There has been quite bit of discussion recently about intravenous therapy practice concerned with the underdosing of intravenous medication when disconnecting infusion sets. It is suggested that when administering small-volume intermittent drug infusions, around 5% to 20% of the prescribed dose is not being infused and remains in the administration set at the end of the infusion and is discarded. A handful of studies support this assumption (eg, Cooper et al, 2018) and that this may pose a risk to patients because they do not receive the total amount of prescribed drug, although it is clear that this may be a problem we just do not know what effect this has on patient outcomes. None of the evidence has looked at the level of drug in the blood plasma to see if the therapeutic range is not being achieved, or if the duration of treatment is longer because the full dose might not be being infused.
This issue has been raised in numerous health-related organisations, yet no standardised guidance is available nationally. The National Infusion and Vascular Access Society (NIVAS) board agreed to take the lead and produce some guidance so that our members and the wider healthcare sector in the UK would have some formal guidance that they can use to inform their organisations about what is accepted practice and what is best practice (see page S16).
Best practice in infusion and vascular access practice is based on research evidence produced by organisations such as the National Institute for Clinical Excellence (NICE), NIVAS, the Infection Prevention Society (IPS) and the Royal College of Nursing (RCN). However, having best practice guidelines available does not necessarily mean that all healthcare institutions and healthcare staff will be aware of or follow them.
The question of how to standardise the use of evidence-based guidelines in infusion or vascular access practice across the whole health sector is yet to be answered but some good work has been started nationally and there are some good national guidelines available that support best practice in a variety of aspects of IV clinical practice, including the National Safety Standards for Invasive Procedures (NatSSIPs). These may be unfamiliar to some readers. NatSSIPs are guidelines that have been developed to set out the key steps necessary to deliver safe care for patients undergoing invasive procedures and allows organisations delivering NHS-funded care to standardise the processes that underpin patient safety. NatSSIPs were introduced in 2015 by NHS England and their purpose was to set out key elements of safe care when undertaking an invasive procedure. It was intended that NatSSIPs could be used as a basis for the development of Local Safety Standards for Invasive Procedures (LocSSIPs).
Any invasive procedure now requires a LocSSIP; this is the case in my organisation, with the exception of peripheral cannulas. All other vascular access devices are included.
Surprisingly, when I speak about LocSSIPs at conferences or networking events the majority of people have not heard of them and this is concerning but also a missed opportunity for vascular access teams across England.
If you are a lead for vascular access or aspire to set up a service, the LocSSIP is definitely going to help you. I hear lots of stories from my peers about the challenges they face when trying to standardise vascular access practice and improve patient safety. The LocSSIP is designed to do just that and should be adhered to by all staff. The LocSSIP is designed to cover the insertion process but does not cover the care and maintenance after insertion. It will cover the referral process, equipment used, the procedure environment, consent and other safety points. You can produce your vascular access LocSSIP to outline who can place your peripherally inserted central catheters (PICCs) or central venous catheters and mandate what techniques to use. PICCs should never be sutured in place yet we sometimes see this in practice, this could be an element of the LocSSIP to prevent it happening.
Most importantly, having a LocSSIP in place for vascular access will ensure that everyone in the organisation will undertake the procedure in the same way, with the same equipment, which should lead to improved safety outcomes. The LocSSIP provides many more safety elements and can reduce the risk of incidents like retained wires and wrong site access. The NatSSIPs website is a useful resource to help you produce your LocSSIP (https://www.england.nhs.uk/2015/09/natssips/) or contact NIVAS via our website (www.nivas.org.uk).