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There is a range of venous-access devices available. This article, the first in a two-part series, outlines a framework designed to aid assessment, decision making and management of devices for individual patients. This article has been fast-tracked for online publication to respond to the corona virus crisis. An updated version, with a print-friendly PDF, will be published shortly
A high proportion of patients require cannulation for vascular access. Peripheral intravenous cannulas are most frequently used, which can cause complications and fail before completion of treatment. Other devices are available, and a framework was developed to aid health workers to choose, insert and assess the most appropriate for each patient. As research continues, the framework is being revised to reflect the latest recommendations. It outlines a framework designed to aid assessment, decision making and management of devices for individual patients. The article should be read in conjunction with part 2, which explains the procedure for inserting a peripheral intravenous cannula.
Citation: Hallam C, Denton A (2020) Vessel health and preservation 1: minimising the risks of vascular access. Nursing Times [online]; 116: 7, rapid online publication.
Authors: Carole Hallam and Andrea Denton are independent nurse consultants, AC Consulting.
- Read part 2 of this series here
Vascular access is an important process for the delivery of many treatments in hospitalised patients: over 80% receive a peripheral intravenous cannula (PIVC) during their hospital stay to deliver essential intravenous (IV) fluids, blood transfusions, analgesics, antimicrobials and other medications (Van Loon et al, 2019a). However, PIVCs remain associated with high rates of complications – including phlebitis (inflammation of the vein), thrombosis and infection, as well as discomfort to the patient (Loveday et al, 2014).
The one million global catheters study, carried out in 2014-15, aimed to compare insertion practices, management practices and outcomes of PIVCs with best practice (Alexandrou et al, 2018). The study analysed data about more than 40,000 PIVCs from 51 countries and found that 10% of the PIVCs caused signs of phlebitis and pain and a further 10% showed signs of malfunction. The study concluded that a stronger focus was needed on PIVC insertion, management and surveillance, as well as improved assessment and decision-making to reduce the risks associated with PIVCs (Alexandrou et al, 2018).
Research has shown that when vascular access is required, limited assessment is performed of the most appropriate device to use; PIVCs are often used as the default despite not being the best device for some patients (Hallam et al, 2016). They are the most commonly used vascular-access device (VAD) and insertion is often delegated to the least experienced staff members, who may be unclear of when to escalate issues (and to whom) and consider an alternative device (Jackson et al, 2013).
There is a high failure rate of PIVCs: up to 50% fail before completion of the intended treatment (Helm et al, 2015). Following insertion, there is often little consideration of the survival of the PIVC, and when the ante-cubital fossa is used for cannulation there is a high risk of dislodgement (Carr et al, 2016). The failure of the PIVC can result in delayed treatments, including analgesia, antibiotics and IV fluids (Alexandrou, 2014), and starts a negative cycle of numerous PIVCs being inserted into fragile veins, resulting in frustration for busy staff and most importantly a poor patient experience (Oliver, 2015). Sharing a personal experience, Horsfield (2014) described how in this negative cycle of cannulations she was given 14 PIVCs over 21 days during a hospital stay, subsequently developing a needle phobia.
Recent evidence suggests there is a group of patients with difficult IV access (DIVA) (Van Loon et al, 2019a; Ehrhardt et al, 2018); Van Loon et al (2019a) found that even the most experienced health professionals who regularly perform cannulation experience difficulty with this group, with up to a 19% failure rate at first-attempt cannulation. Traditionally DIVA patients are identified following numerous failed PIVC insertion attempts, but prospectively identifying these patients can reduce the failure rate of cannulation and improve their experience of care (Van Loon et al, 2019a).
The use of ultrasound-guided (USG) PIVC insertion is increasing and offers health professionals the opportunity to select veins that are not easily seen or palpated (Blanco, 2019). Although the use of USG to insert a PIVC requires additional skills, training and competency assessment, it increases the first-attempt success rate at cannulation significantly, thereby providing a better patient experience and reducing wastage of time and resources (Van Loon et al, 2019b). The use of USG PIVC is particularly important in DIVA patients; it increases the first-attempt success rate from 25-30% without USG to 90% with USG (Blanco, 2019).
There is a direct link between the length of the PIVC and its survival time; standard PIVC length is usually no more than 4.78cm, while extended-length PIVCs are up to 7cm (Bahl et al, 2019). The benefit of selecting a longer-length PIVC is it allows at least two-thirds of the catheter length to reside in the vein, making it less likely to irritate the vessel wall, which can cause chemical phlebitis and infiltration (Chopra el al, 2015). In a study of 255 patients, Bahl et al (2019) found the extended-length PIVC had an average dwell time of 132 hours, compared with a 96-hour average for the standard PIVC.
An alternative peripheral vein device is a midline; this is longer than a PIVC, with a length range of 8-20cm, and usually inserted into the upper arm (Gorski et al, 2016). The midline provides an advantage over the PIVC in that it is located in a larger and faster-flowing vessel of the upper arm (Simonov et al, 2015). As midlines do not reach the central veins, they should only be used for injectable medicines suitable for peripheral administration (Royal College of Nursing, 2016). Midlines can be used for the administration of medications such as antimicrobials, analgesics and fluid replacements that are normally tolerated by peripheral veins (Gorski et al, 2016); guidance suggests they are suitable to administer treatment for up to 14 days (Chopra et al, 2015).
PIVCs and midlines should not be used to administer vesicant drugs, parenteral nutrition or infusates with an osmolarity greater than 900 mOsm/L, due to the potential damage to the vessel (Gorski et al, 2016; Royal College of Nursing, 2016). Guidance relating to osmolarity levels changed in 2016, increasing from 600 to 900 mOsm/L in guidance published by both the Infusion Nurses Society (Gorski et al, 2016) and the RCN (2016). There are over 300 injectable medicines listed on the Medusa injectable medicines guide website, hosted by NHS Wales Informatics Service (medusa.wales.nhs.uk), all of which have the potential to cause damage to the vessel used for administration. The Medusa website provides information on each of the injectable medicines, including pH and osmolarity levels.
Central venous-access devices (CVADs) are used to facilitate the delivery of medications and solutions into the large central veins and include peripherally inserted central catheters (PICCs), non-tunnelled central venous catheters, tunnelled central venous catheters and implanted ports (RCN, 2016). The advantage of CVADs is that they can be used to administer all injectable medicines, due to the central vessels being larger, providing greater haemodilution, reducing the risk of chemical phlebitis and ensuring fast distribution of medication and fluids with rapid clinical effect (Moureau and Alexandrou, 2019).
Guidance for use
To ensure vessel health and preservation, a proactive approach to vascular access is required, rather than a reactive one that can cause pain and damage to vessels and limit further vascular-access options (Moureau et al, 2012). Assessing patients who require vascular access in a proactive and timely way results in intentional placement of the right device to reduce vessel damage and preserve vessels for future use (Moureau et al, 2012). This has the potential both to improve patient experience and to reduce complications and costs in consumables and health professionals’ time (Hallam et al, 2016).
Developing a framework
In 2016, the UK vessel health and preservation (VHP) framework was developed to help address the need for assessment and decision making around VADs (Hallam et al, 2016). Its development was led by the Infection Prevention Society in collaboration with the National Infusion and Vascular Access Society and the RCN, adapting a concept published by Moureau et al (2012) to provide a patient-centred assessment for the most appropriate device to deliver the course of treatment.
The VHP framework was designed as a poster providing visual and straightforward guidance to aid frontline staff with assessment and decision making for suitable VADs for patients requiring vascular access (Hallam et al, 2016). The first and most important question in the VHP framework is whether there is a “genuine need for vascular access”, prompting consideration of alternative routes for administering medication such as oral, nasal or rectal. These alternative routes may provide options with a much lower risk of complications.
The VHP framework has four sections:
- A vein-assessment tool, with a scale of 1-5 for the quality of peripheral veins;
- A medication suitability section, about the safety of the drugs to be given alongside consideration of central vein administration;
- An algorithm for VAD choice, based on vein quality, drug choice and duration of treatment;
- An evaluation section, for daily assessment of the VAD to monitor any complications.
In a small-scale study that explored the impact of using the framework on the insertion and management of VADs on a haematology ward, Weston at al (2017) found an increase in placement of appropriate alternative devices, with reduced time from patient admission to insertion of the most appropriate VAD. The study also showed a significant (approximately 30%) decrease in PIVC placement and found the framework had empowered frontline staff to escalate issues so patients could receive an alternative device (Weston et al, 2017).
Revising the framework
The original VHP framework was evaluated within the first year, using an outcome logic model to measure its short- and medium-term impact and success (Burnett et al, 2017). This evaluation study found that many respondents were aware of the framework and were using it in a range of different ways. Participants reported that the framework was most beneficial in aiding decisions on device choice and peripheral vein assessment and improving clinical practice (Burnett et al, 2017).
The VHP framework, available as a poster for download here, was revised in 2020, incorporating studies published after it was originally printed in 2016. Of these studies, three were paramount in its development. The first, called the MAGIC (Michigan appropriateness guide for intravenous catheters) study, assessed the appropriateness of over 600 scenarios of patients given PICCs and found that 43% were inappropriate. The study provided a matrix for preferred alternatives, including USG PIVCs (Chopra et al, 2015). The matrix also lists appropriate VAD duration, taking account of proposed infusion duration (Chopra et al, 2015). This has altered the suggested VAD duration from the original VHP framework, which was guided by the epic3 guidance on infection prevention and control (Loveday et al, 2014). Table 1 compares the two.
Table 1. Comparison of recommended device duration
|Device||epic3 (Loveday et al, 2014)||MAGIC (Chopra et al, 2015)|
|PIVC||Up to 7-10 days||Up to 5 days|
|Midline||1-4 weeks||6-14 days|
|USG PIVC||N/A||Up to 14 days|
|PICC||4 weeks – 6 months||>6 days|
|Non-tunnelled CVAD||Up to 7-10 days||Up to 14 days|
|Tunnelled CVAD||Months or years||>15 days|
|Implanted port||Months or years||>30 days|
The second study of note highlighted the importance of recognising adult DIVA patients and developed a scale to identify them, called the A-DIVA scale (adult difficult intravenous access scale) (Van Loon et al, 2019a). It concluded that there five variables contributed to difficult vascular access: failed peripheral intravenous cannulation on the first attempt, a previous history of difficult intravenous cannulation, difficult intravenous access as expected by the practitioner, the inability to detect a dilated vein by palpating and/or visualising the extremity, and finally a diameter of the selected vein less of than 3mm. The study used a multicentre approach and over 3,500 adult participants to validate the A-DIVA scale.
The third study included in the review of the VHP framework was the development of the I-DECIDED tool (Ray-Barruel et al, 2020): this is an evidence-based PIVC-assessment and decision-making tool with ‘I-DECIDED’ used as an acronym to aid assessment and prompt removal of the device if needed:
- Identifying if there is a VAD in situ;
- Does the patient need the device;
- Effective function, following local policy for flushing and locking;
- Complications check,
- Infection prevention, including hand hygiene and scrubbing the hub of the VAD;
- Dressings and securement;
- Evaluate and educate;
- Document and record the decision.
The I-DECIDED tool was tested in three different hospitals using an interrupted time-series study and concluded that a pain score of ≥2/10 was a valid complication of PIVCs (Ray-Barruel et al, 2020).
In addition, the VHP framework’s 2020 update says USG PIVCs for therapy are suitable for peripheral administration for a duration of 6-14 days and suggests a combination of USG PIVC or midline is preferable for DIVA patients. The suggested duration of midlines has changed from up to 28 days in the original VHP framework to up to 14 days in the revised version, following Chopra et al’s (2015) MAGIC guidelines. However, the revised framework states that use may be extended beyond the recommended time if no complications are noted and it remains clinically indicated with at least a daily review.
The revised VHP framework continues to provide a vein assessment tool using a scale of 1-5. Additionally it recognises DIVA patients, suggesting they are referred to a vascular access specialist and will require an individualised pathway.
Further changes are seen in the revised framework’s section on suitability of medicines. It states that when assessing the suitability of an infusion to be administered via a PIVC, it is important to consider that all IV medicines potentially pose a threat to vessel health. The safety of a medicine infusate and the prevention of damage to a vessel relate to factors such as pH and osmolarity. However, the updated framework does not provide specific levels for a CVAD, saying only than a CVAD should be the preferred device to administer infusions of vesicant chemotherapy and parenteral nutrition. Instead, the framework says that some medicines given by IV injection will have a high osmolarity and diluting the injection with sodium chloride 0.9% or glucose 5% before administration will reduce the osmolarity. The VHP framework continues to reference the Medusa injectable medicines guide for further information. The following statement has also been added:
“The use of a CVAD is specified for some medicines in the Summary of Medicine Product Characteristics, which is available for all medicines. Where this is the case the recommendation to use a CVAD should be followed.”
Daily inspection of all VADs is recommended, to assess for any complications (Gorski et al, 2016; Loveday et al, 2014) but also to evaluate whether the device is still needed and is the most appropriate device for the patient at that time (Hallam et al, 2016). This is reflected by the evaluation section of the revised VHP framework, which starts with the question ‘does the patient still need IV therapy?’ and asks health professionals to consider ‘has the device been used in the last 24 hours, or [is it] unlikely to be used in the next 24 hours?’ It then lists the following three questions to assess the VAD:
- Are there problems with the functioning of the device?
- Are there any complications present?
- Dressings and securement – are there any complications present?
Following the work of Ray-Barruel et al (2020), the revised VPN framework includes pain as a complication indicator when it is reported as a score of ≥2/10 in the daily evaluation. Complications or problems with the functioning of the VAD may indicate that it is not the most appropriate device to deliver the intended treatment for the patient. This signals that evaluation is required to determine whether the VAD is still appropriate and, if necessary, the framework’s decision tool should be reapplied. The framework includes a list of secondary questions in order to consider individual patient factors when selecting the most appropriate VAD. These include the need to avoid vein damage from PICC or axillary/subclavian catheters for patients who might need long-term dialysis with an arteriovenous fistula.
The original and revised VHP frameworks were developed to be used by frontline staff and IV teams, either as a whole framework or in parts, in order to aid assessment and decision making in selecting and maintaining the right VAD for individual patients. it was essential to update the framework to ensure it continues to provide up-to-date evidence to help maintain best practice in vascular access now and in the future.
Vascular access will continue to be common practice in the administration of medicines and essential fluids to patients. It is important that vessel health is assessed for each individual patient requiring vascular access, in order to protect their veins, minimise damage and complications and provide them with the optimum experience.
The VHP working group is aware of large studies being conducted at present, including a large randomised control trial to determine which VAD offers the best outcome for safety, clinical effectiveness and cost effectiveness. As before, these studies may lead to further changes to the framework.
- Most inpatients require cannulation, and some can be identified as having difficult intravenous access
- Peripheral intravenous cannulas are most common, despite their rate of complications and failure
- A framework was developed to aid assessment and decision making around venous-access devices
- It has been updated to reflect recent research into selection and management of devices
Alexandrou E et al (2018) Use of short peripheral intravenous catheters: characteristics, management, and outcomes worldwide. Journal of Hospital Medicine; 13: 5.
Alexandrou E (2014) The one million global catheters PIVC worldwide prevalence study. British Journal of Nursing; 23: 8, 16-17.
Bahl A et al (2019) Standard long IV catheters versus extended dwell catheters: a randomized comparison of ultrasound-guided catheter survival. American Journal of Emergency Medicine; 37: 4, 715-721.
Blanco P (2019) Ultrasound‑guided peripheral venous cannulation in critically ill patients: a practical guideline. The Ultrasound Journal; 11: 27.
Burnett E et al (2017) Vessel health and preservation framework: use of the outcome logic model for evaluation. Journal of Infection Prevention; 19: 5, 228-234.
Carr P et al (2016) Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the vascular access decisions in the emergency room (VADER) study protocol. British Medical Journal Open; 11: 6, 2.
Chopra V et al (2015) The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Annals of Internal Medicine; 163: 6, 1-48.
Ehrhardt B et al (2018) Making it stick: developing and testing the difficult intravenous access (DIVA) tool. American Journal of Nursing; 118: 7, 56-62.
Gorski L et al (2016) Infusion therapy standards of practice. Home Healthcare Now; 35: 1, 10-18.
Hallam C et al (2016) Development of the UK vessel health and preservation (VHP) framework: a multi-organisational collaborative. Journal of Infection Prevention; 17: 2, 65-72.
Helm RE et al (2015) Accepted but unacceptable: peripheral IV catheter failure. Journal of Infusion Nursing; 38: 3, 189-203.
Horsfield C (2014) A personal experience of care and the lack of it. Journal of Infection Prevention; 15: 3, 82-83.
Infection Prevention Society, National Infusion and Vascular Access Society, Royal College of Nursing (2020) UK Vessel Health and Preservation 2020.
Jackson T et al (2013) Right line, right patient, right time: every choice matters. British Journal of Nursing; 22: 8, 26-28.
Loveday HP et al (2014) Epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals. Journal of Hospital Infection; 86: 1, 1-70.
Moureau N, Alexandrou E (2019) Device selection. In: Moureau N (ed). Vessel Health and Preservation: The Right Approach for Vascular Access. Springer International Publishing.
Moureau NL et al (2012) Vessel health and preservation (part 1): a new evidence-based approach to vascular access selection and management. Journal of Vascular Access; 13: 3, 351-356.
Oliver G (2015) Whose line is it anyway? British Journal of Nursing; 24: 2, S3.
Ray-Barruel G et al (2020) The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation. British Medical Journal Open; 10: e035239.
Royal College of Nursing (2016) Standards of Infusion Therapy.
Simonov M et al (2015) Navigating venous access: a guide for hospitalists. Journal of Hospital Medicine; 10: 7: 471-478.
Van Loon F et al (2019a) The modified A-DIVA scale as a predictive tool for prospective identification of adult patients at risk of a difficult intravenous access: a multicenter validation study. Journal of Clinical Medicine; 8: 2, 144.
Van Loon F et al (2019b) Establishing the required components for training in ultrasound guided peripheral intravenous cannulation: a systematic review of available evidence. Medical Ultrasound; 21: 4, 464-473.
Weston V et al (2017) The implementation of the vessel health and preservation framework. British Journal of Nursing; 2: 8, S18-S22.