Date of Completion
Fall 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Lydia Forsythe
Abstract
Problem: Delayed Port-a-Cath (PAC) access limited timely care on a medical-surgical unit that relied on the vascular access team for routine access. Baseline median PAC access time was 45 minutes, and the vascular access team received an average of 15 PAC-related pages per week.
Aim of the Project: This quality improvement project implemented an evidence-based, nurse-driven PAC access protocol to reduce median access time to 30 minutes or less, achieve competency validation among at least 80% of eligible charge registered nurses, reduce vascular access team paging by at least 50%, and maintain the central line-associated bloodstream infection (CLABSI) rate at or below 0.5 per 1,000 central-line days.
Review of the Evidence: Evidence supported standardized vascular-access practices, structured education, competency validation, infection-prevention measures, and continued access to specialty expertise when nurses assume expanded vascular-access responsibilities.
Project Design: This 12-week quality improvement project used the Institute for Healthcare Improvement Model for Improvement. A focused Plan-Do-Study-Act cycle addressed inconsistent documentation identified during implementation. The OhioHealth Change Management Model supported staff readiness, engagement, skill development, adoption, and sustainability.
Intervention: Infusion Nurses Society standards were translated into a unit-based protocol that allowed competency-validated charge nurses to perform routine PAC access for eligible adult inpatients. The protocol included eligibility criteria, aseptic access procedures, patency verification, documentation requirements, and escalation for complications, unsuccessful access, or conditions requiring provider or specialty evaluation.
Significant Findings/Outcomes: Among 55 PAC access events, median access time decreased from 45 to 34 minutes, an 11-minute or 24.4% reduction; however, the 30-minute target was not achieved. Twelve of 15 eligible charge nurses completed competency validation (80%), meeting the target. Vascular access team paging decreased from 15 to 9.42 pages per week, a 37.2% reduction that did not meet the 50% target. No CLABSI events occurred during 738 unit-wide central-line days, resulting in a rate of 0.0 per 1,000 and meeting the safety target.
Implications for Nursing: The nurse-driven protocol expanded verified nursing capability, improved PAC access timeliness, and reduced specialty-team utilization while maintaining established escalation and safety surveillance. Continued competency support, monitoring, documentation reinforcement, organizational ownership, and additional quality improvement cycles are recommended to support sustainability and address remaining performance gaps.
Recommended Citation
Mehmeti, Enisa, "A Nurse-Driven Port-a-Cath Access Protocol to Improve Timeliness of Vascular Access" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 101.
https://fuse.franklin.edu/dnp-project/101
Rights
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