Implementation and evaluation of peripheral intravenous catheter (PIVC) flushing guidelines: A Stepped Wedge Cluster Randomised Trial

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Introduction and Background: Intravenous access via peripheral intravenous catheters (PIVC) in the hand or arm is frequently required during hospital care to administer hydration fluids, medicines, blood transfusions and nutrition, and to withdraw blood for testing, It is estimated up to 85% of hospital patients require infusion therapy with up to 70% of patients requiring a PIVC. Historically, research and practice has focused (understandably) reducing blood stream infection rates, particularly in central venous catheters (CVCs). Catheter related blood stream infection (CRBSI) rates in PIVCs are extremely low (0.01)6, whereas PIVC failure rates due to dislodgement, occlusion, infiltration or phlebitis sit at 26% in Australia, 38% in Spain and 53% in the USA. Occlusion and infiltration account for 35% of failure. Australian and US Standards of Practice on PIVC maintenance include statements pertaining to securement, monitoring and flushing to maintain patency and function. A range of strategies to prevent or reduce PIVC complications exist. These include preventing failure through continuous or intermittent flushes of saline or heparin saline solution, and use of heparin, antibiotic and/or ethanol locks left inside the PIVC in between uses, continuous infusion and intermittent flushing. The Infusion Nurses Society's Infusion Nursing Standards of Practice clearly define three purposes of catheter flushing; to assess catheter function, to maintain catheter patency, and to prevent contact between incompatible medications or fluids that could produce a precipitate. For effective catheter flushing, the nurse must have an understanding of technique and the equipment used within his/her institution as well as the type of catheter in use. Specific to flushing current practice recommendations included aspiration of blood prior to flush administration to ascertain patency, flushing pre and post drug administration, use of 0.9% sodium chloride solution, amount of flush to at last equal that of device, use of single dose prefilled device, administration via syringe no smaller than 10mL to minimise applied pressure. There were varied recommendations for frequency of flushing. However, clinical trials and practice surveys have identified little if any adherence to these recommendations. Translation and evaluation of current evidence for flushing of PIVCs is urgently required to reduce the unacceptably high failure rate of PIVCs. Aims and Hypothesis. The aim of this implementation study is to evaluate the impact, feasibility and acceptability of a multifaceted intervention tailored to improve post insertion PIVC maintenance - specifically, patency and flushing. Primary hypothesis: the rate of PIVC failure (as measured by a composite of occlusion , infiltration, dislodgement, phlebitis and infection) in patients who receive recommended flushing practice will be lower than those patients who receive standard care.