2002/4 EDTNA/ERCA Journal Club Discussion Summary

The November 2002 EDTNA/ERCA Renal Care Journal Club discussed the paper entitled 'Vascular Access: A role for a renal nurse clinician'by Dee WATERHOUSE, Renal Unit, Manchester, UK

This paper was published in the EDTNA/ERCA Journal XXVIII n° 2 , April-June 2002, ISSN 1019-083X.

The paper was discussed and circulated in a group of 489 JC Members within the world.

Anyone interested in Renal Care can simply become a JC Member by subscribing for free at the Journal Club.

The paper has been actively discussed between Frankie O KANE (Ireland), Helen NOBLE (UK), Jean-Yves DE VOS (Belgium), Liz LINDLEY (UK), Maria SARAIVA (Portugal), Lee CAUBLE (USA), Amy KOCUR (USA), Elisheva MILO (Israel), Stephen CHALLINOR (Singapore), Waltraud KÜNTZLE (Germany), Ros IVISON (UK), Stanley SHALDON (Monaco), Marisa PEGORARO (Italy), Anna MARTI I MONROS (Spain), Georgia THANASA (Greece), John STOCKX (the Netherlands), Althea MAHON (UK), Bertrand BELOT (Switzerland), Hans POLASCHEGG (Austria), Eddy DE CLERCK (Belgium), Nicola THOMAS (UK) and Ronald VISSER (the Netherlands).

DISCUSSION SUMMARY:

Frankie KANE: Vascular access is the Achilles heel of haemodialysis with 25% of hospital admissions directly related to access problems. The vast majority of these admissions are related to line sepsis and patency. All of our lines are inserted by medical staff with a minimal grade of specialist. In my experience medical staff do not have an in depth training programme to put in lines of any type, merely learning on the job. Many nursing staff have talked new medical staff through the process of putting lines in and I am sure will continue to do so. For this reason I do not think it necessary for a nurse to complete a clinical MSc in order to fulfil the role of vascular access nurse. We have considered extending the role of the dialysis nurse to enable them to change non-functioning temporary lines over a guide wire to ensure a quick turnaround time as we have recognised the lack of availability of medical staff to perform these procedures in a timely manner. I think that a nurse placing tunnelled lines in the first instance may be contributing to the lack of AV fistula formations as this patient may well be seen as someone who has permanent access and is thus not a priority for fistula formation.

Helen NOBLE: I have seen our patients wait for many hours to have lines inserted/replaced. The procedure is often time-consuming and difficult and has to be fitted into a doctor' s already busy day. The distress this causes to patients and their relatives is often upsetting and anything that can be done to alleviate this must be a good thing. I would be very interested in hearing of any other initiatives that have taken place to try and resolve these problems.

Jean-Yves DE VOS: I personally can tell that with an experience in about 50 chronic HD patients in our programme in which about 30% have single lumen catheters we are successful in having a fresh line ( temporary and permanent (Tesio)) within less than 15 minutes. All fresh lines are placed by the nephrologist in the dialysis ward except sometimes by the vascular surgeon in the operation theatre only taking maximum few hours waiting time. Catheters needing replacement ( on a regular basis and on demand ) are performed with the Seldinger wire technique by the dialysis nurses while the nephrologist is in-house! I believe it is a question of having sufficient staff in-house at all time. I just wonder if a nurse is placing a fresh catheter whatever type, is this act legally covered? At least it is not according to nursing acts allowed by law in Belgium. Do nurses in the UK ( or elsewhere ) need to have a special insurance? Who is to pay for this?

Liz LINDLEY (UK): I wonder if the paper from Dee and the comments from Frankie and Helen might be indicating a difference between the UK and the rest of Europe? I have always been surprised that the placing of vascular access ( fistulae as well as catheters ) in many UK hospitals is carried out by inexperienced doctors. In these circumstances, a specialist nurse who is able to respond quickly and has a continually growing experience in placing catheters can make a huge difference to the service provided for patients. Is access placement handled differently in other countries?

Frankie O'KANE: The practise of inexperienced doctors placing vascular access catheters in the UK is long established. I agree with all the previous comments that nurses placing catheters are very likely to provide a better service to these patients, both in terms of waiting times and outcomes. However it is imperative that we reduce the number of catheter placements by better use of the surgical teams placing permanent AV fistulas. In Northern Ireland almost 50% of patients are treated with catheters and this has a detrimental effect on dialysis dose delivered and in-patient stays ( due to sepsis and blockage ). I know a unit employing a vascular access co-ordinator with very beneficial effects on waiting times and patient admissions. We are planning this for our unit.

Helen NOBLE: My comments following on is that although nurses are probably better at these procedures we have to be careful when moving responsibilities from doctors to nurses who are not as well paid. I think one way around this is to ensure that relevant training and new titles are given to those practicing this extended role. Another problem is that when we develop specialist roles for nurses there are usually applicants who are then taken away from the bedside. This is a problem that we have in the UK!

Maria SARAIVA: In Portugal nurses ( specialists ) are NOT allowed to build fistulae nor placing catheters. I do not think that it is a task for a nurse. Concerning the inexperienced doctors, they do not have the experience from the beginning but acquire skills when doing often. They have the knowledge in anatomy and physiology usually higher than nurses. We must realise that if there are medical problems following insertion of a catheter these may not always be resolved by nurses. The nurse can act as a doctor assistant but cannot perform the act.

Lee CAUBLE: To the best of my knowledge there are no nurses placing catheters in the US.

Amy KOCUR: This is a very salient topic, especially here in the US with much current discussion on the role and scope of advanced practice nurses. Many times I have had to wait long hours for a physician to arrive to insert a basically femoral line for emergent dialysis when I could have done it myself and had the patient on treatment much sooner. It is my opinion that an advanced practice nurse could safely handle the low-risk cases. I could see a clinical risk assessment scoring tool being developed for this purpose. Allowing specially trained nurses to place catheters in this population could avoid unnecessary and potentially dangerous patient delays in access to care.

Jean-Yves DE VOS: I believe the only right persons to place a catheter ( and fistulae ) are those having enough basic knowledge of practical medicine. You can learn anybody to become experienced but than they will be educated as a Medical Doctor and not an in between product created just because of a specific problem/need existing.

Elisheva MILO: In Israel nurses, no matter in which speciality, are NOT allowed to insert any catheters. It is not legal! It is a procedure done by medical doctors only. I agree they are not always very experienced but they have much more knowledge in anatomy and physiology and can deal with problems if occurring. We do have a vascular access co-ordinator who is a nephrology nurse. Her duty is to see that the patient will start dialysis treatment with ready to work fistulas, to see that the patients with catheters will get an AV fistula and to follow up vascular access problems in general.

Stephen CHALLINOR: I worked for a while in a UK hospital where we had a General Practitioner who came in on a Thursday simply to carry out AV fistulae creations. Needless to say they were usually well done and it was no longer a burden to the general/vascular surgeons.

Waltraud KÜNTZLE: We do have in Germany normally defined regional vascular access surgeons who should be very skilled in access surgery and who are well known/reputed regionally. Their quality is discussed between nurses. Some of the nephrologists do their own access surgery, especially after having experienced bad results from inexperienced surgeons. Central catheters are mostly placed by nephrologists in the ambulant setting, but in hospitals this could be different. The responsibility of access care is huge and the first important impact of access survival is when creating the access. This should be done only in a most careful and skilled way. Whether by a nurse or a doctor, the long-term outcome is important. In Germany so far no nurse would dare to think about a change, but it is a very interesting aspect. Skills can be developed. The dedication and interest is important for the success. Vascular access is an excellent example of quality management.

Ros IVISON: It is perfectly acceptable for Clinical Nurse specialists working in a nephrology area to be trained to perform this procedure. No fistulas, as this is a specialist surgical procedure and needs to be carried out by a surgeon. But placement of uncomplicated temporary vascular access for haemodialysis can save a lot of time and lets face it, a highly experienced nurse in her area can know as much as a doctor and with the right training there is no reason at all why this procedure cannot be carried out by nurses. In the UK specialist courses are being set-up now to allow this.

Prof. Dr. Stanley SHALDON: We live today in a legalistic world where patients or their relatives encouraged by contingency lawyers pounce on medical malpractice rather more easily than when I started to train nurses to place femoral catheters or patients to perform self puncture of AV fistulae in the 1960's. I believe that competence is not the issue. Any trained individual can place an IV catheter. The question is will that person be protected against accidental misadventure by insurance system legally in place in their environment? Nor do I believe that there is a need to have a busy vascular surgeon perform the construction of an AV fistula. I, as a humble physician, always constructed my own fistulae and still have an original AV fistula constructed in London in February 1970 working and in continuous use by a patient who punctures himself.

Marisa PEGORARO: When I heard this paper in Nice ( 2001 ) , I was pleased in one sense and worried on another. I do believe in extended nursing practice above all when it concerns with clinical setting. On the other side I live in a country ( Italy ) in which general mentality and nursing as consequences are very much different from the Anglo-Saxon approach to problems. I do believe in nursing capabilities, and I will be pleased to do the job that our colleague explained in the paper because specific and general knowledge can be achieved by nurses too. What should be cared for is in fact the legal cover/assurance in case of problems and the economical aspect: money, money to live and to perform correct upgrading. In Italy things are still far away. To my knowledge I do not even know a place in which a nurse is allocated to vascular access care as a specific task.

Anna MARTI I MONROS: One thing I am not so sure of is when the author says that by doing it we contribute to develop our role. I do not think that by doing techniques in order to reduce doctors' workload we develop as nurses. We also have a tremendous workload and in countries like the UK they do have a tremendous shortage of nurses too. In Spain, central venous catheters are placed by doctors, nephrologists in most of the cases. As far as I know we do not have a waiting list for line insertion. They are performed the day that the treatment is required. I cannot but agree more with the legal related open questions raised.

Georgia THANASA: As in most of the countries in Hellas too the placing of venous catheters is made by a doctor who in most of the cases is a nephrologist trained to do so. The law is NOT permitting a nurse to place a venous central catheter. The national nurse association ( HENNA ) has discussed the issue quite a lot and thus law is changing. We hope that propositions like nurses having special training in this issue will be a future differentiation in the law.

John STOCKX: It is very interesting to see how problems of this kind are the same all over. In the Netherlands we have/had the ' extended arm theory. Basically this meant that the nurses did everything under the authority of the nephrologists. Even if you are legally not allowed for doing the act, under this theory you were and the nephrlogist stayed responsible in the end. In a relatively new law there is a distinct difference between knowing a procedure and carrying the responsibility for the procedure. With almost 20 years of dialysis experience I know the procedure of inserting a subclavian catheter. Doing it however is something completely different. I do not even think it would enlarge my capabilities as a Renal Nurse. It would only make me to do more techniques. To take care of patients pre, during and post dialysis is however my competency.

Althea MAHON: In the UK the role of the nurse is expanding and creating diverse possibilities. However we need to be cautious. There is a danger that these new roles are created in order to fill a gap. If the problem with access is the lack of junior doctor training or number of staff, then we should focus on medical training. I commend Dee and other access nurses for their highly specialised skills, but am wary that the philosophy of nursing is that of an holistic approach, not that of a super specialised nurse.

Bertrand BELOT: In Switzerland placing central venous catheters are done by a nephrologist or a medical doctor. The only central venous catheter a nurse may insert is a long central catheter in the arm on condition they are trained for it. The doctor stays responsible. As actually we have too many doctors and too little nurses, the issue of nurses placing hemo-catheters is not raised. I think we have enough problems as nurses with more and more patients, with more and more co morbidities, to not add new workload only to have new skills or to help doctors. The biggest problem with catheters is not who inserts and where but why we use it instead of building fistulae.

Hans POLASCHEGG: Inserting catheters requires anatomical knowledge, mechanical skills and meticulous hygiene. I see however no reason why this cannot be acquired by a nurse with appropriate training. The performance of any professional largely depends on motivation and practice. A specialised nurse putting in catheters would be highly motivated because they are confronted with the results directly. EDTNA/ERCA would be the appropriate organisation to initiate a discussion with doctors about a vascular-access nurse curriculum with the goal to gain Europe-wide acceptance.

Helen NOBLE: I would be very interested to hear the view of the physicians and would gladly welcome a discussion regarding this topic within EDTNA/ERCA. As a Europe wide group that supports and educates a very large group of nurses, I believe we should be striving to streamline our practice.

Eddy DE CLERCK: In Belgium the nurses as being the ' extended arm ' of doctors was also present. A law in 1990 changed all this and put the nurse on the same level as the doctor and physiotherapist. A list was made up with what a nurse can do with and without prescription from a doctor. A lot of nurses and doctors do not know this law and so the role of ' extended arm ' lives on. Making that nurses do know the law is more important I think than teaching them things doctors get paid for. It should give them more pride in their profession knowing rights and duties.

Nicola THOMAS: There have been many questions about the legal aspects of the nurse being able to insert central lines. In the UK the Nursing and Midwifery Council has published guidelines on ' scope of practice ' . You can visit the Code of professional practice on : www.nmc-uk.org

Ronald VISSER : We have in Amsterdam a dedicated and experienced nephrologist who puts in lines and we have a special multidisciplinary vascular access team. An experienced and dedicated vascular access surgeon is important to create working fistulas in patients with bad veins. Skilled nurses are needed to cannulate difficult or bad maturing fistulas before taking the next step to implant grafts. Under the umbrella of advanced nursing practice relatively new nursing positions as Clinical Nurse Specialist and Nurse Practitioner emerge.

Hans POLASCHEGG: I think EDTNA/ERCA should put advanced nursing training on the agenda. The European Community allows free movement of professionals within the community. This requires that local regulations are harmonized which is only possible with the help of European directives or standards. EDTNA/ERCA should develop a statement internally and then submit to the European Community.

Helen NOBLE: The term Advanced Nurse Practitioner should be discussed as this would appear to be the way nursing is progressing in many countries. There is a need for a consensus across Europe!

CLOSING WORDS

I would like to thank all of you who contributed to the very dynamic discussions and all of you who followed these lively discussions. I hope you will share this information with your colleagues. I personally would like to stress we should be open to improve our skills at any time, but to take great caution within the process of evolving towards Advanced Renal Care Practitioners not to become too theoretical specialists while a patient needs still good practice !

Jean-Yves DE VOS (BELGIUM)
EDTNA/ERCA JC Manager