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Clinical Practice Keywords Vessel health/Peripheral

intravenous cannula/Infection
Practical procedures
Infection prevention

Vessel health and preservation 2:

inserting a peripheral intravenous cannula

T
he concept of vessel health and training, and are equipped with the neces-
Authors Carole Hallam and Andrea preservation (VHP) was first sary skills, knowledge and competence to
Denton are independent nurse introduced in the United States in undertake insertion of a PIVC. All regis-
consultants, AC Independent Nursing an attempt to provide a system- tered nurses (RNs), including nursing
Consultants. atic approach to vascular access device associates, are accountable and may be
(VAD) selection, insertion and ongoing required to explain their actions. Any dele-
Abstract This article, the second in a maintenance (Moureau et al, 2012). The UK gation of a task or element of patient care
two-part series, provides a step-by-step VHP framework by Hallam et al (2016), pro- to another health professional, patient,
guide to maintaining vessel health vided an adapted approach to the US ver- relative or carer also comes under the
when a peripheral intravenous catheter sion; it was updated by the Infection Pre- remit of the RN who remains accountable
is inserted. The article should be read in vention Society et al in 2020. This updated (Nursing and Midwifery Council, 2019).
conjunction with part 1 of the series framework has incorporated evaluation
(Bit.ly/NTVesselHealth1), which explores and research studies from the initial frame- Risk assessment
the principles of vessel health and work (Weston et al, 2017; Hallam et al, 2016) As discussed in part 1 of this series, the ini-
preservation. and further international evidence-based tial risk assessment before insertion of a
studies linked to vein assessment, device PIVC should:
Citation Hallam C, Denton A (2020) selection and duration, suitability of medi- l I nclude whether there is a genuine need
Vessel health and preservation 2: cines, and evaluation/ongoing care and for intravenous (IV) access/therapy;
inserting a peripheral intravenous maintenance of the VAD. Key points to con- l Q uestion whether a more suitable
cannula. Nursing Times [online]; sider before and during the procedure to alternative is available (Hallam and
116: 8, 38-41. insert a peripheral intravenous catheter Denton, 2020).
(PIVC) are outlined in Box 1. It is important that any VAD is clinically
indicated. Risk assessment should also
Accountability include a peripheral vein assessment to
Health professionals must ensure they ensure the grade of the vein is compatible
have had the relevant education and with the nature of the IV therapy pre-
scribed, the setting where treatment will
Box 1. Key points in maintaining vessel health be delivered (outpatient, long-term or
inpatient/acute care) and the length of
l Is a VAD (specifically a PIVC) required for this patient at this time? time the PIVC is required (Fig 1).
l Is there an alternative to IV therapy/access? Fig 2 highlights the descriptors for each
l Does the vessel health, nature and length of treatment indicate an alternative to a grade of the vein: grade 1 indicates there are
PIVC? four or five suitable veins that are visible,
l Are there known difficulties with IV access for this patient? If yes, consult local compressible and ≥3mm in diameter (Van
policies/procedures Loon et al, 2019), while grade 5 indicates that
l Aseptic technique should be used for “any procedure that breaches the body’s no suitable veins can be located with ultra-
natural defences” (Loveday et al, 2014) sound. For each grade there is also a column
l Hand decontamination is a fundamental component of any procedure involving an to indicate insertion management. All
aseptic technique and should be performed at key moments – see My 5 Moments grades indicate that the PIVC should be
for Hand Hygiene (World Health Organization, 2009) inserted by a trained, competent health pro-
l The PIVC site should be cleaned with 2% chlorhexidine with 70% isopropyl alcohol fessional but, as the grade increases, the
(NICE, 2012; Loveday et al, 2014) quality of vein decreases and the insertion
l Ultrasound-guided insertion of a PIVC should be used for veins graded 4 and only management indicates additional steps – for
by health professionals trained in this procedure example, ultrasound-guided technology
l PIVCs should be secured with a sterile, semi-permeable, transparent dressing or a (USG) for grade 4 veins (Blanco, 2019; Franco-
combination of a sterile, transparent, semi-permeable dressing and an integrated Sadud et al, 2019; Van Loon et al, 2019) and
securement device (Marsh et al, 2018) referral for alternative VAD for grade 5 veins.
l All health professionals undertaking any procedure including ultrasound-guided Patients known to have difficult IV
PIVC insertion should be trained and competent in that procedure access (DIVA) should be referred to an IV
l All registered nurses and nursing associates are accountable for any acts or specialist and have an individual pathway
omissions, and delegation of any procedure or element of patient care of care (Van Loon et al, 2019).
IV = intravenous; PIVC = peripheral intravenous catheter; VAD = vascular access device.
If USG (Fig 3) is used, the health profes-
sional performing the procedure should be

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Clinical Practice
Practical procedures

trained and deemed competent in its use.

Fig 1. Assessing vein compatibility
Real-time USG is recommended as this can
Peripheral vein assessment help reduce the total procedure time,
needle insertion attempts and needle redi-
1 2 3 4 5 rection (Franco-Sadud et al, 2019).
Excellent Good Fair Poor Non-identifiable

Outpatient/ <6 months’ <4 months’ 4-6 weeks’ One Not suitable Infection prevention
long-term intermittent intermittent intermittent treatment for An aseptic technique should be used for
care therapy therapy therapy cannulation
any invasive procedure that poses a risk of
Inpatient/ <5 days – PIVC infection, including insertion of a PIVC.
acute 6-14 days – Ultrasound-guided PIVC Poor aseptic non-touch technique and non-
Use may be extended beyond the recommended
adherence to infection prevention and con-
time if no complications are noted and still clinically trol precautions during the procedure can
indicated. Ultrasound-guided PIVC/midline is lead to the transfer of transient organisms
preferable for difficult access that may lead to a localised or systemic
infection (National Institute for Health and
PIVC = peripheral intravenous catheter.
Care Excellence, 2012). Inadequate skin
Source: Infection Prevention Society et al (2020)
decontamination before insertion of a
peripheral cannula or other VAD may lead
Fig 2. Grade descriptors for peripheral veins to infection from micro-organisms (for
example, Staphylococcus aureus) that are
Peripheral vein assessment already present on the skin, including the
Suitable vein definition: visible, compressible and ≥3mm (Van Loon et al, 2019) patient’s own (Loveday et al, 2014).
Grade Number of Insertion management
Non-sterile gloves are required for this
suitable veins procedure as there is a risk of exposure to
body fluid. Sterile gloves are only required
4-5 Insertion by a trained, competent
1 if there is likely to be contact with a key
health professional
part, such as the site for insertion of the
2-3 Insertion by a trained, competent cannula. In this instance, it is unlikely that
2
health professional
sterile gloves will be required unless the
1-2 Insertion by a trained, competent vein needs to be repalpated following skin
3
health professional
disinfection.
No palpable Ultrasound-guided cannulation by
4 visible veins a trained, competent health professional; Documentation
once-only cannulation
Documentation should follow local policy
No suitable Refer for alternative vascular and a PIVC insertion and maintenance
5 veins found access device bundle may be used in some areas; however,
with ultrasound
there is some uncertainty as to whether
Known patients with difficult IV access must be referred to an IV specialist and such bundles are effective at reducing PIVC
will require an individualised pathway
complications and bloodstream infections
IV = intravenous. (Ray-Barruel et al, 2019). As a minimum,
Source: Infection Prevention Society et al (2020) documentation should include:

Fig 3. Ultrasound-guided technique Fig 4. PIVC dressing pack

Nursing Times [online] August 2020 / Vol 116 Issue 8 39 www.nursingtimes.net


Clinical Practice
Practical procedures
Fig 5. Veins of the forearm and hand
Basilic vein
Basilic vein
Median antebrachial vein
l D
 ate and time of the procedure;
l Number of attempts to insert a PIVC;
l Dressing(s) used and the name;
l S ignature and designation of the health
professional undertaking the dressing.
The type and gauge of the PIVC may also
be included. If the procedure was under-
taken by a trainee under supervision, the
name, signature and designation of the
trainer is also required.
Procedure for insertion of a PIVC
Equipment
A PIVC dressing pack (if available; Fig 4) or
dressing pack
l C annula;
l N on-sterile gloves;
l C annula dressing;
l C hlorhexidine gluconate in 70%
isopropyl alcohol swab to clean the skin;
l S harps container.
Procedure
1. Introduce yourself to the patient and
check their identity by asking them to
state their name and date of birth. This
should be checked against their notes and
wristband; their hospital number should
also be cross-checked.
2. Explain the procedure and rationale for
PIVC insertion to the patient and gain their
informed consent. It is important to check
their history of PIVC insertion; this should
include data on difficult PIVC, whether USG
JENNIFER NR SMITH
cannulation was used, and history of infec-
tion or other complications such as extrava-
sation and infiltration. The patient’s med-
ical notes may include this information.
Nursing Times [online] August 2020 / Vol 116 Issue 8
Cephalic vein Cephalic vein
Median cubital vein
Accessory cephalic
vein
Cephalic vein
3. Decontaminate hands with an alcohol-
based hand rub (ABHR), or liquid soap and
water if hands are physically soiled/dirty
or if there is potential to spread organisms
that are alcohol resistant – for example,
C. difficile and other organisms that may
cause diarrhoeal illnesses such as noro-
virus. ABHRs used must conform to
British Standards (NICE, 2012).
4. Prepare the environment for the proce-
dure. If this is the patient’s own home, a
wipeable procedure tray dedicated for an
aseptic procedure should be available. In
acute healthcare settings a clean dressing
trolley or clean procedure tray should be
used. The surface should be cleaned with
detergent, or a detergent wipe, to reduce
the number of viable pathogenic organ-
isms (Loveday et al, 2014).
5. Collect the required equipment, checking
the expiry date and that the packaging is
intact. Open the sterile pack onto a sterile
field; a special sterile PIVC insertion pack
may be available. PIVC choice should be
based on where the catheter will be inserted
and the smallest gauge should be selected –
usually 20-24g (Gorski et al, 2016). The cath-
eter size and areas of insertion should also
be guided by the type of therapy required.
Certain medications may not be suitable via
a PIVC, and Medusa – the injectable medi-
cines guide website (medusa.wales.nhs.uk)
– should be consulted.
6. Perform hand hygiene using an ABHR,
or liquid soap and water if an ABHR is una-
vailable.
40
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Basilic vein
Dorsal venous
network
Dorsal metacarpal
veins
Digital dorsal veins
7. Check the patient’s veins and palpate
before cleaning the site. Fig 5 illustrates the
main veins of the forearm and hands. Areas
of flexion, such as the elbow, should be
avoided, and the device used should be no
larger than a third of the diameter of the
vein – anything greater can reduce blood
flow and cause a thrombus (Sharp et al,
2016). There is also evidence that the veins
on the back of hands can be associated with
PIVC failure (Marsh et al, 2018).
8. If there are no palpable visible veins,
refer to the VHP framework and local
guidelines. Local policy should determine
how many attempts should be made before
escalation. If a patient has had problems
with cannulation in the past, refer them
for an individual pathway of care (Van
Loon et al, 2019).
9. Clean the site with chlorhexidine gluco-
nate in 70% isopropyl alcohol (NICE, 2012)
and leave to dry.
10. Perform hand hygiene using an ABHR.
11. Put on a clean disposable plastic apron
and non-sterile gloves. Avoid touching any
key/critical parts/sites (Fig 6) during the
procedure including:
l T he patient’s skin/vein entry point,
where the PIVC is to be inserted;
l T he catheter that enters the vein;
l U nderneath the injection port cap.
If any key parts are touched, the proce-
dure should be stopped and restarted from
the beginning, using an aseptic non-touch
technique.
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Clinical Practice
Practical procedures
Fig 6. Examples of key parts
Fig 7. Integrated securement device
12. Insert the PIVC according to local
policy. It is important the vein is not re-
palpated once the area has been cleaned
and left to dry.
13. If USG insertion is required, the equip-
ment must be clean and a sterile cover
applied to the probe.
14. Once the PIVC has been inserted, flush
it with sterile 0.9% sodium chloride to con-
firm vein placement and patency (Hill,
2019). The liquid should enter the vein
Professional responsibilities
This procedure should be undertaken
only after approved training, supervised
JENNIFER NR SMITH
practice and competency assessment,
and carried out in accordance with local
policies and protocols.
Nursing Times [online] August 2020 / Vol 116 Issue 8
easily, without causing the patient pain,
and there should be no signs of infiltration.
15. Apply a dressing suitable for a PIVC and
the insertion area; the surrounding skin
should be visible. A sterile semi-permeable
transparent dressing (Loveday et al, 2014)
should be used or a combination of a sterile,
transparent, semi-permeable dressing and
an integrated securement device (ISD,
Fig 7). ISDs can help prevent micro-move-
ment and dislodgement of the PIVC and
subsequent failure (Marsh et al, 2018).
16. Remove your gloves and apron, and
dispose of these before decontaminating
your hands.
17. Perform hand hygiene using an ABHR.
18. Dispose of waste into the correct waste
stream as per local policy and procedures.
41
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Any sharps or pharmaceutical waste
should be disposed of in the appropriate
waste container; sharps should be dis-
posed of at the point of use.
19. Clean the trolley/tray with detergent or
a detergent wipe and store as per local
policy and procedures.
20. Perform hand hygiene.
21. Update the patient’s records according
to local policy. NT
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