1. Considerations for Device Selection xxxxx | Clinical Specialist
Vascular Access Assessment
Considerations for Device Selection
From Schears presentation BAS/EDUC/0816/0050
xxxxx | Clinical Specialist
Bard Access Systems

2. Why is Appropriate Selection So Important?
Scrutiny on Hospital Acquired Conditions (HACs)
More device choices
Potential inappropriate use
Consequences to patient

3. “A good beginning makes a good end.”
Patient Impact
“A good beginning makes a good end.”
Venous Access is essential
Establishing and maintaining reliable access is a priority1
EARLY access planning may help address some IV related complications and negative outcomes for patients and for the hospital2
The choice of which VAD to use is a collaborative process
Bahl article page 1, Helm article reference page 190
Louis L'Amour. (n.d.). BrainyQuote.com. Retrieved January 26, 2017, from BrainyQuote.com Web site:
Louis L’amour
1Bahl A, et al. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed intravenous placement in
difficult access patien..., Am J Emerg Med , 1-5.
2Helm, Robert E., et al. (2015). "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3,

4. Vascular Access Continuum
Not long ago, most of us had a limited selection of devices …
MST
Midline
PICC
CICC GW
PIV
AST
Midline
PLACEMENT TOOLS
USG
PIV
PIV
… but that is changing quickly
POTENTIAL DWELL TIME

5. New device options create the potential to choose a device that:
Is more readily available
Has less risk of serious complications
More closely matches patient needs
Is less costly to place
Shutterstock picture

6. New device options also create the potential to choose a device that may:
Be inappropriate for required infusates
Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

7. New device options also create the potential to choose a device that may:
Be inappropriate for required infusates
Be unable to fulfill all required functions
Shutterstock image CVP
Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

8. New device options also create the potential to choose a device that may:
Be inappropriate for required infusates
Be unable to fulfill all required functions
Be unable to last the duration of therapy
Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

9. New device options also create the potential to choose a device that may:
Be inappropriate for required infusates
Be unable to fulfill all required functions
Be unable to last the duration of therapy
Have risk of serious complications
Helm, Robert E., et al. "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3 (2015):

10. New device options also create the potential to choose a device that may:
Be inappropriate for required infusates
Be unable to fulfill all required functions
Be unable to last the duration of therapy
Have risk of serious complications
Be more costly over course of therapy
Helm, Robert E., et al. "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3 (2015):

11. Critical Assessment is More Important Than Ever
New device options also create the potential to choose a device that may:
Be inappropriate for required infusates
Be unable to fulfill all required functions
Be unable to last the duration of therapy
Have risk of serious complications
Be more costly over course of therapy
Critical Assessment is More Important Than Ever
Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.
Helm, Robert E., et al. "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3 (2015):

12. Key Drivers of Critical Assessment
Type of therapy
Duration of treatment
Difficulty of insertion
Patient factors
Other Factors
Gorski, L., et al. "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1 (2016): S1-S159.

13. Type of Therapy: Vesicants and Irritants
Total Parenteral Nutrition (TPN)
Many chemotherapeutics
Many antibiotics
Vasopressors
Hypertonic saline
Calcium Chloride/Calcium Glutonate
Will your patient need these during the course of therapy?
Chemotherapy and Biotherapy Guidelines and Recommendations for Practice ONS (2009) pg 105

14. New INS Publication “Extravasation Checklist: Prevention & Identification”
“Preadministration assessment:
Identify anticipated duration for administration of vesicants.
Assess appropriateness of vascular access device (VAD) for vesicant administration
Avoid peripheral infusion of vesicants when infusion time exceeds 30 to 60 minutes
Advocate for early central vascular access device (CVAD) placement for continuous vesicant infusions, high-frequency intermittent vesicant drug infusions”1
INS Standards of Practice on Midline Devices: “Use caution with intermittent vesicant administration due to risk of undetected extravasation.”
BAS/EDUC/1116/ NSM presentation
This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems.
1Gorski et al., 2016, Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society (emphasis added)

15. New INS Publication “Noncytotoxic Vesicant Medications & Solutions”
This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. Bard Access Systems has not independently confirmed the information on this list.
Gorski et al., 2016, Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society

16. Non-Vesicant Infusates
New INS Publication “Noncytotoxic Vesicant Medications & Solutions”
Cytotoxic Drugs
(Chemotherapy, etc.)
Use safe handling methods
RED LIST
Well-recognized vesicants with multiple citations and reports of tissue damage upon extravasation
YELLOW LIST
Vesicants associated with fewer published reports of extravasation , published drug information, and infusate characteristics indicate caution and potential for tissue damage
Non-Vesicant Infusates
INS
“It is important to recognize that large infiltrations of non-vesicant medications or solutions may also be associated with severe tissue damage.”1
This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems Bard Access Systems has not independently confirmed the information on this list..
Gorski et al., 2016, Noncytotoxic Vesicant Medications and Solutions, Infusion Nurses Society
This list of “Noncytotoxic Vesicant Medications & Solutions” was developed by a task force of the Infusion Nurses Society for the use and education of its members. The list is provided for informational purposes only. The provision of the list is not meant to replace clinical judgment and does not constitute endorsement by Bard Access Systems. Bard Access Systems has not independently confirmed the information on this list.

17. Type of Therapy: pH
A more complete view on pH … situational questions are important
PIV
Midline
Central line
Continuous vs. intermittent?
Length of therapy?
Patient tolerance?
Multiple infusates?
Need to tread carefully—serious consequences if you push peripheral devices too far.
Grosklags, A et al. “The PICC Book: A Guide for Clinicians.” Bard Access Systems, 2015.

18. Most are known in advance:
Duration of Therapy
Diagnostic categories known to typically require >5 days of IV therapy
Abscess
Cardiac dysrythmias
Craniotomy
Cystic fibrosis
Epidermolysis bullosa
Leukemia
Liver disorders
Lymphomas
Metabolic disorders
Neutropenia
Nutrition disorders
Pneumonia
RSV pneumonia
Spinal procedures
Surgery of: esophagus, duodenum, kidney
Syncope and collapse
Transplants: heart, liver, lung, kidney
Ventricular shunt procedures
Most are known in advance:
Should you start with a longer dwell device?
accessed 8/30/2016

19. Difficulty of Insertion
BAS/EDUC/1116/0055
Shutterstock images

20. Patient history which may contribute to difficult insertion
Chronic diseases
Diabetes
End stage renal disease
Cancer
Cardiovascular diseases
HIV/AIDS
Sickle Cell
Obesity
Elderly
Pediatric
Drug abuser
Sedentary
Edema
Vasculopathy
Cystic fibrosis
Rheumatoid Arthritis
COPD
Bowel disease
Hypovolemia
History of multiple venous cannulations
Most are known in advance:
When should you move to advanced placement technologies?
Hadaway, L. (2005). InfraRed Imaging Systems, 1.
Dychter, S., Gold, D., & Haller, M. (2012). Intravenous therapy: a review of complications and economic considerations of peripheral access. Journal of Infusion Nursing , 35 (2),

21. Patient Considerations
Co-Morbidities
Medical condition(s) existing simultaneously but independently with another condition
Perform a history for:
Potential previous I.V. Therapy
Potential previous hospitalization
Potential previous venous complications – including thrombosis
accessed 8/30/2016

22. Additional Factors # of lumens required- Multiple medications?
Compatible vs Incompatible
Required flow rates
Need for blood draws
Central venous pressure (CVP) monitoring
Power injection

23. Peripheral vs. Central Summary
Become a strong institutional voice in device selection
Take advantage of newer peripheral developments for difficult sticks & intermediate dwell times
Protect patients from inappropriate use of all devices

24. Algorithms Helps with problem-solving
Difficulty following flow when there are multiple steps
Technical difficulty representing complex decision making
Helps with problem-solving
Breaks down task into smaller steps making it more manageable
Improves efficiency
Assists in ensuring all variables are included in decision making process
Provides clarity

25. Flow chart base for I-Consider
An interactive tool for education related to vascular access device selection as prescribed by a physician
Flow chart base for I-Consider

26. I-Consider

27. References
Guidelines for the Prevention of Intravascular Catheter-Related Infections. (2011). Centers for Disease Control and Prevention.
Phillips, L.D. Manual of I.V. Therapeutics. Third Edition F.A. Davis Company
Grosklags, A., et al. (2015) The PICC Book. PICC Manual. Bard Access Systems.
Infusion Nurses Society. Infusion Nursing Standards of Practice. Journal of Infusion Nursing. Jan/Feb Vol 34 Number 35.
Ciocson, M. A., Hernandez, M. G., Atallah, M., & Amer, Y. S. (2014). Central vascular access device: An adapted evidence-based clinical practice guideline. The Journal of the Association for Vascular Access , 19 (4),
Gorski, L., et al. (2016). "Infusion therapy standards of practice." J Infus Nurs 39.suppl 1, S1-S159.
Griffiths, V. (2007). Midline catheters: indications, complications, and maintenance. Nursing Standard , 21 (11),
Helm, Robert E., et al. (2015). "Accepted but unacceptable: Peripheral IV catheter failure." Journal of Infusion Nursing 38.3,
Infusion Nurses Society. (2016). Noncytotoxic Vesicant Medications and Solutions.
Oncology Nursing Society. (2009). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, 105.
Hadaway, L. (2005). InfraRed Imaging Systems, 1.
Dychter, S., Gold, D., & Haller, M. (2012). Intravenous therapy: a review of complications and economic considerations of peripheral access. Journal of Infusion Nursing , 35 (2),
Bahl A, et al. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed
intravenous placement in difficult access patien..., Am J Emerg Med , 1-5.

28. References
Bard Access Systems. (2003, May). BardPort®, SlimPort®, and X-Port ™ Implanted Ports with Open-ended Catheters Instructions for Use. Salt Lake City, Utah.
Bard Access Systems. (2007, March). Hickman®, Leonard® and Broviac® Central Venous Catheters Instructions for Use. Salt Lake City, Utah.
Bard Access Systems. (2015, November). Powerglide Pro® Midline Catheter Instructions for Use. Salt Lake City, Utah.
Bard Access Systems. (2011, September). PowerHohn® Central Venous Catheter Instructions for Use. Salt Lake City, Utah.
Bard Access Systems. (2007, August). PowerPICC® Instructions for Use. Salt Lake City, Utah.
Bard Access Systems. (2016, January). Accucath® Intravascular Catheter. Salt Lake City, Utah.

29. THANK YOU
Bard and PowerPICC are trademarks and/or registered trademarks of C. R. Bard, Inc. All other trademarks are the property of their respective owners. ©2017 C. R. Bard, Inc. All rights reserved.
BAS/EDUC/0117/0066