Accessing CVADs is Like Killing Puppies, Only Worse

A little while ago I was seconded to do some administrative-type work, and one of the things I was asked to do was certify ED nurses in central venous catheter access. CVADs — central venous access devices —  include such things as Hickman catheters, implanted ports and PICCs (peripherally inserted central catheters). They are typically seen in chemotherapy patients or dialysis patients, or people who require very long-term antibiotic therepy, or frequent venous access.

CVADs are fussy and fastidious, rather than difficult; they are somewhat time-consuming and they demand good preparation and strict aseptic technique. In the emergency department, we use them principally to obtain blood draws and to start IV therapy. They are certainly becoming more common, even as the population ages and community care options become more feasible. The case for ED nurses acquiring this skill ought to be a no-brainer: decreased patient discomfort, no new invasive procedures for blood draws and IVs — not insignificant considerations for patients who might be immunocompromised. Unlike many hospitals we have no vascular access team; getting bloods or starting IV therapy was left to the two or three of us who were certified in CVAD access. My job was to get a critical mass of nurses certified so there would be at least a few competent available on every shift. A pretty straight-forward task, or so you would think.

I was frankly taken aback at the vehemence of the resistance to to this initiative. “It’s the worst decision this department has ever made!” one nurse told me in tones which suggested I had asked her to kill puppies with me in the soiled utility room. One interesting thing I noted was there seemed to be a distinct demographic divide. New(ish) nurses I approached for the inservice and certification seemed to be much more receptive* than the old birds (like myself) who were, um, more vocal in their objections. I get/don’t get the objection. I know nurses worry about increased workloads affecting their practice and patient care, I understand the difference between acuity and complexity — and CVADs do add a layer of complexity to patient care. But ultimately it’s about improving patient care — as using CVADs ultimately does. So what’s the problem?

I’m at a bit of a loss to explain this dichotomy. My hunch is that hospital administrators have manipulated and lied to nurses over the past  — what? two decades? — about how this or that new initiative or increase in workload will “improve” patient care, even when patently false, so often that older nurses have given up trying to figure out the the spin from the evidence. My other hunch is that newer nurses are more interested in evidence-based practice than us old dinosaurs — maybe. What I’m also not clear about is how this resistance can be changed into something positive. My sense is that it’s probably not worth the effort, and leadership is not enough. Am I wrong?

__________

*Or fearful of me.

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  1. #1 by Sean on Thursday 03 February 2011 - 1203

    This knee-jerk negative reaction still befuddles me to this day. Instead of embracing a new skill to help raise the level of your care, nurses instead complain that it will be ‘one more thing’ they will have to do.
    These are the same nurses that will complain that their patient is going down the drain and they need an IV nurse to access their port since the patient has no other access. They’ll get mad at the IV nurse for not getting there fast enough, when this new skill can/could prevent this from occurring in the first place.
    Grr.
    GRR
    Grr.
    I would love to learn this skill.

  2. #2 by Boris on Thursday 03 February 2011 - 1352

    Oh, that would have been a really handy skillset for my nurses about 18 months ago. My surgeons wanted a PICC line, but the unit that did that kept bumping me much to their, and my nurses’ frustration.

  3. #3 by Maha on Thursday 03 February 2011 - 1435

    Wow this was a requirement for me to start working in the higher acuity areas of my workplace. My thinking (rightly or wrongly) goes that the more I can do, the leas I have to rely on other teams who have to triage their consults appropriately.

  4. #4 by Wanderer on Thursday 03 February 2011 - 1727

    Huh, we access implanted stuff all the time (except ports, we’re not allowed to touch, only IV therapy can) and never have an issue about it. PICCs? No second thought. Hickmans are just as easy. Not a huge fan of HD caths for all the hoops we have to jump through, but easy enough to access and use.

    I agree w/Sean, would love to learn how to access ports (since I already know the others) to grow my skill set. Why wouldn’t you?

    Only time I complain when a new skill is asked of me is that if that skill is paperwork…

  5. #5 by Jenn Jilks on Thursday 03 February 2011 - 1951

    As a civilian you nearly grossed me out with the beginning of this post! Needles and blood are my gross out points.

    I kept reading, though, knowing there’d be something good to follow

    Thinking of the patient, how much longer does s/he have to wait until someone with the skill arrives? It seems as if there is no such thing as too much information for you professionals.

    Yikes.
    Now my mother was fussy and fastidious. This is a good thing in a hospital. Don’t you think? Everyone should be that way. Sometimes all I need is a friendly word in hospital. Sometime I HOPE I don’t need this, but if so, it’d be good if someone could do it!

  6. #6 by Rachedy on Thursday 03 February 2011 - 2022

    Not sure what the resistance is. I’m an old nurse. If patient comes in with a port I’m all over it, drawing from it, using it, loving it. I had one MD tell me he didn’t want it used because we couldn’t do a CTA with it. I’m like, seriously, you don’t know what you’re talking about, it’s a power port, and a dual lumen at that. I think there is a need for education not only from the medical staff but some of the nursing staff as well . Some ED nurses think 2 18G Iv’s are all a patient needs.

    • #7 by torontoemerg on Friday 04 February 2011 - 0718

      Some ED nurses think 2 18G Iv’s are all a patient needs.

      True, if a little snarky. :)

      We were all taught “go big or go home.” But really this only applied when fluid resus is needed, i.e. with trauma or codes or sepsis. Clearly this doesn’t apply to all patients.

  7. #8 by Zoe on Thursday 03 February 2011 - 2210

    We attempted this a while back, but unfortunately what happened is skills were forgotten between the certification time and actually using the skills. We just don’t see these things often enough. Granted, we are beginning to see them more often, but so far not often enough to solidify the skills.

    In addition, we seem to have a particularly fastidious medical imaging department, that seems to want these devices for their own personal use and gives us all sorts of reasons why we can’t use them (“…they can’t have anything running in it, not even normal saline….”) In the end, people just give up, and start a peripheral line.

    We are lucky to have IV therapy RN on dayshift, and after hours, usually someone on the palliative unit will come down and access them for us. So the staff really haven’t seen the need to become certified.

  8. #9 by nurseXY on Friday 04 February 2011 - 0033

    Ok, this post has confused me a little bit…

    When you say “access” do you mean just using them, or placing them?

    I was under the impression that accessing a line means to use it, but I cannot fathom people resisting learning how to do that… So that makes me wonder if you mean placing them.

    99.99% of my patients on my home unit have either a triple lumen central venous catheter, or a PICC line. I’ve been accessing them since my very first semester of nursing school, the concept isn’t a difficult one…and they make life soooo much easier.

    A good TLC or a PICC and a well placed art line, life is good.

    • #10 by torontoemerg on Friday 04 February 2011 - 0709

      Access=using.

      But look — you’re a new grad. You’re, like, a case in point. :)

  9. #11 by Cartoon Characters on Friday 04 February 2011 - 0645

    I Personally embrace learning new things and go for the challenge – and I would classify myself as an OLD nurse being in the field since the 1970s.
    I found that the more I participated in change and learning, the easier it was – same with certifications such as NRP and the likes…..the more it was done, the easier.
    Every 2 years I would always make sure I did something either totally different or took some sort of class to keep myself from getting into a rut and becoming one of those nurses that resisted change.

    After a while you start to enjoy the challenge…

  10. #12 by Cartoon Characters on Friday 04 February 2011 - 0648

    I don’t see the big deal since the CVADs have been around so long and we have been accessing for years……..???? What’s wrong with a little certification?? i don’t get it….unless I am missing something?

    • #13 by torontoemerg on Friday 04 February 2011 - 0723

      I was thinking about this some more last night and nurses go to ACLS etc without much grumbling, because, I think they see is as central to their practice, and there’s always a waiting list for TNCC .. . . maybe we just need to say, in orrder to be an ED RN, you must have this skill set. . .

  11. #14 by Cartoon Characters on Friday 04 February 2011 - 1922

    Exactly! I agree.

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