For clinicians - Management of Peripheral Intravenous Catheters Clinical Care Standard

What the standard says

A patient requiring medicines or fluids is assessed to identify the most appropriate route of administration for their clinical needs.

What this means for you

If a patient requires medicines or fluids, assess the patient to identify the most appropriate route of administration for their clinical needs before starting therapy. Consider whether another route of administration (for example, the oral, intramuscular, subcutaneous, rectal, intra-osseous or intra-peritoneal route) is appropriate, before using the IV route.

If all other routes of administration have been excluded and IV access is needed, assess whether peripheral or central venous access is appropriate by considering the:

• Patient’s medical history, age, clinical and vascular condition
• Expected duration of therapy
• Likelihood of repeated or prolonged administration of vesicants or irritants such as vancomycin, flucloxacillin, potassium or certain types of chemotherapy
• Patient’s history of infusion therapy and whether there were complications associated with its use – for example, difficulty locating suitable veins
• Availability of appropriate insertion sites and the likelihood of first-time insertion success
• Position of the patient during any planned procedures
• Patient’s lifestyle, body image, and preferences for therapy and location of the device, and whether therapy can be delivered safely in accordance with their preferences
• Availability of resources and ability to care for the device.

Insertion of a PIVC pre-emptively may be appropriate for patients at risk of clinical deterioration. Collection of pathology samples is not a valid reason to insert a PIVC; although this often happens in emergency departments, it can lead to unused PIVCs being left in. If frequent sampling is required, exceptions may be considered after individual assessment; examples include, fourth hourly troponin levels, to optimise patient comfort, or if there is difficult venous access. PIVCs should not be used to obtain blood cultures as this leads to an increased risk of contamination to the blood culture and PIVC.

By discussion with the patient, ascertain that they understand the need for IV therapy, especially if multiple device options are available, specific clinical issues about the therapy need to be raised, or the patient has concerns.

What the standard says

A patient requiring intravenous access receives information and education about their need for the device and the procedure. Their consent is obtained and they are advised on their role in reducing the risk of device-related complications.

What this means for you

Support the patient to have an active role in preventing PIVC-related complications by providing information and education – for example, by using the principles suggested in the IV-WISE discussion tool.

Unless it is an emergency, ensure that the need for IV access is discussed with, and understood by, the patient before the PIVC is inserted. This is especially important if several options are available for delivering therapy intravenously or there are specific clinical issues to raise. If a PIVC is required as part of another procedure, provide information about the PIVC when informing the patient about the procedure. If IV access is required in an emergency, ensure that information is provided to a relative or carer, if available.

Ask the patient about previous PIVC insertions to identify any concerns, such as difficulty with particular access sites, allergies to tapes or antiseptics, or certain sites where a PIVC should not be inserted. This will also help to identify whether insertion is likely to be difficult and whether assistance will be required to increase the chances of first-time insertion success.

Invite the patient to ask questions, and use methods such as teach-back to confirm they understand the information they have received. Continue to ask the patient if they have any concerns while the PIVC is in place and for at least 48 hours after it has been removed. This is important because it helps patients have informed discussions with their healthcare team, adhere to their care plan and participate in activities that may help to reduce the risk of PIVC-related complications.

What the standard says

A patient’s PIVC is inserted and maintained by clinicians who are trained and assessed as competent in current evidence-based practices for vessel health preservation and preventing device-related complications, relevant to their scope of practice. Insertion by a clinician working towards achieving competency is supervised by a clinician who is trained and assessed as competent.

What this means for you

Ensure that you complete training and education as specified by your health service organisation that is relevant to your scope of practice, and that you are assessed as competent in using and adhering to the current, evidence-based practices to preserve vessel health and prevent complications associated with using a PIVC. If you are working towards achieving competency, when you insert a PIVC ensure you are supervised by someone who has successfully completed a competency assessment of their practical skills and knowledge in this area.

Maintain continuing education to ensure that your practical skills and knowledge remain in line with current practice recommendations, and that your competency is maintained and documented according to your health service organisation’s policies.

What the standard says

A patient requiring a PIVC is assessed to identify the most suitable insertion site and PIVC (length and gauge) to meet their clinical needs and preferences for its location.

What this means for you

Identify a suitable insertion site by taking into account the potential risk of infection, mechanical complications and patient comfort, preferably using veins in the non-dominant arm. Ask the patient if they have a preference for the location of the PIVC, and follow their preference if this would allow safe administration of therapy. When choosing an appropriate site, consider for each patient:

• The condition of the patient’s skin and vasculature at the insertion site
• Any contraindication to choosing which limb, for example, axillary lymph node clearance, or presence of arteriovenous fistula
• How painful insertion might be for the patient
• Whether your expertise matches the complexity of the insertion procedure at the site so that the device can be inserted successfully on the first attempt; ultrasound may assist you to identify more appropriate sites.

Use a site that is likely to last the duration of the prescribed therapy to maximise dwell time and patient comfort. This means choosing a site that will promote self-care, prevent accidental removal or blockage, and facilitate the safe administration of therapy. Avoid areas of flexion unless clinically necessary; re-site cubital fossa IVs as soon as appropriate. Do not use veins in the lower extremities unless this is necessary; for example, because of a risk of tissue damage and local site complications in the upper extremities.

Choose the right peripheral device (length and gauge) by considering the type of therapy the patient needs, including whether the PIVC is to be used to administer contrast media for diagnostic purposes, and the duration of treatment. Use devices with safety-engineered protective features to reduce the risk of injury involving a sharp.

What the standard says

The likelihood of inserting a PIVC successfully on the first attempt is maximised for each patient, according to a health service organisation’s process for maximising first-time insertion success.

What this means for you

If the clinical presentation of a patient is such that the likelihood of inserting a PIVC successfully on the first attempt is low given your current experience in PIVC insertion, follow your health service organisation’s policy for guidance on how to maximise first-time insertion success. Strategies to optimise first-time insertion success include escalating to a more experienced clinician, using technology-assisted devices such as ultrasound, or adjunct supportive therapies such as local anaesthetics. For paediatric patients, consider using parental support or child play therapy to maximise the likelihood of successful insertion on the first attempt.

Difficult or unsuccessful insertions can cause bruising, thrombosis, delays in treatment, reduced access to veins for future health needs, and undue pain and anxiety for the patient. This is why it is important to conduct a thorough assessment of risk factors that may contribute to difficult insertion, ask the patient about whether they have had issues with PIVC insertions previously, and escalate as per your health service organisation’s policy when required to maximise first-time insertion success. If more than one attempt to insert the PIVC is required, specify the reason (for example, lack of more experienced staff to escalate to in the after-hours setting, or patient dehydration) in the patient’s medical record and act according to local policy.

What the standard says

A clinician inserting a patient’s PIVC uses standard precautions, including aseptic technique. The device is secured and a sterile, transparent, semipermeable dressing is applied unless contraindicated.

What this means for you

Insert and secure a PIVC using standard precautions, including aseptic technique.

Carry out a risk assessment to identify the standard precautions required to safely perform the procedure, including performing hand hygiene consistent with the ‘5 Moments for Hand Hygiene’, and adhering to aseptic technique. See Box 4 for standard precautions.

If there is hair at the insertion site, remove with clippers as shaving with a razor increases the risk of infection. Decontaminate the skin with 2% chlorhexidine gluconate in 70% alcohol unless contraindicated, allowing for appropriate cleaning and drying time.

Use a sterile, transparent, semipermeable dressing to secure the PIVC, and consider patient characteristics such as allergies to tapes. Secure the dressing, taking care not to contaminate the insertion site. Ensure that the dressing remains intact for the duration of the insertion to prevent complications such as unintended dislodgement.

Ensure that PIVCs are labelled in accordance with the National Standard for User-applied Labelling of Injectable Medicines, Fluids and Lines (the Labelling Standard, see Box 3).

Specifically, catheters must be identified when there is a risk of wrong route of administration (for example, where the patient entry port is distant from the administration site).

What the standard says

A patient with a PIVC will have documentation of its insertion, maintenance and removal, and regular review of the insertion site.

What this means for you

Ensure that the plan of care for a patient’s PIVC is recorded according to local policy in a place that is easily accessible to all clinicians involved in the patient’s care (see Box 5).

What the standard says

A patient’s PIVC and insertion site is inspected by a clinician for signs of complications at least once per shift or every eight hours, when accessing the device, and if the patient raises concerns. Standard precautions including aseptic technique are used when performing site care and accessing the PIVC. Patency is checked and flushing is performed at intervals according to local policy to assess device function and minimise risk of device failure.

What this means for you

Routinely inspect the PIVC and insertion site, for signs of complications that can lead to device failure. This should happen at least once per shift (or per eight hours) and when accessing the device, or if the patient raises any concerns about it. More frequent inspection may be required for some patients, or according to local policy, for example for paediatric patients. In particular, check:

• For signs of pain, swelling or redness at the insertion site, by visual inspection through the transparent dressing and gentle palpation through the dressing
• The condition of the patient’s veins, and whether they have become hardened or thrombosed
• For signs of localised or systemic infection; if either are confirmed, report as per local policy in an incident management system
• For leakage of fluid from the insertion site, signs of occlusion, infiltration or extravasation
• Whether the PIVC remains appropriately dressed and secured.

As part of the review, ask the patient questions to check whether they are tolerating their PIVC, and whether they understand why it is needed and the treatment they are having. Explain the reasons for checking the device, and the signs and symptoms you are looking for that might suggest that problems are developing.

Ask the patient if they have any concerns associated with the use of their PIVC and deal with these concerns. Check that the patient knows what signs and symptoms to report, including local site complications such as pain, redness, swelling, skin irritation or fever. Advise about the importance of telling their clinician if they think complications are developing so that they can be addressed immediately.

Use standard precautions, including aseptic technique, when accessing the PIVC or performing site care to help reduce the risk of PIVC-associated infections. Decontaminate needleless connectors before and after access with 70% alcohol or other solution recommended in current evidence-based or best-practice guidelines, and allow to fully air dry.

Flush the PIVC using a solution recommended in current evidence-based or best-practice guidelines and at intervals according to local policy, to maintain line patency, reduce the risk of blockage, and prevent mixing of incompatible medicines or fluids.

What the standard says

The ongoing need for a patient’s PIVC is reviewed and documented at least daily, or more often if clinically indicated.

What this means for you

Review and document the ongoing clinical need for a patient’s PIVC at least once per day, or more often if clinically indicated. Review whether switching from IV to oral therapy is possible. Remove the PIVC immediately if it is no longer required.

If extended IV therapy is anticipated, consider whether an alternative device, such as a peripherally inserted central catheter or central line, should be inserted (see Quality statement 1).

What the standard says

A patient with a PIVC will have it removed when it is no longer needed or at the first sign of malfunction or local site complications. A new PIVC will be inserted only if ongoing peripheral vascular access is necessary, consistent with the replacement recommendations in the current version of the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

What this means for you

Remove PIVCs as soon as they are no longer needed – for example, if a patient can tolerate oral therapy – or if complications occur. Signs and symptoms that indicate that the PIVC should be removed include:

• Pain and tenderness at the insertion site, with or without palpation
• Warmth, redness or swelling
• Leakage of fluid from the insertion site
• Resistance when flushing or absence of blood return.

Ensure removal and replacement of PIVCs is in accordance with the current version of the Australian Guidelines for the Prevention and Control of Infection in Healthcare. See Box 6 for a summary of the recommendations.

Document the reason for removal of the PIVC and the condition of the site. Observe the insertion site for 48 hours after the PIVC is removed for signs of post-infusion pain, redness or swelling. If the patient is discharged from hospital, explain what signs they should look out for after the PIVC is removed and who they should contact if signs of infection develop.

Replace with a new PIVC if ongoing vascular access is required. If extended IV therapy is anticipated, consider whether an alternative device, such as a peripherally inserted central catheter or central line, should be inserted (see Quality statement 1).

Consider re-siting PIVCs, within 24 hours, when adherence to aseptic technique is uncertain or unknown, such as insertion during a medical emergency.

For hospitalised patients, ensure that PIVCs are removed before discharge, unless the PIVC is intended to continue beyond discharge as part of the patient’s care plan.