Citation Information :
Singh N, Kalyan G, Kaur S, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021; 25 (5):557-565.
Aim and objective: To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.
Materials and methods: The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale used to grade the extent of the two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change and introduction of infection control nurse. These interventions were implemented in sequential Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” were the outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were the process measures.
Result: The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9% and 96.1% to 45% and 55%, respectively, after implementation of all PDSA cycles.
Conclusion: Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation helped in sustaining the goal and attaining long-term success.
Tagalakis V, Kahn SR, Libman M, Blostein M. The epidemiology of peripheral vein infusion thrombophlebitis: a critical review. Am J Med 2002;113(2):146–151. DOI: 10.1016/s0002-9343(02)01163-4.
Cho YH, Yen LL, Yu KL, Chang CC, Chen HL. Reducing the incidence of phlebitis related to intravenous injection in pediatric patients. Hu Li Za Zhi 2015;62(3 Suppl.):49–57. DOI: 10.6224/JN.62.3S.49.
Phlebitis: a painful complication of peripheral IV. Am J Nurs. LWW. [cited 2018 Oct 16]. Available from: https://dev-journals2013.lww.com/ajnonline/Fulltext/2003/02000/Phlebitis_A_painful_complication_of_peripheral_IV.27.aspx.
White SA. Peripheral intravenous therapy-related phlebitis rates in an adult population. J Intraven Nurs Off Publ Intraven Nurs Soc 2001;24(1):19–24.
Kaur P, Thakur R, Kaur S, Bhalla A. Assessment of risk factors of phlebitis amongst intravenous cannulated patients. Iran J Nurs Midwifery Res 2011;7(3):9.
Reingardiene D. Intravenous catheters and nosocomial infection. Med Kaunas Lith 2004;40(1):84–91.
Rosenthal VD, Guzman S, Migone O, Crnich CJ. The attributable cost, length of hospital stay, and mortality of central line-associated bloodstream infection in intensive care departments in Argentina: a prospective, matched analysis. Am J Infect Control 2003;31(8):475–480. DOI: 10.1016/j.ajic.2003.03.002.
Ling ML, Apisarnthanarak A, Madriaga G. The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis. Clin Infect Dis 2015;60(11):1690–1699. DOI: 10.1093/cid/civ095.
Cunha BA. Intravenous line infections. Crit Care Clin 1998;14(2):339–346. DOI: 10.1016/s0749-0704(05)70399-7.
Sodhi J, Satpathy S, Sharma DK, Lodha R, Kapil A, Wadhwa N, et al. Healthcare associated infections in paediatric intensive care unit of a tertiary care hospital in India: hospital stay & extra costs. Indian J Med Res 2016;143(4):502–506. DOI: 10.4103/0971-5916.184306.
Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med 1991;114(10):845–854. DOI: 10.7326/0003-4819-114-10-845.
Park SM, Jeong IS, Jun SS. Identification of risk factors for intravenous infiltration among hospitalized children: a retrospective study. PLoS One 2016;11(6):e0158045. DOI: 10.1371/journal.pone.0158045.
Catney MR, Hillis S, Wakefield B, Simpson L, Domino L, Keller S, et al. Relationship between peripheral intravenous catheter Dwell time and the development of phlebitis and infiltration. J Infus Nurs Off Publ Infus Nurses Soc 2001;24(5):332–341. DOI: 10.1097/00129804-200109000-00008.
Singh N, Kalyan G, Kaur S, Murlidharan J, Ghai S. A study to find out the barriers and facilitators related to IV line insertion and maintenance in pediatric emergency. J Pediatr Crit Care 2018;5(1):63–63. DOI: 10.21304/2018.0501.00252.
Perl TM, Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D. Prevention of central line–associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clin Infect Dis Off Publ Infect Dis Soc Am 2014;59(1):96–105. DOI: 10.1093/cid/ciu239.
Boyd S, Aggarwal I, Davey P, Logan M, Nathwani D. Peripheral intravenous catheters: the road to quality improvement and safer patient care. J Hosp Infect 2011;77(1):37–41. DOI: 10.1016/j.jhin.2010.09.011.
Liang SY, Theodoro DL, Schuur JD, Marschall J. Infection prevention in the emergency department. Ann Emerg Med 2014;64(3):299–313. DOI: 10.1016/j.annemergmed.2014.02.024.
Mauger B, Marbella A, Pines E, Chopra R, Black ER, Aronson N. Implementing quality improvement strategies to reduce healthcare-associated infections: a systematic review. Am J Infect Control 2014;42(10 Suppl.):S274–S283. DOI: 10.1016/j.ajic.2014.05.031.
10 Best strategies for infection prevention and control [Internet] [cited 2018 Oct 16]. Available from: https://www.beckershospitalreview.com/quality/10-best-strategies-for-infection-prevention-and-control.html.
Aseptic non touch technique (ANTT®) for intravenous therapy [Internet] [cited 2018 Oct 16]. Available from: https://www.gosh.nhs.uk/health-professionals/clinical-guidelines/aseptic-non-touch-technique-antt-intravenous-therapy.
Implementing the aseptic non touch technique (ANTT®) clinical practice framework for aseptic technique: a pragmatic evaluation using a mixed method... – PubMed – NCBI [Internet] [cited 2018 Oct 16]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29317909.
Road Map to Eliminate HAI: 2013 Action Plan Conference. 2013;89.
Methods to improve healthcare worker hand hygiene to decrease infection in patient care [Internet] [cited 2018 Oct 16]. Available from: /CD005186/EPOC_methods-improve-healthcare-worker-hand-hygiene-decrease-infection-patient-care.
A culture of support: 4 ways to improve hand hygiene compliance [Internet] [cited 2018 Oct 16]. Available from: https://www.beckershospitalreview.com/quality/a-culture-of-support-4-ways-to-improve-hand-hygiene-compliance.html.
Rowley S, Clare S. ANTT: a standard approach to aseptic technique. Nurs Times 2011;107(36):12–14.
Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs Off Publ Infus Nurses Soc 2006;29(1 Suppl.):S1–S92. DOI: 10.1097/00129804-200601001-00001.
Esteban E, Ferrer R, Urrea M, Suarez D, Rozas L, Balaguer M, et al. The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc 2013;14(5):525–32. DOI: 10.1097/PCC.0b013e31828a87cc.
Institute for healthcare improvement: how to improve [Internet] [cited 2018 Oct 16]. Available from: http://www.ihi.org:80/resources/Pages/HowtoImprove/default.aspx.
VIP score [Internet] [cited 2020 Feb 1]. Available from: http://www.vipscore.net/.
Higgingson R. IV cannula securement: protecting the patient from infection. Br J Nurs Mark Allen Publ 2015;24(8):S23–S24, S26, S28. DOI: 10.12968/bjon.2015.24.sup8.s23.
Webster J, Osborne S, Rickard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 2015;(8):CD007798. DOI: 10.1002/14651858.CD007798.pub4.
Abolfotouh MA, Salam M, Bani-Mustafa A, White D, Balkhy HH. Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications. Ther Clin Risk Manag 2014;10:993–1001. DOI: 10.2147/TCRM.S74685.
Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008;52(2):126–136. DOI: 10.1016/j.annemergmed.2008.03.014.
Lemaster CH, Agrawal AT, Hou P, Schuur JD. Systematic review of emergency department central venous and arterial catheter infection. Int J Emerg Med 2010;3(4):409–423. DOI: 10.1007/s12245-010-0225-5.
de Vos M, Graafmans W, Kooistra M, Meijboom B, Van Der Voort P, Westert G. Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care J Int Soc Qual Health Care 2009;21(2):119–129. doi: 10.1093/intqhc/mzn059.
Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017;9:CD005186. DOI: 10.1002/14651858.CD005186.pub4.
Snyder SR, Favoretto AM, Baetz RA, Derzon JH, Madison BM, Mass D, et al. Effectiveness of practices to reduce blood culture contamination: a laboratory medicine best practices systematic review and meta-analysis. Clin Biochem 2012;45(13–14):999–1011. DOI: 10.1016/j.clinbiochem.2012.06.007.
Hill S. A behavior-focused hand hygiene quality improvement project. Nursing Graduate Publications; 2016.
Forster DH, Krause G, Gastmeier P, Ebner W, Rath A, Wischnewski N, et al. Can quality circles improve hospital-acquired infection control? J Hosp Infect 2000;45(4):302–310. DOI: 10.1053/jhin.2000.0762.
McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft SA, et al. Closing the quality gap: a critical analysis of quality improvement strategies. In: Care coordination, vol. 7. [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 [cited 2020 Feb 1]. (AHRQ Technical Reviews). Available from: http://www.ncbi.nlm.nih.gov/books/NBK44015/.
Weiner BJ, Alexander JA, Shortell SM, Baker LC, Becker M, Geppert JJ. Quality improvement implementation and hospital performance on quality indicators. Health Serv Res 2006;41(2):307–334. DOI: 10.1111/j.1475-6773.2005.00483.x.
Ceballos K, Waterman K, Hulett T, Makic MBF. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses 2013;13(3):154–163;quiz 164–165. DOI: 10.1097/ANC.0b013e318285fe70.
Alhassan RK, Spieker N, van Ostenberg P, Ogink A, Nketiah-Amponsah E, de Wit TFR. Association between health worker motivation and healthcare quality efforts in Ghana. Hum Resour Health 2013;11(1):37. DOI: 10.1186/1478-4491-11-37.