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Only recently have ward nurses been authorised to insert intravenous cannulae. This paper is a report of a ward-based quality improvement project undertaken to assess the effects of nurses performing cannulations, mainly in terms of waiting times. The study was conducted over two, one -month periods, the first month when only medical officers cannulated, and the second month when both medical officers and nurses cannulated. Differences in waiting times were found. When medical officers performed cannulations, patients waited an average of 3.2 hours, whereas when nurses performed cannulations, patients waited an average of 10.66 minutes. This study also looked at the reasons for these delays, and the major reasons for cannulations. Areas for further research are suggested.
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Nurses note problematic situations, and many have alternative views or solutions to such situations. But how can these different solutions or ideas be tested? One method of monitoring a problem and identifying strategies to improve the situation is the quality improvement process.
Quality improvement projects are relatively simple in design and offer an ideal method to enable health care professionals to evaluate their work practice and make improvements. They also provide a more formal way to document problems that have been suspected but not investigated.
This paper is a report of a ward-based quality improvement activity undertaken by nursing staff in 1992 on a 36 bed orthopaedic ward, to evaluate existing practice, identify problems and make suggestions for improvement.
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During a group discussion among nursing staff on the orthopaedic ward, concern was expressed in regard to the length of time patients waited for insertion of intravenous cannula. Nursing staff felt that there were lengthy delays, particularly between the time that a cannula has tissued, and the time of recannulation, and that these delays could affect patient well-being. Many of the patients on the orthopaedic ward required intravenous cannulation for hydration and/or antibiotics, so any delays in cannulation could affect a patients fluid status and/or their infection risk. Nursing staff therefore recommended that the situation be investigated, and three staff members volunteered to coordinate the study.
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Discussion highlighted the fact that no-one knew exactly why these delays occurred or how long these delays were. From this discussion it was decided a study be undertaken to:
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Initially the study was designed to look only at cannulations performed by medical officers. However, because nursing staff on the ward were to be authorised to cannulate, it was decided the study should be divided into two parts, where part one of the study looked at cannulations performed by medical officers, and part two included cannulations performed by both medical officers and nurses. It was felt that by dividing the study into two parts it would enable a comparison to be made between nurse cannulation and medical officer cannulation (particularly in regard to waiting time).
Three registered nurses designed a ward cannulation notice board for data collection. This board was displayed in the main office of the ward above the telephone station, for all staff to see. The following information was recorded on the notice board;All ward staff (ward clerk, nurses, resident medical officers) were alerted the study and the need to record any cannulation that took place in the ward.
It was decided to undertake this survey for one month, firstly to assess ward need over a reasonable time, and secondly, to achieve a workable data base large enough from which to draw conclusions. Data collection for part one began on the 6th August 1992, and finished on the 6th September 1992.
A similar format of data collection was used for part two as for part one, with a minor alteration to the data collection tool. The additional information of 'nurse performed' and 'medical officer performed' cannulation was included for part two of the study.
Part two of the study was also conducted over a one month period, commencing on the 6th November, 1992, and finishing on the 6th December, 1992.
Throughout this one month period one registered nurse was authorised to cannulate, and two other nurses had completed the education component for cannulation, but were still learning to cannulate under the supervision of an assessor (usually another nurse experienced in cannulation or the Intravenous Therapy Nurse Consultant).
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Table 1 illustrates the number of cannulations performed during each one month period and gives the time delays experienced during these periods. The results show the number of cannulations on the ward was similar for both time periods, with 46 cannulations recorded for the first month, and 44 for the second month.
An interesting point to note is that of these 46 cannulations recorded for part one, 40 were recannulations. Part two recorded a similarly high proportion of recannulations (Table 2). Unfortunately this study did not look at the reasons for a cannula resite, that is, did the original cannula tissue, or had the cannula been inserted for the recommended period of time and therefore required changing?
| Part One | Part Two | |
| Time period | 06/08/92 to 06/09/92 | 06/11/92 To 06/12/92 |
| No. of cannulations recorded | 46 | 44 (29 RMO, 15 Nurse) |
| Time delay [min to max] | 30 mins to 6 hrs | 10 mins to 7.5 hrs (RMO) 0 to 1 hr (Nurse) |
| Time delay [average] | 2.989 hrs | 3.2 hrs (RMO) 10.66 mins (Nurse) |
Table 1: Number of Cannulations and Waiting Times
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| Recannulation |
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| Initial Cannulation |
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| Long Line |
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| Non resite [patient commence on orals] |
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| Central line |
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Table 2: Type of Cannulation
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| IVI Antibiotics |
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| IVI Hydration only |
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| IVI Hydration and blood products |
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| Unknown |
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1 |
Table 3: Reason for Cannulation
Table 3 illustrates the main reasons that patients on the ward during the study required intravenous cannula. For both parts of the study, the majority of patients require a cannula for intravenous antibiotic therapy, indicating a high use of antibiotics on the ward.
The waiting time for RM-performed cannulation was similar for both study periods. Surprisingly, a slight increase in length of waiting time was recorded during part two of the study, when medical staff and nurses were cannulating. A factor which may have contributed to this increase in waiting time was the insertion of a central venous line during the second part of the study. Quite lengthy delays are commonly experienced for this type of line insertion, and hence, this delay time may have affected the results obtained for part two of the study.
The average waiting time during part one was 2.989 hrs, with a maximum delay time of 6 hrs. This appears to be a significant waiting time that would have affected patient well-being, and impacted on nursing work.
During part two the average waiting time for medical officer performed cannulations was 3.2 hours, whilst the average waiting time for nurse performed cannulation was 10.66 minutes, an appreciable difference.
Nurse performed cannulation, as can be seen in this study, significantly reduces waiting time. Reduction in waiting time is beneficial to patient well-being due to many factors, the most important of which are continuity of circulatory antibiotic levels and the achievement and maintenance of adequate fluid status.
The two major reasons identified for the delays in medical officer performed cannulation were identical for both parts of this study (see Table 4 and Table 5). Medical officers in both parts of the study were unable to attend the ward to cannulate patients because of their work commitments in the orthopaedic operating theatres, another ward, or the pre-admission clinic. This highlights the need for review of medical officer rostering to provide adequate attention to ward patients.
The main reason given for the delay in nurse performed cannulation was in regard to workload, for example, other patient care activities or ward related matters. Delays were also experienced when a nurse required supervision with cannulation and a supervisor was unable to attend immediately. As more nurses are authorised to cannulate, a further reduction in waiting times would be expected.
The section titled "Other" included various factors such as the medical officer was unable to be contacted, pager did not receive message, or pager not turned on. |
Table 4: Reasons give for delays in Cannulation Part One
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RMO
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NURSE
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Table 5: Reasons given for delays in Cannulation Part Two
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This quality improvement activity has indeed shown there are actual delays in cannulation times, and has identified some common causative factors for these delays. However, while a difference has been identified between nurse performed cannulation and medical officer cannulation in regard to the length of time patients wait before a cannula is inserted, further investigation is required to determine the effects of such delays. How much are patients compromised in terms of fluid status and antibiotic cover? Exactly what effects do the delays have on patient well-being and patient outcomes? Are there differences in infection rates between nurse performed cannulations and medical officer performed cannulations?
This study also highlights the high proportion of recannulations that occur on the ward. Further investigation is required to determine the reason for this. How many of the resites had the initial cannula inserted on another ward, and who inserted the initial cannula? What is the average length of time cannulae remain in situ before requiring recannulation? This information may assist in improving cannulation technique by identifying problems occurring with cannulation.
While the number of cannulations required during both study periods was similar, those cannulations performed by medical staff were dramatically reduced during the second part of the study. Unfortunately this study does not enable a thorough assessment of the effects of nurse performed cannulations. It would be interesting to assess the impact of this reduction in cannulations performed by medical staff, on the workload of medical staff.
Perhaps such a study could address the issue of medical officer workload decreasing to some extent. It would also be of interest to note how medical officers view the role of nurses performing cannulations.
One cannot help surmise that with the introduction of more registered nurses accredited for cannulation, a further reduction in medical workload will occur. Whether this will increase, noticeably, registered nurses' clinical work is yet to be seen. It is worthy to note that a literature search has shown no studies have, as yet, addressed nurse initiated cannulation, the positive and the negative effects. One area suggested for further, more structured research, is that of nurse job satisfaction with relation to increased workload/autonomy in relation to nurse performed cannulation.
Not obtained on the data collection sheet, but commented on by several patients, was the fact that nurse performed cannulation was more comfortable. Could this be attributable to the use of local anaesthetic (Xylocaine 1%) by all registered nurses cannulating, as recommended in the cannulation workshop attended prior to cannulation experience? Did medical staff use local anaesthetic and wait an appropriate time for maximum anaesthetic effect to occur? This could prove an informative area of study for further examination. The nurse-patient relationship may also contribute to the attitude held by patients that nurse performed cannulations were more comfortable. However, this requires further investigation before conclusions can be drawn.
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The original aim of this quality improvement study was to identify time delay for cannulation and reasons the delays. Not only has this study accomplished this, it has also highlighted several other areas of interest to nursing staff, worthy of further research.
This paper illustrates one of the benefits of undertaking a ward based quality improvement activity - to highlight a problem, answer some of the proposed questions and suggest ways of improvement. The next step will be to decide upon an action, implement the action, and evaluate the effects of the action on waiting times.
Quality improvement can also been seen as a precursor to more formal research, not only suggesting areas for study but also providing the necessary motivation to carry out such research. Out of this project have come suggestions for many other areas worthy of research that would provide valuable, usable information.
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