Reduction in ‘just-in-case’ I/V cannula use delivers big benefits

A nurse-led quality initiative at Wellington Regional Hospital’s emergency department (ED) to reduce ‘just-in-case’ intravenous (IV) cannula use is delivering big benefits for patients.

The PRICT (practice responsible IV cannulation today) project encourages doctors and nurses to assess whether there is a clear need to insert an IV cannula, rather than doing so ‘just in case’ it’s needed.

Within four months the project led to a 30 percent reduction in IV cannula use in ED, which audits show is being maintained.

'This is a quality initiative that everyone can achieve,' says ED Associate Charge Nurse Manager and nurse practitioner candidate, Lynne Gledstone-Brown, who led the project.

'While IV cannulas are often an essential emergency medicine precursor to lifesaving treatment, they are not harmless. They can involve pain for the patients and there’s a risk of infection.

'Research also shows that 50 percent of patients presenting to ED who receive IV cannulas don’t need them.

'We think we’re doing better because we’re giving the patient one prick instead of two and it means the blood results can be done while they’re waiting for the doctor.

'But, we have to turn that on its head and question whether we need to be doing it; asking what’s the benefit to the patient and the evidence for doing it, rather than doing something for convenience or because that’s what we’ve always done.'

The project reflects the concepts of the Choosing Wisely campaign, which encourages health professionals to talk to patients about unnecessary tests, treatments and procedures; and patients to discuss with their health professional whether they really need a particular intervention.

Medical colleges and specialist societies have developed lists of recommendations of unnecessary tests, treatments and procedures for their area of practice to help health professionals start a conversation with their patients about what is appropriate and necessary.

There are now around 130 lists of recommendations and resources, spanning a wide range of specialties, as well as a growing number of patient resources to help consumers make better health care choices.

Lynne says the need to take blood is often used as a reason to insert a cannula.

'However, blood taken through an IV cannula rather than directly from the vein is associated with increased rupturing of red blood cells, which accounts for 40-60 percent of blood specimen rejections. This leads to repeated blood draws which can be painful, delay treatment decisions and increase the patient’s length of stay.

'Unnecessary cannulas can also lead to over investigation and medication being given through the IV when it could be given orally. As well as the cost of wasted cannulation equipment, there’s also the issue of the time it takes to insert a cannula which nurses, in particular, could spend doing something else.

'Having a discussion with a patient and focusing on health education is often more appropriate. For example, if you have gastro, let’s give you oral fluids and oral anti vomiting and nausea medication, rehydrate you and send you home. You don’t need an IV.

'The nature of ED is that we have to be continuously revaluating and reassessing our patients. We may have to put in an IV cannula later, but that is clinically appropriate and within the PRICT guidelines.'

She says despite the evidence, adopting the new guidelines represented a 'massive cultural shift' at the hospital.

'Some of the specialties within the hospital may have expected us to have put a line in and take blood, so it’s a matter of making it clear that we’ll assess the patient and refer to the guidelines.'

Nurse and doctor PRICT champions encourage participation and engagement with the project and the guidelines, and PRICT is part of the ongoing orientation and regular teaching of the ED’s nurses and doctors.

PRICT stickers on each patient file are a reminder to practice responsible cannulation and quality boards provide an update on the project’s progress.

'Research shows juniors are more likely to over investigate, so it was important to have 100 percent commitment from the senior management team, so that juniors’ decisions not to put in a line if it’s not appropriate are supported,' says Lynne.

Other assessment areas of the hospital and hospitals are also looking at adopting the PRICT guidelines.