New standard of care for IV cannulas

From today, a new clinical standard will change our approach to peripheral intravenous catheter (PIVC) insertion — a procedure carried out on 7.7 million Australians each year. Also known as a cannulas or ‘drips’, the new standard will provide national guidance on best practice care and skilful use of PIVCs, prompting health workers to consider whether a cannula is really necessary before insertion.

Up to 40%^1-2 of all first-time PIVC insertion attempts are reported to fail, with many patients facing the prospect of undergoing multiple painful attempts before a PIVC is successfully inserted. Once inserted, there is also a risk of complications, some of which are serious.

The Management of Peripheral Intravenous Catheters Clinical Care Standard by the Australian Commission on Safety and Quality in Health Care (the Commission) outlines how to insert, maintain and remove PIVCs safely and effectively. The standard also describes the care that patients should expect to receive if they have a PIVC inserted during a hospital stay.

Associate Professor Amanda Walker, Commission Clinical Director, said it would be easy to overlook the opportunity to improve a medical procedure as common as cannula insertion — yet this makes it vital.

“This new standard for peripheral intravenous catheters will help to improve the techniques used by healthcare professionals and, in turn, reduce the risk for patients who may experience issues with insertion or complications afterwards,” said Associate Professor Walker.

“It aims to ensure the best chance of cannulas being inserted correctly the first time, and once they are in, for them to be well maintained, to avoid blockages, infections and other problems such as leakage into the tissue or inflammation.

“An intravenous cannula insertion is an experience that almost everyone who goes to hospital will have. Yet there is a high failure rate of 40% for first-time insertions, and also a high rate of problems, with up to 69% of cannulas needing to be removed due to complications.^3-6 So let’s embrace this opportunity with the new standard to consider how we can all do it better.”

Associate Professor Amanda Walker, Commission Clinical Director

Associate Professor Walker added, “When people ask why we need this new standard, my answer is simple: ‘patients are not pin cushions’. It doesn’t matter where a clinician fits in the health system, we all have a responsibility to improve patient outcomes.”

She highlighted the importance of patient-centred care and listening to patients about their past experiences with cannula insertion, and what would work best for them. “Let’s ask questions: Is there an alternative to a cannula? Where should it be inserted? Which clinician will get the best outcome for the patient?

“We want to improve the patient experience and to boost the confidence of all healthcare workers in knowing how to manage those difficult cannulations.”

Over time, Associate Professor Walker predicts that complications with vascular access are likely to become a bigger concern as the Australian population ages and becomes more chronically unwell. She says reducing unnecessary PIVC use and preventing device failures will allow resources to be used more efficiently.

Greatest risk of any medical device: unacceptable

For nurse and vascular access expert Dr Evan Alexandrou, Senior Lecturer at Western Sydney University and Clinical Nurse Consultant at Liverpool Hospital in NSW, the new PIVC standard offers the chance to review the procedure in hospitals across the country.

“Peripheral intravenous catheter insertion is one of the most practised clinical procedures in hospitals, yet it carries the greatest risk of failure of any medical device,” Dr Alexandrou said.

“Each day, thousands of PIVCs fail in Australian hospitals, and we continue to accept this unacceptable rate of failure. This standard is a way of resetting our approach. We need to reduce the burden of multiple cannulation attempts on our patients, and to achieve this, a standardised approach to promote first insertion success is necessary.

“Our patients deserve to receive the right device, by the right trained personnel at the right time to minimise delays with treatment and reduce post-insertion failure. It’s time to stop accepting the unacceptable.”

Dr Jennifer Stevens, Anaesthetist and Pain Medicine Specialist at St Vincent’s Hospitals in Sydney, said even if a small percentage of people have complications from PIVCs, this translates into large numbers of people affected because it is such a common procedure.

“The new clinical care standard will help to improve the experience of all patients who have a PIVC,” Dr Stevens said.

“For those patients who have recurrent problems with cannula insertion, it may be appropriate to escalate more rapidly to a senior clinician than we have done in the past, which means adjusting our mindset.

“As an anaesthetist, part of my role is to ensure excellent peripheral access before a patient goes to the ward. The site where a cannula is inserted and the way it is secured — so that the entry point at the skin is visible and movement of the cannula is prevented — are two easy ways to help prevent infection and avoid the need to replace a cannula early. We need to get this right every time when a cannula is being left in.”

Dr Stevens added, “The site of the cannula makes a big difference. For example, a cannula in the elbow crease is painful, makes sleep impossible when the occlusion alarm keeps going off all night, doesn’t last long and is more prone to infections.”

The new standard will be launched via a live-streamed event. The panel discussion will include: the Commission’s Associate Professor Amanda Walker; nurse and vascular expert Dr Evan Alexandrou; anaesthetist and pain medicine specialist Dr Jennifer Stevens; the Australian Government’s Deputy Chief Medical Officer Professor Michael Kidd AM; and infectious diseases physician and microbiologist Professor Peter Collignon AM. NSW Chief Nursing and Midwifery Officer Jacqui Cross is also participating in the launch, with Commission Board Chair Professor Villis Marshall AC.

The new clinical care standard has been endorsed by 19 medical and nursing colleges and other professional bodies, including the Royal Australasian College of Physicians, the Australasian College for Emergency Medicine, the Australian and New Zealand Society for Geriatric Medicine, the Australian College of Nursing and the Australian Vascular Access Society.

Tune in at 1:00 pm AEST Wednesday, 26 May: https://kapara.rdbk.com.au/landers/17b225.html.

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. Jacobson AF, Winslow EH. Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions. Heart Lung. 2005 Sep-Oct;34(5):345-359.

3. 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.

4. 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.

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.

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