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Improving communication during I.V. catheter insertion

Plohal, Ann PhD, RN, ACNS-BC, CRNI, VA-BC

doi: 10.1097/01.NURSE.0000577748.87879.49
Department: INFUSION THERAPY
Free

Ann Plohal is a vascular access RN at St. Joseph Hospital & Medical Center at Dignity Health in Phoenix, Ariz.

The author has disclosed no financial relationships related to this article.

COMMUNICATION AND patient education are crucial aspects of I.V. therapy, in which the clinical nurse is charged with educating the patient and caregiver about the prescribed therapy and plan of care.1 A recent cross-sectional survey of consumer perspectives in 25 countries found that many patients who raised concerns during short peripheral catheter (SPC) insertion felt they were not being heard.2 Using a case study, this article identifies areas in which nurses can improve their communication with patients before and during an SPC insertion and offers recommendations for how to obtain a focused vascular history before an SPC insertion.

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Patient-centered care

Preventable medical errors continue in the US and throughout the world.3 Patients and families report a lack of communication with healthcare providers as one of the leading causes of medical errors.3

In a landmark publication, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine, now known as the National Academy of Medicine, identified patient-centered care as crucial to quality healthcare.4 The report endorsed six patient-centered care components that must be provided to patients: respect for patients' values, preferences, and needs; coordinated and integrated care; information, communication, and education; physical comfort; emotional support; and involvement of family and friends.4,5

The clinical nurse is responsible for educating the patient and caregiver about the prescribed therapy and plan of care, after assessing their learning needs and readiness to learn.1 The optimal practice of evidence-based care incorporates patients' preferences, including learning preferences, into the plan of care.6

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Case study

Carol, an RN, has been working on a medical unit for 1 year and has become proficient in her skills inserting SPCs. Carol receives patient handoff on SM, a 54-year-old female who was admitted with left lower extremity cellulitis. SM is prescribed I.V. ceftriaxone every 12 hours and requires SPC insertion. Carol reviews SM's medical record including diagnosis, reason for admission, history and physical, and recent lab results. Carol learns that SM had a right mastectomy 2 years ago. There are no allergies documented, specifically to chlorhexidine or tape. Carol introduces herself to SM and explains that she will insert an SPC in order to administer the prescribed antibiotic therapy.

Carol assembles the supplies needed to insert an SPC and identifies SM by using two unique patient identifiers. After determining that SM is left-handed, she successfully inserts an SPC in her right forearm.

While documenting the procedure, Carol realizes that she inserted the device on the same side as the mastectomy. Carol has always been taught not to insert SPCs in the arm on the same side as a patient's mastectomy. Realizing her error, Carol informs the charge nurse.

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Current recommendations

Carol inserted the SPC in the ipsilateral arm of the patient's mastectomy, but was this really an error? According to the Infusion Nurses Therapy Standards of Practice, venipuncture on the ipsilateral arm should be avoided in patients after breast surgery with axillary lymph node dissection (ALND) and those with lymphedema.1 Mastectomies may or may not include ALND. If SM had a mastectomy without ALND, the ipsilateral arm may be used for venipunctures and the SPC in her right forearm will not need to be removed. Carol reviewed SM's medical record further and determined that SM's breast surgery did not include ALND. Carol also confirmed this information with SM.

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Focused vascular history

Obtain a focused vascular history before SPC insertion, including the following areas:

  • Past experience with venipuncture/SPCs. Were SPCs inserted with current/previous hospitalizations? Was there any difficulty with SPC insertion? Did the patient experience any adverse reactions to venipuncture, such as vasovagal syncope? Has the patient had experience with other types of vascular access devices, such as implanted ports and peripherally inserted central catheters? Does the patient have any allergies, including to chlorhexidine and tape?
  • Medical history affecting SPC placement. Does the patient have a history of breast surgery? Should venipuncture in one arm be avoided for any reason, such as a history of ALND, lymphedema, arteriovenous fistula, or infection? Perform medication reconciliation, including I.V. chemotherapy and immunotherapy.
  • Vascular history. Does the patient recommend using any specific venous access sites? Ask the patient if he or she has a preference based on veins used in the past. Keep in mind the patient may prefer a specific site, but the vein may not be suitable for an infusion if it is sclerosed.
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Take time to talk

Patients have described nurses as very busy and when it comes to starting SPCs, not always taking the time to listen.2 Despite how busy you are, take the time and sit down, talk with, and listen to your patient.

By involving the patient, Carol successfully educated and communicated the plan of care. She also learned the importance of asking the right questions for a thorough vascular assessment for the SPC insertion.

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REFERENCES

1. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1S):S1–S159.
2. 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.
3. Southwick FS, Cranley NM, Hallisy JA. A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families. BMJ Qual Saf. 2015;24(10):620–629.
4. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
5. Tzelepis F, Sanson-Fisher RW, Zucca AC, Fradgley EA. Measuring the quality of patient-centered care: why patient-reported measures are critical to reliable assessment. Patient Prefer Adherence. 2015;9:831–835.
6. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA. 2013;310(23):2503–2504.
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