Pediatric peripheral IV insertion success rates

Pediatric Nursing, Sept-Oct, 2003 by Rae Ann Lininger

Pediatric peripheral intravenous (PIV) access can be a difficult task. Many hospitals look to their more experienced staff nurses or to IV nurse specialists/teams to routinely achieve PIV access. The skill and success rate of the individual achieving access as well as the number of attempts made are variables that influence patient satisfaction. When evaluating various mode]s for PIV access, cost effectiveness as well as patient satisfaction should go hand in hand. Determining the most successful model needs to be individualized to each hospital population. The model should define the practice standard for PIV insertion attempts and the desired success rate.

Review of Literature

The literature addressing PIV insertions is vast and primarily addresses topics such as technique, cleaning of the insertion site, dressings, and catheter size and type. Unfortunately, the literature specifically addressing pediatric PIV insertion success is limited and is mostly associated with IV nurse specialists/teams.

The focus of these articles frequently is the role of IV nurse specialists/teams and the financial impact of such teams, not the IV insertion success rates. Because of differing study goals, it was difficult to determine a success standard in which to compare. Again, although the focus of existing literature was primarily the role of IV nurse specialists/teams, frequently the title of the professional placing the PIV was identified and, subsequently, his or her success rate was calculated.

Frey (1998) explored the financial impact of an IV nursing team and, to determine the impact of such a team, the PIV insertion success rates of various groups were calculated and compared. This study reported the RN staff nurses to have a 44% success rate compared to physicians (95%) and IV nurse clinicians (98%), thus concluding that RN nursing staff have the least desirable success rate. Frey's study also measured the amount of time required to obtain PIV access and found the average time to be 20 minutes, with a range of 2-90 minutes. A report by Millam (1993) calculated a PIV insertion success rate of 90% when attempted by an IV nurse specialist. Costentino (1984) used seven IV nurse specialists for IV placement. A 100% success rate was reported for these seven individuals within three attempts at placement. Furthermore, it was reported that these seven IV specialists achieved a 91.4% success rate on the first attempt at insertion followed by 98.6% in two attempts. Individually, the IV specialists' success rates ranged from 84.7% to 95%. A study by Brown (1984) found that IV nurse specialists were more successful at IV insertion than non-IV nurse specialists (83% and 50%, respectively). These studies, both adult and pediatric, all support the use of IV nurse specialists/teams.

It is often taken for granted that nurses with greater experience have greater success (Brown, 1984). When a patient presents as a difficult candidate for access, the more experienced staff are usually the resources used. Friedland and Brown (1992) reported the success rate of nurses with at least 5 years of experience to be 74%-86%. It could be hypothesized that IV nurse specialists often are more experienced with PIV insertions. Again, these studies placed their focus on IV nurse specialists/teams and the impact of such specialists/teams.

This study focused not on the need for IV nurse specialists/teams, but on the number of PIV attempts and the calculated success rates for this pediatric population. Thus, for the purpose of this study, the impact of IV nurse specialists/teams was not examined. However, in the absence of other data in the literature, the reported success rates were used as study comparisons, and the comparisons were later used to define acceptable practice standards at the study hospital.

Methods

This prospective study consisted of a non-randomized sample of 249 total IV placements. The PIV insertions included both initial placements and replacements. This specific Midwest Children's Hospital has 72 medical/surgical patient beds. The clinical nurse specialist collected data on all PIV insertions in the medical/surgical area. The inpatient medical/surgical RN staff nurses and patients were used as study participants. The data were collected on three separate occasions over 20 months by self-report. All staff was educated and asked to complete an audit tool after each IV attempt or successful placement. The researcher, a clinical nurse specialist, provided education of the data collection tool during staff meetings, change of shift report, Medical/Surgical staff newsletter, and one-to-one teaching. Staffing numbers and patient census during the study periods remained consistent. Additional data collected included number of P1V cannulations per day, number of attempts to successfully achieve access, and time the insertions occurred.

The practice at this hospital was for the RN directly providing patient care to be responsible for IV cannulation. In accordance with manufacturer recommendations as well as infection control guidelines, only one needle is used per IV stick. Prior to cannulation, the skin is prepped with one alcohol wipe. DuraPrep[R] may be used for children greater than 1 year of age if desired by the individual placing the IV. After cannulation, a t-extension is attached to the catheter hub and approximately 3 cc preservative free normal saline is flushed to determine patency. Once in place and patent, the IV is secured in place with a 2 x 3 inch occlusive dressing and additional tape as needed. The acceptable practice standard did not include routine IV site changes or dressing changes. At the time of this study, there were no IV nurse specialists/teams in place.