Quality improvement with prehospital-placed intravenous catheters in trauma patients

Abstract

The insertion and care of peripheral intravenous (IV) catheters, although a routine nursing task, is not without potential hazard to the patient. As many as 70% of patients in an acute care setting receive IV therapy during the course of their care. 1 About 30 million patients per year in the United States undergo placement of peripheral IV catheters. 2 Patients experiencing multiple trauma may be predisposed to infection as a result of IV catheter insertion and maintenance practices. Ironically, the same invasive interventions used to resuscitate and sustain trauma patients may be equally responsible for the subsequent development of infection. The greatest risk for infection occurs when patients are receiving intensive care, at which time they are more likely to have compromised immune function relative to their acute injury or concomitant medical conditions. 3 Peripheral IV catheters have been associated with several types of complications, including the formation of thrombi and infections ranging from phlebitis to septicemia. Bacteremia from peripherally inserted lines occurs in one of every 200 to 500 patients, or 0.4% of the time. 4 A significant factor influencing infection rates is the technique of insertion. Lines placed in conditions that are often less than ideal when resuscitating trauma patients outside the hospital are an obvious concern. This article will present the issue of an abscess resulting from a fieldplaced IV line and the quality improvement process that followed at a level I trauma center. Serious incident The serious event that precipitated the quality improvement process occurred when an abscess developed at an IV site in a male patient in an intermediate care unit at our institution. A review of all of the complications at our urban level I trauma center was conducted to identify other cases of abscess formation. The review of complications during the past 5 years revealed that 3 documented cases of abscess formation from peripheral lines had occurred during the most recent 18 months. No other cases had been documented in the trauma registry for the previous 5 years, and thus this recent increase in cases represented a significant change. A chart review showed that the 3 cases of abscess formation were associated with IV lines that had been placed before the patients were brought to the hospital. No single prehospital care provider had treated these patients. The prehospital care providers were not involved in the quality improvement process because of the large number of such service providers in our area. An unwritten standard at the medical center was that lines placed before the patient arrived at the hospital should be replaced within 24 hours of admission. This standard was set by the medical director and seemed to be consistent with current practice in trauma care and literature. 5 Materials and methods