Peripheral intravenous catheter performance: investigating peripheral intravenous catheter dwell times Fourie A, RN, Certificate Wound Care (UOFS) Certificate Wound Management (UK), International Interdisciplinary Wound Care Course (SA/Canada) Scientific Affairs and Educational Manager, 3M South Africa Correspondence to: Anika Fourie, e-mail: afourie@mmm.com Keywords: peripheral intravenous catheter, PIV, infiltration, unscheduled restarts, PIV failure rates Abstract Background: The recording and reporting of peripheral intravenous (PIV) line failures is not commonly carried out in South Africa. Statistics are collected on pressure ulcers, catheter-related bloodstream infections or phlebitis, but not on PIV catheter infiltration. Currently, there are no data on the rate of unscheduled restarts due to PIV catheter failures in South Africa. Method: A small, two-phased study was conducted in one ward. The rate of PIV catheter line complications, and current practices with regard to PIV catheter insertion and maintenance, were investigated in Phase 1. PIV catheter failure rates with regard to a new PIV catheter securement dressing were investigated in the second phase. The results of the two phases were compared to try and establish whether or not the implementation of an advanced securement dressing versus the standard flat transparent film dressing minimised complication rates and unscheduled restarts. Results: Data collected in phase 1, using current practices and a standard flat transparent film dressing, showed that 21% of the PIV catheters failed due to infiltration and had to be restarted. After the implementation of a new PIV catheter securement dressing, the infiltration rate decreased to 1.7%, resulting in significant cost savings. This small study showed that better securement minimised unscheduled restarts and could reduce costs. Further studies are required to raise awareness of PIV catheter failure rates and the unnecessary cost that accompanies unscheduled restarts. Conclusion: Limited reporting of PIV catheter infiltration results in scant statistics regarding these incidences. It will be of value to record and report incidences of PIV catheter line infiltration and seek solutions to minimise complications. Catheter stabilisation devices help secure and preserve the integrity of devices, minimise movement, prevent catheter dislodgment, and help to reduce the risk of complications caused by intravascular devices. Medpharm 2015;19(3):7-11 Introduction Peripheral intravenous (PIV) catheters are used to gain access to patients veins, with the purpose of delivering medication, fluids or blood products. Most patients (60-90%) are given a PIV catheter during their hospital stay, and inserting and maintaining PIV catheters is one of the most common procedures in hospitals. 1,2 It is customary for nurses to record and report complications, such as pressure ulcers, phlebitis, catheter-related bloodstream infections (CR-BSIs) and medication errors. [Phlebitis is inflammation of the vein. 3 The main causes in nature are chemical (hyperosmolar fluids or fluids with a ph either lower than 5 or greater than 9), or mechanical (associated with incorrect catheter size, suboptimal insertion sites, incorrect insertion technique and poor securement of the catheter) and bacterial (incomplete skin antisepsis, lack of aseptic technique, incorrect choice of dressing and inadequate stabilisation device)]. However, PIV catheter complications, such as dislodgement, leaking and infiltration, are not routinely reported in South Africa. (Infiltration is the unplanned administration of a non-vesicant solution or medication into a surrounding tissue; the situation in which the intravenous access device pulls out of the vein or pierces the vein; or the diffusion or accumulation in a tissue or cells of substances not normal to it, or in an amount in excess of normal ). 4 7 2015;19(3)
As an example, PIV catheter infiltration is commonly recorded in the nursing notes as patient s IV tissued (sic). This is a daily occurrence, and it has been determined from speaking to nurses in all sectors that they report encountering PIV catheter infiltrations frequently. PIV catheter infiltration is documented, but is generally not reported as an adverse event. Very few institutions are able to report their PIV catheter failure rate in comparison to their CRBSI rate. Unscheduled restarts (a term that is used when a PIV catheter needs to be re-sited owing to PIV catheter failure) due to complications lead to higher costs for the hospital and funders. To re-site a PIV catheter, extra supplies are needed, e.g. an intravenous tray, cleaning solution, catheter, administration set and dressing. Nursing time is another cost of re-siting a catheter. It removes the nurse from her normal duties of care, and adds an extra R86.57 to the unnecessary cost of a PIV catheter restart. An estimated time of 29 minutes 5 is also required to perform a catheter re-siting. Costs also arise when a peripheral line needs to be restarted as there may be a delay in the administration of medication to the patient, leading to a longer hospital stay and added expenses. Nurses strive for quality patient care in both the public and private sectors. Rosenthal 5 emphasises that patient dissatisfaction with PIV catheter care is one of the most prevalent factors mentioned in patient complaint surveys. When a patient is admitted to hospital, the expectation is that their health issues will be attended to satisfactorily, and that they will not suffer unnecessary and preventable complications with their PIV catheter therapy. It is documented that good catheter securement is not the only parameter for successful PIV catheter dwell times, but that factors such as the type of catheter, the method of skin cleansing and preparing the skin, the condition of the patient and the patient s age may also play a role. 6 Since the early 1990s, standard, flat transparent film dressings have been used in most healthcare facilities. These types of dressings are preferred dressings owing to their transparency and because they make it possible for the insertion site of the PIV catheter to be visualised. Guidelines According to the Centers for Disease Control and Prevention (CDC) guidelines: Transparent, semi-permeable polyurethane dressings permit continuous visual inspection of the catheter site and require less frequent changes than standard gauze and tape dressings. 7 The Infusion Nurses Society, USA, added to this criteria in its 2011 standards of practice, 8 by affirming the importance of transparency, as well as the need for better securement: Vascular access device (VAD) stabilisation should be used to preserve the integrity of the access device, minimise catheter movement at the hub, and prevent catheter dislodgement and loss of access. VADs should be stabilised using a method that does not interfere with assessment and monitoring of the access site, or impede vascular circulation or delivery of the prescribed therapy. Schears 9 emphasised that inadequate catheter securement is an under-recognised patient safety issue which contributes significantly to catheter-related complications, including dislodgment, occlusion, infiltration and infection. From summarising current international guidelines and published clinical studies, it can be surmised that the best practice recommendation would be a transparent (to enable monitoring of the site) securement device (to establish stabilisation of the catheter). Historically, clinicians followed a protocol of re-siting peripheral catheters every 48-96 hours. Up until 2011, the Infusion Nurses Society standards of care recommended site rotation every 96 hours due to the risk of vein site complications. Internationally, this practice has now been revised to replace PIV catheters only if clinically indicated due to signs of infection. (Therefore, frequent site visualisation and assessment is imperative). The 2011 Infusion Nursing Standards of Practice 8 states: The nurse should consider replacement of the short peripheral catheter when clinically indicated, and when infusion treatment does not include peripheral parenteral nutrition. The decision to replace the short peripheral catheter should be based on assessment of the patient s condition, access site, skin and vein integrity, length and type of prescribed therapy, venue of care, the integrity and patency of the VAD, and the dressing and stabilisation device. The CDC agrees with this statement and recommends the close clinical monitoring of PIV catheter sites and no need to replace PIV catheters more frequently than every 72-96 hours to reduce the risk of infection and phlebitis in adults. 7 During a short survey in the Free State in 2013 (data on file, a survey carried out in the Free State, unpublished), 97 nurses completed a questionnaire in which it was asked: Does the peripheral venous catheter stay in for the duration that it should? An overwhelming 98% of nurses answered no. If this survey is reflective of reality, then proper reporting of PIV catheter failure rates needs to be conducted in order to rectify this costly problem. International studies show PIV catheter failure rates to be as high as 50%. 1,10-12 When PIV cathethers fail before their intended removal time, unnecessary costs are incurred. When 8 2015;19(3)
they are re-sited, the patient experiences additional pain and dissatisfaction. This will be compounded by the need to treat the minor or severe IV failure-related complication. 3 It is necessary to understand what the current situation is regarding PIV catheter failures in South Africa. Therefore, this small survey was carried out in a local private hospital. PIV catheter failure occurs when the peripheral venous catheter dislodges, or when the PIV catheter needs to be removed before therapy has been completed owing to complications, i.e. infiltration, extravasation and phlebitis. Objectives Phase 1 The objective of phase 1 was to establish the PIV catheter failure rate at a local hospital in South Africa. Phase 2 The objective of phase 2 was to establish whether or not the introduction of an advanced securement dressing would decrease PIV catheter complications. Method An informal study was conducted in the surgical ward of a private hospital in South Africa. This study was regarded as a pilot project, with a view to expanding the study should it be considered necessary in the future. For the purpose of this investigation, the nursing services management at the hospital was approached, and together with the pharmacy manager and the unit under investigation, approval was granted to gather information on PIV catheter dwell times. Phase 1 The following objectives were listed in the proposal given to the hospital management team: To assess PIV catheter complication rates with the current practice of PIV catheter insertion and care in the identified surgical ward. The current practice was for an enrolled nurse or registered nurse to insert the PIV catheter using either a 20-G or 22-G catheter [Jelco (Smiths Medical )]. The PIV catheter was then secured with a standard, transparent flat film dressing (3M Tegaderm Transparent Film Dressing 1626). To monitor whether or not the patients PIV catheters stayed in situ, and also the duration that they should remain in situ according to prescribed treatment, the doctor s prescription or ward protocol. If the PIV catheter was removed before the prescribed time, to analyse the cause of the removal and need for a Developed by Andrew Jackson, Consultant Nurse, Intravenous Therapy and Care, Rotherham General Hospitals, NHS Trust Figure 1: A Peripheral Intravenous Access Documentation form 6 PIV catheter restart. Nursing staff responsible for PIV catheter insertion and care were trained on the correct completion of the data collection forms. These data collection forms were adapted from the Peripheral Intravenous Access Documentation form, developed by Andrew Jackson in the UK (Figure 1). 6 When a PIV catheter was inserted, the nursing staff completed a one-page document, stating who had inserted the PIV catheter and indicating the site of insertion. The same document was used to specify when the catheter was removed, and the reason for it, e.g. the patient was discharged, on doctor s orders, infiltration or other. Rounds were conducted by the investigator three times a week to ensure that accurate and timely completed documents were collated. The PIV catheter file was kept at the nursing station and contained the data collection documents. Reminders to complete the documentation were placed on the noticeboard and tea room of the ward. Data were collected over a three-week period in October 2013. Phase 2 The standard, flat 3M Tegaderm Transparent Film Dressing 1626, was substituted with a newly launched advanced IV dressing, 3M Tegaderm IV Advanced Securement Dressing 1683, in phase 2. (3M Tegaderm IV Advanced Securement Dressing is a US Food and Drug Administrationclassified securement device, i.e. FDA Classification FDA 21 CFR880.5210. An intravascular catheter securement device has an adhesive backing which is placed over a needle or catheter, and is used to keep the hub of the needle or the catheter flat and securely anchored to the skin). 9 2015;19(3)
The dressing replacement was the only variable in phase 2, and the rest of the insertion, maintenance and recording protocol remained unchanged. According to laboratory studies, 3M Tegaderm IV Advanced Securement Dressing1683 plus tape strips withstood nearly twice the pull force when securing a PIV catheter compared to the standard transparent film dressing. Accordingly, this dressing was chosen as the variable in the second phase. Poorly secured catheters not only lead to dislodgement, infiltration and unscheduled restarts, but also irritation of the vein and phlebitis. 3 The measure of failure in this test was that the PIV catheter moved one centimetre (3M internal data on file). Nursing staff at the site were trained on the application of the new PIV catheter dressing and evaluated for competence in dressing application. Data were collected over an eightweek period from June to August 2014. The rate of complications in phase 1 and phase 2 was compared. This was then presented to the hospital management team in January 2015. Results Phase 1: Current practice of peripheral intravenous catheter insertion and maintenance (n = 62) After three weeks of data collection and documentation, the forms were collected for analysis. Sixty-nine patients documents were collected, but data on only 62 patients 25 20 15 10 5 0 Phase 1 Phase 2 Complications Figure 2: A comparison of peripheral intravenous catheter failure rates in phase 1 versus phase 2 could be included in the analysis owing to incompletion of the documentation by the nursing staff. The analysis revealed a significant PIV catheter failure rate of 21%. From a sample of 62 patients, 13 cases of infiltration were reported. All the complications were due to infiltration of the PIV catheters which had to be re-sited. Phase 2: Securement dressing substitution (n = 58) One patient s data could not be used because of the provision of incomplete documentation by the nursing staff. The PIV catheter failure rate was 1.7%; considerably lower in the second phase. PIV catheter infiltration was recorded in only one patient after five days of PIV catheter therapy (Figure 2). Table I details the results from phase 1 and phase 2. Table I: Results from phase 1 and phase 2 Phase 1 Phase 2 62 Number of patients data collected 58 Number of patients data collected 13 Recorded complications 1 Recorded complications 21% PIV catheter failure rate 1.7% PIV catheter failure rate Detail: 17 catheter failures Detail: 1 catheter failure 7 Infiltrations (day of insertion) 1 Infiltration after 5 days, re-sited 1 Infiltration: Day 1, catheter re-sited Day 3, catheter re-sited and Same day infiltration. The patient had 3 PIV catheters in 3 days 6 PIV catheter infiltrations with a hospital stay longer than one day Infiltrated on day 2, day 3 and day 5 3 PIV catheter infiltration after day 3, re-sited, infiltrated again on day 3 and day 7 IV: intravenous, PIV: peripheral intravenous 10 2015;19(3)
Table II: A comparison of the cost analysis for unscheduled restarts in phase 1 and phase 2 Phase 1: Cost of unscheduled restarts (21% in a 3-week period) Supplies [IV tray, catheter, cleaning solution, administration set and dressing (1626 )* ] Phase 2: Cost of unscheduled restarts (1.7% in an 8-week period) R91.19 Supplies [IV tray, catheter, cleaning solution, administration set and dressing (1683 ** )] R95.19 Nursing time to re-insert the catheter: 20 R59.70 Nursing time to re-insert the catheter:20 R59.70 minutes 5 minutes 5 Total cost of restart R150.89 Total cost of restart R154.89 Number of restarts required (17 in 3 weeks) multiplied by restart costs R2 565.13 Number of restarts required (1 in 8 weeks) multiplied by (restart costs R154.89 Restart cost per week R855.04 Restart cost per week R 19.36 Additional costs for unscheduled restarts (per annum) for one ward *3M Tegadern Transparent Film Dressing 1626 **3M Tegaderm IV Advanced Securement Dressing 1683 IV: intravenous R44 462.25 (R855.04 multiplied over 52 weeks) Additional costs for unscheduled restarts (per annum) for one ward R1 006.79 (R19.36 multiplied over 52 weeks) in almost R45 000 in cost savings per annum for one hospital ward. Figure 3: The standard, flat transparent film dressing used in phase 1, i.e. 3M Tegaderm Transparent Film Dressing 1626 This small study showed that better dressing securement minimises unscheduled restarts and may reduce costs. Further studies are required to raise awareness of PIV catheter failure rates and the unnecessary costs which accompany unscheduled restarts. Conflict of interest The author is an employee of 3M South Africa (Pty) Ltd. Figure 4: The newly launched, notched, bordered, advanced securement dressing used in phase 2, i.e. 3M Tegaderm IV Advanced Securement Dressing 1683 Figure 3 is a visual of the standard, flat transparent film dressing used in phase 1, i.e. 3M Tegaderm Transparent Film Dressing 1626. Figure 4 is a visual of the newly launched, notched, bordered, advanced securement dressing used in phase 2, i.e. 3M Tegaderm IV Advanced Securement Dressing 1683. Table II is a comparison of the cost analysis for unscheduled restarts in phase 1 and phase 2. Conclusion By changing one variable (the securement dressing), the PIV catheter failure rates decreased from 21% to 1.7%, resulting References 1. Bausone-Gazda D, Lefaiver CA, Walter S. A randomized controlled trail to compare the complications of 2 peripheral intravenous catheter-stabilization systems. J Infus Nurs. 2010;33(6):371-384. 2. Hadaway L. Short peripheral intravenous catheters and infections. J Infus Nurs. 2012;35(4):230-240. 3. Helm RE, Klausner JD, Klemperer JD, et al. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015;38(3)189-203. 4. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 Suppl):S1-S92. 5. Rosenthal K. Get a hold on costs and safety with securement devices. Nurs Manage. 2005;36(5):52-53. 6. Bernatchez SF. Care of peripheral venous catheter sites: advantages of transparent film dressings over tape and gauze. JAVA. 2014;19(4):256-261. 7. O Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. 8. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1 Suppl):S1-S110. 9. Schears GJ. Summary of product trials for 10,164 patients: comparing an intravenous stabilizing device to tape. J Infus Nurs. 2006;29(4):225-231. 10. Rickard CM, Webster J, Wallis MC. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomized controlled equivalence trial. Lancet. 2012;380(9847):1066-1074. 11. Webster J, Clarke S, Paterson D, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ. 2008;337:a339. 12. Martinez JA, Piazuelo M, Almela M, et al. Evaluation of add-on devices for the prevention of phlebitis and other complications associated with the use of peripheral catheters in hospitalised adults: a randomized controlled study. J Hops Infect. 2009;73(2):135-142. 11 2015;19(3)