Over that past few months, IV therapy and vascular access practice has been the focus of national health departments, with the release of guidelines and protocols to assist with clinical practice. The National Infusion and Vascular Access Society (NIVAS) has been working in collaboration with many of them.
It is evident that one of the many areas of practice the pandemic has highlighted is the importance of vascular access and IV therapy. As our specialty has been noticed more over the past 2 years, so too, unfortunately, have the associated complications. NIVAS members have reported that they have seen an increase in the rates of catheter-related blood stream infections (CRBSIs) and other complications and it is not always easy to understand why this is.
It is well-evidenced that vascular access devices and IV therapy practice pose an increased risk of being a source of infection to our patients. Device-related infection prevention practice is on the national agenda and NIVAS, alongside the Infection Prevention Society, ANTT® and the Association for Safe Aseptic Practice, is about to launch a pathway to help reduce IV CRBSIs and improve patient and staff safety.
CRBSIs are not the only complication that have increased recently. One unusual complication comes from using unsterile ultrasound gel when placing vascular access devices. The UK Health Security Agency (2021) has published guidance on the use of ultrasound gel and good infection prevention practice. Among other recommendations, the guidance advises that sterile ultrasound gel in single-use containers should be used:
- For invasive procedures—that is any ultrasound-guided procedure that involves passing a device through skin into sterile tissue, such as intravenous line insertion or fine-needle aspirate
- If an invasive procedure is likely to be undertaken in the following 24 hours—this includes ‘viewing or initial assessment’ of a site by ultrasound prior to undertaking an (aseptic) invasive procedure
- Where the ultrasound examination is near to an indwelling invasive device, such as an intravenous line or suprapubic catheter
- For examinations of individuals who are severely immunocompromised
- In an intensive-care setting, high-dependency, or equivalent unit, including neonatal intensive care.
Other complications also seen to be increasing are medical adhesive-related skin injuries (MARSIs) and IV therapy-related extravasation. In my own practice, this increase in MARSIs seems to be related to an increased use of steroids during COVID-19 and more hurried clinical practice that is not allowing the chlorhexidine skin cleaner to dry before dressing changes. NIVAS is planning to publish more practical guidance on MARSIs in the coming months.
The biggest issue that has recently come to light in clinical practice is extravasation of non-chemotherapy agents. Extravasation outside of oncology departments is often unrecognised, unreported and misdiagnosed. Recently NHS Resolution (2022) published a document in its ‘Did you know?’ series, which outlines current patient safety themes associated with extravasation. It lists the top 10 injuries caused by extravasation and the key causes of extravasation.
Between 1 April 2010 and 1 December 2021 NHS Resolution received 467 claims relating to extravasation injuries. Of those, 214 were settled with damages, costing the NHS £16 million in legal costs.
Some of the contributory factors to these extravasation injuries included:
- Incorrect medication infusion pump pressures
- Wrong route of administration
- Delay in identifying extravasation injury
- Staff not following manufacturer's or local guidance on administration of intravenous drugs.
According to NHS Resolution's data, only 24% of the extravasation claims involved chemotherapy, the other 76% were associated with non-chemotherapy drugs. We know that the true rate of extravasation nationally is under-reported, mainly because there is no national, standardised reporting of the injury.
NIVAS, in partnership with national oncology and chemotherapy organisations, is producing national guidelines on chemotherapy and non-chemotherapy drug extravasation. NIVAS and Patient Safety Learning are planning to launch a national campaign to improve awareness and support local hospital organisations to improve patient safety in this area. More information, is available on the NIVAS website (NIVAS.org.uk).