1. 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

2. 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):

3. 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)

4. 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 = % or 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):
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.

5. 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

6. 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.

7. Methodology Design: Observational prospective cohort
Area/Setting: 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 .

8. 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

9. 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

10. 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
( yrs)
Gender difference:
Chi2=15.761, P= *
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= *
*: gender difference statistically significant

11. 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= *
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

12. 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= *
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

13. Outcome characteristics
Total(%)
148 (17.58%)
64(7.60%)
33(3.92%)
4(0.48%)
20(2.38%)
Gender difference
Chi2=21.912
P= *
Phlebitis
Pain
Leaking at
site
Extravasations
Occlusion
Dislodged
Chi2=26.194
P= *
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= *
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

14. 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 %

15. Onset of PIV catheter complications
Average time of onset of PIV catheter complications o
In hours:
Average time of onset for overall complications: (CI= ) hours

16. 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= *)
Z-score= 1.409
(P=0.1587)
Z-score=
(P=0.7097)
Risk Ratio
(95% CI)
1 :
( )
1 :
( )
: 1
( ) 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 =
(P= *)
Chi2 = 2.286
(P=0.1306)
Chi2 = 0.080
(P=0.7769)
Risk Ratio
(95% CI)
1 :
( )
1 :
( )
: 1
( )

17. 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=
(P=0.8306)
Z-score= 0.290
(P=0.0771)
Z-score=
(P=0.887) 20
1 :
( )
: 1
( )
: 1
( )
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= )*
Chi2 = 0.003
(P=0.9544)
: 1
( )
: 1
( )
1 :
( )

18. 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=
(P=0.5159)
Z-score= 1.846
(P=0.064)
Risk Ratio
(95% CI)
1 :
( )
1 :
( )
: 1
( ) 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 =
(P=0.9077) 5
Risk Ratio
(95% CI)
1 :
( )
1 :
( )
1 :
( )

19. 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= * P= P= P= P= P= P= P=0.006*
P=000003* P= P= P= P= P= P=0.024* P=0.020*
P=0.0003* P= P=0.034* P= P= P= 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

20. 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< *

21. 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.

22. 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= )
Incidence density by catheter (per 1000 catheter days)
75.84 catheters per 1000 catheter days
(95%CI=66.10–86.80)

23. Thank You…… …..Questions