Vascular Access for Surgical Rehabilitation Patient – Nurse Clinicians in Action – 30

Vascular Access for Surgical Rehabilitation Patient describes how an expert Vascular Access clinician identified co-morbidities in a clinically complex post-surgical patient and worked with the medical team to obtain safe, appropriate vascular access needed to address an infection. Nurse Clinicians in Action is a spotlight series highlighting some of the interesting cases that Vascular Wellness clinicians have encountered and participated in treatment. These cases involve challenging situations or intriguing clinical presentations and may involve more than one Vascular Wellness clinician, as our clinicians have the ability to consult each other while in the field, as well as an on-call Clinical Administrator via a HIPAA (Health Insurance Portability and Accountability) compliant communication app. In addition, our extensive training program and diverse client base, including Level 1 Trauma Centers, Short Term Acute Care Hospitals, Long Term Acute Care Hospitals, and Skilled Nursing Facilities, provide our clinicians with a wide array of clinical experience and why we believe our clinicians, as a group, are the most experienced and best trained and supported vascular access clinicians.

Vascular Access for Surgical Rehabilitation Patient

– Clinical Case

This case occurred in a Rehabilitation Facility with a patient recovering from bowel surgery who had a potential surgical site infection and bilateral swelling due to post-operative restraints. Because the patient’s poor peripheral veins made vascular access difficult, the Rehabilitation Facility could not obtain blood lab samples, including blood cultures, to confirm the suspected infection. Vascular Wellness was consulted to place a midline for 10 days of antibiotic IV therapy. When the Vascular Wellness clinician initially reviewed the ordered therapy, including a request to obtain blood samples, the clinician tentatively agreed with the plan of care. However, upon arrival at the Rehabilitation Facility and further evaluation of the patient and the patient’s medical history, the clinician found co-morbidities that she believed should alter the prescribed vascular access line. The expert vascular access clinician noticed bilateral swelling, with more significant swelling to the left arm and less so to the right. An ultrasound assessment was performed, which revealed microvasculature to the left arm with subcutaneous fluid associated with edema. The right arm was then assessed with ultrasound, and this revealed a largely dilated, non-compressible right brachial vein with significant amounts of intravascular obstruction.

The Vascular Wellness clinician understood the prescribed line would create additional complications, and that further patient assessment would be necessary to determine the most clinically appropriate solution.

Rehabilitative care after hospitalization often specializes in preparing a patient for their return home to independent living. It is especially helpful to have expert consultation at these types of facilities, whether Long Term Acute Care Hospitals or Skilled Nursing Facilities. While these facilities focus on rehabilitation, they may lack specialized clinicians in vascular access. Collaborating with vascular access experts can ensure optimal recommendations for patients’ vascular access needs. In cases involving co-morbidities, the medical team, and vascular access experts work together in an interprofessional collaborative approach to avoid delay cascades, which are sequential delays in diagnosis or treatment that can prolong the time needed for appropriate care, leading to other clinical issues. Having an expert clinician who can identify co-morbidities and promptly place the proper line the first time can significantly reduce patient complications, such as Deep Vein Thrombosis (DVT).

Vascular Access for Surgical Rehabilitation Patient

– Diagnosis and Treatment

Following the Vascular Wellness company culture of teamwork and collaboration, and leveraging the wealth of combined experience and knowledge of her fellow employees, she discussed her concerns internally with other Vascular Wellness clinicians.  With this additional input, she then consulted with the Licensed Independent Practitioner (LIP) caring for the patient and suggested a diagnostic ultrasound to rule out a possible Deep Vein Thrombosis (DVT) in the right arm. Additionally, she suggested that a midline was no longer preferred due to the risk of secondary DVT in the left arm if placed there.  The LIP requested an ultrasound-guided left arm peripheral intravenous line (PIV); however, this was not possible due to vein size and swelling previously identified by the clinician. Ultimately, the clinician recommended an Internal Jugular (IJ) central line. The Nurse Practitioner (NP), not familiar with Vascular Wellness’ expertise, expressed concern about the placement of the IJ catheter and requested time to speak with a colleague. After a brief period, the NP returned to the Vascular Wellness clinician and shared that the patient had already been diagnosed with an upper extremity DVT in the right arm. Recognizing the expertise available, the NP agreed to proceed with an IJ catheter, which would significantly reduce the risk of a secondary DVT, a serious complication. The Vascular Wellness clinician was then able to call the patient’s family and explain the situation while obtaining informed consent for the procedure. The insertion procedure and blood collection were performed without difficulty, allowing for rapid delivery of the prescribed therapy.

Vascular Access Specialists

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Key Points

As Vascular Access Specialists, our clinicians are trained and precepted in placing Ultrasound Guided PIV’s, Midlines, PICCs, and Small and Large bore lines, and in identifying contraindications and comorbidities from physical examination and medical history review to help recommend the most clinically appropriate line, which is evident in this NCIA case. Having a clinician that is able to pivot when a prescribed line can be downgraded or advanced means that your patient can receive prompt care in place, reducing patient complications, avoiding transportation costs, and allowing your medical team to focus on their field of practice. With the ability to place more vascular access devices (e.g., small bore internal juguler, mid-thigh femoral, and axillary central lines) than virtually any other vascular access company, Vascular Wellness can place the right line, as clinically indicated, at the right time, the first time, at the bedside enabling the partnering facility to avoid delay cascades of treatment, improve patient outcomes, and reduce costs.

Our Vascular Access Specialists are Vascular Access Board Certified (VA-BC) and semi-annually skill-verified to ensure we consistently operate at or above industry standards for patient safety, documentation, and evidence-based practices. We have a Director of Research and Development who is responsible for keeping our employees current on the most recent clinical practice guidelines for vascular access and helps continually improve and advance our vascular access services. We actively participate with AVA, INS, CDC, IDSA, Nursing License Boards, Hospital Boards, and The Joint Commission and are known as subject matter experts.

As a client partner, we are a seamless extension of your clinical and administrative teams. We deliver clinical expertise and administrative support, including credentialing, quality, and other reports as needed internally and externally, such as required by The Joint Commission. As a premier vascular access company, we provide services in this essential area of medicine and assist our clients in improving their patient safety, experience, and outcomes.

If you require Vascular Access or want to learn more, speak to the team at Vascular Wellness today.  For the latest articles and insights, follow us on LinkedIn, Facebook, Twitter, YouTube, and Instagram.

Vascular Wellness provides:
(1) Comprehensive vascular access services to North Carolina, South Carolina, and Virginia;
(2) Customized vascular access services to Tennessee, Georgia, and West Virginia; and
(3) Support vascular access services to Pennsylvania, Ohio, and Kentucky.