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Critical Analysis of the QLD Health VAD Guideline (2025): PIVC Selection and Insertion Practices
1. Introduction
1.1 Scope: focus on PIVCs selection and insertion
The Queensland Health Vascular Access Device (VAD) Guideline (Version 5.0, May 2025) provides statewide recommendations for infection prevention across all types of vascular access devices (Queensland Health, 2025). This paper critically appraises its recommendations specifically for peripheral intravenous catheters (PIVCs), addressing both device selection and insertion practices.
1.2 Objectives and structure of the paper
We examine (a) guideline guidance on PIVC device and site selection with evidence on gauge-related infection risks; (b) recommendations for ultrasound-guided and aseptic insertion alongside supporting trials; and (c) align these findings with best practices to propose targeted improvements.
2. Context
2.1 Context and overview of QLD Health VAD 2025 guideline
The VAD Guideline applies to all Queensland Health facilities and all clinicians—medical practitioners, nurses, midwives—responsible for the insertion, management, and removal of vascular devices (Queensland Health, 2025). It encompasses inpatient wards, intensive care units, outpatient and community settings, providing evidence-based minimum standards for infection prevention, clinician education, device and site selection, and standardized insertion bundles. Although covering central and midline catheters, it includes dedicated sections on PIVCs (pp. 23–25) and encourages integration of local policies, competency assessment, and multidisciplinary collaboration with infection prevention and control teams. Key elements include device-selection criteria (Section 4.1), insertion bundles (Section 5), and aseptic technique mandates (Section 5.4) to reduce healthcare-associated infections state-wide (Queensland Health, 2025).
3. Critical Analysis of PIVC Selection
3.1 Guideline Recommendations on Device selection and Supporting Evidence
The guideline advises selecting a catheter that minimizes vessel damage and supports vessel preservation by considering therapy duration, patient factors, and infusate properties (Queensland Health, 2025, p. 20). It recommends choosing the smallest gauge necessary to deliver treatment effectively and securement devices to prevent migration.
Observational data link larger-gauge PIVCs (e.g., 16G) with higher rates of bloodstream infections: Faltoni et al. (2024) found 16G catheters carried a four- to fivefold increased hazard for PVC-associated BSI compared to smaller gauges (HR 4.65, 95% CI 1.19–18.20). This supports guideline emphasis on gauge minimization (Faltoni et al., 2024).
3.2 Guideline Recommendations on Site selection and Supporting Evidence
Site selection criteria include avoiding areas of flexion (antecubital fossa) and choosing peripheral forearm or hand veins to promote catheter longevity and reduce phlebitis (Queensland Health, 2025, p. 23). Securement and avoidance of high-movement sites are emphasized to minimize vessel trauma.
3.3 Evaluation of Evidence and Alignment with Best Practices
The guideline’s device-selection framework aligns with vessel preservation principles, now corroborated by Faltoni et al. (2024). However, the observational design and single-center scope limit generalizability, highlighting the need for multicenter trials on gauge and site effects. Future research should quantify site-selection outcomes for phlebitis and infection rates under randomized conditions.
4. Critical Analysis of PIVC Insertion
4.1 Guideline Recommendations on Ultrasound-guided cannulation
The Guideline supports ultrasound-guided PIVC insertion for difficult access, requiring sterile probe covers, sterile gel, and maximal barrier precautions (Queensland Health, 2025, p. 24). This approach is intended to improve first-attempt success and reduce mechanical complications.
4.2 Guideline Recommendations on Aseptic insertion practices
Standard insertion bundles include hand hygiene, skin antisepsis with 2% chlorhexidine in 70% isopropyl alcohol, aseptic technique, PPE, and device securement (Queensland Health, 2025, pp. 22–23). The guideline discourages routine antibiotic prophylaxis but permits antimicrobial-impregnated catheters in high-risk cohorts.
4.3 Evaluation of Evidence and Alignment with Best Practices
A Cochrane review showed ultrasound guidance improved first-pass success in difficult adult PIVC placements (RR 1.50, 95% CI 1.15–1.95) and reduced attempts, though evidence quality was low to very low due to risk of bias and heterogeneity (Tada et al., 2022). For aseptic practice, the CLEAN-3 trial demonstrated that chlorhexidine + alcohol significantly reduced catheter colonization (adjusted subdistribution HR 0.08, 95% CI 0.02–0.18) and local infections versus povidone iodine + alcohol (Guenezan et al., 2021). These findings validate the guideline’s antiseptic choice. Limitations include single-centre settings and short dwell times; multicentre studies would strengthen evidence.
5. Conclusion
5.1 Synthesis of findings
Queensland Health’s 2025 VAD Guideline provides a robust framework for PIVC selection and insertion, with key principles on gauge minimization, site preservation, ultrasound use, and chlorhexidine antisepsis supported by emerging studies.
5.2 Summary of key recommendations aligned to analysis
Practices should prioritize the smallest effective gauge to reduce BSI risk, employ ultrasound guidance for difficult cannulations, maintain strict chlorhexidine-based asepsis, and adopt evidence-informed insertion bundles. Further multicenter RCTs on selection and insertion variables are warranted to optimize PIVC care.
6. References
Faltoni, M., Catho, G., Pianca, E., Minka-Obama, B., Zanella, M.-C., Chraiti, M.-N., Fortchantre, L., Harbarth, S., & Buetti, N. (2024). Catheter size and risk of short-term peripheral venous catheter-associated bloodstream infections: An observational study. Clinical Microbiology and Infection, 30, 548–551. https://doi.org/10.1016/j.cmi.2023.12.018
Guenezan, J., Marjanovic, N., Drugeon, B., O’Neill, R., Liuu, E., Roblot, F., Palazzo, P., Bironneau, V., Prevost, F., Paul, J., Pichon, M., Boisson, M., Frasca, D., & Mimoz, O. (2021). Chlorhexidine plus alcohol versus povidone iodine plus alcohol for prevention of short-term peripheral venous catheter infection and failure (CLEAN-3 study): An open-label, randomized, two-by-two factorial trial. The Lancet Infectious Diseases, 21, 1038–1048. https://doi.org/10.1016/S1473-3099(20)30738-6
Queensland Health. (2025). Vascular access device clinical management for infection prevention – Queensland Health guideline (Version 5.0, May 2025). https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention
Tada, M., Yamada, N., Matsumoto, T., Takeda, C., Furukawa, T. A., & Watanabe, N. (2022). Ultrasound guidance versus landmark method for peripheral venous cannulation in adults. Cochrane Database of Systematic Reviews, (12), Article CD013434. https://doi.org/10.1002/14651858.CD013434.pub2