Digital Repository Doctoral Projects Spring 2022 Vascular Access Device Policy Standardization in a Hospital System Jennifer Teerlink Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Teerlink, J. (2022) Vascular Access Device Policy Standardization in a Hospital System Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. 1 Vascular Access Device Policy Standardization in a Hospital System by Jennifer Teerlink A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 29, 2022 _______________________________ ______________________________ Jennifer Teerlink, DNP, RN, NPD-BC Date ______________________________ _______________________________ Kristy A. Baron, PhD, RN Faculty LeadDate _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: This form and paper must be submitted by the program director. April 29, 2022 April 29, 2022 April 29, 2022VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 2 Table of Contents Abstract ........................................................................................................................................... 4 Vascular Access Device Policy Standardization in a Hospital System .......................................... 5 Background and Problem Statement ........................................................................................... 5 Diversity of Population and Project Site ..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership ............................................. 6 Literature Review and Framework ................................................................................................. 7 Search Methods ........................................................................................................................... 7 Vascular Access Devices ............................................................................................................ 7 Complications ............................................................................................................................. 8 Care of Lines ............................................................................................................................... 9 Policy .................................................................................................................................... 10 Standardization ..................................................................................................................... 10 Solution for the Care of Lines ............................................................................................... 11 Education .............................................................................................................................. 11 Compliance ........................................................................................................................... 12 Framework ................................................................................................................................ 14 Discussion ................................................................................................................................. 15 Implications for Practice ........................................................................................................... 15 Project Plan ................................................................................................................................... 15 Project Design ........................................................................................................................... 16 Needs Assessment of Project Site and Population .................................................................... 16 Cost Analysis and Sustainability of Project .............................................................................. 17 Project Outcomes ...................................................................................................................... 17 Consent Procedures and Ethical Considerations....................................................................... 18 Instruments to Measure the Effectiveness of Intervention ....................................................... 18 Project Implementation ................................................................................................................. 18 Interventions ............................................................................................................................. 19 Interventions Align with Long- and Short-Term Outcomes ..................................................... 20 Project Timeline ........................................................................................................................ 20 Project Evaluation ......................................................................................................................... 21 Data Maintenance/Security ....................................................................................................... 21 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 3 Data Collection and Analysis.................................................................................................... 21 Findings..................................................................................................................................... 22 Strengths ............................................................................................................................... 23 Weaknesses ........................................................................................................................... 23 Quality Improvement Discussion ................................................................................................. 24 Translation of Evidence into Practice ....................................................................................... 24 Implications for Practice and Future Scholarship ..................................................................... 25 Sustainability......................................................................................................................... 26 Dissemination ....................................................................................................................... 26 Conclusion ................................................................................................................................ 26 References ..................................................................................................................................... 28 Appendix A ................................................................................................................................... 33 Appendix B ................................................................................................................................... 34 Appendix C ................................................................................................................................... 36 Appendix D ................................................................................................................................... 37 Appendix E ................................................................................................................................... 38 Appendix F.................................................................................................................................... 39 Appendix G ................................................................................................................................... 46 Appendix H ................................................................................................................................... 49 Appendix I .................................................................................................................................... 50 Appendix J .................................................................................................................................... 52 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 4 Abstract Lack of standardization in vascular access device management policies can increase nursing care variability, increasing catheter occlusion rates. Catheter occlusions can delay treatments and may increase the risk of further complications for patients, increasing costs. Purpose: This quality improvement project aimed to standardize a hospital systems vascular access device policy and nurse-driven flushing and maintenance protocol. Methodology: A routine audit of an electronic policy system identified over 50 vascular access device care and management policies in 11 hospitals. These policies included outdated procedural steps rather than directing nurses to one evidence-based clinical practice guideline when performing clinical skills. One policy was developed following evidence-based clinical practice guidelines, and all hospitals were asked to retire their existing policies to follow a standardized approach. Results: Each of the 11 hospitals adopted a standardized policy. Survey results of nurses indicated (n = 189) an educational gap in the awareness and use of one evidence-based clinical practice guideline when performing vascular access device care and maintenance, which may have led to increased occlusions. After the policy intervention, the doses of alteplase used for occluded catheters decreased. Implications for Practice: Standardizing policy and directing nurses to one evidence-based clinical practice guideline reduces nursing practice variability and decreases catheter occlusion rates. Nurse education is crucial to change practice and direct nurses to their correct resources when performing nursing skills. Keywords: vascular access device, central venous catheter, catheter, IV, standardization, policy, flushing protocols, evidence-based clinical practice guidelines. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 5 Vascular Access Device Policy Standardization in a Hospital System Eliminating hospital-acquired complications and adopting evidence-based care standards remain essential despite the increasing healthcare costs and the demand for quality patient outcomes, cost reduction, and patient safety through value-based purchasing models. (Centers for Medicare & Medicaid Services [CMS], 2020a). Nurses' delivery of high-quality and cost-effective care to all patient populations is critical. With increasingly complex patient acuity, nurses are expected to follow evidence-based clinical practice guidelines (EBCPG) to provide the standard of care, prevent complications, and reduce costs (Morrell, 2020). Over 7 million vascular access devices (VAD) are placed in the United States annually (Wuerz, 2016). Up to 90% of admitted patients receive an intravenous catheter during their hospital stay (Morrell, 2020), and 25% of patients have a central venous catheter (CVC) in place (Wuerz, 2016). When catheters become occluded, complications may occur, such as the risk of central line-associated bloodstream infections (CLABSI) the need for catheter replacement, potentially causing extended hospital stays and costly treatment modalities. One CLABSI can cost an organization between $5,734 to $22,939 per event and is not reimbursed by CMS because it is listed as a "never event" (Wuerz, 2016). Registered nurses are responsible for assessing and promptly resolving catheter malfunctions. Following evidence-based protocols for flushing and managing catheters becomes essential for preventing catheter occlusions and hospital readmissions (Bolton, 2013). When hospitals do not follow evidence-based procedures and lack standardization in catheter management policies, nursing care variability is evident, and occlusion rates increase. Background and Problem Statement An opportunity for this quality improvement project was recognized when pharmacy leaders identified increased use of alteplase (CathFlo®) for thrombus occluded VADs within an VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 6 11 hospital system. Alteplase doses that numbered 938 doses were instilled in occluded catheters in 11 hospitals in 2020 at the cost of $150.00 per dose of alteplase (S. Leonard, personal communication, January 12, 2021). The organization spent $148,350 on something that might have been prevented with adequate flushing and locking (Goossens, 2015). This usage increase, coupled with 12 education requests from nursing staff on VAD care and management in 2020, contributed to this project's aim: to standardize policy and provide a nurse-driven flushing protocol to decrease the number of occluded catheters and the amount of alteplase used. Diversity of Population and Project Site The project focuses on two populations, nurses and patients, at 11 hospitals in three Western States. Eight hospitals are in Utah, two hospitals are in Idaho, and one is in Alaska. Registered nurses with five years or less of nursing experience comprise 58% of the workforce in these 11 hospitals (R. Hamilton, personal communication, February 9, 2021). These nurses care for diverse patients, such as White, Hispanic, and Alaskan Natives. Significance for Practice Reflective of Role-Specific Leadership With over seven million CVCs inserted each year, organizations' standardization of institutional policy and nurse-driven protocols is a priority (Meyer et al., 2020). As a nurse leader in this organization who has recognized the problem, it is beneficial to the organization to perform a quality improvement initiative that decreases the number of thrombus occluded catheters and alteplase doses by creating one standardized policy and a nurse-driven flushing protocol. A literature review outlines the evidence required to develop the policy and protocol for this quality improvement project. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 7 Literature Review and Framework This literature review explores evidence-based practice standards around developing and implementing a standardized VAD policy and nurse-driven flushing protocol to reduce thrombus occlusions. Themes emerged from the literature review to help guide the policy development: (a) the Infusion Nursing Society (INS) Scope and Standards of Practice is the gold standard to follow when performing line care and developing protocols; (b) utilizing evidence-based clinical practice guidelines helps reduce variability in practice (Morrell, 2020); and (c) nursing education is a critical element in reducing the gaps in nursing knowledge about line care and maintenance (Raynak et al., 2020). The framework used to guide this project is the plan-do-check-act (PDCA) model. Search Methods Search terms for this project include vascular access device management, IV, central line flushing, occluded vascular access devices, alteplase use in catheters, vascular access device management, standardization, nursing policy, clinical practice guidelines, process change, standardized protocols, vascular access device complications, needleless connectors, compliance, and vascular access device insertion bundles. Databases used were PubMed, UpToDate, EBSCO, and CINAHL. Database search exclusion criteria included journal articles older than ten years and articles that do not align with INS's current practice standards. Vascular Access Devices VADs are frequently used in healthcare to deliver wide-ranging treatment modalities to patients in hospitals and the home setting (Raynak et al., 2020). A VAD can be inserted into a peripheral or central vein. A peripheral intravenous catheter (PIV) or midline catheter is designed for short-term therapy. Central venous catheters include peripherally inserted central catheter VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 8 (PICC), tunneled CVC, non-tunneled CVC, surgically implanted ports, and hemodialysis catheters. Depending on the indication, CVC therapy duration can range from short-term to long-term. CVCs are inserted into 43%-80% of patients in critical care units (Takashima et al., 2018). Insertion techniques typically use guided ultrasound or fluoroscopy for correct placement validation (Sadaf & Culp, 2011) and should follow established insertion bundles for infection prevention (The Joint Commission [TJC], 2020a). Placing a VAD does not come without risk to the patients, and the prevalence of severe patient harm from device placement remains high (Takashima et al., 2018). Following standards of care related to insertion and maintenance can improve patient outcomes (Meyer et al., 2020). Complications CVC complications are more significant because the patient population is compromised. Device failure and infection lead to poor patient outcomes, extended hospitalizations, and increased costs (Meyer et al., 2020). Complications can include incision site bleeding; transient arrhythmias; vascular, arterial, or pleural puncture; air embolism; CLABSI; catheter malfunction; venous stenosis; central venous occlusion; device failure; and the most common fibrin sheath, or thrombus formation (Lee & Ramaswamy, 2018). Catheter malfunctions occur when there is inadequate flow through the catheter's lumen. These occlusions can be mechanical, such as catheter malposition or kinks in the catheter. Malfunctions can be related to infection or, most commonly, thrombus or fibrin sheath growth inside or outside the lumen (Matey & Camp-Sorrell, 2016). Proper catheter flushing and locking techniques of VADs are associated with preventing catheter occlusions (Goossens, 2015) and are within the scope of nursing practice. When catheters become occluded with a thrombus, alteplase is more cost-effective than replacing the catheter (Ernst et al., 2014). VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 9 As many as 28,000 patients die from CLABSIs in the United States intensive care units annually (Agency for Healthcare Research and Quality, 2020). Because of the associated CLABSI risk and other complications, The Joint Commission (2020a) recommends CVC insertion guidelines (bundles), which include hand hygiene before insertion; aseptic technique; adequate skin prep with chlorhexidine gluconate, unless contraindicated; insertion checklist usage; optimal catheter site selection; avoidance of the femoral vein; proper maintenance of CVCs; and daily review of line necessity (TJC, 2020a). Consistent nursing assessment and care of lines contribute to decreased complications. Matey and Camp-Sorrell (2016) describe strategies for nurses to identify and troubleshoot complications yet suggest a lack of research in the literature to support a straightforward maintenance practice. The authors suggest nurses utilize EBCPG when performing VAD maintenance and participate in developing policies. Care of Lines The Infusion Nursing Society published the Scope and Standards of Practice to guide nursing practice from VAD insertion to removal. These standards outline fundamental skills within the nursing scope of practice (EBSCO, 2020). Ideally, all nurses follow the established standard of care while following EBCPGs and adhering to institutional policy and procedure when caring for lines (Matey & Camp-Sorrell, 2016). Following these standards can reduce variability among practices. Section six of the Scope and Standards of Practice establishes line care and management standards to include needleless connectors, extension sets and tubing, filters for parenteral nutrition administration; add-on devices; stabilization and securement items; joint stabilization apparatus; and site protectors. Moreover, management skills include flushing and locking techniques, assessment and care, dressing changes, phlebotomy, and VAD removal. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 10 Organizations seeking to standardize policy and procedures should consult the INS Scope and Standards of Practice document as the standard of care. Policy Hospital policies reduce patient harm by meeting accreditation laws and requirements established by governing bodies, guiding organizational decision-making steps that hold staff accountable to evidence-based practice standards (O'Donnel & Vogenberg, 2012). A policy is a formal document outlining an organization's roles, responsibilities, and expectations. Consequences can occur when nurses do not follow the organizational policy. (Gasior, 2017). Procedures are step-by-step instructions for performing a skill or a task. Variation in policy and procedure between facilities within the same healthcare system can be challenging for staff when performing line care. The policy can guide expectations and establish organizational culture yet be independent of the procedure. EBCPGs are the evidence-based clinical practice guidelines for the nursing practice of procedural steps and are referred to as the source of procedural truth in the policy. Maintenance policy and protocols may vary from organization to organization, causing variation in practice skills. These skills performance may differ from nurse to nurse without a system to guide a standardized approach. Jun et al. (2016) investigated the use and barriers to utilizing EBCPGs and hypothesized EBCPGs are essential and act as a standardized tool to guide evidence-based practice. The research concludes using EBCPGs is linked to better patient outcomes. Standardization Throughout history, many organizations and accreditation bodies have contributed to influencing standards in healthcare. The Joint Commission establishes standards to help VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 11 organizations measure, assess, and improve performance essential to providing safe and high-quality care (TJC, 2020b). Standards guide evidence-based practice and quality outcomes. According to Leotsakos et al. (2014), "standardization is the process of developing, agreeing upon, and implementing uniform technical specifications, criteria, methods, processes, designs or practices that can increase compatibility, interoperability, safety, repeatability and quality" (p. 111). Standardization in VAD care can decrease variability in nursing practice while improving patient outcomes. Meyer et al. (2020) recommend organizations be willing to address the lack of standardization in VAD care and management and develop policies and procedures that support current standards of practice (p. 247). Solution for the Care of Lines Implementing educational interventions reflective of policies in different settings can improve the nursing performance of VAD care. McGuire et al. (2019) improve nursing performance on VAD care by raising accountability standards, hardwiring evidence-based standards for patient care, and reducing healthcare costs associated with VADs. The authors suggest educational intervention has the most significant impact on performing audits and providing staff feedback. Moreover, an integrative review conducted by Raynak et al. (2020) suggest identifying helpful educational strategies, working with academic institutions, providing on-the-job training, and continuing nursing education to help bridge the VAD knowledge gap (p. 3913). Furthermore, an evidence-based standardized VAD policy and flushing protocol coupled with nurses adopting the process improves outcomes and reduces nursing practice variation (Conley et al., 2017). Education Nurses need to know where to locate their organizations' VAD policy and how to perform basic VAD management skills, such as flushing, dressing changes, and troubleshooting. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 12 They also need to know where they can access EBCPGs. Nurse leaders should hold staff accountable to the high standards of EBCPG by creating a culture of patient safety and hardwiring best practice within their organization. Organizations should implement strategies to improve VAD practice by focusing on training, education, resources, accountability, and standardization. (McGuire et al., 2019). Educational methods that proved successful include "learn by teaching" or peer tutoring (Park et al., 2017). Furthermore, using standardized guidelines during hands-on and simulation practice in VAD care scenarios achieves optimal learning outcomes (McGuire et al., 2019). Themes emerged in the literature include the importance of providing nursing education surrounding VAD policy and EBCPG use, peer tutoring, and leadership accountability to enforce these practice standards. Compliance The cost of healthcare in the United States is higher than in any other country (Salmond & Echevarria, 2017). The 2019 National Health Expenditure data shows a growth of 4.6% to $3.8 trillion in 2019, or $11,582 per person, and accounted for 17.7% of the gross domestic product for healthcare spending from the previous year. Hospital spending grew 6.2% to $1,192.0 billion in 2019, and out-of-pocket healthcare spending rose 4.6% to $406.5 billion. National health spending is projected to grow 5.4% annually and is expected to reach $6.2 trillion by 2028 (CMS, 2020b). Ernst et al. (2014) looked at hospital length of stay, costs, and readmission of alteplase versus catheter replacement among patients with occluded central catheters by studying 34,579 patients with CVC catheter replacements (n =1028) versus alteplase use (n = 33,551) during the same hospitalization. This retrospective observational study demonstrates the cost of using alteplase to be $317 lower than patients who received a catheter replacement. The adjusted post VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 13 occlusion cost was $1419 lower than replacement due to not needing an operating room, surgery, or other supplies. Vaismoradi et al. (2020) completed a systematic review to explore factors influencing nurses' adherence to patient-safety principles. The dedication to these principles reflected individual and systemic factors. These factors helped enhance nurses' commitment to patient-safety principles and included nursing knowledge improvement, workload reduction, collaboration, appropriate equipment, documentation systems, regular feedback, and process standardization. Although most organizations provide EBCPGs, staff development, and clinical education on VAD maintenance, nursing compliance with following clinical practice guidelines appears inconsistent (Saleh et al., 2020). Compliance is defined as "a willingness to follow a prescribed course of treatment" (Th.e American Heritage, 2007). Compliance with following EBCPGs for line care is essential for decreasing complications and improving quality outcomes. However, there are barriers to nursing compliance. Barriers to EBCPG use included nurses' attitude, knowledge of EBCPG, usability, format, leadership, and organizational culture. A suggestion is that policies be designed to increase nurses' use of EBCPGs (Jun et al., 2016). A quantitative study of 30 ICU staff nurses to determine CVC care knowledge and compliance proved a gap in knowledge and compliance, which showed significant improvement after nurse education and CVC cares visual demonstration. The study confirms the need to update CVC procedural guidelines to meet evidence-based practice, identify innovative ways to teach protocols, perform audits, and monitor quality improvement, leading to better patient outcomes (Gnanarani et al., 2018). Rupp et al. (2013) observed the correlation between CLABSI rates and nursing compliance with central venous catheter dressing and needleless connector recommendations. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 14 The researchers identified almost one-third of the participants' CVC dressings in the study needed changing at the time of observation, which means that care was substandard. Other issues identified included internal jugular catheter sites being more prevalent than other insertion sites for needing a dressing change. Indications for dressing change had blood or visible moisture under the dressing and exposed insertion site. The study recommended a multimodal preventative program, including attention to staff education, insertion bundles, site maintenance, and innovative technology. Contributing to compliance issues in practice may be the 58% of the nursing workforce with less than five years of experience. Most nurses learn about VAD flushing and management in nursing school, yet many nurses have limited exposure to VAD care independently, demonstrating gaps between nursing theory, practice, and performance. New graduate nurses need assistance to navigate healthcare, organizational culture, and policies and procedures (Kavanagh & Szweda, 2017). Framework This quality improvement project utilizes the PDCA model as a framework with Lewin's change theory to address VAD flushing and maintenance practice compliance. The project's focus phase involves validating the need to standardize practice to decrease alteplase usage. The analysis phase includes data collection and identification of evidence-based practice standards for policy and protocol development. The development phase involves implementing the policy and protocol as a standardized VAD management and flushing approach in all 11 hospitals. The development phase addresses Lewin's change theory and the need to unfreeze hospitals' current practices. The execution phase involves the education, implementation, and adoption of the new policy and standards. Finally, the execution phase coincides with Lewin's change process phase. The new practice becomes a standard and leads to refreezing nurses' using the policy, protocol, VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 15 and EBCPG to guide VAD line cares to decrease occluded catheters and reduce the frequency of alteplase use (Petiprin, 2020). Discussion Evidence shows that standardization of VAD policy following INS standards can reduce variability in nursing practice (Meyer et al., 2020). Implementing a standardized approach and nurse-driven flushing protocol by providing nursing education on accessing EBCPG resources and performing line care skills can improve patient outcomes. Barriers in nursing practice may include nurse adherence to policy and the nurse leader's ability to hold staff accountable. Additional research on writing standardized procedures and protocols for nursing practice can benefit other organizations that embark on a standardization journey. Implications for Practice VAD policy standardization improves patient outcomes and reduces complications and variability in nursing practice. Developing and implementing one standardized VAD policy and nurse-driven flushing protocol while utilizing EBCPGs can reduce nursing practice variability and improve patient outcomes. Nursing leadership support can improve nursing compliance in performing daily line care in the implementation phase. Project Plan This project included replacing over 50 VAD policies in 11 hospitals in three Western States with one standardized policy and nurse-driven flushing and maintenance protocol for adult and pediatric patients to reduce catheter occlusions and alteplase use. The plan included influencing nurses to follow EBCPGs when performing VAD care, maintaining lines, and building the protocols into two electronic health records (EHR). Nurse leaders' support and buy-in were essential. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 16 Project Design This quality improvement project aimed to standardize VAD policy and nurse-driven flushing and maintenance protocols. Removing procedural steps from the policy motivated the nursing staff to use the EBCPGs when performing skills. Following EBCPGs when performing skills reduced nursing practice variability and catheter occlusion rates. Needs Assessment of Project Site and Population This quality improvement project impacted a system of 11 hospitals in the three Western States. The main participants were registered nurses who follow the policy, nurse-driven protocols, and EBCPGs. Providers were participants because the protocols include flushing medications initiated through an order set. Quality improvement and infection prevention teams were participants and stakeholders as they were be responsible for performing chart audits and tracking CLABSI rates. Key stakeholders were the Nurse and Pharmacy Executive Leadership teams. They had the support of the Chief Nursing and Medical Executives to influence and enforce the standardized policy approval and adoption in all 11 hospitals. These stakeholders shared the project's vision and have helped align the project with our organizational quality and patient safety goals. The goal of Healthy People 2020 is to "create social and physical environments that promote good health for all" (Healthy People, 2020, para 1). Through policy standardization and following evidence-based practice standards, the goal of promoting good health for all was addressed. Social determinants of health considered for this project included access to health care services, public safety, and health literacy for all people. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 17 Cost Analysis and Sustainability of Project Budgetary requirements for this project have been discussed with the project team and approved for nursing education and printing. The corporation covered the printing costs. Costs included the following:  One education and training hour for 3,164 RNs at an average hourly wage of $35.36 = $111,879.04 education dollars.  One printed and laminated 18 X 24 inch VAD protocol poster for each medication room in each facility at $17.00 each (see Appendix A). The sustainability plan included incorporating nurse education into new hire orientation until the new practice has been hardwired into the organization. Sustainability involved maintaining the printed posters' professional integrity by replacing them as updates in clinical practice were identified or as they became worn-out or soiled. Project Outcomes The project outcomes were evaluated by measurement of the following goals:  All 11 hospitals within the system adopt the new VAD policy and nurse-driven flushing protocols and retire any existing VAD-associated policy, as evidenced by a policy validation audit in PolicyTech.  The hospital system shows fewer nursing education requests related to VAD care and management once the protocols were live in the EHR, as evidenced by Service Central tracking.  The hospital system decreases alteplase use on occluded catheters, as evidenced by the automated dispensing machine dose tracking. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 18 Consent Procedures and Ethical Considerations The Institutional Review Board (IRB) at Weber State University confirmed this project met requirements for quality improvement and did not need formal IRB approval. Because of the quality improvement nature and lack of human subject testing, IRB approval from the hospital system was unnecessary. Furthermore, project survey results were anonymous, aggregated, and protected in a safe place. Instruments to Measure the Effectiveness of Intervention The two instruments, a survey (see Appendix B) and a spreadsheet (see Appendix C), measured the intervention's effectiveness. An original survey was sent to nurses in 11 hospitals to identify EBCPG resources before and after the policy implementation. The results measured whether nurses could locate and follow EBCPG resources when performing VAD care. In addition, pharmacy leaders provided a quarterly Excel spreadsheet of alteplase doses pulled from all the automated dispensing machines. The alteplase data were used to determine if implementing a standardized policy and nurse-driven flushing protocol reduced the number of occluded catheters. Project Implementation This project was implemented when the standardized policy was adopted at all 11 hospitals and their existing policies related to VAD were retired. Hospital adoption of the policy remained essential to the sustainability of this project as the protocols were being built into the EHR using clinical decision support based on the contents of the policy. When performing VAD care, the policy and protocol directed the nurses to the EBCPGs. This implementation used a top-down approach from the Chief Nursing Executive, yet the hospitals were required to approve the policy and buy into the new process. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 19 Interventions Interventions used for this project's implementation included a collaborative, multidisciplinary, and influential approach to leadership communication that facilitated buy-in to the project. The early intervention involved collaborating with the Information and Technology Systems (IT&S) and building teams to identify the correct clinical decision support tools necessary to guide nursing practice while using the protocols within the EHRs at the point of care delivery. The IT&S teams had been holding weekly meetings to demonstrate how the protocols would operate within two EHRs. Having the protocols and links to EBCPGs live in the EHRs eliminated the need for the nurses to look for VAD care protocols outside of their EHRs and aimed to reduce education requests on VAD care. This intervention also decreased alteplase use for occluded lines by offering a standardized flushing and line maintenance approach (see Appendix D for Adult VAD Nurse-Driven Protocols and Appendix E for Pediatric VAD Nurse-Driven Protocols). Because the protocols contained order sets to be included in the physician orders, the following intervention introduced the project and standardized flushing protocols at the 11 hospitals' pharmacy and therapeutics committees. Once the committee approved the flushing order set, it was ready to move to the subsequent approval layer through the medical executive committee for final policy and protocol approval. The last intervention was to email the policy and flushing protocols to the 11 CNOs and explain the steps each hospital must take to implement the policy in PolicyTech and retire existing policies (see Appendix F for VAD Policy). This intervention used a top-down authority approach by the Division Chief Nursing Executive telling the hospital CNOs about the new policy. After the policy was fully approved in all 11 hospitals, it replaced the existing policies in PolicyTech. Communication took place with the PolicyTech Administrators on uploading the VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 20 new policy, and they knew which policies were to be retired. Each PolicyTech Administrator was given a detailed set of instructions and a list of policies to retire at each hospital. PolicyTech was audited to ensure each hospital fully adopted the policy. As this policy went through the final review and approval phases at the medical executive committees, staff nurses completed nursing education (see Appendix G for education). Printed posters of the adult and pediatric protocols were ordered and ready for print from the print center. The evaluation included removing the newborn intensive care unit (NICU) from the scope of practice for this project because they followed the National Association of Neonatal Nurses guidelines for VAD practice. The hospitals continued to follow their established NICU policies. Interventions Align with Long- and Short-Term Outcomes The overarching goal or outcome was that each hospital adopted the new policy and EBCPGs and retired existing and outdated policies. Following a top-down approach, the hospital Chief Nursing Officers were sent an email outlining the instructions for moving the policy through each hospital's approval processes. Included in this email was a list of identified policies each hospital was asked to retire. PolicyTech audits were conducted weekly to ensure each hospital uploaded the standardized policy and retired the existing policies for this project. All 11 hospitals were given a 30-day window to adopt the new policy and retire the existing ones. Project Timeline The project timeline covered the initial research and development of the standardized policy and nurse-driven flushing protocols through the education planning implementation phase. The timeline progressed through the necessary interventions to meet the implementation deadline. It served as a project management tool (see Appendix H for Project Management Tool) to inform the project team of status updates. The project team included the following: VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 21  DNP Student Project Lead  The VP of Clinical Education  The VP of Infection Prevention and Control  The VP of Nursing Operations  The VP of Clinical Informatics  The VP and Director of Pharmacy Project Evaluation The project aimed to standardize the VAD policy and flushing and maintenance protocols at 11 hospitals. After the new policy replaced existing policies, the evaluation process began. This process included surveying nurses' knowledge about the new policy and the EBCPG resources available when performing skills. Another evaluation process included the pharmacist tracking the number of alteplase doses used on occluded catheters in the 11 hospitals. Data Maintenance/Security The survey did not contain any personal or private information, and respondents were notified of their confidentiality when the survey was administered. The survey was created on a personal cloud account in Microsoft Forms and was password protected. Respondents were emailed a secure link and a QR code to complete the survey. Only one person had access to the response files, and the data were stored on a password-protected computer. The alteplase usage report did not identify the patient's personal health information but recognized the prescribing physician and the nurse administering the dose. The data were stored on a password-protected computer, and only one person outside of the pharmacy had access to it. Data Collection and Analysis An original seven-question, multiple response survey was created in Microsoft Forms to identify nurse familiarity with available EBCPG resources. The survey combined qualitative and VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 22 quantitative response items into one seven-question, multiple-response survey. The questions included response options for multiple-choice, Likert scales, and one free text item to identify nurse awareness and utilization of the EBCPG resources available to them. The survey link was emailed to 3164 registered nurses in 11 hospitals before and after the intervention, (n = 189) nurses responded to the survey before the intervention, and (n = 104) responded after the intervention. Initial survey results were used to develop a computer-based education course designed to educate the nurses about the EBCPG resources available to them at the bedside. Post-survey results identified if learning took place. The results were analyzed through the Microsoft Forms Response analysis center. Some question responses were downloaded into an Excel spreadsheet for further analysis and itemization of data (see Appendix I for survey results). Pharmacy leaders collected alteplase data. Alteplase was followed when removed from the automated medication dispensing machine in 11 hospitals and reported quarterly. A quarterly alteplase usage report was emailed to the project lead. The alteplase usage report showed the use of alteplase data by the 11 hospitals beginning quarter four of 2020, when the project was initially identified. The project was implemented end of quarter four of 2021. Alteplase usage and data were tracked for 17 months and three months post-intervention. The Excel spreadsheet evaluated and followed the project's alteplase use (see Appendix J). Findings Since the intervention, no education requests have been submitted for VAD care to Service Central, and all 11 hospitals have fully adopted the standardized policy and flushing protocols. The survey was sent to 11 hospitals. Nurses (n =189) participated in the pre-intervention survey and (n = 104) completed post-intervention survey. Increased awareness of the correct EBCPG resource between the pre-survey (59.2%) and post-survey (73.2%) existed. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 23 However, the survey showed a decreased qualitative free-text option to identify EBSCO: Dynamic Health as the EBCPG when performing clinical skills between the pre (27.5%) and post-survey (26.9%). An increase showed in the frequency of nurses using their iMobile device to access EBCPGs daily between pre-survey (0.5%) and post-surveys (3.8%), and most nurses do not know how to access EBCPGs directly from the EHR (see Appendix I). Alteplase usage and the number of doses used correlated with the hospitals' size, with the larger hospitals using alteplase more frequently. Since the intervention, eight of the 11 hospitals have decreased the number of alteplase doses used. This data suggested the intervention had a positive impact on reducing alteplase doses. The project lead continued to examine the alteplase data to measure sustainability outcomes (see Appendix J). Strengths The strength of this project included the standardized policy and protocols that were implemented in 11 hospitals using a top-down approach and the number of survey participants represented in all 11 hospitals. Another strength was more than half of the nurses surveyed identified the correct EBGPG resource as EBSCO Dynamic Health. The survey identified vital educational gaps in using EBCPGs when performing nursing skills. The data identified a need to train nurses on how and where to access EBCPGs resources when performing nursing skills in hospitals during all educational offerings and new employee orientation. Weaknesses Despite providing education, there were few improvements to the nurses' awareness of the EBCPG resources from the desktop or iMobile device when performing skills. Lack of awareness about EBCPG resources may have resulted from nursing staff who completed the computer-based education quickly and did not transfer the information into practice. The project leader was concerned that staff use Google, YouTube, and other Internet search engines rather VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 24 than the approved EBCPG when performing skills. Although each hospital had adopted the standardized policy and protocols, four hospitals did not retire their existing VAD care policies. This inaction could have confused staff. The project lead continued to work with PolicyTech administrators and the hospital leadership teams to retire existing policies. Quality Improvement Discussion This project aims to standardize a VAD policy and nurse-driven flushing and maintenance protocol for a system of 11 hospitals in three states, reducing occluded catheters and the amount of alteplase used. The interventions for this project include writing the standardized protocol and flushing orders following evidence-based standards, integrating the flushing orders into two EHR systems, implementing the policy and protocols in 11 hospitals, and providing education to over 3000 nurses on EBCPG resources when performing VAD care. The use of the PDCA quality improvement model shows it helped keep the project on track. Other project components identified include additional quality improvement, sustainability, and future nursing education implications. Translation of Evidence into Practice An organizations' standardization of institutional policy and nurse-driven protocols is a priority (Meyer et al., 2020). The INS Scope and Standards of Practice (INS, 2021) is the evidence-based gold standard followed throughout this project to develop one standardized policy and adult and pediatric flushing and maintenance protocols for 11 hospitals. Implementing a standardized policy has reduced variability in clinical practice by removing procedural skills from written policies and directing nurses to one EBCPG. As a result, the data shows a reduced number of occluded lines and the number of alteplase doses used. The standardization of this policy impacts clinical order sets in two EHRs. It reduces the risk of ordering incorrect flush volumes or doses because the doses and volumes are linked to the lines. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 25 New knowledge gained from this project includes an awareness of the lack of nurse leader accountability and follow-through and PolicyTech oversight. However, many implementation barriers are recognized. This project was implemented during a global pandemic. All hospitals were experiencing higher than average nursing turnover, burnout, mandatory overtime, short-staffed units, and frequent COVID-19 policy and procedural changes. Although all hospitals adopted the standardized policy and protocols as their standard VAD policy, not all of the existing policies were retired at each hospital, which may cause confusion and continued variability among nursing staff practice. Nurse leaders and PolicyTech administrators were asked to withdraw the current policies several times. They were sent a list of policies that needed to be retired on more than one occasion, and some facilities did not comply. Other knowledge gained is to not rely on computer-based education as the primary source of education. Instruction on using one EBCPG resource needs to be integrated throughout the year into competency assessment validation methods when teaching nurses how to learn on the fly by utilizing resources. Implications for Practice and Future Scholarship The project findings demonstrate standardization of policy and nurse-driven protocols can reduce costs and the number of alteplase doses used for occluded catheters. Implications for further practices include a longer alteplase observation window. Extending the observation window can better determine whether the costs and number of alteplase doses remain reduced or if the results are reactionary to the policy implementation and nursing education. Suggestions for the future scholarship include providing effective education during a global pandemic with travel restrictions and how to hold nurse leaders accountable when facing a myriad of changes and obstacles. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 26 Sustainability The costs of this project's development and implementation are minimal. The policy is in place, and the order sets have been integrated into two EHR systems. Nursing education is assigned to each newly hired nurse, and the VAD topic is incorporated into new employee orientation. The sustainability of this project includes ensuring the remaining policies are removed from PolicyTech and keeping the current policy updated when evidence-based changes are made. I continue to monitor alteplase use and provide oversight of the policy while making updates as needed. Dissemination This project and its outcomes are shared with the project team. The nurse-driven protocols are disseminated to other divisions within the system enterprise and shared with corporate pharmacy leaders. Because the order sets and clinical decisions are built and working correctly in two EHRs, it is easy to copy the commands to other divisions. I may consider publishing this project or presenting it at a national conference. Another option is to submit a conference poster presentation on the importance and implications of standardizing nursing policy. Conclusion Increased alteplase use on occluded catheters coupled with 12 education requests led to the development and standardization of a VAD policy and nurse-driven flushing and maintenance protocol, decreasing the number of occluded catheters and the amount of alteplase used. By implementing this project, one hospital system shows lowered costs. Since the implementation and nurse education, no evidence exists of education requests submitted through Service Central on VAD care. The standardized policy removes procedural steps and directs VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 27 nurses to one EBCPG when performing VAD care. This project shows organizational standardization can help achieve quality improvement and cost reduction goals. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 28 References Agency for Healthcare Research and Quality. (2020). 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International Journal of Environmental Research and Public Health, 17(6), 1-15. https://doi.org/10.3390/ijerph17062028 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 33 Appendix A Facility Adult Pediatric Total Hospital 1 23 3 $442 Hospital 2 5 1 $102 Hospital 3 5 1 $102 Hospital 4 25 5 $510 Hospital 5 10 2 $204 Hospital 6 10 1 $187 Hospital 7 15 2 $289 Hospital 8 25 5 $510 Hospital 9 25 5 $510 Hospital 10 15 3 $306 Hospital 11 15 1 $272 Total 3,434 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 34 Appendix B VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 35 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 36 Appendix C (Alteplase Spreadsheet) 0 10 20 30 40 50 60 70 80 90 100 Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Alteplase Usage Report Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021 Q12022VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 37 Appendix D Appendix D VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 38 Appendix E Appendix E VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 39 Appendix F SCOPE: All employees, Physician/Licensed Independent Practitioners (LIPs), vendors, agency, and all HCA healthcare affiliated employees who have been trained in vascular access device insertion, management, and maintenance. Students in their fields of study with direct supervision. PURPOSE:  To provide evidence-based guidelines for the safe and aseptic insertion, care, and maintenance of vascular access devices for adult, and pediatric populations.  To identify the appropriate Vascular Access Device (VAD) based on prescribed therapy and medical conditions using a collaborative process among the inter-professional team, the patient, and the patient's caregiver. POLICY: 1. A Licensed Independent Practitioner (LIP) order is obtained for all line placement. 2. A formal "time out" procedure is required for the insertion of all central VADs. 3. A formal "time out" procedure is recommended for Midline placement. 4. All central VADs, with the exception of a PICC, shall be inserted with a second licensed employee at the bedside or in the procedural area. 5. Access, maintenance, and removal procedures are guided by the approved evidence-based clinical practice guideline database. 6. All central VAD catheter tip positions shall be confirmed immediately after insertion (unless otherwise indicated) by chest x-ray and/or other FDA-approved technologies as ordered. 7. Adhere to Central Line-Associated Bloodstream Infection (CLASBI) Reduction Bundle: a. Hand hygiene and gloves are required during the care of all vascular access devices and before any manipulation of the IV system. i. In the NICU, all healthcare workers shall practice bare below the elbows. b. Maximum barrier precautions shall be used during the insertion of central lines. c. Perform Chlorhexidine skin antisepsis: i. On patients older than two months, perform Chlorhexidine (CHG) skin antisepsis when inserting line. 1. For patients with CHG allergy, perform skin antisepsis with sterile alcohol and povidone-iodine swab sticks. ii. On patients younger than two months, perform Chlorhexidine (CHG) skin antisepsis when inserting line. 1. Use CHG with caution. These products may cause irritation or chemical burns. May also use 10% povidone-iodine or 70% isopropyl alcohol. 2. Remove all disinfectants as altogether as possible using sterile water or saline after the procedure is complete. Avoid the use of isopropyl alcohol to remove povidone-iodine or CHG. iii. Follow Adult CHG bathing guidelines post insertion unless contraindicated: 1. If there is a contraindication to the chlorhexidine gluconate, use a tincture of iodine (povidone-iodine), or 70% alcohol. Iodine solution should air dry for at least 2 minutes after application. d. Avoid using the femoral vein for central venous access in adult patients. e. Assess and document the clinical need for all VADs on a daily basis and remove promptly when no longer necessary. f. Complete insertion documentation in the Electronic Health Record (EHR). g. Blood cultures will not be drawn from any vascular line without a physician order unless upon insertion of peripheral IVs. VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 40 8. The Registered Nurse (RN) shall assess all VADs before use, during each shift hand-off assessment, post patient returning to department/floor from testing and procedures, and as needed. 9. Perform sterile dressing changes on all central VADs: a. Every 7 days. b. As needed with clinical judgment if loose, soiled, or wet. c. Within 24 hours of identification of no chlorhexidine gluconate disc or no chlorhexidine gluconate dressing being present, validate chlorhexidine gluconate is not contraindicated. d. A chlorhexidine gluconate disc or chlorhexidine gluconate dressing shall be used on all central VADs and Midline dressings (exclude neonates and patients when contraindicated). e. All VADs shall have a catheter securement device and be changed in accordance with the manufacturer's instructions for use. f. In the NICU, maximum barrier precautions shall be used during dressing changes, as well as insertion. 10. Dressings shall be labeled with date, time, and initials of the last change. 11. Tubing administration sets shall be labeled with the date and time to be changed. 12. Follow VAD flushing guidelines outlined in the standard line care protocol. 13. Disinfection (Scrub-the-Hub) of the needleless connector(s) shall be performed prior to use. a. Disinfecting solutions including only 70% isopropyl alcohol require a vigorous 15-second manual mechanical scrub to be performed on all needleless connectors, followed by a 15-second dry time prior to each use. b. Disinfecting solutions including chlorhexidine gluconate and 70% isopropyl alcohol require a vigorous 5-second manual mechanical scrub to be performed on all needleless connectors, followed by a 5-second dry time prior to each use. 14. Management of needleless connector device replacement include: a. Change every 7 days when used with a continuous infusion system. b. Change as needed: i. When residual blood or debris is noted in the device. ii. When the device has been contaminated or compromised. 15. Management of adult occluded catheters include: a. Stop IV infusion at first suspicion of occlusion and perform a patency assessment. b. If the patient is febrile, contact the Physician/LIP prior to attempting to clear catheter. c. A Physician/LIP order must be obtained for the administration of a specific agent to restore patency of the occluded catheter. 16. A local anesthetic may be used prior to peripheral intravenous cannulation and Port access with Physician/LIP order and training on use. TRAINING: 17. Peripheral Intravenous cannulation/management education provided while completing an academic field of study. 18. Additional documented competency verification is required for nurses who place: a. External Jugular cannulation b. PICC/Midline placement c. Ultrasound-guided IV placement d. Umbilical Venous/Arterial placement (for NICU Transport Team members, where applicable) VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 41 ADULT Peripheral Intravenous Catheter (PIV) Short-term ≤ 7 days  Hand or forearm vein recommended  Vein will accommodate gauge and length of the catheter  Emergent External Jugular (EJ) or lower extremity placement with physician clinical indication, placed by trained RN only  May be inserted, replaced, or removed by an RN, LPN, PM, EMT, imaging technologist, or students with direct supervision  After two failed insertion attempts, seek assistance  Replace PIV within 24 hours if patient arrives at the hospital with PIV in place  Utilize I-TRACE method when accessing and assessing  External Jugular PIV catheters are required to be removed ≤ 96 hours  Do not place in:  ventral surface of the wrist  the affected arm of a post-mastectomy patient  on the side of patient with an arteriovenous fistula  Rotate the site every 7 days or if clinically necessary Pediatric/NICU Peripheral Intravenous Catheter (PIV) Short-term ≤ 7 days  Infants and toddlers: consider scalp up to 9 months of age and foot/leg (if not walking)  May be inserted, replaced, or removed by an RN  No student placement or removal authorized  After two failed insertion attempts, seek assistance  Utilize I-TRACE method when accessing and assessing  Use CHG with caution in premature infants or infants under 2 months of age.  Assess insertion site and catheter patency hourly in NICU  Leave in place until a Physician/LIP orders to discontinue or as clinically indicated Intraosseous (IO) Emergent medical stabilization < 24 hours  Preferred location is Proximal Tibia  May be placed and removed by LIP or ALS/PALS Certified RN/PM, EMT in the event of an emergency or life-threatening resuscitation  Avoid placing in fractured bones or an extremity with vascular interruption and in patients with:  Cellulitis VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 42  An Intraosseous needle should be replaced with a venous line as soon as possible  Burns  Right to left intracardiac shunts Midline Catheter Peripheral Catheter (ML) Short-term < 30 days  Can be placed in the upper arm in the basilic, cephalic, median cubital, and brachial veins  Neonatal midline catheters are placed with the tip residing mid-humorous for arm placement and mid-femoral for leg placement  May be inserted or removed by a trained RN  Does not require radiology confirmation on placement  Utilize I-TRACE method when accessing and assessing  Avoid infusion of vesicant medications, TPN/lipids, or fluids with an extreme pH  Use hair clippers only when indicated for site selection and securement device  Assess hourly for neonates Non-Tunneled VAD (Single Lumen, Double Lumen, Triple Lumen)  Quinton  Multi-med Short-term < 7 days  Avoid Femoral site in all patients  Inserted by credentialed LIP only  Requires procedural consent and insertion bundle  Requires radiology confirmation of placement before use  May be removed by an RN with a LIP order  Utilize I-TRACE method when accessing and assessing  Designate one port to use exclusively for TPN and/or lipids  Immediately notify LIP of signs and symptoms of complications  Consider the replacement of an emergently inserted VAD within 48 hours  Central line hubs that indicate the number 5 or 10 mL/sec are the only lumens indicated for contrast administration  PASV (Pressure Activated Safety Valves) found on the lumen replaces the need for clamps Tunneled VAD (Single Lumen, Double Lumen, Triple Lumen)  Hickman  Broviac Long-term > 3 months  Surgically implanted in the subclavian vein  Inserted and removed by credentialed LIP only  Requires procedural consent and insertion bundle  Requires radiology confirmation of placement before use  Cuff allows for the growth of fibrous tissue into the cuff, which secures the catheter within the tract providing long-term stability while creating a barrier to infection  Use of Heparin is not required in Groshong catheters due to valves VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 43  Groshong (valved)  Multi Large Bore (Permacath, Apheresis)  Utilize I-TRACE method when accessing and assessing  May be cuffed or uncuffed Peripheral Artery Catheter (PAC) (Art-Line) Short-term Assess daily for removal  Adult site: radial artery  Femoral artery in emergency only  Pediatric and neonatal sites: radial, posterior tibia, and dorsalis pedis arteries  Inserted by credentialed LIP or trained RN/RT  Hemodynamic monitoring and blood draws only  Immediately notify LIP of signs and symptoms of complications  Do NOT administer infusion therapy in peripheral arteries Umbilical Arterial Catheter (UAC) Short-term 2-14 days  Placed in the Umbilical Artery with tip in either a low (L3-L4) or high (T6-T10) location  Inserted by credentialed LIP  Placement must be confirmed radiographically  Utilize I-TRACE method when accessing and assessing  Use CHG with caution in premature infants or infants under 2 months of age.  Remove all disinfectants as completely as possible using sterile water or saline after the procedure is complete. Avoid the use of isopropyl alcohol to remove povidone-iodine or CHG.  Hemodynamic monitoring and blood gas analysis use only  Immediately notify LIP of signs and symptoms of complications  Do NOT administer medications or TPN/lipids in umbilical arteries  Umbilical catheters may infuse fluids at a rate of 1-2 mL/hr to maintain artery patency VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 44 Umbilical Venous Catheter (UVC) Short-term 7-14 days Placed in the umbilical vein with tip at the inferior vena cava/right atrial junction  Inserted by credentialed LIP, or NRP trained RN/RT in the event of an emergency  Placement must be confirmed radiographically  Utilize I-TRACE method when accessing and assessing  Use CHG with caution in premature infants or infants under 2 months of age.  Remove all disinfectants as completely as possible using sterile water or saline after the procedure is complete. Avoid the use of isopropyl alcohol to remove povidone-iodine or CHG. Immediately notify LIP of signs and symptoms of complications Peripherally Inserted Central Venous Catheter (PICC) Long-term > 29 days  Adult/Peds sites: basilic, cephalic, or median cubital veins above the antecubital fossa with desired tip location ending in the superior vena cava  Neonatal placement: In neonates, they are inserted with the tip residing in the SVC when inserted in the upper body and in the thoracic inferior vena cava when inserted from a lower extremity  May be inserted by a LIP or RN with documented competency  May be removed by an RN with a LIP order  Placement must be verified by radiology or ECG technology before use  Utilize I-TRACE method when accessing and assessing  Central line hubs that indicate the number 5 or 10 mL/sec are the only lumens indicated for contrast administration and are usually purple  Assess hourly in NICU Implanted Venous Port/Access Device (IVAD) Long-term >3 months Surgically implanted by a provider  Inserted and removed by a credentialed LIP only  Requires informed consent and insertion bundle  Requires radiology confirmation of placement  Only access with non-coring (Huber) needles  "Power Ports" and "Smart Ports" allow for power injection of contrast media. Power Ports can be identified by palpating three points arranged in a VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 45  Utilize I-TRACE method when accessing and assessing  Can be accessed by an RN triangle. Smart Port is identified by patient report or on x-ray by a "halo" surrounding the septum on the top of the port.  Use two identifiers before power injection (identification cards/documentation with palpitation and imaging)  Must be heparinized upon discontinuing Hemodialysis Catheter Short or long-term  Site selection based on the treatment plan  Restricted access!  RN with documented competency in the care and maintenance of hemodialysis catheters may administer prescribed therapies  Can be tunneled or non-tunneled  Temporary hemodialysis catheters with a medial infusion port can be accessed in a critical care setting with a LIP order VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 46 Appendix G (Education) VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 47 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 48 Adopted and updated resource from HCA Healthcare Continental Division VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 49 Appendix H VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 50 Appendix I Table 1 Pre and Post-Vascular Access Device Response Survey Pre-Intervention Survey Results N=189 % Post-Intervention Survey Results N=104 % Which hospital do you work in? Which hospital do you work in? Hospital 1 17 8.9 Hospital 1 9 8.6 Hospital 2 5 2.6 Hospital 2 5 4.8 Hospital 3 8 4.2 Hospital 3 1 1 Hospital 4 44 23.2 Hospital 4 25 24.2 Hospital 5 13 6.8 Hospital 5 12 11.5 Hospital 6 9 4.7 Hospital 6 2 1.9 Hospital 7 13 6.8 Hospital 7 3 2.8 Hospital 8 20 10.5 Hospital 8 8 7.6 Hospital 9 Hospital 10 29 15.3 Hospital 9 16 15.4 20 10.5 Hospital 10 13 12.6 Hospital 11 11 5.8 Hospital 11 10 9.6 What is your resource for accessing EBCPG when performing nursing skills? What is your resource for accessing EBCPG when performing nursing skills? Google 50 26.4 Google 22 21.2 WebMD 14 7.4 WebMD 4 3.8 HCA Healthcare Library 112 59.2 HCA Healthcare Library 76 73.2 YouTube 13 6.8 YouTube 1 1 What site do you use if/when you use the HCA Healthcare library to access EBCPG (Free text answers) What site do you use if/when you use the HCA Healthcare library to access EBCPG (Free text answers) No response 7 3.7 No response 28 26.9 None, N/A, unknown type responses 35 13.2 None, N/A, unknown type responses 11 10.6 EBSCO or Dynamic Health 52 27.5 EBSCO or Dynamic Health 28 26.9 HCA Library or home Intranet 29 15.3 HCA Library or home Intranet 10 9.6 Other databases, Clinical Pharmacology, Clinical Key, Krames, Up-to-date, and 44 23.2 Other databases, Clinical Pharmacology, Clinical Key, Krames, Up-to-date, and 24 23.1 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 51 PolicyTech PolicyTech Google, YouTube, Wikipedia, WebMD, Medscape 7 3.7 Google, YouTube, Wikipedia, WebMD, Medscape 3 2.9 Questions about the survey and miscellaneous responses 15 7.9 Questions about the survey and miscellaneous responses 0 0 How often do you access EBCPG from the desktop when performing Vascular Access Device clinical nursing skills? How often do you access EBCPG from the desktop when performing Vascular Access Device clinical nursing skills? Never 90 47.6 Never 51 49 Sometimes 83 43.9 Sometimes 45 43.3 Often 14 7.4 Often 7 6.7 Daily 2 1.1 Daily 1 1 How often do you access EBCPG from the iMobile when performing Vascular Access Device clinical nursing skills? How often do you access EBCPG from the iMobile when performing Vascular Access Device clinical nursing skills? Never 156 82.5 Never 80 76.9 Sometimes 25 13.2 Sometimes 15 14.5 Often 7 3.7 Often 5 4.8 Daily 1 0.5 Daily 4 3.8 Can you hyperlink to EGCPG from within the Electronic Health Record? Can you hyperlink to EGCPG from within the Electronic Health Record? Yes 55 29.1 Yes 30 28.8 No 134 70.8 No 72 69.2 How long have you been practicing as a nurse? How long have you been practicing as a nurse? Less than one year 10 5.2 Less than one year 5 4.8 1-2 years 27 14.2 1-2 years 12 11.6 3-4 years 19 10 3-4 years 19 18.3 5-6 years 18 9.5 5-6 years 9 8.6 7-9 years 26 13.7 7-9 years 14 13.5 10+ years 89 47 10+ years 45 43.2 VASCULAR ACCESS DEVICE POLICY STANDARDIZATION 52 Appendix J Table 2 Alteplase Usage Report by Hospital Quarter Tracked Hospital Q42020 Q12021 Q22021 Q32021 Q42021 Q12022 n n n n n n Hospital 1 48 70 51 61 46 28 Hospital 2 2 0 0 1 3 1 Hospital 3 2 4 3 2 2 2 Hospital 4 38 21 26 44 39 27 Hospital 5 7 3 1 15 11 6 Hospital 6 0 1 1 7 1 0 Hospital 7 8 4 3 4 8 6 Hospital 8 24 42 24 38 25 25 Hospital 9 91 58 56 60 54 55 Hospital 10 58 39 16 37 37 5 Hospital 11 10 3 4 6 1 2 Total Doses 288 248 185 275 227 157