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Intravascular

QUARTERLY August 2026 Edition: Education and Simulation

Intravascular Intravascular

Q U AQRUT A ERT LY ERLY

Your Practice. Your Career. Your Community.

Global Disclaimer: The views and opinions expressed in the Intervascular Quarterly Newsletter are those of the authors and do not necessarily reflect the official policies or positions of the Association for Vascular Access (AVA) or any of its leaders, volunteers, employees, Protect Patients Protect • Educate Patients Clinicians • Educate • Save Clinicians Lines • Save Lines committees, networks or other groups associated with AVA. For information on this publication, please email ava@avainfo.org.

Protect Patients • Educate Clin

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IQ CONTENT THE RIPPLE EFFECT

GULF COAST VASCULAR ACCESS NETWORK

REIMAGINING VASCULAR ACCESS EDUCATION THROUGH AI & EXTENDED REALITY

TRANSFORMING CLABSI OUTCOMES WITH 15 PREDICTIVE ANALYTICS & PROACTIVE ROUNDING CASE STORY – VESICANT ADMINISTRATION

MIDLINE OPTIMIZATION: QUANTIFYING THE 5-YEAR…UGPIV GUIDANCE PROTOCOL

CASE STORY – NEONATAL PICC WITH BREAKAWAY DEVICE

FROM POOL NOODLES TO PATIENTS

EXPANDING APHERESIS CAPABILITY THROUGH USG PERIPHERAL CANNULATION TRAINING

MASSACHUSETTS ASSOCIATION VASCULAR ACCESS NETWORK

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THE RIPPLE EFFECT LORI KACZMAREK, MSN, RN, VA-BC™ AVA PRESIDENT

A couple of weeks ago, I was reminded that we rarely see the full impact of the work we do. A colleague was attending a routine meeting with a vascular access team in another state as part of his job. During the conversation, he happened to mention my name. One of the vascular access nurses looked up and said, “Lori taught me everything I know about vascular access.” When he shared that story with me later, it was the highlight of my week. Now, I have to set the record straight. Teresa gives me far more credit than I deserve. I certainly didn’t teach her everything she knows. What I did have the privilege of doing was recognizing her passion for vascular access early in her career, encouraging her to pursue it, and watching her grow into an exceptional clinician and leader. That unexpected conversation reminded me of something we often forget. We rarely get to see where our influence goes once it leaves us. A lesson shared, a word of encouragement, or the confidence we help build in someone else can travel farther than we ever imagine. It was a ripple.

Every day, AVA members create those same ripples. We teach a new technique, help a colleague through a difficult case, mentor a novice clinician, comfort an anxious patient, or ask a question that challenges us to think differently. These moments may seem ordinary, but their impact extends well beyond the room where they happen. A successful vascular access procedure may spare a patient pain and anxiety. A conversation with a colleague may change the way they practice for years to come. When we share knowledge and embrace new evidence, we improve care for patients we may never meet. That is the remarkable power of our profession. As President of the Association for Vascular Access, I’ve had the privilege of seeing these ripples throughout our organization. They are reflected in the volunteers who generously give their time, the educators who inspire curiosity, the researchers who expand our evidence base, and the clinicians who are committed to providing the safest possible care every day.

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Together, those individual efforts become something much larger—a community united by a common purpose. In just a few months, many of us will gather for the AVA Scientific Meeting. While continuing education is an important reason to attend, I believe the greatest value of the meeting is the opportunity to learn from one another. Every presentation represents knowledge someone chose to share. Every hallway conversation has the potential to spark a new idea. A chance introduction can become a mentorship, a collaboration, or a lifelong professional friendship. The meeting doesn’t end when we head home.

The ideas you bring back influence your team. The evidence you share shapes practice. The confidence you gain empowers you to advocate for your patients. Those ripples continue through every organization represented at the meeting and ultimately reach the people who matter most.

One of AVA’s greatest strengths has always been its willingness to share knowledge. Our association is built on clinicians who believe that when one of us learns, all of us become better. That spirit of collaboration has advanced our profession for decades, and it continues because members like you are willing to invest in one another. As I reflected on Teresa’s words, I realized the story wasn’t about me. It was about what happens when someone invests in another person. Teresa has undoubtedly mentored clinicians of her own, who in turn will mentor others. The ripple continues, reaching patients and colleagues I’ll never meet. That’s the legacy of our profession. Thank you for the difference you make every day, for your patients, your colleagues, and our profession. Thank you for creating ripples that continue long after you’ve left the room. I look forward to seeing many of you at this year’s AVA Scientific Meeting.

Whether this is your first Scientific Meeting or your twentieth, I encourage you to participate fully. Introduce yourself to someone new. Ask questions. Share your experiences. Listen with curiosity. You never know which conversation may become the ripple that changes someone’s practice, or your own.

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Lori Kaczmarek, MSN, RN, VA-BCTM

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Investing in Education, Leadership, and Connection: GulfVAN Opportunities for Members The Florida Gulf Coast Vascular Access Network (GulfVAN) remains committed to supporting the professional development of vascular access clinicians throughout our region. This summer, GulfVAN members have two exciting opportunities to expand their knowledge, connect with colleagues, and bring valuable information back to their organizations: the GulfVAN AVASM26 Scholarship and our upcoming in-person educational meeting in Tampa.

GULFVAN SCHOLARSHIP OPPORTUNITY FOR AVASM26 Have you been hoping to attend the Association for Vascular Access Annual Scientific Meeting but need financial assistance? GulfVAN is pleased to offer scholarships to help eligible members attend AVASM26, taking place October 2–4, 2026, in Grapevine, Texas, with pre-meeting activities beginning October 1.

AVA’s Annual Scientific Meeting offers vascular access professionals an opportunity to learn from nationally recognized experts, explore emerging evidence and innovations, and connect with colleagues from across the country. Attendees return to their organizations with new ideas, practical strategies, and renewed inspiration to improve vascular access practices and patient outcomes.

Click here to learn more about GulVAN

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JOIN US FOR OUR AUGUST EDUCATIONAL MEETING GulfVAN will also host an in-person educational meeting on Wednesday, August 26, 2026, from 6:00 to 8:00 p.m. at the St. Joseph’s Hospital Main Medical Arts Building, located at 3001 West Dr. Martin Luther King Jr. Boulevard in Tampa, Florida. Tammy Johnson, RN, BS, CPM, will present: “Diagnostic Stewardship’s Significant Impact on Hospital-Onset Bacteremia/Fungemia Rates and Patient Quality Outcomes.” The presentation will explore the development and planned implementation of the hospital-onset bacteremia and fungemia measure, commonly referred to as HOB. Participants will examine the importance of diagnostic stewardship, the preventability of false-positive HOB events, and the role of blood culture contamination. The program will also address the clinical, financial, and public health consequences associated with diagnostic errors and contaminated blood cultures. Participants will receive 1.0 continuing education contact hour. The meeting is sponsored by Magnolia Medical Technologies and Avanos Medical. Registration is available through the GulfVAN website. Whether through a GulfVAN scholarship to AVASM26 or participation in our August educational program, members are encouraged to take advantage of these opportunities to learn, connect, and lead. Together, we can continue strengthening vascular access practice and advancing the quality and safety of patient care throughout Florida and beyond.

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REIMAGINING VASCULAR ACCESS EDUCATION THROUGH AI AND EXTENDED REALITY DAGOBERTO SALINAS If you’ve spent any time in healthcare, you’ve probably heard the old training mantra: “See one, do one, teach one.” After joining the U.S. Navy at 17, I heard it often. For decades, it shaped how clinicians learned procedural skills. But today, many educators question whether that model is sufficient for the complexity of modern healthcare (Kearney et al., 2025; Lackey & Abaza, 2024). It wasn’t until I learned to place PICC lines that I understood why.

Like many clinicians, I eventually became proficient. But the journey involved small mistakes, unexpected complications, and learning to troubleshoot in real time, on real patients. Looking back, the gap between classroom knowledge and independent practice was simply too wide. I understood the procedure, but I lacked the confidence that only deliberate practice can provide. I remember thinking, there has to be a better way. Today’s patients are older, sicker, and often have compromised vascular anatomy. Clinicians are expected to achieve first-stick success while minimizing complications, yet procedural education still relies heavily on apprenticeship and unpredictable clinical opportunities. Simulation has improved patient safety, but traditional simulation labs often depend on instructor availability, standardized scenarios, and subjective feedback, making individualized, scalable learning difficult (Motavalli & Nestel, 2016). Everything changed for me in 2022 while serving as a Navy Hospital Corpsman instructor at Navy Medicine Training Support Center, San Antonio, TX. I had the privilege to mentor a pilot study that aimed to explore the effectiveness of immersive virtual reality (VR) in battlefield medical training. What impressed me wasn’t the technology itself, it was the learning experience. Hospital corpsman students could practice battlefield care protocols repeatedly, receive immediate feedback, and make mistakes in a completely safe environment. My first thought was simple: If this works for trauma training, why couldn’t we adopt this technology to advance vascular access education?

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That question became the foundation for CLINSPEC Solutions. The name itself reflects my roots as a Clinical Nurse Specialist (CNS), an advanced practice nurse whose role centers on translating research into practice, improving systems of care, and advancing evidence-based practice. From the very beginning, the vision wasn’t to build technology for technology’s sake, but to create practical, evidence-informed solutions that could help clinicians deliver safer patient care. Rather than build another simulation product, our team set out to create an intelligent ecosystem that prepares clinicians before they ever touch a patient. Using a backward design philosophy, we asked one fundamental question: What should clinicians know, think, and be able to do before independently performing vascular access? The learning journey begins with foundational knowledge through online education and the Virtual Institute for Vascular Access (VIVA), where learners build anatomy knowledge, ultrasound interpretation, and clinical reasoning using immersive three-dimensional learning. Structured cognitive scaffolding has been shown to improve engagement, retention, and knowledge transfer (Doo et al., 2020).

Next comes communication. Through AI-powered patient conversations, learners practice obtaining informed consent, explaining procedures, answering difficult questions, and building trust before those conversations happen in the clinical environment. This approach promotes self-directed learning while helping clinicians develop AI literacy for future practice (Aulakh et al., 2025; Hoelscher & Pugh, 2025).

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Learners then enter immersive VR, where they repeatedly perform procedures without consuming hospital resources or placing patients at risk. Emerging evidence suggests immersive VR significantly enhances clinical competence and procedural confidence (Bradley et al., 2025; Jallad & Işık, 2025). The final transition combines mixed reality with physical ultrasound task trainers before culminating in cadaver-based training at the H.I.S. Centre in San Antonio. By blending digital guidance with authentic tactile experience, learners bridge the gap between simulation and real-world patient care (Ncube et al., 2025).

Although the idea began with a single question, this ecosystem is the result of an extraordinary team. Clinicians, researchers, curriculum designers, instructional designers, software engineers, simulation specialists, and extended reality (XR) experts have come together around one shared mission: preparing clinicians to deliver safer, more confident patient care. I am not an advocate for AI or XR – virtual, augmented, and mixed reality – replacing experienced educators or clinical mentors. Instead, I believe these technologies can amplify their impact. By moving the inevitable learning curve into intelligent, immersive environments – where mistakes become lessons instead of patient risks – we can better prepare clinicians before they arrive at the bedside.

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References Aulakh, J., Wahab, H., Richards, C., Bidaisee, S., & Ramdass, P. V. A. K. (2025). Self-directed learning versus traditional didactic learning in undergraduate medical education: A systematic review and meta-analysis. BMC Medical Education, 25(1), 70. https://doi.org/10.1186/s12909-024-06449-0 Bradley, C. S., Loomis, A., DiClemente, L., Flaten, C., Rahman, S., Muehlbauer, M. K., Johnson, K., Mathiason, M., & Aebersold, M. (2025). Enhancing nursing competence and knowledge: Evaluating the impact of immersive virtual reality in nursing education. Journal of Nursing Regulation, 16(1), 2–9. https://doi.org/10.1016/j.jnr.2025.04.003 Doo, M. Y., Bonk, C. J., & Heo, H. (2020). A meta-analysis of scaffolding effects in online learning in higher education. The International Review of Research in Open and Distributed Learning, 21(3), 60–80. https://doi.org/10.19173/irrodl.v21i3.4638 Hoelscher, S. H., & Pugh, A. (2025). N.U.R.S.E.S. embracing artificial intelligence: A guide to artificial intelligence literacy for the nursing profession. Nursing Outlook, 73(4), 102466. https://doi.org/10.1016/j.outlook.2025.102466 Jallad, S. T., & Işık, B. (2025). The effectiveness of immersive virtual reality simulation as an innovative learning strategy for acquisition of clinical skills in nursing education: Experimental design. Games for Health Journal, 14(2), 110–118. https://doi.org/10.1089/g4h.2023.0139 Kearney, G. P., Gardiner, N., Carr, D., Kelly, M., & Gormley, G. J. (2025). See one, do one, teach one: Other professionals don’t accept this, so why should the medical profession? BMJ, 389, r432. https://doi.org/10.1136/bmj.r432 Lackey, T. G., & Abaza, M. M. (2024). Is “See One, Do One, Teach One” the best way to learn procedures? The Laryngoscope, 134(1), 1. https://doi.org/10.1002/lary.30853 Motavalli, A., & Nestel, D. (2016). Complexity in simulation-based education: Exploring the role of hindsight bias. Advances in Simulation, 1(1), 3. https://doi.org/10.1186/s41077-015-0005-7 Ncube, E., Ndlovu, B., & Maguraushe, K. (2025). Spatial computing: Towards a virtual reality and augmented reality framework in healthcare. In A. Abraham (Ed.), Smart Computing and Informatics (pp. 310–322). Springer Nature Switzerland. https://doi.org/10.1007/978-3-032-08243-5_28

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TRANSFORMING CLABSI OUTCOMES WITH PREDICTIVE ANALYTICS & PROACTIVE ROUNDING: A Collaborative Approach to Reduce Pediatric Infections JULIANNA STAUB Rising pediatric CLABSI rates demand more than incremental change—they require innovative, data-driven solutions that translate insight into immediate action at the bedside. This session offers a compelling look at how one institution successfully reimagined CLABSI prevention through the integration of predictive analytics, structured high-risk rounding, and multidisciplinary collaboration. At the heart of this work is a practical, scalable model that leverages daily CLABSI risk scoring to identify patients most at risk and prioritize interventions where they matter most. Attendees will see how predictive data can be seamlessly embedded into pediatric workflows, empowering Vascular Access Teams and frontline staff to move from reactive to proactive care. The session outlines a tiered rounding framework that pairs focused Tier 1 bedside assessments with dynamic Tier 2 multidisciplinary huddles—ensuring that modifiable risk factors are quickly recognized and addressed. What makes this work especially compelling is its emphasis on collaboration and shared accountability across multiple disciplinary teams. Integration of support from virtual nursing and engagement from families improves adherence to central line maintenance best practices and extends CLABSI prevention beyond the care team alone. Results demonstrate meaningful impact, with a significant reduction in our CLABSI rate. Beyond outcomes, this session offers attendees actionable strategies for implementation and sustainment. Presenters will share lessons learned from PDSA-driven implementation, including strategies to navigate human factors, overcome resistance to change, and sustain improvements through CLABSI Champion programs and standardized workflows. This is a can’t-miss opportunity for anyone wanting to gain actionable tools and replicable strategies that bridge predictive analytics and clinical practice. If you are looking to elevate your CLABSI prevention efforts and drive meaningful, measurable outcomes at the bedside, this session will provide the roadmap.

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CASE STORY Situation

Please upload any images or other items you want included. Please note TM Submitted by Joe Feierstein BSN, RN, the vascular that youVA-BC must use de-identified images or image-availability access team charge nurse at a level one trauma center with in written consent from the patient.

Wisconsin.

23 yo Male with history of DVT and AML, Admitted for acute respiratory failure secondary to MRSA pneumonia.

Background PICC ordered for vesicant administration and critical access. Triple lumen five french valved PICC placed by the vascular access team to right basilic vein confirmed by ECG. fortyfour days post insertion chest X-ray showed a secondary malposition of the line now flipped and directed into the left internal jugular (IJ) vein.

Assessment 16

Secondary malposition likely due to changes in intravascular pressure from excessive coughing. Ultrasound used to assess the line in the left IJ.

Intervention Line patency confirmed in all lumens. each lumen was simultaneously flushed with a high-pressure injection of 10cc’s of normal saline. While the line was flushed the view of the catheter tip in the IJ was maintained. the highpressure injection was visualized as turbulent flow within the vessel. post intervention the catheter tip was no longer visualized in the IJ.

Outcomes A post intervention chest X-ray confirmed PICC tip now at the cavo-atrial junction

Conclusions

Your Name

Joe Feierstein

Your Email

feiersteinjoe@outlook.com

Alternative interventions included line replacement or rewire both place this patient at increased (414) 828-7823 Your Phone Number risk for infection. Use of ultrasound to assess the presence of the PICC line in the IJ or contralateral brachiocephalic or subclavian vein pre and post power flush assists monitoring for success of the procedure. This practice reduces the need for repeated radiation exposure to assess for PICC tip positioning.

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THE JOURNAL OF THE

Association for Vascular Access We invite you to submit original manuscripts that may improve patient outcomes and our understanding of the vascular access specialists’ role in the healthcare system. Manuscripts could include: • Clinical Practice • Patient Education • Clinician Education • Promoting & Sustaining Change • Vascular Access Research • Legal perspectives • Financial Considerations • Anything to move AVA’s mission forward. For complete instructions, go to Information for Authors at www.avajournal.com If you would like some mentoring help, email AVAFoundation@avainfo. org. The AVA Foundation board can match you with free mentoring for AVA members on research and publication. If you have general questions or don’t know where to start, contact the JAVA editor at: javaeditor@avainfo.org.

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MIDLINE OPTIMIZATION: QUANTIFYING THE FIVE-YEAR CLINICAL, OPERATIONAL, AND FINANCIAL IMPACT OF A VASCULAR ACCESS TEAM UGPIV GUIDANCE PROTOCOL (2021–2025) JONA CAPARAS, MSN, RN, VA-BCTM CYNTHIA VALCORZA, BSN, RN, VA-BCTM 18

ABSTRACT Background: Appropriate vascular access device selection is essential for preserving vessel health, improving patient outcomes, and reducing unnecessary healthcare costs. Midline catheters are valuable devices when clinically indicated; however, inappropriate utilization may consume upper-arm veins needed for future vascular access and expose patients to unnecessary procedures. A Vascular Access Team (VAT)-led ultrasound-guided peripheral intravenous (UGPIV) guidance protocol was implemented to promote objective assessment and reduce unnecessary midline placement. Methods: A retrospective quality improvement analysis was conducted from 2021 through 2025. All midline orders underwent VAT review using standardized assessment criteria. When appropriate, UGPIV placement was recommended instead of midline insertion. Data regarding midline orders, avoided placements, alternative device utilization, and supply cost savings were analyzed. Results: During the five-year period, 4,829 midline orders were reviewed. A total of 2,965 midline placements were avoided, representing a 61.4% avoidance rate. Of the avoided midlines, 2,372 patients (80%) received a UGPIV, while 593 patients (20%) maintained a functional peripheral intravenous catheter. The initiative generated an estimated net supply cost savings of $840,708.59.

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Conclusion: A standardized VAT UGPIV guidance protocol significantly reduced unnecessary midline utilization, preserved upper-arm vasculature, standardized device selection, and produced substantial cost savings. These findings support broader adoption of UGPIV-first assessment strategies consistent with contemporary infusion therapy and vessel preservation principles. Keywords: Midline catheter, UGPIV, ultrasound-guided peripheral intravenous catheter, vessel health preservation, vascular access team, difficult intravenous access, quality improvement.

INTRODUCTION Vascular access device selection is a fundamental component of safe and effective infusion therapy. The chosen device should meet clinical needs while minimizing complications and preserving future vascular access options. The Vessel Health and Preservation (VHP) model emphasizes selecting the least invasive device capable of safely delivering prescribed therapy while protecting venous resources over the patient’s lifetime (Moureau et al., 2012). Midline catheters serve an important role for patients requiring intermediate-duration intravenous therapy or those with difficult vascular access. However, inappropriate use may unnecessarily consume upper-arm veins, limit future access opportunities and potentially increase procedural risks and healthcare costs. Recent infusion practice standards emphasize thorough assessment and device selection based on therapy requirements, vascular anatomy, expected duration of treatment, and patient-specific characteristics rather than convenience or historical practice patterns. The availability of ultrasound-guided peripheral intravenous (UGPIV) technology has transformed the management of patients with difficult intravenous access (DIVA). Numerous studies have demonstrated that UGPIV insertion improves cannulation success rates and decreases the need for escalation to more invasive vascular access devices. Consequently, a UGPIV-first approach may reduce unnecessary midline utilization while maintaining reliable vascular access. At our institution, variability in midline ordering practices and the potential influence of implicit bias were identified as opportunities for improvement. To address these concerns, a standardized Vascular Access Team (VAT) UGPIV Guidance Protocol was implemented. The purpose of this quality improvement initiative was to evaluate the clinical, operational, and financial impact of this protocol over a five-year period.

BACKGROUND The decision to place a midline catheter is often influenced by factors beyond objective clinical assessment. Patients with a history of difficult vascular access may receive automatic requests for midline placement despite having suitable peripheral vasculature that could support UGPIV placement. Reliance on historical assumptions rather than current assessment can contribute to device overutilization and unnecessary consumption of valuable vascular resources.

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Vascular access stewardship principles support ongoing evaluation of whether the least invasive and most appropriate device is being utilized. Preserving upper-arm vasculature is particularly important because these veins may be needed for future procedures, long-term intravenous therapies, dialysis access planning, or other vascular access requirements. Recognizing these challenges, the institution developed and implemented a structured algorithm requiring VAT assessment of all midline requests. The protocol reinforced objective clinical decision-making and encouraged the use of UGPIVs whenever clinically appropriate.

METHODS Design This project was conducted as a retrospective quality improvement study evaluating vascular access practices from January 2021 through December 2025. Data were extracted from electronic health records and vascular access documentation systems. Intervention The intervention consisted of a standardized VAT UGPIV Guidance Protocol with the following components:

• Review of all midline placement orders by a vascular access specialist • Objective assessment of vascular access needs and current vessel condition. • Reinforcement of evidence-based device selection criteria. • Educational efforts to reduce implicit bias and variability in ordering practices. • Recommendation for UGPIV placement when clinically appropriate

OUTCOME MEASURES Primary outcome measures included:

• Total midline catheter orders. • Number of avoided midline placements. • Utilization of UGPIVs as an alternative device. • Estimated supply cost savings associated with avoided midline placements.

RESULTS Between 2021 and 2025, a total of 4,829 midline catheter orders were reviewed through the VAT protocol. Of these, 2,965 midline placements were avoided, yielding an overall avoidance rate of 61.4%. Among the avoided midline cases:

• 2,372 patients (80%) successfully received ultrasound-guided peripheral intravenous catheters. • 593 patients (20%) were found to have functioning peripheral intravenous catheters and therefore required no escalation of vascular access.

• The initiative generated an estimated total net supply cost savings of $840,708.59 during the five-year study period. Additionally, the reduction in unnecessary midline placement preserved upper-arm vessels and reduced utilization of more expensive vascular access devices.

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KEY OUTCOMES Measure

Result

Total Midline Orders

4,829

Midlines Avoided

2,965

Midline Avoidance Rate

61.4%

UGPIVs Inserted

2,372

Functional PIVs Maintained

593

Total Supply Cost Savings

$840,708.59

Data derived from institutional quality improvement records.

DISCUSSION The implementation of a standardized VAT UGPIV Guidance Protocol resulted in a substantial reduction in unnecessary midline utilization. More than six out of every ten ordered midlines were avoided through objective vascular assessment and alternative access strategies. These findings demonstrate the value of vascular access stewardship and support the role of specialized vascular access teams in optimizing device selection. The results align with the 2024 Infusion Therapy Standards of Practice, which recommend selecting the most appropriate vascular access device based on clinical need, therapy duration, medication characteristics, vessel health, and patient-specific considerations rather than convenience or historical practice patterns (Nickel et al., 2024). The successful use of UGPIVs in 80% of avoided midline cases is consistent with existing literature demonstrating improved vascular access success among patients with difficult intravenous access when ultrasound guidance is employed (Bahl et al., 2016; Egan et al., 2013). By using UGPIVs as a first-line intervention when appropriate, healthcare organizations may avoid unnecessary escalation to more invasive devices while maintaining reliable venous access. An additional strength of the protocol was its emphasis on reducing variability in practice and addressing implicit bias. Device selection based on objective criteria ensures consistency among providers and aligns with the Vessel Health and Preservation framework, which advocates preservation of venous resources throughout the continuum of care (Moureau et al., 2012). Financial outcomes were equally notable. The protocol generated more than $840,000 in supply cost savings over the study period. While cost reduction is important, the preservation of upperarm vasculature may represent the most significant long-term benefit, support future vascular access needs, and reduce unnecessary device-related interventions.

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CLINICAL IMPLICATIONS Healthcare organizations seeking to improve vascular access outcomes should consider implementing standardized review processes for midline placement requests. Key elements include:

• Mandatory VAT assessment of midline orders. • Objective device-selection criteria. • UGPIV-first strategies for appropriate DIVA patients. • Education targets implicit bias and practice variation. • Ongoing monitoring of vascular access utilization and outcomes. The findings suggest that UGPIV-first protocols can improve vascular access stewardship while simultaneously enhancing patient care, preserving vessel health, and reducing healthcare expenditures.

LIMITATIONS This project was conducted as a retrospective quality improvement initiative within a single healthcare organization. Outcome measures focused primarily on utilization and supply cost metrics. Additional studies are needed to evaluate patient-centered outcomes, insertion-related complications, dwell times, escalation rates, labor cost savings, and infection-related outcomes.

CONCLUSION 22

The VAT UGPIV Guidance Protocol demonstrated a significant positive impact on vascular access practice between 2021 and 2025. Through standardized review and objective assessment, 2,965 midline placements were avoided, representing a 61.4% reduction in unnecessary utilization. Most avoided cases were successfully managed using UGPIVs, resulting in preservation of upper-arm vasculature and $840,708.59 in supply cost savings. These findings support a UGPIV-first approach and reinforce the importance of evidence-based vascular access stewardship consistent with the principles of Vessel Health and Preservation and the Infusion Therapy Standards of Practice.

References Bahl, A., Pandurangadu, A. V., Tucker, J., & Bagan, M. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access emergency department patients. Journal of Emergency Nursing, 42(2), 127–133. Egan, G., Healy, D., O’Neill, H., Clarke-Moloney, M., Grace, P. A., & Walsh, S. R. (2013). Ultrasound guidance for difficult peripheral venous access: Systematic review and meta-analysis. Emergency Medicine Journal, 30(7), 521–526. Helm, R. E., Klausner, J. D., Klemperer, J. D., Flint, L. M., & Huang, E. (2015). Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing, 38(3), 189–203. Moureau, N., Trick, N., Nifong, T., Perry, C., Kelley, C., Carrico, R., Drewes, T., Harvill, M., Roth, A., & Schmid, V. (2012). Vessel Health and Preservation (Part 1): A new evidence-based approach to vascular access selection and management. Journal of Vascular Access, 13(3), 351–356. Nickel, B., Gorski, L., Kleidon, T., et al. (2024). Infusion Therapy Standards of Practice. Journal of Infusion Nursing, 47(1S Suppl 1), S1–S285.

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CASE STORY KATHY GRIESER Situation A 27-day-old female neonate required central venous access for six-plus weeks of intravenous antibiotic therapy for bacterial meningitis. A peripherally inserted central catheter (PICC) was placed at a children’s hospital in Texas, with a breakaway device applied to the line as part of an institutional evaluation program.

Background

A single-lumen 1.9Fr polyurethane PICC was inserted in the left saphenous vein and secured with standarddressing and stabilization materials. The breakaway device was installed into the IV line and designed to separate automatically if a damaging pulling force was applied stopping fluid flow, triggering the infusion pump alarm, and allowing quick device replacement without needing to restart the patient’s IV. Ultrasound studies have found that pull forces of 1.8kg or more can produce catheter movement within the vessel wall.¹ The patient’s PICC remained in place for a 26-day dwell. During that time, three unintentional separation events occurred during routine caregiving: twice when IV tubing caught on a recliner chair handle while the mother held her child, and once when tension built-up on the line as one parent pushed the baby stroller while the other managed the IV pole. Saline was infusing at the time of each event.

Assessment Neonatal and pediatric patients are especially vulnerable to unintentional catheter dislodgement during ordinary caregiving activities such as holding, transfers, and stroller walks, with mechanical complications reported in roughly 8% of pediatric PICCs.² Without a safeguard, tension events like this risk transmitting damaging forces to the catheter tip, potentially causing migration, dressing disruption, occlusion, or complete loss of vascular access, complications that carry significant clinical and economic consequences including catheter replacement and interrupted therapy.³ These outcomes could also lead to possible sedation or anesthesia and added trauma for a medically fragile infant and her family.

Intervention The breakaway device was installed on the IV line and monitored through an institutional evaluation registry. Each separation event was followed by a clinical assessment of the catheter and dressing, with the separated components replaced with a new device at bedside.

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Outcomes In all three instances, the device functioned as intended: it separated at its activation threshold, stopped fluid flow, and sounded the pump alarm without transmitting force to the catheter. No infiltration, occlusion, catheter tip migration, dressing disruption, or loss of vascular access was recorded across the admission. The PICC remained functional for the full course of therapy and was removed electively at 1 treatment completion, with no unplanned replacement. The infant’s mother reported that understanding the device’s function gave her confidence in performing daily care, including diaper changes, transfers, and holding her child.

Conclusions This case suggests that breakaway device technology can help preserve catheter integrity and reduce the risk of dislodgement-related complications during routine caregiving in vulnerable neonatal and pediatric patients. Broader adoption may support fewer catheter replacements, reduced procedural risk, and improved family confidence in vascular access care.

References 1. Bahl A, Clement V, DiLoreto E, et al. Evaluating the impact of external forces on peripheral intravenous catheter movement using ultrasound: a randomized pilot study. J Vasc Access. 2025;26(1):102-108. 2. Deshwal A, Duffy M, Mac Curtain B, et al. Rates of complications amongst peripherally inserted central catheters in paediatric populations: a systematicreview and meta-analysis. Discov Med. 2024;1:article 122. 3. Moureau NL. Integrative review: complications of peripherally inserted central catheters (PICC) and midline catheters with economic analysis of potential impact of hydrophilic catheter material. Int J Nurs Health Care Res. 2022;5:1347.

AUGUST 2026 | VOLUME XIII | ISSUE 3

FROM POOL NOODLES TO PATIENTS TEACHING NEEDLE ANGLE BEFORE THE FIRST PATIENT AMBER D. WATSON, ACNPC-AG, VA-BC™ Abstract Peripheral intravenous (PIV) catheter insertion is one of the most commonly performed clinical procedures, yet novice learners often struggle with a critical step after successfully entering the vessel. Many obtain flashback but continue advancing the needle at the original insertion angle, puncturing the posterior vessel wall before the catheter can be threaded. This article describes a simple, low-cost teaching strategy that isolates this specific movement before introducing the complete IV insertion procedure. By allowing learners to master one challenging skill at a time, educators can help build confidence before progressing to higher-fidelity simulation and patient care.

EVERY EDUCATOR HAS SEEN IT Every vascular access educator has watched it happen. A novice learner successfully enters the simulated vessel, sees flashback, and smiles with excitement. Moments later, that excitement turns into frustration as the needle continues advancing at the same angle, puncturing the posterior wall before the catheter can be threaded. The learner did not fail to find the vein. They struggled with what happened after they found it. While developing my IV certification curriculum, I realized many novice learners were not struggling to locate the vessel. They could consistently obtain flashback, yet many continued advancing the needle at the original angle, resulting in puncture of the posterior vessel wall before successfully threading the catheter. I wanted to create a way to isolate and teach that single movement before introducing every other component of peripheral IV insertion. I wasn’t trying to teach learners how to start an IV. I was trying to teach them the moment that often determines whether an IV succeeds or fails. One lesson I have learned as an educator is that learners often do not need another explanation of the entire procedure. Instead, they need help mastering the one step preventing success.

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Once that barrier is removed, the remainder of the procedure often comes together much more naturally. Focusing on one movement at a time helped many of my learners experience success earlier, which appeared to increase both confidence and their willingness to continue practicing.

Building on Existing Simulation Simulation has become an important part of vascular access education. Low-cost task trainers provide opportunities for repetitive practice while reducing dependence on expensive commercial simulation equipment. Commercial simulation arms remain invaluable for teaching the complete procedure. However, I found that many novice learners benefited from first practicing one specific movement before attempting the entire skill. Rather than replacing higher-fidelity simulation, this teaching strategy serves as a bridge between basic skill development and complete procedural performance.

The Educational Strategy To address this learning challenge, I developed a simple trainer using sections of a standard pool noodle and IV tubing secured along the surface. The goal was never to recreate a realistic arm.

Instead, the trainer isolates one critical movement:

• Recognizing flashback • Lowering the insertion angle • Advancing the catheter without puncturing the posterior vessel wall By allowing learners to focus on one movement at a time, the trainer simplifies the learning process and helps them master that skill before adding the remaining steps of peripheral IV insertion. Learners receive immediate feedback, make small corrections, and repeat the movement until it becomes smooth and consistent.

From Low-Fidelity to High-Fidelity Simulation Once learners demonstrate consistent technique on the trainer, they transition to commercial simulation arms where they begin combining all aspects of peripheral IV insertion, including aseptic technique, site preparation, stabilization, catheter advancement, securement, and patient communication. Because the most difficult movement has already been practiced repeatedly, many learners approach higher-fidelity simulation with greater confidence and improved control

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Extending Learning Beyond the Classroom One unexpected benefit of this teaching method occurs after class ends. Learning IV insertion in front of peers can be intimidating. Many novice learners worry about missing the vein, slowing down the class, or making mistakes in front of others. Because the trainer is inexpensive and easy to recreate, learners are encouraged to build one of their own and continue practicing independently. This allows learners to continue practicing outside the classroom through repetition, building confidence before performing the skill on a patient. Several participants have shared that practicing at home helped reduce anxiety before performing IV insertion during clinical experiences.

Lessons Learned Although this teaching strategy has not been formally studied, several consistent themes have emerged through learner feedback and instructor observation.

• Learners report feeling more confident before progressing to commercial simulation arms. • Many appreciate being able to recreate the trainer at home for continued practice. • Repetition appears to improve the transition from flashback to catheter advancement. • Learners frequently report feeling less anxious when they have already mastered this movement before attempting the complete procedure.

While these observations are informal, they have reinforced the value of incorporating this simple exercise into my IV certification curriculum.

Practical Tips for Educators Educators interested in implementing this strategy may find the following suggestions helpful.

• Teach needle-angle control before teaching the complete procedure. • Provide immediate feedback after each attempt. • Encourage frequent repetition before progressing to simulation arms. • Have learners build and keep their own trainer. • Reinforce that confidence develops through repetition.

Educator’s Tip Have each learner build and keep their own trainer during class. Ownership encourages continued practice outside the classroom and provides an inexpensive way for learners to strengthen their technique before attempting IV insertion on patients.

Conclusion Commercial simulation arms remain an essential part of vascular access education. My goal has never been to replace them. Instead, I hope to prepare learners to use them more effectively.

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As educators, we often focus on teaching an entire procedure. Sometimes the greatest learning occurs when we slow down and isolate the single movement learners struggle with most. Confidence is built through repetition. Competence follows. Sometimes that journey begins with a pool noodle. Eventually, it leads to a patient whose experience is safer because someone took the time to teach one small movement exceptionally well.

Figure 1: Building Your Own Needle-Angle Trainer

Low-cost pool noodle trainer demonstrating materials, assembly, educational objectives, and practical tips for teaching needle-angle control before progression to higher-fidelity simulation.

References Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988-994. Lateef F. Simulation-based learning: Just like the real thing. J Emerg Trauma Shock. 2010;3(4):348-352. National League for Nursing. Caboodle Noodle 2.0: A low-cost intravenous catheter insertion simulator. INACSL Standards Committee. Healthcare Simulation Standards of Best Practice™: Simulation Design. Clin Simul Nurs.

AUGUST 2026 | VOLUME XIII | ISSUE 3

EDUCATION & SIMULATION: EXPANDING APHERESIS CAPABILITY THROUGH ULTRASOUND‑GUIDED PERIPHERAL CANNULATION TRAINING Abstract

Background: Vessel health preservation is essential for patients requiring repeated therapeutic apheresis, particularly individuals with sickle cell anaemia who frequently experience vaso‑occlusive crises. Reliance on femoral central venous catheters (CVCs) remains common but carries significant risks, discomfort, and resource burden. Ultrasound‑guided peripheral cannulation using longer‑length cannulas offers a safer, patient‑centred alternative. Aim: To evaluate the feasibility and effectiveness of a structured education and simulation‑based training programme designed to upskill apheresis nurses in ultrasound‑guided peripheral cannulation. Methods: Four experienced apheresis nurses participated in a single‑arm pilot involving didactic teaching, simulation training using innovative low‑cost phantoms, and supervised clinical practice. Data on success rates, attempts, time to cannulation, and patient satisfaction were collected prospectively. Results: Over six months, 58 supervised ultrasound‑guided cannulations were performed. Eighty‑five percent were successful on the first attempt, with only 10% requiring a second attempt. Seventy‑five percent of patients preferred ultrasound‑guided cannulation, reporting moderate to extreme comfort. Eighty percent rated the overall experience as good or excellent. Conclusion: Simulation‑enhanced education significantly improved nurse capability and reduced reliance on CVCs for apheresis. Low‑cost phantoms made from tofu and elongated balloons provided accessible, realistic training models. This pilot supports broader adoption of structured ultrasound‑guided cannulation training to expand service capacity and improve patient outcomes.

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EDUCATION & SIMULATION AS DRIVERS OF VASCULAR ACCESS INNOVATION IN APHERESIS Takeaway Upskilling apheresis nurses in ultrasound‑guided peripheral cannulation, supported by simulation and innovative low‑cost phantoms, can meaningfully reduce reliance on central venous catheters, expand service capacity, and improve patient experience. Background: Vessel Health Preservation in Apheresis Patients with chronic conditions such as sickle cell anaemia often require repeated therapeutic interventions, including red cell exchange. Vaso‑occlusive crises can occur suddenly, causing severe pain and requiring urgent access to treatment. Historically, emergency access for apheresis has relied heavily on femoral CVC insertion, a practice associated with:

• Higher infection and complication rates • Significant patient discomfort • Increased procedural time and resource use • Long‑term vessel damage Modern vascular access practice emphasises vessel health preservation, advocating for techniques that minimise trauma, reduce complications, and improve patient experience. Ultrasound‑guided peripheral cannulation using longer‑length cannulas aligns strongly with these principles. Evidence from ultrasound‑guided PIVC education (Jørgensen et al., 2021) and vascular access in therapeutic apheresis (Golsorkhi et al., 2022) reinforces the importance of structured training to ensure safe, effective practice. Aim: Building Capability and Reducing CVC Reliance Although apheresis nurses are highly skilled in superficial cannulation, many lack formal training in ultrasound‑guided techniques. This gap can lead to suboptimal outcomes and unnecessary escalation to CVC insertion. The pilot project at Imperial College Healthcare NHS Trust, led by J. Hitchcock and L. Almerol, aimed to:

• Assess the feasibility of structured ultrasound‑guided cannulation training • Evaluate its effectiveness in improving nurse performance • Explore its impact on patient experience and service capacity Methods: Education, Simulation, and Supervised Practice

AUGUST 2026 | VOLUME XIII | ISSUE 3

Training Structure The programme consisted of:

• Didactic teaching on ultrasound physics, vein identification, and cannulation principles Hands‑on simulation training using a phantom

• Supervised clinical practice with real patients Expert instruction from an experienced ultrasound‑guided cannulation practitioner Innovative Simulation: Tofu & Balloon Phantom A key innovation was the use of a low‑cost, unconventional phantom constructed from:

• Firm tofu blocks • Elongated balloons filled with gel or saline This model provided:

• Realistic tactile feedback • Clear ultrasound imaging • A reproducible, affordable alternative to commercial phantoms • Accessible practice opportunities for nurses 32

This approach aligns with the growing emphasis on simulation‑enhanced vascular access education, supporting skill acquisition without reliance on expensive equipment.

Data Collection For each cannulation attempt, the following were recorded:

• Success rate • Number of attempts • Time to successful cannulation • Patient comfort and satisfaction Descriptive statistics were used for analysis. Results: Improved Capability, Enhanced Patient Experience Over six months (from April 2023):

• 58 supervised ultrasound‑guided cannulations were performed • 85% were successful on the first attempt • Only 10% required a second attempt • 19 patients had previously required CVCs for apheresis • 75% preferred ultrasound‑guided cannulation • Most rated the procedure as moderately to extremely comfortable • 80% rated the overall experience as good or excellent These results demonstrate that structured education and simulation can rapidly improve nurse proficiency, reduce reliance on CVCs, and enhance patient satisfaction.

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Discussion: Education & Simulation as Catalysts for Service Transformation This pilot highlights several key themes:

• Education transforms practice. Nurses can quickly expand their skillset with targeted ultrasound training. Simulation accelerates learning. Low‑cost phantoms democratise access to hands‑on practice.

• Patient outcomes improve. Higher first‑attempt success rates and better comfort scores reflect meaningful clinical impact.

• Service capacity increases. Reduced CVC reliance decreases procedural delays and resource burden. Vessel health is preserved. Avoiding femoral CVCs supports long‑term wellbeing for patients requiring repeated apheresis. These findings align with broader literature, including vascular access for plasma exchange (Ipe & Marques, 2018), which emphasises the importance of safe, sustainable access strategies.

Conclusion Simulation‑enhanced education is a powerful tool for expanding apheresis capability. By upskilling nurses in ultrasound‑guided peripheral cannulation, supported by innovative, accessible phantoms, services can reduce on central venous catheters, improve patient experience, and strengthen vessel health preservation. This pilot provides a scalable model for apheresis units seeking to modernise practice and deliver safer, more patient‑centred care.

Author Bios Leo Andrew Almerol, RN Leo is a vascular access clinical nurse and clinical educator with advanced expertise in ultrasound‑guided peripheral and long‑term venous access. His work focuses on vessel health preservation, simulation‑enhanced education, and service improvement in acute and specialist care settings.

Figure 1: Ultrasound‑guided cannulation training setup using tofu and elongated balloon phantom. A low‑cost, reproducible simulation model providing realistic ultrasound imaging and tactile feedback.

AUGUST 2026 | VOLUME XIII | ISSUE 3

On June 4, 2026, the Massachusetts Vascular Access Network (MAVAN) hosted its annual all-day Vascular Educational meeting at the Hilton Garden Inn in Marlboro MA. The meeting brought together 86 attendees, 16 valued vendor partners and offered 5 CE’s. Throughout the day, attendees participated in educational presentations, connected with colleagues, and explored the latest products and innovations from our industry partners.

Educational opportunities included Risk Management in Vascular Practice: Assessing Catheter-Related Harm and Hospital-Onset Bacteremia presented by Lori Kaczmarek MSN,RN, VA-BCTM, and Russ Nassof JD, and sponsored by HB Fuller Medical Adhesive Technologies. From Assessment to Action: A Comprehensive Approach to DIVA presented by Gabrielle Lord BSN, RN, VA-BCTM and Jon Bell, MSN, RN, VA-BCTM, CEN, sponsored by BD. Follow the Outcomes: A Systematic Review of Needleless Connector Function and Occlusion Incidence presented by Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BCTM and sponsored by Avanos/Nexus Medical. Vascular Access and Infection Prevention: The CLABSI Prevention Connection, presented by Patrick Gordan, DNP, RN, CIC from Beth Israel Lahey Health. The Nose Knows: Improving the Patient Experience During Vascular Access Using Aromatherapy presented by Victoria Graham, BSN, RN, VA-BCTM, Dalida Yeroshalmi, BSN, RN, VA-BCTM, and Mona Inocentes, BSN, RN, VA-BCTM all from Dana Farber Cancer Institute. Attendees also generously participated in a 50/50 drawing that raised $92 for the AVA Foundation.

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AVA's electronic newsle/er Intravascular Quarterly (IQ), keeps vascular access professionals up to date on important AVA news and the latest technological and educa;onal informa;on. IQ is published quarterly as a professional beneﬁt. AVA oﬀers the current issue available as free access. PDF version can be downloaded and shared!

Wri;ng for IQ means presen;ng per;nent informa;on in a brief fun, and crea;ve way. Share your stories - product evalua;on, quality improvement, living with vascular access, case reports, the student experience, the crea;ve educator, etc. CLICK HERE to submit your ar5cle today! 36

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