Substantial harm associated with failure of chronic paediatric central venous access devices

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Pediatric central venous access devices: practice, performance, and costs

BACKGROUND

Healthcare delivery is reliant on a functional central venous access device (CVAD), but the knowledge surrounding the burden of pediatric CVAD-associated harm is limited.

METHODS

A prospective cohort study at a tertiary-referral pediatric hospital in Australia. Children <18 years undergoing insertion of a CVAD were screened from the operating theatre and intensive care unit records, then assessed bi-weekly for up to 3 months. Outcomes were CVAD failure and complications, and associated healthcare costs (cost of complications).

RESULTS

163 patients with 200 CVADs were recruited and followed for 6993 catheter days, with peripherally inserted central catheters most common (n = 119; 60%). CVAD failure occurred in 20% of devices (n = 30; 95% CI: 15-26), at an incidence rate (IR) of 5.72 per 1000 catheter days (95% CI: 4.09-7.78). CVAD complications were evident in 43% of all CVADs (n = 86; 95% CI: 36-50), at a rate of 12.29 per 1000 catheter days (95% CI: 9.84-15.16). CVAD failure costs were A$826 per episode, and A$165,372 per 1000 CVADs. Comparisons between current and recommended practice revealed inconsistent use of ultrasound guidance for insertion, sub-optimal tip-positioning, and appropriate device selection.

CONCLUSIONS

CVAD complications and failures represent substantial burdens to children and healthcare. Future efforts need to focus on the inconsistent use of best practices.

IMPACT

Current surveillance of central venous access device (CVAD) performance is likely under-estimating actual burden on pediatric patients and the healthcare system. CVAD failure due to complication was evident in 20% of CVADs. Costs associated with CVAD complications average at $2327 (AUD, 2020) per episode. Further investment in key diverse practice areas, including new CVAD types, CVAD pathology-based occlusion and dislodgment strategies, the appropriate use of device types, and tip-positioning technologies, will likely lead to extensive benefit.

Unexpected tunnelled central venous access demise: a single institutional study from the UK

PURPOSE

To explore the factors involved in the demise of tunnelled central vascular access devices (CVADs) in children and describe patterns of failure.

METHODS

A retrospective study including children under 16 years of age undergoing CVAD insertion in a tertiary centre between October 2014 and December 2019. The Kaplan-Meier estimator was used to study CVAD survival and piecewise exponential curves to approximate hazard rates. Related factors were analysed using multivariable regression.

RESULTS

Totally, 684 CVADs were inserted in 499 children. Devices were in situ for 213,821 days (median 244.5). Of those, 261 CVADs (38.2%) failed prematurely; 176 (67%) required replacement. Tunnelled external lines (TELs) failed more frequently than totally implantable devices (p < 0.005).TEL displacement occurred in two high-risk phases, falling to baseline after 90 days. Low age at device insertion and open placement were strongly associated with an increased failure rate. Previous CVAD failure did not increase subsequent failure rate. Premature failure increased procedural cost by £153,949 per year.

CONCLUSIONS

TIDs should be placed in preference to TELs where appropriate. TELs are at highest risk of displacement for 90 days and must be well secured for this duration. Meticulous line care offers significant potential cost savings by reducing line replacements.

LEVEL OF EVIDENCE

Level III.

Risk Factors for Central Venous Access Device-Related Thrombosis in Hospitalized Children: A Systematic Review and Meta-Analysis

OBJECTIVE

 To identify the potential associations of patient-, treatment-, and central venous access device (CVAD)-related factors with the CVAD-related thrombosis (CRT) risk in hospitalized children.

METHODS

 A systematic search of PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP database was conducted. RevMan 5.3 and Stata 12.0 statistical software were employed for data analysis.

RESULTS

 In terms of patient-related factors, the patient history of thrombosis (odds ratio [OR] = 3.88, 95% confidence interval [CI]: 2.57-5.85), gastrointestinal/liver disease (OR = 1.85, 95% CI: 0.99-3.46), hematologic disease (OR = 1.45, 95% CI: 1.06-1.99), and cancer (OR = 1.58, 95% CI: 1.01-2.48) were correlated with an increased risk of CRT. In terms of treatment-related factors, parenteral nutrition (PN)/total PN (OR = 1.70, 95% CI: 1.21-2.39), hemodialysis (OR = 2.17, 95% CI: 1.34-3.51), extracorporeal membrane oxygenation (OR = 1.51, 95% CI: 1.31-1.71), and cardiac catheterization (OR = 3.92, 95% CI: 1.06-14.44) were associated with an increased CRT risk, while antibiotics (OR = 0.46, 95% CI: 0.32-0.68) was associated with a reduced CRT risk. In terms of the CVAD-related factors, CRT risk was more significantly increased by peripherally inserted central catheter than tunneled lines (OR = 1.81, 95% CI: 1.15-2.85) or totally implantable venous access port (OR = 2.81, 95% CI: 1.41-5.60). And subclavian vein catheterization significantly contributed to a lower CRT risk than femoral vein catheterization (OR = 0.36, 95% CI: 0.14-0.88). Besides, multiple catheter lines (OR = 4.06, 95% CI: 3.01-5.47), multiple catheter lumens (OR = 3.71, 95% CI: 1.99-6.92), central line-associated bloodstream infection (OR = 2.66, 95% CI: 1.15-6.16), and catheter malfunction (OR = 1.65, 95% CI: 1.07-2.54) were associated with an increased CRT risk.

CONCLUSION

 The exact identification of the effect of risk factors can boost the development of risk assessment tools with stratifying risks.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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