Volume 2 Issue 2

Author contributions: HR, CMR and AVZ designed and conceived the study. HR wrote the study protocol. HR undertook and oversaw data collection. TC performed data collection and prepared the data for statistical analysis. HR analysed the data. HR and CR wrote the manuscript. All authors reviewed and approved the manuscript for publication.

Author declaration

We declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author.

Competing Interests

Heather Reynolds: Nil to declare.

Thomas J Chalk: Nil to declare.

André Van Zundert: Nil to declare.

Claire M Rickard: Professor Rickard is a director of the Alliance for Vascular Access Teaching and Research (AVATAR), Griffith University. AVATAR research is supported by competitive government, university, hospital and professional/organisational research grants as well as industry unrestricted donations, investigator initiated research/educational grants and occasional consultancy payments from the following companies: 3M, Angiodynamics, Baxter, BBraun, BD, Carefusion, Centurion, Cook, Entrotech, Hospira, ResQDevices, Smiths, Teleflex and Vygon. This manuscript is independently prepared and does not reflect any commercial entity.

Acknowledgements

Thank you to medical student, Alana Alves for her contribution to the data collection, and to Gabor Mihala for his statistical support.

Sources of funding

Nil.

A way to go to meet guidelines for prevention of intravenous catheter infection and complications: Audit of perioperative peripheral venous catheter care

Abstract

Background: Peripheral venous catheters are the most frequently used invasive medical device for care of 80% of hospitalised patients. Previous prevalence studies of peripheral venous catheter practice have identified areas for clinical practice improvement with studies addressing insertion in the emergency department, as well as insertion and care in general and oncology hospital wards. However, perioperative insertion and care have not been examined.

Objectives: To compare the clinical practice of insertion and management of perioperative patients’ peripheral venous catheters with guideline recommendations.

Methods: A prospective audit of 102 perioperative patients’ peripheral venous catheters was performed in a 929 bed, tertiary and quaternary referral teaching hospital in Brisbane, Australia. Baseline data were collected after device insertion in the operating theatre, and postoperative data were recorded on one occasion on the following calendar day. Descriptive analyses of data were performed.

Results: The majority of patients (83%) had 18 or 20 gauge peripheral venous catheters inserted by skilled practitioners. Postoperatively, there were 26 (24.5%) unused catheters without ordered medical treatment. Phlebitis was reported in 3 (2.9%) patients and 7 (6.9%) patients had insecure dressings. No insertion site complications were reported for 63 (61.8%) patients. Specific site assessment was not recorded for 69 (67.6%) of cases. The overall complication rate was 10%.

Conclusion: Multiple problems were identified including failure to remove catheters without a known purpose, phlebitis, insecure dressings, non-compliant flushing practice and incomplete documentation. Future perioperative education should focus on these areas to improve device management and patient care.

Not registered in a public registry

Key Words: intravenous catheters; dressings; securement; perioperative; quality improvement

A way to go to meet guidelines for prevention of intravenous catheter infection and complications: Audit of perioperative peripheral venous catheter care

Introduction

Background

Peripheral venous catheters (PVCs) are the most frequently used invasive medical device for care of hospital patients, with 330 million sold annually in the United States of America (USA)¹. It is estimated that up to 70% of patients have a PVC during their hospital admission². Catheter-associated blood stream infection (CA-BSI) has not been specifically studied in these frequently used catheters, even though it is an extensively researched complication in other catheter types, for example central venous catheters. PVC studies have concentrated on the complications of phlebitis, healthcare-associated infection (HAI), local infection/colonisation and patency^2-5. Study findings indicate that up to 38% of PVCs are not necessary for treatment^6-13, but in spite of this, most patients are likely to receive a PVC as a routine part of their admission. PVCs may present a significant risk factor for CA-BSI with the incidence density of PVC-BSI estimated at 0.2 to 0.7 episodes per 1000 device days¹⁴. This seemingly small incidence provides a considerable economic burden in Australia, costing $700 million per annum¹⁵. Prevalence studies of PVC practice identify areas for clinical practice improvement to reduce HAI^{2, 5, 7, 16}. These studies have audited HAI, PVC use and the effect of infection surveillance. Goddard et al¹⁶ reported reduced infection rates after monthly surveys which included staff feedback.

The Executive Director of Nursing Services at the Royal Brisbane and Women’s Hospital formed the Intravenous Access Research Council as one of four Research Councils in 2011 to improve management of PVCs, following the introduction of the Australian National Safety and Quality Health Service Standards¹⁷. This was in response to the mandatory Standard 3 “preventing and controlling healthcare-associated infections”. It was necessary to assess whether patients were receiving the best quality PVC care to prevent and manage infection, by the essential measurement of practice to determine if there was a need for practice change. Local research responded with an emergency department cohort study to assess PVC insertion practice¹⁸ and quality studies of point prevalence surveys to evaluate PVC care in medical and cancer care patients^{19, 20}. These complement findings from international studies which have evaluated prevalence of PVC use and the incidence of HAI in patients with peripheral intravascular access^{21, 22}.

New and colleagues¹⁹ reported poor documentation of PVC care in hospital wards, with inaccuracy in 37% of cases. Insertion dates and site location were poorly documented, with no record for 79 out of 186 (43%) devices. Reinserted catheters did not have the date of reinsertion for 84 of 179 (47%) catheters. These authors noted that the available space on the patient care record concentrated on insertion details, with limited space to document maintenance care. Also, polyurethane dressings were often insecure, requiring replacement, and 83% of devices needing additional dressings. Russell et al¹² concurred with evidence of lack of dressing integrity and similarly found inconsistent documentation of site location, which was inaccurate for 36% of PVCs.

In view of this information, the need to audit care of PVCs inserted for perioperative management was highlighted, with no previous studies performed. In accordance with audit methodology, practice was to be compared with clinical guidelines to provide evidence-based recommendations, as this comparative method has previously provided useful insights to facilitate practice change. Identification of clinical anomalies not aligning with global guidelines and previous research^23-27 was the planned focus for care improvement. The clinical audit cycle was considered a constructive framework and systematic process to facilitate compliance with guidelines, and would provide a means for ongoing evaluation²⁸.

Aim

The study’s overall purpose was to examine the clinical practice of PVC care in the perioperative setting to identify areas for improvement. The following study questions were asked:

1. What were the reasons for PVC insertion?

2. Which management did not match guidelines?

3. What complications were recorded?

4. How accurate was documentation?

Objectives

The study objectives were to compare the use, management, complications and documentation of PVCs in perioperative patients with clinical guidelines, to measure compliance with standards.

Method

Design

A prospective audit was performed assessing the first 100 patients requiring a PVC inserted in the operating theatre at Royal Brisbane and Women’s Hospital from the population whose PVCs were to remain in situ for postoperative care, with no history of allergy to dressing/securement products and no burned/damaged skin, from 26 March 2015. The project was considered by the hospital Human Research Ethics Committee as exempt from full ethical review (Ref No: HREC/14/QRBW/539).

Procedures

The study patients were identified on a daily basis by liaison with the consultant anaesthetist in charge of list management and individual anaesthetists. Data were recorded after direct observation of patient care and from patients’ care records, using a data collection form. Data collection was performed by a research nurse or a medical registrar assisted by a medical student. Baseline data were collected when each patient’s device was inserted in the operating theatre. Postoperatively, data was collected on one visit during the following 24 hours, after patient transfer for postoperative care in either the intensive care/high dependency unit or a hospital ward.

Instrument

A review of the literature was undertaken to include previous vascular access audits and the audit tool was developed by the primary author in a format which facilitated easy completion²⁷. The tool was assessed by the Principal Director of the Alliance for Vascular Access Research and Teaching (AVATAR), Griffith University, and it was tested on two occasions by two data collectors. After discussion, minor modifications were made for ease of use. The assessment items of baseline and postoperative data were as per Figure 1.

Figure 1. Data collection items


 

Statistical Analyses

Data were entered into Microsoft Excel and exported for descriptive analyses with Predictive Analytics Software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Analyses included univariate testing and frequency counts which were presented as numbers and proportions.

Results

Demographic and Clinical Characteristics

The demographic profiles of patients and surgery types were tabulated (see Table 1).


Table 1. Demographic characteristics and surgery types of study participants (n = 102)


 

All PVCs were BD Insyte™ Autoguard™ Shielded IV Catheters (BD™, North Ryde, 2015) and they were inserted by qualified, experienced medical practitioners who were either anaesthetic consultants or trainees. Size 18 or 20 gauge cannulas were inserted in the majority of patients (n = 85; 83.3%).

On the postoperative ward visit, 99 (97.1%) patients had the same PVC in situ as inserted in the operating theatre. There were 66 (64.7%) PVCs in situ for less than 24 hours. Characteristics of PVCs included reasons for PVC, insertion site, dressing/securement type, dressing visibility, dressing security and replacement, complications and documentation, are shown in Table 2.


Table 2. Peripheral venous catheter (PVC) characteristics (n = 102)

 

Discussion

There were twice the number of male to female patients. Different types of surgery had a majority of male patients: Neurology 14/17 (82.4%), ENT 8/10 (80.0%), plastic surgery 11/16 (68.8%) and ophthalmology 3/3 (100%). Male patients were evenly distributed over the age range of 16 to 92. There was no specific explanation for this increased prevalence of males compared with females.

Study findings revealed a quarter of PVCs were in situ without a known reason. More than half of catheters were inserted in the hand. Securement of 96% of catheters was with non-sterile tape, and 6.8% of dressings were insecure. Documentation was missing for insertion dates, catheter type, catheter gauge, intravenous flush orders and time of catheter removal of all catheters.

Best practice guidelines are designed for incorporation into up-to-date policy and workplace education to guide clinical practice. Many clinical guidelines provide evidence-based recommendations worldwide, supporting policy and practice for PVC care^{26, 27, 29, 30}. These documents inform best practice for PVC purpose, insertion site selection, methods of dressing and securement and documentation requirements.

Our results indicate non-compliance with PVC guidelines in many aspects of clinical practice. Our primary study objective was to report the use, management, complications and documentation of PVCs in perioperative patients, to identify lack of compliance and highlight areas of infection risk in the perioperative environment. We found a high incidence of PVCs with no clear purpose in short-term postoperative patients who were recovering well. Guidelines prescribe prompt removal of catheters when not required. However, there were 26 (25.5%) catheters in patients who were stable, which either did not have a written medical order or had been left in situ following verbal medical discussion to remain “just in case” they were needed. Contrary to routine policy, these unused catheters were not recorded as flushed and all lacked documentation of checks of insertion sites and dressing integrity. No caregivers for these 26 patients had sought clarification from the treating medical team, or initiated a plan to remove the catheter, in spite of the absence of treatment orders. Thus, neither nursing nor medical staff seemed to have a defined plan for these PVCs, despite the infection risk. “Redundant” catheters increase the burden of preventable intravascular infection³¹. Our data concurs with previous studies where 28.2% PVCs had no clear purpose¹⁹, and 38.0% were no longer required³². Ritchie et al acted on their similarly high occurrence of unnecessary PVCs with a program of education and follow up audits, reducing the incidence of unwanted catheters to 7.0%⁷. A key recommendation for our healthcare facility is to review our prescription for PVC care to reflect current guidelines, including systematic recording of key care aspects for specified intervals of care. A cyclic program of education for caregivers is also required to ensure effective implementation of this program.

A further key finding in our study was that documentation in the anaesthetic and patient care records was inadequate. Signs of phlebitis causing PVC failure were recorded for 3 (2.9%) patients and insecure dressings for 3 (2.9%) patients, but there was no postoperative documentation of complications at the insertion site for 92 (90.3%) patients. It was concerning that caregivers reported no complications, which is most likely an assumption when there was only insertion site documentation for 33 (32.4%) of cases. Phlebitis is an early complication, but occlusion may occur later. Thus, assumptions were made that there were no complications when documentation was incomplete or missing. Failure to document this information clearly suggests a lack of observation of the insertion site when caring for the patient, with a high possibility of a breakdown in early detection of signs and symptoms of complications. Other studies report complication rates of approximately 25%^{7, 9, 12, 19}, and it appears highly likely that a proportion of the patients with unreported status of their catheter insertion sites would have experienced some type of complication. Existing educational programs are in need of review to improve accuracy of observation and documentation. The educational priority is to inform practitioners of the crucial need to observe for and document the presence of PVC complications at specified time points when caring for these devices. Thus, staff could be alerted to the early onset of localised or catheter-related infection.

Catheter sites with phlebitis were located in the dorsum of the hand² and the cubital fossa¹. Insertion in the dorsum of the hand is a frequent practice, and if considered necessary, is preferred in the dorsal venous arch, but choice of the cephalic or basilic vein is preferable³³. The PVC in a dorsal vein closer to the digits may contribute to greater movement and irritation in the vein by the catheter³⁴. Significantly higher occlusion has been associated with PVCs in the hand and antecubital fossa, and with the infusion of antibiotics³³. Also, significant predictors of accidental removal include hand or antecubital fossa insertion, compared with the forearm³³.

With 7 (6.8%) insecure dressings, but only 4 replaced, this resulted in 3 patients at high risk for accidental catheter removal and catheter-related or local infection. A secure, dry dressing reduces the risk of infection, and together with a dedicated securement device will guard against accidental removal³⁵. The makeshift nature of adding non-sterile tape to secure the borders of a sterile dressing as observed in 95 (93.1%) patients suggests a recognition that simple occlusive polyurethane dressings are inadequate. This has been acknowledged in previous studies of dressing and securement, where other technologies such as bordered polyurethane and dedicated securement devices are preferred^{19, 36-38}. Review of standard dressing and securement of PVCs in the perioperative environment is recommended, with selection of dressing and securement devices from new technologies dedicated to secure the intravenous device, such as cloth adhesive bordered dressings.

Data collected on catheter flushing practices indicated that flushing the PVC at the appropriate time-points was very poorly documented and most likely not well performed. Inadequate flushing following medication administration may contribute to the risk of phlebitis, with the added inconvenience of discomfort and pain, although the evidence for routine PVC flushing is incomplete, with recent studies reporting that it may not have an impact on preventing catheter failure^{39, 40}. With 59 (57.9%) patients prescribed postoperative intravenous medication including 24 (23.5%) prescriptions for antibiotic therapy, the absence of ordered flushes for any patient was surprising, as only 28 (27.5%) patients had a postoperative intravenous administration set in place. The remaining 31 (30.4%) patients had a PVC alone, yet no order or record of any flushes. The absence of any flushing orders and a lack of documentation of flushes indicates a perceived low compliance to hospital policy, which requires flushing pre and post medication administration and every 8 hours, for patients without attached administration sets.

The overall complication rate of 10% is less than the reported 25% complication rate in other clinical studies of PVC practice^{7, 9, 12, 19}. This is likely due to the short term use of less than 24 hours for 65% of catheters in our study, as well as under-reporting in the patients’ records. Systems problems need to be addressed to facilitate accurate perioperative documentation and promote optimal care of PVCs. These audit findings indicate an urgent need for review of current clinical practice.

Limitations
Our study was limited in that data were collected at the time points of insertion, during one postoperative visit and from the patient record. This provides a simple snapshot of PVC use, management and documentation, but includes invaluable baseline information for continuing audits of perioperative PVCs and development of an audit cycle.

ConclusionsMultiple problems with PVC management included failure to remove catheters without a known purpose, phlebitis, insecure dressings, uncertainty in ordering/documentation of flushing procedures, perceived inadequacy of simple polyurethane dressings and incomplete documentation. These problems are the recommended focus for future perioperative education and systems development. Many patients in the operating theatre and postoperative care are at risk of having peripheral PVCs inadvertently dislodged, or suffering other mechanical or infective complications which result in catheter failure. Available studies of PVCs that investigate complications suggest that catheter failure may be prevented by improved catheter dressing and securement, so a better process of workflow and communication between the anaesthetic team and ward nurses will be promoted to facilitate improved care. Continuation of this audit cycle in perioperative care will lead to ongoing improved practice when caring for PVCs, to minimise catheter-related complications such as infection.
 

Author(s)

Heather Reynolds, BA, BHthSc, MN, MAP, PhD a,b,c,d* Thomas J Chalk, MBBS, BExSci, BPhty c,d André Van Zundert, MD, PhD, FRCA, EDRA, FANZCA c,d Claire M Rickard, RN PhD FAAHMS FACN a,b a Alliance for Vascular Access Research and Teaching (AVATAR), Griffith University, Queensland, Australia 4111. b Griffith University, Menzies Health Institute Queensland, Australia 4111. c Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Queensland, Australia 4029. d The University of Queensland, Australia 4072 *Corresponding Author Email: h.reynolds@griffith.edu.au Phone: +614 3886 9594 Pages 2-9

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