Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide
BACKGROUND: Peripheral intravenous catheter (PIVC) use in health care is common worldwide. Failure of PIVCs is also common, resulting in premature removal and replacement.
OBJECTIVE: To investigate the characteristics, management practices, and outcomes of PIVCs internationally. DESIGN: Cross-sectional study.
SETTING/PATIENTS: Hospitalized patients from rural, regional, and metropolitan areas internationally.
MEASUREMENTS: Hospital, device, and inserter characteristics were collected along with assessment of the catheter insertion site. PIVC use in different geographic regions was compared.
RESULTS: We reviewed 40,620 PIVCs in 51 countries. PIVCs were used primarily for intravenous medication (n = 28,571, 70%) and predominantly inserted in general wards (n = 22,167, 55%). Two-thirds of all devices were placed in non-recommended sites such as the hand, wrist, or antecubital veins. Nurses inserted most PIVCs (n = 28,575, 71%); although there was wide regional variation (26% to 97%). The prevalence of idle PIVCs was 14% (n = 5,796). Overall, 10% (n = 4,204) of PIVCs were painful to the patient or otherwise symptomatic of phlebitis; a further 10% (n = 3,879) had signs of PIVC malfunction; and 21% of PIVC dressings were suboptimal (n = 8,507). Over one-third of PIVCs (n = 14,787, 36%) had no documented daily site assessment and half (n = 19,768, 49%) had no documented date and time of insertion.
CONCLUSIONS: In this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.
© 2018 Society of Hospital Medicine
The majority of hospitalized patients worldwide have at least one peripheral intravenous catheter (PIVC),1 making PIVC insertion one of the most common clinical procedures. In the United States, physicians, advanced practitioners, and nurses insert over 300 million of these devices in hospitalized patients annually.2 Despite their prevalence, PIVCs are associated with high rates of complications, including insertion difficulty, phlebitis, infiltration, occlusion, dislodgment, and catheter-associated bloodstream infection (CABSI), known to increase morbidity and mortality risk.2-9 Up to 90% of PIVCs are prematurely removed owing to failure before planned replacement or before intravenous (IV) therapy completion.3-6,10-12
PIVC complication and failure commonly triggers insertion of a replacement device and can entail significant costs.2-4 One example is PIVC-related CABSI, where treatment costs have been estimated to be between US$35,000 and US$56,000 per patient.6,13 Another important consideration is the pain and anxiety experienced by patients who need a replacement device, particularly those with difficult vascular access, who may require multiple cannulation attempts to replace a PIVC.12,14-16 In developing nations, serious adverse events related to PIVCs are even more concerning, because hospital acquired infection rates and associated mortality are nearly 20 times greater than in developed nations.17
A number of evidence-based interventions have been suggested to reduce PIVC failure rates. In addition to optimal hand hygiene when inserting or accessing a PIVC to prevent infection,18 recommended interventions include placement of the PIVC in an area of non-flexion such as the forearm to provide stability for the device and to reduce patient discomfort, securing the PIVC to reduce movement of the catheter at the insertion site and within the blood vessel, and use of occlusive dressings that reduce the risk of external contamination of the PIVC site.11,19,20 Best practice guidelines also recommend the prompt removal of devices that are symptomatic (when phlebitis or other complications are suspected) and when the catheter is no longer required.21,22
Recent evidence has demonstrated that catheter size can have an impact on device survival rates. In adults, large-bore catheters of 18 gauge (G) or higher were found to have an increased rate of thrombosis, and smaller-bore catheters of 22G or lower (in adults) were found to have higher rates of dislodgment and occlusion/infiltration. The catheter size recommended for adults based on the latest evidence for most clinical applications is 20G.3,20,23,24 In addition, the documentation of insertion, maintenance, and removal of PIVCs in the medical record is a requirement in most healthcare facilities worldwide and is recommended by best practice guidelines; however, adherence remains a challenge.1,19
The concerning prevalence of PIVC-related complications and the lack of comparative data internationally on organizational compliance with best practice guidelines formed the rationale for this study. Our study aim was to describe the insertion characteristics, management practices, and outcomes of PIVCs internationally and to compare these variables to recommended best practice.
MATERIALS AND METHODS
Study Design and Participants
In this international cross-sectional study, we recruited hospitals through professional networks, including vascular access, infection prevention, safety and quality, nursing, and hospital associations (Appendix 2). Healthcare organizations, government health departments, and intravascular device suppliers were informed of the study and requested to further disseminate information through their networks. A study website was developed,25 and social media outlets, including Twitter®, LinkedIn®, and Facebook®, were used to promote the study.
