Education & Competency

Common language facilitates communication between professional and organisations, the translation of evidence into clinical practice, data sharing, and research. CNSA, eviQ and eviQ Education are leading vascular access management and education in cancer care in Australia utilizing common, contemporary terminology (Table 1).

Table 1: CVAD terminology

Vascular Access Devices (VAD) - Peripheral Intravenous Cannulas (PIVCs) and Central Venous Access Devices (CVADs) in cancer care are essential for the efficient and effective delivery of anticancer treatments, supportive therapies, parenteral nutrition and repeated or frequent blood sampling (1-5).

Central venous access device occlusions can interrupt essential treatment, compromise patient care and lead to increased health care costs and increased length of stay for the patient (6). Occluded and dysfunctional Peripheral Intravenous Cannulas are replaced (7) which can contribute to vessel depletion (8), patient discomfort and distress, and increased healthcare costs. Frequent, recurrent, or prolonged courses of irritant or vesicant antineoplastic therapies via peripheral venous catheters may lead to venous irritation, thrombosis reducing the number of veins available for future use (8). Education about evidence-based practices is crucial for appropriate and timely choice of peripheral versus central venous access device insertion and management for patients with cancer (9).

The literature identifies variation in practice and recommendations for the type of education, frequency, recipients, and competency assessment. However, the benefits of education for infection prevention and maintaining CVAD patency and reducing occlusion rates are compelling. This question will focus on maintenance of patency.

CNSA recommends that education and competency assessment of all persons involve with CVAD management is essential in order to maintain patency and prevent occlusions of Peripheral Intravenous Cannulas and Central Venous Access Devices for paediatric and adult patients with cancer.

1. Type of education:

CNSA recommends clinicians, patients and carers have access to a diverse educational strategy including theoretical (10-14) and practical (9,12,15-17) components provided by vascular access competent clinicians and educators.

2. Frequency:

CNSA recommends education is provided as:

• part of induction for new clinicians (18) and
• periodically, at least yearly for all clinicians, including new evidence and updated/new clinical procedures (7,19). Refer to local policy for frequency.

3. Competency:

CNSA recommends clinicians, patients and carers involved with peripheral intravenous cannula and central venous access devices management:

• should be deemed competent prior to caring for a device (9,19-22) and
• for persons deemed “Not Yet Competent,” or for new clinicians prior to competency assessment, require direct supervision from a vascular access competent clinician until deemed “Competent”.

Refer to local policies for competency requirements.

4. Recipients:

CNSA recommends that education and competency assessment should be completed for:

• all clinicians involved in vascular access device management (9,11-13,15-20,22-33) and
• patients with and caring for their vascular access devices including carers / family / significant others (13-15,17,19,22,27,29,34)
• patients, family or carers through assessment of their developmental, cultural, cognitive, health literacy and language (35)

Refer to the following sections for details of current evidence for Type of Education, Frequency, Competency Assessment, and Recipients.

Education is a key strategy to effectively and safely manage peripheral intravenous cannula (PIVC) and central venous access device (CVAD) patency. Regular evidence-based education for both peripheral and central venous access device patency management is essential (7). Patency management education includes the causes, flushing and locking practices and occlusion management (7). Cancer care is a clinical practice area that maintains high levels of CVAD education and competency (9,23). A survey across Canada found CVAD education was provided in all healthcare organisations surveyed, however, it was identified there were differences in ‘educational strategies’ (19).

There are a number of benefits of vascular access education.

Homogenous, high standard of care.

Education facilitates homogenous care; standardised, evidence-based care. A prospective observational study concluded that education about consistent flushing techniques and practices are “important determinants to reduce PO” [partial occlusions] (30). A multidisciplinary project identified the “most critical benefit is the decrease in the risk to the patient” (13) from implementation of standardised locking practices via an educational strategy. Also, education facilitates the reduction in the use of ineffective techniques or those that are contraindicated which was identified in an exploratory survey of multiple centres (28) or have been continued due to historical perspective of these practices (29). A retrospective observational study stated education was one of the most important factor required to maintain patient safety (31). A randomised trial concluded flushing practices were safe and effective in maintaining patency of totally implantable venous access devices if nurses strictly complied with educated maintenance practices including flushing and locking techniques (25). Furthermore, “high standards of care were applied through intensive training of staff’ (26) in a prospective, observational study which resulted in a low rate of complications and 0.7% of devices were removed due to flow dysfunction.

Reduction in CVAD occlusion

The benefits of education for maintaining CVAD patency and reducing occlusion rates are compelling. A quality improvement project based on the Joanna Briggs Institute Practical Application of Clinical Evidence System Reduction demonstrated a statistically significant improvement in compliance with evidence-based practices for flushing techniques when education was a key objective and strategy for reform. Occlusion rates were reduced by 50% (9). A retrospective, pre/post-test study evaluating the impact of the introduction of ‘comprehensive educational guidelines’ (12) demonstrated a statistically significant reduction in occlusion rates. Evaluation post introduction of a CVAD educational program and written procedures in a prospective surveillance study in the paediatric cohort demonstrated low occlusion rates of 1.18/1000 catheter days (24). Occlusion rates were minimized by education followed by periodic training for all clinicians in a retrospective observational study (18). Low rates of complications including catheter occlusions, 0.68 per 1000 catheter days were achieved in a prospective, observational study through patient and clinician education and standardised, evidence-based practices (34). Solinas, 2017 noted inexperience and lack of education was the most frequent factor impacting CVAD complications in a retrospective observational study (32). Furthermore, a retrospective observational study identified effective treatment of CVAD occlusion when managed by advanced practice nurses (21).

Reduced frequency in locking of Totally Implanted Venous Access Devices (TIVADS)

Two retrospective observational studies also identified an increased time in between locking Totally Implanted Venous Access Devices (TIVADs) / portacaths was safe and effective and related to expert management by educated nurses (31,32). Solinas, 2017 also noted less frequent flushing of TIVADs was subsequently a more efficient use of expert nurses time and improved patient compliance to attending hospital for the procedure (14).

Patient and carer education

Education of the patient and carers in one pilot, quasi-experimental study demonstrated zero occlusions of Peripherally Inserted Central Catheters compared to documented occlusion rates of 14-36% in the literature (14). In this study, education was provided initially by an expert nurse then continued with the aid of a video on flushing and locking techniques via electronic tablet (14).

The following section will discuss the variances and evidence in teaching modalities, frequency, competency training, and recipients of education.

2.1 Summary of Evidence

The literature identifies two main components of CVAD education: practical and theoretical or didactic. Some studies describe heuristic, experiential, or practical workshops (17), including educational huddles and one on one education (16). For example, practical teaching and then participant demonstration of flushing techniques (9,15). Other studies describe educational sessions (23) supplemented by reference tables with images, written material (13) guidelines and educational material (12) and algorithms (10,11). Implementation of algorithms in one study, improved clinician compliance to a consistent evidence based, multi-disciplinary approach for occlusion management (10). A pilot, quasi-experimental study by Petroulis (2017) with 11 participants over 6 weeks provided CVAD education to patients by initial one on one teaching, practical demonstrations via video on an electronic tablet and continued coaching via the tablet (14). There were no occlusions during this study.

A retrospective, pre/post-test study by Leung et al (2011) evaluated Peripherally inserted central catheters (PICCs) complications before and after a comprehensive education strategy (12). The strategy comprised of establishing a committee, post-insertion care guidelines, educational material, and practical teaching in the clinical area by senior nurses. The results identified a reduction in overall PICC complications and a statistically significant reduction in occlusion rates (12).

A quality improvement project by Chong et al (2013) used an ‘audit, feedback and re-audit cycle as a strategy to improve clinical practice’ for CVAD occlusions (9). Education of the correct flushing technique and manual flush before locking via discussion and teaching sessions, followed by personalised training and re-demonstration by the clinicians, resulted in a statically significant improvement in compliance for using a pulsatile flushing technique and locking solution.

There were no studies specific to the patency and occlusion management of PIVCs for patients with cancer. However expert cancer care opinion identified both practical skills and evidence-based knowledge are required to effectively manage VAD patency (7).

2.2 Type of Education Practice Recommendation

CNSA recommends that clinicians, patients and carers are educated prior to CVAD management and have access to a diverse educational strategy including theoretical and practical components which suits the learning needs of the individual clinician and within the resources of healthcare service

1. Theoretical / didactic component: to include current evidence for occlusion prevention (flushing, locking practices) and occlusion management practices for example:
   • patency algorithms (10,11)
   • guidelines (12)
   • reference materials with images (13)
   • videos demonstrating techniques (14)
   • documentation - rationale for and the components of documentation including all assessments, findings, and interventions.
2. Practical component which may include
   • discussions (16,17)
   • practical demonstrations (9,15)
   • return demonstrations by participants (9)
   • individual instruction (9,12,16)

This includes for the insertion and maintenance phases of Peripheral Intravenous Catheters (PIVC) and Central Venous Access Devices (CVADs), for adult and paediatric patients with cancer.

This is further supported by the Access Device Standards of Practice for Oncology Nursing (36) and Infusion therapy: Standards Of Practice (37).

GRADE: V

Rationale: Most of the studies described education as part of the study design or in the discussion, not as an outcome of the study.

3.1 Summary of Evidence

Trained clinicians involved with CVAD management are identified in numerous studies (9,11,14,16,17,21,23,24,28,30,32,33) however details regarding the frequency of training are lacking. A Canadian survey of multiple haematology and bone marrow transplant centres identified CVAD education was conducted annually in 60% of centres and only when there were policy changes in the remaining 40% (19). Otherwise training is described in two retrospective observational studies as periodic (18) or continued (31) with no details of frequency or on induction of new staff (18).

3.2 Frequency of Education Practice Recommendation

CNSA recommends the frequency of education to include:

1. The induction for new clinicians (18)
2. Periodic education, at least yearly, of all staff including new evidence and updated/new clinical procedures; to be determined by local policy (7,19)
3. Patients are carers prior to discharge and regularly assessed by vascular access competent Hospital in the Home (HITH) or community-based nurses.

This includes for the insertion and maintenance phases of Peripheral Intravenous Catheters (PIVC) and Central Venous Access Devices (CVADs), for adult and paediatric patients with cancer.

GRADE: V

4.1 Summary of Evidence

“Competence goes beyond psychomotor skills and includes application of knowledge, critical thinking, and decision-making abilities. Competency requires a commitment to lifelong learning, self-reflection, and professional ethics” (37).

A sequential quality improvement project concluded nursing competency was crucial in order to prevent occlusions (20). Knowledge and skills need to be demonstrated according to Chong 2013 in a quality improvement project (9). Keeler, 2014 in a multicentre survey across Canada identified that competent CVAD management “requires learning skills, the rationale for device use, and how to avoid complications” (19). Furthermore, competency training and assessment ensures that a consistent, minimum standard of care is maintained (19,21).

There were no studies specific to PIVC competency in cancer care.

4.2 Competency Practice Recommendation

CNSA recommends all clinicians, patients and carers should be assessed for competency after completing an education program (9,19-21) for the insertion and maintenance of Peripheral Intravenous Catheters (PIVC) and Central Venous Access Devices (CVADs), for adult and paediatric patients with cancer.

For clinicians deemed “Not Yet Competent,” or for new clinicians prior to competency assessment, direct supervision from a vascular access competent clinician is required until they are deemed “Competent”. Refer to local policies.

This is further supported by the Access Device Standards of Practice for Oncology Nursing (36) and Infusion therapy: Standards Of Practice (37) and the Australian Commission on Safety and Quality in Health Care (38).

GRADE: V

5.1 Summary of Evidence

Studies identify CVAD education is required for a variety of clinicians: nurses (9,12,15,17,21,23-26,28-31) or nursing and medical staff (11,13,16,18,32), only trained professional staff (34) or any healthcare professional working with CVADs (19,23,25-27,33), interventional radiology technical staff (23) and infection prevention, vascular access team and homecare nurses (34). Other studies include the patient, family and carers (13-15,17,19,27,29,34).

Expert cancer care opinion identified education for nurses is required to effectively manage both peripheral and central venous access device patency (7).

5.2 Recipient Practice Recommendation

CNSA recommends all clinicians, patients, family and carers involved in Peripheral Intravenous Catheters (PIVC) and Central Venous Access Devices (CVADs) management are educated and deemed competent (9,11-,13,15-20,22-33). This includes insertion and maintenance phases of the device.

This is further supported by the Access Device Standards of Practice for Oncology Nursing (36) and Infusion therapy: Standards Of Practice (37).

CNSA recommends to assess the developmental, cultural, cognitive, health literacy and language needs of patients, family or carers for their education (35).

GRADE: V

1. Chopra V, Anand S, Hickner A, Buist M, Rogers MAM, Saint S, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382:311-25.

2. Yap YS, Karapetis C, Lerose S, Iyer S, Koczwara B. Reducing the risk of peripherally inserted central catheter line complications in the oncology setting. European Journal of Cancer Care. 2006;15(4):342-7.

3. Abedin S, Kapoor G. Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer. Pediatr Blood Cancer. 2008;51:251-5.

4. Matsuzaki A, Suminoe A, Koga Y, Hatano M, Hattori S, T. H. Long-term use of peripherally inserted central venous catheters for cancer chemotherapy in children. . Support Care Cancer. 2006;14(153-60).

5. Makary MS, Lionberg A, Khayat M, Lustberg M, AlTaani J, Pan XJ, et al. Advanced stage breast cancer is associated with catheter-tip thrombus formation following implantable central venous port placement. Phlebology. 2019;34(2):107-14.

6. Holt D, Lawrence S. The Influence of a Novel Needleless Valve on Central Venous Catheter Occlusions in Pediatric Patients. JAVA - Journal of the Association for Vascular Access. 2015;20(4):214-20.e2.

7. Gabriel J. Vascular device occlusion: causes, prevention and management. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2011;25(44):49-55.

8. Moureau NLE. Vessel Health and Preservation: The Right Approach for Vascular Access: Springer Open; 2019.

9. Chong LM, Chow YL, Kong SS, Ang E. Maintenance of patency of central venous access devices by registered nurses in an acute ambulatory setting: an evidence utilisation project. Int. 2013;11(1):20-5.

10. Durning S. Multidisciplinary team approach to develop aiorithms to guide clinical practice for key issues in pediatric vascular access. JAVA - Journal of the Association for Vascular Access. 2011;16 (4):214-5.

11. Kefeli U, Dane F, Yumuk PF, Karamanoglu A, Iyikesici S, Basaran G, et al. Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer. Eur J Cancer Care (Engl). 2009;18(2):191-4.

12. Leung TK, Lee CM, Tai CJ, Liang YL, Lin CC. A retrospective study on the long-term placement of peripherally inserted central catheters and the importance of nursing care and education. Cancer Nursing. 2011;34(1):E25-30.

13. Marshall C, Boldt-MacDonald K, McLenon R, Rennie E, Faraon M, Conoff S, et al. A multidisciplinary approach to determine heparin dosing in pediatric vascular devices. J Pediatr Oncol Nurs. 2011;28(1):53-7.

14. Petroulias PL. Use of Electronic Tablets for Patient Education on Flushing Peripherally Inserted Central Catheters. J Infus Nurs. 2017;40(5):298-304.

15. Gerceker GO, Sevgili SA, Yardimci F. Impact of flushing with aseptic non-touch technique using pre-filled flush or manually prepared syringes on central venous catheter occlusion and bloodstream infections in pediatric hemato-oncology patients: A randomized controlled study. Eur J Oncol Nurs. 2018;33:78-84.

16. Klein J, Jepsen A, Patterson A, Reich RR, Mason TM. Heparin Versus Normal Saline: Flushing Effectiveness in Managing Central Venous Catheters in Patients Undergoing Blood and Marrow Transplantation. Clin J Oncol Nurs. 2018;22(2):199-202.

17. Szeinbach SL, Pauline J, Villa KF, Commerford SR, Collins A, Seoane-Vazquez E. Evaluating catheter complications and outcomes in patients receiving home parenteral nutrition. J Eval Clin Pract. 2015;21(1):153-9.

18. Redkar R, Bangar A, Krishnan J, Raj V, Swathi C, Joshi S. Role of Chemoports in Children with Hematological/Solid Tumor Malignancies - Technical Implications and Complications: An Institutional Experience. J Indian Assoc Pediatr Surg. 2019;24(1):27-30.

19. Keeler M. Central line practice in Canadian blood and marrow transplant. Can Oncol Nurs J. 2014;24(2):67-77.

20. Hitchcock J. Preventing intraluminal occlusion in peripherally inserted central catheters. Br J Nurs. 2016;25(19):S12-S8.

21. Sirilerttrakul S, Jirajarus M, Ngamphiaboon N. Nurses role in declotting thrombotic occlusion via implanted port in ramathibodi hospital. Cancer Nurs. 2016;39 (6 Supplement 1):S16-S7.

22. Australian Commission on Safety and Quality in Health Care. Consultation Draft Peripheral Venous Accerss Clincial Care Standard. Sydney: Australian Commission on Safety and Quality in Health Care; 2019.

23. Bonciarelli G, Batacchi S, Biffi R, Buononato M, Damascelli B, Ghibaudo F, et al. GAVeCeLT consensus statement on the correct use of totally implantable venous access devices for diagnostic radiology procedures. J. 2011;12(4):292-305.

24. Cesaro S, Cavaliere M, Pegoraro A, Gamba P, Zadra N, Tridello G. A comprehensive approach to the prevention of central venous catheter complications: results of 10-year prospective surveillance in pediatric hematology-oncology patients. Ann Hematol. 2016;95(5):817-25.

25. Goossens GA, Jerome M, Janssens C, Peetermans WE, Fieuws S, Moons P, et al. Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial. Ann Oncol. 2013;24(7):1892-9.

26. Heibl C, Trommet V, Burgstaller S, Mayrbaeurl B, Baldinger C, Koplmuller R, et al. Complications associated with the use of Port-a-Caths in patients with malignant or haematological disease: a single-centre prospective analysis. Eur J Cancer Care (Engl). 2010;19(5):676-81.

27. Linnemann B. Management of complications related to central venous catheters in cancer patients: an update. Semin Thromb Hemost. 2014;40(3):382-94.

28. Mason TM, Ferrall SM, Boyington AR, Reich RR. Central Venous Access Devices: An Investigation of Oncology Nurses' Troubleshooting Techniques. Clin J Oncol Nurs. 2014;18(4):421-5.

29. Matey L, Camp-Sorrell D. Venous Access Devices: Clinical Rounds. Asia-Pac. 2016;3(4):357-64.

30. Milani A, Mazzocco K, Gandini S, Pravettoni G, Libutti L, Zencovich C, et al. Incidence and determinants of port occlusions in cancer outpatients. Cancer Nurs. 2017;40(2):102-7.

31. Rasero L, Golin L, Ditta S, Di Massimo DS, Dal Molin A, Piemonte G. Effects of prolonged flushing interval in totally implantable venous access devices (TIVADs). Br J Nurs. 2018;27(8):S4-s10.

32. Solinas G, Platini F, Trivellato M, Rigo C, Alabiso O, Galetto AS. Port in oncology practice: 3-monthly locking with normal saline for catheter maintenance, a preliminary report. J. 2017;18(4):325-7.

33. Teichgraber UK, Kausche S, Nagel SN. Evaluation of radiologically implanted central venous port systems explanted due to complications. J. 2011;12(4):306-12.

34. Lo Priore E, Fliedner M, Heverhagen JT, Novak U, Marschall J. The role of a surveillance programme for intro-ducing peripherally inserted central catheters: a 2-year observational study in an academic hospital. Swiss Med Wkly. 2017;147:w14441.

35. Canadian Vascular Access Association. Canadian Vascular Access and Infusion Therapy Guidelines. Pembroke, ON: Pappin Communications.; 2019.

36. Cope DG, Elledge CM, Thompson Mackey H, Moran AB, Rogers MA, Schulmeister L, et al. Access Device Standards of Practice for Oncology Nursing. Society ON, editor. Pittsburgh, Pennsylvania: Oncology Nurses Society.; 2017.

37. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy: standards of practice. J Infus Nurs. 2016;39(1S):S1-S159.

38. Keogh S, Mathew S. Peripheral intravenous catheters: A review of guidelines and research. Sydney: Australian Commission on Safety and Quality in Health Care; 2019.