Is it time to rethink the age-old use of the cannula?

Around 7.7 million Australians get a cannula or 'drip' placed each year and the procedure can be a painful experience. 

That may be about to change with a new clinical standard that aims to provide national guidance on best practice care and skillful use of the peripheral intravenous catheter (PIVC).

Research shows that up to 40 per cent of all first-time attempts to insert a PIVC in an adult fail, and many patients face the prospect of undergoing multiple painful attempts before a PIVC is successfully inserted. 

Once inserted, there is also a risk of complications, some of which are serious.

Nurse and vascular access expert Dr Evan Alexandrou, senior lecturer at Western Sydney University and Clinical Nurse Consultant at Liverpool Hospital in NSW, says that 70 per cent of cannulas need to be removed because of these complications.

"If it was any other product, it would be recalled," he told Nursing Review.

"But I think for far too long we've taken them for granted and we seem to want to accept the unacceptable as clinicians and as patients as well. 

"Whether you're a patient or whether you're a clinician, I think everyone's just come to accept that, 'Oh, well, we're going to put one in. If it fails, we'll just put in another one.' But the issue is if you're on the other end of that needle and you might have difficult veins to cannulate, they could be having one, three, five attempts until they can get that cannula in. And that could be very distressing and very painful to patients."

Alexandrou says that hospitals have increasing presentations of DIVAs (patients that have difficult venous access); around 30 per cent of adult patients, and up to half of paediatric patients present to hospital with hard to see or hard to feel veins and the issue is placing a burden on the health system.

Another problem is the common places clinicians choose to place the PIVC. 

"They're usually placed in the areas of flexion. So, in the elbow crease or in the wrist, or in the top of the hand, which are areas of mobility, so typically it's very hard to stabilise the cannula there. And so it tends to move in and out of the skin, in and out of the vein, causing irritation, pain and swelling."

PIVCs have also become a fallback device, Alexandrou says, when a medication administered might be better suited to another device.

"It's really about that early planning, early escalation of the most appropriate device. At Liverpool Hospital we have this mantra: 'Right patient, right line, right time,'" he says.

"You've assessed the patient, you assess their vasculature or you've assessed their vessels. Is a cannula going to be accommodated? You think about the characteristics of the medication that's going to be given. You think about how long they're going to require that device. And that really is what should guide the type of device you're placing, not what is the most convenient to the clinician."

Just as important as planning or assessment is who physically places the cannula.

Global statistics show that 70 per cent of cannulas are placed by nurses, while that figure is only 26 per cent here in Australia, and Alexandrou believes that this can influence when a cannula is placed.

"In nursing schools in Australia, they are not taught to cannulate. This is usually done at a hospital, once they start working in a hospital. In a medical school, it is taught at an undergraduate level, typically in fifth year, but again, it's typically just breezed over," he says.

"Nurses are there all the time with the patient, there's a vested interest, and because they're not necessarily proceduralist, they see the consequences of failure and they're more likely to take the time and place [a PIVC] in a more appropriate position. And this has already been proven in the vascular access teams.

"In Liverpool [hospital], we have a vascular access service. We're like the hospital plumbers, and we take the time to place them in areas where they're not going to fail. And as an exemplar, when we place these devices, we have up to 70 per cent of these devices staying in until clinically indicated for removal."

The Management of Peripheral Intravenous Catheters Clinical Care Standard by the Australian Commission on Safety and Quality in Health Care (the Commission) outlines how to insert, maintain and remove PIVCs safely and effectively. It also describes the care that patients should expect to receive if they have a PIVC inserted during a hospital stay.

The new clinical care standard has been endorsed by 19 medical and nursing colleges and other professional bodies, including the Royal Australasian College of Physicians, the Australasian College for Emergency Medicine, the Australian and New Zealand Society for Geriatric Medicine, the Australian College of Nursing and the Australian Vascular Access Society.

"What the standards entail is to ensure that there is pre-planning. Is that device in fact actually necessary? Is there another route of providing the medication that the patient requires, whether that'd be orally or giving it through the tissue? Thinking about if we are going to place this device, what can we do to maximise first insertion success?" Alexandrou says.

"Thinking about medication characteristics and what's going through it, and is it appropriate to use a peripheral cannula? Thinking about ongoing management and partnering with consumers or patients so they have a very good idea of the types of device going to be placed, how it's going to be placed, and what they should expect in terms of ongoing management."

Alexandrou says that this standard is a great start to fixing the issue as it sets both clinicians and organisations in a mindset of a patient-centred approach to vascular access.

"But one solution that can come out of this standard, and it will address all aspects of the standard, is the implementation of nurse-led vascular access teams within the hospital."

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