Infection Control Today - 06/2003: Success Story

Tape: A Dirty Business

By Steve Bierman, MD

Would you accept a device into your institution that has a 65 percent or greater failure rate? Would you allow vascular access devices to be secured with a device known to be contaminated with pathogenic bacteria 74 percent of the time? Would you tolerate a 48 percent or greater catheter complication rate -- and the attendant obligation of nurse-time to troubleshoot and restart catheters -- when a truly cost-effective alternative has been proven in literally scores of institutions to reduce such complications to 17 percent?

Most likely, your answer to all three questions is a definitive "No." And yet, chances are you have unwittingly allowed all of these awful events to occur, and to 80 percent of your patients. But you are not alone. Thousands of hospitals are currently immersed in the same sea of avoidable complications and infections.

Fortunately, there is a safe harbor ahead. As we shall see, tape is the offending device with the high failure rate, the intolerable contamination risk, and the associated and unallowable complication rates. The culprit is not the sterile tape you use to hold surgical bandages in place; rather, it's the non-sterile tape you pull out of your pocket or off a Mayo stand and use to secure peripheral IV (PIV) catheters.

Tape causes complications and promotes infections -- all of which also consume precious nursing time. But there is now a safe, cost-effective and abundantly proven alternative method now available to secure PIVs. The implementation of this new securement method dramatically improves clinical outcomes, while at the same time returning valuable time to nurses and reducing overall material costs to the institution.

As background, it's important to first become familiar with some baseline data. At least 80 percent of all hospitalized patients receive intravenous therapy through peripheral IV catheters. Though PIVs become infected far less frequently than central venous catheters, staphylococcal infections of PIVs are not a rarity. Moreover, complications such as infiltration, phlebitis, dislodgment, migration and extravasations are quite common with PIVs. Moreover, because of these frequent complications, the average PIV catheter dwell-time in hospitals is 44 hours, making routine 72-hour scheduled IV restarts more of a wish than a reality.1 Finally, this shortened dwell-time translates into a total average of 36 minutes of troubleshooting and restarting PIVs (29 minutes for the unscheduled restart itself, plus troubleshooting the new IV). That means a nurse charged with watching four IVs will spend more than two full -- and unnecessary -- hours with those IVs over the course of therapy. 1 This is today's reality in most hospitals.

Generally speaking, nurses see this welter of PIV-associated problems and complications as the unavoidable consequence of sticking a relatively hard plastic cannula into a delicate peripheral vein: "Complications," they say, "are bound to happen."

Are they? If so, why in one study was the average dwell-time of a Teflon PIV extended to 95 hours?2 And why, in that same study, were total complications able to be reduced by more than 70 percent?

The answer is quite simple, if often overlooked -- securement. Think of it this way: It is not the catheter that causes complications, but rather movement of the catheter. Catheter movement pistons staphylococcus at the entry site in and out of the wound. Catheter tip movement harasses the blood vessel lining, triggering inflammation, thrombosis and eventual erosion. If you stop catheter movement, you can greatly reduce, and in some cases, eliminate complications.

And how do you stop catheter movement? First, you abandon tape. Then, you test and prove out in your institution a sterile adhesive catheter securement device, and implement it housewide, while at the same time changing your PIV protocol to 96-hour scheduled restarts. This will prevent complications and save considerable time and money.

After all, tape was never really attractive as a PIV securement device; it was simply all that we had. Consider this: in 1999, the University of Toronto published an elegant study demonstrating that after only 24 hours, 74 percent of tape samples (taken from rolls used to secure PIVs) cultured positive for pathogenic bacteria.3 In the aforementioned hospital study, tape allowed a 65 percent rate of PIV complications, resulting in a 63 percent rate of PIV unscheduled restarts (meaning they had to the restart the catheter before the allowed 72 hours).

Beyond that, tape has been clearly demonstrated to tear gloves, thus exposing healthcare workers to dangerous cutaneous contamination from bloodborne pathogens.4 And, well known to all clinicians, tape injures skin at rates up to 67 percent.2 In sum, any objective look at the evidence can lead to only one conclusion: Tape, as a PIV securement device, is a dirty business.

The landmark 1997 study, published in the Journal of Intravenous Nursing, established the baseline complication rate, restart rate and nursing-time consumption associated with taped PIVs.1 The study went on to prospectively (though non-randomly) assess the performance of a sterile adhesive securement device (StatLock, Venetec International, Inc., San Diego, Calif.) with regard to these same parameters.

The results were astounding. StatLock, owing to a sterile, plastic-on-plastic interface that dramatically restricts catheter movement, was demonstrated to reduce PIV-related complications by more than 70 percent. The device also reduced unscheduled restarts by 74 percent and saved nurses 29 minutes per IV during the lifetime of the catheter. Subsequent studies in homecare and skilled nursing facilities demonstrated similar findings.2,5

Most dramatically, however, the manufacturer subsequently undertook to conduct and sponsor literally scores of sequential trials comparing StatLock PIV securement to tape securement.6 These trials were conducted in institutions wishing to: first, evaluate their own baseline data; and second, determine if StatLock would/could provide cost-effective improvement to patient care.

In all, 49 institutions are represented in these trials. Tape securement of PIVs, on average, resulted in an unscheduled restart rate of 69 percent and a total complication rate of 48 percent. (This latter number may be higher, because often the complication requiring the restart was not charted by the institution's nurse, and therefore was not registered in the study.) Included in those total complications was an average phlebitis rate of 6 percent. Results at these 49 institutions to confirm the results published in the 1997 study: 71 percent reduction in unscheduled restarts, and a 62 percent reduction in total complications, including a 69 percent reduction in phlebitis.

Most remarkable, perhaps, is the fact that in 25 of 49 institutions, the securement device accounted for 100 percent elimination of phlebitis. Why? Because, as these studies demonstrate, even so-called "chemical phlebitis" begins with injury to the intima, which results from catheter movement. Think of it ... 25 institutions in which the phlebitis rate was actually reduced to zero.

Tape was not invented for catheter securement; it is intended to hold flat objects to flat surfaces. Sterile, precision-engineered catheter securement devices have been consistently outperforming tape for securement of PIVs since 1997.

This is an era in medicine when nursing time is at a premium and when hospitals face economic pressures to evaluate the cost-effectiveness of the devices and procedures they employ. It's also one where institutions are mandated to protect nurses against unnecessary exposure to medical sharps and accidental needlesticks -- a goal that can be achieved in part by eliminating unnecessary catheter restarts. And it's also a time when hospitals face pressure from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Medicare to improve patient safety.

Against this backdrop, there is a new standard of care for peripheral IV catheters. Polyurethane safety catheters are now being secured with sterile adhesive-anchor devices that save time and money by preventing complications and protecting healthcare workers. This new standard will allow your institution to move to the CDC-sanctioned, 96-hour scheduled PIV restart protocol. The new standard also enables facilities to satisfy JCAHO patient safety concerns, and to meet the mandates of the U.S. Needlestick Safety and Prevention Act. Tape, as a makeshift catheter securement device, is a documented dirty business whose time in the hospital has passed.

Steve Bierman, MD, is the medical director and CEO of Venetec International.

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