It can be difficult to get the tip of a central vascular access device to the targeted area of the caval-atrial junction accurately and precisely when placing a device at the bedside. Tip placement outside this precise location can lead to complications and poor patient outcomes. Malpositions increase patients' radiation exposure, increase costs, and delay treatment. The current standard of using chest radiography to check tip placement has demonstrated discrepancies and is subject to interpretation differences between radiologists. Chest radiography and malpositions can be eliminated with the use of technology that includes Doppler, echocardiography (ECG), and an algorithm. This technology can reduce the cost of labor and supplies in addition to allowing the use of a central vascular access device immediately after placement.

Background: The frequency with which vascular access specialists (VASs) are placing peripherally inserted central catheters (PICCS) has allowed for the improvement and expansion of the skill set by using advanced insertion techniques such as the modified Seldinger technique and ultrasound for real-time imaging. The use of real-time imaging has decreased complications such as arterial puncture and has improved success rates. Due to this positive influence on patient outcomes, many VASs are moving to the placement of central venous catheters (CVC). Method: We describe the service improvement process of expanding a vascular access team (VAT) practice to include the placement of CVCs and arterial lines in a large community hospital in Illinois. We also outline the history of vascular access and the journey of a VAT. Results: By following a methodic approach toward implementation of practice expansion, our VAT has gone from solely placing PICCS to the placement of CVCs in the internal jugular, axillary/subclavian, and femoral veins and to the placement of arterial lines. Conclusions: VASs have the capacity to positively influence patient safety and outcomes even further by placing CVCs, rather than simply staying with the current scope of practice by placing intravenous lines, midlines, and PICCs. Patient outcomes will improve as VASs move to the placement of CVCs, and the costs associated with potential complications will improve also. Moving to the placement of CVCs is vital to the specialty of vascular access and will continue the breadth and depth of service provided by VASs.

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was observed on the posterior wall, once again with the highest correlation of all segments (R=0.314, p=0.015).Conclusions The automated VHA tool demonstrated the posterior wall as the only anatomical segment to be significantly higher in LVAs consistent with dense scar burden (i.e. £0.2mV), when mapped in AF. Mapping rhythm has a substantial impact on surrogate readings of both 'Diseased Tissue' 0.21-0.5mV and 'Dense Scar' £0.2mV on the posterior wall. These findings mandate careful interrogation of posterior wall voltages and may partially explain the debated outcome for posterior wall ablation. It is best interrogated in both rhythms to confirm the presence of arrhythmogenic substrates over artifactitious rhythm effect.