Change in practice: barriers and facilitators

Policy Change

The Center for Disease Control (CDC) endorsed the policy of replacing peripheral intravenous catheters (PIVC) within 48 hours following insertion in order to prevent and decrease local catheter infections. The institution that this author is employed at also made a policy to establish such a procedure based on the CDC's actions. However, there is a large body of empirical research that indicates that the length of the time that the PIVC remains in a patient does not appear to be a major factor that results and infections and/or phlebitis. Thus, this policy of changing the PIVC with 48 hours may be unnecessary.

For instance Zarate, Mandleco, Wilshaw, and Ravert (2008) studied emergency room trauma patients who received a PIVC. The mean number of days before there were indications of phlebitis in these patients was 3.14 days with the range of 1 to 6 days. Phlebitis rates did not differ significantly depending on who inserted the PIVC: nurses, technicians, or paramedics; however, even though instances of phlebitis were rare the rate of phlebitis doubled from nurse insertions of PIVCs to technicians and paramedics. Uslusoy and Mete (2008) found that insertion site (at the elbow) and having more than one IV inserted in the same site were significant risk factors of phlebitis. Lee et al. (2010) determined that minimizing unnecessary prolonged IV fluid infusion and avoidance of insertion in the lower extremity may significantly reduce the incidence of peripheral IV catheter-related soft tissue infection. Lee et al. (2009) found that evidence of phlebitis was more common in cases where catheters removed at between 48 -- 72 hours than those removed between 72 -- and other 131 hours. These studies also suggest that insertion of a catheter by personnel other than an IV therapist and the use of continuous and fusion to maintain patency are to important risk factors to consider for PIVC-related infections. Thus, there is a convincing body of evidence that suggests that there are other variables that contribute to infections in these cases and that the length of time that the IV remains in the patient is not a primary cause of complications like infections and phlebitis. Given this, the practice of changing or removing IVs within 48 hours should be reviewed and a policy implemented to allow a reduction of potential infections in these patients.

The institution in which this writer works is typically ready to hear proposals regarding change, but like most institutions that have potentially high patient liabilities for actual change to occur, there must be good solid reasoning behind the need for the change. So when an organization like the Center for Disease Control recommends a particular policy the particular institution that this writer is employed at pays attention. But the institution in question here is open and progressive. There is already a fair amount of diversity in the workforce and different ideas are discussed freely. The key to change in such an institution is to propose it through formal channels, especially if the changes will affect an institution-wide policy of patient care. If one can present solid empirical evidence for the proposed change one can get a hearing with the appropriate board. Like many institutions the actual change may take some time, but if one approaches the proper channels it is relatively easy to put the issue on the table and get people thinking about it.

Change in a healthcare facility is always going to be unsettling for certain employees. One of the issues that often occurs when a policy that involves nursing and those dealing with patients is about to be changed is the impression that the administration is trying to put more work on the staff. In this particular instance, the justification for a policy implementing less frequent replacing of PIVC's needs to be presented as a safety issue and not as a policy that simply makes for more useless work. Such a proposed change that is accompanied with empirically-based evidence that can demonstrate that the change actually reduces the workload over time would be one way to present this particular issue (of course the workload reduction is obvious). Therefore, if proposed in this manner one could expect that this particular issue would get support from physicians, nurse managers, nurses, and even administrators despite a possible slight increased in costs per patient (by using IV therapists). However, if the issue is not presented as a quality of care issue to physicians and administrators, a time-saving device to nurses and without empirical evidence and backing from a legitimate source, such a proposed change would most likely be met with little support.

Kurt Lewin (1947) proposed a model of change based on his field theory that is appropriate to utilize here. The model incorporates three stages of change:

1. Unfreeze or getting ready for change. When an organization has acted a certain manner for any length of time it becomes stuck in that particular pattern of behavior. The current practices and policies have become routine and the people in the organization are "frozen" in that particular routine. So in this stage we must ready the organization for change, we must "unfreeze" them.

A. First we need to approach the administration with a model for change that would be backed by empirical evidence such as that cited above. A formal proposal would be made to the administration. We can expect some discussion and resistance to the proposed change. This is why we need a strong body of empirical support and figures showing how the change contributes to the quality of care and also saves money.

B. The next step would be to offer mandatory in-services to physicians, nurse managers, and nurses explaining the issue and discussing the solutions. Within these talks we would include an outline of how the change be implemented so that the staff understands when and what will be expected of them the future.

2. Change, the implementation of the new policy.

A. Here we actually start formally changing the procedures having IVs inserted by IV therapists, altering the schedule of changing IVs, and making sure that the staff documents changes in the patient's conditions as these new changes are made. A team of nurses and physicians can evaluate the data and compare it to previous data to see if indeed there is any change in the rate of infections in these patients.