JAVA | 2026 | Supplemental Issue

Glossary of Terms

Chronic Kidney Disease (CKD) A progressive decline in kidney function that influences vascular access planning; requires vessel preservation to support future dialysis access.

Clinically Indicated Replacement A device removal and replacement strategy in which vascular access devices are removed only when clinically necessary (e.g., completion of therapy, signs of complication, or device malfunction), rather than on a fixed schedule.

Practical Note: This approach reduces unnecessary insertions and patient discomfort but requires robust monitoring systems and trained staff to ensure early recognition of complications.

Clinical Nonlicensed Personnel (CNLP) Unlicensed health care personnel who assist in vascular access care under supervision.

Compartment Syndrome A limb-threatening condition caused by increased pressure within a closed fascial compartment, leading to reduced tissue perfusion and potential ischemic injury. In vascular access, compartment syndrome may occur as a severe complication of infiltration or extravasation, particularly when large volumes or vesicant solutions enter surrounding tissue.

Practical Note: Early signs include severe pain, swelling, tightness, diminished capillary refill, and sensory changes. Immediate recognition and escalation to surgical consultation are essential to prevent permanent functional loss.

Computerized Prescriber Order Entry (CPOE) Electronic system for entering and managing medication and infusion therapy orders.

Deep Vein Thrombosis (DVT) Formation of a thrombus in the deep venous system (e.g., axillary, subclavian, brachiocephalic, femoral, iliac). DVTs are clinically significant due to their risk of extension and subsequent pulmonary embolism.

Device Compatibility The ability of a vascular access device and its adjunct components to function safely and effectively together without compromising performance or integrity.

Device Stewardship A clinical framework emphasizing the ongoing evaluation of vascular access devices to ensure necessity, appropriateness, and timely removal when no longer required. Stewardship reduces infection risk, minimizes unnecessary exposure, preserves vessel health, and promotes optimal use of vascular access resources.

Difficult Intravenous Access (DIVA) A clinical condition in which patients present challenges to successful peripheral vascular access due to anatomical, pathological, or historical factors.

Note: While DIVA is widely used in research and clinical shorthand, it should not be used in patient-facing communication due to negative connotations.

Direct-Care Clinician (DCC) A licensed health care professional who provides hands-on patient care at the point of service. This term encompasses all disciplines engaged in direct patient contact, including but not limited to nurses, respiratory therapists, and radiology technologists.

Practical Note: The term DCC is used in this guideline in place of role-specific titles (e.g., bedside nurse, frontline clinician) to recognize the multidisciplinary team members responsible for vascular access assessment, insertion, and maintenance.

Dislodgement Unintended external or internal migration of a vascular access device from its original secure position. Dislodgement may present as changes in external catheter length, securement failure, dressing disruption, or altered catheter function.

Practical Note: Tip migration or malposition is a form of internal dislodgement. Use of engineered securement devices and breakaway connectors reduces risk. Documentation of baseline external length at insertion supports early detection of displacement.

Distal In anatomy, distal means farther from the point of origin or farther from the heart. In vascular access, distal describes a location further away from central circulation, usually out toward the extremities.

Dynamic Needle Tip Positioning (DNTP) An ultrasound-guided insertion technique that emphasizes continuous visualization of the needle tip in real time as it advances toward and enters the vessel. DNTP improves accuracy, enhances safety, and reduces complications compared to static or blind approaches. Both short-axis/out-of-plane and long-axis/in-plane methods may be used, but DNTP ensures the needle tip (rather than only the shaft) is tracked throughout the procedure.

End-Stage Renal Disease (ESRD) The most advanced stage of chronic kidney disease, requiring renal replacement therapy such as dialysis or transplantation.

Engineered Securement Device (ESD) An umbrella category of securement devices designed to stabilize vascular access catheters without sutures. Types include adhesive securement devices, integrated securement devices, subcutaneous anchor securement systems, and tissue adhesives.

Ethylene Diamine Tetra-Acetic Acid (EDTA) A chelating agent used in some catheter lock solutions to disrupt biofilm and reduce catheter-related complications.

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External Length The visible catheter length measured from the skin exit site to a reference point on the catheter (commonly either the stabilization platform or the zero mark). Because many catheters have a gap of ~1 cm between the zero mark and the stabilization platform, documentation must specify which reference point was used.

Practical Note: Baseline external length should be recorded at insertion and reassessed during routine monitoring. An increase may indicate catheter migration outward; a decrease may suggest internal migration.

Extravasation The leakage of a vesicant or irritant solution from a vascular access device into surrounding tissue, with potential to cause inflammation, tissue necrosis, or long-term functional impairment. High-risk agents include vasopressors, hypertonic saline, contrast media, and many chemotherapeutic drugs.

Practical Note: Extravasation is distinguished from infiltration by the nature of the infusate. Even small volumes of vesicant leakage may result in severe injury. Immediate intervention, including drug aspiration, antidote administration when indicated, and supportive care, is required.

Flexion Zones Anatomical regions near major joints with high mobility, such as the antecubital fossa or wrist. Catheters placed in flexion zones are at increased risk for kinking, occlusion, dislodgement, and dressing disruption.

Flushing The routine instillation of preservative-free 0.9% normal saline into a vascular access device to clear residual medications, blood, or infusates. Flushing is performed before, between medications, after drug administration, after blood sampling, or at defined intervals to maintain patency.

Practical Note: Sufficient post-blood draw flushing is essential to remove residual blood, reduce clot formation, and support continued device function.

Guidewire Entrapment A complication during vascular access insertion where the guidewire becomes kinked, looped, or stuck in surrounding structures. Recognition of resistance and immediate cessation of advancement are essential to prevent vascular injury.

Gum Mastic Liquid Adhesive A resin-based liquid that forms a tacky, flexible interface to increase dressing or securement adhesion to the skin without creating a polymerized film.

Hand Hygiene (HH) The act of cleaning hands using soap and water or alcohol-based hand rub. A cornerstone of infection prevention for all vascular access care.

Hemostasis The process of stopping bleeding at a vascular access insertion or removal site through physiologic or mechanical means. Hemostasis is achieved primarily by direct pressure to compress the vessel and promote clot formation, followed by sealing of the site with an appropriate dressing or hemostatic product if needed. Achieving complete hemostasis before dressing application reduces the risk of hematoma formation and failure of dressing adhesion.

Hospital-Associated Infection (HAI) An infection acquired during healthcare delivery that was not present or incubating at admission. HAIs include catheter-related infections (e.g., central line-associated bloodstream infection, catheter-related bloodstream infection), as well as other hospital-acquired infections such as surgical site infections, ventilator-associated pneumonia, and urinary tract infections.

Practical Note: HAI is an umbrella term for surveillance and quality monitoring, not specific to bloodstream infections.

Hospital-Onset Bacteremia and Fungemia (HOB) A surveillance metric that includes all laboratory-confirmed bloodstream infections acquired during hospitalization, regardless of source. HOB captures bacteremia and fungemia events beyond vascular access, providing a broader measure of hospital-associated infection burden.

Practical Note: HOB is increasingly used alongside or in place of central line-associated bloodstream infection for hospital quality reporting because it captures a wider range of bloodstream infection events.

Hydrogel or Hydrophilic Coating Surface modifications applied to catheters to reduce friction, platelet adhesion, and fibrin sheath formation. Designed to lower the risk of thrombosis and improve catheter performance, particularly in high-risk populations.

I-DECIDED® Tool A validated decision-making framework for vascular access device assessment and management. Each element of the acronym represents a step in evaluating device necessity, function, safety, and care:

• I — Identify if a device is present.
• D — Does the patient need the device?
• E — Effective function?
• C — Complication-free?
• I — Infection prevention.
• D — Dressing and securement.
• E — Evaluate and educate.
• D — Document your decision.

The I-DECIDED tool guides clinicians in determining whether a vascular access device should remain in place, be maintained, or be removed, thereby supporting timely device removal, patient safety, and vascular preservation.

Practical Note: Although presented as an acronym, I-DECIDED functions as a structured clinical tool rather than a simple abbreviation.

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Inferior Vena Cava (IVC) The large vein that returns deoxygenated blood from the lower body to the heart. In femoral central venous access, the IVC is the appropriate target vessel for catheter tip placement.

Infiltration The inadvertent leakage of a nonvesicant solution or medication from a vascular access device into the surrounding tissue. Signs include localized swelling, pallor, coolness, discomfort, slowed infusion rate, and damp dressings.

Practical Note: Infiltration differs from extravasation because the infused solution is nonvesicant and typically causes less severe tissue damage. However, if unrecognized, infiltration can still result in pain, functional impairment, or compromised vascular access.

Injection Drug Use (IDU) Use of drugs by injection. See also: People Who Inject Drugs.

Integrated Peripheral Intravenous Catheter (Integrated PIVC) A PIVC with preattached extension tubing and stabilization features that reduce dislodgement, contamination, and mechanical complications. Associated with longer dwell times compared with nonintegrated designs.

Integrated Securement Dressing (ISD) An engineered securement device that combines a sterile adhesive dressing with a molded feature that engages the catheter’s stabilization platform. ISDs provide securement and site protection in a single device, reducing the risk of dislodgement and simplifying dressing changes. Replaced with each dressing change.

Intracavitary Electrocardiography (IC-ECG) A technique used for real-time confirmation of the central venous catheter tip position. By monitoring changes in P-wave amplitude as the catheter advances, IC-ECG identifies when the tip is at the cavoatrial junction. This method improves accuracy and may reduce reliance on post-procedural chest radiography.

Intravenous (IV) Administration of fluids, blood products, or medications directly into a vein.

In-Vessel Catheter Length The portion of a peripheral catheter that resides inside the vessel lumen. Adequate in-vessel length promotes stability, reduces infiltration and dislodgement, and supports longer dwell times. Clinical guidance suggests that, when feasible, at least two-thirds of the catheter should reside within the vessel.

Practical Note: The two-thirds rule assumes that the device length matches vessel depth. Selecting an appropriate catheter length first is essential; short catheters may remain unstable even if two-thirds of the device is intravascular.

Isopropyl Alcohol (IPA) A commonly used antiseptic agent, typically at a 70% concentration, applied to disinfect skin or device surfaces. IPA provides rapid bactericidal activity and short drying time, making it suitable for hub and needleless connector disinfection.

Licensed Independent Practitioner (LIP) A health care professional legally authorized and credentialed to independently evaluate, diagnose, prescribe, and manage patient care. LIPs may also provide hands-on care but are distinguished by their authority to write and direct orders. This group typically includes physicians, nurse practitioners, physician assistants, and other licensed providers as defined by state or national regulation.

Practical Note: In this guideline, licensed independent practitioner is used to distinguish order-writers from direct-care clinicians, recognizing that both groups may participate in vascular access care but with different scopes of responsibility.

Locking The instillation of a solution into a vascular access device lumen after final flushing, when the device is not in active use. The locking solution remains within the lumen to maintain patency and, in some cases, to provide antimicrobial, antibiofilm, or antithrombotic protection. Locking solutions should be device- and patient-specific.

Practical Note: Locking differs from flushing in that the solution remains in the lumen for an extended period. Accurate calculation of lumen volume, complete flushing before lock, and aseptic technique are essential to effectiveness and safety.

Long Peripheral Intravenous Catheter (Long-PIVC) A peripheral catheter designed for intermediate-duration therapy (1–4 weeks), placed in deeper veins than short PIVCs. Preferred term over extended dwell catheter.

Lymphatic Injury Inadvertent cannulation or trauma of a lymphatic vessel during vascular access insertion. May present with lymphatic fluid leakage, local swelling, or risk of infection.

Malposition Catheter tip location outside the intended vessel or prescribed anatomical position, occurring at insertion or due to postinsertion migration.

Maximal Sterile Barriers (MSB) A set of full sterile precautions is required for the insertion of a central vascular access device. MSBs include a sterile gown, sterile gloves, a cap, a mask, and a large sterile drape covering the patient. Their use is consistently associated with a reduction in catheter-related bloodstream infections.

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Medical Adhesive-Related Skin Injury (MARSI) Skin damage caused by medical adhesives is common at vascular access dressing and securement sites.

Medical Liquid Adhesives Medical liquid adhesive is an umbrella term encompassing tissue adhesive and gum mastic liquid adhesive, used to augment dressing or securement adherence.

Modified Seldinger Technique (MST) A variation of the Seldinger technique for vascular access insertion, involving the use of a dilator over a guidewire.

Near-Infrared (NIR) Imaging A vein visualization technology that uses NIR light to detect hemoglobin and project an image of superficial veins onto the skin surface. NIR imaging can improve vein identification, particularly in patients with difficult intravenous access.

Needle-free Connector (NC) A device affixed to the end of a vascular access catheter to enable needle-free access for infusion or aspiration.

Occlusion Partial or complete blockage of a vascular access device lumen, resulting in reduced or absent flow. Occlusions are categorized by etiology:

• Mechanical Occlusion — Positional or device-related obstruction (e.g., kinked tubing, clamp closure, tight securement, pinch-off syndrome).
• Thrombotic Occlusion — Intraluminal clot, fibrin sheath formation, or mural thrombus causing resistance to infusion or aspiration.
• Chemical Occlusion — Precipitate formation or medication incompatibility leading to blockage within the catheter.

Practical Note: Differentiating occlusion type is essential for safe and effective intervention.

Octenidine (OCT) A cationic antiseptic with broad-spectrum antimicrobial activity. In vascular access, OCT is considered a potential alternative to chlorhexidine for patients with sensitivity or skin irritation, with evidence suggesting comparable efficacy in reducing bacterial colonization.

Outpatient Parenteral Antimicrobial Therapy (OPAT) Administration of intravenous antimicrobial therapy in the outpatient setting, including at home, infusion centers, or skilled nursing facilities. OPAT allows patients to complete extended antimicrobial regimens outside the hospital while reducing inpatient stays and associated costs.

Patency The state of a vascular access device being open, unobstructed, and capable of fluid flow and aspiration as intended.

Peripheral Midline (PML) A peripheral vascular access device is inserted into the upper arm veins with the tip dwelling below the axilla. Preferred term over midline catheter.

Peripheral Intravenous Catheter (PIVC) A short peripheral catheter inserted into a superficial vein, typically for therapy for less than 7 days.

People Who Inject Drugs (PWID) A patient-centered term describing individuals who inject drugs. Preferred over injection drug use when referring to patients.

Peripherally Inserted Central Catheter (PICC) A central vascular access device inserted via peripheral veins (e.g., basilic, brachial, cephalic) with the tip terminating in a central vein.

• Tunneled, noncuffed PICC: A PICC inserted with subcutaneous tunneling but no cuff.

Peripheral Vascular Access Device (PVAD) An umbrella category that includes peripheral intravenous catheters, long peripheral intravenous catheters, peripheral midlines, and peripheral arterial catheters.

Pistoning Visible movement of a vascular access device at the insertion site, characterized by repeated retraction and advancement of the external catheter segment through the skin surface. Pistoning can occur during patient movement, inadequate securement, or dressing changes when the catheter is not secured. This motion may permit migration of skin flora along the external catheter segment into the insertion tract, thereby increasing the risk of infection. Micromovement below the threshold of visible motion may still contribute to irritation or microtrauma but cannot be reliably detected during clinical observation.

Port (see also: Totally Implanted Vascular Access Device) Colloquial term for a totally implantable venous access device. Ports are placed under the skin, typically in the chest or arm, and accessed with a non-coring needle for long-term intermittent therapy.

Povidone-Iodine (PVP-I) An iodine-based antiseptic used for skin preparation in patients with sensitivity to chlorhexidine or alcohol. PVP-I has broad antimicrobial activity but lacks the residual antiseptic effect of Chlorhexidine Gluconate (CHG). Often used as an alternative when CHG is contraindicated.

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Pressure-Rated Components Device or accessory elements (e.g., extension sets, connectors, valves) tested and labeled for maximum allowable injection or infusion pressure.

Proximal In anatomy, proximal means closer to the point of origin or to the heart. In vascular access, proximal describes a location nearer to central circulation compared with a more distal location in the same vessel.

Pulmonary Embolism (PE) An obstruction of the pulmonary arteries by thrombus, most often originating from a deep vein thrombosis. Catheter-related pulmonary emboli are included under catheter-related venous thromboembolism in research but are not tracked as a distinct category in most surveillance systems.

Practical Note: Any patient with catheter-related thrombosis who develops chest pain, dyspnea, or hypoxia should be evaluated for PE, regardless of whether the original clot was labeled superficial or deep.

Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO) A structured clinical decision-making tool for selecting vascular access insertion and exit sites. RAVESTO guides assessment of patient-specific factors such as skin integrity, infection risk, and mobility to optimize site selection and catheter care.

Routine Replacement A device removal and replacement strategy in which vascular access devices are exchanged at predetermined time intervals (e.g., every 72–96 hours for peripheral intravenous catheters), regardless of clinical indication.

Practical Note: Once considered standard practice, routine replacement has been shown in systematic reviews to provide no significant advantage over clinically indicated replacement when strong monitoring protocols are in place.

Simulation-Based Mastery Learning (SBML) A structured training approach that emphasizes deliberate practice and assessment until predefined competency standards are achieved.

Stabilization Platform A molded extension of a vascular access catheter located at the catheter hub junction, designed to rest against the skin and provide a surface for securement. The stabilization platform helps reduce catheter movement and dislodgement by allowing adhesive or subcutaneous anchor securement devices to engage the catheter securely.

Practical Note: Stabilization platforms were historically referred to as suture wings, but sutures should not be used as a securement method for vascular access devices.

Subcutaneous Anchor Securement System (SASS) A securement device that has a small subcutaneous anchor deployed beneath the skin, attached to an external base. The base engages the catheter lumen in a soft channel, providing strong and durable fixation that reduces the risk of dislodgement and extends dwell time. This device remains attached to the catheter throughout the entire therapy period.

Subcutaneous Lidocaine A local anesthetic administered by infiltration into the subcutaneous tissue prior to vascular access insertion. Commonly used in concentrations of 1%–2%, subcutaneous lidocaine provides deeper anesthesia than topical agents, particularly for central vascular access device and arterial line placement.

Subcutaneous Track Technique A method of adjusting the angle and depth of the initial needle entry during vascular access insertion to create a longer subcutaneous course before reaching the vessel. Unlike blunt tunneling, this approach uses a single skin puncture.

Superficial Vein Thrombosis (SVT) Formation of a thrombus in a superficial vein (e.g., cephalic, basilic, saphenous). SVT is generally considered lower risk for embolization than deep vein thrombosis, but in the upper extremity, superficial veins often connect directly to the deep system.

Practical Note: In vascular access, the distinction between SVT and deep vein thrombosis is often less meaningful; both can impair device function and cause complications.

Sutures A wound closure device made of sterile thread or material used to approximate tissue edges, ligate vessels, or secure surgical repairs. Sutures may be absorbable or nonabsorbable, and are selected based on tissue type, healing requirements, and procedural needs.

Practical Note: Per manufacturer instructions, sutures are not intended to secure external devices such as vascular access catheters. Engineered securement devices (sutureless securement systems) are recommended for device stabilization to reduce infection risk and prevent catheter-associated complications.

Tip Navigation Systems Technologies that provide real-time catheter guidance during insertion often integrate intracavitary electrocardiography or magnetic tracking to improve the accuracy of tip placement. These systems can reduce malposition rates and may eliminate the need for fluoroscopy or chest radiography in selected patients.

Tissue Adhesive (cyanoacrylate) An engineered securement device that polymerizes on contact with skin, forming a protective barrier. In vascular access, it may be applied at the insertion site to achieve hemostasis, reduce dressing disruption, aid in securement, and lower infection risk. Reapplied with each dressing change.

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Topical Anesthetics Medications applied to the skin surface to numb the underlying tissue. Formulations include sprays (e.g., vapocoolants) and creams (e.g., lidocaine-based). Used to reduce pain associated with venipuncture and vascular access insertion; onset and efficacy vary by formulation and concentration.

Totally Implanted Venous Access Device (TIVAD) A surgically implanted central vascular access device placed entirely under the skin, accessed via a noncoring needle. TIVAD components:

1. Portal Body (Housing or Reservoir)

   • a) The implanted chamber that sits subcutaneously, typically in the upper chest or upper arm.
   • b) Constructed from biocompatible materials such as titanium, stainless steel, or medical-grade polymer.
   • c) Houses the internal reservoir that receives infusate from the noncoring needle.

2. Septum (Self-Sealing Membrane)

   • a) A silicone or polyurethane elastomer membrane that covers the reservoir.
   • b) Designed to be punctured repeatedly by a noncoring needle without tearing or leaking.
   • c) Provides a sterile barrier between the internal chamber and the external environment.

3. Catheter

   • a) A radiopaque, flexible tube connected to the portal body, tunneled subcutaneously, and terminating in the central venous circulation (typically lower superior vena cava). Note: Some totally implanted vascular access devices are placed in the arterial system for specialized therapy.
   • b) Constructed of silicone or polyurethane; may include antimicrobial or antithrombotic coatings.
   • c) The internal lumen is continuous with the portal body, allowing infusion or withdrawal of fluids.

4. Connection Mechanism (Catheter–Portal Body Junction)

   • a) The junction securing the catheter to the portal body, usually via a compression ring, locking collar, or crimp sleeve.
   • b) Must be leakproof and pressure-rated for intended therapies.
   • c) A critical site for manufacturing integrity and risk of detachment or leakage if damaged.

Transparent Semipermeable Membrane (TSM) A dressing that allows moisture vapor transmission while maintaining a barrier to external contaminants.

Trim Length The length of a trimmable catheter that is cut at insertion to achieve correct tip position while minimizing the external segment. Trim length must be documented at insertion and confirmed at removal; discrepancies may indicate catheter fracture or embolization.

Practical Note: Not all catheters are trimmable (e.g., valve-tipped or specialized atraumatic designs). Always follow manufacturer guidance. Document trim length in addition to external length for accurate monitoring and safe removal.

Tunneled Dialysis Catheter (TDC) A tunneled central venous catheter used for dialysis access, generally considered temporary compared with arteriovenous fistulas or grafts.

Ultrasound (US) An imaging modality that uses high-frequency sound waves for real-time visualization during vascular access insertion or assessment. US enables identification of vessels, guidance of needle and catheter placement, and confirmation of catheter position. It is also used diagnostically to assess for complications such as thrombosis, stenosis, or vessel patency, and to evaluate surrounding structures. In post-insertion care, US may help identify pneumothorax, pericardial effusion, or cardiac abnormalities related to central venous access.

Ultrasound (US) Guidance The use of real-time ultrasound imaging to aid vascular access device insertion, including vein identification, puncture, and tip guidance. US guidance improves first-attempt success, reduces complications, and helps preserve vessel health by minimizing failed attempts.

Vascular Access Device (VAD) Any device inserted into a blood vessel for the purpose of delivering fluids, medications, or nutrition, or for monitoring blood pressure and other hemodynamic parameters.

• Peripheral VADs: Peripheral intravenous catheter, long-peripheral intravenous catheter, peripheral midline, peripheral arterial catheters.
• Central VADs: Peripherally inserted central catheter; centrally inserted central catheter (tunneled centrally inserted central catheter; tunneled, noncuffed centrally inserted central catheter); tunneled, noncuffed-peripherally inserted central catheter; totally implanted VAD.

Vascular Access Team (VAT) A team of specialized clinicians responsible for insertion, management, and maintenance of vascular access devices.

Vein Visualization The process of identifying suitable veins for vascular access using inspection, palpation, positioning, or technology-assisted methods. Techniques include near-infrared imaging, transillumination, ultrasound, and simple strategies such as limb dependency or moist heat. Effective vein visualization supports appropriate device selection, reduces insertion attempts, and enhances patient safety.

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Venospasm Sudden constriction of a vein in response to mechanical or chemical irritation. Venospasm may impede catheter advancement, contribute to insertion failure, or reduce flow through an indwelling catheter.

Vessel Health and Preservation (VHP) A clinical framework emphasizing early vessel assessment and selection of the least invasive device needed to preserve vascular integrity over a patient’s lifetime.

Virtual Reality (VR) A computer-generated simulation of a 3-dimensional environment that can be interacted with using special electronic equipment such as a headset. In vascular access, VR distraction has been studied as a nonpharmacologic intervention to reduce patient anxiety and perceived pain during catheter insertion.

Visual Infusion Phlebitis (VIP) Score A validated scoring tool used to assess and document signs of phlebitis at a peripheral intravenous site.

Venous Thromboembolism (VTE) A collective term that includes both deep vein thrombosis and pulmonary embolism. VTE emphasizes the risk of thrombus propagation or embolization.

Practical Note: VTE is a population and research term; clinicians often use catheter-related thrombosis or deep vein thrombosis more directly when documenting patient care.

APPENDIX A

Johns Hopkins Evidence-Based Practice Model for Nursing and Health Care Professionals — Hierarchy of Evidence Guide (Leveling)

Evidence Level — Types of Evidence

Research Evidence

Nonresearch Evidence

© 2022 Johns Hopkins Health System/Johns Hopkins School of Nursing.

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Johns Hopkins Evidence-Based Practice Model for Nursing and Health Care Professionals — Hierarchy of Evidence Guide (Quality)

Quality of the Evidence

APPENDIX B

Dressing Usage Guide for CVAD Skin Impairment Management

Dressing Selection Matrix

*Stabilize catheter with securement device/dressing **Does not provide a microbial barrier ***Assess manufacturer’s contraindications. Recommend consult wound/skin specialist and/or physician.

CVAD-Associated Skin Impairment (CASI) Algorithm

1. Assess Patient

2. Protect Skin and Provide Comfort

• Apply alcohol-free barrier film and appropriate dressing
• Consider anti-inflammatory, anti-pruritic agents and/or analgesics; cool compresses (applied on top of dressing)
• Assess irritated skin every 24 hrs; monitor for signs and symptoms of infection
  • If no improvement to sites with suspected contact dermatitis, consider short-term use of topical corticosteroid (do not apply directly on exit site)
• If no improvement within 3–7 days, consult wound/skin specialist
• Educate staff and/or patients/caregivers on proper dressing selection, atraumatic application/removal, site care
• Identify patients at risk and take precautions with site care (e.g., malnutrition, dehydration, elderly/neonates, dermatologic conditions, low/high humidity, radiation therapy, medications [chemotherapy, anti-inflammatories, including long-term corticosteroid use, anticoagulants])

Assessment Categories:

EXIT SITE INFECTION Redness, induration (hard), and/or tenderness within 2 cm of the catheter exit site; possibly with other signs and symptoms of infection, such as fever or purulent drainage at exit site, concomitant bloodstream infections.

If Exit Site Infection is Suspected:

• Culture site and draw blood cultures
• Collaborate with practitioner; may need to remove catheter
• Topical antimicrobial agent† (based on culture results) or consider non-CHG antimicrobial dressing
• If there is no resolution with topical therapy or it is accompanied by purulent drainage, start systemic antibiotics
• Consider cauterizing exuberant granulation tissue at site of long-term CVAD

†Confirm compatibility with dressing and catheter

SKIN INJURY

• Stripping: Shallow irregular lesions; shiny skin
• Tears: Partial or full thickness tension blisters

Management:

• Consider non-alcohol antiseptic agent
• If skin flap present, approximate viable skin flap edges prior to dressing application
• Control bleeding: pressure at site, alginate and/or hemostatic agent under dressing
• Apply non-alcohol barrier film and absorbent dressing

SKIN IRRITATION / CONTACT DERMATITIS Skin color change (red, dark, shiny, dull) persisting 30 min. after dressing change (often mimics shape of dressing) and/or burning, itchy skin and/or lesions (macules, papules, vesicles, bullae).

Management:

• Rule out infiltration/extravasation, thrombophlebitis and other skin conditions (e.g., eczema, impetigo)
• Identify and avoid suspected irritant:
  • Change type/concentration of cleansing solution (see Fig. 1)
  • Ensure solution and barrier film are allowed to dry fully before dressing application
  • If no resolution, change brand/type of dressing
  • Consider open application test of dressing/antiseptic solution on unaffected skin (see Fig. 2)

WEEPING/OOZING (Non-infectious) Assess color, consistency, odor, amount and location of exudate.

Fig. 1 — Reaction to CHG w/ Alcohol

Try CHG w/o alcohol
        ↓
  No improvement?
        ↓
Try Povidone Iodine
        ↓
  No improvement?
        ↓
Try sterile normal saline

Fig. 2 — Open Application Test

1. Apply product to forearm
2. Monitor for 30–60 min.
3. Reassess in 3–4 days for signs of dermatitis

Reprinted with permission from the Canadian Vascular Access Association. Broadhurst D, Moureau N, Ullman AJ; The World Congress of Vascular Access (WoCoVA) Skin Impairment Management Advisory Panel. Management of central venous access device-associated skin impairment: an evidence-based algorithm. J Wound Ostomy Continence Nurs. 2017;44(3):211-220.

APPENDIX C

I-DECIDED® — Device Assessment and Decision Tool

Always consider local policy, and consult with team & patient as required.

INDEX

A

• Adhesive enhancers, 110, 111
• Adhesive securement devices (ASD), 129
• Air embolism, 28, 30, 78, 90, 91, 93, 123, 124, 129
• Ambulatory and home care, 96
• Antimicrobial dressings, 104, 110
• Antimicrobial lock solutions, 117, 118
• Antiseptic barrier caps, 115, 119, 120, 121
• Arterial catheters, 13, 51, 52, 53, 80, 89, 95, 113, 114, 134, 136
• Aseptic non-touch technique (ANTT®), 31
  • Standard-ANTT®, 129
  • Surgical-ANTT®, 129
  • Key parts, 37, 87, 110, 129
  • Key sites, 86, 110, 129
• Assessment, 11, 13, 20, 21, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 40, 41, 42, 43, 44, 45, 46, 47, 49, 52, 56, 58, 61, 66, 69, 70, 71, 73, 74, 75, 79, 80, 81, 82, 83, 90, 91, 92, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 109, 111, 123, 124, 125, 127, 128, 130, 131, 132, 135, 136, 137
  • Tools, 11, 21, 22, 23, 27, 29, 33, 34, 37, 39, 45, 46, 47, 58, 61, 64, 73, 81, 95, 98, 100, 103, 106, 109, 124
    • CASI algorithm, 98, 109
    • CLISA score, 130
    • I-DECIDED tool, 132

B

• Behavioral, psychosocial, and environmental factors, 43
• Blood culture diversion devices, 120
• Blood sampling from VADs, 115, 117
• Bundles, vascular access, 37, 38
  • Insertion bundles, 20, 23, 37
  • Maintenance bundles, 38, 39, 88

C

• Cardiac complications, 85, 105, 106
• Catheter-associated skin injury (CASI), 109, 129
• Catheter material and design, 53
• Catheter-related thrombosis (CRT), 72, 105, 130
  • CR-DVT, 63, 130
  • CR-VTE, 41, 42, 45, 46, 47, 127, 130
  • Superficial vein thrombosis (SVT), 135
• Centrally inserted central catheter (CICC), 51, 52, 71, 95, 116, 130
• Clinically indicated replacement, 123, 131, 135
• Coagulopathy, 69, 97, 117, 123
• Complications, 3, 11, 13, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 41, 42, 43, 44, 45, 46, 47, 48, 49, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 69, 70, 71, 72, 73, 74, 75, 76, 78, 79, 80, 82, 83, 84, 85, 86, 87, 89, 90, 91, 92, 93, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 111, 112, 113, 114, 115, 116, 118, 119, 120, 121, 122, 123, 124, 125, 129, 130, 131, 133, 135, 136
  • Insertion complications, 89
    • Arterial puncture, 29, 82, 83, 90, 91, 105
    • Hematoma, 72, 73, 82, 83, 90, 91, 96, 97, 98, 103, 132
    • Lymphatic injury, 90, 92, 133
    • Pain, 5, 25, 31, 32, 33, 35, 46, 48, 75, 77, 80, 81, 82, 83, 84, 90, 92, 93, 96, 97, 98, 100, 101, 102, 103, 104, 105, 110, 111, 123, 130, 131, 133, 135, 136, 137
    • Nerve injury, 58, 67, 71, 73, 82, 90, 92
    • Venospasm, 92, 137
  • Postinsertion complications, 100
    • Bleeding, 46, 69, 71, 73, 91, 96, 97, 98, 103, 117, 123, 124, 132
    • CASI, 98, 109, 127, 129
    • CRT, 72, 73, 105, 130
    • Compartment syndrome, 60, 100, 101, 131
    • Dislodgement, 28, 29, 31, 33, 34, 44, 45, 51, 52, 53, 54, 55, 63, 71, 72, 73, 76, 89, 97, 98, 102, 103, 106, 107, 109, 110, 111, 112, 120, 121, 129, 131, 132, 133, 135
    • Extravasation, 33, 34, 52, 58, 60, 61, 66, 67, 96, 99, 100, 101, 103, 104, 106, 107, 108, 114, 122, 123, 131, 132, 133
    • Hematoma, 72, 73, 82, 83, 90, 91, 96, 97, 98, 103, 132
    • Infection, 3, 8, 9, 11, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 46, 48, 49, 51, 52, 53, 54, 55, 56, 57, 58, 59, 62, 63, 64, 65, 66, 70, 71, 72, 73, 74, 76, 86, 87, 88, 91, 92, 93, 95, 96, 97, 98, 99, 100, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 127, 129, 130, 131, 132, 133, 134, 135
    • Infiltration, 34, 51, 52, 57, 60, 61, 67, 75, 76, 80, 82, 89, 96, 97, 98, 100, 103, 104, 106, 122, 123, 131, 132, 133, 135
    • Malposition, 24, 25, 26, 28, 29, 33, 34, 41, 42, 69, 71, 72, 73, 78, 79, 80, 82, 83, 84, 85, 92, 96, 97, 98, 102, 103, 104, 105, 106, 122, 131, 133, 135
    • Migration, 30, 33, 39, 78, 79, 96, 97, 98, 99, 102, 104, 105, 106, 110, 111, 112, 122, 130, 131, 132, 133, 134
    • Occlusion, 22, 24, 28, 42, 53, 54, 55, 57, 59, 62, 63, 65, 69, 70, 71, 73, 85, 91, 98, 100, 101, 102, 107, 115, 117, 118, 119, 120, 121, 122, 123, 124, 125, 132, 134
    • Skin injury, 45, 47, 49, 69, 87, 98, 103, 106, 108, 109, 111, 113, 114, 127, 129, 134
• Contrast injection, 56, 58, 59

D

• Data collection and documentation, 32, 35, 36
• Dermatitis, 69, 109
• Device compatibility, 131
• Device stewardship, 95, 131
  • Necessity assessment, 95
  • Removal planning, 122
  • Vessel preservation, 62, 63, 69, 75, 131
• Difficult intravenous access (DIVA), 45, 75, 81, 89, 108, 131
  • Escalation, 20, 62, 66, 75, 76, 91, 97, 98, 100, 101, 102, 104, 109, 122, 131
  • Failed attempts, 45, 76, 89, 136
  • Ultrasound guidance, 25, 28, 30, 31, 34, 40, 47, 66, 72, 73, 75, 76, 77, 81, 82, 83, 85, 88, 92, 93, 98, 105, 108, 128
• Dislodgement, 28, 29, 31, 33, 34, 44, 45, 51, 52, 53, 54, 55, 63, 71, 72, 73, 76, 89, 97, 98, 102, 103, 106, 107, 109, 110, 111, 112, 120, 121, 129, 131, 132, 133, 135
• Dressing change intervals, 109
• Dressing integrity, 30, 33, 48, 54, 72, 91, 96, 98, 101, 103, 109, 110, 111, 112
• Dynamic needle tip positioning, 77, 82, 127, 131

E

• Education and competency, 26, 28, 29, 30, 34, 38, 47
• Emergency vascular access, 51
• Engineered securement devices (ESD), 110, 111
  • Adhesive securement devices (ASD), 129
  • Integrated securement dressing (ISD), 133
  • Subcutaneous anchor securement system (SASS), 109, 111, 135
  • Tissue adhesive (TA), 111
• Extravasation, 33, 34, 52, 58, 60, 61, 66, 67, 96, 99, 100, 101, 103, 104, 106, 107, 108, 114, 122, 123, 131, 132, 133

F

• Femoral access (see CICC), 41, 51, 72, 97, 103
• Fibrin sheath, 54, 98, 115, 132, 134
• Flushing, 22, 27, 30, 33, 38, 42, 53, 55, 93, 98, 100, 103, 104, 115, 116, 117, 118, 119, 124, 132, 133
• Fragile skin, 47, 103, 104, 109, 110

H

• Hand hygiene, 20, 22, 23, 38, 86, 132
• Hematoma, 72, 73, 82, 83, 90, 91, 96, 97, 98, 103, 132
• Hemostasis, 91, 123, 132, 135

I

• I-DECIDED tool, 132
• Infiltration, 34, 51, 52, 57, 60, 61, 67, 75, 76, 80, 82, 89, 96, 97, 98, 100, 103, 104, 106, 122, 123, 131, 132, 133, 135
• Infection, vascular access-related, 22
  • BSI, 3, 6, 7, 8, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 33, 34, 38, 43, 55, 57, 59, 66, 71, 72, 73, 86, 87, 95, 99, 105, 106, 107, 110, 111, 115, 117, 120, 121, 122, 123, 127, 129, 130
  • CR-BSI, 127, 129, 130
  • CLABSI, 3, 19, 20, 21, 22, 23, 25, 27, 28, 29, 33, 34, 38, 43, 57, 59, 66, 72, 95, 99, 105, 107, 120, 121, 127, 130
  • HOB, 22, 23, 45, 59, 127, 132
• Insertion site selection, 71, 73
• Interprofessional rounding, 20, 21
• Intracavitary electrocardiographic guidance (IC-ECG)
• Intraosseous, 51, 52, 53, 66, 67, 96, 127

J

• Johns Hopkins nursing evidence-based practice model (JHNEBP), 139
• Johns Hopkins evidence-based practice (JHEBP) – level of evidence, 139
• Johns Hopkins evidence-based practice (JHEBP) – quality of evidence, 140

K

• Kidney disease, 24, 41, 45, 46, 48, 52, 59, 63, 70, 105, 127, 131
  • Chronic kidney disease (CKD), 45, 52, 131
  • End-stage renal disease (ESRD), 131

L

• Lidocaine, 80, 81, 82, 83, 135, 136
• Locking solutions, 116, 117, 118, 133
• Lymphatic leak, 97, 103

M

• Malposition, 24, 25, 26, 28, 29, 33, 34, 41, 42, 69, 71, 72, 73, 78, 79, 80, 82, 83, 84, 85, 92, 96, 97, 98, 102, 103, 104, 105, 106, 122, 131, 133, 135
• Medical adhesive-related skin injury (MARSI), 45, 109
• Migration, 30, 33, 39, 78, 79, 96, 97, 98, 99, 102, 104, 105, 106, 110, 111, 112, 122, 130, 131, 132, 133, 134
• Monitoring, post-insertion, 96
  • Catheter function, 73, 76, 89, 97, 102, 105, 106, 115, 131
  • Dressing integrity, 30, 33, 48, 54, 72, 91, 96, 98, 101, 103, 109, 110, 111, 112
  • Securement, 20, 24, 25, 29, 30, 31, 33, 38, 42, 43, 44, 45, 53, 59, 65, 66, 71, 73, 83, 89, 92, 96, 97, 98, 100, 102, 103, 106, 109, 110, 111, 112, 113, 114, 127, 128, 129, 131, 132, 133, 134, 135
  • Symptoms, 33, 97, 98, 100, 102, 103, 104, 106

N

• Needle-free connectors (NC), 134
• Nerve injury, 58, 67, 71, 73, 82, 90, 92
• Near-infrared imaging (NIR), 134

O

• Occlusion, 22, 24, 28, 42, 53, 54, 55, 57, 59, 62, 63, 65, 69, 70, 71, 73, 85, 91, 98, 100, 101, 102, 107, 115, 117, 118, 119, 120, 121, 122, 123, 124, 125, 132, 134

P

• Pain management, 80, 81, 82
• Peripherally inserted central catheter (PICC), 44, 51, 52, 56, 57, 71, 74, 77, 78, 83, 116, 134
• Peripheral intravenous catheter (PIVC), 20, 25, 37, 51, 80, 116, 122, 125, 134
• Peripheral midline (PML), 51, 52, 78, 82, 116, 134
• Pistoning, 134
• Pressure injection, 58, 97, 98
• Psychosocial considerations, 43

Q

• Quality improvement, 3, 13, 14, 20, 21, 22, 23, 25, 30, 32, 33, 34, 35, 36, 37, 38, 39, 48, 49, 59, 62, 65, 108, 109, 112, 114, 115, 118, 119, 122, 124, 127, 128, 139

R

• Removal criteria, 122, 124
• Removal procedures, 124

S

• Securement, 20, 24, 25, 29, 30, 31, 33, 38, 42, 43, 44, 45, 53, 59, 65, 66, 71, 73, 83, 89, 92, 96, 97, 98, 100, 102, 103, 106, 109, 110, 111, 112, 113, 114, 127, 128, 129, 131, 132, 133, 134, 135
  • Adhesive securement devices, 131
  • Integrated securement dressing, 133
  • Subcutaneous anchor securement system, 109, 111, 112, 128, 131, 135
  • Tissue adhesive, 91, 111, 114, 128, 131, 134, 135
• Site selection, 26, 44, 61, 71, 73, 75, 90, 135
• Skin antisepsis, 23, 37, 38, 86, 87, 88, 89, 112, 114, 115
• Skin integrity, 46, 48, 71, 100, 101, 103, 104, 109, 110, 111, 112, 113, 135
• Surveillance, 20, 21, 22, 23, 25, 35, 37, 38, 39, 41, 42, 55, 58, 64, 91, 96, 97, 103, 104, 105, 123, 130, 132, 135

T

• Therapy duration, 47, 51, 58, 60, 61, 62, 63
• Tip navigation, 84, 135
• Totally implanted vascular access device (TIVAD), 134
• Tunneled-cuffed [catheters] (Tc-), 63
• Tunneled-noncuffed [catheters] (Tnc-), 51
• Tunneling, 25, 31, 40, 52, 69, 70, 71, 72, 73, 74, 80, 97, 103, 128, 130, 134, 135

U

• Ultrasound, 8, 19, 20, 25, 26, 27, 28, 29, 30, 31, 32, 34, 40, 43, 45, 47, 48, 49, 53, 57, 59, 65, 66, 67, 70, 72, 73, 74, 75, 76, 77, 78, 79, 81, 82, 83, 84, 85, 87, 88, 89, 90, 92, 93, 96, 98, 99, 102, 103, 105, 108, 121, 122, 128, 130, 131, 136
• Ultrasound guidance, 25, 28, 30, 31, 34, 40, 47, 66, 72, 73, 75, 76, 77, 81, 82, 83, 85, 88, 92, 93, 98, 105, 108, 128

V

• Vascular access devices (VADs), 22, 25, 32, 41, 46, 51, 71, 78, 95, 96, 122
  • Central vascular access devices, 13, 53, 113
  • Peripheral vascular access devices, 13, 66
• Vascular access team (VAT), 22, 136
• Vein visualization, 78, 81, 82, 91, 134, 136
• Vessel health and preservation (VHP), 137

W

• Wound care consultation, 109