Expert versus generalist inserters for peripheral intravenous catheter insertion: a pilot randomised controlled trial

Peripheral intravenous catheter (PVC) insertion is the most commonly performed invasive procedure in hospitalised patients. Worldwide, it is estimated that 2 billion PVCs are sold each year [1] and used for the short-term delivery of intravenous (IV) medications and fluids [2]. However, multiple insertion attempts are common, and post-insertion failures from complications such as occlusion are as high as 69%, triggering the insertion of subsequent catheters [3‐5].

PVC inserter models vary. Traditionally, intravenous therapy teams (IVTTs) were used for most PVC insertions [6, 7]. These teams were made up of nurses with advanced skills in insertion and maintenance [7, 8]. More recently, many IVTTs have been discontinued due to health care budget cuts, leaving PVC insertion to generalist nursing and medical staff [9]. Data supporting cost savings associated with disbanding IVTTs are yet to be reported in literature [9].

The generalist model involves nurses and medical staff at the clinical unit level [8], which ideally enables continuity of care if they are aware of the patient’s diagnosis and clinical history. A belief exists that even though generalists may have minimal PVC insertion skills, this rarely leads to negative outcomes [10]. This belief likely stems from a focus on PVC insertion success alone, but there is an ongoing concern that the varying skill level of generalist inserters leads to multiple needle sticks, patient discomfort and irreversible damage to the venous system, limiting current and future vascular access options [9, 11].

Other workforce models for PVC insertion include the use of vascular access specialists (VASs), who are practitioners with advanced assessment as well as technical skills for all vascular access devices. These practitioners may work within an IVTT [8] or within a specific unit or nursing framework [12] for device insertion, surveillance, research and education.

For the purpose of this trial, a VAS was defined as a clinician with advanced knowledge of vascular access, including catheter technology (materials and design); insertion assistive devices (such as ultrasonography); dressings; processes of catheter access; and management of IV therapy. This advanced level of expertise and knowledge is believed to preserve veins, enhance the patient experience, decrease the incidence of infusion complications and ultimately save on costs associated with clinician time, PVC-related products and length of hospital stay [12].

Effective PVC placement and the prevention of PVC-related complications are not only important clinical objectives but also essential for patient satisfaction [6]. A recent international survey exploring patients’ perspectives on PVC insertion found that consumers wanted standards implemented for inserters in order to feel safe and trust their health care professionals [13]. The level of skill of the PVC inserter is a risk factor for catheter failure [6, 14]. However, limited high-quality research exists exploring the efficacy of a VAS. Observational studies and audits report that VAS-inserted PVCs have fewer first-time insertion attempts [6, 15], less phlebitis [16, 17], less inflammation and catheter-related sepsis [18] and higher patient satisfaction [19]. As some of these studies were conducted before the year 2000 [16, 17, 20], it is unclear what impact more advanced PVC materials, dressings and other IV supportive equipment have had on PVC failure. Other observational studies have reported on the success of PVC insertion but not the subsequent catheter failure rate [6], or on the benefit of a VAS within a hospital but not compared to a generalist inserter [6, 7]. Limitations of previous research include data collected retrospectively [7], secondary analysis of existing datasets [14] or clinical staff assigning their own level of insertion skill [12].

There is a paucity of evidence from high-quality randomised control trials (RCTs) assessing inserter skill levels required for successful PVC insertion and prevention of device failure and complications. This makes it impossible for local and international guideline writers to produce comprehensive clinical practice guidelines for the best PVC insertion model of care. Therefore, it is important to examine the efficacy of different models for PVC insertion used in hospitals.

Improving the knowledge and skill of PVC inserters is likely to reduce the current situation where patients commonly experience multiple PVC insertion attempts and unacceptably high post-insertion catheter failure rates. In this pilot RCT, we compared two inserter workforce models for clinical, patient and feasibility outcomes. All predetermined feasibility outcomes were met; thus, we have established that the tested methods are appropriate for an adequately powered, multicentre RCT. Overall PVC failure was higher in the generalist compared with the VAS group, and although pilot trials are not powered for statistical significance, this result was clinically meaningful and needs testing in a larger RCT. To compare 54% versus 48% post-insertion failure with 80% power (p = 0.05) would require 1084 patients per group (powerandsamplesi​ze.​com).

Under generalist models, establishment of vascular access is frequently left to junior medical and nursing staff who, with minimal knowledge about complications associated with IV medications, may choose a PVC as a default VAD [27, 28]. In our trial, 18% of PVCs were considered an inappropriate VAD by our blinded VAS assessor, as they had IV therapy prescribed for greater than 5 days and/or poor vascular access. Generalist models also lack standardisation of knowledge and technique for clinicians inserting PVCs, meaning that expertise and maintenance of competence cannot be guaranteed across and within health care settings [29]. Such deficiencies likely contributed to the lower first-time PVC insertion success in our generalist group, with multiple insertion attempts occurring almost twice as often with the generalist inserter (35%) than the VAS inserter (19%). An additional three patients allocated to the generalist group were still awaiting PVC placement after 24 h and numerous unpleasant insertion attempts. This is not only a poor patient experience but also has cost implications for clinician time, delayed treatment and potentially extended hospital stay.

More than a quarter of patients allocated to the generalist group in our trial did not receive a PVC, compared to 100% placement by the VAS group. The purpose of placing a PVC is to start or continue treatment, and this was an unexpected result. It may indicate a lack of PVC insertion skill in the generalist group or a lack of comprehensive assessment regarding the requirement for a PVC. Either way we consider that this may be the more appropriate primary endpoint for a follow-on study. The most commonly reported reason in this study for non-placement was the change of antibiotic therapy from intravenous to oral. The decision to change antibiotic route should be based on three key factors: (1) the antimicrobial agent, (2) the patient and (3) the condition being treated, and careful consideration is necessary to provide the best care [30]. Within this trial it was unclear if these factors were the determining considerations, or if this change was due to the unavailability of staff to place the catheter or unsuccessful insertion attempts rather than the patient’s clinical need.

Our multivariable model identified that patients admitted with a medical diagnosis and those who were non-ambulant (bed-bound) were at higher risk of PVC failure. These patients may have a higher risk, as they are likely to have more comorbidities and a history of greater VAD use than ambulant patients and/or those with an acute surgical diagnosis. These patients should be the priority for efforts to improve PVC outcomes. We also found that patients whose PVC was secured with additional non-sterile tape had a significant association with decreased PVC failure. These results reflect a similar finding by a large cohort study at the same hospital that reported significantly lower occlusion/infiltration, phlebitis and dislodgement rates when non-sterile tape was used as an additional PVC securement [31]. This suggests that, despite advances in dressings and securement devices, PVC failure rates have remained high, and even good-quality insertion requires effective securement to maintain function.

This study suggests that less insertion failure and less post-insertion failure occur when catheters are placed by a VAS. This pilot trial has confirmed the feasibility and clinical need for a large, multicentre RCT to test these PVC insertion models to provide evidence for health service delivery improvements.