Arterial revascularization in patients with hand pain dialyzing with upper arm Arteriovenous (AV) fistulas: A single center experience

BACKGROUND

Distal hand ischemia syndrome (DHIS) is a well reported adverse outcome in patients with upper arm AV access. 25%-40% of these patients have been reported to be due to primary arterial disease complicated with significant arterial calcification. The effectiveness of revascularization of the distal arterial circulation on symptom resolution has not been reported yet.

METHODS

Retrospective single center analysis of patients evaluated for hand/forearm pain in patients with upper arm AV access who had arterial revascularization between 01/2016 and 12/2020 were included for the analysis. Fifty-one patients met inclusion criteria. Stenotic lesions greater than 70% in the subclavian, axillary, brachial, radial, or ulnar artery were treated with balloon angioplasty. Institutional approval was obtained to review charts.

OUTCOMES

Successful revascularization, improvement in pain in 48 h, 1 month, and 3 months.

RESULTS

Seventy six percent of patients had an upper arm Arteriovenous Fistula (AVF) and 24% patients had an upper arm Arteriovenous Graft (AVG). Mean access flow was 1210 (556) ml/min. 55% of patients had radial or ulnar arterial stenosis, 45% had brachial/axillary or subclavian artery stenosis. 45% patients had lesions in both radial and ulnar arteries, 88% of patients were successfully revascularized. 76% (18) of patients had improvement in symptoms within 48 h and 68% remained symptom free in 3 months. Mean DHIS stage was 3.1 before intervention and improved to 1.1 post intervention (p < 0.001). Patient satisfaction with their AV access improved from 34% to 72% (p < 0.01). Multiple regression analysis did not reveal statistically significant correlations between time on dialysis vintage and other chronic medical conditions on post procedure symptom improvement.

CONCLUSIONS

DHIS with occlusive arterial disease can be successfully revascularized to improve symptoms. Complete evaluation of the inflow arterial segment and optimal endovascular revascularization could decrease the need for access revision procedures or access abandonment.

Interventions to reduce peripheral intravenous catheter failure: An international e-Delphi consensus on relevance and feasibility of implementation

BACKGROUND

Around 1 billion peripheral intravenous catheters (PIVC) fail annually worldwide before prescribed intravenous therapy is completed, resulting in avoidable complications, dissatisfaction, and avoidable costs surging to ∼€4bn. We aimed to provide an international consensus on relevance and feasibility of clinical practice guideline recommendations to reduce PIVC failure.

METHODS

e-Delphi study with three rounds through an online questionnaire from March-September 2020 recruiting a multispecialty panel formed by clinicians, managers, academic researchers, and experts in implementation from seven developed and three developing countries, reflecting on experience in PIVC care and implementation of evidence. Further, we included a panel of chronic patients with previous experience in the insert, maintenance, and management of PIVC and intravenous therapy from Ireland and Spain as public and patient involvement (PPI) panel. All experts and patients scored each item on a 4-point Likert scale to assess the relevance and feasibility. We considered consensus descriptor in which the median was 4 with less than or equal to 1,5 interquartile intervals.

FINDINGS

Over 90% participants (16 experts) completed the questionnaire on all rounds and 100% PPI (5 patients) completed round 1 due to high consensus they achieved. Our Delphi approach included 49 descriptors, which resulted in an agreed 30 across six domains emerged from the related to (i) general asepsis and cutaneous antisepsis (n = 4), (ii) catheter adequacy and insertion (n = 3), (iii) catheter and catheter site care (n = 6), (iv) catheter removal and replacement strategies (n = 4), (v) general principles for catheter management (n = 10), and (vi) organisational environment (n = 3).

CONCLUSION

We provide an international consensus of relevant recommendations for PIVC, deemed feasible to implement in clinical settings. In addition, this methodological approach included substantial representation from clinical experts, academic experts, patient and public expertise, mitigating uncertainty during the implementation process with high-value recommendations to prevent PIVC failure based contextual and individual features, and economic resources worldwide.

Peripheral intravenous catheter insertion, maintenance and outcomes in Indonesian paediatric hospital settings: A point prevalence study

PURPOSE

This study aimed to assess peripheral intravenous catheter use, maintenance practices, and outcomes of paediatric patients in a developing country setting.

DESIGN AND METHODS

A point prevalence survey using validated checklist was conducted between March and April 2022 in ten hospitals in Indonesia. A total number of 478 participants were approached during the audit. Data were obtained from site observation and medical records.

RESULTS

Of the 386 patients surveyed, >90% (362) had one catheter in-situ. The catheters were mostly inserted by nurses (331, 86%), primarily in the dorsum of the hand (207, 54%) with the purpose of delivering intravenous infusions and medications (367, 95%). Simple transparent dressings (176, 46%) with splint and bandage (295, 76%) were predominantly used for securement methods. Insertion sites were not visible for 182 (47%) patients, and 151 (40%) of daily care practices were poorly documented. Complications were documented in the medical record for 166 (43%) catheters. Adjusted analysis indicated that patient diagnosis, ward, catheter size, location, dressings, infusate, and flushing administration were significantly associated with complications.

CONCLUSIONS

Findings indicate that issues related to paediatric intravenous catheter complications in Indonesia are comparable to developed country settings. Ongoing surveillance is important to evaluate the management practices to benchmark against guidelines, optimise patient safety, and improve outcomes.

PRACTICE IMPLICATIONS

Results demonstrate low and middle-income countries face similar challenges with catheter insertion and care. The study indicates the importance of applying vascular access needs assessments, providing training for inserters, identifying optimum dressing methods, and optimising documentation.

Controlling peripheral intravenous catheter failure by needleless connector design: A pilot randomised controlled trial

AIM

To test the feasibility of a study protocol that compared the efficacy of neutral- and negative-pressure needleless connectors (NCs).

DESIGN

A single-centre, parallel-group, pilot randomised control trial.

METHODS

Our study compared neutral-(intervention) and negative-pressure (control) NCs among adult patients in an Australian hospital. The primary feasibility outcome was measured against predetermined criteria (e.g. eligibility, attrition). The primary efficacy outcome was all-cause peripheral intravenous catheter failure, analysed as time-to-event data.

RESULTS

In total, 201 (100 control; 101 intervention) participants were enrolled between March 2020 and September 2020. All feasibility criteria were met except eligibility, which was lower (78%) than the 90% criterion. All-cause peripheral intravenous catheter failure was significantly higher in the intervention group (39%) compared to control (19%).

CONCLUSION

With minor modifications to participant screening for eligibility, this randomised control trial is feasible for a large multicentre randomised control trial. The neutral NC was associated with an increased risk of peripheral intravenous catheter failure.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

There are several NC designs available, often identified by their mechanism of pressure (positive, negative and neutral). However, NCs can contribute to peripheral intravenous catheter failure. This is the first randomised controlled trial to compare neutral and negative NC designs. Negative pressure NCs had lower PIVC failure compared to neutral NCs, however the results might not be generalisable to other brands or treatment settings. Further high-quality research is needed to explore NC design.

REPORTING METHOD

Study methods and results reported in adherence to the CONSORT Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Midline Compared With Peripheral Intravenous Catheters for Therapy of 4 Days or Longer in Pediatric Patients: A Randomized Clinical Trial

Importance

Peripheral intravenous catheters (PIVCs) frequently fail during treatment causing therapy interruption, pain, recatheterization, and additional health care costs. Midline catheters (MCs) may improve functional dwell time and reduce failure compared with traditional PIVCs.

Objective

To compare device failure of MCs with PIVCs.

Design, Setting, and Participants

This was a pragmatic, randomized clinical superiority trial with an embedded internal pilot study conducted from July 2020 to May 2022. The study took place in a quaternary pediatric hospital in Brisbane, Queensland, Australia. Inclusion criteria were patients aged 1 to 18 years requiring peripherally compatible intravenous therapy for 4 days or longer.

Interventions

Patients were randomly assigned 1:1 to receive a PIVC or MC, stratified by age (≤5 years, >5 years). One catheter was studied per patient.

Main Outcomes and Measures

The primary outcome was all-cause device failure, defined as premature cessation of device function. Secondary outcomes included number of insertion attempts, insertion failure, pain (on insertion), procedural time, patient/parent satisfaction (with insertion), device dwell time, device complications during dwell time, additional vascular access devices required to complete treatment, clinician satisfaction (at removal), and health care costs.

Results

Of the 128 patients randomly assigned to study groups, 127 patients (median [IQR] age, 7 [2-13] years; 71 male [56%]) had a device inserted, with 65 (51.2%) in the PIVC group and 62 (48.8%) in the MC group. All patients were included in the intention-to-treat analysis. Device failure was lower in patients in the MC group (10 [16.1%]) compared with those in the PIVC group (30 [46.2%]; odds ratio [OR], 0.22; 95% CI, 0.10-0.52; P <.001). MCs were associated with fewer insertion attempts (mean difference [MD], -0.3; 95% CI, -0.5 to 0; P = .04), increased dwell time (MD, 66.9 hours; 95% CI, 36.2-97.5 hours; P <.001), and fewer patients required additional vascular access devices to complete treatment in the MC group (4 [6.5%]) and PIVC group (19 [29.2%]; OR, 0.17; 95% CI, 0.05-0.52; P = .002). Compared with PIVCs, use of MCs was associated with greater patient (9.0 vs 7.1 of 10; P = .002) and parent (9.1 vs 8.2 of 10; P = .02) satisfaction and lower health care costs (AUS -$151.67 [US -$101.13] per person; 95% credible interval, AUS -$171.45 to -$131.90 [US -$114.20 to -$87.95]).

Conclusions and Relevance

Findings suggest that MC insertion for patients requiring peripherally compatible intravenous therapy for 4 days or longer should be prioritized to reduce the resource intensive, expensive, and burdensome sequelae of device failure.

Trial Registration

Australia New Zealand Clinical Trials Registry, ACTRN12620000724976.

Short Peripheral Venous Catheters Contamination and the Dangers of Bloodstream Infection in Portugal: An Analytic Study

Peripheral venous catheters (PVCs) are the most used vascular access devices in the world. However, failure rates remain considerably high, with complications such as PVC-related infections posing significant threats to patients’ well-being. In Portugal, studies evaluating the contamination of these vascular medical devices and characterizing the associated microorganisms are scarce and lack insight into potential virulence factors. To address this gap, we analyzed 110 PVC tips collected in a large tertiary hospital in Portugal. Experiments followed Maki et al.’s semi-quantitative method for microbiological diagnosis. Staphylococcus spp. were subsequently studied for the antimicrobial susceptibility profile by disc diffusion method and based on the cefoxitin phenotype, were further classified into strains resistant to methicillin. Screening for the mecA gene was also done by a polymerase chain reaction and minimum inhibitory concentration (MIC)-vancomycin as determined by E-test, proteolytic and hemolytic activity on skimmed milk 1% plate and blood agar, respectively. The biofilm formation was evaluated on microplate reading through iodonitrotetrazolium chloride 95% (INT). Overall, 30% of PVCs were contaminated, and the most prevalent genus was Staphylococcus spp., 48.8%. This genus presented resistance to penicillin (91%), erythromycin (82%), ciprofloxacin (64%), and cefoxitin (59%). Thus, 59% of strains were considered resistant to methicillin; however, we detected the mecA gene in 82% of the isolates tested. Regarding the virulence factors, 36.4% presented α-hemolysis and 22.7% β-hemolysis, 63.6% presented a positive result for the production of proteases, and 63.6% presented a biofilm formation capacity. Nearly 36.4% were simultaneously resistant to methicillin and showed expression of proteases and/or hemolysins, biofilm formation, and the MIC to vancomycin were greater than 2 µg/mL. Conclusion: PVCs were mainly contaminated with Staphylococcus spp., with high pathogenicity and resistance to antibiotics. The production of virulence factors strengthens the attachment and the permanence to the catheter’s lumen. Quality improvement initiatives are needed to mitigate such results and enhance the quality and safety of the care provided in this field.

From little things, big things grow: An exploratory analysis of the national cost of peripheral intravenous catheter insertion in Australian adult emergency care

OBJECTIVE

To estimate the total economic impact of peripheral intravenous catheter (PIVC) or cannula insertion and use in adult Australian EDs, including those cannulas that remain unused for therapeutic purposes.

METHODS

Searches on Australian government websites were conducted to find rates of insertion, complications and cost of cannula; following this, gaps in national data sets were filled with MEDLINE and PubMed searches to estimate the total cost of cannula use in Australian EDs. Once the data were collected, totals were combined to establish an estimated cost for the listed categories.

RESULTS

The estimated cost of cannulation in Australia may be up to A$594 million per year, including the cost of insertion (equipment and staff), cost of complications such as Staphylococcus aureus bacteraemia and phlebitis, and patient-centred costs (lost patient productivity, infiltration, occlusion and dislodgement). Approximately A$305.9 million is attributed to unused cannulas and approximately 11 790 days of clinician time is spent annually inserting cannula that remains idle.

CONCLUSION

The figures developed in the present study represent an important educational opportunity to encourage thoughtful consideration of all interventions, no matter how small. ED cannula insertion represents a large economic and health cost to Australia's health system, many of which remain unused. There are no national data sets that record complications associated with PIVCs and we highlight the urgent need for improved data.

Safety and efficacy of midline catheters versus peripheral intravenous catheters: A pilot randomized controlled trial

BACKGROUND

Despite pervasive need for peripheral intravenous catheters, insertion is often difficult, and approximately two thirds fail prematurely. Midline catheters are an alternative long peripheral catheter, inserted in the upper arm, ideal for patients with difficult access.

AIM

The aim of this study is to test feasibility of the protocol and compare the efficacy and safety of midline catheters to peripheral intravenous catheters.

DESIGN

A parallel-group, pilot randomized controlled trial of adult medical/surgical hospitalized patients, from a single Australian referral hospital.

METHODS

Participants with difficult vascular access (≤2 palpable veins) and/or anticipated ≥5 days of peripherally compatible intravenous therapy were recruited between May 2019 and March 2020. Participants were randomized to (1) peripheral intravenous catheter or (2) midline catheter. Primary feasibility outcome measured eligibility, recruitment, protocol adherence, retention and attrition. Primary clinical outcomes measured device insertion failure and post-insertion failure.

RESULTS

In total, n = 143 participants (71 peripheral intravenous catheters and 72 midline catheters) were recruited; n = 139 were analysed. Most feasibility criteria were met. Peripheral intravenous catheters had shorter functional dwell time, with higher incidence of post-insertion failure compared to midline catheters.

CONCLUSION

Midline catheters appear to be superior for patients with difficult vascular access or receiving prolonged intravenous therapy; a large, multi-centre trial to confirm findings is feasible.

A Retrospective Assessment of Midline Catheter Failures Focusing on Catheter Composition

Vascular access specialists are responsible for assessing the patient in their unique situation and determining the correct vascular access device to complete the therapeutic goal without complication or failure. This retrospective cohort study compared the failure rates of a variety of polyurethane (PU) midline catheters and a midline catheter constructed of an emerging hydrophilic biomaterial (HBM). A total of 205 patients received a midline catheter and were situationally randomized by the facility where they received it. Patients who had received a midline catheter between March 2021 and May 2021 were assessed for catheter-related failures leading to increased staff time, delays in treatment, or replacement with a new vascular access device to complete the therapy. There were 101 patients in the PU cohort and 104 patients in the HBM cohort. Comparing overall failure rates between the groups revealed a 23.8% failure rate in the PU control group and only a 3.8% failure rate in the HBM group. This suggests that a midline catheter constructed of HBM biomaterial is associated with significantly lower rates of failure, thereby improving patient experience and health care economics.

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.

Desinfecção de hubs e conectores de cateteres intravenosos

Objetivo: identificar métodos de desinfecção de hubs e conectores sem agulha dos cateteres intravenosos em pacientes hospitalizados e verificar a efetividade das intervenções para a prevenção de infecções de corrente sanguínea associada a cateter intravenoso. Método: revisão de escopo seguindo as recomendações de Joanna Briggs Institute. Busca realizada em bases de dados eletrônicas Pubmed, Embase, Cochrane Library, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Base de Dados Enfermagem e Bibliografía Nacional en Ciencias de la Salud Argentina, e estudos indicados por experts. A busca foi atemporal até setembro de 2020. Protocolo registrado na Open Science Framework. Resultados: foram incluídos 27 estudos, sendo que cinco foram Guidelines e 22 foram artigos publicados em periódicos. Existe grande variedade de métodos de desinfecção de hubs e de conectores. Para a desinfecção ativa, foram indicados Gluconato de Clorexedina, Isopropanol e Iodopovedina; para a desinfecção passiva, Gluconato de Clorexedina e Isopropanol. A quantidade do agente desinfetante variou de 0,25 mL a 0,6 mL. O tempo de fricção na desinfecção ativa variou de cinco segundos a 30 segundos, e o tempo de contato na desinfecção passiva variou de três minutos a sete dias. O tempo de secagem de agentes desinfetantes foi superior a cinco segundos. Conclusão: verifica-se variedade de métodos de desinfecção; no entanto, não há consenso sobre a melhor indicação. Necessita-se de estudos que evidenciem a quantidade de desinfetante, a pressão e o tempo de fricção e o tempo de secagem. Pesquisas com práticas de desinfecção utilizadas no Brasil e ensaios clínicos randomizados são necessários. 

Cost-effectiveness analysis of bundled innovative devices versus standard approach in the prevention of unscheduled peripheral venous catheters removal due to complications in France

The objective of the study was to perform a cost-effectiveness analysis of bundled devices (BDs) versus standard devices (SDs) for the prevention of unscheduled peripheral venous catheter (PVC) removal due to complication from a French investigator-initiated, open-label, single center, randomized-controlled, two-by-two factorial trial (CLEAN-3 study). A 14-day time non homogeneous semi-markovian model was performed to be fitted to longitudinal individual patient data from CLEAN-3 database. This model includes five health states and eight transitional events; a base case scenario, two scenario analyses and bootstrap sensitivity analyses were performed. The cost-effectiveness criterion was the cost per patient with unscheduled PVC removal avoided. 989 adult (age≥18 years) patients were analyzed to compare the BDs group (494 patients), and the SDs group (495 patients). The assessed intervention was a combination of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes compared with the use of open catheters and three-way stopcocks for treatment administration. For the base case scenario, an unscheduled 1st PVC removal before discharge was significantly more frequent in the SDs group (235 patients (47.5%) in the SDs group and 172 patients (34.8%) in the BDs group, p = 0.00006). After adjustment for 1st catheter time, the number of patients with unscheduled PVC removal per day was of 16 (95%CI: 15; 18) patients (out of 100) in the BDs group and of 26 (95%CI: 24; 28) patients (out of 100) in the SDs group. The mean cost per patient (adjusted on catheter-time) was of €144 (95%CI: €135-€154) for patients in the SDs group versus €102 (95%CI: €95-€109) for patients in the BDs group; the mean saving per patient was of €42 (95%CI: €32-€54). As a consequence, the assessed BDs strategy was less costly and more effective than the SDs strategy. Trail registration: CLEAN-3 study is registered with ClinicalTrials.gov, NCT03757143.

Securing jugular central venous access devices with dressings fixed to a liquid adhesive in an intensive care unit population: a randomised controlled trial

BACKGROUND

Central venous access devices (CVADs) can have high rates of failure due to dressing-related complications. CVADs placed in the internal jugular vein are at particular risk of dressing failure-related complications, including catheter-associated bloodstream infection and medical adhesive-related skin injury. Application of Mastisol liquid adhesive (MLA) may reduce CVAD dressing failure and associated complications, by reducing the frequency of dressing changes. The aim of this study is to investigate whether, in an intensive care unit (ICU) population, standard dressing care with or without the addition of MLA, improves internal jugular CVAD dressing adherence.

METHODS

This two-arm, parallel group randomised controlled trial will be conducted in three Australian ICUs. A total of 160 patients (80 per group) will be enrolled in accordance with study inclusion and exclusion criteria. Patients will be randomised to receive either (1) 'standard' (in accordance with local hospital policy) CVAD dressings (control) or (2) 'standard' dressings in addition to MLA (intervention). Patients will be followed from the time of CVAD insertion to 48 h after CVAD removal. The primary outcome is 'dressing failure' defined as requirement for initial CVAD dressing to be replaced prior to seven days (routine replacement).

DISCUSSION

This study will be the first randomised controlled trial to evaluate the clinical effectiveness of MLA in the adult intensive care unit population and will also provide crucial data for patient-important outcomes such as infection and skin injury.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621001012864 . Registered on 2 August 2021.

Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key

OBJECTIVE

To develop and validate a difficult intravenous access risk assessment and escalation pathway, to increase first time intravenous insertion success in paediatrics.

METHODS

Mixed methods underpinned by literature and co-production principles. Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia.

RESULTS

Interview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February-April 2020) involving 21 stakeholders culminating in the co-production of the "DIVA Key". The DIVA Key was evaluated between May-December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range = 81.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa = 0.71, 95% CI 0.63-0.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2-27.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR) = 10 [8-10]; 8 [8-10 respectively).

CONCLUSION

The DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.

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.

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.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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