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Patient Safety Tip
of the Week
February
26, 2019
Vascular Access Device Dislodgements
It’s staring us
right in the face. It’s so common, we never think about it as a patient safety
issue. But the latest under-the-radar patient safety topic: dislodgement of
catheters and vascular access devices! But it really shouldn’t be a surprise.
Dislodgement of vascular access devices and other devices is important for “the 3 C’s”: comfort, complications, and
cost.
When vascular
access devices are dislodged, delays in treatment occur. Intravenous fluid
replacement falls behind and intravenous medication
administration is delayed. And, in some cases where peripheral sites are
scarce, the need for vascular access may result in the patient getting a more
invasive procedure (central line, subclavian line, etc.). Complications include bleeding, skin tears, air embolism, hematoma,
phlebitis, thrombus formation, infiltration, extravasation, and infection.
Patient comfort is impacted, both by the above mentioned complications and by pain and anxiety during
restarts or need for a more invasive procedure for vascular access.
Very few hospitals
even know the impact of catheter/device dislodgement. They seldom record a
reason when such devices are changed or discontinued. But maybe if they break
out spending on such devices, the problem of dislodgement might garner some
attention. And those cost considerations
do not include the cost of additional time required for care provided by
nursing and other healthcare professionals. Requirements to attend to dislodged
catheters and restarts can take time away from other nursing tasks and even
result in some “missed care” (see our many columns on the impact of missed
care).
A
web-based survey of clinicians (Moureau 2018) found that 68% of
respondents reported often, daily, or multiple times daily occurrence of
accidental dislodgement affecting intravenous (IV) devices. 96.5% identified peripheral
intravenous catheters as most common device experiencing accidental
dislodgement.
The most commonly
reported contributing factors were:
80% Confused
patient
74% Patient
physically removes catheter
65% IV
catheter tape or securement loose
60% Patient
moving around in bed with tangled tubing
51% Any
forceful pull by patient or other
48% Patient
going to bathroom forgetting IV is attached
47% Patient
hair growth or perspiration lifting dressing
38% Bed
transfer of patient
33% Hospital
staff assisting patient when IV dislodged
3% Tubing too long and gets caught when
ambulating
Moureau
gives a conservative projection of accidental dislodgement incidence at 19
million events per year in the United States.
She also notes that,
regarding time for PIV replacement, most clinicians responding to the survey
estimated a range of 6-30 minutes (depending on patient-related factors and
type of hospital setting among other factors).
A
study of peripheral intravenous catheters (PIV’s) in a tertiary hospital in Australia
(Marsh
2018) followed 1000 patients until catheter removal.
Catheter failure occurred in 32% of
1578 PIV’s. Phlebitis occurred in 17%. Factors associated with
occlusion/infiltration risk included intravenous (IV) flucloxacillin, 22-gauge
PIV’s, and female patients. Phlebitis was associated with female patients, bruised
insertion sites, IV flucloxacillin, and dominant side insertion. Paramedic
insertion was a risk for dislodgement. Each increase by 1 in the average number
of daily PIV accesses was associated with occlusion/infiltration, phlebitis and
dislodgement. On the other hand, additional securement products were associated
with less occlusion/infiltration, phlebitis and dislodgement.
The authors note
that their findings regarding the 22-guage PIV’s question international
guidelines, which currently recommend the smallest gauge peripheral catheter
possible. They also note that they did not have good data on the impact of
multiple insertion attempts because they did not witness the insertions.
They note that
their PIV failure rate of 32% is actually lower than
rates in most published studies.
They used a mean
cost of PIV replacement cost of US $51.92 per episode
of IV treatment (Tuffaha 2014) to
calculate the financial impact of PIV failures. For their hospital, which uses
200,000 PIV’s per year, the current level of PIV failure suggests almost US
$4.1 million in waste annually at this site alone.
Another Australian
study (Wallis 2014) performed a secondary data analysis from a
randomized controlled trial of PIVC (peripheral intravenous catheter) dwell
time. They found these potentially modifiable risk factors for occlusion: hand,
antecubital fossa, or upper arm insertion compared with forearm. Larger
diameter PIVC was a risk factor for phlebitis. PIVC’s inserted by the operating
and radiology suite staff had lower occlusion risk than ward insertions. Modifiable
risks for accidental removal included hand or antecubital fossa insertion
compared with forearm, clinical staff insertion compared with intravenous
service, and smaller PIVC diameter. Female sex was a nonmodifiable factor
associated with an increased risk of both phlebitis and occlusion. The authors
conclude that PIVC survival is improved by preferential forearm insertion,
selection of appropriate PIVC diameter, and insertion by intravenous teams and
other specialists.
So how do you
minimize the risk of device dislodgement and many of these other complications
of peripheral IV catheters?
Czajka
et al. (Czajka 2018) show that proper primary and secondary
securement can reduce complications, increase patient comfort, and save money.
In fact, they make a case that decisions related to securement of vascular
access devices should be considered equally as important as the choice of the
catheter itself.
“Primary” catheter
securement directly holds the catheter in place on the skin. “Secondary”
securement acts as an additional anchor for the infusion set tubing or
extension set to reduce any force the primary securement receives when energy
is applied to the tubing by accident or rapid patient movement. They stress
that secondary securement is as important as the primary. Primary stabilization
cannot withstand the forces applied, for example, when IV tubing becomes
trapped in the bed rail during a patient transfer. Without the secondary
securement “shock absorber,” the primary stabilization can fail, resulting in a
lost catheter.
They
note that all lines, whether PVC’s (peripheral venous catheters) or CVC’s
(central venous catheters), should be secured. Proper securement is
particularly important when placing an infusion line in anatomic areas of
greater movement (eg. antecubital veins or saphenous veins in the
foot), and for patients at greater risk of unintentional dislodgment (eg., those who are confused, combative, or developmentally
challenged, or have changes in mental status) and neonates, infants, and
toddlers.
Before replacing an
ESD, it is important to remove all old adhesive to allow for appropriate skin
antisepsis. Watch for adhesive–related injuries associated with the use of or
removal of adhesive- based ESD’s.
They stress that a
dislodged or displaced vascular access device should never be re-advanced into
a vein. Peripheral catheters that become dislodged should be removed. Dislodged
central catheters should be assessed for tip position, infusion therapies, and
other influencing factors. Then stabilize that PICC at the current position; in
some cases, a new catheter insertion may be warranted.
The ECRI Institute
PSO (ECRI 2018) has a nice review on device dislodgement (not only vascular
access devices but also devices like feeding tubes, nephrostomy tubes, and
others) and includes a staff handout pointing out the importance of avoiding
such dislodgements and the steps to prevent them.
So far we’ve been talking primarily about regular peripheral
IV’s rather than peripherally inserted central catheters (PICC lines). We refer
you back to our multiple columns on PICC lines (listed below) that call into
question the often misperceived relative safety of
PICC lines. In addition, a new study (Krein 2019) analyzed PICC-related complications from
the perspective of the patient, both during and after hospitalization. This
included 438 consecutive patients with PICC’s at four US hospitals between 2015
and 2017. During the 70-day follow-up period, 61.4% of patients reported signs
of at least one complication, including potentially serious complications, such
as bloodstream infection (17.6%) and deep vein thrombosis (30.6%).
Correspondence of these reported events with medical record documentation of
the complication was generally low. More than one-quarter (27.9%) of patients
reported minor complications, such as insertion site redness, discomfort or
difficult removal. While the PICC was in place, 26.0% reported restrictions in
activities of daily living, 14.4% social activity restrictions and 19.2% had
difficulty with flushing or operating the PICC. The exact incidence of catheter
dislodgement is not clear because it was lumped together in a category
“Discomfort, inadvertent removal, migration or difficulty when removed” that
was seen in 8.4% of patients.
Have your fiscal
analysts take a look at your supply costs for vascular
access devices. Then add in an estimated cost for the time your nurses or other
healthcare professionals spend dealing with dislodged vascular access sites.
Now that you have everyone’s attention, do an audit of peripheral IV’s and PICC
lines (either specified consecutive cases or a “convenience” sample) so you can
determine rates of dislodgement and complications. Better yet, take one of
those unused customizable fields in your EMR and use it to record a reason for
every new IV insertion or change or removal. Make sure you readily identify the
risk factors in the Moureau, Marsh, and Wallis
papers. Then make sure you are using some of the techniques and best practices
in the Czajka and ECRI papers. And make review of
your vascular access device experiences a regular part of your quality
improvement program.
Some of our other columns on central venous
catheters and PICC lines:
January 21, 2014 “The
PICC Myth”
December 2014 “Surprise
Central Lines”
July 2015 “Reducing
Central Venous Catheter Use”
October 2015 “Michigan
Appropriateness Guide for Intravenous Catheters”
March 27, 2018 “PICC Use Persists”
References:
Moureau
N. Impact and Safety Associated with Accidental Dislodgement of Vascular Access
Devices: A Survey of Professions, Settings, and Devices. Journal of the
Association for Vascular Access 2018; 23(4): 203-215
https://www.sciencedirect.com/science/article/pii/S1552885518300734#!
Marsh N, Webster J,
Larsen E, et al. Observational Study of Peripheral Intravenous Catheter
Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral
Intravenous Catheter Failure. J Hosp
Med 2018; 13(2): 83-89. Published online first October 18, 2017
Tuffaha
HW, Rickard CM, Webster J, et al. Cost-effectiveness analysis of clinically
indicated versus routine replacement of peripheral intravenous catheters. Appl
Health Econ Health Policy 2014; 12(1): 51-58
https://link.springer.com/article/10.1007/s40258-013-0077-2
Wallis MC, McGrail
M, Webster J, et al. Risk factors for peripheral intravenous
catheter failure: a multivariate analysis of data from a randomized controlled
trial. Infect Control Hosp Epidemiol 2014; 35(1): 63-68
Czajka
C, Frey AM, Schears G. Vascular Access Device
Stabilization and Line Securement. Am Nurs
Today 2018; 13(12): 22-24
https://www.americannursetoday.com/vascular-access-device-stabilization-and-line-securement/
ECRI Institute PSO.
Device dislodgements: common but sometimes harmful event. PSO Navigator.
November 2018; 10[4]
https://www.ecri.org/components/PSOCore/Pages/PSONav1118.aspx
ECRI PSO staff
handout on device dislodgements
Krein
SI, Saint S, Trautner BW, et al. Patient-reported
complications related to peripherally inserted central catheters: a multicentre prospective cohort study. BMJ Qual Saf 2019; Published Online First: 25 January 2019
https://qualitysafety.bmj.com/content/early/2019/01/25/bmjqs-2018-008726
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