Authored by Kathryn Burnett*
Abstract
Introduction: Peripheral Venous Catheters (PVC) are an essential component in modern healthcare and their inclusion into a Clinical Procedure Pack has been identified as an area of healthcare where an enhancement in design and implementation could improve practitioner performance and associated patient outcomes.Aim: The aim of this study was to assess the clinical impact of two interventions;
i. procedural kits with an enhanced training programme
ii. a specific feedback mechanism on the rates of inappropriate removal of PVCs within Antrim Area Hospital. Methods: A time series design, using retrospective and prospective data was used. The study consisted of three phases. Phase A aimed to establish existing PVC adverse event rates. Phase B included the introduction and assessment of the first intervention, a PVC procedural kit and associated training package, to specific clinical areas. Phase C involved the introduction and assessment of the second intervention, a performance feedback mechanism.
Results: Analysis of data showed that the difference of mean PVC clinical adverse event rate between Phase A 12.84% (95% CI: 10.86 – 15.03) and Phase B of 9.48% (95% CI: 8.10 – 11.00) was improved (p=0.008). Similarly, the PVC clinical adverse event rate of Phase B of 9.48% (95% CI: 8.10 – 11.00) and Phase C of 5.94% (95% CI: 4.78 – 7.30), was improved (P < 0.001).
Conclusion: In conclusion, the study demonstrated the benefit of introducing a PVC procedural kit with an enhanced training programme and a specific feedback mechanism to significantly reduce clinical adverse events, compared to the previous standard practice.
Keywords: PVC; Adverse events; Procedural pack; Clinical outcomes
Abbreviations: AAH: Antrim Area Hospital; AE: Adverse Event; ANOVA: One-Way Analysis of Variance; ANTT: Aseptic Non-Touch Technique; BSI: Bloods Stream Infection; FY1: Foundation Year one Doctor; ICU: Intensive Care Unit; IQR: Interquartile range; IV: Intravenous; NHS: National Health Service; NHSCT: Northern Health and Social Care Trust; OSCE: Objective Structured Clinical Examination; PCIM: Peripheral Cannula Insertion and Management Form; PVC: Peripheral Venous Catheter; SPC: Statistical Process Control
Introduction
Peripheral Venous Catheters (PVC) are an essential component in modern healthcare, with approximately a third of all UK and US inpatients having at least one device inserted during their hospital stay [1,3]. Peripheral venous cannulation carries a number of risks to both patient and health care staff, resulting in additional workload and increased costs [4,5]. A 2015 study reported that 59% of patients worldwide had at least one PVC in situ during an international prevalence study involving 14 countries [6]. It is estimated that up to 80% of patients require at least one PVC to be inserted during their hospital stay [7].The routine use of PVCs may have led to a certain amount of triviality associated with complications resulting from the procedure [3]. Unplanned PVC restarts are a result of both clinical and non-clinical events, with an overall failure rate ranging from 33% to 69% [4,5,8]. Failure of a single PVC in a patient can result in a negative cycle of catheter removal and reinsertion, increasing risk of complications and cost [9]. Problems associated with the procedure can be broken into major and minor complications.
Major complications result in a new diagnosis as a consequence of the insertion, maintenance or removal procedure. These major complications include blood stream infection, phlebitis, infiltration and extravasation [10,11]. The reported rates of major complications due to peripheral cannulation includes Blood Stream Infection (BSI) at 0.1%, extravasation at 6%, infiltration at 36.3% and phlebitis ranging from 2.1% up to 60% in some cases [11- 15]. The impact to the patient ranges from life-threatening and potential disability through to disruption of treatment and clinical deterioration [11]. Additional treatment, patient anxiety and increased costs are also associated with the occurrence of major complications [11]. While studies show that there are relatively low rates of infection associated with PVC access, it is thought to be an under-reported issue as IV therapy is not usually suspected as the source of the infection [12]. The perceived low rate of infection is still a major cause of concern when the large numbers of PVC devices used on a daily basis are taken into consideration [7].
Minor PVC complications can result in treatment disruption and patient anxiety, but do not cause a serious impact on patients’ clinical wellbeing. Minor complications include dislodgements (accidental removal) and leaking [10,16]. A similar large variable range of rates exist with dislodgement rate ranging from 2.4% to 36% and leaking rates of 3.9% to 12.4% reported [8,10,17]. Complications resulting from PVC use can be assigned to factors relating to the patient or hospital environment [18]. There have been a number of studies aimed at reducing PVC associated adverse event rates, concentrating mainly on phlebitis and BSI [1,19,20]. A singular approach to PVC practice intervention has led to marginal quality improvement, with limited lasting effect [19,21].
Clinical guidelines and well-designed care bundles have been shown to improve patient outcomes, however the implementation of these interventions can also cause problems [1,3,22]. Education and training are one of the main recommendations directed by guidelines for the prevention of intravascular catheter-related infections [18]. Focused educational interventions have been successful in reducing PVC related adverse events [23]. However, education alone seems to have a limited benefit on the reduction of overall adverse events associated with PVC insertion and longterm care [22,23]. The lack of appropriate equipment prior to a procedure has been shown to reduce compliance with care bundle practices [2]. Bespoke procedure packs promote adherence to the recommended procedural method, by ensuring the availability of all essential apparatuses [24,25]. When combined with training and familiarity of a pack, it allows the practitioner to concentrate on the technical aspects of the procedure while utilizing all equipment in the step by step manner in which the pack unfolds [24,25]. Procedural kits were identified as an area where an enhancement in design and implementation could improve practitioner performance and associated outcomes [2].
Materials and Methods
This study uses a multimodal intervention approach involving the introduction of a dedicated procedural kit, smallscale face to face teaching sessions, manikin training tools and direct feedback of error rates. A quasi-experimental time series design, using prospective data was used to evaluate the impact of two interventions on measured adverse events associated with initiation of peripheral venous catheters. The primary endpoint for the study was PVC failure, which was defined as a clinical adverse event resulting in the premature removal of PVC, prior to cessation of treatment. Suitable adverse event endpoints were identified and included blood stream infection, phlebitis, infiltration, and extravasation. Secondary endpoints included the measure of PVC non-clinical adverse events, classified as dislodgements and leaking. The measure of PVC adverse events recorded was compared to the total number of PVC recorded to completion (adverse events / number of PVCs assessed × 100). The impact of the interventions was evaluated by comparing the pre- and post- mean PVC adverse event rate, as calculated through Statistical Process Control p-charts.The study involved a 72-week period of data collection broken up into three phases, from July 2013 to April 2015. Phase A covered an initial 24-week period (July 2013 to December 2013), which was designed to establish existing PVC adverse event rates prior to the introduction of two interventions. Phase B covered an additional 24-week period (March 2014 to September 2014) and included the introduction and assessment of the first intervention, a PVC procedural kit and associated training package, to specific clinical areas. Phase C covered a further 24-week period (November 2014 to April 2015) designed to assess the second intervention, a feedback mechanism.
All adult inpatients in designated clinical medical and surgical wards, who had a PVC inserted and the device removed during their current hospital stay were included in the study. The inclusion criteria included PVCs inserted with correct associated documentation and data recorded to completion. Interventions were aimed at personnel who frequently performed the majority of PVC procedures, namely nursing staff and Foundation Year one (FY1) doctors. The project was classified as a service evaluation in accordance with the National Research Ethics Service ‘Defining Research’ guidelines and therefore did not require ethical review.
Study setting
This project was based within the Northern Health and Social Care Trust (NHSCT) in Northern Ireland, with Antrim Area Hospital (AAH) as the main site for ward-based data collection. Antrim Area Hospital is a 426 bedded district general teaching hospital, the largest in the NHSCT, providing services for a population of approximately 420,000.Peripheral cannula insertion and management form
A new Peripheral Cannula Insertion and Management (PCIM) Form was designed and introduced to the study clinical ward areas, before baseline data was collected. The form was developed by the NHSCT Infection Control Nursing team to improve records on the insertion, maintenance and removal of PVCs. It was additionally modified to record all pertinent information required for this study. The PCIM form provided an individual record for each PVC in-situ and improved accountability for each stage of insertion, on-going care and removal. It supported adherence to PVC guidelines due to the care bundle prompt checklist, colour coding and visual aids. The PCIM Form uses a colour coded observation frequency chart to allow the tracking of a PVC in-situ for up to 72 hours as standard practice, with an additional section available to extend the recording for a further 48 hours. The PVC on- going care bundle chart allowed recording for continuous and non-continuous infusions, which would lead to 6 or 12 hourly record entries. The form was beneficial to adverse events detection as a result of the integrated phlebitis scale, infiltration scale and extravasation guidance.Phases of study
Phase A – baseline data: The first phase was carried out to determine the baseline pre-intervention AAH PVC adverse event rate using the standard insertion procedure, before any interventions were introduced. This included the use of up-todate evidence based guidelines, published from the Department of Health and the manual collection of components to complete the PVC procedure [26].Phase B – intervention (PVC procedural kit and training programme): The PVC procedural kit was introduced to the clinical areas designated for the study. Training was provided on the use of the PVC procedural kit for all nurses and FY1 doctors who performed the PVC insertion procedure and were based on, or rotated through, the designated clinical wards. Phase B intervention training focused on correct use and application of the PVC procedural kit in conjunction with the importance of correct insertion procedure utilising an Aseptic Non-Touch Technique (ANTT) and completion of associated documentation. The PVC procedure training was delivered by members of the NHSCT Infection Control Nursing Team, with educational support material supplied by Iskus Health Ltd, followed by a practical component with Objective Structured Clinical Examination (OSCE) assessment.
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