that delegates need to consider whether there is a need for
the service, if it will improve on what is already in place and if it is
cost effective. Based on Peter’s experience to date, this service has
placed approximately 800 lines, has improved patient experience
and represents significant cost savings.
A systematic review of the effectiveness of
intracavitary electrocardiograph (ECG) guidance
in improving central venous access device (CVAD)
tip placement
Graham Walker, the only student in attendance this year, presented
his findings of a systematic review examining the effectiveness
of ECG-guidance in improving CVAD tip placement. Of the 523
electronically identified citations, five randomised control trials
were included in the review representing a total population size
of 729 patients. Graham’s results show that ECG-guided CVAD tip
placement is approximately eight times more effective compared
with controls and that complications reported were not attributable
to the technique but rather to the nature of the procedure. None of
the studies reported data on patient experience. Graham concluded
his talk by highlighting that further research into ECG technology in
a PICC cohort and a rigorous cost-effective comparison that includes
patient preference is needed to further enhance understanding.
Short presentations from NIVAS members
Paul Lee presented for the audience the benefits of using an IV cannula
insertion pack in a large NHS Health Board. Data on 100 insertions, 50
with a pack and 50 without, showed big differences in the quality of the
insertions. This was measured in terms of percentage of people who
washed their hands, used a tourniquet, complied with the guidelines
and completed the documentation appropriately.
Speaker, Graham Walker
NICE guidelines and quality standard on IV fluid
therapy in adults in hospital
Speaker, Paul Lee
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A well-presented session by Katie Scales offered delegates an
understanding of the workings around guidance development and
also an overview of NICE clinical guidance 174 and NICE quality
standard 66. Katie identified some issues with developing guidance
for vascular access including: time constraints, a broad target
population, lack of high-quality evidence and fraudulent research.
These should be considered, but Katie highlighted that it was a
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worthwhile experience and encouraged delegates to accept the
offer to develop a guideline if given. She also stressed that the aim
of these guidance are to inform and improve clinical practice, and
that a combined effort to read, understand and implement these
recommendations is needed. Katie finished her presentation by
suggesting that the gap in practical education around issues common
in vascular access could be addressed with a more comprehensive
undergraduate curriculum.
interactive, allowing delegates a forum to ask questions and gain
information from their peers and the presenter on the subject of
reviewing chest X-rays.
Workshop sessions
Using ECG technology to guide central venous catheters
tip placement
Gemma Oliver and Matt Jones discussed tips and tricks of using
ECG technology. The workshop looked at how using X-ray for PICC
tip location was not an ideal method and how using ECG could
be used practically to accurately place CVAD devices. Real ECG
traces were examined and discussed as well as the use of ECG
technology for patients in atrial fibrillation. There was an overview
on the accuracy, safety, misconceptions and changes in practice
required to safely adopt ECG technology. The workshop ended
by the groups looking at different ECG traces and debating tip
position with reference to patient’s anatomy and whether the
group would be happy to accept the CVAD tip in that position.
Vein visualisation using technology devices
Andrew Barton and his team from Frimley Health, Maya Guerrero
and Angie Dennison, delivered a workshop on peripheral vein
location. Delegates were shown the latest technology available
in vein visualisation including the Veinlite®, the IV-eye® and the
infrared Veinsite®. Delegates were able to try cannulation using the
Veinsite® on a specially designed phantom vein block. Delegates
were also able to try the Veinsite® and the IV-eye® to visualise each
other’s veins. The workshop also demonstrated ultrasound guided
peripheral vein cannulation. Delegates were shown how to insert
integrated power injectable midlines and cannulas into a phantom
vein using the Prevue® ultrasound machine. The workshop was
fully attended and feedback from the sessions was positive.
Infusion solutions in the community
Beverley Carter and Jill Kayley delivered an open and highly
interactive workshop to reflect the differing needs in the
community. They talked about how diverse care can be, with
different teams delivering different types of care e.g., intermediate
care, private companies and district nursing, and patients being
sent from a variety of referring units. Each of these units has
different protocols and procedures, different venous access
devices and a variety of procedures for using these devices. As
a result of these many variables, community staff need to be
adaptive and responsive which makes standardisation of care and
equipment difficult. Beverley and Jill also discussed intravenous
fluid administration at home, the safety and quality issues this
may present, and whether NICE guidance 174 (IV fluid therapy
in adults in hospital) should be implemented in the community.
The session was well received and highly interactive with lots of
discussion around the above and many other items.
Chest X-ray interpretation and managing common
complications workshop
Moving forward in vascular access in a cash
strapped NHS
Matt Jones presented on his experiences and reflected on
the challenges of establishing a vascular access service in an
economically constrained environment such as the NHS. From
his view point, success in obtaining funding is determined by
how valued IV access work is by a Trust. If a Trust comprehends
that the efforts of an effective IV team are potentially cost saving
and considers them “invaluable”, they will also recognise funding
the service as in their best interest. Stressing that these “tips”
are merely suggestive, Matt encouraged delegates to evolve IV
access teams with enthusiasm and passion, in a direction that is
suitable to each Trust while also investing in training, education,
informative audits and research.
Award for best poster and best oral presentation
Paul Lee was this year’s recipient of the Best Oral Presentation Award
with the enthusiastically-delivered presentation Implementing an
IV cannula insertion pack in a large NHS Health Board in Wales.
Karen Harrold received the Best Poster Award for Proactive
placement of peripherally inserted central catheters.
Closing remarks
Andrew Barton, Board member, commented that this year’s
conference was yet another success, thanked Industry for their
support with two sponsored satellite symposia (Bard and BD) as
well as the exhibitor stands. He closed by thanking the delegates
for attending and making it a collaborative and instructive 2 days.
Chest X-ray interpretation and managing
common complications
Nicola York presented the chest X-ray workshop with the
objective of providing delegates with a systemic approach to
the interpretation of a chest radiograph following insertion of a
CVAD. The workshop defined the correct placement of tip position
of a CVAD and also identified common complications associated
with poor positioning. There were a number of chest X-rays
presented showing incorrectly placed CVAD’s for the delegates to
identify what was normal and abnormal. The workshop was very
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Karen Harrold recieving Best Poster Award
A day in the life of a Band 4 Associate
Practitioner in Vascular Access
Many Trusts are investing in Band 4 Associate Practitioners to
complement and support existing services. Within my Trust I
have two roles; one is supporting Bands 1 to 4 with the care
certificate and the other is as an Associate Practitioner in
Vascular Access. The role of the Associate Practitioner is an
evolving one; my role is unique and is the best part of my week.
Working with the vascular access team has many benefits; it is
an effective way to increase the amount of time my Registered
Practitioner colleagues have to focus on patients in higher
levels of care placing more advanced intravenous (IV) catheters.
Working in the Vascular Access team has enabled me to continue
enhancing my skills, operating at a higher level in order to
broaden my skill set. Also, my role has enabled the service to
develop and deliver a higher quality of care to our patients.
In our Vascular Access team we have Andrew (Lead Nurse), who
oversees our three hospital sites, and Maya (Vascular Access
Specialist Nurse), based at the Frimley site with me. I work one
day a week, usually a Friday; however, occasionally I might see the
odd patient on other days in the week if I’m on the ward doing my
care certificate work and someone needs vascular access.
The services I provide are ultrasound-guided venepuncture and
cannulation and midline insertion. I am skilled at using ultrasound
to insert peripheral cannulas and undertake venepuncture for
patients where long-term illness or frequent invasive treatments
has left veins in a poor condition.
line and port insertion which is carried out by our Lead Nurse.
This is a rewarding part of my job because both these catheters
are placed using local anaesthetic so the patient is awake and
talking throughout; I’m there to make the patient feel safe and
comfortable during the procedure and also to help our Lead Nurse
with anything he needs. I also help Maya during difficult PICCline insertions if the patient is nervous or needs a hand to hold.
I usually set up the equipment beforehand to make the process
quicker. Patient feedback is always positive after these procedures
because we are able to build a rapport with the patient to make
them feel safe and put them at ease.
My roles cross over slightly as I also provide education of Band 2
non-registered staff on performing venepuncture and Band 3 staff
on performing cannulation. After I have provided the training I
can then assess their competencies and sign them off when they
are competent.
We, as a team, have pushed the boundaries of this post and it is
amazing to be part of an ever evolving role in a niche area, which
has huge potential for the future.
Angela Dennison, Frimley Health NHS Foundation Trust
Within a normal vascular access day I will collect and assess the
daily referrals for peripherally inserted central catheters (PICC) lines,
midlines and PowerGlides. I usually work on a Friday in vascular
access because this is the day that my vascular access colleagues
do the oncology PICC list and the wards are always busy referring
patients for PICCs trying to discharge before the weekend, so it’s
all hands on deck. Once I have collected the referrals and sorted
them into the IV devices required, I visit the wards and assess the
patients IV medication and treatment plan requirements. I use
our assessment framework for this. I can then refer them to the
appropriate practitioner or insert a device myself.
I prioritise and insert any cannulas or midlines required using
ultrasound guidance. Another part of my day would be holding
dedicated clinics for computerised tomography scanning,
genitourinary medicine and viral hepatitis; these clinics are set
up for patients that have very difficult veins and require expert
ultrasound-guided insertions. Without this clinic patients would
often have to endure multiple attempts at venepuncture and
cannulation. This improves patient experience and allows those
services to utilise their time more effectively.
On my vascular access days I carry a bleep so the wards can contact
me to help with very difficult venepuncture and cannulation
needs, and this aspect of the job is the busiest. When ward staff or
doctors find it difficult to locate a vein, due to patient conditions
such as oedema or general deterioration, I can use ultrasound to
place a cannula or, more recently a power injectable midline.
I might get called to help redress PICC lines or help provide
education about vascular access device care and maintenance
which I can deliver at the bedside to the clinical staff. Another
aspect of my role would be to help prepare patients for tunnelled
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Angela has worked at Frimley Health for the past 15 years
as a Care Assistant then a Healthcare Assistant Level 3 and
now having undertaken her foundation degree as a Band 4
Associate Practitioner. She has been accepted to undertake
her nurse training and will be leaving our team to start her
nursing degree in September.
Andrew Barton
London Nurse Show 2015
Hello, my name is Kate Granger and I’m the founder
of the #hellomynameis campaign
This year the London Nurse Show ran from the 31st of March
to the 1st of April and is a showcase for nursing best practice.
It was just before the general election so there was a political
undercurrent and the Right Honourable Andy Burnham,
shadow health secretary, led a political presentations session
which also saw representation from the Conservative, Lib Dems
and the Green Party. The question and answer session the end
of Mr Burnham’s speech was predictably fraught with questions
about pay and conditions for nursing staff, weekend working
and pay enhancements. The keynote speech was delivered
by the inspirational Dr Kate Granger, acting consultant from
Pinderfields Hospital. Kate has terminal cancer and this was the
story of her journey since her diagnosis in 2011. Kate started
the #hellomynameis campaign to encourage healthcare staff
to introduce themselves to patients. The campaign has been
endorsed by more than 400,000 doctors, nurses, therapists,
receptionists and porters across over 90 organisations, including
NHS Trusts across England, NHS Scotland and NHS Wales. She
has spoken passionately at many health conferences and her
campaign is supported by the Prime Minister, Nicola Sturgeon,
Health Secretary Jeremy Hunt, many celebrities and a huge
number of leaders in health organisations. Kate has published
two books, The other side and The bright side which tell her story
about being a patient on the other side of the NHS. These two
books are essential reading for healthcare professionals and I
would encourage you to go out a get a copy.
NIVAS was represented by Board members Jackie, Andrew
and Beverley who facilitated a workshop on peripheral
cannulation and vein location technology. The workshop was
well evaluated and generated a lot of interest in NIVAS
membership. The London Nurse show will be back in 2016 , it’s
definitely worth attending.
Royal College of Nursing (RCN) guidelines for
infusion therapy
The RCN is updating the guidelines for infusion therapy which
were last published in 2010. These guidelines have been
a reference point for good practice in vascular access and
intravenous therapy for many organisations and healthcare
professionals. NIVAS is represented on the RCN committee by
Board member, Nicola York. Nicola will be reporting progress for
the RCN committee in our next newsletter and on our website.
Thank you to our NIVAS Corporate Members
For all enquiries, please contact the NIVAS Secretariat at Succinct Medical Communications
Regatta House, 67–71 High Street, Marlow, Buckinghamshire SL7 1AB, UK
Tel: +44 (0)1628 897900, Fax: +44 (0)1628 486972
Email: [email protected]
www.nivas.org.uk
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