Recommendations for Improving Safety Practices With Short Peripheral Catheters

Factors influencing peripheral intravenous catheter practice of nurses in small and medium sized hospitals: a cross-sectional study

BACKGROUND

The importance of the peripheral intravenous catheter (PIVC) practices on patient safety is increasing. Small and medium-sized hospitals play a central role in the provision of healthcare services in South Korea, but lack a system for quality improvement, leaving patient safety at risk. This study aimed to identify the extent to which the PIVC practice knowledge of nurses, the nursing working environment, and the patient safety-culture perception affect PIVC practices and thereby provide basic data for improving the PIVC practices in small and medium-sized hospitals.

METHODS

This study had a cross-sectional descriptive design to identify the factors affecting PIVC nursing practices in small and medium-sized hospitals. Questionnaires returned by 149 nurses collected data on general characteristics, practical knowledge of PIVC nursing, nursing working environment, patient safety-culture perception, and PIVC practices. The questionnaire data were analysed using descriptive statistics, the independent t-test, one-way ANOVA, Scheffé's test, Pearson correlation, and hierarchical regression analysis.

RESULTS

The mean score of PIVC practices was 4.60 out of 5. Length of clinical experience, practical knowledge of PIVC nursing and patient safety-culture perception were significant factors affecting the PIVC nursing practices, with these variables explaining 26.2% of the variance therein.

CONCLUSIONS

The PIVC practices of nurses in small and medium-sized hospitals can be improved by providing education and training based on the latest standard or guideline to facilitate the acquisition of knowledge and skills. And campaigns and programs to strengthen patient safety culture perception specific to small and medium-sized hospital should be implemented. to ensure the safety of PIVC practice.

Successful implementation of safe practice for adult intravenous push medication in a tertiary care hospital: determination of stability of four intravenous antibiotics in syringes

In 2017, a severe shortage of infusion bags resulted in a paradigm change in medication administration practice from intermittent infusion to intravenous push. The Institute for Safe Medication Practices proposed safe practice guidelines for adult intravenous push medications. A different study showed that ready-to-administer medication prepared in the sterile area of a pharmacy reduces the risk of harm, nurses' time for medication administration and the cost of medications. Based on the recommendation of the Institute for Safe Medication Practices, we decided to conduct a pilot study on the implementation of sterile compounding and administration of intravenous push medication in adult patients admitted to the hospital. In the study, the stability of five intravenous push antibiotic syringes was also determined in the syringes.

Near-infrared technology for improved PIVC placement: a clinical technology implementation model

AIMS

To share lessons learned from an evidence-based practice (EBP) initiative that implemented near-infrared (NIR) technology in a large US hospital system. A Clinical Technology Implementation Model (CTIM©) that can be adapted for use in other health institutions is presented.

BACKGROUND

EBP implementation, including the adoption of new cutting-edge technologies, is crucial to improving patient care. Yet there are significant delays in changes to clinical practice, often due to organisational challenges that stifle the implementation process. The evidence-practice gap is increasingly evident in peripheral intravenous access (PIV). Implementation science offers new insights into the challenges of updating clinical practice, which can support EBP implementation.

EVALUATION

Recent literature on implementation science, change theory, PIV access, NIR technology, and patient outcomes were reviewed. A model that can help nurse managers implement technology that aligns with EBP is presented, drawing on experience from the adoption of NIR vein visualisation to enhance PIV access in a large US hospital system.

KEY ISSUE

A pervasive hesitancy in healthcare to embrace technology, coupled with the challenges of implementing a change to practice, has led to limited application of EBP PIV access guidelines and a stagnant standard of care.

CONCLUSION

This article provides nurse managers with the tools necessary to successfully implement EBP, drawing on the experience from implementing NIR in a large US hospital. Nurse managers are uniquely positioned to lead the way in embracing technology to improve care and reduce the evidence-practice gap.

Examining the effect of training with a teaching for understanding framework on intravenous therapy administration's knowledge, performance, and satisfaction of nursing students: a non-randomized controlled study

BACKGROUND

Nursing students require improvement in their intravenous infusion therapy management skills, yet traditional training models possess deficiencies. The Teaching for Understanding (TfU) Framework can enhance the teaching-learning process and support quality education. Therefore, utilizing TfU framework for training may promote the performance of nurses.

METHODS

Utilizing a non-synchronized design, 102 nurses were recruited using a convenience sampling method. Fifty-one student nurses from August 2019 to January 2021 were designated as the control group, and 51 student nurses from February 2021 to July 2022 were included as the intervention group. The control group received traditional teaching methods, while the intervention group was trained based on TfU framework. The impact was gauged through medical education environment perception, theory and practice assessments, and learning satisfaction surveys.

RESULTS

After the training, there was no significant difference between the control group and the intervention group in the theory assessment. However, the practice assessment scores of the intervention group were significantly higher than those of the control group. Compared with the control group, the learning satisfaction scores of the trained nurses in the intervention group were significantly higher, exhibiting significant differences, particularly in communication ability, teamwork cooperation, summing up capability, and interest in learning improvement. Furthermore, the scores of the learning perceptions, atmosphere, social self-perceptions, and total scores of the intervention group were significantly higher.

CONCLUSION

Training using TfU framework can heighten students' understanding and command over knowledge and skills, fuel their learning fervor, and enhance their communication and collaboration abilities. TfU framework should be disseminated in medical education to improve the quality of education.

A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial

OBJECTIVE

Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients.

METHODS

This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model.

RESULTS

Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001).

CONCLUSIONS

Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.

Evaluation of a Point-of-care ultrasound (POCUS) workshop for peripheral intravenous cannulation

BACKGROUND

Point-of-care ultrasound (POCUS) is increasingly used as a non-invasive vascular access assessment method by clinicians from multiple disciplines worldwide, prior and during vascular access cannulations. While POCUS is a relatively new method to establish a vascular access in patients with complex vascular conditions, it is also essential to train and educate individuals who are novices in the techniques of cannulation so that they become proficient in performing this task subsequently on patients safely and successfully. A simulated environment may be a helpful tool to help healthcare providers establish skills in using POCUS safely and may also help them to successfully establish vascular access in patients. With this project, we sought to determine if participants of a simulated POCUS workshop for vascular access can use this technique successfully in their individual clinical environment after their attendance of a half-day workshop.

METHODS

A mixed-methods longitudinal study design was chosen to evaluate a point-of-care ultrasound workshop for peripheral intravenous cannula insertion. The workshops used simulation models for cannulation in combination with multiple ultrasound devices from various manufacturers to expose participants to a broader variety of POCUS devices as they may also vary in different clinical areas. Participants self-assessed their cannulation skills using questionnaires on a 10-point rating scale prior to and directly after the workshop.

RESULTS

A total of 85 Individuals participated in eleven half-day workshops through 2021 and 2022. Workshop participants claimed that attending the workshop had significantly enhanced their clinical skill of using ultrasound for the purpose of cannulating a venous vessel. The level of confidence in using this technique had increased in all participants directly after conclusion of the workshop.

CONCLUSIONS

Globally, clinicians are increasingly using POCUS to establish vascular access in patients, and it is necessary that they receive sufficient and adequately structured and formal training to successfully apply this technique in their clinical practice. Offering a workshop which uses simulation models in combination with various POCUS devices to demonstrate this technique in a hands-on approach has proven to be useful to establish this newly learned skill in clinicians.

Trendelenburg position for internal jugular vein catheterization: A systematic review and meta-analysis

To determine the effect of Trendelenburg position on the diameter or cross-section area of the internal jugular vein (IJV) a systematic review and metanalysis was performed. Studies that evaluated the cross-sectional area (CSA) and anteroposterior (AP) diameter of the right internal jugular vein (RIJV) with ultrasonography in supine and any degree of head-down tilt (Trendelenburg position) were analyzed. A total of 22 articles (613 study subjects) were included. A >5° Trendelenburg position statistically increases RIJV CSA and AP diameter. Further inclination from 10° does not statistically benefit IJV size. This position should be recommended for CVC placement, when patient conditions allow it, and US-guided cannulation is not available.

European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project

Since several innovations have recently changed the criteria of choice and management of peripheral venous access (new devices, new techniques of insertion, new recommendations for maintenance), the WoCoVA Foundation (WoCoVA = World Conference on Vascular Access) has developed an international Consensus with the following objectives: to propose a clear and useful classification of the currently available peripheral venous access devices; to clarify the proper indication of central versus peripheral venous access; discuss the indications of the different peripheral venous access devices (short peripheral cannulas vs long peripheral cannulas vs midline catheters); to define the proper techniques of insertion and maintenance that should be recommended today. To achieve these purposes, WoCoVA have decided to adopt a European point of view, considering some relevant differences of terminology between North America and Europe in this area of venous access and the need for a common basis of understanding among the experts recruited for this project. The ERPIUP Consensus (ERPIUP = European Recommendations for Proper Indication and Use of Peripheral venous access) was designed to offer systematic recommendations for clinical practice, covering every aspect of management of peripheral venous access devices in the adult patient: indication, insertion, maintenance, prevention and treatment of complications, removal. Also, our purpose was to improve the standardization of the terminology, bringing clarity of definition, and classification.

Peripheral Intravenous Catheter Insertion Competence and Confidence in Medical/Surgical Nurses

The objective of this study was to implement an evidence-based practice project to improve peripheral intravenous catheter (PIVC) insertion confidence and competence and to improve first-attempt success. The researcher used a blended online learning module and live simulation to increase PIVC insertion confidence and competence. Internal application of a blended curriculum model improved the first-attempt PIVC insertion success of nurses. A validated confidence assessment was completed by participants (n = 38) preintervention, immediately postintervention, and 30 days postintervention. A Mann-Whitney U test determined that nurses' confidence was significantly higher immediately following the intervention compared with preintervention (P = .003), and the increase was sustained 30 days after the intervention (P < .001). While placing a PIVC in simulation, the observer measured competence using a validated tool verifying 28 steps required, with a 76% success rate for all 28 steps. Nurses' self-reported first-attempt PIVC success increased significantly from the preintervention survey to the 30-day postintervention survey (P = .00004).

Trendelenburg (Head-Down Tilt) and Head Rotation: Ultrasonographic effects on the internal jugular vein for catheterization safety

Most guidelines fail to specify patient positioning during central venous catheterization. The objective was to determine the effects of head-down tilt (Trendelenburg position) and head rotation on the internal jugular vein (IJV). A prospective, observational, longitudinal, and descriptive study using healthy adult volunteers, of both sexes, was performed. The change in position and cross-sectional areas (CSA) of the right IJV and common carotid artery (CA) were measured by ultrasonography during Trendelenburg position (TP) (0°, 5°, 10°, and 15°) and contralateral head-rotation (HR) (0°, 45°, and 90°) for a total of 12 positions. The neutral supine position was first, randomizing the other 11 positions, with 5-minute rest intervals in between. Vital signs and symptoms were recorded. A total of 54 volunteers were recruited between the ages of 21 and 32, of which 30 were men. Any degree of TP or HR significantly increased the CSA. The largest area obtained was 1.78cm² with a TP15HR90 which did not have a statistical difference with TP10HR45 1.59cm² . A HR90 tended to displace the IJV medially, overlaying the CA. Any degree of TP or HR will significantly increase CSA or the right IJV. A 5° to 10° TP is recommended when the patient's condition allows it, with a 45° HR, without significantly displacing the IJV anterior to the CCA. This article is protected by copyright. All rights reserved.

Nurse knowledge and confidence on peripheral intravenous catheter insertion and maintenance in pediatric patients: A multicentre cross-sectional study

PURPOSE

To examine nursing knowledge and confidence of peripheral intravenous catheter insertion and maintenance in pediatric patients.

DESIGN AND METHODS

An online survey using validated questionnaires was conducted in ten (tertiary and district) hospitals in Indonesia from May to September 2020. Multivariable general linear models were used to investigate associations between nurses' characteristics and knowledge and confidence on the catheter insertion and maintenance score.

RESULTS

A total of 413 out of 458 pediatric nurses completed the survey (a response rate of 90%). The mean score of the nurse knowledge on insertion was 18.9(±3.3) (maximum score: 21), and the maintenance score was 6.5(±2.0) (maximum score: 12). The median score of the nurse insertion and maintenance confidence was quite high: 44 (IQR = 7) out of 50 and 37 (IQR = 4) out of 45, respectively. Initial patient assessment, catheter securement, site assessment and management of complications are areas where nurse knowledge and confidence are still lacking. Adjusted analysis indicates that training and work experience were significantly associated with the knowledge and confidence score (p < 0.05).

CONCLUSION

Pediatric nurses were largely confident in their skills but this was not reflected in their knowledge scores. Training and experience were important predictors for nursing knowledge and confidence in catheter insertion and maintenance.

PRACTICE IMPLICATIONS

The results provide nursing and hospital managers and educational institutions to understand areas of intravenous catheter insertion and maintenance in which nurses lack of knowledge and confidence as well as to formulate tailored and ongoing training to improve nurse knowledge, confidence, practices and optimize patients' care.

Hiding in Plain Sight: Peripheral Intravenous Catheter Infections

TOPIC

This article presents an overview of the burden of peripheral intravenous catheter infections and current evidence-based recommendations for prevention.

CLINICAL RELEVANCE

Peripheral intravenous catheters are ubiquitous in most health care settings, fostering an acceptance of the peripheral intravenous catheter as benign and inevitable. This device, however, is far from benign, with reported failure rates as high as 90% from complications such as infection and phlebitis. Although reported rates of bloodstream infection related to peripheral intravenous catheters are much lower than those attributed to central venous catheters, the exponentially higher use of peripheral intravenous catheters indicates that the absolute number of peripheral venous catheter-related bloodstream infections is likely as high as and may surpass the number of central venous catheter-related bloodstream infections, with significant associated morbidity and mortality.

PURPOSE OF PAPER

Sustained improvements in outcomes related to peripheral intravenous catheters will depend on recognition of the root causes of failure and increased commitment to practice patterns consistent with infusion therapy standards of practice, effective education about peripheral intravenous catheters, accurate documentation of all aspects of peripheral intravenous catheter management, and consistent surveillance of patient outcomes related to peripheral intravenous catheters.

CONTENT COVERED

This article reviews the significant burden of peripheral intravenous catheter infections, barriers to effective peripheral intravenous catheter management, and current evidence-based recommendations to prevent this source of patient harm.

Innovative approaches to teaching vascular access to nursing students in the COVID-19 era

PURPOSE

For the student nurse, peripheral venous cannulation is one of the most stressful skills to be learned. Although some healthcare employers/establishments offer courses on vascular access and infusion nursing as part of their onboarding programs, ultimately educational institutions should share the responsibility to ensure that graduating nurses can provide safe infusion therapies.

METHODS

An innovative vascular access and infusion nursing (VAIN) curriculum was created and mapped onto the entry to practice undergraduate nursing program at McGill University in Montréal, Québec, Canada. This presented an opportunity to implement new teaching approaches.

RESULTS

Students experienced multiple new teaching approaches including multimedia and experiential learning and live simulation to ensure acquisition of knowledge and psychomotor skills. The teaching approaches had to be rapidly modified with the advent of the COVID-19 pandemic.

CONCLUSIONS

The VAIN curriculum emphasizes simulation and directed practice, seeking to increase competence, confidence, and knowledge. The pandemic underscored the need for flexibility and creativity in content delivery.

The safety of clinically indicated replacement or routine replacement of peripheral intravenous catheters: A randomized controlled study

OBJECTIVE

The primary purpose of this study was to explore the safety of peripheral intravenous catheter (PIVC) replacement every 96 h compared to that of clinically indicated catheter removal.

METHODS

A prospective, single-blind, randomized controlled trial was conducted. A random number table method was used. Six hundred patients treated with PIVC intravenous infusion in 10 nursing units of a hospital from September to October 2019 were selected. Sixty were collected from each nursing unit, including 30 in the clinically indicated replacement group and 30 in the routine replacement group. The incidence of phlebitis, catheter-related infection (CRI), occlusion, infiltration, and any form of infusion therapy failure were compared between the two groups. SPSS 23.0 software was used.

RESULTS

The dwelling times of PIVC in the clinically indicated replacement group and routine replacement group were significantly different (hours) (83.62 ± 50.08, 69.75 ± 25.54, t = 3.021, p = 0.003). The incidence of any form of infusion therapy failure (RR = 4.448, 95% CI: 3.158-6.265, p < 0.001), phlebitis (RR = 2.416, 95% CI: 1.595-3.660, p < 0.001), occlusion (RR = 6.610, 95% CI: 3.062-14.268, p < 0.001), infiltration (RR = 2.607, 95% CI: 1.130-6.016, p = 0.020), accidental dislodgement (RR = 2.027, 95% CI: 1.868-2.200, p = 0.013), and pain at the insertion site (RR = 2.521, 95% CI: 1.742-3.649, p < 0.001) was higher in the clinically indicated replacement group than that in the routine replacement group. The overall survival curve of PIVC was drawn with Kaplan-Meier survival analysis. The median survival time of intravenous infusion was 59.58 h; the cumulative survival rates of 48 h, 72 h, and 96 h were 77.00%, 51.33%, and 20.33%, respectively.

CONCLUSION

Replacement of PIVC every 96 h is safer than clinically indicated.

A Qualitative Study of Adult Hospitalized Patients With Difficult Venous Access Experiencing Short Peripheral Catheter Insertion in a Hospital Setting

Hospitalized patients require venous access for procedures, treatments, or therapies. The short peripheral catheter (SPC) is one option for patients who need intravenous (IV) access for treatment. Patients with difficult vasculature sometimes require multiple attempts to obtain SPC access. The aim of this study was to gain an understanding of adult patients' experiences with SPC insertion, specifically those with difficult venous access. Ten participants were purposely sampled over a 2-month period for semistructured interviews from the medical, surgical, and telemetry units at an inner city, 750-bed trauma hospital in the southwestern United States. Four key themes developed from the interview data: skills and techniques of the clinicians, distress and the SPC insertion experience, physical and emotional pain, and patient/clinician communication. These themes provided ways that clinicians might improve the patient experience, including: ensuring experienced and confident inserters are available to insert SPCs, utilizing distraction and pain methods to decrease pain perception, communicating with patients regarding site selection and expectations during SPC insertion, and identifying patients with difficult vascular access to limit attempts per patient to preserve vascular sites.

A study on the management of needle-stick and sharps injuries based on total quality management in a tertiary hospital in western China

Objective:

Based on the concept of total quality management, the practice of managing needle-stick and sharps injuries was analyzed to improve nursing quality.

Methods:

Using total quality management, an improvement plan was completed. Standard operating procedures for infusion therapy and monitoring of the circulatory system were made to reduce the utilization of winged metal needles and the frequency of needle-stick injuries. From 2015 to 2018, four cross-sectional surveys were conducted on the use of winged metal needles, peripheral intravenous catheters, central venous catheters, peripherally inserted central catheters, and implantable venous access ports and the status of needle-stick and sharps injuries in our hospital during the 4 years.

Results:

Four cross-sectional surveys showed that the percentage of winged metal needle utilization decreased significantly from 13% to 0.5%, and that of peripheral intravenous catheters increased from 77% to 87%. Zero tolerance of winged metal needles increased from 33 to 60 nursing units, an improvement rate of 81.82%. The number of needle-stick injuries decreased from 71 to 21, a decrease of 70.42%. Needle-stick injuries occurred mainly during waste disposal (34.71%) and needle withdrawal (18.18%) and when recapping needles (9.92%).

Conclusion:

Based on total quality management, the implementation of zero tolerance of winged metal needles is much better. The use of winged metal needles and the incidence of needle-stick injuries are reduced. Total quality management is of great clinical value in preventing needle-stick injuries.

Peripheral Venipuncture Education Strategies for Nursing Students: An Integrative Literature Review

This integrative literature review identified strategies to teach peripheral venipuncture to nursing students. The following databases were searched for primary studies: Biblioteca Virtual em Saúde (BVS), PubMed, Web of Science, Education Resources Information Center (ERIC), SCOPUS, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The final sample was composed of 24 studies. The literature ranged from descriptive studies to controlled clinical trials and methodologic studies to construct products/instruments for teaching peripheral venipuncture. The most frequently identified teaching strategies were theoretical contents taught via theoretical lecture, e-learning courses, video lessons, and demonstration by specialists combined with practical exercises using a mannequin, human arms, and/or haptic devices. Despite the different methods used currently, the best patient outcomes were achieved when the student received the theoretical content in an educational setting before the practical training on a mannequin and/or a virtual simulator.

VIDA-Nursing v1.0: immersive virtual reality in vacuum blood collection among adults

OBJECTIVE

to develop and validate the first immersive virtual reality simulation addressing vacuum blood collection in adult patients - VIDA-Nursing v1.0.

METHOD

methodological study to validate 14 steps of the vacuum blood collection procedure in adults, designed to develop the immersive virtual reality simulator VIDA-Nursing v1.0. It was assessed by 15 health workers and 15 nursing undergraduate students in terms of visual, interactive, movement simulation reality, teaching and user-friendly aspects.

RESULTS

the workers considered 79.6% of the items to be valid, while the students considered 66.7% of the items valid; most of the demands can be implemented in the system by improving future versions.

CONCLUSION

the simulator was considered a promising and innovative tool to teach vacuum blood collection in adults as it can be combined with other resources currently used to introduce this topic and technique in the education of undergraduate nursing students.

A Comparative Study of Blood Sampling From Venipuncture and Short Peripheral Catheters in Pediatric Inpatients

This prospective, comparative study examined blood test results, hemolysis rates, and patient perceptions related to 2 blood sampling methods in pediatric inpatients (N = 95). Blood specimens were drawn via venipuncture and a short peripheral catheter used for fluid administration. Results revealed no significant differences in potassium and glucose levels. No clinically significant difference in hemoglobin was noted. Hemolysis rates were 4% for venipuncture samples and 15% when drawn from peripheral catheters. One catheter became occluded after a blood draw. Patients/parents rated distress and dissatisfaction with venipuncture as significantly greater compared with short peripheral catheter blood sampling (P < .001).

Nurses' Short Peripheral Catheter Flushing Practices: Implications for Patient Care, Nursing Education, and Policy

Nursing practice and institutional policies regarding short peripheral catheter (SPC) flushing vary. These variations result in a lack of understanding about the factors that influence nurses' SPC flushing practices and leave their effect on outcomes unexplored-information that could potentially enhance nurses' clinical education, institutional policy efforts, and patient care. Using a mixed-methods design, this study examined SPC flushing practices and outcomes among a cohort of medical-surgical nurses and explored their rationale for flushing. Trends were noted in the timing of flushes, and the factors that influenced nurses' SPC flushing practices included patient acuity, experience, and workload.

Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: A systematic review

BACKGROUND

Evidence-based bundles have reduced central line bloodstream infection rates in adult intensive care units. To tackle peripheral intravenous catheter (PIVC) bloodstream infection, many hospitals have implemented PIVC insertion and maintenance bundles. However, the efficacy of PIVC bundles in preventing PIVC complications and infection in hospital patients is uncertain. The aim of this paper is to synthesize evidence on the effectiveness of PIVC insertion and maintenance bundles on preventing adverse events.

METHODS

In this systematic review, we searched multiple electronic databases, trial registries, and grey literature for eligible studies published in English (January 2000-December 2018) to identify intervention studies evaluating PIVC insertion or maintenance bundles with two or more components. Search terms: peripheral intravenous catheter/cannula, insertion, maintenance, bundle, infection, infiltration, extravasation, dislodgement, thrombosis, occlusion, and phlebitis. Two reviewers independently conducted data extraction and quality assessments using the Downs and Black checklist.

RESULTS

Of 14,456 records screened, 13 studies (6 interrupted time-series, 7 before-and-after) were included. Insertion and maintenance bundles included multiple components (2-7 items per bundle). Despite testing different bundles, 12 studies reported reductions in phlebitis and bloodstream infection, and one study reported no change in bloodstream infection and an increase in phlebitis rate. Methodological quality of all studies ranked between 'low' and 'fair'.

CONCLUSIONS

The effect of PIVC bundles on PIVC complications and bloodstream infection rates remains uncertain. Standardisation of bundle components and more rigorous studies are needed. PROSPERO registration number: CRD42017075142.

When in Doubt, Pull the Catheter Out: Implementation of an Evidence-Based Protocol in the Prevention and Management of Peripheral Intravenous Infiltration/Extravasation in Neonates

The vast majority of infants in the NICU receive peripheral intravenous (PIV) therapy for administration of fluids, nutrition, medications, and blood products. The potential complications of infiltration and extravasation are common in this population. Consequences of inf.ltration and extravasation may be prevented or mitigated by early detection and prompt treatment. In addition, innovative therapies for wound care are constantly evolving. In order to improve outcomes, a practice guideline for intravenous (IV) infiltration prevention, management, and treatment is presented based on literature review and consultation with wound care experts. The guideline includes preventive measures, standardized IV assessment, staging, an algorithm outlining injury, and wound care recommendations.

Accepted but Unacceptable: Peripheral IV Catheter Failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Impact and Safety Associated with Accidental Dislodgement of Vascular Access Devices: A Survey of Professions, Settings, and Devices

Background: Dislodgement rates with intravenous catheters are reported at 1.8%–24% events per year resulting in failed access, interrupted treatment, and greater resource consumption with catheter replacement. The purpose of this study was to quantitatively evaluate the perceptions of frequency, impact, contributing factors, and safety issues from accidental dislodgement affecting intravenous (IV) devices as reported by healthcare clinicians.

Methodology: A cross-sectional descriptive survey was conducted via a voluntary online web-based survey of clinicians. Subjects were divided as those actively working in a clinical healthcare setting and those no longer active. Analysis of data was performed quantifying responses of clinicians on question of dislodgement.

Results: Survey results indicate clinicians routinely observe a significant percentage of accidental dislodgement, with 68% of the 1561 respondents reporting often, daily, or multiple times daily occurrence and 96.5% identifying peripheral intravenous catheters as most common device experiencing accidental dislodgement. Respondents prioritized 10 contributing factors, with confused patient (80%), patient physically removes catheter (74%), and IV catheter tape or securement loose (65%) as the top 3 causes. Over 95% of respondents consider IV dislodgement a safety risk to patients.

Conclusions: This study reports perceptions and impact of accidental dislodgement with IV devices. Inconsistencies exist with use, application, and management of catheter securement and dressings for IV catheters. Risk of additional complications and complete device failure are increased when dislodgement occurs. Given possible complications, along with necessitating replacement of the IV device in many cases, IV catheter dislodgement was considered a safety risk to patients by nearly all respondents.

Expert versus generalist inserters for peripheral intravenous catheter insertion: a pilot randomised controlled trial

Background

Peripheral intravenous catheters (PVCs) are essential invasive devices, with 2 billion PVCs sold each year. The comparative efficacy of expert versus generalist inserter models for successful PVC insertion and subsequent reliable vascular access is unknown.

Methods

A single-centre, parallel-group, pilot randomised controlled trial (RCT) of 138 medical/surgical patients was conducted in a large tertiary hospital in Australia to compare PVC insertion by (1) a vascular access specialist (VAS) or (2) any nursing or medical clinician (generalist model). The primary outcome was the feasibility of a larger RCT as established by predetermined criteria (eligibility, recruitment, retention, protocol adherence). Secondary outcomes were PVC failure: phlebitis, infiltration/extravasation, occlusion, accidental removal or partial dislodgement, local infection or catheter-related bloodstream infection; dwell time; insertion success, insertion attempts; patient satisfaction; and procedural cost-effectiveness.

Results

Feasibility outcomes were achieved: 92% of screened patients were eligible; two patients refused participation; there was no attrition or missing outcome data. PVC failure was higher with generalists (27/50, 54%) than with VASs (33/69, 48%) (228 versus 217 per 1000 PVC days; incidence rate ratio 1.05, 95% confidence interval 0.61–1.80). There were no local or PVC-related infections in either group. All PVCs (n = 69) were successfully inserted in the VAS group. In the generalist group, 19 (28%) patients did not have a PVC inserted. There were inadequate data available for the cost-effectiveness analysis, but the mean insertion procedure time was 2 min in the VAS group and 11 min in the generalist group. Overall satisfaction with the PVC was measured on an 11-point scale (0 = not satisfied and 10 = satisfied) and was higher in the VAS group (n = 43; median = 7) compared to the generalist group (n = 20; median = 4.5). The multivariable model identified medical diagnosis and bed-bound status as being significantly associated with higher PVC failure, and securement with additional non-sterile tape was significantly associated with lower PVC failure.

Conclusion

This pilot trial confirmed the feasibility and need for a large, multicentre RCT to test these PVC insertion models.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12616001675415. Registered on 6 December 2016.

Peripheral intravenous catheter difficulty - A clinical survey of registered nurse and critical care nurse performance

OBJECTIVES

To describe the characteristics, problems and interventions associated with performing peripheral intravenous catheterisation in difficult situations when registered nurses need support from critical care nurses.

BACKGROUND

Only a few studies have focused on peripheral intravenous catheterisation problems or interventions to promote success. There is limited research on the education, knowledge, confidence and skills of registered nurses associated with successful peripheral intravenous catheterisations.

DESIGN

A descriptive cross-sectional survey design was used.

RESULTS

A total of 101 questionnaires were completed by critical care nurses (n = 32) and 92 by registered nurses (n = 83); the total number of participants was 115. The same critical care nurses and registered nurses could participate several times on different occasions. Statistical analyses were performed using descriptive statistics. The patterns differed in part between the registered nurses who needed support and the critical care nurses who provided the support. Both registered nurses and critical care nurses used ultrasound to a very low extent (2.2% vs. 1.0%). The registered nurses indicated to a significantly higher extent (p = 0.02) that the veins were invisible and that they had performed the optional interventions. The success rate for critical care nurses was considerably high (86.1%). The most common place for successful insertion was the wrist. Critical care nurses performed fewer interventions, and they informed the patients and assessed that the veins were fragile to a higher extent.

CONCLUSIONS

Superior nursing skills are required in order to adapt and assess specific situations related to peripheral intravenous catheterisation difficulties and to choose the adequate interventions. Young and newly graduated registered nurses should be offered individualised training during the post-educational period on how to assess problems and perform peripheral intravenous catheterisations in specific difficult situations.

RELEVANCE TO CLINICAL PRACTICE

Simulation is suggested for practical training in order to increase patient safety related to the performance of technical skills such as peripheral intravenous catheterisation.

Addressing the Silence: a Need for Peripheral Intravenous Education in North America

Background: Greater than 90% of hospitalized patients receive some form of peripheral intravenous therapy for the delivery of fluids, medication, or parenteral nutrition. Nurses are the largest group of clinicians responsible for the placement and management of peripheral intravenous therapies. The literature suggests that many graduate nurses lack the confidence, knowledge, and ability to not only place peripheral intravenous catheters, but also adequately maintain peripheral intravenous sites. This fact, combined with the increasing acuity of hospitalized patients with multiple comorbidities, makes peripheral intravenous placement and management even more challenging. This drove a team of researchers to explore the current state of peripheral intravenous education in health care institutions and examine potential gaps in ongoing professional development and competency assessment.

Methods: A convenience sample of United States and Canadian health care institution representatives were recruited to participate in a 12-item web-based questionnaire regarding peripheral intravenous education and staff competency. Participants were recruited via the Association for Vascular Access listserv, newsletter, and annual meeting. Members were also asked to forward the recruitment e-mail to other health care institutions to ensure a representative sample.

Results: A total of 611 health care institution representatives participated in the study. The large majority (80%) worked in a health care institution with more than 150 beds. Over half (67%) indicated that they provide peripheral intravenous education to their staff using varying modalities to deliver the education. The majority (54%) of health care institutions reported spending between 1 and 5 hours on peripheral intravenous education while, alarmingly, 38% reported spending less than 1 hour on peripheral intravenous education for their staff. Despite these numbers, over half of the participants (58%) believe peripheral intravenous education is a shared responsibility between pre-licensure nursing schools and health care institutions.

Discussion: The study highlights the varying level of peripheral intravenous education and competency evaluation of staff working in health care institutions. The results suggest the need for an evidence-based, standardized peripheral intravenous curriculum that could be used in both health care institutions and nursing education programs.

Conclusion: Currently, there are inconsistencies in the peripheral intravenous education and competency programs used in health care institutions. The authors will use the results of this study to design and examine the effects of a standardized, evidence-based peripheral intravenous curriculum to assist health care professionals responsible for peripheral intravenous education and competency assessment. Given the risk for complications from peripheral intravenous therapy, it is hoped that improved peripheral intravenous education will reduce potential complications and improve patient outcomes.

A Bundled Approach to Decrease the Rate of Primary Bloodstream Infections Related to Peripheral Intravenous Catheters

Background: Peripheral intravenous catheters (PIVs) have been considered as having lower risk of infection than central lines. However, research is limited regarding numbers of primary bloodstream infections related to peripheral lines and prevention of peripheral line-associated bloodstream infections (PLABSI).

Methods: Our aim was to create and monitor compliance with a new PIV maintenance bundle using disinfecting caps and tips and to assess whether this bundle would lead to a decrease in PLABSI rates. Weekly audits were conducted to measure compliance with both the new PIV bundle and our existing central line-associated bloodstream infection (CLABSI) bundle. We also audited the disconnection method used for intravenous line tubing (peripheral and central lines) before and during the study intervention period.

Results: A compliance rate of close to 90% with the use of the disinfecting caps and tips was attained. Using a PLABSI bundle successfully decreased primary bloodstream infections due to PIVs (from 0.57 infections per 1000 patient-days preintervention to 0.11 infections per 1000 patient-days; p &lt; 0.001). We confirmed that improving care for PIVs would decrease primary bloodstream infections associated with these devices.

Conclusions: Using a PIV maintenance bundle including disinfecting caps and tips can effectively lower the rate of primary bloodstream infections attributable to PIV lines.

Complications of Peripheral Venous Access Devices: Prevention, Detection, and Recovery Strategies

Most hospitalized patients have placement of a peripheral venous access device, either a short peripheral catheter or a peripherally inserted central catheter. Compared with central venous catheters that are not peripherally inserted, the other 2 types are generally perceived by health care providers as safer and less complicated to manage, and less emphasis is placed on the prevention and management of complications. Expertise of nurses in inserting, managing, and removing these devices may reduce the likelihood of complications, and increased recognition of complications associated with use of the devices is important to ensure continued improvements in the safety, quality, and efficiency of health care. Complications associated with short peripheral catheters and peripherally inserted central catheters include tourniquet retention, tubing and catheter misconnections, phlebitis, air embolism, device fragment embolization, and inadvertent discharge with a retained peripheral venous access device. Integration of prevention, detection, and recovery strategies into personal nursing practice promotes the quality and safety of health care delivery.

Home infusion teaching practices at federally funded hemophilia treatment centers in the United States of America

BACKGROUND

Home management of hemophilia is standard of care in many countries. This study examined current nursing practices in teaching home infusion (HI) at hemophilia treatment centers (HTC) in the USA.

OBJECTIVES

The aims were to identify and compare tools and resources used, areas of unmet needs, and to discuss implications for nurses in practice.

METHODS

An anonymous electronic survey was distributed to 574 HTC nurses; 156 responses were analyzed.

RESULTS

The data demonstrated that nurses, more specifically nurse coordinators, were most responsible for teaching HI. However, many nurses lack the knowledge and confidence to do so: 23.0% responded feeling somewhat or not very confident with teaching. Of those 36.4% were staff nurses, 11.9% nurse coordinators, and 41.7% advanced practice registered nurses. The majority of nurses have worked more than 5 years as a nurse, with a mean length of time of 23.7 years (SD=11.12, range 3-47) and a mean of 12.9 years (SD=10.29, range 1-42) in a HTC. Thirty-eight and a half percent of nurses have worked less than 5 years in a HTC. Most nurses appeared to follow the Infusion Nurses Society standards when performing venipunctures. Many centers reported using a formal tool or curriculum to teach HI. Nonetheless, these curricula are not uniform and their use is inconsistent between centers and regions.

CONCLUSION

There are currently no national guidelines or standards to assist nurses in this task. The data confirmed the need to develop guidelines and a standardized curriculum to teach HI.

Improving Nurses' Peripheral Intravenous Catheter Insertion Knowledge, Confidence, and Skills Using a Simulation-Based Blended Learning Program: A Randomized Trial

INTRODUCTION

Peripheral intravenous catheter (PIVC) insertion is one of the most common invasive procedures performed in a hospital, but most nurses receive little formal training in this area. Blended PIVC insertion training programs that incorporate deliberate simulated practice have the potential to improve clinical practice and patient care.

METHODS

The study was a randomized, wait-list control group with crossover using nurses on three medical/surgical units. Baseline PIVC knowledge, confidence, and skills assessments were completed for both groups. The intervention group then received a 2-hour PIVC online course, followed by an 8-hour live training course using a synergistic mix of three simulation tools. Both groups were then reassessed. After crossover, the wait-list group received the same intervention and both groups were reassessed.

RESULTS

At baseline, both groups were similar for knowledge, confidence, and skills. Compared with the wait-list group, the intervention group had significantly higher scores for knowledge, confidence, and skills upon completing the training program. After crossover, the wait-list group had similarly higher scores for knowledge, confidence, and skills than the intervention group. Between the immediate preintervention and postintervention periods, the intervention group improved scores for knowledge by 31%, skills by 24%, and decreased confidence by 0.5%, whereas the wait-list group improved scores for knowledge by 28%, confidence by 16%, and skills by 15%.

CONCLUSIONS

Results demonstrate significant improvements in nurses' knowledge, confidence, and skills with the use of a simulation-based blended learning program for PIVC insertion. Transferability of these findings from a simulated environment into clinical practice should be further explored.

Measurement of Vein Diameter for Peripherally Inserted Central Catheter (PICC) Insertion: An Observational Study

Choosing an appropriately sized vein reduces the risk of venous thromboembolism associated with peripherally inserted central catheters. This observational study described the diameters of the brachial, basilic, and cephalic veins and determined the effect of patient factors on vein size. Ultrasound was used to measure the veins of 176 participants. Vein diameter was similar in both arms regardless of hand dominance and side. Patient factors-including greater age, height, and weight, as well as male gender-were associated with increased vein diameter. The basilic vein tended to have the largest diameter statistically. However, this was the case in only 55% of patients.

Accepted but unacceptable: peripheral IV catheter failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Development and Testing of a Short Peripheral Intravenous Catheter Insertion Skills Checklist

To date, there is no published, psychometrically validated, short peripheral intravenous catheter (PIVC) insertion skills checklist. Creating a valid, reliable, and generalizable checklist to measure PIVC skill is a key step in assessing baseline competence and skill mastery. Based on recognized standards and best practices, the PIVC Insertion Skills Checklist was developed to measure all the steps necessary for a best practice PIVC insertion. This includes the entire process from reading the prescriber's orders to documentation and, if the first attempt is unsuccessful, a second attempt option. Content validity was established using 3 infusion therapy experts. Evidence in support of response process validity is described. The PIVC Insertion Skills Checklist was used by 8 trained raters to assess the PIVC insertion skills, in a simulated environment, of 63 practicing clinicians working on medical and surgical units in a US teaching hospital. Internal consistency of the PIVC Insertion Skills Checklist was α = 0.84. Individual item intraclass correlation coefficients (ICCs) between rater and gold standard observations ranged from − 0.01 to 1.00 and total score ICC was 0.99 (95% confidence interval, 0.99–0.99). The current study offers validity and reliability evidence to support the use of the PIVC Insertion Skills Checklist to measure PIVC insertion skill of clinicians in a simulated environment.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.