Mind the gap! Guideline implementation for peripheral venous catheters in paediatric care : documetation, complications, adherence and context

Introduction: There is a knowledge translation gap between evidence, based on research findings and clinical practice. Clinical practice guidelines (CPGs) have been proposed as a strategy to condense and disseminate research findings. However their existence alone does not minimise the gap, they have to be implemented in everyday practice. Registered nurses’ (RNs) work context influences their research use, but little is known on what contextual factors that influence RNs’ adherence to CPGs. Computer reminders have shown potential to minimise the knowledge translation gap, but insights into their effect on patients’ outcomes, RNs’ adherence and in what context they are most effective is still understudied.

Aim: to evaluate the effects of implementing recommendations from a CPG for peripheral venous catheters (PVCs) as reminders in electronic patient records (EPR) and to describe factors of importance for the implementation process and outcomes.

Methods: the setting for all four papers was a large paediatric university hospital in Sweden. Data for paper I was collected from 14 inpatient units through observations of patients and PVCs, and audit of EPRs. This was carried out at baseline and than two times after implementing a documentation template for PVCs. Data on PVCs and patients for paper II were retrieved from the EPR at 12 inpatient units, divided into neonatal and paediatric units. Paper III was a cross-sectional survey, including 23 in- and outpatient units. Data was collected through a questionnaire concerning RNs’ adherence to CPG recommendations and their work context, measured by the Alberta Context Tool (ACT). Paper IV was a cluster randomised study, at 12 inpatient units, with computer reminders based on the CPG. A stratified randomisation of units, based on occurrence of PVCs, was performed. The primary outcome was documented signs and symptoms of PVC-related complications at removal and secondary outcome was RNs’ adherence to the CPG, and their work context measured by the ACT.

Results: A statistical, not clinical, significant increase of PVCs with complete documentation was the result of the PVC template. One of the 22 complications observed at baseline was documented and none of the complications (n=17 and n=9) post-intervention (paper I). Just over one-third (35.4%) of the patients were affected by a PVC-related complication, with infiltration and occlusion occurring most frequently. Complications were more common in younger age patients (paper II). Work context, in the form of structural and electronic resources, information sharing activities, and evaluation, was in different ways associated with RNs’ adherence to the CPG recommendations (paper III). Ninetyone percent of the RNs adhered to the CPG recommendation of disinfection of hands, 64% to usage of disposable gloves and 54% to daily inspection PVC insertion site (paper III). There was no significant effect of the computer reminders, neither on PVC-related complications nor on RNs’ adherence to the guideline recommendations (paper IV). RNs score of their context in both groups (intervention and control) varied from moderately low to moderately high.

Conclusion: The EPR did not provide accurate data on PVCs either before or after the implementation of a PVC template. PVC-related complications, specifically infiltration and occlusion, were common, particularly among younger aged patients. RNs adhered to the recommendation on disinfection of hands, while the use of disposable gloves and daily inspection of PVC insertion site showed greater improvement potential. Diverse contextual factors were in different ways associated with RNs’ adherence to the CPG recommendations. The computer reminders did not have any significant effect on PVC-related complications, or on RNs adherence to the CPG recommendations.

List of scientific papers

I. Förberg U., Johansson E., Ygge B-M., Wallin L. & Ehrenberg A. Accuracy in documentation of peripheral venous catheters in paediatric care: An intervention study in electronic patient records. Journal of Clinical Nursing. 2012 May;21(9-10):1339-44.
https://doi.org/10.1111/j.1365-2702.2011.03949.x

II. Unbeck M., Förberg U., Ygge B-M., Ehrenberg A., Petzold M. & Johansson E. Peripheral venous catheter related complications are common among paediatric and neonatal patients. Acta Paediatrica. 2015 Feb 5.
https://doi.org/10.1111/apa.12963

III. Förberg U., Wallin L., Johansson E., Ygge B-M., Backheden M. & Ehrenberg A. Relationship between work context and adherence to a clinical practice guideline for peripheral venous catheters among registered nurses in paediatric care. Worldviews on Evidence-Based Nursing. 2014 Aug;11(4):227-39.
https://doi.org/10.1111/wvn.12046

IV. Förberg U., Unbeck M., Wallin L., Johansson E., Petzold M., Ygge B-M. & Ehrenberg A. Effects of computer reminders on complications of peripheral venous catheters and nurses’ adherence to a guideline in paediatric care - a cluster randomised study. [Submitted]