The peripheral intravenous (PIV) catheter is the most common invasive device used in the hospital setting (Washington & Barrett, 2012). The placement of “two large-bore PIV catheters” is standard practice during the primary trauma survey per Advanced Trauma Life Support guidelines (American College of Surgeons, 2012, p. 11). As with any invasive device, the presence of a PIV catheter may predispose the patient to the possibility of infection, and longer catheter dwell times may increase the infection risk. The Centers for Disease Control and Prevention (CDC) recommends replacing PIV catheters every 72–96 hr in adults to decrease the chance of phlebitis and infection and replacement by 48 hr for PIV catheters placed in “emergency conditions” (CDC, 2011). A Cochrane review, most recently updated in 2015, recommends that PIV catheters be changed only for clinical indications versus at prescribed dwell times (Webster, Osborne, Rickard, & New, 2015). Clinical indications are described as blockage, infiltration, local infection, phlebitis, redness, tenderness, and swelling. The studies informing the Cochrane meta-analysis included a landmark multicenter, randomized controlled trial of 3,283 subjects (Rickard et al., 2012). Patients in this trial were randomized to routine PIV catheter replacement at 3 days versus PIV catheter replacement only when clinically indicated. No difference in phlebitis or infection rates was found between the two groups. Of note, the studies in the Cochrane review excluded, or did not mention, PIV catheters started in the field.
Sterility may be difficult to maintain when starting PIV catheters in the field due to challenging conditions such as inclement weather, poor lighting, or a dirty or hostile environment. For trauma patients, the risk of infection may be higher because these patients may become immunocompromised related to the inflammation injury initiated by significant trauma (Keel & Trentz, 2005). Geriatric patients, in particular, may be unable to mount a vigorous response to an invading pathogen, may have a fragile vasculature due to medications or preexisting conditions, and may be at an increased risk for cognitive or sensory deficits limiting awareness of early PIV catheter compromise, thus leaving them more vulnerable to infection. A position paper by the Infusion Nurses Society notes, “For the older adult, even small infiltrates can lead to serious complications” (Gorski et al., 2012, p. 291).
Optimal replacement time for PIV catheters started in the field is unclear, including for geriatric trauma patients. The purpose of this study was to evaluate dwell time for PIV catheters placed in the field for geriatric blunt trauma patients with the goal of contributing evidence to support best practice. The research question is “For PIV catheters started in the field for geriatric blunt trauma patients, is a dwell time of greater than 2 days more strongly associated with indicators of infection than a dwell time of 2 days or less?
The study consisted of a retrospective case series conducted at the state-designated trauma referral center, currently granted Level I designation by the American College of Surgeons. During the study period, from January 14, 2008 to March 1, 2015, this trauma center maintained Level II designation and admitted approximately 1,500–2,500 trauma patients per year. Activated trauma team patients with blunt mechanism were eligible for this study if they were 65 years or older and if admitted from the field for more than 7 days with documentation of a PIV catheter placed prehospital. Potentially eligible patients were excluded if referred from another hospital, or if the trauma team was not activated prior to the patient's arrival. The Trauma Registry and CARE*Link electronic medical records were queried for data consisting of demographics, trauma characteristics and injury data, vital signs, Glasgow Coma Scale (GCS), laboratory work, blood transfusion data, disposition, and PIV catheter data.
The Quick Sequential Organ Failure Assessment (qSOFA) score, abnormal white blood cell (WBC) count, and presence of fever were used to describe signs of infection and were evaluated the day before, the day of, and the day after the field PIV catheter removal. Abnormal WBC count was defined as a WBC value less than 4,000 × 103/μL or greater than 12,000 × 103/μL. Fever was defined as temperature of more than 38.3 °C. The qSOFA score is a risk stratification screening tool for sepsis supported by the Surviving Sepsis Campaign (Singer et al., 2016). Studies have shown qSOFA to be more robust than an earlier recommended screening tool: the systemic inflammatory response syndrome (SIRS) score (Freund et al., 2017). A “positive qSOFA score should prompt consideration of possible infection in patients not previously recognized as infected” (Singer et al., 2016, p. 806). The qSOFA score consists of three variables: altered mental status (GCS score ≤13), respiratory rate 22 or more, and systolic blood pressure 100 mmHg or less. The variables must be collected at the same time. The qSOFA score is positive if two of the three variables are present. The components used to describe signs of infection for this study are presented in Table 1. The components of the SIRS score are also listed for comparison. For the purpose of this study, for intubated patients, GCS score of 9 or less was used as the altered mental status variable, accounting for the verbal component of the GCS for intubated patients typically scored as “1.”
Based on power calculation analysis, the enrollment goal was set at 145 subjects. The qSOFA score, WBC count, and the patient's temperature were analyzed in relation to the field-initiated PIV catheter dwell time. Pearson χ2 and Fisher's exact test were used for data analysis, with statistical significance set at p ≤ .05. The Research Institutional Review Committee approved the study, granting waiver of informed consent.
Requirements for inclusion were initially met by 197 subjects. Forty-seven subjects were later excluded because of missing data, leaving 150 subjects eligible for data analysis. Demographic data are presented in Table 2. Of note, more than half of the cohort was older than 75 years, and Asian ethnicity accounted for two thirds of the study population. Falls (56 subjects; 37%), motor vehicle collisions (47 subjects; 31%), and struck pedestrians (41 subjects; 27%) accounted for 95% of the injury mechanism. Total PIV catheter dwell time was 2 days or less for 42 (28%) and more than 2 days for 108 (72%) of the 150 study subjects. The majority of the PIV catheters initiated in the field were size 18 gauge (62%) and placed antecubital (49%). The two dwell time groups were well matched when compared for mortality and indicators of injury severity, as demonstrated in Table 3. Table 4 shows the results of the comparison of the two dwell time groups with the indicators of infection. For dwell time of 2 days or less, 55% of the subjects were positive for qSOFA, but at the longer dwell time of more than 2 days, the percentage of subjects positive for qSOFA was only 37%. A smaller proportion of subjects scored positive for qSOFA despite the longer dwell time. This negative association of longer dwell time with the percentage of positive qSOFA scores was statistically significant (p = .005). Similar results were found for the other indicators of infection, abnormal WBC count and presence of fever. For dwell time of 2 days or less, 67% of subjects had an abnormal WBC count, but at dwell time of more than 2 days, the proportion of subjects with an abnormal WBC count had fallen to 49%. (In the abnormal WBC count group, four subjects had missing data.) A fever was demonstrated by 41% of subjects with dwell time of 2 days or less, whereas only 18% of subjects with dwell time of more than 2 days were positive for fever. A smaller proportion of subjects were positive for both abnormal WBC count and presence of fever despite the longer dwell time of more than 2 days. This negative association with length of dwell time was statistically significant for the presence of fever (p = .003) and approached statistical significance for abnormal WBC count (p = .05).
The reason for the removal of the field-start PIV catheters was recorded in 104 of the 150 study subjects. For this subset, 26 (25%) of the study PIV catheters were removed by dislodgement, four (4%) were removed because of occlusion, and 26 (25%) were removed for nonclinical reasons: “therapy completed,” “change of device,” “intravenous catheter outdated,” or “patient transferred, discharged, or died.” Field-start PIV catheters were discontinued because of infiltration, inflammation, or pain in 48 (46%) of the study subjects. Although the number in this subset is small, the more than 2-day dwell time group when compared with the 2-day-or-less dwell time group also had a negative association for a positive qSOFA score and presence of fever but not with abnormal WBC count (Table 5). Blood culture data for up to 48 hr after field-start PIV catheter discontinuation were collected for this subset. Blood culture results were documented in 15 of these 48 subjects and were not documented in the remaining 33 subjects. Two positive blood cultures were obtained, both in the longer dwell time group of more than 2 days.
Little recent research concerning field-start PIV catheter dwell time and development of complications for trauma patients, or geriatric patients, has been done. Two single-center investigations researched field-start PIV catheters for the trauma population, with an average subject age of 46–47 years. In a prospective, descriptive study of 432 patients, Zarate, Mandleco, Wilshaw, and Raver (2008) evaluated the rate of phlebitis for field-start PIV catheters versus for PIV catheters started in the emergency department. No significant difference in the rate of phlebitis was found. The mean time to signs of phlebitis was 3.14 days. Clemen et al. (2012) measured compliance to trauma service and hospital protocols for replacement of PIV catheters initiated prehospital. These investigators reported an overall complication rate of less than 1% for PIV catheters started in the field. Compliance for replacement of field-initiated PIV catheters by 24 hr was 66.4%. Garrett, Drake, and Holcolmb (2017) also addressed the replacement of field-initiated PIV catheters by 24 hr for trauma patients. They described a process improvement project, developed after noting seven limb-threatening complications requiring surgical treatment over a 5-month period associated with PIV catheters placed in the field, with some related to infection (number not reported). Using FOCUS–Plan-Do-Check-Act methodology (Bader, Palmer, Stalcup, & Shaver, 2003), documentation of field PIV catheter site change improved from 62% to 95%, with PIV catheter-associated complications falling to zero for 39 consecutive months.
Previous studies describe low rates of bloodstream infections (BSIs) related to PIV catheters. Rickard et al. (2012) reported nine BSIs per 1,690 patients (0.05%) for routinely replaced PIV catheters and four BSIs per 1,593 patients (0.02%) for PIV catheters replaced for clinical indications. The Cochrane review (Webster et al., 2015) concluded that no association of phlebitis and PIV catheter-related infection was demonstrated in the meta-analysis and that phlebitis may be caused by the PIV catheter insertion technique, the catheter size, or by administered medications. The Cochrane review (Webster et al., 2015) also noted no difference in infection rates for PIV catheters replaced at 72–96 hr versus those replaced for clinical indications (p = .64). Although the reported number of PIV catheter-related BSIs is low, this may actually be an important problem due to the large number of PIV catheters inserted during routine patient care (Stuart et al., 2013). Reporting of infection rates associated with vascular access devices has focused on central catheters, so infections related to PIV catheters may be underreported (Hadaway, 2012). Capdevila et al. (2016) note that “...catheter-related bacteremia may develop without any suspicion that the catheter may be the cause” (p. 233). Stuart et al. (2013) investigated 137 patients diagnosed with Staphylococcus aureus bacteremia to look for PIV catheter-associated risk factors. Results showed PIV catheter-associated bacteremia of 23.5%, including 20.8% associated with field starts and 45.2% associated with dwell time of 4 days or more. The subjects were older (mean age = 71 years). Stuart et al. (2013) recommend routine replacement of PIV catheters, rather than replacement only for clinical indications, in contrast to the Rickard et al. (2012) multicenter, randomized controlled trial and the Cochrane review (Webster et al., 2015) described earlier. Consistent with the findings of Rickard et al. (2012) and the Cochrane review (Webster et al., 2015), our study results suggest that routine replacement of field-start PIV catheters at a dwell time of 2 days or less may not be necessary, as dwell time of more than 2 days was not associated with an increase of infection indicators.
Advantages of longer dwell times and less frequent restarts are several, as discussed in previous studies, provided longer dwell time does not compromise patient safety. Patient comfort and satisfaction may be increased because of the need for fewer needlesticks. Every PIV catheter insertion creates a new pathway for potential pathogen access to the bloodstream, so decreasing the amount of PIV catheter restarts could potentially lessen the risk of infection (Ansel, Boyce, & Embree, 2017). Longer time to PIV catheter replacement may also have the advantage of reducing nursing tasks along with costs. Using the database from Rickard et al.'s (2012) study, Tuffaha et al. (2014) identified a projected cost savings of U.S. $3.5–$4 million over 5 years if PIV catheters were replaced only for clinical indications versus routinely at 3 days.
Several limitations must be mentioned concerning this study. The data were collected from a single center, so the results may not apply to other centers. Because the study design is retrospective, there was no control for the variables used to calculate the qSOFA score or for the collection of blood cultures to better qualify the presence of infection related to the field-start PIV catheter. Documentation was missing for some study data points, such as the reason for intravenous discontinuation. The qSOFA score used for infection screening is less robust for the included subjects who were intubated. Enrollment took place over a 7-year period, so practice changes may have occurred that influenced the analysis results.
For this study, PIV catheter dwell time of more than 2 days for field-start PIV catheters for geriatric blunt trauma patients had a statistically significant negative association with signs of infection as defined by a positive qSOFA score, abnormal WBC count, and presence of fever when compared with a dwell time of 2 days or less. Consistent with previous studies, these results may support a dwell time of more than 2 days for PIV catheters started in the field, allowing replacement for clinical indications, with the potential benefits of greater patient comfort, decreased RN workload, and improved cost savings. Few studies of PIV catheter dwell time and development of complications such as infection address PIV catheters started in the field, especially for geriatric blunt trauma patients. More research needs to be done to determine optimal dwell time for PIV catheters started in the field for this population. For any indwelling PIV catheter, ongoing assessment for signs of infection is crucial, especially the longer the PIV catheter remains in place.
- Although previous research supports replacing PIV catheters started in hospital for clinical indications versus at prescribed times, the best time to replace field-start PIV catheters is unclear for geriatric blunt trauma patients.
- Infection indicators used for the study were positive qSOFA score as described by the Surviving Sepsis Campaign, presence of fever, and abnormal WBC count.
- A statistically significant lower percentage of infection indicators were demonstrated for patients having field-start PIV catheters with dwell time of more than 2 days versus 2 days or less, suggesting routine replacement of field-start PIV catheters within 2 days of insertion may not be necessary.
The author give special thanks to Wendy Miyamoto, RN, for support and assistance in providing the data from the Trauma Registry.
References marked with an asterisk indicate studies included in the Cochrane meta-analysis.
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