Season 1, Episode 3 Transcript
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From the Association for Vascular Access, this is the ISAVE That Podcast.
Ramzy: Season 1, Episode 3 of the ISAVE That Podcast. This is Ramzy Nasrallah, I’m joined by AVA’s Director of Clinical Education Judy Thompson.
Judy: Hi, guys!
Ramzy: Hey! And Eric Seger, JAVA Editor-in-Chief. Hello, sir.
Eric: What’s going on?
Ramzy: I’m back from WoCoVA, which we’ll talk about a little bit. I finally adjusted off of the time lag which was six hours ahead. But WoCoVA doesn’t sleep, so it was more about being up for 24 hours in a row for four consecutive days. And then Fourth of July, and now we’re back in the swing of things in the dead of summer. That’s what’s going on with me. Eric, talk to me about your world.
Eric: What’s going on in my world? I can’t believe it is almost mid-July already. Summer is just chugging right along and with that AVA 2018 is approaching rapidly. We’re almost to the two-month mark, folks. That’s getting pretty close. And, we’re almost one month away from the Early Bird deadline coming to pass for registration. That comes on August 13, so everyone who is listening to this podcast, if you’re considering coming to conference in Columbus this September, I encourage you get your registration filled out as soon as possible.
I think it’s going to be a really great meeting. We have a ton of great education and a lot of fabulous speakers that are lined up to come to Ohio. We’re excited to host AVA there, and it’s coming along really soon. So, get those registrations in as soon as you can before the end of the summer and that way you can save some money before the price goes up.
Additionally, the next issue of Intravascular Quarterly, or IQ, which is AVA’s electronic newsletter is due out in mid-August. So, next month. If you have a content idea or article you wish to share, you can send me an email at firstname.lastname@example.org. IQ is something that I put together, but I love the help of AVA members or anyone else with a Vascular Access-related topic that they would like to write about or share an article that they already have written. It can be anything about Vascular Access. Infection Prevention, Vascular Access Devices, anything you want shared in the newsletter that you think our membership would see as beneficial.
Also, if you have any feedback for what we’re doing with the podcast, feel free to send us an email at email@example.com. And, you can also reach out to us on any of our social media platforms: Facebook, Twitter, LinkedIn, Instagram and Pinterest. It’s really easy to get a hold of us. We want to hear from you guys, we want to hear what you guys want us to chat about, what we can do better, what needs to be improved on. We’d love to hear feedback.
Ramzy: Podcast@avainfo.org. Or, as the kids say, you can @ us on social media.
Eric: Yeah, as the kids say. But I know Judy has been really busy with a lot of stuff too. Judy, what’s going on in your world out in San Diego?
Judy: My world in San Diego has been insanely hot this last weekend.
Ramzy: By the way, the raspy Judy Thompson is with us.
Judy: Yeah, I sang at some rock concerts. No, I didn’t. I just came across this cold. It was 114-117 in my neighborhood this past weekend. So, warm. Definitely warm. San Diego’s not always 70 degrees, evidently. A 117 temperature was too warm for this girl.
Ramzy: That’s like a Kelvin temperature, it’s ridiculous.
Judy: It is ridiculous. I need to go to Celsius just to make it reasonable now. Seriously, it’s crazy hot. But now that the high-level disinfection/low-level disinfection paper is out, I have been concentrating all my attention again back on the guidelines. Which, I’m super excited about, still very stressed about because they’re not as far alone as I’d like them to be yet. But we have some really good sections. Looking forward to getting those out, getting those into review and published soon.
Ramzy: And that’s practice guidance beyond just a PDF of words to read and then try to interpret. Explain what these, for example, if you’re reading about the guidance for care and maintenance for catheter care. Are you just reading something? Or are you looking at something? What is that going to look like?
Judy: All of the above. That’s the really exciting part. All of the guidelines, I’ve read, you read them and you read them and you read them and you try to find them. This one, it will be searchable but just not searchable in words, but videography. If you want to see how to do a proper dressing change, you go click on care and maintenance and find dressing change and you open it up and you’ll see videography of a dressing change. You’ll see videography of securement in various forms of securement. All of it will be suture-less because on of our AVA practice recommendations is all lines will be secured suture-less or a manufacturer’s securement device. Dressing changes, needleless connector changes, trying to gain patency again – so if you lose patency on a catheter, you can watch a video on the procedure on trying to clear that line.
Eric: It’s going to be awesome.
Judy: I’m excited. There will be hi-def video, hi-def photography and also some illustrations and animations.
Ramzy: Judy, this does not sound like any guideline that I’ve ever seen before in Vascular Access.
Judy: It’s not. It’s not. Hence why some of the deadlines and some of the timelines have been pushed. I had a great talk with Nancy Moureau a couple days ago. We’re talking about a different subject. Actually, we’re talking about high-level disinfection and the guidance that we just put out. Asking me similar questions, I said ‘Yeah, I’m pretty stressed over the guidelines and I said we have one opportunity to make a first impression. And the first impression we make is going to be impressive.’ The sections we get out, we’ll get out as soon as we can, but we’re not putting it out until it’s right. We’re adding some of this videography, which I really think is going to change the way people can learn and instead of going to YouTube to find a video of unknown technique, this will be evidence-based technique. Something that any clinician could emulate and feel comfortable that they’re doing the right thing for their patient.
Ramzy: This is a huge undertaking. And I’ve seen a little bit of what you’re putting together with your team, Judy, and no one can wait for it. We’re all ready for it to hit the public but I think like you said, it needs to be done properly. Once it’s completed and finished, I think it’ll raise all guidelines and expectations for standards when you have them coming out.
Judy: Thanks, I really hope so.
Ramzy: You’re going to put a bow on the low-level infection guidance document and how to actually put that into practice in your institution. But, coming up next, we have an interview with Dr. Matthew Jones from East Kent Hospitals and he’s also a consultant with the National Health Service talking about what you were just referring to – moving away from suturing Vascular Access Devices to more of an engineered stabilization device or a manufactured suture-less device. Not just because of the securement of the catheter, but to mitigate the infection risk and everything that comes with having a tube put in the vein. That interview was made possible by Interrad Medical, the manufacturers of SecurAcath. It’s also part of our WoCoVA interview series that we will be putting into different podcast episodes this summer since the World Congress of Vascular Access basically had the world’s thought leaders on Vascular Access all in one place, we recorded a few interviews. But coming up next we’ll have that guidance from Judy and Hudson.
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Ramzy: It’s Ramzy, and I’m joined today by Dr. Hudson Garrett and Judy Thompson, the Director of Clinical Education for AVA. How are you guys doing?
Hudson: Good. How are you?
Ramzy: I’m doing well. Judy, how’s California?
Judy: It’s hot today but it’s great today, thank you so much. I love California.
Hudson: I think what she really means, Ramzy, is it’s about 85 degrees and is too cold.
Ramzy: Judy is wearing a parka right now, I’m sure of it.
Judy: I’m actually in workout clothes and a tank top. It’s 102. It’s warm.
Ramzy: Oof. Yeah, that is warm.
Judy: But no parka. It’s a parka-free day. Except that I did have fuzzy pajamas on this morning, because it was cold.
Ramzy: Which means it was like 75. You provide a good opportunity here. You said it was hot. What’s also hot is that recently AVA with you two as the authors, published guidance around ultrasound probe disinfection in institutions. The purpose of our chat today is to talk about how we can be practical and apply the guidance that you put together in the institution. It’s one thing to put out a position paper with guidance, it’s another thing to put it into practice.
Let’s do that. How should the new AVA position statement be shared inside of a healthcare institution? If you’re a nurse or a doctor, someone working in a hospital listening to this podcast and they’ve seen the guidance, what do they do now? Hudson, I’ll start with you.
Hudson: Sure, and thanks for setting up such a good question, because I think it’s actually the most important question, Ramzy. We struggle in healthcare, where we have great practice and a good understanding of what great practice looks like, but to the point of the question we don’t really actually implement it.
I think this is a unique example of where Vascular Access can take the lead and disseminate this not only within the Vascular Access community and their own institution but also with their infection prevention and control colleagues and specifically environmental services, biomedical engineering and nursing. So, it’s a great opportunity to bring all of those stakeholders to the table together, talk about what the general disinfection practices are and then make sure that it’s incorporated in your policy and procedures, not just within Vascular Access, but across your institution where these ultrasound transducers might be utilized.
Judy: Absolutely. Well said, by the way, but part of the problem we have is we look at guidance documents and then we look at the difficulty in trying to implement them sometimes. It’s like, ‘Oh my gosh, how do I make that a reality? I’d like to go do it.’ So, we’re trying to make it simple. We’re trying t0 make this a document that’s actually operationalized at the bedside that doesn’t stop the flow of practice, that doesn’t impact your work as it could. Pretty excited about it.
Ramzy: Guidance is good and practical guidance is even better to put it into practice. Hudson, is AVA recommending low-level disinfection for all ultrasound transducers that are used in Vascular Access procedures?
Hudson: Right, so really what we’re looking at is a minimum expectation of low-level disinfection and preferably intermediate level disinfection, which is actually achieved with pretty much most of the hospital grade EPA registered disinfectants that are out there. We know that if that ultrasound transducer is intact, the sterile probe cover is utilized, that we can safely do this practice and still be pragmatic about our application of the Spaulding classification. So, that’s a minimal expectation but preferably intermediate level disinfection.
Ramzy: And so, for those clinicians, how should they be trained in the proper evidence-based practice of disinfecting an ultrasound transducer?
Judy: I think there’s a couple spots we need to talk about. First, just real quickly, I doubt that many people listening were ever trained on how to clean their ultrasound transducer.
Judy: I know I wasn’t. And this is a brand new, like, what? I need training on how to do this? Absolutely you need to have training.
Ramzy: In the meantime, what can Vascular Access clinicians do to further this important clinical topic? It kind of showed up on your radar out of the blue, Judy, we talked about it in Episode 1. Something you weren’t even thinking about, and then all of a sudden now AVA, Hudson, Judy Thompson put out guidance around ultrasound probe disinfection. What can the clinician do to advance this in the same way that you advanced it and made it a topic of conversation?
Judy: I think one of the first things we all need to do is look at the evidence. It’s shocking to me that this information has been out there for so long and it just really reared its head. This is not new information. Many guidance documents have recommended high-level disinfection. Now, again, we’re recommending low-level disinfection for Vascular Access ultrasound probes when they’re sheathed properly and there’s no contamination.
But, the guidance out there from other organizations, many of them have said high-level disinfection and has not hit the radar of my colleagues, myself included, up until about six weeks ago. Data diving and looking at the evidence, really digesting it and seeing how it really affects us.
Ramzy: Combing the literature – anything else you would suggest, Hudson?
Hudson: I think there’s a need, and this is where AVA can be a good partner in this, to collaborate with our industry colleagues on viable solutions both at the device level but also at the disinfection level. I think that’s also going to involved FDA and EPA as well because the legal liability really goes back to the manufacturer’s instructions for use.
So, I’m hopeful that this podcast will be helpful in our manufacturing partners in understanding the risk associated with this and then risk mitigating that with the appropriate instructions for use using EPA registered, hospital grade disinfectants. I think there’s a unique opportunity for AVA to sort of bridge that gap as well because at the end of the day, clinical innovation doesn’t just come from clinicians. It also comes from industry and then also has to pass through our regulatory partners like FDA and EPA in order to be brought to the market. There’s a piece of this pie for everyone to understand and only with all three will we be successful in creating long term sustainable solutions.
Ramzy: Absolutely. That’s one of the unique facets of how AVA works with its members. Our industry partners are our members and they help bridge some of these gaps that come in practice and they give us solutions.
You talked about EPA registered solutions: Are there any EPA registered hospital grade disinfectants appropriate for disinfection for these types of devices?
Hudson: There are. If you look at it, E-quip publishes several different lists of disinfectants that are hospital grade and appropriate for specific pathogens. In the guidance document itself, we actually call out certain claims from a microbiology standpoint that you should be looking for in order to be safe. We know that this is very similar to the glucometer issue that we talked about on the last issue, that there’s going to be primarily exposure to blood. So, with blood, we know the biggest risk is bloodborne pathogens. And, so, we want to make sure that disinfectant is disinfectant against HIV and Hepatitis B virus at a minimum and Hepatitis C is preferred. But looking at your at your multi-drug resistance organisms and your other viruses, that might be problematic. All of that detail is found there. The easiest thing for the Vascular Access clinician or even the infection preventionist to do is pull that information from the guidance document, go get your own hospital grade disinfectant and then go to the manufacturer’s website or the EPA website and you can actually pull down that master label and compare and make sure that all of the relevant claims you have to protect your patients as well as protect your staff.
Judy: The other part, too, that I do want to add to that is when many clinicians, they pull their probe cover off, and they grab the disinfectant wipe first go. We need to remove any of that ultrasound gel that’s on the probe prior to disinfecting. So, it’s similar to cleaning skin prior to us disinfecting skin. We need to clean that probe prior to disinfecting the probe, so the chemicals can actually go do their work.
Ramzy: That’s an important point, Judy. We talked about the ‘what’ early and the ‘how’ you’re putting into practice. Precisely, what elements do you include in your policy and procedure to ensure that all your critical aspects of the recommended infection practice are addressed? How many steps are there? What are you putting into your policy?
Judy: We have not written a policy yet. AVA has not published a policy yet. It’s something that I’d like to work on. But we have 13 steps within the guidance document that discusses things that you should really go down. There’s a checklist as well that is written that you can look at it. But part of the policy development is in the hospital system itself. But training is one. Validating training.
Everyone that does this, if you’re placing devices and your primary job is you place Vascular Access Devices with ultrasound, you need to understand this inside and out and you need to understand the ramifications of the proper disinfection and if you breach that probe cover. So, what happens then? Because that does happen. I’ve seen it out in the clinical world to where the needle goes through the probe cover. So, then what? Then that is not protected. You need to have the ‘what if’ scenarios in there. Hudson put together a lot of these steps. Hudson and I together but Hudson took the primary lead on that and we discuss what to do if the probe cover or the sheath is actually violated with the needle, or it tears, or there’s a malfunction to it.
Ramzy: So, we can expect some sort of a policy to come out of AVA with regard to how you ensure all these aspects of the guidance that you put together are covered.
Judy: Yes. It’s not the hottest thing on the plate right now but definitely something we do want to put together.
Ramzy: I’ve seen the plate. There’s plenty on it. One last question before I let you guys goes: If I’m a nurse or a doctor listening to this podcast, how can I improve compliance with disinfection of ultrasound transducers used by my Vascular Access clinicians?
Hudson: I think there’s a couple things. It’s not different than hand hygiene. If you don’t put it in their face, they’re not going to be able to do it easily. It needs to be on the actual ultrasound machine, whether it’s in a basket, on the cart, or attached to it in some form or fashion. Because then it puts it into place. The same is true for hand hygiene – so have that disinfectant present there.
No. 2 is you need to make sure staff members are actually trained on the use of it and I think Judy mentioned that beautifully earlier. When you go to nursing school or respiratory therapy school, physician, nurse practitioner, whatever, they don’t teach you how to disinfect the equipment. That’s not part of the curriculum. So, we’re expecting clinicians to do things they were never trained to do and while it may sound very, very easy, the consequence of cleaning your home wrong is a lot different than the consequence of cleaning an ultrasound probe incorrectly. Staff members should be working with environmental services personnel, who are the experts in this, to actually do teach backs so they can actually understand how to do that, as well as the manufacturer.
So, if I was a clinical leader in vascular access, the first question I would ask for any equipment I had is, ‘Do I have a way to actually clean it? Is it validated?’ If I cannot clean and disinfect it according to the manufacturer’s instructions, it should not be in my institution. So we need to challenge our manufacturer partners to provide that validated method that’s required by FDA and then roll that all the way throughout the organization, as well as put the product, whatever the disinfectant is, right there at point of care. That will really just make compliance a lot easier for us.
Ramzy: Right. Out of sound, out of mind.
Judy: Make it easier to do the right thing and harder to do the wrong thing.
Ramzy: So, front and center. He is Dr. Hudson Garrett Jr., Assistant Professor of Medicine Division of Infectious Diseases at the University of Louisville School of Medicine. She is Judy Thompson, Director of Clinical Education for the Association for Vascular Access. Thank you both for your contributions to Vascular Access and your time today.
Hudson. No problem.
Judy: Thanks, Ramzy!
Ramzy: Here in Copenhagen at WoCoVA with Dr. Matt Jones, from Great Britain.
Matt: Hi, hi, how are you?
Ramzy: Good to see you, Doctor. We’re at WoCoVA, we’re at this every two-year conference. What is your takeaway of this patient-driven symposia that we’ve been experiencing here on Day 3? What are you going to bring back to your practice from Copenhagen?
Matt: Every time I attend the WoCoVA conference, you pick up something new. There’s always interesting things to learn. There’s a lot this year about securement, fixation, dressings, longevity, making sure your lines aren’t loss. To be, that’s been the big take home message for this year, for me. We should be able to make these lines last in however we do that we need to study that more. Lots of studies going on, going forward.
Ramzy: Both for the therapy and for the comfort and benefit of the patient.
Ramzy: So, tell our listeners a little bit about your background and practice.
Matt: I’m a consultant anesthetist. I’ve been a consultant in the UK for about 15 years now. I have a very specific sub-interest in anesthesia for Vascular Access. I’m also the lead clinician for the Vascular Access service in my hospital in the UK. I have a very well developed (for the UK) Vascular Access service in that hospital. My day-to-day job is a consultant anesthetist, but I have a very special interest in Vascular Access as well.
Ramzy: Good. And being so involved and entrenched with Vascular Access, you deal with a lot of central venous access devices.
Ramzy: What sort of clinical issues are you experiencing with CVCs?
Matt: It really goes back to the fact that we started using the SecurAcath on our PICC lines. We have a very well established PICC line service, but I also work in the intensive care unit. We’re replacing a lot of central lines. CVCs, or centrally inserted catheters. It dawned on me that the product that we were using for the PICC lines seemed to be the evidence was starting to support it. It was showing that we were getting good results, I was looking at whether or not we could use it on our intensive care unit to secure our central venous access devices.
Ramzy: So that’s how you became aware of subcutaneous engineered stabilization devices?
Matt: Yes, originally because of coming to WoCoVA and seeing it worldwide and so forth. But we started using it on PICC lines, there’s a lot of evidence already out there about the advantages of that and I was thinking to myself, ‘Can we use that principle? Extrapolate that into the critical care environment.’ Where, to be frank, what I did was do an audit within my own intensive care unit of my central venous access devices, both the insertion and the initial stabilization and the ongoing care and maintenance. That audit revealed to be that we had a little bit of a problem in terms of keeping these lines clean, safe, secure, dry and infection free. That’s where the idea came from. It sort of transferred over from my PICC line experience. That’s how we went. We started to look at how we could use it on the intensive care.
Ramzy: You saw the gaps with CVC care and maintenance, but also had the positive experience with PICCs and you were able to fill that gap with an intervention that you had already been using, SecurAcath for CVCs.
Matt: That’s right. That’s correct.
Ramzy: Describe that experience taking the securement from the peripheral inserted central catheter and applying it to the CVC.
Matt: Basically, the key message for me was to do away with the suture. I think that suturing a central line on an intensive care unit, you’re asking for trouble. It’s a technique that causes damage to the skin. It causes bleeding and it’s potentially harmful for the operator. We’ve got needlestick injuries to worry about and so forth.
It’s quite poorly done as well. These aren’t surgeons, these aren’t high class surgeons on our intensive care unit. They’re usually anesthetists or intensivists. They’re knot-tying skills are usually not that great. It was very poorly done in a very random kind of way. There were sutures everywhere, different numbers, different ways they were doing it. And it was a mess. It would bleed and it would be a problem.
So, the first thing we had to do was get rid of the suture and replace it with a SecurAcath. Took quite a lot of bold moves on my part. I had to do a bit of an education problem alongside removing the sutures. I didn’t say you couldn’t use it, but if you wanted one, you’d have to walk across the hospital to the theater complex to get one. Or, you could use the object that was right in front of you and I’ll show you how to do it and I’ll show you why it’s better. That was the kind of strategy we used. Took a little while, there was a gradual growth in the use of it and all the time we were using it, of course I was continuing to see more of it. Assessing each line on a daily basis or every two days, depending on how long they’ve been in the unit so that we could see whether there was a change in the way these lines were being looked after.
Ramzy: So, the first step: Removing sutures from the equation, which means you’re removing two additional holes from the patient.
Matt: Sometimes four, once or twice it was six.
Ramzy: Wow, that’s a lot of suturing. And in doing so you’re also removing the barrier to decontamination of the site in between dressing changes because the line is no longer sutured.
Matt: From an infection prevention point of view, there’s two or three issues where the SecurAcath was showing a clear benefit over the suture. Firstly, every time you make a whole in the skin, you’re breaching that barrier, the protective barrier for the patient.
Secondly, when you make a hole in the skin, particularly in critical care patients that often have coagulopathic, you cause a little bit of bleeding, and that bleeding will sit underneath the dressing and becomes a beautiful medium for bacterial growth.
Thirdly, when you come to do your dressing change, I think this is the most important transformational change is that you can’t lift the catheter up. There’s a weak spot underneath the catheter. Once you’ve sutured it down, you can’t clean 360-degrees around the catheter. Being able to lift is vertically up and doing a really nice clean with the chlorhexidine or alcohol-based product, whatever is the policy in your hospital, then laying it back down with a nice, new clean dressing actually makes the biggest difference.
Ramzy: What helps with the change antisepsis, more compliantly, getting 360-degree coverage. From a patient standpoint, and we’re still in Copenhagen right now, this isn’t how you would position it to the patient, but if you were to say, ‘I’m going to take 2-6 holes that we would put in you, remove them, but then also keep you safer during dressing changes, the patient would probably buy into that.
Ramzy: So, that was your strategy removing sutures, the benefit of obviously creating a better environment for preventing the likelihood of infection. What was the experience like putting it into practice? And how has it changed your clinical practice?
Matt: I’ve sort of described how we’ve gone forward. There was a journey educating people. It’s really important that these things are not seen as a one off thing. It’s a change in practice that’s important. Not just using it rather than not using it, but understanding the benefits behind it, understanding the long term benefits over the course of the patients stay in the intensive care unit. And just becoming familiar with it. That was the first thing. We’ve reached that point now where my team might complain if they don’t have a SecurAcath.
Ramzy: It’s normal now. This is the new standard of care.
Matt: Yeah, so that’s the real thing. And for me, that’s a real joy to see that we’ve got to that point where it’s now normal practice.
Ramzy: The shiny toy effect is when you see it on a marketing brochure. The pains of implementation and how to make this feel like the standard of care to now it’s weird to not see it on the patient.
Matt: Correct. Absolutely. Absolutely.
Ramzy: I’ll leave you with this: Would you make a recommendation of SecurAcath to other clinicians for their practice?
Matt: Absolutely. In my experience, it’s definitely something that you should explore as part of your quality improvement program. Obviously, it’s difficult over that initial change in practice, but it’s well worth it in my experience because I think we’ve got some fantastic results, lines are looking cleaner and the early evidence, we’ve got some emerging evidence, that these lines are really not getting infected at all. But we’ll wait and see how it goes. Yeah, it’s a great product.
Ramzy: He is Dr. Matt Jones from Great Britain. The product is SecurAcath and there’s information available at www.securacath.com. Sir, thank you for your time.
Matt: You’re welcome!
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