Interprofessional Safety and Care Transitions

Mandates the integration of vascular access expertise into cross-disciplinary institutional safety programs and establishes the standards for safe care transitions involving patients with indwelling vascular access devices across acute, community, home, and long-term care settings.

policies•Jan 2026•Patient Safety

Interprofessional Safety and Care Transitions Policy

1. Policy Statement

It is the policy of this organization that vascular access expertise shall be formally integrated into all cross-disciplinary institutional safety programs, and that every transition of care involving a patient with an indwelling vascular access device shall be accompanied by standardized, comprehensive transfer documentation designed to ensure continuity of device management and the prevention of device-associated complications, including Central Line-Associated Bloodstream Infection (CLABSI).1

2. Purpose

This policy exists to:

  • Formalize the role of vascular access specialists as essential contributors to institutional safety committees addressing antimicrobial stewardship, medication error prevention, pain management, and infusion pump safety.
  • Establish standardized requirements for the information that must accompany a patient and their vascular access device during every care transition—whether between units within the hospital, from acute care to home care, from acute care to skilled nursing, or between external facilities.
  • Reduce CLABSI and other device-associated complications during care transitions by eliminating communication gaps related to device type, insertion details, maintenance requirements, and infusion protocols.
  • Define the consultative and educational role of the VAST in supporting care delivery in alternative settings, including nurse-run infusion centers and community therapy programs.

3. Scope

This policy applies to:

  • All clinical personnel responsible for initiating, coordinating, or receiving a care transition involving a patient with an indwelling vascular access device.
  • All care transition types, including: intra-facility transfers (unit to unit), inter-facility transfers (hospital to hospital), transitions from acute care to post-acute settings (home care, skilled nursing, long-term acute care, rehabilitation), transitions to outpatient infusion centers, and transitions from one home health agency to another.
  • All vascular access device types, including PIVCs, midline catheters, PICCs, tunneled and non-tunneled central venous catheters, and implanted ports.
  • All institutional safety committees that address topics intersecting with vascular access management.

4. Policy Requirements

4.1 Cross-Disciplinary Safety Program Integration

4.1.1 Antimicrobial Stewardship. The VAST shall hold formal representation on or liaison status with the organization’s Antimicrobial Stewardship Program (ASP). The VAST contribution shall include: ensuring that vascular access device selection matches the prescribed therapy’s anticipated duration, pH, and osmolarity characteristics; identifying opportunities to de-escalate from central to peripheral access when antibiotic therapy permits; and contributing to surveillance of device-related infection patterns that may influence antimicrobial resistance.2

4.1.2 Medication Error Prevention. The VAST shall participate in the organization’s Medication Safety Committee to collaboratively analyze IV-related medication errors, including wrong-route errors, infusion rate errors, and adverse drug reactions associated with vascular access (e.g., vancomycin flushing syndrome, vesicant extravasation).345 Analysis findings shall be incorporated into staff education and system redesign initiatives.

4.1.3 Pain Management. The VAST shall coordinate with the Acute Pain Service and Anesthesiology to ensure consistent delivery of Patient-Controlled Analgesia (PCA) through vascular access devices, prevent lapses in analgesia delivery caused by device malfunction, occlusion, or displacement, and contribute to the development of pain management protocols for vascular access procedures.

4.1.4 Infusion Pump Safety. VAST representatives shall participate in the organization’s Dose Error Reduction System (DERS) committee to: review and refine smart pump drug libraries, analyze pump override data and alert fatigue patterns, and identify programming errors or “workarounds” that bypass safety features. Findings shall be reported to the Medication Safety Committee and integrated into staff competency programs.

4.1.5 Formal Representation Documentation. The VAST Manager shall maintain a current log of all institutional safety committees on which the VAST holds membership or liaison status, including the designated representative, the frequency of meetings, and a summary of VAST contributions to each committee’s work plan.

4.2 Care Transition Standards for Patients with Vascular Access Devices

4.2.1 Standardized Transfer Documentation. Every care transition involving a patient with an indwelling vascular access device shall be accompanied by a completed Vascular Access Transfer Communication Form (or its EHR equivalent) that includes, at minimum:

  • Device identification: Type of device (e.g., PICC, tunneled CVC, implanted port, midline), manufacturer and model (if available), number of lumens, gauge or French size.
  • Insertion details: Date and time of insertion, inserting clinician name and credentials, anatomical site and laterality, vein accessed, catheter length (internal and external), and tip location confirmation method and result (e.g., chest X-ray, ECG-guided confirmation).
  • Current dressing and securement: Type of dressing, type of securement device, date of last dressing change, and date of next scheduled change.
  • Flush and lock protocol: Flush solution (e.g., normal saline, heparin), concentration, volume, and frequency.
  • Current infusion regimen: All medications and fluids infusing through the device, rates, concentrations, and compatibility information.
  • Known complications or concerns: History of device-related complications during the current episode of care, current device patency status, and any unresolved issues requiring follow-up.
  • Line necessity status: Documentation of continued clinical indication for the device.
  • Patient/caregiver education status: Summary of education provided and verified understanding (teach-back or return demonstration outcomes).

4.2.2 Verbal Handoff Requirement. In addition to written documentation, a verbal (telephone or in-person) handoff between the sending and receiving clinicians responsible for the vascular access device shall be completed for all inter-facility transfers and all transitions to home care. The verbal handoff shall follow a standardized communication framework (e.g., SBAR: Situation, Background, Assessment, Recommendation).

4.2.3 Receiving Facility Confirmation. The sending clinician shall confirm that the receiving facility or agency has the clinical capability, equipment, and trained personnel to manage the specific type of vascular access device being transferred. If the receiving facility cannot manage the device, the sending team shall either transition the patient to an appropriate device before transfer or identify an alternative receiving facility.

4.3 Care Standardization Across Settings

4.3.1 The organization shall actively pursue standardization of vascular access management practices between its acute care operations and its affiliated community care organizations, home health agencies, and skilled nursing facilities. Standardization efforts shall focus on: dressing change protocols, flush and lock procedures, site assessment and documentation standards, and complication recognition and reporting pathways.

4.3.2 Evidence Base. Standardization is driven by evidence that aligning vascular access practices between acute and community settings decreases CLABSI rates and other device-associated complications.6781 The VAGC shall track CLABSI rates both within the acute care setting and in post-discharge settings to measure the impact of standardization efforts.

4.3.3 Community-Based Support. The VAST shall provide educational support, consultation services, and protocol guidance to affiliated nurse-run infusion centers, home health agencies, and community therapy programs. The scope of this support shall include: initial training for community-based clinicians on organizational vascular access standards, ongoing consultation for complex cases, and periodic competency validation or audit support as defined by partnership agreements.9

4.4 Setting-Specific Requirements

4.4.1 Home Care Transitions. Patients being discharged to home with an indwelling vascular access device shall have: a completed home readiness assessment (per POL-003, Section 4.3.4), a clear written instruction sheet tailored to the specific device type, 24/7 contact information for emergency vascular access guidance, and confirmation that the home health agency has received and acknowledged the Vascular Access Transfer Communication Form.10

4.4.2 Outpatient Infusion Center Transitions. Patients transitioning to outpatient infusion services shall have their vascular access device information integrated into the outpatient clinic’s scheduling and care plan. The VAST shall ensure that outpatient clinic staff have received training in ultrasound-guided PIVC insertion and CVAD maintenance relevant to the patient population they serve.11

4.4.3 Skilled Nursing Facility Transitions. Patients transitioning to skilled nursing shall have their device management plan explicitly communicated, including the anticipated remaining duration of therapy, the scheduled maintenance protocol, and the criteria for device removal. The VAST shall offer remote consultation and educational support to skilled nursing facility staff as defined by the organizational partnership agreement.

5. Compliance

5.1 Monitoring. Compliance shall be monitored through quarterly audits of Vascular Access Transfer Communication Form completion rates for inter-facility transfers and home care discharges, review of post-discharge CLABSI events attributed to care transition communication gaps, annual review of VAST committee participation logs, and staff and partner facility satisfaction surveys regarding transition communication quality.

5.2 Key Performance Indicators.

  • Vascular Access Transfer Communication Form completion rate (target: 100% for all applicable transitions).
  • Verbal handoff completion rate for inter-facility and home care transitions (target: 100%).
  • Post-discharge CLABSI rate attributable to care transition gaps (target: zero).
  • VAST safety committee participation rate (target: ≥90% meeting attendance for designated representatives).

5.3 Enforcement. Incomplete transfer documentation that results in a device-related adverse event at a receiving facility shall be investigated through the organization’s root cause analysis process. Systemic failures shall be addressed through process redesign; individual failures shall be addressed through the progressive corrective action process.

6. Exceptions

6.1 In emergent transfer situations (e.g., trauma transfer, emergency inter-facility transport), the complete written Vascular Access Transfer Communication Form may be deferred if verbal handoff of critical device information is completed. The sending facility shall transmit the written form within four (4) hours of the patient’s departure.

6.2 Exceptions to committee participation requirements due to staffing constraints shall be documented and reported to the VAGC with a plan for restoring representation.

  • SOP-VA-060: Vascular Access Transfer Communication Procedure
  • SOP-VA-061: Inter-Facility Transfer Verbal Handoff Procedure (SBAR Framework)
  • SOP-VA-062: Home Care Discharge with Vascular Access Device Procedure
  • POL-003: Evidence-Based Selection and Clinical Monitoring Standards
  • POL-005: Service Delivery Models and Operational Scope
  • POL-009: Patient Education in Infusion Therapy
  • Vascular Access Transfer Communication Form (FORM-VA-TRANS-001)
  • SBAR Communication Tool
  • Organizational Care Transitions Policy
  • Joint Commission National Patient Safety Goals: Transitions of Care
  • CMS Conditions of Participation: Discharge Planning

8. Revision History

VersionDateAuthor(s)Description of Change
1.02026-02-01D. Woo, M. Stern, I.M. WrightInitial policy creation and approval
———Scheduled review date: 2027-02-01

References

  1. Krein SL, Harrod M, Weston LE, et al. Vascular access specialist teams and catheter-related bloodstream infection prevention: a multisite qualitative study. BMJ Qual Saf. 2021;30(8):628-638. doi:10.1136/bmjqs-2020-011806 ↩︎ ↩︎

  2. Carrico R, Wiemken T. Vascular access and antibiotic stewardship: an opportunity for improvement? J Assoc Vasc Access. 2016;21(2):83-86. doi:10.1016/j.java.2016.03.002 ↩︎

  3. Wolf ZR. Lessons learned from medication errors. J Infus Nurs. 2016;39(4):235-248. doi:10.1097/NAN.0000000000000175 ↩︎

  4. Mohanty M, Suber S, Edwards K, et al. Epidemiology of harmful medication errors in adult inpatients: a prospective study from a teaching hospital in South India. Ther Adv Drug Saf. 2018;9(8):389-404. doi:10.1177/2042098618782109 ↩︎

  5. Kim JT, Park JY, Lee HJ, Cheon YJ. Guidelines for the management of extravasation. J Educ Eval Health Prof. 2020;17:21. doi:10.3352/jeehp.2020.17.21 ↩︎

  6. Rupp ME, Majorant D. Prevention of vascular catheter-related bloodstream infections. Infect Dis Clin North Am. 2016;30(4):853-868. doi:10.1016/j.idc.2016.06.001 ↩︎

  7. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43(5):553-569. doi:10.1017/ice.2022.87 ↩︎

  8. Martillo M, Zarbiv S, Gupta R, et al. A comprehensive vascular access service can reduce catheter-associated bloodstream infections and promote the appropriate use of vascular access devices. Am J Infect Control. 2020;48(4):460-464. doi:10.1016/j.ajic.2019.09.021 ↩︎

  9. Hodgkins P. Vascular access in community care: community nurses and vascular access. Brit J Nurs. 2021;30(19):S4-S12. doi:10.12968/bjon.2021.30.19.S4 ↩︎

  10. Patton LJ, Hicks FD, Smith K, Hacker D, Mahnke A. Pediatric patients and peripherally inserted central catheter complications in the home care setting. J Pediatr Nurs. 2019;49:37-42. doi:10.1016/j.pedn.2019.08.009 ↩︎

  11. Graham J, Garcia D, Tamminga J, et al. Vascular access in the ambulatory infusion clinic: outcomes from a nurse-led team. J Infus Nurs. 2022;45(1):41-48. doi:10.1097/NAN.0000000000000452 ↩︎

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