Journal of Pediatric Nursing (2015) xx, xxx–xxx
The Effect of Intravenous Infiltration Management Program for Hospitalized Children Soon Mi Park PhD, RN a , Ihn Sook Jeong PhD, RN b,⁎, Kyoung Lae Kim RN a , Kyung Ju Park RN a , Moon Ju Jung RN a , Seong Suk Jun PhD, RN b a
Department of Nursing, Pusan National University Yangsan Hospital, Yangsan, South Korea College of Nursing, Pusan National University, Yangsan, South Korea
b
Received 15 June 2015; revised 14 October 2015; accepted 18 October 2015
Key words: Child; Infusion therapy; Management; Infiltration; Extravasation
Purpose This study aimed to identify the effect of IV infiltration management program among hospitalized children. Design and Methods: This was a quasi-experimental study with history comparison group design with 2,894 catheters inserted during 3 months comparison phase and 3,651 catheters inserted during 4 months experimental phase. The intervention was composed of seven activities including applying poster, documentation of catheter insertion, parents education, making infiltration report, assessment of vein condition before inserting catheter, appropriate site selection, and documentation of catheter insertion, and assessment of peripheral catheter insertion site every shift. Data were analyzed using of X2-test, Fisher's exact test. Results: The infiltration incidence rate was 0.9% for experimental group and 4.4% for comparison group, which was significantly different (x2 = 80.42, p b .001). The catheter maintenance period (p = .035) and infiltration state (p = .039) were significantly different among participants with infiltration between comparison and experimental groups. Conclusions: IV Infiltration management program was founded to be effective in reducing the IV infiltration incidence rate and increasing early detection of IV infiltration. Practice Implications: Considering the effect of IV Infiltration management program, we recommend that this infiltration management program would be widely used in the clinical settings. © 2015 Elsevier Inc. All rights reserved.
INTRAVENOUS (IV) INFUSION is a process often performed on hospitalized patients (Flippo & Lee, 2011; Kagel & Rayan, 2003; Walter & Pitter, 2009). This technique is an effective method for the administration of some drugs, and is also used for delivery of drugs to pediatric patients with absorption defects due to diarrhea, dehydration, or peripheral blood vessel collapse. This method is also used for pediatric patients who need to maintain a high blood drug concentration, being infected with strains of bacteria with a high resistance to antibiotics and therefore must receive
⁎ Corresponding author: Ihn Sook Jeong, PhD, RN. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2015.10.013 0882-5963/© 2015 Elsevier Inc. All rights reserved.
medications through IV insertion for a certain period, and require continuous pain relief. Peripheral IV insertion is a basic nursing technique, but it is also a complex and technically difficult procedure that needs to be performed successfully within a limited time (Thomas, 2007). IV insertion is particularly difficult in children who have thin and weak blood vessels, and move continuously due to the pain associated with insertion (McCullen & Pieper, 2006). According to a previous study, the success rates of peripheral IV insertion performed on pediatric patients were 42.8% for the first trial, 39.7% for the second trial, 37.5% for the third trial, and 38.8% for the fourth trial (Peterson, Phillips, Truemper, & Agrawal, 2012). According to a prospective study on patients in the
2 emergency room with an average age of 53 years, a success rate of 79% for first insertion was observed along with a total success rate of 98.6% (Sebbane et al., 2013). These results indicate that the first trial success rate of peripheral IV insertion for pediatric patients is very low compared to that of adults, and the patients consequently become more vulnerable to IV infiltration and extravasation (hereafter IV infiltration) (Fang, Fang, & Chung, 2011; Sung & Kim, 2007). IV infiltration causes inconvenience or delay in treatment due to re-insertion into the vein, and may also result in the need for surgery due to tissue damage (Talbot & Rogers, 2011; Willsey & Peterfreund, 1997) or cause permanent damage in pediatric patients (CliftonKoeppel, 2006). Therefore, primary prevention of IV infiltration in the early stage is extremely important. An effort to minimize damage by noticing injury at an early stage is also needed. Although the hospital also made efforts to prevent IV infiltration among pediatric patients with the use of posters, education of guardians, and IV infiltration monitoring, the IV infiltration rate has not been decreased. Therefore, we have developed and implemented an IV infiltration management program by establishing a professional team for prevention and effective management of IV infiltration in hospitalized pediatric patients. This management program includes IV infiltration prevention practices that have not been previously enforced in order to reduce the additional occurrence of IV infiltration in this hospital. The aim of this study was to evaluate the effectiveness of a new IV infiltration management program by comparing the occurrence rate of IV infiltration and characteristics of pediatric patients with IV infiltration before and after application of the program.
Methods Research Design This was a synchronized quasi-experimental study using a historical control to analyze the rate of IV infiltration by application of an infiltration and extravasation management program for patients in a children's hospital, and to identify the characteristics of pediatric patients with IV infiltration.
Study Participants The participants in this study were children or teenagers 0 to 19 years old who received peripheral IV insertions when hospitalized from August 1, 2011 to February 29, 2012 at a children's hospital with 126 beds located in Yangsan city, Korea. Patients who were hospitalized from August 1 to October 31, 2011 formed the comparison group in this study and did not participate in the IV infiltration management program, representing a total of 2,894 cases of IV insertion. Pediatric patients who were hospitalized from November 1, 2011 to February 29, 2012 formed the experimental group which received care under the IV infiltration management program, with a total of 3,651 cases of IV insertion.
S.M. Park et al.
Intervention The Comparison Group The comparison group received the routine usual care for preventing IV infiltration. The specific care was as follows: 1. Posters on how to prevent IV infiltration were displayed on the wall(s) of all patient rooms. 2. After IV catheter insertion, the nurses recorded the date and time of IV catheterization, the size of IV catheter, and the name of the practitioner at the site of IV insertion. 3. After IV catheter insertion, the nurses educated the patients' guardians by providing leaflets on how to prevent IV infiltration. The guardians were asked to touch the site of IV insertion, remember the feeling, and make frequent observations to alert the nurses when any abnormalities developed. 4. When IV infiltration occurred, nurses were supposed to immediately stop the infusion, and assess the IV infiltration site, and document this on an ‘IV infiltration record’ including demographics, IV infusion related characteristics (e.g., duration, site, size of IV catheterization, and type of drug injected), and IV infiltration related characteristics (e.g., stage and size of skin damage). The Experimental Group: The IV Infiltration Management Program The ‘IV infiltration management program’ was applied to the experimental group. This program was developed by the research team composed of one pediatric nursing team leader, three pediatric head nurses, and one nursing professor. They reviewed articles and guidelines related to the IV infiltration prevention and management of peripheral intravenous infusion (Doellman et al., 2009; Earhart & McMahon, 2011; European Oncology Nursing Society (EONS), 2007; Hadaway, 2007; Infusion Nurses Society, 2006; Ingram & Lavery, 2005). Because some of recommendations from the IV infiltration prevention guidelines had already been implemented, the team selected other recommendations which had not been included in the original IV infiltration prevention programs. The additional recommendations were as follows: 1. Prior to IV catheter insertion, the nurse assessed the condition of the patients' blood vessel and selected the best vein for peripheral administration. Small size and poor condition of veins were one of the factors contributing to the risk of infiltration (Doellman et al., 2009). Then, he/she decided whether he/she could perform IV catheterization by himself/herself or referred to the IV insertion team. When insertion failed twice, the nurse was supposed to refer to the IV insertion team to complete the task. In the first step, there was no formal assessment tool. The nurse simply
Inttravenous Infiltration Management Program assessed the vein of the patients, and then they made a decision regarding whether they performed IV catheterization by themselves or referred to the IV insertion team. 2. Prior to IV catheter insertion, the nurse assessed the patient's movement or thumb sucking habits, and selected appropriate IV sites to secure. An unstable catheter, poor securing of the IV site, and uncooperative movement by the patient were factors contributing to the risk of infiltration (Doellman et al., 2009). In the second step, there was also no formal assessment tool. The nurse just observed and asked care givers about the patients' activities. 3. After IV catheter insertion, the nurse monitored the IV site at least once every shift and documented the ‘IV insertion record’. There were two types of ‘IV insertion record’: one for the beginning and the other one for maintenance. The ‘IV insertion record’ included general characteristics of the subject, the date of insertion, the site of insertion, the size of the catheter, and the type of infusate, and the drugs injected. Nurses who performed IV catheterization at the start entered this into the ‘IV insertion record’ (for start) and other staff nurses examined the IV site at least once during their shift and made entries in the ‘IV insertion record’ (for maintenance).
Study Instrument The study instrument was the data collection form, consisting of 3 parts; demographics of study participants, IV infusion related characteristics, and IV infiltration related characteristics. The demographics included gender and age. The IV infusion related characteristics were duration, site, size of the IV catheterization, and the type of drug injected. The IV infiltration related characteristics included stage of IV infiltration and type of skin damage incurred. The stage of
Table 1
Infiltration criteria used for this study.
Stage Symptoms 0
1 2
3
4
Absence of redness, warmth, pain, swelling, blanching, mottling, tenderness or drainage. Flushes with ease (no IV infiltration). Absence of redness, swelling. Flushes with difficulty. Pain at site. Slight swelling (less than 1 inch) at site. Presence of redness. Pain at site. Good pulse below site. 1–2 second capillary refill below site. Moderate swelling (1 to 6 inches) above or below site. Blanching. Pain at site. Good pulse below infiltration site. 1–2 second capillary refill below infiltration site. Severe swelling (more than 6 inches) above or below site. Blanching. Pain at site. Decreased or absent pulse. Capillary refill greater than 4 seconds. Skin cool to touch. Skin breakdown or necrosis.
3 IV infiltration was scored on a scale of 0 to 4 by using Flemmer and Chan (1993)'s criteria, where 0 indicated ‘no IV infiltration’ while 1 to 4 indicated the extent of effusion of fluid that had occurred.’ Larger number associated with more severe IV infiltration occurred (Table 1). Flemmer and Chan (1993)'s criteria were easy to grade by observation and touch of IV sites. However, it was not clear from their criteria what size of swelling was defined as slight, moderate, and severe. Thus, we defined the size of swelling as slight when it was less than 1 inch, moderate when it was 1 to 6 inches, and severe when it was greater than 6 inches, based on the Infusion Nurses Society (2006) criteria.
Study Procedure This study was conducted after obtaining approval from the Institutional Review Board of Pusan National University Yangsan Hospital (05-2011-057). First, the ‘IV infiltration management program’ was introduced to nurses working in the pediatric department of the study hospital four times, and the head nurse or nurse in charge monitored whether the program has been applied in clinical practice. Data were collected prospectively and retrospectively by one of the researchers. Data were collected prospectively by using the ‘IV insertion record’ and ‘IV infiltration record’ for the experimental group, and retrospectively from the ‘IV infiltration record’ for the comparison group. The IV insertion record and IV infiltration record’ were filled in by staff nurses and the staging of IV infiltration was graded by staff nurses. For this, head nurses educated staff nurses on how to grade the staging of IV infiltration by using PowerPoint slides, and staff nurses graded the staging of IV infiltration for the patients, which was confirmed by the head nurses before collecting data to enhance the inter-observer reliability.
Data Analysis SPSS Win (version 18.0) was used for data analysis, and a two-tailed test with a significance level (α) of 0.05 was performed. 1) IV infiltration rate was calculated according to the standard method of the Infusion Nurses Society (2006). A chi-square or Fisher's exact test was
Table 2 Infiltration incidence rate between comparison and experimental groups. Variables
Comparison Experimental group group
Number of 2894 intravenous catheter insertion Number of infiltration 127 Infiltration incidence 4.4 rate (%)
3651
34 0.9
x2
p
80.42 b .001
4
S.M. Park et al. performed to evaluate differences in IV infiltration rate between two groups.
IV infiltration rate ð%Þ ¼ ðnumber of IV infiltration occurrence=number of total IV insertionsÞ 100
2) The demographics, IV infusion related characteristics, and IV infiltration related characteristics of patients with IV infiltration were analyzed with frequency and percentage, or average and standard deviation.
Results IV Infiltration Rates For the comparison group, the number of total IV insertions was 2894, the number of IV infiltration occurrences was 127, and the IV infiltration rate was 4.4%. For the experimental group, the number of total IV insertions was 3651, the number of occurrences of IV infiltration was 34, and the IV infiltration rate was 0.9%. A significant statistical difference in the IV infiltration rate was observed between the two groups (X2 = 80.42, p b .001; Table 2).
Characteristics of Participants With IV Infiltration Demographics Demographics of participants with IV infiltration are listed in Table 3. Among the patients with IV infiltration, 58.3% of the comparison group and 67.6% of the experimental group were male. In addition, 34.6% of the comparison group and 23.5% of the experimental group were less than 1 year old and considered infants. One to 3 year old toddlers were 10.2% and 32.4%, respectively, thus the age distributions of the two groups were significantly different (X2 = 14.09, p = .007). IV Infusion Related Characteristics IV infiltration related characteristics of the participants with IV infiltration are listed in Table 4. The most frequent duration of IV catheterization was 24 to 48 hours, accounting for 31.6% of the comparison group and 44.0% of the
experimental group. The period that differed most significantly between the two groups was 48 to 72 hours with 29.1% for the comparison group and 2.9% for the experimental group. A significant difference in the duration of IV catheterization was observed between the two groups (X2 = 11.97, p = .035). The most common intravenous insertion site was the back of the hand, with 48.8% of the comparison group and 50% of the experimental group. The location of the greatest difference between the two groups was the wrist, with 7.9% for the comparison group and 20.6% for the experimental group. However, there was no significant statistical difference in insertion site between the two groups. For the size of the IV catheters, 24G was used more frequently than 22G and there was no significant difference in the effect of the size of IV catheters between the two groups. The most frequently injected fluid was 5% dextrose with 59.7% of the comparison group and 44.1% of the experimental group. The most frequently administered antibiotic was cefotaxime, including 48.0% of the comparison group and 29.4% of the experimental group. There was no significant difference in the fluid types and drugs injected between the two groups. IV Infiltration Related Characteristics IV infiltration related characteristics of the participants with IV infiltration are listed in Table 5. The most frequent IV infiltration stage was ‘stage 2’ with 74.0% of the comparison group and 76.4% of the experimental group. The IV infiltration stage associated with the greatest difference between the two groups was ‘stage 3’ with 20.5% of the comparison group and 5.9% of the experimental group along with ‘stage 1’ with 3.1% and 11.8%, respectively. A significant difference was observed between the two groups (X2 = 8.38, p = .039). ‘No damage’ to the skin was observed most frequently, and accounted for 96.8% of the comparison group and 94.1% of the experimental group. This difference was not significant.
Discussion Table 3 Demographic characteristics among participants with infiltration between control and experimental groups. Characteristics
Gender
Male Female Age (year) b 1 1– b 3 3– b 6 6– b 12 12– b 19
Comparison Experimental x2 group group (n = 34) (n = 127) n (%)
n (%)
74 53 44 13 24 31 15
23 (67.6) 11 (32.4) 8 (23.5) 11 (32.4) 3 (8.8) 5 (14.7) 7 (20.6)
(58.3) (41.7) (34.6) (10.2) (18.9) (24.4) (11.8)
0.99
p
.321
14.09 .007
This study was conducted in order to evaluate the effectiveness of the new IV infiltration management program by comparing the occurrence rate of IV infiltration and characteristics of pediatric patients with IV infiltration before and after application of the program. In this study, three new preventive practices for IV infiltration management were added to the existing nursing practice performed in the study hospital; assessing the condition of the patients’ blood vessel and referring to the IV insertion team, selecting the best IV sites for fixation, and assessing the IV site at least once per every shift. Based on the results, the IV infiltration rate was significantly lower in the experimental group than the comparison group. In fact, the IV infiltration rate for the
Inttravenous Infiltration Management Program Table 4
5
Infusion therapy related characteristics among participants with infiltration between control and experimental groups. Comparison group (n = 127) Experimental group (n = 34) x2
Characteristics
n (%) 0 ~ b 24 31 (24.4) 24 ~ b 48 40 (31.6) 48 ~ b 72 37 (29.1) 72 ~ b 96 15 (11.8) 96 ~ b 144 4 (3.1) Insertion site Dorsum of hand 62 (48.8) Wrist 10 (7.9) Forearm 15 (11.8) Brachium 2 (1.6) Instep 33 (26.0) Ankle 5 (3.9) Catheter size 24G 120 (98.4) 22G 2 (1.6) Hypertonic fluid administered Dextrose 5% 75 (59.1) Dextrose 10% 10 (7.9) TPN 12 (9.5) Isotonic fluid administered Sodium chloride 0.225% 28 (22.0) NS 13 (10.2) Antibiotics administered Cefotaxime 61 (48.0) Sullbacillin 26 (20.5) Shincef 10 (7.9) Vancomycin 9 (7.1) Other medications administered Ambroxol 64 (50.4) 15% Mannitol 13 (10.2) Phenytoin 10 (7.9) Catheter maintenance (hours)
p
n (%) 11 (32.3) 15 (44.0) 1 (2.9) 4 (11.8) 3 (8.8) 17 (50.0) 7 (20.6) 2 (5.9) 1 (2.9) 6 (17.7) 1 (2.9) 33 (97.1) 1 (2.9) 15 (44.1) 2 (5.9) 5 (14.7) 7 (20.6) 3 (8.8) 10 (29.4) 5 (14.7) 2 (5.9) 1 (2.9) 12 (35.3) 2 (5.9) 1 (2.9)
11.97 .035
6.12
.295
1.00
.381
1.54 – – 0.03 – 3.77 0.57 – – 2.45 – –
.214 1.000 ⁎ .359 ⁎ .855 1.000 ⁎ .052 .449 1.000 ⁎ .690 ⁎ .117 .740 ⁎ .460 ⁎
TPN: total parenteral nutrition NS: normal saline. ⁎ Fisher's exact test.
comparison group (4.4%) was considered very low when compared to the two previous research studies conducted in South Korea by 9.3% (Kim, 2006) and by 23.7% (Sung & Kim, 2007). IV infiltration rate for the experimental group (0.9%) was surprisingly lower than reported in the previous
Table 5 Infiltration related characteristics among participants with infiltration between comparison and experimental groups. Comparison Experimental x2 group group (n = 127) (n = 34)
Characteristics
n (%) Stage of infiltration
1 point
2 point 3 point 4 point Dermatologic None injury Erosion Uncer/ Necrosis
4 (3.1)
p
n (%) 4 (11.8)
8.38 .039
94 (74.0) 26 (76.4) 26 (20.5) 2 (5.9) 3 (2.4) 2 (5.9) 123 (96.8) 32 (94.1)
1.06 .589
3 (2.4) 1 (0.8)
1 (2.9) 1 (2.9)
studies. We could provide two explanations for this result. First, this study's hospital was approved by the Joint Commission International and Korea Institute for Healthcare Accreditation and has tried to minimize the occurrence of IV infiltration. Second, selection of an appropriate vein and IV site was very important. The largest, softest, and most pliable vein was the best choice for avoiding IV infiltration (European Oncology Nursing Society (EONS), 2007), and no curvature, no joint area was good for securing the IV catheter (European Oncology Nursing Society (EONS), 2007; Hadaway, 2007). The new IV infiltration program included selection of the best vein and IV sites for fixation as a recommended practice, and assessing the IV site often and regularly. IV infusion related characteristics among patients with IV infiltration were analyzed to further evaluate the specific effects of the program. Characteristics that differed significantly between the two groups were patient age, duration of IV catheterization, and IV infiltration stage. Patient age was categorized as 0 to 1 year old (infants), 1 to 3 years old (toddlers), 3 to 6 years old (preschoolers), 6 to 12 years old (middle childhood), and 12 to 19 years old (teenagers). IV infiltration showed the highest incidence in infants in the comparison group, and in toddlers in the experimental group.
6 This result indicating that the lower age group showed higher IV infiltration was consistent with the previous evidence that using a small blood vessel is a well-known risk factor for IV infiltration (European Oncology Nursing Society (EONS), 2007). However, the reason for the difference in age distribution between the two groups could not be easily explained. We could assume that the new IV infiltration program was very effective in reducing the risk of infants with very high risk of IV infiltration, but was less effective in toddlers because they were likely to be more active and able to move more freely than infants (Sauerland, Engelking, Wickham, & Corbi, 2006). For IV infiltration stage, the experimental group showed higher in 1 point and less in 3 points than the comparison group, suggesting that IV infiltration was detected at an earlier stage in the experimental group than the comparison group. Thus, it was suggested that although the IV infiltration management program could not prevent occurrence of IV infiltration, it was seemingly helpful for early detection of the condition. When it failed to prevent IV infiltration, the IV site were to be monitored with detection at as early stage as possible to reduce the size of skin damage (European Oncology Nursing Society (EONS), 2007). In this program, assessing the peripheral catheter insertion site every shift appeared to be the most important attribute to early detection of IV infiltration. ‘Less than 48 hours’ of the duration of IV catheterization was 56% of the comparison group, and 76% of the experimental patients. That is, the duration of IV catheterization was shorter in the experimental group than the control group. Considering that the patients analyzed had IV infiltrations, this result may support early detection of IV infiltration among the experimental group. Thus, the IV infiltration management program which enforced monitoring the IV site at least once per every shift and recording the findings on the sheets was helpful in detecting the possibility of IV infiltration earlier and more regularly. This study is very significant as it provided a set of nursing practices which can actively prevent occurrence of IV infiltration. However, the following limitations should be considered. First, this study was conducted in one children's hospital and monitored the occurrence of IV infiltrations for 3 months before and after the program. Thus, generalization of the results of this study was limited. This investigation is recommended to be repeated in various institutions for longer periods. Second, the stage of IV infiltrations was based on the records made by nurses in charge of patient care. Although all nurses working at this hospital received training on how to evaluate the stage of IV infiltrations, we did not assess the consistency in measuring the stage among the nurses, which could increase the possibility of measurement error. Third, the IV infiltrations management program was composed of 3 nursing practices. We evaluated the overall effects of the program, but the individual effect of each plan was not assessed. Fourth, while it was recommended to assess the peripheral IV site every hour for
S.M. Park et al. children when infusing (Infusion Nurses Society, 2006; Masoorli, 2003) and every four hours when capped or locked, we assessed the IV site at least once per shift if the IV was infusing, and did not monitor IV site if the IV was locked/capped. More frequent assessment would be helpful to increase the earlier detection of IV infiltration.
Conclusion As a result of implementing the 4-month IV infiltration management program for pediatric patients receiving peripheral IV infusion at a children's hospital, the occurrence of IV infiltrations was less than 1%, which was significantly lower than that of the comparison group who did not receive the program, suggesting that the program may improve prevention. And, the IV infiltration management program was helpful in detecting occurrence of IV infiltration at the early stage. Further studies to determine the individual effect of the IV infiltration management program and for selection of the most effective method are recommended.
Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and future Planning (2015R1A2A2A04003415).
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Inttravenous Infiltration Management Program Kim, H. J. (2006). Factors related to the restart PIV in hospitalized children-data from patients cared by the IV team nurses. (Unpublished master's thesis) Seoul: Younsei University. Masoorli, S. (2003). Pediatrics: Small children at high risk. Journal of the Association of Vascular Access, 8, 42–43. McCullen, K. L., & Pieper, B. (2006). A retrospective chart review of risk factors for extravasation among neonates receiving peripheral intravascular fluids. Journal of Wound Ostomy Continence Nursing, 33, 133–139. Peterson, K. A., Phillips, A. L., Truemper, E., & Agrawal, S. (2012). Does the use of an assistive device by nurses impact peripheral intravenous catheter insertion success in children? Journal of Pediatric Nursing, 27, 134–143. http://dx.doi.org/10.1016/j.pedn.2010.10.009. Sauerland, C., Engelking, C., Wickham, R., & Corbi, D. (2006). Vesicant extravasation part 1: Mechanisms, pathogenesis, and nursing care to reduce risk. Oncology Nursing Forum, 33, 1134–1141. http://dx.doi. org/10.1186/06.ONF.1134-1141. Sebbane, M., Claret, P. G., Lefebvre, S., Mercier, G., Rubenovitch, J., Jreige, R., ... de La Coussaye, J. E. (2013). Predicting peripheral venous
7 access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility. The Journal of Emergency Medicine, 44, 299–305. http://dx.doi.org/10.1016/j. jemermed.2012.07.051. Sung, S. H., & Kim, H. S. (2007). Risk factors of intravenous infiltration in children. Clinical Nursing Research, 13, 61–72. Talbot, S. G., & Rogers, G. F. (2011). Pediatric compartment syndrome caused by intravenous infiltration. Annals of Plastic Surgery, 67, 531–533. http://dx.doi.org/10.1097/SAP.0b013e3182085915. Thomas, J. (2007). Standard practice and evolving trends in pediatric intravenous access. Air Medical Journal, 26, 8–11. http://dx.doi.org/10. 1016/j.amj.2006.10.006. Walter, Z., & Pitter, D. (2009). Peripheral venous catheters: An underevaluated problem. International Journal of Antimicrobial Agents, 34, S38–S42. http://dx.doi.org/10.1016/S0924-8579(09)70565-5. Willsey, D. B., & Peterfreund, R. A. (1997). Compartment syndrome of the upper arm after pressurized infiltration of intravenous fluid. Journal of Clinical Anesthesia, 9, 428–430.
The Effect of Intravenous Infiltration Management Program for Hospitalized Children Soon Mi Park PhD, RN a , Ihn Sook Jeong PhD, RN b,⁎, Kyoung Lae Kim RN a , Kyung Ju Park RN a , Moon Ju Jung RN a , Seong Suk Jun PhD, RN b a
Department of Nursing, Pusan National University Yangsan Hospital, Yangsan, South Korea College of Nursing, Pusan National University, Yangsan, South Korea
b
Received 15 June 2015; revised 14 October 2015; accepted 18 October 2015
Key words: Child; Infusion therapy; Management; Infiltration; Extravasation
Purpose This study aimed to identify the effect of IV infiltration management program among hospitalized children. Design and Methods: This was a quasi-experimental study with history comparison group design with 2,894 catheters inserted during 3 months comparison phase and 3,651 catheters inserted during 4 months experimental phase. The intervention was composed of seven activities including applying poster, documentation of catheter insertion, parents education, making infiltration report, assessment of vein condition before inserting catheter, appropriate site selection, and documentation of catheter insertion, and assessment of peripheral catheter insertion site every shift. Data were analyzed using of X2-test, Fisher's exact test. Results: The infiltration incidence rate was 0.9% for experimental group and 4.4% for comparison group, which was significantly different (x2 = 80.42, p b .001). The catheter maintenance period (p = .035) and infiltration state (p = .039) were significantly different among participants with infiltration between comparison and experimental groups. Conclusions: IV Infiltration management program was founded to be effective in reducing the IV infiltration incidence rate and increasing early detection of IV infiltration. Practice Implications: Considering the effect of IV Infiltration management program, we recommend that this infiltration management program would be widely used in the clinical settings. © 2015 Elsevier Inc. All rights reserved.
INTRAVENOUS (IV) INFUSION is a process often performed on hospitalized patients (Flippo & Lee, 2011; Kagel & Rayan, 2003; Walter & Pitter, 2009). This technique is an effective method for the administration of some drugs, and is also used for delivery of drugs to pediatric patients with absorption defects due to diarrhea, dehydration, or peripheral blood vessel collapse. This method is also used for pediatric patients who need to maintain a high blood drug concentration, being infected with strains of bacteria with a high resistance to antibiotics and therefore must receive
⁎ Corresponding author: Ihn Sook Jeong, PhD, RN. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2015.10.013 0882-5963/© 2015 Elsevier Inc. All rights reserved.
medications through IV insertion for a certain period, and require continuous pain relief. Peripheral IV insertion is a basic nursing technique, but it is also a complex and technically difficult procedure that needs to be performed successfully within a limited time (Thomas, 2007). IV insertion is particularly difficult in children who have thin and weak blood vessels, and move continuously due to the pain associated with insertion (McCullen & Pieper, 2006). According to a previous study, the success rates of peripheral IV insertion performed on pediatric patients were 42.8% for the first trial, 39.7% for the second trial, 37.5% for the third trial, and 38.8% for the fourth trial (Peterson, Phillips, Truemper, & Agrawal, 2012). According to a prospective study on patients in the
2 emergency room with an average age of 53 years, a success rate of 79% for first insertion was observed along with a total success rate of 98.6% (Sebbane et al., 2013). These results indicate that the first trial success rate of peripheral IV insertion for pediatric patients is very low compared to that of adults, and the patients consequently become more vulnerable to IV infiltration and extravasation (hereafter IV infiltration) (Fang, Fang, & Chung, 2011; Sung & Kim, 2007). IV infiltration causes inconvenience or delay in treatment due to re-insertion into the vein, and may also result in the need for surgery due to tissue damage (Talbot & Rogers, 2011; Willsey & Peterfreund, 1997) or cause permanent damage in pediatric patients (CliftonKoeppel, 2006). Therefore, primary prevention of IV infiltration in the early stage is extremely important. An effort to minimize damage by noticing injury at an early stage is also needed. Although the hospital also made efforts to prevent IV infiltration among pediatric patients with the use of posters, education of guardians, and IV infiltration monitoring, the IV infiltration rate has not been decreased. Therefore, we have developed and implemented an IV infiltration management program by establishing a professional team for prevention and effective management of IV infiltration in hospitalized pediatric patients. This management program includes IV infiltration prevention practices that have not been previously enforced in order to reduce the additional occurrence of IV infiltration in this hospital. The aim of this study was to evaluate the effectiveness of a new IV infiltration management program by comparing the occurrence rate of IV infiltration and characteristics of pediatric patients with IV infiltration before and after application of the program.
Methods Research Design This was a synchronized quasi-experimental study using a historical control to analyze the rate of IV infiltration by application of an infiltration and extravasation management program for patients in a children's hospital, and to identify the characteristics of pediatric patients with IV infiltration.
Study Participants The participants in this study were children or teenagers 0 to 19 years old who received peripheral IV insertions when hospitalized from August 1, 2011 to February 29, 2012 at a children's hospital with 126 beds located in Yangsan city, Korea. Patients who were hospitalized from August 1 to October 31, 2011 formed the comparison group in this study and did not participate in the IV infiltration management program, representing a total of 2,894 cases of IV insertion. Pediatric patients who were hospitalized from November 1, 2011 to February 29, 2012 formed the experimental group which received care under the IV infiltration management program, with a total of 3,651 cases of IV insertion.
S.M. Park et al.
Intervention The Comparison Group The comparison group received the routine usual care for preventing IV infiltration. The specific care was as follows: 1. Posters on how to prevent IV infiltration were displayed on the wall(s) of all patient rooms. 2. After IV catheter insertion, the nurses recorded the date and time of IV catheterization, the size of IV catheter, and the name of the practitioner at the site of IV insertion. 3. After IV catheter insertion, the nurses educated the patients' guardians by providing leaflets on how to prevent IV infiltration. The guardians were asked to touch the site of IV insertion, remember the feeling, and make frequent observations to alert the nurses when any abnormalities developed. 4. When IV infiltration occurred, nurses were supposed to immediately stop the infusion, and assess the IV infiltration site, and document this on an ‘IV infiltration record’ including demographics, IV infusion related characteristics (e.g., duration, site, size of IV catheterization, and type of drug injected), and IV infiltration related characteristics (e.g., stage and size of skin damage). The Experimental Group: The IV Infiltration Management Program The ‘IV infiltration management program’ was applied to the experimental group. This program was developed by the research team composed of one pediatric nursing team leader, three pediatric head nurses, and one nursing professor. They reviewed articles and guidelines related to the IV infiltration prevention and management of peripheral intravenous infusion (Doellman et al., 2009; Earhart & McMahon, 2011; European Oncology Nursing Society (EONS), 2007; Hadaway, 2007; Infusion Nurses Society, 2006; Ingram & Lavery, 2005). Because some of recommendations from the IV infiltration prevention guidelines had already been implemented, the team selected other recommendations which had not been included in the original IV infiltration prevention programs. The additional recommendations were as follows: 1. Prior to IV catheter insertion, the nurse assessed the condition of the patients' blood vessel and selected the best vein for peripheral administration. Small size and poor condition of veins were one of the factors contributing to the risk of infiltration (Doellman et al., 2009). Then, he/she decided whether he/she could perform IV catheterization by himself/herself or referred to the IV insertion team. When insertion failed twice, the nurse was supposed to refer to the IV insertion team to complete the task. In the first step, there was no formal assessment tool. The nurse simply
Inttravenous Infiltration Management Program assessed the vein of the patients, and then they made a decision regarding whether they performed IV catheterization by themselves or referred to the IV insertion team. 2. Prior to IV catheter insertion, the nurse assessed the patient's movement or thumb sucking habits, and selected appropriate IV sites to secure. An unstable catheter, poor securing of the IV site, and uncooperative movement by the patient were factors contributing to the risk of infiltration (Doellman et al., 2009). In the second step, there was also no formal assessment tool. The nurse just observed and asked care givers about the patients' activities. 3. After IV catheter insertion, the nurse monitored the IV site at least once every shift and documented the ‘IV insertion record’. There were two types of ‘IV insertion record’: one for the beginning and the other one for maintenance. The ‘IV insertion record’ included general characteristics of the subject, the date of insertion, the site of insertion, the size of the catheter, and the type of infusate, and the drugs injected. Nurses who performed IV catheterization at the start entered this into the ‘IV insertion record’ (for start) and other staff nurses examined the IV site at least once during their shift and made entries in the ‘IV insertion record’ (for maintenance).
Study Instrument The study instrument was the data collection form, consisting of 3 parts; demographics of study participants, IV infusion related characteristics, and IV infiltration related characteristics. The demographics included gender and age. The IV infusion related characteristics were duration, site, size of the IV catheterization, and the type of drug injected. The IV infiltration related characteristics included stage of IV infiltration and type of skin damage incurred. The stage of
Table 1
Infiltration criteria used for this study.
Stage Symptoms 0
1 2
3
4
Absence of redness, warmth, pain, swelling, blanching, mottling, tenderness or drainage. Flushes with ease (no IV infiltration). Absence of redness, swelling. Flushes with difficulty. Pain at site. Slight swelling (less than 1 inch) at site. Presence of redness. Pain at site. Good pulse below site. 1–2 second capillary refill below site. Moderate swelling (1 to 6 inches) above or below site. Blanching. Pain at site. Good pulse below infiltration site. 1–2 second capillary refill below infiltration site. Severe swelling (more than 6 inches) above or below site. Blanching. Pain at site. Decreased or absent pulse. Capillary refill greater than 4 seconds. Skin cool to touch. Skin breakdown or necrosis.
3 IV infiltration was scored on a scale of 0 to 4 by using Flemmer and Chan (1993)'s criteria, where 0 indicated ‘no IV infiltration’ while 1 to 4 indicated the extent of effusion of fluid that had occurred.’ Larger number associated with more severe IV infiltration occurred (Table 1). Flemmer and Chan (1993)'s criteria were easy to grade by observation and touch of IV sites. However, it was not clear from their criteria what size of swelling was defined as slight, moderate, and severe. Thus, we defined the size of swelling as slight when it was less than 1 inch, moderate when it was 1 to 6 inches, and severe when it was greater than 6 inches, based on the Infusion Nurses Society (2006) criteria.
Study Procedure This study was conducted after obtaining approval from the Institutional Review Board of Pusan National University Yangsan Hospital (05-2011-057). First, the ‘IV infiltration management program’ was introduced to nurses working in the pediatric department of the study hospital four times, and the head nurse or nurse in charge monitored whether the program has been applied in clinical practice. Data were collected prospectively and retrospectively by one of the researchers. Data were collected prospectively by using the ‘IV insertion record’ and ‘IV infiltration record’ for the experimental group, and retrospectively from the ‘IV infiltration record’ for the comparison group. The IV insertion record and IV infiltration record’ were filled in by staff nurses and the staging of IV infiltration was graded by staff nurses. For this, head nurses educated staff nurses on how to grade the staging of IV infiltration by using PowerPoint slides, and staff nurses graded the staging of IV infiltration for the patients, which was confirmed by the head nurses before collecting data to enhance the inter-observer reliability.
Data Analysis SPSS Win (version 18.0) was used for data analysis, and a two-tailed test with a significance level (α) of 0.05 was performed. 1) IV infiltration rate was calculated according to the standard method of the Infusion Nurses Society (2006). A chi-square or Fisher's exact test was
Table 2 Infiltration incidence rate between comparison and experimental groups. Variables
Comparison Experimental group group
Number of 2894 intravenous catheter insertion Number of infiltration 127 Infiltration incidence 4.4 rate (%)
3651
34 0.9
x2
p
80.42 b .001
4
S.M. Park et al. performed to evaluate differences in IV infiltration rate between two groups.
IV infiltration rate ð%Þ ¼ ðnumber of IV infiltration occurrence=number of total IV insertionsÞ 100
2) The demographics, IV infusion related characteristics, and IV infiltration related characteristics of patients with IV infiltration were analyzed with frequency and percentage, or average and standard deviation.
Results IV Infiltration Rates For the comparison group, the number of total IV insertions was 2894, the number of IV infiltration occurrences was 127, and the IV infiltration rate was 4.4%. For the experimental group, the number of total IV insertions was 3651, the number of occurrences of IV infiltration was 34, and the IV infiltration rate was 0.9%. A significant statistical difference in the IV infiltration rate was observed between the two groups (X2 = 80.42, p b .001; Table 2).
Characteristics of Participants With IV Infiltration Demographics Demographics of participants with IV infiltration are listed in Table 3. Among the patients with IV infiltration, 58.3% of the comparison group and 67.6% of the experimental group were male. In addition, 34.6% of the comparison group and 23.5% of the experimental group were less than 1 year old and considered infants. One to 3 year old toddlers were 10.2% and 32.4%, respectively, thus the age distributions of the two groups were significantly different (X2 = 14.09, p = .007). IV Infusion Related Characteristics IV infiltration related characteristics of the participants with IV infiltration are listed in Table 4. The most frequent duration of IV catheterization was 24 to 48 hours, accounting for 31.6% of the comparison group and 44.0% of the
experimental group. The period that differed most significantly between the two groups was 48 to 72 hours with 29.1% for the comparison group and 2.9% for the experimental group. A significant difference in the duration of IV catheterization was observed between the two groups (X2 = 11.97, p = .035). The most common intravenous insertion site was the back of the hand, with 48.8% of the comparison group and 50% of the experimental group. The location of the greatest difference between the two groups was the wrist, with 7.9% for the comparison group and 20.6% for the experimental group. However, there was no significant statistical difference in insertion site between the two groups. For the size of the IV catheters, 24G was used more frequently than 22G and there was no significant difference in the effect of the size of IV catheters between the two groups. The most frequently injected fluid was 5% dextrose with 59.7% of the comparison group and 44.1% of the experimental group. The most frequently administered antibiotic was cefotaxime, including 48.0% of the comparison group and 29.4% of the experimental group. There was no significant difference in the fluid types and drugs injected between the two groups. IV Infiltration Related Characteristics IV infiltration related characteristics of the participants with IV infiltration are listed in Table 5. The most frequent IV infiltration stage was ‘stage 2’ with 74.0% of the comparison group and 76.4% of the experimental group. The IV infiltration stage associated with the greatest difference between the two groups was ‘stage 3’ with 20.5% of the comparison group and 5.9% of the experimental group along with ‘stage 1’ with 3.1% and 11.8%, respectively. A significant difference was observed between the two groups (X2 = 8.38, p = .039). ‘No damage’ to the skin was observed most frequently, and accounted for 96.8% of the comparison group and 94.1% of the experimental group. This difference was not significant.
Discussion Table 3 Demographic characteristics among participants with infiltration between control and experimental groups. Characteristics
Gender
Male Female Age (year) b 1 1– b 3 3– b 6 6– b 12 12– b 19
Comparison Experimental x2 group group (n = 34) (n = 127) n (%)
n (%)
74 53 44 13 24 31 15
23 (67.6) 11 (32.4) 8 (23.5) 11 (32.4) 3 (8.8) 5 (14.7) 7 (20.6)
(58.3) (41.7) (34.6) (10.2) (18.9) (24.4) (11.8)
0.99
p
.321
14.09 .007
This study was conducted in order to evaluate the effectiveness of the new IV infiltration management program by comparing the occurrence rate of IV infiltration and characteristics of pediatric patients with IV infiltration before and after application of the program. In this study, three new preventive practices for IV infiltration management were added to the existing nursing practice performed in the study hospital; assessing the condition of the patients’ blood vessel and referring to the IV insertion team, selecting the best IV sites for fixation, and assessing the IV site at least once per every shift. Based on the results, the IV infiltration rate was significantly lower in the experimental group than the comparison group. In fact, the IV infiltration rate for the
Inttravenous Infiltration Management Program Table 4
5
Infusion therapy related characteristics among participants with infiltration between control and experimental groups. Comparison group (n = 127) Experimental group (n = 34) x2
Characteristics
n (%) 0 ~ b 24 31 (24.4) 24 ~ b 48 40 (31.6) 48 ~ b 72 37 (29.1) 72 ~ b 96 15 (11.8) 96 ~ b 144 4 (3.1) Insertion site Dorsum of hand 62 (48.8) Wrist 10 (7.9) Forearm 15 (11.8) Brachium 2 (1.6) Instep 33 (26.0) Ankle 5 (3.9) Catheter size 24G 120 (98.4) 22G 2 (1.6) Hypertonic fluid administered Dextrose 5% 75 (59.1) Dextrose 10% 10 (7.9) TPN 12 (9.5) Isotonic fluid administered Sodium chloride 0.225% 28 (22.0) NS 13 (10.2) Antibiotics administered Cefotaxime 61 (48.0) Sullbacillin 26 (20.5) Shincef 10 (7.9) Vancomycin 9 (7.1) Other medications administered Ambroxol 64 (50.4) 15% Mannitol 13 (10.2) Phenytoin 10 (7.9) Catheter maintenance (hours)
p
n (%) 11 (32.3) 15 (44.0) 1 (2.9) 4 (11.8) 3 (8.8) 17 (50.0) 7 (20.6) 2 (5.9) 1 (2.9) 6 (17.7) 1 (2.9) 33 (97.1) 1 (2.9) 15 (44.1) 2 (5.9) 5 (14.7) 7 (20.6) 3 (8.8) 10 (29.4) 5 (14.7) 2 (5.9) 1 (2.9) 12 (35.3) 2 (5.9) 1 (2.9)
11.97 .035
6.12
.295
1.00
.381
1.54 – – 0.03 – 3.77 0.57 – – 2.45 – –
.214 1.000 ⁎ .359 ⁎ .855 1.000 ⁎ .052 .449 1.000 ⁎ .690 ⁎ .117 .740 ⁎ .460 ⁎
TPN: total parenteral nutrition NS: normal saline. ⁎ Fisher's exact test.
comparison group (4.4%) was considered very low when compared to the two previous research studies conducted in South Korea by 9.3% (Kim, 2006) and by 23.7% (Sung & Kim, 2007). IV infiltration rate for the experimental group (0.9%) was surprisingly lower than reported in the previous
Table 5 Infiltration related characteristics among participants with infiltration between comparison and experimental groups. Comparison Experimental x2 group group (n = 127) (n = 34)
Characteristics
n (%) Stage of infiltration
1 point
2 point 3 point 4 point Dermatologic None injury Erosion Uncer/ Necrosis
4 (3.1)
p
n (%) 4 (11.8)
8.38 .039
94 (74.0) 26 (76.4) 26 (20.5) 2 (5.9) 3 (2.4) 2 (5.9) 123 (96.8) 32 (94.1)
1.06 .589
3 (2.4) 1 (0.8)
1 (2.9) 1 (2.9)
studies. We could provide two explanations for this result. First, this study's hospital was approved by the Joint Commission International and Korea Institute for Healthcare Accreditation and has tried to minimize the occurrence of IV infiltration. Second, selection of an appropriate vein and IV site was very important. The largest, softest, and most pliable vein was the best choice for avoiding IV infiltration (European Oncology Nursing Society (EONS), 2007), and no curvature, no joint area was good for securing the IV catheter (European Oncology Nursing Society (EONS), 2007; Hadaway, 2007). The new IV infiltration program included selection of the best vein and IV sites for fixation as a recommended practice, and assessing the IV site often and regularly. IV infusion related characteristics among patients with IV infiltration were analyzed to further evaluate the specific effects of the program. Characteristics that differed significantly between the two groups were patient age, duration of IV catheterization, and IV infiltration stage. Patient age was categorized as 0 to 1 year old (infants), 1 to 3 years old (toddlers), 3 to 6 years old (preschoolers), 6 to 12 years old (middle childhood), and 12 to 19 years old (teenagers). IV infiltration showed the highest incidence in infants in the comparison group, and in toddlers in the experimental group.
6 This result indicating that the lower age group showed higher IV infiltration was consistent with the previous evidence that using a small blood vessel is a well-known risk factor for IV infiltration (European Oncology Nursing Society (EONS), 2007). However, the reason for the difference in age distribution between the two groups could not be easily explained. We could assume that the new IV infiltration program was very effective in reducing the risk of infants with very high risk of IV infiltration, but was less effective in toddlers because they were likely to be more active and able to move more freely than infants (Sauerland, Engelking, Wickham, & Corbi, 2006). For IV infiltration stage, the experimental group showed higher in 1 point and less in 3 points than the comparison group, suggesting that IV infiltration was detected at an earlier stage in the experimental group than the comparison group. Thus, it was suggested that although the IV infiltration management program could not prevent occurrence of IV infiltration, it was seemingly helpful for early detection of the condition. When it failed to prevent IV infiltration, the IV site were to be monitored with detection at as early stage as possible to reduce the size of skin damage (European Oncology Nursing Society (EONS), 2007). In this program, assessing the peripheral catheter insertion site every shift appeared to be the most important attribute to early detection of IV infiltration. ‘Less than 48 hours’ of the duration of IV catheterization was 56% of the comparison group, and 76% of the experimental patients. That is, the duration of IV catheterization was shorter in the experimental group than the control group. Considering that the patients analyzed had IV infiltrations, this result may support early detection of IV infiltration among the experimental group. Thus, the IV infiltration management program which enforced monitoring the IV site at least once per every shift and recording the findings on the sheets was helpful in detecting the possibility of IV infiltration earlier and more regularly. This study is very significant as it provided a set of nursing practices which can actively prevent occurrence of IV infiltration. However, the following limitations should be considered. First, this study was conducted in one children's hospital and monitored the occurrence of IV infiltrations for 3 months before and after the program. Thus, generalization of the results of this study was limited. This investigation is recommended to be repeated in various institutions for longer periods. Second, the stage of IV infiltrations was based on the records made by nurses in charge of patient care. Although all nurses working at this hospital received training on how to evaluate the stage of IV infiltrations, we did not assess the consistency in measuring the stage among the nurses, which could increase the possibility of measurement error. Third, the IV infiltrations management program was composed of 3 nursing practices. We evaluated the overall effects of the program, but the individual effect of each plan was not assessed. Fourth, while it was recommended to assess the peripheral IV site every hour for
S.M. Park et al. children when infusing (Infusion Nurses Society, 2006; Masoorli, 2003) and every four hours when capped or locked, we assessed the IV site at least once per shift if the IV was infusing, and did not monitor IV site if the IV was locked/capped. More frequent assessment would be helpful to increase the earlier detection of IV infiltration.
Conclusion As a result of implementing the 4-month IV infiltration management program for pediatric patients receiving peripheral IV infusion at a children's hospital, the occurrence of IV infiltrations was less than 1%, which was significantly lower than that of the comparison group who did not receive the program, suggesting that the program may improve prevention. And, the IV infiltration management program was helpful in detecting occurrence of IV infiltration at the early stage. Further studies to determine the individual effect of the IV infiltration management program and for selection of the most effective method are recommended.
Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and future Planning (2015R1A2A2A04003415).
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