BSI: Addressing Clinical Challenges with Catheter Maintenance€¦ · 1. Interaction of the catheter 2. Catheter insertion technique 3. Care and maintenance used 4. Patient response

© 3M 2016. All Rights Reserved

3M Health Care AcademySM

Addressing Clinical Challenges with Peripheral Intravenous Catheter Complications

© 3M 2016. All Rights Reserved 2

Disclosures

Rita Luettinger RN, BSN,CRNI

Dana McReynolds RN, BSN, VA-BC

Vascular Access Clinical Specialists

3M Medical Solutions Division



Learning Objectives

1. Describe the incidence and impact of peripheral

intravenous catheter (PIVC) complications.

2. Identify insertion and maintenance practices which can

lead to peripheral intravenous catheter complications.

3. Describe recommended practices and evidence-based

interventions for catheter maintenance to reduce PIVC

complications.

4. Identify guidelines and clinical studies that support these

practices.

© 3M 2016. All Rights Reserved© 3M 2016. All Rights Reserved 4

PIVC Complications:

• Phlebitis• Infection• Dislodgement• Infiltration/extravasation• Occlusion• Thrombosis• How to track PIV complications


Phlebitis

Phlebitis - Inflammation of a vein; may be accompanied by pain, erythema, edema, streak

formation, and/or palpable cord; rated by a standard scale.16

Common Complications - PIVC


Mechanical Phlebitis

• Related to catheter physical properties or

movement26

• Unsecured catheters may “piston” in and

out of the vessel

• “Engineered Stabilization Device” 2016

INS Standards16


Bacterial Phlebitis

• The skin cannot be sterilized!

• Bacteria or commonly called skin flora

reside on and under the skin surface

• Skin flora regrow in 24-48 hours after skin

antisepsis17

• Unsecured catheters may “piston” in and

out of the vessel and may physically

transport bacteria into the bloodstream


Bacterial Phlebitis57, 58

Antimicrobial Transparent Dressing, skin prepped with 2% CHG in 70% IPA

• The skin cannot be sterilized!

• Bacteria, or skin flora, reside on and

under the skin surface

• Unsecured catheters may physically

transport bacteria into the bloodstream

• Skin flora regrow in 24-48 hours after

skin antisepsis

Skin Flora Concentrations with and without antimicrobial dressing


Phlebitis rate between 2.3% and 60% 3, 5-6, 11-12

Incidence is determined by: 1. Interaction of the catheter2. Catheter insertion technique3. Care and maintenance used4. Patient response

Incidence varies due to:1. The spectrum of inflammatory pathology2. Differences in definition3. Difficulty differentiating from other

catheter failure etiologies.

Diagnosis is challenging Typically require two or more clinical symptoms

Pain

Tenderness

Warmth

Erythema

Swelling

Palpable cord


Dislodgement12-13

• Inadequate stabilization and securement can

cause unintentional dislodgement and

complications requiring premature VAD removal.

• Do not rely on standard, non-bordered

transparent semipermeable membrane dressings

as a means of stabilization.

Infusion Nurses

Society, 2016

Mean Incidence

6.9%


Dislodgement Complications of PIVCs12

Jackson, 2012 Retrospective comparative audit of two peripheral IV securement dressings.

• “The total number of PVC restarts during the comparative audit periods was 9% lower…”

Lower Restarts

• “Statistical analysis showed that during the period of use of the [securement dressing], the number of cannula reaching 72 hours increased by a factor of 2.94…”

Dwell Time Increase

Internal review of 6500 peripheral cannula outcomes - approximately 36% failed as a result of dislodgement

Baseline Data

• Between a 3-month period in 2010 and the same 3 months in 2011. Intervention was implementation of an advanced securement dressing in 2011

Peripheral IV catheter restarts



Infiltration and Extravasation

Extravasation is defined by INS as the inadvertent infiltration of vesicant solution or medication into surrounding tissue; rated by a standard tool.16

Infiltration is defined by INS as the inadvertent administration of a nonvesicant solution or medication into surrounding tissue; rated by a standard tool.16

Image courtesy of N. Costa


Infiltration: The inadvertent administration of a nonvesicant

solution or medication into surrounding tissue; rated by a standard tool

Extravasation: Inadvertent infiltration of vesicant solution

or medication into surrounding tissue; rated by a standard tool

Mean Incidence

23.9%

Infiltration and Extravasation 3, 5-6, 11-12

Hand, wrist, foot, ankle and antecubital fossaPIVs sites most at risk

Observation, palpation, flush prior to infusion to identify resistance

Assessment

Stop infusion immediately, disconnect infusion, aspirate for a blood return and remove PIV

Immediate treatment


Occlusion

• The inability to infuse or inject solution into a

catheter.16

• The inability to aspirate blood from a catheter or

both.16

Common Complications - PIVC

Causes:• Hand location• Female sex• Antibiotics2


Thrombosis

• Tunica Intima is only composed of a single

layer of cells28

• When damaged will initiate inflammatory

response

• PVC thrombosis risk 1.8 – 9.2%29

• Thrombophlebitis rates: 2-80% incidence

and connection to BSI30

• Virchow’s Triad


Infiltration Rates: Number of infiltration incidents

Total number of peripheral catheters

Phlebitis Rates: Number of phlebitis incidents

Total number of peripheral catheters

Peripheral-BSI Rates: Number of PIV-BSI

Total number of PIV line days

How to Track PIV-Related Complications16

X 100 – % peripheral infiltration

X 100 – % peripheral phlebitis

X 1000 = PIV-BSI Rate


PIVC Complications:Incidence and Impact


The Peripheral Vascular Catheter is the most common vascular access device used in healthcare

Peripheral Vascular Catheters4-5, 62

Average cost to insert a catheter is $25-35 each time

The number of peripheral intravenous catheters sold in the US is estimated to be greater than 330 million

35-50% of peripheral vascular catheters fail before the intended dwell time is complete

Greater than 90% of hospitalized patients have a VAD


Complication rates of PIVCs5

Overall Mean PIVC Catheter Failure Rate =

Catheter-Related Phlebitis

Catheter Infiltration

Catheter Occlusion/Mechanical

Failure

Catheter Dislodgment

Catheter-Related BSI (up to)

15.4 % 23.9 % 18.8 % 6.9 % 0.2 %

46%


Complications of PIVCs: Wallis (2014) Infect Ctrl Hosp Epid2

Occlusion

25.6%(n = 1512)

Accidental Dislodgement

6.3%(n = 375)

Phlebitis

4.6%(n = 273)

• Female sex (HR 1.64)• 18 gauge or larger (HR 1.48)

• Hand location (HR 1.47)• Female sex (HR 1.44)• Antibiotics infused (HR 1.41)

• Hand location (HR 2.45)• Inserted by Non-IV Team (HR 1.69)• Antecubital location (HR 1.65)


PIVC Best Practices• Prepare & assess• Insertion• Maintenance Bundle• Removal


Dedicated IV Teams

Non-irritating Infusates

Dwell time of 5-10 days or less

Smallest gauge indicated

INS16 CDC31 APIC32 EPIC333 RoyalCollege34

Prepare & Assess


Peripheral Line Insertion Bundles22, 48

✔

Consider sterile barrier precautions

Use of 2% alcoholic chlorhexidine for skin antisepsis

Use of a barrier film for skin protection

Avoid areas of flexion

Use of a securement dressing

Use of antimicrobial at the insertion site

Use of disinfecting port protectors on all needleless connectors and luers


Peripheral Line Insertion Bundles22, 48

✔

Consider sterile barrier precautions

Use of 2% alcoholic chlorhexidine for skin antisepsis

Use of a barrier film for skin protection

Avoid areas of flexion

Use of a securement dressing

Use of antimicrobial at the insertion site

Use of disinfecting port protectors on all needleless connectors and luers


Routine replacement

Clinically indicated

INS13 CDC31 MAGIC35 EPIC333 Royal

College34

Removal


Clinical Studies


Infection

CR-BSI

0-2.2% meet CDC National Healthcare Safety Network criteria for CR-BSI

Local infection

• 0.1-5.1% local culture tip-positive (0.5 per 1,000 catheter-days)

Peripheral Vascular Catheter Complications5,6, 27

Both classes require

confirmatory positive blood

culture

Lower levels of localized bacterial contamination could lead to early catheter failure through

inflammatory processes

“If we consider that half of the catheters sold are successfully inserted, a rate of 0.1% of these catheters producing a BSI would result in 165,000 patients becoming infected annually”


How many CLABSIs may be related to PIVs?9-10

36%

64%

Primary S. aureas HABSIs

Non-CLABSI

CLABSI

60%

40%

PIV or Midline Contributing to S. aureus HABSI

Non-CLABSI: PIV or Midline were portal of entry

Clear evidence exists in the literature that PIVs and midline catheters are linked to nosocomial bacteremia

47%

CLABSI occurring in patients with multiple lines


Emergently Placed PIV11, 16-17

Stuart, 2016 - 137 S. aureus PVCR-BSIs

• 61% inserted by the ambulance service or ED

• 45% involved PVCs in situ beyond 4 days

Trihn, 2011 – Emergency Department PIVCs

• 67% increased risk PVCR S. aureus bacteremia

1. Consider labeling catheters inserted under suboptimal aseptic conditions in any health care setting

2. Remove and insert a new catheter as soon as possible, preferably within 24 to 48 hours.

Infusion Nurses Society (2016)


PVCR-BSI and Dwell Time 18-24, 29-31, 39

Literature review shows 19%-60% of nosocomial BSIs are due to PIVs

Mean dwell times vary

greatly 0

10

20

30

40

50

60

70

0 1 2 3 4 5 6

Dwell Time in Days

Pe

rce

nt

Oc

cu

rre

nc

e

© 3M 2016. All Rights Reserved 31. All Rights Reserved.20 August 2019© 3M 3M Confidential.

Significant Costs Associated with PIV Failure: Why Move Toward Clinically Indicated?

When facilities move to clinically indicated peripheral IV removal the discussion of securement, stabilization, and

infection control becomes even more important

Recommendation INS 2016 Royal College 2016

Epic3 2014 CDC 2011

Remove peripheral IV catheters when clinically indicated

Pediatrics only

Rickard (2012)8 No difference in phlebitis rates

Webster (2013)34No evidence to support changing catheters every 72-96

hours. Significant cost savings.

Mermel (2017)7Catheter dwell time of >3-4 days has been associated with

increased risk of S. aureus related PVCR-BSIs

Hadaway (2012)6 165,000 PIV bloodstream infections per year

Literature Review17-31 PVC CRBSI at days 1, 2, 3, and >4


Duncan, 201854

A Bundled Approach to Decrease the Rate of Primary Bloodstream

Infections Related to Peripheral Intravenous Catheters

Despite central line initiatives, continued primary BSI occurrences, even in patients without a central line.

• Point prevalence audit conducted on IV tubing management

• Large variation in practice• disconnecting for convenience• looping back onto another port• not capping the male luer

• PIV bundle and education initiated


Duncan, 201854

A Bundled Approach to Decrease the Rate of Primary Bloodstream

Infections Related to Peripheral Intravenous Catheters

• Engaged and educated nurses over a 1 month period

• Weekly audits measured compliance and aided in providing immediate corrective feedback

• PLABSI bundle decreased primary bloodstream infections from 0.57 to 0.11 per 1000 patient days

• Increased compliance rate from 36% to 90% 0

0.1

0.2

0.3

0.4

0.5

0.6

Pre intervention (1/15-6/15) Intervention (11/15-5/16)

PLABSI infections per 1000 patient days58

0.57

0.11

{80% reduction}

Pre intervention(1/2015-6/2015)

Post intervention(11/2015-5/2016)

P =< 0.001


Evidence-Based Practice: Before and After64

Using Kotter’s Model of Change a 144-bed hospital implemented clinically indicated PIV removal policy change from 96 hour dwell time

Pre-Intervention

Pre-Intervention Planning

• Gathered 3 months PIV use, phlebitis, and infections rates.

• Identify Team of Key Stakeholders: • Medical director for infection control• 2 infection prevention specialists• Director of quality and safety• Manager of regulatory preparedness• Director of nursing• Nurse manager and RNs from the pilot unit• Several RNs from other units in the health care system.

• Staff communication given by the project leader during the unit’s monthly staff meetings in advance of implementation

• Online education module



Using Kotter’s Model of Change a 144-bed hospital implemented clinically indicated PIV removal policy change from 96 hour dwell time

Intervention

Intervention Support

• Weekly communication with implementation team:• nurse manager, clinical resource leaders,

infection prevention specialists, and staff RNs

• IP surveillance for three months post

• Each month after the practice change, outcome data were displayed for the staff in a high-traffic area



• PIV catheter use following implementation of 3 month pilot practice change decreased by 14.2%

➢ Despite an increase in patient days

• 70 hours of RN time saved

• There were no peripheral catheter infections during the 3 months following the practice change.

Post-Intervention Data

Pre-Intervention Post-Intervention


Summary


Putting it all together.• Peripheral IVs are the most common vascular access device, yet it is perceived as a simple

procedure.

• Peripheral IVs are, in fact, an invasive procedure with significant complications.

• Evidence and standards reveal it may be advantageous to move to a clinically-indicated peripheral IV removal.

• Longer peripheral IV dwell times may exacerbate infectious complications.

• Regardless of decision, care and maintenance should be standardized with peripheral IV bundles, consider one that includes protecting the insertion site from harmful bacteria.

• Change management must be considered.

• Use of PIV bundles, education on catheter care and maintenance, auditing and feedback can significantly enhance patient outcomes.


Navigating Short Term PIVCs

Exudate


Thank you

Questions?


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Documents

BSI: Addressing Clinical Challenges with Catheter Maintenance€¦ · 1. Interaction of the catheter 2. Catheter insertion technique 3. Care and maintenance used 4. Patient response