Implementation of a vascular access team to support perioperative nursing care – a lean and evidence-based management approach

Introduction

Effective management of nursing staff in intensive care units (ICU) is becoming one of the key challenges of modern healthcare [1]. In the face of the growing demand for highly specialized care, staff shortages and increased complexity of procedures, it is necessary to implement modern management models that allow for the optimization of resource use and improvement of care quality [2]. Lean management and evidence-based management (EBM) are two management approaches that have been gaining importance in healthcare systems in recent years [3, 4]. Lean focuses on eliminating waste and standardizing processes [5], while EBM assumes making organizational decisions based on the best available evidence [6]. Integration of these concepts in clinical practice can significantly increase operational efficiency and strengthen the professional role of nurses, especially in high-risk environments such as ICU [7]. One example of the application of an integrated approach to nursing staff management is the implementation of a vascular access team (VAT) [8]. This team, based mainly on the competencies of nurses, is an innovative organizational solution that supports both the quality of care and the structure of the work of therapeutic teams [9]. This paper describes the model of implementation of the VAT team in an academic hospital, with particular emphasis on its importance as a management tool within the Lean and EBM concepts (Figure 1).
The aim of this paper is to discuss the implementation process of the VAT team in a clinical unit, to identify its key organizational functions, and to assess the potential benefits for the nursing staff management structure. In Poland, VAT teams are only beginning to appear in hospital practice, and this paper is one of the first descriptions of a comprehensive implementation model in our country. The aim of this paper is not only to present our experience, but also to create a practical guide for other facilities considering implementing this solution.

Material and methods

In the analyzed hospital unit, an interdisciplinary VAT was established, the core of which consisted of anesthesiology nurses with additional competencies in the field of midline cannulation [10] (Table 1).
As part of the implementation process, local clinical procedures were developed and a standard for the assessment of upper limb veins was implemented according to the RAPEVA protocol (Rapid Assessment of Peripheral Veins for Access) [11]. The vascular access team operated in the following modes: planned, urgent and acute, in accordance with the in-hospital/hospital notification system. As part of interdisciplinary cooperation, the VAT also supported surgical units, including general and vascular surgery departments, by providing vascular access for patients undergoing surgical procedures or in the postoperative period. The team’s responsibilities included scheduled preoperative cannulations, urgent insertions in cases of hemodynamic instability after surgery, and consultations in situations involving difficult venous access. This organizational model enabled a significant reduction in delays, relieved surgical and anesthetic teams from routine cannulation duties, and improved the coordination of perioperative care. The integration of VAT into surgical workflows aligns with Lean management principles by enhancing process efficiency and minimizing procedural waste. Cannulations were performed after qualification by the “infusion” nurse based on clinical documentation and ultrasound assessment [12]. The standard was to document vessel parameters, puncture location [13]. The team was trained in the cannulation technique, aseptic principles, assessment of difficult vascular access (DIVA) and documentation management [14]. Each nurse in the team was required to complete at least one annual training and ongoing substantive supervision by the team leader. The cannulation procedures were implemented in the operating room, with full equipment protection and in accordance with the Lean principles: standardization of activities, minimization of time and material consumption, elimination of errors [15]. The organizational structure of the team, the method of its integration with existing clinical paths and the supervision of the department management over the quality of the team’s activities were described. The implementation documentation, including VAT assessment forms, procedure cards and reporting data were also analyzed [16].

Implementation description

The implementation of the VAT team in the hospital structure was carried out in stages. In the first stage, an analysis of the frequency of DIVA cases was carried out and the number of complications related to unsuccessful cannulation attempts was assessed [17]. These data were used to justify the need to establish a team specializing in indirect cannulation procedures [10]. The next stage was to prepare the team – recruitment and training of nurses, creation of reporting paths and operating procedures [14]. The team was officially launched in the structure of the Department of Anesthesiology and Intensive Care, where it cooperated with surgical and internal medicine departments. During the implementation process, the VAT was also integrated into clinical pathways for surgical patients, providing vascular access support to surgical teams in both elective and emergency settings. A joint protocol was developed with surgical staff for patients scheduled for procedures, involving early referral for VAT assessment and vein mapping using the RAPEVA protocol. In postoperative settings, the VAT responded to referrals for difficult vascular access, significantly reducing the number of failed cannulation attempts by non-specialized personnel. This approach not only decreased vascular-related complications but also shortened patient preparation time for interventions and improved satisfaction among surgical and nursing staff (Table 2).
In the first weeks of operation, the team operated in pilot mode. Considerable interest and positive reception of the ward staff was noted, which indicated a reduction in frustration related to multiple puncture attempts, a reduction in the procedure time and an improvement in patient comfort [18]. In the next phase, the documentation was standardized, including the VAT assessment card, the report from the performed procedure and the ultrasound image archiving system [13]. Additionally, the team implemented internal quality audit mechanisms, which allowed for ongoing assessment of the correctness and effectiveness of the intervention [19]. The introduction of the RAPEVA protocol allowed for the unification of the criteria for the selection of vessels and increased the safety of the procedures [11]. Thanks to this, VAT nurses operated independently, in accordance with the established algorithms, without the need for each consultation with a physician [12]. Although the analysis of full efficiency data is planned in a separate publication, the following was observed already in the first months of the team’s operation:
Reducing the number of reports to medical teams in case of vascular access problems [18].
Reducing the number of complications associated with cannulation (e.g. extravasation, thrombosis) [20].
Increasing the number of procedures performed by nurses using ultrasound [21].
Improvement of patient and staff satisfaction, assessed on the basis of internal surveys [22]. The vascular access team was then included in the structure of permanent clinical services and included in the planning of human and equipment resources, with a separate budget and administrative responsibility [16].

Results

The implementation of the VAT team in the structure of the intensive care unit in accordance with the principles of Lean management and EBM is strongly confirmed by the results of international studies. The work of Smith et al. [23] proves that VAT teams play a much broader role than only technical insertion of venous catheters – they are active participants in decision-making, educational and quality processes in the field of vascular access [24].
In line with Lean management principles that promote waste elimination and decentralization of decisions, the effectiveness of VAT teams depends on integration with daily clinical and operational processes. In the review by Sou et al. [24] and the analysis of Lean catheter management implementation [25], it was shown that VAT teams that had a greater level of autonomy in selecting the type of catheter (e.g., peripherally inserted central catheter vs. midline) were more responsive to the actual needs of patients, based on clinical analysis rather than only on electronic physician orders.
In the hospital we discussed, similarly to the studies by Bell and Spencer [26], the VAT team not only performed cannulation procedures, but also implemented an educational strategy – aimed at medical and nursing staff and patients – supporting knowledge management in the spirit of EBM. The authors indicate that as many as 75% of VAT teams conducted informal consultations, and 58% – practical training. A similar model was used in our unit: the VAT team was the contact point for the staff, and its members conducted “point of care” education and documented activities using standardized forms, which enhanced the transparency and quality of activities.
Importantly, expert consensus studies [27] confirm that despite the high level of competence and commitment of VAT nurses, their full inclusion in decision-making processes is still limited by cultural resistance from physicians. This indicates the need not only for training and procedures, but also for a conscious change in organizational culture – which is the foundation of the Lean philosophy [28]. Similar findings were reported by Quinn et al. [29], who emphasized the role of decision- support systems in enhancing clinical autonomy among VAT nurses.
In our case, one of the key factors of the success of VAT implementation was the active involvement of management staff and enabling nurses to make independent clinical decisions based on data and protocols (RAPEVA, INS, MAGIC). Both our experience and data from system reviews [30] show that VAT can play not only an operational but also a strategic role: they can support patient safety, optimize the use of resources and act as an internal driver of innovation and change. Silva et al. [31] postulate formalization of roles and responsibilities of VAT teams, standardization of training and creation of decision support systems. We also observed the same needs during the pilot of the VAT team in our unit.
The implementation of the VAT team is an example of the effective application of Lean management and EBM principles in the practice of human resources management. The key element of the innovation of this model is the decentralization of clinical decisions and the strengthening of the role of nurses as independent professionals responsible for advanced vascular procedures [24, 26, 30]. The vascular access team, as an interdisciplinary structure, improves the path of treatment for patients requiring specialist vascular access. Its operation contributes to the better use of staff competencies, reducing the number of errors and complications, and increasing the availability of services [23, 28, 31].
Standardization of procedures using the RAPEVA protocol and the use of a notification system in a planned, urgent and acute mode enable flexible and at the same time structured resource management. From the point of view of strategic management, VAT can be considered as a tool for implementing quality and safety policy in ICU. This model harmonizes with the goals of modern HR strategies, which assume the development of competencies, professional empowerment and organizational efficiency [26, 32].
In the context of Lean management, VAT implements the principle of creating value for the patient while minimizing losses, both in terms of working time and the use of materials and medical interventions.
The presented implementation model, taking into account the specificity of the Polish healthcare system, can be used as:
Organizational chart – ready-to-adapt structure.
Competency guide – training and requirements template.
Process map – sequence of necessary actions.
Argumentative tool – a basis for justifying the need for VAT.

Conclusions

By implementing VAT, the institution can also strengthen the position of the nursing leader as a coordinator of processes and an advocate of clinical standards. The contemporary approach to nursing staff management promotes the idea of ​​“leadership at the point of care”, where decisions are made as close to the patient as possible, by competent professionals who are aware of the clinical context [23, 31]. Implementation limitations may result from the lack of a sufficient number of trained nurses and the need to ensure constant quality supervision. Integration of the VAT team with existing organizational structures and hospital procedures is also crucial. In the long term, the success of implementation depends on a coherent hazard ratio policy, continuous educational support and monitoring of implementation effects [32].
The presented experiences and developed solutions may constitute a valuable starting point for other Polish hospitals undertaking the implementation of VAT teams, shortening their implementation path and allowing them to avoid typical mistakes.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References