Peripherally Inserted Intravenous Catheters; Evaluating Compliance with Australian Guidelines at a NSW Tertiary Hospital

Dr Zoe Gerbner

Abstract

Half of patients admitted to hospital require a peripherally inserted intravenous cannula (PIVC) for the administration of fluids and parenteral medications¹. The insertion of PIVCs is the most common procedure performed for hospitalised patients¹, with insertion being performed in Australia by medical officers, predominantly junior medical officers, as well as nurses. PIVCs are however associated with multiple complications, many of which have been shown to be underappreciated by junior medical doctors², including phlebitis, air embolism, thromboembolism and haematoma. Importantly, Staphylococcus aureus bacteraemia, which is associated with significant morbidity and mortality, is linked to PIVCs in 25% of cases³. This is striking when considering that 50% of PIVCs inserted in an Australian tertiary hospital emergency department were unused⁴. 

One third of adults requiring a PIVC in hospital are reported to have difficult venous access⁵ for a multitude of reasons including obesity, malnourishment, previous chemotherapy and intravenous drug use. These patients are more likely to undergo multiple attempts at PIVC insertion and are more likely to have PIVCs inserted in the antecubital fossa and wrist, though known to be associated with higher risk of phlebitis, thrombosis and catheter related infection.⁶ The cycle then continues as these PIVCs need to be replaced, leading to further vessel damage and depletion of venous sites and this negatively affects patient’s overall hospital experience as these replacements are painful and distressing.⁷ 

The Australian Commission on Safety and Quality in Health Care has developed clinical care standards for the management of PIVCs under multiple domains including need for insertion, competency, site selection (i.e. avoiding sites of flexion such as the antecubital fossa), maximising first insertion success and routine monitoring. These standards aim to promote judicious insertion and reduce complications associated with PIVCs. Alexandrou et al 2018 studied PIVC insertion, management and outcomes in a cross sectional study of health care settings internationally and found that despite international best practice guidelines regarding PIVCs, many PIVCs were suboptimal in their sites, dressing, documentation as well as many being complicated including infections and idle.¹ 

Our cross sectional study aims to similarly evaluate PIVC insertion, management and outcomes at Wagga Wagga Base Hospital, a tertiary referral centre in rural New South Wales. Data will be collected of adult patients admitted to the acute hospital as to presence, characteristics and use of PIVCs using a standardised form. Variables will include location of insertion, anatomical site of insertion, catheter gauge, insertion site assessment and details of IV therapy including whether the PIVC is idle (not required for IV therapy in the preceding 24 hours). The aim of this study is to evaluate compliance with Australian guidelines and thus reveal areas for optimisation of patient care with regards to PIVCs.

References

1. Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. J Hosp Med. 2018;13(5):10.12788/jhm.3039. Published 2018 May 30. doi:10.12788/jhm.3039
2. Sharma M, Paudel S, Shrestha U, Sitaula B. Knowledge of Intravenous Cannulation among Interns of a Teaching Hospital: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc. 2022;60(247):290-293. Published 2022 Mar 11. doi:10.31729/jnma.7222
3. Decker K, Ireland S, O'Sullivan L, et al. Peripheral intravenous catheter insertion in the Emergency Department. Australas Emerg Nurs J. 2016;19(3):138-142. doi:10.1016/j.aenj.2015.12.003
4. 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;62(5):521-525. doi:10.1016/j.annemergmed.2013.02.022
5. Witting MD. IV access difficulty: incidence and delays in an urban emergency department. J Emerg Med. 2012;42(4):483-487. doi:10.1016/j.jemermed.2011.07.030
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7. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015;38(3):189-203. doi:10.1097/NAN.0000000000000100
8. Management of Peripheral Intravenous Catheters Clinical Care Standard. Australian Commission on Safety and Quality in Health Care. 2021. Accessed 11 April, 2024. https://www.safetyandquality.gov.au/sites/default/files/2021-05/management_of_peripheral_intravenous_catheters_clinical_care_standard_-_accessible_pdf.pdf