Many patients admitted to hospital or receiving care in any other setting, including at home, will receive intravenous (IV) therapy at some point (NHS Scotland, 2002; Royal College of Nursing (RCN), 2016; National Institute for Health and Care Excellence, 2017).
These patients will require a peripheral intravenous catheter or cannula (PIVC) or a central venous access device (CVAD) to be inserted to facilitate the delivery of IV treatment. Zhang et al (2016) determined that in the UK, one in three inpatients will have at least one PIVC in situ at some time while in hospital.
Although safe and easy to insert, PIVCs are associated with a number of risks and high failure rates that are costly to patients, practitioners and healthcare systems.
Shaw (2017) and Helm et al (2015), analysed data from the USA and estimated that on average more than 300 million PIVCs are used per year. Moreover, Steere et al (2019) revealed that an average of 10 PIVCs were used per patient admission, which implies there is a very high failure of PIVC insertion and related care and maintenance, and excess cost associated with such interventions.
Accidental dislodgement is one of the most common factors contributing to IV catheter failure, with dislodgement rates estimated at 1.8%–24.5%, and more than five million IV catheters becoming dislodged per year (Moureau, 2018). Current literature (Rickard et al, 2015; Ullman et al, 2016; Moureau, 2018; Blanco-Mavillard et al, 2019) estimates overall IV catheter failure rates to be as high as 50%.
IV catheter dislodgement is an often unrecognised issue of vascular access device care, and it can result in treatment delays and the need for further invasive procedures, which can increase patient anxiety and stress. Helm et al (2015) also explored how PIVC and IV failure could be physically and psychologically costly for individual patients and concluded that failure rates of 35%–50% in the best of hands was simply unacceptable to patients, caregivers and healthcare organisations in general. Moureau (2018) conducted a clinical survey that demonstrated that IV dislodgement is seen nearly every setting, in every IV device and by every type of practitioner; accidental dislodgement was reported often—daily and multiple times per day.
Considering the prevalence of both IV therapy and IV catheter failure as a result of dislodgement, it makes sense to address the problem of dislodgement to improve the patient experience and reduce the associated costs to the healthcare system.
Is dislodgement avoidable?
After placement, IV catheters, whether PIVC or CVAD, will be secured to the catheter insertion site by a variety of methods. Accidental dislodgement of IV catheters occurs when the chosen securement method fails and causes the catheter to become displaced.
Although multiple factors can contribute to IV dislodgement, the results of a clinical survey conducted by Moureau (2018) identified the top three causes as: confused patients (80 %); patients physically removing the IV catheter (74%); and loose IV dressings or securement (65%).
Effective securement reduces movement within the vessel, which will minimise the potential for irritation, inflammation, occlusion and risk of infection (Marsh et al, 2015). The most common securement methods used to stabilise the catheter and hold it in place are sterile standard medical tape and/or a transparent adhesive dressing placed on top of the IV exit site. IV catheters with stabilisation features such as wings may help to secure the catheter because they provide an additional adhesive dressing contact area. To minimise catheter movement and gain more adhesive surface area, extension tubing can be attached to the IV catheter hub (Kaur et al, 2019).
Newer, engineered stabilisation devices provide better securement and stabilisation, and allow better control of the catheter and connected tubing (Rickard et al, 2015; Ullman et al, 2015; 2016; RCN, 2016; Gorski et al, 2021). However, these can also fail if used incorrectly or when greater forces than the securement method was designed to withstand are exerted upon the catheter, for example when patients roll in bed, if IV extensions get caught in bedrails, when patients are being transferred between beds, during trips to the toilet, when paediatric patients interfere with IVs, or disorientated adult patients pull their IV catheters out.
The correct IV catheter securement technique can address some dislodgement cases but cannot resolve those caused by patient behaviour, which accounted for the two causes of dislodgement cited in Moureau's study (2018). To avoid this type of dislodgement, some manufacturers have developed set protection devices that allow tubing to disconnect under undue pressure or pull by using a safety release valve that breaks away and seals off both sides of the tubing in an aseptic manner while shutting off medication flow and preserving IV catheter integrity. These new devices are designed to act as a shield against patient or staff accidentally dislodging IV catheters.
ReLink
ReLink is a patented and CE-approved breakaway connector for IV lines (Figures 1and2), designed to reduce complications and costs associated with accidental disconnection and potential dislodgement of IV catheters.
It features double-sided, self-sealable ports, with weak link activation to protect the catheter placement site and loss of fluid. The pull force required to separate the tube from the catheter has been optimised through rigorous testing to ensure the indwelling catheter remains protected. After separation, both ReLink connector hubs can be simply swabbed and reconnected for rapid reinstatement of IV therapy, providing great efficiency for nursing staff in every environment.
ReLink has a luer-lock connection, making it compatible with all IV catheters and extension tubes that have a luer lock. International and national standards (RCN 2016; Gorski et al, 2021) advocate for the use of luer-lock devices so ReLink should be compatible with most IV accessories.
While most patients receiving IV therapy can benefit from breakaway systems such as ReLink, they can be most useful in the following patient groups:
- Confused and uncooperative patients
- Ambulatory patients
- Paediatric patients.
It is important that clinicians are aware of the burden of accidental IV dislodgement and of the availability of ReLink and other breakaway systems so they can focus on addressing the issue and education for themselves and their colleagues to reduce this complication and its impact on clinical practice and patient safety.
Most nursing professionals are continuously involved in the management of their patients' IV therapy. This empowers them as a key professional group to: monitor and identify eligible patients; promote education and support the standardisation of consistent processes and policies to ensure effective management of IV catheters (insertion, securement and maintenance); and minimise the risk of dislodgement and catheter failure.
The importance of education cannot be overstated as it ties all other practices together (Moureau, 2019). Educating nurses about new clinical products is crucial to ensuring these products or technologies reach all clinical settings. Education must be offered in a variety of platforms—such as online, through journals and face-to-face and hands-on training—to reach and engage everyone.
Although research around IV securement devices and dressings is ongoing, there is a need for case studies and more high-level research on the frequency, causes and impact of IV dislodgement in clinical practice. Dissemination of research findings would help to improve clinical outcomes and patient safety while reducing healthcare costs.
Conclusion
Dislodgement of IV catheters is a common problem for IV therapy delivery in most healthcare settings. Better systems to prevent this and its associated and potentially serious consequences are needed. The impact of accidental dislodgement highlights the need to increase awareness and reduce incidence.
The use of breakaway systems, such as ReLink, in clinical practice may eventually offer patients and healthcare providers a system to prevent dislodgement and IV catheter failure.
As with most new clinical products, there is need for clinical case studies and more robust clinical research to prove the benefits and efficacy of these systems.
KEY POINTS
- Many patients in hospital will require of intravenous (IV) therapy delivered via a peripheral IV catheter or cannula or a central venous access device
- Accidental dislodgement is one the commonest reasons for IV catheter failure
- IV catheters becoming dislodged results in treatment delays and a potential need for further invasive procedures
- Effective IV catheter securement alone cannot prevent accidental dislodgement; it can fail when used incorrectly, or when greater forces than the securement method was designed to withstand are exerted on the catheter
- New set protection device technology with breakaway mechanisms can protect against IV catheter dislodgement and failure
- To reduce accidental dislodgement, practitioners need to be aware of the issue and receive education on it
CPD reflective questions
- In your clinical practice, how does dislodgement of intravenous (IV) lines affect patient care?
- Why is IV catheter dislodgement important?
- How can you avoid IV catheter dislodgement? Is it preventable?
- What factors need to be considered when selecting IV securement devices?