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By Steve Bierman, MD
Would you accept a device into your institution that has a 65 percent orgreater failure rate? Would you allow vascular access devices to be secured witha device known to be contaminated with pathogenic bacteria 74 percent of thetime? 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 scoresof 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 theseawful events to occur, and to 80 percent of your patients. But you are notalone. Thousands of hospitals are currently immersed in the same sea ofavoidable complications and infections.
Fortunately, there is a safe harbor ahead. As we shall see, tape is theoffending device with the high failure rate, the intolerable contamination risk,and the associated and unallowable complication rates. The culprit is not thesterile tape you use to hold surgical bandages in place; rather, it's thenon-sterile tape you pull out of your pocket or off a Mayo stand and use tosecure peripheral IV (PIV) catheters.
Tape causes complications and promotes infections -- all of which alsoconsume precious nursing time. But there is now a safe, cost-effective andabundantly proven alternative method now available to secure PIVs. Theimplementation of this new securement method dramatically improves clinicaloutcomes, while at the same time returning valuable time to nurses and reducingoverall material costs to the institution.
As background, it's important to first become familiar with some baselinedata. At least 80 percent of all hospitalized patients receive intravenoustherapy through peripheral IV catheters. Though PIVs become infected far lessfrequently than central venous catheters, staphylococcal infections of PIVs arenot 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 inhospitals is 44 hours, making routine 72-hour scheduled IV restarts more of awish than a reality.1 Finally, this shortened dwell-time translatesinto a total average of 36 minutes of troubleshooting and restarting PIVs (29minutes 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. 1This is today's reality in most hospitals.
Generally speaking, nurses see this welter of PIV-associated problems andcomplications as the unavoidable consequence of sticking a relatively hardplastic cannula into a delicate peripheral vein: "Complications," theysay, "are bound to happen."
Are they? If so, why in one study was the average dwell-time of a Teflon PIVextended to 95 hours?2 And why, in that same study, were totalcomplications able to be reduced by more than 70 percent?
The answer is quite simple, if often overlooked -- securement. Think of itthis way: It is not the catheter that causes complications, but rather movementof the catheter. Catheter movement pistons staphylococcus at the entry site inand out of the wound. Catheter tip movement harasses the blood vessel lining,triggering inflammation, thrombosis and eventual erosion. If you stop cathetermovement, you can greatly reduce, and in some cases, eliminate complications.
And how do you stop catheter movement? First, you abandon tape. Then, youtest and prove out in your institution a sterile adhesive catheter securementdevice, and implement it housewide, while at the same time changing your PIVprotocol to 96-hour scheduled restarts. This will prevent complications and saveconsiderable time and money.
After all, tape was never really attractive as a PIV securement device; itwas simply all that we had. Consider this: in 1999, the University of Torontopublished an elegant study demonstrating that after only 24 hours, 74 percent oftape samples (taken from rolls used to secure PIVs) cultured positive forpathogenic bacteria.3 In the aforementioned hospital study, tapeallowed a 65 percent rate of PIV complications, resulting in a 63 percent rateof PIV unscheduled restarts (meaning they had to the restart the catheter beforethe allowed 72 hours).
Beyond that, tape has been clearly demonstrated to tear gloves, thus exposinghealthcare workers to dangerous cutaneous contamination from bloodbornepathogens.4 And, well known to all clinicians, tape injures skin atrates up to 67 percent.2 In sum, any objective look at the evidencecan lead to only one conclusion: Tape, as a PIV securement device, is a dirtybusiness.
The landmark 1997 study, published in the Journal of Intravenous Nursing,established the baseline complication rate, restart rate and nursing-timeconsumption associated with taped PIVs.1 The study went on toprospectively (though non-randomly) assess the performance of a sterile adhesivesecurement 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-plasticinterface that dramatically restricts catheter movement, was demonstrated toreduce PIV-related complications by more than 70 percent. The device alsoreduced unscheduled restarts by 74 percent and saved nurses 29 minutes per IVduring the lifetime of the catheter. Subsequent studies in homecare and skillednursing facilities demonstrated similar findings.2,5
Most dramatically, however, the manufacturer subsequently undertook toconduct and sponsor literally scores of sequential trials comparing StatLock PIVsecurement to tape securement.6 These trials were conducted ininstitutions wishing to: first, evaluate their own baseline data; and second,determine if StatLock would/could provide cost-effective improvement to patientcare.
In all, 49 institutions are represented in these trials. Tape securement ofPIVs, on average, resulted in an unscheduled restart rate of 69 percent and atotal complication rate of 48 percent. (This latter number may be higher,because often the complication requiring the restart was not charted by theinstitution's nurse, and therefore was not registered in the study.) Included inthose total complications was an average phlebitis rate of 6 percent. Results atthese 49 institutions to confirm the results published in the 1997 study: 71percent reduction in unscheduled restarts, and a 62 percent reduction in totalcomplications, including a 69 percent reduction in phlebitis.
Most remarkable, perhaps, is the fact that in 25 of 49 institutions, thesecurement device accounted for 100 percent elimination of phlebitis. Why?Because, as these studies demonstrate, even so-called "chemicalphlebitis" begins with injury to the intima, which results from cathetermovement. Think of it ... 25 institutions in which the phlebitis rate wasactually reduced to zero.
Tape was not invented for catheter securement; it is intended to hold flatobjects to flat surfaces. Sterile, precision-engineered catheter securementdevices have been consistently outperforming tape for securement of PIVs since1997.
This is an era in medicine when nursing time is at a premium and whenhospitals face economic pressures to evaluate the cost-effectiveness of thedevices and procedures they employ. It's also one where institutions aremandated to protect nurses against unnecessary exposure to medical sharps andaccidental needlesticks -- a goal that can be achieved in part by eliminatingunnecessary catheter restarts. And it's also a time when hospitals face pressurefrom 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 IVcatheters. Polyurethane safety catheters are now being secured with sterileadhesive-anchor devices that save time and money by preventing complications andprotecting healthcare workers. This new standard will allow your institution tomove to the CDC-sanctioned, 96-hour scheduled PIV restart protocol. The newstandard also enables facilities to satisfy JCAHO patient safety concerns, andto meet the mandates of the U.S. Needlestick Safety and Prevention Act. Tape, asa makeshift catheter securement device, is a documented dirty business whosetime in the hospital has passed.
Steve Bierman, MD, is the medical director and CEO of VenetecInternational.