Improving patient care and clinician safety

by Ron Stoker

 About five years ago years ago, after a relatively simple surgery, I acquired a major hospital-associated infection (HAI) that almost took my life. It was 12 days post surgery that I found a small amount of pus on the back of my left hand. I was immediately concerned about the incision below my left armpit. As I stood in front of the mirror and stretched to look at the incision, I watched as over a quart of pus ruptured the incision open and ran down my side. Since my wife was at work I had to yell at my 19-year-old daughter to ask her to take me to the hospital. I was readmitted to the hospital for a six-day stay to help me get rid of my newly acquired HAI MRSA infection.  

During the afternoon of the first day that I was admitted I was taken down to the radiology suite where a peripherally inserted central catheter (PICC) was implanted. After the radiology nurse had placed my PICC in place he numbed my arm and placed several sutures around the holes on the wing of the PICC catheter to keep it in place.   

At the end of the next week I was sent home and given small “baby bottles” of antibiotics. It seemed that my whole refrigerator was filled with them. Every six hours my wife would take one of these antibiotic bottles and attach it to the PICC coming out of my arm. Every time that I would turn over in bed or the sleeve of my shirt would rub up against the connector, the sutures holding the PICC in place would pull on my skin. Ouch, it was both irritating and painful. Because of the critical nature of my infection (it had advanced into osteomyelitis) I was concerned about more infections. After just a few days home, the skin around each of the sutures was red and slightly inflamed and felt warm to the touch. I kept asking myself “if the area around my sutures is red and inflamed—isn’t this a potential for another infection? If the suture track is infected—just millimeters away from the catheter insertion site, isn’t this another potential for organisms to move down my catheter and risking another serious infection?

When my home healthcare nurse arrived I told her of the concerns that I had about the sutures. “No problem,” she said. “I will replace them with catheter securement devices.”

I was very happy when she snipped the sutures and pulled them out of my arm. As she redressed my arm bandage she placed a StatLock catheter securement device on my arm. It had a small, soft adhesive patch that was stuck on my arm. The holes in the wings of the PICC snapped into place over the pins on the catheter securement device and then it snapped together.

Each time that my home healthcare nurse would come, I would have my StatLock™ catheter securement device replaced. I was most appreciative to have this device connecting me to my catheter instead of the sutures. It was much more comfortable and provided stability to my catheter. After three months I was able to have the PICC removed and the antibiotic therapy stopped.

Securing Catheters with Sutures

Problems with Suture Needles

So, from personal experience I am aware that one problem of suturing a catheter to the patient is that it is not very comfortable for the patient. I know that clinicians make the worst patients but I found it to be irritating and painful and was so glad to have the sutures removed. The fear of catheter-related bloodstream infections was also a major concern for me and should be a concern for clinicians.

Needlestick Injuries to Healthcare Workers

Every time a healthcare worker sutures in a line, they risk being stuck by a contaminated needle. This might not have been an issue when I grew up in the ’60s but in a decade where the AIDS and hepatitis epidemics are rampant, it is important to minimize the use of needles whenever possible. We should be concerned about bloodborne pathogens and sharps injuries because every time that a catheter is sutured into place, clinicians are at risk for a needlestick.

Do needlestick injuries still occur when suturing catheters into place? Every day! Real Needlestick Stories, a common feature in the weekly ISIPS Newsletter frequently shares stories of clinicians who have been stuck unnecessarily because they were suturing a catheter into place. The data indicates that using a mechanized catheter securement device like the StatLock can minimize needlestick injuries. The Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania both conducted studies on catheter securement using sutures. In both of these studies, securement-related needlestick injuries related to catheter securement occurred in the suture group at a 2 percent rate.¹ By using a mechanical device instead of a suture needle the physician and any assistant is provided with protection.

Intravenous (IV) therapy is an essential component of patient treatment. Not all IV therapy is placed through central lines—peripheral IV catheters are also used.

 Problems Securing Catheters with Tape

In the past peripheral catheters have been secured to the patient by either adhesive tape or by suturing the catheter to the patient. These methods have historically had a number of challenges. 

My entire adult life, I have watched clinicians create a little chevron out of tape to hold a catheter down and prevent it from moving. There are many ways to do this but I believe this method is fraught with problems. It starts with tearing or cutting off pieces of adhesive tape to use. I have often watched as nurses would cut or tear off a piece of adhesive tape and stick the tape onto a bed rail or a tabletop so that they would be ready to be used to create the chevron. What do they know about the microbiological status of that bed rail or tabletop? In their desire to be efficient have they successfully adhered microorganisms to the adhesive tape? A second observation is that many nurses tear their glove as they attempt to pull off adhesive tape stuck to their glove. This exposes clinicians to the potential of cutaneous exposure of blood and patients to the flora on the clinician’s hand.

Another problem I have observed is that a fresh roll of adhesive tape is not used for each patient. That means a clinician who has used adhesive tape on an infected patient could potentially transfer microorganisms from one patient to another. In one study, researchers found that 74 percent of specimens of tape collected in one hospital were colonized by pathogenic bacteria.³

On average, every day healthcare facilities place more than 373,000 IV catheters. The traditional method of catheter securement is tape and transparent dressing. This takes a variety of forms with one of the most common being a piece of tape wrapped in a “chevron” around the catheter and hub. However, although the “traditional” way of securing the catheter has been around a long time—it should really be a concern to clinicians. If they only knew that more than 70 percent of peripheral IV catheters that are initially placed and secured with tape require a restart within a 72 hour period.

Studies have shown that up to 48 percent of all tape-secured IV catheter securement result in complications. These complications are primarily caused by the movement of the IV catheter with the vein. This micro motion or pistoning of the IV catheter back and forth and side to side within the vessel wall can potentially create a number of problems. These include:

·        phlebitis;

·        infiltration and extravasation;

·        thrombosis and occlusion;

·        dislodgement.

In studies comparing the use of tape versus catheter securement devices, there were a number of improvements by removing adhesive tape. These included the following:

·       Lowers the rate of total IV complications by approximately 67 percent. ⁴

·       Decreases IV total complication rate from 48 percent to 16 percent. ⁵

·       Decreases phlebitis rate by approximately 80 percent. ⁶

·       Decreases rate of tape-related skin damage which has been documented to be as high as 54 percent. ⁷

In other clinical studies on the use of tape to secure catheters, researchers have also found challenges with the following:

·        Poor catheter securement—catheter movement resulting in dislodgment or catheter migration resulting in unscheduled catheter replacement;

·        Lateral and pistoning movement;

·        Mechanical phlebitis;

·        Adhesive from the tape transferred to the catheter;

·        Tape is difficult to remove;

·        Tape causes glove tears;

·        Cutaneous exposure to blood.

So why did the tape secured catheters have such a poor showing? When a catheter is taped into place it is wrapped by tape and then secured to the skin. When a force is applied to the catheter by IV tubing the catheter will move and this lifts the adhesive tape from the skin. Stabilization devices, however, raise the catheter up off of the skin. The catheter is held firmly in place onto an anchor pad that has a large adhesive surface. This adhesion is increased by proper skin preparation.

 Dwell Time

Tape-secured catheters do not last as long in the vessel as mechanically secured catheters. The average taped secured catheter dwell time is just 44 hours—which is much less than the 72 to 96 hours recommended in the Centers for Disease Control and Prevention (CDC) guidelines. This interruption in IV therapy costs both an increase in time and money. These complications necessitate the unplanned catheter restarts. This happens up to 71 percent more frequently than mechanically stabilized catheters. These catheter restarts require an increase in cost of service from both nursing intervention and the material cost of products. The prevention of IV therapy complications and the resulting unplanned IV restarts can improve patient outcomes, while decreasing nurse intervention time and related patient care costs. Studies have shown that mechanical devices like the StatLock can decrease unscheduled IV starts from 71 percent to 17 percent while increasing catheter dwell times from 44 hours to 98 hours!

One study compared tape secured catheters to a manufactured stabilization device in more than 10,000 patients. The use of the stabilization device reduced restarts by 76 percent in the first three days of IV therapy. Restarts not only inconvenience patients but also cause them distress from repeated venipunctures. ⁸ The study indicated that the complication rate with tape was 47.6 percent. When the device was used, the rate dropped to a mere 16 percent, a 67 percent reduction. This study indicated that reducing complications meant fewer IV extravasations, fewer premature dislodgements and fewer catheter restarts.

 Time Saver

We are all aware that nursing staff is being asked to do more with less. Unplanned IV restarts require nurse intervention. The restarts also increase material costs. With more insurance companies not paying for the cost for treating preventable errors, it is important to minimize the cost of these errors. The prevention of IV therapy complications and the resulting unplanned IV interruptions can dramatically improve patient outcomes, decrease nurse intervention time and decrease patient care costs. By using a catheter securement device 29 minutes of nursing time is saved per IV treatment.

Lab studies demonstrate that mechanical catheter securement devices like the StatLock reduce catheter tip micro motion better than tape and provide greater stability over time. The angled connector also provides better anatomic conformity of the catheter with the blood vessel than any other devices on the market.

 Costs—Spiraling Upward

In today’s economy it is important to look at every aspect of reducing costs. It is also very important to look at all costs; soft cost as well as hard cost. One of the primary complaints about the use of a mechanical catheter stabilization device is the upfront cost. Use of these types of devices typically add some upfront cost, but when all costs are considered they end up being very cost effective. Using mechanical catheter stabilization devices, the cost of maintaining catheter lines and the complication costs associated with them goes dramatically down. Whenever a nurse has to remove a catheter and replace one unexpectedly it requires more nursing time. It also requires more material costs. With mechanical catheter securement devices there are 55 fewer IVs used per 100 catheter starts. Labor and material costs will spiral upward with many restarts. In addition, clinicians are able to place mechanical devices much faster than using a tape chevron. This lowers the labor cost as well. In addition, restarts require more materials to be used. Other complications can lead to additional treatment costs.

Standard of Care for Catheter Stabilization

The use of mechanical catheter stabilization devices has become mainstream and really the standard of care. It is recommended by most healthcare worker advocacy groups.

 OSHA Requirements

Following the release of the revised OSHA Bloodborne Pathogen Standard, OSHA updated their Compliance Directive where in OSHA clarified its position regarding the effective implementation of effective engineering controls to reduce needlestick and other sharps injuries.

Effective engineering controls are required—healthcare facilities must use safer medical devices if they are available to prevent percutaneous injuries before, during or after use through safer design features. The hospital or clinic must promote and use engineering and work practice controls to eliminate or minimize occupational exposure. The facility must have an Exposure Control Plan that is updated on a frequent (at least annual) basis. Each facility that has personnel who potentially will come in contact with human blood or other potentially infectious materials must implement a sharps safety program to evaluate the use of alternative devices to prevent sharps injuries. This includes the evaluation of appropriate catheter securement devices. Failure to document such evaluations can result in significant OSHA fines.

 CDC Guidelines

In the CDC Guidelines for the Prevention of Intravascular Catheter-related Infection Rates, released in 2002, the CDC indicated that “Sutureless securement devices can be advantageous over suture in preventing catheter-related BSIs.” One study compared a sutureless device with suture for the securement of PICCS; in this study, CRBSI was reduced in the group of patients that received the sutureless device. ⁹  Recommendation—use a sutureless securement device to reduce the risk of infection for PICCs.

 INS Standards of Practice

The Infusion Nurses Society (INS) Standards of Practice indicates that “Whenever feasible, using manufactured catheter stabilization is preferred.”¹⁰ Catheter stabilization shall be used to preserve the integrity of the access device and to prevent catheter migration and loss of access. Catheters shall be stabilized using a method that does not interfere with the assessment and monitoring of the access site or impede vascular circulation or delivery of the prescribed therapy.

 Summary

Catheter stabilization products like the StatLock from Bard Medical are designed to minimize the risk of catheter-related bloodstream infections. These products help to combat the epidemic of hospital-acquired infections and improve patient care and clinician safety. They are designed to prevent inadvertent movement and dislodgment of IV catheters. The use of sutures to secure catheters increases the patients’ risks of developing catheter-related bloodstream infections. The use of sutures to secure catheters also places healthcare workers at risk for needlestick injuries, which expose them to bloodborne pathogens including hepatitis B, hepatitis C, and HIV.

The StatLock devices reduce these risks while meeting OSHA’s recommendation for sutureless securement and the INS standards for a manufactured stabilization device. The StatLock catheter stabilization products safely secures the catheter while permitting visual inspection and monitoring of the insertion site. They provide a cost effective way to minimize patient and clinician health risks with simple, effective securement devices.

 References

1. Frey AM, Schears GJ. Why are we stuck on tape and suture? J Infus Nurs. 2006; 29(1):34-38.
2. Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interven Radiol. 2002; 13(1):77-81.
3. Gen Intern Med. 1999 June; 14(6): 373–375. Adhesive Tape and Intravascular-Catheter-Associated Infections, Donald A Redelmeier, MD and Nigel J Livesley, MD.
4. Nursing Management May 2005 – Volume 36 – Issue 5 – pp 52-54.
5. JVIR, Journal of Vascular and Interventional Radiology, Volume 13, Issue 1, Pages 77-81 (January 2002) Sutureless Securement Device Reduces Complications of Peripherally Inserted Central Venous Catheters.
6. Journal of Infusion Nursing: July/August 2006 – Volume 29 – Issue 4 – p 225-231, Summary of Product Trials for 10, 164 Patients: Comparing an Intravenous Stabilizing Device to Tape.
7. Journal of Intravenous Nursing: May/June 1999-Volume 22-Issue 3 – p 151; A Prospective Study of Two Intravenous Catheter Securement Techniques in a Skilled Nursing Facility.
8. Schears GJ. Summary of product trials for 10,164 patients. J Infus Nurs. 2006; 29(4):225-229.
9. Maki DG, Mermel LA, Klugar D, et al. The efficacy of a chlorhexidine impregnated sponge (Biopatch) for the prevention of intravascular catheter-related infection – a prospective randomized controlled multicenter study [Abstract]. Presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy. Toronto, Ontario, Canada: American Society for Microbiology, 2000.
10. http://www.ins1.org/i4a/pages/index.cfm?pageid=3310

 Ron Stoker, MS, is the executive director of the International Sharps Injury Prevention Society (ISIPS). He has 29 years experience in the medical device industry as a researcher, marketer, educator, consultant and healthcare worker advocate. He has written more than 200 medical journal articles, primarily on sharps injury prevention, infection control, and hand hygiene. Mr. Stoker has his BS in Pre-Medical Zoology from Brigham Young University, an MS in Bioengineering from the University of Utah and an “honorary doctorate” from the school of hard-knocks. As a result of a surgical mishap he was rendered a quadriplegic in December 2006. Informed that he would never walk again, with tenacity and a “supportive and mean wife,” he taught himself how to walk again. Mr. Stoker says that he walks like an “alcoholic” but is really just a recovering quadriplegic! He has conducted workshops and Congresses on sharps safety at national and international meetings for the last 10 years. He is a co-founder and lecturer for the Infection Preventionist Boot Camp Series with Peggy Luebbert. For more information contact him at info@infectionpreventionistbootcamp.com

For more Information on the StatLock Stabilization Devices contact Bard Medical at 800.526.4455 or visit the company’s Web site at www.StatLock.com.