Clinical Practice Guidelines for Adults

JANUARY SUPPLEMENT 2026 | VOLUME 31

Journal of the Association for Vascular Access (JAVA)

With Gratitude

The Association for Vascular Access (AVA) and the AVA Foundation extend sincere thanks to Solventum and BD for their generous grant support of the AVA Adult Clinical Practice Guidelines.

These grants supported the work of a professional research librarian who conducted two comprehensive systematic reviews forming the evidentiary foundation of the guidelines. This support was directed solely toward the systematic review process and did not influence guideline content, evidence appraisal, recommendation development, or editorial decision-making.

The AVA Foundation is deeply grateful for this investment in rigorous, independent evidence synthesis. By supporting high-quality research infrastructure, these grants strengthened the scientific integrity of the guidelines and advanced evidence-based vascular access care for clinicians and patients alike.

Clinical Practice Guidelines Table of Contents

Guideline Development and Acknowledgments

The following sections document the development, authorship, and review processes that shaped the Association for Vascular Access (AVA) Clinical Practice Guidelines (CPGs) for Adults. They recognize the individuals and teams whose collective expertise, diligence, and integrity ensured that each recommendation reflects both scientific rigor and practical clinical relevance. This record of contributors, disclosures, and acknowledgments is presented in the interest of transparency, accountability, and appreciation for the many professionals whose efforts brought these guidelines to completion.

The foundation for this project was established by Blake Hotchkiss, MSN, MBA, RN, VA-BC™, then an AVA staff member, and Andrea Raynak, PhD, RN, a volunteer, who initiated the guideline development process in 2021 and created the original protocol. Their early work provided the framework that allowed guideline development to move forward when the formal editorial team assumed responsibility in late 2023.

I. Editors

The editors of the inaugural AVA CPGs carried responsibility not only for oversight but also for active development. Together, they organized author contributions, standardized format and style, and ensured that recommendations reflected both the evidence base and practical clinical application.

Michelle L. Hawes, DNP, CRNI®, VA-BC™, ACRP-CP

Dr. Hawes has been a nurse for over 30 years, with nearly 3 decades of experience dedicated to vascular access. Her background spans pediatrics, home infusion, emergency medicine, and vascular access team building, with a consistent focus on improving patient safety and outcomes. Today, she works primarily as a researcher, editor, and mentor, supporting evidence-based practice and the next generation of vascular access specialists.

Mickey is nationally certified as a Clinical Research Professional (ACRP-CP) and serves as Editor-in-Chief of the Journal of the Association for Vascular Access (JAVA). She has authored multiple peer-reviewed publications as well as presentations and poster abstracts, which have been presented at national and international conferences. Her work emphasizes appraisal, guideline development, and the translation of research into practical clinical guidance to improve patient outcomes.

Disclosures (past 5 years):

• Access Vascular, Inc.
• Covalon Technologies Ltd.
• Data to Wisdom Research Consulting
• Eloquest Healthcare, Inc.
• Interrad Medical, Inc.
• Mighty Well
• Prevahex
• Sterile Care

Antonia Sochor, BSN, RN, VA-BC™

Antonia “Toni” Sochor began her career as a Hospital Corpsman in the United States Navy before transitioning into civilian health care. She became a Registered Nurse (RN) in 2007 and earned her bachelor’s degree in nursing in 2016. For over 17 years, she has specialized in vascular access across diverse hospital settings, with a focus on advancing safe insertion practices, preventing complications, and delivering patient-centered care.

Toni currently serves as Clinical Education Specialist for the AVA and has played an integral role in the development of these CPGs. She is recognized for her dedication to improving patient outcomes through optimal vascular access and her commitment to supporting clinicians through evidence-informed practice.

Disclosures (past 5 years): None

Lois N. Davis, MSN, RN, VA-BC™

Lois Davis is a nurse and health care consultant with decades of experience in vascular access, infusion therapy, and clinical education. She has served in leadership and educator roles with the Vascular Access Certification Corporation, the AVA, and other professional organizations, helping to shape national and international standards of practice. Lois also served as Editor of the JAVA, guiding the publication of peer-reviewed research and clinical innovation. A frequent speaker and published author, she has made significant contributions to advancing best practices, certification, and professional development for clinicians across diverse health care settings.

Disclosures (past 5 years):

• Dynamic Access, Inc.
• H.B. Fuller Medical Adhesive Technologies, LLC
• PICC Excellence

Warren McGlauflin, BS, RN, VA-BC™

Warren McGlauflin has been a nurse for over 25 years, with his early career rooted in emergency medicine before transitioning into vascular access in 2008. He currently serves as a Vascular Access Specialist at Central Maine Medical Center. Since 2015, he has served as a Nurse Leader for the Vascular Access Specialty Team (VAST), where he has contributed to reducing central line–associated bloodstream infections (CLABSIs), developed policies, and implemented staff training initiatives. Warren has been an active member of the AVA since 2010, serving on the Board of Directors as Secretary and Director-at-Large as well as chairing the Design Team for the Annual AVA Scientific Meeting (D-Team). He is also recognized for creating mentorship opportunities to support new vascular access clinicians and for leading quality improvement efforts that have advanced the delivery of safe and effective vascular access care.

Disclosures (past 5 years): None

II. Author Recognition and Disclosures

In addition to conducting evidence appraisal, the guideline authors assumed the added responsibility of synthesizing research findings into clear, actionable recommendations. They screened titles and abstracts, evaluated full texts using the Johns Hopkins–Evidence Based Practice (JH-EBP) framework, and translated the evidence into guidance aimed at improving patient safety and outcomes. Their dual roles as appraisers and recommendation writers reflect the depth of expertise and commitment behind these guidelines.

III. Contributors

Several dedicated colleagues played essential roles in the development of these CPGs, contributing to the foundation on which all recommendations were built. They supported the project through PICO writing, systematic review, and article-level appraisal. Each completed Johns Hopkins Nursing–Evidence-Based Practice (JHN-EBP) training course and participated in screening thousands of titles and abstracts as well as evaluating hundreds of full texts to ensure consistent leveling and grading of the evidence. Although none were available to author recommendations, their expertise and effort were instrumental to the success of this work and are deeply appreciated.

• Ame Allen, MHA, RT (R)(CT), ARRT, CIIP — American Society of Radiologic Technologists
• Lynn Davis-Lussier, MSN, RN, CRNI®, VA-BC™ — Retired
• Robert Helm, Jr., MD — New York Presbyterian Hospital-Cornell Medical Center
• Barbara McElroy, MSN, RN, CRNI®, VA-BC™ — Infusion Therapy Consultant
• Mikaela Olsen, DNP, APRN-CNS, AOCNS, FAAN — Johns Hopkins Hospital and Health System
• John Pilcher, MSN, RN, VA-BC™, CRNI®, CPN, NE-BC — Boston Children’s Hospital
• Shelley Robinson, MSNEd, RN — Beebe Healthcare, Delaware
• Maryam Soomro, MD, MBBS — TuCann Medical and Monash University, Australia
• Mary Alice Vanhoy, MSN, RN, CEN, CPEN, NRP, FAEN — Nursing and EMS Educator

IV. Guideline Review Process

Phase One: Guideline Governance Group

• Belinda Bordeaux, BSN, RN, VA-BC™
• Peter J. Carr, PhD, MMedSc, BSc, HDip, RN
• Chris Cavanaugh, MSN, RN, CRNI®, VA-BC™
• Lois N. Davis, MSN, RN, VA-BC™
• Michelle DeVries, MPH, CIC, AL-CIP, VA-BC™, CPHQ, FAPIC
• Michelle L. Hawes, DNP, CRNI®, VA-BC™, ACRP-CP
• Kristin Jacobs, DNP, MBA, RN, CRNI®, VA-BC™, NEA-BC
• Karen Laforet, MClSc-WH, RN, VA-BC™, CCHN(C), CVAA(C), DAPWCA
• Nadine Nakazawa, BSN, RN, VA-BC™
• Antonia Sochor, BSN, RN, VA-BC™
• Judy Thompson, MSNEd, RN, VA-BC™
• Christine Vandenhouten, PhD, RN, CPH

Phase Two: Clinical Review Teams (not a part of the CPG process)

• Linda Kelly, PhD, CNP, VA-BC™
• Mary Ann Zock, MSN, RN, CRNI®, VA-BC™
• Mary Stormowski, BSN, RN, VA-BC™
• Kristen Shirak-Osowski, MSN, RN, CCRN, VA-BC™
• Molly Judge, BSN, RN, CRNI®, VA-BC™
• Dawn Allsman, MSN, MBA, RN, VA-BC™
• Dustin Mason, RN, VA-BC™
• Raquel Bauer Cechinel, MSN, RN
• Lauren Jones, BSN, RN, VA-BC™
• Shonna Hansen, MSN-IPC, BSN, RN, GERO-BC, CIC, VA-BC™, WCC, LP

Phase Three: Public Review (all who completed the process)

• Dawn Allsman, MBA, MSN, RN
• Jordan Andrew, BSN, RN, VA-BC™
• Amy Bardin, EdD, MSc, RT, FAARC, VA-BC™
• Jon Bell, MSN, RN, VA-BC™, CEN
• Joseph Bunch, RN, VA-BC™
• Jennifer Card, BSN, RN, BC-VA
• Chris Cavanaugh, MSN, RN, CRNI®, VA-BC™
• Vance Clement, BSIE, MBA
• Stacey Coss, MSN, CPS, Vascular Access
• Mary Beth Davis, PhD, RN, VA-BC™
• Michelle DeVries, MPH, CIC, AL-CIP, VA-BC™, CPHQ, FAPIC
• Alexander Eheander, RN, BSN, CEN, CRNI®, VA-BC™
• Kari Ertmer, RN, BSN, VA-BC™, PHN
• Miguel Fernandez
• Matt Gibson, RN, CRNI®, VA-BC™
• Karen Giuliano, PhD, RN, MBA, FAAN
• Davide Giustivi, RN, BSN, Vascular Access Specialist
• Brenda Gray, PharmD, CNSC, CVAA(C), BCNSP, BCSCP, VA-BC™, FASPEN
• Beth Heilman, BSN, VA-BC™
• Jocelyn Hill, MN, RN, VA-BC™, CVAA(C)
• George Holinga, PhD, RAC-US
• Margaret Hough, BSN, RN, CCRN
• Mark Hunter, MN, BSN, RN, CRNI®, VA-BC™
• Edward Korycka, MSN, RN, VA-BC™
• Staci Krebel, BSN, RN, VA-BC™
• Dee Dee Logan, RN, VA-BC™
• Tricia M. Kleidon, NP, PhD
• Keegan Mahoney, BS, RRT, VA-BC™
• Barbara McElroy, MSN, RN, CRNI®, VA-BC™
• William Miller, BSN, RN, VA-BC™
• Holly Montejano, MS, CIC, CPHQ, VA-BC™
• Karen Mueller, CVAA(C)
• Nadine Nakazawa, BSN, RN, VA-BC™
• Amy Rissler, BSN, RN, VA-BC™
• Bob Rogers, CEO and Chairman of the Board
• Mark Rowe, MNSc, RNP
• Crysta Seneski
• Matthew Sotto, RN, BSN, VA-BC™
• Timothy Spencer, RN, APRN, BHSc, DipAppSc, GradCertInt Care, VA-BC™
• Michael Stern, MD
• Martin Viegas, BSN, RN, CRNI®
• Kathleen Vollman, MSN, RN, CCNS, FCCM, FAAN
• Mark Wagner, RN, VA-BC™
• Dawnn Walters, MSN, RN, VA-BC™, NI-BC
• Steve Wilson, RN, Vascular Access
• Tatiana Zhdanova, RN, MSN, PhD, CRNI®, VA-BC™

Phase Four: Review Feedback Integration

• Antonia Sochor, BSN, RN, VA-BC™
• Michelle L. Hawes, DNP, CRNI®, VA-BC™, ACRP-CP

Phase Five: Post Integration Review and Feedback

• Lois N. Davis, MSN, RN, VA-BC™
• Warren McGlauflin, BS, RN, VA-BC™

Phase Six: AVA Board Adoption Adopted January 12, 2026

Phase Seven: Submission to JAVA CPG Editors

Phase Eight: JAVA Guest Editor (not a part of the CPG process) Mark Hunter, MS, BSCN, RN, CRNI®, VA-BC™

V. Acknowledgment of the Research Librarian

The editors extend sincere appreciation to Mary Doug Wright, Research Librarian, whose expertise and diligence supported the systematic review process underlying these guidelines. She executed the search strategies within the parameters provided and later repeated the review to ensure the inclusion of the most current evidence available. Her understanding of systematic review methodology and the realities of literature search design greatly informed the foundation of this work.

VI. Special Recognition

Judy Thomson, MSNEd, RN, VA-BC™

Clinical Education Director for AVA, Judy has overseen this project since its inception in 2021. Judy, along with Blake Hotchkiss, secured the grants that supported development costs and provided consistent guidance and leadership across all phases. Her steady support made it possible for the development team to move the CPGs from concept to reality.

Board Liaisons

• Michelle DeVries, MPH, CIC, AL-CIP, VA-BC™, CPHQ, FAPIC — AVA Board Presidential Advisor (2025)
• Christine Vandenhouten, PhD, RN, CPH — AVA Director-at-Large (2024–2025)

Michelle and Christine served as the CPG Board Liaisons, meeting weekly with the CPG Development Team. They brought an essential outside-the-process perspective, represented the Board’s view, and consistently offered encouragement that sustained the work through its final phase of development.

Together, Judy, Michelle, and Christine provided support, perspective, and leadership that anchored the development process and ensured the guidelines reached completion.

VII. Special Thanks

The editors extend sincere appreciation to the members of the AVA Board of Directors who served between 2021 and 2025. Their ongoing support, vision, and encouragement sustained the CPGs project through its full development cycle. Board members provided leadership, strategic oversight, and steadfast commitment to advancing vascular access practice, ensuring that the inaugural guidelines reflect both the needs of clinicians and the values of the Association.

AVA Board of Directors Members 2021–2025

• Jon Bell, MSN, RN, VA-BC™, CEN
• Paul Blackburn, MNA, BSN, RN, VA-BC™
• Vance Clement, BSIE, MBA
• Joanne Dalusung, DNP, APRN, AGACNP-BC, CCRN, VA-BC™
• Lynn Davis-Lussier, MSN, RN, CRNI®, VA-BC™
• Michelle DeVries, MPH, CIC, AL-CIP, VA-BC™, CPHQ, FAPIC
• Staci Harrison, DNP, RN
• Monte Harvill, MD
• Todd A. Heslep, BSN, RN, Paramedic, VA-BC™
• Tonya Heim, MHA, MSN, RN, NEA-BC
• Nieltje Gedney, BA
• Jocelyn Grecia Hill, MN, RN, CVAA(C), VA-BC™
• Kristin Jacobs, DNP, MBA, RN, VA-BC™, NEA-BC
• Lori Kaczmarek, MSN, RN, VA-BC™
• Swapna Kakani, MPH
• Karen Laforet, MCISC, RN, AHCP, CCHN(C), CVAA, VA-BC™
• Emily Levy, BS
• Warren McGlauflin, BS, RN, VA-BC™
• Nael Maissen, MD
• Russell Nassof, JD
• Chaitenya Razdan, MBA
• Mark Rowe, MNSC, RNP, VA-BC™
• Tonja Stevens, MSN, AGACNP-BC, RN, VA-BC™
• Christine Vandenhouten, PHD, RN, CHP

VIII. Credential

Expert Credentials Behind the AVA CPGs

The inaugural AVA CPGs reflect the collective expertise of a uniquely multidisciplinary team. Contributors include nurses, physicians, respiratory therapists, radiologic technologists, paramedics, and researchers whose combined backgrounds span clinical practice, education, administration, and innovation. The credentials listed here represent not only academic degrees and professional certifications but also state licensure and prestigious fellowships awarded by leading professional organizations.

This extraordinary mix of qualifications underscores both the depth of vascular access expertise and the broad commitment across disciplines to advance safe, evidence-based care. The diversity of perspectives and the caliber of contributors are a defining strength of these guidelines.

IX. Use of AI Disclosure Statement

The AVA Clinical Practice Guidelines represent the work of 26 section authors whose evidence-based contributions were synthesized into practical recommendations for direct care clinicians involved with vascular access. The early phases of development, including PICO construction, systematic review, and evidence appraisal, were completed by guideline developers, contributors, and the research librarian without the structured use of artificial intelligence.

In the final phase of development, artificial intelligence (AI) was introduced as a tool to support the editorial team. Its primary role was to assist with organizing content, standardizing language across multiple authors, and maintaining consistency of style and terminology throughout a complex multisection guideline. All interpretation of evidence, appraisal, grading, and recommendation writing were conducted and confirmed by vascular access experts using the Johns Hopkins Evidence-Based Practice framework, with AI serving as a strictly supportive tool.

The editorial team acknowledges the integral role AI played in harmonizing voices and enhancing clarity, while affirming that the clinical judgments, evidence synthesis, and final recommendations reflect the expertise of human clinicians.

Foreword

Vascular Access is an essential and life-saving tool that is often underappreciated and overlooked as a specialty, yet as we all know, obtaining and maintaining vascular access is a highly complex physical and mental skill that needs to be finely tuned to the clinical situation, patient, and tools or resources available. If you have ever been hospitalized, it is likely that you have had a vascular access device inserted into you, and if you have been a frequent patient, it is likely that you know who is good at putting them in and ask for that person by name. This acutely demonstrates the importance of vascular access to patients. Vascular access is lifesaving; it has the potential to send someone home sooner or land them in the hospital for much longer or, worse yet, even to lose their life. Vascular access should absolutely be treated with the same respect as other clinical specialties and celebrated as a wonder equal to the discovery of penicillin which, by chance, can also be administered through vascular access devices.

Coming back to the field of vascular access, clinical practice guidelines exist for many other aspects of medical care, e.g., for various medicines, surgical procedures, and wound treatment. Vascular access deserves the same level of support for evidence-based clinical decision-making, and this is critical to ensure the best possible patient outcomes (and improved health care efficiency). Add to this the complexity of hospital systems, medical, nursing, and allied health teams that are required to care for increasingly complex patient cohorts, and anything less than care informed by rigorous guidelines and standards of practice would bring unacceptable risk.

We live in a world where science is increasingly questioned in favor of quick and easy soundbites of information. This is not surprising, considering the complexity of the systems and the mental burden this can create. However, we cannot escape the need for deep, science-based knowledge and expertise when it comes to improving people’s lives, particularly in our occupations. We have an incredible responsibility to preserve and enhance life, and clinicians rightly deserve comprehensive but digestible information upon which to guide their decision-making.

On this basis, the Association for Vascular Access (AVA) should be congratulated for drafting its inaugural AVA clinical practice guidelines (CPGs). The CPGs are comprehensive and cover all aspects of vascular access (and most invasive device types) in adults across all clinical settings. It is pleasing to see the adoption of a robust methodology, which was used to identify and evaluate current evidence in the respective areas (including the assessment of level and quality of evidence). The holistic approach, considering not just the state of the patient’s veins but also his or her personal social and economic conditions, is also admirable. As the Co-Leads of the Alliance for Vascular Access Teaching and Research (AVATAR, avatargroup.org.au), we are proud to note the efforts of AVATAR-trained and affiliated researchers in generating the >50 referenced articles which have helped to shape the CPGs. Without AVA and other specialist groups translating published research studies into digestible, trustworthy guidelines for clinicians, the evidence-to-practice gap would be far greater and would be delayed for longer. We acknowledge that the AVA CPGs are just the start of a journey, one that will see them expanded and updated routinely. For clinicians, we see value in the CPG approach of providing clinical considerations to contextualize each recommendation, with commentary on benefits, risks, and implementation factors. We invite others to engage with AVA, whether you want to learn more through conference attendance or if you aspire to help the leadership and review teams identify, read, synthesize, debate, and make conclusions regarding the outcomes of published research. The body of evidence will only grow.

As we look to the future, we call upon researchers, clinicians, and industry partners to work together and expand the evidence base of research from which guidelines are developed. It is acknowledged that this will take time, resources, and valuable funds to generate. Equally, we must ensure that research is conducted without bias, always prioritizing valid research findings above all else, in the pursuit of improving outcomes for patients. The breadth of research should be freely accessible and include benchtop or laboratory studies and observational clinical or cohort studies but ideally be prospective in design and in the form of randomized controlled trials (RCTs). Systematic literature reviews with meta-analyses will then coalesce RCTs to assess the effectiveness of interventions across multiple sites. Let us not forget the importance of implementation trials, in which we seek to understand and evaluate the best ways of instigating and maintaining best practices into clinical environments. Finally, we ask all professionals, be they academic researchers, clinicians, industry executives, lawyers, biomedical engineers, data scientists, cleaners, or administrative officers, to be advocates for improving vascular access care, by raising the problems and solutions with their local, state, and federal representatives or policy makers.

We have come a long way and made incredible leaps and bounds in care over the past 50 years, thanks to the efforts of AVA and other advocacy groups. With AVA’s increasing engagement with researchers, clinicians, and industry professionals, in addition to the development of training resources and guidelines such as these, now is the time to join the mission and work with our professional societies and governments worldwide to make vascular access complications history.

Andrew Bulmer BSc(Hons), PhD Professor of Physiology and Pathophysiology School of Pharmacy and Medical Sciences, Alliance for Vascular Access Teaching and Research (AVATAR), Griffith University, Gold Coast, QLD, Australia [email protected]

Claire M Rickard, RN, PhD, FAAN, FACN, FAHMS. Professor of Infection Prevention and Vascular Access, The University of Queensland and Metro North Health. Adjunct Professor, Alliance for Vascular Access Teaching and Research (AVATAR), Griffith University. Leadership Investigator, National Health and Medical Research Council, Australia. [email protected]

Introduction to the CPG

Purpose of the Guidelines

The Association for Vascular Access (AVA) is honored to introduce the first edition of the AVA clinical practice guidelines (CPGs) for Adults. These guidelines provide a comprehensive, evidence-informed resource to support the delivery of safe, consistent, and high-quality vascular access care across all health care settings.

Vascular access is essential to modern health care, yet despite decades of research and published recommendations, substantial variation in practice persists worldwide, leading to preventable patient harm, inefficiencies, and inequities in care. The AVA CPGs represent a strategic response to these challenges, offering a standardized framework that integrates the best available evidence, expert consensus, and transparent methodology.

These guidelines are more than a set of clinical recommendations; they reflect AVA’s commitment to patients, clinicians, and health systems. Developed through rigorous and transparent processes, they promote interdisciplinary collaboration, enhance clinical reasoning, and strengthen decision-making in practice.

These guidelines are intended to:

• Improve the safety, effectiveness, and consistency of vascular access care.
• Reduce unwarranted variation in practice by addressing both clinical and organizational factors.
• Minimize preventable complications, delays in care, and waste of resources.
• Serve as a trusted reference for clinicians, educators, health care leaders, and policy developers.

By providing a standardized approach to vascular access practice, the AVA CPGs advance excellence in patient care while supporting the professional community dedicated to vascular access. This inaugural edition is both a milestone achievement and a foundation for future updates as research, innovation, and clinical practice continue to evolve.

Scope of the Guidelines

These guidelines address the full life cycle of vascular access devices for adult patients (age ≥ 18 years) across all care environments, including inpatient, ambulatory, long-term postacute care, and home care settings. They provide structured guidance from device planning and selection to insertion, care, complication management, and removal.

The content is organized into 5 major sections:

1. Infrastructure, Teams, and Clinical Foundations
2. Patient Assessment and Planning
3. Device Selection and Procedural Considerations
4. Clinical Considerations for Insertion
5. Ongoing Assessment, Care, and Complication Management

Included Devices

• Peripheral Vascular Access Devices
  • Peripheral Intravenous Catheters (PIVCs)
  • Peripheral Midlines
• Central Vascular Access Devices
  • Peripherally Inserted Central Catheters
  • Centrally Inserted Central Catheters (CICCs)
  • Tunneled-Cuffed CICCs
  • Tunneled Noncuffed CICCs
  • Totally Implanted Venous Access Devices (TIVADs)
• Additional Access
  • Arterial Catheters
  • Interosseous

Not Included

• Neonatal and pediatric vascular access
• Advanced cardiovascular devices:
  • Pulmonary artery catheters — inserted via central veins and advanced into the pulmonary artery for hemodynamic monitoring.
  • Intra-aortic balloon pumps — inserted via femoral artery introducers for cardiac support.
  • Extracorporeal Membrane Oxygenation
• Dialysis requiring vascular surgery access:
  • Arteriovenous fistulas and grafts — surgical vascular access created for hemodialysis.
• Neuraxial and Cerebrospinal Access Devices:
  • Epidural catheters — placed in the epidural space for anesthesia or analgesia
  • Intrathecal catheters and ports — access to the cerebrospinal fluid space for medication delivery
  • Intraventricular catheters (e.g., external ventricular drains) — placed into cerebral ventricles for cerebral spinal fluid drainage and pressure monitoring
• Subcutaneous access devices:
  • Subcutaneous fluid ports, injection ports, or insulin delivery systems — devices placed in subcutaneous tissue that do not access the vascular system

Target Audience

These CPGs are intended for a broad, interdisciplinary audience of health professionals engaged in vascular access care. AVA’s membership spans across many clinical disciplines, licensure levels, and care environments. These CPGs were developed to reflect that diversity. They are designed for individuals who assess, place, manage, maintain, or remove vascular access devices as well as those who contribute to vascular access policy, education, quality improvement, and research.

The primary users are vascular access specialists. However, these guidelines are relevant to all direct care clinicians, educators, preceptors, infection preventionists, clinical administrators, quality improvement teams, and policy developers. These guidelines support clinical decision-making across various settings, including hospitals, long-term care facilities, ambulatory clinics, rehabilitation centers, home infusion programs, outpatient oncology units, emergency departments, and transport environments.

As an international organization, AVA recognizes the global need for practical and adaptable vascular access guidance. These guidelines are therefore intended to be broadly applicable while allowing for flexibility based on local scope of practice regulations, resource availability, and care infrastructure. Although every recommendation is grounded in evidence and clinical consensus, implementation must align with each clinician’s licensure, regulatory authority, institutional policy, and professional competency.

This inclusive, practice-aware approach is a defining characteristic of the AVA guidelines. It represents a conscious effort to move beyond discipline-specific documents toward a more unified and collaborative model of vascular access care.

Guideline Development Process

The AVA CPGs were developed through a rigorous, multiphase process informed by recognized standards for trustworthy guideline development, including those established by the Institute of Medicine, the Conference on Guideline Standardization, and the Council of Medical Specialty Societies (CMSS). This process was designed to promote transparency, mitigate bias, and ensure the development of practical, evidence-based recommendations relevant to a broad range of healthcare professionals.

Development of the guidelines was led by the AVA Guideline Governance Group (GGG) and supported by multiple Guideline Development Teams (GDTs), composed of multidisciplinary volunteers with expertise in vascular access. The work was organized into 6 sections, later consolidated into 5 thematic content areas to reflect the full life cycle of vascular access devices, from administrative and infrastructure considerations, device planning and insertion through care, maintenance, complication management, and removal. For more information on the protocol, see PROSPERO or Sochor et al. (2024).^1,2

Dual Systematic Reviews

Two separate systematic reviews were conducted to support a robust evidence base. The first was initiated early in the project and informed the development of foundational topics. The second review became necessary to include the most up-to-date evidence available. Both systematic reviews were guided by structured population, intervention, comparison, outcome (PICO) questions and search strategies built collaboratively by each GDT. A contracted research librarian conducted a structured search strategy and retrieved titles and abstracts that were uploaded to AVA’s collaborative research platform Rayyan.³ Once the articles for inclusion were established, the full texts were obtained for GDT appraisal.

Each article was appraised independently by 2 reviewers using the Johns Hopkins Evidence-Based Practice model.⁴ Scores for both level of evidence (I–V) and quality of evidence (A–C) were recorded, and discrepancies were resolved through expert analysis. A standardized Excel-based scoring system aggregated results to support transparent documentation. A PRISMA flow diagram summarizing identification, screening, and inclusion is provided (Figure 1).

In areas where evidence was limited or inconclusive, AVA elected not to issue consensus-based recommendations without sufficient justification. These topics have been deferred for potential inclusion in a future edition, following structured consensus methods to ensure integrity.

Stakeholder Involvement

Recommendations were drafted by the GDTs by sections, supported by evidence summaries and structured rationales. These were reviewed internally by the GGG, with extensive feedback. After the consolidation of overlapping information across sections, the final division developed 5 themes. The recommendations were built from the GDT information, GGG feedback, and the included full-text articles. The document was then sent to an AVA internal review by the Clinical Review Team and revised and externally reviewed by independent reviewers and representatives from stakeholder organizations. The review process included advisory committee feedback, a public comment period, and final approval by the AVA Board of Directors before publication. Conflict of interest disclosures were collected and managed throughout the process in accordance with CMSS guidance.⁵

As part of AVA’s commitment to transparency and continuous improvement, this inaugural guideline edition reflects both the depth of current evidence and the limitations inherent in real-world implementation. Recommendations requiring further consensus development or newly emerging evidence are being tracked for inclusion in a future update or supplemental publication.

While every effort was made to ensure comprehensive coverage of the evidence, time constraints limited the feasibility of applying formal consensus methods, such as the RAND/UCLA Modified Delphi technique, for all low-evidence topics. Rather than dilute the integrity of this inaugural edition with premature statements, some content areas that require structured expert consensus have been deferred. AVA intends to revisit these unresolved areas in a future supplement or second edition of the CPG, incorporating formal consensus processes to guide safe and clinically relevant recommendations. This iterative approach supports AVA’s commitment to methodological rigor, transparency, and continuous improvement.

Conflict of Interest Disclosure and Independence

All authors, editors, and contributors to the AVA guidelines disclosed relevant financial and intellectual interests. Many practicing clinicians engage in research, education, or consulting with health care companies because of their expertise in vascular access. These disclosures are published in full within this document. No industry funding was accepted for the development or review of these guidelines.

To uphold independence:

• No single voice or external entity influenced the final recommendations.
• All conflicts of interest were reviewed and managed prior to participation and at the time of this publication.

This approach balances the need for expert input with the responsibility to minimize bias and maintain public trust.

Guideline Users’ Responsibilities

These CPGs are intended to support, not replace, professional judgment. While AVA has made every effort to synthesize the best available evidence and present clear, actionable recommendations, applying these recommendations must be guided by the clinician’s licensure, training, clinical context, and the resources available in their facility or region.

Ethical Responsibilities

Vascular access practice varies significantly across countries, regulatory frameworks, and health systems. Most AVA members practice in the United States, but AVA is an international organization, and these guidelines are designed to be relevant across diverse models of care. Local laws, scope-of-practice regulations, and institutional policies must always be considered when interpreting and applying the recommendations in this document. A strategy that is appropriate and legally permissible for one clinician or setting may be restricted or delegated differently in another setting.

Clinicians are also expected to remain within the bounds of their professional role and training. These guidelines are intended to inform a wide range of users, including advanced practice providers, physicians, direct care clinicians, and specialists in radiology, infusion therapy, or respiratory therapy. No single recommendation should be interpreted as a license to perform procedures beyond one’s defined scope of practice. Interprofessional collaboration is essential when scope boundaries are unclear or overlap to ensure patient safety and appropriate care.

Innovation and evidence development continue even as this edition goes to publication. Clinicians are encouraged to critically appraise and responsibly apply emerging practices, particularly when supported by institutional review, expert consensus, or early data. While not all promising techniques may yet meet the evidentiary threshold for inclusion in the guideline, AVA supports the safe, ethical exploration of novel approaches that serve patients well.

Informed Consent

While these guidelines emphasize evidence-based practice, AVA recognizes that many aspects of ethical care extend beyond what can be graded or cited. Actions such as seeking informed consent, maintaining professional integrity, and respecting patient autonomy are core responsibilities that should guide every aspect of vascular access care.

Because legal requirements and documentation expectations vary across regions, licensure types, and health care systems, this guideline does not prescribe a universal consent format. However, clinicians are expected to ensure that patients, or their authorized representatives, are provided with understandable information about the risks, benefits, and available alternatives for vascular access procedures. This process should be culturally sensitive, tailored to the patient’s level of understanding, and documented in alignment with institutional policy and applicable regulations.

While a PIVC may not require the same level of formal consent as a TIVAD, the principle remains: Patients have the right to understand and participate in decisions about their care. The form of consent — verbal, implied, or written — should be matched to the procedure’s invasiveness, complexity, and the patient’s circumstances.

At times, the language used in this guideline, such as “it may be beneficial to…” or “it is advised to…,” reflects limitations in the published evidence, not a lack of ethical or professional weight. AVA encourages clinicians to interpret these recommendations considering their training, scope of practice, and obligation to deliver ethically sound, patient-centered care.

Future Updates and Review

As the inaugural edition of the AVA CPGs, this document represents a significant step toward unifying vascular access practice under a transparent, evidence-informed framework. However, as with any guideline, it reflects the best available evidence identified through PICO-informed search strategies conducted from 2021 through February 2024.

These guidelines will be reviewed on a rolling basis, with updates issued in response to significant new evidence, evolving technologies, or shifts in regulatory or clinical practice standards. A formal supplemental publication or compendium is anticipated approximately 12 to 18 months after release to address content areas that were deferred in this edition due to time constraints, particularly those requiring structured consensus processes, including the RAND/UCLA Appropriateness Method, a validated modification of the Delphi technique developed by the RAND Corporation and the University of California, Los Angeles. These deferred topics represent important clinical concerns that lacked sufficient high-level evidence for inclusion at the time of publication but are under continued review.

A full second edition of the guidelines is planned within 3 to 4 years. That future edition will revisit all sections, integrate new findings, and evaluate the uptake and implementation of current recommendations across practice settings.

Clinicians are encouraged not only to use these guidelines but also to actively engage in the critical appraisal of emerging research. Systematic reviews, while rigorous, are inherently selective; they are bound by time frames, search strategies, and inclusion criteria that may exclude promising new or early-stage findings. It is the responsibility of health care professionals to remain attentive to new, credible data, especially when it may address previously unanswerable questions, introduce safer techniques, or refine current practices.

Perhaps most importantly, this inaugural edition highlights the ongoing need for high-quality vascular access research. Randomized controlled trials, quasiexperimental studies, and systematic reviews are in short supply relative to the scope and impact of vascular access on patient outcomes and health care systems. AVA strongly encourages researchers, funders, academic centers, and industry collaborators to prioritize vascular access science to advance the next edition of these guidelines and improve the everyday realities of patient care.

These guidelines are a starting point, not a stopping point. AVA will continue to lead, listen, and evolve with the evidence.

Figure 1. PRISMA Flow Chart

2021 & 2024 Combined PRISMA Flow Chart

┌─────────────────────────────────────────────────────────────────────────────┐
│                    2021 & 2024 Combined PRISMA Flow Chart                   │
└─────────────────────────────────────────────────────────────────────────────┘

                    ┌───────────────────────────┐
 IDENTIFICATION     │  Records identified from:  │     Records removed before
                    │  Databases (n = 52,560)    │──►  screening:
                    └─────────────┬─────────────┘     • Duplicate records removed
                                  │                      (n = 20,474)
                                  │                    • 2024 records removed as
                                  │                      duplicates of 2021 search
                                  ▼                      (n = 5,700)
                    ┌───────────────────────────┐
 SCREENING          │ Title and Abstract records │     Records excluded*
                    │ screened (n = 26,386)      │──►  (n = 22,923)
                    └─────────────┬─────────────┘
                                  │
                                  ▼
                    ┌───────────────────────────┐
                    │ Records sought for         │     Reports not retrieved**
                    │ retrieval (n = 3,463)      │──►  (n = 92)
                    └─────────────┬─────────────┘
                                  │
                                  ▼
                    ┌───────────────────────────┐     Full-Texts excluded reasons:
                    │ Full-Texts assessed for    │──►  • Not applicable to PICO
                    │ eligibility (n = 3,371)    │     • Low-level evidence
                    └─────────────┬─────────────┘     • Higher evidence available
                                  │
                                  ▼
 INCLUDED           ┌───────────────────────────┐
                    │ Studies included in the    │
                    │ review and writing         │
                    │ (n = 753)+                 │
                    │ Unique studies included    │
                    │ (n = 572)++               │
                    └───────────────────────────┘

* Wrong: population, device, publication type. Non-English translation.
** Bad URL, retracted publications, non-English (other than the abstract).
+ Across all 6 sections.
++ With duplicates across all sections removed.

Introduction References

1. University of York Centre for Reviews and Dissemination. Thompson J, Sochor A, Hawes M. PROSPERO. 2024. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024379847. Accessed June 2, 2025.
2. Sochor A, Hotchkiss JB, Raynak A, Thompson J. Clinical practice guidelines for adult vascular access: the protocol for the Association for Vascular Access clinical practice guidelines systematic review. JAVA. 2024;29(4):39–48. doi:10.2309/JAVA-D-24-00026
3. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. doi:10.1186/s13643-016-0384-4
4. Dang D, Dearholt S. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, 4th ed. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing; 2021.
5. Council of Medical Specialty Societies. CMSS Code for Interactions with Companies. CMSS. 2015. https://cmss.org/standards/cmss-code-for-interactions-with-companies/. Accessed July 3, 2025.

Section 1: Infrastructure, Teams, & Clinical Foundations

SUPPLEMENTAL ISSUE http://dx.doi.org/10.2309/JVAD-2026-SUPPLEMENT

Vascular access teams (VATs) are critical in enhancing the safety, efficiency, and cost-effectiveness of vascular access device (VAD) management across health care settings. Through standardized best practices and specialized expertise in insertion and maintenance, VATs reduce complications such as central line–associated bloodstream infections (CLABSIs) and peripheral intravenous (IV) catheter failures. These improvements contribute to improved patient safety, timely care delivery, and lower health care expenditures.

The integration of VATs is supported by consistent evidence demonstrating both clinical and operational value. A growing body of observational and quasiexperimental studies has shown that, in high-acuity environments such as emergency departments and intensive care units (ICUs), VATs improve patient flow, optimize resource use, and reduce the incidence of preventable complications. Their presence enhances procedural accuracy, advances staff education, and aligns with institutional priorities for quality, safety, and value-based care.

Evidence has also shown that ultrasound-trained VATs are more successful during challenging insertions, minimizing patient discomfort and delays. In addition, VATs provide a framework for mentoring and supporting other clinicians, strengthening organizational capacity for safe vascular access.

Chapter 1.1 — Vascular Access Teams and Roles

Recommendation 1: Dedicated VATs

Health care organizations may consider establishing dedicated VATs to reduce complications related to VADs. VATs improve patient safety, reduce unnecessary device use, and contribute to cost-effective care.

Summary of Evidence

Dedicated VATs have been shown to significantly reduce central line use, CLABSI rates, and peripheral IV failure when compared with care provided by general staff.^{1(IIb),2(IIIb)} Implementation of these teams is associated with measurable cost savings and alignment with infection prevention standards.^{3(IIIb),4(IIIb)} In 1 cost-benefit analysis of a tertiary hospital’s VAT, substantial financial benefits were reported.^3(IIIb) Authors of 1 study found expert inserters had better insertion outcomes than generalists, while authors of observational studies noted reduced reattempts and complications.^{2(IIIb),4(IIIb)}

Recommendation 2: High-Demand VAT Coverage

It is likely beneficial to prioritize VAT coverage in high-demand departments where streamlined workflows, timely device placement, and optimized resource use are essential for patient safety and throughput.

Summary of Evidence

In high-volume or resource-constrained environments, dedicated VATs have been shown to reduce procedure time, minimize repeat attempts, and improve clinical workflow.^{5(IIIa),6(IIIb),7(IIa),8(IIIb)} In 1 emergency department study, VAT implementation reduced IV diagnostic wait times by over 100 minutes.^5(IIIa) In middle-resource countries, VATs decreased repeated procedures, improving efficiency.^6(IIIb) Ultrasound-trained VATs were also more successful under challenging insertions, minimizing patient discomfort and delays.^7(IIa) Authors of a recent US study confirmed these findings and highlighted the workflow optimization VATs provide in large institutions.^8(IIIb)

Clinical Considerations

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Benefits

• Patient safety, reduction in infection rates, and other complications due to VAT expertise.^1,8
• Financial savings, decreased costs from fewer complications and reduced hospital stay durations.⁵
• Operational efficiency, improved resource allocation and patient throughput, particularly in high-demand settings.^7,8

Risks

• Initial costs, upfront costs for establishing and training VATs, though long-term savings offset these.^2,5,6
• Integration challenges, potential resistance to incorporating VATs within existing workflows.⁸

Implementation Considerations

• Strategic departmental deployment, prioritize VAT implementation in high-demand departments, such as emergency and ICU, where procedural efficiency and patient throughput are crucial.^2,3,5
• Performance monitoring and quality improvement, regularly track VAT performance, including infection rates, cost savings, and procedural success, to demonstrate return on investment and continuously improve VAT services.^4,8

Barriers to Implementation

• Financial barriers, initial training and equipment costs may pose challenges for some institutions, but long-term cost savings outweigh these.^2,6
• Resistance to workflow adjustments, integrating VATs into existing workflows may face initial resistance, requiring consistent communication of their value to patient safety and operational efficiency.^4,7

References

1. Marsh N, Webster J, Larsen E, et al. Expert versus generalist inserters for peripheral intravenous catheter insertion: a pilot randomised controlled trial. Trials. 2018;19(1):564. doi:10.1186/s13063-018-2946-3.
2. Savage TJ, Lynch AD, Oddera SE. Implementation of a vascular access team to reduce central line usage and prevent central line–associated bloodstream infections. J Infus Nurs. 2019;42(4):193–196.
3. Ricou Ríos L, Esposito Català C, Pons Calsapeu A, et al. Implementation of a vascular access specialist team in a tertiary hospital: a cost-benefit analysis. Cost Eff Resour Alloc. 2023;21(1):67. doi:10.1186/s12962-023-00464-6.
4. Chopra V, Kuhn L, Ratz D, et al. Vascular access specialist training, experience, and practice in the United States: results from the national PICC1 survey. J Infus Nurs. 2017;40(1):15–25.
5. Whalen M, Maliszewski B, Baptiste DL. Establishing a dedicated difficult vascular access team in the emergency department: a needs assessment. J Infus Nurs. 2017;40(3):149–154.
6. Federica B, Nizar Yahya B, Hevan Al-Atroushy A, et al. It is possible to create a vascular access team in a middle resource country? Experience of Hevi Paediatric Teaching Hospital at DUHOK—IRAQ. J Vasc Access. 2021;24(5):994–999. doi:10.1177/11297298211055402.
7. Stolz LA, Cappa AR, Minckler MR, et al. Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement. J Vasc Access. 2016;17(4):366–370. doi:10.5301/jva.5000574.
8. Quinn M, Horowitz JK, Krein SL, Gaston A, Ullman A, Chopra V. The role of hospital-based vascular access teams and implications for patient safety: a multi-methods study. J Hosp Med. 2024;19(1):13–23. doi:10.1002/jhm.13253.

Chapter 1.2 — Interprofessional Rounding

Interprofessional rounding is a cornerstone of safe and effective vascular access device (VAD) management. Regular, structured rounds conducted by a multidisciplinary team, including vascular access specialists, direct-care clinicians, physicians, infection preventionists, and pharmacists, enable early recognition of complications and timely intervention to optimize patient outcomes.

These rounds provide a structured forum for collaborative decision-making on catheter necessity, site condition, securement integrity, and adherence to maintenance protocols. They also reinforce infection prevention practices such as insertion bundles, hand hygiene, and maintaining a closed system. When concerns arise, interprofessional rounding facilitates escalation, coordination of catheter removal, and selection of appropriate alternatives.

Embedding vascular access into routine rounding strengthens care coordination, reduces preventable harm, and promotes adherence to evidence-based practices. This proactive, team-based approach ensures that VADs remain appropriate, functional, and safe throughout therapy, while supporting education, accountability, and shared responsibility across disciplines.

Recommendation 1: Composition of Rounding Teams

Organizations should implement interprofessional rounding teams that include vascular access specialists, direct-care clinicians, physicians, pharmacists, and infection preventionists. The diverse expertise of these disciplines facilitates comprehensive catheter assessment, informed decision-making, and the timely identification of vascular access-related concerns.

Summary of Evidence

Collaborative rounding structures support better vascular access outcomes through team-based review of device necessity, site integrity, and maintenance compliance. A systematic review found that central line–associated bloodstream infection (CLABSI) rates are often underreported due to inconsistent surveillance, emphasizing the value of team audits and collaborative oversight.^1(IIb) Similarly, a Spanish hospital’s infection prevention initiative, combining staff education, team-based surveillance, and creation of a catheter infection team, achieved a multiyear decline in peripheral intravenous catheter (PIVC) bloodstream infection (BSI) rates, particularly for Gram-negative infections.^2(IIb)

Recommendation 2: Rounding Functions and Quality Improvement

Interprofessional rounding teams may use structured tools, audit data, and real-time observation to evaluate catheter condition, ensure protocol compliance, and escalate concerns when necessary. Rounding may serve as an optional strategy to guide targeted education and support quality improvement initiatives to reduce complications and optimize device performance.

Summary of Evidence

Rounding teams that incorporate structured assessment tools and direct observation have demonstrated improved adherence to best practices. A quality improvement project used collaborative rounds and audit-informed education to identify and address unit-specific deficiencies.^3(Vb) In intensive care unit settings, Buetti et al. showed that local signs of inflammation at the insertion site during early catheter maintenance were strongly associated with catheter-related BSI (CRBSI), highlighting the importance of routine, structured evaluation to catch early warning signs.^4(IIIa)

Clinical Considerations

Benefits

• Improved infection outcomes: Multidisciplinary rounds and active surveillance programs significantly reduced peripheral venous catheter-associated BSIs rates over time, particularly for Gram-negative infections.²
• Better data accuracy and benchmarking: Collaborative audits and targeted education improve the accuracy of CRBSI surveillance data, making it more valid for benchmarking and quality improvement.¹

Risks

• Underreporting of CRBSI cases: Nationally reported rates may underestimate the true CRBSI incidence, potentially delaying recognition of systemic issues.¹
• Overreliance on visual cues: CRBSI risk may be underestimated if clinical decisions are based solely on absence of local signs, despite their established association with early infection.^4,5

Implementation Considerations

• Use of standardized tools: Incorporating tools like I-DECIDED facilitates structured decision-making for catheter assessments and supports consistent practice across teams.⁶
• Nursing leadership roles: Embedding specialty nursing roles in collaborative rounds enhances consistency in audit feedback and enables unit-specific education.³

Barriers to Implementation

• Resource limitations for audits and rounds: Conducting regular interdisciplinary rounds requires time and personnel, which may not be available in under-resourced settings.⁶
• Variability in adherence across units: Differences in engagement levels or training across departments may limit the consistency and impact of multi-disciplinary rounds.³

References

1. Larsen EN, Gavin N, Marsh N, Rickard CM, Runnegar N, Webster J. A systematic review of central-line-associated bloodstream infection (CLABSI) diagnostic reliability and error. Infect Control Hosp Epidemiol. 2019;40(10):1100–1106. doi:10.1017/ice.2019.205.
2. Garcia-Gasalla M, Arrizabalaga-Asenjo M, Collado-Giner C, et al. Results of a multi-faceted educational intervention to prevent peripheral venous catheter-associated bloodstream infections. J Hosp Infect. 2019;102(4):449–453. doi:10.1016/j.jhin.2019.02.004.
3. Wilder KA, Wall B, Haggard D, Epperson T. CLABSI reduction strategy: a systematic central line quality improvement initiative integrating line-rounding principles and a team approach. Adv Neonatal Care. 2016;16(3):170–177. doi:10.1097/ANC.0000000000000259.
4. Buetti N, Ruckly S, Lucet JC, et al. Local signs at insertion site and catheter-related bloodstream infections: an observational post hoc analysis using individual data of four RCTs. Crit Care. 2020;24(1):694. doi:10.1186/s13054-020-03425-0.
5. Pate K, Brelewski K, Rutledge SR, Rankin V, Layell J. CLABSI rounding team: a collaborative approach to prevention. J Nurs Care Qual. 2022;37(3):275–281. doi:10.1097/ncq.0000000000000625.
6. Ray-Barruel G. I-DECIDED(®)—a decision tool for assessment and management of invasive devices in the hospital setting. Br J Nurs. 2022;31(8):S37–S43. doi:10.12968/bjon.2022.31.8.S37.

Chapter 1.3 — Infection Prevention Infrastructure

A strong infection prevention infrastructure is fundamental to the safe management of vascular access devices (VADs) and the reduction of health care-associated infections. Complications such as central line–associated bloodstream infections (CLABSIs), catheter-related bloodstream infections (CRBSIs), and local site infections contribute to increased morbidity, prolonged hospitalization, and higher health care costs.

Effective prevention requires more than adherence to individual clinical practices; it demands a coordinated, system-wide approach. Institutional policies, interdisciplinary collaboration, and environmental readiness must align to create a framework that consistently supports infection prevention.

Embedding infection prevention principles into organizational culture and daily workflow reduces variation, strengthens patient safety, and improves outcomes. A well-structured infrastructure minimizes complications, fosters accountability, and promotes efficiency. In addition, it provides the foundation for sustainable excellence in vascular access practice and supports continuous quality improvement across all care environments.

Recommendation 1: Vascular Access Team to Reduce Infection

Administrators may consider implementing a vascular access specialist team as part of a comprehensive strategy to reduce CLABSIs.

Summary of Evidence

Implementing a vascular access team (VAT) using evidence-based insertion and maintenance protocols has significantly reduced CLABSI. In 1 quality improvement initiative, creating a VAT resulted in a 45.2% reduction in central line use and a 90% reduction in CLABSI incidence.^1(IIIb) A second hospital-based retrospective analysis showed that, after launching a dedicated vascular access service, CLABSI rates fell from 1.75 to 1.037 infections per 1000 catheter days, a 58% reduction. These findings suggest that VAD specialist teams contribute to decreased device overuse and lower infection risk through protocol adherence and improved insertion and maintenance practices.^2(IIIa)

Recommendation 2: Targeted Infection Prevention

Health care organizations may consider implementing vascular access–specific infection surveillance programs and risk prediction tools to proactively identify high-risk patients, reduce complications, and health care costs.

Summary of Evidence

Targeted surveillance and predictive modeling are essential tools for improving vascular access outcomes. In a large cohort study, researchers found a 3.7% incidence of CRBSI following emergency department insertions, with CRBSI independently associated with in-hospital mortality.^3(IIIb) Risk increased with total parenteral nutrition and multiple insertion attempts, supporting the need for early identification of high-risk patients.^3(IIIb)

Zhu et al. developed a validated predictive model for peripherally inserted central catheter occlusion in critical care patients, identifying factors such as age ≥65, obesity, malignancy, blood transfusion, and parenteral nutrition as independent risks.^4(IIIa) Frequent catheter flushing was protective. The model demonstrated strong predictive accuracy, enabling proactive risk stratification at the time of line placement.^4(IIIa)

Additionally, Yu et al. showed that expanding surveillance from CLABSI to hospital-onset bacteremia and fungemia (HOB) more effectively captured bloodstream infections that are associated with significantly longer hospital stays, increased costs, and higher mortality.^5(IIIb) These findings support broader, risk-adjusted electronic surveillance strategies.

Together, the results of these studies reinforce the value of infection surveillance programs and predictive tools in identifying high-risk patients, guiding preventive interventions, and reducing complications and costs.

Recommendation 3: Hand Hygiene Before All VAD Procedures

Clinicians must perform hand hygiene immediately before, as required during, and after any VAD procedures using either an alcohol-based hand rub (use per the manufacturer’s instructions) or antimicrobial soap and water. This requirement is based on universally accepted infection-prevention standards rather than the strength of individual study designs. Hand hygiene is essential even when gloves are worn and is a foundational component of vascular access infection prevention.

Summary of Evidence

Hand hygiene immediately before VAD procedures is essential to reducing extraluminal contamination and subsequent bloodstream infections. The most common mechanism of CLABSI involves microbial transfer from the inserter’s hands or the patient’s skin at the time of insertion.^6(Vb)

Alcohol-based hand rubs are preferred for hand decontamination unless hands are visibly soiled, in which case antimicrobial soap and water are recommended.^7(IVa) Authors of multiple implementation studies have shown that improved hand hygiene adherence is consistently associated with reduced CLABSI incidence.^6(Vb) As part of a broader insertion protocol, hand hygiene remains a nonnegotiable, evidence-based practice to reduce vascular access complications.

Recommendation 4: Integrate Hand Hygiene into Personal Protective Equipment (PPE) Workflow

Hand hygiene must be performed:

• before donning PPE;
• immediately, if hands become contaminated during PPE removal;
• immediately after removing PPE; and
• before exiting the patient care environment.

Hand hygiene should be explicitly integrated into all vascular access insertion bundles and reinforced as part of routine clinical workflow.

Summary of Evidence

Hand hygiene is a cornerstone of infection prevention and must be embedded within vascular access workflows to minimize transmission of pathogenic organisms. Authors of observational studies and infection surveillance data have consistently shown that missed or improperly timed hand hygiene contributes to contamination and increases the risk of vascular access-related infections.^{6(Vb),8(IIIb)}

Guidelines recommend hand hygiene before donning PPE, when hands are contaminated during PPE removal, immediately after removal, and before exiting the patient care area. These steps are particularly critical during invasive procedures like VAD insertion. Integration into insertion bundles, staff education, and audit-feedback mechanisms has improved compliance and reduced infection rates in intensive care unit (ICU) and non-ICU settings.^{6(Vb),7(IVa),8(IIIb)}

Recommendation 5: Aseptic Technique with Totally Implanted VADs

Health care providers must follow strict aseptic technique during all needle insertions, maintenance, and needle removal of totally implanted VADs (TIVADs) to reduce the risk of HOB and other serious infections.

Summary of Evidence

Aseptic technique, including proper hand hygiene, sterile field setup, skin antisepsis with alcohol-based chlorhexidine gluconate (CHG) solution, and noncoring needles, is foundational to infection prevention. Evidence has supported dressing and needle changes at 7-day intervals when TIVADs are accessed continuously, aligning with best practices to minimize infection risk.^9(IIIb) Implementation of structured care bundles has led to significant improvements in maintenance practices and measurable reductions in port-related infections. For example, in a quality improvement project, the introduction of a TIVAD care bundle reduced CLABSI events from 3 to 0 in the study population, while increasing staff compliance with aseptic steps such as dual verification, nontouch technique, and site monitoring.^10(IIIb)

Additional practice guidance from the Oncology Nursing Society (ONS) has emphasized CHG skin prep, appropriate dressing materials, and clinical judgment regarding mask and glove use, while affirming that weekly needle and dressing changes are safe and evidence aligned.^11(Vb)

Clinical Considerations

Benefits

• Reduction in CRBSIs: Using standardized checklists, procedural bundles, and sterile procedural packs, organizations can reduce contamination and the risk of CRBSIs while promoting consistent adherence to evidence-based practices.^12,13,14,15
• Improved workflow and clinician adherence: Procedural packs enhance efficiency and adherence to infection control protocols.¹⁶
• Institutional cost savings: Standardized packs reduce complications and unnecessary material use, thereby reducing length of stay and need for additional care.^{12,13,16,17,18,19,20,21}

Risks

• Initial implementation costs: Implementation of procedural kits and training requires upfront investment.²²
• Resistance to change: Staff may resist changing familiar workflows, while clinician habits may hinder adherence to new infection control practices; the integration of predictive tools and staff training can increase the initial workload, potentially impacting implementation efforts.^{4,6,17,22,23,24}
• Overdependence on kits: May reduce clinical flexibility in unique cases.¹⁶

Implementation Considerations

• Training and competency validation: Hands-on training, competency assessments with periodic refreshers, and aseptic nontouch technique (ANTT®) education are essential.^12,13,16
• Policy development and institutional support: Institutional policies should mandate the use of standardized procedural packs to reduce infection risk, with strong leadership support playing a critical role in ensuring successful implementation, while collaboration across departments ensures consistency and success.^{12,13,16,17,20,24,25,26,27}
• Electronic health record integration and surveillance tools: Tracking catheter dwell times, infections, and flush reminders, alongside the use of risk assessment tools for catheter selection and infection risk mitigation, supports data-driven decision-making and enhances patient safety.^{28,29,30,31,32,33,34}

Barriers to Implementation

• Limited budget allocation: Institutions may struggle to secure upfront funds for purchasing standardized kits, antimicrobial products, or supporting information technology infrastructure for checklist integration.¹²
• Variability in adherence across different hospital units.^18,25
• Resistance to practice change among health care providers.^18,25,26,35

References

1. Savage TJ, Lynch AD, Oddera SE. Implementation of a vascular access team to reduce central line usage and prevent central line–associated bloodstream infections. J Infus Nurs. 2019;42(4):193–196. doi:10.1097/NAN.0000000000000328.
2. Martillo M, Zarbiv S, Gupta R, Brito A, Shittu A, Kohli-Seth R. 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.2019.08.019.
3. Ahn HM, Kim JS, Park MG, Hwang J, Kim WY, Seo DW. Incidence and short-term outcomes of central line-related bloodstream infection in patients admitted to the emergency department: a single-center retrospective study. Sci Rep. 2023;13(1):3867. doi:10.1038/s41598-023-31100-1.
4. Zhu Y, Li D, Li Y, Cai W. Predictive model for PICC occlusion risk for patients in intensive care units: a retrospective clinical study. Altern Ther Health Med. 2023;29(8):278–285.
5. Yu KC, Jung M, Ai C. Characteristics, costs, and outcomes associated with central-line–associated bloodstream infection and hospital-onset bacteremia and fungemia in US hospitals. Infect Control Hosp Epidemiol. 2023;44(12):1920–1926. doi:10.1017/ice.2023.132.
6. Patel PK. Prevention of central line–associated bloodstream infections. J Clin Outcomes Manage. 2018;25(6):273–277.
7. Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1–S224. doi:10.1097/NAN.0000000000000396.
8. Crowell J, O’Neil K, Drager L. Project HANDS: a bundled approach to increase short peripheral catheter dwell time. J Infus Nurs. 2017;40(5):274–280.
9. Johal J. Implantable venous ports: accessing. JBI EBP Database. 2023;JBI-ES-323-6.
10. Tom A, Acharya AR, Kamath A, Venugopal A, Lashakri HP. Improvement in care and maintenance of Port-A-Cath following the introduction of care bundle. J Indian Assoc Pediatr Surg. 2022;27(5):600–604.
11. Wiley K. Evidence-based standards guide the use and maintenance of venous implanted ports. ONS Voice. 2017;32(8):39–39.
12. Rowley S, Clare S. ANTT® standardisation facilitates new efficiencies with a novel partially-sterile standard-ANTT PIVC pack. Br J Nurs. 2023;32(7):S4–S10. doi:10.12968/bjon.2023.32.7.S4.
13. Rowley S, Clare S. Aseptic non touch technique (ANTT®): a critical competency in infection control. Infusion. 2020;26(1):22–27.
14. Munoz-Mozas G. Preventing intravenous catheter-related bloodstream infections (CRBSIs). Br J Nurs. 2023;32:S4–S10. doi:10.12968/bjon.2023.32.Sup7.S4.
15. Lafuente Cabrero E, Terradas Robledo R, Civit Cuñado A, et al. Risk factors of catheter-associated bloodstream infection: systematic review and meta-analysis. PLoS One. 2023;18(3):e0282290. doi:10.1371/journal.pone.0282290.
16. Santos-Costa P, Alves M, Sousa C, et al. Nurses’ involvement in the development and usability assessment of an innovative peripheral intravenous catheterisation pack: a mix-method study. Int J Environ Res Public Health. 2022;19(17):11130. doi:10.3390/ijerph191711130.
17. Corley A, Marsh N, Ullman AJ, Rickard CM. Peripheral intravenous catheter securement: an integrative review of contemporary literature around medical adhesive tapes and supplementary securement products. J Clin Nurs. 2023;32(9):1841–1857. doi:10.1111/jocn.16237.
18. Hawes ML. Vascular access device securement for oncology patients and those with chronic diseases. Br J Nurs. 2021;30(8):S20–S25. doi:10.12968/bjon.2021.30.8.S20.
19. Menger J, Kaase M, Schulze MH, et al. Central venous catheter contamination rate in suspected sepsis patients: an observational clinical study. J Hosp Infect. 2023;135:98–105. doi:10.1016/j.jhin.2023.02.015.
20. Paje D, Heath M, Heung M, et al. Midline catheters in patients with advanced chronic kidney disease. J Hosp Med. 2023;18(11):969–977. doi:10.1002/jhm.13209.
21. Lima Zandonadi MG, Bolorino N, Tiroli CF, Guassú Nogueira DN, Pieri FM. Peripherally inserted central catheter and costs associated with nursing care: an integrative review. Ciencia, Cuidado e Saude. 2023;22:1–9.
22. van der Kooi TII, Smid EA, Koek MBG, et al. The effect of an intervention bundle to prevent central venous catheter-related bloodstream infection in a national programme in the Netherlands. J Hosp Infect. 2023;131:194–202. doi:10.1016/j.jhin.2022.11.006.
23. Ricou Ríos L, Esposito Català C, Pons Calsapeu A, et al. Implementation of a vascular access specialist team in a tertiary hospital: a cost-benefit analysis. Cost Eff Resour Allocation. 2023;21(1):1–8.
24. Picardi M, Giordano C, Della Pepa R, et al. Intravascular complications of central venous catheterization by insertion site in acute leukemia during remission induction chemotherapy phase: lower risk with peripherally inserted catheters in a single-center retrospective study. Cancers (Basel). 2023;15(7):2147. doi:10.3390/cancers15072147.
25. Stewart AG, Laupland KB, Tabah A. Central line associated and primary bloodstream infections. Curr Opin Crit Care. 2023;29(5):423–429. doi:10.1097/mcc.0000000000001082.
26. Schora D, Patel P, Barza R, et al. Positive and neutral needleless connectors: a comparative study of central-line associated bloodstream infection, occlusion, and bacterial contamination of the connector lumen. J Infus Nurs. 2023;46(3):157–161. doi:10.1097/nan.0000000000000506.
27. Wang P, He Q, Yuan J, Lu Q, Ji A, Peng A. Risk factors for peripherally inserted central catheter-related venous thrombosis in adult patients with cancer. Thromb J. 2024;22(1):1–9.
28. Yuki I, Cammack I, Takeshi Y. Management of a malpositioned central venous catheter in the accessory hemiazygos vein. BMJ Case Rep. 2021;14(12):1–3. doi:10.1136/bcr-2021-245654.
29. Ostroff MD, Moureau N, Pittiruti M. Rapid assessment of vascular exit site and tunneling options (RAVESTO): a new decision tool in the management of the complex vascular access patients. J Vasc Access. 2023;24(2):311–317. doi:10.1177/11297298211034306.
30. Spencer TR, Bardin-Spencer A. Ultrasound guidance for vascular access procedures by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2019;24(4):18–22. doi:10.2309/j.java.2019.004.002.
31. Kamalipour H, Ahmadi S, Kamali K, Moaref A, Shafa M, Kamalipour P. Ultrasound for localization of central venous catheter: a good alternative to chest x-ray? Anesth Pain Med. 2016;6(5):e38834. doi:10.5812/aapm.38834.
32. Glauser F, Breault S, Rigamonti F, Sotiriadis C, Jouannic AM, Qanadli SD. Tip malposition of peripherally inserted central catheters: a prospective randomized controlled trial to compare bedside insertion to fluoroscopically guided placement. Eur Radiol. 2017;27(7):2843–2849. doi:10.1007/s00330-016-4666-y.
33. Yu Y, Yuan L. The electrocardiographic method for positioning the tip of central venous access device. J Vasc Access. 2020;21(5):589–595. doi:10.1177/1129729819874986.
34. Wang L, Liu ZS, Wang CA. Malposition of central venous catheter: presentation and management. Chin Med J (Engl). 2016;129(2):227–234. doi:10.4103/0366-6999.173525.
35. Rowe MS, Arnold K, Spencer TR. Catheter securement impact on PICC-related CLABSI: a university hospital perspective. Am J Infect Control. 2020;48(12):1497–1500. doi:10.1016/j.ajic.2020.06.178.

Chapter 1.4 – Policies, Procedures & Protocols

Vascular access devices (VADs) are integral to modern health care, providing reliable routes for medications, fluids, nutrition, and blood sampling. However, when improperly selected, placed, or maintained, these devices carry significant risks, including central line-associated bloodstream infections, phlebitis, malposition, and premature device failure. Such complications increase morbidity, lengthen hospital stays, and raise health care costs.

To mitigate these risks, health care organizations must establish and adhere to clear clinical governance which include evidence-based policies, procedures, and protocols. Regularly updated guidance supports clinical competency, standardizes practice, and ensures alignment with evolving research, professional standards, and regulatory requirements.

A structured framework that emphasizes thorough documentation, consistent training, and routine evaluation promotes accountability across teams and fosters a culture of reliability. By embedding policies and protocols into daily workflows, institutions strengthen patient safety, sustain high-quality vascular access practice, and improve system-wide efficiency.

Recommendation 1: Directed Use of Kits

Health care institutions should establish and enforce policies directing the use of standardized kits and procedure trays to improve adherence to aseptic technique and reduce variability in clinical practice.

Summary of Evidence

Standardized kits and procedure trays reduce infection risk and improve adherence to aseptic technique by ensuring essential supplies are consistently available and used correctly. Authors of a quality improvement (QI) study showed that implementing a tailored peripheral cannulation pack aligned with aseptic nontouch technique (ANTT) significantly improved equipment handling, reduced contamination, and enhanced technique compliance.^1(IIa) Similarly, in a mixed-method randomized controlled trial and usability study, Santos-Costa et al. found that implementing a preassembled peripheral intravenous catheter (PIVC) kit significantly reduced procedural time and material omissions while promoting uniformity in practice. When the kit was used, nurses reported increased satisfaction, improved infection control, and greater ease in managing supplies.^2(Ib)

Recommendation 2: Clinical Governance for VADs

Health care organizations should develop evidence-based vascular access clinical governance that addresses insertion, maintenance, troubleshooting, and complication prevention. This governance must be interdisciplinary, incorporating input from vascular access specialists, infection preventionists, and direct care clinicians to ensure safe and practical application.

Summary of Evidence

Evidence has supported the development of multidisciplinary, evidence-based vascular access policies to improve clinical consistency and patient outcomes. Clinical governance aligned with national guidelines and built with input from vascular access specialists and infection preventionists improve documentation, standardize procedures, and support competency-based credentialing.^{3(Ib),4(IVb),5(IIb),6(IIIb),7(IIIb),8(Vb)(Ib,IVb,IIb,IIIb,IIIb,Vb,Ia)} Authors of studies have shown that such operational management will reduce complications, enhance surveillance, and bridge the gap between best practice and clinical behavior.

Recommendation 3: Structured Audits

It is recommended that health care organizations consider implementing structured audits, checklist-based reviews, and performance feedback loops to assess compliance with vascular access care policies, identify practice gaps, and guide continuous QI efforts.

Summary of Evidence

Routine evaluation strategies such as audits, checklists, and feedback loops have been shown to improve compliance with vascular access protocols and support safer practices. A prospective audit using the Plastic-in-Patient tool improved documentation and early removal of nonindicated PIVCs.^5(IIIb) Audit-driven feedback and education significantly increased adherence to peripherally inserted central catheter best practices in a unit specific implementation project.^9(IIIb) Similarly, a multidisciplinary QI initiative linked clinician feedback with protocol adherence to support safer peripheral administration of 3% sodium chloride.^6(IIIb)

Recommendation 4: Clinical Governance Updating

It is recommended that health care institutions regularly review and update vascular access clinical governance in response to emerging evidence, evolving clinical standards, and new technologies. Involving frontline clinicians in the update process may improve relevance and facilitate implementation.

Summary of Evidence

Ongoing operational management evaluation is essential to ensure alignment with current standards and technologies. A QI project by Hade et al. demonstrated that updating central venous access device insertion checklists improved documentation and reduced malposition rates.^10(Vb) Barsuk et al. emphasized that simulation-based mastery standards evolve over time and should inform institutional guidelines and competency policies.^11(IIa) Spina et al. underscored the importance of national alignment with international vascular access standards and recommended incorporating innovations like electrocardiogram navigation and simulation training into policy frameworks.^12(IVb)

Clinical Considerations

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Benefits

• Reduced Infection Risks:
  • Standardized procedural packs support adherence to ANTT, helping reduce catheter-related bloodstream infections and contamination.^1,13
  • Evidence-based procedural enhancements, including standardized protocols and accurate documentation practices, help decrease infection rates.^7,14,15
• Improved Workflow and Standardization:
  • Prepackaged sterile materials eliminate the need to gather individual components, streamline setup, and reduce variability and procedural errors.^1,13
  • Protocol-driven site selection, catheter sizing, and documentation reduce variability and improve care consistency.^5,8
• Increased Clinician Confidence and Patient Satisfaction:
  • Nurses report greater confidence and ease of use with standardized packs, while patients benefit from shorter procedures and fewer complications.²
  • Standardized procedural guidelines enhance adherence to best practices and improve patient outcomes.¹⁰
• Cost Savings and Resource Optimization:
  • Standardized packs use only necessary materials, prevent overuse, and reduce complications, resulting in institutional cost savings.^1,2,13
  • Fewer complications reduce the need for catheter replacements and readmissions, translating to lower overall health care costs.^8,10

Risks

• Upfront Costs and Training Requirements:
  • Transitioning to standardized procedural packs requires initial investment in supplies and clinician training.³
  • Increased documentation and the need for procedural training can raise initial implementation costs.⁵
• Resistance to Change:
  • Staff accustomed to previous workflows may resist adopting procedural packs.^1,13
  • Clinicians may push back on added administrative tasks or alterations to familiar workflows.^5,8
• Limited Flexibility in Complex Cases:
  • Overdependence on kits may reduce adaptability; some kits may not suit every clinical scenario.^1,2
• Environmental and Supply Chain Concerns:
  • Increased use of single-use items contributes to medical waste. Supply chain disruptions could impact kit availability.^1,2

Implementation Considerations

• Staff Education and Competency Validation:
  • Conduct hands-on training sessions on procedural packs and ANTT principles, with competency assessments to reinforce best practices.^1,13
  • Conduct mandatory training on ultrasound-guided vascular access, site selection, and risk-based practices.⁷
• Institutional Policy Alignment and Leadership Support:
  • Develop policies mandating procedural packs aligned with infection control standards. Secure leadership and stakeholder support.^1,2
  • Establish policies supporting structured documentation and imaging to guide vascular access.^8,11
• Customization and Flexibility:
  • Ensure packs are adaptable for different patient needs and care settings, such as emergency departments or difficult intravenous access cases.^2,16
  • Tailor implementation to unit needs with support from interdisciplinary teams, ensuring flexibility in integration.^5,17
• Continuous QI:
  • Monitor adherence and outcomes, gather clinician feedback to refine pack contents, and conduct periodic audits to sustain compliance.^1,13,16
  • Leverage electronic health records (EHRs) to track complications, document outcomes, and monitor adherence.¹⁰

Barriers to Implementation

• Lack of Policy Visibility: Staff may be unaware of updated protocols or may not know where to access them.^1,2
• Resistance to Standardization: Clinicians may prefer personalized practices over rigid protocols, especially in complex or high-pressure environments.⁷
• Variable Enforcement: Without consistent auditing or leadership oversight, protocol adherence may vary across shifts or units.⁷
• EHR Integration Gaps: Policies not embedded into clinical documentation or decision-making tools may be bypassed during care delivery.¹⁰

References

1. Rowley S, Clare S. ANTT standardisation facilitates new efficiencies with a novel partially-sterile standard-ANTT PIVC pack. Br J Nurs. 2023;32(7):S4-S10. doi:10.12968/bjon.2023.32.7.S4.
2. Santos-Costa P, Paiva-Santos F, Sousa LB, et al. Nurses’ practices in the peripheral intravenous catheterization of adult oncology patients: a mix-method study. J Pers Med. 2022;12(2):151. doi:10.3390/jpm12020151.
3. Park YS, Pruinelli L. Developing information model of central line-associated bloodstream infection (CLABSI) prevention. Stud Health Technol Inform. 2021;284:408-413. doi:10.3233/SHTI210760.
4. Stolz LA, Cappa AR, Minckler MR, et al. Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement. J Vasc Access. 2016;17(4):366-370. doi:10.5301/jva.5000574.
5. Yagnik L, Graves A, Thong K. Plastic in patient study: prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications. Am J Infect Control. 2017;45(1):34-38. doi:10.1016/j.ajic.2016.09.008.
6. Jannotta GE, Gulek BG, Dempsey JS, et al. Administration of 3% sodium chloride through peripheral intravenous access: development and implementation of a protocol for clinical practice. Worldviews Evid Based Nurs. 2021;18(2):147-153. doi:10.1111/wvn.12501.
7. Spencer TR, Bardin-Spencer A. Central venous access device insertion by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2020;25(1):52-55.
8. Keogh S, Shelverton C, Flynn J, et al. Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial. BMC Med. 2020;18(1):252.
9. Oliveira LB de, Fava YR, Rodrigues ARB, Franulovic AC, Ferreira NT, de Araujo Puschel VA. Management of peripherally inserted central catheter use in an intensive care unit of a teaching hospital in Brazil: a best practice implementation project. JBI Database System Rev Implement Rep. 2018;16(9):1874-1886. doi:10.11124/JBISRIR-2017-003577.
10. Hade AD, Beckmann LA, Basappa BK. A checklist to improve the quality of central venous catheter tip positioning. Anaesthesia. 2019;74(7):896-903. doi:10.1111/anae.14679.
11. Barsuk JH, Cohen ER, Wayne DB, McGaghie WC, Yudkowsky R. A comparison of approaches for mastery learning standard setting. Acad Med. 2018;93(7):1079-1084.
12. Spina R, Mussa B, Tollapi L, Conti F, Cortesi E, Verna R. Adoption and application in Italy of the principal guidelines and international recommendations on venous access. Minerva Med. 2018;109(3):153-202.
13. Rowley S, Clare S. Aseptic non touch technique (ANTT): a critical competency in infection control. Infusion. 2020;26(1):22-27.
14. Corvetto MA, Pedemonte JC, Varas D, Fuentes C, Altermatt FR. Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement. Acta Anaesthesiol Scand. 2017;61(9):1184-1191.
15. Phillips AW, Matthan J, Bookless LR, et al. Individualised expert feedback is not essential for improving basic clinical skills performance in novice learners: a randomized trial. J Surg Educ. 2017;74(4):612-620.
16. Ruegg L, Faucett M, Clawson A, Subedi S. Reducing the prevalence of antecubital fossa peripheral intravenous cannulation. Br J Nurs. 2022;31(2):S8-S14. doi:10.12968/bjon.2022.31.2.S8.
17. Hulse A, Cochrane J. Impact of educational leadership and interprofessional learning on vascular access training. Br J Nurs. 2018;27(19):S4-S18.

Chapter 1.5 – Education & Competency

Safe and effective vascular access procedures depend on clinician knowledge, technical skill, and ongoing competency. Insufficient training or reliance on outdated practices can lead to complications such as infection, occlusion, dislodgement, or device failure, which increases patient risk and health care costs.

Structured education and competency programs are essential for reducing variation in practice and improving outcomes. Simulation-based training, peer-to-peer learning, and formal certification pathways enhance procedural proficiency, support risk-informed decision-making, and reduce complication rates.

Ongoing competency assessment ensures clinicians remain aligned with evolving techniques, technologies, and evidence-based standards. By incorporating multidisciplinary perspectives, competency programs foster collaboration across nursing, medicine, and allied health disciplines. This sustained approach strengthens clinical judgment, supports safe device selection and care, and advances the overall quality of vascular access practice.

Recommendation 1: Initial and Ongoing Competency

It is recommended that vascular access clinicians complete initial and ongoing competency training that incorporates patient-specific factors and promotes individualized, risk-based catheter selection and maintenance strategies.

Summary of Evidence

Ongoing competency training that includes patient-specific considerations is associated with improved catheter outcomes. In a large cohort study, structured ultrasound-guided internal jugular catheter insertion training yielded a 99.3% first-attempt success rate and a low complication rate (3.4%), reinforcing the value of hands-on procedural competency.^1(IIIb) Authors of another study reported that adverse event rates were significantly lower with totally implanted vascular access devices (TIVADs) than with peripherally inserted central catheters (PICCs), particularly when clinicians factored in patient comorbidities and anatomy during device selection. This suggests the importance of individualized, evidence-based decision-making in reducing complications.^2(Ia)

Recommendation 2: Competency in Complication Recognition

Vascular access clinicians must complete initial and ongoing competency training that includes recognition and management of complications, including catheter-related infections and air embolism, using simulation-based scenarios and structured evaluation.

Summary of Evidence

Simulation-based and structured competency training enhances clinician preparedness for vascular access emergencies. Brull et al. described the lethal consequences of vascular air embolism and advocate for simulation and protocolized team response to reduce harm.^3(Vb) Redstone et al. showed that a structured, system-wide competency framework, including standardized insertion checklists, training refreshers, and peer audits, reduced central line-associated bloodstream infection (CLABSI) rates by over 50% in a multisite health system.^4(IIIb) Garces-Carrasco et al. found that PICC-related complications during stem cell transplantation were no greater in patients treated at home than in the hospital, provided caregivers and patients received structured catheter care education.^5(IIIb) These findings support the role of competency-based education as a critical strategy for minimizing vascular access complications.

Recommendation 3: Clinician Insertion Training

Vascular access clinicians should be trained in ultrasound guidance, relevant anatomy, and device selection techniques to ensure accurate placement and reduce insertion-related complications.

Summary of Evidence

Competency in ultrasound guidance and anatomical visualization is essential to safe and effective vascular access. Yu et al. conducted a multicenter study of 433 adult patients receiving ultrasound-guided TIVADs via the brachiocephalic vein, reporting a 94.9% first-attempt success rate and a 6.2% overall complication rate, confirming the technique’s reliability and safety.⁶ Redstone et al. demonstrated that clinician training in insertion technique, including ultrasound guidance, contributed to a 51% reduction in CLABSI across a health system.^4(IIIb) Appropriate training must include technical use of the ultrasound machine and in-depth knowledge of vascular anatomy, procedural technique, and complications such as inadvertent thoracic duct injury or catheter malposition.^6(IIb) Zhou et al. analyzed over 1500 patients and found that thrombosis risk increases with catheter duration and mechanical vessel injury, which can be minimized through anatomically informed ultrasound-guided access.^7(IIIb)

Recommendation 4: National Certification

Organizations should promote initial and ongoing national certification for vascular access clinicians to support clinical proficiency, evidence-based practice, and improved patient outcomes.

Summary of Evidence

Knowledge-based national certification in vascular access is associated with improved clinical performance, reduced complication rates, and greater adherence to evidence-based practices. Certified clinicians report more experience, are more likely to hold leadership roles, and consistently apply best practices such as ultrasound-guided insertion and catheter-to-vessel ratio assessment.^{8(IIIb),9(IIIb)}

Structured competency-based programs incorporating simulation and hands-on deliberate practice improve procedural skills and reduce errors. Corvetto et al. found that residents who completed simulation-based training had significantly improved technical performance and reduced catheter insertion time.^{10(IIb),11(IIb)} Ongoing certification and recertification also play a critical role in maintaining proficiency. Clinical assessment requirements and recent practice directly influenced competency in vascular access procedures.^{12(IIIb),13(Ia)}

Recommendation 5: Periodic Competency Assessments

Structured competency evaluations must be conducted at least annually for all clinicians involved in vascular access care, and semiannually for those performing high-risk procedures such as central venous catheter insertion. These assessments should incorporate validated tools, simulation-based methods, and performance feedback mechanisms to ensure ongoing proficiency and patient safety.

Summary of Evidence

Evidence demonstrates that periodic competency assessments, especially those using simulation and video-based feedback, help maintain clinician proficiency, improve adherence to aseptic technique, and reduce procedural complications. Authors of 1 study emphasized that procedural exposure alone does not guarantee competence, highlighting the need for structured evaluations.^14(IIa) Authors of another study showed video-enhanced feedback supports long-term skill retention, while those of a third study reported that repeated assessment improves procedural success during ultrasound-guided catheter placement.^{15(IIa),16(IIa)}

Recommendation 6: Multidisciplinary Competency Program Development

Facilities should implement vascular access competency programs developed through multidisciplinary collaboration among licensed independent practitioners, direct care clinicians, and educators. These programs must address insertion, care, and maintenance competencies across disciplines to reduce complications, enhance decision-making, and promote standardized best practices.

Summary of Evidence

A multidisciplinary approach to vascular access education and competency development has been associated with improved adherence to guidelines, greater standardization of care, and reduced complications. Keogh et al. demonstrated improved outcomes following the implementation of guideline-based vascular access practices.^13(Ia) Authors of another study emphasized that the roles and collaboration of direct care clinicians, physicians, and educators influence appropriate vascular access device use.^9(IIIb) Survey data have also revealed gaps in clinician awareness and training regarding catheter dislodgement risks and securement strategies, reinforcing the need for interprofessional education and structured monitoring processes.^{17(IIIb),18(IIIb),19(IIIb)}

Recommendation 7: Comprehensive Competency Program

Vascular access competency programs should incorporate simulation-based training, peer-assisted learning, structured video feedback, and performance-tracking systems to ensure clinician readiness, promote skill retention, and address performance deficiencies. These components form the foundation of a rigorous, evidence-informed approach to vascular access education.

Summary of Evidence

Simulation-based training has consistently demonstrated improvements in procedural success and complication reduction, including up to an 85% decrease in CLABSI and arterial punctures.^{14(IIa),20(Ia)} Researchers have confirmed that peer-assisted learning methods are equally effective as instructor-led formats, enhancing procedural confidence and technical skill acquisition.^{21(IIa),22(IIa),23(IIa)} Video-based feedback further accelerates learning and improves performance consistency, making it a valuable adjunct to simulation in structured training programs.^24(IIa)

Clinical Considerations

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Benefits

• Reduced infection risks: Comprehensive training, including aseptic technique, catheter care, and standardized procedures, has been shown to reduce catheter-related bloodstream infections, while simulation-based education enhances adherence to evidence-based protocols and infection prevention standards. Additionally, instruction in securement and maintenance techniques supports reductions in dislodgement, malposition, and infection risk.^{10,25,26,27,28,29}
• Improved access and safety: Early difficult intravenous access recognition and ultrasound-guided training reduce delays and access attempts, while standardized documentation and maintenance minimize complications and enhance safety.^{30,31,32,33,34,35,36,37}
• Support for accreditation and regulatory compliance: Training supports institutional alignment with infection prevention guidelines and accreditation requirements, and consistent documentation practices improve quality reporting and legal defensibility.^25,26,38,39
• Leadership development and professional growth: Certification pathways and continuing education foster clinical leadership and mentorship roles.^8,9

Risks

• Training fatigue or burnout: Mandatory training and frequent reassessments may cause frustration or disengagement among clinicians.^14,40
• Resistance to change: Staff may be reluctant to shift from established practices or adopt new documentation and assessment protocols.^13,25,26,41
• Workflow disruptions: Time spent on training may temporarily reduce staffing availability or delay care delivery.^14,15,36

Implementation Considerations

• Staff education and competency: Implement structured training on aseptic nontouch technique, ultrasound guidance, catheter care, and documentation.^{1,13,25,26,30,32,35,42,43,44,45,46,47}
• Policy alignment and support: Align training with infection control policies, secure leadership support, and designate clinical champions to reinforce best practices.^25,48,49
• Sustained competency: Allocate funds for training, equipment, and certification, and establish regular recertification to maintain proficiency.^25,48,49
• Cross-disciplinary collaboration: Engage infection prevention, nursing, vascular access teams, radiology, and administration to co-develop and deliver training.^38,39,45

Barriers to Implementation

• Resource limitations: Simulation equipment, educator capacity, and physical training space may not be readily available.^13,49
• Time constraints: Competing clinical demands often limit staff availability for training or reassessment.^14,15
• Resistance to reassessment: Experienced clinicians may push back against mandatory competency validation.^14,40

References

1. Ye W, Li D, Ji X, et al. Real-time ultrasound-guided internal jugular vein cannulation by oblique-axis in-plane: practice at the Fourth Hospital of Hebei Medical University. Int J Clin Pract. 2021;75(2):e13673. doi:10.1111/ijcp.13673.
2. Lin L, Li W, Chen C, Wei A, Liu Y. Peripherally inserted central catheters versus implantable port catheters for cancer patients: a meta-analysis. Front Oncol. 2023;13:1228092. doi:10.3389/fonc.2023.1228092.
3. Brull SJ, Prielipp RC. Vascular air embolism: a silent hazard to patient safety. J Crit Care. 2017;42:255-263. doi:10.1016/j.jcrc.2017.08.010.
4. Redstone CS, Zadeh M, Wilson MA, et al. A quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a “zero harm” approach. J Patient Saf. 2023;19(3):173-179. doi:10.1097/pts.0000000000001107.
5. Garces-Carrasco AM, Santacatalina-Roig E, Carretero-Marquez C, Martinez-Sabater A, Balaguer-Lopez E. Complications associated with peripherally inserted central catheters (PICC) in people undergoing autologous hematopoietic stem cell transplantation (HSCT) in home hospitalization. Int J Environ Res Public Health. 2023;20(3):1704. doi:10.3390/ijerph20031704.
6. Yu Z, Sun X, Bai X, et al. Perioperative and postoperative complications of supraclavicular, ultrasound-guided, totally implantable venous access port via the brachiocephalic vein in adult patients: a retrospective multicentre study. Ther Clin Risk Manag. 2021;17:137-144. doi:10.2147/tcrm.S292230.
7. Zhou X, Lin X, Shen R, et al. A retrospective analysis of risk factors associated with catheter-related thrombosis: a single-center study. Perfusion. 2020;35(8):806-813. doi:10.1177/0267659120915142.
8. Chopra V, Kuhn L, Vaughn V, et al. CE: original research: does certification in vascular access matter? An analysis of the PICC1 survey. Am J Nurs. 2017;117(12):24-34.
9. Krein SL, Kuhn L, Ratz D, Winter S, Vaughn VM, Chopra V. The relationship between perceived role and appropriate use of peripherally inserted central catheters: a survey of vascular access nurses in the United States. Int J Nurs Stud. 2017;71:28-33.
10. Corvetto MA, Pedemonte JC, Varas D, Fuentes C, Altermatt FR. Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement. Acta Anaesthesiol Scand. 2017;61(9):1184-1191.
11. Day J, Winchester ZB, Cairns CA, et al. The impact of a comprehensive simulation-based training and certification program on resident central venous catheter complication rates. Simul Healthcare. 2021;16(2):92-97.
12. Garner S, van Dreven A, MacDermott S, Yates M. Assessment and recency drive skill acquisition. Clin Teach. 2019;16(3):232-235.
13. Keogh S, Shelverton C, Flynn J, et al. Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial. BMC Med. 2020;18(1):252.
14. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Residents’ procedural experience does not ensure competence: a research synthesis. J Grad Med Educ. 2017;9(2):201-208.
15. Rammell J, Matthan J, Gray M, et al. Asynchronous unsupervised video-enhanced feedback as effective as direct expert feedback in the long-term retention of practical clinical skills: randomised trial comparing 2 feedback methods in a cohort of novice medical students. J Surg Educ. 2018;75(6):1463-1470.
16. Stolz LA, Cappa AR, Minckler MR, et al. Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement. J Vasc Access. 2016;17(4):366-370. doi:10.5301/jva.5000574.
17. DeVries M, Sarbenoff J, Scott N, Wickert M, Hayes LM. Improving vascular access dressing integrity in the acute care setting: a quality improvement project. J Wound Ostomy Continence Nurs. 2021;48(5):383-388. doi:10.1097/won.0000000000000787.
18. McParlan D, Edgar L, Gault M, Gillespie S, Menelly R, Reid M. Intravascular catheter migration: a cross-sectional and health-economic comparison of adhesive and subcutaneous engineered stabilisation devices for intravascular device securement. J Vasc Access. 2020;21(1):33-38. doi:10.1177/1129729819851059.
19. Moureau N. Impact and safety associated with accidental dislodgement of vascular access devices: a survey of professions, settings, and devices. J Assoc Vasc Access. 2018;23(4):203-215. doi:10.1016/j.java.2018.07.002.
20. Hu Y, Brooks KD, Kim H, et al. Adaptive simulation training using cumulative sum: a randomized prospective trial. Am J Surg. 2016;211(2):377-383.
21. Onder HE, Sari D. Simulation-based teaching is effective in developing peripheral intravenous catheterization skills. Int J Caring Sci. 2021;14(1):309-318.
22. Pelloux S, Gregoire A, Kirmizigul P, et al. Peripheral venous catheter insertion simulation training: a randomized controlled trial comparing performance after instructor-led teaching versus peer-assisted learning. Anaesth Crit Care Pain Med. 2017;36(6):397-402.
23. Su S, Vicdan AK. The effect of peer mentoring model used to teach peripheral intravenous catheter placement on knowledge, skills, self-confidence, satisfaction and fear of nursing students: a randomized controlled trial. Karya J Health Sci. 2022;3(3):343-349. doi:10.52831/kjhs.1172830.
24. Yu J, Lo C, Madampage C, et al. Video modeling and video feedback to reduce time to perform intravenous cannulation in medical students: a randomized-controlled mixed-methods study. Can J Anaesth. 2020;67(6):715-725.
25. Rowley S, Clare S. ANTT standardisation facilitates new efficiencies with a novel partially-sterile standard-ANTT PIVC pack. Br J Nurs. 2023;32(7):S4-S10. doi:10.12968/bjon.2023.32.7.S4.
26. Rowley S, Clare S. Aseptic non-touch technique (ANTT): a critical competency in infection control. Infusion. 2020;26(1):22-27.
27. Corley A, Marsh N, Ullman AJ, Rickard CM. Peripheral intravenous catheter securement: an integrative review of contemporary literature around medical adhesive tapes and supplementary securement products. J Clin Nurs. 2023;32(9):1841-1857. doi:10.1111/jocn.16237.
28. Spencer TR, Bardin-Spencer A. Central venous access device insertion by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2020;25(1):52-55.
29. Phillips AW, Matthan J, Bookless LR, et al. Individualised expert feedback is not essential for improving basic clinical skills performance in novice learners: a randomized trial. J Surg Educ. 2017;74(4):612-620.
30. van Loon FHJ, Buise MP, Claassen JJF, Dierick-van Daele ATM, Bouwman ARA. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis. Br J Anaesth. 2018;121(2):358-366. doi:10.1016/j.bja.2018.04.047.
31. Poulsen E, Aagaard R, Bisgaard J, Sorensen HT, Juhl-Olsen P. The effects of ultrasound guidance on first-attempt success for difficult peripheral intravenous catheterization: a systematic review and meta-analysis. Eur J Emerg Med. 2023;30(2):70-77. doi:10.1097/mej.0000000000000993.
32. Yalcinli S, Karbek Akarca F, Can O, Uz I, Konakci G. Comparison of standard technique, ultrasonography, and near-infrared light in difficult peripheral vascular access: a randomized controlled trial. Prehosp Disaster Med. 2022;37(1):65-70. doi:10.1017/S1049023X21001217.
33. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225.
34. Little A, Jones DG, Alsbrooks K. A narrative review of historic and current approaches for patients with difficult venous access: considerations for the emergency department. Expert Rev Med Devices. 2022;19(5):441-449. doi:10.1080/17434440.2022.2095904.
35. Moss JG, Wu O, Bodenham AR, et al. Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial. Lancet. 2021;398(10298):403-415. doi:10.1016/s0140-6736(21)00766-2.
36. Ostroff MD, Moureau N, Pittiruti M. Rapid assessment of vascular exit site and tunneling options (RAVESTO): a new decision tool in the management of the complex vascular access patients. J Vasc Access. 2021;24(2):311-317. doi:10.1177/11297298211034306.
37. Zawadka M, La Via L, Wong A, et al. Real-time ultrasound guidance as compared with landmark technique for subclavian central venous cannulation: a systematic review and meta-analysis with trial sequential analysis. Crit Care Med. 2023;51(5):642-652. doi:10.1097/ccm.0000000000005819.
38. Wang P, He L, Yuan Q, et al. Risk factors for peripherally inserted central catheter-related venous thrombosis in adult patients with cancer. Thromb J. 2024;22(1):6. doi:10.1186/s12959-023-00574-4.
39. Ricou Rios L, Esposito Catala C, Pons Calsapeu A, et al. Implementation of a vascular access specialist team in a tertiary hospital: a cost-benefit analysis. Cost Eff Resour Alloc. 2023;21(1):67. doi:10.1186/s12962-023-00464-6.
40. Wittler M, Hartman N, Manthey D, Hiestand B, Askew K. Video-augmented feedback for procedural performance. Med Teach. 2016;38(6):607-612.
41. Yagnik L, Graves A, Thong K. Plastic in patient study: prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications. Am J Infect Control. 2017;45(1):34-38. doi:10.1016/j.ajic.2016.09.008.
42. Tran QK, Fairchild M, Yardi I, Mirda D, Markin K, Pourmand A. Efficacy of ultrasound-guided peripheral intravenous cannulation versus standard of care: a systematic review and meta-analysis. Ultrasound Med Biol. 2021;47(11):3068-3078. doi:10.1016/j.ultrasmedbio.2021.07.002.
43. Salleras-Duran L, Fuentes-Pumarola C, Fontova-Almato A, Roqueta-Vall-Llosera M, Camara-Liebana D, Ballester-Ferrando D. Pain and satisfaction perceptions of ultrasound-guided versus conventional peripheral intravenous catheterization: a randomized controlled trial. Pain Manag Nurs. 2024;25(1):e37-e44. doi:10.1016/j.pmn.2023.07.010.
44. Bertoglio S, Annetta MG, Brescia F, et al. A multicenter retrospective study on 4480 implanted PICC-ports: a GAVeCeLT project. J Vasc Access. 2022:112972982110676. doi:10.1177/11297298211067683.
45. Privitera D, Mazzone A, Pierotti F, et al. Ultrasound-guided peripheral intravenous catheters insertion in patient with difficult vascular access: short axis/out-of-plane versus long axis/in-plane, a randomized controlled trial. J Vasc Access. 2022;23(4):589-597. doi:10.1177/11297298211006996.
46. Righetti M, Palmieri N, Bracchi O, et al. Tegaderm CHG dressing significantly improves catheter-related infection rate in hemodialysis patients. J Vasc Access. 2016;17(5):417-422. doi:10.5301/jva.5000596.
47. Oliveira LB, Fava YR, Rodrigues ARB, Franulovic AC, Ferreira NT, Puschel VAA. Management of peripherally inserted central catheter use in an intensive care unit of a teaching hospital in Brazil: a best practice implementation project. JBI Database System Rev Implement Rep. 2018;16(9):1874-1886.
48. Primdahl SC, Weile J, Clemmesen L, et al. Validation of the peripheral ultrasound-guided vascular access rating scale. Medicine (Baltimore). 2018;97(2):e9576. doi:10.1097/md.0000000000009576.
49. Andersen NL, Jensen RO, Posth S, Laursen CB, Jorgensen R, Graumann O. Teaching ultrasound-guided peripheral venous catheter placement through immersive virtual reality: an explorative pilot study. Medicine. 2021;100(27):e26394.

Chapter 1.6 – Documentation

Documentation extends beyond regulatory compliance; it serves as the clinical narrative that guides decision-making, safeguards patient safety, and demonstrates the quality of care delivered. In vascular access, where risks are significant and outcomes hinge on precision, the written record is essential for continuity, accountability, and safety.

Clear, consistent documentation provides a roadmap for all members of the care team, detailing device selection, insertion site, function, and ongoing assessment. These records enable early recognition of complications, timely intervention, and seamless transitions across care settings.

At the organizational level, structured documentation supports quality improvement, adverse event reporting, and policy development. When performed thoroughly, it generates the data needed for institutional learning and system-wide safety initiatives. By embedding documentation standards into daily workflow, institutions strengthen patient care, advance infection prevention, and reinforce professional accountability.

Recommendation 1: Align Documentation Practices

Organizations are encouraged to standardize documentation for vascular access procedures and maintenance to reflect current evidence-based research and clinical guidelines, supporting consistency in care delivery, accurate data collection, and adherence to best practices across teams.

Summary of Evidence

Variations in procedural documentation can undermine clarity, introduce safety risks, and limit alignment with current standards.^1(IIIa) Researchers have shown that standardizing documentation based on best available evidence improves care consistency and enhances team learning.^2(Vb),3(Va) Patient-reported outcome frameworks and safety education models like quality and safety education for nurses further support documentation as a driver of quality improvement and safer infusion therapy.^3(Va)

Recommendation 2: Integrate Documentation into the Electronic Health Record

Electronic health records (EHRs) should include standardized documentation templates for vascular access procedures. These templates must be developed with input from vascular access specialists to ensure relevant data fields are consistently captured.

Summary of Evidence

Standardized EHR templates improve the completeness and clarity of documentation, promote interdisciplinary communication, and support quality monitoring. Authors of a study of central venous catheter templates demonstrated an increase in documentation completeness from 38% to 93%.^4(IIa) Templates developed without input from vascular access clinicians often lack critical data fields such as procedural technique, tip verification, or post-procedural care, limiting their value for tracking complications and evaluating performance.

Recommendation 3: Documentation of Adverse Events

Health care institutions are encouraged to implement structured templates and protocols for documenting adverse events related to vascular access devices (VADs). Documentation should include event details, immediate response, corrective actions, and any care plan modifications.

Summary of Evidence

Underreporting of catheter-related complications is common: Authors of 1 study found that only 1.6% were captured in formal adverse event systems.^5(IIIb) Standardized documentation can uncover the true incidence of complications and help prevent recurrence.^{3(Va),6(IIIb)} Well-documented events also support system-wide learning, root cause analysis, and quality improvement. Including patient-reported experiences enhances the accuracy and utility of adverse event records.^2(Vb)

Recommendation 4: Standardized Documentation Tools

Health care organizations may consider using standardized tools to document vascular access outcomes to promote consistency, support data analysis, and reduce variability across patient records, research studies, and quality-improvement initiatives.

Summary of Evidence

Structured documentation improves consistency in reporting and facilitates retrospective analysis for quality improvement and patient safety. Authors of 1 study demonstrated the benefit of using a central venous access device checklist to improve accuracy and reduce complications associated with malpositioned tips.^7(Vb)

Recommendation 5: Continuously Evaluate Documentation Protocols

Health care organizations are encouraged to conduct periodic audits and solicit staff feedback to maintain accurate, up-to-date vascular access documentation and promote continuous quality improvement.

Summary of Evidence

Regular evaluation of documentation protocols is essential to maintain accuracy, ensure alignment with current standards, and promote safe practices. Thate et al. emphasized how effective documentation supports collaborative decision-making and infection prevention strategies.^8(IIIb) Laan et al. revealed that failure to audit catheter-related documentation led to major underreporting, with only 1.6% of complications recorded.^5(IIIb) Field et al. found that integrating patient experiences into documentation reviews helped tailor tools to real-world needs.^2(Vb) Sherwood and Nickel reported that staff feedback in process reviews promotes a culture of safety and improves infusion therapy outcomes.^3(Va)

Recommendation 6: Postinsertion Documentation

Following VAD insertion, clinicians are encouraged to document external catheter length and trim length, when applicable, to enable detection of catheter migration and ensure safe ongoing assessment.

Summary of Evidence

Recording external and trim catheter length is critical for detecting migration and supporting safe device monitoring. Authors of a prospective study found documentation of insertion variables was highly compliant (93.3%), but removal-related data were often missing or unreliable, limiting the detection of complications.^9(IIIb) Current clinical standards also recommend capturing catheter characteristics at insertion to guide safe ongoing care.^10(IVa)

Recommendation 7: Documentation of VAD Assessment

Each vascular access assessment should be documented and include:

• justification for continued or discontinued use of the VAD,
• assessment findings (site condition, dressing integrity, patency, and securement),
• details of interventions performed (e.g., dressing changes or device adjustments), and
• any patient-reported symptoms (e.g., pain, swelling, or discomfort near the site).

Summary of Evidence

Comprehensive and structured documentation supports clinical decision-making, helps detect complications early, and improves communication across care teams. Failure to document line necessity may result in idle catheters that increase infection risk. Daily audits and EHR-based prompts have been shown to reduce central line days and associated CLABSI rates.^11(Vb) Additionally, documentation of symptoms and interventions helps prevent complications such as extravasation and medical adhesive injury. Bahl et al. also highlighted the consequences of unreliable documentation for catheter-related complications and outcomes.^{9(IIIb),12(Vb),13(Vb)}

Clinical Considerations

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Benefits

• Reduced infection risks: Routine documentation of catheter care, including securement, flushing, and dressing changes, supports early identification of complications and reduces infection risk, while ongoing monitoring for catheter migration and dislodgement ensures adherence to evidence-based infection prevention protocols.^14,15,16
• Improved workflow and standardization: Structured documentation templates and EHR-based prompts streamline clinical entries, promote consistent language among providers, and enhance EHR efficiency, reducing missed steps in catheter care documentation and improving continuity of care.^4,6,17
• Support for accreditation and regulatory compliance: Detailed documentation supports compliance with infection prevention standards and is auditable during quality inspections or legal reviews.^4,8

Risks

• Training fatigue or workflow disruption: Repeated updates to documentation protocols may require frequent training and temporarily disrupt clinical workflows.¹⁷
• Resistance to change: Staff may be reluctant to adopt new documentation templates, especially if perceived as increasing workload.^4,8
• Incomplete or inaccurate documentation: Poorly completed entries or missing data may impair clinical decision-making and hinder infection prevention efforts.¹⁴
• Overdocumentation or redundancy: Excessive or repetitive fields may obscure critical information or delay entry completion.⁴

Implementation Considerations

• Staff education and competency validation: Provide regular training on documentation standards, focusing on infection prevention, device tracking, and structured EHR templates.^6,14,17
• Tailored documentation tools and templates design: EHR templates specific to VADs, accounting for device type, patient acuity, and care setting while allowing flexibility to document adverse events such as dislodgement, infiltration, or infection.^4,6,18,19
• Measurement and feedback loops: Audit documentation for completeness, timeliness, and alignment with clinical outcomes.^4,14

Barriers to Implementation

• System limitations: EHR systems may not be optimized for vascular access documentation or lack customizable templates.¹⁹
• Staff resistance to new workflows: Clinicians may resist additional documentation burdens or prefer unstructured charting.^8,4
• Overdocumentation fatigue: Excessive fields or prompts may result in superficial compliance or bypassing critical steps.^8,4

References

1. Furniss D, Lyons I, Franklin BD, et al. Procedural and documentation variations in intravenous infusion administration: a mixed methods study of policy and practice across 16 hospital trusts in England. BMC Health Serv Res. 2018;18(1):270.
2. Field M, Tullett K, Khawaja A, Jones R, Inston NG. Quality improvement in vascular access: the role of patient-reported outcome measures. J Vasc Access. 2020;21(1):19-25.
3. Sherwood G, Nickel B. Integrating quality and safety competencies to improve outcomes: application in infusion therapy practice. J Infus Nurs. 2017;40(2):116-122.
4. Saliba P, Hornero A, Cuervo G, et al. Interventions to decrease short-term peripheral venous catheter-related bloodstream infections: impact on incidence and mortality. J Hosp Infect. 2018;100(3):e178-e186. doi:10.1016/j.jhin.2018.06.010.
5. Laan BJ, Godfried MH, Geerlings SE. Registration of catheter-related complications in adverse events reporting systems: a major underestimation of the real complication practice. J Infect Prev. 2022;23(1):11-14. doi:10.1177/17571774211012455.
6. Harrod M, Montoya A, Mody L, McGuirk H, Winter S, Chopra V. Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities. J Am Geriatr Soc. 2016;64(10):2059-2064. doi:10.1111/jgs.14341.
7. Hade AD, Beckmann LA, Basappa BK. A checklist to improve the quality of central venous catheter tip positioning. Anaesthesia. 2019;74(7):896-903. doi:10.1111/anae.14679.
8. Thate JA, Couture B, Schnock KO, Rossetti SC. Information needs and the use of documentation to support collaborative decision-making: implications for the reduction of central line-associated blood stream infections. Comput Inform Nurs. 2020;39(4):208-214.
9. Bahl A, Mielke N, Johnson S. Reliability and compliance of peripheral intravenous catheter documentation: a prospective observational study. J Vasc Access. 2024;25(1):89-93. doi:10.1177/11297298221097555.
10. Gorski LA, Lynn Hadaway F, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(Suppl 1):S1-S224. doi:10.1097/NAN.0000000000000396.
11. Beville ASM, Heipel D, Vanhoozer G, Bailey P. Reducing central line associated bloodstream infections (CLABSIs) by reducing central line days. Curr Infect Dis Rep. 2021;23(12):23. doi:10.1007/s11908-021-00767-w.
12. Whitehorn A, Sivapuram MS. Medical adhesive injury: prevention. JBI EBP Database. 2022;JBI-ES-1908-3.
13. Whitehorn A. Chemotherapy drug extravasation: prevention. JBI EBP Database. 2021;JBI-ES-24-2.
14. Wang P, He L, Yuan Q, et al. Risk factors for peripherally inserted central catheter-related venous thrombosis in adult patients with cancer. Thromb J. 2024;22(1):6.
15. Yuki I, Cammack I, Takeshi Y. Management of a malpositioned central venous catheter in the accessory hemiazygos vein. BMJ Case Rep. 2021;14(12):1-3. doi:10.1136/bcr-2021-245654.
16. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225.
17. Rhodes D, Cheng AC, McLellan S, et al. Reducing Staphylococcus aureus bloodstream infections associated with peripheral intravenous cannulae: successful implementation of a care bundle at a large Australian health service. J Hosp Infect. 2016;94(1):86-91. doi:10.1016/j.jhin.2016.05.020.
18. Spencer TR, Bardin-Spencer A. Ultrasound guidance for vascular access procedures by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2019;24(4):18-22. doi:10.2309/j.java.2019.004.002.
19. Zawadka M, La Via L, Wong A, et al. Real-time ultrasound guidance as compared with landmark technique for subclavian central venous cannulation: a systematic review and meta-analysis with trial sequential analysis. Crit Care Med. 2023;51(5):642-652. doi:10.1097/ccm.0000000000005819.

Chapter 1.7 – Data Collection

Accurate, systematic data collection is fundamental to safe and effective vascular access care. Capturing key metrics on device use, complications, and outcomes enables health care organizations to identify trends, benchmark performance, and drive continuous quality improvement.

These data are critical for monitoring adverse events such as hospital-onset bloodstream infections and for evaluating the effectiveness of interventions to reduce risk. Structured data collection also advances broader institutional goals, including regulatory compliance, patient safety, financial stewardship, and operational efficiency.

A robust framework for data collection incorporates both technical outcomes and patient experiences, supporting product evaluation, procedural benchmarking, and adaptation to evolving standards. By assigning responsibility to trained personnel and ensuring clinical oversight, organizations improve data integrity, strengthen accountability, and enable timely intervention. Well-structured systems ultimately enhance safety, optimize resource use, and improve outcomes for patients and health systems alike.

Recommendation 1: Product Evaluations Before Implementation

Before implementing new vascular access devices, organizations should conduct structured product evaluations that include data collection on device performance, patient experience, and clinical outcomes.

Summary of Evidence

Effective product evaluation requires both objective outcome data and qualitative feedback from end users and patients. Thate et al. emphasized that standardized data collection and interdisciplinary documentation are critical for identifying device-related risks and informing collaborative decision-making.^1(IIIb) Larsen et al. found that patient experiences with peripheral intravenous catheter insertion varied significantly based on inserter skill, communication, and device placement, supporting the need for human-centered evaluation during product trials.^2(IIIb) These findings reinforce the value of collecting technical and experiential real-world data before widespread device adoption.

Recommendation 2: Ongoing Evaluation of Products in Use

Facilities should implement ongoing evaluation of vascular access products currently in use to monitor complications, ensure continued effectiveness, and guide quality improvement initiatives.

Summary of Evidence

Ongoing product surveillance is essential to identify device-related complications, ensure clinical effectiveness, and capture the evolving patient and staff experience. Thate et al. highlighted the importance of integrated data collection and standardized documentation to support collaborative decision-making and identified risks related to catheter management.^1(IIIb) Larsen et al. demonstrated how patient feedback reveals critical insights that may not be captured through clinical metrics alone, such as pain, insertion site complications, and device inconvenience.^2(IIIb) These findings underscore the importance of clinical data and human experience in continuous product evaluation.

Recommendation 3: Assignment of Data Entry to Trained Personnel

Personnel with appropriate computer skills, familiarity with vascular access terminology, and demonstrated commitment to data accuracy and clinical relevance should be assigned to vascular access data entry.

Summary of Evidence

Accurate vascular access data are foundational for quality improvement and infection surveillance. Assigning this responsibility to trained personnel has improved data integrity, reduced reporting errors, and strengthened accountability.^3(IIIb) In a national survey, Chopra et al. found that vascular access specialists with formal training reported greater adherence to best practices and documentation protocols.^3(IIIb) Authors of quality improvement studies have further demonstrated that structured, multidisciplinary documentation processes lead to sustained reductions in catheter-related complications and more reliable reporting of infection rates.^{4(IIIa),5(IIIb)}

Recommendation 4: Assignment of Ongoing Data Monitoring

It is recommended that responsibility for ongoing data monitoring be assigned to personnel with relevant clinical expertise who can identify concerning trends, interpret findings in context, and initiate appropriate interventions as needed.

Summary of Evidence

Ongoing data monitoring by clinically experienced personnel enables early detection of complications, facilitates contextual interpretation of findings, and supports timely intervention. Thate et al. emphasized the need for clear and accessible documentation to support collaborative decision-making across care teams.^1(IIIb) Li et al. demonstrated how continuous surveillance and root cause analysis can drive targeted infection prevention strategies.^6(IIIa) Monitoring catheter-related outcomes, as seen in a study by McGuire and Coronado on peripheral vascular access device removal timing, can improve safety and reduce unnecessary device days.^7(IIIa)

Recommendation 5: Establish Monitoring Intervals

It is recommended that data monitoring intervals be established that support the timely detection of clinically significant trends and enable prompt response to critical changes.

Summary of Evidence

Timely and routine data monitoring supports early identification of complications and enables proactive intervention. In the Keystone ICU project, routine implementation of daily safety huddles and checklists significantly reduced catheter-related infections by fostering consistent interdisciplinary review.^8(IIIb) Similarly, Mena Lora et al. demonstrated that hospital-wide daily huddles improved device utilization practices and decreased infection rates, highlighting the value of structured, time-based monitoring.^5(IIIb)

Clinical Considerations

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Benefits

• Patient safety: Enhanced data collection supports patient safety by enabling trend analysis and facilitating adaptability to evolving institutional priorities.^6,9,10
• Adoption of a standardized dataset ensures consistent terminology and outcome definitions, reducing variability in reporting and enabling valid comparisons across studies and institutions.
• Enhanced research and quality improvement: Standardized metrics facilitate meta-analyses, increase sample size and statistical power, and support evidence synthesis to guide practice.
• Benchmarking and learning: Consistent reporting enables tracking of institutional performance, identification of best practices, and contribution to global vascular access learning systems.

Risks

• Additional resources: Increased data collection may disrupt workflows and necessitate additional resources for training and management.^6,11

Implementation Considerations

• Standardization: Use electronic health record templates to standardize data entry and ensure real-time data access for clinical teams.^1,5

Barriers to Implementation

• Resistance to change: Regular training and demonstrating the impact on patient safety can mitigate resistance.^1,6,12

References

1. Thate JA, Couture B, Schnock KO, Rossetti SC. Information needs and the use of documentation to support collaborative decision-making: implications for the reduction of central line-associated blood stream infections. Comput Inf Nurs. 2020;39(4):208-214.
2. Larsen E, Keogh S, Marsh N, Rickard C. Experiences of peripheral IV insertion in hospital: a qualitative study. Br J Nurs. 2017;26(19):S18-S25. doi:10.12968/bjon.2017.26.19.S18.
3. Chopra V, Kuhn L, Ratz D, et al. Vascular access specialist training, experience, and practice in the United States: results from the national PICC1 survey. J Infus Nurs. 2017;40(1):15-25.
4. Han J, Wan J, Cheng Y, et al. A hospital-wide reduction in central line-associated bloodstream infections through systematic quality improvement initiative and multidisciplinary teamwork. Am J Infect Control. 2019;47(11):1358-1364.
5. Mena Lora AJ, Ali M, Krill C, Spencer S, Takhsh E, Bleasdale SC. Impact of a hospital-wide huddle on device utilisation and infection rates: a community hospital’s journey to zero. J Infect Prev. 2020;21(6):228-233. doi:10.1177/1757177420939239.
6. Li X, He M, Wang H. Application of failure mode and effect analysis in managing catheter-related blood stream infection in intensive care unit. Medicine. 2017;96(51):e9339.
7. McGuire R, Coronado A. Evaluation of clinically indicated removal versus routine replacement of peripheral vascular catheters. Br J Nurs. 2020;29(2):S10-S16. doi:10.12968/bjon.2020.29.2.S10.
8. Hsu YJ, Marsteller JA. Influence of the comprehensive unit-based safety program in ICUs: evidence from the Keystone ICU project. Am J Med Qual. 2016;31(4):349-357.
9. Rammell J, Matthan J, Gray M, et al. Asynchronous unsupervised video-enhanced feedback as effective as direct expert feedback in the long-term retention of practical clinical skills: randomised trial comparing 2 feedback methods in a cohort of novice medical students. J Surg Educ. 2018;75(6):1463-1470.
10. Hade AD, Beckmann LA, Basappa BK. A checklist to improve the quality of central venous catheter tip positioning. Anaesthesia. 2019;74(7):896-903. doi:10.1111/anae.14679.
11. Civetta G, Cortesi S, Mancardi M, et al. EA-DIVA score (enhanced adult DIVA score): a new scale to predict difficult preoperative venous cannulation in adult surgical patients. J Vasc Access. 2019;20(3):281-289. doi:10.1177/1129729818804994.
12. Cooke M, Ullman AJ, Ray-Barruel G, Wallis M, Corley A, Rickard CM. Not “just” an intravenous line: consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross-sectional survey of 25 countries. PLoS ONE. 2018;13(2):e0193436.

Chapter 1.8 – Products, Bundles, & Checklists

Standardized products, insertion bundles, and procedural checklists are essential tools for improving the safety, efficiency, and consistency of vascular access care. Their use minimizes variability, supports adherence to evidence-based practice, and ensures that essential supplies and steps are not overlooked during high-risk procedures.

Preassembled kits and trays designed with evidence-based components streamline workflow, reduce contamination risk, and help prevent complications such as catheter-related bloodstream infections. When combined with structured checklists and documentation protocols, these tools reinforce procedural accuracy, enhance accountability, and sustain reliable practice across care teams.

Care bundles that incorporate elements such as skin antisepsis, maximal sterile barriers, and evidence-guided device selection are strongly associated with improved outcomes and reduced infection rates. As part of a systems-based approach, standardized products and bundles support quality improvement initiatives, align with infection prevention priorities, and optimize vascular access care across all settings.

Recommendation 1: Procedural Packs and Kits

It is recommended that health care facilities implement procedural packs and kits to enhance efficiency and consistency while also promoting adherence to proper technique.

Summary of Evidence

Standardized procedural packs have been shown to improve efficiency and reduce variation in vascular access technique. Rowley and Clare reported that using an aseptic nontouch technique (ANTT) peripheral intravenous catheter (PIVC) pack ensured all necessary materials were present, reducing setup time and supporting consistent adherence to aseptic technique.^1(IIa)^ In a mixed-methods study, researchers found that involving nurses in designing and usability testing a PIVC pack led to high satisfaction and perceived improvements in workflow and infection prevention practices.^2(Ib)^ These findings support the role of standardized kits in promoting safer and more efficient vascular access procedures.

Recommendation 2: Sterile Pack Design and Clinician Involvement

It is recommended that all procedural packs and clinical trays be designed to maintain sterility during procedures. Clinicians should also be involved in developing and evaluating these products to ensure usability, clinical relevance, and alignment with best practice guidelines.

Summary of Evidence

Procedural packs support ANTT principles, such as protecting key parts and fields, to improve adherence to infection prevention protocols and reduce contamination risk. Rowley and Clare reported that ANTT-aligned PIVC packs increased clinician compliance and procedural consistency while facilitating safe, aseptic technique.^1(IIa)^ In earlier work, they emphasized that ANTT is a critical competency for vascular access safety and that product design should explicitly support aseptic workflows.^3(Va)^ Involving clinicians in the development and usability evaluation of procedural kits ensures clinical relevance, enhances uptake, and aligns product design with evidence-based practice.

Recommendation 3: Procurement and Inventory Management

Health care organizations should consider implementing robust procurement and inventory management systems to minimize the risk of device and drug shortages, which can increase complications related to vascular access.

Summary of Evidence

Shortages of essential devices and medications are associated with increased infection risk and mechanical failure. Researchers have demonstrated that proactive inventory systems and preventive maintenance protocols help reduce these complications and ensure continuity of vascular access care.^4-6(IIIb, IIIb, IVa)^

Recommendation 4: Use of Alternative Devices and Medications

When primary vascular access devices or medications are unavailable, health care providers may consider appropriate alternative products to ensure uninterrupted patient care. Clinicians must be involved in substitution decisions to ensure clinical safety and procedural continuity.

Summary of Evidence

Moderate-quality evidence has supported the use of alternative vascular access products during periods of shortage, with clinician oversight playing a key role in ensuring safe transitions. Researchers have shown that well-chosen substitutions can maintain functionality while avoiding procedural delays or increased complications.^5,6(IIIb, IVa)^

Recommendation 5: Removal and Reporting of Expired or Defective Products

Expired or defective vascular access products should be immediately removed from patient-use areas, clearly labeled, and a detailed report submitted to the appropriate institutional, manufacturer, or regulatory authorities in accordance with facility policy.

Summary of Evidence

A substantial body of literature has supported the clinical and ethical obligation to report defective vascular access devices. Inconsistent product integrity has been linked to serious complications, including rupture, embolization, and infection. Timely removal and transparent reporting are critical for patient safety, product surveillance, and regulatory oversight.^7-9(Vb, IIIb, IIIb)^

Recommendation 6: Checklist Implementation for Vascular Access Procedures

It is recommended that health care providers implement standardized checklists for vascular access procedures to promote procedural compliance, reduce variability, and support quality improvement initiatives.

Summary of Evidence

Checklists have been shown to improve adherence to aseptic technique and reduce infection rates during central venous access device (CVAD) insertions. In a randomized intensive care unit (ICU) study, introducing an insertion checklist significantly reduced central line-associated bloodstream infections (CLABSIs).^10(IIb)^ Standardized checklist use supports procedural consistency and improves documentation accuracy, both of which are critical for infection prevention and quality assurance.^11-13(Vb, IIIb, IIIa)^ Authors of additional studies have highlighted that structured checklists assist in tracking key vascular access metrics, enabling data-driven decision-making and early identification of risk trends.^12-14(IIIb, IIIa, IIIa)^

Recommendation 7: Standardized Insertion Checklist

All CVAD insertions should be performed using a standardized insertion checklist, ideally with an independent observer, to ensure compliance with aseptic technique and maximal sterile barrier precautions.

Summary of Evidence

In a randomized ICU study, introducing an insertion checklist significantly reduced CLABSI rates by improving compliance with hygiene standards and procedural safety.^10(IIb)^ While using checklists and independent observers is mandated in some health care systems (e.g., CDC/Joint Commission in the US), it is an evidence-based best practice internationally. It should be considered a core infection prevention strategy in all settings.^10(IIb)^

Recommendation 8: Implementation of Standardized Vascular Access Care Bundles

Health care organizations must implement standardized, evidence-based care bundles for vascular access device insertion and maintenance, including both central and peripheral devices. Bundles should be designed to ensure compliance with key infection prevention practices before, during, and after procedures, reducing variability, improving outcomes, and supporting ongoing quality improvement initiatives.

Summary of Evidence

Substantial evidence has supported the use of insertion and maintenance bundles to reduce vascular access device-related infections and complications. Authors of systematic reviews and meta-analyses have demonstrated that standardized bundles significantly reduce CLABSI and PIVC-associated bacteremia rates across ICU and non-ICU settings, with reported reductions ranging from 12% to over 60%.^15-19(Vb, IIb, IIb, IIb, IIb)^

Effective bundles typically include core elements such as:

• hand hygiene,
• aseptic technique with maximal or partial sterile barriers,
• skin antisepsis with an appropriate agent and dry time,
• optimal site and device selection, and
• structured documentation and follow-up.

Authors of multiple implementation studies have also shown that incorporating checklists and team-based safety programs into bundle deployment improves fidelity and leads to better patient outcomes.^11,15,20,21^ Though variations in local protocols may exist, the consistency, structure, and monitoring enabled by standardized bundles are key to improving safety and procedural outcomes in vascular access care.^15,16,22(Vb, IIb, IIIa)^

Clinical Considerations

The following points summarize potential benefits, risks, and implementation factors identified in the literature and practice experience. They are intended to guide clinical reflection and local adaptation rather than serve as prescriptive recommendations.

Benefits

• Reduced infection risk: Bundles that include flushing protocols, securement, and chlorhexidine dressings help prevent infection and catheter complications.^11,19,23,24^
• Improved workflow and standardization: Preassembled kits streamline preparation and promote adherence to best practices by reducing procedural variability.^1,3,27^ Checklists support task completion in a consistent, stepwise manner and enhance inter-provider consistency.^28^
• Cost savings and resource optimization: Bundles reduce waste and prevent overuse of materials by including only necessary components.^1,3,27^ Procedural consistency reduces the rate of complications and catheter replacements, resulting in financial savings.^29,30^
• Improved quality improvement and surveillance: Embedded checklists and bundles support real-time monitoring and structured auditing for infection and procedural quality.^23,28^

Risks

• Upfront costs and product investment: Initial expenses may be incurred when implementing standardized packs, chlorhexidine dressings, or tunneled catheters.^1,25^
• Training burden and workflow disruption: Staff must be trained to correctly use new kits and checklists, which may temporarily reduce productivity.^1,31^

Implementation Considerations

• Staff education and competency validation: Training of clinicians in the correct use of standardized kits, product bundles, and checklists with hands-on and simulation-based learning.^11,32^