Purpose: To promote the safe insertion of short peripheral IV catheter (PIVC) insertion in the skilled nursing and long-term care settings.

 

Policy:  Insertion and removal of vascular access devices are performed by providers and clinicians within the boundaries of their identified scope of practice, based on their licensure, upon documented competency, and in accordance with organizational policies, procedures, and practice guidelines.

 

Use a new, sterile vascular access device for each catheterization attempt, including use of introducers. Do not alter vascular access devices (VADs) outside manufacturers’ directions for use. Secure VADs to prevent complications associated with VAD motion at the insertion site and unintentional loss of access. Use VAD securement methods that do not interfere with the ability to routinely assess and monitor the access site or impede vascular circulation or delivery of the prescribed therapy.

 

Restrict PIVC insertion attempts to no more than two attempts per clinician. Multiple unsuccessful attempts cause pain to the patient, delay treatment, limit future vascular access, increase cost, and increase the risk for complications. After two unsuccessful attempts, escalate to a clinician with a higher skill level or consider alternative routes of medication administration.

 

Physician order is required for insertion of PIVC. The transfusion nurse or LPN are the clinicians designated to insert PIVCs for the purpose of administering short-term IV infusions or transfusions of blood and blood components.

 

At the bedside, the transfusion nurse must verify the patient’s name and date of birth from the facility armband and compare to the physician order before placing a PIVC. Once the infusion/transfusion is completed, the transfusion nurse will remove the PIVC catheter, unless there is a physician order to keep the catheter in place.

 

A PIVC is removed when clinically indicated (e.g., unresolved complication, discontinuation of infusion therapy, or when no longer necessary for the plan of care).  PRVCs are not removed solely on length of dwell time, because there is no known optimal dwell time. Upon removal of the PIVC, pressure is held to the insertion site until hemostasis occurs and a bandage is applied.

 

 

Supplies:

1. Gloves, nonsterile
2. Short PIVC with safety mechanism
3. Vein visualization device, as appropriate
4. Single use Clippers or scissors for hair removal, if indicated
5. Local anesthetic, as indicated
6. Securement device or product
7. Short extension set, if not permanently attached to the catheter
8. Needleless connector
9. Preservative free 0.9% sodium chloride prefilled syringe or primed administration set
10. Intravenous start kit, preferred, or the following:
    1. Single use tourniquet
    2. Antiseptic solution
    3. Sterile alcohol free skin barrier product
    4. Transparent semipermeable membrane (TSM) dressing (preferred)
    5. Sterile gauze and sterile tape for dressing, if indicated
    6. Label
11. Joint stabilizers, if necessary
    1. Joint stabilization devices, such as an arm board or splint, are used to facilitate infusion delivery, maintain device functionality, and minimize infusion therapy complications. They are not considered restraints.
    2. Avoid use, if possible, due to restricted movement of the stabilized body part.
    3. Maintain a functional position by padding the device as needed to support the area of flexion (e.g., hand, arm, elbow, foot) to maintain a functional position.
    4. Apply in a manner that permits visual inspection and assessment of the vascular access site and vascular pathway and does not exert pressure that will cause circulatory constriction, pressure injury, or nerve damage in the area of flexion or under the device.
    5. Use when a PIVC is placed in the antecubital fossa. This site is not recommended, but if a PIVC is present, the joint is stabilized.
    6. Remove periodically for assessment of circulatory status, range of motion and function, and skin integrity.
    7. Caution is recommended when applying the joint stabilization device to the older adult’s hand or wrist area when there is evidence of arthritic joint changes. While positioning the hand or wrist in a functional position is necessary, extra padding under taping surfaces may be required to prevent joint stiffness and resulting discomfort.
    8. The older adult must be checked frequently, and the joint stabilization device removed at regular intervals to allow full range of motion in circulation assessment. Reinforcement of patient teaching should be continued to prevent accidental dislodgment and self injury.
12. Soft restraint, if necessary
    1. Collaborative efforts should be made with the interprofessional team members to develop a plan of care to prevent patient attempts to remove the PIVC while preventing the use of restraints. Use the least restrictive restraining device as necessary.
    2. A soft restraint may be required for older adults who might accidentally dislodge a PIVC. The restraint should not be applied so tightly that the patient circulation, infusate flow, or securement of the catheter is compromised. Careful assessment and documentation are required when using any type of joint stabilization device.

PROCEDURE

 

1. Pre procedure assessment
   1. Review patient’s health record.
      1. Note documented allergies (e.g., antiseptic solution, anesthetic, adhesives, etc).
      2. Patient age and physical condition.

• Assess the characteristics of the prescribed infusion therapy and the anticipated length of therapy to determine if a short PIVC is the most appropriate venous access device.

1. Select the insertion site:
   1. Assess the condition of the skin in previous sites of venipunctures and/or  infusion complications (e.g., phlebitis, infiltration) and avoid these areas for short PIVC  insertion.
   2. Discuss arm preference with the patient and the recommendation for use of the nondominant arm to decrease accidental removal.

• Assess the number and location of peripheral veins that are easily seen and palpated.

1. Assess the patient’s medical history for conditions that may affect the peripheral vasculature and increase the need for visualization technology to assist in locating appropriate venous or arterial insertion sites. Factors that increase difficulty with locating veins by observation and palpation (known as landmark techniques) include, but are not limited to:
   1. Disease processes that result in structural vessel changes (e.g., diabetes mellitus, hypertension)
   2. History of frequent venipuncture and/or lengthy courses of infusion therapy.
   3. Variations in skin between patient populations, such as darker skin tones and excessive hair on the skin.
   4. Skin alterations, such as the presence of scars or tattoos.
   5. Patient age.
   7. Fluid volume deficit.
2. Patient Education
   1. Prior to the procedure, teach patient and/or caregiver:
      1. The purpose of the short PIVC insertion procedure including risks and benefits.
      2. What to expect during the procedure.

• Signs and symptoms of common complications.

1. How and to whom to report complications.

• Pre procedure preparation
  1. Perform hand hygiene before direct contact with patient and subsequently as required throughout the procedural steps.
  2. Verify patient’s identity using two independent identifiers according to organizational policy.
  3. Obtain and review the provider’s order for infusion therapy and PIVC placement.
  4. Obtain informed consent according to organizational policy or patient assent.
  5. Disinfect work area with antimicrobial solution; allow to dry completely.
  6. Prepare for insertion, collect necessary insertion supplies, and set up sterile field.

1. Insertion procedure
   1. Place patient in sitting or recumbent position, as appropriate.
   2. Explanations should be reinforced with each step of the procedure, so the older adult is aware of what to expect. Calmly explain the procedure as it occurs to enhance patient cooperation and compliance. It may be helpful to have another caregiver or family member present to reassure the older adult about the intent and expected outcome of the procedure.
   3. Place the tourniquet to promote venous distention.
      1. Use single-patient-use, latex free tourniquets.
      2. Wrap the area where the tourniquet will be placed with a washcloth or apply  the tourniquet over a piece of clothing to reduce the discomfort, pressure, or pinching sensation. The tourniquet should lie flat against the skin or over clothing for additional comfort.

• Older adults who are disoriented may become more confused during tourniquet application. Reinforcement and reassurance should alleviate the older adult’s anxiety during the procedure.

1. Do to friability of aging skin, the length of time and amount of tension applied to the tourniquet should be limited to avoid inadvertent bruising and skin tears. Venous distention may take longer and tapping the area over the vein and intended venipuncture site may cause accidental bruising.
2. Do not apply tourniquet for more than two to three minutes. Remove tourniquet immediately after assessment.
3. If the tourniquet is too tight or in place for an extended period of time, the vein may become overdistended and/or damaged during venipuncture.

• Limit the length of time and amount of tension applied to the tourniquet in immunocompromised patients to avoid inadvertent bruising and skin tears. Venous distention may take longer and tapping the area over the vein and intended venipuncture site may it cause accidental bruising.  If the tourniquet is too tight or in place for an extended time, the vein may become overdistended and become damaged during venipuncture.
• Do not apply a tourniquet on an extremity within arteriovenous fistula (AVF).

1. Release the tourniquet as soon as possible after the insertion of the PIVC and positive confirmation of blood return.
2. Use an appropriate method to promote vascular distention when inserting a short PIVC, including:
   1. Use of gravity or impeding venous flow with the use of a blood pressure cuff or tourniquet (while maintaining arterial circulation).
   2. If a blood pressure cuff is used to promote venous distention, inflate to just below diastolic pressure. An arterial pulse should be easily palpable distal to the tourniquet location.
3. Assess vascularity of the upper extremity and identify potential sites that are easily seen and/or palpated.
4. If no venous sites are visible or easily palpated, use technology to improve insertion success:
   1. For visible light devices, use only cold light sources designed for vascular visualization to reduce risk for thermal burns. Darken the room to remove ambient light levels when using these devices; ensure adequate light to observe blood return from the catheter.
   2. For near infrared light devices, follow the manufacturers’ directions for use to identify bifurcating veins, tortuosity of veins, and palpable but nonvisible veins.

• For ultrasound guided insertion, assessment of vessel depth is critical since selection of the appropriate length catheter will prevent inadvertent infiltration. Follow the manufacturers’ directions for use of ultrasound equipment.

1. Remove tourniquet.
2. Perform hand hygiene and put on clean gloves.
3. Prepare insertion site:
   1. If visibly soiled, cleanse with antiseptic soap and water.
   2. Remove excess hair, if necessary, by clipping.
4. Administer local anesthesia, if appropriate.
5. Cleanse insertion site using the preferred skin antiseptic agent of alcohol-based Chlorhexidine solution according to manufacturers’ direction for use; allow to dry completely.
   1. Use an iodophor or 70% alcohol if Chlorhexidine solution is contraindicated.
   2. Use aqueous Chlorhexidine if there is a contraindication to alcohol-based Chlorhexidine.

• Antiseptic preparations can cause stinging and irritation, adding to the older adult’s discomfort. Too much alcohol can dry already compromised skin. An older adult will be less likely to cooperate with venipuncture procedures if he or she experiences pain at this early stage. Although antiseptic agents should be applied with friction, be aware that irritated skin may become more damaged, causing further distress and discomfort to the older adult.

1. Prepare equipment.
   1. Flush add-on devices with preservative free 0.9% sodium chloride to remove air from devices.
2. Reapply tourniquet above the intended venipuncture site or use alternative methods to promote venous distention.
3. Use vein visualization technology as needed.
4. If vein palpation is necessary after application of skin antiseptic, apply sterile gloves.
5. Stabilize the selected vein below the intended venipuncture site by stretching the skin taut with the nondominant hand.
   1. In the older adult, stabilization of the vein can be difficult due to changes in underlying tissue structures. The vein wall may be difficult to penetrate because of aging processes as well as other factors.
6. Perform venipuncture and advance catheter according to device specific manufacturers’ directions for use. Observe blood in the catheter and/or flash chamber of the short PIVC that is the color and consistency of venous whole blood.
7. Release the tourniquet.
8. Activate the needle safety mechanism according to manufacturers’ directions for use.
9. Attach needleless connector or other appropriate add-on device primed with preservative free 0.9% sodium chloride and flush PIVC, or attach primed administration set.
10. Observe the site for signs of swelling or patient complaints of discomfort or pain. Remove the catheter if signs are present.
    1. PRVCs must be removed immediately in the following situations:
       1. If nerve damage is suspected, such as when the patient reports severe pain on insertion or paresthesias (e.g., numbness or tingling) related to the insertion; promptly notify the provider.
       2. If the artery is inadvertently accessed, remove the catheter, and apply pressure to the peripheral sight until hemostasis is achieved. Assess circulatory status and if impaired, notify the provider promptly.
    2. Apply securement device or product to catheter. If not available, use only sterile tape.
    3. Apply a TSM dressing over the insertion site; omit this step if integrated securement device or dressing is used.
    4. For added securement, curl the extension set to the side and tape to the arm. Do not wrap the tape around the extremity.
    5. Discard used supplies in the appropriate receptacles.
    6. Remove gloves and perform hand hygiene.
    7. Label dressing with:
       1. Insertion date and time.
       2. Gauge and length of  device.

• Initials of inserter.

1. Document the following in the patient’s health record:
   1. Use of vascular visualization technology.
   2. Date and time of insertion, number of attempts, device functionality, anesthetic used, inserter name and identification.
   3. Identification of the insertion site by anatomical descriptors, laterality, landmarks, or appropriately marked drawings.
   4. Dressing and securement type.
   5. Catheter gauge and length.
   6. Patient response to the procedure.
   7. Patient education.
2. Discontinuation of PIVC
   1. Assess and report all signs and symptoms of PRVC complications and changes in catheter function to provider. Consider the need for alternative vascular access if removal is necessary.
   2. Assess and report all signs and symptoms to the provider for unplanned or early removal of a PIVC due to a complication. Assess the fluids and medications being given and their impact on patient stability. Begin the infusion therapy through a PIVC when possible or contact the provider for altering the orders for peripheral infusion until a new VAD is inserted.
   3. Prior to PIVC removal, determine if the patient is on anticoagulants or has any risk for prolonged bleeding, as increased time may be needed for hemostasis to occur.
   4. In the presence of an elevated body temperature, assess all obvious sources or causes for this elevation. Do not remove a functioning peripheral catheter based solely on temperature elevation or absence of confirmatory evidence of CABSI. Use clinical judgment regarding the appropriateness of removing the catheter if an infection is evidenced elsewhere or if a noninfectious cause of fever is suspected.
   5. Patient education
      1. Prior to procedure, teach patient and caregiver:
         1. What to expect with the removal procedure.
         2. Educate patient on Valsalva maneuver for all PIVC removal procedures. Instruct the patient to perform a Valsalva maneuver at the appropriate point during catheter withdrawal.
            1. If a Valsalva maneuver is contraindicated, have the patient exhale during the procedure. When the Valsalva maneuver is contraindicated, use a Trendelenburg, or left lateral decubitis position, or have the patient hold his or her breath as able to take and follow direction.
         3. Signs or symptoms of increasing redness, pain, or swelling within the 48 hours after the catheter has been removed, and where, how, and to whom to report.
         4. When to remove and/or change the dressing and keep exit site clean and dry until healed.
      2. Procedure (Discontinuation)
         1. Perform hand hygiene before direct contact with patient and subsequently as required throughout procedural steps.
         2. Obtain and review physician order or standard protocol.

• Verify patient’s identity using two independent identifiers, according to organizational policy.

1. Gather supplies.
2. Perform hand hygiene.
3. Put on gloves.

• Discontinue all infusates and/or clamp extension set.
• Place patient in sitting or recumbent position.

1. Remove dressing from insertion site.
2. Remove securement method if present; use appropriate solution as indicated to loosen dressing and securement adhesive.
3. Inspect catheter-skin junction.

• Hold gauze gently to insertion site with nondominant hand. With dominant hand, slowly remove catheter using gentle, even pressure in keeping catheter parallel to skin.
• Apply pressure to site with gauze until hemostasis is achieved.
• Apply gauze and tape dressing or an adhesive dressing to PIVC site.

1. Inspect catheter: it is intact, the tip is not jagged, and the length is appropriate for product, to ensure catheter is removed.

• Discard used supplies in appropriate waste containers.
• Remove gloves and discard.
• Perform hand hygiene.

1. Document  procedure in the patient’s health record:
   1. Date and time of procedure.
   2. Reason for removal.

• Length of catheter and integrity of catheter tip at time of removal.

1. Patient response to the procedure.
2. Patient education.