Outcomes in Action

Optimizing Peripheral Outcomes: Short, Long, Midline Peripheral Catheters

The peripheral intravenous catheter (PIVC) is ubiquitous in healthcare as the preferred initial vascular access device for the majority of infusion needs.1 Options within the category of peripheral vascular access device (VAD) are the most commonly used short PIVC (superficial veins); the long PIVC (often placed in a deeper peripheral vein using visualization); and the midline PIVC (a longer catheter placed in a vein of the upper arm with a distal tip placed near the axillary fold).2 There are many benefits to the use of PIVCs for the delivery of infusates:  lower cost, avoidance of central line-related complications, ease of training and the longer dwell options (long PIVC, midline) that may allow for one PIVC for the entire duration of therapy. However, despite the prevalence of PIVC use within all clinical settings and patient populations, the failure rate (e.g., early removal due to a complication) is unacceptably high, and an accurate picture of PIVC-related patient outcomes remains elusive.1,3

Accurate PIV outcome measurement is a critical gap in clinical knowledge because of the nearly universal impact on the patients served, but also because of the significant shift from the use of central venous access devices (CVAD) to the use of PIVCs, especially the midline PIVC, as a central line-associated bloodstream infection (CLABSI) prevention strategy in the U.S.4 The gap in knowledge regarding PIVC patient outcomes is multi-faceted: generalized lack of standardized education on safe PIVC management (from nursing programs to onboarding to ongoing competency); lack of a standard PIVC site assessment structure; inadequate ongoing assessment of PIVCs based on patient/infusate risk; a sense that PIVC failure is inevitable; overlapping signs/symptoms of PIVC outcomes; well-documented inadequate documentation throughout the life of the PIVC worldwide; and significant heterogenicity in PIVC research methodology and parameters (e.g., PIVC characteristics, infusates, dwell time).2,5-10 Given these substantial limitations and the retrospective nature of a large percentage of PIVC research studies, a true understanding of the safety profile of PIVC management has not been established to the extent that would inform practice and provide effective vessel health and preservation.

Despite the gaps in knowledge, there are clear evidence-based recommendations to improve PIVC management. Many of these recommendations are listed in the 2021 Infusion Nurses Society Infusion Therapy Standard of Practice.2 Clinicians should be trained in proper care of PIVCs from insertion to maintenance to removal, and this education should be targeted to the unique vulnerabilities of PIVCs. This education should then inform and establish competency measurement in:

  • Optimal placement of PIVC catheters (avoiding high complication sites such as areas of flexion, and those distal to injury or with decreased sensation).
  • Escalation to an expert when PIVC placement exceed the clinician’s skill set.
  • Optimal infusates that are considered peripherally compatible (avoiding extremes of pH and osmolarity and limiting continuous infusions to non-irritant, non-vesicant infusates well-tolerated by peripheral vessels).
  • Consistent assessment of PIVC insertion sites based on patient and infusate risks (extremes of pH, osmolarity, cytotoxicity which can damage vessel endothelium and surrounding tissue).
  • Recognition of PIVC complications with accurate documentation.
  • Provider notification and available treatment protocols for PIVC complications (extravasation, compartment syndrome, phlebitis, catheter-related thrombosis).
  • Ongoing PIVC management, including aseptic access of the PIVC administration set, site care, site securement, tubing change, accurate and safe delivery of medications using infusion devices.
  • A process for regular review of line necessity to reduce PIVC continuation when no longer clinically needed.2

Essentially, the standard of care for PIVCs should be as high as that of CVADs since PIVC-related outcomes can progress to serious localized or systemic complications.

To better understand the true patient impact of PIVC-related outcomes, there are several recommendations for further high-quality research. Areas of crucial need include:

  • Establishment of clear PIVC outcome definitions that are validated for use with specific patient populations (e.g., pediatrics, elderly, critically ill).
  • Validation of a “difficult IV access” (DIVA) scale for large patient populations to improve escalation to expert inserters.
  • Establishment of a PIVC management bundle proven to reduce PIVC failure.
  • Validation of daily review resources that improve PIVC management and measure the efficacy of interventions.
  • Identification of the impact of specific infusates on peripheral vessel health to add clarity to the term “peripherally compatible”.
  • Establishment of accurate outcomes regarding the current utilization of the midline peripheral catheter.
  • Accurate measurement of patient cost (emotional, physical, financial) of PIVC failure.11-19

With a sharper focus on PIVC outcomes, we will close the knowledge gap and truly work to improve patient outcomes.

References

  1. Marsh N, Webster J, Ullman AJ, Mihala G, Cooke M, Chopra V, Rickard CM. Peripheral intravenous catheter non-infectious complications in adults: A systematic review and meta-analysis. J Adv Nurs. 2020 Dec;76(12):3346-3362. doi: 10.1111/jan.14565. Epub 2020 Oct 5. PMID: 33016412.
  2. Gorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, Meyer BM, Nickel B, Rowley S, Sharpe E, Alexander M. Infusion Therapy Standards of Practice, 8th Edition. J Infus Nurs. 2021 Jan-Feb 01;44(1S Suppl 1):S1-S224. doi: 10.1097/NAN.0000000000000396. PMID: 33394637.
  3. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015 May-Jun;38(3):189-203. doi: 10.1097/NAN.0000000000000100. PMID: 25871866.
  4. Hadaway L, Mermel LA. Midline Catheters: Could They Replace a Central Vascular Access Device? J Infus Nurs. 2022 Jul-Aug 01;45(4):220-224. doi: 10.1097/NAN.0000000000000471. PMID: 35820127.
  5. Alexandrou E, Ray-Barruel G, Carr PJ, Frost SA, Inwood S, Higgins N, Lin F, Alberto L, Mermel L, Rickard CM; OMG Study Group. Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. J Hosp Med. 2018 May 30;13(5). doi: 10.12788/jhm.3039. PMID: 29813140.
  6. Carr PJ, Rippey JCR, Cooke ML, Higgins NS, Trevenen M, Foale A, Rickard CM. From insertion to removal: A multicenter survival analysis of an admitted cohort with peripheral intravenous catheters inserted in the emergency department. Infect Control Hosp Epidemiol. 2018 Oct;39(10):1216-1221. doi: 10.1017/ice.2018.190. Epub 2018 Sep 10. PMID: 30196798.
  7. Marsh N, Webster J, Larson E, Cooke M, Mihala G, Rickard CM. Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure. J Hosp Med. 2018 Feb 1;13(2):83-89. doi: 10.12788/jhm.2867. Epub 2017 Oct 18. PMID: 29073316.
  8. Ray-Barruel G, Cooke M, Mitchell M, Chopra V, Rickard CM. Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment  and safe removal: protocol for an interrupted time-series study. BMJ Open. 2018 Jun 4;8(6):e021290. doi: 10.1136/bmjopen-2017-021290. PMID: 29866733; PMCID: PMC5988165.
  9. Rickard CM, Ray-Barruel G. Peripheral intravenous catheter assessment: beyond phlebitis. Lancet Haematol. 2017 Sep;4(9):e402-e403. doi: 10.1016/S2352-3026(17)30145-X. PMID:  28863798.
  10. Simin D, Milutinović D, Turkulov V, Brkić S. Incidence, severity and risk factors of peripheral intravenous cannula-induced complications: An observational prospective study. J Clin Nurs. 2019 May;28(9-10):1585-1599. doi: 10.1111/jocn.14760. Epub 2019 Jan 17. PMID: 30589945.
  11. Chopra V, Flanders SA, Saint S, Woller SC, O'Grady NP, Safdar N, Trerotola SO, Saran R, Moureau N, Wiseman S, Pittiruti M, Akl EA, Lee AY, Courey A, Swaminathan L, LeDonne J, Becker C, Krein SL, Bernstein SJ; Michigan Appropriateness Guide for Intravenouse Catheters (MAGIC) Panel. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015 Sep 15;163(6 Suppl):S1-40. doi: 10.7326/M15-0744. PMID: 26369828.
  12. Gavacelt: Choice of device for venous access: VAD Expert. Choice of device for venous access. VAD Expert. http://vadexpert.gavecelt.it/. Accessed June  30, 2021.
  13. Hallam C, Weston V, Denton A, Hill S, Bodenham A, Dunn H, Jackson T. Development of the UK Vessel Health and Preservation (VHP) framework: a multi-organisational collaborative. J Infect Prev. 2016 Mar;17(2):65-72. doi: 10.1177/1757177415624752. Epub 2016 Jan 10. PMID: 28989456; PMCID: PMC5074217.
  14. Larsen EN, Ray-Barruel G, Takashima M, Marsh N, Friese CR, Chopra V, Alexandrou E, Rickard CM. Peripheral intravenous catheters in the care of oncology and haematology patients. Aust J Cancer Nurs. 2022 May;23(1):16-22. doi: 10.33235/ajcn.23.1.16-22. PMID: 35854857; PMCID: PMC9288653.
  15. Moureau N, editor. Vessel Health and Preservation: The Right Approach for Vascular Access; Springer Inc. 2019.  Retrieved from:  Vessel Health and Preservation: The Right Approach for Vascular Access | SpringerLink
  16. Piper R, Carr PJ, Kelsey LJ, Bulmer AC, Keogh S, Doyle BJ. The mechanistic causes of peripheral intravenous catheter failure based on a parametric computational study. Sci Rep. 2018 Feb 21;8(1):3441. doi: 10.1038/s41598-018-21617-1. PMID: 29467481; PMCID: PMC5821891.
  17. Pittiruti M, Van Boxtel T, Scoppettuolo G, Carr P, Konstantinou E, Ortiz Miluy G, Lamperti M, Goossens GA, Simcock L, Dupont C, Inwood S, Bertoglio S, Nicholson  J,  Pinelli F, Pepe G. European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVa  project. J Vasc Access. 2021 Jun 4:11297298211023274. doi: 10.1177/11297298211023274. Epub ahead of print. PMID: 34088239.
  18. Steere L, Ficara C, Davis M, Moureau N. Reaching One Peripheral Intravenous Catheter (PIVC) Per Patient Visit With Lean Multimodal Strategy: the PIV5Rights™ Bundle Journal of the Association for Vascular Access (2019) 24 (3): 31–43. https://doi.org/10.2309/j.java.2019.003.004
  19. Nickel B. Does the Midline Peripheral Intravenous Catheter Have a Place in Critical Care? Crit Care Nurse. 2021 Dec 1;41(6):e1-e21. doi: 10.4037/ccn2021818. PMID: 34851379.
Tags: patient outcomes