Implementation of a Clinical Decision Support System for Peripheral Intravenous Extravasation Management

Abstract

Problem & Purpose: Neonates are particularly vulnerable to peripheral intravenous (PIV) infiltration and extravasation that can lead to necrotic tissue injuries and long-term complications. In an urban mid-Atlantic Level IV Neonatal Intensive Care Unit (NICU), there has been a 2.2-fold increase in the rate of extravasations in the last five years with poor documentation compliance of a paper checklist as part of the unit’s PIV extravasation guideline. Evidence shows that the use of clinical decision support systems (CDSS) improves compliance with unit-based protocols. The purpose of this quality improvement (QI) project is to implement and evaluate the utilization of a CDSS into the EHR to improve PIV extravasation detection and guide management in a Level IV NICU. Methods: This QI project was implemented over a 15-week period in Fall 2021. Interventions included integration of a nursing PIV flowsheet in the EHR with staging guidance and updated SmartText for provider documentation. Weekly data collection consisted of the number of infants with PIV access, monthly adverse event reporting system reports of extravasations and chart audits for nursing and provider documentation. Results: At the end of implementation, the data reflected a rise in documented extravasations indicating utilization of the CDSS. Compliance with all elements of the CDSS documentation demonstrated a trend of increased documentation by nurses. An increase in provider notes for injuries with CDSS documentation reflected improved early recognition and RN to provider notification of injuries. Standardized CDSS documentation led to a decrease in incidence of stage 3 and 4 extravasations in the NICU. Conclusions: The implementation of a PIV clinical decision support system in the electronic charting system improved early recognition of extravasations and decrease severe tissue injuries resulting from stage 3 and 4 injuries. The sustainability of this project was achieved by integrating the CDSS into the EHR and next steps include continued refinement of the EHR-generated reports for data collection, addition of the educational module to annual nurse competencies and clarifying language for signs of different stages of injuries in the unit guideline.