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Clinical governance

Competencies

Nurses who insert devices and/or provide infusion therapy should be competent in all clinical aspects of infusion therapy and have validated competencies in clinical judgement and practice; they should also maintain their knowledge and skills in accordance with the Nursing and Midwifery Council's Code (Collins et al. [82], Hyde [221], NMC [356], RCN [381]).
The RCN ([381]) recommends that any registered nurses who undertake the insertion of VADs or those who manage VADs or administer infusion therapy should have undergone theoretical and practical training in a number of areas (Box 17.2) (Corrigan [89], DH [114], Hyde [222], Loveday et al. [278], MHRA [315], Moureau et al. [335], NICE [350], NMC [356], NPSA [357], [358], RCN [381]). All staff have a professional obligation to maintain their knowledge and skills (HCPC [204], NMC [356]). It is also the responsibility of the organization to support staff and provide them with training and education. This may be in the form of study days, practical sessions using a mannequin and a role development workbook, or simulation (Andreatta et al. [11], Collins et al. [82], Kokotis [245], Phillips et al. [372]).

Consent

Prior to insertion of a peripheral cannula, it is usual to obtain verbal consent from the patient (Hyde [222]). However, prior to insertion of a CVAD, written consent should be obtained (unless required in an emergency) following an explanation of the procedure, the benefits, the alternatives, and the possible complications and the percentage risk of each (these would include pneumothorax, malposition, haemorrhage, thrombosis and infection). This information should be provided verbally and in written form (Hamilton [198], HCPC [204], NMC [356]) and it should follow local and national guidelines (Bodenham et al. [43]).
Box 17.2
Knowledge and skills required of a nurse who inserts vascular access devices and/or provides infusion therapy

Vascular access device insertion

  • Anatomy and physiology of the circulatory system, in particular the anatomy of the location in which the device is placed, including veins, arteries and nerves and the underlying tissue structures.
  • Assessment of patients’ vascular access needs, nature and duration of therapy, and quality of life.
  • Improving venous access, for example the use of pharmacological and non‐pharmacological methods.
  • Selection of veins and problems associated with venous access due to thrombosed, inflamed or fragile veins; the effects of ageing on veins; disease processes; previous treatment; lymphoedemal or presence of infection.
  • Selection of device and other equipment.
  • Infection control issues (e.g. hand washing and skin preparation).
  • Pharmacological issues (e.g. use of local anaesthetics, management of anxious patients, management of haematoma and management of phlebitis).
  • The patient's perspective on living with a vascular access device.
  • Risk management in order to reduce the risk of blood spills and needle stick injury.
  • Professional and legal aspects (e.g. consent, professional guidance, knowledge and skill maintenance, and documentation).
  • Performing the procedure.
  • Prevention and management of complications during insertion (e.g. nerve injury and haematoma).
  • Monitoring and care of the site (e.g. flushing, dressing and removal).
  • Product evaluation.
  • Patient information and education.
  • Documentation.
  • Specific training for insertion of vascular access devices in certain groups (e.g. neonates, children and oncology patients).

Administration of intravenous medication and care of vascular access devices in situ

  • Legal, professional and ethical issues.
  • Anatomy and physiology.
  • Fluid balance and blood administration.
  • Mathematical calculations relating to medications.
  • Pharmacology and pharmaceutics relating to reconstitution administration.
  • Local and systemic complications.
  • Infection control issues.
  • Use of equipment, including infusion equipment.
  • Drug administration.
  • Risk management, and health and safety.
  • Care and management of vascular access devices.
  • Infusion therapy in specialist areas (e.g. paediatrics, oncology, parenteral nutrition or transfusion therapy).
Source: Adapted from Czaplewski ([97]) with permission of Elsevier.
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