Nurses’ knowledge and experiences of peripheral intravenous catheter insertion at a tertiary paediatric health centre

Peripheral intravenous catheterisation is probably the most common procedure performed in paediatric clinics. It has been estimated that 80% of hospitalised children have a peripheral intravenous catheter (PIVC) in place (Ben Abdelaziz et al, 2017).The peripheral intravenous route is an effective and safe way to administer intravenous medication and fluids (Park et al, 2016). All catheters can cause problems. PIVCs may have complications such as occlusion, leakage, infiltration, extravasation and phlebitis although infection rates are low (Rickard et al, 2010).Several studies have demonstrated that PIVC-related complications such as infiltration, extravasation, occlusion and displacement are common in paediatric patients (Malyon et al, 2014; Ben Abdelaziz et al, 2017; Özalp Gerçeker et al, 2018). Moreover, insertion of a PIVC is one of the two most painful interventions undergone by hospitalised children, the other one being the taking of a blood sample (Høvik et al, 2019).

PIVC insertion is generally more difficult in children than in adults. This is because of the inability of infants and toddlers to understand the procedure, needle anxiety in older children, and the anatomical and physiological differences between children and adults, such as the size of veins. These are among the factors causing unsuccessful attempts at and difficulties in PIVC insertion (Park et al, 2016).

Nurses generally learn how to insert PIVCs in the laboratory on simulators in their basic nursing education, and then perform this technique on actual patients in the wards. Failure to gain adequate experience during their education may lower nurses’ success rate in inserting cannulas, resulting in insertion failure when they start their working life (Schuster et al, 2016).Experienced nurses with certification in a specialty were more successful at catheter insertion in one study (Jacobson and Winslow, 2005). There are many patient-, nurse-, material- and environment-related factors affecting the success of PIVC insertions and the prevention of complications; therefore, it is important for nurses to be aware of these factors to increase the likelihood of their interventions being successful.

In Türkiye, nurse education involves a 4-year course at university. Following European Union criteria, more than half of the nursing education curriculum consists of clinical practice (HUÇEP, 2014).During their education, nursing students first learn how to insert a PIVC in simulation laboratories, and then perform it on patients in clinical practice, under the supervision of nurses and teachers, after the patient's consent is received. After graduating, whereas the majority of nurses start working in state hospitals affiliated to the Ministry of Health, some work in private hospitals or university hospitals. All hospitals organise an orientation programme for new nurses. At the end of the orientation programme, newly graduated nurses start working in the clinics under the supervision of a mentor nurse. In accordance with the quality assurance system of the Ministry of Health, each hospital provides in-service training to nurses at certain intervals (Saglıkta Kalite Standartları, 2020).In addition, nurses study for various certificates in subjects such as paediatric intensive care and emergency nursing. There are various specialty nurses in hospitals such as infection nurses and diabetes nurses. However, nurses carrying out intravenous administration are not in a separate team, each nurse has the authority to perform intravenous treatment (Hemsirelik Yönetmeligi, 2011).

Aim

The aim of the study was to determine paediatric nurses’ knowledge and experiences of PIVC insertion at a tertiary paediatric health centre.

Methods

The current cross-sectional study included nurses working in the clinics of a paediatric hospital in İzmir, Türkiye, between May 2019 and September 2019. The hospital is a tertiary paediatric health centre, with 600 000 outpatients annually and approximately 24 000 hospitalisations took place during 2018. The hospital provides health services to all children from birth to 18 years.

No sampling method was implemented in the study. All nurses working in the inpatient clinics were eligible to take part. During the study period, 334 nurses were actively working at the hospital. Of these, 225 (67.4%) of the nurses in the inpatient clinics agreed to take part.

A ‘PIVC knowledge and experience form’ and a ‘Sociodemographic characteristics questionnaire’ were used to collect data. The ‘PIVC knowledge and experience form’ was developed by the authors based on the guidelines of the Infusion Nurses Society (Gorski et al, 2016).After expert opinion was obtained from specialists with doctoral training in paediatric nursing, the form was pilot tested with six nurses, and points that were not understood were revised. The form included 43 multiple-choice questions about the insertion and care of PIVC. The ‘Sociodemographic characteristics questionnaire’, developed by the authors, included questions on the participants’ age, sex, education status, length of service in the profession and the unit in which they work.

After the participants signed a consent form, indicating that they volunteered to participate in the study, the questionnaires were filled in through face-to-face interviews conducted by the first two authors.

Statistical analysis

The data were analysed in the SPSS v25.0 programme and were presented as numbers, percentages, and arithmetic mean in the descriptive statistics.

Ethical approval

Permission to undertake the study was obtained from the ethics committee of the children's hospital (approval number: 2019/295).

Results

Demographic features

Of the 225 nurse participants, 91.6% (n=206) were women and 8.4% (n=19) were men. The mean age of the nurses was 34.59±7.96. Working years as a nurse was 13.6±8.49 years, and 9.35±7.69 years in the paediatric clinics as a paediatric nurse. Of the participants in the study group, 10.2% (n=23) had received a postgraduate education, 64% (n=144) had a graduate degree, 20% (n=45) had an associate degree, and 5.8% (n=13) were high school graduates now undergraduates studying at university.

PIVC insertion practice

Most nurses stated that they had no preference for the right or left hand when placing the PIVC (86.2%). They most often inserted the PIVC on the dorsum of the hand (83.1%). Their choice of vein was affected by the condition of the patient's veins (91.1%), medications (72%) and the patient's activity status (70.2%). The most preferred PIVC size was 24 gauge (98.2%), and the most frequently used cannula was a short peripheral cannula (96.9%). Among the factors affecting the size of the cannula were the vascular structure of the patient (90.2%), difficulty in accessing the vein (71.6%), and viscosity of the medication/fluid to be administered (70.2%) (Table 1).

Hygiene rules applied before the insertion of the PIVC were handwashing (93.3%), wearing gloves (89.3%), and the use of an aseptic non-touch technique (66.7%). A tourniquet was used by 94.2% of the nurses. Nurses kept the tourniquet in place for between 20 to 40 seconds and 1 to 2 minutes.To clean the insertion site of the cannula, 93.8% of the nurses used 70% alcohol (Table 2).

Nurses chose distraction methods in accordance with the age of the child. Distraction methods used while inserting the PIVC were as follows: letting the child play with a toy (51.1%), having the child sit on the mother's lap (45.8%), letting the child watch cartoons (45.3%), and administering oral sucrose (43.6%) (Table 2).

After the PIVC was inserted and secured, of the 225 nurses, 92.4% always labelled the PIVC, 3.6% sometimes labelled it, and 4% never labelled the PIVC. Nearly all the nurses (99.1%; n=223) wrote the date of the catheter insertion on the label and 91.1% of the participants (n=204) wrote the name of the nurse who had inserted the PIVC. In total, 98.7% of the participants recorded relevant information and the date of PIVC insertion in the patient's file, 87.1% recorded the PIVC insertion site. Some 69.3% attached a split septum/vein valve to the PIVC insertion site, and 82.2% of all nurses cleaned the split septum/vein valve with 70% alcohol and waited until it dried before administering the medication. The percentage of the nurses who secured the cannula with sticking plaster was 79.6% (Table 2).

Some 94.7% of nurses performed catheter flushing after inserting a PIVC, 93.8% performed catheter flushing before IV fluid treatment, 89.8% flushed the catheter before drug administration through the bolus method, 53.3% flushed the PIVC catheter with the slow technique and 42.2% flushed it with the intermittent technique.

Nurses’ opinions about unsuccessful PIVC attempts

The nurses’ opinions about the factors leading to the failure of PIVC insertion were as follows: insufficient lighting in the room (94.7%), poor quality of the material used (88.4%), the child was on a low stretcher making insertion difficult (71.1%) and the presence of a parent/parents (67.1%). Some 50.7% of the nurses reported that they tried to insert the PIVC at most three or four times, and 20.9% of them tried repeatedly until the insertion was successful.

The percentage of those who did not use vein-finder devices when inserting the PIVC was 81.8%. Some 76.4% of the nurses stated that it took a long time to insert the PIVC in long-term hospitalised patients because of the previous insertions of the PIVC into their veins, and 67.1% stated that if the patient's vascular access was good and the nurse was experienced, it took a short amount of time to insert the PIVC.

Nurses’ approaches to PIVC maintenance and troubleshooting

Sixty per cent of the nurses said they would pull the clot back from the catheter tip with an empty syringe if the PIVC was blocked, and 41.8% delivered bolus fluid directly to the catheter with a syringe. Some 36.9% of the nurses replaced PIVCs at intervals of between 6 and 48 hours, and 79.1% of them replaced the catheter dressing immediately if it became contaminated. Whereas 73.3% of the nurses monitored the patient for the symptoms of catheter complications during intravenous fluid treatment, 61.8% of them monitored the patient for the symptoms before starting intravenous treatment. In total, 87.1% of the nurses elevated the PIVC site when infiltration or extravasation developed, 75.1% compressed the site with 70% alcohol. The percentage of nurses who kept records of the complications was 89.8% (Table 3).

Discussion

The present study aimed to reveal paediatric nurses’ knowledge and experience of PIVC management using a form composed of 43 multiple-choice questions. Results showed that nurses mostly recorded the data regarding catheter insertion both on the catheter label and in the patient's file. To avoid medication errors, accurate record keeping is essential (Wang et al, 2015; Park et al, 2016).

Since PIVC insertion is one of the leading interventions that cause pain in hospitalised children, paediatric nurses use non-pharmacological interventions to manage pain during PIVC insertion, based on their knowledge and experience. The efficacy of non-pharmacological interventions indicated by paediatric nurses in pain management has been proven (Binay Yaz and Bal Yilmaz, 2022). In the present study, the most common non-pharmacological intervention was using toys. This was followed by having the mother's help, using cartoon shows on a smartphone to distract the attention of the child and administering oral sucrose. However, other technologies such as virtual reality glasses were rarely used by nurses in the study, probably because such technology may not be suitable for young children, there was a shortage of such equipment and the nurses may be unfamiliar with this emerging technology, as another study found (Binay Yaz and Bal Yilmaz, 2022).

Insertion sites preferred by the nurses were the dorsum of the hand and forearm. That is probably because both sites are flat, and nurses can easily grasp and stabilise them, and insert catheters comfortably. Other studies have found that the dorsum of the hand is the preferred site, such as that by Ullman et al (2020). The PIVC size mostly preferred by the nurses was 24 gauge, and they determined the diameter of the catheter by taking into account the viscosity of the medication to be administered. The results of other studies in which the nurses’ catheter diameter preferences were similar to the nurses’ preferences in the present study (Ullman et al, 2020) indicate that the majority of nurses choose catheter gauge by taking the patient's age, development and treatment into account.

The percentage of successful insertions of the catheter at the first attempt varies from one study to another (Jacobson and Winslow, 2005; Vukovic et al, 2016) and is generally lower in children compared with adults. Moreover, the percentage of successful insertions at the first attempt in newborns is lower than that in older children (Legemaat et al, 2016).Newer technologies such as ultrasound and infrared light vein visualisation devices were reported to be effective at decreasing the number of insertion failures (Choden et al, 2019). In the current study, approximately 82% did not use technological devices during PIVC insertion.

The Infusion Nurses Society (2006) guidelines state that no more than two attempts at cannulation by any one nurse should be made to avoid multiple unsuccessful attempts causing trauma to the patient and limiting future vascular access. In the current study, approximately 20% of the nurses continued their attempt to insert the catheter until they succeeded. This is an important finding because, in the current setting, there is no dedicated intravenous team and insufficient available infrared light devices, thus successful venous access in most cases depends on the personal experience of the nurse. Therefore, in clinics, guidelines and algorithms regarding PIVC insertion should be developed in addition to an effective intravenous team.

In the present study, a hypoallergenic nonwoven adhesive fixation tape bandage or non-sterile tape was used as a catheter dressing. In a study involving a child and adult sample in 51 countries, 40 637 catheter dressings were observed, and it was noticed that in 79% of cases, transparent polyurethane was used as a catheter dressing. In paediatric patients, a simple polyurethane dressing, non-sterile tape (in Asia and South America), and sterile gauze and tape (mostly in Pacific, Middle East and Europe) were used as catheter dressings in 53%, 22% and 6% of patients respectively (Corley et al, 2019).Several studies have found that the closure of the catheter insertion site with non-sterile tape often leads to complications and that when dressing and fixation of the insertion site are performed together (using a dressing and sterile tape for fixing), complications decrease and that monitoring the insertion site at 4-hour intervals, and replacing the dressing every 1-3 days leads to better integrity of the catheter dressing (Corley et al, 2019).

In the present study, after the PIVC was inserted, the catheter was flushed with 0.9% sodium chloride before intravenous treatment, and before and after the intravenous administration of the medication. This procedure was used to prevent not only catheter occlusion but also drug interactions in successive drug administrations.To prevent central venous catheter occlusion, the effectiveness of heparin has been compared with that of 0.9% sodium chloride (Bradford et al, 2015). A Cochrane systematic review found that there is not enough research evidence to prove whether heparin or 0.9% sodium chloride is superior, and no clear conclusion was reached (Bradford et al, 2015).In a recent article from the authors’ centre, focusing on central line bundles in different clinical settings, single-use prefilled flushing 0.9% sodium chloride syringes were found to be an important step in the central line bundle, and these bundles should be adapted to include PIVCs (Karaoğlan et al, 2022).

Peripheral intravenous catheterisation is one of the most frequently performed procedures in children, and up to 50% of the hospitalised children are estimated to undergo this procedure. (Ullman et al, 2020).The nurses participating in the present study stated that they regularly monitored the patient for the symptoms of PIVC complications during intravenous treatment and that if there were any complications, these were documented. The Infusion Nurses Society guidelines (Gorski et al, 2016), state that nurses should monitor the PIVC site for symptoms of infiltration and extravasation before, during and after each infusion, and that the patient and family should be trained to recognise these symptoms (Gorski et al, 2016). However, the present study's findings indicated that there is no standardisation regarding the frequency of follow-up of catheter complications as shown by the nurses in this study, and the frequency of PIVC monitoring performed varied from nurse to nurse.

Limitations

Although the present study was carried out in the largest comprehensive children's hospital in the region, the study gave information about one hospital and the findings cannot be generalised for other countries. Around 68% of the nurses took part in the study, which is a relatively low percentage. In the hospital, active central line bundles are in use in the intensive care units, thus the nurses might be aware of some procedures. However as a result of this study, it is hoped that further studies will be conducted on introducing standardisation in PIVC interventions. Because the present study was conducted in 2019, the 2016 INS guidance was used, which was the latest version available (Gorski et al, 2016). The INS 2021 guidelines have since been published (Gorski et al, 2021). Greater use could also be made of the DIVA (difficult intravenous access) scoring tool (Schults et al, 2022), used for the identification of children with difficult intravenous access.

Conclusion

When performing PIVC interventions, the nurses in the present study generally acted in accordance with the criteria specified in the Infusion Nurses Society guidelines (Gorski et al, 2016). To improve PIVC practice at the hospital, the use of vein visualisation tools should be expanded. It would also be helpful if the hospital infection control committee and nursing quality managers developed algorithms that include standards to prevent and manage PIVC insertions and complications.

KEY POINTS

• A study examining nurses’ practice of using peripheral intravenous catheters (PIVC) in children was undertaken in a paediatric hospital in Türkiye
• In total, 225 nurses took part in the study, the majority working in line with the Infusion Nurses Society guidance available at the time (2016)
• The authors concluded that standardisation of PIVC procedures is needed so that all nurses follow the same techniques throughout the hospital

CPD reflective questions

• Would establishing an intravenous team of experienced nurses in your clinical area increase the success of peripheral intravenous catheter (PIVC) insertion?
• How useful are bundles in standardising PIVC application?
• Would the introduction of a simulation programme to increase the paediatric PIVC skills of student nurses increase the clinical success of PIVC insertion and monitoring?