Lehigh Valley Health Network LVHN Scholarly Works Patient Care Services / Nursing Routine vs. Clinically Indicated Peripherally Inserted Intravenous Catheter Changes Juliet Hahn BSN, RN Lehigh Valley Health Network, juliet_t.hahn@lvhn.org Zinah Heisel BSN, RN Lehigh Valley Health Network, zinah_b.heisel@lvhn.org Devin Pond BSN. RN Lehigh Valley Health Network, devin_m.pond@lvhn.org Follow this and additional works at: http://scholarlyworks.lvhn.org/patient-care-services-nursing Part of the Nursing Commons Published In/Presented At Hahn, J., Heisel, Z., & Pond, D. (2015, October 28). Routine vs. Clinically Indicated Peripherally Inserted Intravenous Catheter Changes. Poster presented at LVHN UHC/AACN Nurse Residency Program Graduation, Lehigh Valley Health Network, Allentown, PA. This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org.
Routine vs. Clinically Indicated Peripherally Inserted Intravenous Catheter Changes Juliet Hahn, TNICU RN Zinah Heisel, TNICU RN Devin Pond TNICU RN
Background/Significance Purpose: To compare the rates of phlebitis and infection rates of peripherally inserted intravenous catheters that are changed when clinically indicated rather than routinely (every 72 hours) When talking to nurses: Many times after a thorough IV site assessment a pt s IV will be patent with blood return after 72 hours, as per hospital policy the IV will be removed and the pt will have a new IV placed only to no longer need the IV in another 24 hours. Pt s that are difficult sticks may require up to 4 attempts before obtaining a new IV. Extending the usage of a usable IV could save patients the discomfort of multiple IV placement attempts.
PICO QUESTION In ICU patients, how do phlebitis and infection rates compare when peripherally inserted IV s are changed routinely versus when clinically indicated? P: ICU patients with peripheral IVs I: Clinically indicated peripheral IV changes C: Routine peripheral IV changes O: Rates of infection and phlebitis
TRIGGER? Problem Focused Trigger Reported frustration of nurses with frequent IV changes Insufficient evidence to support routinely changing IV s every 72 hours Increased cost Decreased patient satisfaction
EVIDENCE Search Engines: EBSCOhost Research database, CINAHL, Medline, Cochrane Database of Systematic Reviews Key Words: Clinically indicated replacement vs. Catheter removal; Peripherally inserted catheter; Catheter removal and peripherally inserted central catheter; Catheter related infections or catheter related blood stream infections or catheter related complications or catheter related thrombosis and catheter related infections/pc and Treatment outcomes or nursing outcomes See attached evidence table and following slides for more information
EVIDENCE Decreased or equal rates of phlebitis Phlebitis occurred in 7% of patients with both clinically replaced IVs and routinely replaced IVs Peripheral venous thrombophlebitis developed in 11/26 patients in the control group and 1/21 patients in the study group (P = 0.003). Independent of study group, the rate of phlebitis and/or occlusion at 96 hours was 23.4% (74 of 316 IVs), which was identical to the rate of phlebitis and/or occlusion associated with the 111 IVs used beyond 96 hours. No significant difference in phlebitis or infiltration rates in the intervention group(38%) compared with the control group(33%). When the analysis was based on failure per 1000 device days (number of failures divided by number of days catheterised, divided by 1000), no difference could be detected between the groups. The rate of phlebitis in both groups was low (4% in intervention group, 3% in control group). Decreased or equal rates on infection No significant difference between CRBSI rate. No IVD related blood stream infections in either groups
EVIDENCE Decreased costs More IVDs placed per patient in the control or the routinely changed PIV group, with higher hospital costs per patient Cost of cannula replacements in the control group AUD$3,837.56 and in the intervention group was AUD$3,183.62 Infusion related costs were higher in the control group (mean $A41.02) than intervention group ($A36.40). Increased patient satisfaction Decreased replacements (decreased sticks) of PIV Overall decreased or equal complication rates IVD complication rates 68 per 1,000 IVD days for clinically indicated replacement and 66 per 1,000 IVD days for routine replacement A thorough assessment and maintenance of PIVs can save a nurse more time in the long run!
Current Practice at LVHN "Peripheral short catheters sites should be changed every 72 hours in the adult population. Catheters placed in pre-hospital or institutions other than LVH Facilities are to be replaced within 24 hours of admission unless contraindicated. (Infusion Nursing Standard Practice Jan/Feb 2006. 29. pp. S51)."
IMPLEMENTATION (outline) 1. Process Indicators and Outcomes 2. Baseline Data 3. Design (EBP) Guideline(s)/Process 4. Implemented EBP on Pilot Units 5. Evaluation (Post data) of Process & Outcomes 6. Modifications to the Practice Guideline 7. Network Implementation
IMPLEMENTATION 1. Indicators and Outcomes Indicators: Adverse Affects of Routine vs. Clinically Indicated IV Changes Patient Satisfaction of PIV Insertion and Replacements Outcome Measurements: Patient Satisfaction Time Saved Cost Efficiency
IMPLEMENTATION (cont.) 2. Baseline Data Obtained In TNICU Approximately 90% of patients have a PIV at some point during stay on unit. Approximately 65% keep PIV throughout stay in hospital Patient X hospitalized 90 days Total IV s 39 ( 3 IV s pulled prior to 72hrs) Estimated PIV s needed for 72 hour changes =30 Estimated PIV s needed for 95 hour changes =23 Average estimated cost per PIV insertion placed on initial attempt $41.00. Estimated saving if PIV use extended to 96 hours ( 7 less PIV s) $287.00. According to U.S. News and World Report LVH-CC had 44,853 admissions in 2014. With an average estimated cost of $41.00 per PIV insertion, if obtained on the initial attempt. If PIV usage was extended to 96 hours and each admission had one less PIV s and estimated $1,838,973 would be saved in one year.
EBP Guidelines/Process Change Assessment of Peripheral I.V. at least every 4 hours No Infiltration No Extravasation No Infection Continue to reassess site every 4 hours up to 96 hours
IMPLEMENTATION (cont.) 4. Implemented EBP on Pilot Units Project approval denied by Infectious Disease therefore unable to implement on TNICU 5. Evaluation (Post data) of Process & Outcomes Not applicable Theoretically, based on research data no change or increase in infection and phlebitis rates when PIV s are changed routinely as current policy dictates versus when clinically indicated per research 6. Modifications to the Practice Guideline None at this time 7. Network Implementation Continue to research data on PIV maintenance and suggested replacement times to present to Infectious Disease
RESULTS Theoretically, based on research data no change or increase in infection and phlebitis rates when PIV s are changed routinely as current policy dictates versus when clinically indicated per research
Implications for LVHN This project has the potential to increase patient satisfaction, decrease hospital costs, and continue to maintain safety for patients in terms of infection and phlebitis rates related to PIV s
Lessons Learned Ample research and data is needed in order to obtain approval for changes in hospital policy It is difficult to change a policy that was implemented due to past safety issues Previously, there were rises in infection and phlebitis rates related to PIV s that were not changed routinely In order to implement change within the hospital, teamwork and cooperation are needed among multiple interdisciplinary groups
References Aziz, A. (2009). Improving peripheral IV cannula care: implementing high-impact interventions. British Journal of Nursing, 18(20), 1242-1246. Barker, P., Anderson, A. G., & MacFie, J. (2004). Randomised clinical trial of elective re-siting of intravenous cannulae. Annals Of The Royal College Of Surgeons Of England, 86(4), 281-283. Dychter, S., Gold, D., Carson, D., & Haller, M. (2012). Intravenous Therapy: A review of complications and economic considerations of peripheral access. Journal of Infusion Nursing, 35(2), 84-91. Nishanth, S., Sivaram, G., Kalayarasan, R., Kate, V., & Ananthakrishnan, N. (2009). Does elective re-siting of intravenous cannulae decrease peripheral thrombophlebitis? A randomized controlled study. The National Medical Journal Of India, 22(2), 60-62. Rickard, C., McCann, D., Munnings, J., & McGrail, M. (2010). Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicates resite: a randomised controlled trial. BMC Medicine, 8(53). Rickard, C., Webster, J., Wallis, M., Marsh, N., McGrail, M., French, V., &... Whitby, M. (2012). Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet, 380(9847), 1066-1074. Salgueiro-Oliveira, A, Parreira, P, & Veiga, P. (2012). Incidence of phlebitis in patients with peripheral intravenous catheters: The influence of some risk factors. Australian Journal of Advanced Nursing, 30(2), 32-39. Van Donk P, Rickard CM, McGrail MR, Doolan G. (2009). Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: a randomized controlled trial. Infection Control and Hospital Epidemiology, 30(9):915 917. Webster, J., Clarke, S., Paterson, D., Hutton, A., van Dyk, S., Gale, C., & Hopkins, T. (2008). Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ (Clinical Research Ed.), 337-339. Webster, J., Lloyd, S., Hopkins, T., Osborne, S., & Yaxley, M. (2007). Developing a Research base for Intravenous Peripheral cannula re-sites (DRIP trial). A randomised controlled trial of hospital in-patients. International Journal Of Nursing Studies, 44(5), 664-671. Webster, J., Osborne, S., Rickard, C., & New, K. (2013). Clinically indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Of Systematic Reviews, (4).
Make It Happen Questions or comments may be directed to: Juliet Hahn Zinah Heisel Devin Pond TNICU 610-402-8930