Peripheral vascular cannulation is one of the most common invasive clinical procedures undertaken in modern healthcare. Common indications for peripheral catheters include intravascular access being required to administer medications, fluid and electrolyte therapy, as well as for aiding diagnostic procedures. The use of intravascular catheters is associated with risk of local and systemic infections. Catheter-associated bloodstream infection (BSI) is a significant risk.
Strategies to minimise the risk of catheter-associated BSI include replacing peripheral vascular cannulas (PVCs) at regular intervals; however, international guidelines vary on the frequency of replacement. The US Centers for Disease Control guidelines recommend replacing peripheral intravenous (IV) catheters no more frequently than every 72–96 hours (O'Grady et al, 2011). A Cochrane review update (Webster et al, 2015) found no evidence to support changing catheters at 72–96 hours, reaffirming the original Cochrane recommendation in 2010 (Webster et al, 2010).
Intravascular catheter care bundles and education have been successful in reducing catheter-related BSIs (Eggimann et al, 2000; Berenholtz et al, 2004). However, a systematic review found it was not clear which particular ones were more beneficial or effective (Ray-Barruel et al, 2019). It is recommended that PVCs should be replaced when clinically indicated rather than routinely (Loveday et al, 2014). However, practices vary between healthcare providers.
Comparable data on infection rates and other complications related to PVCs are limited. In Ireland, hospital-acquired Staphylococcus aureus BSI is a national key performance indicator (KPI) for acute hospitals. This KPI and other targets for patient safety have renewed the focus on optimal management of intravascular devices. The Irish national guidelines on the prevention of infection incorporate the epic3 recommendations on safe management of PVCs (Loveday et al, 2014).
In the authors' facility, a tertiary acute adult hospital in Dublin, the guidelines were updated to incorporate international best practice on the insertion of PVCs and their ongoing management. This paper reviews the outcome of this and lessons learnt from implementing a policy to replace PVCs according to clinical indication, focusing on the impact on patients, practitioners and resources.
Implementation
Nurses, as well as other clinical personnel, who have been certified as competent, insert PVCs in the hospital. Standard precautions training, including hand hygiene, is mandatory for all staff when they are first employed and every two years thereafter. Alcohol-based hand hygiene stations are available at the point of care. Hand-hygiene practice is audited routinely and reported at intervals for quality assurance. For skin disinfection before cannulation and for disinfection of needle-free connection ports, alcoholic 2% chlorhexidine wipes are used.
In the authors' hospital, the visual infusion phlebitis (VIP) score (Jackson, 2003) and a care bundle are routinely used to standardise PVC care. Action taken depends on the VIP score. For example, a VIP score of ≥2 means the PVC has to be removed. Historically in the authors' hospital, the care bundle was composed of the following elements to check: that the catheter is in still needed; absence of inflammation or extravasation; dressing is intact; duration ≤72 hours; and the documentation is complete. It is hospital policy that disconnection of administration sets must be avoided and, if they are disconnected, the line tip must be closed with a sterile, single-use cap. The use of a sterile, single-use cap is intended to minimise any potential risk of contamination of the disconnected line tip. Practitioner education focused on preventing vascular catheter infection on device insertion, maintenance and the requirement to discard uncapped administration sets.
Clinically indicated replacement of PVCs was implemented in May 2018, and assessment of disconnected administration sets was included as an additional component of the care bundle with the policy change. Standard operating procedures were revised to reflect the change. The record of peripheral IV cannula insertion, VIP score assessment and care bundle was incorporated into a single document to meet a variety of needs. Focused education sessions and nursing practice coordinators aided training on catheter insertion site assessment on each use, each shift and at a minimum of once every 12 hours. Reminders were used at nursing shift handover to communicate the change of policy to all team members.
The safe use of peripheral intravascular catheters in patients is monitored by audits of care bundle documentation and evaluation of clinical practice (Wall, 2010). Care bundle compliance is measured as all or nothing. If all of the care bundle elements are in order, it is assessed as being compliant. Compliance with the PVC care bundle is an institutional KPI, and audited monthly in all inpatient units in each clinical directorate.
Audit methodology
A baseline point prevalence audit was performed before the clinically indicated PVC replacement policy was introduced throughout the whole hospital. This was followed by a point prevalence audit 6 months after the introduction of PVC replacement or removal on clinical indication using consistent methodology. Patients with PVCs were assessed by the auditor and VIP scores assigned. The auditor then transcribed the latest practitioner-assigned VIP score on to the audit form. The duration (in days) of PVC use was recorded.
Ongoing laboratory-based surveillance of hospital-acquired S. aureus BSI is performed by the infection prevention and control team. Nationally in Ireland, the rate of S. aureus BSI is reported per 10 000 bed-days used (BDU), which is used consistently to report the outcome.
Ethical approval
The clinical audit was approved by the institutional audit committee. All procedures were performed in compliance with relevant laws and institutional guidelines.
Results
Device and care bundle
Of the 563 patients covered by the audit 6 months after the policy was brought in, 57.2% (n=322) had a PVC in place. Of these cases, 94.72% were compliant with all elements of the care bundle. More than one catheter insertion was observed in 149 patients. Overall, 495 PVCs were used in these patients over this period.
The duration of PVC use varied, ranging from 1 to 15 days. More information on the numbers and duration of use of the indwelling devices is shown in Table 1. The average device utilisation rate was 3.07 line-days per device, based on cumulative 1523 line days for 495 PVCs.
| Number of days in situ | Number of PVCs n (%) | Device days |
|---|---|---|
| 1 | 149 (30.1) | 149 |
| 2 | 98 (19.7) | 196 |
| 3 | 80 (16.1) | 240 |
| 4 | 58 (11.7) | 232 |
| 5 | 30 (7.6) | 150 |
| 6 | 22 (4.4) | 132 |
| 7 | 19 (3.8) | 133 |
| 8 | 15 (3.0) | 120 |
| 9 | 3 (0.6) | 27 |
| 10 | 8 (1.6) | 80 |
| 11 | 1 (0.2) | 11 |
| 12 | 2 (0.4) | 24 |
| 14 | 1 (0.2) | 14 |
| 15 | 1 (0.2) | 15 |
| Total | 495 (100) | 1523 |
The auditor and practitioner VIP scores were the same for all 322 patients. Disconnection of administration sets was uncommon. Where the administration sets had been disconnected, in 60% (n=9) of cases, this was in agreement to the policy.
Staphylococcus aureus BSI rate
In the preceding 12 months before the intervention, the rate of hospital-acquired S. aureus BSI was 1.326/10 000 BDU. One year after the introduction of clinically indicated replacement of PVCs, the rate of hospital-acquired S. aureus BSI was 1.166/10 000 BDU.
Discussion
Audit and timely feedback are essential components of any quality improvement programme. Timely feedback promotes a Hawthorne effect (where people modify behaviour because they are aware they are being observed) and enables staff to maintain vigilance and sustain improvement.
The baseline point prevalence audit, carried out when PVCs were being replaced routinely, showed that 48% of patients (n=244) had a PVC in place. After the policy to replace catheters when clinically indicated was implemented, 57% (n=322) of patients had a peripheral cannula. National prevalence surveys have found the proportion of adult acute inpatients with a PVC to be 23% in France and 30% in Scotland (Mermel, 2017), and 49% in Ireland (Health Protection Surveillance Centre (HPSC), 2018). The high prevalence of PVCs among patients in the authors' hospital is partially explained by the type of service provided; it is a tertiary acute national referral hospital for many specialities and has a complex case mix. The high catheter device use most likely reflects the greater acuity of patients treated in the hospital, as evidenced by the care bundle compliance that the device is needed.
A bundle is a structured way of improving the processes of care and patient outcomes: it is generally a set of 3–5 straightforward, evidence-based practices that, when performed collectively and reliably, have been proven to improve patient outcomes (Resar et al, 2005). Four clinical practice components form this PVC care bundle:
There is also a quality component—that the care bundle documentation is complete.
The PVC insertion site should be inspected frequently for evidence of localised inflammation or infection (Webster et al, 2010; O'Grady et al, 2011; Mermel, 2017). In practice, pain at the insertion site is elicited from the patient on assessment, and this is used to assign VIP score. A score of 1 necessitates action, and a score of ≥2 requires removal of the catheter. Practice of hand hygiene, as outlined by the World Health Organization's 5 Moments for Hand Hygiene (2009), is embedded in clinical practice, promoted as an essential aspect of patient safety and, per se, not included in the care bundle document as a separate item.
The components of care bundles can vary; however, in a bundle of interventions, the number of items is limited to the essential minimum. In the authors' experience, care bundles that are short, easy to use and less time consuming are preferred by practitioners, and achieve a higher level of compliance and positive patient outcomes, as has been reported elsewhere (Resar et al, 2005; Jarvis, 2007).
Compliance with the PVC care bundle improved from 88.9% to 94.7% following the intervention, and was sustained for many months, which is evidence of staff being aware and translating this into practice; it showed good clinical judgment and a narrowing of the education-practice gap (Orsolini-Hain, 2010; Limoges and Acorn, 2016). The consistency of VIP scores assigned by the auditor and practitioners show further evidence of positive transfer of knowledge to sound clinical judgement and good practice. Sustaining care bundle compliance beyond the short-term Hawthorne effect was possible through practitioner engagement as safety champions, auditors and participants in root cause analysis of device-associated BSIs.
A Cochrane review (Ullman et al, 2013) concluded that there was no evidence that changing IV administration sets more frequently than every 96 hours reduced the incidence of BSI. Guidelines are unclear on the use of administration sets that are aseptically disconnected and maintained. In practice, administration sets are disconnected for a variety of reasons. This practice is not supported by robust evidence, nor does it make economic sense to discard infusate and administration sets that are aseptically disconnected and maintained as a closed system.
Following the introduction of clinically indicated replacement of PVCs, the authors observed that most catheters (85.45%; n=423) were used for up to 5 days. In comparison, during the routine replacement period, 83% (n=203) of peripheral catheters were replaced after 72 hours. This study provides further proof that replacement of PVCs must be guided by clinical indication rather than number of hours or days. By extending the duration of PVC use beyond 72 hours, the authors avoided a significant number of unnecessary cannulations. If they had continued with catheter replacement at 72 hours, 728 peripheral catheters would have been placed on patients they assessed. However, only 327 PVCs were used. The clinically indicated replacement strategy facilitated safe, continued use of peripheral catheters that were assessed as healthy, which in turn avoided 401 cannulations. Avoiding insertion of a significant proportion of peripheral cannulae improved patient comfort by preventing pain associated with skin prick and the risk of infection. Minimising the use of sharps meant also reduced the risk of sharps injury to healthcare workers from avoidable exposure to sharps.
Annually, with 25 000 admissions and an estimated 60% of patients having PVCs during their hospital stay, this translates to a minimum of 8250 cannulations being avoided. The estimated time for a cannulation procedure is about 20 minutes (Rickard et al, 2010). Given the estimated cost of €15 (about £13.90) per cannulation, this simple, evidence-based intervention could save the hospital €123 750 (about £114 500) a year. Nationally, with 1.7 million inpatient and day case discharges (HPSC, 2017), on a conservative estimate of 25% of patients requiring PVC for delivery of healthcare and 55% of these not receiving a replacement catheter with clinically indicated replacement, implementing this policy could save around €3.5 million (about £3.24 million) annually to the Health Service Executive.
S. aureus BSI data are reported nationally as a KPI. The rate of hospital-acquired S. aureus BSI declined to 1.166/10 000 BDU from 1.326 in the routine replacement phase, a noticeable rate of reduction of 0.16. A 2–year review of 445 S. aureus BSIs from North America identified that 7.6% (n=34) of BSIs related to PVCs, and the majority of these infections were related to old intravascular insertion sites (Austin et al, 2016).
Root cause analysis of device-associated S. aureus BSI is performed by a multidisciplinary clinical team in the authors' hospital. Removal of the PVC on signs of infection is standard practice, so most if not all PVC-associated S. aureus BSI could be related to the device insertion site. However, it is unclear whether skin colonisation at the PVC insertion site after device removal is of significance, unless local infection was evident on device removal. The reduction in the number of S. aureus BSI the authors observed is encouraging, and could be argued to result from optimal care of vascular access devices during insertion, as well as aftercare.
While skin and hand antisepsis are essential, early intervention by catheter removal on pain, redness or phlebitis at the insertion site and other clinical indications minimise the potential for catheter-associated BSI. This provides evidence for the use of clinically indicated rather than routine replacement. The authors' comprehensive documentation on PVC insertion, maintenance and removal includes recommendations for action, thereby accountability and patient safety.
Conclusion
Where clinically indicated, PVCs can be used for a prolonged duration with significant benefits to patients and practitioners. Fewer cannulations result in less pain, enhance patient comfort and reduce the risk of infection. The learning and outcome on implementation of the clinically indicated replacement strategy can be easily emulated by other healthcare providers.