1. Decreased Vascular Access Complications:
The Positive Impact on Patients, Clinicians, and Healthcare Settings
Michele Biscossi, ACNP-BC, MS, RN, CNL, VA-BC

2. Speaker Disclosures BD Angiodynamics Genentech Medcomp Ethicon PDI
I will not be discussing any off label use of products or procedures.

3. Presentation Objectives
Understand the cause and effect that peripheral intravenous device (PIV) complications have on catheter dwell time.
Highlight the impact that longer PIV dwell times have on patient outcomes, clinician efficiency, and associated costs.
Recognize that by applying evidence-based best practice standards longer PIV dwell times are obtainable.
Be empowered to become a change agent in your organization to promote vascular access best practice.

4. Peripheral Intravenous Catheter (PIV) History
IV catheter therapy has been used for more than years.
PIVs have played a central role in patient care since first plastic PIV was introduced more than 70 years ago.
PIVs are the most common invasive hospital procedure performed worldwide.
PIV Catheters – Today
PIVs are necessary for direct administration of fluids and medications into the bloodstream.
More than 300 million PIVs are sold each year in the United States.
60% to 90% of hospitalized patients require an IV catheter during their hospitalization.
Helm (2015)

5. PIVs Are Not Without Complications
Most rigorously performed studies indicate overall PIV catheter complication rate lies between 35% and 50%!
PIV complications are costly to patients, caregivers, and the healthcare system.
Analysis of mechanisms underlying persistent PIV complication rate reveals opportunities for improvement.
Helm (2015)

6. Five PIV Complications That Can Impact Dwell Time
Phlebitis
Infiltration
Dislodgment
Mechanical complications (e.g., occlusion, leakage)
Site or bloodstream infection
Helm (2015); ONS (2017); INS (2016)

7. Infection CR-BSI & Local Insertion Site
Both confirmed: + culture  connected by clinical data  indwelling catheter
CR-BSI attributable to PIVs ranges from 0% to 2.2% in prospective studies
Break in aseptic technique during initial catheter-insertion & dressing-placement process (i.e. assembly of add-on extension set, flushing, capping, securement)
External surfaces of PIV hubs become contaminated during insertion because hub is grabbed with non-sterile gloves
Improper disinfection of needle free connectors
Improper use of alcohol caps
Catheter-related bacterial infection can be divided into 1) CR-BSI and 2) Local catheter insertion site infection.
Intraluminal contamination of the surface can occur at the time of catheter insertion as a result of break points in aseptic technique during the currently complex & highly variable initial catheter-insertion & dressing-placement process (e.g., flushing, capping, securement).
Helm (2015); ONS (2017)

8. Cause & Effect of PIV Complications on Patients
May increase pain/discomfort
May experience complication- related sequelae
May prolong or delay treatment/care
May increase dissatisfaction with staff, hospital
May affect overall hospital experience
Early PIV catheter replacement due to complications
Helm (2015); ONS (2017)

9. Cause & Effect of PIV Complications on Clinical Efficiency
May increase clinician workload
May increase clinician stress
May result in delays of clinician administration of medications and/or medical therapies
May cause decreased clinician satisfaction
Early PIV catheter replacement due to complications
Helm (2015); ONS (2017)

10. Cause & Effect of PIV Complications on Healthcare Facilities
May increase cost to facility
May increase length of hospital stay
May decrease patient satisfaction scores
May damage reputation of hospital
Early PIV catheter replacement due to complications
INS (2016) S95; Helm (2015); ONS (2017)

11. Potential Impact on Patient Outcomes
The 1st IV placed during admission could be the only PIV they will need for their entire hospital stay.
Fewer IV starts can also help contribute to vessel preservation  Has real benefits for individual patients on future admissions.
Treatment not delayed due to lack of venous access.
PIV Dwell Times
Source: DeVries (2015)
DeVries (2015)

12. Potential Impact on Clinical Efficiency
Time saved for bedside nurses not having to arbitrarily restart PIVs – can be redirected to focusing on site assessment of the devices or any other multitude of tasks with competing priorities.
Bedside nurses will agree that sparing the patient the procedure is a great goal.
May free up dollars to ensure that the best products are selected when developing PIV insertion bundles to support longer dwell times of vascular access devices.
On the administration side, PIV BSI can influence patient satisfaction.
Stress is reduced for clinicians caring for patients with longer PIV dwell times.
Potential results include improved clinician job satisfaction.
PIV Dwell Times
Source: DeVries (2015)
DeVries (2015)

13. Potential Impact on Associated Costs
Average cost for a PIV insertion is between $28 & $35
Supply costs lowered (catheter & associated products).
Potential avoidance of costs associated with complications:
Prolonged hospital stay
Extended treatment costs
PIV Dwell Times
First Bullet: PIV insertion in US
Supportive technology employed: Dressing type, needless connectors, extension tubing, dedicated stabilization device.
The initial insertion cost, as well as costs identifying, removing, & reinserting the failed PIV is repeat each time a failed catheter is replaced.
Helm (2015); DeVries (2015)

14. Benefits of Longer PIV Dwell Times
Reduced number of PIV insertions
Reduced supply costs
Reduced PIV complications
Increased patient satisfaction
Reduced staff workload
Improved clinical efficiency
Improved patient outcomes
Decreased needled sticks
Longer PIV Dwell Times
It’s all interconnected AND it’s based on evidence.
Helm (2015); ONS (2017)

15. Can We Achieve Longer PIV Dwell Times with Clinical Indication?
YES!
Can We Achieve Longer PIV Dwell Times with Clinical Indication?
Clinical Indication is evidence-based (INS 2016); ONS (2017)
Reproducible across all healthcare settings
Efficient for patients and clinical staff
Helm (2015); INS (2016) ppS91; ONS (2017) pp30.

16. All Clinicians are Accountable for ‘The Standard of Care’
2016 Infusion Therapy Standards of Practice
Standards that are upheld in a court of law
PIV-related complications may impact patient litigation

17. Technology To Decrease PIV Complications
Vessel identification devices
Closed integrated PIV catheters
Novel catheter designs
Hub cap cleansing/sterilization covers
Improved stabilization
Guidewire technology
Integrated catheter dressing systems
Dressings
Needle free connectors
Helm (2015); INS (2016)

18. Vascular Access Device (VAD) Planning
The VAD selected is of the smallest outer diameter with the fewest number of lumens and is the least invasive device needed for the prescribed therapy.
Recommendation: Use a PIV catheter that enables higher flow rates on smaller gauge catheters (22 G–24 G) for power injection. Impact: Less likely to cause phlebitis, minimizes insertion-related trauma.
INS Standard 26.3, page S51, Practice Criteria I.B.3, page S51

19. Vascular Access Device (VAD) Planning
Consider a larger-gauge catheter (16-20 gauge) when rapid fluid replacement is required, such as with trauma patients, or a fenestrated catheter for a contrast-based radiographic study.
Recommendation: A fenestrated 20 G PIV instead of a non- fenestrated 18 G catheter. Impact: Catheter will accommodate the prescribed therapy and may contribute to less complications.
Utilize the evidence: A clinical study demonstrated that a fenestrated 20-gauge IV catheter performed at least as well as a non-fenestrated 18-gauge catheter for adult patients undergoing IV contrast-enhanced 128-MDCT with infusion rates of 5.0 to 7.5 mL/sec.1
INS (2016) Practice Criteria I.B.3, page S51

20. Vascular Access Device (VAD) Planning: Site Selection
Use the venous site most likely to last the full length of prescribed therapy.
Best sites include forearm, dorsal & ventral surfaces of the upper extremities.
Recommendation: Use the evidence to promote proper site selection. Impact: Prevents accidental removal and occlusions, risk of tissue damage, thrombophlebitis, ulceration and decreases pain.
Do not use veins of the lower extremities. Avoid the ventral surface of the wrist, areas of flexion & areas of pain on palpation.
INS (2016) Practice Criteria: I, page S54

21. Needleless Connectors
Consider use of an extension set between the peripheral catheter and needle free connector to reduce catheter manipulation.
Recommendation: Utilize a PIV with an integrated system with a pre-attached extension set. Impact: Reduces catheter manipulation.
INS (2016) Practice Criteria B, page S68

22. Add-On Devices Limit the use of add-on devices whenever possible.
Add-on devices are of luer-lock design to ensure a secure junction, reduce manipulation, and minimize the risk of disconnection.
Recommendation: Use all-in-one integrated systems with pre-attached extension tubing and luer-lock connection(s) at the catheter hub. Impact: Reduction of manipulation, minimize risk of disconnection.
INS (2016) Practice Criteria B, page S68, Standard 36/2, page S71; Practice Criteria A, A.1 and A.2, page S72

23. Add-On Devices: Disinfecting Caps
Use of passive disinfection caps containing disinfecting agents per manufacturer’s recommendations
Discard after removal.
Consider vigorous second scrub with each subsequent entry into VAD depending on NC design.
Recommendation: Utilization of disinfecting caps on PIV Impact: Reduction of extraluminal microbial contamination. For PIV evidence is limited but should be considered.
INS (2016) Practice Criteria G, page S69

24. Vascular Access Device (VAD) Stabilization
Stabilize and secure vascular access devices (VADs).
Avoid use of tape or sutures, as they are not effective alternatives to an engineered stabilization device (ESD).
Do not rely on VAD dressings as a means for VAD stabilization.
Recommendation: For peripheral catheters, consider two options for catheter stabilization: (1) an integrated stabilization feature on the peripheral catheter hub combined with a bordered polyurethane securement dressing or (2) a standard round hub peripheral catheter in combination with an adhesive ESD. Impact: Prevents VAD movement, which can cause unintentional dislodgement, leading to complications requiring premature VAD removal, interruption in therapy and possible increase in costs.
INS (2016) Standard 37.1, page S72; Practice Criteria A, pages S72-S73; Practice Criteria B, C, D, page S73

25. Vascular Access Device (VAD) Removal
VADs are not removed based solely on length of dwell time because there is no known optimum dwell time.
According to the INS Standards on PIV removal, remove short peripheral and midline catheters in pediatric and adult patients when clinically indicated, based on site assessment, clinical signs and symptoms of systemic complications.
Recommendation: Choose vascular access devices with technology that aligns closely with the INS Standards and meets your dwell time needs. Look for clinical studies on longer dwell times and low rates of PIV complications. Impact: PIVs removed only when unresolved complications, D/C of therapy or no longer needed may decrease patient pain/ discomfort, increase vein preservation, clinician efficiency, and may reduce costs.
INS (2016) Standard 44.3, page S91; Practice Criteria B, page S91; Helm 2015

26. Care & Maintenance
Assess
Short PIVs: Assess minimally at least every 4 hours; the clinical need for each PIV is assessed on a daily basis. Perform dressing changes on short PIVs if the dressing becomes damp, loosened, and/or visibly soiled & at least every 5-7 days. Perform a vigorous mechanical scrub for manual disinfection of the needleless connector prior to each VAD access and allow it to dry. Vascular access devices (VADs) are flushed and aspirated for a blood return prior to each infusion. Flushed after each infusion to clear and locked after completion of the final flush.
Recommendation: Assess per standard at least every 4 hours, and perform care and maintenance per standard. Impact: Minimizes risk of complications.
Dressing
Disinfect
Flushing
& Locking
Assess every 1 to 2 hours for patients who are critically ill/sedated or have cognitive deficits; hourly for neonatal/pediatric patients; and more often for patients receiving infusions of vesicant medications. A sterile dressing is applied & maintained on all peripheral catheters.
Site care, including skin antisepsis & dressing changes, are performed at established intervals.
Perform dressing changes on short peripheral catheters if the dressing becomes damp, loosened, and/or visibly soiled & at least every 5-7 days.
INS (2016) Practice Criteria C2., page S81; Standard 44, page S91; Practice Criteria I, page S82; Practice Criteria F, page S68; Standard page S77;

27. Unacceptable Failure Rates
A mean failure rate of nearly 50% would be unacceptable for food processing, automobile driving, cell phone use, let alone airplane flights.
Why has it been accepted for the most commonly performed invasive hospital procedure performed worldwide?
Routine replacement of PIVs is ineffective at decreasing complication rates.
Cashin-Garbutt (2012)

28. Clinically Indicated is the INS Standard of Care
Dwell time defined as the “length of time an inserted IV catheter maintains its safe function.”
INS Standard:
The clinical need for each peripheral and non-tunneled central vascular access device (CVAD) is assessed on a daily basis.
Vascular access devices (VADs) are removed upon an unresolved complication, discontinuation of infusion therapy, or when deemed no longer necessary for the plan of care.
Remove short peripheral catheters in pediatric and adult patients when clinically indicated, based on findings from site assessment AND/OR clinical signs and symptoms of systemic complications (e.g., bloodstream infection).
INS (2016)-S91; Helm (2015)

29. Achieving Longer PIV Dwell Times:
Back to What We Know Already
Assessment of current practice
Policies based on INS Standards of Practice
Staff retraining/competencies (PIV insertion, care & maintenance)
Development/usage of PIV “bundle”
Measured compliance with aseptic technique skin prep
No-touch technique at insertion
Strive for the best PIV location, size catheter
Utilize stabilization
Who will follow PIV complications & measure outcomes when moving to best practice standards? CICs, Quality?

30. Section Four:
How Do You Lead and Effect Change Within Your Organization?

31. Vascular Access Team
Clinicians with specific training & experience: aka ‘The IV team’ have a significantly higher first-time insertion success rate, which has been associated with a lower incidence of complications.
Standardization of PIV use & care before/after insertion through the use of specially trained IV nurses is also of proven benefit in reducing the incidence of phlebitis & other complications.
Helm (2015)

32. Defining the Specialty of Vascular Access Through Consensus: The Specialist
Focuses on cost-effective patient-focused strategies!
Concerned with all aspects of vascular access, vessel health & patient safety.
Encompasses more than device insertion.
Influences outcomes through care & maintenance, education, research, and patient advocacy.
Partner with industry to bring about evidence- based innovations.
Select the most appropriate device through comprehensive product knowledge.
Uses accepted products & medical technology that are readily available, reasonably reliable for their purposes.
Davis (2016)

33. Strategies to Limit Unnecessary Venous Perforation
Specially trained personnel using standardized & optimized technique
Dedicated IV team for DIVA, morbidly obese & pediatric populations
Bevel-down insertion in small vessels
Local anesthetics
Topical visualization agents
Double tourniquet technique
Patient reassurance maneuvers
Ultrasound guided placement of PIVs
Forearm utilization to increase dwell time, decrease pain during dwell time as opposed to the upper arm
HOW TO EFFECT CHANGE: Become the ‘go-to’ PIV specialist within your organization & across multiple hospital systems!
Helm (2015); INS (2016); ONS (2017)

34. PIV Case Study
625+ bed hospital developed an insertion bundle to support the safe implementation of a policy of extended dwell time for inpatient PIVs.
Conducted surveillance on all lab-confirmed BSIs for the past 13 years.
A cluster of primary bacteremia occurred on a unit of the hospital during pre-implementation phase.
Internal evaluation of practices through direct observation as well as evidence-based guidelines & historic data on PIV BSI’s helped drive PIV bundle creation.
A surveillance plan was in place to continue measurement of these outcomes during post-implementation period.
DeVries (2016)

35. PIV Case – Components of the Protected Clinical Education Bundle
BUNDLE ITEM
REASON
Sterile gloves
CDC & INS both indicate sterile gloves for palpation after skin prep. Direct observation pre-implementation indicated an opportunity to enhance compliance.
CHG-impregnated sponge
Indicated to reduce infection/colonization. With extended dwell apply same standard for CVADs. CHG dressings can effectively kill commonly found skin bacteria.
Securement
device
With ability to allow catheter to dwell until clinical reason for removal, securement was identified as a strong element in preventing pistoning within the vein.
Alcohol disinfection caps
Provide intraluminal protection; however, the nurse must perform a vigorous mechanical scrub for manual disinfection of the NC prior to each VAD access and allow it to dry.
DeVries (2016)

36. PIV Case Study – Results:
PIV Improvements:
PIV care & maintenance
PIV line management focus
PIV product
Patient satisfaction scores – opportunity
System-wide Education
Vendor assisted product training for staff by nurses
PIV insertion & site selection
1 Year Post Implementation:
19% reduction in PIV BSI’s
48% reduction in PIV start kits
A sample of 364 admitted patients 18 months after implementing PIV insertion bundle to support longer dwell times. All PIVs present during that admission were evaluated to assess average dwell time – 35% of PIVs placed were remaining in for 5 days or longer.
Average dwell time in this sample was calculated to be 4.2 days consistent with findings in Rickard et al., (2012).
Opportunity to improve patient satisfaction by reducing number of IV restarts based solely on elapsed time
Moved to clinically indicated PIV replacement
DeVries (2016)

37. Clinical Case Study: Biscossi
Large urban teaching hospital
78 y/o diverticulitis PIV  fluids + antibiotics
Day 3: PIV – BSI
Culture data captured by IP nurses
Developed endocarditis
E coli  valve replacement surgery
In SICU for days
Total Cost $243,000
OUTCOME: Patient recovered No PIV – BSI reimbursement
Three days later, patient develops a PIV BSI (positive cultures from periphery & PIV ) grow E coli & time to positivity is same for both sites.
Outcome: Patient eventually recovered but institution did not recapture reimbursement for PIV- BSI not to mention what the iatrogenic infection impact had on the patient & his family ( satisfaction

38. Lessons Learned: Biscossi
All PIV infections to be tracked by infection prevention nurses.
“Deep dive” found that PIVs inserted in the ED were not following INS standards for insertion, care & maintenance.
Lead vascular access NP – everyone retrained! All RNs retrained per INS Standards of Practice & report feedback.
RNs report increased satisfaction with not re-sticking patients with fully functioning PIVs.
Patients report increased satisfaction scores with PIV dwell time (specifically measured over a 6 month period post-implementation).
PIV infection rates reduced by 30%.

39. The Key to PIV Best Practice Is Education
INS conducted their Safety Practice Survey in 2013
Participants were asked: “Were you taught to insert short PIVs while in school?” (N=344)
43% YES
57% NO
“If no, how did you learn to insert short PIVs?” (N = 235)
On the job training
71%
See one, do one, teach one
11%
Trial & error 5%
Attended a PIV insertion workshop 9%
Other 4%
Vizcarra (2013)

40. Audience Call to Action:
Become experts: Know your standards/best practice and use them.
Conduct evidence-based clinical practice assessments & compile your data.
Look to peers with great clinical outcomes – collaborate.
Partner with device manufacturers who will make a long-term commitment to product support.
Do your own research and embrace new technologies.
Share analysis & current standards with senior leadership, nursing, and providers to convey why they should support change:
“This is not good enough and I’m going to tell you why.”
We need to meet the standards and best practice for our patients.
Here is the evidence to support it.

41. So What Have We Learned?
PIV complications affect PIV dwell time, patients, clinician efficiency, and cost.
Longer PIV dwell times are achievable.
Use evidence-based practice and integrated closed systems to decrease complications.

42. Questions? Thank you for your time.
Thanks to BD for sponsoring this lecture.
Please feel free to reach out for further collaboration:

43. References
Helm RM, et al. Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing. 2015;38(3):
Infusion Nurses Society. Infusion Therapy Standards of Practice. Journal of Infusion Nursing. 2016;39(supplement): S1-S159.
Rickard CM, et al. Routine versus clinically indicated placement of peripheral intravenous catheters; a randomized controlled equivalence trial. Lancet. 2012;380 (9847):
Bausone-Gazda, et al. A randomized controlled trial to compare the complications of 2 peripheral intravenous stabilization systems. Journal of Infusion Nursing. 2010;33(6):
Webster J, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. British Medical Journal. 2008;337: 1-6.
Smith JP. Thrombotic complications in intravenous access. Journal of Intravenous Nursing. 1998;21(2):
Jackson A. Retrospective comparative audit of two peripheral IV securement dressings. British Journal of Nursing ;21(supplement 1): S10-S15.
Cashin-Garbutt , A . Intravenous catheter replacement: an interview with Claire Rickard. medical.net/news/ /Intravenous-catheter-replacement-an-interview-with-Claire-Rickard.aspx. Published on October 30, 2012.
Davis L, et al. Defining the specialty of vascular access through consensus: Shaping the future of vascular access ;21(3):
DeVries, M, et al. Protected clinical indication of peripheral intravenous lines: Successful implementation. Journal Association for Vascular Access. 2016;21(2):
Vizcarra, C. Recommendations for improving safety practices with short peripheral catheters (SPC) think safety, insert safely. INS Safety Practice Survey. 2013
Access device standards of practice for oncology nursing. Edited by Dawn Camp-Sorrell & Laurl Matey. Oncology Nursing Society
DeVries, M. 2/4/15. Peripheral IVs: Fewer & better replacing PIVs only when clinically indicated offers many advantages.