Chapter 1
Establishing (and Maintaining) a Venous Access Service
A more appropriate title of this chapter might have been Maintaining (and Establishing) a Venous Access Service. Obviously, this appears backwards: One must have a catheter service before one can maintain it, but the implication is that one must make a major commitment to provide the necessary services before attempts are made at starting a venous access service. The establishment of a successful venous access service resembles the establishment of a surgical practice more than it does that of a radiology practice. A catheter service is not simply a venous access placement service (hence we chose not to title this book Placement of Venous Catheters: A Practical Manual). The key term is service. Service must be provided before, during, and after placement of catheters. The service requires expertise, especially for such a critical procedure that is so important for the long-term care of the patient. Therefore, the experts should perform these procedures. Whoever plans to perform them must have the desire and commitment to become an expert. This is not to say that one must place catheters and care for these patients all the time as a full-time job. The commitment must be made to learn as much as possible about the subject, however, and then one must be ready to be involved at all times and in all facets— before, during, and after the procedure.
To establish a good catheter service, one must provide the following:
• Expert consultation
• Clinical responsibility
• Technical proficiency
• Consistency of service
We know from personal experience the difficulties of acquiring this expertise. Information on these subjects either is scattered in numerous articles or absent. A great deal must be learned by trial and error. Nonetheless, this book will allow the reader to benefit from the experience of persons who have had active, successful services. We have attempted to explain and provide expert advice for every step of this process: consultation, placement, care of the catheter, and its removal. We hope this book will assist the reader in becoming the catheter expert.
THE EXPERT CONSULTANT
Because of the wealth of information and therapeutic options and the focused training of specialists, it now has become imperative for physicians to rely on the expertise of others. Referring physicians must place the responsibility for their patients having a functioning, well-maintained venous catheter on members of the vascular access service, either surgeons or interventional radiologists, who must be the “expert,” not merely a technician who places a catheter whenever requested. The referring physicians are not aware of the different catheter options and need advice about the best option for a given patient. Therefore, the catheter expert must be familiar with the various options, their properties, flow rates, indications for use, cost, and so on. It is essential that the catheter expert not become trapped in a routine of placing the same catheters in all patients simply because of familiarity with a particular catheter. It is a disservice if the optimal catheter is not placed in a particular circumstance warranting its use. Catheter placement procedures are very important to patients; therefore, placement must be done correctly the first time it is attempted. Close communication with the referring physician is critical, both before and after procedures. Numerous questions must be answered before deciding on the best catheter and the best approach for a particular patient: What is the patient’s history? Why is a catheter needed? What will it be used for? How long will it be needed? Has the patient had other procedures that might influence the choice of venous access sites (e.g., a mastectomy and axillary lymph node dissection)? Has the patient had central catheters in the past? If so, were any problems associated with the previous catheter? Only after acquiring this information from the patient, along with the patient’s medical records (if available), and discussing the case with the referring physician, can the decision be made about which catheter to place and where and how to place it.
CLINICAL RESPONSIBILITY
The referring physician sends the patient to the venous access service because of the expertise this service offers and does not expect to be contacted to make decisions concerning the catheters. Obviously, if a complication occurs or if the plans change (e.g., there are venous occlusions and an alternative route of access must be used), the referring physician must be kept informed. The purpose of these calls is to inform the physician of the game plan, not to consult about what should be done. If a complication occurs or if a patient requires prolonged observation after the procedure, the venous access service should offer to admit the patient to the service. If a case is especially complex (because of multiorgan failure) and the radiologist is not comfortable with assuming responsibility for the general care of the patient, the patient can be admitted to the venous access service, with the referring physician assuming the complex medical care as a consultant. Alternatively, referring physicians can admit patients to their service. In either case, the venous access service must closely monitor all aspects of catheter care. It is not acceptable for the service to insert catheters and then expect the referring physician to do the rest. Furthermore, the referring physician usually prefers not to fill this role. The catheter service must stand by, ready to provide emergency coverage for any catheter problems, such as infection, hematoma, vein thrombosis, hemorrhage, and to remove the catheter when necessary.
Inpatients who have had a venous catheter placed should be followed up regularly by the venous access service while in the hospital, and a brief progress note should be written daily (at least for the first week after placement). The admitting service greatly appreciates these efforts. These visits should monitor for complications, check wound healing, and ensure that the catheter is maintained in a secure position and functioning adequately. All aspects of catheter care must be done by the catheter service (e.g., orders for flushing, dressing changes). It is important for the catheter service to talk with the nurses and inquire about catheter function and any problems. As soon as problems arise, suggestions must be made to handle them. The catheter service must be the experts on dealing with complications and must be available at all times. Patients who are in the hospital for an extended time need not be seen every day but can be seen once or twice a week after the first week or so if the catheter is working well. A general rule is that a note always must be written on the chart. If a patient is seen three times a day, then three notes should be written. The referring physicians must know that the service was concerned enough to follow up often with the patient.
After the patient’s discharge, the service must try to maintain contact with the patient, for example, by asking the patient to stop in for a brief office visit whenever he or she is in the facility for visits to the referring physician or for other therapies. These visits need last only a few minutes—to ask the patient whether the catheter is working well and to check the skin site. Suture removal also can be done at the appropriate time; otherwise, the referring physician can be asked to contact the catheter service if any problems arise with a catheter in any patient. If the referring physician’s office is nearby, a member of the catheter service might go there while the patient is in the office. A good way to maintain contact with patients is to give the patient a business card when the catheter is placed. The patient should be given instructions on how to contact a member of the venous access service 24 hours a day. In this case, one must expect to receive and answer direct phone calls from patients with questions and concerns. The main objective should be close follow-up of patients and to be aware of complications or problems as soon as they develop. This is the only way to perform adequate quality control. By no means should the referring physician consult a second service to deal with problems arising from a catheter placed by the initial service. Likewise, the catheter service should not be consulted to deal with problems with catheters placed by other services. If this does occur, the catheter service should contact the initial service to inform them of the problems.
TECHNICAL PROFICIENCY
Obtaining the technical skills to place venous catheters is the easiest aspect of initiating a vascular access service. Literature about the techniques and methods of catheter placement abounds. Every effort must be made to learn these techniques fully. Difficulties arise when procedures do not go as planned. Solutions to many problems must be learned as one goes along because individual situations can be unique, and it is impossible to anticipate (and report) every possible scenario. We attempt to include most of the commonly encountered situations and how to resolve them. Special circumstances may not be dealt with in the literature, and the catheter service physician’s problem-solving abilities and creativity can make all the difference. To maintain the highest level of expertise, continuing education of the entire team, including radiologists, technologists, physician’s assistants, and nurses, is essential. Attendance and active participation at society meetings, “angio club” meetings, refresher courses, and tutorials are important and ongoing. New information is always appearing that may benefit physicians and their patients. It is also important to maintain communications with colleagues, both within one’s specialty and in other specialties. Frequent discussions on subjects such as “What would you do in this circumstance?” are important sources of information.
CONSISTENCY OF SERVICE
First-class service must be provided 24 hours a day, 365 days a year. This is usually not a problem in large medical centers with several well-trained persons on staff; however, smaller practices may find it difficult to provide such around-the-clock service. Smaller groups typically have a single person who is trained to place and care for central venous catheters. Obviously, that single person cannot be available at all times to provide the necessary service. The following are suggestions on how smaller groups can provide consistently good catheter service.
• Most evening calls can be delayed until the next morning, when the catheter service physician is available. If a catheter suddenly stops working and a treatment must be given, an intravenous catheter can be started and the treatment given.
• Situations that are deemed urgent by a referring physician necessitate a call to the catheter service physician. Frequently, these problems can be handled over the phone or at least stabilized adequately until the next day.
• Educating emergency room physicians in the basics of venous catheter care can help to eliminate some calls.
• When the vascular access service physician is off or away from work, patients must be scheduled accordingly, with no elective procedures scheduled on that day. If an emergency procedure arises and there is no adequate backup within the group, the patient should be referred to another hospital or another service in the same hospital. Arrangements for another service (whether it be surgical or radiologic coverage) to provide backup for urgent procedures should be made in advance. The covering service must be one that can be trusted to provide excellent service.
• Many questions can be answered by other members of the team, provided they are well educated in catheter care. If another physician in one’s group is interested in helping with the catheter service, this could be an answer to the problem; however, if this person has no formal training in the field, it is imperative that this person obtain the necessary training. This can be done by attending tutorials, conferences, and such; but, most importantly, the catheter expert must work with this person as much as possible.
