Season 1, Episode 2 Transcript
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From the Association for Vascular Access, this is the ISAVE That Podcast.
Ramzy: And it’s Episode 2, Season 1 of the ISAVE That Podcast from the Association for Vascular Access. In Indianapolis, this is Ramzy Nasrallah, joined by JAVA Editor-In-Chief and Director of Communications for AVA, Eric Seger…
Eric: Hi, there!
Ramzy: …the Director of Clinical Education, Ms. Judy Thompson…
Judy: Hey, there!
Ramzy: …and AVA President-Elect, Dr. Ken Symington.
Ken: Good day, Ramzy! How are you?
Ramzy: It’s a great day.
Eric: It’s great that we were renewed for another episode.
Ramzy: I know. The big network bosses to renew AVA for a whole first season. So, you’ll be hearing us all summer, through WoCoVA and heading into our scientific meeting in Columbus, Ohio, in September. And we are all in Indianapolis right now as part of our annual Board of Directors retreat that AVA conducts each year to discuss association business initiatives, and a lot of the work that has to go into our biggest event of the year, the annual scientific meeting. But this year we had a couple of big initiatives that were on the radar and discussed. We’re going to spend a little time talking about them. Later in the show we’ll have Dr. Hudson Garrett on to talk about the second one, which is guidance around ultrasound probes. The first one, which was mentioned conspicuously at last year’s scientific meeting in Phoenix – the CVAD Guidelines, presented by AVA. Judy, where are we at with the CVAD Guidelines?
Judy: Oh, gosh. We are busy in the CVAD Guidelines. We had hoped to have them published actually by this time, but we are going to have the best quality we can get out and we have a couple chapters left to be written. So, we still have a couple authors that are writing their sections. Eighty-five percent of the sections are written and ready for peer review. We have a few more and as soon as we get those in we’ll a first round edit and they’ll be going to peer review.
Ramzy: What’s a chapter that’s been written/reviewed that you’re especially proud of this far into the process?
Judy: Complications Management. Actually, my friend Ken Symington was the lead author on that section. It’s exceptional. It is.
Ken: Thank you. I think to our credit or depending on how you look at it, our discredit, we just keep making this thing bigger and bigger, and longer and longer, and of better quality. So, we’ve gotta stop someplace and we’re drawing the line in 2018. That’s it.
Ramzy: And there’s always the opportunity for revision and expansion. How big is this instrument for Vascular Access going to be? How many pages? Is it going to be a book? How is it going to be delivered to the Vascular Access Specialist?
Judy: There will be an option to buy a physical copy of it. But by and large, the strong push on this is digital, because with a digital copy we can make small updates incrementally when a big research article comes out and maybe guides practice a little differently. We can go change that guideline and we can push that out digitally. We will review this document probably every three years and have it published with a new revision number on it. But I think the digital copy should be the way to go. Besides, we’re going to have high-def videos in, some really strong photography in, illustrations, animations … so you won’t get those in the paper copy. I really encourage people to go digital.
Ken: It’s everything you would expect out of a modern, digital learning center. We’re really excited about it. We’re learning a lot as we go on ourselves and we couldn’t be more excited to see the finish line actually in the near future.
Eric: Light at the end of the tunnel?
Judy: There’s a light! I can see it. A couple of the other sections that we actually added: We had to add a section on intraosseous. Because one of the tenants that we’re talking about is requiring ultrasound for every central venous access insertion. So, by requiring that, even if it’s emergent, and you cannot get immediate access – meaning within the first couple of minutes – we say forget the central line, go IO. So, we had to have a section for IO.
Ken: And that’s a great Segway into the topic of this particular interview is going to be with Hudson Garrett and you. Disinfection.
Ramzy: That’s right. Sprouts sprout out of other sprouts. On our first episode, the inaugural episode, you talked about how high-level disinfection of ultrasound probes had suddenly appeared on your radar. We had not been talking about it but had this pressing urgency to get guidance out from AVA on how exactly ultrasound probe disinfection should be handled. We’ll be talking to Hudson shortly, but could you talk about briefly before we get to that discussion to what went into the document, how did that conversation start? Where did it come from?
Judy: Conversation started through social media surprisingly enough. My good friend Chellie DeVries posted a draft of a guideline from another society. And that draft recommended high-level disinfection between patients for all ultrasound-guided procedures, regardless if you put a sheath on it. And that posed some huge problems for the people in our community. So, we had to address it.
Ramzy: The deterrent for how cumbersome high-level disinfection would be versus the risk associated with perhaps low-level disinfection and that’s something you ended up doing a full literature search, exhaustive amount of discussion with Hudson, with Ken, with others.
Judy: Other Infection Preventionists – Frank Myers in San Diego, Kim Dellahonte, Chellie DeVries, other Vascular Access Specialists. So, we got down to the key players and the people that do this for a living. It’s not an ivory tower document. It’s actually something that can be used and operationalized and won’t stop your formal practice.
Ramzy: I can attest to that having seen the document and looked at it. You’ve got a very strong consensus voice from a variety of different stakeholders with not only what their recommendation is, but why it was made.
Ramzy: It’s a real world, practical recommendation. Looking forward to talking more about that. So, after the break, we’ll have Dr. Garrett on to talk to Judy and Ken. But first, a word from our episode sponsor.
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Ramzy: And we are joined now by Dr. Hudson Garrett Jr., an infectious disease expert and the President for the Board of Directors for the Vascular Access Certification Corporation. How are you, Hudson?
Hudson: I’m good, how are you Ramzy?
Ramzy: I’m good. I’ve got Judy Thompson and Dr. Ken Symington here. I’m going to pass the control chair to them and you guys are going to discuss high-level disinfection.
Judy: Hi, Hudson!
Ken: Hey, Hudson! Ken here. Nice to speak with you.
Ken: We’re going to have a really lively discussion, I hope, on the use of the ultrasound transducer in Vascular Access. Because there’s some concern with the risk of infection from the use of ultrasound probes and what level of disinfection is necessary to prevent transmission. Judy, I’m going to throw this out to you first of all. I’ve heard a lot of rumors regarding the guidelines for ultrasound probe disinfection. And I don’t really understand – what’s the 411 on those?
Judy: The 411 on those? The information on it? Chellie DeVries, good friend of ours, put a draft version of a guideline out for review saying, ‘Hey, folks, this is out there!’ In that draft version, it recommended high-level disinfection for ultrasound probes when you use them for Vascular Access. That’s a huge concern for us and the folks that do what we do for a living because there’s a lot of reasons behind it, but one of the big problems with recommending high-level disinfection is by doing that, we could negate or stop the drive toward using ultrasound for all Vascular Access insertions. Just because there’s a lot of things to it more so than just making sure the probe’s clean and Hudson I know will talk about this a little bit further as we discuss what AVA is doing about it.
Ken: High-level disinfection – that’s a big deal, right?
Judy: It’s a big deal. It’s a big deal – for Vascular Access, we’re specialists in insertion, care and maintenance of Vascular Access Devices. But high-level disinfection and sterilization of medical devices? That’s a specialty within itself that we, in fact until I read the draft guideline, I had never even considered high-level disinfection.
Ken: I use ultrasound probes every day and I don’t even think about those things at all.
Judy: There you go. And I think that’s true with everyone within the Vascular Access world.
Ken: Well, thanks to you and Hudson for bringing this to our world and raising our level of concern and also education in this regard.
Judy: And thanks to Chellie, honestly. She’s a contributor on the document that Hudson and I authored together.
Ken: Well, Chellie if you’re out there, you’re listening, thank you so much! So, Judy, what is the short version of our, meaning AVA’s, position on probe disinfection?
Judy: Well, the short version is the risk-benefit of high-level disinfection versus low-level disinfection is AVA is going to recommend low-level disinfection of ultrasound probes for the insertion of Vascular Access Devices within the Vascular Access community. But with some caveats and with some recommendations on how to do that safely to make sure that we don’t transmit diseases between patients.
Ken: So, they’ll be some caveats, some critical thinking that’s involved in the use of ultrasound probes?
Judy: And guidance. Hudson has just been so helpful and added so much expertise in bringing the infection prevention portion of this document to bring it to where it’s a useful document and where we can actually operationalize keeping the probe protected, yet not sending it down to sterile processing every day.
Ken: Always the risk versus the benefits.
Ken: Well, that’s a good Segway to asking Hudson a question. Hudson, I’ve heard the term “Spaulding classification” and honestly, until I had this discussion with Judy, I had no idea what that even was. I’m hoping you can tell us what it is and how it may impact the practice of Vascular Access.
Hudson: Sure. So, it’s really a system that was designed by Dr. Spaulding many years ago looking at different categorization of medical devices and instrumentation and the associated risk, but also, what’s the appropriate level to disinfect those particular devices. So, if we take a blood pressure cuff, which, obviously, everybody is familiar with, that’s what’s considered a non-critical item. It’s an item that comes in contact with intact skin and that device requires a low-level disinfection as a minimum.
You take it a step above that, and you think about semi-critical devices and probably one of the best examples are endoscopes or endoscope blades. Vaginal ultrasound probes are another example. These are coming intact with mucus membranes or non-intact skin. So that is where the whole high-level disinfection piece comes in.
And lastly, what Vascular Access uses a lot of are critical devices which are things that come in a sterile pouch or sterile packaging. These are items that come in contact with sterile tissue or blood, so needles, syringes, all the things that we actually insert into the human body would fall into this categorization. So, it’s really meant to be sort of a guideline for how to do what for what. So, it depends on the type of item and that way it gives you an idea for the level of appropriate disinfection for that. Infection prevention and control and biomed and other fields have used this for many years with great success to appropriately disinfect and/or sterilize devices.
Judy: Spaulding’s been around for a long time, right Hudson?
Hudson: It has. I think where this is coming up today is there are adaptations of the original Spaulding classification. That’s really where this conversation came from was how do you deal with these Vascular Access Devices that are used with ultrasound? If the skin is not intact. It does create an opportunity for discussion and as you mentioned earlier it also creates an opportunity for really looking at a risk analysis for a patient to make sure that they’re safe, our clinicians are safe and that we properly maintain our equipment.
Ken: It kind of puts you between a rock and a hard place. Your scanning something that is initially intact skin but then you’re doing something to somebody with that same probe that is now making the entire skin no longer intact, eh?
Hudson: Right and I think one of the cool correlations here is think about a glucometer, which we use on a daily basis with patients in acute care and non-acute care settings. That is probably the best correlation because a glucometer has actually been known to transmit Hepatitis B virus. We’ve seen it actually happen. CDC has done outbreak investigation and yet that device is still considered non-critical. So, it’s a minimum of a low-level disinfection.
Additionally, there’s not any type of sheath used on glucometers. So we’ve made lots of alterations in our clinical practice where we can reduce that risk and I think the same can be said for what we’re talking about today, which is your ultrasound probes used for Vascular Access devices.
Ken: That’s very interesting. Why is proper cleaning and disinfection so important when reprocessing ultrasound probes used for Vascular Access devices anyways?
Hudson: When you think about the definition of cleaning, most clinicians don’t understand the difference between cleaning and disinfection. Cleaning is simply the removal of bowel burden or soil from a surface. It’s actually not designed to activate or kill any microorganisms whatsoever. So, if you have something that’s visibly soil, like blood or other bodily fluids, it needs to physically be removed from that surface first. That can be done with a cleaning product or disinfect product. And then the clinician should come behind that and do a formal disinfection process. Most often they’re going to use a low-level disinfectant wipe or spray or soap. And really, if you look at the CDC Guidelines, they actually go above that and go into an intermediate level, if possible. So, these are EPA-registered products that you can find readily on the US market and are already available in hospitals and other healthcare facilities. It’s really just a matter of using a disinfectant that’s already carried in your facility that’s compatible with the specific ultrasound device.
Judy: Our document of guidance just got published with what to do with this. You and I have had a ton of discussion about the risk-benefit of the recommendation AVA has given. I just want to kind of bounce off and play a little devil’s advocate with you. If we had gone high-level disinfection – if we had said that is our recommendation, we’re going to the platinum route and say everybody has to go through HLD, high level disinfection between patient use – what’s that impact?
Hudson: I think the impact is that you take away that technology from thousands of patients every single day. We know that the clinical benefit of ultrasound technology is tremendous with patient satisfaction and reducing patient pain overall as well as vessel preservation. I think that’s on the benefit side. On the risk side, if you have a device that’s not properly cared for or you have Vascular Access clinicians that are not skilled in understanding the manufacturer’s IFUs and doing the cleaning and disinfection, then there is theoretically that risk particularly for bloodborne pathogen transition.
So, that’s really where this document comes in as serving as a reference guide to Vascular Access clinicians across the world to say, ‘Here’s a summation of the clinical evidence that exists. Here’s some of the steps that we strongly believe will make sure that patients are safe as well as the clinicians, but also preserve the integrity of the device.’ Because I think that’s one of the biggest concerns for us as far as medical devices. It’s got to be properly maintained. If it’s not, that risk exponentially goes up and then we have a problem. The document is not meant to be a one size fits all but providing very thorough guidance to work with in your own facility and collaborate with infection prevention and control to actually address this issue in a very cautious, yet pragmatic approach.
Ken: Right. I think that’s really important. The idea of being pragmatic, because we live in the real world. I want to just say that this has been very interesting to me and I have another question that’s a toss-up question for both of you to answer.
Judy: Uh, oh. Here we go!
Ken: So here you go: What level of disinfection is most appropriate do you think for ultrasound probes used for Vascular Access Device insertion and what should Vascular Access clinicians know specifically about this whole process.
Judy: Well, Hudson, I think that is most appropriate for right now for you and I’ll add a couple comments after that. How’s that?
Hudson: Well, Ken, it looks like she turfed the question already, so.
Judy: Hey wait, I didn’t, whoa…
Ken: She’s letting you open it and she’s going to close it!
Judy: That was good. I’ll get you back!
Hudson: That’s OK. I think when we think about most appropriate, there’s two ways to answer that question. I think there’s a minimal expectation of low-level disinfection, which is really what is stated in the CDC guidelines when you look at that sort of definition of non-critical items. I always tell people, though, from an infection prevention standpoint, to use an intermediate level when at all possible. So, minimum expectation is low-level. Preferred expectation is intermediate level. And just so everyone is clear, intermediate level disinfection, the difference there is efficacy against microbacterium. Microbacterium is a very resistant organism on environmental surfaces, including medical devices. The best-known example of that category, microbacterium tuberculosis. But, certainly, we’re not considered with TB living on surfaces, but that family of organisms is extremely difficult to kill. So, if you’re using an intermediate level disinfectant, which ironically is what most hospitals and healthcare facilities are already using, then that’s going to give you your highest level of environmental infection without having to go to HLD. So, really the big difference between that and HLD is simply going to be some of the bacterial spores. Really, it’s going to give you the required protections that you’re looking for as it relates to the risk analysis for vascular access insertion for ultrasound.
Ken: That’s interesting. I didn’t even know about the intermediate level that was actually targeted at microbacterium.
Hudson: Correct. I think that’s something that most Vascular Access clinicians are not aware of which leads sort of the second question you asked, Ken, which was great: What do people need to know? As Judy rightfully mentioned at the beginning of this discussion, this is not an area of specialty for Vascular Access. We really rely on environmental surfaces and infection preventionists to sort of guide this. But those times are changing. If we’re going to essentially be responsible for ultrasound equipment in our practice, we also need to know how to properly use it. I look at it no different than when you administer a drug. You better know how that drug is going to interact and work in the patient’s body. We also need to know how devices can be properly cleaned and disinfected. That’s really a collaborative conversation with environmental services, infection prevention, biomed, the manufacturer, as well as your materials management or clinical value analysis professionals. Because nothing should get in your building unless it’s got validated instructions for use for cleaning and disinfection with an EPA registered germicide so that’s really a big takeaway here and a homework item for all of our members listening to this podcast.
Judy: Hudson, I just want to make sure that people listening to this and read the paper that we wrote, understand the rigor we went through to make the recommendation because there are other organizations out there that talk about high-level disinfection for the same procedures we’re recommending low-level. Real briefly, I want to go through what you did, and I know I did a thorough lit review and Cochran review but so did you. Let’s walk through that just a bit so they understand that this wasn’t just an arbitrary decision because it may be seen as easier, but this was evidence-based.
Ken: Well, I know Judy’s been working on this a long time because I’m waiting for her so we can do the CVAD Manual and she’s been doing this for weeks! So, I know she’s worked really hard on this. Please, let’s hear what you guys have done because this is important.
Hudson: Sure. I think when Judy and I had an initial conversation about this, we looked at what sort of was the initial question. That sort of clinical question that’s posed which is what is the appropriate level of disinfection for these devices? Comparing that to what exists in the literature is the example I mentioned before, is both commoners and then looking at not only the clinical guidelines but as Judy mentioned doing an extensive literature search. From that, that led us to many different opinions that came out in the literature search. Some were on the side of HDL. Some were on the side of low-level disinfection. Some were right in the middle. And some quite frankly didn’t know.
So, from that, we had conversations with conversations with colleagues at the Centers for Disease Control and Prevention as well as some other colleagues at the University of Louisville School of Medicine Division of Infectious Disease to really look at a pragmatic approach to this. I think that much of this work has been started in another area that is tangentially related, which is vaginal ultrasound probes, which do require HLD because they’re routinely coming in contact with mucous membranes. So, there’s been a lot of discussion that started there.
But really, I think the most important thing for members to know is this was a careful balance between what does the science say? What is the risk that we know is present? What is the documented incidence of outbreaks? Which there haven’t been really specific ones associated with this. And then, what do we think makes the most sense to protect the patient as well as our clinicians? And that’s really where this guidance document came in. That’s the key. That’s why it’s a guidance document and not a guideline. AVA is coming together with different resources to provide our members with specific evidence-based recommendations to what they should do in their own practice but to also bring them to a bigger conversation with other stake holders at the table in their institution, like infection control.
Because each time we face these issues it arms us for doing even better things with our patients. And as the clinical technologies increase, our acuity changes for our patients, we too have to change and rise to that occasion and broaden our specialty’s knowledge and include infection prevention in that expertise.
Judy: Thanks, I agree! I think one of the things on my wish list would be a process that would give better efficacy to the disinfection of probes. Because right now, inserting devices, I was never taught how to disinfect a probe. I teach these procedures and I don’t teach, or I haven’t in the past, I can guarantee in the future I will. But I never taught a clinician the proper way to disinfect a probe. This has not been on anyone’s radar until now. So processors or manufacturers that are hopefully listening to this that will find a process or a device that will help us clean these more thoroughly, education that will get our clinicians to clean these better and then possibly some sort of manufactured device that from patient to patient that could be a bedside HLD-type device. If I could do my dream, it would be almost like a bucket that as we go from patient to patient, I could have my probe sitting in before I see my next patient.
Ken: Then we won’t have an issue.
Judy: Then we won’t have an issue! And then what are we gonna do? We’ll find a new one, I have no doubt.
Ken: Well, until then, we’ll have to do what medical professionals do all the time, or should do all the time, and that is use good judgement, use common sense and use critical thinking.
Judy: And the best evidence we can find.
Ken: And the best evidence we can find. And find the right thing, what you would want to have done to one of your loved ones. And still get the job done.
Judy: One of the loved ones you love, and like! That’s for sure. Hudson, I can’t thank you enough for popping on the call and joining us on this. And honestly, co-authoring this paper with me. This has been a great experience and I can’t wait to do more.
If you’d like to hear our full interview with Dr. Hudson Garrett, you can as an AVA member benefit. Just visit avainfo.org/podcast. When we return from break, we’ll hear from Melissa Chittle, and author of an article published in the summer issue of the Journal of the Association for Vascular Access. And, a bit later, we’ll get you caught up on all the upcoming AVA network events and much more. Stay tuned.
Eric: For this week’s Beyond the Manuscript segment of the ISAVE That Podcast, I’m joined by Melissa Chittle, a Physician’s Assistant and the Lead Advanced Practice Provider in the Interventional Radiology department at her hospital, and also the lead author of the article titled, “Utilizing a Sedation Aid in Ambulatory Venous Access Placement: Effects on Patient Choice, Workup, and Recovery Time,” which was recently published in the summer version of the Journal of the Association for Vascular Access. Melissa, how are you doing this morning?
Melissa: I’m doing great, Eric. Thanks so much. It’s great to be here!
Eric: It’s great to talk to you! I appreciate you taking some time out of your busy day to sit down and chat with me about the research and the article you and your team put together on the sedation decision aid. Let’s start right there: I’m really curious about the genesis of your decision to create this decision aid. I know it came as a follow-up to an initial publication that you guys did on the shared decision-making process as the standard of care regarding levels of sedation for individual patients on a case by case basis. But what made you see that putting together this decision aid was really the next necessary move?
Melissa: It’s a great question. Typically, in our department, we put in totally implanted venous access devices for patients who require long term venipunctures, who are going to be constantly receiving a medication through an IV. In order to prevent them from constantly having to get a venipuncture, we put in these totally implanted venous access devices called ports. We do thousands of them a year.
And I had one patient one day, who came to the department for their port and she looked terrified. So, I immediately said to her, ‘Don’t worry! I’m going to sedate you, put you to sleep, you’ll be pleasantly unconcerned, you’ll wake up and this will all be over.’ And she looked at me and said, ‘It’s not my cancer diagnosis, the chemotherapy, the radiation or the surgery that scares me the most. What scares me the most is sedation and that feeling of a loss of control and being out of it. That is what is terrifying me.’
So, I looked at her, because typically we always sedate patients, we never ask them their opinions or preferences. So, I said, ‘I guess we could try this without doing sedation.’ And that was the first time I ever performed this procedure without utilizing any type of sedation and when I was finished, the patient absolutely raved about it. She said, ‘That was absolutely tolerable. I’m so glad you were able to do that for me. It was a wonderful experience and it was consistent with what I was hoping for and would prefer.’ That was the eye-opener, first off, to think that there might be different patient preferences for sedation. It might be variable. And not just what we do as an institution or what I do as a provider.
That was the impetus for even employing shared decision-making and it was right around that time that the decision science center at our institution was putting on a course about how to do shared decision-making and how to create tools. It just all kind of worked together. I then got that email later that day or something, signed up for the course and during the course I knew that this was what I wanted to do. I wanted to do the shared decision-making with patients, offering them options for sedation. Because there are options. There are options for just doing it with local anesthetic, to just having a mild sedation, minimal sedation, to doing a procedure with what we call procedural sedation, which is a combination of medications to make patients pleasantly unconcerned and relaxed. There are three options there and they all have risks and benefits and reasons for choosing and not to choose. So, everything just kind of worked out perfectly and it all happened around that same time I took that course. That was how I learned to do shared decision-making and how to create a tool to help do it. Because I think that helps ensure that you are consistently doing it the same way every time and it really can help support being implemented in your daily practice if you have a tool and an aid that is given to patients, reminds you to do it and support those conversations. That was the whole impetus of doing this and then designing an aid to help with it.
Eric: It sounds like it was perfect timing and then also a fabulous way to continue to put the patients first and that’s what we want to do, protecting the patient at all costs. It sounds like a terrific standard of care there. And I understand that a portion of this tool, you gave patients – asked them to rate five separate common features of importance to them. What were those five tiers? Can you tell me a little bit about them?
Melissa: Absolutely. There were basically five statements that appeared as sort of the first thing on the decision aid. That was just to help frame it in the patient’s mind, give them a sense of what might be important to them. The way we came up with these five different statements is actually some feedback from patients about things that they actually were hoping for. When I used to do more of an open discussion – what were your goals for today? What were you hoping for? These were some of the things that patients actually said to me, so that’s why I ended up using them on our decision aid because these were real life comments they were making.
Those five statements that we rate on our decision aid are: The first is, I don’t want to feel groggy or out of it. I’ve heard that from patients, so I had them rate that. Is that something that is Not Important to you? Or is that Very Important? The second one was, I want to be awake as long as I don’t feel pain. Again, a common thing that patients would say to me. So, I had them rate that from Not Important to Very Important.
The next is I don’t want to a long recovery time. Often, patients have multiple visits scheduled at our institution that day and it’s a very busy day. And usually, that is something that is very important to patients, they say, ‘I want to be able to get to the next appointment. I don’t want my family and friends to be waiting.’ So, again, I ask them to rate that.
The next one is I want to be drowsy and wake up with the procedure is over. A very common statement. And again, I had them rate that as Not Important to Very Important. And the last one was I want to be able to drive or work today. Often, patients who are coming for these procedures, they have had multiple medical visits. They have already had significant time away from activities and work and have depended on a support system to help them get through this. But there are patients that want to finally be able to do things after their appointment – to continue to function and carry on their daily life. That was a thing that we constantly heard. So, again, we had them rate that. That’s how we did that.
Eric: Those are all really worthwhile questions and I know that a lot of that can hit home, especially with patients, as you mentioned, that continue to come to hospitals time and again for different procedures or visits. Were there any hiccups or challenges that you faced when you put together this idea and started your research?
Melissa: That was very interesting and a great question because we were basically changing the entire philosophy of an institution in a department by doing this. We looked at a historical number of patients who would come to IR to have these brief procedures, these portacath placements. Basically, a majority, a majority of the time – I’d say about 83% or more – always had sedation for the procedure because nobody asked them what they would like to have. It was the standard for the department, it was just the philosophy, that of course they would want to be sedated for this. That was the assumption. No one asked them. So, when you look back, it’s staggering to see that that was what was always done to them. A reason it wouldn’t be done in the past was if we found that a patient wasn’t appropriate or the risk for sedation were too high. So, we weren’t even offering it to them. Or that was the reason they were totally not an eligible candidate. It was the norm that patients were always sedated. The entire philosophy of the department was that is how the procedure is done. It was interesting to try and educate people about shared decision-making and to show that there are different preferences out there.
Eric: To institute the idea, yeah.
Melissa: It was met with resistance initially. People said, ‘Well, this can’t possibly be the best care to not sedate somebody.’ The nurses in the room, the technologists in the room were speaking up, voicing their concern about not sedating someone. Are they going to be too uncomfortable? Is this going to be a horrific experience for them? That’s the challenges we met – making sure we are educating the group about the benefit of this. I would go to different meetings for the different teams, the nurses meeting, or the technologists meeting, and present to them what we are doing here and the data that had shown high satisfaction with it and had shown how there were variable preferences and that by not sedating patients we are not withholding, we are actually enhancing the level of care and making it more patient-centered.
That’s where I found a little bit of push back as we did something new and different. Just getting people to buy into it and show them how it was really benefitting the patients because their concerns are always for the patients and this is truly giving the patient the best care for their individual needs. That was very interesting to run into that as a team. The patients have been very happy with it.
The other issue I always run into is to make sure it remains consistent. You always get excited, you start something new, and it’s just making sure it’s built in to be there now indefinitely. It needs to become part of the workflow and ingrained. Always working on that whenever you develop something new and not just kind of continuing to do it every day. To remind people to give the option to the patient as they come to the department. Just reminding them.
Eric: Definitely, and that is a nice Segway into my last question, I’ll get you out of here on this: What’s kind of the objective, or the goal with readers, physicians, or nurses, after they see your research, to take away with this decision aid.
Melissa: I think the most eye-opening thing to us was that patient sedation preference is variable. I had no idea. I’d been doing this for 10 years without ever asking a patient their preference. So, the thing I would want providers or readers to take from this is that there are things that patients may have a preference for that is not consistent with what you might want, and I might be the person that says I want to be sedated for these procedures, but that’s me reflecting what my values are, my preferences are. So, it’s really eye-opening to simply ask patients what their preference is because you’ll be amazed at what you find. Like I said, we went down from the majority of patients always being sedated to less than half. We cut that in half so it’s amazing what preferences might not be what you think.
The second thing is the impact on departmental flow. I think for us to see recovery room times – we have a huge bottleneck in our recovery room, with patients just recovery after sedation. This can take up to 90 minutes to just wear off the effects of sedation. What we saw by simply asking patients their preferences, they’re less likely to choose that higher level of sedation and as a result they recover for less amount of time. And we are now seeing recovery times less than a half an hour compared to 90 minutes.
Melissa: That was incredible for our department flow and turnover and the satisfaction of the nurses in the recovery room saying how it easy it was to do discharge planning and discussion because patients aren’t heavily sedated. We didn’t expect that, but that was incredible, especially as people are trying to make things as efficient and get patients in and out and onto the next thing. I think that was really neat. That’s important to share. I think about this and they’re facing bottlenecks and patient pressures to get things in and out and that this was just a natural result of this decision aid.
Eric: That’s a staggering statistic: Down from 90 minutes to 30 minutes or less. That’s really fabulous. I really want to thank you, Melissa, for joining me to talk about this. For AVA members and journal subscribers, you can read this article on avajournal.com/current. It is online and it has been published. For AVA members specifically and other subscribers to the Journal of the Association for Vascular Access, your hard copy is currently be printed and mailed, so check your mailboxes soon for those. Thanks again, Melissa, it was great to chat with you.
Melissa: Thank you again, Melissa, pleasure to be here.