Peripheral intravenous cannulas (PIVCs) are among the most used devices in hospitalised patients (Carr et al, 2017; Australian Commission on Safety and Quality in Healthcare (ACSQH), 2021a). Optimal management of PIVCs is important to reduce the risks of infection, including healthcare-associated Staphylococcus aureus (Staph. aureus) bacteraemia (HA-SAB) bloodstream infections (BSIs) (New South Wales (NSW) Ministry of Health, 2019). PIVCs account for almost a quarter of the HA-SABs in Australia (Rhodes et al, 2016) ahead of surgical site infections and infections caused by central venous catheter and other indwelling devices (Rhodes et al, 2016; ACSQH, 2021b).
On insertion, a PIVC breaches and traumatises the skin, the natural barrier to foreign objects and, potentially, provides a conduit for microorganisms to form biofilms on the catheter (Grice and Segre, 2011; Byrd et al, 2018). When bacteria colonise the external surface of the catheter, there is potential for them to migrate down the length of the catheter and enter the bloodstream (Mermel, 2017; Bitmead and Oliver, 2018). Bacteria can also enter the bloodstream through the contamination of the hub/lumen of the PIVC (Mermel, 2017; NSW Ministry of Health, 2019; ACSQH, 2021a).
The antecubital fossa (ACF) has more Staphylococcus species than any other area of the upper and lower arm, and as it is a point of flexion, there is an increased risk of causing trauma to the PIVC insertion site, allowing bacteria to travel into the bloodstream (Hawkins et al, 2018).
HA-SABs are reportable and associated with significant morbidity and mortality (Stuart et al, 2013; Rhodes et al, 2016; Bitmead and Oliver, 2018). The mortality rate associated with Staph. aureus bacteraemia (SAB) in Australia is approximately 20% (Gosbell, 2005; Turnidge et al, 2009; ACSQH, 2021a). HA-SABs can be associated with poor hand hygiene practices, sub-optimal insertion or management of indwelling medical devices (Stuart et al, 2013; Rhodes et al, 2016; Mermel, 2017; Mitchell et al, 2017; Ruegg et al, 2018; NSW Ministry of Health, 2019). In Australia, HA-SAB episodes have become a national performance indicator, with rates of individual health services' HA-SABs publicly reported on the My Hospitals website (Australian Institute of Health and Welfare, 2020). Preventive measures such as avoiding placement of the PIVC in the ACF area, as well as aseptic technique, staff education around improved documentation, standardised insertion packs and alerts for timely removal may reduce the overall risk of acquiring an HA-SAB (Stuart et al, 2013; Queensland Health, 2015; Rhodes et al, 2016; NSW Ministry of Health, 2019).
Staph. aureus is both a commensal bacterium and a known human pathogen. Almost 30% of the human population is colonised with Staph. aureus. Staph. aureus nasal carriage has been identified as a risk factor for HA infections in general hospital populations and hands are the main route for transmitting Staph. aureus between patients and healthcare staff (Wertheim et al, 2005; El Aila et al, 2017). Staph. aureus is also the leading cause of bacteraemia and device-related infections, including those attributed to PIVC (Tong et al, 2015; Mermel, 2017).
This study was conducted in light of the rise in the rates of HA-SAB in the authors' health service in the third quarter of 2019 to 1.62/10 000 patient bed days; compared with 0.60/10 000 bed days in the first and 1.00/10 000 in the second quarter of 2019. Thirty-three percent of these BSIs were attributable to a PIVC. Other causes of HA-SAB included infections of the skin and soft tissue, urinary tract and bone and joints. In absolute numbers, there were 25 HA-SAB infections from January 2019 to December 2019, of which 17 were attributed to intravascular devices, 3 to skin and soft tissue infections, 2 to bone and joint infections, 2 to an unknown source and 1 to a urinary tract infection.
Eight of the 17 SABs attributed to intravascular devices in the 2019 calendar year were due to a PIVC. Six of the eight PIVCs were inserted in the ACF. A review of all PIVC-related HA-SABs over 8 years demonstrated that 80% were attributed to ACF insertions. The authors' institutional surveillance highlighted a growing trend of increased placement in the ACF. In 2018, 60% of all PIVCs were inserted in the ACF.
The primary objective of this study was to implement an educational programme to enhance awareness and reduce the overall prevalence of ACF cannulas inserted in the emergency department (ED) and four key wards in the authors' hospital. The secondary objective was to reduce the overall rates of HA-SAB.
Methods
Patient population
Sunshine Coast Hospital and Health Service (SCHHS) is a major provider of public health services, health education and research in the Sunshine Coast, Gympie, and Noosa local government areas of Queensland, Australia. This includes the Sunshine Coast University Hospital (SCUH), a tertiary teaching hospital where the study was conducted. Patients presenting to the ED and two medical and two surgical wards at SCUH were included in the study. The study was approved by the Prince Charles Hospital Human Research Ethics Committee (Project ID 57398).
Pre-intervention period
The Vascular Access Surveillance and Education (VASE) team routinely performs quarterly audits of all adult inpatients in the SCHHS with PIVCs. Information is collected on anatomical location, whether the device is in use, dwell time, adequacy of documentation, presence of phlebitis, the location and circumstances of insertion—particularly if they were inserted in the ED.
As part of routine practice, all BSIs in the SCHHS are rigorously investigated. Following a laboratory confirmed bloodstream isolate, all HA-SABs are investigated in real time in consultation with an infectious diseases physician and clinical nurse consultants from the VASE team and Infection Management Service (IMS). All HA-SABs are reported to the hospital executive through the Infection Prevention Control Committee. Electronic feedback is provided to treating teams on all device-related BSIs.
Intervention period
The intervention period spanned 12 weeks from November 2019 to January 2020. The authors used a multimodal intervention that heightened awareness around ACF cannulas and the risks of infection. This included:
- A baseline digital survey to identify root causes for clinical decision making related to PIVCs in addition to raising staff awareness about the project
- Widespread education with a significant focus on the ED staff, who insert a large proportion of the cannulas in hospital
- Recruiting clinical change champions among senior medical and nursing staff in the ED
- Weekly audits and feedback on four key wards at SCUH
- Advertising and promotion of the study, using posters and screen savers.
The digital survey comprised eight questions that assessed the respondents' clinical role, their knowledge on the dwell time of PIVCs and their understanding on the role of site selection when inserting PIVCs. The rationale was to prompt clinicians to think about the best anatomical place for the PIVC based on patient status, medication or treatment plan prior to cannulation.
Education and advertising comprised promotional material delivered at clinical handover scrums in the ED.
For education the authors used the institution's existing ‘I-Care bundle’ for insertion and management of cannulas. (Queensland Health, 2015). This included reinforcing the significance of aseptic technique and hand hygiene when inserting a PIVC, the use of a dedicated PIVC trolley, the importance of accurate documentation, including date and time of PIVC insertion, as well as the gauge and anatomical site, skin preparation and removal/replacement details.
Feedback on the audit results from the ED were provided fortnightly by the VASE team. An example of promotional material was a ‘Think before you cannulate’ poster and screensaver (Figure 1). This visual was a reminder to staff to consider the ‘ACF criteria’ for cannulation and reserve the ACF where possible for resuscitation, administration of large fluid boluses, adenosine and for administration of contrast for CT angiography studies (Queensland Health, 2015; Bitmead and Oliver; 2018).
The four wards and ED were audited weekly with data collected to track if the PIVC was inserted in the ACF, met the ACF criteria, was inserted in the ED or the ward, was compliant with PIVC dwell time guidelines and included adequate documentation (Queensland Health, 2015). Each ACF PIVC was investigated by a medical officer to determine if it met the ACF criteria.
Post-intervention period
The SCHHS PIVC quarterly point prevalence audit was performed routinely for the period January 2019 to December 2020 using the hospital's standard audit tool. The proportion of ACF cannulas in the ED and the wards were noted. HA-SAB rates were measured quarterly and considered to be a secondary outcome.
Definitions
An SAB infection was defined as HA if:
- The patient's first Staph. aureus-positive blood culture was collected >48 hours after admission to hospital or <48 hours after discharge or
- The patients first Staph. aureus-positive blood culture was collected ≤48 hours after admission to hospital and key clinical criteria were also met
- SAB infection was a complication of an indwelling medical device.
Analysis
The authors used simple linear regression to look at the trend of ACF cannulation rates over time. HA-SAB rates were calculated per 10 000 bed days (ACSQH, 2021b). For the comparison of ACF insertion practices pre- and post intervention period, chi-square was used (McHugh, 2013). A P value of <0.05 was considered statistically significant.
Results
Baseline digital survey
Before commencing the quality improvement study, a baseline digital survey comprising eight questions was sent to all clinical staff involved on insertion and/or maintenance of PIVCs. There were 581 respondents, including 191 (33%) registered nurses, 103 (18%) senior medical officers, 76 (13%) clinical nurses, 64 (11%) registrars and 61 (10.5%) resident medical officers; 86 preferred not to give their profession. Two hundred and fourteen (37%) respondents were from the ED.
Twenty-five per cent of respondents believed that all patients admitted to the ward from the ED should have a PIVC in situ. Seventy-eight per cent of the respondents believed both medical and nursing staff are responsible for PIVC removal. Twelve per cent of respondents were not aware of the local rules around PIVC dwell time in various scenarios, including the emergency setting. Only 58% of respondents correctly identified the clinical indications for placing a PIVC in the ACF.
Twenty-four per cent of the respondents were not aware of the increased risk of infection associated with ACF PIVCs; 8% of respondents stated they always chose the ACF site first as it is larger and easier to cannulate and only 4% felt they were not confident in their cannulation skills, therefore chose the ACF to have first time success on insertion. The survey provided the authors with an understanding of the baseline knowledge deficits of staff around PIVC insertion and maintenance and the clinical indications of ACF cannulas.
Intervention period
During the 12-week intervention, 646 patients with a PIVC were audited. Fifty per cent of all the PIVCs audited were inserted in the ED. The highest rate of ACF cannulation in ED patients was observed in week 1 at 78%, the lowest rate in week 9 at 33% and there was a general trend towards reduction in the proportion of ACF cannulas (P=0.4) (Figure 2). There was an improvement in the indication rate (the indication/criteria for placement of an ACF cannula) from 8% vs 56% between week 1 and 12. The poster and screensaver were visual reminders to staff to consider the ‘ACF criteria’.
The overall ACF cannulation rates in the hospital continued to improve in the post-intervention period (Figure 3). The ACF cannulation rates decreased by 0.03% per day during the study, although this did not quite reach statistical significance (P=0.06). There were no PIVC associated HA-SAB events during the intervention period. The HA-SAB rates decreased by 0.02% per day over the period of the study (Figure 4).
Improved insertion documentation regarding the insertion date, name of the clinician inserting the PIVC and location of PIVC was also observed during the course of the intervention period (Figure 5). In contrast, the ACF cannulation rates did not improve on the wards (P=0.69) (Figure 2).
Discussion
The inspiration for this study came from the rising SAB rates in the authors' health service and the anecdotal observation that ACF PIVC was more likely to be associated with HA-SAB, similar to that reported in the literature (Stuart et al, 2013; Rhodes et al, 2016). The study demonstrated that a multi-faceted intervention focusing on education and change using clinical champions successfully reduced the proportion of ACF cannulas in the ED. The ED was included in this study because, historically, more than 50% of PIVC insertions in the ED in the authors' health service were placed in the ACF, similar to that reported in the literature (Carr et al, 2016). Furthermore, there were no SAB during the intervention period and overall downward trending SAB rates during the course of the study (Figure 4). During the course of the study, the ACF cannulation rate decreased by 0.03% and the SAB rate by 0.02% per day, although both trends were not statistically significant in linear regression.
During the intervention period, we provided real-time audit feedback to staff working on the ground. Weekly face-to-face education sessions were also held during clinical handovers, focusing on the results of the audit and improvement strategies. In the authors' experience, real-time feedback is highly effective, as it provides an opportunity to the clinicians to make an immediate change to the patient's management based on the information provided at that time.
The baseline digital survey highlighted the knowledge deficits of staff around PIVC dwell time, clinical indications for ACF cannulas and the risks of infection associated with ACF cannulas. Based on this information, the authors were able to focus the face-to-face education and promotional material around the specific knowledge deficits, such as the clinical indication for ACF cannulas. In contrast to the ACF cannulation rates on the ward, the ED ACF cannulation rates had an overall downward trend during the intervention period (Figure 2). The authors believe this was due to the fact that the ED had clinical champions from within the department who helped promote the study and highlight its cause. The highest rate of ACF PIVC in the ED was observed on week 1. The rate gradually declined every week (Figure 5); however a spike in the rate was noted in weeks 11 and 12, which coincided with the introduction of new medical officers and interns to the health service. During the intervention period, the indication rate improved from 8% in week 1 to 56% in week 12, which was likely due to the education, promotional posters, and screen savers introduced (Figure 1).
Documentation of PIVC insertion in the ED has been historically very poor in the authors' health service and this was demonstrated in the audits. There was some improvement in documentation, the highest rate was observed in week 9 at 56%; however, this has not been sustained, and quarterly audit results averaged to 38% over the 2 years of the study. Barriers to documenting PIVC insertion at the bedside must be identified and addressed to facilitate the success of any point-of-care documentation (Hawkins et al, 2018). Increased time to log on and off from the integrated electronic medical record (ieMR) system, clinical priorities and workload have been some of the barriers reported by the clinicians. Documentation of PIVC insertions is important to ensure they are removed in a timely manner, as per local guidelines (Queensland Health, 2015; ACSQH, 2021a). Removal of a PIVC is an automatically generated order within the ieMR when insertion data is entered. Dwell time and evidence of insertion is difficult to identify if documentation is poor (Hawkins et al, 2018).
The impact of ongoing interventions such as the ‘bare below the elbows’ rule and hand-hygiene compliance were not analysed to see if they were contributory to the drop in HA-SABs rates during the intervention period; this may be seen as a limitation to the study.
Conclusion
Sustainable culture change requires time and buy-in from all disciplines in the whole department. The authors demonstrated through this study that change through clinical champions, education and regular audit and feedback was able to reduce ACF cannulation and HA-SAB rates. Given the financial and personal implications of HA-SAB, the authors suggest future studies should look at the impact on HA-SAB rates of reducing dwell time of ACF cannulas to 24 hours.
KEY POINTS
- Specialised vascular access teams are a growing specialty group who insert and manage vascular access catheters and also monitor healthcare-associated bloodstream infection secondary to use of Intravenous devices
- Specialist teams can identify trends from routine point prevalence audits and implement quality improvement activities to promote best practices and ultimately improve practices and patient safety
- Sustainable culture change requires time and buy-in from all disciplines
- Regular audit and feedback were able to reduce antecubital fossa cannulation rates and healthcare-associated Staphylococcus aureus bacteraemia bloodstream infection rates in one hospital
CPD reflective questions
- Is the rate of antecubital fossa cannulation an issue in your hospital?
- Have you noticed a correlation between bloodstream infections and PIVC location in your hospital?
- Treating a bacteraemia is costly financially and personally for the patient. Can your current insertion and management of PIVCs be improved?
- Are your procedures reviewed regularly to align with current evidence and recommendations?