Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review

Acute care nurses' decisions to recognise and respond to patient improvement: A qualitative study

AIM

To explore and describe acute care nurses' decisions to recognise and respond to improvement in patients' clinical states as they occurred in the real-world clinical environment.

DESIGN

A descriptive study.

METHODS

Nine medical and eleven surgical nurses in a large Australian metropolitan hospital were individually observed during nurse-patient interactions and followed up in interview to describe their reasoning and clinical judgements behind observed decisions. Verbal description of observations and interviews were recorded and transcribed. Reflexive thematic analysis was used to analyse the data.

RESULTS

The three themes constructed from the data were as follows: nurses checking in; nurses reaching judgements about improvements; and nurses deciding on the best person to respond. Acute care nurses made targeted assessment decisions based on predicted safety risks related to improvement in clinical states. Subjective and objective cues were used to assess for and make judgements about patient improvement. Acute care nurses' judgment of patient safety and a desire to promote patient centred care guided their decisions to select the appropriate person to manage improvement.

CONCLUSIONS

The outcomes of this research have demonstrated that the proven safety benefits of acute care nurses' decision making in response to deterioration extend to improvement in patients' clinical states. In response to improvement, acute care nurses' decisions protect patients from harm and promote recovery.

IMPLICATIONS FOR PATIENT CARE

Early recognition and response to improvement enable acute care nurses to protect patients from risks of unnecessary treatment and promote recovery.

IMPACT

This study makes explicit nurses' essential safety role in recognising and responding to improvement in patients' clinical states. Healthcare policy and education must reflect the equal importance of assessment for and management of deterioration and improvement to ensure patients are protected and provided with safe care.

Impact of the restraint decision tree for physical restraint use in South Korean neurointensive care units

BACKGROUND

Nurses in neurointensive care units (NCUs) commonly use physical restraint (PR) to prevent adverse events like unplanned removal of devices (URDs) or falls. However, PR use should be based on evidenced decisions as it has drawbacks. Unfortunately, there is a lack of research-based PR protocol to support decision-making for nurses, especially for neurocritical patients.

AIM

This study developed a restraint decision tree for neurocritical patients (RDT-N) to assist nurses in making PR decisions. We assessed its effectiveness in reducing PR use and adverse events.

STUDY DESIGN

This study employed a baseline and post-intervention test design at a NCU with 19 beds and 45 nurses in a tertiary hospital in a metropolitan city in South Korea. Two-hundred and thirty-seven adult patients were admitted during the study period. During the intervention, nurses were trained on the RDT-N. PR use and adverse events between the baseline and post-intervention periods were compared.

RESULTS

Post-intervention, total number of restrained patients decreased (20.7%-16.3%; χ2 = 7.68, p = .006), and the average number of PR applied per restrained patient decreased (2.42-1.71; t = 5.74, p < .001). The most frequently used PR type changed from extremity cuff to mitten (χ2 = 397.62, p < .001). No falls occurred during the study periods. On the other hand, URDs at baseline were 18.67 cases per 1000 patient days in the high-risk group and 5.78 cases per 1000 patient days in the moderate-risk group; however, no URD cases were reported post-intervention.

CONCLUSIONS

The RDT-N effectively reduced PR use and adverse events. Its application can enhance patient-centred care based on individual condition and potential risks in NCUs.

RELEVANCE TO CLINICAL PRACTICE

Nurses can use the RDT-N to assess the need for PR in caring for neurocritical patients, reducing PR use and adverse events.

Effects of the low-speed continuous infusion catheter technique on double-lumen central venous catheters: A randomized controlled trial

BACKGROUND

Central venous catheters are widely used in clinical practice, and the incidence of central venous catheter occlusion is between 25 % and 38 %. The turbulence caused by the pulsatile flushing technique is harmful to the vascular endothelium and may lead to phlebitis. The low-speed continuous infusion catheter technique is a new type of continuous infusion that ensures that the catheter is always in a keep-vein-open state by continuous low-speed flushing; hence, avoiding the problem of catheter occlusion.

OBJECTIVE

To investigate the effectiveness of the low-speed continuous infusion catheter technique and the routine care of double-lumen central venous catheters.

DESIGN

This was a prospective, randomized, controlled, open-label trial.

SETTING

Patients were recruited from 14 medical institutions in China between February and June 2023.

PARTICIPANTS

In total, 251 patients were recruited, with 125 in the intervention group and 126 in the control group.

METHODS

Patients who used double-lumen central venous catheters for infusion treatment were selected, and those who met the sampling criteria were randomly divided into intervention and control groups using the random envelope method. The intervention group used the low-speed continuous infusion catheter technique to maintain catheter patency, whereas the control group used routine care with a trial period of 7 days. The primary outcome was the occlusion rate. The secondary outcomes included nursing satisfaction and complication rates of the two groups.

RESULTS

After 7 days, the rate of catheter occlusion was 28.0 % (35/125, 95 % confidence interval (CI):0.203, 0.367) in the intervention group and 53.97 % (68/126, 95 % CI: 0.449-0.629) in the control group, with a statistically significant difference (χ2 = 17.488, p < 0.001); at 3 days of intervention, the rate of catheter blockage was 8.0 % (10/125, 95 % CI: 0.039-0.142) in the intervention group and 23.8 % (30/126, 0.167-0.322) in the control group, with a statistically significant difference (χ2 = 11.707, p < 0.001). Nurse satisfaction was significantly higher in the intervention group (115/125, 92.0 %, 95 % CI: 0.858-0.961) than in the control group (104/126, 82.54 %, 95 % CI: 0.748-0.887) (χ2 = 5.049, p = 0.025). There were no statistically significant complication rates in either group (p = 0.622).

CONCLUSION

The low-speed continuous infusion catheter technique helps maintain catheter patency, improves nurse satisfaction, and provides a high level of safety.

REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200064007, www.chictr.org.cn). The first recruitment was conducted in February. https://www.chictr.org.cn/showproj.html?proj=177311.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study

BACKGROUND

Peripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks.

OBJECTIVE

To determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions.

DESIGN

Prospective, interrupted time-series study.

SETTINGS

Seven adult inpatient wards in three Australian hospitals.

PARTICIPANTS

825 adults with 867 peripheral intravenous catheters.

METHODS

Between August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections.

RESULTS

Of 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD -4.4%, 95% CI -8.5, -0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD -5.2%, 95% CI -9.7, -0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD -5.2%, 95% CI -10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention).

CONCLUSIONS

Implementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter.

ANZCTR TRIAL REGISTRATION

ACTRN12617000067370. Date of registration 13 January 2017. Date of first data collection 3rd August 2017.

TWEETABLE ABSTRACT

#IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

Evolution of Scientific Production on Phlebitis Secondary to Vascular Access: A 71-Year Bibliometric Analysis

Phlebitis secondary to vascular access is one of the most frequent complications in hospital care. This study aims to evaluate the scientific activity related to this complication through a bibliometric analysis. The search was performed on a single day, 23 January 2023, to ensure the inclusion of all articles and to avoid bias caused by the daily updates of the open access database. The data were recovered from Web of Science. The sample comprised a total of 1596 publications that met the inclusion criteria. The United States was the country with the largest number of publications, citations, and international cooperation with respect to phlebitis and vascular access. The most important author was Rickard CM. Of all the publications selected, a total of 1586 (99.37%) were original articles. The highest number of articles on the subject was recorded in 2021, and the most common research areas were General Internal Medicine and Nursing. The analysis of the clusters (KeyWords Plus and Author keywords) and co-occurrences enabled identification of areas of interest and their possible development. These areas included the prevention, risk, and associated complications of catheter-associated phlebitis. Other aspects that are a priori relevant, such as assessment and treatment, were found to be little investigated. While research on this subject is increasing internationally, more collaborations are still required between researchers, as well as new approaches related to the management of catheter-associated phlebitis. The dimensions that should continue to be considered in new research, according to the findings of this review, are instruments for phlebitis assessment and their validation, and the treatments to follow in the case of established phlebitis. For this reason, the bibliometric information presented is key for new or consolidated researchers in the field, especially because of its practical and clinical implications for patient safety.

Implementation of a vascular access specialist team in a tertiary hospital: a cost-benefit analysis

BACKGROUND

The use of peripherally inserted central catheters and midline catheters is growing due to their potential benefits. These devices can increase patient safety and satisfaction while reducing the use of resources. As a result, many hospitals are establishing vascular access specialist teams staffed by nurses who are trained in the insertion and maintenance of these catheters. The objective of the study is to evaluate previously to the implementation whether the benefits of introducing ultrasound-guided peripheral venous catheters, midline catheters and peripherally inserted central catheters compared to current practice by a vascular access specialist team outweigh their costs.

METHODS

Cost-benefit analysis from the perspective of the healthcare provider based on administrative data. The study estimates the reduction in resources used when changing the current practice for the use of ultrasound-guided midline and PICC catheters, as well as the additional resources required for their use.

RESULTS

The use of an ultrasound-guided device on peripherally inserted central carheter, results in a measurable resource reduction of approximately €31. When 3 peripheral venous catheters are replaced by an ultrasound-guided peripherally inserted central catheter, the saving is €63. Similarly, the use of an ultrasound-guided device on a midline catheter, results in a reduction of €16, while each ultrasound-guided midline catheter replacing 3 peripheral venous catheters results in a reduction of €96.

CONCLUSION

The benefits of using ultrasound-guided midline and PICC catheters compared to current practice by introducing a vascular access specialist team trained in the implantation of ultrasound-guided catheters, outweigh its cost mainly because of the decrease in hospital stay due to the lowered risk of phebitis. These results motivate the implementation of the service, adding to previous experience suggesting that it is also preferable from the point of view of patient safety and satisfaction.

Care bundle for the prevention of peripheral venous catheter blood stream infections at a secondary care university hospital: Implementation and results

BACKGROUND

Venous catheterization for diagnostic and therapeutic purposes is part of routine hospital practice, as approximately 70% of hospitalized patients have a peripheral venous catheter (PVC). This practice, however, can lead to both local complications, (e.g., chemical, mechanical and infectious phlebitis) and systemic complications (e.g., PVC-related bloodstream infections [PVC-BSIs]). Surveillance data and activities are central to preventing nosocomial infections, phlebitis and improving patient care and safety. The aim of this study was to evaluate the impact of a care bundle on reducing PVC-BSI rates and phlebitis at a secondary care hospital in Mallorca, Spain.

METHODS

Three-phase intervention study targeting hospitalized patients with a PVC. The VINCat criteria were used to define PVC-BSIs and calculate incidence. In phase I (August-December 2015), we retrospectively analyzed baseline PVC-BSI rates at our hospital. In phase II (2016-2017), we conducted safety rounds and developed a care bundle with the goal of reducing PVC-BSI rates. In phase III (2018), we expanded the PVC-BSI bundle to prevent phlebitis and analyzed its impact.

RESULTS

The incidence of PVC-BSIs decreased from 0.48 episodes per 1000 patient-days in 2015 to 0.17 episodes per 1000 patient-days in 2018. The 2017 safety rounds also detected a reduction in phlebitis (from 4.6% of 2.6%). Overall, 680 healthcare professionals were trained in catheter care and five safety rounds were conducted to assess bedside care.

CONCLUSION

Implementation of a care bundle significantly reduced PVC-BSI rates and phlebitis at our hospital. Continuous surveillance programs are needed to adapt measures to improve patient care and guarantee safety.

CE: Evidence-Based Practice for Peripheral Intravenous Catheter Management

ABSTRACT

Peripheral intravenous catheters (PIVCs) are among the most common invasive devices used in hospitalized patients, with over 300 million sold in the United States each year. However, about one-fourth of PIVCs are left in situ with no prescriber orders for IV medications or solutions, "just in case" they might be needed. PIVC insertion can be painful, is often unnecessary, and may increase a patient's risk of developing a bloodstream infection. This article reviews the evidence for the appropriate use of short PIVCs in hospitalized patients, assesses the ongoing need for PIVCs, provides recommendations for alternative options, and argues for promptly removing a PIVC that is no longer in use.

Awareness of Peripheral Intravenous Catheters Among Nurses, Physicians, and Students

OBJECTIVES

Peripheral intravenous catheters (PIVCs) are frequently used to meet patients' short-term health care needs. However, many PIVCs are not promptly removed at the completion of treatment, placing patients at risk of avoidable harm from serious complications including local and systemic infection. This study aims to report the proportion and accuracy of health care staff/students awareness of the presence of their patient's PIVC.

METHODS

We asked staff/students to recall the presence or absence of a PIVC in a patient under their care, as well as details of the date of insertion and PIVC location. We recorded concordance of responses with direct observations. To achieve this, face-to-face interviews were conducted with clinical staff/students at 2 adult hospitals.

RESULTS

Overall, 90% (n = 216) of staff responses (94% of nurses, 100% of nursing students, 76% of medical staff) correctly identified the presence/absence of a PIVC. Clinicians correctly identified the PIVC location 55% (n = 71) of the time.

CONCLUSIONS

Health care services must recognize the implications of this lack of awareness and implement and evaluate tailored quality improvement efforts to address this.

The effect of the multimodal intervention including an automatic notification of catheter days on reducing central line-related bloodstream infection: a retrospective, observational, quasi-experimental study

BACKGROUND

A central venous catheter (CVC) is an important medical device, but it could be preceding infection and the risk of central line-associated bloodstream infection (CLABSI). CLABSI is a common healthcare-associated infection but results in high cost and mortality; therefore, various efforts to reduce CLABSI have been attempted.

METHODS

This is a retrospective, observational, quasi-experimental study in the intensive care unit (ICU) of a single tertiary care hospital. We reviewed and analysed the data of CLABSI rates and days from the insertion to the removal of the temporary CVC between January 2018 and June 2021 with transient periods over 9 months. Sequentially, all patients with the CVC in the ICU underwent the following interventions: maximal barrier precaution, automatic notification of catheter days and 2% chlorhexidine gluconate bathing. A segmented regression analysis of interrupted time series was conducted to compare the CLABSI rates before and after the introduction of multimodal interventions. During study periods, the impact of interventions on CLABSI was evaluated using multivariate logistic regression analyses.

RESULTS

A total of 76,504 patient-days, 28,312 catheter days and 66 CLABSI cases were reviewed in ICU-hospitalised patients. As additional interventions, the CLABSI rate declined from 3.1 per 1000 CVC days to 1.2 per 1000 CVC days in post-interventions. In the pre-intervention and post-intervention periods, 4146 patents had one more short-term CVC. In the multivariate logistic regression analyses, multimodal intervention was one of determinants reducing CLABSI rates (odds ratio (OR), 0.52 [95% confidence interval {CI}, 0.28-0.94]). Indwelling time of CVC over 10 days was the risk factor for CLABSI rates (OR, 6.27 [95% CI, 3.36-12.48]). Of the three interventions, the automatic notification of catheter days was associated with decreased median monthly total CVC days and duration of CVC days per patient.

CONCLUSIONS

Multidisciplinary and evidence-based interventions could lead to a decrease in the CLABSI rates. Moreover, the automatic notification of catheter days of the electronic medical healthcare system has shortened the time of indwelling CVC.

I-DECIDED®-a decision tool for assessment and management of invasive devices in the hospital setting

Indwelling medical devices, including vascular access and urinary catheters, pose a risk for infection, and therefore daily assessment and consideration of their continued need is a patient safety priority. The I-DECIDED® device assessment and decision tool is an evidence-based checklist, designed to improve the assessment, care and timely removal of invasive devices in acute hospitalized patients. This paper explains each step of the tool, with rationale for inclusion.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion Training Reduces Use of Midline Catheters in Hospitalized Patients With Difficult Intravenous Access

OBJECTIVES

Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients.

METHODS

We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period.

RESULTS

One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period.

CONCLUSIONS

A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA.

Prevalence of peripheral intravenous catheters and policy adherence: A point prevalence in a tertiary care university hospital

AIMS AND OBJECTIVES

To determine prevalence and policy adherence for peripheral intravenous catheters (PIVC) in adult inpatients at a tertiary care university hospital (with about 83,000 inpatient admissions annually).

BACKGROUND

Up to 80% of hospitalised patients receive intravenous therapy, most commonly via PIVCs. However, these devices are not risk-free. Studies indicate that PIVC management standards in clinical practice are inadequate despite established policies promoting best practice. This leads to premature failure resulting in treatment delays, extended length of stay and potential compromised venous access for subsequent IV therapy.

DESIGN

Observational point prevalence study.

METHODS

Study undertaken on all adult acute care medical, surgical and oncology wards. Data were collected by senior registered nurses working in pairs on a single day. Descriptive statistics used to analyse data. SQUIRE 2.0 checklist for quality improvement reporting used.

RESULTS

There were 449 adult inpatients in 19 wards on survey day. One hundred and ninety-seven had one or more PIVCs in situ. The total number of PIVCs in-situ was 212. PIVC Prevalence was 47%. PIVCs were inserted in points of flexion such as antecubital fossa, back of hand or wrist in 52% of patients. Only 19% of cases had documented assessment of 8-hourly visual infusion phlebitis (VIP) score. Patients had local signs of phlebitis in 14.4% of cases. Patients were not aware of the reason/need for their PIVC in 44% of cases.

CONCLUSIONS

Discrepancies between evidence-based guidelines and local policy in clinical practice were identified including high rates of PIVC insertion in points of flexion and poor documentation. These quality problems increase likelihood of adverse patient outcomes especially when associated with limited patient awareness of the reason for their PIVC.

RELEVANCE TO CLINICAL PRACTICE

Poor adherence to best practice standards is 'accepted but unacceptable'. PIVC failure is costly to both patients and health systems. A strong focus on improvement in PIVC care and management is needed.

Idle peripheral intravenous cannulation: an observational cohort study of pre-hospital and emergency department practices

BACKGROUND

Unused ('idle') peripheral intravenous catheters (PIVC) are those not used within 24 hours of insertion. There is little data on cannulation practices and idle PIVC rates in emergency settings, especially the pre-hospital environment.

METHODS

This was an observational cohort study set in south-east Queensland, Australia using data from a large tertiary level emergency department (ED) and the local statutory ambulance service. Demographic, clinical and PIVC data were collected over two periods; 9 February-18 March 2017 and 5 January-4 February 2018. Adult patients were included if they were allocated an Australasian triage scale (ATS) category between 2 and 5, and had a PIVC inserted in the pre-hospital setting or ED. PIVC use was defined as idle if no fluids, medications or contrast were administered intravenously within 24 hours of insertion. Comparisons between pre-hospital and ED practice and idle PIVC status were undertaken using descriptive statistics and logistic regression.

RESULTS

A total of 1249 patients with a PIVC (372 pre-hospital; 877 ED) were included. Overall, 366 PIVCs (29.3%; 95% CI 26.9%-31.9%) remained idle at 24 hours. In the pre-hospital group, 147 (39.5%) PIVCs inserted were not used pre-hospital, and 74 (19.9%) remained idle. In comparison, 292 (33.3%) PIVCs placed in the ED remained idle. ED staff more frequently inserted PIVCs in the antecubital fossa than paramedics (65.5% vs. 49.7%), where forearm PIVC insertion was more common pre-hospital than in ED (13.7% vs. 7.4%). Nursing staff inserted idle PIVCs at a rate of (35.1%) compared to doctors (29.6%) and paramedics (19.9%). Having a PIVC inserted in the ED was the only factor significantly (p ≤ .001) predicting an idle outcome (Odds Ratio: 2.4; 95% CI 1.7-3.3).

CONCLUSION

One-third of PIVCs inserted within the emergency setting remained idle, suggesting unnecessary risk and costs. Pre-hospital and ED PIVC insertion practices differed, with idle PIVCs 2.4 times more prevalent if inserted in the ED than pre-hospital and with greater use of antecubital insertion. Reasons for these differences are not well understood and requires more targeted research.

Hiding in Plain Sight: Peripheral Intravenous Catheter Infections

TOPIC

This article presents an overview of the burden of peripheral intravenous catheter infections and current evidence-based recommendations for prevention.

CLINICAL RELEVANCE

Peripheral intravenous catheters are ubiquitous in most health care settings, fostering an acceptance of the peripheral intravenous catheter as benign and inevitable. This device, however, is far from benign, with reported failure rates as high as 90% from complications such as infection and phlebitis. Although reported rates of bloodstream infection related to peripheral intravenous catheters are much lower than those attributed to central venous catheters, the exponentially higher use of peripheral intravenous catheters indicates that the absolute number of peripheral venous catheter-related bloodstream infections is likely as high as and may surpass the number of central venous catheter-related bloodstream infections, with significant associated morbidity and mortality.

PURPOSE OF PAPER

Sustained improvements in outcomes related to peripheral intravenous catheters will depend on recognition of the root causes of failure and increased commitment to practice patterns consistent with infusion therapy standards of practice, effective education about peripheral intravenous catheters, accurate documentation of all aspects of peripheral intravenous catheter management, and consistent surveillance of patient outcomes related to peripheral intravenous catheters.

CONTENT COVERED

This article reviews the significant burden of peripheral intravenous catheter infections, barriers to effective peripheral intravenous catheter management, and current evidence-based recommendations to prevent this source of patient harm.

'How many audits do you really need?': Learnings from 5-years of peripheral intravenous catheter audits

BACKGROUND

Peripheral intravenous catheters (PIVCs) are medical devices used to administer intravenous therapy but can be complicated by soft tissue or bloodstream infection. Monitoring PIVC safety and quality through clinical auditing supports quality infection prevention however is labour intensive. We sought to determine the optimal patient 'number' for clinical audits to inform evidence-based surveillance.

METHODS

We studied a dataset of cross-sectional PIVC clinical audits collected over five years (2015-2019) in a large Australian metropolitan hospital. Audits included adult medical, surgical, women's, cancer, emergency and critical care patients, with audit sizes of 69-220 PIVCs. The primary outcome was PIVC complications for one or more patient reported symptom/auditor observed sign of infection or other complications. Complication prevalence and 95% confidence interval (CI) were calculated. We modelled scenarios of low (10%), medium (20%) and high (50%) prevalence estimates against audit sizes of 20, 50, 100, 150, 200, 250, and 300. This was used to develop a decision-making tool to guide audit size.

RESULTS

Of 2274 PIVCs evaluated, 475 (21%) had a complication. Complication prevalence per round varied from 7.8% (95% CI, 4.2-12.9) to 39% (95% CI, 32.0-46.4). Precision improved with larger audit size and lower complication rates. However, precision was not meaningfully improved by auditing >150 patients at a complication rate of 20% (95% CI 13.9%-27.3%), nor >200 patients at a complication rate of 50% (95% CI 42.9%-57.1%).

CONCLUSION

Audit sizes should be 100 to 250 PIVCs per audit round depending on complication prevalence.

Safety and efficacy of vasopressor administration through midline catheters

CONTEXT

Vasopressors are commonly administered through Central Venous Catheters (CVCs) as it is considered unsafe to administer them via peripheral IVs, mainly due to the concern of local tissue injury. Unlike peripheral IVs, midline catheters provide a wider lumen with the catheter tip ending in a large peripheral vein. The use of vasopressors through midline catheters has not yet been evaluated.

OBJECTIVE

The primary objective of this study is to determine the safety and efficacy of long term administration of vasopressors through a midline catheter.

DESIGN

This is a retrospective study between 2016 and 2019 looking at the outcomes of midline catheters.

SETTING

45 bed Tertiary level ICU in a 600-bed teaching hospital.

PATIENTS

A total of 248 patients received vasopressors via midline catheters.

RESULTS

The average midline dwell time was 14.7 ± 12.8 days and the average duration of continuous vasopressor infusion was 7.8 ± 9.3 days. Vasopressors used with their average dose (AD) were norepinephrine (n = 165, 16.8 CE ± 10.7 μg/min), epinephrine (n = 56, 9.1 CE ± 6.0 μg/min), vasopressin (n = 123, 0.05 CE ± 0.02 units/min), phenylephrine (n = 158, 91.4 CE ± 64.7 μg/min) and Angiotensin II (50 CE ± 27.6 ng/kg/min). Early Complication rate was 3.6% due to Bloodstream infection (n = 6), drug extravasation (n = 1), thrombophlebitis (n = 1) and arterial puncture (n = 1). Late Complication rate was 0.8% (n = 2) due to midline-associated DVTs. There were no complications related to ineffective drug delivery or limb endangerment.

CONCLUSIONS

Many medical centers are attempting to limit the use of central venous catheters (CVCs) to avoid central line-associated bloodstream infections (CLABSIs). This study demonstrates that midline catheters are a safe alternative to CVCs, for the safe and efficacious administration of vasopressors for prolonged periods of time.

Prevalence and risk factors of inappropriate use of intravenous and urinary catheters in surgical and medical patients

BACKGROUND

Previously, the RICAT (Reduction of Inappropriate use of intravenous and urinary CATheters) study had been conducted by ourselves to reduce inappropriate use of intravenous and urinary catheters in medical wards to prevent healthcare-associated infections.

AIM

To compare surgical and medical wards, and to determine risk factors for inappropriate catheter use.

METHODS

A cross-sectional study was performed from October, 2017, to May, 2018, in surgical wards of two university hospitals in the Netherlands. Patients were prospectively observed every other week for seven months. Inappropriate use was compared with non-surgical wards in the RICAT study.

FINDINGS

In all, 409 surgical patients were included, and they were compared with 1781 medical patients. Inappropriate use occurred in 36 (8.5%) out of 425 peripheral intravenous catheters in 373 surgical patients, compared to 400 (22.9%) out of 1747 peripheral intravenous catheters in 1665 medical patients, a difference of 14.4% (95% confidence interval (CI): 11.1-17.8; P < 0.001). Inappropriate use of urinary catheters occurred in 14 (10.4%) out of 134 surgical patients, compared to 105 (32.4%) out of 324 medical patients, a difference of 22.0% (95% CI: 14.7-29.2; P < 0.001). Subgroup analysis in the two university hospitals confirmed these differences. The main risk factor for inappropriate use of peripheral intravenous catheters was admission in medical wards (odds ratio (OR): 3.50; 95% CI: 2.15-5.69), which was also one of the main risk factors for urinary catheters (OR: 2.75; 95% CI: 1.36-5.55).

CONCLUSION

Inappropriate use of catheters is more common in medical wards compared to surgical wards. Prevention strategies to reduce healthcare-associated infections should primarily focus on sites with high prevalence of inappropriate use.

Peripheral intravenous cannula insertion and use in a tertiary hospital emergency department: A cross-sectional study

INTRODUCTION

Peripheral intravenous cannula is often a first line invasive intervention for patients in the emergency department. It is used to facilitate blood sampling, deliver essential fluids, blood products and medication. However, the insertion and use of the peripheral intravenous cannula is not without complication. This study surveyed the number of peripheral intravenous cannulas inserted in the emergency department and identify the level of and reason for use.

METHODS

A cross-sectional study was conducted in the emergency department of a large tertiary hospital in Queensland. Descriptive and inferential statistics were used to describe peripheral intravenous cannula use and to explore associations.

RESULTS

Of the 224 patients assessed, 159 (71%) had at least one peripheral intravenous cannula inserted in emergency department. Of the 159 peripheral intravenous cannulas inserted, 54 (34%) remained unused while the patient was in the emergency department. For patients classified as Australasian Triage Scale categories 3, 4 and 5, 40% of peripheral intravenous cannulas remained unused. Overall, poor documentation was observed with 29% of peripheral intravenous cannulas insertions not documented at all.

CONCLUSION

This study identified a high proportion of unused peripheral intravenous cannulass in the emergency department and inadequate documentation. An intervention to promote best practice, raise awareness of the risks of peripheral intravenous cannulas use, possible alternatives therapies, and improve documentation is required.

De-implementation strategy to reduce inappropriate use of intravenous and urinary catheters (RICAT): a multicentre, prospective, interrupted time-series and before and after study

BACKGROUND

Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections.

METHODS

In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438.

FINDINGS

Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p<0·0001). Time-series analyses showed an absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6·65% (95% CI 2·47 to 10·82, p=0·011). Inappropriate use of urinary catheters occurred in 105 (32·4%, 95% CI 27·3 to 37·8) of 324 patients in the baseline group compared with 96 (24·1%, 20·0 to 28·6) of 398 patients in the intervention group (IRR 0·74, 95% CI 0·56 to 0·98, p=0·013). Time-series analyses showed an absolute reduction in inappropriate use of urinary catheters of 6·34% (95% CI -12·46 to 25·13, p=0·524).

INTERPRETATION

Our de-implementation strategy reduced inappropriate use of short peripheral intravenous catheters in patients who were not in the intensive care unit. The reduction of inappropriate use of urinary catheters was substantial, yet not statistically significant in time-series analysis due to a small sample size. The strategy appears well suited for broad-scale implementation to reduce health care-associated infections.

FUNDING

Netherlands Organisation for Health Research and Development.

The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation

OBJECTIVE

To describe the clinimetric validation of the I-DECIDED tool for peripheral intravenous catheter assessment and decision-making.

DESIGN AND SETTING

I-DECIDED is an eight-step tool derived from international vascular access guidelines into a structured mnemonic for device assessment and decision-making. The clinimetric evaluation process was conducted in three distinct phases.

METHODS

Initial face validity was confirmed with a vascular access working group. Next, content validity testing was conducted via online survey with vascular access experts and clinicians from Australia, the UK, the USA and Canada. Finally, inter-rater reliability was conducted between 34 pairs of assessors for a total of 68 peripheral intravenous catheter (PIVC) assessments. Assessments were timed to ensure feasibility, and the second rater was blinded to the first's findings. Content validity index (CVI), mean item-level CVI (I-CVI), internal consistency, mean proportion of agreement, observed and expected inter-rater agreements, and prevalence-adjusted bias-adjusted kappas (PABAK) were calculated. Ethics approvals were obtained from university and hospital ethics committees.

RESULTS

The I-DECIDED tool demonstrated strong content validity among international vascular access experts (n=7; mean I-CVI=0.91; mean proportion of agreement=0.91) and clinicians (n=11; mean I-CVI=0.93; mean proportion of agreement=0.94), and high inter-rater reliability in seven adult medical-surgical wards of three Australian hospitals. Overall, inter-rater reliability was 87.13%, with PABAK for each principle ranging from 0.5882 ('patient education') to 1.0000 ('document the decision'). Time to complete assessments averaged 2 min, and nurse-reported acceptability was high.

CONCLUSION

This is the first comprehensive, evidence-based, valid and reliable PIVC assessment and decision tool. We recommend studies to evaluate the outcome of implementing this tool in clinical practice.

TRIAL REGISTRATION NUMBER

12617000067370.

Global Pediatric Peripheral Intravenous Catheter Practice and Performance: A Secondary Analysis of 4206 Catheters

PURPOSE

To describe worldwide characteristics, performance and risk factors of peripheral intravenous catheters (PIVCs), in pediatrics.

DESIGN

A secondary, subgroup analysis of pediatric (<18 years) data was undertaken, using a global, cross-sectional study of PIVCs. Practice characteristics included: demographic, diagnostic, utility, management, performance and resources. Multivariate regression identified complication risks factors.

RESULTS

Data from 4206 children in 278 hospitals across 47 countries. Most PIVCs (outside of Australia, New Zealand) were inserted by nurses (71%; n = 2950), with dedicated teams only common in North America (23.2%; n = 85). Large gauges (≤18G) were mostly used in South America, Europe and Africa. Regions predominantly placed 24G (49%; n = 2060) except in Australia and New Zealand, who more commonly placed 22G (38.7%; n = 192). The most common placement was the hand (51%; n = 2143), however North America, Australia and New Zealand frequently utilised the antecubital fossa (24.5%, n = 90; 21.4%; n = 106). Polyurethane dressings were most used (67.1%; 2822), and many were not clean, dry and intact (17.1%; n = 715). Over 8% of PIVCs were idle, with the highest rates in North America (21.2%; n = 78). PIVC local complication risk factors included: >2 years age (odds ratio [OR] > 1.58; 1.2-2.1); ambulance/emergency insertion (OR 1.65; 1.2-2.3); upper arm/antecubital placement (OR 1.44; 1.1-2.0); poor dressing integrity (OR 5.4; 4.2-6.9); and 24-72 h dwell (OR > 1.9; 1.3-2.6).

CONCLUSIONS

There is global inconsistency in pediatric PIVC practice, which may be causing harm.

CLINICAL IMPLICATIONS

Improvements in pediatric PIVC placement, dressings, and gauge selection are needed.

The incidence and risk of infusion phlebitis with peripheral intravenous catheters: A meta-analysis

Introduction:

Phlebitis is a common complication associated with the use of peripheral intravenous catheters. The aim of this study was to estimate the incidence of phlebitis with peripheral intravenous catheter use and to identify risk factors for phlebitis development.

Method:

Literature survey was conducted in electronic databases (CINAHL, Embase, Google Scholar, Ovid, and PubMed), and studies were included if they used peripheral intravenous catheter for therapeutic or volumetric infusion and reported phlebitis incidence rates. Random effects meta-analyses were performed to obtain overall and subgroup phlebitis incidence rates and odds ratio between males and females in phlebitis incidence.

Results:

Thirty-five studies were included (20,697 catheters used for 15,791 patients; age 57.1 years (95% confidence interval: 55.0, 59.2); 53.9% males (95% confidence interval: 42.3, 65.5)). Incidence of phlebitis was 30.7 per 100 catheters (95% confidence interval: 27.2, 34.2). Incidence of severe phlebitis was 3.6% (95% confidence interval: 2.7%, 4.6%). Incidence of phlebitis was higher in non-intervened (30% (95% confidence interval: 27%, 33%)) than in intervened (21% (95% confidence interval: 15%, 27%)) groups, and with Teflon (33% (95% confidence interval: 25%, 41%)) than Vialon (27% (95% confidence interval: 21%, 32%)) cannula use. Odds of developing phlebitis was significantly higher in females (odds ratio = 1.42 (95% confidence interval: 1.05, 1.93); p = 0.02). Longer dwelling time, antibiotics infusion, female gender, forearm insertion, infectious disease, and Teflon catheter are important risk factors for phlebitis development identified by the included studies.

Conclusion:

Incidence of phlebitis with the use of peripheral intravenous catheters during infusion is 31%. Severe phlebitis develops in 4% of all patients. Risk of phlebitis development can be reduced by adapting appropriate interventions.

Prevalence of idle peripherally inserted central catheters in adult patients: A multicenter cross-sectional study

Background:

Increasing studies concern about idle vascular access devices, but still scant data on idle peripherally inserted central catheters. We aimed to assess the prevalence and risks of idle peripherally inserted central catheters in adult patients.

Methods:

A multicenter cross-sectional observational study was performed between April 2018 and July 2018. Patient demographics and peripherally inserted central catheters–related information were abstracted using a site questionnaire by directly inquiring and medical records reviewing right after their peripherally inserted central catheters were removed.

Results:

Three hundred and fifty-eight patients with peripherally inserted central catheter episodes who met the inclusion criteria were studied. Of the 58,000 total catheter-days recorded, 5311 (9.2%) were considered as idle based on our study criteria. Two hundred and fifty-five (71.2%) patients had at least 1 idle catheter-day with a mean duration of 14.84 (19.31) idle days. The incidence of catheter-related complications in patients with idle peripherally inserted central catheters was lower than that in patients without idle peripherally inserted central catheters, though the difference did not reach statistical significance (odds ratio = 0.635, 95% confidence interval = 0.367–1.099, p = 0.103).

Conclusion:

In conclusion, idle peripherally inserted central catheters were common in adult patients, but the low risks of catheter-related complications may justify maintaining a peripherally inserted central catheter for further observation when necessary.

Derivation of a clinical decision-making aid to improve the insertion of clinically indicated peripheral intravenous catheters and promote vessel health preservation. An observational study

Background

It is well established that the idle peripheral intravenous catheter (PIVC) provides no therapeutic value and is a clinical, economic and above all, patient concern. This study aimed to develop a decision aid to assist with clinical decision making to promote clinically indicated peripheral intravenous catheter (CIPIVC) insertion in the emergency department (ED) setting. Providing evidence for a uniform process could assist clinicians in a decision-making process for PIVC insertion. This could enable patients receive appropriate vascular access healthcare.

Methods

We performed a secondary analysis of data from a multicentre cohort of emergency department clinicians who performed PIVC insertion. We defined CIPIVC a priori as one used for a specific clinical treatment and or procedure such as prescribed intravenous (IV) fluids; prescribed IV medication; or IV contrast (for computerized tomography scans). We sought to refute or validate an assumption if the clinician performing or requesting the insertion decided the patient was >80% likely to need a PIVC. Using logistic regression, we derived a decision aid for CIPIVCs.

Results

In 817 patients undergoing PIVC insertion, we observed 68% of these to be CIPIVCs. Admitted patients were significantly more likely to have a CIPIVC, Odds Ratio (OR) = 3.05, 95% confidence interval (CI) = 2.17–4.30, p = <0.0001. Before insertion, patients who definitely needed IV fluids/medicines OR = 3.30, 95% CI = 2.02–5.39, p = <0.0001 and who definitely needed a contrast scan OR = 3.04, 95% CI = 1.15–8.03, p = 0.0250 were significantly more likely to have a device inserted for a clinical indication. Patients who presented with an existing vascular access device were more likely to have a new CIPIVC inserted for use OR = 4.35, 95% CI = 1.58–11.95, p = 0.0043. The clinician’s pre-procedural judgment of the likelihood of therapeutic use >80% was independently associated with CIPIVC; OR 3.16, 95% CI = 2.06–4.87, p<0.0001. The area under the receiver operating characteristic curve was 0.81, and at the best cut-off, the model had a specificity of 0.81, sensitivity of 0.71, a positive predictive value of 0.89 and negative predictive value of 0.57.

Conclusions

Using the derived decision aid, clinicians could ask:- “Does this patient need A-PIVC?” Clinicians can decide to insert a CIPIVCs when: (i) Admission to hospital is anticipated and when (ii) a Procedure requires a PIVC, e.g., computerised tomography scans and where an existing suitable vascular access device is not present and or; (iii) there is an indication for IV fluids and or medicines that cannot be tolerated enterally and are suitable for dilution in peripheral veins; and, (iv) the Clinician’s perceived likelihood of use is greater than 80%.

Interventions to reduce unnecessary central venous catheter use to prevent central-line–associated bloodstream infections in adults: A systematic review

Objective

To identify, describe, and evaluate interventions to reduce unnecessary central venous catheter (CVC) use to prevent central-line–associated bloodstream infections (CLABSIs) in adults.

Design

Systematic review.

Methods

The review has been registered in PROSPERO, an international prospective register of systematic reviews. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health (CINAHL) from inception until August 28, 2018, to collect experimental and observational studies. We included all studies that implemented interventions to reduce unnecessary CVC use, defined as interventions aimed at improving appropriateness, awareness of device presence, or prompt removal of devices.

Results

In total, 1,892 unique citations were identified. Among them, 1 study (7.1%) was a randomized controlled trial, 9 studies (64.3%) were quasi-experimental studies, and 4 studies (28.6%) were cohort studies. Furthermore, 13 studies (92.9%) demonstrated a decrease in CVC use after intervention despite different reporting methods, and the reduction rate varied from 6.8% to 85%. Also, 7 studies (50.0%) that reported the incidence of CLABSI described a reduction in CLABSIs ranging from 24.4% to 100.0%. Data on secondary outcomes were limited, and results of the descriptive analysis showed 70%–84% compliance with these interventions, less catheter occlusion, shorter duration of hospitalization, and cost savings.

Conclusions

Interventions to reduce unnecessary CVC use significantly decrease the rate of CLABSI. Healthcare providers should strongly consider implementing these interventions for prevention of CLABSI in adults.

The idle central venous catheter in the NICU: When should it be removed?

PURPOSE

There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements.

METHODS

Patients in the NICU with T-CVCs placed between 11/2008 and 8/2015 (n=134) or PICCs placed between 7/2013 and 10/2015 (n=467) were included. Demographics and outcomes were compared.

RESULTS

The most common indications for line placement were parenteral nutrition for PICCs (74%) and lack of access for T-CVCs (53%). T-CVCs had a greater proportion of idle days (T-CVC- 25.2% vs PICC- 5.1%, p<0.001) and removal within 24h of discharge (T-CVC-53% vs PICC-5.8%, p<0.001). Conversely, 81% of PICCs were removed within 24h of nonuse. Line replacement after removal for nonuse was required in 6% of PICCs and zero T-CVCs. In both groups, the central line-associated bloodstream infection (CLABSI) rate was lower in idle lines compared to ones in use.

CONCLUSION

Patients treated with PICCs and T-CVCs are different populations and should have different guidelines for removal. In neonates with difficult access, the low risk of CLABSIs in idle surgically placed catheters may justify maintaining access until discharge.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Comparison of complications in midlines versus central venous catheters: Are midlines safer than central venous lines?

BACKGROUND

With the rising use of midline catheters (MCs), validation of their safety is essential. Our study aimed to evaluate the incidence of bloodstream infections (BSIs) and other complications related to the use of MCs and central venous catheters (CVCs).

METHODS

A retrospective cohort study was performed at a tertiary care hospital in Detroit, Michigan, from March-September 2016. Adult patients with either MC or CVC were included. Outcomes assessed were catheter-related BSI (CRBSI), mechanical complications, hospital length of stay, readmission within 90 days of discharge (RA), and mortality. Statistical analysis was performed using SAS software.

RESULTS

A total of 411 patients with MC and 282 patients with CVC were analyzed. More CRBSIs were seen in patients with CVC (10/282) than MC (1/411) (3.5% vs 0.2%, respectively; P = .0008). More mechanical complications were seen in patients with MC (2.6%) than CVC (0.3%; P = .03). Patients with CVC had a higher crude mortality (17.3% vs 5.3%; P < .0001), RA (58% vs 35%; P ≤ .0001), line-related RA (2.8% vs 0.2%; P = .0041), and transfer to intensive care unit after line placement (9% vs 5%; P = .01). CVC was a significant exposure for a composite of mortality, CRBSI, mechanical issues, thrombosis, and readmission because of a line-related complication (odds ratio, 3.2; 95% confidence interval, 1.8-5.8).

CONCLUSIONS

Our findings show use of MC is safer than CVC, but larger studies are needed to confirm our findings.

Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: protocol for an interrupted time-series study

INTRODUCTION

Millions of acute care hospital patients need a peripheral intravenous catheter (PIVC) each year. However, up to half of PIVCs remain in situ when not being used, and 30%-50% of intravenous (IV) catheters develop complications or stop working before treatment is finished, requiring the insertion of a new device. Improved assessment could prompt timely removal of redundant catheters and prevent IV complications. This study aims to validate an evidence-based PIVC assessment and decision-making tool called I-DECIDED and evaluate the effect of implementing this tool into acute hospital clinical practice.

METHODS AND ANALYSIS

The protocol outlines a prospective, multicentre, mixed-methods study using an interrupted time-series (multiple measures preintervention and postintervention) implementation at three Australian hospitals between August 2017 and July 2018. The study will examine the effectiveness of the I-DECIDED assessment and decision-making tool in clinical practice on prompting timely PIVC removal and early detection of complications. Primary outcomes are prevalence of redundant PIVCs (defined as device in situ without a clear purpose), IV complications (occlusion, dislodgement, infiltration, extravasation and phlebitis) and substandard dressings (loose, lifting, moist or soiled); device utilisation ratios; and primary bloodstream infection rates. Secondary outcomes including staff barriers and enablers to PIVC assessment and removal, patient participation, documentation of PIVC assessment and decisions taken to continue or remove the PIVC will be recorded. Using the Promoting Action on Research Implementation in Health Services framework, we will undertake staff focus groups, bedside patient interviews and PIVC assessments and chart audits. Patients aged 18 years or more with a PIVC will be eligible for inclusion.

ETHICS AND DISSEMINATION

Ethical approval from Queensland Health (HREC/17/QPCH/47), Griffith University (Ref No. 2017/152) and St Vincent's Health and Aged Care Human Research and Ethics Committee (Ref No. 17/28). Results will be published.

TRIAL REGISTRATION NUMBER

ANZCTR: 12617000067370; Pre-results.

Tools, Clinical Prediction Rules, and Algorithms for the Insertion of Peripheral Intravenous Catheters in Adult Hospitalized Patients: A Systematic Scoping Review of Literature

BACKGROUND

First-time peripheral intravenous catheter (PIVC) insertion success is dependent on patient, clinician, and product factors. Failed PIVC insertion are an under-recognized clinical phenomenon.

OBJECTIVE

To provide a scoping review of decision aids for PIVC insertion including tools, clinical prediction rules, and algorithms (TRAs) and their findings on factors associated with insertion success.

METHODS

In June 2016, a systematic literature search was performed using the medical subject heading of peripheral catheterization and tool* or rule* or algorithm*. Data extraction included clinician, patient, and/or product variables associated with PIVC insertion success. Information about TRA reliability, validity, responsiveness, and utility was also extracted.

RESULTS

We screened 36 studies, and included 13 for review. Seven papers reported insertion success ranging from 61%-90% (4030 insertion attempts), 6 on validity, and 5 on reliability, with none reporting on responsiveness and utility. Failed insertions were associated with obesity (odds ratio [OR], 0.71-1.7; 2 studies) and smaller gauge PIVCs (OR, 6.4; 95% Confidence Interval [CI}, 3.4-11.9). Successful inser tions were associated with visible veins (OR, 0.87-3.63; 3 studies) or palpable veins (OR, 0.79-5.05; 3 studies) and inserters with greater procedural volume (OR, 4.4; 95% CI, 1.6-12.1) or who predicted that insertion would be successful (OR, 1.06; 95% CI, 1.04-1.07). Definitions of insertion difficulty are heterogeneous such as time to insert to a number of failed attempts.

CONCLUSIONS

Few well-validated reliable TRAs exist for PIVC insertion. Patients would benefit from a validated, clinically pragmatic TRA that matches insertion difficulty with clinician competency.