Vascular access devices (VAD) are among the most commonly used devices in emergency rooms (Wouters et al., 2019). The devices are broadly categorized into peripherally inserted central catheters (PICC), intravascular devices, central venous catheters, and peripheral arterial devices. These devices are primarily used for medications, blood products, and fluids; and can also be used to monitor hemodynamic function, collecting of blood samples, and dialysis. Vascular access devices can provide avenues for healthcare-related infections particularly blood or local infections (The Royal Children's Hospital Melbourne, 2018). Prevention of infections related to invasive devices is a principal patient safety concern contemplated under Standard 3 of the Australian National Safety and Quality Health Service Standards (NSQHS). In line with this standard, several policy documents and guidelines outlining the administration, maintenance, and management of these devices have been developed both at Federal and State levels. This paper analyses the guideline for practice when using a peripheral intravenous catheter (PIVC) on patients, developed by the Queensland state Department of Health in 2015. For purposes of this assignment, this paper shall and critically evaluate the contents of the selected guideline with particular emphasis on the selection and/or insertion of the device.
Queensland’s guide to PIVC is a vascular access device guide designed to be used by all consultants, contractors, and employees within the health services and hospitals, commercial business units and divisions within the public health system of Queensland State of Australia. The document was developed through the lens of the i-care intervention series for administration and use of intravenous devices. The guide outlines best practice recommendations pertaining to the utilization and supervision of intrusive devices on the basis of most recent research outcomes for control and or prevention for healthcare-related infections. The document draws its roots from several authorizing policies and standards such as the NSQHS Standard 3, Hand hygiene guideline, guideline for surveillance of healthcare-associated infection and Australian guidelines for the prevention and control of infection in healthcare (Gorski, 2017).
According to Gottlieb, Sundaram, Holladay, and Nakitende (2017), the proper and careful selection of a VAD is the first step in ensuring the safety of a patient in the insertion and management of PIVCs. It is important for the medic to put into consideration the size of the target vein against the gauge or size of the device to be used. The clinician should put into thought factors such as the age of the patient, conditions of veins in the preferred site, surgical or medical interventions and lastly the level of cardiovascular stability. As such, it is recommended that clinicians use the smallest gauge and shortest possible length to minimize the risk of phlebitis (Frykholm et al., 2015). This is also corroborated by Marcy et al. (2014) and Joing et al. (2012) who both view it as part of the conformation to Federal and international standards. Unlike Gorski et al. (2016), the guideline does not specify the gauge of the smallest size needle. The guideline is consistent with the provisions of Autralian health policies on the qualifications of the persons conducting cannulation as it should be done only by qualified personnel who are presumed to be competent enough to discern various sizes of needles by simply looking. As Mimoz et al. (2015) agree with the requisites of the guideline, procedures such as resuscitation and rapid infusions require large-bore catheters and consequently large veins with low fluid flow resistance. Although vein and needle size mismatch is known to cause phlebitis, Frykholm et al. (2015) finds no evidence to linking the incongruity to VID-related infection. Like the rest of the guidelines across the world, the Queensland document does not indicate any preference for closed intravenous access systems. However, they are the most preferred both internationally and in Australia since they are less probable to cause Catheter-related bloodstream infections as compared to open systems.
Cannulation is a VID insertion technique that involves piercing and laying a cannula inside a vein to provide venous access. The Queensland guideline, recommends that no more than two attempts should be made at cannulation before seeking assistance from an experienced clinician. This is consistent with the Australian Commission on Safety and Quality in Healthcare (2012) which limits the number of insertion trials to two per practitioner. However, for medical emergency cases, clinicians are allowed to make more attempts since most of the emergency operations are critical and highly time-bound. This clause is to some extent ambiguous in the sense that it gives the emergency room clinician unlimited trials of cannulation for emergency room staff without seeking assistance. While it is true that based on the circumstances in the emergency room environment, several more attempts could be required for the personnel working in these places, allowing endless cannulation attempts without seeking help or second opinion from another qualified clinician is indeed dangerous and puts the life of the patient at risk (Dienhart & Balint, 2015). The guideline further emphasize the need for assistance when inserting a PIVC to guarantee asepsis and appropriate procedure although this has not been substantiated in any of the existing literature. Adhesive labels indicating the details of the insertion should be stuck on the dressing. This is a requirement by both international and Australian standards. However, the guideline ought to have listed these specific details of the insertion sticker to be more precise and clearer.
The guideline outlines a step-by-step procedure for inserting PIVC by use of the aseptic technique; from patient assessment to equipment cleaning and routine hand hygiene. However after the assessment, the guideline requires a practitioner to proceed with explaining the subsequent procedures to the patient but does not give room for patient participation of feedback prior to the insertion procedure. One major strength of the guideline is its availing of this procedure both in the schematic diagram and video form to the patients. Ray-Barruel and Rickard (2018) emphasizes on the need for use of redundant means of communication in medical literacy. The first step of the procedure is to assess the patient. The said assessment ought to have been elaborated at least in detail or by use of another reinforcement term such as physical so as to be read as physical assessment. According to Australian Commission on Safety and Quality in Healthcare (2012), out of the estimated 30 million peripheral intravenous catheters (PIVC) insertions conducted in Australia each year, more than 4 percent of these administrations are unnecessary. This is attributed to improper or lack of physical assessment to determine if indeed the patient needs a VAD assistance. For example in the South Australian state guidelines for VAD management, it is categorical that the clinician must ratify that the VAD is undeniably crucial for the patient. Rather than simply assessing the patient, the document must emphasize the need for clinicians to ascertain that the VAD is actually essential for the patient. The guideline like its counterparts across Australia is categorical that the person conducting the VAD insertion should be competent and if training, then he or she should be under the close supervision of a qualified practitioner. Ray-Barruel and Rickard (2018), insist on frequent workshops to keep the nursing staff even more competent to avoid cases of failed insertions or multiple attempts in doing so.
Site preparation is part of the wider VAD insertion procedures that deals with making the selected site conducive for insertion. The guideline recommends that before the insertion procedure, the clinician should clean the site by removing hair where necessary using clippers to enhance adherence of the dressing. Although all the VAD guidelines across the globe seem to be in agreement that hair should be removed from the site, there is uncertainty over the preferred mechanism of doing so (Loveday et al., 2014). While previous literature has no issues with shaving as a site preparation technique, modern guidelines including the Queensland guide lean towards the use of clippers or scissors on grounds that it reduces infection. There is, however, no evidence to prove this assertion (Liu et al., 2018). In addition, the clinician should physically clean the site using water and soap before applying the antiseptic solution. It recommends the use of chlorhexidine solution to disinfect the site. The document discourages the use of antimicrobial creams and ointments for site preparation. It also forbids the use of anti-inflammatory agents and venodilators near the insertion site. These restrictions are also observed in similar documents in Australia and the USA (Loveday et al., 2014).
This report provided a summary of the quality of the Queensland State guideline on a peripheral intravenous catheter (PIVC) as sample representative of the quality of the existing guidelines on insertion and management of VADs in Australian health facilities. Based on the findings, it is evident that although the analyzed guide scores highly in terms of its comprehensiveness, there are several limitations evident such as absence of universal standards of practice, little emphasis on physical examination and little patient input during the entire VAD administration process. To avert these shortcomings, this paper first recommends that the federal government develops a federal clinical care standard for adoption and use by all state and private clinical facilities to reduce VAD related infections, failures, and complications. In addition, there is a need for evidence-based physical examination of patients to assess their need for these devices and if so, the consideration of the type and size of the device. Thirdly, patients should be taught about the procedure, allowed to ask questions, and given responses to those questions they raise prior to the VAD administration procedure. Lastly, the paper suggests more frequent refresher training of medical and nursing staff especially those in emergency care centers on modern-day evidence-based VAD selection and insertion and overall maintenance care.
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