Changing Practice for Peripheral IV Sites From “Every 72 Hours” to “As Clinically Indicated”

Rationale Review of Literature

Background

PICO Question

• The high risk obstetric patient have prolonged hospitalizations• Many of our patients require a site change every 72-96 hours which resulted in poor

venous availability for access at the time of emergent medical need. • This creates the potential for no available peripheral IV access and increased risk

for central line placement, which can lead to further complications associated with central lines in this vulnerable population.

• Patients are dissatisfied with the pain associated with frequent IV site placement. • Nurses questioned the rationale for re-accessing a site that functioned properly and

didn’t display clinical indications for a restart. • This increased the bedside nurse’s workload, as well as increased supply cost. • Current practice varied from leaving the PIV out due to poor vasculature, changing

the PIV routinely, or calling the physician to leave the PIV until painful, reddened, or swollen.

I

Changing Practice for Peripheral IV Sites From “Every 72 Hours” to “As Clinically Indicated”Karni Olsen, BSN, RNC, Ronda Coultrap, RNC, Teresa Sharkey, BSN, RNC, Melinda Marra, RN, Alma Martinez, RN,

Chris Tussey, RNC,CNS; Ann Earhart, RN, PhD(c), ACNS-BC, CRNI

Implementation Plan

Discussion

Baseline Data

Methods

• Staff developed and provided input and education of the data required for baseline data of IV practices.

• Forms and processes were developed by staff for data collection throughout the patient’s stay from admission to discharge to capture the IV site insertion assessment.

• Data included site location, length of time in place, medications administered, and reason for IV removal.

• Education was provided to the staff to stress the importance of accurate IV documentation on the electronic medical record for data collection.

• The Infusion Nurses’ Society phlebitis scale is incorporated into the documentation and provided a consistent method to document and measure redness and pain at

• Baseline data was collected for 5 months• Bright colored folders created for data collection• CNS and leadership reminded staff of data collection• No change in IV rotation was made during Baseline data collection.• Literature and internal data will be presented to Physician Committees• With approval, implement practice/policy changed to removing and replacing peripheral IV only

when clinically indicated after baseline data collected.• Post implementation, data collected to analyze change in practice.

• This program helped identify baseline data of multiple practices. • The project for change in practice occurred due to the strong support by nursing staff. • The project identified routine IV restarts occurring for patients being discharged in the

following day, as well as nursing assessment of IV sites being changed as needed when red and swollen before the three days.

• The pain and swelling increased as this was the clinical indication for change• The patient satisfaction increased, with patients having IVs in place 10-32 days without

routine changes• Cost of supplies for reinsertion decreased.• Plan implementation into next area, telemetry/PCU, a different patient population for

validation of results.

Contact InformationKarni Olsen, BSN, RNC – [email protected] Coultrap, [email protected]

• Routine practice for care and maintenance of peripheral intravenous (PIV) sites includes routine restarting every 72-96 hours.

• Nursing identified needing to change PIVs for all patients, which is difficult for the high risk OB patient who can remain hospitalized for weeks and months during a complicated pregnancy.

In the high risk OB patients who are admitted and staying longer than 4 days needing a PIV, how does changing the IV site when clinically needed versus the current practice of changing the IV site every 72-96 hours affect phlebitis rates, patient satisfaction, and cost?

A Cochrane Review “Clinically-Indicated Replacement Versus Routine Replacement of Peripheral Venous Catheters” by Webster, Osborne, Rickard, and Hall (2010) found no statistical increase in 5 different clinical trials in phlebitis (9% versus 7.2%) when changing PIV sites when clinically indicated versus every 72-96 hours. The findings also found increased patient and nursing satisfaction, as well as decreased cost of supplies. • Rickard, C., McCann, D. Munnings, J. & McGrail, M. (2010). Routine resite of peripheral

intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: A randomized controlled trial. BMC Medicine, 8(53), 1-10.

• Webster. J., Lloyd, S., Hopkins, T., Osborne, S., & Yaxley, M. (2007). Developing a research base for intravenous cannula re-sites (DRIP trial). A randomized controlled trial of hospital in-patients. Science Direct, 44, 644-671.

IV sites n-27IV location: hand n-7, forearm n-7, wrist n-7, AC-n-5Insertion attempts: (1) n-23; (2) n-3; (3) n-1. Average days in place: 3.9 daysReason Removed: painful n-5, discharge n-10, routine change n-12

Implementation DataIV sites n-31IV location: hand n-5, forearm n-14, wrist n-7, AC-n-5Insertion attempts: (1) n-23; (2) n-5; (3) n-2; (5) n-1. Average days in place: 7.4 daysReason Removed: painful n-8, swelling n-4, leaking n-1, dislodged n-5, discharged n-13.

Documents

Changing Practice for Peripheral IV Sites From “Every 72 Hours” to “As Clinically Indicated”