The use of a securement bundle to prevent peripheral intravenous catheter failure

Background: Peripheral intravenous catheters (PIVCs) are the most common invasive medical device and up to 70% of hospitalised patients require one or more during their hospital stay. However, up to 69% of PIVCs fail before treatment is complete, resulting in pain and discomfort for patients from reinsertion attempts, and financial liability for healthcare institutions. Effective PIVC dressing and securement is an important nurse-led strategy to prevent PIVC complications and failure; however, the most effective way of achieving this is yet to be determined. PIVC securement bundles are a multiproduct combination consisting of a primary dressing and securement in addition to supplementary securement products to provide extra stability. Despite growing evidence that a single dressing or securement product is not effective at preventing PIVC complications and failure, there has been very limited research attention to date on the concept of a securement bundle for the prevention of PIVC failure. Aims and objectives The overarching aim of this PhD was to investigate the use of a securement bundle to reduce PIVC complications and failure. There were three objectives guiding the research: 1) describe global usage of dressing and securement products, including supplementary securements, to secure PIVCs; 2) determine associations between (a) PIVC dressing and securement products, individually and in combination, and PIVC complications, and (b) patient, PIVC, and institutional factors, and suboptimal dressing integrity; and 3) establish the feasibility of testing securement bundles to prevent PIVC complications and failure in a pilot randomised controlled trial (RCT). Design Two frameworks were used to guide this research. The Vessel Health and Preservation Framework was used to contextualise this research within the PIVC continuum of care. The methodological framework underpinning the research methods was the Canadian Critical Care Trials Group programmatic model of research. This work was informed by an integrative review of contemporaneous literature regarding medical adhesive tapes and supplementary securement products and consisted of two phases: a secondary analysis of an existing data set of PIVC insertion, maintenance, and outcome data; and a pilot RCT testing two dressing and securement bundles against standard care for the prevention of PIVC complications and failure. Phase 1 Study design: Secondary analysis of a global cross-sectional study of PIVC characteristics, management, and outcomes. Setting: 407 rural, regional, and metropolitan hospitals in 51 countries. Sample: 40,637 PIVCs in paediatric and adult patients. Measurements: Institution, PIVC, and patient-level data were collected in the parent study. Selected data were extracted from the parent study data set for the secondary analysis, specifically those focusing on PIVC dressing and securement policy and practice. Main results: Dressing and securement practices, and local hospital policy regarding dressing change frequency varied. One-fifth of dressings (21%, n = 8519) were not clean, dry, and intact. The prevalence of PIVC insertion site complications was 16% (n = 6503), with signs of phlebitis commonly observed (11.5%, n = 4587). Compared to non-bordered polyurethane dressings, sterile gauze and tape dressings were associated with fewer insertion site complications (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.50, 0.68) and better dressing integrity (OR 0.68; 95% CI 0.59, 0.77). Compared with no securement, non-sterile tape at the insertion site was associated with more site complications (OR 2.39, 95% CI 2.22, 2.57) and poorer dressing integrity (OR 1.64, 95% CI 1.51, securement combinations were associated with fewer site and dressing complications, compared with a bordered polyurethane dressing and non-sterile tape. Local PIVC guidelines advocating 4-hourly insertion site inspection (OR 0.84, 95% CI 0.72, 0.98) and dressing replacement between 1 3 days (OR 0.80, 95% CI 0.71, 0.90) were associated with better PIVC dressing integrity than those inserted prehospital (OR 1.84, 95% CI 1.52, 2.24); or with no documentation of site assessment within the last 24 hours (OR 1.63, 95% CI 1.54, 1.72); and the absence of hospital PIVC insertion and maintenance guidelines (OR 2.58, 95% CI 2.38, 2.81). Phase 2 Study design: A non-masked, single centre, three-group pilot RCT. Setting: General medical/surgical wards of a large quaternary hospital in Queensland, Australia. Sample: Adult patients requiring a PIVC for > 24 hours, who had no laboratory-confirmed positive blood culture within 24 hours of screening. Interventions: Participants were randomised into one of three groups: 1. Standard care sterile with Border 1635, 10.5 x 8.5cm, 3M, St Paul, Minnesota, USA); plus two non-H Soft Cloth Surgical Tape, 3M, St Paul, Minnesota, USA). 2. Securement bundle 1 one sterile tape strip in chevron pattern around PIVC hub and one sterile tape strip over hub (Steri- Minnesota, USA); plus Standard care 3. Securement bundle 2 Bundle 1; plus non-compression tubular bandage (Tubifast, Mölnlycke Heath Care, Belrose, Australia). Outcome measures: The primary outcome was the feasibility of conducting a fully powered definitive RCT based on a composite of eligibility, recruitment, retention, protocol fidelity, missing data, participant/staff satisfaction at insertion and removal, and the ability to provide effect estimates. Secondary outcomes included: PIVC failure, PIVC dwell time, adverse skin events, PIVC colonisation and cost. Main results: Of 109 randomised participants, 104 were included in final analyses. Feasibility outcomes were met, except for the eligibility criterion (79%) indicating that screening processes should be streamlined. Absolute PIVC failure was 38.2% (13/34) for Bundle 2, 25% (9/36) for Bundle 1, and 23.5% (8/34) for Standard care. The incidence rate ratio for PIVC failure/1000 catheter days, compared to Standard care, was 1.1 (95% CI 0.4, 2.7) and 2.1 (95% CI 0.9, 5.1) for Bundles 1 and 2, respectively. The incidence of adverse skin events, commonly bruising, was 13%. Additional securements, either non-sterile tape and/or a tubular bandage, were applied in 45% of PIVCs; however, this practice occurred more commonly in the standard care arm compared to the securement intervention arms. Conclusion: Global PIVC dressing and securement practice is associated with site complications and poor dressing integrity, both of which are highly prevalent in clinical practice. Phlebitis symptoms and poor dressing integrity are associated with the use of non-sterile tape at the PIVC insertion site, and this practice should be de-implemented. This research introduced the novel concept of securement bundles as an intervention to address current high PIVC failure rates and showed promising results, with three of the four bundles tested in a secondary analysis of a large global data set being significantly associated with fewer site complications, and two of the four associated with fewer dressing complications. Subsequent pilot testing of two securement bundles against standard care demonstrated it is feasible and safe to conduct a large definitive trial testing this intervention to address PIVC failure. Importantly, the interventions were acceptable to staff and participants. Nurses commonly apply reinforcements to PIVC dressings, the reasons for which are not clear and require further exploration. Innovative dressing and securement solutions are needed to reduce unacceptable PIVC failure rates, and securement bundles should be investigated as a matter of priority to improve patient outcomes. This doctoral research program has advanced the understanding of the role of dressing and securement in PIVC failure, demonstrated that securement bundles should be tested in a definitive trial, and has made an important contribution to addressing the pervasive problem of PIVC failure.

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