Vascular access devices are essential to the administration of I.V. solutions and medications. Peripheral I.V. catheters (PIVCs) are the most frequently placed vascular access devices and the most common invasive procedure in healthcare. We hear nurses say, “It’s just a peripheral I.V.” However, PIVC failure rates are alarmingly high, with 33% to 69% of PIVCs failing before the completion of I.V. therapy. Annually, the United States purchases an estimated 350 million PIVCs. The high failure rate of these devices, coupled with their widespread use in healthcare, poses a significant risk to patient safety and underscores the urgent need for improvements in clinical practice.

Gaps in education and guidance

Many nursing students receive minimal formal instruction on infusion therapy and the use of PIVCs. Thus, significant gaps exist in education and training related to infusion therapy. The public generally expects healthcare professionals to have full competence in their practice upon completing post-secondary education. Furthermore, little standardization exists in PIVC education and competency programs across healthcare organizations for licensed nurses, which contributes to inconsistencies in preparedness and proficiency.

Despite published evidence-based standards of practice, the insertion, use, and care of PIVCs frequently is substandard, with inconsistencies between policy and practice. Several factors contribute to the failure of PIVCs, including a lack of risk awareness, acceptance of substandard care by patients, and nurses’ lack of knowledge, skills, and competence resulting in unnecessary patient harm.

Advancements in technology and new evidence continue to enhance practice, making it difficult for nurses providing direct patient care to keep up with the latest standards, such as the Infusion Nurses Society (INS) Infusion Therapy Standards of Practice (Standards), which is updated and published every 3 years. Many nurses providing direct patient care and nurse educators may not be familiar with the INS Standards or have access to or can read each standard and practice statement related to PIVCs and then apply them in practice. (Standards of practice promote safe care based on the latest research evidence and expert consensus; while guidelines are evidence-based recommendations that offer best practices.)

Impact on patients, nurses, and healthcare organizations

The negative outcomes of substandard PIVC use, care, and management impact patients, nurses, and healthcare organizations. Financial and human costs accrue with repeated PIVC cannulation attempts and PIVC failures due to complications such as phlebitis, occlusion/mechanical failure, catheter dislodgement, infection, and infiltration. These costs lead to increased nurses’ workloads, delays in patient care and treatment, increased use of supplies, and decreased patient comfort and satisfaction.

Guidance developed

Because PIVCs are used across all healthcare settings, their failure has far-reaching consequences that impact various areas of clinical practice and specialty care. To help address the issue of substandard PIVCs in healthcare, a multidisciplinary team of 15 experts in infusion therapy and vascular access formed to develop a guidance document for nurses, managers, and healthcare organizations. The collaborative team included a patient; nurses with experience in vascular access, infusion therapy, critical care, pediatrics, home infusion, nursing education, and nursing leadership; an infection preventionist; and a physician. The recently published, open access guidance document, Standards of Care for Peripheral Intravenous Catheters: Evidence-Based Expert Consensus, aims to positively impact the care for patients receiving a PIVC for their treatment by providing a comprehensive and concise tool that informs practice.

The team, led by a project methodologist, used the RAND/UCLA Appropriateness Method to develop best practice statements. This method is used to reach agreement to promote real world application of evidence. Two of the authors drafted best practice statements, which they compiled from published standards, including the INS 2024 Standards, published guidelines, and evidence. The panel of 13 experts then rated the statements and recommendations and revised the statements as needed. They sent the document to public comment, which resulted in 476 substantive comments. After reviewing those comments, the panel made revisions.

The final guidance document includes 123 recommendations within the following 16 domains:

1. Assess Intravenous Access Needs
2. Educate, Inform, and Collaborate with Patients and Caregivers
3. Clinician Education and Competency
4. Ensure Safety
5. Choose the Right Insertion Site and Device
6. Pain Reduction and Comfort Strategies
7. Maximize First Insertion Success
8. Insert and Secure
9. Routine Use and Post-Insertion Care
10. Ongoing Need
11. PIVC Removal
12. Documentation
13. Remove and Replace Only if Needed
14. PIVC Quality Management
15. Psychological and Cultural Safety
16. Health Equity and Social Determinants of Health

Conclusion

PIVCs are the most commonly placed vascular access devices in healthcare, with a high rate of failure cited in the literature and noted in clinical practice. As clinical experts, it’s our responsibility to provide guidance and education to the greater healthcare community who insert, care for, and use PIVCs in practice.

Beyond being clinicians, we may all one day experience the need for a PIVC or be the caregiver/family member of a loved one or friend receiving infusion therapy via a PIVC. The issue of PIVC failure impacts us all as clinicians, care recipients, and patient advocates.

This guidance document consolidated the current industry standards of practice to provide clinical guidance that promotes safety and improves patient care. The best practice statements can be used to create policy change, bring awareness to optimal PIVC practices, and improve patient outcomes. As a result of our publication team’s collaboration, other clinical organizations associated with patients who receive PIVCs endorsed this work, further demonstrating the importance of safe care for patients whose treatment includes PIVCs.

Endorsing Organizations

• Alliance for Vascular Access Teaching and Research • American Academy of Emergency Nurse Practitioners • American Association of Critical-Care Nurses • American Association of Nurse Anesthesiology • Association for Professionals in Infection Control and Epidemiology • Association for Safe Aseptic Practice • Association for Vascular Access • Beyond Acute Care Special Interest Group • Canadian Vascular Access Association • ECRI • Emergency Nurses Association • Infusion Nurses Society • International Nosocomial Infection Control Consortium • Pediatric and Neonatal Special Interest Group • Society for Healthcare Epidemiology of America • Society of Nurse Scientists, Innovators, Entrepreneurs & Leaders

Marlene Steinheiser, PhD, RN, CRNI®, is Director of Clinical Education for the Infusion Nurses Society in Norwood, Mass.

This project was funded by the AVA Foundation through the generous support of B. Braun Medical Inc. in the form of an unrestricted grant.

References

Cooke M, Ullman AJ, Ray-Barruel G, Wallis M, Corley A, Rickard CM. Not “just” an intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross-sectional survey of 25 countries. PLoS One. 2018;13:e0193436. doi:10.1371/ journal.pone.0193436

Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: Peripheral IV catheter failure. J Infus Nurs. 2015;38:189-203. doi:10.1097/NAN.0000000000000100

Hunter M, Vandenhouten C, Raynak A, Owens AK, Thompson J. Addressing the silence: A need for peripheral intravenous education in North America. J Vasc Access. 2018;23(3):157-65.doi:10.1016/j.java.2018.06.001

Marsh N, Larsen EN, Ullman AJ, et al. Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis. Int J Nurs Studies. 2024;151:104673. doi:10.1016/j.ijnurstu.2023.104673

Nickel B, Gorski L, Kleidon T, et al. Infusion therapy standards of practice. J Infus Nurs. 2024;47(1S Suppl 1):S1-285. doi:10.1097/NAN.0000000000000532

Ray SR, Taylor E, Sherrill KJ, Steinheiser MM, Berndt DL. Effect of infusion therapy interactive modules on nursing student’s knowledge and self-confidence. Teach Learn Nurs. 2022;17(1):109-12. doi.org/10.1016/j.teln.2021.10.006

Thompson J, Steinheiser MM, Hotchkiss JB, et al. Standards of care for peripheral intravenous catheters: Evidence-based expert consensus. Br J Nurs. 2024;33(21):S32-46. doi:10.12968/bjon.2024.0422