Research Project: Peer Editing

Your instructor will send you the first draft submitted by one of your peers through the classroom email system.

Copyedit the other student’s paper using copyediting marks or the Track Changes editing function in Microsoft Word.

Provide feedback related to the key problems in scientific writing and relevance as described in Lecture 4.

This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

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PIV BUNDLES

Grand Canyon University

Bachelor of Science in Nursing
BIO-317V

PERIPHERAL INTRAVENOUS BUNDLE AND END CAPS, A CHEAP SOLUTION TO A HIDDEN PROBLEM? FIRST DRAFT
Christopher J. Stanford R.N.
December 2, 2020
Words:

Peripheral Intravenous Bundle and End Caps, a Cheap Solution to a Hidden Problem?

Christopher Stanford

Grand Canyon University

ABSTRACT

Objective: This paper will review the risks of peripheral intravenous lines and their maintenance, as well as explore options to reduce complications from this common act. Methods: The author used a literature search to begin framing the problem. Results: While interest in certain nosocomial infections is growing, there is little interest in defining why they happen and prevention as a whole, with most efforts being concentrated on infections with reimbursement consequences. Initial studies in dropping infection rates from these lines are promising with more studies and multicenter analysis is required.
Key Words: Intravenous Catheter, sepsis, nosocomial infections, bundle, end caps, swab caps, mortality.

INTRODUCTION

Admission to the hospital usually brings the thought of seeing a Doctor, the nurse, many support staff, having blood drawn, and having an intravenous line placed in a limb. This common procedure occurs in over 25 million patients per year 1 and in the author’s experience, often times occurs without a Providers’ order. The understanding and institutional policy is to maintain patent intravenous access at all times, with a system generated order only being place in the Electronic Health record in the last 2 years. The United States stopped paying for certain hospital acquired conditions with the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005 2. This stop-payment resulted in big shifts to the ways healthcare approached Central Line and Urinary catheter maintenance, as evidenced by a rapid decline in the number of infections billed to Medicare 2. This change culminated with a set of best practice guidelines from the Joint Commission 3, culminating years of research regarding novel strategies on how to prevent Central Lines Associated Blood Stream Infections 3-5
Peripheral Intravenous Lines have received nearly no regulatory attention, with 150 million individual catheters being used yearly, despite estimates that nearly 20 percent are wholly unnecessary 6. The relative risk of a Peripheral Cather based bloodstream infection is low, but when combined with ubiquity of the therapy raises the risk level to one nearing that of Central Lines outside of the Intensive Care Unit 6. The concern for this route of sepsis is not unwarranted, often with fatal results for the most critically ill patients and a possible vector of feared Gram-Negative and Fungal pathogens 7.

Methods

The research of this topic spanned a variety of databases, from PubMed, Google Scholar and the Grand Canyon University Library. Key words such as “peripheral intravenous”, “sepsis”, “dwell times” and “swab caps” were searched. After identifying a possible solution, the author was able to work backwards from these articles to verify the validity of the solution, as well as help frame the author’s argument. For this research, the identification and searching of vascular related terms, such as “contaminated end caps”, “luer locks” and “CLABSI” provided to be a major turning point in this research.

Results

Facts
Peripheral catheters face a multitude of issues, namely that they are inserted so often that large variations exist in their insertion and maintenance, with deviations from facility policies often being the normal 8. Research in this field is so scare that best practices are usually not being based in science, with something as simple as securement techniques being incorrectly touted by manufacturers, with almost no large trials as there are in other branches of medicine 9. Only one relevant study was undertaken regarding the scope of the problem of peripheral catheter mediated sepsis 7, with supporting articles more being focused on policy 7,9. Still, hospitals are desperate for fiscal saving in this modern health care environment 2, with attention being paid to cost savings by fewer site rotations and intravenous tubing replacement intervals 10. Despite efforts to quantify it, research suggests that this problem may be a significant driver of mortality 1,6,7 in American healthcare as well as a probable, yet unstudied significant added cost on the American taxpayer.
Relevant Related Research
Nearly all of the relevant research is contained by the central line bundle issued by the Joint Commission 3. This standardized care across the country, setting standards for preparation, insertion techniques, dressings and maintenance 3. From this research, a pattern of how lines most often become contaminated occurs, namely at the luer lock where tubing and flushes connect11. This frequent11 source of contamination is typically scrubbed with alcohol pads for a set period of time, then accessed11. As previously mentioned, variations in clinical practice are commonplace8, leading to the novel concept of passive disinfectant caps, which maintain the sterility of a luer device until it is used12. These luer covering caps, usually containing alcohol and/or chlorohexidine gluconate reduce blood stream infection on central lines by 50 percent13,14, and the author’s place of employment adopted them with similar reductions infection, with a reduction in healthcare cost 13 with little actual cost per cap 15. Similar outstanding results have been observed with passive disinfection of central line access sites 5,14.
The copying of elements of the central line bundle, namely, covering exposed luers, passive disinfection of exposed lines and ensuring compliance is a novel way to drastically reduce peripheral intravenous associated infections16. The combination of preventing tubing and needless connector contamination showed great promise against the most common causes of infected catheters7.

DISCUSSION

Bundles 3,16 are a great way to standardize practices with evidence-based practice as well as an easy way to ensure compliance. While estimates of incidence and severity of these infections vary 1,4,7,12,16, the current goals in healthcare are striving towards zero defects 17, namely that nosocomial infections are a “never” event. While the incidence and savings 1,4,6,7,12,16 numbers may vary, providers should be able to agree that there exists a significant gap in knowledge, as well as opportunities to further define best practice. Novel bundles such as for intravenous lines already have wide use and are easily replicated across facilities, with clear ethics that do not routinely require informed consent 16. Further investigation is warranted across large health care systems, especially as the refinement of Electronic Medical Records would make the data mining portion of the study significantly easier 16. These can be performed not just as quality performance improvement project 16, but also as blinded studies, where similar size facilities in systems do or do not participate, then combine results. In effect, the large and sprawling nature of modern healthcare makes blinding these results even easier due to lack of communication between facilities on a personal level. For reference, the author works a University Medical Center, in a system that contains 5 of them and has little to no idea what research projects are in process.
Post Central Line Bundle 3, the implementation of passive disinfectant caps and passive disinfectant dressings applied under occlusive dressings has reduced once common infections down to events that hard to study due to their infrequency 4-7, 11-14, 16. No published study has thought to combine a peripheral bundle, passive caps and disinfectant dressings into one intervention, nor have any been adequately researched on peripheral intravenous lines. Modern medicine is rightfully focused on outcomes, evidence-based practice and adding value at every step of the way. There are only a handful of modern studies regarding a procedure that is performed 150 million times per year 6. This is even more baffling as the United States began offering more access to doctoral level nursing programs 18 and debates phasing out the master’s degree for Advanced Practice Registered Nurses19 and the general focus of the nursing field on research, quality and outcomes. This is even more baffling when one notes the plethora of research available on infection control and prevention, complete with grades of evidence, that never mentions peripheral intravenous access 20. In fact, medicine seems to be attempting to justify pushing the limits on these peripheral catheters, perhaps with the thought that infections and complications from them seem rare 21, when in fact they are just rarely studied.
The author is recommending several larger studies or quality improvement projects that will directly study the effects of each of the above interventions, as well as larger, blinded multicenter analyses that will go on to become the standard of care for an industry. The author also wonders if appealing to private researchers is the wrong way to bring about this change and if having the federal government withhold payment for more conditions may be the driver of quality care one hopes to see when they study medicine. While this method is cumbersome, the author wonders if the recent trend of hospital mega-mergers has caused research to be stifled in favor of maximizing reimbursement patterns without rocking the boat regarding new areas for improvement. This is the classic “if it ain’t broke, don’t fix it” school of thought that evidence-based practice has sought to smash through. The private medical industry showed no signs of looking to improve quality before the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005 2, as well as showing an alarming lack of preparation due to the current COVID-19 pandemic. In fact, this pandemic has underlined the shortcuts that have been taken regarding insurance reforms, public health and payment for services22. This may very well be the last push into full value-based purchasing and cause a full transformation of healthcare as we know it.

References
1. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med. 1998;158(5):473-477. doi:10.1001/archinte.158.5.473
2. Peasah S, McKay N, Harman J, Al-Amim M & Cook R. Medicare Non-Payment of Hospital-Acquired Infections: Infection Rates Three Years Post Implementation. Medicare & Medicaid Research Review, 2013 3(3). http://dx.doi.org/10.5600/mmrr.003.03.a08
3. The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: Useful Tools, An International Perspective. 2013. http://www.jointcommission.org/CLABSIToolkit
4. DeVries M, Mancos P S, & Valentine M J. Reducing Bloodstream Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection. Journal of the Association for Vascular Access. 2014, 14(2), 87–93. https://doi-org.lopes.idm.oclc.org/10.1016/j.java.2014.02.002
5. Safdar N, O’Horo J C, Ghufran A, Bearden A, Didier M E, Chateau D, & Maki D G (2014). Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis*. Critical care medicine. 2012, 42 (7), 1703–1713. https://doi.org/10.1097/CCM.0000000000000319
6. Zingg W, Pittet D. Peripheral venous catheters: an under-evaluated problem. International Journal of Antimicrobial Agents. 2009;34(Supplement 4):S38-S42. doi:10.1016/S09248579(09)70565-5
7. Sato A, Nakamura I, Fujita H, et al. Peripheral venous catheter-related bloodstream infection is associated with severe complications and potential death: a retrospective observational study. BMC Infect Dis. 2017;17(1):434. Published 2017 Jun 17. doi:10.1186/s12879-017-2536-0
8. Nickel B. Peripheral Intravenous Access: Applying Infusion Therapy Standards of Practice to Improve Patient Safety. Critical Care Nurse. 2019, 39 (1), 67-71.
9. Stace S, Symes M, & Gillett M. A Comparison of Two Commonly Used Methods for Securing Intravenous Cannulas. Journal of acute medicine. 2017, 7(2), 61–66. https://doi.org/10.6705/j.jacme.2017.0702.003
10. Lai KK. Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours. Am J Infect Control 1998, 26(1):66-70. doi: 10.1016/s0196-6553(98)70063-x. 
11. Moureau N & Flynn J Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review.  Nursing Research and Practice. 2015 https://doi.org/10.1155/2015/796762
12. DeVries M. Mancos P S, & Valentine M. J Reducing Bloodstream Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection. Journal of the Association for Vascular Access. 2014, 19 (2), 87–93. https://doi-org.lopes.idm.oclc.org/10.1016/j.java.2014.02.002
13. Kamboj M, Blair R, Bell N, et al. Use of Disinfection Cap to Reduce Central-Line-Associated Bloodstream Infection and Blood Culture Contamination Among Hematology-Oncology Patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408. doi:10.1017/ice.2015.219
14. Sweet M A, Cumpston A, Briggs F, Craig M, & Hamadani M Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line–associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. AJIC: American Journal of Infection Control. 2012, 40 (10), 931–934. https://doi-org.lopes.idm.oclc.org/10.1016/j.ajic.2012.01.025
15. Vitality Medical.com SwabCap Disinfecting Cap. https://www.vitalitymedical.com/swabcap-disinfecting-connector-cap-icu-medical.html
16. Duncan M, Warden P, Bernatchez S & Morse D A Bundled Approach to Decrease the Rate of Primary Bloodstream Infections Related to Peripheral Intravenous Catheters. Journal for the Association for Vascular Access. 2018, 23 (1), 15-22. https://doi.org/10.1016/j.java.2017.07.004
17. The Joint Commision. Leading the Way to Zero. https://www.jointcommission.org/performance-improvement/joint-commission/leading-the-way-to-zero/
18. Ketefian S, Redman RW. A critical examination of developments in nursing doctoral education in the United States. Rev Lat Am Enfermagem. 2015;23(3):363-371. doi:10.1590/0104-1169.0797.2566
19. McCauley LA, Broome ME, Frazier L, et al. Doctor of nursing practice (DNP) degree in the United States: Reflecting, readjusting, and getting back on track. Nurs Outlook. 2020;68(4):494-503. doi:10.1016/j.outlook.2020.03.008
20. Mehta Y, Gupta A, Todi S, et al. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med. 2014;18(3):149-163. doi:10.4103/0972-5229.128705
21. Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019;34(1):26-33. doi:10.1177/0885066616686035
22. Blumenthal D, Fowler E, Abrams M & Collins S. Covid-19 –Implications for the Health Care System. N Engl J Med 2020 383:1483-1488

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