IV guide prompts coordination, cooperation

Assists in coordinating care between care settings

What started as the development of a practical vascular access guide for nurses in the Sharp HealthCare system of San Diego has, in the course of two years, developed into a board of multispecialty professionals that keep the entire Sharp system updated and on track with the latest business, clinical, and legal issues in the vascular access field.

Two years ago, the Sharp Grossmont Hospital home infusion company realized home care nurses needed assistance to provide successful home infusion. As vascular access became more scientific and home infusion felt increasing pressures from managed care, it became apparent nurses and their home infusion patients would benefit from the leadership of an infusion clinical nurse specialist.

"We were asking the nurses to do the right thing the right way the first time, and they deserved educational and clinical support," says Pamela Johnson, MSN, MBA, CNS, and an infusion nurse for Sharp HealthCare/Sharp Grossmont Hospital Homecare, who was given the task of providing that support.

"The first thing that was apparent to me was that our patients were coming from different settings," she says. "Some came from our inpatient setting; sometimes they were seen in ambulatory care, [or] were seen in home care or their doctors’ offices. The patients were told different things regarding their infusion in each setting. Not only were the patients confused, they didn’t think the professionals ever talked to one another."

Seeking structure

To alleviate the problem, Johnson decided to compile a vascular access guide that clarified the various policies and procedures of each care setting within Sharp HealthCare, then disseminate this information to the system’s professionals. (See charts, p. 31.)

"The first thing I did was talk to the inpatient and ambulatory IV nurses [to] try to set up something that provided structure by matching all the Sharp procedures and policies," she says. "That’s why some of the sections have ranges. Inpatient nurses tended to change dressings more frequently, and we didn’t want to ask them not to do that."

Johnson adds that is why the resource is called a guide.

"The frequency of dressing changes or the amount of saline flush to use in one setting may not be strictly the same in another setting," she says. "That is why some of the guidelines have a range instead of a specific answer."

Not a strict guide

The guide’s purpose is not to tell nurses exactly what to do, but to stimulate the nurses’ thinking and give a general guideline for the nurse to make decisions about care.

Also, when nurses know other parts of the health care continuum may approach a patient procedure in a slightly different way, they can better educate patients on the basics of vascular access care, rather than have patients memorize a list of steps that makes little sense to them.

"I didn’t want to say, This is the bottom line,’ because the guide just gives you an idea of what everyone is doing," adds Johnson, noting she also reviewed existing standards of recognized organizations while compiling the guide.

"We tried to work with the standards we had and make them meet with Oncology Nurses Society, Intravenous Nurses Society, and Centers for Disease Control standards, which can be a bit vague sometimes because there is not much research available, especially for site care and dressing changes to recommend anything hard and fast," adds Johnson.

She also points out the guide is a living document and is updated every six months or so to remain current with the most recent studies and research on vascular access and patient care.

Upon completion, copies of the document were posted at all the home care companies. At each orientation, every home care nurse receives a copy of the orientation packet. Sharp has also used the guide to market its services to physicians by showing what vascular access devices are available, when to select each device, and how Sharp treats patients with them.

"Familiarity with the management of the many vascular access devices is knowledge many physicians lack, while infusion nurses are comfortable and skilled in this area," says Johnson. "We see this as a unique opportunity to gain credibility and respect from our physician colleagues."

While compiling the guide, Johnson realized the various resources strewn throughout Sharp’s system could be changed from negatives to positives. That very idea eventually led to the development of Sharp’s Vascular Access Council last March.

"We worked under the vice president of ambulatory care for the system and formed the council," says Johnson. "It reports to two systemwide medical staff committees: infection control and quality assurance."

Laurie Ecoff, RN, MS, director of ambula- tory services for Grossmont Hospital, Sharp HealthCare, says the council adds the council was a result of the evolution of vascular access within the system.

"There was a need to address vascular access issues from a systemwide approach," she says, "and this meant bringing the experts together that are involved in vascular access across the continuum of care."

Ecoff says the council is in its formative stages.

"We spent a number of the meetings developing our charter and quality plan that establishes what we want to do," she says. "We see this as a quality improvement activity to link all the different sites and infusion centers together to ensure the best practice throughout the entire system."

Ecoff points out the Vascular Access Council will focus on standardizing clinical practice through looking at quality improvement as well as the latest clinical research. The process thus far has been time consuming, but not necessarily challenging.

"It’s a matter of trying to meet with people across the system throughout San Diego County and get everyone together once a month," says Ecoff. "It has helped to send information [via] e-mail so members can review minutes and charter plans between meetings."

The Vascular Access Council has an advisory function; any questions relating to vascular access can be presented for review and recommendations. Seated on the council are members from interventional radiology, infection control, inpatient, and ambulatory settings, as well as the cancer center — basically anyone having anything to do with vascular access.

The council meets monthly and addresses the need to inform the system that it exists and what it can do. Plans are to use the entity-based Quality Councils to help disseminate information, as well as consider different groups within the system the Vascular Access Council can present information to.

Each member of the council also has an obligation to disseminate information. "Members of the council need to make sure they bring the information back to their leadership and staff at each entity," says Ecoff.