Upskilling the surgical workforce for vascular access provision during the COVID-19 pandemic – The Salisbury experience

Abstract

A vascular access device is defined as a catheter inserted into veins allowing fluids and medicines to be delivered intravenously¹. The need for such devices in acutely unwell patients has remained steady throughout the COVID-19 pandemic. We describe here our experience of up-skilling the resident plastic surgery and maxillofacial surgical registrars to provide a vascular access service to reduce the workload on our intensive care colleagues. We hope that our practice and an ‘all hands on deck’ approach to the utilisation of baseline skills within the existing workforce will inform other departments to help ease the burden on critical care departments as we progress through the next stages of the COVID-19 pandemic.

Dear Sir,

In contrast to any other speciality, the COVID-19 pandemic has most severely impacted the anaesthetic and intensive care services in almost every hospital within the United Kingdom. Up until the 5th of July 2020, 285,416 people tested positive for the virus and up to 44,220 deaths were recorded². Within the surgical departments at Salisbury District Hospital (SDH), all non urgent and elective operating had ceased during the lockdown period. The junior surgical workforce had been redeployed to medical areas leaving the registrar body to staff a 24-hour rota but with profoundly reduced workload even with the provision of trauma services. This trend of redeployment of surgical staff was echoed across the United Kingdom.³

In order to support and ease the burden of responsibility on our critical care colleagues, plastic surgery and maxillofacial registrars were identified as being readily available and familiar with the anatomical knowledge required, to form a new team that could provide vascular access in the form of mid-lines and Peripherally Inserted Central Catheter (PICC) for hospital inpatients. At SDH, prior to COVID-19, the vascular access team traditionally consisted of anaesthetics doctors and nurses.

Mid-lines and PICC lines allow mid to long term access (30 days and 6 weeks respectively) for the delivery of fluids, medication or parenteral nutrition and phlebotomy.^{1 , 4} These catheters provide robust, longer term vascular access options for patients with difficult venous access who would otherwise require multiple venepuncture attempts.⁴ A standard cannula requires re-siting every 72 h and the use of mid to long term lines in the correct patient directly reduces the required clinical input.

Over the course of a single week, 12 plastic surgery and maxillofacial surgical registrars were trained to place mid and PICC lines. The technique was initially taught using a simulation arm model (Peter PICC™) and an ultrasound (USS) machine. Trainees were encouraged to familiarise themselves with the anatomical appearance of relevant structures using the USS machines on themselves and colleagues under the watchful guidance of the anaesthetics consultants. Once deemed competent with the simulation process, all trainees were then supervised placing lines in patients on the wards.

The service was coordinated on a daily basis by the existing 4 plastic surgery trauma coordinators who are nurses by background. Coordination responsibilities include identification of all available doctors against a register taken daily, as well as, review of all referrals using an effective protocol to determine device selection and indication illustrated in Figure 1 .^{3 , 4} PICC tip placement length was calculated using the Lum forumula.⁵

Figure 1.

Protocol to aid Device Selection and Indication for individual patients requiring vascular access.

Over the course of the pandemic, the placement of the lines progressed to rely very little on the anaesthetic team with the majority of lines eventually placed unsupervised by the surgical trainees across the entire hospital as illustrated in Figure 2 . The anaesthetics team still provided support, where necessary, in determining patient suitability, type of line required as well as review of post PICC insertion radiographs. For these, an anaesthetics doctor was available over the phone but could be available in person if the need arose.

Figure 2.

A Comparison of the number of Mid/PICC lines placed by speciality over the course of the Covid-19 Pandemic.

From April to June 2020, 31 lines have been inserted (17 mid lines and 14 PICC lines). Following a request for line insertion – if deemed suitable, time to placement was less than 24 h. An entry pertaining to the insertion was left in the notes and an audit proforma filled out on each occasion in line with existing anaesthetics practice. Line placement had a 97% success rate overall with only one line thrombosis two weeks post placement.

It is evident that the workload for vascular access has remained steady throughout the COVID-19 pandemic. The surgical workforce upskilling to provide this service has significantly reduced the workload for our critical care colleagues and will remain the model of provision for as long as COVID-19 creates unprecedented demand on the intensive care services within our hospital. Surgeons already possess the fine motor skill required for line placement and coupled with their understanding of the anatomy, makes them the obvious choice for this role. The development of the team has been received positively and enthusiastically by the surgical registrars, particularly whilst their own training has been restricted during the pandemic. The success of the new team affirms the adaptability of the medical workforce to transfer skills beyond the domain of specialised practice. We hope that our practice and an ‘all hands on deck’ approach to the utilisation of baseline skills within the existing workforce will inform other departments to help ease the burden as we progress through the next stages of the COVID-19 pandemic.

Funding

N/A

Ethical approval

N/A

Declaration of Competing Interest

None