Site Protection and Joint Stabilization for Vascular Access Devices Policy

1. Policy Statement

All vascular access devices (VADs) placed or maintained within this organization must have appropriate site protection measures implemented to safeguard the insertion site and device from patient manipulation, inadvertent dislodgement, and environmental contamination. Site protection and joint stabilization strategies must be individualized based on patient-specific risk, implemented as complements to—not replacements for—primary securement methods, and selected using the least-restrictive approach consistent with the clinical goal. Physical restraint as a routine site protection strategy is not supported by evidence, is inconsistent with patient-centered care, and must be avoided. Joint stabilization devices applied to facilitate infusion delivery and minimize mechanical complications are classified as therapeutic interventions and are not subject to physical restraint policies. Clinicians must regularly evaluate the continued need for all site protection and joint stabilization measures and discontinue them promptly when no longer clinically required.

2. Purpose

• To protect vascular access device insertion sites from patient manipulation, accidental dislodgement, and environmental contaminants across all care settings and patient populations.
• To establish a clear distinction between joint stabilization as a therapeutic intervention and physical restraint as a behavioral management strategy.
• To minimize the use of physical restraint in VAD management by providing a structured framework for identifying and implementing less restrictive alternatives.
• To delineate evidence-based site protection interventions appropriate for pediatric patients, cognitively impaired adults, patients with behavioral risk, and other high-risk populations.
• To reduce the physical and psychological harms associated with unnecessary restraint use, including skin trauma, pressure injury, anxiety, agitation, delirium, and limb complications.
• To establish education requirements for patients and caregivers regarding site protection rationale, device care, and complication recognition.

3. Scope

This policy applies to:

• All licensed and unlicensed clinical staff involved in the insertion, maintenance, and monitoring of vascular access devices.
• All inpatient, outpatient, procedural, critical care, home infusion, and long-term care settings operated by or affiliated with this organization.
• All vascular access device types placed in any anatomical location accessible to patient manipulation or subject to dislodgement from limb movement.
• All patient populations, with specific guidance for neonates, pediatric patients, adults with cognitive impairment, and patients who use injection drugs.
• Decisions regarding the application, continuation, and discontinuation of site protection measures, joint stabilization devices, and physical restraints in the context of VAD management.

4. Policy Requirements

4.1 Definitions

4.1.1 Site Protection

4.1.1.1 Site protection encompasses all strategies employed in addition to primary VAD securement methods to reduce dislodgement risk and protect the insertion site. Site protection interventions include:

• Products and interventions designed to reduce the mechanical force transmitted to the VAD insertion site from movement of the administration set or patient activity.
• Devices that protect or conceal the VAD from patient manipulation, including covers, mittens, and vests.
• Barriers that prevent exposure of the insertion site to water, bodily fluids, or environmental contaminants.

4.1.1.2 Site protection measures complement but do not replace primary securement. The securement method remains the primary mechanical anchor for the VAD; site protection reduces external forces that may overcome that anchor.

4.1.2 Joint Stabilization

4.1.2.1 Joint stabilization is the application of a supportive device—including arm boards, splints, or padded stabilizers—to an anatomical area of flexion where a vessel has been accessed for VAD placement. The purpose of joint stabilization is to minimize catheter dislodgement or kinking caused by limb movement at the access site.

4.1.2.2 Joint stabilization devices applied to facilitate infusion delivery, maintain VAD functionality, and minimize mechanical complications are classified as therapeutic interventions. They are not classified as physical restraints and are not subject to physical restraint policies.

4.1.3 Physical Restraint

4.1.3.1 A physical restraint is any manually applied method or device that immobilizes or reduces a patient’s ability to move their arms, legs, or body freely. Physical restraints represent the most restrictive form of site protection and must only be used when a patient’s behavior directly interferes with necessary medical treatment and less restrictive alternatives have been systematically evaluated and found insufficient.

4.2 Dislodgement Risk Assessment

4.2.1 High-Risk Populations

4.2.1.1 Clinicians must identify and document elevated VAD dislodgement risk at the time of device insertion and reassess throughout the dwell period. High-risk populations include:

• Pediatric patients, including neonates, infants, and children, in whom developmental factors and natural exploratory movement increase dislodgement risk.
• Adults with active delirium, dementia, acute confusion, or other cognitive impairment affecting ability to recognize the VAD and its purpose.
• Patients with agitation related to pain, withdrawal states, metabolic disturbances, or psychiatric conditions.
• Neonates with peripherally inserted central catheters (PICCs), in whom small catheter caliber and limited securement surface area increase vulnerability.

4.2.1.2 Consequences of accidental dislodgement that must be considered in risk assessment include: delays in treatment delivery, additional venipuncture or catheter insertion attempts, complications arising from interrupted therapy (particularly for vasoactive agents, anticoagulants, and antibiotics), and psychological distress from repeated procedural interventions.

4.3 Site Protection Interventions

4.3.1 General Requirements

4.3.1.1 When elevated dislodgement risk is identified, site protection measures must be implemented to complement the primary securement strategy. Site protection measures must be selected based on dislodgement risk, patient characteristics, and the least-restrictive principle.

4.3.1.2 Site protection measures must not prevent access to the insertion site for visual assessment, must not compress underlying tissue or restrict circulation, and must not interfere with infusion therapy delivery.

4.3.2 Force-Activated Separation Devices

4.3.2.1 Force-activated separation devices—also known as breakaway connectors or force-displacement connectors—are designed to detach at the administration set junction when excessive pulling force is applied to the tubing. These devices protect the VAD insertion site from traumatic dislodgement caused by unintentional tubing traction.

4.3.2.2 Force-activated separation devices must be considered for patients with identified dislodgement risk due to patient movement or administration set tension and are particularly appropriate for mobile patients and pediatric patients.

4.3.3 Central Line Vests

4.3.3.1 Central line vests and similar products designed to reduce tension at central venous catheter connection points must be considered for pediatric patients and others in whom CVAD protection from manipulation is clinically indicated. Available evidence supports the use of central line vests in reducing CVAD dislodgement in pediatric populations.

4.3.4 Protective Mittens

4.3.4.1 Protective mittens may be applied to patients at risk for self-directed VAD removal when the patient lacks the cognitive or volitional capacity to refrain from manipulating the device.

4.3.4.2 Protective mittens are not classified as physical restraints when both of the following conditions are met:

• They are applied without accompanying physical restraint devices.
• The patient retains the independent ability to remove the mittens.

4.3.4.3 When protective mittens are used, the underlying insertion site and extremity must be assessed at a minimum of every two hours for circulation, sensation, and skin integrity.

4.3.5 Tubular Sleeves

4.3.5.1 Patient-removable tubular sleeves may be used as a secondary barrier over secured dressings to provide an additional layer of protection from physical disruption of the dressing and securement device. Tubular sleeves must be readily removable to allow site inspection and must not restrict circulation.

4.3.6 Water and Contaminant Protection

4.3.6.1 Patients must be provided with appropriate site protection barriers to prevent water exposure to the VAD insertion site and dressing during bathing or showering. Commercially available waterproof covers or instructions for improvised protection with water-resistant materials are acceptable.

4.3.6.2 Patient and caregiver education on water protection for VAD insertion sites must be documented as part of VAD education encounters (see Section 4.7).

4.4 Special Population Considerations

4.4.1 Patients Who Use Injection Drugs

4.4.1.1 VAD misuse rates among patients who use injection drugs receiving home infusion therapy are relatively low. When VAD protection concerns exist in this population, clinicians may implement tamper-evident dressing or connection procedures in collaboration with the patient.

4.4.1.2 Any tamper-evident or protective measures implemented for patients who use injection drugs must be applied within a harm reduction framework that prioritizes patient dignity, therapeutic alliance, and evidence-based practice. These measures must not be applied as punitive responses or in a manner that compromises the patient-clinician relationship.

4.4.1.3 Clinicians must document the rationale for tamper-evident measures, the patient education provided, and the patient’s response in the medical record.

4.4.2 Pediatric Patients Undergoing Painful or Invasive Procedures

4.4.2.1 Age-appropriate pain management strategies are the preferred approach to maintaining patient cooperation during vascular access procedures in pediatric patients. Strategies must include:

• Topical anesthetic agents applied prior to venipuncture or catheter insertion.
• Distraction techniques appropriate to the patient’s developmental stage.
• Comfort positioning including therapeutic holding by a caregiver, when appropriate.
• Pharmacological analgesia and anxiolysis per provider orders when indicated.

4.4.2.2 Brief procedural positioning to maintain patient safety and preserve aseptic technique during CVAD insertion may be appropriate and differs from ongoing behavioral restraint. This positioning must be performed by trained personnel, must be the minimum required to safely complete the procedure, and must be discontinued immediately upon procedure completion.

4.5 Physical Restraint in VAD Management

4.5.1 Prohibition of Routine Restraint

4.5.1.1 Physical restraint as a routine or prophylactic site protection strategy is not supported by evidence and must not be employed. The evidence for restraint efficacy in preventing VAD removal is lacking despite historical common use in intensive care settings.

4.5.1.2 Physical restraints compromise patient dignity, may exacerbate anxiety and agitation, and carry documented physical complications that may equal or exceed the risks they are intended to prevent.

4.5.2 Decision-Making Before Restraint

4.5.2.1 Before applying physical restraints for VAD protection, clinicians must systematically evaluate and document the following alternatives:

• Reorientation and education of the patient regarding the VAD and its clinical necessity.
• Addressing underlying causes of agitation including pain, urinary retention, constipation, fear, and sensory deprivation.
• Modification of the VAD site protection approach using less restrictive methods (mittens, covers, sleeves, force-activated connectors).
• Environmental modifications to reduce stimulation contributing to agitation.
• Clinical consultation with pharmacy, psychiatry, or palliative care regarding pharmacological management of agitation.

4.5.2.2 Structured decision-making tools, such as clinical decision wheels or restraint alternative algorithms, must be available to clinical staff and used to guide systematic consideration of alternatives prior to restraint application.

4.5.3 When Physical Restraint Is Required

4.5.3.1 Physical restraint for VAD protection is permissible only when all of the following criteria are met:

• The patient is actively and repeatedly removing or attempting to remove a VAD that is essential to ongoing medical treatment.
• Less restrictive interventions have been evaluated and are insufficient to prevent patient harm.
• The restraint is the least restrictive method that will achieve the clinical goal.
• A physician or authorized provider order for restraint has been obtained.

4.5.3.2 Physical restraints applied for VAD protection must be time-limited, reassessed at minimum every two hours, and discontinued at the earliest time the clinical situation permits.

4.5.4 Restraint Complication Monitoring

4.5.4.1 When physical restraints are in use, clinicians must monitor at minimum every two hours for the following complications:

• Skin trauma and pressure injury at and distal to the restraint application site.
• Circulatory compromise including impaired capillary refill, peripheral edema, or diminished pulse in the restrained extremity.
• Nerve injury symptoms including paresthesia or loss of sensation.
• Muscle discomfort, joint stiffness, and restricted range of motion.
• Psychological effects including increased agitation, anxiety, and delirium.

4.5.4.2 Any complications identified must be documented, reported to the responsible provider, and managed promptly.

4.6 Joint Stabilization

4.6.1 Indications

4.6.1.1 Arm boards, splints, or padded joint stabilizers must be applied when VADs are inserted in or proximal to anatomical areas of joint flexion that may cause catheter kinking, migration, or dislodgement with limb movement, including the antecubital fossa, wrist, and ankle.

4.6.2 Application Principles

4.6.2.1 Joint stabilization devices must be applied according to the following principles:

• Position the extremity and stabilization device to minimize pressure over bony prominences and prevent skin breakdown.
• Add padding as needed to protect skin and soft tissue at contact points.
• Maintain the extremity in a functional anatomical position that does not compromise joint integrity or neurovascular status.
• Ensure the stabilization device does not cover the VAD insertion site or obstruct visualization for assessment.

4.6.2.2 Wooden tongue depressors must not be used as improvised joint stabilizers in preterm infants or immunocompromised patients. Documented cases of fungal infection attributable to tongue depressor use as arm boards in this population preclude their use.

4.6.3 Monitoring and Maintenance

4.6.3.1 Joint stabilization devices must be assessed at minimum every four hours and whenever the patient’s condition changes for:

• Adequate fit without excess tightness causing circulatory constriction, pressure injury, or nerve compression.
• Skin integrity at all contact points.
• Distal circulatory status including capillary refill, warmth, and sensation.

4.6.3.2 Joint stabilization devices must be removed at regular intervals, with a minimum of every eight hours, to:

• Perform full assessment of the extremity circulatory status and skin integrity.
• Provide range-of-motion activities to the affected joint.
• Perform hygiene care of the extremity as needed.

4.6.3.3 Joint stabilization devices must be cleaned according to manufacturer instructions for use. Visibly soiled or damaged stabilization devices must be replaced.

4.6.4 Discontinuation

4.6.4.1 The need for each joint stabilization device must be evaluated at each assessment interval. Joint stabilization devices must be discontinued when:

• The VAD has been removed or relocated to a site not requiring joint stabilization.
• The clinical condition has changed such that the risk of device dislodgement from joint movement is no longer elevated.
• The patient has demonstrated consistent ability to protect the VAD site during movement without the stabilization device.

4.7 Patient and Caregiver Education

4.7.1 Education Requirements

4.7.1.1 All patients with VADs and their caregivers must receive education on site protection prior to discharge from any care setting in which site protection measures have been implemented. Education must address:

• The purpose and clinical importance of the VAD and the site protection measures in use.
• Correct use and care of any site protection device provided to the patient (covers, sleeves, waterproof barriers).
• Signs and symptoms of complications requiring immediate clinical notification, including dislodgement, bleeding at the insertion site, pain, redness, swelling, and leakage.
• Expected duration of the site protection measure and circumstances under which it may be discontinued.
• Safe practices for activities of daily living, including bathing, dressing, and mobility, to protect the VAD.

4.7.1.2 Patient and caregiver education must be documented in the medical record, including the content provided, the patient’s and caregiver’s demonstrated understanding, and any barriers to learning encountered.

5. Compliance

5.1 Key Performance Indicators

• Rate of unplanned VAD dislodgement per 1,000 catheter-days, stratified by device type and patient population, trended over time.
• Incidence of physical restraint use for VAD site protection, tracked per unit and care area, with a goal of continuous reduction.
• Percentage of patients with documented dislodgement risk assessment at VAD insertion (target: 100%).
• Percentage of patients with physical restraint for VAD protection who have documented evidence of less-restrictive alternative evaluation prior to restraint application (target: 100%).
• Rate of joint stabilization-associated complications (pressure injury, nerve injury, circulatory compromise) reported through the adverse event reporting system.
• Completion rate of patient and caregiver VAD site protection education, documented in the medical record (target: ≥95% of patients receiving home infusion or discharge with VAD).
• Staff completion rate for annual competency in site protection and joint stabilization practices.

5.2 Enforcement

Compliance with this policy is a condition of clinical practice within this organization. Clinicians who apply physical restraints for VAD management without documented evaluation of less-restrictive alternatives and an authorized provider order are subject to review through the organization’s quality management and performance improvement processes. Joint stabilization devices improperly applied—including use of tongue depressors in preterm or immunocompromised patients—will be treated as reportable safety events. This policy will be reviewed by the Vascular Access Governance Committee no less than every two years or when significant new evidence or regulatory guidance becomes available.

6. Exceptions

• Brief procedural positioning during CVAD insertion, arterial line placement, or other vascular access procedures to maintain patient safety and aseptic technique is not subject to the restraint requirements of this policy; however, this positioning must be the minimum required and must cease upon procedure completion.
• Patients under general or regional anesthesia in procedural settings are exempt from the conscious-patient behavioral restraint provisions of this policy; standard positioning and padding requirements apply.
• Documented clinical situations in which a patient’s acute medical instability or the acuity of the care environment temporarily prevents full compliance with assessment interval requirements must be documented with clinical rationale, and full compliance must be restored at the earliest feasible time.

7. Related Documents

• Vascular Access Device Securement Policy
• Vascular Access Device Insertion Policy
• Vascular Access Device Site Care and Dressing Change Policy
• Physical Restraint and Seclusion Policy
• Patient Rights and Dignity Policy
• Pain Management Policy
• Pediatric Procedural Preparation and Pain Management Guideline
• Pressure Injury Prevention and Management Policy
• Fall Prevention Policy
• Adverse Event Management and Reporting Policy
• Home Infusion Therapy Patient Education Standards

8. Revision History