Background: Peripheral venous catheter (PVC) insertion is a crucial nursing action during life support. Several factors that increase the risk of thrombophlebitis associated with PVCs have been reported. Objective: We wish to evaluate the impact of a quality improvement regarding PVC treatment for patients with coronary heart diseases. Method: A longitudinal, quantitative observational study was carried out in 2008 and 2013 in a hospital in southern Sweden with 360 consecutive patients suffering from acute chest pain. New routines for PVC treatment were included in the hospital with daily inspection according to a checklist. A structured observation protocol was used to survey the prevalence of thrombophlebitis between 2008 and 2013. Also, we examined the relationship between the location and luminal diameters of PVCs. Results: The student’s t-test showed significant differences between 2008 and 2013 with respect to luminal diameter of PVCs (p = 0.002), prevalence of thrombophlebitis (p = 0.003) and number of days with PVC left in situ (p < 0.001). Conclusion: These findings emphasize the value of using systematic daily inspections and checklists to achieve quality and safety in patients with acute chest pain having PVC-based treatment.
Insertion of a peripheral venous catheter (PVC) is a crucial nursing action during life support in emergency (prehospital or hospital) settings for patients with symptoms of acute myocardial infarction. In hospitalized patients, administration of pharmaceutical substances via the intravenous route is the most common invasive procedure [
Risks associated with intravenous therapy include thrombophlebitis (prevalence of 2.3% - 35%) and intravenous catheter-related bacterial infection (≈0.8%) [
Evidence-based PVC treatment results in reduced risks for patients and excessive healthcare costs [
In the Swedish healthcare system, nurses are responsible for informing patients why PVCs need to be inserted, as well as their maintenance, removal and documentation. Each year in Sweden, nurses insert ≈5 million PVCs [
The present study took place in County Hospital in southern Sweden. Ward review revealed that ≈6% - 10% of patients at County Hospital had suffered from infections that could lead to thrombophlebitis upon PVC-based treatment. Therefore, it was decided at the departmental level to work with quality improvements (QIs) for nurses regarding PVC management.
The intended improvement was to reduce the prevalence of bacterial infections and phlebitis. To achieve improvements in PVC-based treatment, efforts from healthcare professionals are needed [
Quality Improvement (QI) is being adopted increasingly in healthcare in Sweden and overseas. In the present study, a QI method, root cause analysis (RCA) [
This was a longitudinal, quantitative, observational study carried out in 2008 and 2013 at a surgical and medical clinic in County Hospital in South of Sweden. A total of 360 (2008: n = 145; 2013: n = 215) consecutive patients with symptoms of chest pain admitted to the Emergency Ward and then transported immediately to the Department of Cardiac Diseases where enrolled in the study.
QI was initiated by a development leader after review of the prevalence of thrombophlebitis on the ward. Using local data and discussion of the prevalence with those involved can lead to deeper understanding of local problems [
A structured observational protocol was used for data collection (
If a complication was noted, observation of symptoms continued after PVC removal until the patient was asymptomatic. If complications remained after discharge from hospital, or symptoms recurred, patients were requested to visit their general practitioner.
The study followed the principles outlined in the Declaration of Helsinki, and was approved by the Ethics Committee [
Background variables are presented as the mean, 95% confidence interval (95% CI), frequency, and percentage. Comparisons between categorical variables in 2008 and 2013 were made with the chi-squared test. But when more than 20 percent of the cells had an expected value less than five have instead Fisher’s exact test been used. Bootstrapping was used to calculate 95% CIs. Analysis of crosstabs with more than four cells have also Correspondence analysis have been used [
Degree | Symptom of thrombophlebitis | Intervention for PVC | |
---|---|---|---|
0 | No complication | No discomfort or slight discomfort; tenderness upon insertion. | No action. |
1 | Slight thrombophlebitis | Redness and tenderness < 15 × 15 mm. | Stop treatment and remove the PVC. Hirudoid® ointment applied one to several times daily. |
2 | Medium thrombophlebitis | Redness, tenderness pain, swelling > 15 × 25 mm; increased temperature in the area. | Stop treatment and remove the PVC. Hirudoid® ointment applied one to several times daily. Inform the attending physician. |
3 | Severe thrombophlebitis | Redness, tenderness pain, swelling > 25 × 50 mm; increased temperature in the area and palpable cord in the vein. | Stop treatment and remove the PVC. Inform the attending physician. |
4 | Very severe thrombophlebitis | Redness, pain, swelling more than 50 × 50 mm; increased temperature in the area and palpable cord in the vein; pain spreading up to the arm; possible fever | Stop treatment and remove the PVC. Inform the attending physician. |
Modified checklist from Lundgren et al., 1993 [
PVC in | PVC | Flush | Flush | PVC out | Thrombophlebitis | Complications | Intervention |
---|---|---|---|---|---|---|---|
Date Clock: /Sign | Size Place /Sign | Date /Sign | Date /Sign | Date Clock: /Sign | Degree 0-4 /Sign |
Intervention | Process |
---|---|
To improve the way to PVC-based treatment is carried out | *A comprehensive review of international and national literature on PVC treatment was done *A checklist was composed based on the review *Secure assessment of thrombophlebitis by defining the extent of thrombophlebitis *Information for all staff on the ward for people with heart disease using the new guideline |
To test and evaluate compliance to the checklist | *Follow-up of 60 patients was conducted *Nurses’ documentation and comments regarding the new working process was reviewed |
To improve the checklist further and working practices | *Meetings with nurses where follow-up was discussed *Create conditions to facilitate compliance with the new guideline. The checklist included equipment for appropriate PVC-based treatment. |
To establish the new guideline as a routine | *Follow-up of working practices as a regular discussion at monthly meetings |
To secure the quality of the new routine | *Continuous follow-up of the checklist |
ple t-test was used. However, none of these variables had a normal distribution according to Kolmogorov- Smirnov and Shapiro-Wilk tests (p < 0.05). Therefore, a non-parametric test and Mann-Whitney U-test were also used. Both tests reported significant and non-significant variables, so only p values for the independent sample t-test are reported. Significance was set at α = 0.05. Statistical analyses were made using SPSS v22 (IBM, Armonk, NY, USA).
QI on the ward resulted in significant reductions in the prevalence of complications associated with PVC-based treatment by healthcare professionals (PVC 2-4) in 2013 compared with those in 2008 (p = 0.04). Upon treatment by paramedics (PVC1), the prevalence of complications increased significantly (p = 0.03) (
2008 | 2013 | ||||||||
---|---|---|---|---|---|---|---|---|---|
n | % | 95% CI | n | % | 95% CI | p | |||
Location of PVC1 (paramedics) | Upper hand | 57 | 41.9 | 33.8 - 50.0 | 86 | 41.5 | 35.3 - 48.3 | 0.96 | |
Forearm | 57 | 41.9 | 33.8 - 50.0 | 85 | 41.1 | 34.8 - 47.8 | |||
Antecubital | 22 | 16.2 | 10.3 - 22.8 | 36 | 17.4 | 12.6 - 22.7 | |||
Neck | - | - | - | - | - | - | |||
Legs | - | - | - | - | - | - | |||
Location of PVC2-4 (healthcare professionals) | Upper hand | 16 | 20.3 | 11.4 - 29.1 | 28 | 20.3 | 13.8 - 26.8 | 0.08 | |
Forearm | 30 | 38.0 | 27.8 - 42.4 | 69 | 50.0 | 42.0 - 58.0 | |||
Antecubital | 30 | 38.0 | 26.6 - 48.1 | 41 | 29.7 | 22.5 - 37.7 | |||
Neck | 1 | 1.3 | 0 - 3.8 | - | - | - | |||
Legs | 2 | 2.5 | 0 - 6.3 | - | - | - | |||
Luminal diameter (mm) PVC1 (paramedics) | Yellow (0.7) | 1 | 0.7 | 0 - 2.1 | - | - | - | 0.002 | |
Blue (0.9) | 44 | 31.2 | 23.4 - 39.0 | 35 | 16.9 | 11.6 - 22.0 | |||
Pink (1.1) | 89 | 63.1 | 54.6 - 70.9 | 147 | 71.0 | 64.7 - 77.3 | |||
Green (1.3) | 7 | 5.0 | 2.1 - 9.2 | 25 | 12.1 | 7.7 - 16.4 | |||
Luminal diameter (mm) PVC 2-4 (healthcare professionals) | Yellow (0.7) | 1 | 1.3 | 0 - 5.1 | - | - | 0.07 | ||
Blue (0.9) | 18 | 22.8 | 13.9 - 32.9 | 16 | 11.7 | 6.6 - 16.8 | |||
Pink (1.1) | 54 | 68.4 | 58.2 - 78.5 | 96 | 70.1 | 62.8 - 77.4 | |||
Green (1.3) | 6 | 7.6 | 2.5 - 12.7 | 25 | 18.2 | 12.4 - 24.8 | |||
Complications PVC1 (paramedics) | No thrombophlebitis | 143 | 97.9 | 95.2 - 100 | 176 | 92.6 | 88.9 - 96.3 | 0.03 | |
Thrombophlebitis | 3 | 2.1 | 0 - 4.8 | 12 | 7.4 | 3.7 - 11.1 | |||
Complications PVC 2-4 (healthcare professionals) | No thrombophlebitis | 50 | 87.7 | 78.9 - 94.7 | 83 | 96.5 | 91.9 - 100 | 0.04 | |
Thrombophlebitis | 7 | 12.3 | 5.3 - 21.1 | 3 | 3.5 | 0 - 8.1 | |||
First PVC (PVC1), second PVC (PVC2), third PVC (PVC3), fourth PVC (PVC4) and age in years for 2008 and 2013 in terms of number (n), percentage (%), 95% confidence interval (95% CI) and probability (p).
2008 | 2013 | |||||||
---|---|---|---|---|---|---|---|---|
n | % | 95% CI | n | % | 95% CI | p | ||
Female | 65 | 44.5 | 36.3 - 52.7 | 80 | 38.1 | 31.9 - 45.2 | 0.23 | |
Male | 81 | 55.5 | 43.7 - 67.3 | 130 | 61.9 | 54.8 - 68.1 | ||
Age in years | 146 | 69.9 | 68.0 - 71.1 | 210 | 70.6 | 68.5 - 72.7 | 0.62 | |
Days PVC1 Days PVC2 Days PVC3 Days PVC4 | 127 | 2.1 | 1.9 - 2.2 | 184 | 2.5 | 2.3 - 2.7 | <0.001 |
m: mean
tribution, followed by a green PVC (1.3 mm) and then a yellow PVC (0.7 mm), and the difference was significant. PVCs with a smaller luminal diameter (e.g., blue, 0.9 mm) were used less often and those with a larger luminal diameter (e.g., green, 1.3 mm) were used more often in 2013 compared with 2008. Yellow PVCs (0.7 mm) were not used at all in 2013 compared with 2008. PVCs with larger luminal diameters were used more often in 2013 compared with 2008.
Six-year follow-up of an improvement intervention in patients who received treatment for acute chest pain in a coronary care unit highlighted the benefits of avoiding unnecessary changes of PVCs. PVCs were replaced for clinical indications or every 72 h. This result supports the work of Rickard et al., who use clinical indicators to decide if PVCs should be replaced or removed, as opposed to the usual prescribed length of time (≤72 h), the PVC has been in situ [
From a QI perspective, patients’ knowledge of the symptoms and signs of thrombophlebitis is important. Lundgren et al. showed that residual symptoms of thrombophlebitis after PVC removal could be apparent ≤ 5 months after hospital discharge [
During the period of the survey (2008-2013), a significant reduction in the prevalence of thrombophlebitis was noted in patients who had their PVC replaced as a result of clinical indications or every 72 h. This treatment was a part of the improvement work implemented by all nurses on the ward (
An improvement intervention must be evaluated through systematic collection of data to measure the effects of that intervention [
Zingg et al. also found that if untrained or inexperienced healthcare workers insert PVCs, the risk of thrombophlebitis increases [
From 2008 to 2013, when paramedics inserted PVCs, a significant increase in the prevalence of thrombophlebitis (p = 0.04) was noted (
National and local guidelines recommend that paramedics should insert PVCs with luminal diameters of ≥1.1 mm in patients with acute chest pain. Our results showed a significant reduction in use of PVCs of luminal diameter 0.7 mm and 0.9 mm to favor of 1.1 mm. In 2008, PVCs with a luminal diameter of 1.1 mm were inserted in 63% of patients, whereas in 2013 it was 71%, which should have reduced the risk of thrombophlebitis. Studies have shown that a smaller luminal diameter increases the risk of thrombophlebitis because small catheters allow more blood flow into adjacent tissues [
Paramedics who instigated PVC-based treatment did so in significantly more upper-arm locations in 2008 and 2013 (
2008 | 2013 |
---|---|
1 Ketogan Novum®, 5 mg/mL *Ketobemidone | 1 Morphine® diluted to 1 mg/mL and not diluted to 10 mg/mL *Morphine |
2 Ringer-Acetat® *Isotonic crystalloid solution | 2 Ringer-Acetat® *Isotonic crystalloid solution |
3 Stesolid novum® 5 mg/mL *Diazepam | 3 Perfalgan® 10 mg/mL *Paracetamol |
4 Adrenalin® 0.1 mg/mL *Adrenalin | 4 Stesolid novum® 5 mg/mL *Diazepam |
5 Furix® 10 mg/mL *Furosemide | 5 Zofran® 2 mg/mL *Ondansetron |
*Genericname
larger vein (e.g. in the forearm) in patients suffering from chest pain [
Significant increases in the prevalence of thrombophlebitis could be explained by inappropriate disinfection of skin in conjunction with PVC-based treatment [
One of the strengths of our follow-up study was that we could record changes over time that may have been affected by new work practices [
QI on the ward showed a significant reduction in the prevalence of thrombophlebitis. These findings emphasize the value of using systematic daily inspections and checklists to achieve quality and safety in healthcare. In improvement interventions regarding PVC-based treatment, the impact that healthcare professionals in other units has on patient care must be considered. In addition, patients must be encouraged to take part in the follow-up of improvement interventions.
The authors acknowledge the support of the Department of Cardiology, County Hospital Ryhov, Jönköping, Sweden. We would also like to express gratitude to the Medical Research Council of Southeast Sweden (FORSS) for financial support.
There are no conflicts of interest to disclose.
DanMalm,BoRolander,Eva-MarieEbefors,LisaConlon,AnnetteNygårdh, (2016) Reducing the Prevalence of Catheter-Related Infections by Quality Improvement: Six-Year Follow-Up Study. Open Journal of Nursing,06,79-87. doi: 10.4236/ojn.2016.62008