Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial

Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters

BACKGROUND

Millions of peripheral intravenous catheters are used worldwide. The current guidelines recommend routine catheter replacement every 72-96 h. This practice requires increasing healthcare resource use. The clinically indicated catheter replacement strategy is proposed as an alternative.

OBJECTIVES

To assess the cost effectiveness of clinically indicated versus routine replacement of peripheral intravenous catheters.

METHODS

A cost-effectiveness analysis from the perspective of Queensland Health, Australia, was conducted alongside a randomized controlled trial. Adult patients with an intravenous catheter of expected use for longer than 4 days were randomly assigned to receive either clinically indicated replacement or third-day routine replacement. The primary outcome was phlebitis during catheterization or within 48 h after catheter removal. Resource use data were prospectively collected and valued (2010 prices). The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations. Additionally, value of information (VOI) and value of implementation analyses were performed.

RESULTS

The clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60 (95% confidence interval [CI] 4.96-10.62) and a non-significant difference in the phlebitis rate of 0.41% (95% CI -1.33 to 2.15). The incremental net monetary benefit was AU$7.60 (95% CI 4.96-10.62). The expected VOI was zero, whereas the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5 million over 5 years.

CONCLUSION

The clinically indicated catheter replacement strategy is cost saving compared with routine replacement. It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinically indicated.

Intravascular device use, management, documentation and complications: a point prevalence survey

Objective To examine the use, management, documentation and complications for intravascular devices in cardiac, medical and surgical inpatients. Methods A point prevalence survey was undertaken in a large tertiary hospital in Queensland. Descriptive statistics were used to analyse data. Results Of the 327 patients assessed, 192 (58.7%) had one or more devices in situ. Of the 220 devices, 190 (86.4%) were peripheral venous catheters, 25 (11.4%) were peripherally inserted central catheters and five (2.3%) were central venous catheters. Sixty-two of 220 devices (28.2%) were in situ without a clear purpose, whereas 54 (24.7%) had one or more complications, such as redness, pain, tracking, oedema or oozing. There was no documentation on the daily patient care record to indicate that a site assessment had occurred within the past 8 h for 25% of the devices in situ. Conclusions The present study identified several problems and highlighted areas for improvement in the management and documentation for intravascular devices. Ongoing education, promoting good clinical practice and reauditing, can be applied to improve the management of devices. What is known about the topic? Intravascular devices are associated with health care-related infections, including rare but serious bloodstream infections Measures for reducing healthcare-associated infection related to devices include surveillance with feedback. What does this paper add? This paper complements other surveillance data undertaken in similar-sized institutions with similar patients. Ongoing surveillance and education is required to maintain best clinical practice and management of devices. What are the implications for practitioners? Health care-associated infections are a serious problem and have negative outcomes for both patients and organisations. Intravascular devices may be associated with bloodstream infections, so prudent clinical care and management of devices is important. All devices should be assessed at least daily for their continued need and removed promptly if no longer required.

Hospital-wide survey of the adequacy in the number of vascular catheters and catheter lumens

BACKGROUND

Removal of unnecessary catheters has been proposed as an important measure to reduce catheter-related morbidity. Nevertheless, there is scarce information about the potential magnitude of such intervention.

OBJECTIVE

The present study was aimed at analyzing the appropriateness of use of vascular catheters and catheter lumens in the inpatient setting.

DESIGN

Cross-sectional survey.

SETTING

The entire population of adult inpatients admitted to a 1368-bed tertiary-care hospital in a single day.

MEASUREMENTS

We used a set of preestablished criteria to evaluate the appropriateness of use of vascular catheters and catheter lumens according to the number and administration regimen of intravenous drugs.

RESULTS

Out of 834 patients, 575 (68.9%) had ≥1 vascular catheters in place on the day of the survey. The type and distribution of the 703 surveyed catheters were peripheral venous catheter, 80.6%; central venous catheter, 15.8%; and arterial catheter, 3.6%. We found an overall mean of 2.06 ± 0.82 lumens per catheter, with significant differences between intensive care units and conventional wards (P < 0.0001). Based on our criteria, 126 out of 575 patients (21.9%) had an inappropriate number of catheters (medical wards, 20.0%; surgical wards, 23.9%; intensive care units, 26.3%), and 631 out of 14248 nonarterial catheter lumens (43.6%) were considered unnecessary.

CONCLUSIONS

Significant room exists for improving the adequacy of the number of vascular catheters and catheter lumens as a potentially useful tool for decreasing the incidence of catheter-related bloodstream infection.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Functional evaluation and practice survey to guide purchasing of intravenous cannulae

Background

There are wide variations in the physical designs and attributes between different brands of intravenous cannulae that makes product selection and purchasing difficult. In a systematic assessment to guide purchasing, we assessed two cannulae – Cannula P and I. We proposed that the results of in-vitro performance testing of the cannulae would be associated with preference after clinical comparison.

Methods

We designed an observer-blinded randomised head-to-head trial between the 18, 20 and 22 gauge versions of Cannula P and I. Our primary end-point was pressure (mmHg) generated during various flow rates and our secondary end-point was the force (Newton) required to slide the catheter away from the needle. This was followed by a prospective electronic survey following a two-week clinical trial period.

Results

The mean difference in resistance between Cannula P and I was: 307 mmHg.L^-1.hr^-1 (95% CI: 289–325, p < 0.001) for 22G; 135 mmHg.L^-1.hr^-1 (95% CI: 125–144, p < 0.001) for 20G; and 27 mmHg.L^-1.hr^-1 (95% CI: 26–28, p < 0.001) for 18G. The mean difference in the force needed to displace the catheter away from its needle was: 1.41 N (95% CI: 1.09-1.73, p < 0.001) for 22G; 0.19 N (95% CI: -0.04-0.41, p = 0.12) for 20G; and 1.96 N (95% CI: 1.40-2.52, p < 0.001) for 18G. After a trial period, all 16 anaesthetist who had used both cannulae preferred Cannula I to P.

Conclusions

The evaluation process described here could help hospitals improve efficient product selection and purchasing decisions for intravenous cannulae.

Assessing the Quality of Central Venous Catheter and Peripherally Inserted Central Catheter Videos on the YouTube Video-Sharing Web site

Background: Video sharing networks such as YouTube have revolutionized communication. Whilst access is freely available uploaded videos can contain non peer-reviewed information. This has consequences for the scientific and health care community, when the challenge in teaching is to present clinical procedures that follow empirical methods.

Objective: To review 50 central venous catheter and peripherally inserted central catheter videos posted on YouTube. The aim was to appraise these videos using current evidenced-based guidelines.

Methods: We searched YouTube using the key words central venous cannulation and peripherally inserted central catheter insertion on September 21, 2012. We consecutively reviewed 50 videos for both procedures.

Results: There was poor adherence to evidence-based guidelines in the critiqued videos. There was a difference in adherence with the use of appropriate skin antisepsis in the 2 groups (18% for central venous catheters vs 52% for peripherally inserted central catheters; p = 0.009). And a large proportion in both groups compromised aseptic technique (37% for central venous catheters vs 38% for peripherally inserted central catheter; p = 0.940). The use of ultrasound guidance during procedures was also different between the 2 groups (33% for central venous catheters vs 85% for peripherally inserted central catheters; p = 0.017).

Conclusions: This critique of instructional videos related to the insertion of central venous catheters and peripherally inserted central catheters uploaded to YouTube has highlighted poor adherence to current evidence-based guidelines. This lack of adherence to empirical guidelines can pose risks to clinical learning and ultimately to patient safety.

Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services

OBJECTIVES

To determine the incidence, risk factors for and outcomes of Staphylococcus aureus bacteraemia (SAB) associated with peripheral intravenous catheters (PIVCs).

DESIGN, SETTING AND PATIENTS

A review of prospectively collected data from two tertiary health services on all health care-associated SAB episodes occurring in adults aged > 17 2013s from January 2007 to July 2012.

MAIN OUTCOME MEASURES

Numbers of health care-associated SAB episodes; device type, location of insertion, device dwell time and outcome at 7 and 30 days for all SAB episodes associated with use of a PIVC; rates of SAB per 10 000 occupied bed-days (OBDs).

RESULTS

Overall, 137 of 583 health care-associated-SAB episodes (23.5%) were deemed to be PIVC associated, with an incidence of 0.26/10 000 OBD. The mean dwell time for PIVCs was 3.5 days (range, 0.25-9 days) and 45.2% of SABs occurred in PIVCs with a dwell time ≥ 4 days. Of the PIVC-associated SAB episodes, 39.6% involved PIVCs inserted in the ED, 39.6% involved PIVCs inserted on wards and 20.8% involved PIVCs inserted by the ambulance service. Of the PIVC-associated SABs occurring within 4 days of insertion, 61% were inserted by ED staff or the ambulance service. PIVC-associated SAB were associated with a 30-day all-cause mortality rate of 26.5%.

CONCLUSION

PIVC-associated SAB is an under-recognised complication. The high incidences of SAB associated with PIVCs inserted in emergency locations and with prolonged dwell times support recommendations in clinical guidelines for routine removal of PIVCs.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Search Co-ordinator searched the PVD Specialised Register (December 2012) and CENTRAL (2012, Issue 11). We also searched MEDLINE (last searched October 2012) and clinical trials registries.

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials with a total of 4895 patients were included in the review. Catheter-related bloodstream infection (CRBSI) was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 but the confidence interval (CI) was wide, creating uncertainty around the estimate (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001).

AUTHORS' CONCLUSIONS

The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.