Maintenance of patency of central venous access devices by registered nurses in an acute ambulatory setting: an evidence utilisation project

Authors


Correspondence: Ms Lee Moy Chong, National University Cancer Institute, National University Health System, Singapore. Email: mary_CHONG@nuhs.edu.sg

Abstract

Aim

The aim of the project was to implement the best practice for the maintenance of patency for central venous access devices by registered nurses in an acute ambulatory setting.

Method

This project utilised the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs to facilitate a process of change using an audit, feedback and re-audit cycle as a strategy to improve clinical practice. The team conducted the project in three phases over a 5-month period (July to November 2011). It involved a sample size of 29 registered nurses.

Results

The compliance rate for both criteria increased post-implementation, demonstrating a positive improvement in compliance to the best practice. The pulsated flushing technique improved from 25% (baseline) to 93% (post-implementation) compliance rate. This showed a statistically significant improvement of 68% (χ2 = 29.375, P = 0.000). The second criterion, the use of sterile normal saline to flush and lock the catheter, improved from 68% compliance in the baseline audit to 100% compliance rate in the post-implementation audit (χ2 = 14.215, P = 0.005).

Conclusion

This project utilised the process of audit, feedback and re-audit cycle as a strategy to improve clinical practice. It demonstrated the feasibility of translating evidence-based practice into the clinical setting, with remarkable improvement in maintaining patency of central venous access devices for patient with cancer. Finally, it is evidenced that the commitment and enthusiasm of team members and all the registered nurses in maintaining the patency of central venous access devices were the crucial factors for the success of this project. The support and assistance provided by the stakeholders also played an important role in the sustainment of the project.

Background

Central venous access devices (CVADs) are small, flexible tubes inserted directly or indirectly into the superior vena cava of patients who require frequent access to the bloodstream without the need for multiple venepunctures. These devices are referred to as venous access ports or catheters.[1, 2] Central venous access devices have become invaluable for patients with cancer who require long-term venous access and especially for those who have poor peripheral access. In cancer treatment, healthcare professionals use CVADs to facilitate the intravenous administration of chemotherapy, nutrient admixtures, blood products, antibiotic therapy and blood sampling. The two common types of CVADs for patients who require long-term treatment are the central venous catheter or the implantable subcutaneous port systems.[3]

There are complications associated with CVADs such as site infection, catheter occlusion, dislodgment and Twiddler's syndrome, catheter migration, catheter pinch-off syndrome, vessel thrombosis, damaged catheter, superior vena cava syndrome and skin erosion. Among these complications, catheter occlusion comprises up to 36% of the device complications associated with CVADs.[4]

Maintaining the patency of CVADs is the primary goal of nurses working in the oncology setting. One of the primary interventions to prevent catheter occlusion is flushing the catheter adequately after each use.[5] Flushing the CVADs with normal saline (NS), heparinised saline or a combination of both using the pulsated technique has the potential to decrease catheter occlusion.[6-8] Approximately 13% of patients receiving treatment at the ambulatory Cancer Centre in National University Cancer Institute, Singapore (NCIS) have CVADs. In January 2011 to June 2011, there were 22 cases of catheter occlusions occurred in the department in which two catheters were removed after several failed attempts of de-clotting the devices. A new CVAD has to replace these dysfunctional CVADs, which sometimes lead to patients' dissatisfactions with the services provided by the hospital.

Replacing a dysfunctional CVAD is an expensive procedure, as catheter replacement requires a new venous access site and payment for surgery or radiology consultation charges and sedation. In addition to the financial costs incurred by the patients, catheter replacement can pose a clinical risk and affect patients' quality of life.[6] The cost of replacing a device ranged from SGD$1500 to $2000, depending on the type of CVADs.

Hence, nurses working in ambulatory Cancer Centre at the NCIS must take appropriate steps to prevent thrombotic occlusion in order to prevent delay in treatment and compromise in patient safety. Thus, the purpose of this project was to improve the patency of the CVADs.

Audit questions

To what extent are registered nurses engaging in the best practice in the flushing of CVADs?

Aim/objectives

The aim of this project was to implement the best practice for the maintenance of patency of CVADs by registered nurses in an acute ambulatory setting.

The specific objectives were the following:

  • To educate registered nurses on the importance of using the correct pulsated flushing technique
  • To demonstrate to registered nurses the correct pulsated flushing technique
  • To monitor the compliance to the best practice

Methods

This project utilised the Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRIP) programs to facilitate a process of change using an audit, feedback and re-audit cycle as a strategy to improve clinical practice.[9] The project was conducted in three phases, over a period of 5 months (July 2011 to November 2011).

Ethical consideration

This project was a quality improvement project and ethical approval was not required. No personal information of the registered nurses was collected in the project, and the team adhered to the principles of confidentiality and anonymity throughout the project.

Phase 1: Preparation for the audit

The first phase comprised activities such as identification of the audit topic, establishment of the project team and identification of setting and sample. The team utilised the JBI PACES program in the selection of audit criteria and conducting baseline, and the GRIP program to identify barriers and develop action plan.

Identification of the topic

The topic of this project was maintenance of patency of CVADs by registered nurses in an acute ambulatory setting. The team selected this topic as the department had encountered 22 cases of CVAD occlusions from the period of January 2011 to June 2011. Maintaining the patency of CVADs is the primary goal of the department with patients having CVADs.

Establishment of the project team

There were three members in the project team. The nurse clinician, who was the team leader, had two senior staff nurses to assist her in conducting the project. One of the senior staff nurses was the co-leader and both the team leader and co-leader attended the Joanna Briggs evidenced-based Clinical Fellowship Program sponsored by the department. The team leader selected another senior staff nurse who worked in the same department with the team, as she was able to embrace change with a positive attitude. The team leader explained roles and responsibilities to every team member. All three members constituted the audit team in the project. The team leader conducted fortnightly meetings to brief the stakeholders and the team members on the details of the project, highlighting the importance of the project, audit criteria and compliance, the process of the audit and the timeline of the project. The stakeholders were a senior nurse manager and a nurse manager in charge of the department. The briefing intended to establish open communication with all the stakeholders, with the goal of having their support in providing budgeted time for the team members in conducting the project.

Identification of setting and sample size

This project was conducted at the Cancer Centre, an ambulatory care setting at NCIS. The sample size was the entire population of 29 registered nurses working in the treatment area of ambulatory care setting. The team excluded other registered nurses who did not work in the treatment area, as they did not provide direct care to patients with CVADs.

Selection of audit criteria

The team searched through the JBI Database of Recommended Practice to identify criteria based on the best practice recommendation and the level of evidence related to central venous catheter flushing.[9] Recommendations contained in JBI Recommended Practice are graded on the basis of both the level of evidence that supports them and their clinical appropriateness/relevance. Joanna Briggs Institute Grades of recommendation relate to the feasibility, appropriateness, meaningfulness or effectiveness of an intervention or procedure.[10, 11]

The team utilised two audit criteria from the JBI PACES Program to design the audit tools before conducting the baseline audit.

These two criteria were the following:

  1. A pulsated flushing technique by maintaining positive pressure is implemented when the catheter is flushed (3B).
  2. Sterile NS for injection is used to flush and lock catheter lumens that are in frequent use (4A).

Designing of audit tools

The team leader designed the audit tools together with a senior nurse clinician before piloting it on three newly joined registered nurses. The team leader gathered the feedback from these registered nurses and the audit team. With the feedback, the team decided to add in the validation of documentation at the fourth column of the audit tools as it served as an evidence that flushing had been performed (Table 1).

Table 1. Flushing of central venous access audit tool
Flushing of Central Venous Access Devices Audit Tool
Staff Name: ______________________Department: ______________________
Date of Audit: ______________________Name of Auditor: ______________________
Type of CVADs: PICC/Power PICC/Hickman's Line/Implanted Port
S/NJBI criteriaObservationValidate documentationMetNot metRemarks
  1. CVAD, central venous access devices; JBI, Joanna Briggs Institute; PICC, peripherally inserted central catheter; RN, registered nurse; S/N, serial number.
1A pulsated flushing technique by maintaining positive pressure is implemented when catheter is flushed

Observe the RN during the flushing of CVAD

  • A brisk push-pause technique (1 mL at a time)
  • Creating a positive pressure while flushing
Check nursing notes for the documentation of CVAD flushing   
2Sterile normal saline for injection is used to flush and lock catheter lumens that are in frequent use

Procedure: CVADs flushing before or after chemotherapy or for CVADs flushing

The RNs prepare and use

  • 10-mL syringe filled with at least 5 mL sterile normal saline
Check nursing notes for the documentation of CVAD flushing   

Conducting the baseline audit

All three members of the team conducted the baseline audit during the period from 18 July 2011 to 29 July 2011. Each member of the team conducted the audit in the assigned treatment area, delegated by the team leader. The audit team observed the registered nurses performing the flushing of CVADs, particularly using the pulsated flushing technique on patients who required flushing of CVADs. The audit team recorded the baseline results on the printed designed audit tools and keyed them into the JBI PACES program upon completion of the baseline audit. The team leader shared the results of the audit with the stakeholders, team members and the registered nurses in the weekly in-service sessions. The team leader and co-leader facilitated the session using the JBI GRIP program to identify the barriers and developed action plans with the registered nurses.

Getting Research into Practice strategies

The team identified two barriers and developed action plan and strategies in the criteria related to the pulsated flushing technique. The first barrier was that the registered nurses utilised the wrong pulsated flushing technique in flushing the CVADs after checking the return backflow and before connection of continuous infusion to the CVADs. The second barrier was the knowledge deficit of the registered nurses on the use of additional saline to flush the CVAD lumens before flushing the heparin lock. The nurses did not use additional saline in a syringe to flush the catheter lumen when they discontinued the saline infusion connected to CVADs.

The following strategies were then developed:

For criterion 1:

  • Demonstrate the correct pulsated flushing technique and encourage daily practice
  • Provide a mannequin with CVADs and ensure its availability at all time for practices
  • Reinforce and create awareness on the importance of correct pulsated flushing technique

For criterion 2:

  • Conduct sharing sessions and re-educate the registered nurses to use additional saline in a syringe to flush catheter lumens before heparin lock.
  • Reinforce to registered nurses on the importance of using saline in a syringe to flush the catheter lumen before heparin lock.

Phase 2: Implementation of the best practice

The team implemented the best practice over an 8-week period from 29 August 2011 to 21 October 2011. The team leader re-educated the registered nurses from the first to the third week of August 2011. During the in-service training, the team leader demonstrated to the registered nurses the correct pulsated flushing technique using a mannequin with CVADs attached. The registered nurses were to perform a return demonstration on the mannequin after the demonstration from the team leader. The nurses practiced daily under the supervision of the audit team until they mastered the skill. During the implementation phase, the team members were in the treatment area daily on weekdays over a period of 3 weeks to observe the pulsated flushing technique, while simultaneously providing support and answering queries from the registered nurses.

Phase 3: Post-implementation audit

In this phase, the team leader briefed the audit team on the audit process. The post-implementation audit was conducted over a period of 2 weeks from 7 November 2011 to 18 November 2011. The audit team utilised the same methodology as in the baseline audit to conduct the post-implementation audit. The team leader collated and analysed the baseline and post-implementation results using the JBI PACES and the Statistical Package for the Social Sciences program (SPSS Inc., Chicago, IL, USA).

Results

Baseline audit result

Figure 1 shows the baseline audit results. The results reported that seven out of 29 registered nurses (25%) performed the correct pulsated flushing technique (criterion 1) and 19 nurses (68%) used sterile NS to flush before heparin lock (criterion 2).

Figure 1.

Baseline audit results. Criteria legend: 1. A pulsated flushing technique by maintaining positive pressure is implemented when the catheter is flushed. 2. Sterile normal saline for injection is used to flush and lock catheter lumens that are in frequent use.

Post-implementation audit result

Figure 2 shows the results of both the baseline and post-implementation audit. The compliance rate for both criteria increased, demonstrating a positive improvement in compliance to the best practice. The compliance rate for the pulsated flushing technique improved from 25% (baseline) to 93% (post-implementation). This showed a statistically significant improvement of 68% (χ2 = 29.375, P = 0.000), as illustrated in Table 2. Compliance for the second criterion, the use of sterile NS to flush and lock the catheter, improved from 68% in the baseline audit to 100% in the post-implementation audit (χ2 = 14.215, P = 0.005).

Figure 2.

Post-implementation audit results. Criteria legend: 1. A pulsated flushing technique by maintaining positive pressure is implemented when the catheter is flushed. 2. Sterile normal saline for injection is used to flush and lock catheter lumens that are in frequent use.

Table 2. The number of samples for each criteria and the degree of compliance
No.CriteriaPre-auditPost-auditχ2P-value (P < 0.05)
N#Y%YN#Y%Y
  1. #Y, number complied with criteria; N, the total number audited; P, probability of a significant difference.
1A pulsated flushing technique by maintaining positive pressure is implemented when the catheter is flushed29725%292593%29.3750.000
2Sterile normal saline for injection is used to flush and lock catheter lumens that are in frequent use291968%2927100%14.2150.005

Discussion

From the results, the project demonstrated success in achieving positive outcomes in the implementation of the best practice for maintenance of patency for CVADs. The project highlighted that reinforcement and return demonstration are the key educational strategies to educate registered nurses in the maintaining of patency in CVADs.

Both criteria showed an increase in compliance rate. Criterion 1, which involved using the pulsated flushing technique in maintaining patency of CVADs, showed a significant improvement of 68% compliance among the registered nurses. For criterion 2, which was related to the use of sterile NS to flush and lock after each use, there was a modest improvement of 32% in compliance. There were two interventions that contributed to the improvement in the compliance rate. The first intervention was the discussion-cum-education sessions facilitated by the audit team. The audit team conducted six sessions to achieve full attendance of registered nurses and utilised these educational sessions to assess the knowledge and skills of the nurses. In addition, the audit team trained the registered nurses on the correct pulsation flushing technique by engaging them in social interactions and building their confidence in a positive manner.[12]

The second intervention was the personalised training provided to individual registered nurses by the team leader.[13] The team leader demonstrated and supervised each registered nurse until mastery of skill in the pulsated flushing technique was achieved. According to the feedback obtained from the registered nurses, individual training and learning led them to achieve mastery in the skill. However, imparting education to each and every individual was time consuming and challenging, as it needed to fit into the nurses' working schedules.

Challenges encountered during the audit phase

During the baseline audit and post-implementation phases, the audit team found it difficult to get opportunities to observe the registered nurses performing the flushing of CVADS. The majority of patients with CVADs received treatment in the early hours of the day in the treatment area. As a result, some of the registered nurses who were working in late shifts were unable to provide direct care to this group of patients. The team leader had to work with the nurse manager of the department to reschedule the working hours of these registered nurses so that the audit team could have opportunities to audit them while they are performing the flushing of the CVADs.

Success factors

The success of this project is attributed to the team members who worked collaboratively to overcome the challenges and completed the project with a positive attitude. However, the involvement of stakeholders was equally valuable, as they too had contributed their effort, commitment and enthusiasm in this project.

Sustaining the outcomes

Adopting the evidence-based practices is critical and crucial for maintaining patency for CVADs. However, sustaining the compliance to the best practice is a tough challenge, as it is an ongoing process. The audit team planned to delegate responsibility to two competent registered nurses and involved them in ensuring that other registered nurses followed the best practice. The team also planned to train two senior registered nurses in providing teaching and guidance in maintaining patency of CVADs to junior registered nurses.

For ongoing monitoring, the team will continue to conduct quarterly audits for a year, subsequently followed by six-monthly audits. Figure 3 shows the quarterly audit results done in February and June 2012. The compliance rate for the pulsated flushing technique improved by 1%, from 93% (post-implementation) to 94% (February) and 95% (June). The compliance rate for the second criterion, the use of sterile NS to flush and lock the catheter, maintained at 100% for the both audit months. The team also monitored the occurrence of catheter occlusions every six monthly. The incidents of catheter occlusions were reduced from 22 cases (January to June 2011) to 11 cases (January to June 2012). There is an improvement of 50% in the reduction of catheter occlusions during the 6-month sustainment period. Based on the good outcome, the team intends to spread this project to the inpatient oncology wards. In addition, for the subsequent audit plan, the team intends to look into the swabbing of the positive displacement connectors attached to the CVADs and the clamping of CVADs after flushing.

Figure 3.

Pre- and post-implementation quarterly audit results. Criteria legend: 1. A pulsated flushing technique by maintaining positive pressure is implemented when the catheter is flushed. 2. Sterile normal saline for injection is used to flush and lock catheter lumens that are in frequent use. CVADs, central venous access devices.

Conclusion

This project utilised the process of audit, feedback and re-audit cycle as a strategy to improve clinical practice. It demonstrated the feasibility of translating evidence-based practice into the clinical setting, with remarkable improvement in maintaining patency of CVADs for patients with cancer. Finally, it proved that the commitment and enthusiasm of all team members and all the registered nurses in maintaining patency of CVADs were the crucial factors for the success of the project. The support and assistance provided by the stakeholders were also essential in the sustainment of the project.

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