Innovative strategy, empowerment and amendment of guidelines to prevent IV complications

Merlin grace1*, Jaslin. S2, Lydia Annie3, Abhilasha. S4 Sasikala. J5, Arya M Nair6, Kavitha. R7, Adhilakshmi 8

Department of Nursing, Kauvery hospital, Radial road, Chennai

Introduction

Intravenous cannulation and drug infusion are the most common procedures (80%) performed in the emergency departments and in all inpatient areas.  IV complications such as phlebitis and infiltrations are common due to administration of IV fluids, infusion of irritant drugs and puncturing the vein inappropriately.

Need for Quality Improvement Project

In the recently launched hospital, all measures to prevent IV fluid administration related complications were implemented like – assessment of IV by Visual Infusion Phlebitis (VIP) scoring, flushing before and after medicines, scrub the hub, aseptic technique and appropriate removing of IV lines when indicated. But still, in Sep and Oct 2023, ten instances of phlebitis and one infiltration were reported in the newly established hospital. The following strategies were framed towards the QIP.

Strategies Implemented

  1. Audit on current practice – IV insertion and maintenance bundle care
  2. Education and training on non- confirmations (NC) observed
  3. Implementing the IV Extension Band (a Nurse invented IV band) to prevent Infiltration
  4. Revising the protocols of IV maintenance bundle.
  5. Re audit on the IV line maintenance
  6. Sustenance Audit

Audit of current practice on IV Line and maintenance bundle care

Gaps identified

  1. Aseptic technique followed – 57% (Dangling IV extensions touching the patient environment and patient’s skin flora)
  2. Flush protocol compliance before and after medication administration – 33%
  3. Lack of clinical judgement – 80%

It was also observed that phlebitis was identified after 48hr of IV insertion with continuous fluid therapy, high-end antibiotics and irritant drugs (83%). Phlebitis occurred in patients over 60yrs with sensitive skin (17%) within 24 hr.

Education and Training on IV line insertion and maintenance

 

Implementing the IV extension Band to prevent Infiltration

 

Despite of all the precautions taken in Dec, one case of infiltration was reported. Brainstorming identified a dangling IV extension as the root of the problem. After the brainstorming session, the team came out with an innovation of wrist band which has pockets to anchor the lumen extension. The nurses were trained and instructed to use the same.

Revising the protocols of IV maintenance bundle

The guideline was amended based on the observation at our institution:

Although guidelines say 72–96 hr of indwelling time for peripheral IV catheters, the policy, after careful consideration, was amended as;

  • The patients who are receiving highly irritant drugs and elderly with wrinkled skin – the catheter indwelling time is amended to 48hrs – 72 hrs.
  • Encouraged and empowered nurses to apply clinical judgement in changing lines. They will not start the irritant drugs on the existing line which has an indwelling time of more than 48 – 72 hrs. Refusal consent is implemented.
  • Empowered nurses to flush the lines in between the drugs and especially with the irritant drugs. List of irritant drugs were displayed.
  • To prevent dangling extensions – a Nurse invented IV band which was stitched using the non-woven material from OT which often gets wasted after a surgery. (No cost involved)

Re audit on the IV line maintenance

Formula TargetJulAugSepOctNovDecJanFebMarAprMayJun
Total no of early- identified Infiltration/ total IV line days * 1000001001000000
359758997166010991237122113301613140815511391
000.1000.08000000

Conclusion

The proactive application of clinical judgement in reinsertion of cannula has benefited both ways. It helps the nurse to understand the need for re-cannulation as early as 48–72hr (based on VIP score–1) and guides them to follow the protocol without any deviation.

Scrubbing the hub as reduced rate of contamination and formation of biofilm, which has reduced infection due to IV access. Flushing the line between every drug ensures the lines stay clean and prevents blockages.

The IV band, which was invented by the nursing team, was effective against phlebitis and prevention of infiltrations. It was thought that the weight of the extensions might cause the cannula to irritate the vein and might puncture the tunica intima. A research, with quasi experimental design was conducted on the effectiveness of the IV band and the results  proved that the K bandss was effective against prevention of phlebitis and infiltrations / extravasations.

Reference

  • Abbas, S. Z., de Vries, T. K., Shaw, S., & Abbas, S. Q. (2007). Use and complications of peripheral vascular catheters: A prospective study. British Journal of Nursing, 16, 648-652. https://doi.org/10.12968/bjon.2007.16.11.23675

 


Ms. Jasline. S
Quality and Patient Safety Nurse


Ms. Abhilasha S
Nurse Educator

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