Devices and dressings to secure peripheral venous catheters to prevent complications

Dressings and securement devices to prevent complications for peripheral arterial catheters

BACKGROUND

Peripheral arterial catheters (ACs) are used in anaesthesia and intensive care settings for blood sampling and monitoring. Despite their importance, ACs often fail, requiring reinsertion. Dressings and securement devices maintain AC function and prevent complications such as infection.

OBJECTIVES

To evaluate the effectiveness of peripheral AC dressing and securement devices to prevent failure and complications in hospitalised people.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus up to 16 May 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to 16 May 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different dressing and securement devices for the stabilisation of ACs in hospitalised people.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias using Cochrane's RoB 1 tool. We resolved disagreements by discussion, or by consulting a third review author when necessary. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included five RCTs with 1228 participants and 1228 ACs. All included studies had high risk of bias in one or more domains. We present the following four comparisons, with the remaining comparisons reported in the main review. Standard polyurethane (SPU) plus tissue adhesive (TA) compared with SPU: we are very uncertain whether use of SPU plus TA impacts rates of AC failure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.20 to 0.98; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Neither study (165 participants) reported catheter-related bloodstream infections (CRBSI), thus we are very uncertain whether SPU plus TA impacts on the incidence of CRBSI (very low-certainty evidence). It is very uncertain whether use of SPU plus TA impacts AC dislodgement risk (RR 0.54, 95% CI 0.03 to 9.62; I² = 44%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts AC occlusion rates (RR 1.20, 95% CI 0.37 to 3.91; I² = 3%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts rates of adverse events with few reported events across groups (RR 0.89, 95% CI 0.09 to 8.33; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Bordered polyurethane (BPU) compared to SPU: we are very uncertain whether use of BPU impacts rates of AC failure (RR 0.67, 95% CI 0.21 to 2.13; 1 study, 60 participants; very low-certainty evidence). BPU may make little or no difference to CRBSI compared to SPU (RR 3.05, 95% CI 0.12 to 74.45; I² = not applicable as 1 study (60 participants) reported 0 events; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to the risk of AC dislodgement compared with SPU (RR 0.75, 95% CI 0.17 to 3.22; I² = 0%; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to occlusion risk compared with SPU (RR 0.80, 95% CI 0.60 to 1.07; I² = 0%; 2 studies, 572 participants; low-certainty evidence). It is very uncertain whether BPU impacts on the risk of adverse events compared with SPU (RR 0.33, 95% CI 0.01 to 7.87; 1 study, 60 participants; very low-certainty evidence). SPU plus sutureless securement devices (SSD) compared to SPU: we are very uncertain whether SPU plus SSD impacts risk of AC failure compared with SPU (RR 0.78, 95% CI 0.40 to 1.52; I² = 0%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain if SPU plus SSD impacts CRBSI incidence rate with no events in both groups (2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of dislodgement (RR 0.14, 95% CI 0.01 to 2.57; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of AC occlusion (RR 1.94, 95% CI 0.50 to 7.48; I² = 38%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain whether SPU plus SSD impacts on the risk of adverse events (RR 1.94, 95% CI 0.19 to 20.24; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). Integrated securement dressings compared to SPU: integrated securement dressings may result in little or no difference in risk of AC failure compared with SPU (RR 1.96, 95% CI 0.80 to 4.84; 1 study, 105 participants; low-certainty evidence); may result in little or no difference in CRBSI incidence with no events reported (1 study, 105 participants; low-certainty evidence); may result in little or no difference in the risk of dislodgement (RR 0.33, 95% CI 0.04 to 3.04; 1 study, 105 participants; low-certainty evidence), may result in little or no difference in occlusion rates with no events reported (1 study, 105 participants; low-certainty evidence), and may result in little or no difference in the risk of adverse events (RR 0.35, 95% CI 0.01 to 8.45; 1 study, 105 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the relative clinical effectiveness of AC dressing and securement products. Limitations of current evidence include small sample size, infrequent events, and heterogeneous outcome measurements. We found no clear difference in the incidence of AC failure, CRBSI, or adverse events across AC dressing or securement products including SPU, BPU, SSD, TA, and integrated securement products. The limitations of current evidence means further rigorous RCTs are needed to reduce uncertainty around the use of dressing and securement devices for ACs.

Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial

Importance

Peripheral intravenous catheters (PIVCs) facilitate essential treatment. Failure of these essential devices is frequent and new securement strategies may reduce failure and improve patient outcomes.

Objective

To evaluate clinical effectiveness of novel PIVC securement technologies for children to reduce catheter failure.

Design, Setting, and Participants

A 3-arm, parallel group, superiority randomized clinical trial was conducted at 2 regional Australian hospitals from February 5, 2020, to January 14, 2022. Children aged 6 months to 8 years who were anticipated to require admission with a PIVC for at least 24 hours of in hospital treatment were eligible. Data were analyzed from May 25, 2022, to February 20, 2024.

Interventions

Participants were randomly allocated in a 1:1:1 ratio to standard care, bordered polyurethane (Tegaderm [3M]), integrated securement dressing (SorbaView SHIELD [Medline]), and integrated securement dressing with tissue adhesive (Secureport IV). One catheter was studied per patient.

Main Outcomes and Measures

Primary outcome was PIVC failure, defined as premature cessation of PIVC function for any reason prior to completion of planned treatment. Secondary outcomes were PIVC complications (any time dislodgement, occlusion, infiltration, partial dislodgement, extravasation, device leaking, phlebitis, pain), PIVC longevity, intervention acceptability (clinicians, participants, caregivers; 0-10 scale), and pain on removal (participants and caregivers; 0-10 scale relevant to age), adverse events, and health care costs.

Results

A total of 383 patients (51% female; median age 36 [25th-75th percentiles, 22-72] months) were randomized 134 to standard care, 118 to integrated securement dressing, and 131 to integrated securement dressing with tissue adhesive. PIVC failure was lowest in integrated securement dressing with tissue adhesive (15 [12%]; adjusted hazard ratio [aHR], 0.47; 95% CI, 0.26-0.84) compared with integrated securement dressing (24 [21%]; aHR, 0.78; 95% CI, 0.47-1.28) and standard care (43 [34%]). Direct costs were significantly lower for integrated securement dressing with tissue adhesive (median, Australian dollars [A$], 312 [A$1 is equal to $0.65 US dollars]; IQR, A$302-A$380) and integrated securement dressing (median, A$303; IQR, A$294-A$465) compared with standard care (median, A$341; IQR, A$297-A$592; P ≤ .002) when considering the economic burden related to failure of devices. PIVC longevity and intervention acceptability were similar across all groups.

Conclusions and Relevance

In this study, PIVCs secured with integrated securement dressings and tissue adhesive, in comparison with standard care, bordered polyurethane dressings, were associated with significantly reduced PIVC failure, for children admitted to hospital via the emergency department. Further research should focus on implementation in inpatient units where prolonged dwell and reliable intravenous access is most needed.

Trial Registration

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12619001026112.

Impact of terminal tip location of midline catheters on catheter-related complications and indwelling duration in elderly patients

AIM

To investigate the relationship between the position of the midline catheter tip and the frequency and type of complications associated with its placement.

DESIGN

A cohort study was performed on patients between May 2018 and December 2021 who underwent midline catheter placement at our institution. Patients were divided into two groups, superficial implementation and deep implementation, based on the midline catheter tip location relative to the clavicle.

METHODS

Clinical data and outcome parameters, including the numbers and types of midline catheter-related complications, day of occurrence and catheter indwell duration, were recorded.

RESULTS

Catheter-related complications occurred in 14 individuals. Compared with the superficial implementation group, the incidence of complications in the deep catheterization group was significantly reduced, with a delayed first occurrence time, and a prolonged catheter indwelling time. The results suggested that locating the midline catheter tip in the distal segment of the axillary vein may reduce catheter-related complication incidence and prolong the indwelling duration.

Observational study of peripheral intravenous catheter outcomes in an internal medicine department

BACKGROUND

In elderly patients hospitalised in internal medicine departments, risk factors, preferable placement area and methods of securement of short peripheral venous catheters (SPVC) a unclear.

AIM

To determine the incidence and risk factors of adverse events using a transparent bordered dressing for securement in the dorsum of the hand or cubital fossa in consecutive patients hospitalised in an internal medicine department.

METHODS

In a prospective observational study of patients admitted to a regional hospital with a SPVC, the dependent variable was the need to replace the catheter because of an adverse event (phlebitis, accidental removal, infiltration/occlusion). The independent variables were age, gender, disorientation, placement area, intravenous antibiotic therapy and indwelling time. Risk factors were determined by Cox regression model analysis.

RESULTS

There were 709 catheters placed in 499 patients. Per catheter placed the mean age was 75 ± 17 years. Accidental removal, infiltration/obstruction and phlebitis occurred in 21.5, 16.2 and 15.0 events per 1000 days respectively. There was a significantly increased risk on Day 3 compared to Days 2 and 4. An older age, intravenous antibiotics and disorientation increased the hazard for accidental displacement, whereas phlebitis was associated only with intravenous antibiotics and occlusion/infiltration only with age.

CONCLUSIONS

The observed low rates of adverse events suggests that placement in the dorsum of the hand or cubital fossa secured by a transparent dressing is acceptable. It is important to consider the indwelling catheter time when studying adverse events, and elderly patients, disoriented patients and/or patients receiving intravenous antibiotics deserve special attention.

Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP)

BACKGROUND

Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally.

METHODS

A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place.

RESULTS

During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management.

CONCLUSION

Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Knowledge and practice of intravenous infusion among nurses in university of Calabar teaching hospital

This study aimed at assessing the knowledge and practice of intravenous infusion among nurses in University of Calabar Teaching Hospital. Two (2) objectives with the corresponding research questions were formulated. A descriptive research design was adopted for the study. The population and sample comprised of 160 registered nurses working in University of Calabar Teaching Hospital. Convenient sampling technique was employed to select 114 nurses to form the sample for this study. A self-developed and structured questionnaire was used to obtain data and analyzed using simple frequency and percentage tables. Findings of Results in table 2 reveals that majority 87(76.3) of the respondents said yes that As a nurse I know that intravenous infusion is carried out in most hospital by both doctors and nurses while 27(23.7%) said no. 114(100) of the respondents said yes that As a nurse I know that most management in the hospital do not allow nurses to carryout intravenous infusion on their patients for fear of replacement. 

Peripheral intravenous catheter securement: An integrative review of contemporary literature around medical adhesive tapes and supplementary securement products

AIM

To synthesise evidence related to medical adhesive tapes and supplementary securement products for peripheral intravenous catheters in adults, to prevent complications and device failure.

DESIGN

Integrative review informed by Whittemore and Knafl and reported in accordance with the PRISMA 2020 statement.

DATA SOURCES

The Cochrane Central Register of Controlled Trials, US National Library of Medicine National Institutes of Health, EMBASE/MEDLINE and Cumulative Index to Nursing and Allied Health were searched from 2000-21 September 2020.

REVIEW METHODS

Studies enrolling hospitalised participants >16 years with peripheral intravenous catheters secured by medical adhesive tapes, or supplementary products (bandage, splint and sutureless securement device), were eligible. Quality appraisal was performed using Critical Appraisal Skills Program checklists.

RESULTS

Nineteen studies met criteria, including 43,683 peripheral intravenous catheters. Quality appraisal identified high or unclear risk of bias in 58% of studies. Nonsterile tape was the most common intervention tested (14 studies), alone or in multiproduct combinations. Nonsterile tape directly over insertion sites was associated with increased PIVC failure and complications. Sutureless securement devices potentially reduce failure and complications. Multiproduct combinations were very common. Practice recommendations regarding other tapes and secondary securement products are challenging, due to conflicting, or lack of, evidence.

CONCLUSION

Tapes and secondary securement product evidence are limited, and over half of the studies are of low methodological quality. This review found nonsterile tape was associated with increased failure and complications; multiproduct dressing and securement bundles were prevalent; and significant evidence gaps exist particularly regarding bandages and splints. The results provide nurses with evidence of medical adhesive tapes and supplementary product effectiveness for peripheral intravenous catheter securement, and future research directions to reduce unacceptably high failure and complication rates. Larger rigorously conducted randomised controlled trials are needed to add to current evidence.

Virtual reality environment using a dome screen for procedural pain in young children during intravenous placement: A pilot randomized controlled trial

We assessed the feasibility and potential efficacy of a virtual reality (VR) environment using a dome screen as a distraction method in young children during intravenous (IV) placement in the pediatric emergency department. This randomized controlled pilot study enrolled children aged 2 to 6 years who underwent IV placement into either the intervention group or the control group. Children in the intervention group experienced VR using a dome screen during IV placement. The child’s pain intensity was measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at four time points of IV placement: immediately after arrival to the blood collection room (base); immediately after the child laid down on the bed (preparation); when the tourniquet was applied (tourniquet); and the moment at which the needle penetrated the skin (venipuncture). The guardian’s satisfaction and rating of the child’s distress were assessed using a 5-point Likert-type questionnaire. We recruited 19 children (9 in the intervention group and 10 in the control group). Five children in the control group were excluded from the analysis because of missing video recordings (n = 3), failed first attempt at IV placement (n = 1), and the child’s refusal to lie on the bed during the procedure (n = 1). No side effects of VR were reported during the study period. Although the average FLACC scale score at each time point (preparation, tourniquet, venipuncture) was lower in the intervention group than the control group, the difference was not statistically significant (2.3, interquartile range [IQR]: 2.0–3.0; vs. 3.3, IQR: 2.7–6.7, P = 0.255). There were no statistically significant differences between the groups in the guardian’s satisfaction and anxiety or his/her rating of the child’s pain and anxiety. The guardians and emergency medical technicians reported satisfaction with the use of VR with a dome screen and considered it a useful distraction during the procedure. VR using a dome screen is a feasible distraction method for young children during IV placement. A larger clinical trial with further development of the VR environment and study process is required to adequately evaluate the efficacy of VR using a dome screen.

Quality of care for peripheral intravenous catheters (PIVCs) in Nepal: a cross-sectional study on feasibility and inter-rater agreement of the Peripheral Intravenous Catheters-mini Questionnaire (PIVC-miniQ) in a tertiary care hospital

OBJECTIVES

There is a lack of data regarding the quality of peripheral intravenous catheter (PIVC)-related care from low-income and middle-income countries, even though the use of PIVCs may lead to local or severe systemic infections. Our main objective was to assess the feasibility and inter-rater agreement on the PIVC-mini Questionnaire (PIVC-miniQ) in a tertiary care hospital in Nepal.

DESIGN

We performed an observational cross-sectional quantitative study using the PIVC-miniQ to collect information on PIVC quality.

SETTING

Secondary care in a Nepalese hospital. All patients with PIVCs in selected wards were included in the study and PIVCs were assessed independently by two raters. Eight Nepalese nurses, one Nepalese student and three Norwegian students participated as raters.

PRIMARY AND SECONDARY OUTCOME MEASURES

The intraclass correlation coefficient (ICC), positive, negative, absolute agreement, Scott's pi and sum score were calculated using PIVC-miniQ. We also aimed to describe PIVC quality of care, as it is important to prevent PIVC-associated complications such as phlebitis or catheter-associated bloodstream infections.

RESULTS

A total of 390 patients (409 PIVCs) were included in the study. The ICC between raters was 0.716 for Nepalese raters, 0.644 for Norwegian raters and 0.481 for the pooled data. The most frequently observed problems associated with PIVCs were blood in the intravenous line (51.5%), pain and tenderness on palpation (43.4%), and fixation with opaque tape (38.5%). The average sum score was 3.32 deviations from best practice for PIVCs fixed with non-sterile opaque tape and 2.37 for those fixed with transparent dressing (p<0.001).

CONCLUSION

The PIVC-miniQ is a feasible and reliable tool for nurses assessing PIVC quality in hospitalised patients in Nepal. The study revealed gaps in PIVC quality and care that could be improved by providing transparent PIVC dressings for all patients and requiring all PIVC insertions to be documented in patient charts.

The Efficacy, Safety, and Convenience of a New Device for Flushing Intravenous Catheters (Baro Flush™): A Prospective Study

Background and Objectives: An effective flushing technique is essential to reduce intravenous (IV)-related complications and improve patient care. New technology should contribute to such improvements, while reducing costs and increasing care efficiency. This study evaluated the efficacy, safety, and convenience of a new flushing technique using a Baro Flush™ controller. Materials and Methods: We evaluated the efficacy and safety of Baro Flush™ by measuring the infusion flushing volume and pressure in vitro. Afterwards, we prospectively enrolled 3000 patients with flushing and assigned 1500 patients with a new technique for flushing and 1500 with a conventional flushing method, which was performed by 48 registered nurses (RNs) at the Gil Medical Center in June 2018. The efficacy, safety, and convenience of the new flushing method were evaluated though a questionnaire survey. Results: The average flushing pressure was 12.5 ± 0.6 psi (86.18 ± 4.14 kPa) with 1.2 ± 0.2 mL per flush, as recommended by the Centers for Disease Control and Prevention based on 85 experiments. No IV-catheter-related complications were reported by the RNs during the study. More than 80% of the RNs reported that the new flushing method was easier to learn, improved care efficacy, and was more convenient than conventional flushing. Conclusions: The new flushing method using a Baro Flush™ controller showed improved efficacy, safety, and convenience compared with the conventional flushing method, and no IV-catheter-related complications occurred, including occlusion and inflammation. The new flushing method promises to reduce IV-catheter-related complications and shows improved efficacy, safety, and convenience.

“Sticking It to Them”—Reducing Migration of Peripherally Inserted Central Catheters

TA for stabilization and securement of PICCs reduced catheter migration. This solution to catheter migration was safe, inexpensive, and highly effective. TA reduced migration rates from 19.35% to 1.4% in more than 411 inpatients. There was no evidence of phlebitis, cellulitis, or microbial contamination. There also was no evidence of central line infections.

Double-chamber syringe versus classic syringes for peripheral intravenous drug administration and catheter flushing: a study protocol for a randomised controlled trial

BACKGROUND

The prevention of catheter-related complications is nowadays an important topic of research. Flushing catheters is considered an important clinical procedure in preventing malfunction and several complications such as phlebitis or infection. Considering the latest guidelines of the Infusion Nurses Society, the flushing should be carried out both pre- and post-drug administration, requiring different syringes (with associated overall increased times of preparation/administration of intravenous medication by nurses, and also increasing the need for manipulation of the venous catheter).

METHODS/DESIGN

A multi-centre, two-arm randomised controlled trial with partially blinded outcome assessment of 146 adult patients. After eligibility analysis and informed consent, participants will receive usual intravenous administration drugs with flushing procedures, with a double-chamber syringe (arm A) or with classic syringes (arm B). The outcomes assessment will be performed on a daily basis by an unblinded ward team, with the same procedures in both groups. Some main outcomes, such as phlebitis and infiltration, will also be evaluated by nurses from a blinded research team and registered once a day.

DISCUSSION

The study outlined in this protocol will provide valuable insight regarding the effectiveness and safety of this new medical device. The development of this medical device (dual-chamber syringe, for drug and flush solution) seems to be an important step to facilitate nurses' adoption of good clinical practices in intravenous procedures, reducing catheter manipulations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04046770. Registered 13 August 2019.

Peripheral intravenous catheter dressing and securement practice is associated with site complications and suboptimal dressing integrity: A secondary analysis of 40,637 catheters

BACKGROUND

With over 2 billion peripheral intravenous catheters used globally each year, avoiding complications is crucial for patients and healthcare organisations. Effective catheter dressing and securement is a key nursing strategy to reduce catheter failure and resultant patient harm.

OBJECTIVES

To describe global catheter dressing and securement practices and policy; and identify factors associated with catheter insertion site complications, and suboptimal dressing and securement.

DESIGN

Secondary analysis of a global cross-sectional study of peripheral intravenous catheter characteristics, management and outcomes.

SETTING

Four hundred and seven rural, regional and metropolitan hospitals in 51 countries.

PARTICIPANTS

Paediatric and adult patients with 40,637 catheters.

METHODS

Patient-, catheter-, and institution-related factors which could be associated with catheter site complications and suboptimal dressings were extracted from the parent database. Global trends in catheter dressing and securement policy and practice were described. Potential predictors of catheter and dressing complications were explored using logistic regression.

RESULTS

Dressing and securement practices, and local hospital policy regarding dressing change frequency varied. One fifth of dressings (21%, n = 8519) were not clean, dry and intact. The prevalence of catheter insertion site complications was 16% (n = 6503), with signs of phlebitis commonly observed (11.5%, n = 4587). Compared to non-bordered polyurethane dressings, sterile gauze and tape dressings were associated with fewer insertion site complications (odds ratio 0.58, 95% confidence interval 0.50-0.68) and better dressing integrity (odds ratio 0.68; 95% confidence interval 0.59-0.77); whereas, compared with no securement, non-sterile tape at the insertion site was associated with more site complications (odds ratio 2.39, 95% confidence interval 2.22-2.57) and poorer dressing integrity (odds ratio 1.64, 95% confidence interval 1.51-1.75). Two 'bundled' dressing and securement combinations were associated with fewer site and dressing complications, when compared with the reference category. Local catheter care guidelines which advocate 4th hourly insertion site inspection and dressing replacement between 1-3 days were associated with better catheter dressing integrity.

CONCLUSION

Modifiable risk factors for peripheral intravenous catheter site and dressing complications were identified and are amendable to further interventional testing.

Incidence of peripheral intravenous catheter failure among inpatients: variability between microbiological data and clinical signs and symptoms

Background

Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices among inpatients. Catheter-related bloodstream infections (CRBSI) are serious yet preventable events for patients. Although the contribution of PIVCs towards these infections is gradually being recognised, its role in the Spanish setting is yet to be determined. We aimed to estimate the rate and incidence of PIVC failure at Manacor hospital (Spain) as baseline within a wider quality improvement initiative.

Methods

Tips from all PIVC removed during December 2017 and January 2018 in hospital wards were cultured semiquantitatively. The study population included all PIVCs inserted in adult patients admitted to any of three medical and one surgical wards, emergency department, critical care unit and operating rooms. Clinical, microbiological and ward information was collected by clinical researchers for each PIVC from insertion to removal on the study sites. CRBSI was defined per international guidelines (i.e., Centers for Disease Control and Prevention, USA). Data was analysed descriptively.

Results

Seven hundred and eleven tips were cultured, with 41.8% (297/711) reported as PIVC failure. The PIVC failure rate density-adjusted incidence for hospital length of stay (HLOS) was 226.2 PIVC failure/1000 HLOS. 5.8% (41/711) tips yielded positive isolates, with most frequent microorganisms Staphylococcus spp (S. epidermidis 29/41, 70.7%, S. aureus 2/41, 4.9%, S. hominis 2/41, 4.9%), and Acinetobacter baumannii (1/41, 2.4%). One S. aureus isolate was methicillin-resistant. 53.6% (22/41) positive cultures were obtained from patients with local signs and symptoms compatible with catheter-related infection (CRI), 2.4% (1/41) were compatible with CRBSI type 2 and that clinical signs improve within 48 h of catheter removal (density-adjusted incidence for hospital stays of 16.7 PIVC-CRI/1000 hospital-stays and 0.76 PVC-BSI/1000 hospital-stays respectively) and no patients were diagnosed CRBSI type 3 with a bacterial growth concordant in tip and blood cultures. Most cases responded favourably to catheter removal and management.

Conclusions

Our findings show that almost 42% PIVCs resulted in unplanned removal, amplifying the importance in terms of morbidity, mortality and patient safety. A high number of positive tip cultures without clinical signs and symptoms was observed. We underpin the importance to remove unnecessary PIVCs for the prevention of CRBSI.

Knowledge and practice towards care and maintenance of peripheral intravenous cannula among nurses in Chitwan Medical College Teaching Hospital, Nepal

AIM

The study is mainly concerned about the care and maintenance of peripheral intravenous cannulation: to determine the knowledge and practice of nurses towards care and maintenance of IV cannula and to find out the obstacles encountered in caring and maintaining IV cannula. Intravenous cannulation is a common procedure performed by nurses in every hospital and closely associated with the risk of nosocomial infections if standard care is not provided.

DESIGN

A descriptive cross-sectional study design was carried out.

METHODS

Nurses' knowledge and practice towards care and maintenance of peripheral intravenous cannula were assessed using a validated semi-structured self-administered questionnaire through the census method. Data were analysed through SPSS program. The comparison was done between knowledge and practice.

RESULTS

The findings revealed that 84.72% respondents were doing correct practices despite the fact that only 82.47% respondents had proper knowledge. Most nurses have good knowledge of caring and maintaining peripheral intravenous cannulation but there were some without proper knowledge and practice. This could be a potential risk factor for patient safety.

Improving Vascular Access Outcomes and Enhancing Practice

With most hospitalized patients requiring peripheral intravenous catheters (PIVCs), PIVC-related process improvement may substantially affect the health, safety, and satisfaction of patients and health care workers, in addition to reducing costs. This study examined PIVC practice-related metrics before and after a comprehensive process improvement program, which included a change to closed catheter technology. Data were obtained from observations, clinician interviews, and patient records. Metrics included assessment of risk, especially blood exposure and contamination; measurement of insertion efficiency; and quantification of PIVC failure. A significant improvement in most metrics was achieved after the process improvement program.

A novel integrated dressing to secure peripheral intravenous catheters in an adult acute hospital: a pilot randomised controlled trial

BACKGROUND

The reported incidence of peripheral intravenous catheter (PIV) failure has been as high as 69%. This is in part due to inadequate stabilisation or securement to the skin, which allows micro-motion of the catheter within the vein.

METHODS

A pilot open randomised controlled trial of 300 patients was conducted in the medical and surgical wards of a large tertiary hospital. A superiority parallel pragmatic design was used. Eligible patients over the age of 16 years were randomised using a centralised service (randomly varied block sizes and 1:1 ratio) to have PIV dressings of either (i) a bordered polyurethane dressing (BPU, standard care) or (ii) the integrated securement device (ISD). Allocation was concealed until entry. The primary outcome of feasibility addressed eligibility, consent, protocol adherence and retention rates. All-cause PIV failure was an additional primary outcome. This was a composite of infection (laboratory-confirmed local or bloodstream infection), occlusion or infiltration, dislodgement, phlebitis and thrombosis. Group comparisons were by proportions, incidence rates per 1000 PIV days and hazard ratios. Secondary outcomes were local or bloodstream infection, occlusion or infiltration, dislodgement, phlebitis, thrombosis, PIV dwell time, safety and adverse events and patient satisfaction with study products. Analysis was by intention to treat and the patient was the unit of measurement. Multivariable modelling was undertaken.

RESULTS

Feasibility outcomes were 91% of screened patients were eligible, 98% of invited patients consented, 100% of randomised participants received the allocated intervention on insertion and 1/300 (< 1%) were lost to follow-up. In total, 792 PIV days were studied. PIV failure occurred in 43/150 BPU patients (29%) and 40/150 ISD patients (27%) (119 vs 93 per 1000 PIV days; incidence rate ratio 0.78, 95% confidence interval, CI 0.50-1.23). In the multivariate model, ISD (hazard ratio 0.51, 95% CI 0.29-0.89) and admission for a surgical emergency were significantly associated with decreased failure, while female gender, wound, hand insertion and more frequent PIV use were significantly associated with increased PIV failure.

CONCLUSION

ISDs were significantly associated with decreased failure in the multivariable modelling. Feasibility outcomes were supportive of the need to undertake a larger trial to confirm these results.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000984493 . Registered 27 July 2016.

Integrated versus nOn-integrated Peripheral inTravenous catheter. Which Is the most effective systeM for peripheral intravenoUs catheter Management? (The OPTIMUM study): a randomised controlled trial protocol

INTRODUCTION

Peripheral intravenous catheters (PIVCs) are frequently used in hospitals. However, PIVC complications are common, with failures leading to treatment delays, additional procedures, patient pain and discomfort, increased clinician workload and substantially increased healthcare costs. Recent evidence suggests integrated PIVC systems may be more effective than traditional non-integrated PIVC systems in reducing phlebitis, infiltration and costs and increasing functional dwell time. The study aim is to determine the efficacy, cost-utility and acceptability to patients and professionals of an integrated PIVC system compared with a non-integrated PIVC system.

METHODS AND ANALYSIS

Two-arm, multicentre, randomised controlled superiority trial of integrated versus non-integrated PIVC systems to compare effectiveness on clinical and economic outcomes. Recruitment of 1560 patients over 2 years, with randomisation by a centralised service ensuring allocation concealment. Primary outcomes: catheter failure (composite endpoint) for reasons of: occlusion, infiltration/extravasation, phlebitis/thrombophlebitis, dislodgement, localised or catheter-associated bloodstream infections.

SECONDARY OUTCOMES

first time insertion success, types of PIVC failure, device colonisation, insertion pain, functional dwell time, adverse events, mortality, cost-utility and consumer acceptability. One PIVC per patient will be included, with intention-to-treat analysis. Baseline group comparisons will be made for potentially clinically important confounders. The proportional hazards assumption will be checked, and Cox regression will test the effect of group, patient, device and clinical variables on failure. An as-treated analysis will assess the effect of protocol violations. Kaplan-Meier survival curves with log-rank tests will compare failure by group over time. Secondary endpoints will be compared between groups using parametric/non-parametric techniques.

ETHICS AND DISSEMINATION

Ethical approval from the Royal Brisbane and Women's Hospital Human Research Ethics Committee (HREC/16/QRBW/527), Griffith University Human Research Ethics Committee (Ref No. 2017/002) and the South Metropolitan Health Services Human Research Ethics Committee (Ref No. 2016-239). Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000089336.

Vascular access specialist teams for device insertion and prevention of failure

BACKGROUND

Most people admitted to hospitals worldwide require a vascular access device (VAD). Hundreds of millions of VADs are inserted annually in the USA with reports of over a billion peripheral intravenous catheters used annually worldwide. Numerous reports suggest that a team approach for the assessment, insertion, and maintenance of VADs improves clinical outcomes, the patient experience, and healthcare processes.

OBJECTIVES

To compare the use of the vascular access specialist team (VAST) for VAD insertion and care to a generalist model approach for hospital or community participants requiring a VAD in terms of insertion success, device failure, and cost-effectiveness.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1); Ovid MEDLINE (1950 to 7 February 2018); Ovid Embase (1980 to 7 February 2018); EBSCO CINAHL (1982 to 7 February 2018); Web of Science Conference Proceedings Citation Index - Science and Social Science and Humanities (1990 to 7 February 2018); and Google Scholar. We searched the following trial registries: Australian and New Zealand Clinical Trials Register (www.anzctr.org.au); ClinicalTrials.gov (www.clinicaltrials.gov); Current Controlled Trials (www.controlled-trials.com/mrct); HKU Clinical Trials Registry (www.hkclinicaltrials.com); Clinical Trials Registry - India (ctri.nic.in/Clinicaltrials/login.php); UK Clinical Trials Gateway (www.controlled-trials.com/ukctr/); and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (www.who.int/trialsearch). We searched all databases on 7 February 2018.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) that evaluated the effectiveness of VAST or specialist inserters for their impact on clinical outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane and used Covidence software to assist with file management.

MAIN RESULTS

We retrieved 2398 citations: 30 studies were eligible for further examination of their full text, and we found one registered clinical trial in progress. No studies could be included in the analysis or review. We assigned one study as awaiting classification, as it has not been accepted for publication.

AUTHORS' CONCLUSIONS

This systematic review failed to locate relevant published RCTs to support or refute the assertion that vascular access specialist teams are superior to the generalist model. A vascular access specialist team has advanced knowledge with regard to insertion techniques, clinical care, and management of vascular access devices, whereas a generalist model comprises nurses, doctors, or other designated healthcare professionals in the healthcare facility who may have less advanced insertion techniques and who care for vascular access devices amongst other competing clinical tasks. However, this conclusion may change once the one study awaiting classification and one ongoing study are published. There is a need for good-quality RCTs to evaluate the efficacy of a vascular access specialist team approach for vascular access device insertion and care for the prevention of failure.

Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure

BACKGROUND

Almost 70% of hospitalized patients require a peripheral intravenous catheter (PIV), yet up to 69% of PIVs fail prior to completion of therapy.

OBJECTIVE

To identify risk factors associated with PIV failure.

DESIGN

A single center, prospective, cohort study.

SETTING

Medical and surgical wards of a tertiary hospital located in Queensland, Australia.

PARTICIPANTS

Adult patients requiring a PIV.

MEASUREMENTS

Demographic, clinical, and potential PIV risk factors were collected. Failure occurred if the catheter had complications at removal.

RESULTS

We recruited 1000 patients. Catheter failure occurred in 512 (32%) of 1578 PIVs. Occlusion/infiltration risk factors included intravenous (IV) flucloxacillin (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.19-3.31), 22-gauge PIVs (HR, 1.43; 95% CI, 1.02-2.00), and female patients (HR, 1.48; 95% CI, 1.10-2.00). Phlebitis was associated with female patients (HR, 1.81; 95% CI, 1.40-2.35), bruised insertion sites (HR, 2.16; 95% CI, 1.26-3.71), IV flucloxacillin (HR, 2.01; 95% CI, 1.26-3.21), and dominant side insertion (HR, 1.39; 95% CI, 1.09-1.77). Dislodgement risks were a paramedic insertion (HR, 1.78; 95% CI, 1.03-3.06).Each increase by 1 in the average number of daily PIV accesses was associated (HR 1.11, 95% CI 1.03-1.20)-(HR 1.14, 95% CI 1.08-1.21) with occlusion/infiltration, phlebitis and dislodgement. Additional securement products were associated with less (HR 0.32, 95% C-0.46)-(HR 0.63, 95% CI 0.48-0.82) occlusion/infiltration, phlebitis and dislodgement.

CONCLUSION

Modifiable risk factors should inform education and inserter skill development to reduce the currently high rate of PIV failure.

Peripheral Venous Catheter-Related Adverse Events: Evaluation from a Multicentre Epidemiological Study in France (the CATHEVAL Project)

Introduction

Peripheral venous catheters (PVC) are medical devices most frequently used during hospital care. Although the frequency of specific PVC-related adverse events (PVCAEs) has been reported, the global risk related to the insertion of this device is poorly estimated. The aim of this study is to determine the incidence of PVCAEs during the indwell time, after catheter removal, and to identify practice-mirroring risk factors.

Methods

A prospective observational study was conducted as a part of a research project, called CATHEVAL, in one surgery ward and four medicine wards from three public general tertiary care hospitals in Northern France that were invited to participate between June-2013 and June-2014. Each participating ward included during a two-month study period all patients older than 15 years carrying a PVC. All inserted PVCs were monitored from insertion of PVC to up to 48 hours after removal. Monitored data included several practice-mirroring items, as well as the occurrence of at least one PVCAE. A multivariate Cox proportional hazard model, based on a marginal risk approach, was used to identify factors associated with the occurrence of at least one PVCAE.

Results

Data were analysed for 815 PVCs (1964 PVC-days) in 573 patients. The incidence of PVCAE was 52.3/100 PVCs (21.9/100 PVC-days). PVCAEs were mainly clinical: phlebitis (20.1/100 PVCs), haematoma (17.7/100 PVCs) and liquid/blood escape (13.1/100 PVCs). Infections accounted for only 0.4/100 PVCs. The most frequent mechanical PVCAEs, was obstruction/occlusion of PVC (12.4/100 PVCs). The incidence of post-removal PVCAEs was 21.7/100 PVCs. Unstable PVC and unclean dressing were the two main risk factors.

Conclusion

Limitation of breaches in healthcare quality including post-removal monitoring should be reinforced to prevent PVC-related adverse events in hospital settings.

Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries

Introduction

The unintentional arterial placement of a central venous line can have catastrophic complications. The purpose of this systematic review is to assess and analyse the available evidence regarding the use of the various vascular closure devices (VCDs) for the management of iatrogenic thoraco-cervical arterial injuries (ITCAI).

Methods

A systematic review was performed according to PRISMA guidelines.

Results

Thirty-two relevant case series and case reports were identified with a total of 69 patients having being studied. In the majority of the studies, plug-based VCDs were used (81%) followed by suture-based devices (19%). The majority of studies reported successful outcomes from the use of VCDs in terms of achieving immediate haemostasis without any acute complications. Long-term follow-up data were only available in nine studies with only one case of carotid pseudoaneurysm being reported after 1-month post-procedure. All other cases had no reported long-term complications. Five studies performed direct or indirect comparisons between VCDs and other treatments (open surgery or stent grafting) suggesting no significant differences in safety or effectiveness.

Conclusion

Although there is limited evidence, VCDs appear to be safe and effective for the management of ITCAIs. Further research is warranted regarding the effectiveness of this approach in comparison to surgery and in order to identify those patients who are more likely to benefit from this minimally invasive approach.

Complications of intravascular catheters in ICU: definitions, incidence and severity. A randomized controlled trial comparing usual transparent dressings versus new-generation dressings (the ADVANCED study)

PURPOSE

To describe all post-insertion complications involving most used intravascular access, and to determine whether the use of a new-generation transparent dressing (3M™ IV Advanced) might reduce their number and impact on ICU patient outcomes.

METHODS

Patients older than 18, with an expected length of stay ≥48 h and requiring at least one central venous catheter (CVC), arterial catheter (AC), haemodialysis catheter (HDC), pulmonary arterial catheters (PAC) or peripheral venous catheter (PVC) were randomized into two groups: a new-generation transparent dressing, or the hospital's classical transparent dressing, and were followed daily for any infectious and non-infectious complications. Complications were graduated for severity by an independent international multicentre multidisciplinary panel of practitioners using a Delphi process.

RESULTS

We included 628 patients, 2214 catheters (873 PVCs, 630 CVCs, 512 ACs and 199 HDCs and PACs) and 4836 dressings. Overall incidence rate was of 60.9/1000 catheter-days. The most common complication was dysfunction (34.6/1000 catheter-days), mainly for PVCs (16/1000 catheter-days) and ACs (12.9/1000 catheter-days). Infectious complications incidence rate in CVCs and ACs was of 14.5/1000, mostly due to colonization (14.2/1000 catheter-days). Thrombosis incidence was of 3.8/1000 catheter-days with severe and very severe complications in 16 cases (1.8/1000 catheter-days) and one thrombosis-related death. 3M™ IV Advanced dressing did not decrease the rate of catheters with at least a minor complication [57.37/1000 vs. 57.52/1000 catheter-days, HR 1.03, CI (0.84-1.27), p = 0.81]. Incidence rates for each single complication remained equivalent: infectious [HR 0.93 (0.62-1.40), p = 0.72], deep thrombosis [HR 0.90 (0.39-2.06), p = 0.80], extravasation and phlebitis [HR 1.40 (0.69-2.82), p = 0.35], accidental removal [1.07 (0.56-2.04), p = 0.84] and dysfunction [HR 1.04 (0.80-1.35), p = 0.79].

CONCLUSION

The ADVANCED study showed the overall risk of complications to intravascular catheters in ICU patients being dysfunction, infection and thrombosis. The 3M™ IV Advanced dressing did not decrease complication rates as compared to standard dressings.

Infection risks associated with peripheral vascular catheters

BACKGROUND

Peripheral vascular catheters (PVC) are the most frequently used invasive medical devices in hospitals, with 330 million sold each year in the USA alone. One in three UK inpatients at any one time has at least one PVC in situ according to the Scottish National Prevalence survey.

METHOD

A narrative review of studies describing the infection risks associated with PVCs.

RESULTS

It is estimated that 30-80% of hospitalised patients receive at least one PVC during their hospital stay. Despite their prevalence, PVCs are not benign devices, and the high number of PVCs inserted annually has resulted in serious catheter-related bloodstream infections and significant morbidity, prolonged hospital stay and increased healthcare system costs. To date, PVC infections have been under-evaluated. Most studies focus on central venous catheter rather than PVC-associated bloodstream infections. Risks associated with PVC infection must be addressed to reduce patient morbidity and associated costs of prolonged hospital admission and treatment.

DISCUSSION

This article discusses the sources and routes of PVC-associated infection and outlines known effective prevention and intervention strategies.