In this blog post, Nicola Beaney, MRCVS, and Hannah Young, RVN, from Newnham Court Vet Hospital discuss how their practice implemented clinical audits and checklists to investigate and improve their IV complication rates.
A few of our un-favourite things
“Cats with fat feet and fluid-filled elbows,
Blood clots in drip lines and grim t-connectors,
Extravasation of fluids causing limping front legs,
These IV complications have us scratching our heads.”
Those who have worked in practice will find the song a little familiar. In our practice, we seemed to be having complications with our intravenous (IV) catheters on a daily basis. The team had put it down to ‘some vets doing the tape too tight’ or ‘the dog just kept on moving’ but it was getting easy to blame anything for these complications, which had led to a culture of distrust.
After a particularly busy weekend, our Continous Care Veterinary Surgeon, Nicola, discovered an IV checklist and thought that it would be a good introduction to help tackle some of the issues we were seeing.
Once the lists were distributed, they took several months to implement. Our team includes 25 nurses and 15 vets, all working different shifts to offer 24-hour care. Initially, due to a communication breakdown, those who had not been present at the original meeting thought the checklist was optional. This, combined with a busy working environment, meant compliance was slow, with the additional sheet quickly being forgotten.
After discussing the list during kennel rounds, it was identified to be quite ambiguous in places. With feedback from the team, we adapted it, researching alternatives and creating a list that suited our needs perfectly. We also implemented ‘checklist champions’ to support the team and remind them to fill it out. They also reminded the team to record any complications on the audit spreadsheet. Due to the size of the team, we had a different checklist champion in the prep room, inpatient area and during out-of-hours.
Nicola volunteered to audit the IV complications, along with help from the checklist champions. They all informed the team of the outcomes, so we could discuss any changes.
The first audit was completed over four months and showed that 30 of our patients (17 dogs and 13 cats) had suffered from IV complications. These included swollen paws, erythema, swelling proximal to the IV, discharge in the t-connector, pain in the IV limb, and pyrexia. These ended up being our baseline figures, and we would work to improve them.
Swollen paws (without any other complications) accounted for 17% of dogs and 76% of cats. It was agreed that a swollen paw (and no other complications) was likely to be caused by the tape or bandaging. Swollen paws with concurrent swelling or erythema were more likely to be due to subcutaneous fluids or phlebitis.
The cases with evidence of phlebitis were reviewed for risk factors; neutropenia, fluids containing glucose, prolonged hospitalisation, and prolonged use of IV. Out of these cases, two had the IV in situ for longer than three days (both cats), five had prolonged hospital stays, and two had no known risk factors.
From the initial audit the following changes were discussed:
- Cats represented a high number of patients with a swollen paw. The tape used could restrict if pulled a little tight, so a trial of a different tape was initiated. A self-adherent cohesive bandage was not to be used, as this had the potential to constrict. Instead, a knitted conforming bandage was to be trialled.
- Due to some of the patients developing phlebitis, we ordered a t-connector with a closed connection device. The checklist was adapted so that the type of t was recorded.
- The IV placement protocol was reiterated to all members of the team, and placed on display in the kennel areas.
These changes seemed ideal in theory; however, in practice, some had to be adapted. The tape we had changed to was not as adhesive, and we found that we had a higher instance of IVs just falling out. In some patients the conforming bandage would unravel too easily, meaning we had to revert to the cohesive bandage. The improvement we were aiming for would be achieved through trial and error!
During the second audit, a total of 42 cases had IV complications; 25 cats and 17 dogs. The recorded number of complications was higher, but the number of recorded cases was also higher. Subjectively speaking, it is likely that there were still a number unrecorded. Compliance among the team had improved but was, and still is, a work in progress.
We had a reduction of swollen paws, which was surprising considering the bandaging changes. The increased perception of swollen paws seemed to be ensuring that the team allowed the cohesive bandage to relax beforehand. Swollen paws without other complications accounted for 40% of cats (36% less than previously), and 10% of dogs (7% less than previously).
The number of patients with ‘blown IVs’ had increased, and accounted for 32% of cat cases and 76% of dog cases. This suggested that the change in tape was more likely to lead to subcutaneous fluid administration and ineffective securing of the IV.
Overall, we had reduced phlebitis in our patients, but not enough cases were recorded to identify whether the closed connection t-connectors were beneficial or not.
We are still in the early stages of auditing and using our checklist. We made changes that weren’t successful, but they just give us something else to learn from.
We have introduced more training for the team on the application of tapes and dressings and encouraged people to record any potential problems on the checklist. There are many times where the patient’s compliance or skin condition haven’t been ideal, and it’s useful to have somewhere to record this so that potential complications can be followed up on.
As a team, the checklist has been of great use in ensuring that all patients are getting the same standard of care, and it certainly encourages us to think about what we are doing.
The list has been really helpful for SVNs and our Nursing auxiliaries; they can fill out the list after assisting with the IV, taking some pressure off other team members. This also helps them learn what factors we look at, helping them to identify any problems.
When a complication does arise, instead of immediately looking for blame, we look towards other factors that could have contributed, and work on improving those, which has improved our working environment.
The whole process is a continuing one, but one that is worth it. Completing the audits and the checklists has led to an environment where we have better clinical outcomes. We use quality improvement to inform changes and improve patient welfare, and that creates an environment where we strive for excellence and consistently foster the attitude ‘could this be done better, and how?’