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HMS Critical Care Vascular Access Toolkit

In critical care, evidence-based vascular access guidelines, decision support tools, and structured communication protocols reduce complications, enhance patient safety, and support consistent, high-quality, and cost-effective care.

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  5. Develop, Share and Integrate Institutional Guidelines for Vascular Access Use in Critically Ill Patients

Develop, Share and Integrate Institutional Guidelines for Vascular Access Use in Critically Ill Patients

Background, Rationale and Suggested Implementation Strategies
  • Establishing clear guidelines for vascular access use ensures consistency in the quality of care across departments and practitioners. This reduces variability, which is often associated with increased rates of complications.
  • Developing guidelines based on the latest research and clinical evidence ensures patients receive care that is in line with current best practices, reducing the likelihood of adverse events.
  • Standardized protocols can lead to better patient outcomes by minimizing complications related to vascular access, such as infections or thrombosis, thereby improving overall safety and patient satisfaction.
  • Guidelines serve as a valuable educational resources for all staff, ensuring that all healthcare providers are knowledgeable about the best practices in vascular access management.
  • Instituting guidelines provides a framework for continuous quality improvement initiatives. Data on vascular access outcomes can be collected, monitored, and used to refine guidelines over time.
  • Customize by leveraging national or international guidelines and tailoring recommendations to address specific institutional needs, such as patient demographics or logistical constraints
  • Conduct workshops, seminars, and hands-on training sessions to educate staff about the guidelines. Ensure educational materials are accessible and that there are opportunities for staff to ask questions and seek clarifications.
  • Incorporate guidelines into the institution’s electronic health records (EHR) system, providing prompts or checklists to support adherence during the clinical decision-making process.
Resources and Tools
References
  • Chopra, V. et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method Annals of Internal Medicine 2015.
    • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts.
  • Timsit, J. et al.Expert Consensus-Based Clinical Practice Guidelines Management of Intravascular Catheters in the Intensive Care Unit. Annals of Intensive Care 2020.
    • The French Society of Intensive Care Medicine established 36 guidelines for managing central venous, arterial, and dialysis catheters in ICUs using the GRADE methodology, emphasizing infection prevention through subclavian vein use and one-step chlorhexidine-alcohol disinfection. Recommendations suggest avoiding antiseptic or antibiotic-impregnated CVCs and advise using ultrasound guidance to minimize complications, while also proposing specific pediatric strategies and future areas for investigation. A NEJM randomized trial that included both critically ill and non-critically ill adults and children assigned 1098 individuals undergoing PICC placement to receive a hydrophobic PICC, a chlorhexidine PICC, or a standard polyurethane PICC (1:1:1 ratio). The risk of device failure due to noninfectious or infectious complications similar for hydrophobic or chlorhexidine PICCs compared with standard polyurethane PICCs. Device failure occurred in 5.9 percent of the hydrophobic group, 9.9 percent in the chlorhexidine group, and 6.1 percent in the standard-polyurethane group. However, more complications from any cause occurred for chlorhexidine compared with standard polyurethane catheters (OR 2.35, 95% CI, 1.68 to 3.29).
  • Takashima, M. et al. Complication and Failures of Central Vascular Access Device in Adult Critical Care Settings SCCM 2018.
    • The study systematically reviewed 63 studies to examine failure rates and complications of central venous access devices in adult ICUs, finding a 5% overall failure rate, with hemodialysis catheters experiencing the highest failure and non-tunneled devices showing the highest infection rates. Despite relatively low rates of bloodstream infections, a significant proportion of devices were removed due to suspected infections, highlighting the need for more comprehensive guidelines to better inform the decision-making process in suspected infection cases.