The European working time directive (EWTD) is

Iv therapy supplement A pilot intravenous cannulation team: an Irish perspective Peter J Carr, Ronan W Glynn, Brendan Dineen, Thomas JB Kropmans The European working time directive (EWTD) is European law intended to protect the health and safety of workers. The EWTD limits the number of hours (n=<48 from 9) that doctors are allowed to work over an average week, and became part of Irish law in 4 (Garvin et al, 8). Peripheral intravenous cannulation (PIVC) was first reported in the 185s, and has been invaluable in treating illness, disease and injury. Insertion of a cannula into a peripheral vein is the most common method of vascular access in hospital setting; it is performed mostly by doctors for the purpose of intravenous (IV) therapy in hospital (Gallieni et al, 8). A skillful insertion technique requires expertise to avoid failed or repeated attempts as well as pain and distress (Dougherty, 1996; Jackson, 3; Lavery and Smith, 7; Dougherty, 8). According to Hoctor (9), in the Republic of Ireland 6% of patients undergo cannula insertion at some point during their hospital stay. Given that an increasing number of patients being treated for acute and chronic illnesses will need an IV device at some point during their course of treatment (Waitt et al, 4; Camp-Sorrell 7), the impact of the EWTD may present nurses with new opportunities, and the potential for role expansion, which may benefit patients. Nurse-led approaches to vascular access devices are becoming increasingly common, and research suggests advantages include a reduction in healthcare-associated infections (HCAIs), an increase in patient satisfaction and a decrease in waiting times (Kelly, 9). In addition, there are economic benefits, as a team approach to IV cannula insertion has been shown to reduce costs. A 3-month study in the early 199s in the USA reported savings of $17 a year (Scalley et al, 1992). A business plan revealing the economic benefits of expanding an IV team s service commitment across a large hospital in the UK also provides evidence of this (Bolton, 9). This study identified potential savings of 27 a year, as a result of shorter hospital stays, administration of medication on time, and a reduction in HCAIs. Methods An IV cannulation team was introduced as a pilot scheme in a university teaching hospital for the provision of peripheral IV cannulation. The service ran from October 6 until December 7. The team leader was a senior phlebotomist with over 15 years of cannulation experience, the majority of it in an emergency care centre in USA. The IV nurses were seconded from emergency, intensive care, oncology and general surgery. Abstract Peripheral intravenous cannulation (PIVC) is a potentially painful and distressing procedure for patients, and is traditionally carried out by medical personnel. A university hospital in Ireland was chosen to initiate a pilot intravenous (IV) cannulation team, to ascertain whether this procedure could be performed effectively by a team of nurses. The team was introduced to support the implementation of the European working time directive (EWTD). A team of four registered general nurses, led by a senior phlebotomist, provided PIVC. Request books were placed on each ward and data was recorded before and after each insertion. A constantly increasing percentage of first-time cannulation success is displayed from the first five months of the study. In-depth analysis on an orthopaedic ward reveal a preference for distal site insertion and routine change at 72 hours. IV teams performing IV cannulation can effectively reduce insertion rate attempts, and potentially offer a solution to the manpower issues arising as a result of implementation of the EWTD. Key words: European working time directive (EWTD) Peripheral intravenous cannulation (PIVC) Non-consultant hospital doctors (NCHD) Nurse team Nurse insertion Cannula size Cannula location All team members completed an in-service venepuncture and cannulation study day, accredited by Ireland s governing body for nurse practice, An Bord Altranis. The hospital policy for venepuncture and cannulation was adhered to, and the number of attempts per practitioner was limited to a maximum of two per patient. The type of cannulas used were B. Braun Vasofix Safety and Introcan Safety Cannula. The extension set applied to the cannulas was the B. Braun smallbore T-Port Extension Set. Initial working hours were 7am 7pm, Monday Friday. A 4-week induction was provided where the team leader demonstrated the insertion of cannulas and supervised Peter J Carr is Emergency Department RGN and final year Masters of Medical Science Health Informatics Student; Dr Ronan W Glynn is Senior House Officer Surgery and PhD Researcher, Department of Surgery; Brendan Dineen is Researcher in Medical Informatics and Medical Education (MIME); and Thomas JB Kropmans is Director/ Lecturer Postgraduate Diploma/Master of Medical Science (Health Informatics), School of Medicine; all at National University of Ireland Galway, Ireland. Accepted for publication: April 1 British Journal of Nursing, 1 (Intravenous Supplement), Vol 19, No 1 S19

Figure 1. The request sheet used on each ward. Data from this sheet were used for audit and research. Intravenous Cannula Request Sheet Date: Ward/Department: Patient name Location Consultant/ specialty See Box 1 Time requested Time inserted Reason for insertion See Box 2 Reason for change See Box 3 Inserted Y/N No of attempts Catheter size/ location See Box 4 Bloods sample (Y/N) Nursing documentation /comments Y/N Box 1: Specialty 1 Haematology/oncology 6 Urology 11 Radiology/CT 2 Cardiology 7 Obs & gynae 12 ENT/ophthalmology 3 General medicine 8 General surgery 13 A&E 4 Neurology 9 Plastic/oral surgery 14 Orthopaedics 5 Geriatric assessment 1 Paediatrics 15 OGD/procedures Box 2: Reason for insertion Box 3: Reason for change Box 4: Location 1 New IV cannula 2 Intravenous medication (IV) 3 IV antibiotics 4 IV fluids 5 Blood/blood products 6 Pre-op fluids 7 Chemotherapy 1 Dislodged 2 Infection/pain 3 Standard change 4 Other 1 Back of hand (L1/R1) 2 Wrist (L2/R2) 3 Arm (L3/R3) 4 Antecubital fossa (L4/R4) 5 Other S British Journal of Nursing, 1 (I NTRAVENOUS SUPPLEMENT ), Vol 19, No 1

Figure 2: Service efficacy in first-time cannulation success over first 5 months of pilot IV team. 9 7 6 5 3 A Mann-Kendall trend test statistic was calculated where S was equal to 1. This value was statistically significant (p-value <.5) indicating the presence of an increasing monotonic (constantly increasing) trend in the percentage of first-time cannulation success over the 5 months of the pilot PIVC team. The Sen s slope estimate of a linear trend (percentage change per month) for this data was 13.73. It displays a 98% success rate in first-time insertions at the end of 5 months. each team member performing randomized cannula insertions. Team members serviced all wards covered (n=14) three times daily at 4-hourly intervals. Twenty-four hour cover was not provided in the pilot scheme. The IV team established a book for cannulation requests (Figure 1). Each ward was given a request book so that all cannulation requests could be documented. Staff nurses and medical doctors were permitted to insert requests for cannulas. Information recorded in the request sheet included patient details and ward location, consultant and specialty, time requested, reason for PIVC, and reason why cannula change was required. Following cannula insertion, the IV team member responsible for the insertion updated each request log. Included in this update were the time inserted, whether the PIVC was inserted successfully or otherwise, the number of attempts required to achieve insertion, the size of cannula used and the site of insertion. Figure 3. First and second time insertions of PIVC. Number of cannulas 6 October 6 (n=89) November 6 (n=936) December 6 (n=972) of first-time cannulation success Sen s estimate January 7 (n=1197) February 7 (n=1135) Second insertion First insertion Medical Oncology Surgical Geriatric Urology Orthopaedic Successful first and second insertion attempts are shown; the success rate in first-time insertions was % on urology and orthopaedic wards. Data were collected for audit from the first 5 months (October 6 February 7) to assess first-time insertion rate success. A follow-up audit was performed on figures from May 7 to assess ongoing practice in six wards with defined care groups. In addition, practice was audited on one specialty ward orthopaedics (July August 7). Variables recorded for analysis on the orthopaedic ward included the number of insertion attempts, size of cannulas, site of insertion of cannulas, change of cannulas and the median waiting time for cannula insertion. Prospective descriptive statistics were carried out on data retrieved from the request sheets. Data were inserted into a Microsoft Excel spreadsheet and analyzed using an Excel template, MAKESENS (Salmi, 2), and SPSS version 17 (Field, 5). Results Introduction of IV team service The team commenced with three registered general nurses (RGNs) in late September 6. The working week was Monday-Friday, 7am 7pm; this was expanded to a 7-day week service following a 1-month orientation in the skill of peripheral IV cannulation. One month later, another nurse joined the team to deal with the increased workload. Cannulation requests were signed by the practitioner following successful insertion. This adhered to local guidelines, and assisted with traceability and surveillance of IV cannulas. Improvement in first-time insertions To display effectively the results collated, the MAKESENS software template from Excel was used. From this, a Mann- Kendall trend test statistic was calculated, where S was equal to 1. This value was statistically significant (p-value <.5) indicating the presence of an increasing monotonic (constantly increasing) trend in the percentage of first-time cannulation success over the 5 months of the pilot IV team. The Sen s slope estimate of a linear trend (percentage change per month) for the data was 13.73. A graphic representation of results is displayed in Figure 2. It displays a 98% success rate in first-time insertions at the end of 5 months of the pilot scheme, with consistent improvement demonstrated over the study period. The number of cannulas inserted each month increased and in February a total of n=1135 were inserted when our 98% success rate was achieved. This improvement was maintained across patient specialties in May 7, and is demonstrated in Figure 3. Over this month, all PIVC requests on the orthopaedic and urological wards were inserted on the first attempt. Table 1 shows data on the orthopaedic specialty ward, based on a sample of 99 insertion requests. First attempts over the month Ninety-seven cannulas were inserted on the first attempt, giving a 98% first-time success rate. The remaining 2% were inserted on the second attempt. Gauge size of cannulas: Ninety-six (92.3%) of the cannulas inserted were 22 gauge; two cannulas were gauge, and one cannula was 18 gauge in size (Figure 4). S22 British Journal of Nursing, 1 (Intravenous Supplement), Vol 19, No 1

Figure 4. Size of device inserted - 18 gauge, gauge, 22 gauge on the orthopaedic specialty ward. 6 18 22 Size of IV The preference for cannulas of the peripheral intravenous cannulation team was for 22 gauge. This was established as a core working principle. Cannulas with an 18 or gauge were inserted only if specified on the request sheet. Figure 5. Site of insertion of PIVC on the orthopaedic ward. 6 Back of hand Wrist Arm Antecubital Fossa Location The PIVC team attempted to insert cannulas distally at the first attempt. The bar chart below reveals a preference for back of hand insertions, with 82% inserted distally. Figure 6. Reason for change of cannulas on the orthopaedic ward. 5 3 1 Dislodged Infection/pain Standard change Other Reason for change 1 Forty-nine cannulas were reported dislodged; this figure may lead to investigation into securement devices. Eight cannulas were removed for fear of infection or complaints of pain (these may have been inserted by the IV team or other practitioners). Forty-one cannulas were removed after 72 hours. Location: Eighty-two cannulas (82.8%) were inserted in the back of the hand, nine (9.1%) were inserted in the antecubital fossa, and 7 (7.1%) were inserted in the region between the antecubital fossa and the wrist. The remaining one (1%) was inserted in the wrist (Figure 5). Change of cannula: Forty-nine (47.1%) cannulas were reported dislodged. Eight were reported as infected/ painful. Forty-one (39.4%) were reported as a standard change which implies that the cannulas had stayed in 72hours. One cannula was removed or changed for another reason; the likely rationale for this was that a larger gauge of cannula was needed. Median time for insertion: The period between the time of request for cannulation and the actual time of insertion was calculated, and a median time of 5 minutes was returned. Data entry: No problems with insertion of data into IV cannulation request sheet were reported. Bleeping of doctors and waiting for their response was decreased and this was reported to have supported time management on wards. Discussion This paper provides evidence that first-time insertion of cannulas increases with consistent performance of the task. Given that the IV team provided peripheral cannulation to a variety of specialties, the data extrapolated indicates consistency in first-time insertions across all specialties. Role expansion of the nurse to support EWTD implementation is achievable. However, the evidence for this Table 1. Insertion requests from orthopaedic ward Total cannula insertion requests 99 Cannula insertion (success rate) First attempt 97 (98%) Second attempt 2 Gauge size of cannulas 22 gauge 96 gauge 2 18 gauge 1 Location Back of hand 82 Antecubital fossa 9 Between antecubital fossa and wrist 7 Wrist 1 Change of cannulas Dislodged 49 Infection/pain 8 Standard change 41 Other 1 Median time for insertion (mins) 5 S24 British Journal of Nursing, 1 (Intravenous Supplement), Vol 19, No 1

Iv therapy supplement is scant; a low response rate from non-consultant hospital doctors makes it difficult to accurately report a reduction in doctors hours. The report provides results of reduction in doctors hours from 59 hours to 5 hours per week up to August 7. During this period, the IV cannulation team was servicing wards. Non-compliance (no hours provided) with the EWTD in was reported August 9 when the IV cannulation team was no longer a working entity (Department of Health and Children National Implementation Group (DHC NIG), 8). The debate regarding nurses performing tasks traditionally carried out by doctors is controversial, with some commentators arguing that it represents neither expansion nor extension of their scope of practice, but rather change of it (Sheperd, 1993). A debate on who is most appropriate to perform IV cannulation has been raised in nursing literature (Jackson, 3). Nurses performing traditional medical tasks can ensure continuity of holistic care, and the associated autonomy can create personal and professional satisfaction (Workman, ). The opportunity for nurses to take ownership of a team approach to IV cannulation should be embraced and promoted. From our analysis of the service provided on an orthopaedic ward, three themes emerged that require discussion. They are: site selection; cannula size; and cannula re-sites. Site selection What is the best site for insertion? Previous international commentaries on peripheral cannulation suggest distal site insertion should be used first (Scales, 5; Ingram and Lavery, 7). The IV team adhered to this and, in so doing, supported the hospital policy. Interestingly, a recent Italian study disagrees; Cicolini et al (9) demonstrated an increased rate of thrombophlebitis at dorsal/distal vessels. However, this study had a number of limitations; the time difference between cannula insertion and removal was not included, and the number of distal insertions varied from the number of insertions at other sites. In addition, there was a preference for large or 18 gauge cannulas (Cicolini et al, 9). The results of the Irish experience display a preference for distal insertions. Furthermore, our results are similar to evidence produced by a vascular access team in the UK which attempts to site % of cannulas at distal site of upper extremities (Jackson, 7). Distal insertion advantages include reduced infection, avoiding the antecubital region, and thus the elbow joint, and possible reduction in occlusion of infusions. What size of cannula? The most common size of cannula inserted by the IV team was 22 gauge. This is in agreement with initial working Vygon at Integrated solutions for minimumm complicationsions Topic: PICC placement with ultrasound and VYGON Sapiens Tip Location System Topic: IV team experience in the Netherlands Topics: Venipuncture under ultrasound guidance, PICC insertion with turkey leg or mannequin, Sapiens Tip Location System. Introducing Maximum 3psi (bar). Minimum complications to a zero-complication target. MaxfloM British Journal of Nursing, 1 (Intravenous Supplement), Vol 19, No 1 S25

principles that smaller gauge cannulas should be inserted first, and that larger cannulas should be inserted only if specified, for example where rapid infusion of solution is required (Harvey et al, 7). The size of device used can potentially determine the prevalence of thrombophlebitis (Ahlqvist et al, 6); it is accepted that smaller cannulas (22 gauge) can be used for most types of IV therapy (Campbell and Lunn, 1997). Inserting larger gauge cannulas is unnecessary, and can cause pain and trauma to patients; a review of studies on the size of cannulas revealed increased infection rates when larger size cannulas were inserted (Tagalakis et al, 2). In our adult population, 24 gauge cannulas were not considered, although, on occasion for particular patients, it was an adequate and successful size. Elective re-sites Routine change of IV cannulas after 72 hours was encouraged by the infection control team, in an attempt to decrease the potential for infection and related complications. This was also in accordance with hospital policy and national policy, and similar to UK guidelines and care bundles for peripheral cannulation (Department of Health (DH), 7). The scientific evidence to support elective replacement and reduce incidence and severity of infection is small but may, perhaps, be significant. A randomized control trial on elective removal of IV cannulas suggested that elective replacement/re-siting of cannulas becomes the standard practice for patients receiving IV therapy (Barker et al, 4). A systematic review of studies on elective replacement of IV cannulas by Idvall and Gunningberg (6) suggest evidence for elective replacement in an attempt to reduce thrombophlebitis is limited. A time frame for elective replacement hours is debatable, and published literature provides differing opinions. IV cannulas require regular monitoring and 48 hours may be the optimum time for removal (Jackson, 3). A recent study from India agrees with Jackson and found that thrombophlebitis peaked on day 3 of cannula stay; the authors suggest that elective replacement should be at 48 hours (Nishanth et al, 9). The median cannula size here was 18 gauge; randomized control trials that involve 22 gauge cannulas are perhaps required. Lee et al (9) add further evidence as, in their prospective analysis, they found no significant difference in local infection, if the IV cannula stay was extended from 48 to 72 hours and then from 72 to 96 hours. Moreover, the study found that cannulation performed by experts in IV care and insertion was a statistically significant factor in reducing infection rates (Lee et al, 9). Study limitations Accurate correlation of the IV team s impact with infection rates was unachievable as no surveillance evidence was available. Patient and staff convenience/satisfaction studies were never performed. As the IV team is no longer running, a pre-post IV team investigation would help evaluate which system was most efficient (staff), effective (patient) and economical (hospital). Conclusion Peripheral cannulation is an invaluable adjunct for patient treatment in the hospital setting. If the EWTD is to be fully implemented, and non-consultant hospital doctors hours reduced, then provision of and responsibility for peripheral cannulation should fall to IV teams. The remit of these teams could then be expanded to the use of other vascular access devices. The EWTD National Implementation Report for Ireland found that: The role of the IV Cannulation Team should be extended to provide 24-hour cover. This role should incorporate the taking of blood cultures and the accessing of central lines (DHC NIG, 8). The results of this analysis suggest that the introduction of IV teams can be clinically effective and efficient, and may be one solution to the growing manpower issues surrounding implementation of the EWTD. They may be an option to support research/audit in this area of patient care. IV teams will allow doctors to focus on patient care. Acute critical review of patients will not be interrupted by doctors being required to perform IV cannulation on a different patient. The transfer of cannulation skills to ward nurses will not be a key requirement. They can continue to perform patient care and other duties without having responsibility for cannula insertion. It is our opinion that IV teams would support current guidelines on IV cannulation in Ireland and would assist with transition of care bundles for IV cannulation to the clinical environment. IV teams would support Saving Lives and high impact intervention bundles for peripheral cannulation, as published in the UK (DH, 7). BJN Acknowledgement Peter Carr currently works at Galway University Hospital and was formerly a member of the IV team. The authors would like to acknowledge the team leader and nurses of Ireland s first IV cannulation team; Tommie Mellet, Chief Phlebotomist and team leader; IV team members Lorraine O Dea, Susan Nolan, Maureen O Grady; and Karen Browne and staff of the Phlebotomy Department, Galway University Hospitals. Ahlqvist M, Bogren A, Hagman S et al (6) Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines. J Clin Nurs 15(11): 1354 1361 Barker P, Anderson ADG, MacFie J (4) Randomised clinical trial of elective re-siting of intravenous cannulae. Annals of the Royal College of Surgeons of England 86(4) 281 3 Bolton D (9) Writing a business case for the expansion of service: expanding the IV therapy team, from start to finish. Journal of Infection Prevention 1(1) Suppl, s27 s32 Camp-Sorrell, D (7) Clinical dilemmas: vascular access devices. Semin Oncol Nurs 23(3): 232 239 Campbell T, Lunn D (1997) Intravenous therapy: current practice and nursing concerns. Br J Nurs 6(21): 1218 28 Cicolini G, Bonghi AP, Di Labio L, Di Mascio R (9) Position of peripheral venous cannulae and the incidence of thrombophlebitis: an observational study. J Adv Nurs 65(6): 1268 73 Department of Health (7) High Impact Intervention No 2. Peripheral Intravenous Cannula Care Bundle. tinyurl.com/hii-no2 Department of Health and Children National Implementation Group (NIG) European Working Time Directive & Non Consultant Hospital Doctors- Final Report December 8. tinyurl.com/ie-eu-wtd (accessed 17 May 1) Dougherty L (8) IV therapy: recognizing the differences between infiltration and extravasation. Br J Nurs 17(14): 896, 898 Dougherty L (1996) The benefits of an IV team in hospital practice. Prof Nurse 11(11): 761 3 Field A (5) Discovering Statistics Using SPSS. Sage, London Gallieni M, Pittiruti M, Biffi R (8) Vascular access in oncology patients. 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Iv therapy supplement Cancer J Clin 58(6): 323 46 Garvin JT, McLaughlin R, Kerin MJ (8) A pilot project of European Working Time directive compliant rosters in a university teaching hospital. Surgeon 6(2): 88 93 Harvey M, Thumma V, Cave G (7) Technique for upgauging peripheral venous cannulae in volume resuscitation. Emerg Med J 24(5): 371. Hoctor B (9) Nurse cannulation: introducing an advanced clinical skill. Nurs Manag (Harrow) 16(6): 28 3 Idvall E, Gunningberg L (6) Evidence for elective replacement of peripheral intravenous catheter to prevent thrombophlebitis: a systematic review. J Adv Nurs 55(6): 15 722 Ingram P, Lavery I (7) Peripheral intravenous cannulation: safe insertion and removal technique. Nurs Stand 22(1): 44 8 Jackson A (3) Reflecting on the nursing contribution to vascular access. Br J Nurs 12(11): 657 65 Jackson A (7) Development of a trust-wide vascular access team. Nursing Times 13(44): 28 9 Kelly LJ, Buchan E, Brown A, Tehrani Y, Cowan D (9) Exploring how the development of a nurse-led vascular access service has benefited patients. Nursing Times 15(24): 16 18 Lavery I, Smith E (7) Peripheral vascular access devices: risk prevention and management. Br J Nurs 16(22): 1378, 1382 3 Lee WL, Chen HL, Tsai TY et al (9) Risk factors for peripheral intravenous catheter infection in hospitalized patients: a prospective study of 3165 patients. Am J Infect Control 37(8): 683 6 Nishanth S, Sivaram G, Kalayarasan R, Kate V, Ananthakrishnan N (9) Does elective re-siting of intravenous cannulae decrease peripheral thrombophlebitis? A randomized controlled study. Natl Med J India 22(2): 6 2 Salmi T, M. A., Anttila.P, Ruoho-Airola.T, Amnell.T (2). Detecting trends of annual values of atmospheric pollutants by the MANN-KENDALL test and SEN S slope estimates the EXCEL template application MAKESENS. F. M. Institute. Helsinki, Finnish Meteorological Institute Vuorikatu, Helsinki, Finland. Scales K (5) Vascular access: a guide to peripheral venous cannulation. Nurs Key Points Practitioners who undertake peripheral intravenous cannulation must understand the importance of site selection. Practitioners must realize that risk of infection is increased with the use of larger cannulas. Consistent distal insertion can ensure success in first-time attempts. The team approach to peripheral intravenous cannulation insertion and management can become the standard for large hospitals. Stand 19(49): 48 52. Scalley RD, Van CS, Cochran RS (1992) The impact of an i.v. team on the occurrence of intravenous-related phlebitis: a 3-month study. J Intraven Nurs 15(2): 9 Sheperd J (1993) Nurses are changing not extending their roles. Br J Nurs 2(9): 447 Tagalakis V, Kahn SR, Libman M, Blostein M (2) The epidemiology of peripheral vein infusion thrombophlebitis: a critical review. Am J Med 113(2): 146 51 Waitt C, Waitt P, Pirmohamed M (4) Intravenous therapy. Postgrad Med J (939): 1 6 Workman B () Enhancing the nursing role: why nurses want to cannulate. Br J Nurs 9(5): 281 6 The UK s largest online archive of nursing articles provides access to an extensive library of thousands of peer-reviewed clinical articles in all areas of nursing For subscription details, visit or call free on 1371 NOW with a clean new look and improved search engine MA Healthcare Ltd, Jesses Farm, Snow Hill, Dinton, Nr Salisbury, Wiltshire SP3 5HN tel 1722 716997 fax 1722 716926 British Journal of Nursing, 1 (Intravenous Supplement), Vol 19, No 1 S27