Clinical practice guidelines (CPGs) are tools that support the delivery of high-quality, evidence-based nursing care and, more broadly, are the basis for achieving the Institute of Medicine's 6 aims of quality health care.1,2 Developed to accelerate the translation of research into practice, CPGs contain recommendations intended to improve clinical decision-making and to optimize patient care.3 A trustworthy CPG is explicitly informed by a systematic review of the scientific literature and updated when new evidence demonstrates that current practice no longer adds value to patient care and may even be harmful.3,4
Integrating updated CPGs into nurses' established and everyday practice, however, is a complex process influenced by clinician, guideline, system, and implementation characteristics, and hindered by numerous barriers.5 Tests of a practice change using a systematic quality improvement (QI) approach build knowledge sequentially and ultimately can facilitate implementation of new guidelines into nursing practice.6,7 With the need to test a change before full implementation, a QI project, guided by Lean principles, was undertaken to test a CPG for replacing peripheral intravenous catheters (PIVCs) on a medical unit at a community hospital.
Specifically, we investigated how updating our current practice of routinely replacing PIVCs with the most recent evidence-based CPG for clinically indicated PIVC replacement8 would impact the quality of patient care, patient safety, and nurses' workflow. Care provided for patients should be evidence-based; however, evidence-based practice (EBP) includes not only the best evidence and clinician expertise, but also patient preferences and concerns.1 Thus, we reviewed the unit's Press Ganey patient surveys and found comments from patients about their negative experiences with PIVC insertions (eg, “a great deal of pain” and “multiple attempts”). Patients' discomfort and distress further coalesced staff nurses, nurse managers, and nursing administrators to prioritize a shared goal of updating the current PIVC replacement practice to comply with the new guideline.
PIVCs are frequently used venous access devices in hospitals. Compared to central venous access devices (CVADs), PIVCs are more easily placed and have fewer insertion complications.9 In the United States, 330 million PIVCs are used annually for treatments such as anti-infective therapy, hydration, blood administration, and pain management.10,11 Although PIVCs have fewer insertion complications than CVADs, the risks of PIVCs to patients include discomfort and pain from insertion, phlebitis, and catheter-related bloodstream infections (CRBSIs).12,13
A persistent question in the management of PIVCs has been how often to replace functioning PIVCs to prevent the primary complications of phlebitis and CRBSIs in hospitalized adults. In 2011, the Centers for Disease Control and Prevention (CDC)14 recommended that peripheral catheters do not need to be changed more frequently than 72 to 96 hours. This recommendation was based on Category 1B evidence (ie, strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies), reported in 2 observational studies15,16 and 1 randomized controlled trial (RCT).17 Lacking sufficient evidence to recommend clinically-indicated PIVC replacement, the CDC recommendation was commonly interpreted in hospital policy as requiring functional PIVCs to be replaced every 72 to 96 hours.
As further research was conducted8 and more advanced methods were used to develop CPGs,4 PIVC replacement recommendations were updated. In 2015, Webster and colleagues8 conducted a systematic review for the Cochrane database with 7 RCTs that compared routine and clinically indicated replacement of PIVCs. The quality of the evidence was rated as high for most outcomes and moderate for CRBSIs. No differences were found in PIVC-related CRBSI, phlebitis, local infections, or catheter occlusions between the 2 groups. Routinely replacing PIVCs every 72 to 96 hours was not supported by the evidence, which led reviewers to recommend changing PIVCs only when clinically indicated, rather than routinely.8 The Cochrane review was updated in 2019 with 2 new trials, for a total of 9 RCTs.18 The findings were the same as the earlier analysis; no difference was found in the occurrence of complications between routine replacement of PIVCs and clinically indicated replacement. Morrison and Holt19 reached the same conclusion based on their systematic review with 4 RCTs and 2 meta-analyses.
In addition to ensuring patient safety when updating CPGs, it also is important to consider the value associated with changing nursing practice. Results from a cost-effective analysis conducted in public hospitals in Queensland, Australia, and converted to US equivalents,20 demonstrated that clinically indicated PIVC replacement would spare patients from undergoing 2.5 million unnecessary PIVC insertions annually and save 1 million hours of staff time. Over 5 years, health costs would be reduced by an estimated $400 million.
Translating this expanding body of high-quality research into a test of change at our hospital would address a knowledge and practice gap in PIVC replacement that could ensure patients' received care based on the latest, best evidence.21 The objectives of this QI project were to (1) conduct a small test of the updated CPG to replace PIVCs when clinically indicated and evaluate the impact of the change on: reducing routine PIVC replacements; reducing unnecessary, painful PIVC insertions; and improving nurses' workflow; (2) maintain patient safety by closely monitoring and assessing the occurrence of phlebitis and CRBSIs throughout the test of clinically indicated PIVC replacement to ensure complication rates do not increase; and (3) evaluate staff nurses' perceptions of the clinically indicated PIVC replacement guideline related to their practice and the quality of patient care.
The QI basis for this project was the Lean approach, which has previously been integrated into EBP projects to achieve targeted quality, safety, and financial outcomes.22 At its core, Lean is a way of thinking about work that leverages employee knowledge and experience to identify and eliminate waste from processes that do not add value to patient care (J. Lanphere, e-mail communication, May 13, 2019). Lean also enhances problem-solving; it complements the goals of improving the quality of patient care.
We used Lean change concepts and tools to assess patient concerns about PIVC replacement and to deepen our understanding of the process by conducting a stakeholder analysis. Creating a high-level flowchart and value stream map clarified value-added and wasted steps in the PIVC replacement process. A comprehensive data collection and project implementation plan was developed and used to record daily PIVC insertion and removal activity. To assess whether the change was an improvement, basic statistical analyses were conducted and graphical displays were used to compare baseline and test data.
The setting for testing the clinically indicated PIVC replacement guideline was a general medical unit at a 261-bed community hospital affiliated with an academic medical center in the Northeast. Over 2000 patients were admitted to the 38-bed unit annually. Specific patient populations included those with cystic fibrosis, stroke, sickle cell anemia, alcohol withdrawal, and cancer.
A clinical microsystem assessment highlighted the critical features of the unit that were needed for testing the practice change. More than 94% of patients admitted to the unit had one or more PIVCs inserted during hospitalization, which provided a sufficient population to address the project objectives. Routine replacement of PIVCs every 72 to 96 hours was a well-established practice on the unit, a necessary condition for observing and assessing the clinically indicated PIVC replacement process change. When patients had limited venous access, PIVCs could be extended for additional consecutive 24-hour periods with a provider (ie, physician, nurse practitioner, and physician assistant) order. Nurses would independently manage the clinically indicated PIVC replacement process; thus, eliminating this step was an opportunity to improve the efficiency of nurses' workflow. A detailed analysis of the process waste associated with the current practice included 14% (14/102) of PIVCs extended for 24 hours by provider order, and 5% (5/102) of PIVCs replaced routinely at 96 hours. These findings simultaneously demonstrated the waste associated with routinely replacing PIVCs and the potential to improve performance with the updated CPG recommendation.
Testing the implementation of clinically indicated PIVC replacement consisted of 4 main components: establishing a QI team; developing a provisional PIVC replacement policy; creating staff education materials, recruiting project champions, and presenting in-services; and developing a communication plan. In addition to the QI team leader, who was a clinical nurse leader (CNL), the other team members included an infectious disease specialist, a nursing administrator, and a nursing faculty member. Because this project involved only one medical unit, a provisional policy for replacing PIVCs when clinically indicated was developed and approved by the hospital nursing standards committee, nursing administrator, unit nurse manager, and medical director.
A new workflow process was designed, and teaching materials and in-services were developed and presented to the unit nursing staff. A poster board was created as a resource for staff that included detailed information about the CPG recommendations for clinically indicated PIVC replacement. Additional content was provided about patient exception criteria, PIVC insertions using sterile technique, CDC's catheter selection guidelines,14 signs and symptoms of PIVC complications, Infusion Nurses Society phlebitis scale,23 electronic medical record (EMR) documentation of nurses' PIVC assessment and removal indications, and the test of change timeline.
Three unit champions were recruited—a nursing staff member, assistant nurse manager, and unit nurse educator—to present in-service sessions at different dates and times over 2 weeks to discuss the guideline test with the nursing staff and to review PIVC best practices. Each in-service session lasted approximately 20 minutes. The QI team leader and champions also met with the unit nursing staff 1 week following the implementation of the updated guidelines to review the PIVC change policy and answer questions. Forty-nine of 52 nurses participated in the in-service sessions.
To keep all stakeholders informed during the test of change, the QI team leader communicated with nurses through e-mails, presented at the unit council meetings, and attended daily safety huddles. She also provided project status updates during monthly unit quality meetings, which were attended by the unit medical director, nurse manager, and quality coordinator.
Design and measures
Using a pretest-posttest design, baseline data were collected from October 3, 2017, to November 3, 2017. Nurses then managed patients' PIVCs according to the updated CPG of clinically indicated PIVC replacement for 3 months from November 15, 2017, to February 15, 2018. Patients with CVADs in place for infusions were excluded from the test.
Three types of measures were collected to evaluate the impact of clinically indicated PIVC replacement (Table 1). Process measures to assess the impact of the updated CPG (objective 1) included provider orders to extend PIVCs for 24 hours and clinical indication for PIVC removal. The outcome measures were rates of routine and clinically indicated PIVC replacements and PIVC dwell time. Consistent with the systematic reviews, the incidence of phlebitis and CRBSIs complications (objective 2) were used as balancing measures. Evaluating staff nurses' perceptions of the clinically indicated PIVC replacement guideline (objective 3) focused on their views about nurses' role in decision-making about when to replace PIVCs, competence in assessing the clinical indications for removing PIVCs, eliminating the provider order to extend a PIVC for 24 hours, and the impact of clinically indicated PIVC replacement on the quality of patient care. This test of change initiative was determined to be QI and did not require research subject review board review.
Data were extracted from several sources and recorded on a master PIVC tracking log. Patient information and PIVC management activities (eg, dates initiated, replaced, and removed) were collected from the EMR. Monitoring for signs and symptoms of phlebitis and CRBSI complications included recording patients' body temperatures daily during hospitalization and for 72 hours post-PIVC removal, or until discharge. Blood culture results from laboratory reports were also reviewed and logged for patients with a sudden fever greater than 38°C.
Nurses' perceptions of clinically indicated PIVC replacement were collected using a survey developed by the QI team leader based on the Human Performance Improvement Technology model.24 The survey contained 10 pretest questions and 12 posttest questions. The 2 additional posttest questions were written to elicit nurses' views of the guideline after using it during the test. Survey responses were measured on a 5-point Likert scale, ranging from strongly disagree to strongly agree. The survey was administered online 30 days before and 2 months after the small test of change.
Descriptive statistics were used to compare PIVC management activities pretest and posttest. Mean proportions and the corresponding standard deviations (SDs) were calculated. Catheter dwell time was calculated by subtracting PIVC insertion date from PIVC removal date. We used logistic regression to model the impact of catheter dwell days on routine PIVC removal. Furthermore, a mid-p exact test was applied in comparing complication rates between phlebitis groups at a 2-tailed .05 significance level. The Likert-scale items on the survey were summed and proportions of responses in each category were compared to detect differences in nurses' perceptions of clinically indicated replacement on pre- and posttest measures. As the surveys were administered anonymously, the responses were not matched to the nurse. Analyses were conducted using SAS, version 9.4 (SAS Institute, Inc, Cary, North Carolina) and Open Epi software.25
During the 3-month testing period, 469 admitted patients received a total of 1033 PIVCs, compared with the shorter 1-month pretest period of 184 patients receiving 449 PIVCs. To evaluate objective 1, corresponding to assessing the impact of clinically indicated PIVC replacement on the quality of patient care and workflow, we first determined that zero provider orders were obtained to extend PIVCs 24 hours. We then analyzed the clinical indications for removing PIVCs in place for more than 96 hours in both groups and found differences (χ2 = 110.10, df = 6, P < .001). Supplemental Digital Content, Figure 1, available at: http://links.lww.com/JNCQ/A629, shows that during the test, 47% of PIVCs were removed because the course of treatment was completed compared with only 28% of the PIVCs replaced routinely prior to the test. Related to this finding, PIVCs removed routinely fell from 32% pretest to 4% posttest. In addition, Supplemental Digital Content, Figure 2, available at: http://links.lww.com/JNCQ/A630, shows that increases in catheter dwell days resulted in significantly reducing routine PIVC replacements on average from 34% (n = 24) pretest to 3% (n = 5) posttest (P < .001). Overall, PIVC dwell time during the test for patients hospitalized for 4 or more days ranged from 4 to 20 days (mean = 7.4, SD = 2.1).
The close monitoring and assessment of patients for complications that might be associated with clinically indicated PIVC replacement corresponds to objective 2. Only one CRBSI was observed, occurring within the first 72 hours of placement of a PIVC in the pretest period. No cases occurred during the testing period. Table 2 shows that the phlebitis rate posttest was 2.9% (30/1033), a slight increase from 2.2% (10/449) pretest, but the difference was not statistically significant (P = .47). In the subset of PIVCs in place greater than 96 hours in both groups, there was also no difference in phlebitis rates (1.3% vs 3.4%, P = .41). Furthermore, phlebitis rates did not differ for PIVCs inserted for less than 96 hours and more than 96 hours during the test (2.8% vs 3.4%, P = .65).
Corresponding to objective 3 to assess nurses' perceptions of clinically indicate PIVC replacement, 35 nurses pretest and 36 nurses posttest completed surveys for a response rate of 67% and 69%, respectively. There was no change from pretest (94%) to posttest (97%) in the majority of nurses believing that PIVC management decisions should be based on nursing judgment, t(69) = −0.94, P = .35. There was also no change from pretest (96%) to posttest (97%) in the majority of nurses' feeling competent to assess the clinical indications for removing PIVCs, t(69) = −0.43, P = .66. These findings suggest that nurses regarded PIVC management to be within their scope of practice and felt prepared to implement the guidelines.
An interesting change found in the survey was that 89% of nurses posttest, compared to 60% of nurses pretest, viewed the policy requiring a provider order to extend PIVCs 24 hours to be wasted effort for both nurses and providers, t(69) = −2.50, P = .01. Perhaps nurses may not fully appreciate routinized waste until they actually experience an improvement change. In addition, nurses overwhelming agreed (94%) that replacing PIVCs when clinically indicated had a positive impact on the quality of care.
Two unanticipated issues occurred during the test. One patient in the pretest group developed a CRBSI with thrombophlebitis. A second patient during the test developed a PIVC-related partial thrombus on the seventh day of insertion. The common factor in both cases was the PIVC inserted in the antecubital (AC) fossa, which is known to be associated with a higher risk of deep vein thrombosis or mechanical phlebitis.23,26 Thus, PIVC insertion in the AC fossa should be carefully considered and avoided if possible.
The second issue related to PIVC management activities involved changing PIVC dressings every 7 days based on the Infusion Nurses Society recommendations.23 During the daily PIVC observation checks, we realized the nurses were missing the dressing changes, as the required change did not appear on the daily EMR worklist. The nurses were alerted to the situation and monitored dressing changes closely. Longer term, a revision to the EMR could be made to capture the dressing changes on the nurses' worklist.
Advances in PIVC research increased the trustworthiness of an evidence-based CPG and as a result synergized improvements in the quality of patient care, patient safety, and nurses' workflow on the unit. Adopting the updated CPG of clinically indicated PIVC replacement extended catheter dwell time and correspondingly reduced routine replacements and patients' exposure to unnecessary, painful PIVC insertions, without increasing complications. In addition, nurses reported that clinically indicated PIVC replacement had a positive impact on the quality of patient care. These results are consistent with recent systematic reviews that clinically indicated PIVC replacement can safely be implemented in hospitalized adult populations.8,18,19 Furthermore, consistent with the Lean principle of improving performance by minimizing waste,6 eliminating the step of obtaining a provider order to extend a functioning PIVC for 24 hours gave nurses control over managing PIVC replacement and enabled them to practice to a fuller extent of their education and experience.27
A limitation of this QI initiative is that the results of the test of change may not be generalizable to other units due to differences in setting, resources, teamwork, and access to experts. Also, patients—who are key stakeholders in the approach to PIVC replacement—were not directly involved in the test of change. Incorporating patient-reported outcomes into future initiatives would improve planning and decision-making by providing measures of the quality of PIVC replacement and nursing practice from the patients' perspectives.
The strengths of this study included the CNL leading the QI team and managing all details of the testing. Another strength was collaboration among nursing administration and nursing staff and interprofessionally with providers and content experts in infection prevention. We found that when team members across the professions and at all levels of the organization collaborate to improve care delivery processes, they play a critical role in facilitating the change process.
The QI team's test of change was successful, and they were subsequently, involved in implementing clinically indicated PIVC replacement hospital-wide throughout the other adult inpatient units. The nursing policy was updated to clarify that PIVCs in the AC fossa should be avoided if possible and carefully monitored for clinically indicated replacement. The EMR support team is adding PIVC dressing changes to the daily worklist and building in data tracking of PIVC complications. Another hospital affiliate of the academic medical center has begun efforts to implement clinically indicated PIVC guidelines. Overall, the systematic approach used in this QI project, starting with the clinical microsystem assessment and a small test of change, then progressing to implementation hospital-wide highlights and advances the role of the CNL in transforming health care.
1. Melnyk BM, Fineout-Overholt E, eds. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
3. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011.
4. Shekelle P, Woolf S, Grimshaw JM, Schünemann HJ, Eccles MP. Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines; updating guidelines; and the merging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development. Implement Sci. 2012;7:62. doi:org/10.1186/1748-5908-7-62.
5. Gurses AP, Marsteller JA, Ozok AA, Xiao Y, Owens S, Pronovost PJ. Using an interdisciplinary approach to identify factors that affect clinicians' compliance with evidence-based guidelines. Crit Care Med. 2010;38(suppl 8):S282–S291.
6. Scoville R, Little K. Comparing Lean and quality improvement: IHI white paper. http://www.ihi.org/resources/Pages/IHIWhitePapers/ComparingLeanandQualityImprovement.aspx
. Published 2014. Accessed August 12, 2015.
7. Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass; 1996.
8. Webster J, Osborne S, Rickard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2015(8):Cd007798. doi:10.1002/14651858.CD007798.pub4.
9. Washington GT, Barrett R. Peripheral phlebitis
: a point-prevalence study. J Infus Nurs. 2012;35(4):252–258.
10. Hadaway L. Short peripheral intravenous catheters and infections. J Infus Nurs. 2012;35(4):230–240.
11. Ansel B, Boyce M, Embree JL. Extending short peripheral catheter dwell time: a best practice discussion. J Infus Nurs. 2017;40(3):143–146.
12. Pien BC, Sundaram P, Raoof N, et al The clinical and prognostic importance of positive blood cultures in adults. Am J Med. 2010;123(9):819–828.
13. Gorski LA, Hallock D, Kuehn SC, Morris P, Russell JM, Skala LC. Recommendations for frequency of assessment of the short peripheral catheter site. J Infus Nurs. 2012;35(5):290–292.
14. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
. Published 2011. Accessed May 20, 2017.
15. Tager IB, Ginsberg MB, Ellis SE, et al An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J Epidemiol. 1983;118(6):839–851.
16. Lai KK. Safety of prolonging peripheral cannula and IV tubing use from 72 hours to 96 hours. Am J Infect Control. 1998;26(1):66–70.
17. Maki DG, Ringer M. Risk factors for infusion-related phlebitis
with small peripheral venous catheters: a randomized controlled trial. Ann Intern Med. 1991;114(10):845–854.
18. Webster J, Osborne S, Rickard CM, Marsh N. Clinically‐indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2019;1:Cd007798. doi:10.1002/14651858.CD007798.pub5.
19. Morrison K, Holt KE. The effectiveness of clinically indicated replacement of peripheral intravenous catheters: an evidence review with implication for clinical practice. Worldviews Evid Based Nurs. 2015;12(4):187–198.
20. 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.
21. Kilo CM. Improving care through collaboration. Pediatrics. 1999;103(1):384–393.
22. Halm MA, Alway A, Bunn S, et al Intersecting evidence-based practice with a Lean improvement model. J Nurs Care Qual. 2018;33(4):309–315.
23. Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S54–S96.
24. Dessinger JC, Moseley JL, Van Tiem DM. Performance improvement/HPT model: guiding the process. Perf Improv. 2012;51(3):10–17.
25. OpenEpi. Open source epidemiologic statistics for public health. Version 3.01 (Computer software). http://www.openepi.com/Menu/OE_Menu.htm
. Updated 2013. Accessed April 5, 2018.
26. Lavery I. Infection control in IV therapy: a review of the chain of infection. Br J Nurs. 2010:19(19):S6–S14.
27. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.