1. ESTABLISHING AN EFFECTIVE MIDLINE PROGRAM GORDON J. SIGL, MSN, APN, VA-BC, NP-C, FNP-BC

2. Financial Disclosures 1. Disclosure of Relevant Financial Relationships I have the following financial relationships to disclose: Speaker’s Bureau for: Access Scientific 2. Disclosure of Off-Label and/or investigative Uses I will not discuss off label use and/or investigational use in my presentation

3. Establishing the Need A Multi-Front Approach o Central Line Associated Blood Stream Infections (CLABSI) Impact on the patient - Mortality rate 12 – 25% 1 Impact on the organization - Publicly reported data - CMS “Never Event”  Associated costs not reimbursable  $16,550 cost to the organization/CLABSI 2 o Impact on efficiency Time to insert Cost of supplies

4. The Midline Advantage Multiple Objectives o Follows CDC guideline for Central Venous Catheter (CVC) avoidance 3 Reduction in Central Line Associated Blood Stream Infections (CLABSI) - Improved clinical outcomes - Significant cost avoidance in “value-based purchasing” reimbursement model o Provides timely insertion for patients with difficult intravenous access (DIVA). “Improved time to therapy” o Provides extended dwell resulting in less patient sticks and therefore less pain Improved patient satisfaction

5. Device Selection Using keen critical thinking skills o Blood Flow impacts dilution Lower arm: 20-40mL/Minute Upper arm: 100-150mL/Minute 4 o Size of vessel vs. size of midline catheter Does the “tail wag the dog”? - Don’t let brand loyalty cloud your judgment o Is there a one device solution? Vessel Size + Vessel Depth = Midline Device Selection

6. Putting it all together… Culture Change o Driven by the Vascular Access Team o Establish yourself as the “specialist” o Education o Certification o VA-BC o Collaboration Bedside nurses Providers Patients

7. Putting it all together… Subject Matter Experts o Utilize “teachable moments” Coaching others - Builds confidence in your message - Lead by example - Share your knowledge -Nursing grand rounds -Competency Fair o Identify ideal patients Central line avoidance or removal prior to CLABSI Extended stay patients (beyond 6 days)

8. Putting it all together… Broadcast your successes o Staff meetings o “Safety Huddles” o With individuals o Get published o Speak locally and nationally

9. Cement the change Policy development o Midline as a peripheral IV Inserter’s discretion No provider order Stock an appropriate range of devices o Formalize patient selection

10. Device selection

11. Outcomes

13. References 1 Centers for Disease Control and Prevention. (2011, March 1). Morbidity and Mortality Weekly Report. 60. Atlanta, GA, USA. Retrieved August 15, 2015, from http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdfhttp://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf 2 The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May 2012. http://www.PreventingCLABSIs.pdf.http://www.PreventingCLABSIs.pdf 3 O’Grady N, Alexander M, Burns L, et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Centers for Disease Control. 2011:1-83. 4 Anderson N. Midline Catheters: The middle ground of intravenous therapy administration. J Infus Nurs. 2004; 27(5): 313-321.