A game changing way to better secure an IV catheter?

Mark Schreiner MD, Lynn D Martin MD MBA, and Myron Yaster MD

Although not as good as my teacher Dr. Terry Lee, the Zen master of IV insertion at the Children’s Hospital of Philadelphia during my residency and fellowship, I was good, really good at doing this most basic of pediatric anesthesia procedures.  Although expert at placing them, once universal precautions required wearing gloves during IV insertion, I hated/dreaded securing them.  Invariably the tape would get stuck to my gloves, or I’d bend and occlude the catheter at the insertion site, or lose the IV during the taping process.  In today’s PAAD¹ and accompanying editorial,² Charters et al.,¹ in a randomized clinical trial, investigated 3 different ways of securing peripheral IV catheters and found a clear winner!  As you will see, I think the evidence presented is so overwhelming it will and should change your practice.  How to implement this change, like all new ideas and procedures, will be a challenge facing you in your practice.  Myron Yaster, MD

Original article

 Charters B, Foster K, Lawton B, Lee L, Byrnes J, Mihala G, Cassidy C, Schults J, Kleidon TM, McCaffery R, Van K, Funk V, Ullman A. Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial. JAMA Pediatr. 2024 Apr 1:e240167. doi: 10.1001/jamapediatrics.2024.0167. Epub ahead of print. PMID: 38558161; PMCID: PMC10985620.

Editorial

Bettencourt A, Ruppel H, Bonafide CP. Advancing Evidence-Based Peripheral Intravenous Catheter Securement. JAMA Pediatr. 2024 Apr 1. doi: 10.1001/jamapediatrics.2024.0177. Epub ahead of print. PMID: 38557797.

As you all know, peripheral IV catheters have a short life, and if secured in the usual way have a failure rate of 30%.^1-3  “Charters et al¹ randomized patients to standard care, a bordered polyurethane dressing (Tegaderm [3M]), an integrated securement dressing (ISD) (SorbaView SHIELD with sizes dependent on child (Nano [SV118UDT-6], Micro [SV226UDT-6], or Peripheral [SV233UDT-6 (Medline)] and a ISD with tissue adhesive (TA) skin preparation. The ISD and TA arm had 1 drop of Secureport IV (Adhezion Biomedical) at the PIVC skin site and 1 under the PIVC hub 30 seconds prior to ISD dressing application. (Note: The tissue adhesive is essentially Crazy Glue or Dermabond).   PIVC failure was defined as the removal of the PIVC prior to the completion of treatment, regardless of reason.

The results are game changing and best visualized in the Kaplan-Meir survival curve below.  PIVC failure rate was highest with standard securement and, although not significantly lower with ISD alone, failure risk was significantly lower in the ISD with TA group compared with standard securement. Importantly, after accounting for costs associated with failed PIVCs, the ISD with TA was significantly more cost-effective than standard care, although direct costs were slightly higher.

The results of this study are a call to action and should change your practice as soon as possible.  No one wants a peripheral IV catheter to fail and no one wants to replace them in any patient, particularly children.  This simple solution will dramatically increase PIV survival time. 

The next question is how to implement this change across your enterprise?  As I (LDM) have learned from the multiple quality improvement studies we’ve highlighted in previous PAADs, success depends on the use of common change management principles.⁴  Start with (1) creating the vision by highlighting the need for change and (2) the benefits the improvement will achieve (i.e., secure PIVs), (3) develop comprehensive training to provide the required new skills, (4) assure the necessary resources are immediately available (i.e., new PIV insert kit on anesthesia cart), and (5) an implementation plan that includes clear expectation with ongoing support, coaching, and data to drive towards the sustained success needed.  Using peer champions on each clinical shift and site of practice along with the development and posting of clear ‘how to’ and ‘how not to’ photographic guides and instruction sheets are required education tools, but aren’t the solution alone. Rather, process improvement requires a defined change management plan to achieve the buy-in and support from all of the stakeholders  to insure successful implementation.

Send your thoughts and comments to Myron who will post in a Friday reader response.

References

1.            Charters B, Foster K, Lawton B, et al. Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial. JAMA pediatrics 2024 (In eng). DOI: 10.1001/jamapediatrics.2024.0167.

2.            Bettencourt A, Ruppel H, Bonafide CP. Advancing Evidence-Based Peripheral Intravenous Catheter Securement. JAMA pediatrics 2024 (In eng). DOI: 10.1001/jamapediatrics.2024.0177.

3.            Marsh N, Webster J, Flynn J, et al. Securement methods for peripheral venous catheters to prevent failure: a randomised controlled pilot trial. J Vasc Access 2015;16(3):237-44. (In eng). DOI: 10.5301/jva.5000348.

4.            Rampersad SE, Low DK, Martin LD.  Change Management in Modern Anesthesia Practice.  Internat Anesth Clinics 2016;54(3): 83-92. PMID: 27285074.