Inter-rater agreement on PIVC-associated phlebitis signs, symptoms and scales

The performance and complications of long peripheral venous catheters: A retrospective single-centre study

BACKGROUND

Intravenous therapies are essential for hospitalised patients. The rapid dissemination of portable ultrasound machines has eased ultrasound-guided intravenous access and facilitated increased use of long peripheral venous catheters (LPCs). This study aimed to evaluate the clinical performance and complications of LPCs.

METHODS

Retrospective, observational single-site study. Data from all consecutively inserted LPCs during a period of 18 months was evaluated. The primary endpoint was the all-cause incidence rate of catheter removal. Secondary endpoints included specific reasons for the catheter removal and the associations between predefined characteristics of the patients, the infusions and the catheters with catheter failure.

RESULTS

During the period, 751 PVCs were inserted in 457 patients. The reasons for catheter removal were recorded in 563 cases. The overall incidence rate of catheter removal was 95.8/1000 catheter days (95% CI 88.4-103.8). The median dwell time was 8 days (IQR 5-14), and the total dwell time was 6136 days. Catheter failure occurred in 283 (50.3%) cases, of which the most common cause was phlebitis (n = 101, 17.9%). In multivariable analyses, the use of the cephalic vein was significantly associated with both all-cause catheter failure (p < .001) and catheter failure due to phlebitis (p < .001). In multivariable analyses, vancomycin infusion was not significantly associated with all-cause catheter failure (HR 1.15 (0.55-2.42), p = .71) or catheter failure due to phlebitis (HR 1.49 (0.49-4.53), p = .49).

CONCLUSION

The overall incidence rate of catheter removal was 95.8/1000 catheter days, and the most common causes of catheter failure were phlebitis, infiltration and unintended catheter removal. The use of the cephalic vein was significantly associated with catheter failure in multivariable analyses. We did not find an association between vancomycin infusion and catheter failure in multivariable analyses.

Protect peripheral intravenous catheters: a study protocol for a randomised controlled trial of a novel antimicrobial dressing for peripheral intravenous catheters (ProP trial)

INTRODUCTION

Peripheral intravenous catheters (PIVCs) are the most commonly used vascular access device in hospitalised patients. Yet PIVCs may be complicated by local or systemic infections leading to increased healthcare costs. Chlorhexidine gluconate (CHG)-impregnated dressings may help reduce PIVC-related infectious complications but have not yet been evaluated. We hypothesise an impregnated CHG transparent dressing, in comparison to standard polyurethane dressing, will be safe, effective and cost-effective in protecting against PIVC-related infectious complications and phlebitis.

METHODS AND ANALYSIS

The ProP trial is a multicentre, superiority, randomised clinical and cost-effectiveness trial with internal pilot, conducted across three centres in Australia and France. Patients (adults and children aged ≥6 years) requiring one PIVC for ≥48 hours are eligible. We will exclude patients with emergent PIVCs, known CHG allergy, skin injury at site of insertion or previous trial enrolment. Patients will be randomised to 3M Tegaderm Antimicrobial IV Advanced Securement dressing or standard care group. For the internal pilot, 300 patients will be enrolled to test protocol feasibility (eligibility, recruitment, retention, protocol fidelity, missing data and satisfaction of participants and staff), primary endpoint for internal pilot, assessed by independent data safety monitoring committee. Clinical outcomes will not be reviewed. Following feasibility assessment, the remaining 2624 (1312 per trial arm) patients will be enrolled following the same methods. The primary endpoint is a composite of catheter-related infectious complications and phlebitis. Recruitment began on 3 May 2023.

ETHICS AND DISSEMINATION

The protocol was approved by Ouest I ethic committee in France and by The Queensland Children's Hospital Human Research Ethics Committee in Australia. The findings will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05741866.

Management from a multidisciplinary perspective of phlebitis related to peripheral venous catheter insertion: An international Delphi study

AIM

To determine the consensus and importance of care practices related to the management of peripheral venous catheter (PVC)-related phlebitis in hospitalized patients through the views of experts from different disciplines.

BACKGROUND

PVCs are commonly used in hospitals but are associated with complications such as phlebitis. Their management differs widely, and studies are heterogeneous.

DESIGN

Delphi method.

METHODS

Four stages: problem area (with Web of Science bibliometric review in July 2022), panel members, two Delphi rounds and closing criteria. In the Delphi survey, experts answered an online questionnaire based on assessment, treatment and follow-up dimensions (September 2022-February 2023). Statistical analyses were conducted of frequencies, percentages, measures of central tendency and levels of dispersion (QD). A space for comments was created, and a thematic analysis conducted of them.

RESULTS

Eighteen experts (nurses, doctors and pharmacists) participated in the Delphi rounds. Forty-five activities were identified: 19 in assessment, 15 in treatment and 11 in follow-up. A high consensus level (QD ≤ 0.6) was found in five activities (11.12%), moderate level (0.6 < QD < 1.0) in 19 (42.22%) and low level (QD > 1.0) in 21 (46.66%). Seven themes were determined (patient perspective, lack of consensus, low evidence-based practices, stage-based treatments, prevention activities, high variability in practice and specialist teams and interdisciplinary work).

CONCLUSION

The importance of systematic assessment scales is highlighted together with consensus on signs and symptoms (pain, redness, inflammation, palpable cord and induration). Treatment according to severity and daily visual recording and monitoring are emphasized along with the need for patient participation and healthcare literacy. A high level of consensus was obtained in 11% of the activities, showing the large variability of criteria and interventions for phlebitis management. Highlighted needs include working in a team, the use of specialist teams and promoting evidence- and prevention-based activities.

RELEVANCE TO CLINICAL PRACTICE

Clinical variability is noted and, therefore, the importance of consensus on standardized care for PVC phlebitis and evidence-based practice.

REPORTING METHOD

Delphi studies (CREDES).

PATIENT OR PUBLIC CONTRIBUTION

Experts contribution.

Assessment, Treatment, and Follow-Up of Phlebitis Related to Peripheral Venous Catheterisation: A Delphi Study in Spain

BACKGROUND

Phlebitis related to peripheral venous catheters (PVCs) is a common complication in patients who require these devices and can have important consequences for the patients and the healthcare system. The management and control of the PVC-associated complications is related to nursing competency. The present study aims to determine, at the national level in Spain, the consensus on the assessment, treatment, and follow-up of PVC-related phlebitis and the importance of the actions taken.

METHOD

A three-round Delphi technique was used with clinical care nurses who are experts in the field of in-hospital intravenous treatment in Spain. For this, an online questionnaire was developed with three open-ended questions on the dimensions of phlebitis assessment, treatment, and follow-up. For the statistical analysis of the results, frequencies and percentages were used to determine consensus, and the measures of central tendency (mean, standard deviation, and the coefficient of variation) were used to rank importance. The coefficient of variation was set as acceptable at ≤30%.

RESULTS

The final sample was 27 expert nurses. At the conclusion of round 3, actions were ranked according to their importance, with six items included in the PVC-related phlebitis assessment (symptomatology/observation, redness, the Maddox scale, induration, temperature, and pain), two in treatment (catheter removal, pentosan polysulphate sodium ointment + application of cold), and just one in follow-up (general monitoring + temperature control).

CONCLUSIONS

There is a major disparity in relation to the PVC-related phlebitis assessment, treatment, and follow-up actions. More clinical studies are therefore needed to minimise the complications associated with the use of PVCs, given their impact on the quality of care and patient safety and their economic cost.

A safe and effective winged peripheral intravenous cannula for use in clinical practice

Vascular access continues to be a key factor for the reliable and safe delivery of intravenous (IV) therapy to patients in any healthcare setting. Clinical guidelines advocate for the right vascular access device selection, in order to reduce avoidable complications, eg multiple stabs, phlebitis, thrombophlebitis, insertion site infection, and blood stream infection, while improving efficiency and reducing costs. Peripheral intravenous catheters or cannulas (PIVCs) remain widely used for gaining vascular access in all clinical settings, with both adults and children, because they provide a relatively cheap and simple way to provide blood sampling and the prompt administration of IV medications. Although safe and easy to insert, PIVCs present with associated risks that can be costly to the organisation. The case studies included with this article introduce Nipro's Safetouch Cath Winged with Injection Port as a new cost-effective choice of PIVC, which is now available from NHS Supply Chain.

N-acetylcysteine attenuates the incidence of phlebitis induced by carbomer/vinorelbine gel

Background

The high incidence and severe clinical manifestations of phlebitis pose a complex and urgent clinical challenge. The rapid and simple establishment of animal phlebitis models and the development of preventive strategies are crucial to resolving this problem.

Methods

In this study, we established such models by mixing vinorelbine ditartrate (VNR) and carbomer to form a sustained-release gel carrier, and then injected it around the veins rather than inside the vessels. Furthermore, we analyzed the efficacy of the carbomer/VNR gel in inducing phlebitis by monitoring the morphology of the veins using HE staining, immunohistochemical and immunofluorescence staining, and western blotting. Reactive oxygen species (ROS) and lipid peroxidation levels were determined using flow cytometry. Finally, we evaluated the inhibitory effect of N-acetylcysteine (NAC) on VNR-induced phlebitis in rabbits and rats.

Results

Our findings suggested that the carbomer/VNR gel rapidly and easily induced phlebitis due to by retention of the gel in situ, wrapping the veins, and the prolonged release of VNR. NAC alleviated the VNR-induced oxidative stress response and expression of inflammatory cytokines by attenuating mitochondrial damage in venous endothelial cells, thereby preventing the occurrence of phlebitis in rabbits and rats.

Conclusion

The in situ carbomer/VNR gel provides a rapid and simple method for establishing an animal model to study the pathogenesis of phlebitis. Furthermore, the observed therapeutic effect of NAC highlights its novel and efficacious role in preventing and treating phlebitis.

Cyanoacrylate glue reactions: A systematic review, cases, and proposed mechanisms

OBJECTIVE

Cyanoacrylate glue closure was first used in humans 10 years ago to treat venous reflux of the axial veins. Studies have since shown its clinical efficacy in vein closure. However, great need exists to elucidate further the types of specific adverse reactions that cyanoacrylate glue can cause for better patient selection and to minimize these events. In the present study, we systematically reviewed the literature to identify the types of reported reactions. In addition, we explored the pathophysiology contributing to these reactions and proposed the mechanistic pathway with inclusion of actual cases.

METHODS

We searched the literature for reports of reactions following cyanoacrylate glue use in patients with venous diseases between 2012 and 2022. The search was performed using MeSH (medical subject headings) terms. The terms included cyanoacrylate, venous insufficiency, chronic venous disorder, varicose veins, vein varicosities, venous ulcer, venous wound, CEAP (clinical, etiologic, anatomic, pathophysiologic), vein, adverse events, phlebitis, hypersensitivity, foreign body granuloma, giant cell, endovenous glue-induced thrombosis, and allergy. The search was limited to the literature reported in English. These studies were evaluated for the type of product used and the reactions noted. A systematic review, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method, was performed. Covidence software (Melbourne, VC, Australia) was used for full-text screening and data extraction. Two reviewers reviewed the data, and the content expert served as the tiebreaker.

RESULTS

We identified 102, of which, 37 reported on cyanoacrylate use other than in the context of chronic venous diseases and were excluded. Fifty-five reports were determined appropriate for data extraction. The adverse reactions to cyanoacrylate glue were phlebitis, hypersensitivity, foreign body granuloma, and endovenous glue-induced thrombosis.

CONCLUSIONS

Although cyanoacrylate glue closure for venous reflux is generally a safe and clinically effective treatment choice for patients with symptomatic chronic venous disease and axial reflux, some adverse events could be specific to the properties of the cyanoacrylate product. We propose mechanisms for how such reactions can occur based on histologic changes, published reports, and case examples; however, further exploration is necessary to confirm these theories.

European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project

Since several innovations have recently changed the criteria of choice and management of peripheral venous access (new devices, new techniques of insertion, new recommendations for maintenance), the WoCoVA Foundation (WoCoVA = World Conference on Vascular Access) has developed an international Consensus with the following objectives: to propose a clear and useful classification of the currently available peripheral venous access devices; to clarify the proper indication of central versus peripheral venous access; discuss the indications of the different peripheral venous access devices (short peripheral cannulas vs long peripheral cannulas vs midline catheters); to define the proper techniques of insertion and maintenance that should be recommended today. To achieve these purposes, WoCoVA have decided to adopt a European point of view, considering some relevant differences of terminology between North America and Europe in this area of venous access and the need for a common basis of understanding among the experts recruited for this project. The ERPIUP Consensus (ERPIUP = European Recommendations for Proper Indication and Use of Peripheral venous access) was designed to offer systematic recommendations for clinical practice, covering every aspect of management of peripheral venous access devices in the adult patient: indication, insertion, maintenance, prevention and treatment of complications, removal. Also, our purpose was to improve the standardization of the terminology, bringing clarity of definition, and classification.

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.

Reducing the incidence of phlebitis in medical adult inpatients with peripheral venous catheter care bundle: a best practice implementation project

BACKGROUND

One major complication of the insertion of a peripheral venous catheter (PVC) is phlebitis, often resulting in delay of treatment, increased healthcare costs and prolonged hospitalization.

AIMS

The current study sought to evaluate the effectiveness of a standardized PVC care bundle in increasing the compliance of PVC care and assessment and reduce the occurrences of phlebitis rates.

METHODS

A pre and postimplementation audit approach was used in this study and adopted the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice program. This study was carried out in three phases over a 10-month period, from March 2017 to December 2017 across three medical wards in a hospital in Singapore with a sample size of 90 patients. The study involved educating nurses on phlebitis assessment, implementing a PVC care bundle and monitoring compliance. An audit tool comprising four criteria from the Joanna Briggs Institute Practical Application of Clinical Evidence System was developed.

RESULTS

One-month and 3-month postimplementation findings revealed significant improvement in Criteria 1, 3 and 4 (P < 0.001) but no significant improvement in Criterion 2 (P > 0.05). Six-month postimplementation findings showed significant improvement in all four criteria (P < 0.05). An interesting finding was that the number of reported occurrences of phlebitis increased after implementing the PVC care bundle.

DISCUSSION

The increase in phlebitis rates could be attributed to the care bundle facilitating prompt and early identification of phlebitis. Despite the initial increase in occurrences 1 month post implementation, the general effectiveness of the care bundle in reducing occurrences of phlebitis was seen 6 months post implementation. The effectiveness of the care bundle to reduce phlebitis rates may be even more evident across a longer implementation period.

CONCLUSION

The current study showed that the implementation of a standardized PVC care bundle can significantly enhance the assessment and identification process of phlebitis and can aid in reducing the incidence of phlebitis. The nurses' compliance in practicing the PVC care bundle was determined by the post and preimplementation audits, thus, the audit approach was beneficial in translating evidence into practice.

Undergraduate nursing students' perceptions of the current content and pedagogical approaches used in PIVC education. A qualitative, descriptive study

BACKGROUND

The peripheral intravenous catheter (PIVC) is the most frequently used invasive medical device. PIVCs fail for a variety of reasons and failure often results in serious adverse events leading to patient discomfort, delays in treatment, increased health care costs and even death. Undergraduate nurses assess and manage PIVCs as part of their clinical learning. To date, no study has explored undergraduate nurses' perceptions of the education they receive about PIVCs.

AIM

We sought to critically explore the current state of education regarding PIVCs from the perspectives of undergraduate nurses.

METHODS

This qualitative study involved semi-structured interviews with third-year undergraduate nurses. Data were collected across two sites in Queensland, Australia. Fourteen face-to-face interviews were conducted and a modified 5-step qualitative content analysis was used to analyze the data.

FINDINGS

We identified three key domains relating to participants' experiences of PIVC education: 1) Universities provide foundational knowledge about PIVC assessment, management and removal; 2) Clinical practice consolidates and drives undergraduate nurses' knowledge, skills and confidence about PIVCs; and 3) inconsistencies in clinical practice and between individual clinicians impedes learning and knowledge translation about PIVCs.

CONCLUSION

Nursing students benefit from theoretical content delivered in the university setting. Practical application of theory and skill development whilst on clinical placement is variable. The current undergraduate curriculum, related to management of patients with a PIVC, is disjointed and inconsistent and this inconsistency may negatively impact patient safety.

The Development and Testing of a Chemotherapy-Induced Phlebitis Severity (CIPS) Scale for Patients Receiving Anthracycline Chemotherapy for Breast Cancer

A chemotherapy induced phlebitis severity (CIPS) scale was developed in patients receiving anthracycline chemotherapy for breast cancer. A five-point severity scoring scale for chemotherapy-induced phlebitis was tested for inter-rater reliability. Ease of use was observed through timing assessments and a review of the completeness of documentation. A comparison of CIPS scale grade with participant reported severity scores was made. The final version was tested for inter-rater reliability, with 122 patient assessments. There was an 89.3% (109 of 122) agreement between the assessors (κ = 0.82, SE ± 0.042, 95% CI 0.74–0.90). Mean time to complete the scale was 1 min 36 s and documentation was fully completed for 98% of assessments. Patient reported severity closely matched the CIPS grade (κ = 0.54, SE ± 0.045, 95% CI 0.46–0.63). This new scale provides a list of symptoms associated with chemotherapy phlebitis, which can be scored quickly and accurately. It provides a reliable method for assessing chemotherapy-induced phlebitis, enabling a better understanding of its impact on patients’ quality of life, and to inform the appropriate choice of peripheral or central intravenous administration. Multicentre testing of the CIPS scale is recommended.

Monitoring quality of care for peripheral intravenous catheters; feasibility and reliability of the peripheral intravenous catheters mini questionnaire (PIVC-miniQ)

BACKGROUND

Peripheral intravenous catheters (PIVCs) account for a mean of 38% of catheter associated bloodstream infections (CABSI) with Staphylococcus aureus, which are preventable if deficiencies in best practice are addressed. There exists no feasible and reliable quality surveillance tool assessing all important areas related to PIVC quality. Thus, we aimed to develop and test feasibility and reliability for an efficient quality assessment tool of overall PIVC quality.

METHODS

The Peripheral Intravenous Catheter- mini Questionnaire, PIVC-miniQ, consists of 16 items calculated as a sum score of problems regarding the insertion site, condition of dressing and equipment, documentation, and indication for use. In addition, it contains background variables like PIVC site, size and insertion environment. Two hospitals tested the PIVC-miniQ for feasibility and inter-rater agreement. Each PIVC was assessed twice, 2-5 min apart by two independent raters. We calculated the intraclass correlation coefficient (ICC) for each hospital and overall. For each of the 16 items, we calculated negative agreement, positive agreement, absolute agreement, and Scott's pi.

RESULTS

Sixty-three raters evaluated 205 PIVCs in 177 patients, each PIVC was assessed twice by independent raters, in total 410 PIVC observations. ICC between raters was 0.678 for hospital A, 0.577 for hospital B, and 0.604 for the pooled data. Mean time for the bedside assessment of each PIVC was 1.40 (SD 0.0007) minutes. The most frequent insertion site symptom was "pain and tenderness" (14.4%), whereas the most prevalent overall problem was lack of documentation of the PIVC (26.8%). Up to 50% of PIVCs were placed near joints (wrist or antecubital fossae) or were inserted under suboptimal conditions, i.e. emergency department or ambulance.

CONCLUSIONS

Our study highlights the need for PIVC quality surveillance on ward and hospital level and reports the PIVC-miniQ to be a reliable and time efficient tool suitable for frequent point-prevalence audits.

Peripheral intravenous catheter dressing and securement practice is associated with site complications and suboptimal dressing integrity: A secondary analysis of 40,637 catheters

BACKGROUND

With over 2 billion peripheral intravenous catheters used globally each year, avoiding complications is crucial for patients and healthcare organisations. Effective catheter dressing and securement is a key nursing strategy to reduce catheter failure and resultant patient harm.

OBJECTIVES

To describe global catheter dressing and securement practices and policy; and identify factors associated with catheter insertion site complications, and suboptimal dressing and securement.

DESIGN

Secondary analysis of a global cross-sectional study of peripheral intravenous catheter characteristics, management and outcomes.

SETTING

Four hundred and seven rural, regional and metropolitan hospitals in 51 countries.

PARTICIPANTS

Paediatric and adult patients with 40,637 catheters.

METHODS

Patient-, catheter-, and institution-related factors which could be associated with catheter site complications and suboptimal dressings were extracted from the parent database. Global trends in catheter dressing and securement policy and practice were described. Potential predictors of catheter and dressing complications were explored using logistic regression.

RESULTS

Dressing and securement practices, and local hospital policy regarding dressing change frequency varied. One fifth of dressings (21%, n = 8519) were not clean, dry and intact. The prevalence of catheter insertion site complications was 16% (n = 6503), with signs of phlebitis commonly observed (11.5%, n = 4587). Compared to non-bordered polyurethane dressings, sterile gauze and tape dressings were associated with fewer insertion site complications (odds ratio 0.58, 95% confidence interval 0.50-0.68) and better dressing integrity (odds ratio 0.68; 95% confidence interval 0.59-0.77); whereas, compared with no securement, non-sterile tape at the insertion site was associated with more site complications (odds ratio 2.39, 95% confidence interval 2.22-2.57) and poorer dressing integrity (odds ratio 1.64, 95% confidence interval 1.51-1.75). Two 'bundled' dressing and securement combinations were associated with fewer site and dressing complications, when compared with the reference category. Local catheter care guidelines which advocate 4th hourly insertion site inspection and dressing replacement between 1-3 days were associated with better catheter dressing integrity.

CONCLUSION

Modifiable risk factors for peripheral intravenous catheter site and dressing complications were identified and are amendable to further interventional testing.

To Replace or Not to Replace? Replacing Short Peripheral Catheters Based on Clinical Indication

Short peripheral catheters (SPCs) are the most frequently used medical devices in hospital settings. Many hospital policies state that SPCs be replaced at 96 hours, which can be unnecessary and costly. A pre-post quality improvement initiative was implemented following complications surrounding removal of timed SPC catheters compared with those removed by clinical indication, using the Visual Infusion Phlebitis (VIP) scale. Data collected included patient demographics, SPC characteristics, nursing time, and product use. SPCs replaced based on clinical indication remained intact longer and had fewer complications than those in the group with routinely replaced SPCs. Decreasing SPC replacements by use of clinical indication resulted in cost savings of $7263.60/unit/month.

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%.

Use of infrared thermography in the detection of superficial phlebitis in adult intensive care unit patients: A prospective single-center observational study

Common methods to detect phlebitis may not be sufficient for patients in the intensive care unit (ICU). The goal of this study was to investigate the feasibility of infrared (IR) thermography to objectively detect phlebitis in adult ICU patients. We included a total of 128 adult ICU-patients in a pilot and subsequent validation study. Median [interquartile range] age was 62 [54–71] years and 88 (69%) patients were male. Severity of phlebitis was scored using the visual infusion phlebitis (VIP)-score, ranging from 0 (no phlebitis) to 5 (thrombophlebitis). The temperature difference (ΔT) between the insertion site and a proximal reference point was measured with IR thermography. In 78 (34%) catheters early phlebitis and onset of moderate phlebitis was observed (VIP-score of 1–3). In both the pilot and the validation study groups ΔT was significantly higher when the VIP-score was ≥1 compared to a VIP-score of 0 (p<0.01 and p<0.001, respectively). Multivariate analysis identified ΔT (p<0.001) and peripheral venous catheter (PVC) dwell time (p = 0.001) as significantly associated with phlebitis. IR thermography may be a promising technique to identify phlebitis in the ICU. An increased ΔT as determined with thermography may be a risk factor for phlebitis.

Incidence and risk factors of peripheral venous catheter-related adverse events in cardiology department of a Tunisian university hospital: A prospective observational study

AIM

The purpose of our study was to determine the incidence and risk factors of Peripheral Venous Catheter-Related Adverse Events (PVCAEs) in a cardiology department of a university hospital.

PATIENTS AND METHODS

We carried out a prospective observational study from Mars 2017 to May 2017 in the cardiology department of the University Hospital of Farhat Hached in Sousse, Tunisia. During this period, we actively followed-up all inserted PVCs (every 12hours) from insertion up to 48hours after removal. Regression analyses were applied and significance limits were set at P<0.05.

RESULTS

Data were analysed for 210 PVCs (794 PVC-days) in 148 patients. The incidence of PVCAEs was 33.33% with density of incidence of 8.81/1000 PVC-days. PVCAEs were mainly pain (50%) and mechanical events (31.42%). Infections accounted for 11.42%. The most frequent mechanical PVCAEs, was haematoma (15.71%). Multivariate analysis revealed as independent factors for the occurrence of PVCAEs: the hydro electrolytic nature of the injected product (OR=13.42, P<10-3), the medicinal nature of the injected product (OR=5.08, P=0.003), bad cutaneous state (OR=8.08, P=0.003), admission during nightshift (OR=3.76; P=0.014) and advanced age (OR=1.04, P=0.042).

CONCLUSION

Multicenter studies would be very useful to better analyze risk factors associated with PVCAEs.

From insertion to removal: A multicenter survival analysis of an admitted cohort with peripheral intravenous catheters inserted in the emergency department

BACKGROUND

Most patients admitted to the hospital via the emergency department (ED) do so with a peripheral intravenous catheter/cannula (PIVC). Many PIVCs develop postinsertion failure (PIF).

OBJECTIVE

To determine the independent factors predicting PIF after PIVC insertion in the ED.

METHODS

We analyzed data from a prospective clinical cohort study of ED-inserted PIVCs admitted to the hospital wards. Independent predictors of PIF were identified using Cox proportional hazards regression modeling.

RESULTS

In 391 patients admitted from 2 EDs, the rate of PIF was 31% (n=118). The types of PIF identified were infiltration, occlusion, pain and/or peripheral intravenous assessment score >2 (ie, the hospital's assessment of PIVC phlebitis), and dislodgement (ie, accidental securement device failure or purposeful removal). Of the PIVCs that failed, infiltration and occlusion combined were the most common causes of PIF (n=55, 47%). The median PIVC dwell time was 28.5 hours (interquartile range [IQR], 17.4-50.8 hours). The following variables were associated with increased risk of PIF: being an older patient (for a 1-year increase, hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P=.0001); having an Australian Triage Scale score of 1 or 2 compared to a score of 3, 4, or 5 (HR, 2.04; 95% CI, 1.39-3.01; P=.0003); having an ultrasound-guided PIVC (HR, 6.52; 95% CI, 2.11-20.1; P=.0011); having the PIVC inserted by a medical student (P=.0095); infection prevention breaches at insertion (P=.0326); and PIVC inserted in the ante cubital fossa or the back of hand compared to the upper arm (P=.0337).

CONCLUSION

PIF remains at an unacceptable level in both traditionally inserted and ultrasound-inserted PIVCs.Clinical trial registrationAustralian and New Zealand Trials Registry (ANZCTRN12615000588594).

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.

Insertion site assessment of peripherally inserted central catheters: Inter-observer agreement between nurses and inpatients

INTRODUCTION

Many patients are discharged from hospital with a peripherally inserted central catheter in place. Monitoring the peripherally inserted central catheter insertion site for clinical and research purposes is important for identifying complications, but the extent to which patients can reliably report the condition of their catheter insertion site is uncertain. The aim of this study was to assess the inter-observer agreement between nurses and patients when assessing a peripherally inserted central catheter site.

METHODS

The study was based on inpatients who were enrolled in a single-centre, randomised controlled trial comparing four different dressing and securement devices for peripherally inserted central catheter sites. A seven-item peripherally inserted central catheter site assessment tool, containing questions about the condition of the dressing and the insertion site, was developed. Assessment was conducted once by the research nurse and, within a few minutes, independently by the patient. Proportions of agreement and Cohen's kappa were calculated.

RESULTS

In total, 73 patients agreed to participate. Overall, percentage agreement ranged from 83% to 100% (kappa = .65-.82). For important clinical signs (redness, swelling, ooze, pus and tracking), there were high levels of percentage agreement (99%-100%).

CONCLUSION

The high level of agreement between nurse/patient pairs make the instrument useful for assessing peripherally inserted central catheter-associated signs of localised infection, allergic or irritant dermatitis or dressing dislodgement in a community setting.

Complications of Peripherally Inserted Central Venous Catheters: A Retrospective Cohort Study

BACKGROUND AND AIM

The use of venous catheters is a widespread practice, especially in oncological and oncohematological units. The objective of this study was to evaluate the complications associated with peripherally inserted central catheters (PICCs) in a cohort of patients.

MATERIALS AND METHODS

In this retrospective cohort study, we included all patient carrying PICCs (n = 603) inserted at our institute between October 2010 and December 2013. The main variables collected were medical diagnosis, catheter care, location, duration of catheterization, reasons for catheter removal, complications, and nursing care. Complications were classified as infection, thrombosis, phlebitis, migration, edema, and/or ecchymosis.

RESULTS

All patients were treated according to the same "nursing care" protocol. The incidence rate of complications was two cases per 1000 days of catheter duration. The most relevant complications were infection and thrombosis, both with an incidence of 0.17 cases per 1000 days of the total catheterization period. The total average duration of catheterization was 170 days [SD 6.06]. Additionally to "end of treatment" (48.42%) and "exitus", (22.53%) the most frequent cause of removal was migration (displacement towards the exterior) of the catheter (5.80%).

CONCLUSIONS

PICCs are safe devices that allow the administration of long-term treatment and preserve the integrity of the venous system of the patient. Proper care of the catheter is very important to improve the quality life of patients with oncologic and hematologic conditions. Therefore, correct training of professionals and patients as well as following the latest scientific recommendations are particularly relevant.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol

INTRODUCTION

Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency.

METHODS AND ANALYSIS

We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule.

ETHICS AND DISSEMINATION

The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used.

TRIAL REGISTRATION NUMBER

ACTRN12615000588594; Pre-results.