Barriers to and attitudes towards the use of safety engineered devices for paediatric cannulation in emergency care.

This article describes a report of the attitudes towards and barriers to the use of safety cannulas in paediatric patients. The evaluation was prompted by a lack of engagement from both doctors and nurses who continued to use non-safety-engineered devices (non-SEDs) after safety-engineered devices (SEDs) were introduced into a paediatric emergency department (ED). A survey was conducted among doctors and nurses working in the paediatric ED with questions focusing on the participants' clinical experience, views on safety, access to training and device preference, providing both quantitative and qualitative data. The findings highlighted several issues, including a difference in opinion between professional groups towards safe sharps. Significant differences in access to training and education between doctors and nurses were also identified; including those with up-to-date training appearing more likely to use a SED than those without. Recommendations including strategies for improving compliance have been proposed, with a plan to conduct a clinical audit to measure compliance at a later date.

Keywords: Cannula; Safety-engineered-devices; Non-safety engineered devices; Education; Paediatric; Compliance

This article describes the results of a survey of compliance rates in the use of safety cannulas in a paediatric emergency department (ED) in the author's trust. The report was prompted by the witnessed lack of engagement from doctors and nurses who continued to use non-safety-engineered devices (non-SEDs) after safety-engineered devices (SEDs) had been introduced.

This research focused on evaluating and exploring the change to, and clinical acceptability of, safety products when performing cannulation in paediatric patients. A literature search found no studies looking at the clinical acceptability of safety devices and health professionals' behaviour towards the use of safety devices in paediatrics. The main themes discussed in this article include device preference, compliance, education and the barriers that impact on the need to bring about change in attitudes and behaviours towards SEDs in paediatrics.

One in three patients in the UK will have at least one cannula inserted during their stay in hospital ([23]). It is a procedure that is vitally important to get right, and to get right safely, to minimise the risk of causing harm to patients and clinicians ([1]).

An important resource for medical and nursing staff, to help them assess and select the best vascular access device to meet the individual patient's needs and to preserve veins for future use, is the Vessel Health and Preservation (VHP) Framework ([17]). The framework aims to establish a standardised approach to vascular access to promote best practice ([12]).

The insertion of peripheral intravenous cannulas (PIVCs) is one of the most frequently performed procedures in paediatric EDs ([24]). The success rates in paediatric cannulation depend on a range of factors, including the clinician's experience, access to training, choice of device, vessel health and the patient's compliance ([6]).

Risks associated with needlestick injuries (NSIs), such as the transmission of blood-borne pathogens, including hepatitis B and HIV, is relatively low in paediatric settings in comparison to adult areas ([13]). Regardless, the procedure can still cause an element of psychological fear among health professionals who are performing or assisting with the procedure ([6]). [19] stated that these levels of fear can significantly increase when dealing with a scared or uncompliant child. Such a situation could lead to an NSI or a patient safety incident. [7] found that nurses working in stressful conditions in EDs, with a lack of organisational arrangements and support, can experience NSIs.

One way of reducing NSI-related complications is by choosing an appropriate safety device ([22]).

Whereas the introduction of SEDs is associated with a substantial decline in NSIs compared with non-SEDs ([10]), they are not widely embraced across all acute paediatric settings. The [14] published guidance on the use of sharps, stating that the exclusive use of SEDs 'must not compromise patient care'. As 'ease of use' is another factor the HSE stated should be considered, this allows for some flexibility so that non-SEDs can be available as well, in specific circumstances.

With a lack of literature on this topic, and with the support of a clinical specialist team from medical devices and technology company BD, the author conducted an evaluation of the use of the 24-gauge safety PIVCs that were introduced into the paediatric ED setting in the author's trust. The purpose of the project was to explore and evaluate the barriers, behaviours and attitudes of doctors and nurses towards the use of safety devices in a paediatric setting.

The rationale for this review came after 24-gauge SEDs were introduced into the paediatric ED and received a lot of negative criticism. Initially, there was no clear reason why health professionals seemed to prefer using non-SEDs. When clinicians and nurses discussed the matter, it was highlighted that the design of the SED was an issue during the insertion and securing stages; particularly with the infant and neonatal patients.

Further enquiry concluded that the insertion technique used with PIVCs (widely adopted across both nursing and medical teams) did not meet [15] guidance for the insertion of cannulas. Furthermore, 'bad habits' were identified among users, such as the 'fishing' or 're-insertion' technique, as described by [1].

Non-SEDs continued to be used in the paediatric ED despite the standardisation of SEDs in all other clinical areas within the trust. This raised the question of why health professionals were reluctant to use SEDs in paediatric patients despite local trust policy and the [22] guidance on using SEDs.

Up to 80% of hospitalised children require insertion of a PIVC for treatment such as intravenous fluids and antibiotics, yet despite its frequent use, paediatric cannulation is not without risk ([5]). Local and national studies have demonstrated that, even after successful insertion, some paediatric PIVCs are associated with high rates of local and systemic complications, including infiltration, extravasation, phlebitis, embolism and dislodgement ([15]). According to [1], harm associated with insufficient IV cannulation training, including line care and management, is an under-recognised patient safety issue.

[8] described a cannula embolism as one example of many consequences caused by poor insertion technique. Cannula emboli can occur when a piece of the cannula breaks off while the cannula is in situ within the patient's vascular system ([1]). It is most likely caused by reinsertion of the stylet into the cannula ([18]), often referred to as 'fishing' during insertion of a PIVC. SEDs are designed so that reinsertion of the stylet into the cannula is impossible once the needle has been retracted and the safety mechanism activated. The design stops users adopting the 'fishing' or 're-insertion' techniques, reducing the risk of complications and overall promoting correct and safe cannulation practice ([15]).

Changes to practice are frequent occurrences in healthcare, with evidence-based practice dictating the protocols followed and the recommended products to use, making change a complex and challenging process ([3]). Understandably, there is always concern about the risk of patient harm associated with a lack of clinical skill or following dated practice, especially when contemporary training and equipment are available. [2] noted that adapting to product change requires a combination of technological- and people-oriented solutions, never one or the other.

Establishing the needs and wants of the clinicians enhances the patient's experience in the insertion of a PIVC. It also provides pertinent information to NHS suppliers, so that they can improve the quality of products used if needed and to trusts to develop the clinical team's knowledge and skills through education and introducing evidence-based changes to clinical practice.

Gauge-24 safety peripheral intravenous cannulas (SPIVCs) were introduced to the author's paediatric ED in 2019 in keeping with the trust's vascular access policy that safe products should be used in all clinical settings trust wide. This process was carried out in accordance with the trust's procurement team. Information brochures on how to use the new devices were circulated and in-house support from trained users was available, as well as external support if required from the clinical specialist team at BD. Evaluation forms were completed throughout this period and 100% of returned surveys stated that users would 'Definitely/Probably' use the SPIVCs. Following the procurement process and evaluation, SPIVCs became a permanent item on the stock list for the paediatric ED.

Within the first 2 months of their introduction, however, there were a number of comments and issues raised regarding the SPIVCs, specifically when cannulating babies and infants (children under 2 years of age). This negative criticism did not reflect the themes in the preliminary evaluation, which raised the question of why these issues had not been captured during the product-selection phase.

Fourteen surveys were completed during the procurement phase, which accounted for less than 30% of the medical staff who performed cannulation in the paediatric ED. Clinicians who did not complete the evaluation reported that this was because they still had access to non-SEDs, they opted to use what they were comfortable with and had not tried the SPIVC during the procurement and selection phase. This potentially explained the discrepancy between the responses following the preliminary survey results and the responses to the permanent introduction of the SPIVC.

This stage included a review of the academic literature, including national and local guidance on the use of safety cannulas in paediatrics. The literature search found no studies conducted looking at the clinical acceptability of or behaviours towards safety devices when performing cannulation in paediatric patients. This finding, and the responses to the safety devices within the team, supported further investigation.

The author met with an expert clinical specialist team from medical devices and technology company BD to discuss the proposal of a collaborative evaluation within the paediatric team. This evaluation would seek to explore and understand the barriers to and attitudes towards the use of SPIVCs in paediatric patients.

Approval for the study was sought from the trust's Child Health Business Unit. Approval was also granted by the director of nursing and the lead nurse for vascular access within the trust.

It was agreed that an electronic survey would be used for data gathering. Focus groups were considered but excluded. The main disadvantages of using a focus-group strategy was the high acuity of patients on the paediatric ED, which would mean it would be difficult to protect time for colleagues to sit down together. There were additional concerns that staff in a focus group might not express their honest opinions and could be influenced by others. In addition, the COVID-19 pandemic had reached the UK and reduced footfall on the paediatric ED and face-to-face meetings were largely discouraged during this time. The advantages of data gathering via an online survey were that participants were more likely to be honest, as there was the option to remain anonymous, and it would be likely to increase the response rate as it would be more convenient for the doctors and nurses to complete.

The clinical specialist from BD and the author considered the themes to explore independently before agreeing the survey questions. The questionnaire focused on participants' clinical experience, access to training, attitudes towards safety and device preference.

The data gathered would be both quantitative and qualitative. The quantitative data – gathered through closed questions – would be used to quantify the issues through transforming results into usable statistics for analysis and writing up a report. The qualitative data would capture the human element and explore ideas and experiences in depth by inviting free-text answers. Questions using a Likert scale would be used to structure parts of the survey to help uncover the degrees of opinion and give a deeper understanding of the feedback from the team. Compared with binary questions where there are only two answers to choose from, Likert-type questions would provide more detailed feedback.

The survey was disseminated to all nurses and doctors working in the paediatric ED to deliberately target all IV practitioners.

The online survey was circulated to the participants, requesting responses within a 4-week period, with polite reminders sent at weeks 2 and 3.

A total of 55 participants were sent the survey and 46 participants responded (25 nurses and 21 doctors), giving a response rate of 83.6%.

The remaining 9 (16.3%) accounted for staff who were on leave (10.9%) or relatively new staff nurses who had not received cannulation training (5.4%).

In this final stage the survey data were consolidated and summarised to review the key themes. There was a good response across the range of professionals who worked in the paediatric ED, which was helpful in supporting the validity of the results.

The data indicated that the majority of participants showed an obvious preference for non-SEDs over the SEDs and yet it was interesting to note that 95% of participants stated that safety was one of their main considerations when performing cannulation. Therefore, it was necessary to perform a deep dive into the results, by narrowing down specific responses to certain questions to understand where the barriers lay with the SED.

Following an in-depth look the key themes included:

• An agreement on the importance of safety in vascular access among all participants Education Non-SEDs product preference/design when cannulating infants and neonates Human factors.

All participants in the survey agreed that safety is an important consideration in cannulation and the vast majority of participants said they considered safety when performing PIVC insertion.

The survey highlighted the issue of access to teaching and education. In total, 93% of participants agreed that 'Education is a critical part in managing change'. The data revealed that within the senior medical team (consultants, associate specialists and registrars) 50% had never had an update on vascular access since their initial training and the other 50% had not been updated within the past 5 years.

The most up-to-date training on vascular access includes the VHP Framework. The framework provides visual and straightforward guidance to help clinicians with assessment in vascular access ([12]). The framework includes a peripheral vein assessment which indicates if and by whom a cannulation should be attempted ([17]). For example, if a patient has no palpable or visible veins the framework advises that the cannulation should be performed by an experienced clinician guided by ultrasound ([12]). Ultrasound-guided cannulation is not routinely used on the paediatric ED where the audit took place, instead clinicians would adopt incorrect 're-insertion' or 'fishing' techniques to find a suitable vein, going against the framework.

An experienced specialist associate registrar stated:

'SED [is] harder to use, not able to adjust position as easily if not threading into vein on first attempt.'

The VHP framework was first introduced in 2012 ([21]), which is relevant to note as 72% of the doctors identified during the survey qualified more than 15 years ago and had never revisited their cannulation training. In total, 95% of the nurses had either had cannulation training or a refresher course within the past 5 to 10 years as part of their mandatory competency training. This divide in training suggests there are clear discrepancies between doctors' and nurses' understanding of what is the best recommended practice and what is actually being practised and it would appear that the introduction of the SED highlighted this. Nurses were more likely to use the SEDs – in the survey 60% stated that a SED could meet all cannulation needs in 0–16 year olds. Only 33% of doctors stated this.

In total, 46% of participants felt the design of the SED was an issue when cannulating smaller children and the majority of participants would be very willing to use SEDs in older, more compliant children. The remaining 54% felt the barriers were a mix between confidence, education and a dislike of change. Some typical comments were:

'Can be fiddly and bulky when dealing with a difficult patient.'

'Hub is too big and heavy so hangs over the child's hand and falls out easier, meaning children need to have more attempts at cannulation.'

'Too heavy cannula for small children, often safety part of cannula withdraws inserted cannula from patient under <6 months of age, difficult manipulation if not immediately in vein.'

According to [16], infants and toddlers are more difficult to cannulate compared to bigger children as their veins are smaller, less visible and less palpable. [20] stated that cannulating such patients is stressful and clinicians never know if the first insertion attempt will be successful. This point is key in helping to explain why non-SEDs were preferred for cannulating babies and younger children. If health professionals anticipate a difficult cannulation in a smaller child, the non-SED will allow for them to adopt the re-insertion technique if they fail the first time. However, in an older child where health staff anticipate an uncomplicated cannulation, the SED will be the device of choice as they are more likely to be successful at the first insertion, as suggested by the survey data.

One experienced advanced paediatric nurse practitioner stated:

'Size 24G safety cannulas have been tried in babies and they have a high rate of failure even when used by the most experienced clinicians on shift. This really takes away the confidence in using the size 24G safety cannula.'

This comment underlines the general perception of the safety PIVC, particularly when a practitioner, no matter how experienced, can be affected by seeing another practitioner fail.

Fear of change often underlies resistance ([11]). Health professionals who are competent in a skill such as cannulation will know what to expect, yet in a situation where they unexpectedly fail it causes feelings of uncertainty. In these situations, [9] noted that individuals do not often express their true feelings, instead they say 'it's not a good idea' or 'that doesn't work as well', thus blaming other aspects of the situation. A conclusion could be drawn that this statement was echoed by the doctors and nurses in this survey, who were suddenly failing at a clinical skill at which they had rated themselves proficient. This may explain their preference for continuing to use non-SEDs.

The key aim of this study was to understand the barriers to, and attitudes towards, the use of SEDs being used in a paediatric ED. It was evident that there was a preference for non-SEDs but there was a lack of clarity as to why. Reviewing the data has provided further insight into this.

There is a clear gap in training and education, particularly among the senior medical team, on cannula insertion technique. With this cohort there were obvious discrepancies between best recommended practice and what is actually practised and it would appear the introduction of SEDs in a 24G highlighted this. It could be that rather than acknowledging the lack of education, it was easier to blame the product in the first instance, especially when they had been successful using other products. Since the survey the following measures have been taken:

• The team has continued to stock safety and non-safety devices in all gauges (promoting the use of safe sharps, but giving clinicians the autonomy to choose their device as we recognise that for some clinicians there will be a transition period) Up-to-date vascular access training and refresher courses are now offered to all paediatric doctors as well as the nurses, with an emphasis on the VHP and insertion technique Staff who are undertaking cannulation for the first time are trained using SEDs only A clinical audit is currently under way to assess further compliance with the trust's vascular access policy.

The design of the product was also mentioned as a barrier. When this was explored further, the majority of participants were willing to use an SED in older children who were more likely to be compliant. The issue was using the product when cannulating smaller and younger children. This issue is being assessed again in the clinical audit.

This report was intended to inform NHS Providers, suppliers and manufacturers of some of the barriers to using SEDs in paediatric patients. Although the survey has been able to identify areas to help improve compliance in one specific paediatric ED, the barriers and attitudes may be completely different in another. The issues highlighted within this local team around education and compliance is something that they are building upon by putting in place relevant training and education programmes for those who would benefit. In relation to product design, it would be beneficial to cast the research net wider and target staff in a number of paediatric EDs across the country to understand if the themes found in the author's trust are consistent or different. If further research suggests the design of SEDs is a common theme among paediatric ED staff when cannulating younger patients, this could give NHS supply teams and manufacturers information on which to base possible future product design.

• The insertion of peripheral intravenous cannulas (PIVCs) is one of the most frequently performed procedures in paediatric emergency departments (EDs) This article reports on a survey investigating the use of newly introduced safety peripheral intravenous cannulas among staff in one paediatric ED Harm associated with lack of cannulation training, insertion and management is an under-recognised patient safety issue To successfully introduce product change, a combination of technological- and people-oriented solutions should be used in the transition When introducing change, it is vitally important have in place the appropriate resources and education and to foster a team culture

• Is there scope to improve the selection of peripheral intravenous cannulas in your trust? How effective is the education provided in your trust on peripheral intravenous cannulation? Have there been occasions where the patients' or staff's experience of peripheral intravenous cannulation could have been better? If so, how could this have been achieved?

the author would like to acknowledge the assistance of staff from BD in the preparation of this article