Increasing Utilization of Extended-Dwell Peripheral Intravenous Catheters in the Neonatal Intensive Care Unit: A Quality Improvement Project

Background: Repeated pain exposure in neonates is often associated with decreases in long-term cognitive and motor outcomes. Peripheral intravenous (PIV) catheterization attempts are a common source of pain. PIVs need to be replaced frequently given the nature of neonatal peripheral blood vessels. Extended-dwell PIVs are a longer-term option for vascular access, potentially minimizing neonatal exposure to painful vascular access attempts. Local Problem: Extended-dwells PIVs were already utilized at the neonatal intensive care unit (NICU) for this project, but with low usage rates. This unit needed a way to standardize which patients qualified for which vascular access device. Methods: Pre- and post-implementation surveys were sent to the NICU staff to determine opinions of and barriers to vascular access. Pre- and post-implementation chart reviews were used to determine rates of PIV usage/attempts and extended-dwell PIV usage/attempts. Pre-implementation data were pulled from the year prior to implementation, and post-implementation data were pulled from the three months following implementation. Interventions: A decisional flowchart was implemented for the nurses and providers to assist utilization of extended-dwell PIVs and minimize the average vascular access attempts per vascular access day. Following pre-implementation survey collection, education on the flowchart was provided to the NICU medical staff, where they provided feedback and suggested changes. The NICU nursing staff was then educated on the flowchart prior to its implementation. Results: No statistically significant change was observed in extended-dwell PIV usage between the pre- implementation and post-implementation chart reviews, but the descriptive statistics showed a slight improvement in extended-dwell PIV usage from 7.1% (N=22/311) to 8.2% (N=6/73). The average vascular access attempts per vascular access day was calculated and categorized according to which devices were attempted during a neonate's NICU stay. Prior to implementation, the neonates who had PIVs and extended-dwell PIVs attempted had an average of 1.4 access attempts per vascular access day (N=17/311); throughout post-implementation, the average attempts increased to 2 access attempts per vascular access day (N=6/73). Comparatively, the neonates who only had PIVs attempted during their stay had a pre-implementation average of 1.5 access attempts per vascular access day (N=264/311) and a post-implementation average of 1.6 access attempts per vascular access day (N=62/73). The pre-implementation survey showed that 64% (n=18/28) of respondents were not satisfied with the unit's current vascular access practices; in addition, 82% (n=23/28) felt the unit could improve extended- dwell PIV usage. The post-implementation survey showed 67% (n=2/3) of respondents felt the flowchart improved the unit's use of extended-dwell PIVs. The respondents noted some barriers to the flowchart included confusing wording and processes, and forgetting to utilize the flowchart during admissions. Conclusion: The flowchart could be a useful tool in improving extended-dwell PIV utilization and decreasing the pain exposures in neonates from repeated PIV attempts. Adjustments to the flowchart's wording and process could greatly impact the usability and satisfaction of nurses regarding its usage. Further data collection is required to determine if extended-dwell PIVs reduce the average vascular access attempts per vascular access day