Treatment injury case study

Septicaemia from intravenous cannula site infection

Event: Intravenous cannulation
Injury: Septicaemia

September 2015 Issue 79

Jonathan, a 56-year-old gentleman, was admitted to hospital with congestive heart

failure and required intravenous medications and observation.
Jonathan presented to hospital in the early afternoon with fatigue and mild
swelling in his ankles. In the emergency department Jonathans nurse had
difficulty inserting an intravenous (IV) cannula as his veins were difficult to
locate and palpate. After two failed attempts a second nurse was requested
to make a third attempt and was successful in inserting and securing
a 20g IV cannula in the dorsal aspect of Jonathans right hand. A crepe
bandage was wrapped around the right hand and wrist to assist in securing
and supporting the IV cannula. Following investigations and medical
assessment, Jonathan was admitted to the medical ward with a diagnosis
of congestive heart failure and was administered IV frusemide.
On day two Jonathans condition was improving and he was switched
from IV frusemide to an equivalent oral dose. The IV cannula was left in
place, although he had no further medications charted to be administered
intravenously. The medical team decided to keep Jonathan in for a further
24 hours to monitor his condition, although documentation by nursing staff
reflected he was feeling good and keen to go home.
On day three Jonathan appeared generally unwell following an uneasy
night of fever and difficulty sleeping. Jonathans morning observations
identified that he was febrile with a temperature of 38.5C. Jonathan told
the nurse that he had a lot of discomfort and pain in his right hand at his IV
cannula site. The nurse unravelled the crepe bandage on his right hand and
noted that the IV cannula was loose, with the supportive tape peeling away

Key points
Perform cannulation in response to clinical need only
Cannula-associated infection is essentially avoidable
through compliance with key elements of care
The greatest opportunity for exposure to infection is at
insertion
Hand hygiene is crucial to achieve aseptic conditions for
insertion of an IV cannula
Appropriate skin preparation and sterile IV dressings
must be used to avoid the risk of IV cannula site
contamination
Cannula insertion attempts should be limited to no more
than two per inserter provided there is another suitably
qualified health care provider available
Assess the cannula site by using assessment tools such
as the visual infusion phlebitis score, which combines
observed signs and symptoms so the user can decide a
score out of 5, informing any action
Assess the cannula every shift for clinical need, ensuring
prompt removal at the cessation of treatment.

from the hand. The nurse also noted swelling and redness around the IV
cannula site, wrist and lower forearm. The IV line was unable to be flushed
and the nurse removed the cannula and took swabs, which were sent to the
laboratory. On reviewing the clinical notes, there was no documentation of
any phlebitis scores or the patency of the IV cannula.
The nurse attempted to resite the IV cannula; however, they failed to gain
access on two attempts. Further observations identified that Jonathan was
deteriorating. His temperature was now 39.1C despite cooling cares, and
his blood pressure was recorded as 84/61 with a heart rate of 116. Jonathans
level of consciousness was starting to decrease and his veins had become
increasingly difficult to cannulate.
The medical registrar was paged and arrived immediately to assess
Jonathan. She identified that Jonathan had likely septicaemia and
requested IV fluid and antibiotics to be drawn up while she attempted
to insert an IV cannula. After three failed attempts an IV clinical nurse
specialist (CNS) was called to attempt insertion. The IV CNS was able to
gain access and a new IV cannula was secured. Further blood samples,
including blood cultures, were taken and Jonathan was administered the IV
antibiotics and fluids.
Jonathans observations remained unstable and he was transferred to the
intensive care unit. After 24 hours his condition stabilised; however, he
spent a further four days in intensive care and required an intensive course
of IV antibiotics. Jonathans blood and swab culture results identified
methicillin-resistant Staphylococcus aureus (MRSA). Jonathans doctor
determined that he had developed septicaemia secondary to an IV cannula
site infection.
Jonathan had a prolonged hospital stay of two weeks due to the infection.
The medical registrar who was part of the team looking after Jonathan
completed a treatment injury claim form and lodged this with Jonathans
consent with ACC. Jonathan eventually made a full recovery and returned
to work.
ACC accepted a treatment injury claim for an IV cannula infection resulting
in septicaemia. ACC was able to assist Jonathan with compensation for
some of his lost income from his prolonged hospital stay.

Expert commentary

Carolyn Kirker, Clinical Nurse Specialist, Intravenous and Related

Therapies, Capital & Coast District Health Board (CCDHB) BN, PG Cert
Healthcare
Cannula-associated infection is essentially avoidable through compliance
with key elements of care. Cannulation and ongoing cannula use
education programmes must clearly identify the risks posed through poor
adherence, which can result in significant patient morbidity and even
death.
Hand hygiene moments must be performed before and after each contact
with the patient and the environment and immediately before cannula
insertion and manipulation. Gloves must always be used and other barrier
precautions may be needed to limit cross-contamination.

Case study

Documentation of insertion and ongoing use allows the early identification

of complications and premature device failure. Hospitals are advised
to ensure regular monitoring and reporting of complications, and use
assessment tools such as the visual infusion phlebitis score, which
combines observed signs and symptoms so the user can decide a score
out of 5, informing any action. Patients should be educated to report
immediately any concerns such as pain, burning, swelling, tingling or
bleeding to their health care professionals (HCPs).
Cannula insertion in patients with difficult veins should only be attempted
by experienced HCPs, as the risk of injury and infection increases with
every attempt. Attempts should be limited to no more than two per
inserter, provided there is another suitably qualified HCP available. Many
hospitals have advanced vascular access health professionals who can
assist with this.
The greatest opportunity for exposure to infection is at insertion. Recent
studies have found no statistically significant difference in rates of
complication between patients whose cannulas were changed routinely at
72-96 hours and those changed when clinically indicated. Presently, most
New Zealand hospitals are maintaining 72- to 96-hour routine cannula
replacement policies.
The two best infection prevention strategies continue to be:
1.

perform cannulation in response to clinical need only and not just in

case

2. assess all cannulas every shift for clinical need, ensuring prompt
removal at the cessation of treatment.

How ACC can help your patients following treatment injury

Many patients may not require assistance following their treatment injury.
However, for those who need help and have an accepted ACC claim, a
range of assistance is available, depending on the specific nature of the
injury and the persons circumstances. Help may include things like:
contributions towards treatment costs
weekly compensation for lost income (if theres an inability to work
because of the injury)
help at home, with things like housekeeping and childcare.
No help can be given until a claim is accepted, so its important to
lodge a claim for a treatment injury as soon as possible after the
incident, with relevant clinical information attached. This will ensure
ACC is able to investigate, make a decision and, if covered, help your
patient with their recovery.

ACC7275 ACC 2015

Printed on stock that complies with environmentally

responsible practices and principles. Please recycle.

1 OF:
2 OF:

Use sterile, semi-permeable dressings that control moisture at insertion

sites and allow visual inspections during periods of ongoing device use.
Correct securement with sterile tape minimises cannula micro movements
causing secondary site contamination from the skin, and prevents accidental
dislodgement. If high-flexion sites must be used, adequate splinting will
help to reduce the risk of injury through accidental dislodgement.

Slight pain near IV site

Slight redness near IV site

0
1

Pain at IV site
Erythema

Swelling

ALL OF:

To achieve asepsis, insertion (key) sites must be prepared using 0.52% chlorhexidine gluconate and 70% alcohol or 10% povidine iodine
preparations (if chlorhexidine sensitivity exists). Cleaning applications must
include the use of friction and an allowance for drying. Care must be taken to
not re-touch key parts and sites after cleaning.

Phlebitis Score Card

Pain along path

of cannula

Erythema
Induration

ALL OF:

Contamination can occur from the patients resident flora via the skin or
through haematogenous spread. Equally, cross-contamination can occur
through poor aseptic manipulation of sterile equipment.

Current professional standards guidelines

Pain along path

of cannula
Erythema

Palpable
venous cord
Induration

ALL OF:

Intravenous therapy procedures must be performed using non-touch

techniques that identify and provide key part and key site (sterile or
cleaned components that can directly or indirectly come in to contact with
the bloodstream) protection.

Pain along path

of cannula
Erythema
Induration

Palpable
venous cord
Pyrexia

IV site appears healthy

no signs of phlebitis

Observe Cannula
possible first signs

Observe Cannula
early stage of phlebitis

Resite Cannula

mid-stage of phlebitis

Resite Cannula
Consider Treatment
advanced stage of phlebitis
or start of thrombophlebitis

Resite Cannula
Consider Treatment

advanced stage of thrombophlebitis

Initiate Treatment
Resite Cannula

Visual infusion phlebitis score, CCDHB 2015.

References/Websites
1. Centers for Disease Control. (2011). Guidelines for the Prevention of
Intravascular Catheter-related Infections. Retrieved from www.cdc.gov/
hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
2. Department of Health. (2011). High Impact Intervention: Peripheral
Intravenous Care Bundle. Retrieved from: http://webarchive.
nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/whatdoido/
high-impact-interventions/
3. Goosens, G. & Hadaway, L. (2014). Key strategies for improving
outcomes of patients with peripheral venous catheters: Report of an
international panel discussion. Journal of Advanced Vascular Access. 19 (3),
135-137.
4. McCallum, L. (2012). Care of peripheral venous cannula sites. Nursing
Times. 108 (34-35), 13-15.
5. Moureau, N. (2009). Are your skin-prep and catheter maintenance
techniques up to date? Nursing (May), 15-16.
6. Rowley, S. & Laird, H. (2006). Aseptic non touch technique in practice. In
E. Trigg & T.A. Mohammed (Eds.) Childrens Nursing: Guidelines for hospital
and community. Churchill Livingstone: Edinburgh.
7. Webster, J., Osborne, S., Rickard, C.M. & New, K. (2015). Clinicallyindicated replacement versus routine replacement of peripheral venous
catheters (Review). The Cochrane Library, 8, 1-45.
8. World Health Organization. (2009). WHO Guidelines on Hand Hygiene
in Health Care: First global patient safety challenge, clean care is safer care.
Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK144013/

Claims information
Between July 2005 and the end of June 2015 ACC made 4127 decisions
relating to venous access claims. These claims involved the following
events: venous puncture, IV cannulation and venous catheterisation. Of
these decisions, 3291 (80%) were accepted.
The most common injuries caused by venous access events related to
infection, which accounted for 47% of all accepted venous access claims.
Other injuries included haematoma (20%) and nerve injury (13%).

About this case study

Sharing information to enhance patient
safety
This case study is based on information amalgamated from a number of
claims. The name given to the patient is therefore not a real one.
The case studies are produced by ACCs Treatment
Injury Centre, to provide health professionals with:

an overview of the factors leading to treatment injury

expert commentary on how similar injuries might be avoided in
the future.
The case studies are not intended as a guide to treatment injury cover.
Send your feedback to: TI.info@acc.co.nz