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Department: NURSING RESEARCH

Nursing attitudes and practices for routine I.V. catheter resiting

Evers, Frances MSN, RN, CMSN; Morelock, Skip PhD, RN, NEA-BC; Walsh, Judith PhD, RN; Khoja, Sharifa MSN, RN, RN-C

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doi: 10.1097/01.NURSE.0000659388.75935.4f
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TODAY'S HEALTHCARE professionals are keenly sensitive to patient experience. Insertion of short peripheral catheters (SPCs) can represent a challenge for nurses and may lead to complications or pain in patients. For many years, resiting SPCs every 48 to 72 hours was considered standard practice, later updated to 72 to 96 hours.1 This meant that patients with a short length of stay (LOS) could be subjected to additional and sometimes unnecessary reinsertions or resiting.

The 2016 Infusion Nurses Society Standards of Practice state that SPCs should be removed from adult patients “when clinically indicated, based on findings from site assessment and/or clinical signs and symptoms of systemic complications.” Because the optimum elapsed time following insertion (dwell time) is unknown, the guidelines state that SPCs should not be removed based solely on dwell time.2 At the time of the investigation described in this article, the authors' facility was still operating according to routine resiting guidelines of 72 to 96 hours.1,3

At a medium-sized regional referral and trauma center in north Texas, the authors posed a question: Why routinely resite a functioning SPC in the absence of signs and symptoms of infection, phlebitis, or infiltration and/or if the patient's anticipated discharge is within 24 hours? This article explores research that challenges the common and entrenched nursing practice of resiting SPCs every 72 to 96 hours regardless of functional status.

Literature review

Each year, an estimated 150 to 200 million SPCs are inserted in US hospitals.3 Many nurses consider the insertion and maintenance of SPCs to be an everyday part of patient care, but these practices are associated with many potential complications, the most common being phlebitis, infiltration, extravasation, and systemic infections. The latter represents a serious threat to life and may add as many as 7 days to LOS.3,4 Despite the potential time savings in healthcare facilities, would a new practice be safe for patients? A 2015 meta-analysis of six articles found no increase in the risk of phlebitis or systemic infections due to SPC resites based on clinical judgment.5

Research has also shown that frequent, routine catheter resiting of functional catheters is unnecessary and increases the risk of complications. In one study involving 89 insertion sites, researchers compared dwell times and catheter patency. They found that 30 sites were patent at 96 hours, 5 were patent at 200 hours, and 4 remained functional and without signs or symptoms of phlebitis or systemic infection at 300 hours. The results support the theory that a well-placed SPC, coupled with astute nursing assessment and no signs or symptoms of complications, may remain in place indefinitely.6

Another prospective observational study examined the development of phlebitis in 218 SPCs and found that only 13 were removed due to complications. Rather than finding an increased incidence of phlebitis with longer dwell times, the researchers found that 100% of phlebitis-related events happened before day 3, with no occurrences thereafter.7 Another report noted that the incidence of phlebitis increased dramatically in the first 48 hours after SPC insertion, followed by a moderate decrease in incidence after day 3.8 Two years later, a different group of researchers discovered that, by switching to nonroutine resiting of SPCs, hospitals could significantly reduce the cost of I.V. therapies while controlling the incidence of complications.9

Methods

This exploratory research was conducted in the authors' Magnet® healthcare facility, which is designated as a level II trauma center, recognized as a comprehensive stroke center, and accredited for chest pain. Organizational policy required all SPCs in adult patients to be resited after 96 hours and as needed. Clinical nurses reported frequent patient complaints about resiting if the current SPC was functioning well, if there was no pain or clinical indications of infection, and if patient discharge was anticipated within 24 hours. The authors began planning this study in 2017.

The acute care teams were included in the study, as was the high-risk obstetric team due to a high percentage of patients with SPCs. Following Institutional Review Board approval, an online questionnaire was developed to collect information on nurses' attitudes and practices toward SPCs, as well as their patients' reactions to resiting. Nursing managers from each of the participating units strongly supported the research and provided principle investigators with employee distribution lists.

The survey also collected demographic data, such as specialties, years of practice, and highest degrees. It was sent via email at weekly intervals for 4 consecutive weeks and included an embedded hyperlink. After it closed, a database containing survey information and analysis was built using the Statistical Package for the Social Sciences software.

Table
Table:
Nursing demographics

Results

Out of 203 eligible nurses, 81 (39.9%) completed at least a portion of the survey. (See Nursing demongraphics.) Among the 81 participating nurses, 64 (79%) reported an average of one or two SPC insertions per shift, while 6 (7.4%) reported that they averaged three or more. Most nurses (46, 56.8%) reported spending less than 15 minutes to insert or resite an SPC. However, 23 (28.4%) nurses reported spending between 16 and 30 minutes to insert or resite an SPC, and 12 (14.8%) reported needing between 31 and 45 minutes to insert or resite an SPC. Similarly, 46 (56.8%) participants described the resiting procedure as either moderately or very disruptive to patient care. However, 24 (29.6%) nurses described the process as slightly disruptive and 11 (13.6%) reported no disruption at all.

Almost all participating nurses (80, 99%) were aware of the existing organizational SPC policies, and 76 (93.8%) were supportive of a practice or policy change that would allow them to use clinical judgment in resiting an SPC. When answering one survey question that asked participants to check all that apply, 78 nurses (96.3%) selected “patient satisfaction” as a key driver toward a policy change, 52 (65%) selected “nurse satisfaction,” and 51 (63%) selected “cost considerations.”

Analysis

The Spearman's rank-order correlation, a nonparametric test that measures statistical correlation, was used to test for significant relationships in the survey responses due to a small sample size and the presence of assumption violations, or situations in which a theory is not achieved.10,11 Although it is not as robust as the Pearson's Product-Moment correlation coefficient, which measures linear statistical relationships, it is the preferred method for analysis when violations of normality are present, such as a small sample size.12

The survey results support the perception that SPC insertions and resiting can be time-consuming and disruptive to the flow of care. A nurse's years of experience were weakly correlated to how disruptive an SPC resiting was for patients (r = -.288; P = .009), as was the number of SPC starts per shift (r = .301; P = .007). This weak negative correlation between a nurse's years of experience and the disruption caused by an SPC insertion suggests that the more experienced the nurse, the less disruptive the process. Similarly, more common resitings correlated to an increase in the perceived disruption. The time required to resite was moderately correlated to how disruptive the process was for patients (r = .491; P = .000).

The strongest correlation occurred between patients who had requested no SPC resite and the reported disruption from SPC resiting (r = .566; P = .000). We interpreted this finding to mean that the nurse is aware that the patient does not wish to have the SPC resited. This may magnify the perception that the process is more disruptive than it is in reality.

Discussion

The demographics reported in this study differ significantly from national and state nurse databases. For example, the authors' facility has robust recruitment initiatives that target graduating nursing students. As such, participants under age 30 made up 16% of this study, whereas nurses age 25 and younger comprise less than 2.1% of the total nursing population in Texas.13 Similarly, nurses age 55 and older account for approximately 40.3% of the total national workforce, but only 13.5% of participants in this study were 51 or older and just one participant was over age 60.14

Most participating nurses (76, 93.8%) supported a resiting practice change, and 35 (43.2%) reported that between 76% and 100% of their patients request no resiting of functional SPCs at 96 hours. Not only does the evidence support the safety of not routinely resiting SPCs, but this practice may also have time-saving benefits. For example, one 2015 study found that resiting requires a mean time of 15 minutes.15 In the authors' facility, eliminating 20 SPC resitings a week could result in a savings of approximately 300 nursing minutes per week (5 nursing hours). As previously noted, 46 (56.8%) survey participants reported the time required for resiting as up to 15 minutes, 23 (28.4%) reported the process taking between 16 and 30 minutes, and 12 (14.8%) required 31 to 45 minutes. This indicates that the time savings may be higher than the authors' estimates.

Additionally, the practice of not routinely resiting SPCs may have financial benefits for healthcare organizations. Inefficient practices and those that are not evidence-based may contribute to between 13% and 20% of total hospital costs.15 Using fewer prepackaged SPC kits and required saline could result in overall facility savings.

For example, the authors' hospital uses a prepackaged SPC product, costing $.98 per unit. It includes skin antiseptic, single-use tourniquets, labels, and a dressing. Catheters are packaged separately, as is the saline used to flush and maintain patency. The combined cost of a single SPC insertion is approximately $4.16. The savings potential of reducing the current usage by 20 occurrences per week could amount to a savings of more than $4,300 annually in each nursing unit. Given the number of units in the facility, this is not insignificant. Additionally, because the cost of the nurses' time was not factored into the original calculations, the potential for cost savings may be even greater.

Moving forward

Based on the survey results, as well as an extensive review of the existing SPC policy and direct feedback from nurses, the hospital's Evidence-Based Practice and Research Council made a formal recommendation to amend the policy to remove the requirement that all SPCs be discontinued and resited after 96 hours. Instead, nurses may use clinical judgment, including their training, expertise, and assessment skills, to determine whether an SPC requires resiting.

The recommendation was approved by the CNO's council and the system-wide infection control committee. Full approval and implementation began in August 2019. Post hoc analysis and monitoring will determine the efficacy, efficiency, and any unanticipated consequences of the amended SPC resiting policy.

The use of SPCs is a valuable adjunct in treating patients. These devices are not without risk, however, and it makes sense to reduce their use if possible. Routine resiting does not reduce complications and may not be the most efficient use of time for the nursing staff. Based on this survey and the current evidence, assessment-based SPC resiting seems to make clinical sense over a prescriptive policy-based practice and may benefit both the patient and the healthcare system.

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