Standards of care for peripheral intravenous catheters: evidence-based expert consensus

The significance of peripheral intravenous catheters

In the landscape of modern healthcare, peripheral intravenous catheter (PIVC) insertion is a cornerstone procedure, critical for the administration of therapies, medications, and fluids to a wide array of patients in a variety of settings. Annually, the US alone purchases an estimated 350 million PIVCs, making it the most frequently performed invasive procedure in healthcare.¹ Its prevalence is underscored by Helm et al, who highlighted that 60%-90% of hospitalized patients in the US require a PIVC during their care and experience PIVC failure rates ranging from 35%-50%.² This high failure rate has been persistent, as shown by Cooke et al, who reported even higher global rates of 33%-69% PIVC failures before treatment completion.³

Despite its commonality, PIVC practice variability leads to a range of complications such as infiltration, infection, and patient discomfort. Reports such as that by Zingg et al, corroborate a troubling global prevalence of PIVC failure, marked at 35% to 50%.⁴ The Australian Commission on Safety and Quality in Health Care further amplifies this concern with indications of complication rates up to 70%.^5,6 The consistency in these findings is echoed in a systematic review by Marsh et al, which noted that at least one-third of PIVCs inserted globally fail before the completion of the intended therapy.⁷ Such complications are not just statistical concerns; they represent a grave risk to patient welfare and highlight the urgency for improved insertion and care practices.

Scope and implications for healthcare professionals

Inspired by the Australian Commission on Safety and Quality in Health Care's publication ‘Management of Peripheral Intravenous Catheters: Clinical Care Standard’, in 2023, the Association for Vascular Access (AVA) led a collaboration with representatives from the Infusion Nurses Society (INS), the American Association of Critical-Care Nurses (AACN), ECRI, and content experts.⁶ AVA initiated the collaboration seeking to provide clinical guidance to improve and standardize PIVC practices. First, by integrating currently published standards of practice into a singular, comprehensive document, this framework aims to advance the quality of care and enhance patient safety. Second, this work was further informed by the collective interdisciplinary guidance of key stakeholders in healthcare, vascular access, and infusion therapy. Third, this work was vetted through public comment. We anticipate this document will impact healthcare professionals and policymakers and, most importantly, will significantly improve patient experiences by promoting consistent high-quality treatment, safety, and comfort.

Methods

Representatives from AVA, INS, AACN, and ECRI collaborated to convene 15 experts in vascular access and infection prevention, including registered nurses, epidemiologists, researchers, critical care specialists, nurse leaders, professional development specialists, a medical doctor and a patient representative. All experts completed conflict of interest disclosures.

Approach

We used a modified RAND/UCLA Appropriateness Method for development of the best practice statements.⁸ This method has been widely used to reach agreement about the real-world application of evidence in healthcare. A project methodologist with consensus expertise defined the process, created the rating forms, calculated scoring, reported the ratings, and facilitated the in-person meeting. Informed by our focus on real-world implementation of these recommendations, we developed rating scales for both impact on patient outcomes and impact on health system resources. A standard RAND/UCLA 9-point scale was used, with the scale for outcome ratings defined as 1=no impact; 5=uncertain; 9=high impact, and the scale for the resource ratings defined as 1=no resource needs; 5=uncertain; 9=high resource needs. Outcome ratings were prioritized for the consensus process, with resource ratings providing implementation context. We defined scoring a priori, with an ‘uncertain’ score to be assigned if a recommendation statement had a median score in the 4–6 range and ‘disagreement’ to be assigned if individual ratings for a recommendation statement fell in both the 1–3 category and the 7–9 category.

Best practice statement development

The drafting team reviewed the literature for published guidelines, standards of practice, and key evidence. They drafted an initial set of recommendations, organized into clinically and operationally meaningful groupings. The drafting team did not participate in the ratings or consensus process described below.

The panel, consisting of 13 experts were oriented in a virtual meeting. Panelists then conducted independent ratings of the draft recommendations using an online form. The project methodologist scored the first round of ratings using the scoring method previously described to indicate median scores, uncertainty, and disagreement. Summary results were sent via email to all panelists.

Panel members met for a one-day meeting facilitated by the methodologist. During the meeting, panelists discussed the recommendations, focusing on those with ratings reflecting uncertainty and disagreement, and proposed refinements. After the meeting, the revised recommendations were integrated into the second rating form. Panelists re-rated each recommendation in an online survey. The methodologist rescored the second ratings. Final recommendations were those that achieved a median score of 7–9 in the second rating.

A brief description of the project and the recommendations were posted for public comment in February 2024. Communications were distributed from supporting organizations and contributors through email, social media, and other digital campaigns. At the close of the public comment period, all submitted comments were reviewed for relevancy and inclusion into the final recommendations and manuscript. The expert panel convened to conduct review and revisions based on public comments. The expert panel then completed a final round of voting, indicating whether a recommendation should be maintained or removed for the final statement. A simple majority was used for scoring.

Results

At the completion of the second round of ratings, 14 categories with 81 recommendations were finalized for public comment. During the public comment period, we received responses from 92 respondents with 476 substantive comments. After revisions based on public comment, the panelists voted on 16 categories with 122 recommendations. The final 16 categories and 123 recommendations are presented below.

Themes from public comment

There were 476 substantive comments received during the open public comment period. Of these, many demonstrated positive reception for the recommendations. There were several themes that presented through the remaining comments, which were reviewed for adoption within the recommendations where appropriate or for revision of the recommendations for clarification. One theme that emerged was the need for enhanced awareness of the psychological, behavioral, and emotional needs of patients. Another theme that emerged was the need to strengthen the focus on diversity, equity, and inclusion in the recommendations. Another theme illustrated the need to improve the practices for assessing patients for difficult intravenous access. Some public comments reiterated recommendations that already existed within the document. The drafters were grateful for the public's interest in these recommendations, their detailed analysis, and the comments received.

Definitions

The panelists adopted or established the following definitions for the recommendations:

Assess intravenous access needs

Educate, inform, and collaborate with patients and caregivers

Clinician education and competency

Ensure safety

Choose the right insertion site and device

Pain reduction and comfort strategies

Maximize first insertion success

Insert and secure

Routine use and post-insertion care

Ongoing need

PIVC removal

Documentation

Remove and replace only if needed

PIVC quality management

Psychological and cultural safety

Health equity and social determinants of health

Disclaimer

Consensus statements are developed by expert panels and/or professional organizations to provide recommendations based on the collective expertise and available evidence at the time of their publication. While consensus statements aim to provide guidance for clinical practice, it is important to note that they do not replace individual clinical judgment or consideration of specific patient circumstances.

The information provided in consensus statements is intended for general informational purposes only and should not be considered as a substitute for expert clinical advice, diagnosis, or treatment. Clinicians should exercise their professional judgment when applying consensus statements to individual patient cases, considering factors such as patient preferences, unique circumstances, available resources, and local regulations or laws.

It is essential to understand that consensus statements are not legally binding documents. They do not establish a standard of care that must be followed in all circumstances. Consensus statements may become outdated as new evidence emerges or medical practices evolve. It is essential for healthcare professionals to stay updated with current research and guidelines relevant to their specialty area.

While efforts are made to ensure the accuracy and reliability of consensus statements, no warranty or guarantee is given regarding their completeness, accuracy, reliability, suitability, or applicability. The use of any information contained in a consensus statement is solely at the discretion and responsibility of the healthcare provider.

For specific medical advice or concerns related to an individual patient's care, it is recommended that healthcare professionals consult with appropriate specialists and refer to relevant consensus statements specific to their region or institution.

Recommendations specify the level of confidence that the recommendation reflects the net effect of a given course of action. The use of words like ‘must’, ‘must not,’ ‘should’, and ‘should not’ indicates that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating clinician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating clinician in the context of treating the individual patient. Use of the information is voluntary. AVA and partnering organizations do not endorse, devices, services, or therapies used to diagnose, treat, monitor, or manage vascular access care. Any use of a brand or trade name is for identification purposes only. AVA and partnering organizations provide this information on an ‘as is’ basis and make no warranty, express or implied, regarding the information. AVA and partnering organizations assume no responsibility for any injury or damage to persons or property arising out of or related to any use of this information, or for any errors or omissions.

Stephanie Pitts – the opinions expressed herein are my own and do not reflect the views of B. Braun Medical Inc, B. Braun of North America or any other related company.