July 27, 2016

Advanced Practice Nurse Creates and Validates Vascular Access Tool

Using algorithm improves pediatric IV starts

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During her 36 years as a pediatric nurse, Jane Hartman, MSN, RN, PNP-BC, has watched nurses struggle to start IV lines. “Because nurses are so task oriented, we will keep doing something over and over again until we get that box checked off,” says Hartman, an advanced practice registered nurse with Cleveland Clinic Children’s. “I’ve seen kids get poked five to 10 times – far too many.”

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When Hartman began working in the clinical nurse specialist role at Children’s four years ago, she developed the Hartman Baker Pediatric Peripheral Vascular Access Algorithm. Then, she initiated a pediatric vascular access quality improvement initiative and transitioned it into a research project to assess whether the algorithm increased first-attempt IV starts and decreased the overall number of IV attempts.

Vascular access is a top priority

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Jane Hartman, MSN, RN, PNP-BC

Some people are talented at playing the piano or painting. Hartman says her gift is starting an IV in children, often on the first try. She’s keenly aware of the importance of vascular access initiation for patients, their families and healthcare organizations.

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“The more IV attempts on a child, the tougher it is for the nurses to insert the IV, both physiologically and psychologically,” says Hartman. “At the same time, parents become more anxious, which creates more anxiety for the child.” That anxiety could lead to a lifetime fear of medical personnel and a compromise of satisfaction and confidence in healthcare personnel.

In addition, delays in venous access may cause delays in clinical treatments, which could prolong hospital length of stay or affect patient outcomes.

Algorithm focuses on the process, not the task

Hartman devised a formula to reduce the number of attempted IV starts, then turned it into an algorithm with help from colleague John Baker, MSN, MBA, RN, Assistant Nursing Director at Cleveland Clinic Children’s. “The algorithm helps people think of vascular access as a process instead of a task,” Hartman explains. “It sets you up to do the right thing for both the nurse and patient.”

The Hartman Baker Pediatric Peripheral Vascular Access Algorithm considers four factors:

  • The necessity of the IV
  • A comfort plan incorporating nonpharmacological and pharmacological interventions to help calm the patient
  • The patient’s grade, which determines the complexity of IV access
  • The expertise and skill level of the nurse in vascular access

The algorithm provides guidance for nurses on how many times they should attempt an IV, when to ask for assistance from a more experienced nurse or a member of the pediatric vascular access team, and when to stop and consult with a resident or attending physician about a change of the plan of care. The goal is to pair patients with the right nurse, who can competently start an IV, despite the patient’s IV access complexity. So, for instance, a novice nurse gets one chance to start an IV on a patient with a low vascular access grade (indicating greater likelihood of easier vascular access), and more experienced nurses are called in for patients with high grades.

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Selecting a specific nurse to start the IV rather than leaving the task to whomever is assigned to care for the patient makes sense, says Hartman. She cites an anecdotal example: “The national average for starting an IV on a dehydrated two-year-old is four pokes. Why would we want inexperienced pediatric nurses to start an IV in that situation? They’re not likely to get the IV started, and the patients and nurses would suffer.”

Study validates the algorithm and patient IV grading tool

Hartman conducted a two-cohort nonequivalent group comparative study at Cleveland Clinic Children’s. Pre-intervention group data, collected between October 2011 and March 2013, was used in the quality improvement initiative and also to compare differences in IV access with the post-intervention group. Post-intervention patient and nurse data were collected on 330 patients after implementation of the four-factor Hartman Baker Pediatric Peripheral Vascular Access Algorithm at the healthcare system’s main campus. Additionally, nurses provided a self-assessment of their general clinical and IV start competence.

Research findings provided assurance that the algorithm, which included the patient IV grading tool, was useful in guiding IV starts. The first-attempt IV start rate increased, and the number of IV attempts per patient decreased.

Based on research findings, Hartman is revising the algorithm. Patient grade and nurse experience information are being fine-tuned to optimize decisions that lead to pairing of nurses and patients for IV starts. Hartman also is making plans to implement the algorithm and collect data at Cleveland Clinic Fairview and Hillcrest regional hospitals. She believes the algorithm may also have value in adult populations. “Now that we’ve completed research and had great results, I really feel the algorithm could change local and national nursing practice,” says Hartman.

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