Peripheral venous cannulation observed at a university hospital in Ethiopia

Peripheral venous cannulation observed at a university hospital in Ethiopia: patient- & clinician-related factors contribute to first-attempt cannulation failure
INTRODUCTION
Background
Establishing safe and effective vascular access using a vascular access device (VAD) is an integral aspect of health care for acute and chronic patients with any ageADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “DOI” : “10.3322/CA.2008.0015”, “author” : { “dropping-particle” : “”, “family” : “Gallieni”, “given” : “Maurizio”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Pittiruti”, “given” : “Mauro”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Biffi”, “given” : “Roberto”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “6”, “issued” : { “date-parts” : “2008” }, “page” : “323-346”, “title” : “Vascular Access in Oncology Patients”, “type” : “article-journal”, “volume” : “58” }, “uris” : “http://www.mendeley.com/documents/?uuid=9850fcee-0348-4e4d-b789-f14fafea179a” } , “mendeley” : { “formattedCitation” : “(1)”, “plainTextFormattedCitation” : “(1)”, “previouslyFormattedCitation” : “(1)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(1)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Ryan”, “given” : “Diane”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” }, { “dropping-particle” : “”, “family” : “Thompson-mchale”, “given” : “Stuart”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “id” : “ITEM-1”, “issue” : “July 2013”, “issued” : { “date-parts” : “2018” }, “page” : “1-15”, “title” : “No Title”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=d684e576-d410-44e7-b4c8-293a74a91db2” } , “mendeley” : { “formattedCitation” : “(2)”, “plainTextFormattedCitation” : “(2)”, “previouslyFormattedCitation” : “(2)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(2)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “author” : { “dropping-particle” : “”, “family” : “Development group of the clinical practice guideline on intravenous therapy with temporary devices in adults.”, “given” : “”, “non-dropping-particle” : “”, “parse-names” : false, “suffix” : “” } , “collection-title” : “Clinical practice guidelines in the SNS”, “id” : “ITEM-1”, “issued” : { “date-parts” : “2014” }, “publisher” : “Ministry of health, social services and equality. Health technologies assessment agency of andalucu00eda (AETSA)”, “title” : “Clinical practice guideline on intravenous therapy with temporary devices in adults.”, “type” : “report” }, “uris” : “http://www.mendeley.com/documents/?uuid=dfdb3247-aa74-48c2-94dd-8439b3279a91” } , “mendeley” : { “formattedCitation” : “(3)”, “plainTextFormattedCitation” : “(3)”, “previouslyFormattedCitation” : “(3)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(3)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “No Title 3. Vizcarra C, Cassutt C, Corbitt N, Richardson D, Runde D, Stafford K.Recommendations for improving safety practices with short peripheral catheters. J Infus Nurs 2014;37:121u2013124.”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=740f44b9-37a9-45bb-9438-ba67bbbfbaa6” } , “mendeley” : { “formattedCitation” : “(4)”, “plainTextFormattedCitation” : “(4)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(4). In modern health care, about 70 to 80% of patients coming to hospital will require some form of VADADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “No Title Rivera, A.M, Strauss, K.W., Van Zundert, A.A.J. and Mortier, E.P. (2007) Matching the peripheral intravenous catheter to the individual patient. Acta Anaesth. Belg. 58(1): pp. 19-25.”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=dfbefbc0-f78a-4e18-b62b-867646d2363a” } , “mendeley” : { “formattedCitation” : “(5)”, “plainTextFormattedCitation” : “(5)”, “previouslyFormattedCitation” : “(4)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(5)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “No Title 1. Alexandrou E, Ramjan L, Murphy J, Hunt L, Betihavas V, Frost S. Trainingof undergraduate clinicians in vascular access: an integrative review. Assoc Vasc Assess 2012;17(3):146u2013160.”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=be9c57af-00f9-4ab9-b70e-8f6c1150d880” } , “mendeley” : { “formattedCitation” : “(6)”, “plainTextFormattedCitation” : “(6)”, “previouslyFormattedCitation” : “(5)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(6)ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “No Title 3. Vizcarra C, Cassutt C, Corbitt N, Richardson D, Runde D, Stafford K.Recommendations for improving safety practices with short peripheral catheters. J Infus Nurs 2014;37:121u2013124.”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=740f44b9-37a9-45bb-9438-ba67bbbfbaa6” } , “mendeley” : { “formattedCitation” : “(4)”, “plainTextFormattedCitation” : “(4)”, “previouslyFormattedCitation” : “(6)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(4) to allow for the type of therapy being given, and for the patient’s quality of life needs 7; G6. Reports describe the use of peripheral intravenous cannula (PIVC) as the first choice VAD for patient treatment in varies health care settings 1, 22; (15)2; 1–34. Today, the insertion and management of PIVC is one of the most widely and frequently used universal procedure performed by health care professionals in the health care setting 1,26; 310; Lopez et al 200412; 3; 4310; 11; 3; 10; 4G12. It is estimated that over half (50% to 70%) of all patients admitted to hospital will require the insertion of a PIVC to receive some form of life saving IV therapy ADDIN CSL_CITATION { “citationItems” : { “id” : “ITEM-1”, “itemData” : { “id” : “ITEM-1”, “issued” : { “date-parts” : “0” }, “title” : “1. Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, Lin F, Alberto L, Mermel L, Rickard CM. International prevalence of the use of peripheral intravenous catheters. J Hosp Med. 2015;10(8):530u20133.”, “type” : “article-journal” }, “uris” : “http://www.mendeley.com/documents/?uuid=772024ec-8f3c-4cdd-add5-92bb1c8a7706” } , “mendeley” : { “formattedCitation” : “(7)”, “plainTextFormattedCitation” : “(7)”, “previouslyFormattedCitation” : “(7)” }, “properties” : { “noteIndex” : 0 }, “schema” : “https://github.com/citation-style-language/schema/raw/master/csl-citation.json” }(7); 3G12; 12. When hospitalized, an increasing patients require intravenous therapy as a safe way to administer treatment Ingram ; Lavery 2005 1. However, it is often poorly undertaken 2G and DiVA occurs frequently 242G. Preserving venous anatomy from repeated skin punctures is a challenge in clinical settings 2; and procedures are a frequent source of patient adverse events 2G. PIVC insertion is one of the most common, and typically the first invasive clinical procedure frequently used when patients attended in hospitals worldwide 310; Mermel, 20014G; 210; 2, 35; Mermel, 20014G. It is often the source of considerable patient discomfort, inconvenience, morbidity, and mortality 2G; G8. 2G; 4G; Mestre, 2012 4G.

Now a days, insertion of PIVC is becoming a technically difficult, challenging, and complex task for many health care professionals, and limit insertion of devices in varies patient populations presented to clinical settings 110; 23; 310; 11; 3; 2G; 3G; G8. Whereas many patients are admitted to hospital with non-visible or -palpable veins 5. Over a third of adults and up to half of the children that present to hospital who require a PIVC, are reported to have DiVA 4, 55; G8. The failure to obtain an IV access in patient presents a unique challenge in the healthcare setting 11; 3. This can be a challenging to even the most experienced nurse 3G. Even though it is a prevalent, technically difficult, and invasive procedure, most health care practitioners, who have not been trained as VA experts, receive little substantive peripheral VA education, training, or opportunities to practice skills until competent 1,3–64.
Existing studies suggest first-attempt insertion failure incidence rate range from 2 to 82% (or 18 to 98% success rate) in the diverse study populations, stings, and designs with or without intervention 7, 82; Walker, 20093G; 5; 2; 3; Paxton, 20094; Leidel et al. 20093G; Katsogridakis, Seshadri, Sullivan, and Waltzman 20083G; 33; 8–104; Lininger 20033G; 23; 13; 2-52; which vary in frequency depending on patient, catheter, and clinician/operator related factors 2; 2G; 4. This variability in clinical practice also involves patient suffering, the deterioration of their venous system, the risk of suffering from local and systemic infections and inadequate use of existing resources 4G.
Patients with DiVA often subjected to multiple or repeated needle puncture attempts at cannulation (to gain peripheral VA) by multiple practitioners due to failed IV attempts 5; G8; 75; Witting, 20123G; 4G; Katsogridakis et al., 20083G; 5; 14,154; G8. Of interest, the patients had undergone an average of 6.4 attempts Walker, 2009 3G; and at least a second attempt was required for 47% Lininger 20033G to 62% 13 of patients with the conventional catheter insertion. About 9% 23 to 30% G8 of patients had more than four attempts before peripheral IV access is obtained.
These may lead to increased morbidity, delayed treatment, prolonged hospitalization 6, 7 G12, and the repercussions of complications on survival and quality of life related to health Mestre, 2012 4G; 312G.
Patient pain, stress and anxiety are often increased by repeated or multiple needle (IVC) insertion attempts to obtain VA 9, 102. 53; 5G; 75; 53; 5; 4G; 1G; G8; 53; 5; G8; G6; Royal College of Nursing IV Therapy Forum 2005, Hawes 2007, Cicolini et al. 2009, Infusion Nurses Society 2011, Abolfotouh et al. 2014 1. Patients with multiple cannulation attempts reported much severe pain 53; 5G, 5, G8.
Evidences also illustrates the impact of needle pain which can cause anxiety, phobia and significantly reduce patient satisfaction with the health care facility 215. Patients may experience mild to severe needle/blood phobias or fears Dougherty and Lister, 2011 G6; (Fink et al., 2009)3G; this probably increased by repeated/multiple insertion attempts. Intern, anxiety may leads to further DiVA. Anxiety can cause constriction of peripheral veins thereby making the procedure more difficult Dougherty and Lister, 2011 G6, this may adversely affect the practitioner’s success and further compound the patient’s fears Weinstein, 2007 G6. Repeated needle insertion attempts also impact negatively on patient satisfaction 9, 102; 215; Patient satisfaction is a valued and highly sought after predictor of quality of care in the healthcare facility 1,211; 11.
Patient pain and overall suffering are increased by repeated attempts to obtain VA, which in many cases lead to the insertion of PIVCs in inappropriate locations such as flexion or high mobility areas (wrist, elbow or antecubital fossa); lower extremities/foot, and near a bony prominence; and may be re-inserted a cannula following an abortive attempt as a malpractice or other situation in turn increasing the risk of subsequent complications, impede patient safety, and may hamper other procedures such as blood pressure recording Royal College of Nursing IV Therapy Forum 2005, Hawes 2007, Cicolini et al. 2009, Infusion Nurses Society 2011, Abolfotouh et al. 20141. G6; 25, 265; G12; 4G; Weinstein 2007G6; RCN 2010; INS 200612; Philips, Collins and Doherty, 2011G6.
It has been well described that multiple/repeated attempts at cannulation, the placement of PIVCs in high flexion areas or in lower extremities (which is typical among DiVA patients) and re-insertion of a cannula following an abortive attempt increases the risk of varies local and systemic chatter-related complications. These complications include infiltration, extravasation, phlebitis, thrombosis, thrombophlebitis, haematomas, embolisms, and catheter-related blood stream infection 12; Regueiro Pose et al 2005 and Owens et al 199812; Dougherty 20081; 3–86; 74; 7G12; 7-12G12; 1G; 2G; G8; 4G; 3–86; 49G12; 6; Royal College of Nursing IV Therapy Forum 20051; 1G; 7-12G12; G12; 9, 102; RCN 2010; INS 200612; 1G; 4G –7-12G12; 13G12; RCN, 2010; Weinstein 2007G6; Phillips, Collins and Dougherty 2011G6; 1G; 4G; 8G12; O’Grady et al 201112; O’Grady et al 200212; 8G12; G6; 7-12G12. 7G12; 4G; G6; Perucca, 2010G6; Philips, Collins and Doherty, 2011 ––– most of which lead to premature device (catheter) failure 10, 115;12. PIVCs have an underappreciated failure rate G8. Often resulting catheter failure (premature removal) 5. Difficult access leads to premature failure of PIVC G8. Increased failure rates compared to patients with good access G8. A recent analysis revealed overall PIVC catheter failure rates ranging from 35% to 50% leading to premature removal before the catheter’s intended dwell time 74. Up to 90% of PIVCs are prematurely removed or dislodge before they are due for removal G8; then the need for re-siting/reinsertion of the IV catheters 7,96; G8; Phillips, Collins and Dougherty 2011G6, and may render the vein unsuitable for further cannulation Perucca, 2010G6. This in turn, results in further painful, and often unsuccessful insertion attempts to gain alternate peripheral VA, leading to further increased anxiety of patient, vessel damage and eventual venous depletion or loss of access sites G12; 125; Hawes 20071; G8; 4G. This contribute to greater limitations and exhaustion of VA Hawes 20071 and create a challenge to such clinical environs 2, and then Needing CICC or PICC G8.

Furthermore, complication rates due to premature removal of PIVCs include phlebitis (15.4%), infiltration (23.9%), catheter occlusion (18.8%), catheter dislodgement (6.9%), and catheter-related infection (0.2%) 74. These complications (haematomas, extravasation, infiltration) may lead to further adverse events, such as skin necrosis, neuropathy, compartment syndrome 106; 7G12; 49) G12; East Midlands Cancer Network, 2012G6; Scales, 2008G6; Clayton and Stock 2006; Rivas Doblado et al 200412; Dougherty and Lister, 2011G6; Clayton and Stock 2006; Rivas Doblado et al 200412; 1G; 4G; 12; G6; 12; G8; G6, which can increase not only the period of hospitalization and medical expenses for treatment 11,126; G12; 2G but also permanent damage or sequelae in patients 136; 7G12. Moreover, catheter-related infection may contributes to the development of biofilms, leading to an evasion of host defense mechanisms and to a phenotypic resistance to antimicrobial agents Von Eiff et al 200512.

Patients frequently experience delays in diagnosis and initiation of treatment, and this is more likely among those with DiVA 3G. Importantly, there can be many clinical implications from DiVA, to be exact: a delay in establishing IVA (due to DiVA) can lead to: (DiVA also leads to) a delay in diagnosis (where important laboratory tests are required), a delay in the commencement of lifesaving treatment (delays in the administration of medication), missed medication doses (partial or total loss of the prescribed dose), a prolonged treatment course, increased length of stay (prolonged hospitalization/ increase in the number of hospitalization days), and potentially place the patient at risk for decompensation during the period when IVA is not available. 11; 5, 8, 95; 5, 8, 95; Witting, 20123G; Hawes 20071; Mestre, 20124G; 3G; G8. DiVA also leads to the need to place central venous lines, representing a greater risk for patients Hawes 20071. It also causes an increase in the use of materials, nurse time Hawes 20071, costs associated with complications and length of hospital stay 1.
After a PIVC has been placed, each removal due to complication and subsequent reinsertion may also lead to the use of more invasive VADs 74. Common alternatives to the failed blind IV placement include continued attempts at blind IV placement by a more experienced nurse or IV team, placement of a central venous catheter (CVC), or placement of an ultrasound guided peripheral IV (USGIV). The placement of USGIVs has quickly become the rescue method of choice for failed blind IV access, mostly due to its improved safety profile when compared to riskier alternatives such as CVC 8,911. Often patients are presenting for PICCs insertion after multiple insertion attempts (20-30 attempts) G8; resulted in unable to insert PICC due to extensive bruising or thrombosis – and then required to insert CVC G8. However, they are known to increase phlebitis and when necessary need re-siting Dougherty and Lister, 2011G6. In addition, some patients may not be able to tolerate the presence of a cannula G6. Require long-term access. 2G
Moreover, multiple failed intravenous attempts cause even conflicts between the patient/relatives and healthcare providers 53.

Proficiency of IV insertion may prevent serious patient complications including pain 910. Therefore, success rate and time to vascular cannulation are crucial to the optimal management of a critically-ill patient 3G. Interventions to ensure higher success rates on the first attempt are important 3; 2; 13; 8,911 to provide quality nursing care 3; consequently to improve patient safety and satisfaction, and overall clinical outcome.

Justification
Objectives