British Undergraduate Emergency Journal. 2012, 1.8
Peripheral Venous Cannula (PVC) Labelling in an Accident and Emergency Department
Sheelagh M.A. Harwell, Year 4 Medical Student, University of Glasgow, BSc (Hons)
Writing the time and date of insertion of peripheral venous cannulas (PVC) on the transparent occlusive dressing is recommended in guidelines, as it allows for correct PVC care on the ward. In a busy accident and emergency (A&E) setting, labelling a PVC can often be overlooked. The rates of PVC labelling in the Southern General A&E before and after an educational poster campaign and verbal reminder were examined. The rate of PVC labelling was roughly 60% both before and after the campaign. Poster campaigns have been previously shown to be unsuccessful at inﬂuencing the rate of PVC labelling in other countries. It was concluded that a more multifaceted approach to encouraging adherence to guidelines on PVC labelling should be attempted, in order to ensure patient safety and to decrease rates of complications associated with a long duration of PVC in situ.
Peripheral venous cannulas (PVCs) are the most commonly inserted catheters . It has been estimated that in a 500 bed hospital, 18,000 PVCs are inserted a year . Worldwide, infected PVCs are the commonest cause of hospital-acquired bacteraemia [3, 4]. A year-long study in Australia found the rate of nosocomial bacteraemia was 3/1000 admissions, of which PVC-related infection was responsible for 70% . Hospital-acquired bacteraemia is a serious infection associated with a high mortality of 13%, prolonged hospital stay and extra cost [3, 5]. PVCs disrupt skin integrity and this direct opening into the vascular system creates an entrance for pathogens to enter the bloodsteam . Documented infective complications include: cellulitis, catheter-related sepsis (CRS) usually with Staphylococcus aureus, septic thrombophlebitis and other systemic infections [6, 7]. Patients with alcoholism, leucopenia, renal impairment and diabetes mellitus are at higher risk of suﬀering CRS .
The risk of complications associated with PVCs is proportional to the time that the PVC remains in situ . An Australian study of intravascular CRS showed that in >90% of cases, the PVC had been in situ for over 3 days . A Swedish study showed that thrombophlebitis occurred less frequently in patients with PVC in situ less than or equal to 24 hours . The patients’ problems increased in frequency on day 2 and also gave more prolonged and severe symptoms . The CDC in 2011 stated that PVCs should be replaced every 72-96 hours to reduce the risk of infection and phlebitis in adults, or sooner if complications are suspected [1, 6]. They also recommend removing the PVC as soon as possible if no longer needed  and if longer dwell times are unavoidable, maintaining regular site assessment by visual inspection (through a transparent dressing) or palpation, assessing for redness, swelling, exudate, heat, or tenderness at the site . The Visual Infusion Phlebitis (VIP) Score can be used to determine whether the PVC requires removal or not. PVCs are sometimes left in situ for prolonged periods unnecessarily . Improved documentation, i.e. recording PVC insertion, maintenance and replacement, could signiﬁcantly reduce the risks of infection associated with PVCs . This could also establish clear monitoring systems and enable surveillance through ‘root cause analysis’ in the event of hospital-acquired bacteraemia resulting .
A simple and eﬀective way of reducing the risk of leaving a PVC in for too long, is by securing the PVC with a sterile transparent occlusive dressing and writing the time and date of insertion on the dressing. This is recommended by NHS Greater Glasgow and Clyde (GGC) and the CDC [1, 6]. Compliance with recommendations regarding the management and prevention of CRS has been shown to lower associated mortality rates markedly .
Data were collected on 12/03/12. All patients attending the A&E department at the Southern General Hospital, Glasgow were examined for the presence of a PVC over a twelve hour period.
For each patient, the presence of a PVC was recorded, along with whether the date of insertion of the device was recorded on the transparent occlusive dressing. The grade of the person inserting the PVC was noted: medical student, nurse, junior doctor, senior doctor. The patient’s chart and clinical notes were checked for a record of the time and date of PVC insertion. The patient’s medical records and laboratory results were also reviewed where relevant for demographic details and presence of risk factors for CRS, including diabetes mellitus, renal impairment, leucopenia and alcoholism .
The primary endpoint was the percentage of PVCs that were dated for time of insertion in situ.
After this initial data collection, posters were posted around the accident and emergency department and a reminder in each of the cubicles above the PVC equipment. These posters stated GGC’s guidelines on PVC labelling. A verbal reminder was also given to all staﬀ at midday. Three days later, data were recollected during a comparable twelve hour period from every patient that attended the A&E department. These data were then compared with the initial data.
On initial data collection, 36 patients were seen in a twelve hour period. Of those patients, 26 had a PVC inserted. The majority of PVCs were inserted by A&E doctors (Figure 1). One PVC was inserted before admission; the patient arrived via helicopter following an accident outwith Glasgow.
Figure 1: Bar chart indicating number of PVCs inserted by diﬀerent staﬀ members in initial data collection. Of the 26 PVCs, 16 were correctly timed and dated in accordance with guidelines. 12 were not (Figure 2). Of those 12, one was the PVC inserted before admission at the accident scene, and 11 unlabelled PVCs were inserted by doctors. Two of the patients admitted with unlabelled PVCs had diabetes and one had chronic alcohol abuse, and were therefore at higher risk for CRS. Interestingly, 80% of the PVCs inserted before midday were labelled but only 44% of PVCs inserted after midday were labelled.
Figure 2: Pie chart: percentage of PVCs labelled correctly
Three days later, data were recollected during the same twelve hour period, from patients attending A&E. 39 patients were seen, of which 30 had a PVC inserted, mainly by doctors (Figure 3).
Figure 3: Bar chart indicating number of PVCs inserted by diﬀerent staﬀ members in second data collection.
Of the 30 PVCs, 19 were correctly timed and dated, 11 were not (Figure 4). The 11 unlabelled PVCs were all inserted by doctors. Two of the patients admitted with unlabelled PVCs had diabetes and one had chronic kidney disease, and were therefore at higher risk for CRS. 60% of the PVCs inserted before midday were labelled and 56% of PVCs inserted after midday were labelled.
Figure 4: Pie chart: percentage of PVCs labelled correctly
The data collected on the two separate days is very similar, with 62% labelled on initial data collection, and 63% on recollection of data. It can therefore be concluded that the educational poster and verbal campaign alone had limited inﬂuence on the labelling of PVC in accordance with guidelines. This has been shown in previous studies in other countries .
Interestingly, it was found that the concordance with guidelines on PVC insertion was reduced after midday on the initial day. This could have been due to many factors, for example increased volume of patients and workload in the afternoon, decreased concentration and increased tiredness of staﬀ, or a change in staﬀ, with a member of staﬀ coming on for the afternoon shift who did not label PVCs correctly. The verbal reminder at midday may have had an inﬂuence on PVC labelling – on the afternoon of the initial data collection 44% of PVCs were labelled correctly, whereas on the recollection of data after the intervention, 56% of PVCs inserted in the afternoon were labelled. However, if one member of staﬀ does not label PVCs correctly and was not working on the recollection of data day, then there would be fewer unlabelled PVCs. An extended study that includes all staﬀ on diﬀerent rotas could eliminate this bias. Six patients in this study were admitted into a ward from A&E with an unlabelled PVC in situ, with risk factors, including diabetes, chronic kidney disease and alcohol abuse. These patients are at increased risk of acquiring CRS if their PVC is not maintained and changed within the 72-96 hours recommended . The nurses on the wards that these patients were admitted to would not have known the correct time of insertion, thus making the PVC care more diﬃcult.
While the results from this audit suggest that a poster campaign in the A&E department had limited inﬂuence on practise, a longer study is required to analyse guideline implementation in the department. It has been found in previous studies that multifaceted methods of implementing guidelines are most eﬀective, for example: combining audit and feedback, reminders, marketing and local consensus process . Indeed, the verbal reminder at midday appeared to increase compliance with the guidelines. A further study could introduce a welldesigned promotional campaign along with reminders over a longer period of time. This would be valuable in increasing knowledge about the eﬀectiveness of interventions on correct PVC labelling, with the aim of ﬁnding methods to increase compliance, ultimately to protect patients vulnerable to morbidity and mortality from CRS.
Dr Cieran McKiernan
Dr Lynn Valentine
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