Brighton and Sussex University Hospitals NHS Trust
The insertion of peripheral venous cannulas is one of the most frequently performed procedures in hospitals. It enables the administration of intravenous fluids and medication, nutrition and haemodynamic monitoring. In the UK, one in three patients will have at least one cannula inserted during their stay in hospital.
Cannula insertion is painful and causes distress to patients. The risks associated with it include infection, phlebitis and infiltration.
Current guidelines in England are to routinely re-site peripheral cannulas every 72-96 hours. However, recent studies have challenged the need for routine re-cannulation, producing evidence that the risk may actually be increased because the skin integrity is breached more frequently.
Deborah Bolton, Clinical Procurement Manager (CPM), at Brighton and Sussex University Hospitals NHS Trust, and the Trust Intravenous Therapy (IV) Team developed a project plan to look at the new evidence with the aim of implementing this change in the Trust.
The project was far-reaching. Its aims included enhancing patients’ experience of peripheral cannulation; improving patient outcomes by decreasing the potential complications that occur due to peripheral cannulation, and decreasing staff anxiety with regard to routinely re-siting cannulas in patients with poor peripheral vascular access.
It was proposed that a reduction in the number of cannulations performed on an annual basis would decrease the total amount of clinical waste - reducing costs for disposal, and increase productivity by saving staff time.
For Deborah and the project team, it was also important to evidence any measurable and sustainable financial savings gained as a result of the change.
The challenge that faced Deborah and the team was to reassure clinicians, managers and directors that changing practice would not result in an increase to health care acquired infection.
Ward staff and patients were key stakeholders so Deborah spoke to both groups to see if they supported the idea. This ‘bottom up’ approach to change management ensured that clinical staff and patients were engaged from the very beginning.
A literature review was carried out, highlighting the evidence for change. The results of this were presented to the Infection Prevention and Control Action Group (IPAG), which included the Trust Chief Executive, Medical Director and Chief Nurse.
The group were understandably nervous about making changes that might impact on the Trusts’ Healthcare Associated Infections (HCAI) statistics. They wanted reassurance that cannulas were being maintained in accordance to the Trusts policy and asked for some local evidence to support this.
A Trust-wide audit was completed by the project team, including two prevalence days to investigate the compliance of staff to the Trust policy. The results were presented to IPAG in October 2013. IPAG then approved the recommended change.
The agreed change was presented to ward managers, lead nurses and junior doctors. A launch was planned, including an agreed ‘go live’ date.
Laminated information cards were placed in all clinical areas and information was circulated to medical staff by the Medical Director. The change was advertised in the Chief Nurses’ weekly newsletter, on the staff intranet and incorporated into teaching on IV study days.
The project found that, with regular training, nurses are well placed to make a clinical judgement with regard to whether a cannula should be remain in situ or be re-sited.
The primary outcomes of the first 6 months from implementation suggested that patients were not adversely affected.
The change provided a significant reduction in financial costs to the Trust, enabling a stock reduction of 25%. 22,500 clinical hours were saved for busy clinical staff, which equates to 3000 working days.
The most important outcome has been for patients, who have been spared the unnecessary pain and potential risks repeated insertion of cannulas when there has been no clinical indication to do this.