Herein we evaluate the outcomes of a multidisciplinary vascular access team created in response to the COVID-19 pandemic in the UK. We highlight the successful redeployment, structured training and governance that resulted in achieving the main objectives of the service - supporting ICU colleagues at the time of intense clinical pressure and demand. Overall, the VAST team were able to successfully help with vascular access in complex patients being treated in a challenging environment with only minimal complications.
The COVID-19 pandemic and the severity of infection [10, 11] with the SARS-CoV-2 has resulted in extreme pressures on health services across the world with reports describing war-like circumstances necessitating rapid innovation to provide emergency care [12]. The urgency for these developments were most evident in ICU settings with several reports highlighting the need for a rapid increase in ICU capacity including beds, vital equipment and personnel [13–18]. It is, however, well recognised that a rapid increase in ICU workload may result in adverse patient outcomes [12, 19] and that specific COVID-19 protocols and interventions are needed to reduce strains on available ICU resources [13, 15, 16, 18].
Over a 2-month period of this study, our centre saw more than 1500 positive cases of COVID-19 during the first wave of the pandemic. In order to cope, outpatient and elective activity was reduced significantly, which facilitated the redeployment of personnel where they were needed most. Within days of the pandemic our Trust sent questionnaires to all healthcare professionals asking about previous experience including central line insertion. These data were used to develop VAST. As opposed to other similar teams [20], we did not restrict ourselves to surgical specialities but chose members with complementary clinical skill-sets to minimise pressures on any specific speciality that were required to maintain emergency services across the hospital. We believe that the diversity of the team resulted in improved process review, a wider discussion and better sharing of ideas that was needed to rapidly adapt to the challenging environment and the distinct patient cohort that was being treated. The team was made of attendings with previous relevant experience. This was vital as only minimal targeted, or refresher training and simulation was needed and the team was ready to be deployed rapidly. The team design including two clinicians with a central collection point for kit allowed full outsourcing of the service across the multiple critical care areas in the hospital, allowing the team to safely deliver the service with minimal support from stretched ICU teams.
Such approach can be used in the future in response to COVID-19 or other emergent scenarios. Although VAST commenced with only a few team members at the start, from the outset, the team design and structure allowed for the continuation of recruitment and training of additional members if needed. If cases of COVID-19 had continued to increase, we had planned to add an extra four members to the team. Ultimately, this was not required but we remain prepared in case there is a second peak in the future.
With respect to outcomes, the team was able to perform 190 line insertions during the 5-week study peak period. This freed ICU teams to perform other essential tasks like reviewing and managing complex patients or talking to family members. In addition to our team, a separate team was developed to insert tracheostomies, a proning team to and a chest drain insertion team.
Recognised complications from central venous line insertion include infection; line related thrombosis; bleeding; pneumothorax; haemothorax; retained guidewires, and; iatrogenic arterial injury [21–23]. Complication rates seems to be significantly higher in the ICU environment. The ADVANCED study (prospective, single centre, randomised study) analysed 628 patients admitted to the ICU for an expected stay of at least 48 h requiring a catheter insertion as part of their clinical care (2214 catheters: 873 PVCs, 630 CVCs, 512 ACs and 199 HDCs and PACs). The overall complication rate was nearly 30%. In the complications related to central venous access, 7% were classified as severe and 3% as life threatening. In the complications associated with temporary dialysis catheter access, 17% were considered severe and 2% considered very severe. The most frequent CVC and temporary dialysis catheter complications leading to early catheter removal was infection [24]. Complication rates by our VAST service were, in comparison, low despite challenges with PPE and working within a busy critical care environment. Technical challenges faced by the team included a high proportion of patients requiring ECMO, and many patients had pre-existing line related thrombi that needed to be considered. In addition, there was a general trend to increase anticoagulation in order to manage a COVID-19 associated prothrombotic state. Our low complication rates underscore the effectiveness of the VAST service. Our findings are similar to the recent multi-centre report by Chun et al [18], highlighting the important contribution of a similar service in centres outside of the UK and adds weight to their findings.
There have been several publications on central and peripheral access training as well as on volume, technical errors and decision making in this area. In times of crisis, concentrating tasks, such as line insertion, allows people to focus on one duty with improved outcomes [25–27]. Nearly 30% of our patients in this report were receiving ECMO and patients were often managed in units that were converted to critical care to manage the unprecedented demand. In established ICU areas, more patients per unit of ICU surface area led to a limited space around the patient to navigate equipment. Additional limitations included the need to wear full PPE. Despite these significant challenges we believe that the use of attendings to staff VAST allowed for non-technical skills, including situation awareness, decision making and communication, to be utilised effectively [28]. We have summarised our thoughts relating to the opportunities and challenges when considering a vascular access support team during a healthcare crisis in Table 4.
Table 4
Opportunities and challenges of vascular access support teams during health care crises
Opportunities | Challenges / risks |
Efficient use of staff | De-skilling of critical care staff |
Procedures performed by team of experts | Potential need to make adjustments/changes rapidly in response to dynamic situation |
Reduction of workload of critical care team | Need for personal protective equipment |
Application of standardised techniques | Unavailability of team for other clinical duties |
Opportunities for training of junior staff | Need for close oversight and governance |
Multi-disciplinary team working | |
Cross-fertilisation | |
Preparedness for future pandemics | |
Limitations to this study include its retrospective nature with complications limited to those documented in the health records. We additionally did not actively look for thrombosis or complications outside of our centre and may have missed complications occurring in the following days or weeks after discharge. Further, changes in ITU management were made during the study period as our ‘learning’ regarding COVID-19 evolved including guidance regarding thromboprophylaxis, types of sheaths that were optimal and intravascular fluid status of patients on ITU. These are additionally likely to influence complication rates and resulted in a more heterogenous group.