Difficult Access Requires Thought, Training and Technology (DART3): An implementation study investigating the effect of a co-developed escalation pathway on peripheral intravenous catheter insertion success and insertion-related complications in patients with difficult intravenous access.

Early identification and management of patients with difficult intravenous access (DIVA) is complex and dependent on patient, illness or injury, and provider characteristics. Prospective identification of patients with DIVA using vessel assessment instruments, combined with the use of high-quality clinical guidelines or escalation pathways (to more skilled inserters) is recommended in order to maximise first-time insertion success and to prevent peripheral intravenous catheter (PIVC) insertion failure. Our preliminary work demonstrates a strong need for a DIVA identification process which accurately highlights those patients who have DIVA; and links to an insertion escalation pathway, incorporating the use of ultrasound (US) if needed, so that DIVA patients have a better chance of having a PIVC successfully inserted on the first attempt. The current study aims to evaluate the clinical and cost-effectiveness of DIVA identification and escalation pathways. Co-production of a DIVA identification tool (e.g., screening for DIVA risk factors) and escalation pathways (e.g., escalation based on DIVA classification and inserter skill) with an Advisory group, will be undertaken by the research team at each site. Implementation strategies will be underpinned by the Behaviour Change Wheel intervention functions and policy categories and be evidence informed. Core components which the pathways must contain include: DIVA identification pathway - Able to be used across all disciplines/clinical areas where PIVCs are inserted - Applicable to all patients - History of DIVA should be assessed – Patient-reported, and medical records - Prompt user to consider whether there is a clear indication for vascular access/PIVC insertion (refer user to ACSQHC PIVC Standards: Device Appropriateness) - Vein visibility and palpability assessment as minimum requirements for DIVA assessment - Lack of vein palpability and visibility should automatically classify a patient as DIVA, overriding other criteria - Inserter skill and confidence should be assessed: - Should not be prescriptive – allow integration of clinical judgement in decision-making process Escalation pathway - Timely response: Escalation to occur in reasonable timeframe - Pathway must be applicable at all hours across all days of the week - Distinct escalation pathways for inserters of different skill levels, and for non-DIVA and DIVA patients - Sites should strive to construct an ideal escalation pathway, that may not be achievable initially, but can be a goal to reach towards - Pathway must consider the urgency of PIVC insertion, and not be applicable for Resus/Code Blue situations Implementation strategies - Implementation strategies should: o Be multimodal (i.e. same content delivered via different platforms/ media) o Leverage off existing staff and workflows at each site for promoting best practice PIVC insertion, care and removal (not solely rely on research staff and investigators) o Consider evidence-based strategies from previous vascular access or other clinical implementation projects (e.g. bundles in published papers) - Intensity of implementation strategies should be flexible and adjusted throughout the project as necessary - Education must include content to improve awareness of device appropriateness and vascular access requirement - DIVA information resource should be provided to patients to facilitate patient empowerment (i.e. to request US insertions if history of DIVA is known) - Sites will ensure appropriate infection prevention measures are in place for ultrasound equipment: o Consider use of “DIVA Pack” containing sterile probe covers, disinfectant wipes, sterile gel, etc. o Consider providing laminated card outlining cleaning procedures for US - Site investigators will garner support for pathway within hospital (including executives and clinical staff) - Change champions should understand the escalation pathway and DIVA tool well to guide others in its use - Advisory group to consider the cohort/s of inserters to escalate to given the number of projected DIVA patients and advanced inserter availability at different times/days - Method should be developed by advisory groups to ensure that ultrasounds are accessible/locatable when needed. - Formal implementation plan should be developed by site advisory groups addressing each component of an implementation plan template developed by Core Group o Advisory groups must identify or create workforce for escalation. o Site-specific advisory groups must consider methods of changing clinician viewpoints on ultrasound-guided PIVC insertion, and normalising it as a part of standard practice The intervention will involve (delivered via stepped wedge cluster RCT [with inbuilt process evaluation]) the implementation and evaluation of the DIVA identification and escalation pathways’ effect on clinical and implementation outcomes from four clusters at the Queensland Children’s Hospital (QCH), Royal Brisbane and Women’s Hospital (RBWH), and Gold Coast University Hospital (GCUH). All 12 hospital clusters (wards/departments) will start the trial in the control phase for two months, with baseline measures taken. Following this, one cluster per hospital will randomly (computer generated) step-up to implementation every two months over an 8-month period, until all are fully implemented. The exposure to the intervention will differ per cluster (depending on randomisation) but be between 6 and 12 months. At each time point, a random sample of a minimum 20 PIVC insertion procedures will be studied per cluster. This will be achieved by randomly selecting dates for data collection, rostering research nurses on those dates and collecting a minimum of 20 PIVC insertions that occur sequentially while the research nurse is available. An internal process evaluation will be undertaken guided by the Consolidated Framework for Implementation Research to i) establish the extent to which the intervention is implemented as intended (implementation fidelity), over time and across different sites; ii) to ascertain how staff understand and respond to the intervention, over time and across different sites; and iii) to explore the context over time and across different sites and determine factors (including managerial, economic, organisational and work level) that affect implementation. Up to 5 staff per cluster will be interviewed (in-person or via telephone) by a member of the research team. Purposive sampling will be used to select staff involved in implementation or intervention delivery. Intervention fidelity will be promoted by the Project Manager who will develop a study manual, train ReNs (Research Nurses), monitor allocation integrity and data quality, and work with investigators/ReNs to address any issues. Education and training to implement the intervention willl reflect literature, pilot educational programs developed by the partners, sound educational principles, and standards, (e.g., the Australasian Society for Ultrasound in Medicine requires >/=2 hours of teaching (>1 hour practical), a post-test, two supervised (marked, interactive) formative assessments and a third summative assessment) and will be delivered in-person, where feasible, by the ReNs or another member of the research team (e.g., Project Manager). Implementation education will provide evidence-based advice, but individual clinicians will make decisions (e.g. insertion site) based on patient needs.