A critical analysis of audit in practice: PICC Line
Introduction
Central venous access constitutes one of the common procedures that are undertaken by medical practitioners in different clinical settings (Kornbau et al. 2015). Different medical tools and equipment have been developed to assist medical practitioners in undertaking such medical procedures. The Peripherally Inserted Central Catheter (PICC) line is one of the medical tools that is widely applied in administering treatment and medication to patients who require long-term venous access (Kornbau et al. 2015). The PICC line is also used by medical practitioners such as nurses in drawing blood. One of the core benefits of a PICC line is that it enables medical practitioners to spare the patient’s veins from frequent injections using needle sticks (Fuhrman 2011). Kamala et al. (2002) affirm that PICC lines are considerably safer compared to conventional central lines. Moreover, the PICC line may also be left in position for a considerably longer duration.
Despite their usefulness in assisting nurses in administering treatment, PICC lines are not free from complications. Kombau et al. (2015) assert that one of the main sources of complications in using PICC lines in delivering treatment and care to patients relates to their placement. The complication may arise from blockage of the PICC line. Complications arising from ineffective placement or management of PICC lines can result in the occurrence of death, injury, or disease. As a result, it is crucial to apply the PICC line effectively.
The rationale of the audit is to gain insight into the issues that might lead to complications in using the PICC lines and how such complications can be overcome. The audit is based on past research studies on the application of PICC in caring for patients in a ward in the UK. Thus, the research study focused on patients in the orthopedic ward in the UK. The audit of the PICC is undertaken about complications arising from blockage of the PICC lines.
Literature review
To gain insight into the application of PICC lines in delivering care, an extensive literature review was conducted. The review was undertaken by evaluating available empirical research studies on the subject. The literature materials were obtained from credible online databases, amongst them PubMed, ProQuest, and EBSCO, and print resources. According to Fuhrman (2011), placement and management of PICC require clinicians to possess adequate skills to avoid complications. A study conducted by Barrier et al. (2012) reveals that over 30% of PICCs used in administering treatment to immunocompetent pediatric patients developed at least one complication. Similarly, a study involving 1,148 patients on whom PICCs were administered showed that 164 of the administered PICC lines were characterized by problems as a result of migration or blockage of the line (McCoy et al. 2011). This finding indicates that occurrence problems in the administration of PICC lines are a major technical issue that healthcare practitioners should consider addressing. McGee and Gould (2003) are of the view that air embolism may occur in the process of inserting the PICC line or when flushing the catheter. The air locked in the catheter may pose a significant risk to patients. For example, the air may reach the pulmonary artery, which can lead to fatal complications.
Design
In undertaking the audit, the researchers interviewed junior doctors and nurses in the trauma and orthopedic ward on how they applied and managed the PICC lines. The rationale of this approach was to gain insight into the nurses’ care and knowledge in applying the PICC. A set of questionnaires that entailed evaluating the nurses’ confidence and competency level about the application of the PICC lines was designed. Moreover, the audit further involved observing nurses apply the PICC lines in treating 7 patients in the trauma and orthopedic ward. The observation lasted for two months. Through this approach, the researchers were able to develop an adequate understanding of how nurses and doctors use the PICC.
One of the issues that the research sought to gain insight into relates to the nurse's and junior doctors' knowledge of flushing the PICC, which constitutes an important aspect of using PICC. The audit further involved assessing the success with which nurses are effective in minimizing risk arising from blockage and splitting of the lines.
Findings
To determine the level of confidence in the application of the PICC lines, a 5-point Likert scale was employed. The average confidence level amongst the junior nurses was 38%, while a confidence level of 65% was recorded among the nurses. The research revealed that 70% of patients on whom PICC lines were used in administering the treatment experienced blockage. In some instances, multiple cases of blockage were noted (Piorkowska, Al-Raweshidy & Yeong 2013). Despite the extensive occurrence of blockages, there was a significant gap in recording or documenting such occurrences. Of the 5 blockages that occurred, two of them were not successfully unblocked. In resolving the problem, the PICC lines were exchanged. The exchange of the PICC lines might result in an understatement of the full scale of the problem that the nurses or healthcare practitioners might be facing in managing the PICC lines (Piorkowska, Al-Raweshidy & Yeong 2013).
The increase in the incidence of blockages of the PICC lines recorded from the trauma and orthopedic ward motivated the hospital management to undertake a hospital-wide audit on the application of the PICC. Over 192 cases of patients whose treatment was administered using the PICC lines as one of the medical equipment for the period ranging between October 2011 and 2012 were reviewed.
Twenty-five percent (25%) or 48 of these patients were drawn from the trauma and orthopedic ward. Twenty-one (21) PICC lines were replaced across the hospital. Eight (8) out of the 48 patients drawn from the trauma and orthopedic ward, or 17% of these patients, required a complete replacement of the PICC. This represents a substantially high number of replacements compared to 13 replacements that were recorded from the 144 patients drawn from other wards (Piorkowska, Al-Raweshidy & Yeong 2013). Regarding PICC blockage, the average rate of blockage was recorded at 14%, which aligns with the findings of a randomized study conducted by Kamala et al. (2002). This aspect indicates the existence of a significant problem with the usage and management of the PICC in the hospital’s trauma and orthopedic ward. Nevertheless, the fact that the incidences of blockages are aligned with a study by Kamala et al. (2002) indicates that the problem is not only confined to the hospital under evaluation. On the contrary, it indicates that the management of PICC continues to be a significant healthcare challenge.
Analysis of findings
The findings above indicate that the administration and management of PICC lines is a major challenge in the healthcare sector. The problem is prevalent among different categories of healthcare practitioners, such as nurses and doctors. This assertion is supported by the high blockage rate, 70%, which was recorded from the audit. This indicates the existence of a considerable gap in nurses’ knowledge and skills in administering and managing the PICCs. The audit showed that the blockages were largely necessitated by limited knowledge of the application of catheters. Amongst the core factors that were identified to be the major cause of complication and blockage in the usage of PICCs was the fact that the nurses were faced with long and contradictory guidelines on the administration and provision of care on PICCs.
Polaschegg and Shah (2003) define flushing as the process of cleaning the catheter by applying the appropriate solutions and measurements. Flushing is typically accomplished by injecting sodium chloride or normal saline at a rate of 0.9%. Conversely, locking involves injecting a specified volume of liquid into the catheter for a substantial amount of time when the catheter is not in use. The rationale of locking is to prevent the formation of clots in the catheter, which might significantly increase the risk of occlusion. Bowers et al. (2008) assert that mistakes or ineffective flushing of the PICCs significantly increase the risk of occlusion. Effective flushing significantly increases the patency of the intravenous catheter. Goossens (2015) asserts that clinicians and medical practitioners such as nurses must possess adequate knowledge of how to flush and lock intravenous catheters to prevent the occurrence of occlusion or blockage.
Amongst the aspects that nurses should possess adequate knowledge of are flushing techniques, the appropriate flushing volumes, and fluid dynamics. Polaschegg (2008) asserts that knowledge of these issues increases the success with which medical clinicians administer different types of intravenous catheters, including the PICC lines. The review further showed that medical practitioners are not sufficiently accountable for PICC flushing. This poses a significant problem in enhancing the optimal administration of PICCs. In addition to these aspects, the research study identified ineffective management of shifts amongst nurses and clinicians as one of the factors that increase the occurrence of blockages of PICCs.
Through this aspect, it is possible for clinicians to optimally track the management of the PICCs, for example, determining whether subsequent nurses and clinicians have complied with the flushing requirement. Such information should be availed to all clinicians responsible for providing care to patients whose treatment involves the application of intravenous catheters. In addition to this aspect, medical practitioners must ensure that flushes are optimally defined in the drug charts. Possessing adequate knowledge of the administration of the PICCs is critical in improving the quality of health care offered to patients.
The findings of the audit underline the importance of clinicians and medical practitioners developing relevant skills and knowledge about the administration and management of PICC lines. One of the noticeable issues revealed from the audit conducted entails the fact that most of the complications arising from the blockage of PICC lines are a result of human error. Inefficient application of PICCs might pose significant risks to patients, among them death and other health complications. Thus, healthcare practitioners should consider the administration and management of PICCs to be one of the fundamental elements in their quest to provide high-quality care to patients.
Conclusion
The audit reveals that there are a number of issues that should be taken into consideration in clinical practice. In order to eliminate the risk posed by ineffective administration and management of PICC lines, it is imperative for healthcare practitioners and hospital management teams to take into account the following issues.
Nurses should be adequately trained on how to follow PICC care guidelines. This will significantly reduce the likelihood of errors occurring. Clinicians and nurses should depict a high degree of accountability in managing the PICCs, for example, effective flushing of the PICC lines.
The process of administering and managing PICCs should be based on a comprehensive recording of information and notes on the patient.
Reference List
Barrier A, William D, Connelly M & Creech C 2012, ‘Frequency of peripherally inserted central catheter complications in children’, Paediatric Infectious Disease Journal, vol. 31, no. 5, pp. 519-521.
Bowers, L., Speroni, L., Jones & Atherton, M. 2008, ‘Comparison of occlusion rates by flushing solutions for peripherally inserted central catheters with positive pressure luer-activated devices’, Journal of Infusion Nursing, vol. 31, no. 1, pp. 22–27.
Fuhrman, B. 2011, Paediatric critical care, Elsevier Saunders, Philadelphia, PA.
Goossens, G. 2015, ‘Flushing and locking of venous catheters; available evidence and evidence deficit’, Nursing Research and Practice, vol. 4, no. 8.
Kamala F, Boo N, Cheah F & Birider, K 2002, ‘Randomised controlled trial of heparin for prevention of blockage of peripherally inserted central catheters in neonates’, Acta Paediatrica, vol. 28, no. 6, pp. 1350-1356.
Kornbau, C., Lee, K., Hughes, G., & Firstenberg, M. 2015, ‘Central lines complications’, International Journal of Critical Illness and Injury Science, vol. 5, no. 3, pp. 170-178.
McCoy M, Bedwell S & Noori S 2011, ‘Exchange of peripherally inserted central catheters is associated with an increased risk for bloodstream infection’, American Journal of Perinatology, vol. 28, no. 6, pp. 419-424.
McGee D & Gould, G 2003, ‘Preventing complications of central venous catheterisation’, National Journal of Medicine, vol. 348, pp. 1123-1133.
Piorkowska, M., Al-Raweshidy, Z., & Yeong, K. 2013, ‘Improving peripherally inserted central catheter care on trauma and orthopaedics ward’, BMJ Quality Improvement Report, vol. 2, no. 2.
Polaschegg, H. & Shah, C. 2003, ‘Overspill of catheter locking solution: safety and efficacy aspects,’ American Society for Artificial Internal Organs Journal, vol. 49, no. 6, pp. 713–715.
Polaschegg, P 2008, ‘Catheter locking solution spillage: theory and experimental verification’, Blood Purification, vol. 26, no. 3, pp. 255–260.
