Note from the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO): In December 2007, the RNAO) reviewed the current practice recommendations for this topic. A review of the most recent studies and relevant guidelines published since the development of the original guideline does not support changes to the recommendations. However, the panel has identified several inaccuracies in the original guideline as well as several gaps in the available evidence, which are outlined below (marked as "updated in 2008").
The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Site Selection: Peripheral
Recommendation 1.0
Nurses will select a peripheral insertion site appropriate for the required therapy and with the least risk of complication.
(Level of Evidence = IV)
Site and Catheter Care: Safety/Infection Prevention Control
Recommendation 2.0
Nurses will prevent the spread of infection by following routine practices and using additional precautions.
(Level of Evidence = IV)
Skin Antisepsis
Recommendation 3.0 (Updated in 2008)
Nurses will consider the following factors when performing catheter site care using aseptic technique:
- Catheter material (composition)
- Antiseptic solution
- Client's tolerance (skin integrity, allergies, pain, sensitivity, and skin reaction)
(Level of Evidence = IV)
Although the evidence supports the original recommendation, the panel would like to include an alert:
Aseptic technique must include choice of solution, use of friction, and adequate contact time in order to be considered an effective use of technique. Please consult your institutional policy or infection control policies for more details.
Tip Placement
Recommendation 4.0 (Updated in 2008)
Nurses will not use the central venous access device (CVAD) until tip placement has been confirmed.
(Level of Evidence = IV)
Although the evidence supports the original recommendation, the panel would like to include an alert:
Anatomical tip location must be documented by a radiologist/attending physician following insertion, and this documentation must be accessible to all the client's health care providers throughout the continuum of care.
Please note: the original discussion of the evidence referred to an illustration (Appendix D of the original guideline document) which is inaccurate; please refer to Appendix B of the 2008 supplement for a revised visual representation of correct tip placement.
Dressings
Recommendation 5.0
Nurses will consider the following factors when selecting and changing venous access device (VAD) dressings:
- Type of dressing
- Frequency of dressing changes
- Client's choice, tolerance, and lifestyle
(Level of Evidence = IV)
Securement
Recommendation 6.0
Nurses must stabilize the VAD in order to:
- Promote assessment and monitoring of the vascular access site
- Facilitate delivery of prescribed therapy
- Prevent dislodgement, migration, or catheter damage
(Level of Evidence = III)
Patency/Flushing/Locking
Recommendation 7.0 (Updated in 2008)
Nurses will maintain catheter patency using flushing and locking techniques.
(Level of Evidence = IV)
See Appendix C of the 2008 supplement for detailed and updated flushing and locking interventions.
Recommendation 8.0
Nurses will know what client factors, device characteristics, and infusate factors can contribute to catheter occlusion in order to ensure catheter patency for the duration of the therapy.
(Level of Evidence = IV)
Occlusion
Recommendation 9.0
Nurses will assess and evaluate vascular access devices for occlusion in order to facilitate treatment and improve client outcomes.
(Level of Evidence = IV)
Blood Withdrawal
Recommendation 10.0
Nurses will minimize accessing the central venous access device (CVAD) in order to reduce the risk of infection and nosocomial blood loss.
(Level of Evidence = IV)
Add-Ons
Recommendation 11.0
Nurses will change all add-on devices a minimum of every 72 hours.
(Level of Evidence = IV)
Documentation
Recommendation 12.0
Nurses will document the condition of vascular access devices including:
- The insertion process
- Site assessment
- Functionality
(Level of Evidence = III)
Client Education
Recommendation 13.0
Nurses will help clients to attain the highest level of independence through client education.
(Level of Evidence = IV)
Education Recommendations
Recommendation 14.0
The principles and practice of infusion therapy should be included in the basic education curriculum, be available as continuing education, be provided in orientation to new employees, and be made available through continuing professional development opportunities.
(Level of Evidence = IV)
Recommendation 15.0
Schools of Nursing will include Registered Nurses' Association of Ontario (RNAO) best practice guidelines Assessment and Device Selection for Vascular Access and Care and Maintenance to Reduce Vascular Access Complications as reference material for core curricula.
(Level of Evidence = IV)
Organization & Policy Recommendations
Recommendation 16.0
Health care organizations will have policies that address components of vascular access therapy in order to ensure positive client outcomes.
(Level of Evidence = IV)
Recommendation 17.0
Health care organizations, in collaboration with their infection control teams, will monitor complications of infusion therapy and use data to employ risk reduction strategies.
(Level of Evidence = IV)
Recommendation 18.0
Health care organizations will implement the use of safety engineered devices and equipment to reduce the nurse's risk of sharps injuries that can lead to blood borne diseases. The organization's risk management program will monitor assessment of these practices and incidents.
(Level of Evidence = III)
Recommendation 19.0 (Updated in 2008)
Health care organizations have access to infusion therapy nursing expertise to support optimal vascular access outcomes.
(Level of Evidence = III)
Note: Although the evidence supports the original recommendation, the panel would like to emphasize the importance of health care organizations having access to credentialed infusion therapy nurses to support optimal vascular access outcomes.
Recommendation 20.0
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education.
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
- Dedication of a qualified individual to provide the support needed for the education and implementation process.
- Ongoing opportunities for discussion and education to reinforce the importance of best practices.
- Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Care and Maintenance to Reduce Vascular Access Complications.
(Level of Evidence = IV)
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
