Peripheral Intravenous Catheters: Pattern and Complications at KAMC Prof Mostafa A. Abolfotouh Mr. Mahmoud Salam Mr. David White Dr. Hanan Balkhy King Abdullah International Medical Research Center (KAIMRC), King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia Quality management department, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Peripheral Intravenous Catheters - Overview Insertion of an intravenous catheter in one of the various peripheral veins situated between fingers and upper arm. Procedure is mostly performed by nurses. Aseptic technique during insertion (Betadine vs alcohol) Various dressing types applied (Gauze vs transparent) Keep Vein Open (KVO) vs treatments Dwell time: 3 days vs 4 days vs change when clinically indicated Maki, D., Kluger, D., & Crnich, C. (2006). The Risk of Bloodstream Infection in Adults with Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies. Mayo Foundation for Medical Education and Research. 81(9):1159-1171.

Types of PIV complications PIV complications are classified into minor and major categories based on the severity of symptoms. Minor complications Occlusions Accidental removals Needle phobia Pain Major complications Phlebitis / infection Extravasations Altered skin injuries [4]. Machado, A., Pedreira, M., & Chaud, M. (2008). Adverse Events Related to the Use of Peripheral Intravenous Catheters in Children According to Dressing Regimens. Artigo Journal. 16(3). 362-367

Literature Evidence based studies targeted both pediatrics and adult populations. 1st Mayo Foundation for Medical Education and Research: * Meta analysis of 110 prospective studies (1966 – 2005) * 10,910 PIVs and 28,720 catheter days. * Infection = 0.1-0.2% or 0.2-0.9 per 1000 catheter days. [1] 2nd Maine Medical Center Portland: * Observed 851 PIV sites among 513 patients * Phlebitis = 6.2% , leaking = 12.4%, infiltration=7.4%. [3]. 1. Maki, D., Kluger, D., & Crnich, C. (2006). The Risk of Bloodstream Infection in Adults with Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies. Mayo Foundation for Medical Education and Research. 81(9):1159-1171. 2. Webster et al. (2008). Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomized controlled trial. British Medical Journal. Online First. 1-6.

Study rationale - Significance Peripheral Intravenous Catheter (PIV) insertion is a commonly performed procedure in hospitalized patients. PIVs are invasive catheters that may endure risks of clinical complications affecting health care outcomes and patient satisfaction. [2]. At KAMC, no studies targeted PIV pattern and complicatiosn among adult populations

Purpose of our study Investigate the PIV pattern and complications among patients admitted to various wards of King Abdulaziz Medical City (KAMC). To estimate the Cumulative Incidence (CI) and Incidence Density (DI) of PIV complications. To determine the association : Patient characteristics: gender, age, chief complain upon admission PIV catheter related characteristics: catheter size, site of insertion, dressing type, type of infusates (Infused solutions), dwell times. Outcome characteristics: pain, phlebitis, leaking, dislodgment, occlusion, etc.

Methodology Design: Observational prospective cohort Area/Setting: 14 wards at KAMC- CR Emergency, Cardiac, Intensive, Medical, surgical . Date: Period: Nov, 2012 till Feb, 2013 (35 days) Inclusion criteria: Hospitalized adult patients with PIVs Non immunosupressed cases PIVs inserted at KAMC Sampling technique: Consecutive (convenient) Ethical consideration: IRB approval. Arabic Consent. Voluntary, confidential Identifiers were used for followup .

Data collection Team of 11 qualified ICPs Simulation competency workshop International adopted tools (Visual + interview): Phlebitis scoring scale Pain classification Signs and symptoms of PIV complications Two ICPs evaluated the same catheter at all times (consistency) Quadramed

Sample distribution by Hospital wards Emergency (n=31) Intensive (n=36) Intermediate (n=41) Cardiac (n=185) Medical / Surgical (n=66) Patients Recruited (N=359) 8.65% 10.02% 11.42% 51.53% 18.38% Emergency (n=107) Intensive (n=133) Intermediate (n=39) Cardiac (n=237) Medical / Surgical (n=326) PIV catheters Observed (N=842) 38.70% 12.80% 15.80% 4.60% 28.10% 134 (34%) 104 (26%) 51 (13%) 37 (10%) 14 (6%) 10 (4%) 4 (3%) 1 (1%) 2 3 5 6 7 8 9 Catheter per patient Percentage of patients Number of PIV catheters observed per individual patient Insert Remove Total Catheter duration (days) 2505 days Average number of catheters per patient 2.34

Patient characteristics Male (n=204) Female (n=155) , 56.80% 43.20% Gender distribution (N=359) 18 – 45 (n=77) 46 – 64 (n=102) 65 & above (n=180) 21.44% 28.41% 50.15% Age Distribution (60.37+18.8 yrs) Gender difference: Chi2=15.761, P=0.000378* Medical disorders (n=276) Infectious (n=37) Trauma/Surgery, (n=46) 76.88% 10.30% 12.82% Chief Complaints (N=359) Gender difference: Chi2=16.761, P=0.000334* *: gender difference statistically significant

PIV catheter characteristics Male (n=492) Female (n=350) , 58.43% 41.57% Gender distribution (N=842) G16 (n=14) G18 (n=192) G20 (n=318) G22 (n=308) G24 (n=10) 36.57% 22.80% 37.76% Angiocath size (N=842) Gender difference: Chi2=15.761, P=0.000378* Transparent (n=697) Gauze (n=145) 82.77% 17.23% Dressing type (N=842) Gender difference: Chi2=3.620, P=0.057 *: gender difference statistically significant

PIV catheter characteristics- Continued Patency (n=54) Hydration (n=387) Electrolytes (n=45) Antibiotics (n=241) Blood products, (n=107) Multiple (n=8) 6.41% 45.96% 5.34% 28.62% 12.7% 0.97% Infusate type (N=842) Gender difference: Chi2=6.541, P=0.257 Junior nurse (n=325) Senior nurse (n=489) IV team (n=28) 38.59% 58.07% 3.34% Care provider (N=842) Gender difference: Chi2=15.761, P=0.000378* Cubital fossa (n=79) Gender difference: Chi2=11.211, P=0.024* Insertion site (N=842) Hand (n=263) Wrist (n=250) Lower arm (n=8) Upper arm (n=242) 31.23% 29.69% 28.74% 9.38% *: gender difference statistically significant

Outcome characteristics Total(%) 148 (17.58%) 64(7.60%) 33(3.92%) 4(0.48%) 20(2.38%) Gender difference Chi2=21.912 P=0.00003* Phlebitis Pain Leaking at site Extravasations Occlusion Dislodged Chi2=26.194 P=0.00001* Chi2=0.383 P=0. 536 Chi2=0.118 P=0. 732 Chi2=1.849 P=0. 174 Chi2=0.021 P=0. 886 Cumulative Incidence of Complications (CI = # complications per 100 catheters) Incidence of Complications (%) Type of complication 190 (22.56%) Chi2=31.599 P=0. 00001* Total *: gender difference statistically significant **: complications by catheter are mutually exclusive 12.4 3.7 4.3 0.4 0.2 2.4 17.7 24.9 13.1 3.4 0.6 0.9 2.3 29.4 5 10 15 20 25 30 35 40 45 50 Male Female

Frequency of 273 PIV complications Non mutually exclusive frequency of Overall complications over a daily timeline Frequency of 273 PIV complications 10 20 30 40 50 Day 1 Day 2 Day 3 Day 4 Day 5 Days %

Onset of PIV catheter complications Average time of onset of PIV catheter complications o In hours: Average time of onset for overall complications: 44.33+32.41 (CI=40.46-48.19) hours

Med/Infect vs Trauma/surgery Cumulative incidence: Bivariate Analysis of Patient related characteristics regarding overall complications 140 Gender Male vs Female Age group 18 – 45 vs 46 & above Complaint Med/Infect vs Trauma/surgery 120 100 101.57 Incidence density: Complicated catheter Per 1000 cath days 79.77 80 76.64 70.55 60 58.35 60.54 40 20 Z-score= 3.856 (P=0.000115*) Z-score= 1.409 (P=0.1587) Z-score= 0.3723 (P=0.7097) Risk Ratio (95% CI) 1 : 1.74 (1.30-2.31) 1 : 1.31 (0.89-1.93) 1.08 : 1 (0.89-1.93) 40 35 29.42 30 Cumulative incidence: Complicated catheter Per 100 catheters 25 23.66 22.72 21.49 20 17.68 18.23 15 10 5 Chi2 = 16.147 (P=0.000059*) Chi2 = 2.286 (P=0.1306) Chi2 = 0.080 (P=0.7769) Risk Ratio (95% CI) 1 : 1.66 (1.29-2.13) 1 : 1.29 (0.91-1.83) 1.05 : 1 (0.71-1.55)

Cumulative incidence: Bivariate Analysis of Catheter related characteristics regarding overall complications Dressing Gauze vs Transparent Cath size Small vs large Staff Junior vs Senior 140 120 100 Incidence density: Complicated catheter Per 1000 cath days 80 76.39 74.60 73.33 77.90 74.87 76.50 60 40 Z-score= 0.2139 (P=0.8306) Z-score= 0.290 (P=0.0771) Z-score= 0.1417 (P=0.887) 20 1 : 1.04 (0.71-1.51) 1.04 : 1 (0.78-1.39) 1.02 : 1 (0.76-1.36) Risk Ratio (95% CI) 40 35 34.26 30 Cumulative incidence: Complicated catheter Per 100 catheters 25 22.53 22.76 22.47 22.63 20 18.53 15 10 5 Risk Ratio (95% CI) Chi2 = 0.004 (P=0.951) Chi2 = 22.74 (P=0.0000001)* Chi2 = 0.003 (P=0.9544) 1.01 : 1 (0.72-1.40) 1.84 : 1 (1.44-2.36) 1 : 1.01 (0.77-1.30)

Bivariate Analysis of Catheter related characteristics regarding overall complications 140 Site Hand-Wrist vs Fore-upperarm Infusate Hydration vs Medication Dwell time 72-96 hrs > 96 hrs 120 100 86.10 Incidence density: Complicated catheter Per 1000 cath days 80 80.19 72.90 65.80 56.3 60 40 38.3 Z-score= 1.738 (P=0.0822) 20 Z-score= 0.6497 (P=0.5159) Z-score= 1.846 (P=0.064) Risk Ratio (95% CI) 1 : 1.10 (0.82-1.46) 1 : 1.30 (0.98-1.74) 1.46 : 1 (0.94-2.27) 40 35 30 24.62 26.68 Cumulative incidence: Complicated catheter Per 100 catheters 25 21.25 20 18.82 19.33 19.78 15 10 Chi2 = 1.305 (P=0.2542) Chi2 = 7.43 (P=0.006*) Chi2 = 0.0134 (P=0.9077) 5 Risk Ratio (95% CI) 1 : 1.15 (0.90-1.49) 1 : 1.41 (1.10-1.82) 1 : 1.02 (0.69-1.51)

Logistic Regression Model Gender Age Complaint Dressing Catheter size Staff Site Infusate Phlebitis Other Complications 0.5 1 1.5 2 2.5 2.09 1.14 2.59 1.01 1.04 1.25 1.37 3 2.44 1.43 1.03 1.2 1.53 1.55 Overall complications 1.94 1.19 1.38 1.06 1.09 1.33 1.6 P=0.000001* P=0.440 P=0.294 P=0.773 P=0.946 P=0.612 P=0.098 P=0.006* P=000003* P=0.175 P=0.905 P=0.982 P=0.340 P=0.926 P=0.024* P=0.020* P=0.0003* P=0.607 P=0.034* P=0.953 P=0.290 P=0. 290 P=0.049* P=0.121 Male Female 18 – 45 46 & above Medical/Infectious Trauma/Surgery Gauze Transparent Small (G22-24) Large (G16-20) Junior Staff Senior Staff Hand-Wrist Fore /upper arm Hydration Medication

Mantel-Haenzel Summary Impact of frequency of catheter insertions per individual patient on the incidence of complications Mantel-Haenzel Summary (Dose response model) 1 2 3 4 5 (22.39) (33.65) (49.02) (67.57) (57.14) (90.00) (100.0) One Two Three Four Five Six Seven Eight Nine 30/134 35/104 25/51 25/37 8/14 9/10 3/3 5/5 1/1 Catheter/Patient Patients with complicated catheter Odds Ratio Chi-square for linear trend= 20.30, P<0.00000668*

Conclusions and Recommendations Better insertion techniques to extend the onsets beyond day 3 and 4. Better compliance of nurses with the CDC recommendations. Documenting PIV catheter insertions, observations and removals on electronic system. Reporting of a complication deems non punitive actions. Developing a task force to implement corrective action plans Reevaluate the pattern and complications of PIVs through future investigational studies.

Summary of Results Number of patients 359 patients Number of PIV catheters 842 catheters Total Catheter duration (days) 2505 days Number of complications 273 complications Number of patients with complications 141/359 (39.3%) patients Number of complicated catheters 190/842 (22.6%) catheters Cumulative incidence (%) 22.56 catheters per 100 catheters (95%CI=19.87 – 25.51) Incidence density by patient (per 1000 catheter days) 56.28 patients per 1000 catheter days (95%CI=47.90-66.00) Incidence density by catheter (per 1000 catheter days) 75.84 catheters per 1000 catheter days (95%CI=66.10–86.80)

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