Tools, Clinical Prediction Rules, and Algorithms for the Insertion of Peripheral Intravenous Catheters in Adult Hospitalized Patients: A Systematic Scoping Review of Literature
BACKGROUND: First-time peripheral intravenous catheter (PIVC) insertion success is dependent on patient, clinician, and product factors. Failed PIVC insertion are an under-recognized clinical phenomenon.
OBJECTIVE: To provide a scoping review of decision aids for PIVC insertion including tools, clinical prediction rules, and algorithms (TRAs) and their findings on factors associated with insertion success.
METHODS: In June 2016, a systematic literature search was performed using the medical subject heading of peripheral catheterization and tool* or rule* or algorithm*. Data extraction included clinician, patient, and/or product variables associated with PIVC insertion success. Information about TRA reliability, validity, responsiveness, and utility was also extracted.
RESULTS: We screened 36 studies, and included 13 for review. Seven papers reported insertion success ranging from 61%-90% (4030 insertion attempts), 6 on validity, and 5 on reliability, with none reporting on responsiveness and utility. Failed insertions were associated with obesity (odds ratio [OR], 0.71-1.7; 2 studies) and smaller gauge PIVCs (OR, 6.4; 95% Confidence Interval [CI}, 3.4-11.9). Successful inser tions were associated with visible veins (OR, 0.87-3.63; 3 studies) or palpable veins (OR, 0.79-5.05; 3 studies) and inserters with greater procedural volume (OR, 4.4; 95% CI, 1.6-12.1) or who predicted that insertion would be successful (OR, 1.06; 95% CI, 1.04-1.07). Definitions of insertion difficulty are heterogeneous such as time to insert to a number of failed attempts.
CONCLUSION: Few well-validated reliable TRAs exist for PIVC insertion. Patients would benefit from a validated, clinically pragmatic TRA that matches insertion difficulty with clinician competency.
© 2017 Society of Hospital Medicine
Up to a billion peripheral intravenous catheters (PIVCs) are inserted annually; therefore, the importance of this invasive device in modern medicine cannot be argued.1 The insertion of a PIVC is a clinical procedure undertaken by a range of clinical staff and in a variety of patient populations and settings. In many clinical environments (for example, the emergency department [ED]), PIVCs are the predominant first-choice vascular access device (VAD).2,3 Researchers in one study estimated over 25 million PIVCs are used in French EDs each year,3 and intravenous therapy is the leading ED treatment in the United States.4
The purpose of this systematic scoping review was to investigate what PIVC decision-making approaches exist to facilitate FTIS of PIVCs in adult hospitalized patients. Our intention was to systematically synthesize the research on TRAs, to review significant associations identified with these TRAs, and to critique TRA validity and reliability.
METHODS
Scoping Review
We selected a scoping review method that, by definition, maps the evidence to identify gaps,13,14 set research agendas, and identify implications for decision making. This allowed a targeted approach to answering our 3 research questions:
- What published clinical TRAs exist to facilitate PIVC insertion in adults?
- What clinical, patient and/or product variables have been identified using TRAs as having significant associations with FTIS for PIVCs in adult patients?
- What is the reported reliability, validity, responsiveness, clinical feasibility, and utility of existing TRAs for PIVC insertion in adults?
Our aim was to identify the amount, variety and essential qualities of TRA literature rather than to critically appraise and evaluate the effectiveness of TRAs, a process reserved for systematic review and meta-analysis of interventional studies.13,14 We followed scoping review guidelines published by members and collaborators of the Joanna Briggs Institute, an internationally recognized leader in research synthesis, evidence use, and implementation. The guidance is based on 5 steps: (i) scoping review objective and question, (ii) background of the topic to support scoping review, (iii) study selection, (iv) charting the results, and (v) collating and summarizing results.15 Clinicometric assessment of a TRA or any clinical prediction rule requires 4 specific phases: (i) development (identification of predictors from data), (ii) validation (testing the rule in a separate population for reliability), (iii) impact analysis or responsiveness (How clinically useful is the rule in the clinical setting? Is it resource heavy or light? Is it cost effective?), and (iv) implementation and adoption (uptake into clinical practice).16
Search Strategy
We included studies that described the use or development of any TRA regarding PIVC insertion in the adult hospitalized population.
Inclusion Criteria
Studies were included if they were published in the English Language, included TRAs for PIVC insertion in adult hospital patients, and prospectively assessed a clinical category of patient for PIVC insertion using a traditional approach. We defined a traditional PIVC insertion approach as an assessment and/or insertion with touch and feel, therefore, without vessel-locating technology such as ultrasound and/or near infrared technology.
Exclusion Criteria
Exclusion criteria included pediatric studies, authors’ personal (nonresearch) experience of tools, TRAs focused on postinsertion assessment of the cannula (such as phlebitis, infiltration, and/or dressing failure), and papers with a focus on VADs other than PIVCs. We excluded studies using PIVC ultrasound and/or near infrared technology because these are not standard in all insertions and greatly change the information available for pre-insertion assessment as well as the likelihood of insertion success.
