Intravenous (IV) catheter insertion is a common procedure performed by health-care providers. Unsuccessful peripheral line attempts cause increased pain, anxiety, and dissatisfaction for patients. IV catheter insertions can also increase stress and anxiety for the nurse, which may unfavorably impact peripheral venous access attempts (Page & Taylor, 2010).
Evaluation of current research
A topical vapocoolant spray, ethyl chloride, has been used to produce an immediate analgesic effect on the skin. Ethyl chloride, when applied to a procedure site evaporates rapidly and decreases the skin temperature resulting in a temporary interruption of pain sensation (Page & Taylor, 2010). Earlier studies have shown that topical vapocoolants reduce pain and increase patient satisfaction during intravenous insertions in dialysis and in pediatric patient populations (Celik et al.,2011; Shah, Taddio, & Rieder, 2010). However, there is not sufficient evidence supporting the use of topical vapocoolants in adult patient populations and also evaluations from a nursing perspective are missing in the literature.
The purpose of this project was to compare the patients’ perceptions of pain and the nurses' experience during IV insertions, with and without the use of a topical vapocoolant and to evaluate patients’ and nurses’ feedback with the application procedure.
Following the institutional protocol for initiating an IV insertion, data were collected on patients who had IV insertions without the use of the topical vapocoolant (n=50) and those who had insertions using the vapocoolant (n=51) from March 26, 2014 through September 14, 2014. Patients were surveyed about their level of perceived pain, their assessment with the skill level of the nurse and their satisfaction with the IV insertion procedure using a pain rating scale (0 = no pain, 10 = worst pain). Nurses were surveyed about the IV insertion procedure with and without the vapocoolant.
Results and Key Issues
Descriptive statistical analysis demonstrated that patients who did not receive the vapocoolant prior to the IV insertion reported significantly higher levels of pain (M=3.8) compared to patients who received the vapocoolant (M=2.2, z=-2.25, p=.024).
There were no significant differences found for the patients’ assessments of the nurses’ skill level (p=.102) or patients’ perceived satisfaction with the IV procedure (p=.438), as patients rated nurses very high for skill and satisfaction in both groups. The size of the IV catheters (M=20.7 vs. 20.4), number of IV attempts (M=1.7 vs. 1.4), and number of RNs attempting insertions (M=1.3 vs. 1.2) were the same, regardless of insertions without or with the topical vapocoolant, respectively. Importantly, nurses voiced application safety concerns (e.g. medication stream diverting unexpectedly away from the intended site) that were not addressed in earlier studies. The nurses experiences and feedback were collected using open-ended questions related to the application process.
This project showed a significant decrease in pain scores during IV insertion in the topical vapocoolant group compared to patients who did not receive the vapocoolant. However, on-going nursing safety concerns related to the application process forced us to re-assess whether routinely using this topical vapocoolant for IV insertions was best practice. Our project demonstrates the importance of nurses’ clinical expertise and feedback when implementing evidence-based practice. Even though some evidence was available from earlier studies, our findings related to the patients’ pain experience as well as the nurses’ clinical expertise were important to consider before making a decision regarding a practice change.
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