Chronic Central Venous Access: From Research Consensus Panel to National Multistakeholder Initiative

An mHealth application for chronic vascular access: Consumer led co-creation

PURPOSE

Children with chronic and complex health conditions frequently need intravenous devices. The current approach to intravenous device selection, insertion, and monitoring is inconsistent, and healthcare consumers are often negatively affected by siloed health information, and poor future planning. Despite child- and family-centred care being recognised as a pillar of paediatric nursing care, limited implementation for vascular access device planning and management is evident.

DESIGN AND METHODS

To address this, we conducted a multi-phased approach to co-create, then evaluate, a mobile health (mHealth) application: IV Passport. Co-creation involved a prioritisation survey, followed by a Passport advisory panel consensus meeting. Following confirmation of the required content and features of the Passport, the mHealth application was designed and content validation achieved via survey.

RESULTS

The prioritisation survey yielded recommendations for seven features (e.g., graphical presentations of current/past devices). Content for nine device types (e.g., totally implanted ports) was suggested, each with 10 related items (e.g., insertion site). Content items for device-associated complications, future vascular access plans, and educational resources were also suggested. Following design, the application was released through Apple and Android platforms; and adapted to a paper version. Content validation was established; 100% strongly agreed the application was easy to use; 80% agreed/strongly agreed that they would recommend the Passport to others.

CONCLUSION

IV Passport embodies effective child- and family-centred care through consumer co-creation to empower patients and families manage vascular access devices.

PRACTICE IMPLICATIONS

IV Passport remains active; and can be utilised across many healthcare settings and patient populations.

An mHealth application for chronic vascular access: A multi-method evaluation

BACKGROUND

Healthcare consumers require diverse resources to assist their navigation of complex healthcare interactions, however, these resources need to be fit for purpose.

AIM

In this study, we evaluated the utility, usability and feasibility of children, families and adults requiring long-term intravenous therapy using a recently developed mobile health application (App), intravenous (IV) Passport.

DESIGN

Multi-site, parallel, multi-method, prospective cohort study.

METHODS

A multi-site, multi-method study was carried out in 2020-2021, with 46 participants (20 adults, 26 children/family) reporting on their experiences surrounding the use of the IV Passport for up to 6 months.

RESULTS

Overall, utility rates were acceptable, with 78.3% (N = 36) using the IV Passport over the follow-up period, with high rates of planned future use for those still active in the project (N = 21; 73%), especially in the child/family cohort (N = 13; 100%). Acceptability rates were high (9/10; IQR 6.5-10), with the IV Passport primarily used for documenting new devices and complications. Thematic analysis revealed three main themes (and multiple subthemes) in the qualitative data: Advocacy for healthcare needs, Complexity of healthcare and App design and functionality.

CONCLUSION

Several recommendations were made to improve the end-user experience including 'how to' instructions; and scheduling functionality for routine care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The IV Passport can be safely and appropriately integrated into healthcare, to support consumers.

IMPACT

Patient-/parent-reported feedback suggests the Intravenous Passport is a useful tool for record-keeping, and positive communication between patients/parents, and clinicians.

REPORTING METHOD

Not applicable.

PATIENT CONTRIBUTION

Consumers reported their experiences surrounding the use of the IV Passport for up to 6 months.

Venous Access: National Guideline and Registry Development (VANGUARD): Advancing Patient-Centered Venous Access Care Through the Development of a National Coordinated Registry Network

There are over 8 million central venous access devices inserted each year, many in patients with chronic conditions who rely on central access for life-preserving therapies. Central venous access device-related complications can be life-threatening and add tens of billions of dollars to health care costs, while their incidence is most likely grossly mis- or underreported by medical institutions. In this communication, we review the challenges that impair retention, exchange, and analysis of data necessary for a meaningful understanding of critical events and outcomes in this clinical domain. The difficulty is not only with data extraction and harmonization from electronic health records, national surveillance systems, or other health information repositories where data might be stored. The problem is that reliable and appropriate data are not recorded, or falsely recorded, at least in part because policy, payment, penalties, proprietary concerns, and workflow burdens discourage completeness and accuracy. We provide a roadmap for the development of health care information systems and infrastructure that address these challenges, framed within the context of research studies that build a framework of standardized terminology, decision support, data capture, and information exchange necessary for the task. This roadmap is embedded in a broader Coordinated Registry Network Learning Community, and facilitated by the Medical Device Epidemiology Network, a Public-Private Partnership sponsored by the US Food and Drug Administration, with the scope of advancing methods, national and international infrastructure, and partnerships needed for the evaluation of medical devices throughout their total life cycle.

Venous thromboembolism associated with central venous catheters in patients with cancer: From pathophysiology to thromboprophylaxis, areas for future studies

Symptomatic catheter related thrombosis (CRT) occurs in 4%-8% of cancer patients. The mean incidence of CRT, detected either by echography or Doppler ranges between 12 and 14% with a high negative predictive value of about 95%, allowing the subsequent occurrence of CRT (symptomatic and asymptomatic) to be safely excluded. Despite its frequency and its medico-economic consequences, no thromboprophylaxis has been validated to date. In most patients, CRT occurs immediately after catheter insertion, most often within the first week and almost all within the first month after insertion. Meta analyses show a reduction of asymptomatic and symptomatic CRT incidence by about 55%-60% using either vitamin K antagonists or low molecular weight heparins without an increased risk of major bleeding. This pharmacological prophylaxis is only effective when started before the central venous catheter insertion at prophylactic doses and thereafter continued at subtherapeutic doses. Since no population at high risk of CRT has been identified, this review focuses on pathophysiology, epidemiology and clinical supportive data that could lead to a new CRT prophylaxis strategy.

Management of Central Venous Access in Children With Intestinal Failure: A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group

ABSTRACT

Intestinal failure requires the placement and maintenance of a long-term central venous catheter for the provision of fluids and/or nutrients. Complications associated with this access contribute to significant morbidity and mortality, while the loss of access is an increasingly common reason for intestinal transplant referral. As more emphasis has been placed on the prevention of central line-associated bloodstream infections and new technologies have developed, care for central lines has improved; however, because care has evolved independently in local centers, care of central venous access varies significantly in this vulnerable population. The present position paper from the Intestinal Failure Special Interest Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) reviews current evidence and provides recommendations for central line management in children with intestinal failure.

Primary Open Versus Closed Implantation Strategy for Totally Implantable Venous Access Ports: The Multicentre Randomized Controlled PORTAS-3 Trial (DRKS 00004900)

OBJECTIVES

PORTAS-3 was designed to compare the frequency of pneumothorax or haemothorax in a primary open versus closed strategy for port implantation.

BACKGROUND DATA

The implantation strategy for totally implantable venous access ports with the optimal benefit/risk ratio remains unclear.

METHODS

PORTAS-3 was a multicentre, randomized, controlled, parallel-group superiority trial. Adult patients with oncological disease scheduled for elective port implantation were randomized to a primary open or closed strategy. Primary endpoint was the rate of pneumothorax or haemothorax. Assuming a difference of 2.5% between the 2 groups, a sample size of 1154 patients was needed to prove superiority of the open group. A logistic regression model after the intention-to-treat principle was applied for analysis of the primary endpoint.

RESULTS

Between November 9, 2014 and September 5, 2016, 1205 patients were randomized. Of these, 1159 (open n = 583; closed n = 576) were finally analyzed. The rate of pneumothorax or haemothorax was significantly reduced with the open strategy [odds ratio 0.27, 95% confidence interval (CI) 0.09-0.88; P = 0.029]. Operation time was shorter for the closed strategy. Primary success rates, tolerability, morbidity, dose rate of radiation, and 30-day mortality did not differ significantly between the groups.

CONCLUSION

A primary open strategy by cut-down of the cephalic vein, if necessary enhanced by a modified Seldinger technique, reduces the frequency of pneumothorax or haemothorax after central venous port implantation significantly compared with a closed strategy by primary puncture of the subclavian vein without routine sonographic guidance. Therefore, open surgical cut-down should be the reference standard for port implantation in comparable cohorts.

TRIAL REGISTRATION

German Clinical Trials Register DRKS 00004900.

Meta-analysis of primary open versus closed cannulation strategy for totally implantable venous access port implantation

BACKGROUND

There is still no reference standard for the implantation of totally implantable venous access ports (TIVAPs). A recently published multicentre randomised controlled trial (RCT) revealed a significantly greater risk of pneumothorax after closed cannulation than after an open strategy. The aim of this meta-analysis was to provide an update of the available evidence for the safety and effectiveness of primary open versus closed cannulation strategy.

METHODS

RCTs comparing outcomes of open cut-down of the cephalic vein and closed cannulation of the subclavian vein were sought systematically in MEDLINE, Web of Science and CENTRAL. The primary outcome was the occurrence of pneumothorax. A beta-binominal model was applied to combine the respective outcomes, and results are presented as odds ratios (OR) with 95% confidence interval (CI).

RESULTS

Six RCTs with a total of 1831 patients were included in final analysis. Meta-analysis showed statistically significant superiority of the open cut-down technique regarding pneumothorax (OR 0.308, 95% CI 0.122 to 0.776), but a statistically significant higher failure of the primary technique for the open cut-down technique than for closed cannulation (OR 2.364, 95% CI 1.051 to 5.315). There were no significant differences between the two procedures regarding other morbidity endpoints.

CONCLUSION

This meta-analysis shows a general superiority of open cut-down of the cephalic vein over closed cannulation of the subclavian vein regarding the occurrence of pneumothorax. Open cut-down should be the first-line approach for TIVAP implantation. Closed cannulation should be performed with ultrasound as second-line procedure if the open technique fails.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005180.

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.

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

OBJECTIVES

Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds.

RESULTS

The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized.

CONCLUSIONS

In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

Developing Appropriateness Criteria for Pediatric Vascular Access

OBJECTIVES

To describe the methodology undertaken to provide guidance on the appropriateness, as well as inappropriateness, of vascular access device selection, characteristics, and insertion technique for pediatric patients.

METHODS

The RAND Corporation-University of California, Los Angeles Appropriateness Method was used. After definition of key terms and scope, a systematic review of the pediatric vascular access literature was undertaken. Clinical scenarios were developed to reflect the common indications for vascular access across pediatric health care. These were sectioned according to (1) device selection, (2) device characteristics, and (3) insertion technique. An interdisciplinary panel of experts (N = 14) consisting of leading experts representing diverse pediatric clinical disciplines including anesthesiology, cardiology and cardiac surgery, critical care and emergency, general surgery, hematology and oncology, hospital medicine, infectious disease, interventional radiology, pharmacology, regional pediatric hospitalist, and vascular access nursing specialties was convened. The scenarios were rated for appropriateness by the panel over 2 rounds (1 [highly inappropriate] to 9 [highly appropriate]). Round 1 ratings were completed anonymously and independently by panel members and classified into 3 levels of appropriateness: appropriate, uncertain, and inappropriate, or disagreement. For round 2, panelists met in-person to discuss the round 1 ratings and independently rerated the indications. All indications were reclassified into 3 levels of appropriateness or disagreement.

CONCLUSIONS

The RAND Corporation-University of California, Los Angeles Appropriateness Method provides a rigorous, in-depth and transparent methodology to develop the first appropriateness criteria for the selection of pediatric vascular access devices in a range of patient groups.

Development of a paediatric central venous access device database: A retrospective cohort study of practice evolution and risk factors for device failure

AIM

To describe practice evolution, complications and risk factors for multiple insertion attempts and device failure in paediatric central venous access devices (CVADs).

METHODS

A paediatric retrospective cohort study using prospectively collected data from CVAD database 2012-2014. Data included were patient (i.e. age, condition), insertion (i.e. indication, device, technique) and removal (complications, dwell). Descriptive statistics and incidence rates were calculated per calendar year and compared. Risk factors for multiple insertion attempts and failure were explored with logistic regression and cox regression, respectively.

RESULTS

A total of 1308 CVADs were observed over 273 467 catheter-days in 863 patients. Multiple insertion attempts remained static (14%) and significantly associated with non-haematological oncology (odds ratio 2.19; 95% confidence interval (CI) 1.08-4.43), respiratory (3.71; 1.10-12.5), gastroenterology (4.18; 1.66-10.5) and other (difficult intravenous access) (2.74; 1.27-5.92). CVAD failure decreased from 35% (2012) to 25% (2014), incidence rate from 1.50 (95% CI 1.25-1.80) to 1.28 (1.06-1.54) per 1000 catheter-days. Peripherally inserted CVAD failure was significantly associated with lower body weight (per kilogram decrease, hazard ratio (HR) 1.02; 95% CI 1.00-1.03), cephalic vein (1.62; 1.05-2.62), difficult access (1.92; 1.02-3.73), sub-optimal tip placement (1.69; 1.06-2.69) and gastroenterology diagnosis (2.27; 1.05-4.90). Centrally placed CVAD failure was significantly associated with younger age (per year, HR 1.04; 95% CI 1.00-1.07), tunnelled device (3.38; 2.41-4.73) and gastroenterology diagnosis (1.70; 1.06-2.73).

CONCLUSIONS

While advancement in CVAD practices improved overall CVAD insertion and failure outcomes, further improvements and innovation are necessary to ensure improved vessel health and preservation for children requiring CVAD.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.