A legal framework on advanced practice nursing in Belgium: what do we and don't we know?

OBJECTIVES: Presenting the Belgian new framework for Advanced Practice Nursing (APN) - 'Verpleegkundig Specialist [VS]'/"Infirmier de pratique avancée [IPA]" outlined in the Law of 22 April 2019, followed by a discussion of the lack of clarity, the current challenges and future opportunities. METHODS: The framework was analyzed by an expert in healthcare legislation and discussed by academics in Nursing Science and members of the board of directors of the Belgian Society of APN. RESULTS: Relevant paragraphs within this new law are"Article 46 §1. No one is allowed to carry the title of 'VS/IPA' who does not possess a bachelor in nursing mentioned in article 45 and who does not meet the requirements specified in this article. At the minimum, a master's degree in Nursing Sciences is also required. §2. Additional to the scope of practice of nursing as mentioned in article 46, the 'VS/IPA' perform, in the context of complex nursing care, medical interventions in order to maintain, improve or restore the health of the patient. Care is provided in the context of a specific target group of patients and in close concertation with the physician and potential other healthcare professionals. CONCLUSION: Although the legal recognition of the title of VS/IPA is a major breakthrough that will innovate healthcare, clarification is needed: How do VS/IPA distinguish themselves from other nursing functions, what is complex nursing care, which medical interventions can be performed, what is meant by specific target group of patients, what does 'in close concertation with the physician' entail, and will advisory power be possible?

Diagnostic accuracy of the Catheter Injection and Aspiration (CINAS) classification for assessing the function of totally implantable venous access devices.

PURPOSE: Intravenous catheters are used for the administration of intravenous therapy and for blood sampling. These devices are considered as well-functioning if both the injection and aspiration are easy. Malfunction is frequently observed and usually vaguely described as occlusion. We developed the CINAS, the Catheter Injection and Aspiration scheme. The CINAS is a catheter function classification tool, which classifies both the injection and the aspiration ability in a uniform way. Each CINAS class consists of a combination of an injection (IN) and an aspiration (AS) code: e.g. IN1AS1 is the CINAS class for a well-functioning catheter. In this series, we aimed to determine the accuracy of the CINAS class reported by nurses, after minimal training, versus a trained researcher, acting as a reference standard. METHODS: Catheter function was assessed during a standard blood sampling procedure through a totally implantable venous access device in a convenience sample of 150 oncology patients. One nurse researcher and 111 oncology nurses both scored the catheter function according to the CINAS classification scheme, independently. Concordance between the scores was calculated. RESULTS: For the 140 catheters scored as well-functioning (IN1AS1 score) by the researcher, 139 or 99.3 % (95 % confidence interval (CI) 96.1-99.9 %) were scored correctly by the nurse participants. Nine out of ten or 90 % (95 % CI 55.5-98.3 %) of malfunctioning catheters (researcher scores different from IN1AS1) were also identified as malfunctioning by the nurse participants and received exactly the same CINAS score in eight cases (80 %, 95 % CI 44.4-97.5 %). The overall accuracy of the CINAS scored by the nurse participants versus the researcher is (139 + 9)/150 or 98.7 % (95 % CI 95.3-99.8 %). CONCLUSIONS: Nurse participants were able to classify the catheter function of totally implantable venous access devices with the CINAS accurately after a brief explanation about the classification options.

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial.

BACKGROUND: Heparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking. PATIENTS AND METHODS: We randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as 'easy injection, impossible aspiration' at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4. RESULTS: Three hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%-4.69%) and 3.92% (95% CI 3.09%-4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%-1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group. CONCLUSION: NS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.

Feasibility and safety of endovascular stripping of totally implantable venous access devices.

PURPOSE: To evaluate the safety and feasibility of percutaneous stripping of totally implantable venous access devices (TIVAD) in case of catheter-related sleeve and to report a technique to free the catheter tip from vessel wall adherence. MATERIALS AND METHODS: A total of 37 stripping procedures in 35 patients (14 men, 40%, and 21 women, 60%, mean age 53±14 years) were reviewed. Totally implantable venous access devices were implanted because of malignancy in most cases (85.7%). Catheter-related sleeve was confirmed as cause of persistent catheter dysfunction despite instillation of thrombolytics. A technique to mobilize the catheter tip from the vessel wall was used when stripping with the snare catheter was impossible. Technical success, complication rate, and outcome were noted. RESULTS: A total of 55.9% (n=19) of the 34 technically successful procedures (91.9%) could be done with the snare catheter. In 15 cases (44.1%), additional maneuvers to free the TIVAD's tip from the vessel wall were needed. Success rate was not significantly lower before (72.4%) than after (96.7%) implementation of the new technique (P=0.09). No complications were observed. Follow-up was available in 67.6% of cases. Recurrent catheter dysfunction was found in 17 TIVADs (78.3%) at a mean of 137.7 days and a median of 105 days. CONCLUSIONS: Stripping of TIVADs is technically feasible and safe, with an overall success rate of 91.9%. Additional endovascular techniques to mobilize the distal catheter tip from the wall of the superior vena cava or right atrium to allow encircling the TIVAD tip with the snare catheter may be needed in 44.1% of cases.

Functional evaluation of conventional 'Celsite' venous ports versus 'Vortex' ports with a tangential outlet: a prospective randomised pilot study.

GOAL OF WORK: Totally implantable venous access ports are widely accepted in cancer patient treatment, but withdrawal occlusion (WO) can hamper the use of the device. A newly designed Vortex VX port, with a tangential outlet, should allow better clearance of the chamber, thereby reducing occlusion of the device. The present study compared the Vortex port to the classically shaped Celsite port with regards to functional complications. MATERIALS AND METHODS: Two hundred cancer patients were included in a prospective, randomised controlled trial and randomly assigned to the implantation of a Vortex or a Celsite port. Insertion details such as used vein, catheter tip position and infusion or aspiration abilities were recorded. Data were collected concerning ease of access, and functional evaluation was performed each time the port was accessed, regarding the ability to infuse fluids with a syringe and to withdraw blood by measuring the filling time of a Vacutainer blood tube. MAIN RESULTS: Ninety-nine patients received a Celsite port, and 101 had a Vortex port. Demographic variables and insertion details were comparable in both groups. All functional complications, including WO, total occlusion, sluggish inflow and sluggish withdrawal, were higher in the Celsite group (16.12%) than in the Vortex group (11.36%). This difference was not statistically significant. CONCLUSIONS: This study revealed that functional problems occurred less frequently in Vortex compared to Celsite ports. Differences were small and not significant, which indicates that functional problems may be related to other factors.

Vacutainer filling time through subcutaneous venous access devices.

INTRODUCTION: The functionality of subcutaneous venous access devices is evaluated at least every time the device is accessed. This evaluation is subjective and actions are only undertaken when blood withdrawal and/or fluid injection become problematic. The function of these devices has rarely been evaluated objectively. The present study tried to find an objective and standardized way to evaluate the withdrawal speed of a newly inserted port. METHODS: Between October 2001 and December 2002, a prospective randomized study of 3 types of ports was carried out. The ability to infuse heparinized normal saline and to withdraw blood was evaluated by recording the filling time of a 10 ml Vacutainer tube in 876 newly inserted central venous ports at the end of the surgical procedure. RESULTS: The patient groups were comparable in age, gender and insertion procedure characteristics (vein used, position of the port on the body and length of the catheter). The median time needed to fill a 10 ml Vacutainer tube in all ports was 17.00 sec (range 11.43-63.62 sec). The median filling time for BardPort was 16.36 sec (range 13.48-39.00 sec), for Celsite 18.35 sec (range 12.03-40.00 sec) and for Port-a-cath 16.43 sec (range 11.43-63-62 sec). A significant difference in filling time was found between the large bore catheters (BardPort, Port-a-cath) and the small bore catheter (Celsite) of 2 seconds median value. CONCLUSION: Measurement of withdrawal speed provides an objective criterion for the quality description of blood withdrawal immediately after insertion. A value of more than 20 seconds for filling a 10 ml Vacutainer tube could therefore be suggested a useful trigger for further investigation.