Management of arterial lines and blood sampling in intensive care: a threat to patient safety

Emergency Nurse Arterial Line Education Using QR Code Reader

INTRODUCTION

Arterial lines provide vital information regarding a critically ill patient's hemodynamic stability. It is essential that emergency nurses managing arterial lines are confident in their ability to care for patients with these lines.

PROBLEM

Depending on which emergency department, managing and setting up arterial lines may not be frequently required. This was a problem in 1 area emergency department, where the nurses were found to be unable to set up and manage these lines confidently.

METHODS

Fifteen registered nurses were asked to view a short but comprehensive educational video illustrating the setup and management of arterial lines accessed with the use of a quick response code. A pre- and post-test using a 5-question pre-/post-Likert-style scale questionnaire were administered to participants to evaluate their confidence related to the management of arterial lines and analyzed for a variation in scores.

RESULTS

Of the 5 content areas evaluated on the questionnaires, there was an increase in reported confidence level in all content areas after watching the educational video. Data analysis using a paired t test calculation shows a significant P value of .002. The areas included on the questionnaries included where to find materials, how to zero and flush the line, how to draw blood from the line, how to troubleshoot the line, and confidence with the overall management and setup of the line.

DISCUSSION

Educational tutorials can enhance clinical skills leading to a more confident nurse. Video tutorials accessible by quick response code are a quick and efficient educational resource for nurses. This method of teaching should be considered when providing education to nurses in the emergency department.

Adverse events with arterial catheters in intensive care units: a scoping review

INTRODUCTION

The installation of an arterial line is one of the invasive procedures performed for hemodynamic monitoring and, even with its clear importance in intensive care, it is still an invasive procedure and liable to cause harms to the patients.

OBJECTIVE

To identify the adverse events associated with the use of arterial catheters in critically-ill patients in the world scientific production.

METHODOLOGY

The present scoping review was conducted according to the JBI methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used for reporting. The research question was "Which adverse events related to the use of arterial catheters in patients admitted to intensive care are more evident in the literature?". Data collection took place in the following databases: LILACS; MEDLINE; EMBASE; CINAHL, EBSCOhost; and WEB OF SCIENCE.

RESULTS

Through the search strategies, 491 articles were found in the databases. After exclusion of duplicates, peer analysis of titles and abstracts, full reading and screening of lists of references, the final sample of studies included was 38 articles. The main harms cited by the publications were as follows: limb ischemia, thrombosis, hemorrhage, accidental removal, inadvertent connection of inadequate infusion solution, pseudoaneurysm and bloodstream infection.

CONCLUSIONS

It was evidenced that patients are subjected to risks of adverse events from the insertion moment to removal of the arterial catheter, focusing on the infusion solution used to fill the circuit, the type of securement and dressings chosen, as well as the Nursing care measures for the prevention of bloodstream infection.

The practice of arterial catheters in ICUs and nurses' perceptions of infection prevention: A multicentre cross-sectional study

BACKGROUND

Peripheral arterial catheters (AC) are increasingly used in intensive care units (ICUs). Arterial catheter-related bloodstream infection is a serious complication that can increase patients' morbidity and length of stay. Standardised infection prevention practices are important when using AC. However, the current practices regarding AC insertion, use and removal and the perceived infection prevention attitudes of nurses in ICUs are unknown.

METHODS

This was a multicentre cross-sectional study; 20 tertiary general hospitals were selected with a stratified random method in Beijing, China, using a self-reported internet survey.

RESULTS

A total of 981 valid questionnaires were collected. Overall, some infection prevention practices, such as AC insertion and disinfection of the blood sample hub, were generally consistent with clinical guidelines, whereas others were inconsistent: eye protection, skin antiseptic solution, dressing choice, blood sample collection and replacement of AC. More than 60% of participants mentioned occasionally or never having used eye protection. Only 6.0% of them stated using the chlorhexidine dressings. Among the participants, 80.6% reported that they replaced AC routinely rather than based on clinical indications, 64.2% self-rated that they did not routinely culture a catheter specimen after removal and 53.4% of participants positively agreed that AC could cause infection. Nurses with a higher education level were more likely to agree that an infection risk with AC exists (trend χ2 = 5.456, p = 0.019*).

CONCLUSIONS

Significant heterogeneity exists across hospitals in China in terms of antiseptic techniques and perception of infection prevention during AC insertion, use and removal. Critical care nurses' practices partially complied with guideline recommendations. Educational level was found to be a risk factor for their perceived infection prevention attitudes. Nurses with a lower education level underestimated the infection risk of AC. Future research may examine optimal preventive strategies for reducing infection.

The knowledge and practice of maintaining the patency of arterial catheters

BACKGROUND

Maintaining the patency of arterial catheters-routinely inserted in critically ill patients in intensive care units (ICUs)-is essential for obtaining physiological measurements and enabling blood sampling.

AIM

This study aims to evaluate current ICU nurse knowledge and practice of maintaining the patency of arterial catheters and explore the factors that influence nurses' knowledge level.

DESIGN

This was a cross-sectional survey conducted in China.

METHODS

This research was conducted in 20 tertiary hospitals in Beijing, China between March and June 2020. The data were collected by electronic questionnaire, which was designed in accordance with the literature and consisted of 28 questions. Descriptive and inferential statistics were used to analyse the data.

RESULTS

A total of 576 completed questionnaires were returned. The mean score of nurses' knowledges was 3.66 ± 1.35, which is a moderate level. There was a statistically significant difference between the mean scores of nurses with different professional titles and work experiences (mean 3.58 vs 4.04/7; mean 3.50 vs 3.58 vs 3.94/7). Considering ICU nurses' practice of maintaining the patency of arterial catheters, 376(65.3%)nurses replaced the pressure transducer as per the manual, and 347 (60.2%) nurses zeroed the pressure transducer once per shift. More than 90% ICU nurses aligned the transducer with the heart surface marker during zeroing procedures. Furthermore, 79.9% of nurses performed fast-flush tests routinely, 459 (85.9%) nurses flushed the arterial catheter routinely, and 80% of nurses evaluated the patency of the arterial catheter every shift.

CONCLUSIONS

This study found that the practices of ICU nurses varied, and their knowledge of how to maintain the patency of arterial catheters was moderate and could be improved. ICU nurses should be trained effectively to develop a unified standard of arterial catheter management.

RELEVANCE TO CLINICAL PRACTICE

Training programmes on arterial catheter management for ICU nurses are essential for improving knowledge and practice.

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique*

Background

Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia.

Methods

Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination.

Results

(1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique.

Conclusion

Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

The incidence, significance, and management of accidental intra-arterial injection: a narrative review

This narrative review discusses the incidence, risk factors, mechanisms of injury, complications, and treatment regimens for accidental intra-arterial injection of medications. Despite awareness of the issue and the establishment of safety recommendations by national agencies, accidental iatrogenic intra-arterial injection of medications continues to occur. Most of these injuries are caused by accidental injection into an established arterial cannula or the inadvertent and unrecognized cannulation of an artery instead of a vein. Although many medications have been injected into arteries without significant consequence, a number of drugs are consistently associated with severe morbidity, including the need for amputation, making early incident recognition and treatment vital. Accidental intra-arterial injection of medications has also been increasingly reported in those who use illicit drugs, as these intravenous injection attempts can be misdirected into an artery. These reports have improved understanding of these injuries and possible treatment modalities. While the characteristics of injuries from illicit injections are diverse and the optimal treatment modalities are still uncertain, a regimen that includes anticoagulation and intra-arterial injection of thrombolytics and prostaglandins may improve outcomes. Steroids, vasodilators, and sympathetic blocks do not appear to influence amputation rates. Owing to the small and sporadic number of cases, no definitive clinical trial evidence exists, but the treatment modalities found to be useful in the illicit intra-arterial injection group may benefit treatment of similar iatrogenic injuries.

Finding a solution: Heparinised saline versus normal saline in the maintenance of invasive arterial lines in intensive care

BACKGROUND

We assessed the impact of heparinised saline versus 0.9% normal saline on arterial line patency. Maintaining the patency of arterial lines is essential for obtaining accurate physiological measurements, enabling blood sampling and minimising line replacement. Use of heparinised saline is associated with risks such as thrombocytopenia, haemorrhage and mis-selection. Historical studies draw variable conclusions but suggest that normal saline is at least as effective at maintaining line patency, although recent evidence has questioned this.

METHODS

We conducted a prospective analysis of the use of heparinised saline versus normal saline on unselected patients in the intensive care of our hospital. Data concerning duration of 471 lines insertion and reason for removal was collected.

RESULTS

We found a higher risk of blockage for lines flushed with normal saline compared with heparinised saline (RR = 2.15, 95% CI 1.392-3.32, p ≤ 0.001). Of the 56 lines which blocked initially (19 heparinised saline and 37 normal saline lines), 16 were replaced with new lines; 5 heparinised saline lines and 11 normal saline lines were reinserted; 5 of these lines subsequently blocked again, 3 of which were flushed with normal saline.

CONCLUSIONS

Our study demonstrates a clinically important reduction in arterial line longevity due to blockages when flushed with normal saline compared to heparinised saline. We have determined that these excess blockages have a significant clinical impact with further lines being inserted after blockage, resulting in increased risks to patients, wasted time and cost of resources. Our findings suggest that the current UK guidance favouring normal saline flushes should be reviewed.

The effect of hyperglycaemia on haemostasis testing--a volunteer study

We investigated whether the contamination of samples with glucose subsequently tested for haemostasis affected the results, including prothrombin time, activated partial thromboplastin time and fibrinogen concentration. Venous blood was collected from 12 healthy subjects and divided into four aliquots, which were subjected to different degrees of contamination with standard glucose solution (0%, 5%, 10%, 20%). With increasing glucose contamination, prothrombin time increased from mean (SD) 11.0 (0.7) s to 11.2 (0.7) s, 11.5 (0.7) s and 12.2 (0.8) s, all p < 0.001. Activated partial thromboplastin time decreased from 32.3 (0.9) s to 30.9 (0.8) s, 30.8 (0.8) s, and 29.7 (0.7) s, all p < 0.001. Fibrinogen concentration decreased from 3.8 (0.7) g.l(-1) to 3.7 (0.6) g.l(-1), 3.6 (0.6) g.l(-1), and 3.4 (0.6) g.l(-1), all p < 0.001. Bias was clinically meaningful from 5% contamination for activated partial thromboplastin time, 10% contamination for prothrombin time and 20% contamination for fibrinogen concentration. We conclude that if glucose contamination of haemostasis samples is suspected or has occurred, the specimens should not be analysed.

Observational Study of the Effect of Heparin-Containing Flush Solutions on the Incidence of Arterial Catheter Occlusion

The National Patient Safety Agency (NPSA) highlighted potential dangers associated with arterial lines in 2008, recommending the use of saline-only flush solutions. The incidence of catheter thrombosis appeared to increase following the implementation of this guidance in some units. The objective of the current study was to observe local practice regarding the use of heparin in arterial catheter flush solutions, and subsequent arterial catheter occlusion rates. This was an observational study in which data were collected prospectively from 445 catheter insertions in unselected intensive care patients in eight member hospitals of the Association of North Western Intensive Care Units (ANWICU). Catheters flushed with heparinised solutions had a significantly increased median lifespan of 102 hours versus 72 hours for saline-flushed catheters (p<0.01). The likelihood of line blockage was significantly decreased in the heparin group (7.9%) compared with the saline group (41.2%, p<0.0001). Our results suggest that routine use of heparinised flush solutions is associated with increased catheter lifespan and reduced catheter thrombosis. We believe that there is justification for an adequately powered, randomised controlled trial. Current NPSA guidance may need to be reviewed.

An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Incident reporting is promoted as a key tool for improving patient safety in healthcare. We analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units each year in the North West of England between 2009 and 2012; 452 (20%) of these incidents led to harm to patients. Although 1461 (65%) incidents were judged to have been preventable, there was no reduction in the rate of incidents per 1000 days between 2009 and 2012 (5.9 in 2009, 6.6 in 2012). Furthermore, in the 2012 data, there were wide variations in the incident rates between units, the median (IQR [range]) rate per 1000 patient days for individual units being 6.8 (3.8-11.0 [1.3-37.1]). The variation in the percentage that could have been avoided was narrower, with a median (IQR [range]) of 70% (61-80% [38-100%]). The most commonly reported drugs were noradrenaline (161 incidents, 92 with harm), heparins (153 incidents, 29 with harm), morphine (131 incidents, 14 with harm) and insulin (111 incidents, 54 with harm). The administration of drugs was the stage in the process where incidents were most commonly reported; it was also the stage most likely to harm patients. We conclude that the wide range in reported rates between units, and the scope for preventing many incidents, suggest that quality improvement initiatives could improve medication safety in the units studied.

Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis

In 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose-containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. We report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. We report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. We discuss the nature of the errors that occurred and list the consequent changes in practice implemented on our unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.