Evidence Based Practice Regarding Venous Catheterisation: Comparison

Evidence Based Practice Regarding
Venous Catheterisation: Comparison
between the UK, Greece & Lithuania
Sophie Porter, Josephine Guzman,
Ben Lambton, Magda and Lauryna
Aims of the presentation
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What is venous cannulation?
Why do we use it?
The risks on insertion and management
Complication statistics
The guidelines on insertion and management
in the UK, Greece and Lithuania
• Conclusion of international differences
• Discussion and scenarios with the audience
INTRODUCTION
What is Venous Cannulation
• Peripheral intravenous cannulation is a
procedure in which the patient’s skin is
punctured with a needle to allow insertion of
a temporary plastic tube into a vein (Jackson,
2003)
• The peripheral IV cannula is usually inserted
into the metacarpal vein on the back of the
hand or a vein in the lower arm, either the
cephalic or basilic vein. (Dougherty, 2008)
Image from:dermatologic.com.ar
Why do we use venous cannulation?
• Peripheral vascular access devices (VADs) can
be inserted for intravenous (IV) access for
medication, fluid, blood or nutrient delivery,
haemodynamic monitoring or blood sampling
(Lavery and Ingram, 2006)
Cannula placement
• When selecting a vein to perform peripheral venous
cannulation consider:
– Patient’s age
– Patient’s preference
– Patient’s activity
– Previous medical history
– Presence of a shunt or graft
– Time of therapy
– Type of solution
– Condition of vein
– Cannula size
(Ahmed, n.d)
Risks of cannulation and what to
look out for
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Infection
Haemmorhage
Haematoma
Vaso-vagal episode
Needle phobias
Catheter embolism
Pain
Nerve damage
Arterial puncture
Allergies
Needle stick injuries
The RCN IV Therapy Forum (2010)
Risks after insertion
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Phlebitis- septic, mechanical, chemical
Infection
Drug reaction (allergy)
Infiltration
Extravasation
Thrombosis/ Embolism
Speed shock
Fluid overload
The RCN IV Therapy Forum (2010)
Infection statistics related to
cannulation
• UK; A survey conducted that 5% of a total of
554 patients on 20 general wards with a
cannula inserted developed site infection. The
survey concluded that the low rate is due to
the 72hrs policy of changing the cannula, thus
validates the 72hr policy (Creamer et al 2003).
UK
Governing registration bodies in
different countries
• UK- Nursing and Midwifery Council (NMC) – provide a
RN pin on completion of degree/diploma. Code of
Conduct (2008) must be respected and adhered to by
all registered nurses. There is also the “Guidance on
Professional Conduct for Student Nurses and Midwifes”
(2011)
• Registered nurses must ensure their knowledge and
skills related to the management of PVCs are up to
date and evidence based (Nursing and Midwifery
Council, 2008)
Who performs cannulation in UK?
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Doctors
Phlebotomists
Nurses after training
Health care assistant after training for an
instance in A&E
Training for nurses in the UK
Registered nurses undertaking the insertion of
vascular access devices will have undergone
theoretical and practical training in the following:
Anatomy and physiology of the circulatory
system, in particular, the anatomy of the location
in which the device is placed including veins,
arteries and nerves and the underlying tissue
structures
• Assessment of patients’ vascular access needs,
nature and duration of therapy and quality of life
• improving venous access, for example the use of
pharmacological and non-pharmacological
methods
• Selection of veins and problems associated with
venous access due to thrombosed, inflamed or
fragile veins, the effects of ageing on veins,
disease process, previous treatment,
Lymphoedema or presence of infection
• Selection of device and other equipment
• Infection control issues (hand-washing, skin
preparation)
• Pharmacological issues (use of local anaesthetics,
Management of anxious patients, management of
Haematoma, phlebitis, etc.)
Hence, the nurse inserting devices and/or providing
infusion therapy must be competent in all clinical
aspects of infusion therapy and have validated
competency in clinical judgement and practice, and
practice in accordance with the NMC’s Code: that is,
they will maintain their knowledge and skills (Collins et
al., 2006; Hyde, 2008; NMC, 2008).
Training contd.
Nurses undertaking the administration • local and systemic complications
of infusion therapy and care and
• infection control issues
management of vascular access
• use of equipment, including infusion
devices will have undergone
equipment
theoretical and practical
• drug administration
training in the following aspects
• risk management/health and safety
• legal, professional and ethical issues • care and management of vascular
• anatomy and physiology
access devices
• fluid balance and blood
administration
• mathematical calculations related to
medications
• pharmacology and pharmaceutics
(Lonsway, 2001; NICE, 2003; Hyde;
related to
NMC, 2008a; Hyde, 2008)
reconstitution and administration
UK Peripheral Venous Cannulation
(PVC) Guidelines
• High Impact Intervention: Peripheral
intravenous cannula care bundle (Department
of Health (DH) , 2011)
• Health Protection Scotland (2012)- Targeted
literature review: What are the key infection
prevention and control recommendations to
inform a PVC maintenance care quality
improvement tool?
What do the guidelines say?
Insertion:
• Ensure clinical indication for PVC
• Hand hygiene is performed immediately prior to PVC
insertion
• Skin antiseptic containing 70% ispropyl antiseptic is
used to clean skin and left to dry prior to insertion studies have advocated that proper skin preparation
before IV medication (2% chlorhexidine and 70%
alcohol) for 30 seconds has shown to reduce
infection(Aziz 2009:244; Hadaway & Millam 2005:4)
• Aseptic technique is maintained throughout
• Sterile transparent, semi-permeable dressing is used to
cover catheter site. Date should be written on dressing
What do the guidelines say?
Management:
• Clinical need for PVC reviewed and documented each day
• The need for IV drugs is reviewed daily by medical staff and
switched to oral as soon as possible
• Hand hygiene is performed prior to line access
• PVC site is assessed using VIP score and removed where phlebitis
and infection are clinically indicated
• PVC dressing is in tact
• 70% isopropyl alcohol is used to clean access ports for at least 15
seconds prior to access.
• Remove after 72-96 hours unless clinically indicated sooner or if
there is limited venous access it may be left in longer.
• (Health Protection Scotland, 2012) and Department of
Health (2011)
Daily Assessment of Peripheral Venous
Catheters (PVC) in the UK
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CDC guidelines recommend replacement of peripheral intravenous (IV) catheters
every 72 to 96 hours which is based on evidence which showed that the longer a
PVC is in situ the greater the risk of complication. (Health Protection Scotland,
2012)
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However a cochrane review has been published since which concluded that there
was insufficient evidence of benefit from routinely removing catheters every 72 to
96 hours and suggested that catheters including PVCs, should be changed on
clinical indication (Webster, et al, 2010)
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Visual Infusion Phlebitis Scale (Jackson, 1998) -Assists nurses in asessing and
managing PVC sites (Royal College of Nursing (RCN), 2012)
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RCN (2010) and Health Protection Society (HPS) (2012) recommend that PVC sites
are checked at least on a daily basis as well as during infusion of drugs and fluids.
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If two or more signs indicative of phlebitis are present (Jackson, 1998), or if the
PVC is not functioning, it should be removed immediately; it should only be resited if the clinical need for a PVC remains (HPS, 2012).
Visual Infusion Phlebitis Scale
(Jackson, 1998)
Is the VIP score still reliable and valid?
• Study by Gallant and Schaultz (2006)
• Descriptive correlational design
• Aim : to look at the effectiveness of the VIP score in
determining when to remove a catheter to reduce rates of
phlebitis
• 851 PIV sites in 513 patients were monitored
• Results: overall found to be clinically useful because it not
only provided descriptions but also suggested actions by
the nurse based on the scale score. Was considered to be a
valid and reliable measure for determining when a PIV
catheter should be removed.
• Considerations: Inter user reliability – persons using the VIP
score must have expert knowledge in using it for
assessment and management purposes.
Documentation of PVCs in the UK
• Documentation plays an important role in the audit
process, facilitates the generation of measurable realtime data (HPS, 2012; DH, 2011), and has been found
to improve staff compliance with care bundles.
• Document date, reason for insertion, catheter size,
operator undertaking insertion and if insertion was
high risk with signature (DH, 2011)
• Document in notes details of date and time of removal
of cannula, operator undertaking removal with
signature and phlebitis score (RCN, 2012)
Anecdotal practices in PVC insertion in
the UK
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Torniquet or manual compression by assistant (Mbmalu and Banerjee, 1999) Restricting blood flow for a short time (2-3 minutes) causes venous dilation and
increased blood volume.
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Gravity – dangling arm below level of heart helps to dilate veins (Alberta Health
Services, 2004)
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Gentle slapping of the skin overlying the vein (Mbmalu and Banerjee, 1999)
contradicted by evidence that suggests slapping causes reflex vasoconstriction via
pain receptors.
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Using warming mittens for 10-15 minutes- Study by Lenhardt et al (2002)
concluded that the use of carbon fibre heat mittens on lower arm and hand PVC
insertions decrease the time staff spend inserting cannulas, reduce supply costs,
and improve patient satisfaction
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Spray GTN spray to vasodilate the veins- personal experience – no evidence base
of using in cannulation but there is evidence to support that Glyceral Trinitrates
cause vessel dilation- we know as we use commonly in angina and heart
conditions! – CLINICAL EXPERTISE (LEVEL 5 EVIDENCE)
LITHUANIA
Nursing education in Lithuania
• The general nurse qualification is acquired at higher education
after completion of a nursing degree program. An overseas
nurse qualification is gained which is recognised by Lithuanian
legal acts.
• This qualification gives you the right to engage in the general
practice of nursing to a person of the Republic of Lithuania.
This is according to the law, that you must be trained as a
nurse and to hold a professional qualification
• General nurses are guided by the Republic of Lithuania laws
and regulations, the standard of medicine, the place of
employment, statutes (regulations) and the internal rules of
their job descriptions (MN 2011).
Registration body for nurses:
LITHUANIA medical standards
MN 28
• This rule establishes the medical nurses
professional activities, rights, duties, powers
and responsibilities.
• This medical standard is mandatory for all
Republic of Lithuania nurses, their employers,
as well as institutions in developing and
improving the specialists and controlling their
activities (Sukys 2011).
Rights, duties, competencies and
responsibilities in Lithuania
• The general practice nurses who make
mistakes, are guilty of negligence, improper
assigned functions or violation of the
requirements of bioethics, as well as the
obligations of the Republic of Lithuania, are
responsible to the MN where they are
exceeding the statutory procedure (MN 2011).
Rights, duties, competencies and
responsibilities in Lithuania
• Cannulation must only be carried out by a
member of medical staff (doctors) or
appropriately experienced NURSES.
• Peripheral venous cannulation should only be
performed by a member of staff who is
competent and confident to perform or during
a period of supervised practice by an
assessor who is competent (NMC 2002).
Guidelines for pheripheral venous
cannulation in Lithuania
Basic steps:
• To check the name of the patient against the
patient’s wristband.
• To confirm the name of the patient verbally.
• If verbal identification of identity is not possible,
check patient’s identity with a second
practitioner.
• To assess individual needs of the patient.
• To select where appropriate a suitable person
for assisting with the procedure.
Guidelines for pheripheral venous
cannulation in Lithuania
• To follow infection control precautions
• To prepare and demonstrate correct
and appropriate use of equipment.
• To identify a suitable vein and position
the patient appropriately.
• To insert a peripheral cannula correctly
(Addison 2003 ).
Guidelines for pheripheral venous
cannulation in Lithuania
• To flush the cannula with 0.9% saline using a
10ml syringe.
• To fixate the cannula using the appropriate
dressing.
• Safely dispose of all equipment according to
Trust policies.
• To document the procedure correctly (Addison
2003)
Documentation
You will see lots of different charts, forms and
documentation. Every hospital, care home and
community nursing service will have the same
basic ones, but with small variations that work
best locally.
Documentation
Catheter insertion documentation
include:
• Is the individual patient in any form of localised
discomfort or pain?
• The results of a risk assessment prior to
Catheterisation.
• Consent obtained for the procedure;
• If the insertion was easy or difficult
• Indications used to ensure catheter was inserted
correctly . (Rando, 2005)
GREECE
Ε.Ν.Ε (Nurses Association ,Greece)
• E.N.E is the public law entity,totally selfgoverning,which is under the supervision of the
Ministry of Health.
• It is also the government's and public
establishments and undertakings adviser,which
supervise on the items of primary,secondary and
tertiary health care and health policy.
• All nurses of higher education are registered
members .
Venous cannulation in Greece
• According to the 4th Health Region of
Macedonia & Thraki, inserting a venous
catheter is defined as a nursing process.
A nursing student is trained in venous
cannulation during the second year of their
study, either in the laboratory or during
clinical practice at hospital.
Greek Guidelines for venous
cannulation-preparation
• perform hand hygiene and organize the equipment
• confirm
patient's identity and explain the procedure to obtain
consent
• select size and type of venous catheter
• Select with top priority left hand for right handed and
respectively vica versa
• Wear gloves and choose vein(mainly forearm,then
wrist or dorsal surface of palm)
*avoid volute or manifold veins
Procedure guidelines for venous
cannulation in Greece
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fit elastic strapping 5-10cm from the cannulation point(carefully to the elderly
and if it needed over the clothes)
*do tied more than 90 seconds
Check for presence of arterial pulse
locate the exact site for venipuncture and clean with a solutione.g
chlorrexidinis
Use your thumb and apply slight tendency to the distal end of vein for stability
Start from an angle 30 and continue with reduction of the angle during the
insertion
ease the catheter in to the vein gradually pulling the needle out at the same
time
Inserting all the catheter,apply slight tendancy to its the distal end stabilize
and connect any lines as appropriate
After two failed attempts you must ask the assistance of someone experienced
Update and sign the patients hospital card
monitoring of the venous catheter
following insertion - Greece
• overview gateway of venous cathetr observing for
redness,edema,outflow etc and dressings on a
daily basis
• If there are no points of phlebitis change venous
catheter every 96 hours
• Change dressing in the case of ablation,fluid,
blood escaping or moisture
• Instruct the patient to observe for possible signs
or symptoms of phlebitis and inform the nurse if
they are concerned
Nursing documentation
• Recorded in patient's hospitalization card:
the date of catheter placement
the point of catheter placement
the type and the size of the used catheter
the name and the signature of the nurse
which perform the vein cannulation
also...
• Recording in a prominent spot on the suffix:
the date of catheter placement
• The following is also documented in patients notes :
• the level of cooperation with the patient
• dressings that are used
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the level of understanding instructions on the mobility
restrictions as a result of catheterization
• The instructions given about
subsequent changes on venous catheter or suffix
Conclusion
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As you can see the procedure for insertion of a peripheral venous catheter is much
the same in all three countries. However , in the UK the guidelines are national,
provided by two very reputable bodies and are published, adhered to and used by
all medical staff, allied health professionals and nurses which are trained. Both
Greece and Lithuania have local trust policies and university guidelines, and so
they may vary from trust to trust.
The main differences appear in the management and documentation. Although all
three countries follow the 72- 96 hour rule the main difference is the use of the
VIP score in the UK.
Perhaps in Greece and Lithuania nurses are trusted to observe for phlebitis
through clinical judgement and expertise. However in the UK there is what has
been proven to be a very useful tool in reducing phlebitis and aiding a nurse in
determining when to remove a cannula and what steps to make next. Despite the
fact that it is dated.
Other differences are in who performs cannulation, and the training undertaken.
As previously discussed, in the UK you have to obtain a licence or training to
perform such a skill. It is not something taught to you as a student nurse. This is
much the same in countries like the US and Finland. However in both Lithuania
and Greece, student nurses are taught in skills laboratories and on clinical
placement. They are also allowed to perform this procedure on patients under the
supervision of a registered nurse.
scenarios
Scenario 1
• A foreign male patient who does not speak your
language is admitted to the ward where you
work. He requires a cannula to be inserted to
administer IV antibiotics promptly. However he is
very scared of needles and does not understand
why he needs a cannula.
• How do you solve this situation and explain the
reason for and the risks of having a cannula
inserted?
• And how do you make sure he understood?
Scenario 2
• A female patient is admitted and requires IV
fluids. She does not mind to have a cannula
inserted, however she does not understand what
to look out for and she is moving her arm and
touches both the cannula and the bag of fluids all
the time which interrupts the flow and increases
risk of irritation to her skin.
• How do you explain to her that she must not do
this?
• And how do you make sure she understood?
References
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Collins M, Phillips S and Dougherty S (2006) A structured learning programme for
venepuncture and cannulation, Nursing Standard, 20 (26), pp.34-40. (III)
Nursing and Midwifery Council (2008b) The code:standards of conduct,
performance and ethics for nurses and midwives, London: NMC.
Hyde L (2008) ‘Legal aspects of IV Therapy’, in Dougherty L and Lamb J (editors)
Intravenous therapy in nursing practice (2nd edition), Blackwell Publishing: Oxford.
(III)
Lonsway RA (2001) ‘IV therapy in the home’, in Hankins J, Lonsway RA, Hedrick C
and Perdue MB (editors) Infusion therapy in clinical practice (2nd edition),
Pennsylvania: WB Saunders, pp.501-534. (III)
Nursing and Midwifery Council (2008a) Standards for medicines management,
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NICE (2003) Infection control: prevention of healthcare-associated infection in
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Jackson, A (2003) Reflecting on nursing contribution to vascular access. British
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Dougherty, L (2008) Obtaining peripheral venous access In: Dougherty, L and Lamb,
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Image from dermatologic.com.ar
Lavery, I and Ingram, P (2006) Prevention of infection in peripheral intravenous
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Ahmed, N (n.d) Revisiting Peripheral Intravenous Cannula Insertion. pp. 1-6
Jackson A (1998) Infection control: a battle in vein infusion phlebitis. Nursing
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Royal College of Nursing (RCN) (2012). Care of peripheral cannula venous sites.
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Nursing and Midwifery Council (NMC)(2008). The Code: Standards of conduct, performance and ethics for nurses
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