Study Changes the Course of Clinical Thought on Catheter Securement

In this Q&A interview, Gregory Schears, MD, a pediatric intensivist and board-certified anesthesiologist practicing at the Mayo Clinic in Rochester, Minn., discusses data from his recent study on catheter securement and implications for infection prevention and control, including a comparison of securing peripheral IVs via tape vs. StatLock, a catheter stabilization device. Schears found that the manufactured stabilization device reduced phlebitis, overall complication rates, and the number of IV restarts, as well as reduced costs associated with materials and healthcare personnels time. Schears findings have been pivotal in driving the Infusion Nurses Society (INS) to change course and issue new recommendations suggesting that whenever possible, these devices are preferred.

Q: This is the largest-ever outcomes study on intravenous (IV) therapy. How big is it, and from what patient pool did you draw?

A: We collected data from 83 hospitals across the country that were participating in a product trial of a catheter stabilization device, also known as a securement device. The total number of patient participants was 10,164, so it was really quite a large trial. Nothing like this had been done before, especially with this type of catheter stabilization device. There are three IV studies in the literature that among them include only 286 patients. So, the current study provided additional evidence in support of the smaller studies.

Q: Regarding the securement/stabilization of IV catheters, the new Infusion Nurses Society Standards of Practice for the first time state a preference for a particular method of catheter stabilization. Specifically the new standards state, Whenever feasible, using manufactured catheter stabilization is preferred. Your study compared non-sterile tape to StatLock IV, the only evidence-based stabilization device that currently meets the new INS standards. Why did you choose to compare outcomes for StatLock vs. tape?

A: There are several reasons. First, when I initially saw the device, I recognized that it should work better than tape because of its physics. The catheter sits on top of and is securely attached to an adhesive pad. The pad provides a large, uniform adhesive surface that adheres to the skin, so the adhesion is less likely to be disrupted than with the traditional method of placing the catheter on the skin and placing tape on top of it. With the taping method, catheter movement caused by tension on the pigtails and IV lines tend to create a wedge that disrupts the tape securement. The devices design just made so much more sense, and I realized that approach was going to be stronger than the other methods we were using. My second reason for testing StatLock was that there really isnt another securement method or device that made sense to me like this device does.

Q: Youve also conducted previous studies that have examined catheter stabilization/securement for PICC lines and central venous catheters. The new research considers peripheral IVs. Whats the specific value of studying stabilization of peripheral IVs in a large, prospective, observational study?

A: Complications related to peripheral IVs have been largely neglected by researchers, and yet peripheral IVs are the most common type of venous access, by far. If you want to help the maximum number of patients that you may be able to help with your research, peripheral IVs are the place to start. Whats more, the Centers for Disease Control and Prevention (CDC) has recently stated that we can allow peripheral IVs to stay in place for 96 hours or more, as long as theyre functioning well and the patient isnt showing signs of infection. So it behooves us to look for strategies such as better securement that will allow these catheters to stay in place longer. For one thing, longer dwell times will prevent painful restarts for our patients. We dont want our patients to be human pincushions. For another, every time we re-stick a patient there is the potential for a healthcare worker to suffer a needlestick injury. So, with better stabilization and longer dwell times, we can both reduce the risk to healthcare workers and reduce the discomfort to patients.

Q: What did your study find that relates to patient safety?

A: There were a number of patient-safety-related implications. One was that the rate of restarts was significantly lower in the stabilization device category compared to tape. The percent reduction was 76 percent. Second, we found that the rate of phlebitis with the securement device was much lower. That makes sense to me because the device holds the catheter in place so much better than tape, there is probably less catheter movement and hence less irritation of the vein. That makes it more comfortable for patients, as well. Third, there was a 67 percent overall reduction in complications. That last figure is an extremely positive benefit encompassing multiple categories.

Q: Tell us more about your findings regarding overall complication rates and the incidence of phlebitis in patients and why these findings are significant.

A: By securing catheters better, you help to reduce or eliminate a number of problems associated with poor securement. From the complication standpoint, the catheters are being held in place better, so theres less lateral and pistoning movement. This in turn reduces the possibility of phlebitis, vein puncture resulting in infiltration, leaking, infection, and several other complications. Theres also a downstream economic benefit to improved securement. Youre reducing dislodgements so the catheters are staying in place longer, which means lower material costs because of avoided replacements and fewer personnel hours required to restart the catheters. Patients, healthcare workers, and the institution itself all benefit from better securement. Its a win, win, win.

Q: Your study also highlights the issue of unscheduled catheter restarts; why is this important?

A: A high restart rate means a high rate of catheter complications. If the therapy needs to be ongoing, the catheter needs to be restarted. This often means a delay in therapy until someone is able to replace the catheter. Restarts create the logistical problem of finding personnel to address the catheter issue, which also means increased labor costs and poor use of nursing time. And, of course, the worker who performs the restart risks a needlestick injury. The high restart rate means that we have to deal with whatever the complication is that resulted in the restart such as the tissue injury from the drug infiltration or the phlebitis. It could be as simple as a hot pack or as involved as ongoing plastic surgery consult with eventual skin grafting. So with restarts, as with other problems related to poor stabilization, there are not only a number of problems but also a domino effect where one problem leads to another. By making the simple change of selecting a better, proven stabilization method, we have a huge impact on the care we provide to patients and reduce the downstream series of events needed to deal with the complications.

Q: You also did a cost-benefit analysis that found savings for hospitals using devices like StatLock. Can you provide an example?

A: We picked a typical hospital using X number of catheters per year and made mathematical calculations based on the numbers of catheters used and the rate of restarts they would need using tape. By securing catheters with a stabilization device instead, we were able to show a material cost savings of $18,000 per year for such a hospital, and overall annual savings of $277,000, including the personnel time required to re-secure the catheters and deal with avoidable complications.

Q: The new INS standards, which took your study into consideration, break with the traditional use of tape for catheter stabilization and recommend use of a manufactured device. How significant do you think this change is for those in clinical practice?

A: I think the change is really significant. I am gratified that the INS and other healthcare agencies are paying attention to this issue. Weve been doing much better with some of the major patient problems, thanks to the national patient safety movement. Now were starting to focus on some of the less recognized or smaller complications, and I think this will have a large impact on patient care. Also, whenever some area receives attention, theres apt to be additional research and/or products directed toward it. So I think in the future we will see additional securement devices and thus further improvement in patient care.

Q: What do your research findings say about healthcare for the average patient who needs an IV today?

A: For the average patient, it says that we now have another means to make their experience in the healthcare system better. This stabilization device has shown time and time again that its contributing to longer-lasting IVs, fewer restarts, and fewer overall complications. 

Securement Devices vs. Tape

Patients do better when caregivers use a catheter securement device instead of tape or suture to secure IV catheters, according to a recent article in the Journal of Infusion Nursing. In the new article, Why Are We Stuck on Tape and Suture? the authors, Gregory Schears, MD, a pediatric specialist, and Ann Marie Frey, RN, a pediatric IV access specialist at Childrens Hospital of Philadelphia, reviewed seven published papers. Those papers encompass 429 patients and compare a securement device with tape or suture securement. In all studies, the rate of patient complications in the securement device, StatLock, was lower than for the standard means of securement. Moreover, when StatLock was compared to suture, potentially lethal catheter-related bloodstream infections were reduced by up to 80 percent and accidental needlestick injuries were 100 percent eliminated.

These studies demonstrate that using the catheter securement device helps to reduce catheter-related complications such as dislodgement and catheter-associated infection, says Schears. This reduces the need for replacement catheters during the treatment course, which means fewer needlesticks for patients. To better protect patients, its time for clinicians who are still stuck on using tape or suture to adopt better, clinically proven technology.

The Occupational Safety and Health Administration (OSHA) now requires healthcare facilities to annually review their catheter securement protocols, and to assess suture-free and tape-free alternatives. Federal infection control guidelines also support the use of suture-free securement. The CDC Guidelines for the Prevention of Intravascular Catheter- Related Infections state, Sutureless securement can be advantageous over suture in preventing catheterrelated bloodstream infections.

For more information about the Infusion Nurses Societys Policies and Procedures for Infusion Nursing, which teaches proper usage of mechanical stabilization devices in general, go to www.ins1.org.