​ECRI and the ISMP PSO Patient Safety Brief

• Staff had a difficult time inserting the intravenous (IV) line needed. It required seven or eight attempts to achieve a successful insertion.

• A patient who previously had a complete mastectomy on one side had three IV lines and an A line on the affected extremity and was not wearing a 'restricted' arm band. The patient was given a 'restricted extremity' bracelet, access on the patient's other side was gained, and all lines were removed from the restricted side.

• The patient's arm, where an IV line had been placed a few days prior, was very red, warm, and swollen. An infectious disease consult was requested, and antibiotics were adjusted. Surgical intervention may be needed. 

Situation

In the United States, nearly 200 million peripheral intravenous catheters (PIVCs) are inserted annually; moreover, PIVCs are the most common invasive devices used in inpatient care. However, from 35% to 50% of PIVC insertions result in failures.

Background

The ECRI and the ISMP PSO reviewed 27,320 events related to PIVC complications that occurred in 2019. Of these events:

• 6,119 were related to infection.
• 21,201 events were noninfection-related, and included phlebitis, presence of infiltrates, burns, leaks, redness, erythema, swelling, draining, and ecchymosis. 
  

Assessment

Complications associated with PIVCs may be inconsistently coded or reported, resulting in a muddied picture of the organization's exposure to risk regarding PIVC failure. However, complications associated with PIVC can result in worse outcomes, such as increased length of stay, cost, and risk of mortality.

Recommendations

ECRI and the ISMP PSO recommends the following:

• Consider establishing formal, multidisciplinary vascular-care service lines, led by a certified vascular access professional. In cases where this is not feasible, such as outpatient or ambulatory settings, establish evidence-based policies, procedures, and competencies following national standards and guidelines.
• Set and uphold a goal of line placement in as few attempts as possible—e.g.,  two attempts.
• Ensure that appropriate catheters are selected for the patient and intended use. Likewise, ensure that catheters are secured with appropriate, proven technology.
• When training or reviewing competence of clinicians and staff who insert and care for PIVCs, focus on forearm placement, and ensure that anatomic "complication zones," such as antecubital areas and joints, are avoided as appropriate. Likewise, review appropriate use of ultrasound technology to confirm line placement. Further, review preinsertion disinfection and preparatory practices, such as use of a sterile line placement kit, use of sterile technique and components, and alcohol application prior to insertion.
• Establish a limit of 72 hours (or as clinically indicated) for line dwell time in adults.