Time to rethink our approach to using cannulas

Associate Professor Amanda Walker, Clinical Director of the Australian Healthcare Safety and Quality Commission, explains why a consistent approach is needed to use the cannula.

Peripheral venous catheter (PIVC) or cannula insertion is one of the most common procedures performed in hospitals and is experienced by 7.7 million Australians each year.1-4 Most inpatients are familiar with procedures that involve all medical professionals in the hospital directly or indirectly.

Nevertheless, PIVCs are often associated with a variety of problems, including unnecessary cannulations, multiple insertion attempts, and in some cases serious complications such as infection. Staphylococcus aureus Bloodstream.2,3,5,6

As many clinicians know, PIVC insertion and sequelae can be a painful and difficult experience for the patient, becoming infected, very ill, and thinning veins and skin. Doing so can cause other complications. Evidence that we can do better is clear and encourages us to ask: Is there an alternative to PIVC? Where should I insert it? Which clinician is best to insert PIVC to ensure the best possible patient outcome?

To provide guidance and bring consistency to our entire healthcare system Australian Commission on Healthcare Safety and Quality The Commission has developed the first ever national clinical care standard for peripheral venous access.

NS Peripheral Vein Catheter Management Clinical Care Criteria Spotlight key areas to improve the safe and effective use of PIVC, such as insertion, maintenance and removal. The Commission has extensively consulted with leading experts in vascular access, pain management, infection control, and researchers and consumers enthusiastic about improving the use of PIVC in Australia.

Complications of PIVC are common. Difficult to insert, prone to obstruction and shedding, can cause venous inflammation (phlebitis, or thrombophlebitis if thrombophlebitis is also formed) and, in some cases, severe catheter-related bloodstream infections It can cause illness. ..

All clinicians who insert PIVCs should be aware of potentially detrimental consequences if this general procedure is not successful. The new standard outlines ways to avoid these complications and improve the patient’s experience. There are 10 quality statements (see Box 1), all of which are important for using PIVC best practices.

Do you need venous access?

According to various studies, up to a quarter (4-28%) of inserted PIVCs are unnecessary, the highest percentage in emergency departments where patients are more likely to receive peripheral lines as a normal hospitalization procedure. Increases to 50%. You will need it later “just in case”.4,8

Of concern, an international comparative study on the use of PIVCs reported that Australia had the highest prevalence of redundant PIVCs, with undocumented IV orders for liquids or medicines in 43% of cases. , PIVC may not have been needed.9

In palliative care, patients with venous sclerosis repeatedly attempt painful cannula insertion and do not actually take any medication or fluid that requires cannula. Equally frustrating, these cannulas are often inserted to administer drugs that are easy to administer subcutaneously. There is no annoyance or inconvenience of the forearm IV line and the risk of complications associated with it.

As clinicians, we sometimes focus on the drug given rather than the method given, which can lead to PIVCs used when another route is more appropriate. The new criteria will help healthcare professionals and service organizations assess the adequacy of IV administration early and continue this assessment as the diagnosis is established and treatment progresses.

Maximize the success of the first insert

It’s amazing to look at the data on PIVC insertion.Up to 40% of all first attempts to insert PIVC in adults fail and 65% of all first attempts in children failTen failure. This means that many patients undergo multiple painful attempts before the PIVC is successfully inserted. The standard aims to maximize the success of the first insertion, which will definitely improve the patient’s experience.

In my experience, junior doctors often feel the pressure to keep trying until they line up. Asking for help can be seen as a sign of failure. However, the maxim “If the first attempt fails, try again” does not apply to vascular access. If you cannot insert the cannula on the first attempt, ask for help. It is even more important to seek advice if you find it difficult to access the patient’s blood vessels. Successful insertion of PIVC into people with IV access often requires advanced techniques such as highly skilled inserters or ultrasound.7

Senior clinicians and health service managers have a common responsibility to help change the culture, and junior staff when faced with difficulties rather than establishing a culture of “keeping there.” Encourages to escalate. Doctors can exercise leadership in the round by regularly checking both the insertion site and whether the line is still needed.

When asked why this new standard is needed, my answer is simple. The patient is not a pincushion.

Reduce the risk of infection

As a medical student, you are taught that every time you break your skin, you run the risk of getting infected, so the risk of getting infected is considered unavoidable. It is true that every attempt to insert a PIVC is a breach of the patient’s protective barrier, and one should aim to limit this as much as possible.

However, the risk of infection as a result of that breach can be significantly reduced using well-known infection control techniques and practices that are clearly stated in the Australian Infection Control Guidelines.3

When PIVC fails

PIVC-related complications remove up to 90% of catheters before catheter replacement is planned or treatment is complete.Five In the event of a PIVC failure, it is often necessary to insert a replacement device.

This can put a heavy burden on the patient and the medical system. It can lead to delays in IV therapy and extended hospital stays. Hospital staff and resources are required to reinsert PIVC so that treatment can continue.

The cost of managing a PIVC failure can also be significant. For example, PIVC-related bloodstream infections are estimated to cost the US healthcare system $ 35,000 to $ 56,000 per patient.

I used to think that costs were inevitable. Not — we can do better. Apart from the financial burden, multiple trials are required to successfully reinsert PIVC, especially in terms of the pain and discomfort experienced by the patient as a result of failure, especially when access is difficult.3,9

Involve consumers

According to Australian and international data, a significant proportion of patients do not receive best practice care for the use of PIVC. The new standards support discussions to ensure that patients are informed about the procedure and empowered to participate in their care decisions.

NS IV-WISE Discussion Tool It provides clinicians and patients with important points of discussion, facilitates decision sharing, prevents PIVC-related complications, and makes patients as comfortable as possible (see Figure 1).

Measurement of improvement

PIVC is used daily in hospital environments, but often the only measure of how well PIVC is used is infection rate. Performing a point prevalence audit on a ward or service can help identify quality improvement needs and monitor changes over time.

Clinical care standards include a set of indicators that healthcare service organizations can use for this purpose, so we can track their performance and strive for better results. The changes required may be relatively small, but they can make a big difference overall.

When it changes

Complications of vascular access can become even more problematic in the future as Australia’s population ages and becomes chronically ill. The associated costs also increase, putting additional strain on our healthcare system.

It is more important than ever for healthcare service organizations to focus on deciding whether to use the right device for the right patient at the right time. We are all helping to reduce the number of unnecessary cannulations, failed attempts and avoidable infections. New management clinical care standards for peripheral venous catheters set us on a positive path to achieving this goal.

Box 1: Management of Peripheral Venous Catheter Clinical Care Standards — Quality Statement
  1. Assess your needs for intravenous access.
  2. Inform and cooperate with patients.
  3. Ensure competencies.
  4. Select the appropriate insertion site and PIVC.
  5. Maximize the success of the first insert.
  6. Insert and fix.
  7. Document your decisions and care.
  8. Routine use: inspection, access, flash.
  9. Check your ongoing needs.
  10. Remove it safely and replace it if necessary.

Read the full quality statement at

Figure 1: IV-WISE Discussion Tool

Download the tool at

This article was produced by Christina Lane and Alice Bhasale of the Commission’s Clinical Care Standards Team.

Associate Professor Amanda Walker was the clinical director of the Australian Healthcare Safety and Quality Commission and led the development of managed clinical care standards for peripheral venous catheters. On the committee, she focuses on developing clinical care standards, resources for dealing with complications of nosocomial infections, and support for clinicians to provide comprehensive care. She is a palliative medicine expert in Southern Highlands, New South Wales, and has led state-wide end-of-life care work at the New South Wales Clinical Excellence Commission.


  1. Cooke M, Ullman AJ, Ray-Barruel G, Wallis M, Corley A, Rickard CM. The venous line is not “just”: A consumer perspective on the peripheral venous cannula (PIVC). International cross-sectional survey of 25 countries. PLoS One. 2018; 13 (2): e0193436.
  2. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but not accepted: Peripheral IV catheter failure. J Infus Nurse. May-June 2015; 38 (3): 189–203.
  3. Marsh N, Webster J, Larsson E, Cook M, Mihara G, Likert CM. Observational study of peripheral venous catheter outcomes in adult inpatients: multivariate analysis of peripheral venous catheter failure. J Hopmed. February 1, 2018; 13 (2): 83–89.
  4. Zingg W, Pittet D. Peripheral Intravenous Catheter: An Underestimated Problem. IntJ antibacterial agent. 2009; 34 Suppl 4: S38–42.
  5. Alexandrou E, Ray-Barruel G, Carr PJ, Frost SA, Inwood S, Higgins N, et al. Use of short peripheral venous catheters: features, management, and worldwide results. J Hopmed. May 30, 2018; 13 (5).
  6. Wallis MC, McGrail M, Webster J, Marsh N, Gowardman J, Playford EG and more. Risk Factors for Peripheral Venous Catheter Disorder: Multivariate Analysis of Data from Randomized Controlled Trials. Infection Control Hospital Epidemiol. January 2014; 35 (1): 63–68.
  7. Sou V, McManus C, Mifflin N, Frost SA, Ale J, Alexandrou E. A clinical pathway for managing difficult venous access. BMC Nurse. 2017; 16:64.
  8. Limm EI, Fang X, Dendle C, Stuart RL, Egerton Warburton D. Half of all peripheral venous lines in Australia’s tertiary emergency department are unused. Do you have any pain? Ann Emergmed. November 2013; 62 (5): 521-525.
  9. Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, et al. International spread of the use of peripheral venous catheters. J Hopmed. August 2015; 10 (8): 530–533.
  10. Malyon L, Ulllman AJ, Phillips N, Young J, Kleidon T, Murfield J, and others Peripheral venous catheter duration and failure in pediatric acute care: a prospective cohort study. Emerg Med Australas December 2014; 26 (6): 602-608.
  11. Australian Commission on Healthcare Safety and Quality. National security and quality health service standards. Second Edition Sydney: ACSQHC; 2017.

Image courtesy of the Australian Commission on Healthcare Safety and Quality.

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