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Reducing the Number of Pediatric IV Infiltration

Abstract

Intravenous infiltration can be often met in the clinical setting as an intravenous injection complication. It can provoke negative health consequences. The paper is focused on the ways to reduce the level of this condition occurrence among children as they have the greatest prevalence in a case of this complication. These rates are in a strong relationship with the lack of experience and education among nurses and the insufficient understanding and involvement of families. The problem can be reduced through the education program implementation that will provide participants with more proficient knowledge, practice, and awareness of the problem. The project is based on the QSEN safety competency.

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This is a four-month program in which nurses will attend lectures for the first two months and then have practice with a preceptor during the following two months. Concurrently, families will receive the informational package during the whole timeframe of the program. The infiltration rate data will be gained before and after the project while nurses will complete surveys regarding their competencies at the same time. After the program through the data comparison, it would be possible to conclude if the presented training was successful. Therefore, the education project, aimed at increasing the experience and the education of nurses as well as efficient families’ involvement, can decrease the IV infiltration prevalence among children.

Introduction

Intravenous (IV) infiltration and extravasation can be explained as the fluid leaking from the blood vessel. It is believed to be the most common challenge of peripheral intravenous therapy with different morbidity degrees. The possible problems include litigation, raised hospital costs, prolonged hospitalization, disfigurement, infection, and pain. Pediatric patients are different from the adults in terms of emotional, cognitive, developmental, and physiological perspectives. They are more fragile and demand more experience from the medical staff. Nonetheless, children usually suffer from the greatest prevalence of IV infiltration. There is a noticeable connection between the education level among nurses and the degree of parents’ understanding and involvement with the IV infiltration rates among children.

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Numerous researchers proved that it is possible to reduce this condition occurrence through more proficient education and experience among nurses as well as broader understanding and involvement of families. Predominantly, the lack of the first two elements provokes medical errors that cause harmful effects on children. The main idea is to decrease and, in some cases, even prevent the pediatric IV infiltration rate due to the high level of education and experience of the nurses and appropriate families’ involvement. Therefore, the education project is focused on increasing the experience and the education of nurses and efficient families’ understanding to decrease the IV infiltration prevalence among children.

Background

The infiltration is an increasing challenge among the pediatric population. It was found that 78% of pediatric peripheral intravenous (PIV) lines become infiltrated and around 11% of pediatric intensive care unit patients have IV extravasation with a high prevalence among children (Beaulieu, 2012; Amjad, Murphy, Nylander-Housholder, & Ranft, 2011; Thigpen, 2007). Besides, it was found that 43% of mentioned infiltrations lead to tissue sloughing and nerve, muscle, or skin damage (Tofani et al, 2012; Thigpen, 2007). Another research revealed that infiltration is the most widespread challenge related to PIV use among infants. Thus, it appears more often among children rather than adults. An even higher incidence rate was found in the other research, particularly among 58% of patients with age under one year (Driscoll, Langer, Burke, & Metwally, 2015). Hence, the condition has a common prevalence among children.

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The experience and the education of the medical staff are of significant importance from this problem’s perspective. In particular, it was found that vein wall injury during the insertion was admitted to be the infiltration contributing factor. Besides, the appropriate site selection and the flection joints avoidance are critical in infiltration prevention (Major & Huey, 2016). It was identified that the most critical risk factor for this condition was an infusion of antibiotics and IV fluids, repeated insertion on the same site, catheter size, insertion site, dwell time, previous experience of peripheral catheter insertion, and child weight (Ahmed, G. E. N., 2017). At the same time, nowadays there is an urgent need for affordable and high-quality care, even with the increasing healthcare spending. Challenges to intravenous therapy can seriously influence the care costs as well as impact the mortality and morbidity rates among patients. The Centers for Medicare and Medicaid Services perceive the intravenous infiltrates as a preventable case (Beaulieu, 2012; Amjad et al, 2011). In particular, in 2007, CMS made a discount on reimbursement for infections that were provoked by intravenous catheters, and in 2008, reimbursement was discontinued for challenges that were related to the procedure of repairing injuries acquired while hospitalization (Amjad et al, 2011). Currently, hospitals are accountable for such challenges prevention and reducing the stay length. Beaulieu (2012) states that

More than two percent of all injury claims in a period from 1970 to 2001 were found to be in strong relation to the peripheral intravenous catheter infiltrates and additionally nurses were named in malpractice suits, including the IV medications and fluid administration, at up to ten million dollars per claim.

Hence, pediatric intravenous infiltration became a considerable challenge to the healthcare system.

At the same time, IV infiltrations are usually scale-graded. The first scale was established by Millam in 1988, and this tool was applied as a basis for many other ones (Beaulieu, 2012). There were many different variations of the grading applications, but only a few scales adequately provide size results that can be generalizable to the children (Beaulieu, 2012). Therefore, the significance of the problem is evident. Essentially, it can be prevented in a case the healthcare provider has the knowledge and experience to understand the roots of the disorder and avoid some mistakes. Nonetheless, there is a complex problem of insufficient nurse education that influences the appropriate healthcare service in cases of pediatric IV infiltration. Similarly, due to the lack of knowledge, patients can provide challenges to nurses in their function's performance.

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Assessment

The patients experience infiltration in a 34-bed level IV pediatric unit. The problem happens due to the peripheral IV catheter. Most of our admissions come from the E.R, and it is possible to notice several infiltrating IVs, especially during the night shift. The night-shift nurses in the mentioned unit are fairly new and lack experience in placing pediatric IVs. At the same time, families and patients are usually exhausted when they are admitted to this unit at night and sometimes do not want the nurses to enter the room as frequently as the child sleeps. Overall, it constitutes a pressing problem. As an example, 28% of peripheral IVs occur among pediatric unit patients, while this rate for children under one year is 33% (Driscoll et al., 2015). Hence, this condition is highly challenging and demands wide experience and knowledge in addressing such patients from the nurses and families. The raised risk of the PIV infiltrating in children can be due to the blood vessel size, fragility, and the lack of subcutaneous tissues (Driscoll et al., 2015). Moreover, the infants’ inability to express distress or pain can be critical for infiltrating predisposition. Therefore, this unmonitored condition can progress rapidly and lead to the tissue necrosis and perfusion. It can be stated that the number of infiltration cases can be reduced with the help of implementing proper techniques. Some of them include ensuring pump alarm sensitivity, avoiding unnecessary coverage of the insertion site, and checking catheter after, before and during the vesicants administration (Driscoll et al., 2015). Consequently, such interventions make the problem extremely challenging.

The mentioned condition can fit the QSEN safety category. It is defined as the harm risk minimization to the providers and the patients through personal performance and system effectiveness (Cronenwett et al., 2009). There is a strong need for a solution because the complications can be avoided due to the appropriate understanding and enough practice. On contrary, without it, children are suffering from the low quality of healthcare services. It is obligatory that support and resources concentrated on QSEN competencies are in place in order to accommodate the new graduate nurse’ needs to maintain safe, quality patient care while retaining the same on the profession and organizations (Cronenwett et al., 2009). The preparation of the medical staff in providing the service of the highest quality demands a common vision among participants aimed at the commitment and meeting the patients’ needs. Hence, all healthcare providers have to be educated in the appropriate way to deliver efficient care. Consequently, the safety competency is highly critical in dealing with the represented problem because, without the appropriate education, the patients’ safety is under threat.

Therefore, the Quality and Safety Education (QSEN) project represents six competencies that are crucial for the competed nurse and underlines the importance of attitudes, skills, and knowledge important for each competency development within the nursing education. Thus, QSEN defines the patient safety as the harm risk minimization to the providers and the patients through individual performance and system efficiency (Cronenwett et al., 2009). The knowledge obtained should contain the description of factors that develop the safety culture, such as open communication and appropriate education regarding the disorder. The required skill is the efficient application of strategies aimed at risk reduction among patients. The chosen attitude is the valuation of own role in error prevention.

Statement of Proposal/ Solution

In the analyzed pediatric care unit, the relation between the lack of education among nurses and families and negative outcomes of IV infiltration among children was noticed. Specifically, it was seen among night shift nurses because they had insufficient experience with such a disorder, thus having the risk of being understaffed. At the same time, the superficial understanding between nurses, patients, and their families was identified as well due to the lack of knowledge regarding the problem. Therefore, the main solution for reducing the IV infiltration among children in the presented unit can be the promotion of education for the nurses and families of patients in regards to IVs and better monitoring/assessment of the IV site. In particular, it is possible to prepare a project aimed at increasing the knowledge level among families and nurses (Driscoll et al., 2015). The main goal of this solution is to strengthen the critical thinking process, clinical skills, and education level among nurses. The development of such an initiative leads to the improvement of the new graduate nurse transition from the beginner to the well-prepared specialist and promotes behavior consistent with the unit values and missions. The IV training is highly critical for the pediatric unit due to the high frequency of cases among children.

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There is a vital need to concentrate on infiltration prevention among the pediatric population. Additionally, education plays a fundamental role in improving the intravenous therapy holistic delivery by assuring that nurses are competent and knowledgeable in their practice. Infiltrate education has to encompass the legal consideration, cost implication, consequences, risk factors, site assessment, catheter securement, and IV insertion (Anson, Edmundson, & Teasley, 2010). The children are at a high risk of infiltration, and the outcomes can be challenging for the healthcare providers, the children, and the families. The infiltration results can vary from edema in the extremity to full-thickness skin loss, muscle or tendon necrosis, or even amputation (Anson, et al., 2010). Furthermore, the family and patient’s education on early recognition and limiting the tissue harm is essential as well. Making parents aware of the “normal site, complaints of IV pain from children, raise the anxiety and agitation among children in infusion device alarms can assist in providing important information that can be used by the parent to alert the nurse to potential issues” (Dougherty, 2008). Without appropriate parental involvement in the proficient educational base, it is difficult to solve the problem. Hence, nurses and families play a critical role in this case.

One of the studies was aimed to detect the IV infiltration management program's influence on hospitalized children. It was the quasi-experimental research that provided the historical comparison group design with 2894 catheters inserted during the three-month comparison phase and 1652 catheters inserted during the four-month experimental phase (Park et al., 2016). The intervention was conducted with seven activities that involved peripheral catheter insertion site each shift, catheter insertion documentation, appropriate site selection, vein condition assessment before the catheter insertion, infiltration report performance, parents’ education, catheter insertion documentation, and, applying poster. The findings identified that IV infiltration management program was efficient in reducing the IV infiltration prevalence and raising its early detection (Park et al., 2016). Therefore, parents’ education is one of the variables that can help to decrease the occurrence rate of pediatric IV infiltration.

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Another research was focused on the improvement strategies directed at the peripheral intravenous infiltration and the injuries extravasation (Tofani et al., 2012). The provided activities involved the sharing of compliance outcomes, performance monitoring, PIV site assessment mandatory demonstration, staff education, and the development of the touch-look-compare method for hourly PIC site assessment. The authors found that a significant injury rate reduction was noticed right after the implementation of the intervention (Tofani et al., 2012). Hence, staff education is the critical aspect that provokes the prevention of pediatric IV infiltration.

Implementation Plan

The proposed project will be represented by nurses, nurse administrators, unit managers, and patients’ families for four months. Nurse managers and unit leaders must have enough time to consider and analyze the proposed plan to schedule both the preceptors and the nurses. Hence, they need one month to shape the timetable of the project. According to Horton, DePaoli, Hertach, and Bower (2012), it proves a vital role of the unit support for the preceptor because in a case the latter can perform their work effectively, the inexperienced nurses will learn more quickly and efficient way. It will continue for four months, where half of the program will be theoretical while the second part will provide practical knowledge for the nurses. All this period, families will receive the learning materials. The project will be launched on 1 March and continue until 1 July. In particular, March and April will be devoted to the lectures while May and June will be focused on the practice. The expected results will be reduced pediatric IV infiltration cases, which were previously occurring due to the nurses’ inexperience and families’ misunderstanding.

Hence, the training has to include two parts. The first one is the two-hour lecture series for nurses that represent all critical information regarding pediatric IV infiltration. The nurses will learn the ethical and legal aspects of the practice, different modalities, current standards focused on the infection, physiological and anatomical-control principles, and treatments such as pain medication, antineoplastic agents, nutritional solutions, pharmacological agents, blood components, and parental fluids (MacLean, Obispo, & Young, 2007). Besides, the lectures will involve the hospital policy overview, guidelines, and the use of needed tools. After the lecture series, the nurses will start the second part focused on practical information. They will work with a preceptor that would conduct lessons and observe the participants attending to their pediatric patients. After several successful cases, the preceptor has to accept the nurses as capable to perform by themselves. During the whole period of this program, families will also gain their education course. In particular, all families and patients will receive the self-learning packets that will include printed material and videos regarding the disorder. The provided information concentrates on the QSEN safety competency, but the knowledge, skills, and attitudes that have strong connections to the same can be engaged in the training as well. In addition, the learning focuses can be individualized for the participants based on the result of the interview held every month of the program.

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Such an attitude to families and nurses’ involvement is highly efficient. It was found that through family engagement and evidence-based education, it is possible to reduce the pediatric IV infiltration prevalence (Major et al., 2016). The positive results showed a decrease in infiltration rates over the three months. Moreover, the reduction was noticed in the general percent of the IVs that infiltrated in the first twenty-four hours (Major et al., 2016). Additionally, there was noticed a significant rise in the nurses’ education level was noticed while the family engagement strategy revealed parental responses to be 88% positive (Major et al., 2016). Hence, the care quality was improved, which led to providing patient-focused, efficient, and safe IV therapy.

The author will provide one meeting each month of the project and will have interviews with participating nurses regarding their success in enhancing education and experience. Similar meetings will be organized for the parents every month. After the project will be finished, nurses and families will complete the knowledge assessment survey. It will be based on the knowledge gaps, past safety events, and current literature. The assessment survey’s aspects will involve the medication identification of the infiltrate risk increase, the INS infiltrate scale to use for the infiltrate event grading, the difference between phlebitis, extravasation and infiltrate, and the application of the proper tools. The results will be evaluated by the author. In addition, before and after the project, the rates of pediatric IV infiltration cases will be compared. Such data is measurable and needed to obtain this program's success. It can be easily gained by the management team. The success will be determined through the comparison of data regarding the participants’ education and the comparison of IV infiltration cases among patients before and after the program.

Conclusion

Overall, there is a high prevalence of pediatric IV infiltration cases, which is in a strong relationship with the lack of education and experience among nurses and the insufficient understanding and involvement of parents. The risks related to the poor IV technique involve pain that is experienced commonly by children due to their unique psychology and physiology. Besides, their anatomy contributes to the complications, and the nurse has to be able to palpate or visualize veins that are fragile, small, and hard to locate. Preparing patients and families for the procedure is also critical, and nurses have to be attuned to their involvement, including their proper emotional responses. Therefore, the lack of education and experience can provoke serious complications through the misunderstanding from the families’ perspectives as well as medical errors from the nurses’ side. There is an urgent need for an education program that will involve training for nurses and information representation for families. This is a four-month project in which nurses for two months will attend lectures and for two next months will have a practice with a preceptor. At the same time, families all this period will receive the informational package. The infiltration rate data will be gained before and after the project while nurses and families will complete surveys regarding their competencies. The data will be collected regarding the education level among nurses and families before and after the education program as well. Therefore, it would be possible to identify if the presented training was successful.

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