Time to rethink our approach to using cannulas

Associate Professor Amanda Walker, Clinical Director at the Australian Commission on Safety and Quality in Health Care, explains why it’s time for a consistent approach to using cannulas.

Inserting a peripheral intravenous catheter (PIVC) or cannula is one of the most common procedures performed in hospitals, experienced by 7.7 million Australians each year.^1-4 Most hospital patients will be familiar with the procedure, which all healthcare professionals in hospitals will be involved in, either directly or indirectly.

Despite this, PIVCs are often associated with a range of problems including unnecessary cannulation, multiple insertion attempts and, on occasion, significant complications such as infection, including Staphylococcus aureus bacteraemia.^2,3,5,6

As many clinicians are aware, the insertion of a PIVC and the after-effects can be a painful and difficult experience for patients, and harmful if they get an infection, are very unwell or have damaged veins or thin skin that can cause other complications. The evidence is clear that we can do better, and prompts us to ask: Is there an alternative to a PIVC? Where should it be inserted? Which clinician is best placed to insert a PIVC to ensure the best possible patient outcome?

To provide guidance and bring consistency across our health system, the Australian Commission on Safety and Quality in Health Care (the Commission), has developed the first-ever national clinical care standard for peripheral venous access.

The Management of Peripheral Intravenous Catheters Clinical Care Standard spotlights key areas for improvement in the safe and effective use of PIVCs, including insertion, maintenance and removal. The Commission consulted broadly with leading experts in vascular access, pain management and infection control, as well as researchers and consumers, who are all keen to improve the way we use PIVCs in Australia.

PIVC complications are common — they can be difficult to insert, are prone to blockage and dislodgment, can cause inflammation of the vein (phlebitis, or thrombophlebitis if a blood clot also forms) and in some cases, can cause serious catheter-associated bloodstream infections.

All clinicians inserting PIVCs need to recognise the potentially harmful consequences if this common procedure is not done well. The new standard outlines how we can avoid these complications and improve patient experience. It has 10 quality statements (see Box 1), which are all important for best-practice use of PIVCs.

Is venous access required?

Various studies estimate that up to one-quarter (4–28%) of PIVCs inserted are not needed, with rates increasing to up to 50% in emergency departments, where patients are more likely to receive a peripheral line as a routine admission procedure or ‘just in case’ it is needed later.^4,8

Concerningly, international comparative studies on PIVC use have reported that Australia has the highest prevalence of redundant PIVCs, with no documented IV order for fluids or medicines in 43% of cases, suggesting that the PIVC may have been unnecessary.⁹

In palliative care, I often see patients with sclerosed veins undergoing multiple painful attempts at cannulation, and never actually receiving medication or fluids that require a cannula. Equally frustrating, those cannulas are often inserted to administer medications which could easily be given subcutaneously — without the hassle and inconvenience of an IV line in their forearm and the accompanying risk of complications.

As clinicians we sometimes focus on the drug being given rather than the way it is given, and this can lead to a PIVC being used when another route is more appropriate. The new standard supports healthcare professionals and health service organisations to assess the appropriateness of IV administration early, and to continue this assessment as the diagnosis is established and treatment progresses.

Maximising first insertion success

It is astonishing to consider the data on PIVC insertions. Up to 40% of all first attempts to insert a PIVC in adults fail, and 65% of all first attempts in children¹⁰ fail. This means many patients undergo multiple painful attempts before a PIVC is successfully inserted. The standard seeks to maximise first insertion success, which will certainly improve the patient experience.

In my experience, junior doctors often feel pressure to keep trying until they get a line in. Seeking help can be seen as a mark of failure. However, the adage ‘if at first you don’t succeed try, try again’ cannot apply to vascular access. If you can’t get the cannula in on the first attempt — get help. If you recognise a patient has difficult vascular access, it’s even more important to seek advice. Highly skilled inserters or advanced techniques such as ultrasound are often needed to successfully insert a PIVC in someone with difficult IV access.⁷

Senior clinicians and health service managers have a shared responsibility to help shift the culture, and encourage junior staff to escalate when they are having difficulty, rather than entrenching the culture of ‘keep going until you get there’. Doctors can show leadership on rounds by routinely reviewing both the insertion site and whether a line is still needed.

When people ask me why we need this new standard, my answer is simple: patients are not pin cushions.

Reducing risk of infection

As medical students, we are taught that every time you breach the skin you introduce a risk of infection, and therefore it is assumed that the risk of infection is unavoidable. It is true that every attempt to insert a PIVC is a breach in the patient’s protective barriers, and we should aim to limit this as much as possible.

However, the risk of infection as a result of that breach can be decreased significantly using well-known infection control techniques and practices, which are clearly described in the Australian Guidelines for Infection Control.³

When a PIVC fails

PIVC-related complications result in up to 90% of catheters being removed before they are planned to be replaced or before therapy is finished.⁵ When a PIVC fails, the insertion of a replacement device is often needed.

This can impose a significant burden on the patient and the health system. It can lead to delays in IV therapy and increased length of hospital stay. Hospital staff and material resources are required to reinsert the PIVC so that therapy can continue.

The cost of managing a PIVC failure can also be significant. For example, a PIVC-related bloodstream infection has been estimated to cost the US health system between US$35,000 and US$56,000 per patient.

We used to think the cost was inevitable. It’s not — we can do better. Apart from the financial burden there is the human cost, in terms of the pain and discomfort experienced by the patient as a result of the failure, particularly where access is difficult, multiple attempts are required to successfully reinsert a PIVC.^3,9

Involving consumers

A significant proportion of patients do not receive best-practice care for the use of PIVCs, according to Australian and international data. The new standard supports discussion to ensure patients are informed about the procedure and are empowered to participate in decisions about their care.

The IV-WISE Discussion Tool provides key discussion points for clinicians and patients, to encourage shared decision-making, prevent PIVC-related complications and enable patients to stay as comfortable as possible (see Figure 1).

Measuring improvement

While PIVCs are used in hospital settings every day, often the only measure of how well they are being used is infection rates. Carrying out a point prevalence audit in a ward or service can help identify quality improvement needs and monitor changes over time.

The clinical care standard includes a set of indicators that health service organisations can use for this purpose, so we can keep track of how we are performing and strive to do better. The changes required might be relatively small but can make a big difference overall.

Time for change

Complications with vascular access are likely to become a bigger issue in the future as the Australian population gets older and more chronically unwell. Associated costs will also increase, further burdening our health system.

It has never been more important for health service organisations to focus on determining the use of the right device, for the right patient, at the right time. We all have a part to play in reducing the number of unnecessary cannulations, unsuccessful attempts and avoidable infections. The new Management of Peripheral Intravenous Catheters Clinical Care Standard sets us on a positive path to achieve this goal.

Box 1: Management of Peripheral Intravenous Catheters Clinical Care Standard — Quality Statements

1. Assess intravenous access needs.
2. Inform and partner with patients.
3. Ensure competency.
4. Choose the right insertion site and PIVC.
5. Maximise first insertion success.
6. Insert and secure.
7. Document decisions and care.
8. Routine use: inspect, access and flush.
9. Review ongoing need.
10. Remove safely and replace if needed.

Read the full quality statements at safetyandquality.gov.au/pivc-ccs.

Figure 1: IV-WISE Discussion Tool

Download the tool at safetyandquality.gov.au/pivc-ccs.

This article was developed with Christina Lane and Alice Bhasale from the Commission’s Clinical Care Standards team.

Associate Professor Amanda Walker is Clinical Director at the Australian Commission on Safety and Quality in Health Care and led the development of the Management of Peripheral Intravenous Catheters Clinical Care Standard. At the Commission, she is focused on the development of clinical care standards, resources to address hospital-acquired complications and support for clinicians to provide comprehensive care. She is a specialist in palliative medicine in the Southern Highlands of NSW and has led state-wide work in end-of-life care at the Clinical Excellence Commission in NSW.

References

1. Cooke M, Ullman AJ, Ray-Barruel G, Wallis M, Corley A, Rickard CM. Not "just" an intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross-sectional survey of 25 countries. PLoS One. 2018;13(2):e0193436.
2. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015 May-Jun;38(3):189–203.
3. Marsh N, Webster J, Larson E, Cooke M, Mihala G, Rickard CM. Observational study of peripheral intravenous catheter outcomes in adult hospitalized patients: a multivariable analysis of peripheral intravenous catheter failure. J Hosp Med. 2018 Feb 1;13(2):83–89.
4. Zingg W, Pittet D. Peripheral venous catheters: an under-evaluated problem. Int J Antimicrob Agents. 2009;34 Suppl 4:S38–42.
5. Alexandrou E, Ray-Barruel G, Carr PJ, Frost SA, Inwood S, Higgins N, et al. Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. J Hosp Med. 2018 May 30;13(5).
6. Wallis MC, McGrail M, Webster J, Marsh N, Gowardman J, Playford EG, et al. Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomized controlled trial. Infect Control Hosp Epidemiol. 2014 Jan;35(1):63–68.
7. Sou V, McManus C, Mifflin N, Frost SA, Ale J, Alexandrou E. A clinical pathway for the management of difficult venous access. BMC Nurs. 2017;16:64.
8. Limm EI, Fang X, Dendle C, Stuart RL, Egerton Warburton D. Half of all peripheral intravenous lines in an Australian tertiary emergency department are unused: pain with no gain? Ann Emerg Med. 2013 Nov;62(5):521-525.
9. Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, et al. International prevalence of the use of peripheral intravenous catheters. J Hosp Med. 2015 Aug;10(8):530–533.
10. Malyon L, Ullman AJ, Phillips N, Young J, Kleidon T, Murfield J, et al. Peripheral intravenous catheter duration and failure in paediatric acute care: A prospective cohort study. Emerg Med Australas. 2014 Dec;26(6):602-608.
11. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.

Image courtesy of the Australian Commission on Safety and Quality in Health Care.