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A step-by-step guide to vascular access device audits

Posted by Gillian Ray-Barruel & Amanda Ullman on 8 June 2017
A step-by-step guide to vascular access device audits

Recent VA audits indicate that VA practice is not perfect, particularly in the areas of redundant devices, insertion site complications, substandard dressings, and poor documentation of site assessment (Alexandrou et al, 2015; McGuire, 2015; New et al, 2014; Russell et al, 2013; Ullman et al, 2017a).

Conducting VA audits can provide evidence that best practice VA policies and procedures are being effectively implemented in the workplace. Less than ideal audit results can provide direction where you need to refocus your efforts (Ray-Barruel, 2017a).

If you've decided to conduct a VA audit, it's best to take a systematic, cyclical approach, with the goal of continuous quality improvement to improve clinical practice and patient outcomes. A Cochrane systematic review confirmed that clinical audits, when done properly, can lead to small but important improvements (Ivers et al, 2012). An audit's effectiveness depends on several key criteria: management support; baseline performance; trained personnel collecting the data; data quality; frequency of auditing; and feedback processes (Ivers et al, 2012).

By following a simple cycle of Plan-Do-Study-Act, you can measure performance and implement practice improvements. Here are some simple steps for conducting a successful VA audit.

A. Plan
What's your audit focus? Are you checking for redundant devices? Soiled or loose dressings? Poor documentation? Don't try to audit too many processes at once. Select the topic that needs the most improvement, as this will increase interest and support from management and the clinical team (Verma, 2009). Early consultation with your local VA team or infection control team can prevent you trying to reinvent the wheel, because they'll know what VA topics are already being monitored in your hospital, and they will also be able to offer suggestions for how to proceed. 

Clinical practice guidelines can be used to develop audit criteria (Dixon et al, 2010). There are a range of VA guidelines available to guide your audit criteria (INS, 2016; RCN, 2016; Loveday et al, 2014).
Your audit is much more likely to succeed if the audit leader is passionate about VA practice and is prepared to take responsibility for driving the audit process and ensuring overall integrity and timeliness (Copeland, 2005). Auditing works best with a team approach, so involve clinicians, safety and quality experts, patient and family representatives, and management early in the planning process, and keep them informed of the progress (Verma, 2009). Identify clinical leaders and local champions who will drive support for your audit and planned improvements.

Before you start collecting data, you need to know how much data will provide an accurate estimation of clinical practice. Confidence levels provide a level of certainty that your results will be correct within a range of ± 5% accuracy (Dixon et al, 2010). Also consider the logistics of your audit. While it may be ideal to audit every patient in the hospital for a VA device, with limited resources it could be more feasible to limit your audit to one type of device or a handful of wards.

Surveys, checklists and chart reviews are popular for VA audits because they are simple to develop and use. However, it's important to test the tool for validity (does it really measure what it's supposed to measure) and reliability (does the tool get similar results when used by different people at different times?) (Bannigan & Watson, 2009; Rattray & Jones, 2007). Involve experts in your audit team and run practice tests of the tool, compare results, resolve discrepancies, and modify the tool if needed, before conducting your audit (Bannigan & Watson, 2009).

B. Do
When planning data collection, be sure to take into account the clinical, resource and institutional considerations. Ideally, two data collectors (an experienced clinical expert and an experienced data collector) should work together to collect data (Dixon et al, 2010). Open discussion with the audit leader regarding any concerns with the process or inconsistencies with data quality during the early stages will improve data collection. Either paper or electronic data collection tools can be used, with all data checked for entry errors such as missing data, extreme variations (high or low), and impossible results (e.g. age = 198 years) (Ray-Barruel et al, 2017b).

C. Study
After you've collected your data, review and analyse your findings. For instance, to determine the percentage of redundant devices, calculate the number of devices not in use divided by the total number of patients audited and multiply by 100. To determine the rate of redundant devices, keep track of the number of redundant devices over 1000 catheter days. The percentage is a snapshot, but the rate can provide useful information over time.

Benchmarking indicates how your unit's VA performance compares to other units. Internal benchmarking compares your own results over time via repeated audits. External benchmarking is a comparison of your data with external VA guidelines or similar hospitals. Either way, this can stimulate fruitful discussions and encourage the desire for implementing local strategies for improvement (Ettorchi-Tardy et al, 2012).

D. Act
Dare to share! Clinicians, patients and management have the right to know the audit results. Feedback should be seen as a chance for improvement, not punishment. For best effect, use a range of feedback strategies (Ivers et al, 2012), such as interactive workshops, in-service sessions, laminated displays, emails, newsletters, and screensavers. Displaying your unit's VA audit results in a prominent place, such as the hallway or staff tearoom, can stimulate participation, discussion and ownership of the findings and motivate people to embrace change (Ray-Barruel et al, 2017b).

Once you have identified areas needing improvement, work with your stakeholders to develop an action plan with clear targets and timeframes and person responsible (Benjamin, 2008). Brainstorming, benchmarking your findings, and keeping abreast of current literature can provide helpful ideas for improving practice. Education strategies and availability of resources must be carefully considered in any planned practice change. Again, it's best to implement changes incrementally rather than all at once. Be aware of factors that will encourage (supportive manager) or discourage the planned changes (such as too many changes at once), so you can devise appropriate strategies (Baker et al, 2015).

Once you've implemented a new process or practice change, evaluate the results at least once (and preferably on a regular basis) to see if you have been successful. Changes don't happen overnight. They require commitment and possibly some tweaking along the way. When you achieve the desired results, remember to share and celebrate your successes with the team. And move on to the next audit challenge!

Audits provide valuable information and direction for clinical practice improvements, but they must be carefully planned, keeping a clear goal in mind, and involving stakeholders at every step (Ullman et al, 2017b; Ray-Barruel et al, 2017b). Following a structured cycle for quality improvement such as the PDSA described above can greatly enhance the success of your VA audit, leading to sustainable improvements in clinical practice and better patient outcomes.

References
Alexandrou E, Ray-Barruel G, Carr PJ, et al. (2015). International prevalence of the use of peripheral intravenous catheters. J Hosp Med, 10(8), 530-33.

Baker R, Camosso-Stefinovic J, Gillies C, et al. (2015). Tailored interventions to address determinants of practice. Cochrane Database Syst Rev, 4:Cd005470.

Bannigan K, Watson R. (2009). Reliability and validity in a nutshell. J Clin Nurs, 18, 3237-43.

Benjamin A. Audit: how to do it in practice. Br Med J. 2008;336(7655):1241-5.

Copeland G. (2005) A practical handbook for clinical audit. NHS Clinical Governance Support Team.

Dixon N, Pearce M, Quest HQ. (2010). Guide to ensuring data quality in clinical audits. London: Healthcare Quality Improvement Partnership.

Ettorchi-Tardy A, Levif M, Michel P. (2012). Benchmarking: a method for continuous quality improvement in health. Healthcare Policy. 7(4), e101-e19.

Infusion Nurses Society. (2016). Infusion Therapy Standards of Practice. J Infus Nurs, 39(1S).

Ivers N, Jamtvedt G, Flottorp S, et al. (2012). Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev, 6:Cd000259.

Loveday HP, Wilson JA, Pratt RJ, et al. (2014). Epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals. J Hosp Infect, 86 (Suppl. 1), S170.

McGuire R. (2015). Assessing standards of vascular access device care. Br J Nurs, 24(8), S29-35.

New KA, Webster J, Marsh NM, Hewer B. (2014). Intravascular device use, management, documentation and complications: a point prevalence survey. Aust Health Rev 38(3), 345-9.

Rattray J, Jones MC. (2007). Essential elements of questionnaire design and development. J Clin Nurs, 16, 234-43.

Ray-Barruel G. (2017a). Using audits as evidence. Br J Nurs, 26(8), S3. (Invited editorial)

Ray-Barruel G, Ullman AJ, Rickard CM, Cooke M. (2017b). Clinical audits to improve critical care: Part 2: Analyse, benchmark and feedback. Aust Crit Care. In press. DOI: http://dx.doi.org/10.1016/j.aucc.2017.04.002

Royal College of Nursing. (2016). Standards for Infusion Therapy. RCN, London.

Russell E, Chan RJ, Marsh N, New K. (2013). A point prevalence study of cancer nursing practices for managing intravascular devices in an Australian tertiary cancer center. Eur J Oncol Nurs, doi: 10.1016/j.ejon.2013.11.010

Verma R. Data quality and clinical audit. Anaesthesia and intensive care medicine. 2009;10:400-2.

Ullman AJ, Cooke M, Kleidon T, Rickard CM. (2017a). Road map for improvement: Point prevalence audit and survey of central venous access devices in paediatric acute care. J Paediatr Child Health, 53(2), 123-30.

Ullman AJ, Ray-Barruel G, Rickard CM, Cooke M. (2017b). Clinical audits to improve critical care: Part 1: Prepare and collect data. Aust Crit Care, In press. DOI: http://dx.doi.org/10.1016/j.aucc.2017.04.003

Author: Gillian Ray-Barruel & Amanda Ullman
Tags: intravenous catheter vascular access devices central vascular access devices IV management dressings AVATAR group

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