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Gina Ward
Vanco through Midlines being pushed by Hosp Leadership

 

Our hosptial leadership is really coming down with big directive to reduce the number of PICC lines, any central lines. They are looking hourly at our % versus other hospitals in our division, we are having to explain in detail daily why and how  each pt still has the line.   

Recently I had a conversation with the Chief Medical Director regarding INS stance on Vanco via Midline from the INS standards .   He is saying getting Vanco is not an indication for a Picc line.   If we know it will be short term, less than 6 days we will try to give peripheral or midline if needed, but if we know it will extend greater than 5 days we go or a PICC line.

so.....now they are trying to continually pull up articles to say the INS standards are not correct or valid and expect me to change our practice.   I basically told them , that INS  standards are what I am held accountable to  and that is how I will base my clinical decisions.  That I will not make a change in my practice everytime a new article is released.  When INS reviews these articles and the body of evidence  if and when it is appropriate then they will make a change in their standards and we will adjust our practice accordingly.

I wanted to attach this new article and get any input from anyone else.  This article/study states that Vanco, regardless of the length of time  is fine in a midline.   I personally find many areas of vague data collection or information posted but wanted others input. 

thanks in advance,  Gina Ward R.N., VA-BC

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lynncrni
That is the report of

That is the report of outcomes from the same author as the original one for up to 6 days but it is not so new anymore. I can assure you that what is in the 2016 INS SOP was current as of the beginning of 2015. but there are many more studies since then and you can update your practice based on those studies. Other studies have identified 4 drugs that produce the greatest problems through a midline and vancomycin was not one of those drugs, don't remember the 4 though. I would have to seek information about the real reason behind this push. It sounds like there is a problem with CLABSI and their approach is a common, but misguided one. No central lines means no CLABSI and no CLABSI means the revenue paid to the hospital is not reduced. As we speak, CDC is in the process of revising HAI definitions to address this issue. We think new information may not be available until 2021 but no one is really sure. Once this problem is corrected, no hospital can choose a PIV or midline to avoid CLABSI after CDC releases their next work. So you may loose this battle but hopefully we will win the war by having hospitals forced to report all BSIs and this issue greatly diminishes. I am not asking for you to post your current CLABSI rates, but I do think you need to know what they are. If high rates are not the driving force behind this, then learn what is. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
update practice based on this study/article

Thanks so much for your response.

I wanted to clarify;   did you say I CAN update my practice in response to this study?    

I am thinking I dont know if its an accurate study, was it biased, does it weight heavy enough in its reliability /evidence etc...  that would warrant a standard change in current practices????  I thought the INS needs to be the one to review and update  standards to guide us in our practice.  I do realize it is up to us to keep abreast of changes and changes with vascular access but I also thought the INS would be the leader in it and guide us.

I am not satisfied with all the info I read in this report in regards to complications with the midlines during this therapy.  some of the outcomes or severity or cause were "supposed" as this was a retrospective study .  I can see a big chance of incorrect data collection strictly from looking at the record because I see how many times things are not documented;  failure to start iv attempts, infiltrates etc....

I look forward to your response as I certainly respect your knowldege and guidance.

Gina

 

 

Gina Ward R.N., VA-BC

lynncrni
No standards or guidelines

No standards or guidelines are mandatory to follow. Compliance is always voluntary even with documents from the CDC. OSHA and CMS are the ones that can impose consequences for not following their standards. INS SOP is updated and released every 5 years. You certainly can look at all new studies, take these to your appropriate committees and make the decision that is best for your patients. This study is not a high level study and there are concerns about it. But there are far more studies available than just this one. My online CE course on midlines is an examination of the literature on midlines with downloadable evidence tables. That course may help you with learning what has been published about midlines and their use. www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
I am concerned then, if we do

I am concerned then, if we do decide to impliment changes and allow Midline useage for longer time frame and then pts experience complications....who knows....extravasation or something and we end up in court.   they review the current INS standards and this is not in line with what they recommend but......thats ok????  because all the hospital leadership agreed?? 

I thought that was a standard that we would be held to in the court of law?   How would we defend our actions??   By showing the articles/studies that led us to make the decisions, documents of our discussions??   

I definitely dont have the time or knowledge to continually be searching for updated articles and studies to keep up with all this..   So.....what if things change and newer literature out there saying something different but I am not aware and we should be doing something different.  Thats why I really  valued us basing our decisions on INS standards and letting them do all the work.   I realize though that alot changes in 5 years.   

I will definitely have to look at your course because as stated above I am not able to do literature searches.

I will  make another comment  regarding why the hospital leaders are doing this whole thing but......it is not that we are having an issue with infections but......they re in the mindset.....NO CVC  then ....NO CLABSI  .   It is a big HCA corporate initiative.

 

Gina Ward R.N., VA-BC

lynncrni
You would defend yourself by

You would defend yourself by having your experts use the new evidence in studies published after any standard or guideline was released. this could also apply to your own internal data collection in the QI process. Yes, NO CVAD means no chance of CLABSI. First we went overboard on use of CVADs for far too many patients leading to increased CLABSI. We have gone overboard on this issue the other way and that is why CDC is assessing these definitions again. I think they will change the BSI definitions to include all peripheral and central VADs. That way there is no issue over peripheral vs central. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
thank you so much!!!  

thank you so much!!!  

You have really helped me out on my understanding of the standards and our decision making process.   I think I took your Midline course several years ago but reading the description it appears to have been updated.  I have purchased it and look forward to taking that course and the wealth of information  it will provide.

I think I also took your other online courses long ago as well.  Has new material been added to any of them where I would benefit taking them.

thanks so much! Gina

 

Gina Ward R.N., VA-BC

lynncrni
Yes, the midline course has

Yes, the midline course has been updated, so lots more studies included. I am not sure what the other course was from a long time ago - Chest Radiograph Assessment? That one has remained about the same. There are a few more courses available now. Between now and the end of the year I will be moving the courses to a different learning management system and updating them all. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
Great, thanks.

Great, thanks.

Gina Ward R.N., VA-BC

JackDCD
Vanco

Gina

This is a very interesting topic for me. Vanco was a villian for a very long time and with it's ph it was warranted. However, recent studies (Lynn is right, again) show Vanco was given for longer periods and had positive outcomes. I feel comfortable putting in a Midline for Vanco and I would gladly pull out the syudies in court if I needed to. However, there is still alot of apprehension about this subject. And regardless of what the recent literature says, there is still going to be some that will become irritated giving Vanco through a Midline. My concern here is, if you happen to get one of those patients, and they get a raging phlebitis , that will not bode well. Play devils avocate: So explain why you gave the Vanco through the Midline?..."well the studies now show"....oh so it's perfectly safe and all patients can be assured not to have the reaction that was feared for so many years?.....But Miss Ward, if you know for a fact that patients wont develop symptoms, why wouldn't you just place a PICC...and Nurse Ward please don't tell the jury that PICC's cause infections and Midlines don't because that would be a lie. You put the Midline in because THE HOSPITAL didn't want to get giged for CLABSI...am I right Miss Ward....ouch!!

Gina Ward
My thoughts exactly!    We

My thoughts exactly!    We havent had a CLABSI for approx 1 1/2 years and that one was an infusaport.   they say they are concerned about the pt and reducing the risk of CLABSI but I know good and well that the pt is not their concern .  Because the next breath is how about putting in IVS or midlines for the pts with long term vanco  and then....on day of  discharge put in the PICC line then.  So.....  yeah, lets stick the pt multiple times and avoid the appropriate device, increase vessel trauma, infiltrates , phlebitis etc...  ( all of wich we see regular)  but we are " protecting them from clabsi" that hasnt occured in over a year.    ok, rant over.  LOL

I feel more secure acting on the INS standards, but....  I realize they are only updated 5 years and alot changes and there is more evidence /studies out there as stated in this discussion.     Yes, the only reason I am considering changing this is due to the pressure from Coporate Leadership.    But....   I have not made them aware that I am even considering this change.  I have told them I am  continuing to practice in accordance to the INS Standards.  but.....  now I learn that isnt necessary in part with  up and coming literture.  

I want to make appropriate changes in our practice for the right reasons and in the patients best interest.    I havent convinced myself that changing our current practice would be doing that.

 

Gina Ward R.N., VA-BC

lynncrni
LOL! I can hear the plaintiff

LOL! I can hear the plaintiff lawyer doing exactly that. Then it becomes a battle of the opinion of the experts hired by each side. And which one is the most believable and likeable to the jury. You would of course be emphasizing in the medical record where you charted your assessment and reasoning that led to your decision that this was the most appropriate VAD for this patient at this time. Your measurement of catheter to vein ratio, your length measurement to ensure correct tip location outside the shoulder. Why you chose that specific insertion site for this patient. The method of stabilization and securement. Plus your confirmation that the dilution of the Vancomycin was no more than 4 mg/mL. You would support this by your knowledge of how the pharmacy compounds vancomycin by a written policy that includes this, a policy that has been developed in collaboration with the pharmacy. This great documentation will prove that you met the standard of care. Oh, and how quickly was this raging phlebitis discovered and how appropriately it was treated. Of legal cases that actually go to a jury trial, defense wins 80-90% of them. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
Excellent information. 

Excellent information.  thanks so much.  I feel much better about things.

Gina Ward R.N., VA-BC

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