Nurses’ clinical reasoning concerning management of peripheral venous cannulae

Impact of Physician Inspection in the Detection of Phlebitis and Factors Contributing to it in Admitted Children of a Tertiary Care Hospital: A Prospective Study

OBJECTIVE

To determine whether additional dedicated observations by a doctor would increase the pickup rate of phlebitis and related complications due to intravenous cannulation. Also, to identify the common demographic and clinical factors predisposing to phlebitis in children.

METHODS

This prospective study was conducted from January 2019 through December 2019. A total of 184 children with 341 cannulations were enrolled. The authors added dedicated inspection of cannula by the physician during rounds in attempt to increase the detection of phlebitis. The difference in detection rates of thrombophlebitis by physician and routine observation along with the demographic and clinical variables contributing to thrombophlebitis in hospitalized children were studied.

RESULTS

Total incidence of thrombophlebitis was 35/341 (10.3%), which included 2 extravasations. Nineteen events (55%) were picked up by routine nursing observations and an additional 16 (45%) by the physician. Among the factors contributing to phlebitis, maternal education status <12th standard (41.7% vs. 15.1% P = 0.018), cannula located on forearm (p value 0.008), bigger cannula size (18% vs. 8.6% P = 0.008), non-splinted cannula (14.4% vs. 7.7% P = 0.046) intravenous fluid containing potassium (15.4% vs. 2.9%, P = 0.001) and concentrated infusions in particular aminophylline and magnesium sulphate (26.3% vs. 9.3%, P = 0.018) were found to be significantly associated with the development of phlebitis.

CONCLUSIONS

Physician inspection during rounds can improve phlebitis detection and will also increase the sensitivity of nursing observation.

Nurses' protocol-based care decision-making: a multiple case study

AIM

To describe and explain nurses' protocol-based care decision-making.

BACKGROUND

Protocol-based care is a strategy to reduce variability in clinical practice. There are no studies looking at protocol-based care decision-making. Understand this process is key to successful implementation.

METHOD

A multiple embedded case study was carried out. Nurses' protocol-based care decision-making was studied in three inpatient wards (medical, surgical and medical-surgical) of a university hospital in northern Spain. Data collection was performed between 2015 and 2016 including documentary analysis, non-participant observations, participant observations and interviews. Analysis of quantitative data involved descriptive statistics and qualitative data was submitted to Burnard's method of content analysis (1996). The data integration comprised the integration of the data set of each case separately and the integration of the findings resulting from the comparison of the cases. The following the thread method of data integration was used for this purpose. The SRQR guideline was used for reporting.

RESULTS

The multiple embedded case study revealed protocol-based care decision-making as a linear and variable process that depends on the context and consists of multiple interrelated elements, among which the risk perception is foremost.

CONCLUSION

This study has allowed progress in protocol-based care decision-making characterisation. This knowledge is crucial to support the design of educational and management strategies aimed at implementing protocol-based care.

RELEVANCE TO CLINICAL PRACTICE

Strategies to promote protocol-based care should address the contexts of practice and the ability of professionals' to accurately assess the degree of risk of clinical activity. Hence, it will promote quality of care, patient safety and efficiency in healthcare cost.

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.

Nurses' decision-making about intravenous administration set replacement: A qualitative study

AIMS AND OBJECTIVES

To explore nurses' decision-making regarding intravenous administration set replacement for vascular access device infusions in paediatric and adult clinical settings.

BACKGROUND

Intravenous administration sets are routinely replaced at regular intervals in clinical practice with the goal of preventing catheter-related bloodstream infection; however, emerging evidence is challenging traditional hang-time durations. Nurses' perceptions and contextual factors affecting decision-making for administration set replacement have not been assessed previously.

DESIGN

Qualitative study using focus groups with contextualism methodology and inductive analysis.

METHOD

During November-December 2016, eight semi-structured focus groups were conducted with 38 nurses at two metropolitan hospitals in Queensland, Australia. Interviews were audio-recorded and transcribed. Two authors independently reviewed transcripts and extracted significant statements using Braun and Clarke's 7-step method of thematic analysis. The COREQ checklist provided a framework to report the study methods, context, findings, analysis and interpretation.

RESULTS

Five key themes emerged from the analysis: (a) infection prevention, (b) physical safety, (c) patient preference, (d) clinical knowledge and beliefs, and (e) workload. Administration set replacement can be a complex task, particularly when patients have multiple infusions and incompatible medications. Nurses drew on perceptions of patient preference, as well as previous experience, knowledge of peer experts and local policies, to aid their decisions.

CONCLUSIONS

Nurses use clinical reasoning to balance patient safety and preferences with competing workplace demands when undertaking administration set replacement. Nurses rely on previous experience, hospital and medication manufacturer policies, and peer experts to guide their practice.

RELEVANCE TO CLINICAL PRACTICE

Nurses at times deviate from clinical guidelines in the interests of patient acuity, nurses' experience and workload. The findings of this study indicate nurses also balance considerations of patient preference and safety with these competing demands.

To Replace or Not to Replace? Replacing Short Peripheral Catheters Based on Clinical Indication

Short peripheral catheters (SPCs) are the most frequently used medical devices in hospital settings. Many hospital policies state that SPCs be replaced at 96 hours, which can be unnecessary and costly. A pre-post quality improvement initiative was implemented following complications surrounding removal of timed SPC catheters compared with those removed by clinical indication, using the Visual Infusion Phlebitis (VIP) scale. Data collected included patient demographics, SPC characteristics, nursing time, and product use. SPCs replaced based on clinical indication remained intact longer and had fewer complications than those in the group with routinely replaced SPCs. Decreasing SPC replacements by use of clinical indication resulted in cost savings of $7263.60/unit/month.

Establishing the competences of clinical reasoning for nursing students in Taiwan: From the nurse educators' perspectives

BACKGROUND

Clinical reasoning is an essential core competence for nurses. Maintaining quality of care and safety of patients results from cultivation of student's clinical reasoning competency. However, the concept of clinical reasoning in nursing students is complex and its meaning and process needs further clarification.

OBJECTIVES

The objectives were to explore the meaning of clinical reasoning competency in Taiwanese nursing students and to operationalize the concept in order to structure a framework illustrating the process of clinical reasoning.

SETTING AND PARTICIPANTS

Thirteen seasoned nursing experts who had more than ten years of experience in nursing education or clinical practice participated in the interviews. The interviews were conducted in settings that the participants perceived as convenient, quiet and free of disturbance.

METHODS

Semi-structured interviews were conducted. The interviews were audio-recorded and field notes were taken. The data were analyzed using Waltz et al.'s (2010) method of content analysis.

RESULTS

The data revealed four domains and 11 competency indicators. The four domains include: awareness of clinical cues, confirmation of clinical problems, determination and implementation of actions, and evaluation and self-reflection. Each domain comprises of 2-4 indicators of clinical reasoning competency. In addition, this study established a framework for cultivation of clinical reasoning competency in nursing students.

CONCLUSION

The indicators of clinical reasoning competency in nursing students are interwoven, interactive and interdependent to form a dynamic process. The findings of this study may facilitate evaluation of nursing students' clinical reasoning competency and development of instruments to assess clinical reasoning in nursing students.

Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: protocol for an interrupted time-series study

INTRODUCTION

Millions of acute care hospital patients need a peripheral intravenous catheter (PIVC) each year. However, up to half of PIVCs remain in situ when not being used, and 30%-50% of intravenous (IV) catheters develop complications or stop working before treatment is finished, requiring the insertion of a new device. Improved assessment could prompt timely removal of redundant catheters and prevent IV complications. This study aims to validate an evidence-based PIVC assessment and decision-making tool called I-DECIDED and evaluate the effect of implementing this tool into acute hospital clinical practice.

METHODS AND ANALYSIS

The protocol outlines a prospective, multicentre, mixed-methods study using an interrupted time-series (multiple measures preintervention and postintervention) implementation at three Australian hospitals between August 2017 and July 2018. The study will examine the effectiveness of the I-DECIDED assessment and decision-making tool in clinical practice on prompting timely PIVC removal and early detection of complications. Primary outcomes are prevalence of redundant PIVCs (defined as device in situ without a clear purpose), IV complications (occlusion, dislodgement, infiltration, extravasation and phlebitis) and substandard dressings (loose, lifting, moist or soiled); device utilisation ratios; and primary bloodstream infection rates. Secondary outcomes including staff barriers and enablers to PIVC assessment and removal, patient participation, documentation of PIVC assessment and decisions taken to continue or remove the PIVC will be recorded. Using the Promoting Action on Research Implementation in Health Services framework, we will undertake staff focus groups, bedside patient interviews and PIVC assessments and chart audits. Patients aged 18 years or more with a PIVC will be eligible for inclusion.

ETHICS AND DISSEMINATION

Ethical approval from Queensland Health (HREC/17/QPCH/47), Griffith University (Ref No. 2017/152) and St Vincent's Health and Aged Care Human Research and Ethics Committee (Ref No. 17/28). Results will be published.

TRIAL REGISTRATION NUMBER

ANZCTR: 12617000067370; Pre-results.

Critical care nurses' experiences of performing successful peripheral intravenous catheterization in difficult situations

The aim of this study is to describe the experiences of critical care nurses (CCNs) when performing successful peripheral intravenous catheterization (PIVC) on adult inpatients in difficult situations. This study uses a descriptive design with a qualitative approach. Semistructured interviews were given to CCNs (n = 22) at a general central county hospital in northern Sweden. The interview text was analyzed with qualitative thematic content analysis. Three themes emerged: "releasing time and creating peace," "feeling self-confidence in the role of expert nurse," and "technical interventions promoting success." CCNs stated that apart from experience, releasing enough time is the most crucial factor for a successful PIVC. They emphasized the importance of identifying the kinds of difficulties that may occur during the procedure, for example, fragile or/and invisible veins. CCNs explained that compared to when they were newly graduated, the difference in their approach nowadays has changed to using their hands more than their eyes and that they feel comfortable with bodily palpations. To further optimize PIVC performing skills, continued possibilities to train and learn in hospital settings are necessary, even after formal education has been completed.

Fragmentation of care threatens patient safety in peripheral vascular catheter management in acute care--a qualitative study

Background

The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.

Methods

Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.

Results

Four key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.

Conclusion

Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.

Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial

BACKGROUND

The millions of peripheral intravenous catheters used each year are recommended for 72-96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement.

METHODS

This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370.

FINDINGS

All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI -1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred.

INTERPRETATION

Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications.

FUNDING

Australian National Health and Medical Research Council.

Managing peripheral venous catheters: an investigation on the efficacy of a strategy for the implementation of evidence-based guidelines

RATIONALE, AIMS AND OBJECTIVES

Until now, the evaluation of the effectiveness of guideline implementation in nursing and allied health professions has received relatively little attention. The aims of this study were (i) to describe the development process of guidelines concerning the management of peripheral venous catheters (PVCs) implemented in an Italian hospital; and (ii) to evaluate the effectiveness of guideline dissemination in terms of both clinical outcomes (signs of infection) and process outcomes (measures of appropriateness of PVC management).

METHODS

An observational study was conducted before and after the adoption of a new protocol in the CTO-CRF-Maria Adelaide Hospital. Data from 306 PVCs (153 before and 153 after) were collected. For each PVC, a wide range of outcome measures was collected, including: data on fixation system type of dressing; visibility of the insertion site; registration of the insertion date; duration of catheter insertion; presence of connectors, taps and needles; and signs of infection. The effect of guideline implementation was evaluated using a logistic regression model to adjust for the confounding variable represented by the nurses' average years of working experience.

RESULTS

The risk of using inappropriate dressing was significantly reduced [odds ratio (OR) 0.43; 95% confidence interval (CI) 0.27-0.70], while the use of transparent dressing increased (OR 2.39; 95% CI 1.46-3.89).

CONCLUSION

Our study shows significant improvement in practices relevant to the correct management of PVCs 2 months after guideline implementation. A second survey (after a minimum of 6 months) is necessary to assess persistence of improvement in clinical practices.

Nurses' clinical reasoning: processes and practices of medication safety

In this article, we describe the depth of knowledge and skill nurses used in making decisions regarding the safe processes and practices of medication administration. Using grounded theory, we identified the essence of medication safety by nurses as the theme of clinical reasoning. Nurses used two medication safety processes within the clinical reasoning theme-maintaining medication safety and managing the environment-together with six categories of patient-focused medication safety practices in the first process and four categories of environmental-focused safety practices within the second process. These processes and practices present an emerging model of safe medication administration developed from the narratives of 50 medical-surgical nurses. This model provides researchers with the basis for the development of systemic policies for safer medication administration for patients. Health care professional educators might also find the results useful in developing curricula focused on patient safety as the foundation of quality care.