Medway Maritime NHS Foundation Trust is a 655-bed hospital providing acute and specialist care across Medway and Swale in Kent for a population of 405,000.
Historically vascular access was provided by the Trust’s Interventional Radiology (IR) department, Oncology nurse team and a separate orthopaedic service.
At that time the orthopaedic service was run by the Matron using ultrasound and blind placement of Peripheral Inserted Central Catheters (PICCs).
In 2014 the orthopaedic service purchased a SiteRite 5 with 3CG Technology on a netbook to provide patients with the right vascular access device to commence their intravenous treatments earlier and enable a timely safe discharge. The SiteRite5 device provides ultrasound technology to identify a suitable vein and the 3CG Tip confirmation system tracks the PICC using magnetic tip navigation with ECG providing tip confirmation in the presence of detectable P waves.
Practice described in this example relates to NICE Medical Technology Guidance (MTG) 24.
Example
Aims and objectives
The aim of our business case was to create a fully functional vascular access service that would adhere to the Trust’s values and beliefs whilst following NICE Medical Technologies Guidance.
The Trust wanted to improve clinical standards of infusion therapy and care using best practice including technology.
A key goal was to reduce device related complications including catheter related blood stream infections. Previously there were several separate services and we wanted to standardise practice using a direct referral system for ease of access. Some patients had PICCs placed in Interventional Radiology (IR) and 3CG technology provided a safe, bedside placement alternative that could run at a greatly reduced cost in comparison to IR.
Patient flow throughout ED and the hospital had been highlighted as an issue and creation of a vascular access service would reduce length of stay enabling prompt discharge. Reducing the delay to insertion of PICCs so that they were placed within 48hrs, and ideally within 24hrs, would allow us to provide of prescribed intravenous treatment on time and reduce missed medications.
The Trust’s vision is to provide the highest quality of care for our patients so improving the patient’s journey and outcomes is very important to all that we do.
A further aim of setting up a vascular access service was to have access to a range of vascular access devices to be able to assess the patient and insert the most appropriate device with best method of insertion to suit each patient and intravenous therapy. We also wanted to enable ultrasound guided cannulation by nursing staff to reduce medical staff workload.
Reasons for implementing your project
Prior to establishing the VAS and purchasing the additional equipment the long delays impacted patient safety. While waiting for PICC insertion patients frequently required acute CVCs to be inserted with increased risk of complications (Tan 2009).
Acute CVCs are inserted by an Anaesthetist and as per Trust guidelines should be cared for in critical care areas. Some of these patients could not be stepped down to wards, blocking costly critical care beds.
Patients waiting for suitable vascular access device were at risk of missed doses and safe administration of medications delaying chemotherapy and commencement of parenteral nutrition. Interventional radiology did not have capacity to provide a proactive vascular access service therefore patients had to wait over a week for a PICC line.
Insertion in IR is routinely performed using fluoroscopy and requires a Radiologist, scrub assistant and health care assistant along with a radiographer – insertion using 3CG can be carried out by a single trained practitioner. The IR department inserted a different PICC line to the rest of the trust creating safety risks and did not provide any education, training, or follow up care within the Trust or the community.
The NICE medical technology MTG24 state that IR placement cost £106 more than placement using 3CG technology. Before introduction of SiteRite5 all patients required a Chest X-Ray to confirm tip confirmation prior to use of the PICC. Inpatients often required transfer in their beds to radiology requiring a nurse escort and a porter. X ray reporting, averaging 2-3 days, delayed start of intravenous treatments and extended length of stay.
How did you implement the project
The initial implementation of 3CG technology in 2014 advanced our practice to provide a more efficient, safe service. Following implementation, we shared our experience with NICE to support the assessment of the technology for NICE Medical Technology Guidance.
We then used the published guidance MTG24 to present a business case to the trust for additional funding for a dedicated vascular access team and additional 3CG technology. By then the Site Rite® 8 Ultrasound System hardware had become available. The device has an updated user interface which highlights the P wave and has Green Diamond Technology to identify optimal tip location easier.
The business case was approved to set up a vascular access service and to purchase a Site Rite® 8 Ultrasound System with Sherlock 3CGTM Diamond TCS. The vascular access service forms part of Surgical Medical Acute Response Team (SMART) and works closely with community services to provide an OPAT (Outpatient parenteral antimicrobial therapy) service. Initial staffing plan agreed from the business case was for one Band 8 (0.64 WTE) and two Band 6 WTE. BD (formally BARD which is now part of BD) provided a competency-based training programme for the new nurse specialists to provide full training to enable them to place PICCs using 3CG Technology. This allowed the service to continue and develop whilst new members were receiving full training.
Continuous support was provided by the company which gave the team the confidence and guidance required, not only with placing the lines, but also with the development of other aspects of a vascular access service such as trouble shooting and care and maintenance of the PICCs.
The training included provision of full training materials with access to online training modules. The SiteRite 8 with Sherlock 3CG technology has enabled the team to work confidently and independently to expand the service. Two nurses can now place PICCs at the same time and the service has increased from five days to six days in line with all acute frontline NHS services moving towards seven-day provision.
Before purchasing the Site Rite 8 with 3CG Technology we completed an audit of 40 patients who had PICCs placed with the Site Rite 5 and netbook to compare tip position on chest x ray with tip position with 3CG technology. The audit proved the accuracy of 3CG technology which enabled X ray free PICC placement. Meeting infection control requirements whilst adhering to EPIC 3 (standard principles).
Key findings
Having a dedicated expert vascular access team responsible for assessment, placement, troubleshooting, care and maintenance, education and training of ward staff has enhanced patient safety.
We review all patients with PICCs 24 hours post insertion and then weekly thereafter to ensure best practice. We have established a single online referral process and all appropriate device placements take place within 24-48 hours.
The need for acute CVCs as temporary access while waiting for PICC has reduced requirement for on call anaesthetist support and enables patients no longer requiring critical care to be stepped down to the appropriate wards. Where the service started with 1 picc placer and had one device with 3CG technology we now have a second device and a team of 4 nurse specialists which allows us to offer a 6 day service not only for inpatients in the hospital but also for patients in the community.
Following our initial audit with Site Rite 5 and 3CG technology we were Chest X ray free for most patients. The advanced Diamond TCS technology available on the Site Rite 8 improved confidence in accurate tip location reducing the number of patients having chest X rays further. This avoids unnecessary exposure to X ray for patient safety and allows immediate access to the PICC. The reduction in X ray confirmation is also cost saving for both the radiology department and the wards. Part of Medway’s focus is to improve patient flow through ED and the whole Trust including reducing wait times.
In 2019 a Same Day Emergency Care Centre was set up (SDEC) which enables patients to be assessed, referred to the appropriate speciality and have immediate access to diagnostic procedures for prompt commencement of treatments. This avoids unnecessary admissions and reduces the number of inappropriate patients attending ED. Provision of vascular access without delay is critical to the running and success of SDEC and Medway’s vision.
Key learning points
Gather baseline data about vascular access provision across the whole of the Trust before creating a business case to identify the need for vascular access service and 3CG technology.
Engage with key stakeholders e.g. oncology, anaesthetists, Interventional Radiology and Trust Leadership to help to drive the business case. Establish costs of all existing services to be able to compare with a dedicated vascular access service using 3CG Technology.