Evidence-Based Practice (EBP) and Research in Vascular Access

Establishes the organizational commitment to evidence-based practice in vascular access, mandates the continuous revision of policies based on current research, defines the implementation science framework for translating evidence into bedside practice, and outlines the infrastructure requirements for supporting clinician-researchers.

policies•Jan 2026•Research

Evidence-Based Practice (EBP) and Research in Vascular Access Policy

1. Policy Statement

It is the policy of this organization that all vascular access clinical practice shall be guided by the highest quality available research evidence, integrated with clinical expertise and patient values.123 Organizational policies, procedures, and clinical protocols related to vascular access shall be treated as living documents subject to continuous revision in response to new clinical evidence.45 The organization shall provide the infrastructure, mentorship, and ethical oversight necessary to support clinicians in conducting original research and disseminating findings to advance the science of vascular access both internally and within the broader professional community.678

2. Purpose

This policy exists to:

  • Mandate that all vascular access clinical decisions, policies, and protocols be grounded in current, peer-reviewed clinical evidence, not in tradition, habit, or anecdotal experience.191011
  • Require the continuous, scheduled revision of vascular access policies and procedural manuals to incorporate new clinical publications, emerging guidelines, and updated professional standards.45
  • Define the implementation science framework through which the organization bridges the gap between research evidence and bedside clinical practice.1213
  • Establish the professional responsibility of all vascular access clinicians to participate in knowledge sharing and evidence dissemination, both within the organization and externally.1415161718
  • Outline the organizational infrastructure required to support clinician-led research, including mentorship, library resources, Institutional Review Board (IRB) access, and skill development in research methodology and academic publishing.619202178

3. Scope

This policy applies to:

  • All clinical personnel involved in vascular access and infusion therapy practice.
  • All members of the Vascular Access Governance Committee, Product Evaluation Committee, and Clinical Education Department.
  • All organizational policies, standard operating procedures, and clinical protocols related to vascular access and infusion therapy.
  • All research activities related to vascular access conducted within or sponsored by the organization.
  • The organizational Research Department, IRB, library services, and any affiliated academic institutions.

4. Policy Requirements

4.1 Professional Responsibility in Knowledge and Evidence

4.1.1 Continuous Revision of Clinical Documents. All organizational vascular access policies, standard operating procedures (SOPs), and clinical protocols shall be reviewed on a scheduled basis—at minimum every two (2) years, or sooner if prompted by the publication of major new clinical evidence, updated professional society guidelines, regulatory changes, or sentinel event findings.459 The VAGC shall maintain a master document review schedule that tracks the last review date, next scheduled review date, and assigned reviewer(s) for each document.122

4.1.2 Evidence Grading. When revising policies and protocols, the VAGC shall grade the supporting evidence using a recognized hierarchy (e.g., the Johns Hopkins Evidence-Based Practice Model or the GRADE framework).511 The evidence grade shall be documented within the policy or protocol to allow clinicians to understand the strength of the evidence behind each recommendation.511

4.1.3 Knowledge Dissemination as Professional Duty. It is a professional responsibility of vascular access clinicians to share clinical innovations, quality improvement outcomes, and research findings both internally (through in-services, grand rounds, journal clubs, and institutional publications) and externally (through peer-reviewed journal submissions, poster and podium presentations at professional conferences, and contributions to professional organization work).1415161718 The organization shall recognize and support these activities as legitimate professional contributions.78

4.2 Implementation Science Framework

4.2.1 Bridging Evidence to Practice. The organization recognizes that the existence of evidence is insufficient—the critical challenge is translating evidence into consistent bedside practice.110212 The VAGC shall apply implementation science principles to all evidence-based practice change initiatives, including: assessing organizational readiness for the change, identifying barriers and facilitators, selecting an evidence-based implementation strategy, measuring adoption and fidelity, and sustaining the change over time.1213 Evidence-based practice has been consistently associated with improved patient outcomes and a measurable return on organizational investment when implementation is structured and sustained.123

4.2.2 Critical Synthesis. Clinical teams, led by the VAGC and supported by Clinical Education, shall regularly participate in the critical evaluation and interpretation of published evidence.42425 Activities shall include: regularly scheduled journal clubs focused on vascular access literature, structured literature reviews conducted as part of policy revision cycles, and rapid evidence appraisals conducted in response to clinical questions arising from practice.2425

4.2.3 Collaborative Decision-Making. Product selection, technology adoption, protocol development, and standards of care shall be decided through a collaborative framework involving frontline clinicians, vascular access specialists, researchers (when available), clinical educators, and organizational leadership.2627 No single individual or department shall unilaterally mandate a practice change without evidence review and collaborative input.222627 Meaningful patient and family engagement in organizational decision-making processes enhances the relevance and acceptability of evidence-based changes.2627

4.3 Infrastructure for Clinician-Researchers

4.3.1 Mentorship. The organization shall facilitate connections between bedside clinicians interested in research and qualified mentors, including Nurse Scientists, Clinical Nurse Specialists, Doctoral-prepared nurses, or organizational librarians, to support the research process from question formulation through publication.6282930

4.3.2 Ethical Oversight. All research involving human subjects conducted within or sponsored by the organization shall be reviewed and approved by an Institutional Review Board (IRB) or Ethics Committee before data collection begins. Clinicians shall receive training in research ethics, informed consent for research participation, and the protection of human subjects (e.g., completion of CITI training or equivalent).

4.3.3 Skill Development. The organization shall provide or facilitate access to educational resources that build clinician research competency, including: workshops or seminars on research design, data collection, and statistical analysis;192021 training in abstract writing and poster development for conference submissions;15 guidance on the manuscript preparation and peer-review process;1416 and access to medical librarian services for literature searching and database navigation.2425 Structured writing skill development programs have demonstrated effectiveness in increasing clinician publication rates.141518

4.3.4 Resource Allocation. The organization shall, within budgetary constraints, allocate resources to support vascular access research activities, including: protected time for clinician-researchers to conduct approved research,78 funding support for conference attendance and poster printing, access to statistical consultation services, and institutional support for IRB application fees and research administration costs.23

4.4 Integration of EBP into Daily Practice

4.4.1 Bedside Accessibility. Evidence-based vascular access guidelines and organizational protocols shall be readily accessible to clinicians at the point of care, through the organization’s intranet, EHR-embedded clinical decision support, or printed reference materials.45 Nurses who interact with research literature report that accessibility and organizational support are primary determinants of EBP utilization.2425

4.4.2 EBP Champions. The VAGC shall designate unit-based EBP Champions who serve as local resources for evidence-based vascular access questions, facilitate adoption of new evidence-based practices on their units, and communicate bedside concerns and clinical questions back to the VAGC.301931 The EBP Champion role requires defined responsibilities, ongoing organizational support, and formal acknowledgment to remain sustainable over time.30

4.4.3 Tracking EBP Adoption. The VAGC shall maintain a log of all evidence-based practice changes implemented within the vascular access program, including the evidence basis, the implementation date, the adoption metrics, and the outcome data.12223 Standardized vascular access registries and minimum datasets provide the infrastructure necessary to evaluate the impact of practice change on patient outcomes at scale.3231

5. Compliance

5.1 Monitoring. Compliance shall be monitored through tracking of policy and SOP review completion against the master document review schedule (target: 100% on schedule), annual accounting of knowledge dissemination activities (internal presentations, external publications, conference submissions),161718 IRB approval documentation for all active research studies, journal club attendance and participation rates,2425 and EBP Champion activity logs.30

5.2 Key Performance Indicators.

  • Percentage of vascular access policies and SOPs reviewed within the scheduled review cycle (target: 100%).4
  • Number of evidence-based practice changes implemented per year.122
  • Number of internal knowledge dissemination events per year (target: minimum four journal clubs or in-services per year).2425
  • Number of external publications, poster presentations, or conference submissions per year.141618
  • Number of active IRB-approved vascular access research studies.

5.3 Enforcement. Failure to complete scheduled policy reviews shall be escalated to the VAGC Chair and the CNO. Conducting research without IRB approval is a serious violation subject to immediate cessation of the research activity, disciplinary action, and potential regulatory reporting.

6. Exceptions

6.1 In situations where clinical evidence is insufficient, conflicting, or absent for a specific vascular access question, the VAGC may approve interim practice recommendations based on expert consensus, clearly labeled as such within the policy document.511 These interim recommendations shall include a plan for evidence monitoring and shall be revisited when new evidence becomes available.

6.2 Requests to deviate from the evidence-based standard of care for an individual patient shall be processed as clinical exceptions under the relevant clinical policy (e.g., POL-001) and shall be documented with the clinical rationale.

  • SOP-VA-100: Policy and SOP Review and Revision Procedure
  • SOP-VA-101: Journal Club Planning and Facilitation Procedure
  • SOP-VA-102: IRB Application Process for Vascular Access Research
  • POL-003: Evidence-Based Selection and Clinical Monitoring Standards
  • POL-007: Competency and Competency Validation in Vascular Access
  • Master Document Review Schedule (maintained by VAGC)
  • Evidence-Based Practice Change Log (maintained by VAGC)
  • Organizational IRB Policies and Procedures
  • CITI Training Requirements
  • Johns Hopkins Evidence-Based Practice Model (or organizational equivalent)

References

8. Revision History

VersionDateAuthor(s)Description of Change
1.02026-02-01D. Woo, M. Stern, I.M. WrightInitial policy creation and approval
1.12026-02-23D. Woo, M. Stern, I.M. WrightAdded comprehensive academic references
———Scheduled review date: 2028-02-01

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