Initiation of an IV Access Scoring Tool and Vascular Access Algorithm in a - PowerPoint Presentation

1. Initiation of an IV Access Scoring Tool and Vascular Access Algorithm in a Pediatric Cardiac Stepdown UnitCatelyn VanDerKolk CPNP-AC, Meredith Broberg MD, Lisa Welsh RN, John Lozier MD, and Sarah Plummer MD

2. BackgroundIt is well known that patients with congenital heart disease or cardiac arrhythmias can decompensate quickly These patients require frequent reassessment of stability and need for IV accessFollowing incidents of delayed IV access in infants with cardiac disease, we pursued a protocol to determine need for IV access in our Stepdown Unit

3. AimsCreate and validate objective criteria for determining which patients need IV access in the Cardiac Stepdown Unit (CSDU)Create algorithms to ensure that IV access is obtained in a timely fashion

4. MethodsDeveloped and implemented 6/1/2020:Scoring system for IV access needs in CSDU patients AgeVital signsClinical statusUnderlying anatomyGuideline for obtaining IV access in the CSDULimited time per stepLimited number of attemptsFinite amount of time before calling for central line

5. Cardiac Stepdown Unit IV Access Scoring Tool +1+2+3TotalAge<1 year<4 months<1 month Arrhythmia Prior arrhythmia Recent SVT  FeedsVomiting or diarrhea Not tolerating goal feedsNPO for >8 hours Heart Lesion Unrepaired /PalliatedCyanotic or Single Ventricle FeverFever > 38.0 in past 48 hoursFever for > 12 hoursFever resistant to antipyretics Oxygen SupportNasal cannulaHFNC < 1L/kgHFNC > 1L/kg PEWSScore 2Score 3-4Score >4 Post-OperativePOD #8-10POD #4-7POD #0-3 Post-CathPOD #2-3POD #0-1Tachycardia10-20 bpm > prior 48 hour baseline or normal rate for ageMore than 20 bpm > prior 48 hour baseline or normal rate for age  Tachypnea5-10 bpm > prior 48 hour baseline or normal rate for ageMore than 10 bpm > prior 48 hour baseline or normal rate for age  The following patients must have intravenous access in place while on the CSDU:Chest tube in place < POD#7Pacing wires in placePulmonary hypertension on continuous infusion medications via home pump during titrationRequires intravenous medication or TPNSingle ventricle patient prior to Glenn (except when nearing discharge status, IV/line removal must be approved by HOME team)SCORING:Patient to be scored once per shift at initial assessment and then as needed.Score 0-4: Discuss need for access every 24 hoursScore 5-7: Discuss need for access every 8 hoursScore >8: Patient meets criteria for needing IV access, immediate team (nurse/resident/fellow/NP/attending) discussion to consider IV placement if not already in place

6. Cardiac StepDown Unit Vascular Access Algorithm*difficult intravenous accessGoal is to obtain vascular access within 3 hours of determination of needEach individual/team is limited to 2-3 attempts at obtaining access before moving to next stepAfterhours, skip unavailable steps as necessaryAfter failed attempts, resident/fellow/NP should be notified when moving to step in the algorithmIf vascular access not obtained within 2 hours, plan to call for ICU/interventional cardiology/pediatric cardiac anesthesia supportAt hour 3, should consider placing IO for access depending on patient statusNoUse Cardiac StepDown Unit IV Access Scoring Tool to determine patient’s individual need for IV access. If IV access is deemed necessary based on the score (IV access score >8), follow the algorithm below to obtain IV access in a timely fashion. YesIf comfortable, a bedside nurse may attempt PIV placement x 2 in 30 minute periodIs patient ill-appearing or IV access score >10?Pediatric Vascular Access Team may attempt PIV placement x 3 in 30 minute period (7am-11pm M-F, 9am-9pm Sat/Sun) Afterhours NICU/PICU nurse may attempt PIV placement x 2 in a 30 minute periodPICC Team may attempt PIV placement x 2 in 30 minute period if available within 30-60 minutes(7am-7pm M-F) Afterhours or if PICC team not available, NP/fellow may attempt PIV placement x 2 in 30 minute period if available within 30-60 minutesIs patient known to be a DIVA* NoYesCall PACT Consult for ICU evaluation/consideration of central venous access and to consider contacting interventional cardiology/pediatric cardiac anesthesia for support Consider IO placement if access not obtained within 3 hours depending on patient statusHour 2Hour 3

7. Thus far, CSDU nurse and team feedback has been positiveHave been able to use scoring tool to justify maintaining/obtaining IV access in more tenuous patientsHas empowered nurses to speak up about IV access needs/concernsHas prevented replacing IV access when not necessaryIV Access Project

8. Heart Center IV Access Project TeamSue Bergant, RNMeredith Broberg, MDRenee Devor, MDJess Gittinger, NPJohn Lozier, MDMoira McErlean, RNShelley Ohliger, MDSarah Plummer, MDDavid Speicher, MDCate VanDerKolk, NPLisa Welsh, RNThe following team members represent the pediatric cardiothoracic ICU, cardiac stepdown unit, vascular access, anesthesia, and nursing teams: