The Need for Comparative Data in Vascular Access: The Rationale and Design of the PICC Registry

Mapping progress in intravascular catheter quality surveillance: An Australian case study of electronic medical record data linkage

Background and significance

Intravascular (IV) catheters are the most invasive medical device in healthcare. Localized priority-setting related to IV catheter quality surveillance is a key objective of recent healthcare reform in Australia. We sought to determine the plausibility of using electronic health record (EHR) data for catheter surveillance by mapping currently available data across state-wide platforms. This work has identified barriers and facilitators to a state-wide EHR surveillance initiative.

Materials and methods

Data variables were generated and mapped from routinely used EHR sources across Queensland, Australia through a systematic search of gray literature and expert consultation with clinical information specialists. EHR systems were eligible for inclusion if they collected data related to IV catheter insertion, care, or outcomes of hospitalized patients. Generated variables were mapped against international recommendations for IV catheter surveillance, with data linkage and data export capacity narratively summarized.

Results

We identified five EHR systems, namely, iEMR, MetaVision ICU®, Multiprac, RiskMan, and the Nephrology Registry. Systems were used across jurisdictions and hospital wards. Data linkage was not evident across systems. Extraction processes for catheter data were not standardized, lacking clear and reliable extraction techniques. In combination, EHR systems collected 43/50 international variables recommended for catheter surveillance, however, individual systems collected a median of 24/50 (IQR 22, 30) variables. We did not identify integrated clinical analytic systems (incorporating machine learning) to support clinical decision making or for risk stratification (e.g., catheter-related infection).

Conclusion

Current data linkage across EHR systems limits the development of an IV catheter quality surveillance system to provide timely data related to catheter complications and harm. To facilitate reliable and timely surveillance of catheter outcomes using clinical informatics, substantial work is needed to overcome existing barriers and transform health surveillance.

Beyond Bean Counting: Gathering and Using Data to Drive Improvements

Data collection of process and outcome measures for vascular access procedures and devices is recommended in all relevant guidelines and standards. A variety of strategies for achieving these objectives and how the findings can be aggregated and presented to improve patient care is discussed, along with a review of specific recommendations.

International recommendations for a vascular access minimum dataset: a Delphi consensus-building study

BACKGROUND

Data regarding vascular access device use and outcomes are limited. In part, this gap reflects the absence of guidance on what variables should be collected to assess patient outcomes. We sought to derive international consensus on a vascular access minimum dataset.

METHODS

A modified Delphi study with three rounds (two electronic surveys and a face-to-face consensus panel) was conducted involving international vascular access specialists. In Rounds 1 and 2, electronic surveys were distributed to healthcare professionals specialising in vascular access. Survey respondents were asked to rate the importance of variables, feasibility of data collection and acceptability of items, definitions and response options. In Round 3, a purposive expert panel met to review Round 1 and 2 ratings and reach consensus (defined as ≥70% agreement) on the final items to be included in a minimum dataset for vascular access devices.

RESULTS

A total of 64 of 225 interdisciplinary healthcare professionals from 11 countries responded to Round 1 and 2 surveys (response rate of 34% and 29%, respectively). From the original 52 items, 50 items across five domains emerged from the Delphi procedure.Items related to demographic and clinical characteristics (n=5; eg, age), device characteristics (n=5; eg, device type), insertion (n=16; eg, indication), management (n=9; eg, dressing and securement), and complication and removal (n=15, eg, occlusion) were identified as requirements for a minimum dataset to track and evaluate vascular access device use and outcomes.

CONCLUSION

We developed and internally validated a minimum dataset for vascular access device research. This study generated new knowledge to enable healthcare systems to collect relevant, useful and meaningful vascular access data. Use of this standardised approach can help benchmark clinical practice and target improvements worldwide.

Analysis of central venous access injuries from claims to the Swedish Patient Insurance Company 2009-2017

INTRODUCTION

Insertion and use of central venous access devices (CVADs) can be associated with serious adverse events. The incidence is generally low but considering the vast use of CVADs the consequences can, from a patient safety and health economics perspective, be severe. No exact knowledge exists of number of catheters or complications in Sweden, as there is currently no comprehensive registry. The aim was to analyse injuries reported to the Swedish National Patient Insurance Company (Löf) within 7 days after insertion or removal of a CVAD.

METHODS

A retrospective analysis of all injuries filed in the period 2009-2017 was performed, evaluating patient data, type of catheter, insertion technique and type of injury. If the injury was deemed avoidable by Löf, degree of disability and mortality was registered.

RESULTS

A total of 87 claims of injuries were found of which 36 (41%) were assessed as avoidable. The most common injuries were: bleeding (18%), early infection (17%), pneumothorax (17%) and early thrombosis (15%). No patients died of their injuries, but 17 of 36 suffered permanent disability of varying degrees. Ultrasound-guided insertion was used in 19% of the cases.

CONCLUSION

In Sweden, few injuries related to CVAD use are reported to Löf. About 40% of filed claims were categorized as having an avoidable injury and therefore eligible for compensation. About half of the compensated patients suffered a permanent disability. The results indicate underreporting of CVC-related injuries in Sweden during the studied time-period.

Peripherally Inserted Central Catheter Postinsertion Complications: A Retrospective Study

PICC offers safe intravenous access for medium- to long-term use with inpatients. There is no association between overall complication rates and PICC material type. Oncology status is the strongest predictor of complications.

Comparison of Two Lidocaine Administration Techniques on Perceived Pain From Bedside Procedures: A Randomized Clinical Trial

BACKGROUND

Lidocaine is used to alleviate procedural pain but paradoxically increases pain during injection. Pain perception can be modulated by non-noxious stimuli such as temperature or touch according to the gate control theory of pain. We postulated that lidocaine dripped onto the skin prior to injection would cool or add the sensation of touch at the skin surface to reduce pain perception from the procedure.

METHODS

A randomized clinical trial of patients referred to the procedure service from February 2011 through March 2015 was conducted. All patients received 1% subcutaneous lidocaine injection. Patients randomized to the intervention group had approximately 1 to 2 ml of lidocaine squirted onto the skin surface prior to subcutaneous lidocaine injection. Patients were blinded to the details of the intervention and were surveyed by a blinded investigator to document the primary outcome (severity of pain from the procedure) using a visual analog scale.

RESULTS

A total of 481 patients provided consent and were randomized to treatment. There was a significant improvement in the primary outcome of procedural pain (control, 16.6 ± 24.8 mm vs 12.2 ± 19.4 mm; P = .03) with the intervention group as assessed by using the visual analog scale score. Pain scores were primarily improved for peripherally inserted central catheters (control, 18.8 ± 25.6 mm vs 12.2 ± 18.2 mm; P = .02) upon subgroup analysis.

CONCLUSIONS

Bedside procedures are exceedingly common. Data regarding the severity of procedural pain and strategies to mitigate it are important for the informed consent process and patient satisfaction. Overall, pain reported from common bedside procedures is low, but pain can be further reduced with the addition of lidocaine onto the skin surface to modulate pain perception.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01330134; URL: www.clinicaltrials.gov.

Umbilical Venous Catheter Versus Peripherally Inserted Central Catheter in Neonates: A Randomized Controlled Trial

Peripherally inserted central catheter (PICC) and umbilical venous catheter (UVC) in terms of success rate, complications, cost and time of insertion in neonatal intensive care were compared. Neonates requiring vascular access for minimum 7 days were included. Sample size of 72 per group was determined. Trial was registered at Clinical Trials Registry of India (CTRI/2015/02/005529). Success rates of the UVC and PICC were 68.1% and 65.3%, respectively (p = 0.724). Mean (SD) time needed for PICC and UVC insertion was 34.13 (34.69) and 28.31 (17.19) min, respectively (p = 0.205). Mean (SD) cost of PICC insertion vs. UVC insertion was 60.9 (8.6) vs. 11.9 (8.7) US dollars (p < 0.0001). Commonest cause for failure of UVC was displacement [6 (8.3%)] and that for PICC was blockage [9 (12.5%)].

CONCLUSIONS

UVC is a cheaper alternative to PICC, with similar success rate, short-term complications and time needed for insertion.

Open- vs Closed-Tip Valved Peripherally Inserted Central Catheters and Midlines: Findings from a Vascular Access Database

Today's patients are more complex in terms of comorbidities and other conditions requiring multiple, long-lasting therapies such as chemotherapy, total parenteral nutrition, blood transfusion or blood component infusions, and frequent blood sampling. The use of central venous catheters represents an important aspect of care for many patients. It is essential to inform health care workers of the risks associated with central venous catheters such as systemic and infectious complications, mechanical complications, and/or thrombotic complications. To maintain monitoring of our peripherally inserted central catheter team's activity, we developed and adopted a database in which all the data regarding each catheter are recorded. By doing that, we have improved catheter management, clinical efficiency, as well as achieved a cost reduction. We implanted 1416 vascular access devices in 1341 patients of both sexes (632 male and 709 female) for a total of 135,778 vascular access device-implant days between March 2010 and December 2013 for several indications. We have followed-up total complications and we correlated them with the need for catheter removal. The results were that open-tipped catheters resulted in both more complications and a greater need for removal.

A Comparative Study on the Mechanical Behavior of Polyurethane PICCs

Purpose

This study describes a comparative analysis of eight commercial polyurethane, single-lumen peripherally inserted central venous catheters (PICCs) from different vendors. The aim was to investigate the mechanical response of the catheters providing objective and quantitative data to support a comparison among them. Such data could help nurses and physicians to select a central venous catheter (CVC) not only on the basis of the expected dwell duration or of the assessment of the vessels at the desired insertion site but also of the chemical and mechanical properties of the CVC and of the projected response of the body to these properties.

Methods

An experimental procedure was defined and tests were performed to assess some main characteristics of the PICC lines, including macro and microgeometric features, chemical and physical properties, and mechanical response. Preliminary measurements were performed to accurately define all geometric characteristics, including length, inner and outer diameters, and any inherent initial curvature of the catheter. Micro-geometric features were investigated using surface roughness analysis, optical microscopy, and scanning electron microscopy. Mechanical properties were studied by means of dynamic mechanical thermal analysis, simple uniaxial tensile tests, and kinking tests.

Results

Results are discussed in order to compare the different PICC lines. In particular, they show that polyurethane catheters can have a different mechanical behavior, which might play a role in the onset of pathologic processes and result in an increased risk and incidence of catheter-related complications.

Conclusions

This study provides useful information that can help identifying and facilitate the choice of a PICC.

Navigating venous access: a guide for hospitalists

Venous access is the foundation for safe and effective hospital-based care. Inpatient providers must have a deep knowledge of the different types of venous access devices (VADs), their relative indications, contraindications, and appropriateness. However, such knowledge is difficult to come by and usually only gleaned through years of clinical experience. To bridge this gap, we provide an in-depth summary of the relevant anatomical considerations, physical characteristics, advantages, and disadvantages of VADs commonly used in the hospital setting. In doing so, we seek to improve the safety and share the science of vascular access with frontline clinicians. To aid decision-making, we conclude by operationalizing the available data through algorithms that outline appropriate vascular access for the hospitalized patient.