Infusion Therapy

Evidence: The first word in safe I.V. practice

When you believe that a practice at your facility is outmoded or unsafe, there’s only one thing to do: Prove it! Conduct a well-structured study, and the truth will emerge.

That’s what we did when we believed that the methods for dressing I.V. sites and stabilizing peripheral I.V. catheters for the patients in our surgical admission suite (SAS) weren’t best practices. We knew that the Infusion Nurses Society (INS) standards and the Centers for Disease Control and Prevention (CDC) guidelines suggested specific superior methods.

According to the 2000 Infusion Nursing Standards of Practice, “a sterile dressing shall be applied and maintained on vascular and nonvascular access devices.” And according to the CDC guidelines, we should have been using “either sterile gauze or sterile transparent semi-permeable dressings” to cover the catheter site.

But based on a procedure established years earlier, nonsterile, clear plastic tape was placed directly over the I.V. site without sterile gauze. The I.V. line was then directly connected to the hub of the catheter and the connection secured with more tape. Before a patient’s transfer from the post-anesthesia care unit (PACU) to the hospital floor, the PACU nurse removed the dressing, added extension tubing per hospital protocol, secured the catheter with nonsterile tape, and placed a sterile tape and gauze dressing or transparent dressing, also per hospital protocol.

We believed this method consumed too much time, created a risk of blood exposure and infection, and could result in catheter dislodgement and unnecessary patient discomfort. But believing is not proving. So we set out to show that this method was unsafe and ineffective—and to identify a safe, effective method that would meet the needs of the anesthesia team and nursing staff and that was consistent with the recommendations of regulatory agencies and experts in the field.

Reviewing the evidence
Our review of studies on I.V. dressings and stabilization methods revealed some interesting findings. First, using nonsterile tape to stabilize I.V. catheters exposes patients to infectious material from 50% to 100% of the time. And infections increase the length of stay and treatment time and, of course, require restarting I.V. therapy.

The one stabilization device manufactured specifically to stabilize I.V. catheters is superior to nonsterile tape. This device, however, hasn’t been compared to other sterile stabilization devices.

The results of studies evaluating the use of tape and gauze versus the use of transparent dressings are mixed. But the common theme of all the studies is that a sterile dressing over a well-stabilized catheter results in lower complication rates, reduced hospital time, increased healthcare worker safety, and lower overall costs to patients and institutions.

Our study
We designed a study to compare the existing method of dressing pre-operative I.V. sites and stabilizing peripheral I.V. catheters with three other methods. We hypothesized that, compared with the current method, one of the three other methods would produce better adherence and stability, take less nursing time, and cause less blood exposure.

We conducted the study in a surgical admission suite and PACU of a large academic medical center. We included first-case adult elective surgical patients who arrived at the hospital on the day of their scheduled procedure. The study group included 105 patients undergoing orthopedic, gynecologic, neurosurgery spinal, or bariatric surgeries. Patients needing paper tape because of allergies or skin friability weren’t included.

Four methods
Each morning, we reviewed the surgical schedule and identified patients who met our entry criteria. Then, the unit clerk randomly assigned one of the four methods to each patient by drawing a colored paper square from a box. The four methods were the existing method, the U-method, the Tegaderm method, and the Versaderm method.

Collecting data
We collected the following data:

  • time and date of I.V. insertion
  • type of surgery
  • dressing method
  • method of stabilization
  • length of time (in seconds) to place the dressing
  • adhesiveness and stabilization of the dressing on return to the PACU
  • blood exposure during dressing change and the time (in seconds) to change the set-up.

Other findings noted by the PACU nurse, such as infiltration or phlebitis, were also recorded. Infection wasn’t used as an endpoint because patient stays in our department are short.

Our analysis and results
We determined descriptive statistics for all variables of interest. The relationship between the taping method and outcome variables (adhesiveness, stabilization, and blood exposure) were determined with the chi-square test. Nursing time was evaluated using the Kruskal-Wallis test. Significance was set at P=0.05. We estimated cost savings based on the nursing time needed to redo the taping method.

Regarding adhesiveness and stabilization, we found no statistically significant difference among the methods. However, the current method did result in significantly more exposure to blood (P=0.001) and took more time than the other three methods

Given these findings, our next question was this: Which of the three other methods would best meet the needs of the nurses in the SAS and PACU, the anesthesiologists, and the hospital? Other studies haven’t established a clear benefit for using tape and gauze as opposed to using clear dressings. The CDC suggests one benefit of transparent dressings: They need to be changed only every 72 to 96 hours.

Since we completed our study, the INS has issued new guidelines recommending catheter stabilization to preserve the integrity of the access device. The U-method we studied used nonsterile tape for stabilization, which isn’t optimal practice. The Versaderm method, however, involved using the Versaderm dressing, which comes with sterile foam stabilization tape and a transparent center. Thus, we selected the Versaderm method. Compared with the current method, the Versaderm method also has the advantage of saving thousands of dollars a year in nursing time.

And because our selection is evidence-based, our institution has adopted it in all units.

Selected references
Giles D, O’Riordan L, Carr D, Frost J, Gunning R, O’Brien I. Gauze and tape and transparent polyurethane dressings for central venous catheters (review). The Cochrane Database of Systematic Reviews 2004.

Infusion nursing standards of practice. J Infus Nurs. 2002;23(6S):S42.

O’Grady N, Alexander M, Dellinger E, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep. 2002;51(RR10):1-26.

Redelmeir DA, Livesley

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