The Challenge:

Venous Access Devices (VADs) are a group of devices used to create an artificial portal of entry through a vein or artery, typically for drug or fluid administration and physiological monitoring. They are an integral part of today’s healthcare with 60% to 90% of hospitalised patients requiring this intervention during their hospital stay (Jackson et al 2013; Hallam et al 2016; Helm et al 2015). VADs cause a wide range of complications, some of which can be life threatening, and are considered to be the single most important cause of healthcare associated blood stream infections (Loveday et al 2014; Moureau et al 2012).

Different VADs have different properties and the clinical assessment process should result in patients receiving the most appropriate device according to vein quality, duration of treatment and medication to be administered, taking into consideration patient preference. However, in practice this decision making process does not always happen with clinicians most often selecting a peripheral intravenous cannula (PIVC) even when not the most appropriate. Almost one in five attempts to cannulate patients fails on the 1^st attempt increasing the pain reported by patients (van Loon et al 2016). Once PIVCs are in-situ the failure rate is high (35% to 50%) due to phlebitis, infiltration, occlusion, mechanical failure, dislodgement and infection resulting in removal of the device before its intended dwell time (Helm et al 2015). The failure of in-situ PIVC results in removal of the device and reinsertion which develops into a negative cycle as each subsequent reinsertion becomes more difficult (Helm et al 2015). Failed PIVCs contribute to negative patient outcomes, pain, delays to critical medication, delayed treatments and therapy, prolonged hospitalisation and increased mortality and morbidity (Kagel and Ryan 2004, Carr et al. 2016). Moreover, the ongoing documentation of IV device placement, assessment and monitoring is often lacking or absent (Vizcarra et al 2013) which makes assessing the scale of the problem difficult.

 

In summary

• Very little is known about the patient experience of PIVC insertion.
• Second, there is very little information available about PIVC safety and approaches that can reduce patient harm around avoidable PIVC insertion and re-insertion.
• Third, little is known about the effectiveness of health professional decision-making with regard to the choice of VAD and the prevalence of associated complications.

Proposal

 The project intends to change the culture of the reactive placement of PIVC to a proactive patient-centred approach which is fundamental to vessel health and preservation. Our first focus will be to understand the barriers faced for clinicians to be able to assess if a VAD is required or can an alternative route of administration be found and secondly, if required selecting the most appropriate VAD for the patient. The second focus will be to explore the barriers to the reassessment, management and escalation for an alternative VAD, if required.

We propose to use the Achieving Behavioural Change toolkit (http://www.improvementacademy.org/patient-safety/behaviour-change-for-patient-safety.html) supported by the Yorkshire & Humber AHSN Improvement Academy developed by Professor Rebecca Lawton and the Yorkshire Quality and Safety Group. The toolkit is based on the Theoretical Domains Framework (Michie et al 2005) and is a five stepped approach to behaviour change. This involves establishing an implementation team supported by the executive team; identifying a target behaviour; understanding the barriers to change; developing intervention strategies that address these barriers and monitoring change.

 Alongside this work the clinical team at the Trust will be exploring clinical pathways for each vascular access device and considering where further training, skills and equipment are required. Progress of the work will be tracked using process measures such as missed doses of medication, cannula harm and procurement of devices. Outcome measures are more challenging due to the current lack of data but significant harm from devices (infections, phlebitis) will also be measured.

Benefits:

This work will contribute to redesigning the patient pathway around VAD assessment, insertion and management. Once this work has taken place it will assist in improving the patient experience, reduce delays to drug administration, reduce patient harm (thrombosis, infection and extravasation) and improve efficient use of appropriate devices. The development of an educational tool kit and an understanding of the context for implementation with individual barriers and levers for change will contribute to long term development and sustainability within the clinical setting. Setting up surveillance systems to monitor patient harm will provide a benefit for the organisation in being able to understand the cost benefits of change and potentially result in a reduced spend on VADs and clinicians time.

Benefits for Q Community

The scale is hard to quantify despite awareness of the impact of poor device selection (patient harm, acute capacity and patient experience). Although the vessel health pathway has an evidence base, there is little published QI work to show how to implement such a pathway into practice in the UK. This could have a positive impact and lead to increased interest which we can share through publication.