Because vascular access for infusion therapy is the most common invasive experience of all hospitalized patients, the emphasis on vessel health and preservation is of utmost importance. Timely planning for vascular access affords each patient the basic right to minimized risk and maximized optimal outcomes in the short and long term.

Reducing risk and unnecessary harm in the hospital environment begins with assessment of the patient's condition, history and relative vessel health. Matching the patient's current state of health with the need for intravenous access prevents unnecessary IV restarts, reduces medication delays and provides for optimal outcomes. The recommendations presented here are from the Joint Commission (TJC), National Patient Safety Goals (NPSG) and The Society for Healthcare Epidemiology of America (SHEA) strategies.

The Vessel Health and Preservation Protocol provides the steps to ensure timely, reliable access from any portal of hospital entry using the device most specific to the patient's medical condition that helps preserve vessel health.

There are three main types of CVC devices: Nontunneled, tunneled and implanted ports. Each of these devices has an intended purpose and should be used according to the manufacturer's instructions for use and in accordance with national standards of practice or guidelines (INS or CDC).

Selection of the most appropriate device for a specific patient is aided using the Vessel Health and Preservation Right Line Tool. The Right Line Tool reviews the diagnoses/conditions that apply to the patient and guides you through a series of decisions that lead to the most appropriate device. If more than one device is suggested, you should choose the device that allows for the safest delivery of all prescribed medications. The protocol then guides you through the Right Patient Tool to determine if the patient has risk factors, complications or a medical history that contraindicates use of the indicated line (10)*.

For example, patients in critical condition need a device with multiple access ports to allow high flow gravity infusions such as a triple lumen (and perhaps antimicrobial) CVC. Patients undergoing dialysis need to preserve vasculature for long term access and should not receive a peripherally inserted central catheter (PICC). While a PICC may be indicated based on the Right Line Tool, the Right Patient Tool provides a more in-depth patient analysis and indicates the best initial device to be a dual dialysis catheter with an additional CVC infusion port, or a traditional dialysis catheter (10)*.

In situations where a patient requires parenteral nutrition, a device enabling maximum dilution of the intravenous nutrition is necessary. If nutrition is required for only a few days and a PICC is contraindicated, a centrally inserted CVC is acceptable. Patients with chronic nutritional needs require an implanted port. Some acute patients who require irritating medications or prolonged infusion therapy may also benefit from use of a central venous access device (10)*.

* 10. Moureau N, Trick N. Driving clinical practice to the next level: a collaborative project on vessel health and preservation. Accepted and presented at Association of Vascular Access 24th Annual Scientific Meeting, National Harbor MD, September 24-26, 2010.

Aseptic placement and daily assessment of the device are just as important to patient safety as device selection. The Institute for Healthcare Improvement (IHI) has established a care bundle (grouping of best practices) to be followed when inserting and maintaining central venous catheters (7)*.

These include:

• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Optimal catheter site selection
• Daily review of line necessity

A detailed description of this bundle is provided in the next section of this manual.

* 7. Implement the central line bundle. Available at: IHI Website. Accessibility verified April 7, 2011.