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How a agency benefited from an advanced IV team
For several years, Visiting Nurse Service of Webster, NY, had a dedicated IV team for its 100-plus nursing staff. But when the team informally fell by the wayside, the result was a reduction in nursing skills as well as increased nursing visits. As a result, Visiting Nurse Service recently re-established its IV team to the benefit of staff and patients alike.
Sharon Billings, RN, senior RN for infusion therapy for Visiting Nurse Service, says there were two reasons for getting the advanced IV team up and running again.
"Previously, any referral that had infusion therapy automatically went to a member of the IV team to case manage," she says. "When the team disbanded, a referral for infusion therapy didn’t necessarily go to a member of the infusion therapy team."
The result was that all nurses were expected to handle standard infusions; but if an advanced skill was needed (such as epidurals or urokinase), a member of the original IV team would co-visit or take over the patient even though the team was no longer in existence.
"The advanced IV nurses were not getting the IV patients like they used to, so there was a diluting of skills," says Billings. "Instead of doing peripherals on a weekly basis, they were only doing them a couple of times a year."
While nurses who were adept and enjoyed infusion therapy were receiving fewer infusion patients, the opposite was happening at the other end of the spectrum.
"We also found that many nurses were not comfortable with infusions, yet they had to case manage this population. It increased our need for co-visits with these patients," says Billings. "The quality is not what it used to be, so it was determined that in the best interest of quality and our patients, we needed to return to our IV teams."
The first step in establishing an advanced IV team was to develop an advanced infusion therapy class. Over the course of a month, Billings worked with another original member of the advanced IV team and an advanced practice nurse to decide what basic IV skills should be required of all nurses and what advanced IV skills should be addressed in the advanced class, which was to consist of a four-hour lecture and a four-hour skills lab.
"There is no way to teach all the various aspects of infusion therapy in eight hours, so we started by determining what our patient population consisted of and looked to address all the skills we needed to have for those patients," Billings explains.
She notes that advanced IV skills necessary for her staff included peripheral catheters, IVADs, epidurals, and the urokinasing. Billings used the original IV team’s class as a guide, then conducted research using journal articles to update the information.
Because all Visiting Nurse Services staff must pass a basic infusion class included in the orientation program, the advanced class was simply building on the skills presented in the orientation. The basic class included dressing changes, hanging infusions, and flushing central lines. Separated from that and addressed in the advanced class were skills such as peripheral lines, pumps, IVADs, epidurals, and urokinase installation.
Next was to select the nurses who would form the IV team.
"One of the important considerations was finding nurses who were interested. Because, unless we get a nurse who is committed and has an interest in infusion therapy, we weren’t going to have a nurse who would take it upon herself to continue her learning," says Billings. "To be on the advanced IV team, first and foremost they had to express an interest and desire to do it. Then, they needed to go through the advanced program and follow through with co-visits for any new skills."
The advanced program consists of a formal, eight-hour class broken down into a four-hour lecture and a four-hour skills lab.
For the skills lab, Visiting Nurse Service invited area vendors to attend so nurses could get hands-on experience with equipment used by the various vendors and ask questions. The lab also includes an opportunity for nurses to cannulate a vein on each other, a lab that showed urokinase installation and repairing a PICC line.
Billings notes that advanced nurses don’t repair PICC lines, a job that is left for a core group of the advanced IV team.
"There are just nine members of the core group. It is the group that does the more advanced troubleshooting of pumps, and more specifically, they are the ones that are trained at removing and repairing PICC lines," says Billings. Three members of the team have received certification to insert PICC lines through training at a local hospital.
The lecture portion of the class addresses:
• An overview of the different types of lines.
• Policy and procedures (addressed in the basic class as well).
• Peripheral lines.
"Each of the above sections includes indications for use, skilled techniques, patient education, nursing implications, documentation requirements, copies of skills checklists for all the different procedures, subcutaneous pumps, IVADs, infusion therapy pumps, and controllers, epidurals, urokinase and legal implications," Billings explains.
"It also includes a piece on anatomy and physiology of the different veins in the arms; and for all the different sections, we found journal articles that would be interesting, and included them as well."
Now that the advanced IV team is back up and running, combined with the basic IV skills required of all nurses, Billings says the staff and patients have the best of both worlds.
"When we have an infusion patient, that patient goes to a member of the IV team," says Billings. "The benefit is that the accountability for the patient remains with a member of an IV team. But if that nurse is overwhelmed that day, she can use a member of the basic nursing staff to do a revisit because they are able to use basic IV nurses for some visits."
This is in sharp contrast to what happened when all nurses were receiving IV patients. For example, if a patient had a PICC line and a member of the basic nursing team made a visit and the line was occluded, a second nurse with advanced IV skills was called to come out and assist the original nurse.
"Now there is one nurse who is accountable," says Billings, "and each IV patient is being primaried by a member of the infusion therapy team. Yet, if that team member is unable to see the patient on any given day for any reason, they can at least float it to a nurse with basic skills."
Billings says there are 35 nurses on the advanced team who case manage, but a total of 50 nurses on the team in order to allow for 24-hours-a-day, seven-days-a-week coverage.
In the nine months the team has been back in place, Billings says she has already seen a difference. "We haven’t collected data, but I see an increase in staff satisfaction, and I am not doing near as many co-visits," she says.