Compliance of the Health Care Providers on the Standards

of Proper Peripheral Intravenous Insertion

in a Hospital Setting

A Term Paper Presented to the Faculty of Graduate

Schools of Arts, Sciences and Education

Our Lady of Fatima University

In Partial Fulfillment of the Requirements for the

Degree of Master of Arts in Nursing

Major in Nursing Administration

By:

Echevarria, George R.

Bondoc, Dessa Andrea

Abrera, Mariefe

Chapter 1

Introduction

The ability to obtain peripheral intravenous (IV) access is an

essential skill in medicine and is performed in a variety of settings by

health care providers such as nurses and physicians. Although the

procedure can appear deceptively simple when performed by an

expert, it is in fact a difficult skill which requires considerable practice

to become adept in performing it. Along with mastering the skill to

insert an intravenous line, one has to be continuously conscious of

following the aseptic and safe way of doing it. However, due to the

busy setting or the lack of proper monitoring in hospitals, some

healthcare providers are unable to comply with these standards.

Nurses in some hospitals have been required to have an intravenous

therapy license. The medical interns do not have such license

requirements yet they are allowed to insert I.V. lines.

The Code of Ethics for nurses uphold the standards of safe

nursing practice. The legal basis allowing nurses to perform IV therapy

was first established by R.A. 7164 otherwise known as The

Philippine Nursing Act of 1991. Section 27 “provides that

intravenous injection is within the scope of nursing and that, in

the administration of intravenous injections, special training

shall be required according to protocol established.”

R.A. 7164 was repealed by a newer law which is the RA No.

9173, otherwise known as “Philippine Nursing Act of 2002.” Under

Section 28 (a) of this law entitled Scope of Nursing, it is stated that

“Nursing care includes, but not limited to, traditional and

innovative approaches, therapeutic use of self, executing

health care techniques and procedures, essential primary

health care, comfort measures, health teachings, and

administration of written prescription for treatment, therapies,

oral topical and parenteral medications, internal examination

during labor in the absence of antenatal bleeding and

delivery.”

The Association of Nursing Service Administrators of the

Philippines, Inc. (ANSAP) believes that the certification of Registered

Nurses for IV Therapy should be continued to have a safe nursing

practice. Believes that only registered nurses who have been properly

trained and who have completed the training requirements of the IV

Therapy Program should be allowed to practice intravenous therapy.

In giving IV injections, nurses should follow the policies of their

agencies. Board of Nursing Resolution No.8 Sc. 30 © Art. VII or

administratively under Sc. 21 Art. III – states that any registered nurse

without training and who administers IV injections to patients shall be

held liable, either criminally, administratively or both.

Objectives

This study aims to:

1. Find out whether the standards of intravenous insertion is

followed by health care providers beginning with the preparation

of the materials up to the securing in place of the intravenous

line.

2. Discover possible barriers to the correct and proper adherence of

the health care provider to the standards of peripheral

intravenous therapy.

3. Specify the legal basis of allowing doctors and nurses to perform

peripheral intravenous injection.

4. Synthesize available studies that cover concerns on the safety of

intravenous insertions, including infection that occur due to non-

aseptic practices.

Assumptions

1. Lack of knowledge of the provider puts the client at great risk.

2. Health care providers know how to perform aseptic hand

washing inside and outside health facilities.

3. Nurses and resident doctors are duly licensed by the Philippine

Regulatory Board (PRC).

4. Safety is the top priority.

5. Encourage patient’s awareness of the nursing practice.

6. Agency policies must be consistently monitored.

Significance of the Study

The ability to obtain intravenous (IV) access is an essential skill

in medicine and is performed in a variety of settings by paramedics,

nurses and physicians. Although the procedure can appear deceptively

simple when performed by an expert, it is in fact a difficult skill which

requires considerable practice to perfect.

Intravenous cannulation is undertaken in a high proportion of

hospitalized patients. Much attention has been given to the use of care

bundles to reduce the incidence of infection in these patients.

However, less attention has been given to the systems required to

ensure availability of the equipment needed to support these care

bundles.

The researchers are interested in observing the compliance of

health care providers in a specific hospital and finding out the barriers

towards compliance. In compiling secondary sources from books,

journals and reliable internet sources, and in gathering primary

sources of knowledge through observation, the researchers hope to

bring the issue of IVT compliance to the forefront, and benefit the

following groups:

For patients, their awareness and participation about nursing

practice is encouraged. Timely, efficient, patient-centered delivery of

care is critical to quality and patient satisfaction. The patients may

learn from this study the dangers of unsafe peripheral intravenous

injection. Being knowledgeable on how it should be done can help the

patient voice out observations and concerns to the nurse-in-charge or

the hospital administrators. Patient satisfaction can serve as an

effective indicator to measure the success of doctors and hospitals.

For the staff nurses, resident doctors and medical interns,

this research is significant for the enrichment of their knowledge on

the consequences of unsafe peripheral intravenous insertions. The

awareness of evidence-based studies on infections and other risks of

unsafe IV insertions may help the health practitioners in becoming

more compliant to the set of standards.

For the hospital administrators, this study may serve as an

eye opener to be more keen in observing if their health care providers

are conforming to the standards of peripheral intravenous insertion.

For the nurse educators, may benefit from this research

through enlightenment of the difference in theory and actual practice

observed in the hospital. The nurse educators may use this study as an

example to the nursing students and emphasize to them at an early

stage to be compliant of what their future nursing licenses demand

from them.

Eligibility Criteria

The researchers would like to observe the compliance of nurses

and resident doctors to the standards of peripheral intravenous

insertions. By hospital practice, these health providers are usually the

ones who prepare the I.V. materials and perform the I.V. insertions in

the hospitals. The specific hospital wherein the researchers will be

observing health care providers do not allow medical clerks or

undergraduates of medicine to train in its facility.

Limitation of the Study

Since this is a term paper, the researchers will include a

narrative report of the observations in the hospital instead of statistical

analysis.

In the interest of reporting an unfiltered observation of health

care providers’ peripheral IV performance without compromising the

reputation of the chosen hospital, the researchers wish to keep the

name of the hospital in confidence and will only be revealed to the

term paper adviser.

Catheter - a hollow flexible tube for insertion into a body cavity, duct,

or vessel to allow the passage of fluids or distend a passageway. Its

uses include the drainage of urine from the bladder through the

urethra or insertion through a blood vessel into the heart for diagnostic

purposes.

Compliance - The degree of constancy and accuracy with which a

patient follows a prescribed regimen, as distinguished from adherence

or maintenance.

Health care provider - any individual, institution, or agency that

provides health services to health care consumers.

Intravenous cannulation - is a technique in which a cannula is

placed inside a vein to provide venous access. Venous access allows

sampling of blood as well as administration of fluids, medications,

parenteral nutrition, chemotherapy, and blood products.

Medical intern - an advanced student or graduate in medicine

gaining supervised practical experience.

Resident Doctors - is a person who has received the title of

"physician" or in some circumstances, another health sciences

terminal degree who practices medicine usually in a hospital or clinic.

Iatrogenic - of or relating to illness caused by medical examination or

treatment.

Iatrogenesis or Iatrogenic Effect - a Greek term, meaning "brought

forth by the healer", is any consequence of medical treatment or

advice to a patient. Some iatrogenic effects are clearly defined and

easily recognized, such as a complication following a surgical

procedure (e.g., lymphedema as a result of breast cancer surgery).

Review of Related Literature

Air Bubbles of Death

As patients look warily at the small bubbles of air travelling down

the IV line and into the arm, the nurses and doctors administering

peripheral intravenous injection try to assure the patients that the

small bubbles of air are harmless. But how much of those little air

bubbles are actually dangerous?

Venous air embolism (VEA) is a complication that occurs when

atmospheric gas is introduced into the systemic venous system of a

person. This medical condition was mostly associated in the past with

neurological procedures that were performed while on sitting position.

More recently, venous air embolism has been associated with other

procedures such as central venous catheterization, thoracentesis,

penetrating chest trauma, high pressure mechanical ventilation,

hemodialysis, lumbar puncture and peripheral intravenous lines. VEA is

a predominantly iatrogenic complication wherein two preconditions

must exist for it to occur: 1) a direct communication between a source

of air and vasculature and 2) a pressure gradient favoring the passage

of air into one’s circulation.

Large volumes of air rapidly entering the systemic venous

circulation places a substantial strain on the right ventricle (> 0.30

mL/kg/min). If there is a substantial increase in pulmonary artery

pressure this can lead to right ventricular outflow obstruction and

further compromise pulmonary venous return to the left side of the

heart. When the pulmonary venous return decreases, it will result to

decreased left ventricular preload, which in turn can decrease cardiac

output and eventual systemic cardiovascular collapse.

Although VAE is primarily caused by surgical procedures, it is

notable to mention that peripheral intravenous injection was also

mentioned as a risk factor.

Generally, the small packets of air are fragmented into small

particles in the capillary bed and are absorbed from the circulation

without producing undesirable signs. Complications have been

recounted with as little as twenty (20) ml of air – the length of an

unprimed IV infusion tubing – that was injected intravenously. As little

as 0.5 mL of air injected in the left anterior descending coronary artery

may cause ventricular fibrillation. Two to three (2-3) mL of air into the

cerebral circulation can cause fatality. In gist, the closer the vein of

entrainment is to the right side of the heart, the smaller the lethal

volume is.

Symptoms in patients who are awake

Acute dyspnea

Continuous cough

"Gasp" reflex (a classic gasp at times reported when a bolus of

air enters the pulmonary circulation and causes acute

hypoxemia) Dizziness/lightheadedness/vertigo

Nausea

Substernal chest pain

Agitation/disorientation/sense of "impeding doom"

Signs

Cardiovascular

Dysrhythmias (tachyarrhythmias/bradycardias)

Hypotension

Myocardial ischemia

Nonspecific ST-segment and T-wave changes and/or evidence of

right heart strain

Pulmonary artery hypertension

Increased CVP

Circulatory shock/cardiovascular collapse

Pulmonary

Adventitious sounds (rales, wheezing)

Tachypnea

Hemoptysis

Cyanosis

Decreased end-tidal carbon dioxide, arterial oxygen saturation,

and tension

Hypercapnia

Increased pulmonary vascular resistance and airway pressures

Pulmonary edema

Apnea

Neurological

Acute altered mental status

Seizures

Transient/permanent focal deficits (weakness, paresthesias,

paralysis of extremities)

Loss of consciousness, collapse

Coma (secondary to cerebral edema)

Ophthalmologic

Funduscopic examination may reveal air bubbles in the retinal

vessels.

The above neurologic, hemodynamic, and pulmonary complications

primarily result from gas gaining entry into the systemic circulation,

occluding the microcirculation and resulting to ischemic damage to

these end organs. Animal studies have also suggested the presence of

secondary tissue damage cause by the release of inflammatory

mediators and oxygen free radicals as a response to air embolism.

When the health provider chooses to use glass or collapsible

intravenous containers

A small air bubble that gets into the blood circulation and is

stopped at the lungs very rarely produces symptoms. However, death

may occur if a large amount of air or gas becomes lodged in the heart,

stopping blood from flowing from the right ventricle and into to the

lungs. As little as 20 ml/sec of air may show symptoms and 70-150

ml/sec of air can be fatal.

Plastic IV containers have mostly replaced the glass IV bottles

because of several advantages such as ease of using plastic bottles

with rapid infuser system, and safe and easy handling. Self-collapsible

plastic IV infusion bags are preferred though over the conventional

plastic containers for increased margin of safety when it comes to the

danger of inadvertent air embolism.

However, a report by ________________________ mentions a case

involving a near fatal air embolism through the central venous catheter

using a rapid infuser system and self collapsible plastic bag. Although

this case mentions central venous catheter, the danger of

inadvertently infusing air into a peripherally inserted IV site due to

unreplaced empty bottles may pose the same danger.

Theoretical Framework

Thinking about nursing is as important as doing nursing. The

conceptual structure of the discipline of nursing must be known by

those who practice nursing and those who teach nursing. Nurses in

practice must be able to identify the phenomena that are of concern,

and must have a framework for reflecting on their practice. Dorothea

Orem’s general theory of nursing, referred to as the Self-Care Deficit

Nursing Theory, provides starting point for the development of the

nurse’s understanding of the practice.

"Orem's model focuses on each individual's ability to perform self-care,

defined as 'the practice of activities that individuals initiate and

perform on their own behalf in maintaining life, health, and well-

being.'" (Allison, 2007).  The basic premise of the model is that

individuals can take responsibility for their health and the health of

others. In a general sense, individuals have the capacity to care for

themselves or their dependents.

The responsibilities of today’s nurses are as demanding as they

are varied. Broadly, the nurse’s task is that of modifying interventions

and techniques in approved directions. Stated in another way, the

nurse has the basic responsibility of translating and implementing

medical objectives into functional and valuable learning experience for

patients.

Florence Nightingale’s Environmental Theory advocates two

essential behaviors by nurses. First area of assessment is to ask what

is needed or wanted, i.e. ask many questions to know the actual status

of the patient. Also warned against asking leading questions and

advocated asking precise questions. The second was the use of

observation. She used precise observations concerning all aspects of

the clients’ physical health and environment.

Conceptual Framework

Conceptual framework of Nightingale’s theory