[HIPSLEY, Kate]

Thanks for the topic Richard, and thanks Lindy for the kind words.

Paramedics are trained and credentialed to perform IV cannulation, however is impossible to guarantee that all NSW Ambulance inserted cannulas are done aseptically. They could be inserted in people’s bedrooms, in bathrooms or toilets, on sporting fields or in confined locations eg MVAs and in every different possible weather condition.

We have worked to improve our procedure (chlorhexidine/alcohol swabs used), equipment and dressing/labelling techniques. We have also worked to address attitudes regarding cannulation ie does this patient need a cannula? If the paramedic intends to, or thinks they may need to provide IV treatment, then they should cannulate. However we discourage those cannulas that are only done to make the hospital / triage staff happy.

Our procedure is to document the date and time of IVC insertion on the IV dressing, and then because our IVC dressings look like hospital IVCs, the procedure stipulates a yellow AMBULANCE INSERTED sticker be placed on all of our IVC dressings. Hospitals can then decide which AMBULANCE INSERTED cannulas to change, remove etc on a local basis.

We currently ask 4 Local Health Districts (LHDs) in NSW to provide quarterly feedback about any SABSIs they have identified related to NSW Ambulance inserted cannulas. We investigate each report, request feedback from the inserting clinician and then feedback to our Clinical Governance Committee. We also appreciate any LHD or facility approaching us directly with this information at any time – see my contact details below.

The majority of SABSIs reported to us are related to Ambulance IVs that are kept in by the facilities for an extended period of time and usually >24 hours.

Happy to discuss off line as needed.

Regards to all,
Kate Hipsley
Manager, Infection Control | Clinical Services
Balmain Road, ROZELLE NSW 2039
p: 02 9320 7868 | m: 0428 238 789 | f: 02 9320 7729 | khipsley@ambulance.nsw.gov.au
http://www.ambulance.nsw.gov.au
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Dear Andrew

No we have not taken this direct approach at present but other work has been undertaken to address this concern & I largely can only speak for my experience what I also know NSW ambulance are doing which is being driven by Kate Hipsley their Infection prevention & control manager and data I have to hand locally . Other sites within NSW may have a different view

In NSW all PHO (including ambulance ) are guided by our PIVC insertion & post insertion GL (attached) and in feedback from stakeholders such as ambulance it was identified that not ALL PIVCs that are inserted by them are undertaken in an emergency situation and I am assured by Kate Hipsley (NSW Ambulance ICP) that they are assessed to insert using PIVCs using aseptic technique in the first instance and are they are also required to place an big yellow AMBULANCE insertion sticker and date indicating they are inserted using aseptic technique, which I know Kate reviews and audits as she can ( …when she came to my site recently to do some workshops with local command to do VHF training she also spent some time checking pts arriving via ambulance with PIVCs inserted as they came in the ED door ……along with their Hand hygiene & cleaning etc….so although sporadic I saw for myself at the coal face that the message is slowly getting through…. They all knew who she was and what she was looking for …she is a bit of a superwoman …I reckon!!! ).

So If they are inserted in an emergency situation by ambo then they wont be stickered and yes do need to be reviewed re if they are needed and replaced….

Interestingly Additional Feedback from other NSW stakeholders prior to the release of NSW PIVC guideline – particularly rural/ remote / smaller PHO indicated that they may not always have another person available to re sight a PIVC (particularly if the person had difficult / poor access as part of their condition- chronic/acute etc ) that get inserted in an emergency situation or arrive at their service/ clinic with an ambo inserted PIVC to be able to readily change them (even within 24hrs) – so the NSW guidelines considered the feedback and decided to not just target ambulance but to provide advice as per below & the time frame to be a recommendation rather than a mandate to raise (& also to in the first instance to consider if there is even a need to have another inserted – rather than just routinely change as standard)

9.4.4 Remove PIVCs that may have been inserted without full aseptic procedure (e.g. emergency situation) as soon as practical, preferably within 24 hours, and replace if clinically warranted.

I do know that Our NSW Ambulance Infection Prevention & Control manager Kate Hipsely has undertaken a lot of great work and consultation with her ambulance management & staff across NSW in regard to insertion, care, documentation and management of PIVC and she is constantly engaging NSW ICPs/ facilities regarding PIVC/BSIs infections related to ambulance insertions – so she would be best placed to provide feedback on what NSW is seeing in regard to ambulance inserted PIVC related infections/BSI from her end. Perhaps your Victorian ambulance service Infection control officer is doing something similar?

I know from my experience I don’t recall coming across any pts that I have been able to directly link to BSI’s here or in my previous role to ambos in a long time …although not so sure about PIVC site infections (as I don’t believe I can hand on my heart that I get them all reported to me …no matter how much I ask/ push staff to report ..so cant be 100% here!) & I have like many ICP s agreed to provide Kate with data/ feedback if & when we do see any infections from ambo PIVC insertions (so she can follow up to assist with evaluating the work she has been doing) ) .

Also I am unable to clearly define that the PIVCs/BSIs I am seeing are directly related to urgent/ emergency insertions ….in this and my last role its seems I saw more cases related to ?poor compliance with asepsis during standard insertion procedure (+ documentation)… and more markedly post procedure care & monitoring (+documentation again)…often the boxes are ticked on the paperwork but when I speak with the pts there are differences???… again it seems we still insert too many routinely and do not get them out quickly enough given staff now seem to see them as normal part of a pt being in hospital and a safety thing for them to have access & not as a dangerous risk…… (although our insertion/aseptic technique audits say we are doing fine???) …my current data on PIVC infection is low though so I may be a little harsh & picky….

Given we all know that insertion for PIVCs is the highest risk point for an infection we are all hoping to avoid unnecessary PIVC insertion where we can …hence me acknowledging Kate from NSW ambulance ICP has been very proactive & forward thinking with her managements support in promoting and educating around preventing PIVC even needing insertion by Ambos if no access is needed based on pt condition …even if they are needing to be transferred to an acute service (again I think you could contact her re feedback with the success around with reducing this risk and what data she may be getting from other ICPs re PIVC infections related to ambo insertion)

In a former role a decision was made / supported by senior clinicians/ dept. head in one area where they were seeing higher BSI rates related to PIVCs that the medical team would be required to consider / agree to pts ongoing need to have a PIVC institute as part of accepting their admission to the ward (s) & they if they did need to have a PIVC they had to check & document their condition every day as part of their medical daily review standard checklist protocol for the JMO

The department head would get a daily base count number of how many pts in each ward had a PIVC & challenge them as to why there was that number) . It was actually amazing to see the number of pts each day in the ward(s) with a PIVC dramatically decrease as a result almost instantly and hence the BSI rate decrease (maybe not a very scientific approach but it worked) ……..perhaps its education/ processes/ joint management- clinician push re getting staff to consider other options & not insert / remove more promptly and alternate therapy considered more rapidly rather than to look to mandating replacement in the first instance? Just a thought …I know there are far more experts in IV insertion, management and data than me who may have more value to add?

Anyhow hope this feedback useful

Kind regards

Lindy

Lindy Ryan

Infection prevention & Control Clinical Nurse Consultant (CNC) | Coffs Harbour Health Campus
Pacific Hwy Coffs Harbour NSW 2450
Tel (02) 6656 7770 | lindy.ryan@ncahs.health.nsw.gov.au
http://www.health.nsw.gov.au

Hi Everyone,
At Western Health currently the procedure for Peripheral IV cannulas (PIVC) inserted by ambulance personnel in the community, and any PIVC that are inserted in a non-sterile manner in hospital (e.g. emergency situation) are resited within 24 hours. Due to an increase in cannula related infections and amongst other actions, which I’m happy to share, we are also considering to resite all PIVCs inserted by ambulance and all those inserted in the Emergency departments immediately after admission to the wards rather than within 24 hours.
Has any other hospital taken this approach?

Regards,
Richard

Richard Bartolo
Manager Infection Prevention
Western Health
Gordon Street, Footscray VIC 3011
Ph. 03 8345 6113 Pager. 03 8345 6666 No. 506
Mob. 0438 560 441
Email. richard.bartolo@wh.org.au
Web. http://www.westernhealth.org.au

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