Peripheral intravenous catheter (PIVC) therapy has been paramount to medical science for more than 350 years.1 Peripheral intravenous catheters are needed for 60%–90% of all patients during hospitalization and the likelihood of PIVC failure is 35%–50% with common failures including infiltration, phlebitis, accidental removal, occlusion, and infection.2 Breaking the body's skin with a direct route to the circulatory system predisposes patients to life-threatening infections.3 Healthcare organizations must recognize the inherent risk of PIVCs, strategically intervene, and reduce preventable adverse events.4 The practice of routinely replacing PIVCs without clinical indication is not beneficial and every PIVC should be scrutinized for removal according to patient need.5 The Infusion Nursing Society recommends PIVC replacement when clinically indicated and does not put a specific time frame on the appropriate length of total PIVC dwell time.6 Further, it is recommended to remove any PIVC when no longer necessary to the plan of care or when the PIVC has not been utilized for 24 hours.6 The Centers for Disease Control and Prevention (CDC) recommends replacement of PIVCs every 72–96 hours.7 Some studies suggest that the incidence of phlebitis increases when PIVCs remain in a patient for longer than 96 hours, but the evidence is inconclusive.8,9 In order to decrease healthcare costs, eliminate an uncomfortable repeat venipuncture, and maximize nursing resources, studies suggest clinically indicated replacement of PIVCs as opposed to routine replacement.10-13 Meticulous care of PIVCs can decrease potentially harmful effects therein and literature is clear that scrutinizing the use of PIVCs is warranted.4,5 Also, routine replacement could very well be considered a “Thing We Do for No Reason.” A thorough review published in The Cochrane Library recommends policies for clinically indicated PIVC replacement as routine replacement does not appear to positively affect phlebitis and bacteremia rates.12
Although many studies recommend clinical indication to determine replacement of PIVCs compared to routine replacement, few describe efforts taken to reduce total dwell time. In the summer of 2015, a patient at a large tertiary-care hospital experienced an adverse event related to phlebitis. A seemingly harmless PIVC site became infected and developed into sepsis in an otherwise stable patient, prompting (our institution) to report a sentinel event to The Joint Commission. A multispecialty workgroup, facilitated by a quality/safety project manager, was formed to investigate PIVC practice and policy. A primary finding from the workgroup's review indicated that the hospital lacked a daily monitoring strategy for evaluating the clinical necessity for PIVCs, which were often left within patients until their time of discharge when removal was plausible hours or days earlier. Clinical nurses were assessing the PIVC site every 4 hours for signs of failure but were not routinely, proactively reviewing its necessity. A project charter was submitted to the hospital's Performance Improvement (PI) division in order to further review PIVC practice and establish early removal criteria for daily nursing assessment. Our institution utilizes CDC guidelines for routine replacement of PIVCs at 96 hours of dwell time as opposed to clinical indication.7 Routine replacement appears to be inferior to clinical replacement, which is replacing PIVCs once they have failed (i.e., upon infiltration).12
A literature search revealed multiple research articles describing the potential harm associated with PIVCs. The potential harm includes infiltration, pain, discomfort, phlebitis, sepsis, and the catheter breaking.2 Yet, a limited amount of articles mention any distinct, innovative approaches to proactively assess the necessity of use and potentially remove PIVCs sooner than the status quo. The chief recommendation of one particular article is to develop a nursing-based algorithm for establishing a saline-lock PIVC on an adult telemetry unit as patients rarely require immediate intravenous access for medication administration.14 The efforts taken at our institution determined if establishing defined criteria for PIVC use would decrease the amount of time a PIVC remained within a patient after becoming clinically unnecessary. The gap addressed in this study relates to the lack of current literature surrounding proactive approaches to decrease PIVC dwell time and increasing proactive removal. Therefore, this quality improvement project aims to proactively remove PIVCs as soon as possible by empowering nurses and providers to clinically evaluate the necessity of every PIVC on a daily basis.
The project idea was submitted to the Institutional Review Board (IRB) and deemed to be a quality improvement project related to organizational procedures and not subject to IRB approval. The project was deployed on a 60-bed general medical unit within a 629-bed medical center, a teaching affiliate of a college of medicine. The provider coverage consists of academic medical residents and employed hospitalists. Every adult patient over the age of 18 was subject to the scrutiny of daily PIVC necessity.
The project team was led by a PI Specialist project manager with subject matter experts from the hospitalist physician group, quality/safety, nursing, pharmacy, infection control, and nursing education. The subject matter experts on the team created a list of criteria, approved by medical staff, for PIVC usage for clinical nurses. A daily process for nurses was created to apply criteria for PIVC necessity, with follow-up contact to the attending provider for any PIVC not meeting criteria. The provider would either approve or disapprove of removing the PIVC. The nurse would then log the decision on a standardized paper workbook that included date, time, PIVC location, medical diagnosis, and provider information. The nurse would provide a reason if the provider did not approve of the PIVC's removal. Comprehensive education was provided for the pilot unit and its providers through department meetings, shift-change huddles, and electronic mail. The education consisted of the risks of PIVCs, a case study of an adverse PIVC event, an evaluation of current nursing processes, and an explanation of the pilot project and related changes. Importance was placed on addressing deeply held cultural beliefs regarding PIVCs prior to the start of the pilot; namely, patients require a PIVC to be considered the status of an inpatient and a PIVC is the critical, first-line intervention for cardiac arrest.15-17
The project leaders provided education and Q&A opportunities at several provider venues such as resident rounds and hospitalist department meetings prior to the start date. The misconception that a patient must have a PIVC to be deemed an “inpatient” was thoroughly addressed in the education and during the pilot. Inpatient status versus “outpatient” or “under observation” is determined by a privileged provider's order for inpatient hospitalization with corresponding orders for care. The specific orders, such as a PIVC, do not determine the admission status of a patient.15,16
Addressing the “just in case” fear was paramount to the project, as this fear could have been the most difficult bias to overcome considering the persuasive argument of a patient suddenly arresting and not having a PIVC for rapid medication administration. The “just in case” misconception was addressed through education from an organizational scholar who specializes in proper code response. Current guidelines support the notion that excellent chest compressions and early defibrillation are the most important immediate interventions during a code and supersede the importance of PIVC access.17 Overall, nurses and providers were open to discussion and change when the biases were addressed. Leading up to the start date, the project team gathered nursing input from executive leadership and the clinical nurses on the pilot unit. During the pilot, the project leaders would make weekly visits to the unit in order to collect input and answer questions from clinical nurses, unit-level leadership, and any providers that were present.
The new criteria for PIVC management was implemented on March 1, 2017, and evaluated monthly for 3 months. The same time frame (March, April, and May) of the previous calendar year (2016) was selected as an appropriate preintervention control group. The steps involved with applying the PIVC criteria for continued use were described in a process map (Figure 1). The nurse would utilize the following criteria to determine necessity of the PIVC:
- Does the patient currently have medication(s) prescribed where PIVC route of delivery is preferred and/or required?
- Does the patient have intravenous fluids actively infusing?
- Does the patient have a diagnostic or surgical procedure scheduled that requires intravenous access?
Data for all PIVCs removed on an adult general medical unit were extracted from the hospital's electronic medical record (EMR) for the 3-month period of March 1, 2017 to May 31, 2017 after implementing established criteria for PIVC management in adult patients. The same report was used for the same time period in the previous calendar year and served as the control group. Peripheral intravenous catheter records were grouped by patient admission in order to select the last PIVC the patient received before discharge. This was done to ensure that the PIVC was not removed and immediately replaced as part of routine maintenance. Dwell time was calculated as the time between the placement and removal times recorded in the EMR for each specific PIVC. If the PIVC was placed on another unit before the patient was transferred to the study unit, dwell time was calculated as the time between when the patient transferred onto the unit until the PIVC was removed. This was done to ensure we only captured dwell time that could be impacted by the interventional protocol.
Due to previous concerns that PIVCs were left in place until the moment of discharge, we compared the amount of time between PIVC removal and patient discharge. The amount of time between the removal of the patient's last PIVC and the time of discharge from the hospital was calculated and categorized based on the number of hours prior to discharge that the PIVC was removed. Four categories were constructed: within 24 hours, 24–47 hours, 48–71 hours and over 72 hours, and the proportion of patients that fell into each category was compared between the preintervention and postintervention time frames. The probability of a PIVC being removed at discharge was also compared between time frames while controlling for other variables.
Statistical analysis was conducted using the open source statistical program R (version 3.3.2). All statistical tests were performed against a two-sided alternative hypothesis with a significance level of 5% (α = 0.05). A p-value of <0.05 indicates statistical significance. Basic demographic information such as age, gender, and length of time (days) on the unit was collected. Mean age was compared between the preimplementation and postimplementation time frames using an independent samples t-test. The proportion of patients of each gender was compared using a chi-square test. The number of days on the unit was positively skewed and the median number of days on the unit was compared using a nonparametric Wilcoxon rank-sum test. Independent sample t-tests were used to determine if there was a statistically significant difference between the mean dwell times in the preintervention and postintervention time frames. A 2 × 4 chi-square test was used to determine if there was a difference in the proportion of PIVCs removed within 24 hours of discharge, within 24–47 hours of discharge, within 48–71 hours of discharge and more than 72 hours prior to discharge. Additionally, a 2 × 2 chi-square test was used to compare the proportion of patients from the pre- and post-time frames within each individual category. A logistic regression was used to determine the impact of the intervention on the probability of a PIVC being removed on the day of discharge while controlling for the amount of time on the unit.
Although the EMR was utilized to extract the data for statistical analysis, a project tracking log was also deployed on the unit. The nurses logged 138 PIVCs not meeting criteria for use and possible early removal. Of the 138 instances, there were 27 PIVCs in which a provider did not approve of removal and limited refusal information was written on the tracking log. The extracted data were specific to PIVCs, specifically placement and removal times; however, some patient variables were collected such as age, gender, and days on the unit. The descriptive statistics for these variables are presented in Table 1. Before the implementation of the new criteria, from March 1 to May 31, 2016, a total of 1,100 PIVs were removed on the general medical unit with a mean dwell time of 43.5 ± 34.1 hour. These PIVCs represent the last PIVCs removed from patients prior to discharge. After the implementation of the new criteria, from March 1 to May 31, 2017, a total of 790 PIVCs were removed with a mean dwell time of 41.8 ± 30.6 hours. The difference between mean dwell times was not statistically significant, t(1888) = 1.16, p = .25. Nonetheless, there was a significant shift between groups in how PIVC removals were distributed over categorized days before discharge (χ2 [df = 3, n = 1,890] = 64.2, p < .05). Figure 2 displays the proportions of PIVCs removed within 24 hours before discharge, between 24 and 47 hours, 48–71 hours and over 72 hours prior to discharge preimplementation and postimplementation of the new criteria. Significantly more PIVCs were removed within 24 hours of discharge prior to the new criteria (85.3%) compared to after the implementation (70.1%), χ2 (df = 1, n = 1,890) = 62.6, p < .05. After the implementation of the new criteria, significantly more PIVCs (12.5%) were removed between 24 and 47 hours before discharge compared to before (6.8%), χ2 (df = 1, n = 1,890) = 18.0, p < .05. In addition, more PIVCs were removed 48–71 hours (7.1%) and more than 72 hours (10.3%) prior to discharge after the implementation of the new criteria compared to before, 2.7% and 5.3%, respectively, χ2 (df = 1, n = 1,890) = 20.1, p < .05 and χ2 (df = 1, n = 1,890) = 16.7, p < .05.
A Wilcoxon rank-sum test found a significant difference in the number of days on the unit between the preintervention and postintervention time frames, with patients in the postintervention time frame having a higher median number of days on the unit (Table 1). Patients that were on the unit longer were also found to be less likely to have their PIVCs removed at discharge (OR = 0.68, β = –0.38, SE = 0.02, p < .05). However, the postcriteria implementation time frame was found to be significantly associated with a decreased likelihood of a PIVC being removed on the day of discharge after controlling for the number of days on the unit (OR = 0.52, β = –0.65, SE = 0.24, p < .05). This indicates that postcriteria patients were less likely to have their PIVCs removed on the day of discharge, independent of how many days they were on the unit (Figure 3).
The project was conducted on one medical unit in one hospital. The assumption is that patients prefer to have their PIVCs removed as soon as possible; however, patient input was not gathered. Retrospectively, the tracking log process could have been improved to ensure that capturing PIVCs not meeting criteria for use were acted upon. Clinical nurse discretion and remembering to call the provider was imperative to logging PIVCs that could have been removed early. At the same time, reliance on the EMR for data extraction allowed for more accurate analysis regarding the time of PIVC removal before discharge and overall dwell time as opposed to documentation on a paper tool.
The results indicate that more PIVCs were removed prior to the day of discharge and subsequently less were being removed on the day of discharge. We determined that early removal of PIVCs is possible with strategic criteria for use and addressing deeply held biases of the true need and value of a PIVC. In order to improve care, hospital leadership should thoroughly assess preconceived ideas of nurses and providers, utilize factual information to curb those biases, and educate pertinent staff before any implementation to decrease PIVC utilization.
Hospital leadership engagement and support was crucial in order to move forward with the study. It was vitally important to engage nursing leadership and clinical nurses from the beginning of the project as they were tasked to initiate the removal process. Moreover, as the approvers of PIVC removal, provider engagement was important for this initiative to be successful. The project team utilized change management by presenting at provider department meetings and specific nursing councils in order to discuss the project and alleviate any concerns. Nurse and provider collaboration was critical to remove unneeded invasive PIVCs similar to how urinary catheters and central venous catheters are evaluated for necessity. With newly established policy, PIVCs can be removed sooner, especially leading up to discharge. Decreasing the length of time a PIVC remains in a patient's vein likely reduces complication rates although this is an area for future research. The results of this project support the notion that clinical indication for the replacement of PIVCs is superior to the routine replacement model. Altering the PIVC assessment process with new criteria for use has the ability to positively change the number of PIVCs removed prior to patient discharge. Patients are less likely to have an unneeded PIVC in their vascular system when nurses and providers collaborate on a daily basis and proactively remove unneeded PIVCs.
The study did not assess if removing PIVCs sooner truly reduced the likelihood of complications (i.e., infiltration or phlebitis rates) and is an area of future research. Future research could examine patients' and healthcare providers' reactions to early removal of PIVCs. Furthermore, this information provides a platform for future research as to whether PIVCs are even necessary to insert in the first place as we did not assess whether the PIVCs being removed proactively were even warranted to begin with and utilized appropriately. Lastly, future work will need to address how to build workflow processes and organizational culture in order to maintain staff motivation to remove unnecessary PIVC's.
Strategically caring for patients with PIVCs is needed as PIVCs are common and invasive, breaking the body's natural defense against infection. Healthcare organizations should apply rigor and scrutiny to every PIVC and remove PIVCs that are not needed or being utilized. Hospitals should evaluate current PIVC practice and specifically review removal criteria. Peripheral intravenous catheters can be strategically removed with appropriate criteria for use and removal. The study supports hospitals updating policies that direct nurses and providers to scrutinize the use and dwell time of each PIVC. When caregivers are empowered with aligned strategy for earlier PIVC removal, hospitals are reducing the chance of a patient acquiring dangerous complications such as sepsis related to PIVCs.
A fringe benefit was noted during the weekly visits to the unit when numerous nurses stated that the new criteria and process actually improved their workflow and allowed them greater awareness of their patient's PIVCs. Nurse feedback indicated that removing PIVCs earlier allowed them to allocate more time to other care-related tasks. In many ways, PIVC strategy has lagged compared to central venous catheters and urinary catheter devices; therefore, applying the same scrutiny for use to the most common hospital procedure has many benefits for patients. Proactively removing PIVCs is possible with set criteria for use, keen participation, and buy-in from frontline nurses and providers. Strategic education for nurses and providers along with criteria for PIVC use can significantly impact the number of PIVCs being removed on the day of discharge and decrease their average dwell time.
The authors would like to acknowledge the leadership and staff from the Adult Medical Specialty Unit at OSF HealthCare Saint Francis Medical Center and the project team (Lori Grooms, Lisa Schuck, Bridget Mattson, Elaine Frye, Sheryl Emmerling, Cassandra Horack, Keara Wright, Emily Corona, Toufic Khairallah, Suzette Swanson, Dane Christ, Dr. Rachael Davis, Dr. Harshavardhan Tathireddy, and Sharie Metcalfe) whose cumulative efforts have made this work possible. Lastly, the authors thank Kristi Williams for providing publication mentorship.
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13. Tuffaha HW, Rickard CM, Webster J, et al. Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters
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Ryan A. Loudermilk, MHA, R.T.(R)(T), is a Performance Improvement Specialist at OSF HealthCare Saint Francis Medical Center in the Performance Improvement division, Peoria, IL. As a Performance Improvement Specialist, he facilitates quality improvement initiatives across the medical center. He was a Radiation Therapist and Physicist Assistant in Radiation Oncology for 13 years at OSF HealthCare prior to joining Performance Improvement.
Layne E. Steffen, MSN, RN, is a Safety Project Manager within the Quality/Safety division at OSF HealthCare Saint Francis Medical Center, Peoria, IL. Layne was a Performance Improvement Specialist prior to moving to the hospital's Quality/Safety division. Prior to project management, Layne was a registered nurse in the Emergency Department working as a Trauma Nurse Specialist and Certified Emergency Nurse.
Jeremy S. McGarvey, MS, is a Statistician within the Healthcare Analytics division of OSF Healthcare, Peoria, IL. Jeremy's work focuses primarily on the statistical analysis of clinical research data, as well as data related to performance improvement, quality improvement and business decision support projects.
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at www.nahq.org/journal/ce. This continuing education offering, JHQ  ([40.5 September/October 2018]), will provide 1 hour to those who complete it appropriately.
Core CPHQ Examination Content Area
IV. [Domain – Domain 4: Patient Safety].
Strategically Applying New Criteria for Use Improves Management of Peripheral Intravenous Catheters
- Describe the value, risks, and recommendations for removal of PIVCs
- Describe project management techniques used to improve PIVC care
- Identify potential benefits of a project to improve management of PIVCs
- 1. What is the estimated likelihood of a PIVC failure?
2. When does the Infusion Nursing Society recommend PIVC replacement?
3. What was the gap that was identified by the project team when reviewing current PIVC practice after reporting a sentinel event to The Joint Commission?
- 48 Hours
- 72 Hours
- 96 hours
- When clinically indicated
4. What potential harm is usually not associated with a PIVC?
- Nurses were not completing hand hygiene before PIVC insertion
- The hospital failed to discharge patients in a timely manner
- The hospital lacked a daily monitoring strategy for evaluating clinical necessity of PIVCs
- Antibiotics were not being ordered for thrombophlebitis
5. What bias was the most difficult and important to overcome for the project team?
6. As a result of the interventions instituted in this project, what percentage of PIVCs were removed within 24–47 hours of discharge postimplementation of criteria?
- Patients need a PIVC “just in case”
- Inpatients must have a PIVC
- PIVCs are required for billing
- Pain medication given through PIVC
7. What other variable was found to be significantly different between groups and contributed to the likelihood of the PIVC being removed on the day of discharge?
8. What chief insight did the project identify and should be explored further by other acute care facilities?
- Age of patient
- Gender of patient
- Days on the unit
- Weight of patient
9. What were the limitations that were identified in this project?
- Patients should have a PIVC in order to best prepare for cardiac arrest
- Early removal of PIVCs is possible with strategic criteria for use and addressing deeply held biases of the true need and value of a PIVC
- PIVCs can cause a serious infection leading to death and should be reported to governing bodies for root cause analysis and process improvement
- Improving nurse and physician relationships can improve the overall nursing quality outcomes metrics
10. Which unexpected benefit was noted during weekly visits to the unit?
- Project was conducted on one medical unit in one hospital
- Patient input was not gathered
- Tracking log process could have been improved
- All of the above
- Nurses stated that the new criteria and process improved their workflow
- Patients preferred their pain medications orally
- Patients' total length of stay decreased
- Patient complaints decreased during the pilot study
Keywords:© 2018 National Association for Healthcare Quality
peripheral intravenous catheters; criteria for removal; IV necessity; and proactive removal