Peripheral intravenous catheters: the road to quality improvement and safer patient care

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Summary

Huge success has been noted internationally in reducing catheter-related bloodstream infection with ‘care bundles’ for central venous catheters in intensive care units. A multidisciplinary team from the Infectious Diseases Unit at Ninewells Hospital, Dundee designed a ‘bundle’ for peripheral venous catheters (PVCs) based on drafts developed by Health Protection Scotland (details available online). A senior medical student collected weekly data, carried out monthly ‘plan, do, study, act’ (PDSA) cycles and displayed the results on the ward in real time. Data consisted of measures to assess objectively clinical performance for insertion (recording date, indication and location) and maintenance (daily review of necessity, clinical appearance of site, duration less than 72 h and timely removal). Care bundle compliance was assessed for each patient and percentage compliance plotted weekly. The initial compliance of 54% improved by 1.11% per week to 82% (95% confidence interval: 0.6–1.6%; P = 0.0001). This was attributed to multiple interventions including daily assessment of PVC necessity, weekly audit and feedback, monthly patient safety meetings to discuss issues with compliance, the introduction of new PVC dressings and the promotion of new PVC care plans. In conclusion, we demonstrated a significant improvement in PVC management on a single unit by using a care bundle approach. In order to improve compliance, further implementation of the PVC care bundle throughout the hospital has been necessary.

Introduction

Bloodstream infections are life threatening, common and can be preventable. A reduction in cases of Staphylococcus aureus bacteraemia (SAB) has consistently remained one of the core performance targets for the UK’s National Health Service (NHS) over recent years. A further reduction of 15% of cases by 31 March 2011 is a new NHS Scotland treatment target which necessitates new approaches to be taken.1 The successful reduction of catheter-related bloodstream infection (CRBSI) by using central venous catheter (CVC) care bundles in intensive care units has been widely published on an international scale.2, 3, 4 These ‘bundles’ are now deemed standard practice in the UK.5 Peripheral venous catheters (PVCs), such as those routinely inserted in busy admissions units all over the UK, can also cause infection, ranging from local phlebitis to cellulitis to severe sepsis.6 Data regarding the frequency of phlebitis or cellulitis related to PVCs is not routinely collected; however, data concerning patients with SAB is collected by infection control practitioners in our hospital, who investigate all cases and assess relationship to PVCs. Between May and October 2007, 10% of all SABs in our hospital were associated with PVCs (unpublished data) which is in line with the 11% estimated in the wider community of UK hospitals.7 The Scottish National Prevalence Survey highlighted that as many as one in three of all in patients in the UK have at least one PVC in situ.

The NHS in Scotland is divided into 14 regions. NHS Tayside provides publicly funded healthcare to about 400 000 residents in eastern Scotland and incorporates Ninewells Hospital, Dundee, which is one of the largest teaching hospitals in the UK. Staff across NHS Tayside have been working alongside experts from the Institute for Healthcare Improvement (Boston, MA, USA) and The Health Foundation (London, UK) since they piloted the Safer Patients Initiative (SPI) in 2004. The success of the SPI resulted in the development of the Scottish Patient Safety Programme (SPSP) in 2007 which has emphasised a reduction in healthcare-acquired infection (HAI), with the fundamental objective being to prevent unnecessary patient harm from medical intervention. By implementing a care bundle approach to the management of PVCs it may be possible to reduce the incidence of PVC-related infection. The aims of this study were to introduce a ‘PVC bundle’ as a tool to improve the management of PVCs, and to audit compliance over a 25 week period, with feedback in real time, to assess sustainability of this quality improvement measure with the long term goal being to implement the PVC bundle throughout NHS Tayside.

Section snippets

Methods

This study was carried out at the Infectious Diseases Unit (IDU) in Ninewells Hospital, Dundee between September 2007 and March 2008. This is an 18-bedded unit consisting mainly of single rooms. Although the majority of patients are under the care of the infectious diseases team, the unit also has a few patients from general medical specialties. It was considered the ideal site to pilot and test an improvement project aimed at eventually reducing infection across NHS Tayside, as it is a

Results

One hundred PVCs were analysed over a 25 week study period, with an average of four PVCs/week. Overall, there was a gradual improvement in compliance with the PVC bundle (Figure 2). Regression analysis was used to calculate the gradient of the trendline and its statistical significance, m = 1.106 [95% confidence interval (CI): 0.614–1.598; P = 0.0001]. A steady and sustained improvement in completion of the bundle by 1.11% per week (95% CI: 0.6–1.6%; P = 0.0001) corresponds to an improvement of about

Discussion

Care bundles were introduced by the Institute for Healthcare Improvement (IHI) in order to help healthcare providers improve the reliability of the delivery of evidence-based healthcare processes.11 They are defined as ‘a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are ‘bundled’ together and, when combined, significantly improve patient care outcomes.’12 This 25 week study was a pilot

Acknowledgements

We thank the patients, students and staff in Ninewells Hospital and Medical School, Dundee, Scotland, UK; with particular thanks to Miss E. Burnett and Miss G. Stevenson from the Infection Control Team and Dr S. Ogston for his assistance with statistical analyses.

References (24)

  • J. Reilly et al.

    NHS Scotland national HAI prevalence survey. Final report 2007

    (2007)
  • G. Langley et al.

    The improvement guide: a practical approach to enhancing organizational performance

    (2009)
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