TITLE: Optimizing the Vascular Access Specialty Team Throughput with Lean Methodology: One Needlestick Every time using the ONE VAST Bundle

PROJECT LEADS: Vascular Access Support Team Members: Michele Nomura, MSN, RN, VA-BC, CNRN; Riza Magat, MS, BSN, RN, VA-BC; Felix Piamonte, MS, BSN, RN, VA-BC

EXECUTIVE SPONSORS: Lynne Tom, MSN, BSN, RN (Unit Director, VAST), Elizabeth Sin, MS, BSN, RN (Patient Care Director) 

 ABSTRACT:

Peripheral intravenous catheter (PIVC) insertion is the most common invasive procedure a hospitalized patient will experience. Data shows that 350 million PIVCs are sold in the United States, and 37 million hospital admissions occur annually. The numbers indicate an average usage of 10 PIVCs per patient admission, indicating a high failure, low success rate, and excess cost. Recognizing that IV access is vital to the administration and delivery of treatment, the leadership must consider efforts to establish timely access as a strategy for hospital cost reduction and patient safety.

In FY2022, the Vascular Access Specialty Team (VAST), received 5,640 requests for ultrasound guided peripheral intravenous catheters (USGPIVs) and was able to assist with 2,192 requests. The number of requests received exceeded the number of placements. The team's mandate is to support patient flow by prioritizing peripherally inserted central cathters (PICCs) and midlines (ML) for discharge, TPN, and chemotherapy. USGPIV insertion support is contingent on the team's availability and timing which leads to variability in PIVC insertion practices, multiple insertion attempts, delays in care, escalation of inappropriate PICC and ML orders, and dissatisfaction from clinicians and patients. 

The proposal aims to support UCSF Health True North Pillars of creating an exceptional patient experience, optimal work environment, improving clinical outcomes, and supporting solid financial performance and learning health system. The proposal will utilize the Lean methodology to define, measure, analyze, improve, and control processes of the PIVC insertion practices at UCSF Parnassus. The systematic approach will improve throughput by eliminating variations in practice while identifying areas of waste that will lead to increased efficiency and cost reduction. The Lean method led the team to create a bundle named ONE VAST.  

TEAM 

Adult Vascular Access Specialty Team at UCSF Parnassus Campus

PROBLEM

PIVC failures cost the health care system millions of dollars in waste, redundancy, and inefficiency. PIVC failures lead to multiple insertion attempts, wasted nursing and other clinician time, wasted supplies and inefficient care delivery. Multiple PIVC replacements contribute to patient pain, distress and dissatisfaction with care, interruptions and delays in treatment, increased burden to nursing and medical workload.

The team comprises of eight vascular access nurses with advanced training, experience, procedural competency and proficiency assuring 99% first stick success rate. The group supports the organization's need to facilitate patient flow by prioritizing PICC and ML insertions for discharge, chemotherapy, and total parenteral nutrition (TPN). VAST hours of operation are from 0700 hours until 1930 hours, seven days a week. USGPIV insertion is contingent on the team's availability. As a result, several clinician groups including bedside nurses, advanced practice providers and medical doctors are attempting to establish a PIVC, and there are an excessive number of patients requiring more than two attempts or inappropriate escalation of requests to PICC and ML catheters due to failure to establish a PIVC. The team conducts on average 45-minute thorough chart review for all venous access insertion orders, course corrections and recommendations based on clinical indication, duration of treatment, and appropriateness. In 2022, the team corrected 840 orders that may have led to a potential reduction and avoidance of central line days and other PICC and ML complications such as central line-associated bloodstream infection (CLABSI) and venous thromboembolism (VTE). Furthermore, the response time to a PIVC request is variable and can take up to an average 6 hours of wait time. A decentralized approach to insertion and maintenance increases the risk for vein injury, vein depletion, infection and other preventable PIVC complications such as occlusion, phlebitis, and infiltration. The proposal aims to identify the PIVC dwell time and related complications, catheter discontinuation, or catheter failure. Furthermore, the proposal aims to examine the value of a VAST centralized model for PIVC insertion and maintenance, promoting system efficiency, and avoiding procedure redundancy and practice variations. The proposal aims to explore the cost avoidance or aversion as a result of inserting a PIVC instead of PICC or ML. 

Apart from the economic impacts of a PIV team, the proposal aims to support bedside clinicians from developing the "second victim" phenomenon where clinicians feel personally responsible for the failed PIVC attempts and second-guess their clinical skills and knowledge base. In an era, where short staffing and patients require the most complex care, the proposal has the potential of saving nursing hours that can be utilized for clinical tasks other than PIVC insertion. Moreover, patient satisfaction with care received may suffer due to losing trust in the clinician's ability to establish venous access. The proposal aims to examine the difference in patient experience and satisfaction with PIVC insertion with VAST and bedside clinician. 

TARGET:

The goal is to perform one needle stick every time when establishing a peripheral venous access for all admitted intervention group patients at UCSF Parnassus by implementing the ONE VAST bundle. By doing so, we aim to:

• increase patient satisfaction through timely PIVC placements from VAST with 99% first stick success rate. 
• relieve bedside clinician's burden of establishing a PIVC.  
• proactively assess and anticipate current and future PIVC needs for the inpatient.
• reduce the request response time from six hours to one hour or less.
• promote inpatient throughput by reducing delays in administering treatment and diagnostic tests requiring a PIVC.
• promote cost savings by mindful use of supplies and VAST. 
• reduce inappropriate and premature ordering of PICC and ML catheters for failure to establish a PIVC by 10%.
• advocate for each patient the most appropriate vascular access device based on the treatment plan (i.e., vesicant infusion, duration, and vasculature considerations).

GAPS:

UCSF Parnassus currently has a VAST team which is composed of eight vascular access nurses with advanced training, experience, procedural competency, and proficiency, assuring a 99% first-stick success rate, supporting the organization’s need to facilitate patient flow by prioritizing PICC and ML insertions for discharge, chemotherapy, and TPN. PIVC support is contingent on the team's availability rendering multiple failed attempts by bedside clinicians in establishing a venous access. Current workflow results in variations in practice, delays in therapy and treatment, inefficient use of resources, and supply waste. The current method of documenting PIVC attempts, successes, failures, and consultations must be more consistent. Additionally, the existing workflow relies on the accuracy of the clinician to text the patient identifier information (i.e., patient name and bed number) to VAST via Voalte, which is sometimes inaccurate or missing information. VAST then manually adds the patient to a team share folder within APeX to identify which patients are awaiting USGPIV placement. This leads to inefficient use of time texting multiple clinicians on the same patient. The current design to support bedside clinicians who failed to establish venous access is reactive instead of proactive, which makes PIVC requests unpredictable and challenging for VAST to meet all demands, particularly towards the end of the day. Limited to no time is allotted to learning opportunities about the value and harms associated with various vascular access devices. For instance, in January 2022, the VAST course corrected 30 inappropriate PICC and ML orders by placing USGPIVs. Most of these orders were prematurely escalated due to the failure to establish a PIVC before seeking a VAST consultation. VAST course corrections have substantial quality and safety implications for CLABSI and VTE prevention. It is essential to note that significant savings and harm reductions are achieved by avoiding inappropriate use of PICC and ML.

It is important to note that multiple reasons affect the VAST team's current workflow for PIVC placement. The reasons are but not limited to:

• The team is not designed as an elective service and procedure requests or orders cannot be pre-scheduled and can come throughout the day.
• Requests and orders are reactive, depending on when a need for VAD is identified.
• Dependent on patient availability and consent to the procedure.
• Dependent on when the provider writes the order.

In particular, the PIVC requests are most unpredictable when they get to the VAST team, affecting our ability to respond promptly and effectively. The initiative aims to improve workflow and efficiencies within the VAST team, identify and utilize areas of opportunity to proactively assess the functionality of the current PIVC, or intervene if a new PIVC is needed. Creating predictability within the VAST workflow by influencing when a PIVC need will be achieved by early daily rounding and assessment of PIVC functionality. Furthermore, early assessment can also lead to early identification of a need for an alternative device like a ML or a PICC.

INTERVENTION:

The proposal will utilize the Lean Method and will define, measure, analyze, improve, and control work processes using the ONE VAST care bundle. The method originated with the Toyota's Production system with focus on delivering value as defined by the consumer, eliminating waste, reducing costs, and continuous process improvement. The team will identify a medical-surgical unit to conduct a small test of change for three to six months based on the following steps:

1. The first step is to define the goal of one needle stick when establishing peripheral venous access for all admitted intervention group patients at UCSF Parnassus.
2. The second step is to review the short PIVC consumption for FY 2022. VAST will collect the data from yearly supply chain records. Identifying PIVC usage is a challenge to extract from the electronic health record (EHR) due to inconsistent or lack of accurate charting of PIVC attempts by clinicians. Current PIVC consumption will be measured and identified from the test unit.
3. The third step is to analyze the annual PIVC consumption against the UCSF Parnassus patient admission to establish the total and average PIVC use per patient admission. The action will identify the supply and labor costs utilized for PIVC insertion. Supply includes PIVC, IV start kit, and normal saline flush. VAST supply cost is similar to bedside clinicians with the addition of the ultrasound (US) gel. Data shows that the VAST time allotted for PIVC insertion is 20 minutes. The step will also identify the bedside clinician hours savings. VAST will analyze the current average PIVC usage from the test unit.
4. The fourth step is to improve and control workflow by implementing the ONE VAST PIVC care bundle. See Table 1.

A.             ONE- One Needlestick Everytime is the goal to minimize waste and costs and promote patient satisfaction with PIVC care.

B.             Vein means inserting the right and the most appropriate venous access device at the right time for the right clinical indication and not due to failure to establish a PIVC. Vein preservation means always using the ultrasound machine for assessment, using optimal vein and catheter selection, and avoidance of areas of flexion and joints and the hands.

C.             Advanced Assessment and Accurate Review mean a VAST RN will proactively round on all patients in areas identified for small tests of change. VAST will document daily assessment of current PIVC (catheter function through NS flushing or documentation of line in use or infusing, site assessment, dressing adherence, and patient satisfaction) on the PIVC assessment flowsheet and a VAST data collection tool. PIV VAST RN will enter a new PIVC consult and insert the device if the need is identified during rounding. PIVC is maintained by the VAST until no longer clinically indicated.

D.             Specialty and Supplies mean utilizing experienced and proficient VAST RNs trained in USGPIV assessment and placement. Supplies are standardized for insertion, securement, and dressing to minimize supply waste. Of note, PIVC will be of polyurethane material only.

E.             Technology and Transformative Training mean utilizing the US on all PIVC insertions avoids "blind sticks." It provides real-time guidance in placing a cannula into a peripheral vein under the direct vision of the machine. The US allows real-time assessment of the quality of the vein, therefore, aids the VAST RNs' decision-making in providing the most appropriate PIVC (gauge, length, and depth) that the vein can safely accommodate. Technology means utilizing the EHR to streamline work processes and improve efficiency. Transformative training means that the VAST team will continue to provide learning opportunities for bedside clinicians and learners on USGPIV and the fundamentals of PIVC insertions, care, and maintenance.

Proposal Workflow: See Table 2.

1. Build a VAST PIV consult in the EHR. RN, MD, and other APP to document the number of failed insertion attempts or enter the reason for not attempting, i.e., difficult intravenous access (DIVA), deep vein thrombosis (DVT), arteriovenous fistula/graft (AVF/AVG), obesity.
2. Consult will appear on the VAST workflow.  
3. Triage PIV consults according to the urgency of the request.
4. Start PIVC according to the care bundle.
5. Enter requests into the VAST data collection tool, i.e., vein selection, location, number of insertion attempts, date of insertion, catheter type, size, and length, type of inserter, visual aids, procedure satisfaction scale, date, and reason for PIVC removal.
6. Modify the existing PICC Navigator flowsheet to capture PIV activity in the VAST detail summary report.
7. Build a report to capture 1, 5, and 6.
8. Identify nursing units to implement a small test of change: At this time, approval from 10CVT leadership has been established.
9. VAST RN will proactively round on all intervention group patients in areas identified for small tests of change (daily assessment of current PIVC function through normal saline flushing or infusion, site assessment, dressing adherence) in place will be documented on the PIV assessment flowsheet and VAST data collection tool. PIV VAST RN will enter a new PIV consult if VAST identifies the need to insert a new PIVC during rounding.
10. PIV VAST RN will be responsible for the daily rounding and insertion of new PIVC requests or recommend alternate lines such as ML or PICC per clinical indication.
11. PIV VAST RN will be responsible for doing a chart review for the control group to include LDA assessment and documentation, dwell time, reason, date, and time of removal. 

PROPOSED EHR MODIFICATIONS: See Informatic PPT attachment.

Our existing EHR system will be modified to capture PIVC consult and insertion requests. Currently, PIVC requests are texted or called through Voalte. The team already uses the "Adult-Inpatient PICC and/or ML" consult and insertion order sets. The same system can be created for PIVC requests for better data collection and efficient workflow. The proposed modification will reduce unnecessary phone calls, inaccurate patient identifiers, and duplicate texting between VAST and bedside clinicians. The current APeX PIV Data Collection Report will capture data points relevant to PIVC insertion location, vein used, complications, catheter failure or removal causes, and dwell time.

COST: 

The team estimated that the proposed cost would be spent on VAST RNs' time to implement the small tests of change and materials such as posters, flyers, and quick reference cards for the ONE VAST bundle. Leveraging the VAST expertise on PIVC management and care and the use of US technology is standard work for the team. Still, process improvements need to happen regarding EHR modifications to track and capture sources of waste and inefficiencies accurately. Simplifying supplies and work processes and standardizing VAST workflow will allow a comprehensive examination and assessment whether additional FTEs will be required in order to sustain a dedicated PIVC team if implemented throughout UCSF Parnassus.

For FY 2022, UCSF Parnassus admitted 27,332 patients and used 86,020 PIVCs, which gave an average of 3.14 catheters used per patient visit. Bedside clinicians' standard work time of 20 minutes is dedicated to PIVC insertion, meaning that 28,673 bedside clinician hours were utilized annually. The average hourly rate of a bedside nurse is $98, therefore labor costs for a 20-minute PIVC insertion procedure is $32.67. The supply cost per PIVC insertion is calculated at $5, which includes the PIV catheter, PIV start kit, and NS. The total cost for a PIVC insertion, including labor and supply costs, is $37.67. The VAST USGPIV model has a 99% first-stick success rate. Applying the same numbers of PIVC consumption to the first-time insertion success illustrates the value of a VAST-led dedicated PIV team. 

Published evidence reports that the average cost of short PIVC insertion is $28 -35 for a straightforward first stick. Patients with PIVC failure have prolonged and more expensive hospitalizations averaging two additional hospital days at over $3,000. The failure of one PIVC initiates a damaging and costly cycle of catheter removal and reinsertion at $69. Accidental dislodgement is reported to be more than $266 million annually. PIVC failure rates and complication incidence are as high as 53%, or approximately 1 in 2 catheters fail to make it to 5 days or the end of treatment. The proposal aims to identify the PIVC dwell time and related complications, catheter discontinuation, or catheter failure. 

Given that VAST hours of operation only cover 12 hours in 24 hours, the proposal adjusted the cost savings to reflect a conservative distribution of 50%, assuming this is the percentage that happens between the two shifts. Anecdotally, the majority of patient admissions, diagnostic procedures and care activities requiring a PIVC happen during the day shift. Intravenous medications are more frequently administered during the day shift than night shift. Many PIVC requests overflow from the night shift to the VAST team. The VAST productivity only reflects output produced during the day shift. The proposal aims to examine the economic impacts of the VAST model of care by measuring the nursing hours savings and cost savings. Additionally, an assumption of 10% of the overall catheter usage happens in 10CVT. See Table 3.

Economic Impacts of PIV Team Proposal comparing the Bedside Clinician vs. VAST Model 

• Annual Time Savings  = 14,304 - 4,555 = 9,749 nursing/other clinician hours
• Annual Cost Savings  = $1,616,457 - $514,798 = $1,101,659

Bedside Group on a 12 hour Day Shift (Annualized: *27,332 admits and 86,020 catheter usage for FY22)

• Calculation Based on a 12-hour day shift                                                                      (10%)
• Admits in 12 hours day shift                                      13,666                                    (1,367)
• Insertion Attempts                                                      3.14                                        (3.14)
• Total PIVC Usage at 3.14 attempts                            42,911                                    (4,291)
• Total bedside hours used for PIVC                            14,304                                    (1,430)
• Labor Cost per RN, attempt at 20 minutes                $32.67                                     ($32.67)
•  
• IV Costs: 
• Labor cost (42,911 X  $32.67)                                   $1,401,902.37                       ($140,190.23)
• Supply cost (42,911 X  $5.00 )                                  $214,555.00                           ($21,455.60)
• Total                                                                           $1,616,457.37                       ($161,645.74)

 VAST Intervention Group on a 12 hour Day Shift (Annualized: *27,332 admits and 86,020 catheter usage for FY22) 

• Calculation Based on a 12-hour day shift                                                                      (10%)
• Admits in 12-hour day shift                                        13,666                                    (1,367)
• Insertion Attempts x1                                                1                                              (1)
• Total PIVC Usage at one attempt                              13,666                                    (1,367)
• Total VAST RN hours used for PIVC                         4,555.33                                  (456)
• Labor Cost per VAST RN attempt at 20 minutes       $ 32.67                                    ($32.67)
•  
• IV Costs:
• Labor cost for a (13,666 X  $32.67)                           $446,468.22                           ($44,646)
• Product cost in (13,666  X  $5.00)                             $68,330.00                             ($6,833)
• Total (Cost of Intervention)                                        $514,798.22                           ($51,479.82) 

In FY2022, the VAST team corrected 840 orders that may have led to a potential reduction and avoidance of central line days and other PICC and ML complications such as CLABSI and VTE. For instance, in January 2022, the VAST course corrected 30 inappropriate PICC and ML orders by placing USGPIVs. VAST course corrections have substantial quality and safety implications for CLABSI and VTE prevention. Significant savings and harm reduction may be realized by avoiding the inappropriate use of PICCs and ML. According to AHRQ, management and care of each CLABSI case can cost up to $48,000, and each PICC and ML-associated DVT is $16,000. Assuming that one or all 30 course corrections resulted in these complications, cost avoidance ranges from $48,000 up to $1.4 million and $16,000 up to $480,000 respectively. The course corrections of inappropriate PICC and ML orders have significant savings in supply and labor costs.

 SUSTAINABILITY: 

The VAST team is a unique and highly specialized group with a shared desire to improve patient outcomes. As this proposal outlines, the current decentralized approach and VAST team's "insertion when available only” lead to variations in practice, wastes, and increased costs, affecting patient satisfaction with care. Once the economic impacts of a VAST PIVC model are proven with small tests of change, the proposal can be replicated throughout the hospital. Hardwiring the new work process will be sustained through the EHR modifications and in partnership with nursing and provider educators about PIVC management, care, and maintenance. The engaged executive leadership can help facilitate the spread of the proposal and support with addressing potential barriers to facilitations.

BUDGET: 

• Apex modifications: $10,000
• Material costs (photocopies, badge buddies, posters, info flyers, binders): $1,000
• Salary for project implementers (VAST Team): $36,225
• Breakfast/lunch incentives for test units: $1,000
• TOTAL Budget: $48,225

SUPPORTING DOCUMENTS: See attached PDF file and PPT.