1220
region failed significantly more often than those inserted into PIVCs placed in the forearm or upper arm. However, only a small number of upper-arm insertions were included in this study, so these interpretations must be viewed with caution. Given that >50% of PIVCs are inserted in the ante cubital fossa region, better decision making is needed with regard to site of insertion.21 Although it was beyond the scope of this study, this finding does suggest that PIF is associated with other mechanistic causes and is certainly worthy of further investigation.22 The PIVCs inserted by medical students appear to be a clinician
factor associated with PIF. This finding may be relevant to this group’s first clinical exposure to PIVC. However, this finding pro- vides a potential opportunity for greater proctoring, use of simulation and mentoring regarding PIVC-related procedures. Additionally, it may promote better decision making regarding venous site selec- tion, PIVC size, and the use and care of add-on devices. An issue underlying PIVC PIF stems from the variety of clinicians from different disciplines who insert and access them, which points to a lack of standardized approach to education, insertion practice, device care and management, from within disciplines and between individual practitioners. Without clinical agreement and an acceptance of common standards of assessment, insertion, and maintenance, PIVC care will remain dependent on individual clinicians from a variety of disciplines with different experience levels and different practices performing less than acceptable care. This study found USG-PIVC to be associated with signi-
ficantly higher PIF. Although we acknowledge the small number of these catheters studied, previous studies have also identified more postinsertion failure when ultrasound-guided approaches are used.23 This finding may be due to the higher-risk group in which ultrasound is more commonly used, or to the longer-length PIVC that is used. In this study, all the USG-PIVC inserted were 48 mm in length. Clearly, given the cost associated with advanced insertion techniques such as using ultrasound, USG-PIVCs should survive longer. In our study, USG-PIVCs had a median dwell time of 31.9 hours (range, 2–42 hours). Infiltration and occlusion were the most common form of PIF
observed in this study; they occurred in 47% of PIVCs. Evidence- based infiltration and occlusion prevention strategies remain scarce. Because current PIVC assessment tools specifically focus on phlebitis, rather than other complications, a clinically credible PIVC assessment tool covering all aspects of failure is needed. In this study, 63% of all insertions involved a clinical breach, which is concerning because hospitals spend considerable money implementing concepts such as aseptic nontouch technique to prevent infections. Our study has some limitations, and we must interpret these
results with caution. We used a convenience sampling method due to limited funding and resources. With regard to infiltration, it was not feasible to identify the rates and speed of infusion, which is likely to be an important consideration22 nor the number of PIVC flushes used, nor whether the PIVCs were used for blood sampling. In terms of occlusion, we did not perform USG assessment of the site to determine whether if thrombus wasapredictorofocclusion andor infiltration. We did not power our study to accept or reject any hypothesis, we primarily wanted to identify causes of PIF pro- spectively. Therefore, our data may be vulnerable to type 2 error. We sought to determine the rates of PIF for use in future studies. Finally, this study identifies an association, and in no way represents cause and effect that an interventional design would seek to identify. We have used a generalizable sample, and our failure rates are in line with previous studies. Our results of 30% succumbing to
Peter J. Carr et al
PIF echoes recent reports of similar failure due to largely mod- ifiable reasons.5 To our knowledge, this is the first study to report that PIF is greatest when the PIVC is inserted by medical students in the ED as opposed to 6 other clinician types who provide insertion. Future strategies could develop a specific PIVC edu- cational intervention for all staff inserting PIVCs and perhaps specifically for medical students to assess the validity of this result. This study is one of the first to identify prospectively that PIVCs inserted with aseptic nontouch technique are associated with less PIF. Furthermore, where it is clinically achievable, the ante cubital fossa region and back of the hand should be avoided in favor of the upper arm and/or forearm veins for PIVC place- ment. Finally, targeted educational and workforce strategies should be considered for patients with ATS scores of 1 and 2 and for those undergoing USGPIVC who experience PIF.
Supplementary materials. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.190
Acknowledgments. The authors wish to thank the patients who presented to the ED and allowed us to observe their PIVC insertions. We are also extremely grateful to the clinicians of both Sir Charles Gairdner Hospital and Fiona Stanley Hospital who consented to allow us to observe their procedures. We are also grateful to the staffs of both EDs. We are grateful to Ms Shannon Nell, RN, who assisted with observational data collection, to Ms Mel Sarti, CN, for follow up data collection, and to Ms Pip Bain, CN, and Ms Lisa Douglas Smith, CN, for data entry.
Financial support. We acknowledge Associate Professor Karen Bradley and the WA Nursing and Midwifery Health Department for an academic support grant to complete this work.
Conflicts of interest. Peter J Carr is an academic researcher and has received speaker’s bureau payment from CareFusion in 2013 and from Becton Dickinson (BD) in 2014 for lectures on vascular access. He received a grant from CareFusion (facilitated by his institution at the time) to attend a scientific meeting on vascular access in the United States in 2012. Marie L Cooke is an academic researcher. Griffith University (not Prof Cooke) has also received unrestricted, educational grant from Baxter to support the develop- ment of educational materials on PIVC insertion, maintenance, and removal. Griffith University (not Professor Cooke) has also received unrestricted, grant- in-aid donations from manufacturers of IV catheters and related equipment (Becton Dickinson, Centurion, Entrotech). Claire M Rickard is an academic researcher and speaker in the field of vascular access. Griffith University (not Prof Rickard) has received payments from manufacturers of intravenous (IV) catheters and related equipment for her to give educational lectures or expert opinion on products (3M, Bard, BBraun, BD, Carefusion, Mayo, ResQDevices, Smiths Medical). Griffith University (not Prof Rickard) has also received unrestricted, grant-in-aid donations from manufacturers of IV catheters and related equipment (3M, Adhezion, Angiodynamics, Bard, Baxter, BD, Centurion, Carefusion, Cook, Entrotech, Flomedical, Medtronic, Smiths Medical and Teleflex) to (1) support Prof Rickard’s independent research and (2) to support travel costs for research staff and students to present their independent research at conferences. Manufacturers had no involvement in study design, execution, data handling, publication preparation or approval. All other authors report no conflicts of interest relevant to this article.
References
1. Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of short peripheral intravenous catheters: characteristics, management, and outcomes world- wide. J Hosp Med 2018;13(5).
https://doi.org/10.12788/jhm.3039.
2. Carr PJ, Glynn RW, Dineen B, Kropmans TJ. A pilot intravenous cannulation team: an Irish perspective. Br J Nurs. 2010;19 Suppl 3:S19–S27.
3. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs 2015;38:189–203.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144
