Why vascular access leadership skills are important in the workplace

leaderI just read a great article on leadership by Stephanie C. from the UK. She states that quality leadership skills are often sought after by many employers; they not only show that you have good interpersonal skills, they also show that you have the ability to co-ordinate, motivate and shape a team. She raises 3 points on what makes leadership skills important in the workplace – points that ring true in our specialty field of practice –

  • Initiative: Often good leadership skills make you more likely to have a good sense of initiative. This means you don’t wait for other’s to tell you to perform tasks or actions. You are forward-thinking and as a result more prepared to deliver solutions to problems that arise.
  • Innovativeness: Leadership skills improve your ability to find new ways of doing things in an organisation. You are driven by the ability to change or re-invent common practices, all of which can serve to benefit an organisation.
  • Pro-activeness: Leadership skills improve your ability to be proactive. Leaders do not just ‘plan to do’, they actually ‘do’. The ‘do-ers’ are the ones whom are identified as being the most reliable and productive. If you are able to successfully execute written plans into practice, you are showing that you are able to take control of situations rather than just responding to them.

I often hear many vascular access clinicians say they want to change clinical practices within their institutions and facilities. I applaud their desire to make change for the better; for themselves, professionally; for their patients, to provide better care, and for their institution, to improve efficiencies, reduce complications and improve patient safety; however many of them are either frustrated or overwhelmed at the prospect of approaching senior administrators and high level clinicians who may be potential barriers to growth.

It is not with out the 3 elements that Stephanie describes above that change can be implemented. Things that need to be put in place to make these changes are some the following traits that leaders require to help them in their journey to facilitate change.

  • Strategic Thinking: Do you think strategically? In this case, what this means is that you often plan effectively for the forthcoming future based on a range of objectives which you set for yourself or your team. Strategic-thinkers are visionary, creative and willing to take risks. They are focussed on the long-term goals and implications of meeting them.
  • Decision-making: You can easily choose between one or two courses of action at least 70% of the time. You are able to make firm and prompt decisions with ease despite all of the options available also shows you have exceptional problem-solving skills.  A good decision-maker bases their decisions through a good balance of emotional and logical reasoning; this means considering the facts as well as the way in which a decision will effect others.
  • Time-management: This skill goes hand in hand with being organised. Do you find it easy to keep to a schedule which you set out for yourself. Are you able to prioritise effectively with tasks and deadlines. This is even more important when you are in the position of leading a team as you will need to effectively map out timelines for others.
  • Charismatic: Are you considered to be confident, assertive and/or charming? Leaders possess a certain strength of character and a strong sense of individualism. Charisma is a natural characteristic that makes it easy to influence others. Public speaking skills directly develop your level of charisma and ability to be listened to.
  • Listening: Contrary to popular belief, leaders are not always bossy. In fact they are supposed to know when to listen and when to direct. Being able to listen to suggestions and ideas effectively will help a leader implement the correct plans according to their team strengths, weaknesses, concerns and capabilities.

Vascular access specialists have an important role to fulfil within healthcare as others do – however, they also crossover and service nearly all clinical specialties within the healthcare environment as vascular access is the most performed invasive procedure globally. If your a clinician who wants to lead change within your team or facility, develop these elements, grab the evidence, inject it into your passion to improve things, and strive forward, recruiting those who will assist you in the process. It is a tough challenge, but in the end the benefits will be much greater for all.

Air Embolism – understanding WHY it occurs and HOW to prevent it

Air EmbolismAir Embolism (AE) is often a life-threatening complication of large bore intravascular device insertion and removal. Although much focus has been with the insertion phase, device removal is just as potentially dangerous.

There is becoming an increased awareness of AE through patient advocacy groups and from a patient safety perspective taught by experienced healthcare clinicians. There are more frequent publications related to AE and certainly this complication is getting a wider girth of awareness.

Essentially, ANY intravascular device – intravenous (IV) or intra-arterial (IA), can cause an AE. Although IA is potentially a lesser risk, it does not mean that it doesn’t occur.

Devices, particularly IV, should be removed with the patient satisfying the following criteria;

  1. The patient/client should be in a supine (flat) or slight Trendelenburg position (15-20° head-down) – particularly for CVADs and PICCs.
  2. Should be removed at end-expiration – for all devices.
  3. Should have an air-occlusive, paraffin or petroleum-based dressing over the removal site for 48 hours, until the exit site wound has sealed closed.

Many clinicians who remove these types of devices MUST be educated and aware of potential for AE to occur, and need to ensure that preventative measures are in place BEFORE a device is removed.

Following the three actions listed above will reduce the risk of AE in most situations.
An easy to remember way is to think, ‘the patient should be in the same position for removal of the device as for the insertion of the device’. Easy.

When air embolism is suspected, the patient should be placed on 100% oxygen and on the left lateral decubitus position, which may improve right ventricular outflow by keeping air in the right atrium or in the apex of the right ventricle, away from the pulmonary artery and right ventricular outflow tract.

AE should also be included during ‘mock’ codes – simulated scenarios for training purposes. This is one way of ensuring the education is met on a regular (or even mandatory) level within healthcare facilities for clinicians who are associated with intravascular device removal.

Here are several links to recent articles on air embolism prevention (courtesy of JVA);

Tunneled central venous catheter exchange: techniques to improve prevention of air embolism

Over-catheter tract suture to prevent bleeding and air embolism after tunnelled catheter removal

Cerebral air embolism after central dialysis line removal: the role of the fibrin sheath as portal (mechanism) of air entry

#vascularaccess #FOAMva

Michelle DeVries on Exploring Approaches ‘Beyond the Bundle’ to Help Decrease Vascular Access Device-Associated Infections

Fellow colleauge and infection prevention guru Michelle DeVries recently published in Infection Control Today and shares some evidence that it may be time to look beyond insertion and care & maintenance bundles to examine additional approaches that may be beneficial – for the patient and the institutions.

Exploring Approaches ‘Beyond the Bundle’ to Help Decrease Vascular Access Device-Associated Infections

#vascularaccess #FOAMva

Why is pH and Osmolality/Osmolarity important in vascular access? #FOAMva #vascularaccess

With a shift in the 2016 INS Standards of Practice to remove the pH of medication administration guideline, and despite swinging voters (clinicians) choices on the topic, I wanted to address the basic underlying science of the terminology. pH maybe no longer in the current SOP, but it still a serious factor that infusion therapy and vascular access specialists must take into consideration when assessing the patient for a device. There is more too it than meets the eye..

ph-scale

Published standards on acceptable IV fluid pH or osmolality values are somewhat harder to find; but becoming more frequently investigated and reviewed. A pH range of around 4 – 8 is mostly seen for todays’ commonly used IV fluids. Fluid pH doesn’t really matter from a systemic acid-base perspective (which depends entirely on the effective Strong Ion Difference (SID) and ATOT (total plasma concentration of inorganic phosphate, serum proteins and albumin) concentrations in the fluid), but fluid pH is likely to be important in the genesis of local effects.

The main concerns are the potential for the following;

  • haemolysis,
  • endothelial damage with platelet adherence and vessel occlusion,
  • extravasation,
  • inflammation,
  • tissue necrosis.

The question is complicated by the variable dilutional blood flow environments into which the IV fluid is infused/deposited. Worst case scenario is infusing fluids at extremes of pH and/or osmolality without co-infusions into a small peripheral veins, whereas you can administer fluid of almost any pH or osmolality by slow infusion centrally. Larger cubital fossa veins lie somewhere in between. Add in a mixture of various parenteral medications, all with their own elements of pH and Osmo, and things start to change notably.

It is important not to confuse osmolality with osmolarity. For example, you will find when you measure the osmolality of 0.9% sodium chloride that it is about 284 mOsm/kg (vs the quoted osmolality of over 300 mOsm/L). Baxter and other fluid manufacturers use the term ‘osmolality’ incorrectly here. Similarly the measured osmolality of Compound Sodium Lactate is 258 mOsm/kg, not 274. Osmolality is a function of particle activity as well as concentration. Ionic activity relative to concentration decreases with increasing total ionic concentration. Hence ionic activity is less than concentration (and thus osmolarity) except at infinite dilution. As you know osmolality is usually measured by freezing point depression.

In fact the below neutral pH of commonly used IV fluids is mainly due to dissolved atmospheric CO2. If PCO2 = 0, commonly IV fluids should have a neutral pH of around 7.0 at room temp, although phthalate anions from the PVC container may still drop it a bit below 7.0, and slight caramelisation of dextrose due to heat sterilisation may also occur.

If you want to read and understand more about acid-base, check out the links below;

AcidBase.org

Michael Bookallil’s Acid Base of the Blood

Repositioning of CVADs using high flow flushing technique – practice and cost review

Although it’s a little self-indulgent, I am also very excited. I just had a manuscript accepted for publication on repositioning of CVADs utilizing a high flow flushing technique (HFFT) in the Journal of Vascular Access. This is something I investigated and started monitoring a few years ago (after a discussion on its relatively unknown use) and decided to start writing a more formal paper on this technique. The manuscript has not been allocated an edition currently, but will be available as advanced online publication at the JVA website very soon.

HFFT

Screen Shot 2017-05-04 at 10.23.30 PM

Updated list of Non-Cytotoxic Vesicants and Irritant medications

Many medications and drug therapies actually cause damage to the vessel wall – the endothelial layer (which in turn is only one cell layer thick) is the prime area that is predisposed to injury during exposure to the administered medication – here are the latest from the Infusion Nurses Society in regards to non-cytotoxic vesicant and irritant medication administration. Be mindful that many of these medications CANNOT be administered via a peripheral device, which includes midline catheters..

LargeRollover.00129804-201705000-00000.CV

Development of an Evidence-Based List of Noncytotoxic Vesicant Medications and Solutions