Restoring Patency to Central Venous Access Devices

With Cindy Winfield, RN, MN, CON(C) and Tayreez Mushani

2010-04-29 18:00:58 Stephanie@ONS Welcome to the ONS Virtual Journal Club!! THis evening we will be discussing Restoring Patency to Central Venous Access Devices with Cindy Winfield, RN, MN, CON(C) and Tayreez Mushani. Please feel free to start asking questions to the authors. Welcome!!
2010-04-29 18:05:21 Stephanie@ONS What is the clinical problem that is addressed in the article?
2010-04-29 18:07:08 cwinfield this article looks at addressing de-clotting of central lines as an economical and patient centered way to maintain patency to central catheters using t-PA
2010-04-29 18:09:01 Stephanie@ONS How did you collect the evidence about the problem of de -clotting?
2010-04-29 18:10:29 tayreez We used evidence from the literature. Primarily studies known as COOL-1 & COOL-2 . These were research studies looking at the safety and efficacy of tPA use in central lines for cancer patients.
2010-04-29 18:11:01 Stephanie@ONS Steph199 do you have any questions for the authors?
2010-04-29 18:13:24 steph199 How many patients in the study, was this doctor office pt and hospital?
2010-04-29 18:15:46 cwinfield The COOL 2 study involved 995 patients from various hospitals with central lines. Study patients were not recruited from physician offices.
2010-04-29 18:18:25 cwinfield Our interest in this work was initially as a result of Hoffman LaRoche seeking a steering committe to develop guidelines for use of Cathflo to declot lines. We were able to work with colleagues across Canada to develop the guidelines and saw rapid uptake in our own organization.
2010-04-29 18:19:57 tayreez What we found missing was a standard, evidence based protocol to use when declotting central lines. By coming together as a national group, we were able to develop consensus based guidelines for use across the country.
2010-04-29 18:22:37 cwinfield From nurses' perspective a new option became available for patients as the protocol allowed for the declotting agent to dwell overnight. Thus patients were not obligated to remain at the hospital for hours waiting for line clearance. Nurses were able to reschedule patinet appointments to the next day. This was very satisfying to the nurses and to the patients.
2010-04-29 18:22:55 Stephanie@ONS What complications were you finding patients experiencing?
2010-04-29 18:24:19 Stephanie@ONS Welcome to the chat racyrn!
2010-04-29 18:25:27 tayreez Stephanie, I'm interpreting your question to mean complications from clotted lines. In that case, treatment delays was the biggest factor as venous access was not available and patients had to wait for the line to be cleared or for the insertion of a new line.
2010-04-29 18:27:20 cwinfield In the clinical trials, there were no major bleeding complications identifed that were related to Cathflo. As well, the drug has a very short half life and is rapidly metablolized. Caution is necessary with patients at risk of bleeding or in those with a suspected infection in their line.
2010-04-29 18:28:00 Stephanie@ONS racyrn, do you have any questions for the authors?
2010-04-29 18:28:26 racyrn I do not at this time
2010-04-29 18:30:55 tayreez This research project enabled us to address the nurses' fears about using an agent such as tPA for declotting as they were concerned about the potential of internal bleeding. By presenting the evidence on the safety of the dose used, the nurses' concerns were addressed.
2010-04-29 18:32:23 Stephanie@ONS Did this study enable you to bring about a national standard or guideline?
2010-04-29 18:34:22 cwinfield While there really is no mechanism for a national standard, this national group reached consensus and published this paper. Although not an official guideline there is certainly a great deal of Canadian wide input and acceptance of the recommendations contained in this paper.
2010-04-29 18:36:13 Stephanie@ONS How did the protocol, in the article, come about?
2010-04-29 18:39:01 tayreez The goal for the consensus group was to develop easy-to-follow guidelines that could be used by a nurse caring for cancer patients in any setting and not just on an oncology unit. The evidence provided by the trials enabled us to map out the protocol contained in the paper. We brainstormed the scenarios and applied the evidence to formulate the protocol.
2010-04-29 18:40:42 steph199 was t-PA used on any ports
2010-04-29 18:41:25 cwinfield When we first looked at de-clotting lines we realized there were a number of unanwered questions. One particulary was whether or not a physician's order was required for the declotting agent. The algorithm ultimately calls for this but there are organizations from our group who do not require a doctor's order.
2010-04-29 18:41:54 tayreez Yes, tPA is used in ports. The volume is larger due to the nature of the device.
2010-04-29 18:42:38 Stephanie@ONS Steph199 and racyrn have either of you used this in your practice?
2010-04-29 18:43:17 steph199 No, any decloting if done was done in Specials in Radiology
2010-04-29 18:44:00 racyrn I have not used t-pa in ports, only in PICC and tunnelled catheters
2010-04-29 18:45:16 tayreez In our experience, the preference of interventional radiologists was to pull the lines and replace them. It was the nurses who were advocating to somehow save the lines and tPA provided an answer.
2010-04-29 18:46:15 cwinfield Racyrn and Steph 199, is the instillation of Cathflo a skill that requires certification within your organizations?
2010-04-29 18:47:17 racyrn no, all nurses who have been checked off on central line and central line blood draws may instill cathflo into a central line
2010-04-29 18:47:52 tayreez Is your protocol similar to what is in the article?
2010-04-29 18:48:29 steph199 As I understand it, CL or ports are decloted in radiology, cathflo not used on the floors
2010-04-29 18:49:18 cwinfield Steph 199, just wondering how that practice came about-is there a specific rationale that you can share?
2010-04-29 18:49:25 racyrn it is. Our pharmacy has an order set for it, and we just get an order for "t-pa per pharmacy"
2010-04-29 18:51:46 steph199 small hosp,, yrs back had a an IV team and they would attempt to declot, no IV team for several years (cost cutting) but Rad Specials now inserts picc, cl, and declots
2010-04-29 18:52:17 steph199 and they have been doing this for quit awhile now
2010-04-29 18:53:21 tayreez What is your opinion on this? Given that it is a skill nurses can easily acquire, is this the best use of the Radiology department and is this being done by physicians only?
2010-04-29 18:54:50 steph199 However, they do use an outside company that can be used to insert piccs if approved by rad.........they are he ones that would call the company when lines needed. if pt has poor access then it's done down in rad under floroscopy...
2010-04-29 18:54:58 racyrn I would think it would increase the cost to the patient, and is a skill a nurse can acquire.
2010-04-29 18:57:20 cwinfield Agree racyrn. In Canada we have a different payment system so the patient does not absorb the cost of the procedure. I imagine if I were a patient I would question the need for the involvment of a physician when nurses competently and safely perform this task.
2010-04-29 18:57:51 Stephanie@ONS We will be starting the ONS Hot Topic Chat in a few minutes.
2010-04-29 18:58:04 Stephanie@ONS Are there any final questions for the authors?
2010-04-29 18:59:22 steph199 Thank you for your time, it has been informative
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