Catheter management

Examination of nursing drug administration practices via central venous catheter: An observational study

AIM

To determine the compliance with nursing drug administration procedure steps associated with access to the central venous catheter for bolus infusion in intensive care units.

METHODS

This observational study was conducted with 30 nurses working in an intensive care unit of a university hospital. The drug administrations practiced by nurses via central venous catheter were monitored simultaneously at 12:00 a.m., 02:00 p.m., and 06:00 p.m. by two observers. The data were collected using a data collection form and central venous catheter drug administration procedure steps.

RESULTS

A total of 90 different drug administrations were observed in three different treatment hours from 30 nurses. The interobserver conformity was found to be moderate in two steps (kappa = 0.520-0.627, P = 0.01) and perfect in all other steps (kappa = 0.821-1.000, P = 0.000). According to the drug administration procedure steps via a central venous catheter, all nurses applied the following steps correctly during all treatment hours: drug card control, preparation of treatment materials, checking the patient's identity, and steps of drug treatment administration. The following tasks were frequently performed incorrectly or not at all: hand hygiene (before treatment 87.8%; after treatment 82.2%), scrubbing the three-way stopcock entrance with an alcohol swab (55.6%), waiting for the alcohol to dry (81.1%), and flushing the lumen with a compatible fluid (before treatment 84.4%: after treatment 75.6%).

CONCLUSION

Observation of drug administration procedure steps via central venous catheter according to the treatment hours showed that the nurses performed many incomplete or inaccurate drug administration procedure steps and the mistakes increased toward the evening hours.

Phase II Trial on Extending the Maintenance Flushing Interval of Implanted Ports

PURPOSE

Retrospective studies suggest that it may be safe to extend the maintenance flushing interval of implanted ports from once every month, as recommended by the manufacturer, to once every 3 months, but no prospective cohort studies have been done specifically assessing the safety and feasibility of this intervention.

METHODS

This was a phase II study in oncologic patients who retained a functional port after completion of systemic chemotherapy. Patients enrolled in the study had their port flushed once every 3 months and were observed until completion of five scheduled flushes (one on enrollment and four additional flushes, one every 3 months) or development of any port-related complication, including infections, thrombosis, and occlusions. The primary end points were frequency of port-related complications and port failure requiring removal.

RESULTS

A total of 87 patients were enrolled in the study. The median follow-up time was 308 days, accounting for a total of 24,202 catheter-days. There were 10 port-related complications (11.49%; 95% CI, 4.85% to 18.14%). No infection or symptomatic thrombosis occurred. The mean time to port-related complication was 184 days. No patients developed port failure while on protocol, but on subsequent medical record review, four patients developed a complication that required port removal or port revision within 30 days of being removed from the trial (4.6%; 95% CI, 0.4% to 8.8%; 0.17/1,000 catheter-days).

CONCLUSION

Extending the maintenance flushes of implanted ports in adult oncologic patients to once every 3 months is safe, effective, and likely to increase patient adherence and satisfaction while decreasing the associated cost.

Catheter-Related Bloodstream Infections (CR-BSI) in Geriatric Patients in Intensive Care Units

Catheter-related bloodstream infections (CR-BSIs) are bloodstream infections that, through specific laboratory testing, identify the intravascular catheter as the source of the bloodstream infection. By 2015, the rate of elderly patients 80 years of age and older admitted to the intensive care unit (ICU) will represent 1 in 4 admissions. Approximately 80 000 CR-BSIs occur in ICUs annually, potentially resulting in as many as 56 000 CR-BSIs occurring in the geriatric ICU patient, with 20% of these cases resulting in death. To minimize the occurrence of CR-BSIs in these patients, specific knowledge about the geriatric patient will have to be factored into the ICU health care professional's practice, including the development of a vascular access plan, which includes selection of the correct device and proper insertion of that device along with an evidence-based care and maintenance program. Intensive care unit health care professionals may be at a loss when it comes to navigating the vast array of vascular access medical devices available today. The Healthcare and Technology Synergy framework can assist the ICU health care professional to logically review each vascular access device and select those devices that best meet patient needs.

Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review

Background. Needleless connectors (NC) are used on virtually all intravascular devices, providing an easy access point for infusion connection. Colonization of NC is considered the cause of 50% of postinsertion catheter-related infections. Breaks in aseptic technique, from failure to disinfect, result in contamination and subsequent biofilm formation within NC and catheters increasing the potential for infection of central and peripheral catheters. Methods. This systematic review evaluated 140 studies and 34 abstracts on NC disinfection practices, the impact of hub contamination on infection, and measures of education and compliance. Results. The greatest risk for contamination of the catheter after insertion is the NC with 33-45% contaminated, and compliance with disinfection as low as 10%. The optimal technique or disinfection time has not been identified, although scrubbing with 70% alcohol for 5-60 seconds is recommended. Studies have reported statistically significant results in infection reduction when passive alcohol disinfection caps are used (48-86% reduction). Clinical Implications. It is critical for healthcare facilities and clinicians to take responsibility for compliance with basic principles of asepsis compliance, to involve frontline staff in strategies, to facilitate education that promotes understanding of the consequences of failure, and to comply with the standard of care for hub disinfection.

Central Venous Catheter Securement: Using the Healthcare and Technology Synergy Model to Take a Closer Look

Proper securement provides a safe vascular access device environment for both patients and health care providers. Successful securement protects central venous catheters from several sources of failure until the end of therapy by preventing central venous catheter movement during all phases of care. Movement causes vein trauma, bacterial migration, distal tip location variation, loss of dressing integrity, and even total dislodgement. Any of these events can have serious consequences, including catheter-related bloodstream infection, thrombosis, delay of treatment, catheter replacement, and potential hemorrhage, all of which can be life-threatening events, and increase costs. We review patient issues, practice issues, and the types of securement currently used in clinical settings.

Nurses' knowledge regarding the handling of the totally-implanted venous access device

In the light of nurses' questions regarding the handling of the totally-implanted venous access device, this study aimed to evaluate these professionals' knowledge. This is a descriptive study with a qualitative approach, whose sample was made up of 28 nurses working on the Internal Medicine ward and in the Emergency Room. The study was undertaken in two stages: interviewing, to evaluate knowledge regarding the handling of the implanted port; and an integrative review to clarify the doubts identified. The results indicated that the nurses' knowledge was inadequate regarding when to use the implanted port, its purpose, the puncture technique, maintenance and handling. It is concluded that the knowledge of the subjects evaluated is inadequate, and that it is necessary for these professionals' clinical skills to be standardized and for them to receive theoretical-practical training.

The Healthcare and Technology Synergy (HATS) Framework for Comparative Effectiveness Research as Part of Evidence-Based Practice in Vascular Access

The development of frameworks for nursing research, practice, and education is in its infancy. The focus in clinical research has commonly been on the variables patient and practice, not on the significant variable, technology products. However, in interventional and medical cardiology and orthopedic surgery, for example, products used are significant variables that affect clinical outcomes and subsequent recalls. The purpose of this article is to introduce the Healthcare and Technology Synergy (HATS) framework and discuss its use in comparative effectiveness research on health care-associated infections as well as its usefulness in nursing practice, education, and policy. Research in nursing that focuses on product as a variable has examined intravenous connectors and their association with catheter-related bloodstream infections, but more research specific to technology products is needed. The significance of products in nursing has been underappreciated, and the variable has been underutilized in research. This is a study limitation that can significantly affect research outcomes. Use of the HATS framework in nursing research can facilitate the development of clinically relevant nursing curricula, practice interventions, and policy based on research results. Appropriate development and evaluation of research that uses the HATS framework also has implications for cost-benefit analyses, product evaluation, and implementation of evidence-based practices.

Thrombotic obstruction of the central venous catheter in patients undergoing hematopoietic stem cell transplantation

This is an integrative literature review with the aim of summarizing the prevention measures and treatment of thrombotic obstruction of long-term semi-implanted central venous catheters, in patients undergoing hematopoietic stem cell transplantation. The sample consisted of seven studies, being two randomized controlled clinical trials, three cohort studies and two case series. Regarding the prevention measures, one single study demonstrated effectiveness, which was a cohort study on the oral use of warfarin. In relation to the treatment measures, three studies evidenced effectiveness, one highlighted the efficacy of streptokinase or urokinase, one demonstrated the benefit of using low-molecular-weight heparin and the other treated the obstruction with heparin or urokinase. Catheter patency research shows a restricted evolution that does not follow the evolution of transplantations, mainly regarding nursing care.

In Vitro Comparisons of Two Antimicrobial Intravenous Connectors

Fifty percent of catheter-related bloodstream infections (CR-BSI) caused by organism migration through the fluid pathway (intraluminal) via a connector can be colonized within 24 hr. With a mean hospital stay of 4.8 days, intraluminal contamination is a primary source of CR-BSI. Purpose of this research was to determine which antimicrobial needleless connector produced the least bacterial colony-forming units (CFUs) in vitro and to compare these CFUs to the leading nonantimicrobial connector shown in previous research to have the lowest CFUs. Independent laboratory tested 2 antimicrobial (Baxter V-Link™, RyMed-7001 Nano®) and 1 nonantimicrobial (RyMed-5001) connector, 20 connectors each, 3 controls, each of 4 days, 4 organisms, under the same laboratory conditions. Baxter V-Link™ produced 2.0 to 8.8 times more bacteria than the RYM-5001 ® and RYM-7001® connectors, regardless of bacteria type. The antimicrobial connector with the most and consistent bacteria (13, 675 CFUs) over 4 days was the V-Link™ and the connector with no consistent bacteria was the RyMed-7001®. Nurses and researchers must include technological design, connector types, and methods of coating/ impregnating connectors as factors in evaluation.