Optimal Changing Frequency of Peripheral Intravenous Catheters

On September 29th, 2018 in the surgical intensive care unit (SICU) my registered nurse (RN), G.W. decided against replacing the peripheral intravenous (IV) catheter for a patient in our care. This particular patient had cerebral palsy and autism spectrum disorder and was admitted to the unit because of complications related to pneumonia.

Because of his conditions he had severe contractures to both upper limbs which made it very difficult to place a new IV set. Additionally, because of his cognitive deficits he was very much afraid of needles and not eager to have his IV replaced.

This combination would have put him through unnecessary pain and a traumatic experience, so the nurse opted to not replace his IV catheter.

Yet, Metropolitan Methodist Hospital policy indicates that peripheral IV replacement should take place every 96 hours (Wood, 2018). This replacement schedule is implemented to reduce cases of phlebitis, infiltration, and IV-related bloodstream infections. By choosing not to replace the patient’s peripheral IV catheter the patient’s risk of phlebitis, infiltration, and IV-related bloodstream infections is increased.

According to Benner (2000), a critical incident can be, “an incident that is very ordinary and typical.” (p. 300). Changing IV catheters, as is normally done every 96 hours, is very typical in a hospital setting. What makes this situation a critical incident is the risks associated with not changing his IV access. We have a critically ill patient who is needing medication to treat his pneumonia. If IV access was compromised due to an IV-related infection or because the IV site presented with phlebitis or infiltration his medications would not be able to be administered routinely.

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According to Huether, McCance, Rote & Basher (2016), appropriate antibiotic administration is essential to the treatment of pneumonia and preventing acute respiratory distress syndrome.

Woods (2018) designed the IV care and maintenance policy for Metropolitan Methodist Hospital. As previously stated, the policy outlines that peripheral IV catheters need to be changed every 96 hours unless clinically indicated beforehand. This ensures the patient’s risk is minimized as much as possible. By not changing the current IV catheter the nurse may cause a negative outcome for the patient. The Nursing Practice Act (1999) states, that grounds for disciplinary action includes, “failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the board’s opinion, exposes a patient or other person unnecessarily to risk of harm” (§301.452(b) (13)). Failure of the nurse to comply with the policies and procedures established by the hospital will not only place the patient at risk, but also the nurse and the institution.

Problem Statement

The patient is at an increased risk of phlebitis, infiltration, and IV-related bloodstream infections while the current peripheral IV set remains in place.

Rating Scale

No Risk, Minimal, Moderate, High Risks to the Patient Risks to the Nurse Legal/Ethical Risks

• Option 1: Risk: Moderate Risk: Moderate Risk: Minimal

Change the peripheral IV catheter as indicated by hospital policy. Analysis: For this particular patient the changing of his IV may cause him unnecessary pain in the absence of clinical indications other than hospital policy (Wood, 2018).

Analysis: There is moderate risk to the nurse when changing or starting an IV. In particular this patient may fight back or move aggressively because of his cognitive deficits. This may cause a needle stick to the nurse or anyone else present. Analysis: When the nurse changes the IV, she is following guidelines to ensure her patient has a positive outcome. (Nursing Practice Act, 1999).

• Option 2: Risk: Minimal Risk: Minimal Risk: Moderate

Request a physician order to leave the current peripheral IV catheter in place longer than hospital policy delegates.

Analysis: According to Webster, Osborne, Rickard, and New (2013), research has found no evidence to support changing catheters every 96 hours. Thus, changing catheters only when clinically indicated would provide cost-savings and spare patients unnecessary pain.

Analysis: The risk to the nurse is minimal. She will have more time to interact with the patient and provide teaching. Time that would have otherwise been spent to start a new IV. Additionally, she will have time to spend with other patients under her care as well.

Analysis: If the nurse fails to prevent an infection or the site is lost to phlebitis or infiltration the patient’s insurance will most likely not pay for the extra treatment (Frei & Daniels, 2012). Further, the nurse may be held responsible for any adverse effects or negative patient outcomes (Nursing Practice Act, 1999).

• Option 3: Risk: High Risk: Moderate Risk: High

Restrain the patient and change the peripheral IV catheter.

Analysis: According to the Patient Safety Monitor Journal (2015), evidence shows that restraints do not always prevent patient harm and in some cases, can contribute to serious injuries. Restraining this patient would cause unnecessary trauma. Further, he may hurt himself trying to fight over the restraints.

Analysis: Restraining this patient may cause him to fight back or move aggressively because of his cognitive deficits. This may cause a needle stick to the nurse or anyone else present.

Analysis: There is high legal risk to the nurse if the patient is restrained. Restraining the patient may be considered unlawful and the nurse may be held responsible. This may warrant disciplinary action if the patient is injured or suffers any harm (Texas Board of Nursing, 2013).

• Option 4: Risk: Moderate Risk: Low Risk: Moderate

Request that a physician place a midline catheter for this patient. Analysis: According to Xu et al. (2016), the decision to use a midline catheter (MC) is not without risk. MC’s are associated with serious complications such as bacteremia. Yet, in this case the benefits may outweigh the risks. MC’s have a recommended dwell time of up to 4 weeks and is appropriate for intravenous solutions and medications. Having access for up to 4 weeks may limit unnecessary pain to the patient by avoiding multiple catheter changes.

Analysis: The nurse is at a low risk if she chooses this option. Only certain personnel can perform this procedure, so her involvement would be limited. However, she would need to monitor the access site per hospital protocol.

Analysis: Midline catheters are not without risk. If the nurse does not monitor the site appropriately or fails to prevent an IV-related infection, the nurse will be contributing to the increased costs associated with the patient’s hospital stay (Frei & Daniels, 2012). Furthermore, if the nurse fails to assess the IV site correctly she will be placing the patient at an increased risk of harm, leading to adverse outcomes (Texas Board of Nursing, 2013). Consequently, the nurse will undergo disciplinary action and may lose his or her license to practice (Nursing Practice Act, 1999).

Chosen Option

Request a physician order to leave the current peripheral IV catheter in place longer than hospital policy delegates.

Rationale for Selection

To providing safe, patient-centered care, I would have requested an order to leave the current IV catheter in place. Changing the IV catheter would have placed unnecessary pain upon the patient. Further, he would have been traumatized by having to endure the needle stick and be held in a position he is not comfortable with because of his severe contractures. Additionally, the most recent evidence-based practice suggests that IV catheter replacement should happen only when clinically indicated not routinely. So, the patient would not be at an increased risk of phlebitis, infiltration, or infection by leaving the current catheter in place.

The staff nurse chose to keep the catheter in place after securing an order from the physician on duty. The nurse explained that her rationale behind the decision was avoiding unnecessary pain to the patient and knowing that the current IV site was still functioning as intended. The staff nurse’s decision to keep the IV site in place indicates an expert level of nursing expertise (Benner, 2000). The staff nurse has been practicing as a critical care nurse for thirteen years and would be considered a proficient nurse, her decision demonstrated an understanding of current evidence-based practice and knowledge of her patient. She knew that he would struggle with having a new IV placed and that because the current site was still operating as intended, a change was not clinically indicated. By knowing current evidence and her patient, she was able to provide outstanding patient-centered care.

Conclusion

Prior to this incident I was unfamiliar with current evidence-based practice regarding peripheral IV catheter replacement. In analyzing the incident, it is important to look at the situation holistically. In doing so, we can factor in the safety of the patient, the fact that his current IV access is intact, and that starting a new IV would be a traumatic event for the patient. Further, research suggests that there is no significant difference in the rate of phlebitis or other complications between the clinically indicated and routine peripheral catheter replacement strategies. So, changing catheters only when clinically indicated reduces costs and better utilizes staff time, without increasing the risks to the patient.