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Insertion of a peripheral access device is associated with risks including infection. This second article in a two-part series provides a guide to maintaining vessel health when a peripheral intravenous vascular catheter is inserted. 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
This article, the second in a two-part series, provides a step by step guide to maintaining vessel health when a peripheral intravenous vascular catheter is inserted. The article should be read in conjunction with part 1 of the series, which explores the principles of vessel health and preservation.
Citation: Hallam C, Denton A (2020) Vessel health 2: inserting a peripheral IV vascular cannula. Nursing Times [online]; 6, rapid online publication.
Authors: Carole Hallam and Andrea Denton are independent nurse consultants, AC Independent Nursing Consultants.
- Read part 1 of this series here
The concept of vessel health and preservation (VHP) was first introduced in the US in an attempt to provide a systematic approach to vascular access device (VAD) selection, insertion and ongoing maintenance (Moureau et al, 2012). The UK VHP framework, originally published in 2016 (Hallam et al, 2016), provided an adapted approach to the US version and has subsequently been updated in 2020 (Infection Prevention Society et al, 2020). The updated framework has incorporated evaluation and research studies from the initial framework (Weston et al, 2017; Hallam et al, 2016) and further international evidence-based studies linked to vein assessment, device selection and duration, suitability of medicines and evaluation/ongoing care and maintenance of the VAD. Key points for the procedure are outlined in Box 1.
Box 1. Key points in maintaining vessel health
- Is a VAD (specifically a PIVC) required for this patient at this time?
- Is there an alternative to IV therapy/access?
- Does the vessel health, nature and length of treatment indicate an alternative to a PIVC?
- Are there known difficulties with intravenous access (DIVA) for this patient? If yes, consult local policies/procedures
- Aseptic technique should be used for “any procedure that breaches the body’s natural defences” (Loveday et al, 2014)
- Hand decontamination is a fundamental component of any procedure involving an aseptic technique and should be performed at key moments – see My 5 Moments for Hand Hygiene (WHO, 2009)
- PIVC site should be cleaned with 2% chlorhexidine with 70% isopropyl alcohol (NICE, 2019; Loveday et al, 2014)
- Ultrasound-guided insertion of a PIVC should be used for veins graded 4 and only by health professionals trained in this procedure
- PIVCs should be secured with a sterile semipermeable transparent dressing or combination of sterile transparent semipermeable dressing with an integrated securement device (Marsh et al, 2018)
- All health professionals undertaking any procedure including ultrasound-guided PIVC insertion should be trained and competent in that procedure
- All registered nurses and nursing associates are accountable for any acts or omissions and delegation of any procedure/patient care
PIVC = peripheral intravenous vascular catheter; VAD = vascular access device
Health professionals must ensure they have had the relevant education and training and are equipped with the necessary skills, knowledge and competence to undertake insertion of a peripheral intravenous vascular catheter (PIVC). All registered nurses, including nursing associates, are accountable and may be required to explain their actions. Any delegation of a task or patient care to another health professional, patient, relative/carer also comes under the remit of the registered nurse who remains accountable (Nursing and Midwifery Council, 2019).
As discussed in Part 1 of this series the initial risk assessment prior to insertion of a PIVC should include whether there is a genuine need for intravenous (IV) access/therapy and question whether there a more suitable alternative available (Denton and Hallam, 2020). It is important that any VAD is clinically indicated. Risk assessment should also include a peripheral vein assessment to ensure that the grade of the vein is compatible with the nature of the IV therapy prescribed, the setting where treatment will be delivered – outpatient, long term or inpatient/acute care – and the length of time the PIVC is required.
Descriptors for each grade of the vein can be seen on the UK Vessel Health and Preservation 2020 framework, which is available for download here; grade 1 indicates there are 4-5 suitable veins that are visible and compressible and 3mm in diameter or larger (Van Loon et al, 2019) and grade 5 indicates no suitable veins can be located with ultrasound. For each grade there is also a column to indicate insertion management. All grades indicate that the PIVC should be inserted by a trained and competent health professional but as the grade increases the quality of vein decreases and the insertion management indicates additional steps for example ultrasound-guided technology (USG) for grade 4 (Blanco, 2019; Franco-Sadud et al, 2019; Van Loon et al, 2019) and referral for alternative VAD for grade 5.
Patients known to have difficult IV access (DIVA) should be referred to an IV specialist and have an individual pathway of care (Van Loon et al, 2019).
If USG is used, the health professional performing the procedure should be trained and deemed competent in its use. It is recommended that real-time USG is used as this can help reduce the total procedure time, needle insertion attempts and needle redirection (Franco-Sadud et al, 2019).
An aseptic technique should be used for any invasive procedure that poses a risk of infection including insertion of a PIVC. Poor aseptic non-touch technique and non-adherence to infection prevention and control precautions during the procedure can lead to the transfer of transient organisms which may lead to a localised or systemic infection (National Institute for Health and Care Excellence, 2017). Inadequate skin decontamination prior to the insertion of a peripheral cannula or other VAD may lead to infection from microorganisms that are already present on the skin including the patient’s own, for example Staphylococcus aureus (Loveday et al, 2014).
Non-sterile gloves are required for this procedure as there is a potential risk of exposure to body fluid. Sterile gloves are required if there is likely to be contact with a key part or key site. In this instance it is unlikely that sterile gloves will be required unless the vein needs to be re-palpated following skin disinfection.
Documentation should follow local policy and an PIVC insertion and maintenance bundle may be used in some areas; however, there is some uncertainty as to whether insertion and maintenance bundles are effective in reducing PIVC complications and bloodstream infections (Ray-Barruel et al, 2019). As a minimum documentation should include, the date and time of the procedure, the number of attempts to insert a PIVC, dressing(s) used and the name, signature and designation of the health professional undertaking the dressing; the type and gauge of the PIVC may also be included. If the procedure was undertaken by a trainee under supervision, then the name, signature and designation of the trainer is also required.
Procedure for insertion of a PIVC
- PIVC dressing pack or dressing pack
- Non-sterile gloves
- Cannula dressing
- Chlorhexidine gluconate in 70% isopropyl alcohol swab to clean the skin
- Sharps container
- Introduce yourself to the patient and check the patient’s identity by asking them to state their name and date of birth. This should be checked against the patient’s notes and wrist band and hospital number should also be cross checked.
- Explain the procedure and the rationale for PIVC insertion to the patient and gain their informed consent. It is important to check the patient’s previous history of PIVC insertion. This should include any history of difficult PIVC, whether ultrasound-guided cannulation was used, any history of infection or other complications such as extravasation and infiltration. The patient’s medical notes may also provide this information.
- Decontaminate hands with an alcohol-based hand rub (ABHR) – or with liquid soap and water if physically soiled or dirty or where there is potential to spread organisms that are alcohol resistant, for example Clostridioides difficile and other organisms that may cause diarrhoeal illnesses such as norovirus. ABHRs used must conform to British Standards (NICE, 2017).
- Prepare the environment for the procedure. If the procedure is in the patient’s own home, then a wipeable procedure tray dedicated for an aseptic procedure should be available. In acute healthcare settings a clean dressing trolley or clean procedure tray should be used. The surface should be cleaned with detergent or a detergent wipe to reduce the number of viable pathogenic organisms (Loveday et al, 2014).
- Collect the required equipment; checking the expiry date and that the packaging is intact. Open the sterile pack onto sterile field; a special sterile PIVC insertion pack may be available. Choice of PIVC should be based on the area where the catheter will be inserted and the smallest gauge should be selected – usually 20-24g (Gorski et al, 2016). The size of catheter and areas of insertion should also be guided by the type of therapy required. Certain medications may not be suitable via a PIVC and Medusa – the injectable medicines guide website – should be consulted.
- Perform hand hygiene using ABHR (or soap and water if ABHR is unavailable).
- Check the patient’s veins and palpated prior to cleaning the site. Areas of flexion, such as the elbow, should be avoided, and the device used should be no larger than a third of the vein diameter; anything greater can reduce blood flow and cause a thrombus (Sharp et al, 2016). There is evidence that the veins on the back of hands can be associated with PIVC failure (Marsh et al, 2018).
- If there are no palpable visible veins refer to the VHP framework and local guidelines. Local policy should determine the number of attempts that should be made prior to escalation. If a patient has had problems with cannulation in the past make a referral for an individual pathway of care (Van Loon et al, 2019).
- Clean the site with chlorhexidine gluconate in 70% isopropyl alcohol (NICE, 2019) and leave to dry.
- Perform hand hygiene using ABHR.
- Put on a clean disposable plastic apron and non-sterile gloves. Avoid touching any key/critical parts during the procedure including:
- The patient’s skin/vein entry point where the PIVC is to be inserted;
- The catheter that enters the vein;
- Underneath the injection port cap.
If any key parts are touched, the procedure should be stopped and restarted from the beginning using an aseptic non-touch technique.
- Insert the PIVC according to local policy. It is important that the vein is not re-palpated once the area has been cleaned and left to dry.
- If ultrasound-guided insertion is required, the equipment must be clean, and a sterile cover applied to the probe.
- Once the PIVC has been inserted flush it with sterile 0.9% sodium chloride to confirm vein placement and patency (Hill, 2019). The liquid should enter the vein easily, without causing the patient pain, and there should be no signs of infiltration]
- Apply a dressing suitable for a PIVC and the insertion area; the surrounding skin should be visible. A sterile semipermeable transparent dressing (Loveday et al, 2014) should be used or a combination of sterile transparent semipermeable dressing with an integrated securement device (ISD). ISDs can help to prevent micro movement and dislodgement of the device and subsequent failure (Marsh et al, 2018).
- Remove your gloves and apron and dispose of these prior to hand decontamination.
- Perform hand hygiene using ABHR.
- Dispose of waste into the correct waste stream as per local policy and procedures. Any sharps or pharmaceutical waste should be disposed of in the appropriate waste container; sharps should be disposed of at the point of use.
- Clean the trolley/tray with detergent or detergent wipe and store as per local policy and procedures.
- Perform hand hygiene.
- Update the patient records according to local policy.
Blanco P (2019) Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline. The Ultrasound Journal; 11: 27.
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Franco-Sadud R et al (2019) Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. Journal of Hospital Medicine; 14: E1-E22.
Gorski L et al (2016) Infusion Therapy Standards of Practice. Journal of Infusion Nursing; 39: 1S.
Hallam C et al (2016) Development of the UK Vessel Health and Preservation (VHP) framework: a multi-organisational collaborative. Journal of Infection prevention; 17, 65-72.
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