These guidelines are not binding for nurses, other health providers or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from RNAO. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses' Association of Ontario (RNAO). Vascular access. 2nd ed. Toronto (ON): RNAO; 2021.This work is funded by the Government of Ontario. All work produced by RNAO is editorially independent from its funding source.In the context of RNAO best practice guideline development, the term "conflict of interest" (COI) refers to situations in which a RNAO staff member or expert panel member's financial, professional, intellectual, personal, organizational or other relationships may compromise their ability to conduct panel work independently. Declarations of COI that might be construed as constituting a perceived and/or actual conflict were made by all members of the expert panel prior to their participation in guideline development work using a standard form. Expert panel members also updated their COI at the beginning of each expert panel meeting. Any COI declared by an expert panel member was reviewed by the RNAO Best Practice Guideline Development and Research Team and expert panel co-chairs. No limiting conflicts were identified. See "Declarations of Conflicts of Interest Summary" at / guidelines/vascular-access-second-edition.# Vascular Access

# Second Edition
Vascular Access -Second Edition

# Greetings from Doris Grinspun, Chief Executive Officer, Registered Nurses' Association of Ontario
The Registered Nurses' Association of Ontario (RNAO) is delighted to present the second edition of the clinical best practice guideline (BPG) Vascular Access, Second Edition. Evidence-based practice supports the excellence in service that health providers are committed to delivering every day.
We offer our heartfelt thanks to the many stakeholders who make our vision for BPGs a reality. First, and most important, we thank the Government of Ontario that recognized in 1999 RNAO's capacity to lead a program that has gained worldwide recognition and is committed to funding it. We also thank the co-chairs of the RNAO expert panel, Nancy Moureau, RN, PhD (chief executive officer, PICC Excellence) and Darlene Murray, RN, MSN (interprofessional education specialist, The Hospital for Sick Children), for their invaluable expertise and stewardship of this BPG. Thanks to RNAO staff Amy Burt (guideline development lead), Christine Buchanan (guideline development methodologist), Verity Scott (guideline development project coordinator), Glynis Gittens (guideline development project coordinator), Nafsin Nizum (senior manager, guideline development and research) and the rest of the RNAO best practice guideline development and research team for their intense and expert work in the production of this BPG. Special thanks to the expert panel for generously providing their time, knowledge and perspectives, especially during these challenging times of the COVID-19 pandemic, to deliver a rigorous and robust evidence-based resource that will guide the education and practice of health providers. We couldn't have done it without you! Successful uptake of BPGs requires a concerted effort from educators, clinicians, employers, policy-makers, researchers and funders. The nursing and health communities, with their unwavering commitment and passion for excellence in patient care, provide the expertise and countless hours of volunteer work essential to the development of new and next edition BPGs. Employers have responded enthusiastically by becoming Best Practice Spotlight Organizations (BPSO  ) -with over a 1,000 service and academic institutions in Canada and abroad. BPSO have sponsored best practice champions, implemented BPGs, and evaluated their impact on patient and organizational outcomes. Governments at home and abroad have also joined in this awesome journey. Together, we are building a culture of evidence-based practice that benefits everyone.
We invite you to share this BPG with your colleagues from nursing and other professions, with the patient advisors who are partnering within organizations, and with the government agencies with which you work. We have so much to learn from one another. Together, we must ensure that the public receives the best possible care every time they come in contact with us-making them the real winners of this great effort!

# Table of Contents
Vascular Access -Second Edition 

# Table of Contents
Vascular Access -Second Edition 

# How to Use This Document
This best practice guideline G - (BPG) is a comprehensive document that provides guidance and resources for evidence-based nursing practice G . It is not intended to be a manual or "how-to" guide; rather, it is a tool to guide best practices and enhance decision making for nurses G , the interprofessional team G , educators, health-service organizations G , academic institutions, and persons G and their families G or caregivers G This BPG should be reviewed and applied in accordance with the needs of individual health-service organizations, academic institutions or other practice settings, and with the preferences of persons with a vascular access device G (VAD). This document provides evidence-based recommendation G statements and descriptions of: (a) practice, education and organizational policy; (b) benefits and harms; (c) values and preferences; and (d) health equity considerations.
Nurses, other members of the interprofessional team, educators and administrators who lead and facilitate practice changes will find this document invaluable for developing policies, procedures, protocols and educational programs to support service delivery. Nurses and other members of the interprofessional team in direct care will benefit from reviewing the recommendations and supporting evidence.
The RNAO convened an expert panel to determine the scope of the second edition of this BPG and to develop recommendation questions G to inform the systematic reviews G . The expert panel was interprofessional in composition. It was composed of individuals with knowledge and experience in clinical practice, education, research and policy across a range of health-service organizations, academic institutions, practice areas and sectors. These experts shared their insights on supporting and caring for persons with a VAD across the continuum of care (see page 24 for the list of RNAO best practice guideline expert panel members).
A comprehensive review and analysis was completed by the RNAO best practice guideline development and research team and the expert panel to determine the scope and priority recommendation questions for this BPG (see Appendix C).

# Scope
To determine the scope of this BPG, the RNAO best practice guideline development and research team conducted the following steps:
 reviewed the previously published RNAO BPGs: Care and Maintenance to Reduce Vascular Access Complications (1) and Assessment and Device Selection for Vascular Access (2);
 conducted an environmental scan of existing guidelines;
 led 11 telephone key informant interviews with health providers G , administrators, educators and researchers;
 held three telephone discussion groups with nursing students, health providers, managers, administrators and educators; and
 consulted with the expert panel.
As with all procedures, health providers must be aware of scope of practice and follow regulatory body guidelines. Health providers should only be caring for or inserting VADs for which they have the necessary knowledge, skill and judgement. Health providers should also follow organizational policies and procedures related to VAD insertion and maintenance. This BPG addresses recommendations requiring advanced skill.

# CAUTION BAC K G R O U N D
Vascular Access -Second Edition  Recommendation Question #6: Should the use of visualization technologies (e.g., ultrasound and vein finders) for the insertion of peripheral vascular access devices be recommended?
Outcomes: Success rate on the first attempt/number of failed attempts, patient satisfaction and complications.
 Recommendation Question #7: Should pain management strategies (including pharmacological and nonpharmacological strategies) during the insertion of a vascular access device be recommended?
Outcomes: Patient's rating of pain, patient comfort, fear/anxiety (related to poke/needle phobia) and patient satisfaction.
Note: These priority recommendation questions are condensed versions of the more comprehensive PICO research questions developed by the expert panel to guide the systematic reviews and development of this BPG. For the PICO research questions and the detailed process of how the expert panel determined the priority recommendation questions and outcomes, see Appendix C.

# Good Practice Statement and Recommendations
The recommendations and resources in this BPG address topics such as the insertion, assessment, maintenance and management of VADs. Specifically, the guideline focuses on the following areas:
 person and family education about VADs;
 specialized training requirements for health providers;
 daily review of PVADs;
 the use of visualization technologies to insert PVADs and peripheral arterial catheters;
 the use of VADs for obtaining blood samples; and
 pain management strategies during the insertion of a VAD.
The evidence-based recommendations in this BPG are applicable to all practice settings where persons with a VAD are accessing services (e.g., acute care, long-term care, rehabilitation, primary care and community settings).
In this BPG, no recommendation questions were identified that addressed the need for conducting an assessment of persons prior to initiating vascular access. Please refer to the good practice statement on assessment that nurses and other members of the interprofessional team can use in their practice. The good practice statement is believed to be so beneficial that conducting a systematic review to prove its efficacy would be unreasonable. The resulting statement is not based on a systematic review, and it does not receive a rating of the certainty or confidence in the evidence or strength (i.e., a rating of conditional or strong) (7).

# RNAO BPGs and Other Resources That Align with This BPG
Other RNAO BPGs and evidence-based resources may support implementation of this BPG. See Appendix B for RNAO BPGs and other evidence-based resources on the following related topics:
 client-centred learning;
 pain management;
 strategies to support self-management in chronic conditions;
 implementation science, implementation frameworks and resources;
 interprofessional collaboration; and
 person-and family-centred care G .

# BAC K G R O U N D
Vascular Access -Second Edition

# Interpretation of Evidence and Recommendation Statements
RNAO BPGs are developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) G methods. For more information about the guideline development process, including the use of GRADE methods, refer to Appendix C.

# Certainty of Evidence
The certainty of evidence (i.e., the level of confidence we have that an estimate of effect is true) for quantitative research is determined using GRADE methods (8). After synthesizing the evidence for each prioritized outcome, the certainty of evidence is assessed. The overall certainty of evidence is determined by considering the certainty of evidence across all prioritized outcomes per recommendation. GRADE categorizes the overall certainty of evidence as high, moderate, low or very low (see Table 1 for the definition of these categories).

# Table 1: Certainty of Evidence

# CERTAINTY OF EVIDENCE DEFINITION High
We are very confident that the true effect lies close to that of the estimate of the effect.

# Moderate
We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

# Low
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

# Very Low
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
Source: Reprinted from: The GRADE Working Group. Quality of evidence. In: Schunemann H, Brozek J, Guyatt G, et al., editors. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach . ; 2013 . Table 5.1, Quality of evidence grades. Available from: #h.wsfivfhuxv4r. Reprinted with permission.

# Note:
The assigned certainty of evidence can be found directly below each recommendation statement. For more information on the process of determining the certainty of the evidence and the documented decisions made by RNAO guideline development methodologists, please see Appendix C.

# BAC K G R O U N D
Vascular Access -Second Edition

# Strength of Recommendations
Recommendations are formulated as strong or conditional by considering the certainty of evidence and the following key criteria (see Discussion of Evidence, below, for definitions):
 balance of benefits and harms,  values and preferences, and  health equity.
According to Schunemann et al., "a strong recommendation reflects the expert panel's confidence that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention)" (8). In contrast, "a conditional recommendation reflects the expert panel's confidence that the desirable effects probably outweigh the undesirable effects (conditional recommendation for an intervention) or undesirable effects probably outweigh desirable effects (conditional recommendation against an intervention), but some uncertainty exists" (8). Table 2 outlines the implications of strong and conditional recommendations.  There is little variability in values and preferences among persons in this situation.
 There is a need to consider the person's circumstances, preferences and values.
 The benefits of a recommended course of action probably outweigh the harms. Therefore, some persons could receive the recommended course of action.
 There is greater variability in values and preferences, or there is uncertainty about typical values and preferences among persons in this situation.
 There is a need to consider the person's circumstances, preferences and values more carefully than usual.

# For persons receiving care
 Most persons would want the recommended course of action, and a small portion would not.
 The majority of persons in this situation would want the suggested course of action, but many would not.
For policy-makers  The recommendation can be adapted as policy in most situations  Policy-making will require substantial debate and involvement of many stakeholders. Policies are also more likely to vary between regions.
Source: Adapted from: The GRADE Working Group. Quality of evidence. In: Schunemann H, Brozek J, Guyatt G, et al., editors. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach . ; 2013 . Table 6.1, Implications of strong and weak recommendations for different users of guidelines. Available from: / handbook.html#h.wsfivfhuxv4r

# BAC K G R O U N D
Vascular Access -Second Edition Note: The strength of each recommendation statement is detailed directly below it and in the Summary of Recommendations (page 13). For more information on the process used by the expert panel to determine the strength of each recommendation, please see Appendix C.

# Discussion of Evidence
The Discussion of Evidence that follows each recommendation includes the following main sections:
- Benefits and Harms: Identifies the potential desirable and undesirable outcomes reported in the literature when the recommended practice is used. Content in this section solely includes research from the systematic review.

# Values and Preferences:
Denotes the relative importance or worth placed on health outcomes derived from following a particular clinical action from a person-centered perspective. Content for this section may include research from the systematic reviews and, when applicable, observations and/or considerations from the expert panel.

# Health Equity:
Identifies the potential impact that the recommended practice could have on health across different populations or settings and/or the barriers to implementing the recommended practice in particular settings. This section may include research from the systematic reviews and, when applicable, observations and/ or considerations from the expert panel.

# Expert Panel Justification of Recommendation:
Provides a rationale for why the expert panel made the decision to rate a recommendation as strong or conditional.
Practice Notes: Highlights pragmatic information for nurses and other members of the interprofessional team. This section may include supporting evidence from the systematic review and/or from other sources (e.g., the expert panel).
Supporting Resources: Includes a list of relevant resources (e.g., websites, books and organizations) that support the recommendations. Content listed in this section was assessed based on five criteria: relevancy, credibility, quality, accessibility and timeliness of publication (i.e., published within the last 10 years). Further details about this process and the five criteria are outlined in Appendix C. The list is not exhaustive and the inclusion of a resource in one of these lists does not imply an endorsement from RNAO. Some recommendations may not have any identified supporting resources. Note: all supporting resources are freely available or open access unless otherwise noted.

# BAC K G R O U N D
Vascular Access -Second Edition

# Summary of Recommendations

# GOOD PRACTICE STATEMENT
The expert panel recommends health providers complete a systematic assessment of the person prior to inserting a vascular access device .
As a good practice, this statement does not require application of the GRADE system . For more information on the good practice statement in this BPG, please see page 37 .

# RECOMMENDATIONS STRENGTH OF THE RECOMMENDATION Recommendation Question #1:
Should providing education to persons and their families about their vascular access device be recommended?
Outcomes: Hospital re-admission rate and complications .

# Recommendation 1.1:
The expert panel recommends that health providers provide comprehensive health teaching to persons and their families/caregivers about their vascular access device .

# Strong
Recommendation Question #2:
Should practical education for the insertion and management of vascular access devices for health providers be recommended?
Outcomes: Complications (including insertion-related complications), number of successful observed attempts and provider attitude/confidence .

# Recommendation 2.1:
The expert panel recommends health-service organizations implement practical education on the insertion and/or management of vascular access devices for health providers .

# Strong
Recommendation Question #3:
Should vascular access specialist teams be recommended?
Outcomes: Complications (including insertion-related complications) and number of successful observed attempts .

# Recommendation 3.1:
The expert panel suggests that acute care health-service organizations implement vascular access specialists or vascular access specialist teams to support the insertion and management of vascular access devices .

# Conditional BAC K G R O U N D
Vascular Access -Second Edition

# Recommendation Question #4:
Should blood draws from a vascular access device versus blood draws from venipuncture be recommended?
Outcomes: Specimen rejection, patient satisfaction, contamination rate (specific to blood cultures) and dwell time .

# Recommendation 4.1:
The expert panel suggests health providers perform venipuncture when drawing blood samples to maintain specimen integrity .

# Conditional
Recommendation Question #5:
Should the daily review of peripheral vascular access devices by health providers be recommended?
Outcomes: Complications .

# Recommendation 5.1:
The expert panel recommends that acute care health-service organizations implement a multi-component peripheral vascular access device care protocol . This protocol includes a minimum of a daily review by health providers, in collaboration with persons and their families .

# Strong
Recommendation Question #6:
Should the use of visualization technologies (e .g ., ultrasound and vein finders) for the insertion of peripheral vascular access devices be recommended?
Outcomes: Success rate on the first attempt/number of failed attempts, patient satisfaction and complications .

# Recommendation 6.1:
The expert panel recommends that health providers use ultrasound-guided technique for the insertion of peripheral arterial catheters .

# Strong

# Recommendation 6.2:
The expert panel suggests that health providers use ultrasound-guided technique for the insertion of peripheral vascular access devices in persons with difficult intravenous access .

# Conditional BAC K G R O U N D
Vascular Access -Second Edition Recommendation Question #7:
Should pain management strategies (including pharmacological and non-pharmacological strategies) during the insertion of a vascular access device be recommended?
Outcomes: Patient's rating of pain, patient comfort, fear/anxiety (related to poke/needle phobia) and patient satisfaction .

# Recommendation 7.1:
The expert panel recommends that health providers offer adults nonpharmacological and pharmacological pain management strategies during the insertion of a vascular access device .

# Strong

# Recommendation 7.2:
The expert panel recommends that health providers offer non-pharmacological and pharmacological pain management strategies during the insertion of a vascular access device to infants and children, tailored to their age and developmental stage .
Strong BAC K G R O U N D Vascular Access -Second Edition

# Best Practice Guideline Evaluation
As you implement the recommendations in this BPG, we ask you to consider how you will monitor and evaluate its implementation and impact.
The Donabedian model, which informs the development of indicators for evaluating quality health care, includes three categories: structure, process and outcome (9).
 Structure describes the required attributes of the health system or health-service organization to ensure quality care. It includes physical resources, human resources, and information and financial resources.
 Process examines the health-care activities being provided to, for and with persons or populations as part of the provision of quality care.
 Outcome analyzes the effect of quality care on the health status of persons and populations, health workforce, health-service organizations or health systems (9).
For additional information, please refer to the RNAO, in partnership with Healthcare Excellence Canada (HEC), Leading Change ToolkitTM (10).
The following indicators have been developed to support evaluation and quality improvement. Consider Tables 3, 4 and 5, which provide a list of structure, process and outcome indicators to assess the impact of BPG implementation and are derived from BPG recommendations. Each table also identifies if the indicator aligns with other indicators in local, provincial, national and/or international data repositories and/or instruments. Alignment with data repositories/instruments is determined by comparing the following criteria with the developed indicators: the operational definition; if the indicator is nursing sensitive; and the inclusion/exclusion criteria. Depending upon the level of alignment, an indicator may be described to have full, partial or no alignment with external data repositories/ instruments.
The following indicators will support quality improvement and evaluation. Select the indicators most relevant to the changes being made in practice, education and/or policy based on BPG recommendations that are prioritized for implementation.

# BAC K G R O U N D
Vascular Access -Second Edition Table 3 provides structure indicators associated with specific recommendation statements that are related to human resources, educational recommendations and/or other organizational factors.  
BAC K G R O U N D Vascular Access -Second Edition
Table 5 provides outcome indicators to assess the impact of implementing evidence-based practice changes. 

# Stakeholder Acknowledgment
As a component of the guideline development process, feedback was obtained from participants across a wide range of health-service organizations, academic institutions, practice areas and sectors. Participants include nurses and other members of the interprofessional team, educators, students, individuals with lived experience and knowledgeable administrators. Stakeholders G representing diverse perspectives were also solicited for their feedback (see Appendix C). RNAO wishes to acknowledge the following individuals for their contribution in reviewing this BPG.

# BAC K G R O U N D
Vascular Access -Second Edition

# Background Context Vascular Access and Vascular Access Devices
Vascular access is the most common invasive procedure undergone by persons in the health system (12). Vascular access devices (VADs) are catheters inserted into central or peripheral veins or arteries that can be implanted or inserted under the skin (3). Catheters inserted into veins can be used to deliver fluids and medicines directly into the bloodstream of a person (3). Catheters inserted into arteries can be used to monitor therapy and patient status (i.e., hemodynamics) (3). There are different types of VADs that are used depending on the person's need. This includes devices such as:
 peripheral vascular access devices (PVADs), such as short peripheral intravenous catheters (PIVs) and extended dwell, midline catheters;
 central vascular access devices (CVADs), such as peripherally inserted central catheters (PICCs), tunneled catheters, non-tunneled catheters and implanted vascular access devices (IVADs);  peripheral arterial catheters; and  phlebotomy devices.
Appendix F provides an overview of the VADs listed above.
In the simplest sense, a VAD consists of a hub, a hollow tube divided into one or multiple sections (lumens) and a tip that may terminate within a peripheral or central blood vessel (13). VADs can be classified differently based on the insertion site and location of the device (13). PVADs remain in the periphery, with the terminal tip below the level of the axillary vein for upper extremity placement (14). CVADs are inserted with the terminal tip entering central circulation and advancing towards the heart. Except for haemodialysis catheters, terminal tip placement of all CVADs is in the vena cava (14).
Infusion therapy using VADs has historically been delivered in a hospital setting. However, infusion therapy and use of VADs increasingly is expanding into alternative health settings, including community care, infusion clinics and self-administration in the home (15). With wider use of VADs and a changing health landscape, it is important to recognize and support nurses, other members of the interprofessional team, and persons with vascular devices and their families with the administration of therapies involving VADs (15).

# Complications
Reliable vascular access is fundamental for safe and effective care (13). Ensuring safe insertion and management of VADs should be a priority for all health providers. Despite their important role, VADs are often the source of hospital-acquired infections and other types of complications G (13). In the United States, approximately 250,000 catheter-related blood stream infections occur each year, with an associated increase in length of stay and hospital costs (16).
Central line-associated blood stream infections (CLABSI) G are associated with particularly high morbidity and mortality: mortality is estimated to be between 4% and 20% (17). One CLABSI case prolongs hospitalization by an average of seven days and costs an estimated $3,700 USD to $29,000 USD (17). Other complications that can occur during the insertion or management of CVADs include catheter occlusion, catheter breakage/leakage, bleeding,
BAC K G R O U N D
Vascular Access -Second Edition thrombosis or thrombo-embolism, perforation of vessels, pneumothorax, cardiac arrhythmias, air embolisms and central venous stenosis (12). Safe vascular access and management is integral to ensure low risk and better outcomes for persons receiving care: care bundles or multi-component care protocols G have been widely used to address these complications in CVADs.
Common complications associated with PVADs include phlebitis G , infiltration G and extravasation G (18). Phlebitis is the most common complication of PVADs, occurring when there is acute inflammation of a vein in the presence of intravenous therapy (19). Infiltration occurs when infusing fluids leak into the surrounding tissue, caused by dislodgment of the VAD catheter, improper placement or damage to the vessel (18). Finally, extravasation occurs when there is infiltration of a vesicant G medication or other agent that can cause tissue damage, pain, inflammation, irritation, blistering or necrosis (18).

# Holistic and Person-and Family-centred Care
Person-and family-centred care means that the health provider is attentive to the emotional needs of the person with a VAD and their family or caregiver(s) (15). The nurse and other members of the interprofessional team play a large role in delivering care that is holistic and person-and family-centered. The selection, insertion and management of VADs by health providers have important implications for the person receiving care and their family. A person's preferences of VADs are unique and will depend on their diagnosis and intended treatment (12), their reasons for requiring a VAD, their health care context and their prior experience. As such, a person's preferences regarding infusion therapy may differ from those of health providers (15).
It is important to consider a variety of factors when choosing which VAD is most appropriate for a person. This consideration should be based on their condition as well as principles of person-and family-centred care. The use of only one device may not meet the vascular access needs of the person, necessitating the use of several devices throughout therapy (20). Considerations about preserving and minimizing vessel trauma, such as protocols that limit the number of VAD insertion attempts by a health provider, are also important (20).
VAD considerations are also likely to change across a person's lifespan. PVAD insertion can be more difficult in children due to their thin blood vessels, the deepness of the vessels, the cooperation level of the child (21), and because young children such as infants and toddlers have more subcutaneous tissue than older children and adults (22). Additionally, the type and frequency of complications in pediatric populations may differ from adults. These complications may be influenced by the smaller vessel size inherent in children and the length of therapy, and they most commonly include occlusion, migration, thrombosis and infection of CVADs (20).
Establishing and maintaining vascular access in older adults can also be challenging (23). Aging causes changes to the skin, vein walls and circulation; the skin loses tone and elasticity, and it becomes more fragile and prone to bruising (23). This can create problems when trying to establish VADs. In addition, older adults are more likely to have comorbidities and a weakened immune system, putting them at greater risk for infection (23). Finally, certain populations may require increased considerations when choosing and maintaining VADs. Some conditions associated with difficult intravenous access G (DiVA) include obesity, chronic illness, hypovolemia, substance use and vasculopathy (24).

# BAC K G R O U N D
Vascular Access -Second Edition

# Vascular Access Specialization
A vascular access specialist team (VAST) G refers to a grouping of health providers who have advanced knowledge and skills in the assessment, insertion, care and management of VADs, such as intravenous therapy teams and individual vascular access specialists (VAS) G (nurses, physicians, respiratory therapists, technicians and physician assistants) (3). Some organizations may implement VASTs or VAS to assist the interprofessional team in caring for persons with VADs. It is important that both nurses and the other members of the interprofessional team have the critical thinking skills to perform comprehensive vascular access assessments, and that they collaborate on necessary comprehensive assessments related to appropriate VAD selection. This includes prescribed therapy, person preference, language barriers and other variables (1). These specialist health providers or individual health providers can also be leaders of excellence and quality of care in vascular access within an organization (25).

# Conclusion
There is a need for up-to-date evidence to guide health provider practices regarding safe vascular access. This guideline aims to provide nurses (e.g., nurse practitioners, registered nurses, registered practical nurses and nursing students) and other members of the interprofessional team with evidence-based recommendations and resources related to the insertion, assessment and maintenance of VADs across the lifespan of individuals.

# Guiding Framework and Principles

# Guiding Frameworks
Acquisition of training and skills for VAD insertions and management is necessary to establish and maintain competence and ensure the safety of the person with a VAD. The supervisor or trainer is responsible for identifying the level of clinical competence of the learner as they guide them to higher levels of competence. Global rating scales are a helpful tool to document competence for certain procedures (such as ultrasound-guided peripheral catheter insertions). These scales are used as formal evaluation instruments to determine competence and may be used for annual assessment of competence (26). Benner's Stages of Clinical Competence may also be used to assess the learner or for education planning purposes. Benner (27) notes that health providers, specifically nurses, can advance through five levels of clinical competence during the acquisition and development of a new skill: novice, advanced beginner, competent, proficient and expert. This framework is foundational for recommendations and research questions on health provider education.

# Guiding Principles
The following principles provide fundamental prerequisite knowledge for each of the recommendations included in this BPG. It is expected that the recommendations are applied within the context of these guiding principles. It is recommended that nurses and other health providers receive adequate education and training with respect to these principles and apply them in their clinical practice.

# BAC K G R O U N D
Vascular Access -Second Edition

# Routine Practices and Additional Precautions
Routine practices and additional precautions are the expected processes and practices of care to be used in all health settings. Microorganisms have been transmitted from both symptomatic and asymptomatic people, so routine practices are expected in the care of all persons, at all times, across the continuum of care (28). Routine practices include the following:
 point-of-care risk assessment;
 hand hygiene;
 source control (triage, early diagnosis and treatment, respiratory hygiene and spatial separation);
 patient placement, accommodation and flow;
 aseptic technique (e.g., Aseptic Non Touch Technique G ) (29);
 use of personal protective equipment (PPE);
 sharps safety and prevention of blood-borne pathogen transmission;
 management of the patient care environment (including cleaning and handling of waste and linen);
 education of patients, families and visitors on infection prevention and control; and  visitor management (28).
Similarly, as stated by Infection Prevention and Control (IPAC) Canada, health providers require IPAC core competencies (30). These competencies include, but are not limited to:
 an understanding of point-of-care risk assessment;
 an understanding that routine infection prevention and control practices are the key to preventing transmission of organisms among health-care providers, persons and visitors/family members;
 an understanding and demonstrated use of appropriate PPE; and
 an understanding of how to prevent and manage occupational exposures to sharps and blood/bodily fluids in an appropriate way (30).
For a full list of infection prevention and control competencies, please refer to IPAC Canada guidelines and standards available at  (30).
Additional precautions should be used for patients with suspected or known infections or colonization G with microorganisms (28). Additional precautions are conventionally divided into the following categories (28):
 Contact precautions for microorganisms of very low infective dose or situations where heavy contamination G of the person's environment is anticipated.
 Droplet precautions for microorganisms primarily transmitted by the large droplet route.
 Airborne precautions for microorganisms transmitted through the air over extended time and distance by small particles. 

# Hand Hygiene
Hand hygiene is a comprehensive term that refers to handwashing, hand antisepsis and actions taken to maintain healthy hands and fingernails (31).
Hand hygiene plays a central role in infection prevention and control, especially in relation to hospital-acquired infections.
Public Health Ontario defines four key moments for hygiene (32). It recommends that health workers clean their hands at the following times:
- Before initial contact with patient environment.
- Before an aseptic procedure.
- After body fluid exposure.
- After patient/patient environment contact (32).
For details on supporting evidence, techniques (including choice of hand hygiene product) and other considerations, see the guidelines on hand hygiene from the World Health Organization (WHO) or PHAC (31)(32)(33), or the Canadian Vascular Access Association (CVAA) guideline for hand hygiene related to vascular access (25). Appendix M also provides further resources and details on infection control specifically for CVAD care.

# Aseptic Technique
Aseptic technique is the purposeful prevention of the transfer of microorganisms from the patient's body surface to a normally sterile body site, or from one person to another, by keeping the microbe count to an irreducible minimum (28). Aseptic techniques are used when performing procedures that expose the patient's normally sterile sites, such as the intravascular system, to keep them free from microorganisms.
One approach to standardizing aseptic practices is ANTT. ANTT has been shown to support the reduction of health care-acquired infection (29,34). Given the high potential for patient harm from poorly applied aseptic technique, assurance that all staff are compliant with safe aseptic technique for all clinical procedures should be a priority for all health-care organizations (34).

# Use of Personal Protective Equipment
PPE is part of routine practices and additional precautions, and it is required to prevent exposure of infectious or harmful agents to patients, health-care workers and other staff (28). PPE may include gloves, gowns, masks and facial protection (face shields or eye protection) (28).

# Sharps Safety
VADs pose a risk to health providers through needlestick injuries and potential exposure to blood-borne pathogens (35). The United States Centers for Disease Control and Prevention (US CDC) estimates that 385,000 needlestick and other sharps-related injuries are sustained by hospital-based health workers each year (35). To prevent these injuries, PHAC recommends the following (28):
 Safety engineered devices or needle-free systems be used wherever possible.
 Needles should not be recapped. Used items should be placed immediately in a designated puncture-resistant container that is easily accessible at the point-of-care.

# BAC K G R O U N D
Vascular Access -Second Edition  Health providers should cover open skin areas or lesions on hands and arms with a dry dressing at all times. Hand hygiene is still essential, so consultation is necessary if the dressing interferes with this procedure.
 Eyes, nose and mouth should be protected if splashes with blood or body fluids are anticipated.
 Immediately perform first aid if someone has been exposed to blood or body fluids. First aid should include:
 thoroughly rinsing the injury site with running water, and gently cleaning with soap and water (if possible);
 flushing the eyes, nose or mouth with running water if they have been exposed; and  rinsing broken skin thoroughly.
 Follow established organization policies and procedures for needlestick injuries, including reporting the incident and exposure immediately to your employer.
 Follow instructions for further treatment and follow-up from medical professionals, where necessary.

# RECOMMENDATIONS
Vascular Access -Second Edition

# Recommendations

# GOOD PRACTICE STATEMENT:
The expert panel recommends health providers complete a systematic assessment of the person prior to inserting a vascular access device.
This is a good practice statement that does not require application of the GRADE system (7). Conducting an initial assessment of a person before developing a plan of care or any intervention is a standard of professional practice (36).
As such, completing a systematic assessment of persons prior to having a VAD inserted is good clinical practice and a pre-requisite for providing other clinical interventions.
The use of VADs, especially PVADs, is common throughout the health system. Any time a VAD is used as part of a care plan, it increases a person's risk for infection and other complications. Therefore, it is important that all persons requiring vascular access, regardless of duration of therapy, have a systematic assessment completed prior to the initiation of therapy (25,37). This systematic approach will include a vascular assessment, including determination of clinical indication, psychosocial assessment, site selection and device selection. See the "Practice Notes" below for the suggested components of a systematic assessment before initiating vascular access.
Assessment is necessary in all settings where a VAD may be inserted. It is especially important in home-care settings, where persons are sent home with a VAD. Furthermore, for persons in a hospital setting, assessing persons for the most appropriate device upon admission or early in their hospital stay leads to improved person-centred outcomes and is more cost-effective (20). Certain factors-such as age and diagnosis of the person-also need to be considered when choosing to initiate vascular access. For example, pediatric and elderly populations will have different VAD care considerations due to their smaller or more fragile veins; a systematic assessment and choosing the appropriate device are essential for optimizing person-centred outcomes in these specific populations. Health providers will need to consult with the interprofessional team when advocating for the best device for the person, based on a systematic assessment of the person.

# Practice Notes

# Considerations from the expert panel
It may not be possible to complete all components of a systematic assessment of persons needing vascular access in an emergency care situation. Health providers should not delay life-saving vascular access interventions.

# RECOMMENDATIONS
Vascular Access -Second Edition  Vascular assessment is to include an assessment of current medications, including those that may increase complication risk, such as anticoagulants and immunosuppressant medications.
 VAD assessment and planning is an ongoing process through the person's course of treatment (25).
 Depending on the planned therapy and person receiving the VAD, the assessment may be more focused or more comprehensive. 

# Psychosocial assessment

# RECOMMENDATIONS
Vascular Access -Second Edition

# COMPONENTS OF ASSESSMENT DETAILS OF ASSESSMENT

# Device selection and vesicant medications
 Determine if the planned therapy poses an infusate risk or if the medication is a vesicant.
 Do not use peripheral catheters for continuous vesicant therapy or infusates with an osmolarity greater than 900 mOsm/L (37). Use caution with parenteral nutrition.
 Consultation with a pharmacist may be required for high risk or vesicant medications.
 See Appendix H for a list of vesicant medications.
 It is important to select the least invasive device for the duration and type of treatment, and one that promotes vessel preservation (25). When selecting a VAD (25):
 Use a device with the minimum number of lumens.
 Select the smallest gauge catheter that will accommodate the prescribed therapy.
 See further details in Appendix F for considerations for different types of VADs and Appendix G for the right line decision tool (as included in the UK Vessel Health Preservation Framework) (38).

# Site selection
 To select the site for VAD insertion, assess the person's vascular structure and integrity at and above the insertion site (25).
 The following sites should be avoided for vascular access (25):
 area of flexion ;
 chest wall, digits or breast;
 lower legs, except in a non-walking child;
 insertion area that is painful on palpation;
 vein that is obviously compromised (e.g., thrombosis, redness, cording, bruising, infiltration, phlebitis or engorgement);
 extremity with a planned or actual arteriovenous fistula/graft site; and  extremity affected by lymphedema, paralysis, extravasation, acute infection, tissue injury or acute trauma.
 When selecting sites, health providers also must consider any previous history of breast cancer surgery and any potential sites for tissue donation.
 If a short PVAD is deemed appropriate based on a comprehensive assessment of the person-and the health provider has the knowledge, skill and judgement to perform PVAD insertions-the health provider will select an insertion site appropriate for the required therapy that has the least risk of complication.

# RECOMMENDATIONS
Vascular Access -Second Edition

# Supporting Resources

# RESOURCE DESCRIPTION
Canadian Vascular Access Association. Canadian vascular access and infusion therapy guidelines. Pembroke (ON): Pappin Communications; 2019.
 Canadian Vascular Access Association guideline.
 Includes details on assessment and device selection.
 Note: this is a resource for which there is a fee. The expert panel recommends that health providers provide comprehensive health teaching to persons and their families/caregivers about their vascular access device.

# Strength of the recommendation: Strong
Certainty of the evidence of effects: Very low

# Discussion of Evidence: Benefits and Harms
Comprehensive health teaching G involves a combination of learning experiences designed to help improve knowledge and skills related to self-management in persons and their families or caregivers (39-42). The evidence was focused on comprehensive health teaching for CVAD care in particular. Two studies focused on self-management education (39, 40), while seven studies focused on family or caregiver education (41)(42)(43)(44)(45)(46)(47), with the majority of these focused on parents or caregivers providing care for children.
Evidence suggests that comprehensive health teaching may reduce complications and hospital re-admission rate (39-49). However, the evidence is very uncertain.
Most studies reported a decrease in complications in persons who received health teaching when compared to either baseline or control groups (39, 40,. For instance, CLABSI rates decreased in three studies (43)(44)(45), and incidence of occlusion decreased in three studies (39,40,47). In one study, clotting was lower in the group that received education than in the control group (46). One study compared hospital readmission rates due to CLABSI before and after implementing a CVAD care class to family members: there were no hospital re-admissions related to CLABSI in one month of follow-up (42).
The studies did not report harms as a result of persons and families receiving health teaching about their VAD.
The certainty of the evidence was rated as very low due to serious limitations in how individual studies were conducted, serious imprecision related to the small number of total events or participants, and inconsistency in how outcomes were measured. For more detailed information on the impact of health teaching on the prioritized outcomes (hospital readmission rate and complications), refer to the evidence profiles available here: . ca/bpg/guidelines/vascular-access-second-edition.
Further details of the intervention noted in the literature are outlined below, under "Practice Notes. "

# RECOMMENDATIONS
Vascular Access -Second Edition

# Values and Preferences
Three studies gathered data on patient satisfaction (39, 41,46). Where this information was collected, persons and families reported improved satisfaction with the health teaching (39, 41), including feeling more comfortable with their care (46).

# Health Equity
No evidence was identified in the systematic review that directly assessed the impact of comprehensive health teaching on health equity. More research is required on this topic.

# Expert Panel Justification of Recommendation
This recommendation could have been a good practice statement however, the expert panel agreed that it was important to pose a recommendation question to examine the evidence on providing comprehensive health teaching to persons about their VAD. In addition, this evidence can support health providers by providing detailed information on the content and delivery of this education outlined in the evidence. There may be benefits to providing comprehensive health teaching to persons with a VAD and their families or caregivers. There were no harms reported. The expert panel felt that persons and their families or caregivers would value comprehensive health teaching, and that it would align with principles of informed consent, person-and family-centred care, self-management and autonomy. The expert panel also noted the potential for harms if health teaching was not completed. This included device failure or catheter-associated infection. Therefore, despite the very low certainty of the evidence, the expert panel determined the recommendation to be strong due to the potential for harms without health teaching. Although the literature was only on CVADs, the expert panel felt that health teaching on all types of VADs would be beneficial and determined the recommendation to be inclusive of all types of VADs.

# Practice Notes
Considerations from the expert panel  At the very least, health teaching is to include signs and symptoms of complications. This should also include details about where, how and with whom to follow up and seek assistance if complications arise when discharged home with a VAD.
 The amount of and formalization of health teaching will be dependent on the type of device and the discharge plan. For example, a person with a PVAD that is to be removed prior to discharge will have lower learning needs than a person discharged with a PICC line for a defined amount of time or a person with a long-term CVAD, who will require an in-depth understanding of the device.
 Health teaching is to be tailored to the following (for further details, refer to "Supporting Resources, " below):
 type of device;
 type and duration of treatment (including type of infusion or medication);
 discharge plan;  person's age and developmental stage (including tailoring to children, adolescents and the needs of older adults);
 person and family/caregiver's individual learning needs and preferences; and
 person or family/caregiver capability for self-care.

# RECOMMENDATIONS
Vascular Access -Second Edition  For more complex health teaching (if available and appropriate), consider referral to a VAS or VAST.
 Health teaching is to be documented and included in the health record.
 Comprehensive health teaching is to follow a teaching plan or checklist. See Appendix I for an example of a PICC health teaching guide.  (44).

# Health provider providing the health teaching
 In all but one study, health teaching was completed by a nurse (39, 40,. This was further described in the studies as one of the following:
 nurse educator (44),
 infusion nurse (39), or  classes taught by specially trained registered nurses and reinforced by a bedside nurse (42).
 In one study, health teaching was completing by the study investigator (41).

# Use of technology
 Several studies used audiovisual demonstration through DVDs or videos to enhance education (39, 41,44,46,47).
 One study used video calling technology to enhance coaching and accessibility of the education through one-on-one video chatting (39).

# Individualized or tailored approach
 Most of the health teaching interventions tailored the teaching to the individual needs of the learner through various strategies (39-41, 43, 44). In the evidence these strategies included the following:
 providing one-on-one health teaching (39, 41),
 asking persons to express emotions and fears related to CVAD management and give opportunities to ask questions and receive feedback (40), and  promoting family member autonomy in providing care (43).  Models: Three education programs offered a chance to practise on mannequins or models (40,43).

# RECOMMENDATIONS
 Evaluation or assessment:
 In one study, the family member undergoing training was required to "room in" and provide total care for 24 hours to demonstrate their competency (44).
 On the day before discharge, persons with a VAD were evaluated on how well they could perform the self-management tasks and were provided with feedback (40).
 Another study assessed learner understanding through "teach back" strategies (42).
 Finally, caregivers in one study were asked to demonstrate skills based on a checklist, and to re-demonstrate skills when the person they were caring for was re-admitted (45).

# Supporting Resources

# RESOURCE DESCRIPTION
Canadian Vascular Access Association. Canadian vascular access and infusion therapy guidelines. Pembroke (ON): Pappin Communications; 2019.
 Canadian Vascular Access Association guideline.
 Includes patient education as a core practice principle.
 Note: this is a resource for which there is a fee.  In particular, see Table 2 and Figure 1 within the document for self-management strategies.

# RECOMMENDATIONS
Vascular Access -Second Edition

# RECOMMENDATION QUESTION #2:
Should practical education for the insertion and management of vascular access devices for health providers be recommended?
Outcomes: Complications (including insertion-related complications), number of successful observed attempts and provider attitude/confidence.

# RECOMMENDATION 2.1:
The expert panel recommends health-service organizations implement practical education on the insertion and/or management of vascular access devices for health providers.

# Strength of the recommendation: Strong
Certainty of the evidence of effects: Low

# Discussion of Evidence: Benefits and Harms
For the purposes of this BPG, practical education G refers to skills practice, supervised insertion and management of VADs, hands-on training or one-on-one training for health providers. It also includes (but is not limited to) highfidelity simulation G training. Practical or skills lab training follows a structured teaching concept: it takes place under supervision and in consideration of foundational concepts, and it ideally creates an atmosphere that allows the repeated, risk-free practice of targeted clinical skills (50). The types of practical education provided varied across the evidence. Programs included a didactic theory session followed by simulation component (51)(52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69)(70), an online or video component followed by in-class group simulation or a practical component (67,(71)(72)(73)(74)(75)(76)(77)(78)(79)(80)(81)(82)(83), a simulation experience alone (84) or individualized mentoring or supervision (57,85).
The evidence suggests that practical education for health providers improves the number of successful attempts, probably reduces complications in persons with a VAD, and may improve provider attitude and confidence and insertion-related complications, although the evidence is uncertain  . One systematic review reported higher success rates and marginally lower complications when practical education was compared to traditional education (51). Provider attitude and confidence was examined in 23 studies, with the majority reporting improvement in provider confidence from pre-to post-implementation of education or compared to a control group (55-60, 62, 63, 66, 67, 69-72, 74-76, 78, 79, 81, 82, 84). The majority of studies focused on practical education for CVAD insertion and management, but some studies also focused on PICC management (61), PVAD insertion (55,(67)(68)(69)(70)(71)(72)(73)85), and arterial catheter insertion (54,56,78,84). There was no evidence specifically examining PVAD maintenance.
There were no studies that reported harms as a result of health providers receiving practical education on the insertion and management of VADs.

# RECOMMENDATIONS
Vascular Access -Second Edition
The overall certainty of the evidence was rated as low due to serious concerns in how individual studies were conducted, inconsistency in the measurement of the outcomes, and imprecision related to the small number of total events or participants across the studies. For more detailed information on the impact of practical education on the prioritized outcomes (complications, insertion-related complications, number of successful observed attempts G and provider attitude/confidence), refer to the evidence profiles available here: .
Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
Where reported, health providers in seven studies highly valued the practical education offered (60,62,66,67,76,81,82). In one study, in addition to the improved self-reported confidence, nurses described that the simulation environment was a safe place to learn, stating that they were able to concentrate on learning without being interrupted or disturbed (60). Medical residents that participated in a single 60-to 90-minute ultrasound-guided CVAD training session reported enjoying the practical training sessions because they were very realistic and rated higher perceived educational benefits (76).

# Health Equity
No evidence was identified in the systematic review that directly assessed the impact of practical education for health providers on health equity. More research is required on this topic.

# Expert Panel Justification of Recommendation
Conventionally based on GRADE, this recommendation could have been voted conditional since the certainty of the evidence of the effects was low. Based on the balance of benefits and harms, including the harms of not following the recommendation, as well as values and preferences, the expert panel came to consensus on a strong recommendation.
There are benefits to practical education for health providers on the insertion and management of VAD. The expert panel noted the risk of potential harms of health providers not receiving practical education on the insertion and management of VADs. Practical education was highly valued by health providers in the literature. Although the certainty of the evidence was rated as low, the expert panel voted the recommendation as strong as there were no harms noted in the studies, and they felt that all health providers would benefit from practical education.

# Practice Notes

# Considerations from the expert panel
 Education is to be standardized within the health-service organization, with specific educational competencies outlined. See Appendix J for an example of a global rating scale for ultrasound-guided PVAD insertion. Additionally, organizations are to document competencies and review them on a regular basis through a formal process.
 Due to loss of skills over time among health providers, refresher and ongoing education is to be offered.
 Educators providing practical education need formal training, including skill development in debriefing.
 High-fidelity simulation is preferable for complex cases and skills. However, it is recognized that high-fidelity simulation may not be feasible in all practice settings due to cost or accessibility issues.

# RECOMMENDATIONS
Vascular Access -Second Edition  If simulation labs are used, simulation experts should be involved in their planning. It is important to note the consideration of the clinical experience levels of the learners when creating and conducting practical education sessions. Benner's Stages of Clinical Competence Framework may be used to tailor training to levels of expertise (see Guiding Framework and Principles on page 33). The expert panel suggests that acute care health-service organizations implement vascular access specialists or vascular access specialist teams to support the insertion and management of vascular access devices.

# Strength of the recommendation: Conditional
Certainty of the evidence of effects: Low

# Discussion of Evidence: Benefits and Harms
A VAST refers to a grouping of health providers who have advanced knowledge and skills in the assessment, insertion, care and management of VADs. This includes intravenous therapy teams and individual VAS (e.g., nurses, physicians, respiratory therapists, laboratory technicians, radiology technologists and physician assistants) (3).
The evidence suggests the implementation of VASTs and VAS may reduce complications, and that it probably improves successful attempts of VAD insertions (86)(87)(88)(89)(90)(91)(92)(93). Most studies focused on the insertion and management of CVADs, including PICCs (86)(87)(88)(89)93). The remaining studies focused on the insertion and management of PVADs (90)(91)(92).
In terms of complications, most studies reported an overall decrease in complications rates, catheter failure, catheterrelated blood stream infections and deep vein thrombosis rates when a VAST or VAS was involved in providing care (86-89, 91, 93). Three studies reported on the number of successful attempts and noted more successful insertions in persons who received care from VASTs compared to those who did not (90,92,93).
All studies except one reported no harms as a result of persons receiving care from a VAST. One study reported that the incidence of phlebitis was five per cent higher in VAS-inserted PVADs than for generalist insertions (90).
All studies took place in acute care settings. This recommendation therefore is specific to acute care.

# RECOMMENDATIONS
Vascular Access -Second Edition
The overall certainty of the evidence was rated as low due to serious concerns about imprecision related to the small number of total events or participants across studies, and due to some concerns about how individual studies were conducted. For more detailed information on the impact of VASTs and VAS on the prioritized outcomes (complications, number of successful attempts), refer to the evidence profiles available here: / guidelines/vascular-access-second-edition.
Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
One study reported on patient satisfaction and found higher patient satisfaction rates among persons who received care from a VAS compared to those who did not (90). The median score of patient satisfaction with PVAD insertion was higher among those who received care from a VAS compared to those who received PVAD insertion from generalist health providers (9 versus 7, on a scale out of 10) (90).

# Health Equity
One study noted that persons with hematological malignancy may particularly benefit from VASTs and VAS compared to persons with other disorders (89). Of the persons who had a catheter-related bloodstream infection, 3 out of 4 of them also had a hematological malignant disorder (75%), and of the persons with a catheter-related deep venous thrombosis 3 out of 10 of them also had a hematological malignant disorder (30%) (89). The incidence of deep venous thrombosis in persons with hematological malignancy was 0.4/1000 catheter days, compared to 0.17/1000 catheter days in the overall cohort (89).

# Expert Panel Justification of Recommendation
There may be benefits to implementing VASTs and VAS in acute care health-service organizations. However, the certainty in the evidence was low. There also may be few harms of implementing VASTs and VAS. All people may not benefit equally from this intervention. Specific groups may benefit more from this intervention, such as older adults, children, persons with cancer and those with repeated need for device insertion. The expert panel recognized that there is limited evidence on the cost-effectiveness of VASTs or VAS. In addition, some health-service organizations may have challenges accessing VASTs or VAS due to cost or organization size. The expert panel felt the benefits of VASTs were important but that the evidence was not sufficient to make a strong recommendation.

# Practice Notes
Considerations from the expert panel  The type of device needs to be considered when designing VASTs. For example, CVAD insertion and care are more likely to need VAST or VAS care than PVAD insertion and care.  This recommendation excludes some health settings, such as home care and long-term care, but the expert panel feels that there are likely benefits to VASTs in these areas. However, there was no evidence from these health settings. See Table 15 on page 80 for research gaps and future implications.

# RECOMMENDATIONS
Vascular Access -Second Edition  (88,(90)(91)(92).
 Responsible for difficult PVAD insertions and difficult blood draws (87).
 Responsible for all CVAD insertions (86) or all PICC insertions (88)(89)(90)94).
 The VAS intervention in one study included individual assessment to identify the person's expected tolerance of the procedure (i.e., their sedation and pain management needs) (87).

# VAD management:
 Responsible for CVAD dressing changes (87).
 Education for persons and staff caring for persons with a short PVAD (87,88).
 Responsible for all CVAD maintenance (including removal) (86).
 Monitoring of VAD, including necessity (88,91).
 Assessment and maintenance of CVAD and PVAD, as needed (92).

# VAS health provider in the evidence
 Exclusively nurses (88)(89)(90)(91)(92)(93).
 Nurse-led (87).
 Nursing, medical and respiratory therapy (86).  The expert panel suggests health providers perform venipuncture when drawing blood samples to maintain specimen integrity.
VAST

# Strength of the recommendation: Conditional
Certainty of the evidence of effects: Very low

# Discussion of Evidence: Benefits and Harms
The evidence suggests that venipuncture G for drawing blood samples may reduce specimen rejection and may reduce contamination of blood cultures compared with drawing blood from a VAD (94)(95)(96). However, one study also suggests that venipuncture for drawing blood samples may reduce patient satisfaction, when compared with drawing blood from a VAD (95). The certainty of the evidence was very low.
A systematic review concluded that blood sample collection through PVADs is associated with a higher risk of hemolysis G compared with blood drawn by venipuncture (94). Two additional non-randomized controlled trials were identified for the outcome of specimen rejection. One of the studies supported the findings of the systematic review (95). The other study reported lower rates of hemolysis in blood draws from a VAD compared with venipuncture, but it was blood drawn from a PICC (96).
The systematic review also reported on contamination of blood cultures based on two individual studies with mixed results (94). One study included in the review reported higher rates of blood culture contamination and false positives when blood was drawn from a PVAD compared with venipuncture (97). The other study included in the review reported no difference in blood culture contamination when blood was drawn from a PVAD within one hour of insertion when compared with venipuncture (98).
One study examined patient satisfaction, which was assessed on a scale from 0 to 10 (95). The study reported a mean difference of 1.27 in favour of blood draws from a PVAD (95). Finally, only one study reported on dwell time and concluded that blood draws from PVAD had little to no effect on dwell time (99). There were no additional harms reported in the studies.

# RECOMMENDATIONS
Vascular Access -Second Edition
The certainty of the evidence was rated as very low due to limitations in how individual studies were conducted, inconsistency across study results and a low number of total events and participants for some outcomes.
For more detailed information on the impact of the venipuncture compared to blood draws from a VAD on the prioritized outcomes (specimen rejection, patient satisfaction, contamination rate and dwell time), refer to the evidence profiles available here:  .

# Values and Preferences
One study reported that 99 per cent of people preferred blood draw from a PVAD compared with venipuncture (95).
Additionally, one study reported lower pain when blood was drawn from a VAD (96).

# Health Equity
No evidence was identified in the systematic review that directly assessed the impact of venipuncture or blood draws from a VAD on health equity. More research is required on this topic. See Table 15 on page 80 for research gaps and future implications.

# Expert Panel Justification of Recommendation
There may be some benefits to using venipuncture compared to blood draws from a VAD, but the certainty of the evidence was very low. The evidence indicates that there are harms to performing blood draws from a VAD, such as specimen rejection of blood samples or contamination of blood cultures. Additionally, patient satisfaction may be lower when blood is drawn using venipuncture. The expert panel noted the potential for additional harms that were not captured in the body of evidence, including microclots in the samples and delayed treatment or misdiagnosis when blood draws are performed from a PVAD. Additionally, the expert panel felt that blood draws using venipuncture may not be appropriate at all times for all people. The examples of young children, people with cancer requiring repeated blood sampling or older adults with difficult intravenous access were given as potential populations where venipuncture may sometimes be more harmful than beneficial. Following an individualized riskbenefit assessment, other individuals also may not be appropriate candidates for venipuncture. Therefore, the expert panel determined the strength of the recommendation to be conditional.
Venipuncture is the preferred method of blood sampling. If this method is not feasible following an individualized risk-benefit assessment, then a blood draw from a VAD may be considered.
With any blood draw, health providers must adhere to a standardized blood sampling protocol or organizational policy.  Health providers need adequate training and education on blood draws and VADs to support this recommendation. Specifically, the expert panel noted that health providers need to be educated on additional harms associated with blood draws from VADs (e.g., hemolysis and contamination of the specimen leading to false positive results and unnecessary treatment). Additionally, health-service organizations are to document competency of staff and review competencies on a regular basis through a formal process.
 Health-service organizations are to develop policies based on their equipment and in collaboration with the VAD vendor specifications.
 When developing policies, health-service organizations are to collaborate with laboratory guidelines and personnel.
 Where an arterial blood sample is needed (e.g., for arterial blood gases), health providers are to follow established best practices for drawing blood from an artery or arterial catheter. See "Supporting Resources" (below) for guidance on arterial sampling procedure.
 For persons with a CVAD in situ, see "Supporting Resources" (below) for guidance on sampling procedure. Decisions around blood draws from a CVAD also require an individualized risk-benefit assessment (see the factors listed above). The expert panel recommends that acute care health-service organizations implement a multicomponent PVAD care protocol. This protocol includes a minimum of a daily review by health providers, in collaboration with persons and their families.

# RECOMMENDATIONS

# Strength of the recommendation: Strong
Certainty of the evidence of effects: Low

# Discussion of Evidence: Benefits and Harms
A multi-component care protocol G is a group of evidence-based interventions that can ensure the delivery of a standardized method of care (100). When these interventions are performed together, they can have a better outcome than if performed individually (this may be referred to as a "care bundle") (100). The evidence suggests that multicomponent PVAD care protocols may reduce complications (91,(101)(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112).
The multi-component care protocol involved PVAD daily review and documentation (91,(101)(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112)  At a minimum, daily review involved an assessment of signs and symptoms of PVAD complications (91,(101)(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112).
A majority of the studies also included assessment of device necessity as part of the PVAD daily review (91, 101-105, 108, 109, 111, 112).
Eleven out of 13 studies reported a decrease in complications when a multi-component PVAD care protocol with daily review was implemented (91,(101)(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112). Steere et al. (2019) reported an overall decrease in complication rates and catheter failure rates (91). Infiltration was the most commonly assessed complication across studies, and its rate decreased in all the studies in which the outcome was reported (91,101,102,104,107,110,111). Phlebitis rate also decreased in the majority of the studies in which the outcome was reported (91,101,105,110). Furthermore, infection was assessed in three studies, and all studies reported a decrease in infection rate after implementation of a multi-component PVAD care protocol that included a daily review (103,106,109). There were no harms reported in the studies related to the use of a multi-component PVAD care protocol with daily review.

# RECOMMENDATIONS
Vascular Access -Second Edition
The certainty of the evidence was rated as low due to serious limitations in how individual studies were conducted.
For more detailed information on the impact of the multi-component PVAD care protocols, including a daily review on the prioritized outcomes (complications), refer to the evidence profiles available here: / guidelines/vascular-access-second-edition .
Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
Another study conducted interviews with caregivers as part of intervention development (108). The following themes emerged related to PVAD care: the importance of communication, apprehension and fear around the device, an appreciation of skilled health providers and technology, and a recognition of the role of the caregiver (108).

# Health Equity
No evidence was identified in the systematic review that directly assessed the impact of multi-component PVAD care protocols on health equity. More research is required on this topic. See Table 15 on page 80 for research gaps and future implications.

# Expert Panel Justification of Recommendation
Conventionally based on GRADE, this recommendation could have been voted conditional since the certainty of the evidence of the effects was low. Based on the balance of benefits and harms, including the harms of not following the recommendation, as well as values and preferences, the expert panel came to consensus on a strong recommendation.
There may be benefits of implementing PVAD multi-component care protocols that include a daily review.
Additionally, there was some evidence to suggest that multi-component PVAD care protocols would be highly valued by persons and families or caregivers, particularly when caregivers were involved. The expert panel also noted that a daily review of a PVAD in particular would avoid additional harms not captured in the literature, as short PVAD complications can greatly impact a person's safety. A strong recommendation was selected by the panel to align with person's safety as well as values and preferences.

# Practice Notes
Considerations from the expert panel  Daily reviews of PVADs are to be completed a minimum of once daily. More frequent assessment will be necessary for specific populations (such as neonatal or pediatric) and for infusing catheters.
 PVAD care is not just the responsibility of an individual health provider; it also needs to be incorporated into health-service organization policies and procedures. Discussion of PVAD necessity, functionality and utilization is to include bedside and interprofessional team members.
 Health-service organizations need to be responsible for education, training and monitoring related to multicomponent PVAD care policies and protocols. Additionally, organizations are to document competency of staff and review competencies on a regular basis through a formal process.
All studies took place in acute care settings. This recommendation therefore is specific to acute care.

# RECOMMENDATIONS
Vascular Access -Second Edition  The assessment of a PVAD needs to follow an established protocol. See Appendix L for an example of a PVAD assessment protocol and Appendix G for daily evaluation included in the UK Vessel Health Preservation Framework.
 Although this recommendation is for acute care settings, the expert panel felt that a multi-component PVAD care protocol would be beneficial in other settings, including long-term care and home care. More research is needed in these areas. See Table 15 on page 80 for research gaps and future implications.
 This recommendation applies to PVADs. The expert panel did not feel that a recommendation on CVAD care was necessary, as there are many established multi-component care protocols (or "care bundles") currently in use. For more information on CVAD care, see Appendix M. 

# PVAD daily review process
 PVAD reviews were at minimum once per shift in some studies (107,109,110,112). They were once per day in others (91,101,102,109,110,112). Additionally, three protocols mandated hourly site assessment (104,108,111). One study required that assessment be completed whenever solutions changed or drugs were added to the intravenous therapy (105).
 The acronym TLC (touch, look, compare) was used in one study (102), while ACT (assess, compare, touch) was used in another (104).
 The acronym PIVCS formed the maintenance bundle in two studies: prompt removal, inspect hourly, vein patency by intermittent flush of 0.9% sodium chloride, clean hands, scrub the hub with 2%, chlorhexidine gluconate and 70% alcohol swab (108,111).

# PVAD dressings/ securement devices
 Chlorhexidine antimicrobial bordered securement dressing (91).
 Transparent dressing (91,101).
 Semi-transparent polyurethane sterile dressing (106).
 Sterile self-transparent adhesive gauze (105).
 Bordered polyurethane dressing (108,111).
 An additional elastic bandage was applied to reduce the risk of inadvertent withdrawal (105). The expert panel recommends that health providers use ultrasound-guided technique for the insertion of peripheral arterial catheters.

# RECOMMENDATIONS

# Strength of the recommendation: Strong
Certainty of the evidence of effects: Moderate

# Discussion of Evidence: Benefits and Harms
Evidence suggests that the use of visualization technologies-specifically ultrasound-guided technique G -for the insertion of peripheral arterial catheters will increase the success rate on first attempts and will likely reduce complications (113)(114)(115)(116)(117)(118). Ultrasound-guided technique refers to ultrasound imaging (an image created by using sound waves within the body) that allows health providers to see surrounding anatomical structures such as arteries and veins (119). It is used to aid the health provider when inserting a PIV or peripheral arterial catheter. In particular, the use of ultrasound-guided technique was more effective when compared to the palpation technique in adult and pediatric populations (118).
Hematoma was the most frequently reported complication in the evidence. The systematic review reported fewer incidences of hematoma when using ultrasound-guided technique for arterial catheter insertion compared to palpation or traditional methods (118). Additional randomized controlled trials G that were included supported these findings (113)(114)(115)(116)(117).
Ultrasound-guided technique could provide greater value in the care of certain subpopulations. Based on subgroup analysis, one review noted that first attempt success rate of ultrasound-guided technique versus traditional palpation techniques for radial artery catheterization was particularly beneficial in children and persons undergoing emergent procedures (118).
There were no studies that reported on the outcome of patient satisfaction.
There were no harms reported in the studies.
The evidence was of moderate certainty due to some limitations in how individual studies were conducted. For more detailed information on the impact of the intervention (ultrasound-guided technique for arterial catheter insertion) on the prioritized outcomes (success rate on first attempt, patient satisfaction and complications), refer to the evidence profiles available here:  .

# RECOMMENDATIONS
Vascular Access -Second Edition Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
There was no evidence identified in the systematic review that reported on the values and preferences of persons with a VAD related to the use of ultrasound-guided technique for the insertion of a peripheral arterial catheter.

# Health Equity
It is important to note that implementation barriers such as the cost of ultrasound devices may limit the feasibility and accessibility of ultrasound-guided technique in some health-service organizations.

# Expert Panel Justification of Recommendation
The benefits of using ultrasound-guided technique outweigh the harms, and there was moderate certainty of evidence for this. The expert panel agreed that the technique was feasible in most health-service organizations, and that it was acceptable to patients.
Overall, the expert panel noted that the potential harms of not using ultrasound-guided technique can be severe.
The expert panel noted the potential for additional harms that were not captured in the body of evidence, including ischemia, hemorrhage and thrombosis. Therefore, the expert panel determined the recommendation to be strong.

# Practice Notes

# Considerations from the expert panel
 Training on the use of ultrasound needs to include a basic understanding of ultrasound technology, as well as ongoing maintenance of competencies (not a one-time certificate). Additionally, health-service organizations are to document competency of staff and review competencies through a formal process on a regular basis.
 Training of health providers in ultrasound-guided techniques should involve practical education with the technology (see Recommendation 2.1 for details on practical education).
 Two health providers may be required when using ultrasound, depending on the expertise and experience level of the health provider (i.e., one to hold the ultrasound probe and the other to insert the needle).
 When using ultrasound-guided technique for the insertion of arterial catheters, it is important that health providers ensure correct positioning of the VAD prior to initiating treatment.
 See Appendix K for an example of ultrasound-guided technique.
Appropriate scope of practice and level of training or expertise needs to be considered when applying this recommendation and determining the most appropriate health provider to insert the peripheral arterial catheter.

# CAUTION

# RECOMMENDATIONS
Vascular Access -Second Edition  (119). In subgroup analysis, it was noted that those with ultrasound expertise had a higher first attempt success rate than those with no expertise (119).
 Previous experience may improve the results and success of ultrasound-guided technique (120).

# Details of ultrasound technique
 Short axis view, out-of-plane (113,(118)(119)(120).
 One review noted that there was higher incidence of first attempt success in the subgroup analysis of pooled trials that used short axis out-of-plane ultrasound-guided approach (118).
 Dynamic Needle Tip Positioning (DNTP) technique (a modified ultrasound technique that requires confirmation of the needle tip position in the vessel before advancing the catheter) (113,117).
 Long axis view, in plane (115,118).
 Seldinger technique (119,120)  Single or double wall technique (120).
 Vascular transducer used (120).

# Supporting Resources

# RESOURCE DESCRIPTION
Bardin-Spender A, Spencer TR. The expert panel suggests that health providers use ultrasound-guided technique for the insertion of PVADs for persons with difficult intravenous access.

# Strength of the recommendation: Conditional
Certainty of the evidence of effects: Very Low

# Discussion of Evidence: Benefits and Harms
Evidence suggests that the use of visualization technologies, specifically ultrasound-guided technique, for the insertion of PVADs in persons with difficult intravenous access may increase the success rate on first attempts and decrease complications, and that it likely will increase patient satisfaction (121)(122)(123)(124)(125)(126)(127)(128). However, the certainty of the evidence was very low.
Ultrasound-guided technique refers to ultrasound imaging (an image created by using sound waves within the body) that allows health providers to see surrounding anatomical structures, such as arteries and veins (119). It is used to aid the health provider when inserting a PVAD or peripheral arterial catheter.
Ultrasound-guided technique can be particularly useful for persons with DiVA, which is defined as a clinical situation where multiple attempts or special interventions are required to obtain and maintain peripheral venous access (129). How DiVA was determined varied across studies and included previous failed attempts (121,122), history of difficult access (121,122,127), health provider assessment (121,122,124,125,128), self-report (121,130) or certain comorbidities, such as sickle cell disease, obesity or intravenous drug use (121,124). Some studies focused on pediatric populations with different levels of venous access difficulty, or different ages and behaviours that may have influenced their cooperation with the procedure (22,123).
In adults and children with DiVA, ultrasound-guided PVAD insertion resulted in a higher success rate when compared to traditional techniques of palpation and direct visualization (22,(122)(123)(124)(125)(126)(127)(128). Furthermore, the evidence reported that adults and children with DiVA (or their parents/guardians) who received ultrasound-guided technique for the insertion of PVADs reported higher patient satisfaction than those who did not receive PVADs through ultrasound-guided technique (122,124,125).
Most studies reported fewer complications during the use of ultrasound-guided technique (121,125). There were no additional harms reported in the studies.
Of note were two systematic reviews that examined the effect that the use of near-infrared devices during PVAD insertion had on the success rate of first attempts (21, 130). Both systematic reviews found no difference in first attempt success rate when using near-infrared devices. Due to the limited evidence on this intervention, it was determined more research is needed in this area. As a result, the recommendation is solely focused on ultrasoundguided technique. See Table 15 on page 80 for research gaps and future implications.

# RECOMMENDATIONS
Vascular Access -Second Edition
The evidence was of very low certainty due to limitations in how individual studies were conducted and inconsistency in the reported results. For more detailed information on the impact of the intervention (ultrasound-guided technique) on the prioritized outcomes (success rate on first attempt, patient satisfaction and complications), refer to the evidence profiles available here: .
Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
There was no evidence identified in the systematic review that reported on the values and preferences of persons with a VAD related to ultrasound-guided technique beyond the patient satisfaction outcome reported above.

# Health Equity
It is important to note that implementation barriers, such as the cost of ultrasound devices, may limit the feasibility and accessibility of ultrasound-guided technique in some health-service organizations. No evidence was identified in the systematic review that directly assessed the impact that visualization techniques for PVAD insertion had on health equity. More research is required on this topic. See Table 15 on page 80 for research gaps and future implications.

# Expert Panel Justification of Recommendation
There may be benefits to using ultrasound-guided technique in persons with DiVA in terms of insertion success rate and improvement of patient satisfaction. There was a reduction in the number of complications when using ultrasound-guided technique compared to traditional methods. The expert panel felt that the success of this recommendation would be dependent on individual considerations of the person receiving the PVAD and the expertise of the health provider. The certainty in the evidence was very low. Therefore, the expert panel determined the recommendation to be conditional.

# Practice Notes

# Considerations from the expert panel
 Training on the use of ultrasound needs to include a basic understanding of ultrasound technology and ongoing maintenance of competencies (not a one-time certificate). Additionally, health-service organizations are to document and review competencies of staff on a regular basis through a formal process. See Appendix J for a validated scale on ultrasound-guided PVAD insertion and Appendix K for an example of ultrasound use during VAD insertion.
 Health providers caring for persons in the community or home-care settings may need to refer persons with DiVA to an acute care setting to utilize ultrasound technology (if traditional methods of PVAD insertion are unsuccessful).
Appropriate scope of practice and level of training or expertise needs to be considered when applying this recommendation and determining the most appropriate health provider to insert the PVAD.

# CAUTION RECOMMENDATIONS
Vascular Access -Second Edition  A validated scale can be used to determine DiVA. DiVA status should be assessed by an expert in PVAD insertion or a health provider who is appropriately trained to use the validated DiVA scale. Referral to VAS or VASTs may be needed to support the insertion of VADs in DiVA patients using ultrasound-guided technique (in organizations where available).
 When using ultrasound-guided technique for the insertion of PVAD, it is important that health providers ensure correct positioning of the VAD prior to initiating treatment.   It was noted that provider comfort and previous experience affected the success and implementation of the intervention (122,123,125).
 One systematic review reported that provider expertise level and technique (e.g., one-person versus twoperson, and dynamic versus static) were associated with better results (122).
 One study reported significant health provider effect on needle redirections, total time and needle manipulation time (123).
 One study noted that attending physicians and nurses may have had higher success rates inserting PVADs than fellows because of more experience with placing ultrasound-guided VADs (125).

# Details of ultrasound technique
 Dynamic Needle Tip Positioning (123,(125)(126)(127).
 Short axis (121,123,125).
 Long axis (121).
 Single-operator technique (121,(125)(126)(127).
 Two-provider technique (22,121,122).
 One nurse operated the equipment and examined vessels in transverse and longitudinal directions with a 90-degree angle of the transducer, then chose the vein to be used. Another nurse performed skin antisepsis and the catheter insertion, analyzing the image on the screen (22).

# RECOMMENDATIONS
Vascular Access -Second Edition 

# Should pain management strategies (including pharmacological and non-pharmacological strategies) during the insertion of a vascular access device be recommended?
Outcomes: Patient's rating of pain, patient comfort, fear/anxiety (related to poke/needle phobia) and patient satisfaction.

# RECOMMENDATION 7.1:
The expert panel recommends that health providers offer adults non-pharmacological and pharmacological pain management strategies during the insertion of a vascular access device.

# Strength of the recommendation: Strong
Certainty of the evidence of effects: Moderate

# Discussion of Evidence: Benefits and Harms
Evidence suggests that both pharmacological and non-pharmacological pain management interventions probably decrease pain, fear and anxiety, increase patient satisfaction during the insertion of a VAD for adults, and may increase patient comfort . Various needle procedures were examined across the studies, including CVAD insertion (131), arterial blood gas draw (147)(148)(149), intramuscular injections (141-143, 156), venipuncture (132,140,143,146), implanted port access (152), and PVAD insertion (132, 133, 136, 138, 143-145, 150, 151, 153-155).
Various types of pharmacological interventions were used in the studies, including fentanyl prior to CVAD insertion (131), a "needle-free powder lidocaine delivery system" given prior to venipuncture or PVAD insertion, and a variety of topical anesthetics (e.g., lidocaine-prilocaine cream, diclofenac patch, ketoprofen patch and tetracaine 4 per cent) (133-138, 148, 149). Specifically, the evidence reports that members of the "caine" family of drugs were estimated to be much more effective at reducing pain compared to no treatment (133).
Non-pharmacological interventions included both physical and psychological interventions (e.g., distraction techniques, acupressure, a vibrating cold device, vapocoolant spray, crushed ice, heat application, aromatherapy, a virtual reality device or hypnosis) (132,(140)(141)(142)(143)(144)(145)(146)(147)(148)(149)(150)(151)(152)(153)(154)(155)(156). The evidence reported that non-pharmacological techniques probably decrease pain and increase patient satisfaction (132,(140)(141)(142)(143)(144)(145)(146)(147)(149)(150)(151)(152)(153)(154)(155)(156).
The evidence demonstrated that overall, there was minimal or no difference in patient comfort levels when they were given pharmacological or non-pharmacological pain management interventions when compared to no pain management intervention (131,132,142,155). For the outcome of patient fear/anxiety, two systematic reviews demonstrated minimal to no difference when patients were given pharmacological or non-pharmacological pain management interventions when compared to no pain management intervention (132,143).

# RECOMMENDATIONS Vascular Access -Second Edition
The harms reported in the literature were due to side effects from pharmacological interventions. These included episodes of decreased oxygen saturation related to fentanyl use (131), nausea and pruritis related to fentanyl use (131), and mild skin reactions related to topical medications (e.g., skin blanching, rashes, petechiae, erythema and edema) (132,134,136,137).
The evidence was of moderate certainty due to how individual studies were conducted and inconsistency in the measurement of the outcomes. For more detailed information on the impact of the intervention (pharmacological and non-pharmacological pain management strategies) on the prioritized outcomes (patient's rating of pain, patient comfort, fear/anxiety related to poke or needle phobia, and patient satisfaction), refer to the evidence profiles available here: .
Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
Several studies reported on patient satisfaction. Persons reported they were satisfied with the experience of topical anesthetic application, and more than 76 per cent were willing to use the cream again (134). Persons given lidocaine by injection for their procedure were more likely to want it next time than those who had never had lidocaine (133). Many persons also had a preference for lidocaine when asked to choose between lidocaine, guided imagery or nothing prior to PVAD insertion (133). All of those who chose lidocaine said they were satisfied with the PVAD insertion compared to those who chose no pain relief (133).
For non-pharmacological pain management, it was noted that individual differences-such as the desire to attend a medical procedure-may impact an individual's ability to engage with a distraction intervention (143). In one study that used heat and cold application prior to PVAD insertion, 93.3 per cent of those in the hot application group stated that they were satisfied with the application, whereas 80.0 per cent stated that they wanted the application again (150). Conversely, 50 per cent of those in the cold application group stated that they were not satisfied with the application, and 56.7 per cent expressed that they did not want the application again (150).

# Health Equity
Minimal considerations related to health equity were reported in the evidence. There were some studies that discussed accessibility issues. Non-pharmacological pain management devices such as the "needle-free powder lidocaine delivery system" and vibrating cold devices are currently unavailable in Canada (as of May 2021) (157).
In addition, not all settings may have access to lidocaine-prilocaine cream (134), particularly in some developing countries that restrict its use as a routine medication for PVAD insertion (136). One study recommended using diclofenac gel instead of lidocaine-prilocaine cream because of increased accessibility and domestic production in general (135).

# Expert Panel Justification of Recommendation
There are likely benefits to offering non-pharmacological and pharmacological pain management strategies. Although there were some harms in the form of side effects associated with pharmacological pain management strategies, the expert panel felt that the benefits greatly outweighed the harms. The interventions were also highly valued by persons, and the expert panel felt that the recommendation aligned with person-and family-centred care principles. It is important to note that the expert panel chose the action word "offer" for this recommendation to highlight that pain

# RECOMMENDATIONS
Vascular Access -Second Edition management strategies need to be person-and family-centred and that ultimately the person with a VAD will make the decision whether or not to receive pain management. The certainty in the evidence was moderate. Therefore, the expert panel determined the recommendation to be strong.

# Practice Notes
Considerations from the expert panel  Aseptic technique needs to be maintained during VAD insertion, regardless of the type of pain management strategy used.
 The expert panel recognized that time constraints experienced by health providers may be a barrier to providing pain management strategies. In these situations, pain management strategies should still be offered. Health providers may consider faster acting strategies, such as thermotherapy or cryotherapy, while keeping in mind the preferences of persons and their families/caregivers.
 The expert panel noted that some individuals may not prefer topical anesthetic due to the increase in overall procedure time (i.e., topical anesthetic can take longer to take effect).
 A physician order may be required prior to administration of pharmacological pain management interventions.
 Decisions around pharmacological pain management interventions may require an individualized risk-benefit assessment, including (but not limited to) factors such as the following:
 person preference;
 presence of needle phobia, or fear/anxiety about the procedure;
 DiVA score/history of DiVA; and  type of pharmacological intervention and potential side effects, such as vasoconstriction associated with some topical medications. 

# RECOMMENDATIONS
Vascular Access -Second Edition  Arterial catheter insertion: There were three studies that examined using ice or topical anesthetics for arterial blood gas draws, and these were found to be effective pain management strategies (147)(148)(149).
 CVAD insertion: One study examined the use of fentanyl for CVAD insertion (131). This type of intervention may not be necessary for less invasive procedures, such as venipuncture or PVAD insertion.

# Local anesthetic administration
 Choice of drug: One systematic review and network meta-analysis found that drug members of the "caine" family (e.g., lidocaine and iontocaine) were most effective in reducing patient pain when undergoing needle procedures (133).
 Timing: Three studies reported that topical anesthetic cream should be applied 60 minutes prior to the procedure in order to be most effective (134)(135)(136).

# RECOMMENDATIONS
Vascular Access -Second Edition

# KEY INTERVENTION DETAILS FROM THE EVIDENCE Distraction
 The evidence examined various types of distraction techniques (143,144,(152)(153)(154)(155).
 Verbal cues were found to have a mixed effect in reducing a person's pain. These interventions included giving a verbal signal to the person to warn them of the impending needle poke (e.g., "sting" or "sharp scratch") (143).
 Visual distraction techniques may include having people look through a kaleidoscope (143), distraction cards containing optical illusion pictures (154) or virtual reality devices (154).
 Hypnosis was used in one study, involving classical non-verbal hypnotic tools adapted to the subject and indirect suggestion of comfort by body language (155).
 Aromatherapy, including lavender, eucalyptus or peppermint essential oils inhaled by persons prior to needle insertion, was used in two studies (152,153). For aromatherapy interventions, health providers should be aware of any allergies prior to administering the aromatherapy oils.
 Breathing techniques may include things such as the "cough trick" or Valsalva maneuver G (143) or spirometry (144). The Valsalva maneuver is a breathing technique that can be used as a pain management strategy during VAD insertion. It involves a deep inhale, followed by a forceful holding of the breath during which the venous cannulation insertion occurs (143).
 For breathing techniques, health providers should be aware of the person's health history and status and related contraindications to the Valsalva maneuver or coughing, including respiratory conditions such as COPD and asthma.

# Scope of practice considerations
 Acupressure: If considering acupressure as a pain management intervention, it is important to recognize that health providers would need additional education and training in order to utilize this pain management strategy.
 Opioids: One study found that the use of intravenous fentanyl given prior to CVAD placement procedure was effective in reducing person's pain (131). Health providers need to be aware of scope of practice surrounding prescribing or administering opioids. They should consult with the interprofessional team about opioid administration in circumstances where it would be beneficial to advocate for this pain management strategy for the person with a VAD.
 Hypnosis: One study examined the impact of hypnosis on PVAD insertion, but it is important to note that the health providers received additional certifications in hypnosis prior to delivering the intervention (155).  Pain toolkit for older adults.

# RECOMMENDATIONS
 Includes pain scales and pain management strategies.

# RECOMMENDATIONS
Vascular Access -Second Edition

# RECOMMENDATION 7.2:
The expert panel recommends that health providers offer non-pharmacological and pharmacological pain management strategies during the insertion of a vascular access device to infants and children, tailored to their age and developmental stage.

# Strength of the recommendation: Strong
Certainty of the evidence of effects: Low

# Discussion of Evidence: Benefits and Harms
Research evidence suggests that both pharmacological and non-pharmacological pain management interventions may decrease pain (139,156,(158)(159)(160)(161)(162)(163)(164)(165)(166)(167)(168)(169)(170)(171)(172)(173)(174)(175) fear and anxiety (162,164,166,171,173,174), and increase comfort (176), and that they probably increase patient or parent/guardian satisfaction ( 139) during the insertion of a VAD for infants and children.
The majority of studies examined non-pharmacological interventions. These included psychological interventions (e.g., distraction techniques, virtual reality devices, cartoons, aromatherapy and informational materials about the procedure) (164,165,168,(171)(172)(173)(174)(175) and physical interventions (e.g., breastfeeding and other feeding interventions, a vibrating cold device, ice, heat therapy, acupressure and holding/positioning techniques) (139, 156, 160-163, 166-168, 170, 176, 177, 179, 180, 182, 197-220). One systematic review showed that interactive distraction interventions-such as virtual reality, a toy accompanied by a reading activity and video games-were most effective in reducing fear/anxiety prior to the needle procedure (164). Furthermore, a meta-analysis reported a positive effect on the outcome of fear/anxiety among children who received distraction during the insertion of a VAD compared to those who did not receive distraction (164). Types of non-pharmacological interventions used in the studies varied with child and infant age and developmental stage. Further details of effective non-pharmacological pain management strategies are outlined below, under "Practice Notes. "
Various pharmacological interventions were used in the studies, including oral melatonin 30 minutes before venipuncture (221), and lidocaine-prilocaine cream (169), 5 per cent lidocaine cream (169), vapocoolant spray (156), amethocaine, paracetamol and ibuprofen before needle procedures (158,159). Lidocaine-prilocaine cream and oral melatonin were found to reduce pain scores, and it was noted that lidocaine-prilocaine cream had the highest probability of being most effective in reducing pain (158,159). In addition, children who received melatonin had lower anxiety than those treated with placebo (221). Paracetamol and ibuprofen were not shown to reduce pain scores (158).
The harms reported in the literature were due to side effects from pharmacological interventions or adverse events associated with non-pharmacological interventions. In one review, two studies reported skin blanching as an adverse effect of lidocaine-prilocaine cream application (159). Feeding-related adverse events included choking while drinking formula milk during vaccination (not leading to additional interventions or complications) (212), or infants coughing, gagging and vomiting following sucrose administration (116,160,199,207). One study reported that when using non-nutritive sucking, some infants may refuse to suck and should not be forced to do so, as it may increase distress (162). Mild to moderate nausea was noted in some children when participating in a virtual reality intervention (187), and in another study examining virtual reality as an intervention two children took off the headset

# RECOMMENDATIONS
Vascular Access -Second Edition during the procedure stating that they felt distressed (175). Finally, one study on breathing techniques reported adverse events: three of 50 children reported respiratory difficulties when asked to engage in a specialized form of deep breathing (164).
The evidence was of low certainty due to some concerns over how individual studies were conducted, inconsistency in the measurement of the outcomes, and variability in the types of needle procedures examined. For more detailed information on the impact of the intervention (pharmacological and non-pharmacological pain management strategies) on the prioritized outcomes (patient's rating of pain, patient comfort, fear/anxiety related to poke or needle phobia, and patient satisfaction), refer to the evidence profiles available here: / vascular-access-second-edition.
Specific components of the intervention noted in the literature are outlined below, under "Practice Notes. "

# Values and Preferences
An important consideration reported in the literature was recognizing the developmental stage of the child and how it may influence their preferred pain management intervention. In addition, children in a study using a virtual reality intervention reported positive satisfaction: one child explained that he was "nervous at the idea of blood draw,  the virtual reality game truly helped distract  from the feeling of the needle being inserted" (187). Another study that used virtual reality as an intervention reported that users of the virtual reality headsets stated that the device was effective in reducing pain and anxiety and offered a pleasant experience (190).
The evidence also reported infant feeding/positioning preferences. Not all mothers may want to breastfeed (or formula feed) their child, especially during immunization, if they are anxious themselves (208). One study stated it is important to consider the parental wishes for infant procedures (e.g., they could stay in the room or leave during the procedure, or they could offer comfort measures to the child) (200). In one study, parents preferred to have their children sitting up for the injections (162).

# Health Equity
Multiple studies examined breastfeeding as an intervention and noted it to be inexpensive, readily available and convenient (182,209). However, it is important to recognize person-and family-centred care principles: not all persons have the ability to breastfeed, or they simply may prefer not to do so.
No additional considerations for health equity were reported in the studies.

# Expert Panel Justification of Recommendation
Conventionally based on GRADE, this recommendation could have been voted conditional since the certainty of the evidence of the effects was low. Based on the balance of benefits and harms, including the harms of not following the recommendation, as well as values and preferences, the expert panel came to consensus on a strong recommendation. There are likely benefits to offering non-pharmacological and pharmacological pain management strategies. Although there were some harms in the form of side effects associated with pharmacological pain management strategies and feeding, the expert panel felt that the benefits greatly outweighed the harms. The interventions were also highly valued by children, infants and parents/guardians, and the expert panel felt that they aligned with person-and family-centred care principles. It is important to note that the expert panel chose the action word "offer" for this

# RECOMMENDATIONS
Vascular Access -Second Edition recommendation to highlight that pain management strategies need to be person-and family-centred and that ultimately the decision whether or not to receive pain management is up to the child and/or parents/guardians.
The certainty of the evidence was low, but due to the reasons stated above, the expert panel determined the recommendation to be strong.

# Practice Notes
Considerations from the expert panel  Aseptic technique needs to be maintained during VAD insertion, regardless of the type of pain management strategy used.
 The expert panel emphasized the importance of offering children, infants and parents/guardians the choice of a variety of pain management interventions. The expert panel noted that some children do not prefer topical anesthetic due to the increase in overall procedure time (i.e., topical anesthetic can take longer to take effect). An additional example was given of some children disliking the feeling associated with cryotherapy (such as aerosol vapocoolant sprays).
 A physician order may be required prior to administration of pharmacological pain management interventions. 

# RECOMMENDATIONS
Vascular Access -Second Edition  One study reported that "the receptivity of infants to distraction is hypothesized to vary due to developing motor and cognitive capacities. On the basis of developmental milestones, a two-month old would seem less likely to benefit from distraction. However, a child older than 12 months would seem to have greater ability to benefit from distraction" (165).
 Another study reported that distraction methods such as toys or books are generally preferred for children aged 7-12 years (190).
 Information and preparation materials should be tailored to the age of the child. Storybooks that include age-appropriate health education messages and pictures enable children to better understand their treatment regimen (189).

# Psychological techniques
 Various distraction interventions may be used by health providers. These include movies, cartoons, video games, storybooks, toys, cards, blowing bubbles, chewing gum, balloon inflation, virtual reality, music, parent distraction, a medical clown or squeezing a rubber ball.
 Interactive or directed distraction may confer a larger benefit than non-directed distraction interventions. For example, one study stated that passive distraction by watching a cartoon may be less effective in reducing procedural pain than virtual reality motion videos, such as riding a roller coaster (190).
 One systematic review that examined combined cognitive behavioural therapy and breathing interventions for reducing children's needle-related pain or distress found that combining multiple psychological strategies can be beneficial (164).
Positioning and touch  Positioning of infants for the vascular access procedure may be different than it is for children.
 Children: Parents may want to hold their older child sitting upright during the procedure (162,214). Holding the child in a parent's lap in a gentle hug, with the child's legs on either side of the parent, may be one way to deliver this intervention (162).
 Infants: Skin-to-skin, swaddling, hugging, caressing, or facilitated tucking may be appropriate interventions (161,162,219).

# Infant feeding
 Breastfeeding was shown to confer the greatest benefit as a nonpharmacological pain management intervention, since it combines the therapeutic effects of feeding, skin-to-skin care and infant positioning (161).
 Formula feeding, non-nutritive sucking and sucrose were also found to be effective interventions if breastfeeding is not an option based on person-and family-centred care principles (162,212).
 One study noted that non-nutritive sucking may be particularly beneficial for infants with latching difficulties or those who are unable to breastfeed (173).

# RECOMMENDATIONS
Vascular Access -Second Edition

# KEY INTERVENTION DETAILS FROM THE EVIDENCE
Acupressure/massage  Three studies examined acupressure or massage therapy (216,220,222).
 One study reported that "acupressure is a safe, inexpensive and easy-tolearn technique. Therefore, nurses can teach this technique to patients and involve them in their own treatment, and thereby enhance their self-confidence" (222).
 However, it is important to note that health providers need additional training to perform acupressure.
 The study that used this intervention noted that the acupressure intervention was implemented in two steps, with a 30-minute interval in between, and that it was performed by someone who had received the necessary acupressure training from an acupressure specialist (222).
 Another study also noted that the researcher performing acupressure received certification prior to performing the intervention (220).

# Aromatherapy
 One study demonstrated that aromatherapy using inhaled lavender essential oil for infants prior to heel lance reduced pain (197).
 A systematic review demonstrated that inhaled maternal milk odor prior to heel lance was also effective in reducing pain in infants (167).
 For aromatherapy interventions, health providers should be aware of any known allergies prior to administering the aromatherapy oils.

# Heat therapy
 Two studies examined forms of heat therapy prior to heel lance or PVAD insertion in infants and children (176,218).
 Electric heating pad: In one study of children aged 5-18 years, an electric heating pad (40C) was applied at the site of the identified PVAD insertion for 10 minutes before PVAD insertion (218). The child was asked to inform the health provider if the heating device caused discomfort when applied to the chosen site (218).
 In another study, infants in the experimental group received a heating pad ("thermophore") application for five minutes before a heel lance procedure (176). The warmth of the pad was kept between 34-37 C. To prevent the heating pad from directly contacting the sole of the infant's foot, it was wrapped in a cloth and placed on the sole from which the heel lance would be taken (176).
 Health providers should be aware of the potential for burns, irritation and skin discomfort when using heat therapy interventions.

# RECOMMENDATIONS
Vascular Access -Second Edition 

# Supporting Resources

# RESOURCE DESCRIPTION

# Research Gaps and Future Implications
In reviewing the evidence for this BPG, the RNAO best practice guideline development and research team and expert panel identified priority areas for future research (outlined in Table 15). Studies conducted in these areas would provide further evidence to support high-quality and equitable support for persons with VAD. The list is not exhaustive; other areas of research may be required.  Studies that explore blood draws from a VAD and their impact on device dwell time.
 The impact of blood draws from a VAD versus blood draw from venipuncture on person and family values and preferences.
 Qualitative studies examining the impact of blood draw technique on person and family experience (including a range of ages and cognitive needs).
 Studies that explore blood draws from CVADs and their impact on infection and specimen integrity.

# RECOMMENDATION QUESTION #5:
Should the daily review of peripheral vascular access devices by health providers be recommended?
Outcomes: Complications.
 Randomized controlled trials exploring the effectiveness of multi-component care protocols or daily PVAD reviews.
 Long-term follow-up studies exploring the effect of PVAD care on rare complications.
 Qualitative studies examining the role of PVAD care in person and family experience.  Studies exploring pain management strategies for CVAD insertion and arterial catheter insertion.
 Studies exploring the impact of routine use of topical anesthesia for PVAD insertion or venipuncture in adults.
 Studies exploring person and family satisfaction and experience with pain management strategies (including people of various ages and cognitive needs).
 Qualitative studies exploring pain management strategies for VAD insertion in adults and children.

# Applicable to all recommendation questions
 Studies exploring the health equity implications of VAD insertion and management.

# RECOMMENDATIONS
Vascular Access -Second Edition

# Implementation Strategies
Implementing guidelines at the point of care is multi-faceted and challenging. It takes more than awareness and distribution of BPGs for practice to change must be adapted for each practice setting in a systematic and participatory way to ensure that recommendations fit the local context (223). The RNAO Leading Change ToolkitTM (2021), available online at  provides evidence-informed processes for this (see Appendix Q).
The Leading Change ToolkitTM uses two complementary frameworks to guide evidence uptake and sustainability (see Figure 1). They can be used together to maximize and accelerate change.

# Figure 1: Leading Change ToolkitTM Two Complementary Frameworks to Accelerate your Success
The Social Movement Action Framework ( 224) is descriptive and identifies the defining elements of a social movement for knowledge (e.g., BPGs) uptake and sustainability. It integrates a 'bottom-up' , people-led approach to change for a shared concern (or common cause) in which change agents and change teams mobilize individual and collective action to achieve goals. The framework's elements, categorized as preconditions, key characteristics and outcomes, are dynamic, inter-related and develop spontaneously as the social movement evolves.
The Knowledge-to-Action Framework uses a process model of action cycle phases to systematically guide the adaptation of the new knowledge (e.g., BPG) to the local context and implementation. This framework suggests identifying and using knowledge tools/products, such as guidelines, to determine gaps and begin the process of tailoring the new knowledge to local settings.

# RECOMMENDATIONS
Vascular Access -Second Edition
The Leading Change ToolkitTM is based on emerging evidence in health and social sciences that successful uptake and sustainability of best practice in health care is more likely when:
 BPGs are selected for implementation through a participatory process led by change agents and change teams;
 The selected BPGs reflect priority areas for a shared concern that is credible, valued and meaningful, or an urgency for action;
 Stakeholders are identified and engaged throughout implementation to engage in individual and collective action;
 Receptivity for implementing BPGs, including environmental readiness, is assessed;
 Implementation strategies are tailored to the local context and designed to address barriers;
 Use of the BPG is monitored and sustained;
 Evaluation of the BPG's impact is embedded in the process to determine if the goals and outcomes have been met;
 There are adequate resources to complete all aspects of the uptake and sustainability of the BPG; and,  The BPG is scaled up, out, or deep, where possible, to widen its influence and create lasting health improvements.
RNAO is committed to widespread deployment and implementation of our BPGs. We use a coordinated approach to dissemination, incorporating a variety of strategies, including the following:
- The Nursing Best Practice Champion Network, which develops the capacity of individual nurses to foster awareness, engagement, and adoption of BPGs.
- The BPG Order Sets TM provide clear, concise and actionable intervention statements derived from practice recommendations. BPG Order Sets TM can be readily embedded within electronic records, but they can also be used in paper-based or hybrid environments.
- The BPSO designation supports implementation at the organization and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate and sustain multiple RNAO BPGs.
In addition, we offer annual capacity-building learning institutes on specific BPGs and their implementation.
Information about our implementation strategies can be found at: 
 RNAO

# R E F E R E N C E S
Vascular Access -Second Edition

# A P P E N D I C E S
Vascular Access -Second Edition Good practice statement: A good practice statement is directed primarily to nurses and the interprofessional teams who provide care to persons and their families across the spectrum of care, including (but not limited to): primary care, acute care, home care and long-term care. It refers to a practice already accepted as beneficial or to practical advice.
In the case of this BPG, the good practice statement is believed to be so beneficial that conducting a systematic review to prove its efficacy would be unreasonable. These statements are not based on a systematic review and do not receive a rating of the certainty or confidence in the evidence or strength (i.e., conditional or strong) (7).

# Grading of Recommendations Assessment, Development and Evaluation (GRADE):
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a methodological approach to assess the certainty of a body of evidence in a consistent and transparent way, and to develop recommendations in a systematic way. The body of evidence across identified important and/or critical outcomes is evaluated based on risk of bias, consistency of results, relevance of studies, precision of estimates, publication bias, large effect, dose-response and opposing confounding (8).
When using GRADE, five components contribute to the assessment of confidence in the evidence for each outcome. These components are as follows:
- Risk of bias, which focuses on the flaws in the design of a study or problems in its execution. 2. Inconsistency, which looks at a body of evidence and assesses whether the results point in the same direction, or if they are different. 3. Imprecision, which refers to the accuracy of results based on the number of participants and/or events included, and the width of the confidence intervals across a body of evidence. 4. Indirectness, whereby each primary study that supports an outcome is assessed and a decision is made regarding the applicability of the findings to the population, intervention and outcome outlined in the research question. 5. Publication bias, where a decision is made about whether the body of published literature for an outcome potentially includes only positive or statistically significant results (237).
Health provider: Refers to both regulated workers (e.g., nurses, physicians, and respiratory therapists) and unregulated workers (e.g., physician's assistants and paramedics) who are part of the interprofessional team.

# Regulated health provider:
In Ontario, the Regulated Health Professional Act, 1991 (RHPA) provides a framework for regulating 23 health professions, outlining the scope of practice and the profession-specific controlled or authorized acts that each regulated professional is authorized to perform when providing health services (5).
Unregulated health provider: These providers fulfill a variety of roles in areas that are not subject to the RHPA. They are accountable to their employers but not to an external regulating professional body (e.g., the College of Nurses of Ontario). Unregulated health providers fulfill a variety of roles and perform tasks that are determined by their employer and employment setting. Unregulated health providers only have the authority to perform a controlled act as set out in the RHPA if the procedure falls under one of the exemptions set out in the Act (6).

# A P P E N D I C E S
Vascular Access -Second Edition Health-service organization: In this BPG, health-service organization refers to any health setting or workplace in which persons and/or families receive care from a health provider related to a VAD. . Hemolysis: "Destruction of the membrane of the red blood cells, resulting in the liberation of hemoglobin, which diffuses into the surrounding fluid" (228) . Blood samples that are hemolyzed due to improper handling or drawing of blood samples cannot be processed. This is the leading cause of samples being rejected by clinical laboratories.

# Implanted vascular access device (IVAD):
Permanent catheters that are characterized by a subcutaneous reservoir with a diaphragm that acts as a receptacle for infusion. The reservoir is connected to a central vein in the chest with a catheter (229). Port-a-caths (single or double) and broviacs (single or double) are examples of IVADs.
Implementation science: Defined as "the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care" (page 1) (270).
Infiltration: "The inadvertent administration of medication or solution into the surrounding subcutaneous or subdermal tissue instead of into the intended vascular pathway" (238). This has been reported to be the most frequent complication that is associated with short PVADs, specifically when located in the hand (102).
Interprofessional team: team comprising multiple health providers (regulated and unregulated) who work collaboratively to deliver comprehensive and quality health services to people within, between and across health settings (4). Key interprofessional team members supporting persons with vascular devices may include: nurses, nurse practitioners, physicians, respiratory therapists, physician's assistants, paramedics and child life specialists. It is important to emphasize that persons with a VAD and their chosen family are at the centre as active participants of the team.
Meta-analysis: systematic review that uses statistical methods to analyze and summarize the results of the included studies (239).

# See systematic review
Multi-component care protocol: A group of evidence-based interventions that can ensure the delivery of a standardized method of care; when these interventions are performed together, they can have a better outcome than if performed individually (also sometimes called a "care bundle") (adapted from (100).
Nurse: "Refers to registered nurses, licensed practical nurses (referred to as registered practical nurses in Ontario), registered psychiatric nurses and nurses in advanced practice roles, such as nurse practitioners and clinical nurse specialists" (5).

# A P P E N D I C E S
Vascular Access -Second Edition Osmolarity: The number of osmotically active particles in a solution (228).
Outcomes: A dependent variable, or the clinical and/or functional status of a patient or population, that is used to assess if an intervention is successful. In GRADE, outcomes are prioritized based on if they are critical for decision making, important but not critical for decision making, or not important. In so doing, the literature search and systematic reviews are more focused (8).

# See Grading of Recommendations Assessment, Development and Evaluation (GRADE)
Peripherally inserted central catheter (PICC): "A catheter inserted through veins of the upper extremity or neck in adults and children. For infants, the PICC may be inserted through veins of the scalp or a lower extremity. The catheter tip is located in the superior or inferior vena cava, preferably at its junction with the right atrium, regardless of insertion site" (228).
Peripheral Vascular Access Device (PVAD): "VAD inserted in peripheral vein with its tip not extending into the central vasculature" (25).
Person: An individual with whom a health provider has established a therapeutic relationship for the purpose of partnering for health. Replaces the terms "patient, " "client, " and "resident, " which are used across healthservice organizations (235).
Person-and family-centred care: An "approach to care  certain practices that put the person and their family members at the centre of health services. Person-and family-centred care respects and empowers individuals to be genuine partners with health providers for their health" (235).
Phlebitis: Redness, swelling, tenderness, pain, purulent discharge and/or induration (palpable cord) at the insertion site of a vascular device (240,241).

# PICO research question:
A framework to outline a focused question. It specifies four components: 1. The patient or population that is being studied.
- The intervention to be investigated.
- The alternative or comparison intervention. 4. The outcome that is of interest (8).

# Practical education:
For the purposes of this guideline, practical education refers to deliberate practice, supervised insertions of VADs, hands-on training or one-on-one training for health providers. Practical or skills lab training follows a structured teaching concept, takes place under supervision and in consideration of foundational concepts, and ideally creates an atmosphere that allows the repeated, risk-free practice of targeted clinical skills (50).

# A P P E N D I C E S
Vascular Access -Second Edition Quasi-experimental study: A study that estimates causal effects by observing the exposure of interest, but in which the experiments are not directly controlled by the researcher and lack randomization (e.g., before-andafter designs) (242).
Randomized controlled trial: An experiment in which the investigator assigns one or more interventions to participants who are randomly allocated to either the experimental group (receives intervention) and the comparison (conventional treatment) or control group (placebo or no intervention) (239).
Recommendation: A course of action(s) that directly answers a recommendation question (also known as a PICO research question). A recommendation is based on a systematic review of the literature and is made in consideration of its (a) benefit and harms, (b) values and preferences, and (c) health equity. All recommendations are given a strength-either strong or conditional-through panel consensus.
It is important to note that recommendations should not be viewed as dictates, because recommendations cannot take into account all of the unique features of individual, organizational and clinical circumstances (8).

# Recommendation question:
A priority research area of practice, policy or education identified by expert panel members that requires evidence to answer. The recommendation question may also aim to answer a topic area around which there is ambiguity or controversy. The recommendation question informs the research questions, which guides the systematic review (8).
Simulation (simulation learning): "Simulation is the imitation of some real thing, state of affairs or process.
In health professions education, simulation is a methodology to help achieve educational goals. Health-care simulation encompasses a range of activities that share a broad but common purpose: to improve the safety, effectiveness and efficiency of health-care services" (243). "Simulation activities can include computer-based simulation, e-learning, high-fidelity patient simulators, role playing and other blended approaches" (244).
Social movement in the context of knowledge uptake and sustainability: Individuals, groups and/or organizations who, as voluntary and intrinsically motivated change agents, mobilize to transform health outcomes (266).
Stakeholder: "An individual, group or organization that has a vested interest in the decisions and actions of organizations, and which may attempt to influence decisions and actions" (245). Stakeholders include all of the individuals and groups that will be directly or indirectly affected by the change or solution to the problem.

# Successful Observed Attempt (or Successful VAD insertion attempt):
A PVAD insertion attempt is deemed to be successful if there is evidence of blood flashback in the catheter upon insertion, and if the device flushes easily with no signs of infiltration, swelling or leakage upon flushing (adapted from ( 126), (127), and ( 128)).
Note: If ultrasound-guidance technique is used, it should be evident on ultrasound that the catheter is positioned properly in the vein. A CVAD insertion attempt should be confirmed with x-ray.

# A P P E N D I C E S
Vascular Access -Second Edition Systematic review: A comprehensive review of the literature that uses clearly formulated questions and systematic and explicit methods to identify, select and critically appraise relevant research. A systematic review collects and analyzes data from the included studies and presents them, sometimes using statistical methods (239).

# See meta-analysis
Ultrasound-guided Technique: Ultrasound imaging (an image created by sending sound waves through soft tissue) allows health providers to see surrounding anatomical structures (119). It can be used to aid the health provider when inserting a PVAD, CVAD or peripheral arterial catheter. Ultrasound guidance allows visualization of both the needle and the target vessel on the monitor, using either the short-axis or long-axis view (123).
Valsalva maneuver: A breathing technique that can be used as a pain management strategy during VAD insertion. It involves "a deep inhale, followed by a forceful holding of the breath, during which the venous cannulation insertion occurs" (143).

# Vascular access device (VAD):
Vascular access devices (VADs) are defined as a catheter (thin tube) inserted into veins that can be implanted or inserted under the skin, allowing fluids and medicines to be delivered into veins (adapted from ( 3)). Catheters inserted into arteries can be used to monitor therapy (adapted from ( 3)).

# Examples of VADs include:
 peripheral vascular access devices (PVADs), such as short peripheral intravenous catheters (PIVs) and extended dwell, midline catheters;
 central vascular access devices (CVADs), such as peripherally inserted central catheters (PICCs), tunneled catheters, non-tunneled catheters and implanted vascular access devices (IVADs);  peripheral arterial catheters; and  phlebotomy devices.

# Vascular access specialist team (VAST) or vascular access specialists (VAS)\
; "A grouping of health providers who have advanced knowledge and skills in the assessment, insertion, care and management of VADs" (3). This includes infusion/intravenous, intravenous therapy teams and individual vascular access specialists (nurses, physicians, respiratory therapists, laboratory technicians and physician assistants) (3).
Venipuncture: "A procedure in which a needle is used to take blood from a vein, usually for laboratory testing. Also called blood draw and phlebotomy" (246).
Vesicant: "An agent capable of causing tissue damage when it escapes from the intended vascular pathway into surrounding tissue" (228). Tissue damage can cause injury, blistering, necrosis and redness of the skin.

# A P P E N D I C E S
Vascular Access -Second Edition *Note: An updated edition of the infusion therapy standards of practice published in early 2021, and this updated version was used as a supporting resource in this BPG, and to inform the good practice statement, glossary and appendices where applicable.
 Canadian Vascular Access Association. Canadian vascular access and infusion therapy guidelines. Pembroke (ON): Pappin Communications; 2019.
 Score: 5 out of 7.
 This guideline was used as a supporting resource in this BPG, and to inform the background, good practice statement, glossary and appendices.
Telephone key informant interviews. Eleven interviews were conducted with experts in the field-including direct care health providers, researchers, educators and managers-to understand the needs of nurses, members of the interprofessional health team and persons with lived experience.
- Telephone discussion group sessions. Three sessions were convened to understand the needs of nurses, members of the interprofessional health team and persons with lived experience.

# Assembly of the Expert Panel
RNAO aims for diversity in membership of an expert panel; this is in alignment with its Organizational Statement on Diversity and Inclusivity, which is part of the RNAO Mission and Values (248).
RNAO identifies and selects members of an expert panel through numerous different avenues. This includes the following:
 searching the literature for researchers in the topic area;
 soliciting recommendations from key informant interviews;
 drawing from established professional networks, such as RNAO Interest Groups, the Nursing Best Practice Champions Network and BPSOs; and
 drawing from other nursing and health provider associations, topic-relevant technical associations or organizations, and advocacy bodies.
For this BPG, the RNAO best practice guideline development and research team assembled a panel of experts from nursing practice, research and education, as well as other members of the interprofessional team, to represent a range of sectors and practice areas (see members of the RNAO Best Practice Guideline Expert Panel on page 24).
The expert panel engaged in the following activities:
 approved the purpose and scope of this BPG,  determined the recommendation questions and outcomes to be addressed in this BPG,  participated in a consensus G development process to finalize recommendation statements,  provided feedback on the drafts of this BPG,  participated in the development of evaluation indicators,  helped develop BPG Order SetsTM, and  identified appropriate stakeholders to review the draft guideline prior to publication.

# A P P E N D I C E S
Vascular Access -Second Edition
In addition to the above, the expert panel co-chairs engaged in the following activities:
 participated in monthly meetings with the guideline development methodologists and guideline development project coordinator,  facilitated expert panel meetings,  provided in-depth guidance on clinical and/or research issues, and  moderated voting processes.