Assessment of Knowledge and Practice of Peripheral Intravenous Cannulation in Government Cardiology Hospital in Pakistan

Insertion of peripheral cannula is very commonly used procedure world-wide in hospital settings. Aim of the study is to assess the nurses knowledge about care of intravenous cannulation and to observe their practices during cannula insertion. The current cross sectional study assesses the knowledge and practice of peripheral intravenous cannulation among the nurses of Government hospital, Lahore Pakistan. The data was collected by 170 nurses from the nurses of government hospital Lahore, Pakistan through convinent sampling technique. The results of the study represent that nurses have good understanding about care of cannula but there is lacking in practices.


Introduction
Insertion of peripheral cannula is very commonly used procedure world-wide in hospital settings.This product is being sold more than billions annually but 30-50% rate of its failure rate lies (Bertoglio et al., 2017).Peripheral cannula insertion is very easiest, simplest and fastest way to get the access for medication administration, hydration, diagnostic purpose etc.In United Kingdom, one patient from every three patient has peripheral cannula intact (Zhang et al., 2016) Peripheral cannula insertion is a skill which comes with practice and experience.There are so many complications related to peripheral cannula insertion which can be redness, swelling, pain, itching, extravasation (Sato et al,2016)%.If cannula is not inserted at right place, into the vein then using such cannula can be result into feeling of pain by the patient, during administration of any medication or fluids it can cause swelling, if chemotherapy or any vesicant drug is being administered then it can cause extravastion too.
Inserting the peripheral cannula is an invasive practice which is performed in emergencies, in hospitalized patients and in radiology department etc (Gargar, Cutamora, & Abocejo, 2017) Infection related to cannulation is called as phlebitis.There are so many easily occurring complications can be related to this procedure (Arbaee, 2016).
In developed country like United State of America, there are about 80,000 catheter related blood stream infection and 250,000 cases of CRBSIs found in intensive care units per annum (Opilla, 2019) Failing to pass intravenous cannula can obstruct the patient trust on nurses as it increases their level of apprenhention and agitation.This can be the cause of constriction of peripheral veins, that's why it becomes difficult to complete the job (McNamara, 2018) When primary nurses or clinical staff fail to pass the peripheral intravenous line then they contact to expert team like anesthetist to come and attempt for cannulation.Anesthetist attempt and get the access of IV cannulation after having many attempts.This time period is very terrible, sad and increase the suffering for the patient (Carr et al., 2016).
Complications related to cannulation can be prevented very easily if health care facilitators like nurses stick to the guidelines of maintaining intravenous cannulation like uses of an aseptic non touch technique, cleaning the patient's skin with approved bactericidal agent and covering the cannulation site with sterile and transparent dressing (Barton, 2018) In Pakistan a recent studies on peripheral cannulation insertion by (Qamar, Muhammad, Kousar, Waqas, & Gilani, 2017)reported that nurses have enough knowledge about the steps of peripheral cannula insertion, and they know the care of iv lines but they have no enough resources to follow the steps of cannulation and do the care appropriately.
It is diring need of the current state of health in Pakistan, that nurses should be able to raise the voices on behalf of patient advocacy to prevent the transmission of infection.They should be well knowledgeable and should be equipped with enough resources to provide high quality care of the patient.In addition to this, hand washing is most important way in order to prevent transmission of infection from one person to another person.Washing with soap and water for atleast 40-60 seconds is best recommendation by World Health Organization when hands are visibly dirty or get soiled with blood or body fluids.To break the chain of spread of infection hand washing is more important key.Washing with hand sanitizer is more quick and less time taking process.If hands are visibly dirty, then it can be the reason of transmission of mircro-organisms to others especially to neonates (Isichei-Ukah & Enabulele, 2018).Selection of hand sanitizer to achieve best result in killing the micro-organisms is matter a lot.Select the alcohol based hand sanitizer in order to reduce the spread of infection (Hayat & Munnawar, 2016).
Furthermore, aim of this study is to assess the nurse's knowledge and practices of peripheral cannula insertion among the public hospital of Lahore, Pakistan.

Scope of the study
This study helped the nurses to increase their understanding and knowledge about care of peripheral insertion cannula.This study guide the nurses to reduce the infection rate related to peripheral intravenous cannulation insertion and during handling of cannulas.This study help the patients to reduce their sufferings related to IV cannulation and improve the quality care of the hospital.

Literature Review
Obtaining consent before any procedure is the foremost right of the patient.The professional who is going to do any procedure, is responsible to take the consent from his/her client.According to Joint Commision the person who has constitutional rights to provide care, treatment and all needed services to the clients is responsible to inform to the client about procedural information and what could be the effects and side-effects of the procedure (Farmer & Lundy, 2017).
For this reason, Nurses has to take initiative steps to actively involve the patient's while giving consent for any procedure either they are agreed for the procedure or they want to refuse it (Felicilda-Reynaldo, 2016).
A study was conducted in Itlay, this study reported the need to level of knowledge of nurses' about some fact-based recommendations peripheral cannula care, it can be direct to less compliance with guiding principle of clinical practice, which can result into harmful effects for the safety of patients.Since then they have established a link between educational level / learning experience and improved understanding score, nurses must strengthen both the role of education and training programs in collaboration with hospital.This study recommends that promote the theory into the practice.Students can acquire core competencies with this aspect become professional nurses.This study offer significant approach for nurse educators which priorities they should plan their academic / teaching program.(Simonetti et al., 2019) it is suggested to prepare refreshing courses by experienced nurses and suitable teachers for inexperienced nurses.In addition, health care providers are responsible for providing safe and excellent care to patients, so they must be well equipped and properly trained.Adding up, management of government hospital must focus refresher training for senior nurses and registered nurses to comply with practice protocols in order to provide quality care.(Lamsal & Shrestha, 2019) Hand hygiene remains important component in reduction of the infection control process before or after doing any health care procedure.It helps to prevent the cross transfer of important viral and multi-resistant bacterial pathogen.Authors suggested that future research must be focused about the optimal implementation methods and monitoring of hand hygiene strategies (Huang, Stewardson, & Grayson, 2014).
Furthermore, it was suggested that it is domain of administration to provide sufficient resources of hand washing in clinical areas, in the patient's room, in the corridor, at the counters and in the medication room.(Masroor, Doll, Stevens, & Bearman, 2017).
For difficult cannulation, venous dilation is important aspect which can be achieved by application of torniquete.(Biyik Bayram & Caliskan, 2016).

Methodology
Descriptive observational study design will be use in this study.This study will be conducted in inpatients and emergency department of Government Cardiology Hospital.Target Population is nurses working in Government Cardiology Hospital.Inclusion Criteria is that all staff nurses and student nurses who are doing bedside nursing in inpatient units and emergency department who are willing to participate in the research.Exclusion Criteria is that nurses who are performing managerial/administrative task will not part of the study.Nurses who are not willing to participate in the research will not be the part of research.This Study consists of convenience sampling technique of all nurses working in inpatient and emergency department of PIC hospital.For assessment of nurses knowledge and care of peripheral intravenous cannula, tool was taken by Author Ahmad Niazl Mohm Ghazali and colleagues (Arbaee, 2016).
Data collection about steps of peripheral cannula insertion will be done through valid and reliable tool which is derived from (Dougherty & Lister, 2015) observational checklist.Data analysis would be done on SPSS 20 version.
Valid and reliable tool which is derived from (Dougherty & Lister, 2015) observational checklist.Tools for data collection consist of three parts: 1 st part consists of characteristics of study participants which include, age, sex, education, year of experience, qualification, working department and any workshops attended related to peripheral intravenous cannulation.2 nd part consists of knowledge questions related to insertion of peripheral intravenous cannulation.3 rd part consists of observational checklist of cannulation insertion.Checklist questionnaire will be used and will be distributed among 170 nurses in PIC

Problem Statement
Peripheral insertion of cannula is very common procedure in hospital settings of the Pakistan.As per one study in Pakistan, increased infection rate related to this procedure is about 20% (Ahmed, Khan, & Beg, 2016).Infection always cost effective and it increased the burden of the hospital and increase the suffering of the patients and families too.To reduce the infection rate among the hospitals, it is important to conduct a study among the public hospitals to control the infection rate and make it strictly implemented to be stick with the guidelines of cannulation insertion while performing this procedure.

Purpose of the study:
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Discussion
All participants were female.(Knowledge questions interpretation)48.8%staff nurses reported that 14-20G Is suitable in adult patient and 22-24G in pediatric patient while 50.6% said no and only 0.6% has no any idea about that.96.5% participants said that veins at dorsal and ventral surface of the upper extremities are used for IV cannulation.Whereas 3.5% said no. 53.5% participant said that peripheral IV cannula must be removed every 12-72hrs from insertion time, whereas 44.1% said no and only 2.4% participant that don't know about this.90% Participant reported that IV cannula can be used 48-72hrs if no signs and symptoms of complication, whereas 6.5% said no and only 3.5% has no any information about that.93.5% participants reported that phlebitis is the most identifiable infection whereas 6.5% said no. 58.8% participant reported that environment sanitation influent the risk of IV infection.15.9% reported that there is no any risk of IV infection due to environment sanitation and only 25.3% have no any information about this.44.1% reported that hand hygiene before IV cannula insertion prevents infection.28.8 % reported that hand hygiene before iv cannula insertion do not prevents infection and 27.1% have no any idea about that.53.5% reported that maintaining aseptic technique only during IV insertion helps to prevent infection.27.1% reported that maintaining aseptic technique during IV Sample size was According to solvin's formula.Solvin's formula is n = N / (1+Ne 2 ) Whereas: n = Number of Samples 10 N = Total Population 2 60 E = Margin of Error 0.05% Research Instruments are observational checklist and knowledge Questionnaire Data Collection Techniques are by direct observation during cannulation procedure in Punjab Institute of Cardiology.
with the non-dominant hand by applying manual traction on the skin a few centimeters below the proposed site of insertion 170in the dominant hand, ensure that it is in the bevel-up position and place the device directly over the vein; insert the cannula through the skin at the selected angle according to the depth of by decreasing the angle between the cannula and the skin.Advance the cannula slightly to ensure entry into the lumen of the vein.slightly with the dominant hand and a second flash-back of blood will be seen along the shaft of the cannula 170with the non-dominant hand and using the dominant hand, slowly advance the cannula off the stylet and into the vein.
job experience.67.1% have job experience of 1-5years, 23.5% have job experience of 6-10 years and only 9.4% have more than 10years job experience.