André van Zundert MD PhD FRCA EDRA
Professor of Anesthesiology,
Eindhoven and University of Maastricht,
University of Ghent, Belgium
Peripheral intravenous (IV) catheters sare one of the most common devices used in the delivery of medications and solutions to patients both in the hospital and alternative healthcare site settings. Over 330 million short peripheral intravenous devices are used every year in the US.(1) The traditional device has comprised a small catheter tubing (1/2 – 2 inches) on an open adapter, which is used as the connection point to an IV administration set. The insertion of this device, as it is commonly performed, predisposes the patient to risks of infection and the healthcare worker to risk of exposure, and potentially increases the risk of cross-contamination from room to room and from patient to patient. Closed IV catheter systems reduce these risks for both patients and healthcare workers.
Minimising patient risk
Closed IV catheter systems integrate individual components usually assembled by the clinician during the insertion of a peripheral IV cannula. The components incorporated into these new devices can include the IV catheter, a stabilisation platform or feature, an extension set and a needle-less access site. Because peripheral IV catheter insertion is not considered a sterile procedure, the pre-assembly of these components greatly reduces the risk of accidental contamination of the device during the process, which could lead to bloodstream infections.
Intravenous catheters are now reported to be the single most common source of bacteraemia and fungaemia, yet infections associated with short peripheral catheters receive very little attention. Infections associated with central vascular access devices (CVAD) present a greater risk from bloodstream infections (BSI). CVADs have larger diameters and longer lengths, are longer-dwelling catheters, and have become the focus of many rate reduction campaigns within hospitals. The total number of patients receiving short peripheral catheters is far greater than those exposed to CVADs. Data on infection rates with short peripheral catheters are limited; however, a Spanish study on infection rates from peripheral venous catheters reported infection rates similar to the rates from CVADs.(2,3)
In a recent paper, Trinh and colleagues(4) reported on peripheral IV catheter-associated infections and identified 24 (18 definite and six probable) peripheral venous catheter (PVC)-related Staphylococcus aureus (S. aureus) bacteraemias (estimated incidence density: 0.07 per 1000 catheter-days) with a median duration of catheterisation of three days (interquartile range: 2–6). They acknowledge that PVC infections have been de-emphasised, because most of the preventative efforts have focused on CVCs. Based on their findings, they estimated 32,529,144 adult patient discharges from US hospitals from 2005–2007, which could mean as many as 10,028 PVC-related S. aureus bacteraemias each year in adults hospitalised in the USA. They recommended that hospitals should assess their risk of PVC-related infections and initiate interventions to mitigate risk if such infections are found.
Other patient advantages include reduced risks of complications, such as phlebitis, infiltration/extravasation and dislodgement, all of which can result in unscheduled restarts before site rotation protocol dictates. These complications are often a result of poor stabilisation of the device after insertion. One closed IV catheter system available on the market today (BD Nexiva™ Closed IV Catheter System; BD Medical) incorporates a stabilisation platform, which significantly reduces many of these complications.(5,6)
The US Centers for Disease Control and Prevention (CDC) 2011 guideline for the prevention of intravascular-related bloodstream infections recommends the use of a suture-less securement device to reduce risk of infection for intravascular catheters. It also states that appropriate securement of the device is recognised as an intervention to decrease the risk of phlebitis, catheter migration and dislodgement, and that it might be advantageous in preventing catheter-related BSIs.
Protecting healthcare workers
Closed IV catheter systems offer protection to the clinician inserting the device. Beyond the risk of exposure associated with needlestick injury, clinicians also face the risk of mucocutaneous exposure. According to the CDC, approximately 384,325 healthcare professionals in the US are exposed to blood and other bodily fluids resulting from needlestick and mucocutaneous exposures every year.(7) During the insertion of a traditional or open IV catheter, the clinician is at risk of blood exposure, both during the actual insertion and during the handling and disposal of the contaminated materials. With traditional open catheter devices, the blood spillage from the catheter hub can only be controlled by complete vessel occlusion following needle removal.
In a recent survey of nurses, 11% of the respondents did not mention wearing gloves.(1) In other research it was reported that only two-thirds of the healthcare workers reported that they routinely wore gloves during an invasive procedure.(8) A survey conducted by Jagger et al(9) in 2011 described the rate of at-risk blood exposures from IV catheter insertions to be 128 per 100,000 procedures. The authors draw attention to the comparison with needlestick injuries from safety-engineered IV catheters, which is 1.2 per 100,00 devices in one study and 0.7 per 100,000 in 2000.(9)
The under-reporting of blood exposure has been discussed and highlighted in medical literature.(8,10-14) In one survey of German hospitals, the under-reporting rate was 45%; in the USA, it was 82%.15 Reasons for not reporting ranged from time required to confidentiality issues, to not understanding its importance. These findings emphasise the value that technologies such as the closed IV catheter systems can bring to a very common procedure that carries significant risk.
Blood that leaks, splashes or spills during IV catheter insertion can contaminate the bed, floor, shoes, clothing, unprotected skin or gloves. Once this initial contamination occurs, the clinician can cross-contaminate other items in or outside the patient’s room, such as the bedrail, infusion equipment, linen hamper and doorknobs. The gloves used during the procedure often have blood droplets that are difficult to spot; the clinician then touches other items and contaminates surfaces, potentially exposing other workers to the patient’s blood.(1)
This situation not only puts other healthcare workers who might touch those surfaces without appropriate personal protective equipment at risk; it also allows contamination in another patient room. Boyce reported that healthcare-associated pathogens, such as methicillin-resistant S. aureus, vancomycin-resistant enterococci and Clostridium difficile can survive from days to weeks on environmental surfaces.16 He summarised that contaminated surfaces contribute to the transmission of healthcare-associated pathogens by serving as sources of hand (or glove) contamination among healthcare workers, and by direct spread of pathogens to susceptible patients.
There are also significant costs associated with the clean-up supplies.In one survey, it was estimated that the average cost was $0.30 per incident of blood leakage.17 Supplies described during the clean-up process were gauze, absorbent drapes, towels and sheets.(1)
With closed system devices, once the catheter has been advanced into the vessel and the needle is removed, blood is contained within the closed system and the infusion can be initiated without any blood spillage from the catheter hub. The blood flow observed in the integrated tubing also provides a visual confirmation of vessel access during the catheter threading process.
In summary, advances in IV catheter technology, such as the development of closed IV catheter systems, can reduce patient complications, provide another level of safety from blood exposure for the healthcare worker and reduce the risk of the spread of pathogens to patients.
- Peripheral IV catheters are one of the most common devices used in the delivery of medications in both the hospital and other healthcare settings.
- IV catheters are reported as the single most common source of bacteraemia and fungaemia.
- The insertion of IV catheters predisposes the patient to risk of infection and the clinician to risk of exposure and contamination.
- Because peripheral IV catheter insertion is not considered a sterile procedure, pre-assembly of the components greatly reduces the risk of accidental contamination of the device during the process.
- Closed IV catheter systems, such as BD Nexiva, offer better access to peripheral veins, with less pain to patients and with rapid and clearly visible primary and secondary flashback of blood, while also dramatically reducing risks of needlestick and blood exposure
- Richardson D, Kaufman L. Reducing blood exposure risks and costs associated with SPIVC insertion. Nurs Manage 2011;42:31–4.
- Pien BC et al. The clinical and prognostic importance of positive blood cultures in adults. Am J Med 2010;123:819–28.
- Pujol M et al. Clinical epidemiology and outcomes of peripheral venous catheter-related bloodstream infections at a university-affiliated hospital. J Hosp Infect 2007;67:22–9.
- Trinh TT et al. Peripheral venous catheter-related Staphylococcus aureus bacteremia. Infect Control Hosp Epidemiol 2011;32:579–83.
- Van Zundert A. New closed IV catheter system. Acta Anaesth Belg 2005;56:283–5.
- Bausone-Gazda D, Lefaiver CA, Walters SA. A randomized controlled trial to compare the complications of 2 peripheral intravenous catheter-stabilization systems. J Infus Nurs 2010;33:371–84.
- Lee JM et al. Needlestick injuries in the United States: epidemiologic, economic, and quality of life issues. AAOHN J 2005;53:117–33.
- Doebbeling BN et al. Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk? Clin Infect Dis 2003;37:1006–13.
- Jagger J et al. Blood exposure risk during peripheral I.V, catheter insertion and removal. Nursing 2011;41:25–6.
- Nagao M et al. Accidental exposures to blood and body fluid in the operation room and the issue of underreporting. Am J Infect Control 2009;37:541–4.
- Schmid K, Schwager C, Drexler H. Needlestick injuries and other occupational exposures to body fluids amongst employees and medical students of a German University: incidence and follow-up. J Hosp Infect 2007;65:124–30.
- Dement JM et al. Blood and body fluid exposure risks among healthcare workers: results from the Duke Health and Safety Surveillance System. Am J Ind Med 2004;46:637–48.
- Gerson R et al. Non-hospital based registered nurses and the risk of bloodborne pathogen exposure. Ind Health 2007;45:695–704.
- Beltrami EM et al. The nature and frequency of blood contacts among home healthcare workers. Infect Control Hosp Epidemiol 2000;21:765–70.
- Kessler CS et al. Underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey. Am J Infect Control 2011;39:129–34.
- Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect 2007;65 Suppl 2:50–4.
- O’Grady N et al. Guideline for the prevention of intravascular catheter-related infections. Centers for Disease Control. www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html (accessed 13 April 2012).