1. Meyer, Britt M. MSN, RN, CRNI(R), VA-BC, NE-BC
  2. Chopra, Vineet MD, MSc

Article Content

Inserting, securing, and maintaining vascular access is a fundamental component of patient care. Whether in the inpatient or ambulatory setting, the ability to infuse medications, obtain lab draws, and administer intravenous fluids in a timely fashion affects patient outcomes, length of stay, and satisfaction. In all of medicine, there may be no better example of a more ubiquitous requirement for safe and reliable care.

Britt M. Meyer, MSN,... - Click to enlarge in new windowBritt M. Meyer, MSN, RN, CRNI(R), VA-BC, NE-BC
Vineet Chopra, MD, M... - Click to enlarge in new windowVineet Chopra, MD, MSc

It comes as little surprise, then, that recent research related to complications associated with vascular access devices has led to substantial improvements in the science of vascular access.1-3 This revolution is due in large part to a national focus on reducing hospital-acquired complications in which devices such as peripheral venous catheters, central catheters, and peripherally inserted central catheters (PICCs) are often implicated. Historically, physicians with access to large patient populations and experience conducting research studies have generated much of this evidence. Though nursing research into device complications and efficacy of new products has gained significant momentum in recent years, much of the high-quality research for vascular access continues to be generated by physicians.


Nevertheless, translation of these research findings into practice is paradoxically dependent not only on the physicians who generate these data but also on nurses who deliver clinical care. After all, it is nurses at the bedside-in vascular access teams, infusion clinics, or home care settings-who are most often responsible for insertion, use, and care of vascular access devices. Knowledge regarding patterns of use, complications, and outcomes is of greatest value to these frontline clinicians.


This disconnect between those who generate the evidence and those who use it may fuel differing perspectives. In the field of vascular access, this problem may be more relevant as physician-researchers often ask questions that have value only within their particular specialty or area of interest. Often focusing on complications, physicians may not consider answering the clinical questions that nurses face every day. For example, which peripheral IV site or catheter is most likely to fail? What practices and medication doses are most effective for restoring patency to partially clotted PICCs? Are heparin flushes better than normal saline for maintaining patency? Which securement device or mechanism is most comfortable for patients and also less likely to present risk of infection? What is the relative risk of drawing blood from devices in relation to infection and occlusion? These questions are often not on a physician-scientist's radar, yet these issues occupy center stage in a nurse's daily routine.


Such dissonance creates several problems. First, opportunities to translate evidence into practice are often missed because the right questions may not be asked. Second, appreciation of the research and impact on practice becomes less certain. When questions do not reflect the values or problems of nursing, the answers-no matter how important-are less relevant. Finally, and perhaps most important, an unhealthy mistrust of the research generated by physicians may emerge.4 Such distrust is counterproductive for both parties: nurses do not have usable evidence to support best practices for daily work, while physicians generate data that are not applicable to patients at the point of care.


For example, Chopra and colleagues2 examined the risk of thrombosis with PICCs compared with central venous catheters. Their study found that PICCs are associated with a 2.5-fold greater risk of thrombosis, with a greater risk in critically ill and cancer patients. Similarly, Itkin and colleagues5 describe the influence of tapered vs nontapered catheters on the development of thrombosis. Although no difference between these 2 designs was noted, the overall rates of asymptomatic deep vein thromboses for both types of catheters were remarkably high. Translation of evidence from both of these studies into clinical practice depends not on these physician-scientists but on nurses' ability to articulate the researchers' motives, understand the relevant findings, and contextualize the implications to their practice. Nurses who place such devices may ask: Was the location of the PICC tips verified, and if so, how? Was an appropriately sized vein selected? What types of PICCs were used and in which patients? Does asymptomatic thrombosis associated with PICCs really matter when patients need venous access for critical medications? Without attention to these confounders, the ability to trust and translate research findings to practice is attenuated. Furthermore, because nurses often influence product selection decisions in their organizations through various committees, the ability to relate and articulate research findings is pivotal to inform decisions that ensure optimal evidence-based care.


To move the needle forward, we must create a better intersection between research evidence and clinical practice. Bedside and vascular access nurses, nurse-researchers, and physician-scientists must partner in a way that generates shared questions, promotes transparency of the research process, and generates mutually beneficial products. This intersection can be realized by focusing not on who conducts the research or why but by focusing on what's best for patient care-the common ingredient that unites all clinicians. Such a partnership will require several fundamental shifts. First, communication between nurses and researchers must take place before decisions about study questions are made. Physicians must work to understand and incorporate the views of nursing colleagues when it comes to vascular access research. Once physicians lead this charge to collaborate, nurses must embrace the relationship as trust begins with bidirectional sincerity aimed at helping both parties succeed and improve practice. Physicians who understand practice, nuances, and the clinical challenges nurses face will produce not only more valid research but also findings more likely to influence patient care.


Second, nurses must become active users of evidence-based medicine. By engaging with physician-researchers and champions, participating in hospital-based committees, and exchanging ideas in national meetings and scholarly settings, nurses must work to influence research and generate the evidence they want. These approaches should begin from the ground up, with educational activities, research journal clubs, and periodic assessments of the literature built in to the practice of vascular access professionals. Engagement should continue with invitations from nurses to physician-researchers to speak in local and national meetings, where earnest dialogue begins. Rather than merely inserting and caring for devices ordered by a provider, the nurse then becomes empowered in helping decide which device is appropriate for the patient early in the plan of care.


Finally, this collaboration should aim to create an atmosphere in which multidisciplinary approaches can flourish. Vascular access is by no means a solo sport. It is only when radiologists, hospitalists, and surgeons team up with advanced practitioners and bedside and infusion nurses that translatable findings that improve patient outcomes will be realized. The field of vascular access is fortunate to have a few examples of such champions, but many more are needed. Although such dialogue has started in national meetings, a local approach is needed since the majority of practicing vascular access and infusion nurses don't belong to such organizations. Because bedside nurses who care for these devices have little access to this specialty knowledge, a grassroots effort can help ensure a rising tide of evidence-based practitioners.


Innovation and efficiency are necessary if we are to keep up with changing reimbursement structures while continuing to provide the best vascular access and infusion care. Nurses and physicians acting in silos engender competition rather than cooperation. We must refocus our attention back on the needs of the patient and refrain from inserting devices on the basis of clinician comfort or convenience. To this end, research matters because it gives us insight into how we may improve patient care and outcomes from the lens of policy, practice, and safety. To generate research evidence that never makes its way into practice is, quite simply, a disservice to our patients. We can no longer afford the luxury of such inefficiency. It is time to move the needle forward in vascular access.




1. Barrier A, Williams DJ, Connelly M, Creech CB. Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J. 2012;31(5):519. [Context Link]


2. Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382(9889):311-325. [Context Link]


3. Evans R, Sharp J, Linford L, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):795-802. [Context Link]


4. Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs. 2004;13(8):913-924. [Context Link]


5. Itkin M, Mondshein JI, Stavropoulos SW, Shlansky-Goldberg RD, Soulen MC, Trerotola SO. Peripherally inserted central catheter thrombosis-reverse tapered versus nontapered catheters: a randomized controlled study. J Vascular Intervent Radiol. 2014;25(1):85-91. [Context Link]