Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide

Approval was granted by the Griffith University Human Research Ethics Committee in Australia (reference number NRS/34/13/HREC). In addition, evidence of study site and local institutional review board/ethics committee approval was required prior to study commencement. Each participating site agreed to follow the study protocol and signed an authorship agreement form. No financial support was provided to any site.

Hospitalized adult and pediatric patients with a PIVC in situ on the day of the study were eligible for inclusion. Sample size was determined by local capacity. Hospitals were encouraged to audit their entire institution if possible; however, data were accepted from as little as one ward. Data collectors comprised nurses and doctors with experience in PIVC assessment. They were briefed on the study protocol and data collection forms by the local site coordinator, and they were supported by an overall global coordinator. Clinicians assessed the PIVC insertion site and accessed hospital records to collect data related to PIVC insertion, concurrent medications, and IV fluid orders. Further clarification of data was obtained if necessary by the clinicians from the patients and treating staff. No identifiable patient information was collected.

Data Collection

To assess whether clinical facilities were following best practice recommendations, the study team developed three data collection forms to collect information regarding site characteristics (site questionnaire), track participant recruitment (screening log), and collect data regarding PIVC characteristics and management practices (case report form [CRF]). All forms were internally and externally validated following a pilot study involving 14 sites in 13 countries.¹

The CRF included variables used to assess best practice interventions, such as catheter insertion characteristics (date and time, reason, location, profession of inserter, anatomical site of placement), catheter type (gauge, brand, and product), insertion site assessment (adverse symptoms, dressing type and integrity), and information related to the IV therapy (types of IV fluids and medications, flushing solutions). Idle PIVCs were defined as not being used for blood sampling or IV therapy in the preceding 24 h.

Data collection forms were translated into 15 languages by professional translators and back-translated for validity. Translation of some languages included additional rigor. For example, Spanish-speaking members from the Spanish mainland as well as from South America were employed so that appropriate synonyms were used to capture local terms and practice. Three options were provided for data entry: directly into a purpose-developed electronic database (Lime Survey^® Project, Hamburg, Germany); on paper, then transcribed into the survey database at a later time by the hospital site; or paper entry then sent (via email or post) to the coordinating center for data entry. Once cleaned and collated, all data were provided to each participating hospital to confirm accuracy and for site use in local quality improvement processes. Data were collected between June 1, 2014 and July 31, 2015.

Statistical Analysis

All data management was undertaken using SAS statistical software (SAS Institute Inc., Cary NC, USA). Results are presented for eight geographical regions using descriptive statistics (frequencies, percentages, and 95% CIs) for the variables of interest. To assess trends in catheter dwell time and rates of phlebitis, Poisson regression was used. All analyses were undertaken using the R language for statistical analysis (R Core Team, Vienna, Austria). The (STROBE (Strengthening the Reporting of Observational Studies in Epidemiology statement) guidelines for cross-sectional studies were followed, and results are presented according to these recommendations.²⁶

Of the 415 hospitals that participated in this study, 406 had patients with PIVCs on the day of the study (the others being small rural centers). Thus, a total of 40,620 PIVCs in 38,161 patients from 406 hospitals in 51 countries were assessed, with no more than 5% missing data for any CRF question. There were 2459 patients (6.1%) with two or more PIVCs concurrently in situ. The median patient age was 59 y (interquartile range [IQR], 37–74 y), and just over half were male (n = 20,550, 51%). Hospital size ranged from fewer than 10 beds to over 1,000 beds, and hospitals were located in rural, regional, and metropolitan districts. The majority of countries (n = 31, 61%) contributed multiple sites, the highest being Australia with 79 hospitals. Countries with the most PIVCs studied were Spain (n = 5,553, 14%) and the United States (n = 5,048, 12%).

General surgical (n = 15,616, 39%) and medical (n = 15,448, 38%) patients represented most of the population observed. PIVCs were inserted primarily in general wards or clinics (n = 22,167, 55%) or in emergency departments (n = 7,388, 18%; Table) and for the administration of IV medication (n = 28,571, 70%) and IV fluids (n = 7,093, 18%; Table).

Globally, nurses were the primary PIVC inserters (n = 28,575, 71%); however, Australia/New Zealand had only 26% (n = 1,518) of PIVCs inserted by this group (Table). Only about one-third of PIVCs were placed in an area of non-flexion (forearm, n = 12,675, 31%, Table) the majority (n = 27,856, 69%) were placed in non-recommended anatomical sites (Figure 1). Most PIVCs were placed in the hand (n = 13,265, 32.7%) followed by the antecubital veins (n = 6176, 15.2%) and the wrist (n = 5,465, 13.5%). Site selection varied widely across the regions; 29% (n = 1686) of PIVCs in Australia/New Zealand were inserted into the antecubital veins, twice the study group average. Over half of the PIVCs inserted in the Middle East were placed in the hand (n = 295, 56%). This region also had the highest prevalence of devices placed in nonrecommended sites (n = 416, 79%; Figure 1).

The majority of PIVCs (n = 27,192, 67%; Table) were of recommended size (20–22G); however, some devices were observed to be large (14–18G; n = 6,802, 17%) or small (24-26g; n = 4,869, 12%) in adults. In Asia, 41% (n = 2,617) of devices inserted were 24-26G, more than three times the global rate. Half of all devices in Asia (n = 3,077, 48%) and the South Pacific (n = 67, 52%) were of a size not recommended for routine IV therapy (Figure 2).

The primary dressing material used was a transparent dressing (n = 31,596, 77.8%; Table); however, nearly 1 in 5 dressings used had either nonsterile tape alone (n = 5,169, 13%; Appendix 4), or a sterile gauze and tape (n = 2,592, 6%; Appendix 4.1). We found a wide variation in the use of nonsterile tape, including 1 in every 3 devices in South America dressed with nonsterile tape (n = 714, 30%) and a larger proportion in Africa (n = 543, 19%) and Europe (n = 3,056, 18%). Nonsterile tape was rarely used in North America and Australia/New Zealand. Although most PIVC dressings were clean, dry, and intact (n = 31,786, 79%; Table), one-fifth overall were compromised (moist, soiled, and/or lifting off the skin). Compromised dressings (Appendix 4.2) were more prevalent in Australia/New Zealand (n = 1,448; 25%) and in Africa (n = 707, 25%) than elsewhere.

Ten percent of PIVCs (n = 4,204) had signs and/or symptoms suggestive of phlebitis (characterized by pain, redness and/or swelling at the insertion site; Appendix 4.3). The highest prevalence of phlebitis occurred in Asia (n = 1,021, 16%), Africa (n = 360, 13%), and South America (n = 284, 12%). Pain and/or redness were the most common phlebitis symptoms. We found no association between dwell time of PIVCs and phlebitis rates (P = .085). Phlebitis rates were 12% (Days 1-3; n = 15,625), 16% (Days 4-7; n = 3,348), 10% (Days 8-21; n = 457), and 13% (Day21+; n = 174). Nearly 10% (n = 3,879) of catheters were observed to have signs of malfunction such as blood in the infusion tubing, leaking at the insertion site, or dislodgment (Appendix 4.4).

We observed 14% (n = 5,796) of PIVCs to be idle (Appendix 4.5), defined as not used in the preceding 24 h. Nearly one-fourth of all devices in North America (n = 1,230, 23%) and Australia/New Zealand (n = 1,335, 23%) were idle. PIVC documentation in hospital records was also poor, nearly half of all PIVCs (n = 19,768, 49%) had no documented date and time of insertion. The poorest compliance was in Australia/New Zealand (n = 3,428, 59%; Appendix 4.6). We also observed that 1 in 10 PIVCs had no documentation regarding who inserted the PIVC (n = 3,905). Thirty-six percent of PIVCs (n = 14,787) had no documented assessment of the PIVC site on the day of review (Appendix 4.7), including over half of all PIVCs in Asia (n = 3,364, 52%). Overall, the median dwell at the time of assessment for PIVCs with insertion date/time documented was 1.5 d (IQR, 1.0–2.5 d).