Understanding the Benefits of Clinically Indicated PIV ...
Decreased Vascular Access Complications: The Positive Impact on Patients, Clinicians, and Healthcare Settings Michele Biscossi, ACNP-BC, MS, RN, CNL, VA-BC Speaker Disclosures BD Angiodynamics Genentech Medcomp Ethicon PDI I will not be discussing any off label use of products or procedures. 2 Presentation Objectives Understand the cause and effect that peripheral intravenous device (PIV) complications have on catheter
dwell time. Highlight the impact that longer PIV dwell times have on patient outcomes, clinician efficiency, and associated costs. Recognize that by applying evidence-based best practice standards longer PIV dwell times are obtainable. Be empowered to become a change agent in your organization to promote vascular access best practice. 3 Peripheral Intravenous Catheter (PIV) History IV catheter therapy has been used for more than 350 years. PIVs have played a central role in patient care since first plastic PIV was introduced more than 70 years ago. PIVs are the most common invasive hospital procedure
performed worldwide. 4 Helm (2015) PIV Catheters Today PIVs are necessary for direct administration of fluids and medications into the bloodstream. More than 300 million PIVs are sold each year in the United States. 60% to 90% of hospitalized patients require an IV catheter during their hospitalization. PIVs Are Not Without Complications Most rigorously performed studies indicate overall PIV catheter complication rate
lies between 35% and 50%! PIV complications are costly to patients, caregivers, and the healthcare system. Analysis of mechanisms underlying persistent PIV complication rate reveals opportunities for improvement. 5 Helm (2015) Five PIV Complications That Can Impact Dwell Time 1.Phlebitis 2.Infiltration 3.Dislodgment 4.Mechanical complications (e.g., occlusion, leakage) 5.Site or bloodstream infection 6 Helm (2015); ONS (2017); INS (2016)
Infection CR-BSI & Local Insertion Site Both confirmed: + culture connected by clinical data indwelling catheter CR-BSI attributable to PIVs ranges from 0% to 2.2% in prospective studies Break in aseptic technique during initial catheter-insertion & dressing-placement process (i.e. assembly of add-on extension set, flushing, capping, securement) External surfaces of PIV hubs become contaminated during insertion because hub is grabbed with non-sterile gloves Improper disinfection of needle free connectors Improper use of alcohol caps 7 Helm (2015); ONS (2017) Cause & Effect of PIV Complications on Patients CAUSE
EFFECT May increase pain/discomfort May experience complicationrelated sequelae Early PIV catheter replacement due to complications May prolong or delay treatment/care May increase dissatisfaction with staff, hospital May affect overall hospital experience 8 Helm (2015); ONS (2017) Cause & Effect of PIV Complications on Clinical Efficiency
CAUSE EFFECT May increase clinician workload Early PIV catheter replacement due to complications May increase clinician stress May result in delays of clinician administration of medications and/or medical therapies May cause decreased clinician satisfaction 9 Helm (2015); ONS (2017) Cause & Effect of PIV Complications
on Healthcare Facilities CAUSE EFFECT May increase cost to facility Early PIV catheter replacement due to complications May increase length of hospital stay May decrease patient satisfaction scores May damage reputation of hospital 10 INS (2016) S95; Helm (2015); ONS (2017)
Potential Impact on Patient Outcomes PIV Dwell Times The 1st IV placed during admission could be the only PIV they will need for their entire hospital stay. Fewer IV starts can also help contribute to vessel preservation Has real benefits for individual patients on future admissions. Treatment not delayed due to lack of venous access. 11 DeVries (2015) Potential Impact on Clinical Efficiency
PIV Dwell Times Time saved for bedside nurses not having to arbitrarily restart PIVs can be redirected to focusing on site assessment of the devices or any other multitude of tasks with competing priorities. Bedside nurses will agree that sparing the patient the procedure is a great goal. May free up dollars to ensure that the best products are selected when developing PIV insertion bundles to support longer dwell times of vascular access devices. On the administration side, PIV BSI can influence patient satisfaction. Stress is reduced for clinicians caring for patients with longer PIV dwell times. Potential results include improved clinician job satisfaction. 12
DeVries (2015) Potential Impact on Associated Costs PIV Dwell Times Average cost for a PIV insertion is between $28 & $35 Supply costs lowered (catheter & associated products). Potential avoidance of costs associated with complications: Prolonged hospital stay Extended treatment costs 13 Helm (2015); DeVries (2015) Benefits of Longer PIV Dwell Times
Longer PIV Dwell Times 14 Helm (2015); ONS (2017) Can We Achieve Longer PIV Dwell Times with Clinical Indication? YES! Clinical Indication is evidence-based (INS 2016); ONS (2017) Reproducible across all healthcare settings Efficient for patients and clinical staff 15 Helm (2015); INS (2016) ppS91; ONS (2017) pp30.
All Clinicians are Accountable for The Standard of Care 2016 Infusion Therapy Standards of Practice Standards that are upheld in a court of law PIV-related complications may impact patient litigation 16 Technology To Decrease PIV Complications Vessel identification devices Closed integrated PIV catheters Novel catheter designs Hub cap cleansing/sterilization covers Improved stabilization Guidewire technology Integrated catheter dressing systems Dressings Needle free connectors
17 Helm (2015); INS (2016) Vascular Access Device (VAD) Planning The VAD selected is of the smallest outer diameter with the fewest number of lumens and is the least invasive device needed for the prescribed therapy. 18 INS Standard 26.3, page S51, Practice Criteria I.B.3, page S51 Recommendation: Use a PIV catheter that enables higher flow rates on smaller gauge catheters
(22 G24 G) for power injection. Impact: Less likely to cause phlebitis, minimizes insertion-related trauma. Vascular Access Device (VAD) Planning Consider a larger-gauge catheter (16-20 gauge) when rapid fluid replacement is required, such as with trauma patients, or a fenestrated catheter for a contrast-based radiographic study. 19 INS (2016) Practice Criteria I.B.3, page S51
Recommendation: A fenestrated 20 G PIV instead of a nonfenestrated 18 G catheter. Impact: Catheter will accommodate the prescribed therapy and may contribute to less complications. Vascular Access Device (VAD) Planning: Site Selection 20 Use the venous site most likely to last the full length of prescribed therapy. Recommendation: Use the evidence to promote proper site
selection. Best sites include forearm, dorsal & ventral surfaces of the upper extremities. Impact: Prevents accidental removal and occlusions, risk of tissue damage, thrombophlebitis, ulceration and decreases pain. INS (2016) Practice Criteria: I, page S54 Needleless Connectors Consider use of an extension set between the peripheral catheter and needle free connector to reduce
catheter manipulation. 21 INS (2016) Practice Criteria B, page S68 Recommendation: Utilize a PIV with an integrated system with a pre-attached extension set. Impact: Reduces catheter manipulation. Add-On Devices Limit the use of add-on devices whenever possible. Add-on devices are of luer-lock design to ensure a secure junction, reduce manipulation, and
minimize the risk of disconnection. Recommendation: Use all-in-one integrated systems with pre-attached extension tubing and luer-lock connection(s) at the catheter hub. Impact: Reduction of manipulation, minimize risk of disconnection. INS (2016) Practice Criteria B, page S68, Standard 36/2, page S71; Practice Criteria A, A.1 and A.2, page S72 22 Add-On Devices: Disinfecting Caps Use of passive disinfection caps containing disinfecting agents per manufacturers
recommendations Discard after removal. Consider vigorous 5 -15 second scrub with each subsequent entry into VAD depending on NC design. 23 INS (2016) Practice Criteria G, page S69 Recommendation: Utilization of disinfecting caps on PIV Impact: Reduction of extraluminal microbial contamination. For PIV evidence is limited but should be considered. Vascular Access Device (VAD) Stabilization
Stabilize and secure vascular access devices (VADs). Avoid use of tape or sutures, as they are not effective alternatives to an engineered stabilization device (ESD). Do not rely on VAD dressings as a means for VAD stabilization. 24 Recommendation: For peripheral catheters, consider two options for catheter stabilization: (1) an integrated stabilization feature on the peripheral catheter hub combined with a bordered
polyurethane securement dressing or (2) a standard round hub peripheral catheter in combination with an adhesive ESD. Impact: Prevents VAD movement, which can cause unintentional dislodgement, leading to complications requiring premature VAD removal, interruption in therapy and possible increase in costs. INS (2016) Standard 37.1, page S72; Practice Criteria A, pages S72-S73; Practice Criteria B, C, D, page S73 Vascular Access Device (VAD) Removal VADs are not removed based solely on length of dwell time because there is no known optimum dwell time. According to the INS Standards on PIV removal,
remove short peripheral and midline catheters in pediatric and adult patients when clinically indicated, based on site assessment, clinical signs and symptoms of systemic complications. 25 Recommendation: Choose vascular access devices with technology that aligns closely with the INS Standards and meets your dwell time needs. Look for clinical studies on longer dwell times and low rates of PIV complications. Impact: PIVs removed only when unresolved complications, D/C of therapy or no longer needed may
decrease patient pain/ discomfort, increase vein preservation, clinician efficiency, and may reduce costs. INS (2016) Standard 44.3, page S91; Practice Criteria B, page S91; Helm 2015 Care & Maintenance Assess Short PIVs: Assess minimally at least every 4 hours; the clinical need for each PIV is assessed on a daily basis. Dressing Perform dressing changes on short PIVs if the dressing becomes damp, loosened, and/or visibly soiled & at least every 5-7 days. Disinfect Perform a vigorous mechanical
scrub for manual disinfection of the needleless connector prior to each VAD access and allow it to dry. Recommendation: Assess per standard at least every 4 hours, and perform care and maintenance per standard. Impact: Minimizes risk of complications. Flushing Vascular access devices (VADs) are & Locking flushed and aspirated for a blood return prior to each infusion. Flushed after each infusion to clear and locked after completion of the final flush.
26 INS (2016) Practice Criteria C2., page S81; Standard 44, page S91; Practice Criteria I, page S82; Practice Criteria F, page S68; Standard 40.1-3 page S77; Unacceptable Failure Rates A mean failure rate of nearly 50% would be unacceptable for food processing, automobile driving, cell phone use, let alone airplane flights. Why has it been accepted for the most commonly performed invasive hospital procedure performed worldwide? Routine replacement of PIVs is ineffective at decreasing complication rates. 27 Cashin-Garbutt (2012) Clinically Indicated is the INS Standard of Care
Dwell time defined as the length of time an inserted IV catheter maintains its safe function. INS Standard: The clinical need for each peripheral and non-tunneled central vascular access device (CVAD) is assessed on a daily basis. Vascular access devices (VADs) are removed upon an unresolved complication, discontinuation of infusion therapy, or when deemed no longer necessary for the plan of care. Remove short peripheral catheters in pediatric and adult patients when clinically indicated, based on findings from site assessment AND/OR clinical signs and symptoms of systemic complications (e.g., bloodstream infection). 28 INS (2016)-S91; Helm (2015) Achieving Longer PIV Dwell Times: Back to What We Know Already Assessment of current practice Policies based on INS Standards of Practice Staff retraining/competencies
(PIV insertion, care & maintenance) Development/usage of PIV bundle Measured compliance with aseptic technique skin prep No-touch technique at insertion Strive for the best PIV location, size catheter Utilize stabilization Who will follow PIV complications & measure outcomes when moving to best practice standards? CICs, Quality? 29 Section Four: How Do You Lead and Effect Change Within Your Organization? 30 Vascular Access Team Clinicians with specific training & experience: aka The IV team have a significantly higher first-time insertion success rate, which has been associated with a lower incidence of
complications. Standardization of PIV use & care before/after insertion through the use of specially trained IV nurses is also of proven benefit in reducing the incidence of phlebitis & other complications. 31 Helm (2015) Defining the Specialty of Vascular Access Through Consensus: The Specialist Focuses on cost-effective patient-focused strategies! Concerned with all aspects of vascular access, vessel health & patient safety. Encompasses more than device insertion. Influences outcomes through care & maintenance,
education, research, and patient advocacy. 32 Davis (2016) Partner with industry to bring about evidencebased innovations. Select the most appropriate device through comprehensive product knowledge. Uses accepted products & medical technology that are readily available, reasonably reliable for their purposes. Strategies to Limit Unnecessary Venous Perforation Specially trained personnel using
standardized & optimized technique Dedicated IV team for DIVA, morbidly obese & pediatric populations Bevel-down insertion in small vessels Local anesthetics Topical visualization agents Double tourniquet technique Patient reassurance maneuvers Ultrasound guided placement of PIVs Forearm utilization to increase dwell time, decrease pain during dwell time as opposed to the upper arm 33 Helm (2015); INS (2016); ONS (2017) HOW TO EFFECT CHANGE: Become the go-to PIV specialist within your organization & across multiple
hospital systems! PIV Case Study 625+ bed hospital developed an insertion bundle to support the safe implementation of a policy of extended dwell time for inpatient PIVs. Conducted surveillance on all lab-confirmed BSIs for the past 13 years. A cluster of primary bacteremia occurred on a unit of the hospital during pre-implementation phase. Internal evaluation of practices through direct observation as well as evidence-based guidelines & historic data on PIV BSIs helped drive PIV bundle creation. A surveillance plan was in place to continue measurement of these outcomes during post-implementation period. 34 DeVries (2016) PIV Case Components of the Protected Clinical Education Bundle
BUNDLE ITEM REASON Sterile gloves CDC & INS both indicate sterile gloves for palpation after skin prep. Direct observation pre-implementation indicated an opportunity to enhance compliance. CHG-impregnated sponge Indicated to reduce infection/colonization. With extended dwell apply same standard for CVADs. CHG dressings can effectively kill commonly found skin bacteria. Securement device With ability to allow catheter to dwell
until clinical reason for removal, securement was identified as a strong element in preventing pistoning within the vein. Alcohol disinfection caps Provide intraluminal protection; however, the nurse must perform a vigorous mechanical scrub for manual disinfection of the NC prior to each VAD access and allow it to dry. 35 DeVries (2016) PIV Case Study Results: PIV Improvements: PIV care & maintenance PIV line management focus PIV product Patient satisfaction scores
opportunity System-wide Education Vendor assisted product training for staff by nurses PIV insertion & site selection Moved to clinically indicated PIV replacement 36 DeVries (2016) 1 Year Post Implementation: 19% reduction in PIV BSIs 48% reduction in PIV start kits A sample of 364 admitted patients 18 months after implementing PIV insertion bundle to support longer dwell times. All PIVs present during that admission were evaluated to assess average dwell time 35%
of PIVs placed were remaining in for 5 days or longer. Average dwell time in this sample was calculated to be 4.2 days consistent with findings in Rickard et al., (2012). Clinical Case Study: Biscossi 37 Lessons Learned: Biscossi All PIV infections to be tracked by infection prevention nurses. Deep dive found that PIVs inserted in the ED were not following INS standards for insertion, care & maintenance. Lead vascular access NP everyone retrained! All RNs retrained per INS Standards of
Practice & report feedback. 38 RNs report increased satisfaction with not re-sticking patients with fully functioning PIVs. Patients report increased satisfaction scores with PIV dwell time (specifically measured over a 6 month period post-implementation). PIV infection rates reduced by 30%. The Key to PIV Best Practice Is Education INS conducted their Safety Practice Survey in 2013 Participants were asked: Were you taught to insert short PIVs while
in school? (N=344) 43% YES 57% NO 39 Vizcarra (2013) If no, how did you learn to insert short PIVs? (N = 235) On the job training 71% See one, do one, teach one 11% Trial & error
5% Attended a PIV insertion workshop 9% Other 4% Audience Call to Action: Become experts: Know your standards/best practice and use them. Conduct evidence-based clinical practice assessments & compile your data. Look to peers with great clinical outcomes collaborate.
Partner with device manufacturers who will make a long-term commitment to product support. 40 Do your own research and embrace new technologies. Share analysis & current standards with senior leadership, nursing, and providers to convey why they should support change: - This is not good enough and Im going to tell you why. - We need to meet the standards and best practice for our patients. - Here is the evidence to support it.
So What Have We Learned? PIV complications affect PIV dwell time, patients, clinician efficiency, and cost. Longer PIV dwell times are achievable. Use evidence-based practice and integrated closed systems to decrease complications. 41 Questions? Thank you for your time. Thanks to BD for sponsoring this lecture. Please feel free to reach out for further collaboration: [email protected]
42 References 1. Helm RM, et al. Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing. 2015;38(3): 189-203. 2. Infusion Nurses Society. Infusion Therapy Standards of Practice. Journal of Infusion Nursing. 2016;39(supplement): S1-S159. 3. Rickard CM, et al. Routine versus clinically indicated placement of peripheral intravenous catheters; a randomized controlled equivalence trial. Lancet. 2012;380 (9847): 1066-1074. 4. Bausone-Gazda, et al. A randomized controlled trial to compare the complications of 2 peripheral intravenous stabilization systems. Journal of Infusion Nursing. 2010;33(6): 371-384. 5. Webster J, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. British Medical Journal. 2008;337: 1-6. 6. Smith JP. Thrombotic complications in intravenous access. Journal of Intravenous Nursing. 1998;21(2): 96-100. 7. Jackson A. Retrospective comparative audit of two peripheral IV securement dressings. British Journal of Nursing. 2012;21(supplement 1): S10-S15. 8. Cashin-Garbutt , A . Intravenous catheter replacement: an interview with Claire Rickard. http://www.news-medical.net/news/20121030/Intravenous-catheter-replacement-an-interview-with-Claire-Rickard.aspx. Published on October 30, 2012. 9. Davis L, et al. Defining the specialty of vascular access through consensus: Shaping the future of vascular access. 2016;21(3):125-130. 10.DeVries, M, et al. Protected clinical indication of peripheral intravenous lines: Successful implementation. Journal Association for Vascular Access. 2016;21(2): 89-92. 11.Vizcarra, C. Recommendations for improving safety practices with short peripheral catheters (SPC) think safety, insert safely.
INS Safety Practice Survey. 2013 12. Access device standards of practice for oncology nursing. Edited by Dawn Camp-Sorrell & Laurl Matey. Oncology Nursing Society. 2017. 13.DeVries, M. 2/4/15. Peripheral IVs: Fewer & better replacing PIVs only when clinically indicated offers many advantages. https://www.psqh.com/analysis/peripheral-ivs-fewer-and-better/ 43
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