International recommendations for a vascular access minimum dataset: a Delphi consensus-building study

Determining the required data elements to develop the information management system for Iranian traditional medicine

BACKGROUND

Currently, there is no agreed-upon data collection tool for comprehensively structured documentation of Iranian traditional medicine (ITM) from the information management perspective. As ITM practice varies significantly from current medicine in diagnosis and treatment approaches, it is not appropriate to use data platforms or information systems developed for current medicine. Consequently, the collected data are non-comparable, reducing the verdicts' generalization. Therefore, this research aims to create a minimum data set (MDS) for unified reporting of ITM diseases and interventions.

METHODS

This multi-phased method study was performed from December 30, 2022 to March 20, 2023. The first phase involved a literature review, the second phase utilized the Delphi technique, and the third phase focused on validating the MDS-ITM. A list of potential data items was prepared after searching scientific databases, and grey literature, as well as reviewing existing information systems, forms, and websites related to ITM. A modified Delphi technique, including a two-round survey, was then employed. A panel of 34 individuals with clinical and research experience in ITM, was selected via purposeful sampling to rate the importance of candidate data items for inclusion in the ITM-MDS using a 5-point Likert scale. Items with an agreement level of 80% or more were deemed acceptable for inclusion in the final ITM-MDS. Finally, the content validity of the developed MDS was assessed using the content validity ratio (CVR) and content validity index (CVI) criteria.

RESULTS

Consensus was reached on an ITM-MDS containing 291 items grouped into seven categories: Patient admission, past medical history, six principles of health preservation, objective signs, subjective symptoms, examination of body systems, and care plans.

CONCLUSIONS

The development of this MDS will enable ITM care settings  to exchange information and share resources more easily. It also provides an inclusive dataset and structured documentation of medical records. This MDS can contribute to delivering high-quality care and improving clinical decision-making.

A Comparison of Peripherally Inserted Central Catheter Materials

BACKGROUND

New catheter materials for peripherally inserted central catheters (PICCs) may reduce the risk of device failure due to infectious, thrombotic, and catheter occlusion events. However, data from randomized trials comparing these catheters are lacking.

METHODS

We conducted a randomized, controlled, superiority trial in three Australian tertiary hospitals. Adults and children who were referred for PICC placement were assigned in a 1:1:1 ratio to receive a hydrophobic or chlorhexidine PICC or a standard polyurethane PICC and were followed for 8 weeks. The primary outcome was device failure, which was a composite of infectious (bloodstream or local) or noninfectious (thrombosis, breakage, or occlusion) complications.

RESULTS

A total of 1098 participants underwent randomization; 365 were assigned to the hydrophobic group, 365 to the chlorhexidine group, and 368 to the standard-polyurethane group. Device failure occurred in 21 of 358 participants (5.9%) in the hydrophobic group, in 36 of 363 (9.9%) in the chlorhexidine group, and in 22 of 359 (6.1%) in the standard-polyurethane group (risk difference, hydrophobic vs. standard polyurethane, -0.2 percentage points [95% confidence interval {CI}, -3.7 to 3.2; P = 0.89]; and chlorhexidine vs. standard polyurethane, 3.8 percentage points [95% CI, -0.1 to 7.8; P = 0.06]). In the hydrophobic group as compared with the standard-polyurethane group, the odds ratio for device failure was 0.96 (95% CI, 0.51 to 1.78), and in the chlorhexidine group as compared with the standard-polyurethane group, the odds ratio was 1.71 (95% CI, 0.98 to 2.99). Complications from any cause during the period of PICC placement occurred in 77 participants (21.5%) in the hydrophobic group, in 140 (38.6%) in the chlorhexidine group, and in 78 (21.7%) in the standard-polyurethane group (odds ratio, hydrophobic vs. standard polyurethane, 0.99 [95% CI, 0.69 to 1.42]; and chlorhexidine vs. standard polyurethane, 2.35 [95% CI, 1.68 to 3.29]). No adverse events were attributable to the interventions.

CONCLUSIONS

Among adults and children who were referred for PICC placement, the risk of device failure due to noninfectious or infectious complications was not lower with hydrophobic or chlorhexidine PICCs than with standard polyurethane PICCs. (Funded by the National Health and Medical Research Council of Australia; PICNIC Australian New Zealand Clinical Trials Registry number, ACTRN12619000022167.).

Central venous access device adverse events in pediatric patients with cancer: a systematic review and meta-analysis

PURPOSE

To systematically review the proportion and incidence of CVAD-associated complications in pediatric patients with cancer.

METHODS

PubMed, Embase, and the Cumulative Index of Nursing and Allied Health Literature were searched from 2012 to 2022. Cohort studies and the control arm of randomized controlled trials, which reported CVAD-associated complications in pediatric patients aged 0-18 years, were included. CVAD complications were defined as CVAD failure, central line-associated bloodstream infection (CLABSI), local infection, occlusion, CVAD-associated venous thromboembolism, dislodgement/migration, breakage/rupture, and dehiscence. The pooled proportion and incidence rate (IR) for each CVAD-associated complication were reported.

RESULTS

Of 40 included studies, there was mixed quality of methods and reporting. Approximately 31.4% (95% confidence interval [CI] 22.5-41.1; 6920 devices) of devices experienced a CVAD-associated complication, and 14.8% (95% CI 10.2-20.1; 24 studies; 11,762 devices) of CVADs failed before treatment completion (incidence rate (IR) of 0.5 per 1000 catheter days (95% CI 0.3-0.8; 12 studies; 798,000 catheter days)). Overall, 21.2% (95% CI 14.3-28.9; 26 studies; 5054 devices) of CVADs developed a CLABSI, with an IR of 0.9 per 1000 catheter days (95% CI 0.6-1.3; 12 studies; 798,094 catheter days). Tunneled central venous catheters (TCVC) and peripherally inserted central catheters (PICCs) were associated with increased complications in comparison to totally implanted venous access devices (TIVADs).

CONCLUSION

CVAD complication rates in this population remain high. TCVCs and PICCs are associated with increased complications relative to TIVADs. Insufficient evidence exists to guide device selection in this cohort, necessitating further research to determine the role of PICCs in pediatric cancer care.

PROSPERO

CRD42022359467. Date of registration: 22 September 2022.

Determining the minimum data set of geriatric assessment at the Iran primary health care referral system: shifting from fragmentation to integration care for older people

BACKGROUND

Geriatric assessment (GA) is a multidimensional process that disrupts the primary health care (PHC) referral system. Accessing consistent data is central to the provision of integrated geriatric care across multiple healthcare settings. However, due to poor-quality data and documentation of GA, developing an agreed minimum data set (MDS) is required. Therefore, this study aimed to develop a GA-MDS in the PHC referral system to improve data quality, data exchange, and continuum of care to address the multifaceted necessities of older people.

METHODS

In our study, the items to be included within GA-MDS were determined in a three-stepwise process. First, an exploratory literature search was done to determine the related items. Then, we used a two-round Delphi survey to obtain an agreement view on items to be contained within GA-MDS. Finally, the validity of the GA-MDS content was evaluated.

RESULTS

Sixty specialists from different health geriatric care disciplines scored data items. After, the Delphi phase from the 230 selected items, 35 items were removed by calculating the content validity index (CVI), content validity ratio (CVR), and other statistical measures. Finally, GA-MDS was prepared with 195 items and four sections including administrative data, clinical, physiological, and psychological assessments.

CONCLUSIONS

The development of GA-MDS can serve as a platform to inform the geriatric referral system, standardize the GA process, and streamline their referral to specialized levels of care. We hope GA-MDS supports clinicians, researchers, and policymakers by providing aggregated data to inform medical practice and enhance patient-centered outcomes.

Securement to Prevent Noncuffed Central Venous Catheter Dislodgement in Pediatrics: The SECURED Superiority Randomized Clinical Trial

Importance

Catheter dislodgement is a common complication for children with tunneled or peripherally inserted noncuffed central venous catheters (CVCs). A subcutaneous anchor securement system (SASS) may reduce this risk compared with traditional adhesive securement.

Objective

To compare dislodgement of noncuffed CVCs secured with SASS with dislodgement of noncuffed CVCs secured with sutureless securement devices (SSDs).

Design, Setting, and Participants

The SECURED (Securing Central Venous Catheters to Prevent Dislodegment) trial was a pragmatic, multicenter, superiority randomized clinical trial with an internal pilot and was conducted from August 5, 2020, to August 30, 2022, at 2 Australian quaternary pediatric hospitals. Data analysis was performed in January 2023. Patients aged 0 to 18 years requiring a noncuffed CVC (≥3F catheter) were eligible for inclusion. Follow-up duration was 8 weeks or until device removal.

Interventions

Patients were randomly assigned 1:1 to receive an SASS or SSD, stratified by hospital and catheter type. Only 1 catheter was studied per patient.

Main Outcomes and Measures

The primary outcome was dislodgement (partial or total), defined as movement of the catheter tip by greater than 1 cm (change in external catheter length) at any point during catheter dwell. Dislodgement, reported as a risk ratio (RR), was estimated using a generalized linear model with binomial family and log link. Secondary outcomes were reported as incidence rate ratios and were analyzed using Poission regression. Outcomes reported as mean differences (MDs) were analyzed using linear regression.

Results

Of 310 randomized patients, 175 patients (56.5%) were male and median (IQR) patient age was 48 (16-120) months. A total of 307 patients had a catheter device inserted, of which 153 (49.8%) were SASS and 154 (50.2%) were SSD, and were included in the intention-to-treat (ITT) analysis. Device dislodgement was lower with SASS (8 dislodgements in 153 patients [5.2%]) compared with SSD (35 dislodgements in 154 patients [22.7%]) (RR, 0.23; 95% CI, 0.11-0.48; P < .001). The per-protocol analysis was consistent with the ITT analysis. Partial dislodgement accounted for most dislodgement events, including 6 partial dislodgements in the SASS group (3.9%) and 30 partial dislodgements in the SSD group (19.5%) (RR, 0.18; 95% CI, 0.08-0.42). This contributed to fewer complications during dwell in the SASS group (37 reported complications [24.2%]) vs the SSD group (60 reported complications [39.0%]) (RR, 0.62; 95% CI, 0.44-0.87). Staff reported greater difficulty removing devices anchored with SASS vs SSD (mean [SD], 29.1 [31.3] vs 5.3 [17.0], respectively; MD, 23.8; 95% CI, 16.7-31.0). However, use of SASS resulted in reduced per-participant health care costs of A$36.60 (95% credible interval, 4.25-68.95; US $24.36; 95% credible interval, 2.83-45.89).

Conclusions and Relevance

In the SECURED trial, noncuffed CVCs secured with SASS had fewer dislodgements compared with SSDs, with a lower cost per patient and an acceptable safety profile. Future efforts should be directed at SASS implementation at the health service level.

Trial Registration

anzctr.org.au Identifier: ACTRN12620000783921.

Incidence and risk factors of complications during central venous access devices removal in children

PURPOSE

To quantify the rates and identify risk factors for the complications of central venous access devices (CVADs) removal in children.

METHOD

Retrospective (2018-2023) review of children undergoing CVADs removal at a single institution. Data are reported as frequency, percentages and median. Logistic regression analysis was used to identify risk factors associated with difficult removal. Receiver Operating Characteristic Curve (ROC) analysis was conducted to identify the age cut-off and positive likelihood ratio (+LH) for the indwelling time associated with complicated removal. p-Value <0.05 were considered statistically significant.

RESULTS

We identified 208 CVAD removals with a median age of 7.2 (0.2-18.4) years including 116 (55.8%) males. The median CVAD placement duration was 1.26 years (0.4-5.7) years. Indications for insertion included acute lymphoblastic leukaemia (ALL; 78/208, 37.5%), lymphomas (31/208, 14.9%), other malignancies (58/208, 27.9%). Removal indications included completion of treatment (144/208, 69.2%), infection (22/208, 10.6%), malfunction (7/208, 3.4%) and other reasons (35/208, 16.8%). There were 20 (9.6%) complications characterised by difficulty removing the CVAD. Complicated removals were more likely to occur in children with ALL as the primary diagnosis (p = 0.001); independently of the indication for insertion, longer indwelling time was associated with higher risk of complicated removal (p < 0.001). Indwelling time >2.09 years was associated with a 2.87 increased risk of difficult removal.

CONCLUSION

In our experience, almost 10% of CVAD removals in children result in complications. These findings are associated with an indwelling time >2 years; strategies to prevent complicated removals should be considered in children requiring long-term central venous access.

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.

Peripherally inserted central catheter design and material for reducing catheter failure and complications

BACKGROUND

Peripherally inserted central catheters (PICCs) facilitate diagnostic and therapeutic interventions in health care. PICCs can fail due to infective and non-infective complications, which PICC materials and design may contribute to, leading to negative sequelae for patients and healthcare systems.

OBJECTIVES

To assess the effectiveness of PICC material and design in reducing catheter failure and complications.

SEARCH METHODS

The University of Queensland and Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the WHO ICTRP and ClinicalTrials.gov trials registers to 16 May 2023. We aimed to identify other potentially eligible trials or ancillary publications by searching the reference lists of retrieved included trials, as well as relevant systematic reviews, meta-analyses, and health technology assessment reports. We contacted experts in the field to ascertain additional relevant information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating PICC design and materials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were venous thromboembolism (VTE), PICC-associated bloodstream infection (BSI), occlusion, and all-cause mortality. Secondary outcomes were catheter failure, PICC-related BSI, catheter breakage, PICC dwell time, and safety endpoints. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 12 RCTs involving approximately 2913 participants (one multi-arm study). All studies except one had a high risk of bias in one or more risk of bias domain. Integrated valve technology compared to no valve technology for peripherally inserted central catheter design Integrated valve technology may make little or no difference to VTE risk when compared with PICCs with no valve (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.19 to 2.63; I² = 0%; 3 studies; 437 participants; low certainty evidence). We are uncertain whether integrated valve technology reduces PICC-associated BSI risk, as the certainty of the evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Integrated valve technology may make little or no difference to occlusion risk when compared with PICCs with no valve (RR 0.86, 95% CI 0.53 to 1.38; I² = 0%; 5 studies; 900 participants; low certainty evidence). We are uncertain whether use of integrated valve technology reduces all-cause mortality risk, as the certainty of evidence is very low (RR 0.85, 95% CI 0.44 to 1.64; I² = 0%; 2 studies; 473 participants). Integrated valve technology may make little or no difference to catheter failure risk when compared with PICCs with no valve (RR 0.80, 95% CI 0.62 to 1.03; I² = 0%; 4 studies; 720 participants; low certainty evidence). We are uncertain whether integrated-valve technology reduces PICC-related BSI risk (RR 0.51, 95% CI 0.19 to 1.32; I² = not applicable; 2 studies (no events in 1 study); 542 participants) or catheter breakage, as the certainty of evidence is very low (RR 1.05, 95% CI 0.22 to 5.06; I² = 20%; 4 studies; 799 participants). Anti-thrombogenic surface modification compared to no anti-thrombogenic surface modification for peripherally inserted central catheter design We are uncertain whether use of anti-thrombogenic surface modified catheters reduces risk of VTE (RR 0.67, 95% CI 0.13 to 3.54; I² = 15%; 2 studies; 257 participants) or PICC-associated BSI, as the certainty of evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces occlusion (RR 0.69, 95% CI 0.04 to 11.22; I² = 70%; 2 studies; 257 participants) or all-cause mortality risk, as the certainty of evidence is very low (RR 0.49, 95% CI 0.05 to 5.26; I² = not applicable; 1 study; 111 participants). Use of anti-thrombogenic surface modified catheters may make little or no difference to risk of catheter failure (RR 0.76, 95% CI 0.37 to 1.54; I² = 46%; 2 studies; 257 participants; low certainty evidence). No PICC-related BSIs were reported in one study (111 participants). As such, we are uncertain whether use of anti-thrombogenic surface modified catheters reduces PICC-related BSI risk (RR not estimable; I² = not applicable; very low certainty evidence). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces the risk of catheter breakage, as the certainty of evidence is very low (RR 0.15, 95% CI 0.01 to 2.79; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Antimicrobial impregnation compared to non-antimicrobial impregnation for peripherally inserted central catheter design We are uncertain whether use of antimicrobial-impregnated catheters reduces VTE risk (RR 0.54, 95% CI 0.05 to 5.88; I² = not applicable; 1 study; 167 participants) or PICC-associated BSI risk, as the certainty of evidence is very low (RR 2.17, 95% CI 0.20 to 23.53; I² = not applicable; 1 study; 167 participants). Antimicrobial-impregnated catheters probably make little or no difference to occlusion risk (RR 1.00, 95% CI 0.57 to 1.74; I² = 0%; 2 studies; 1025 participants; moderate certainty evidence) or all-cause mortality (RR 1.12, 95% CI 0.71 to 1.75; I² = 0%; 2 studies; 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter failure (RR 1.04, 95% CI 0.82 to 1.30; I² = not applicable; 1 study; 221 participants; low certainty evidence). Antimicrobial-impregnated catheters probably make little or no difference to PICC-related BSI risk (RR 1.05, 95% CI 0.71 to 1.55; I² = not applicable; 2 studies (no events in 1 study); 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter breakage (RR 0.86, 95% CI 0.19 to 3.83; I² = not applicable; 1 study; 804 participants; low certainty evidence).

AUTHORS' CONCLUSIONS

There is limited high-quality RCT evidence available to inform clinician decision-making for PICC materials and design. Limitations of the current evidence include small sample sizes, infrequent events, and risk of bias. There may be little to no difference in the risk of VTE, PICC-associated BSI, occlusion, or mortality across PICC materials and designs. Further rigorous RCTs are needed to reduce uncertainty.

Establishing a paediatric critical care core quality measure set using a multistakeholder, consensus-driven process

Introduction

Monitoring healthcare quality is challenging in paediatric critical care due to measure variability, data collection burden, and uncertainty regarding consumer and clinician priorities.

Objective

We sought to establish a core quality measure set that (i) is meaningful to consumers and clinicians and (ii) promotes alignment of measure use and collection across paediatric critical care.

Design

We conducted a multi-stakeholder Delphi study with embedded consumer prioritisation survey. The Delphi involved two surveys, followed by a consensus meeting. Triangulation methods were used to integrate survey findings prior tobefore the consensus meeting. In the consensus panel, broad agreement was reached on a core measure set, and recommendations were made for future measurement directions in paediatric critical care.

Setting and participants

Australian and New Zealand paediatric critical care survivors (aged >18 years) and families were invited to rank measure priorities in an online survey distributed via social media and consumer groups. A concurrent Delphi study was undertaken with paediatric critical care clinicians, policy makers, and a consumer representative.

Interventions

None.

Main outcome measures

Priorities for quality measures.

Results

Respondents to the consumer survey (n = 117) identified (i) nurse-patient ratios; (ii) visible patient goals; and (iii) long-term follow-up as their quality measure priorities. In the Delphi process, clinicians (Round 1 n = 191; Round 2 n = 117 [61% retention]; Round 3 n = 14) and a consumer representative reached broad agreement on a 51-item (61% of 83 initial measures) core measure set. Clinician priorities were (i) nurse-patient ratio; (ii) staff turnover; and (iii) long term-follow up. Measure feasibility was rated low due to a perceived lack of standardised case definitions or data collection burden. Five recommendations were generated.

Conclusions

We defined a 51-item core measurement set for paediatric critical care, aligned with clinician and consumer priorities. Next steps are implementation and methodological evaluation in quality programs, and where appropriate, retirement of redundant measures.

Dressings and securement devices to prevent complications for peripheral arterial catheters

BACKGROUND

Peripheral arterial catheters (ACs) are used in anaesthesia and intensive care settings for blood sampling and monitoring. Despite their importance, ACs often fail, requiring reinsertion. Dressings and securement devices maintain AC function and prevent complications such as infection.

OBJECTIVES

To evaluate the effectiveness of peripheral AC dressing and securement devices to prevent failure and complications in hospitalised people.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus up to 16 May 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to 16 May 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different dressing and securement devices for the stabilisation of ACs in hospitalised people.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias using Cochrane's RoB 1 tool. We resolved disagreements by discussion, or by consulting a third review author when necessary. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included five RCTs with 1228 participants and 1228 ACs. All included studies had high risk of bias in one or more domains. We present the following four comparisons, with the remaining comparisons reported in the main review. Standard polyurethane (SPU) plus tissue adhesive (TA) compared with SPU: we are very uncertain whether use of SPU plus TA impacts rates of AC failure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.20 to 0.98; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Neither study (165 participants) reported catheter-related bloodstream infections (CRBSI), thus we are very uncertain whether SPU plus TA impacts on the incidence of CRBSI (very low-certainty evidence). It is very uncertain whether use of SPU plus TA impacts AC dislodgement risk (RR 0.54, 95% CI 0.03 to 9.62; I² = 44%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts AC occlusion rates (RR 1.20, 95% CI 0.37 to 3.91; I² = 3%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts rates of adverse events with few reported events across groups (RR 0.89, 95% CI 0.09 to 8.33; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Bordered polyurethane (BPU) compared to SPU: we are very uncertain whether use of BPU impacts rates of AC failure (RR 0.67, 95% CI 0.21 to 2.13; 1 study, 60 participants; very low-certainty evidence). BPU may make little or no difference to CRBSI compared to SPU (RR 3.05, 95% CI 0.12 to 74.45; I² = not applicable as 1 study (60 participants) reported 0 events; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to the risk of AC dislodgement compared with SPU (RR 0.75, 95% CI 0.17 to 3.22; I² = 0%; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to occlusion risk compared with SPU (RR 0.80, 95% CI 0.60 to 1.07; I² = 0%; 2 studies, 572 participants; low-certainty evidence). It is very uncertain whether BPU impacts on the risk of adverse events compared with SPU (RR 0.33, 95% CI 0.01 to 7.87; 1 study, 60 participants; very low-certainty evidence). SPU plus sutureless securement devices (SSD) compared to SPU: we are very uncertain whether SPU plus SSD impacts risk of AC failure compared with SPU (RR 0.78, 95% CI 0.40 to 1.52; I² = 0%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain if SPU plus SSD impacts CRBSI incidence rate with no events in both groups (2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of dislodgement (RR 0.14, 95% CI 0.01 to 2.57; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of AC occlusion (RR 1.94, 95% CI 0.50 to 7.48; I² = 38%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain whether SPU plus SSD impacts on the risk of adverse events (RR 1.94, 95% CI 0.19 to 20.24; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). Integrated securement dressings compared to SPU: integrated securement dressings may result in little or no difference in risk of AC failure compared with SPU (RR 1.96, 95% CI 0.80 to 4.84; 1 study, 105 participants; low-certainty evidence); may result in little or no difference in CRBSI incidence with no events reported (1 study, 105 participants; low-certainty evidence); may result in little or no difference in the risk of dislodgement (RR 0.33, 95% CI 0.04 to 3.04; 1 study, 105 participants; low-certainty evidence), may result in little or no difference in occlusion rates with no events reported (1 study, 105 participants; low-certainty evidence), and may result in little or no difference in the risk of adverse events (RR 0.35, 95% CI 0.01 to 8.45; 1 study, 105 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the relative clinical effectiveness of AC dressing and securement products. Limitations of current evidence include small sample size, infrequent events, and heterogeneous outcome measurements. We found no clear difference in the incidence of AC failure, CRBSI, or adverse events across AC dressing or securement products including SPU, BPU, SSD, TA, and integrated securement products. The limitations of current evidence means further rigorous RCTs are needed to reduce uncertainty around the use of dressing and securement devices for ACs.

Totally Implantable Venous Access Device Care Practices and Experiences of Pediatric and Adult Oncology Nurses

This study aimed to determine the practices of nurses working in pediatric and adult oncology clinics regarding totally implantable venous access device (TIVAD) care. The descriptive study was conducted with 227 oncology nurse members of the Oncology Nursing Association. The data were collected online with a survey form, which included questions about the participants' sociodemographic characteristics, professional experience, and TIVAD implementation practices. Descriptive statistics and ꭓ2 tests were used for the analysis of the data. It was determined that 44.1% of the nurses used 0.9% NaCl for active TIVAD flushing; 15.9% of them used a positive-pressure 0.9% NaCl-filled syringe; 12.3% used antireflux connectors; 85.5% used manual positive pressure technique; and 53.7% used the pulsatile technique. A statistical difference was found between nurses' training on TIVAD care and TIVAD occlusion rate in the clinic, TIVAD infection rate, following the guidelines, and using the pulsatile technique (P < .05). This study revealed that there are differences in the practices for TIVAD care and that the recommendations in the literature/guidelines are not implemented at the desired level to ensure continuity and prevent complications.

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

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

BACKGROUND

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

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

IMPACT

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

REPORTING METHOD

Not applicable.

PATIENT CONTRIBUTION

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

Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial

Importance

Peripheral intravenous catheters (PIVCs) facilitate essential treatment. Failure of these essential devices is frequent and new securement strategies may reduce failure and improve patient outcomes.

Objective

To evaluate clinical effectiveness of novel PIVC securement technologies for children to reduce catheter failure.

Design, Setting, and Participants

A 3-arm, parallel group, superiority randomized clinical trial was conducted at 2 regional Australian hospitals from February 5, 2020, to January 14, 2022. Children aged 6 months to 8 years who were anticipated to require admission with a PIVC for at least 24 hours of in hospital treatment were eligible. Data were analyzed from May 25, 2022, to February 20, 2024.

Interventions

Participants were randomly allocated in a 1:1:1 ratio to standard care, bordered polyurethane (Tegaderm [3M]), integrated securement dressing (SorbaView SHIELD [Medline]), and integrated securement dressing with tissue adhesive (Secureport IV). One catheter was studied per patient.

Main Outcomes and Measures

Primary outcome was PIVC failure, defined as premature cessation of PIVC function for any reason prior to completion of planned treatment. Secondary outcomes were PIVC complications (any time dislodgement, occlusion, infiltration, partial dislodgement, extravasation, device leaking, phlebitis, pain), PIVC longevity, intervention acceptability (clinicians, participants, caregivers; 0-10 scale), and pain on removal (participants and caregivers; 0-10 scale relevant to age), adverse events, and health care costs.

Results

A total of 383 patients (51% female; median age 36 [25th-75th percentiles, 22-72] months) were randomized 134 to standard care, 118 to integrated securement dressing, and 131 to integrated securement dressing with tissue adhesive. PIVC failure was lowest in integrated securement dressing with tissue adhesive (15 [12%]; adjusted hazard ratio [aHR], 0.47; 95% CI, 0.26-0.84) compared with integrated securement dressing (24 [21%]; aHR, 0.78; 95% CI, 0.47-1.28) and standard care (43 [34%]). Direct costs were significantly lower for integrated securement dressing with tissue adhesive (median, Australian dollars [A$], 312 [A$1 is equal to $0.65 US dollars]; IQR, A$302-A$380) and integrated securement dressing (median, A$303; IQR, A$294-A$465) compared with standard care (median, A$341; IQR, A$297-A$592; P ≤ .002) when considering the economic burden related to failure of devices. PIVC longevity and intervention acceptability were similar across all groups.

Conclusions and Relevance

In this study, PIVCs secured with integrated securement dressings and tissue adhesive, in comparison with standard care, bordered polyurethane dressings, were associated with significantly reduced PIVC failure, for children admitted to hospital via the emergency department. Further research should focus on implementation in inpatient units where prolonged dwell and reliable intravenous access is most needed.

Trial Registration

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12619001026112.

Central venous access device terminologies, complications, and reason for removal in oncology: a scoping review

BACKGROUND

Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation.

METHODS

A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data.

RESULTS

From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies (n = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies.

CONCLUSION

Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review

BACKGROUND

Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years.

METHODS

Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework.

MAIN FINDINGS

Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study

OBJECTIVES

This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs.

METHODS

A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate.

RESULTS

Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively).

CONCLUSIONS

Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Leaving no culture undrawn: Time to revisit the CLABSI and CAUTI metrics

Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are quality metrics for many ICUs, and financial ramifications can be applied to hospitals and providers who perform poorly on these measures. Despite some perceived benefits to tracking these metrics, there are a range of issues associated with this practice: lack of a solid evidence base that documenting them has led to decreased infection rates, moral distress associated with identifying these infections, problems with their definitions, and others. We discuss each of these concerns while also including international perspectives then recommend practical steps to attempt to remediate use of the CLABSI and CAUTI metrics. Specifically, we suggest forming a task force consisting of key stakeholders (e.g., providers, Centers for Medicare & Medicaid Services (CMS), patients/families) to review CLABSI and CAUTI-related issues and then to create a summary statement containing recommendations to improve the use of these metrics.

Quality of care in peripheral venous catheterization: A scoping review

OBJECTIVE

To map the current status of parameters and tools to assess quality of care related to peripheral venous catheter use in adults.

METHODS

Scoping review, conducted in 2022 in the MEDLINE, LILACS, CINAHL and SCOPUS databases and with a publication time limit from 2013 to 2022.

RESULTS

The sample consisted of 15 articles, summarized in the following categories: Indication, documentation and registration, coverage assessment, connection, stabilization and signs and symptoms inherent to the catheter. The use of a complete instrument, with the domains observed in this review, may have a positive impact on a more effective and safe clinical practice.

CONCLUSIONS

The present review mapped the evidence about the insertion and maintenance of peripheral venous catheters that can be improved with training of good practices and the quality of the team, regarding the use of tools, materials and instruments for the evaluation of care.

Peripheral intravenous catheter material and design to reduce device failure: A systematic review and meta-analysis

BACKGROUND

Patients require vascular access for medical treatments, diagnostic procedures and symptom management. Current failure rates of peripheral intravascular catheters (PIVCs) are unacceptably high (40-50%). This systematic review aimed to determine the effect of different PIVC materials and designs on the incidence of PIVC failure.

METHODS

A systematic search was conducted in November 2022 using CINAHL, PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases. Randomised controlled trials that compared PIVC novel PIVC material/design and standard material/design were included. The primary outcome was all causes of PIVC failure, any reason for device removal due to cessation of device function; and secondary outcomes included individual PIVC complications and infection (local or systemic), and dwell times. Quality appraisal was conducted using the Cochrane risk of bias tool. A meta-analysis was performed using random effects model.

RESULTS

Seven randomised controlled trials were eligible for inclusion. In meta-analysis, the impact of material and design on PIVC failure in the studies favoured the intervention arms (RR 0.71, 95% CI 0.57-0.89), however there was substantial heterogeneity (I2 = 81%, 95% CI 61-91%). Through subgroup analyses, a significant difference on PIVC failure favoured the closed system over the open system (RR 0.85, 95% CI 0.73 to 0.99; I2 = 23%, 95% CI 0-90%).

CONCLUSION

Catheter material and design can impact PIVC outcome. Conclusive recommendations are limited due to the small number of studies and inconsistent reporting of clinical outcomes. Further rigorous research of PIVC types is necessary to improve clinical practice and device selection pathways should reflect the resulting evidence.

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.

Performance of tunnelled, non-cuffed central venous catheters in infants: A scoping review

AIM

To summarise and critique existing knowledge and evidence relating to the utility, and post-insertion complications surrounding tunnelled non-cuffed central venous catheters (tncCVCs) in infants.

METHODS

A scoping review of original research studies reporting the use of, and post-insertion complications associated with, tncCVCs in infants was completed. MeSH terms were used to formulate a systematic search, and data were extracted using a customised data extraction form. Data were analysed descriptively across key themes based on the research questions. Study quality was evaluated using the Mixed Methods Appraisal Tool.

RESULTS

The systematic search generated 3994 studies, of which 9 studies met final inclusion criteria. Studies included 644 tncCVCs in infants based in the USA, Europe and Australia. Most studies were retrospective cohort studies. The most common vein of insertion, where individually specified, was the internal jugular (n = 177). Tunnel length, where reported, was 2.5-5 cm. Infection rates were most commonly reported (eight studies), with results ranging from 0 to 12.8%, and device dislodgements of up to 20% reported. Participant follow-up and definition of complications varied greatly between studies. Study quality across all papers was sound.

CONCLUSIONS

This review has identified only a small number of studies, with small participant numbers, reporting the performance of tncCVCs in infants. Definitions of complications measured varied significantly between studies, and vastly different patient follow-up protocols were reported. Further larger-scale studies on the performance of tncCVC, employing internationally recognised reporting standards is warranted to ensure clinicians can make informed choices for medication and infusion delivery.

Protecting patients through surveillance of device-related bacteraemias

Susan Rowlands, IV Resource Team Lead, The Royal Wolverhampton NHS Trust, susan.rowlands1@nhs.net, was a Silver Award winner in the Vascular Access Nurse of the Year category of the BJN Awards 2023.

Quality measurement and surveillance platforms in critically ill children: A scoping review

BACKGROUND/AIM

The objective of this study was to describe current surveillance platforms which support routine quality measurement in paediatric critical care.

METHOD

Scoping review. The search strategy consisted of a traditional database and grey literature search as well as expert consultation. Surveillance platforms were eligible for inclusion if they collected measures of quality in critically ill children.

RESULTS

The search strategy identified 21 surveillance platforms, collecting 57 unique outcome (70%), process (23%), and structural (7%) quality measures. Hospital-associated infections were the most commonly collected outcome measure across all platforms (n = 11; 52%). In general, case definitions were not harmonised across platforms, with the exception of nationally mandated hospital-associated infections (e.g., central line-associated blood stream infection). Data collection relied on manual coding. Platforms typically did not provide an evidence-based rationale for measures collected, with no identifiable reports of co-designed, consensus-derived measures or consumer involvement in measure selection or prioritisation.

CONCLUSIONS

Quality measurement in critically ill children lacks uniformity in definition which limits local and international benchmarking. Current surveillance activities for critically ill children focus heavily on outcome measurement, with process, structural, and patient-reported measures largely overlooked. Long-term outcome measures were not routinely collected. Harmonisation of paediatric intensive care unit quality measures is needed and can be achieved using prioritisation and consensus/co-design methods.

International Consensus Recommendation Guidelines for Subcutaneous Infusions of Hydration and Medication in Adults: An e-Delphi Consensus Study

Infusion of fluids and medications is traditionally performed intravenously. However, venous depletion in patients has led to the quest for vessel health preservation. A safe, effective, acceptable, and efficient alternative is the subcutaneous route. A lack of organizational policies may contribute to the slow uptake of this practice. This modified e-Delphi (electronic) study aimed to derive international consensus on practice recommendations for subcutaneous infusions of fluids and medications. A panel of 11 international clinicians, with expertise in subcutaneous infusion research and/or clinical practice, rated and edited subcutaneous infusion practice recommendations from evidence, clinical practice guidelines, and clinical expertise within an Assessment, Best Practice, and Competency (ABC) domain guideline model. The ABC Model for Subcutaneous Infusion Therapy provides a systematic guideline of 42 practice recommendations for the safe delivery of subcutaneous infusions of fluids and medications in the adult population in all care settings. These consensus recommendations provide a guideline for health care providers, organizations, and policy makers to optimize use of the subcutaneous access route.

Improving difficult peripheral intravenous access requires thought, training and technology (DART3): a stepped-wedge, cluster randomised controlled trial protocol

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most used invasive medical device in healthcare. Yet around half of insertion attempts are unsuccessful leading to delayed medical treatments and patient discomfort of harm. Ultrasound-guided PIVC (USGPIVC) insertion is an evidence-based intervention shown to improve insertion success especially in patients with Difficult IntraVenous Access (BMC Health Serv Res 22:220, 2022), however the implementation in some healthcare settings remains suboptimal. This study aims to co-design interventions that optimise ultrasound guided PIVC insertion in patients with DIVA, implement and evaluate these initiatives and develop scale up activities.

METHODS

A stepped-wedge cluster randomized controlled trial will be conducted in three hospitals (two adult, one paediatric) in Queensland, Australia. The intervention will be rolled out across 12 distinct clusters (four per hospital). Intervention development will be guided by Michie's Behavior Change Wheel with the aim to increase local staff capability, opportunity, and motivation for appropriate, sustainable adoption of USGPIVC insertion. Eligible clusters include all wards or departments where > 10 PIVCs/week are typically inserted. All clusters will commence in the control (baseline) phase, then, one cluster per hospital will step up every two months, as feasible, to the implementation phase, where the intervention will be rolled out. Implementation strategies are tailored for each hospital by local investigators and advisory groups, through context assessments, staff surveys, and stakeholder interviews and informed by extensive consumer interviews and consultation. Outcome measures align with the RE-AIM framework including clinical-effectiveness outcomes (e.g., first-time PIVC insertion success for DIVA patients [primary outcome], number of insertion attempts); implementation outcomes (e.g., intervention fidelity, readiness assessment) and cost effectiveness outcomes. The Consolidated Framework for Implementation Research framework will be used to report the intervention as it was implemented; how people participated in and responded to the intervention; contextual influences and how the theory underpinning the intervention was realised and delivered at each site. A sustainability assessment will be undertaken at three- and six-months post intervention.

DISCUSSION

Study findings will help define systematic solutions to implement DIVA identification and escalation tools aiming to address consumer dissatisfaction with current PIVC insertion practices. Such actionable knowledge is critical for implementation of scale-up activities.

TRIAL REGISTRATION

Prospectively registered (Australian and New Zealand Clinical Trials Registry; ACTRN12621001497897).

A systematic review of studies reporting the development of core outcome sets for use in routine care

OBJECTIVES

Core outcome sets (COS) represent the minimum health outcomes to be measured for a given health condition. Interest is growing in using COS within routine care to support delivery of patient-focused care. This review aims to systematically map COS developed for routine care to understand their scope, stakeholder involvement, and development methods.

METHODS

Medline (Ovid), Scopus, and Web of Science Core collection were searched for studies reporting development of COS for routine care. Data on scope, methods, and stakeholder groups were analyzed in subgroups defined by setting.

RESULTS

Screening 25,301 records identified 262 COS: 164 for routine care only and 98 for routine care and research. Nearly half of the COS (112/254, 44%) were developed with patients, alongside input from experts in registries, insurance, legal, outcomes measurement, and performance management. Research publications were often searched to generate an initial list of outcomes (115/198, 58%) with few searching routine health records (47/198, 24%).

CONCLUSION

An increasing number of COS is being developed for routine care. Although involvement of patient stakeholders has increased in recent years, further improvements are needed. Methodology and scope are broadly similar to COS for research but implementation of the final set is a greater consideration during development.

Nursing Practices and Sensitive Outcomes Related to Peripheral Intravenous Catheterization in Portugal: A Scoping Review

Implementation of evidence-based practice (EBP) is essential for ensuring high-quality nursing care. In Portugal, nurses are responsible for care delivery to patients who require peripheral intravenous access. However, recent authors emphasized the predominance of a culture based on outdated professional vascular access practices in Portuguese clinical settings. Thus, the aim of this study was to map the studies conducted in Portugal on peripheral intravenous catheterization. A scoping review was conducted based on the Joanna Briggs Institute recommendations, with a strategy adapted to different scientific databases/registers. Independent reviewers selected, extracted, and synthesized the data. Of the 2128 studies found, 26 were included in this review, published between 2010 and 2022. Previous research shows that Portuguese nurses' implementation of EBP was found to be relatively low overall, while most studies did not attempt to embed EBP change into routine care. Although nurses are responsible for implementing EBP at an individual patient level, the studies conducted in Portugal report nonstandardized practices among professionals, with significant deviations from recent evidence. This reality, combined with Portugal's absence of government-endorsed evidence-based standards for peripheral intravenous catheter (PIVC) insertion and treatment and vascular access teams, may explain the country's unacceptably high incidence of PIVC-related complications reported over the last decade.

Gaining consensus on clinical quality outcomes for eating disorders: Framework for the development of an Australian national minimum dataset

OBJECTIVES

Eating disorders (EDs) are complex psychiatric illnesses requiring multidisciplinary care across both mental and medical healthcare settings. Currently, no nationally comprehensive, consistent, agreed on or mandated data set or data collection strategy exists for EDs in Australia: thus, little is known about the outcomes of care nor treatment pathways taken by individuals with EDs. InsideOut Institute was contracted by the Australian Government Department of Health to develop a minimum dataset (MDS) for the illness group with consideration given to data capture mechanisms and the scoping of a national registry.

DESIGN

A four-step modified Delphi methodology was used, including national consultations followed by three rounds of quantitative feedback by an expert panel.

SETTING

Due to social distancing protocols throughout the global SARS-CoV-2 pandemic, the study was conducted online using video conferencing (Zoom and Microsoft Teams) (Step 1), email communication and the REDCap secure web-based survey platform (Steps 2-4).

PARTICIPANTS

14 data management organisations, 5 state and territory government departments of health, 2 Aboriginal and Torres Strait Islander advising organisations and 28 stakeholders representing public and private health sectors across Australia participated in consultations. 123 ED experts (including lived experience) participated in the first quantitative round of the Delphi survey. Retention was high, with 80% of experts continuing to the second round and 73% to the third.

MAIN OUTCOME MEASURES

Items and categories endorsed by the expert panel (defined a priori as >85% rating an item or category 'very important' or 'imperative').

RESULTS

High consensus across dataset items and categories led to the stratification of an identified MDS. Medical status and quality of life were rated the most important outcomes to collect in an MDS. Other items meeting high levels of consensus included anxiety disorders, depression and suicidality; type of treatment being received; body mass index and recent weight change.

CONCLUSIONS

Understanding presentation to and outcomes from ED treatment is vital to drive improvements in healthcare delivery. A nationally agreed MDS has been defined to facilitate this understanding and support improvements.

Vascular access device type for systemic anti-cancer therapies: a scoping review protocol

INTRODUCTION

Vascular access devices (VADs) are the most common invasive procedure performed in acute medicine and cancer patients undergo multiple invasive vascular access procedures. Our aim is to identify the type of evidence available regarding the best choice of VAD for cancer patients undergoing systemic anti-cancer therapy (SACT). In this article, the authors frame the scoping review protocol used, which will systematically report all published and unpublished literature around the use of VADs for the infusion of SACT in oncology.

INCLUSION CRITERIA

For studies to be included, they must focus on people or populations aged 18 years or older and report on vascular access in cancer patients. The concept is the variety of VAD use in cancer and reported insertion and post-insertion complications. The context surrounds the intravenous treatment of SACT whether in a cancer centre or non-cancer setting.

METHODS

The JBI scoping review methodology framework will guide the conduct of this scoping review. Electronic databases (CINAHL, Cochrane, Medline and Embase) will be searched. Grey literature sources and the reference lists of key studies will be reviewed to identify those appropriate for inclusion. No date limits will be used in the searches and studies will be limited to the English language. Two reviewers will independently screen all titles and abstracts and full-text studies for inclusion, and a third reviewer will arbitrate disagreements. All bibliographic data, study characteristics and indicators will be collected and charted using a data extraction tool.

Long peripheral catheters in children: A scoping review

BACKGROUND AND OBJECTIVES

Long peripheral catheters (LPCs) are emerging vascular access devices used for short-medium term vascular access needs. Literature in adults suggests LPCs have longer dwell-times than peripheral intravenous catheters (PIVs) and lower rates of serious complications than peripherally inserted central catheters (PICCs). The role of LPCs in children is less established. The objective of this scoping review is to describe and synthesize the existing literature on the effectiveness and safety of LPCs in children.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Searches were done in MEDLINE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection, Scopus, CINAHL (Ebsco), and Google Scholar most recently on February 22, 2022. Studies were included if published in English on or after 2000 and included patients <18 years of age.

RESULTS

Twenty-one studies were included. The body of literature is variable in quality, measurements, and reported outcomes. Median dwell-time ranged from 5 to 14 days. The rate of completion of therapy ranged from 20% to 86%. Dislodgement, occlusion, and infiltration were the most common complications reported (0%-31%). Venous thromboembolism rates ranged from 0% to 13%. The rate of catheter-related bloodstream infection was 0% in 9 of 10 studies. Less than 50% of studies reported comparative outcomes.

CONCLUSION

LPCs show promising outcomes in select populations, with longer dwell-time than PIVs and possibly lower rates of serious complications than PICCs. However, more research is needed to clarify the optimal use of LPCs in pediatrics.

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.

Evidence-Informed Development of a Bundle for Peripheral Intravenous Catheterization in Portugal: A Delphi Consensus Study

Contrary to many international settings, there are no clinical guidelines for peripheral intravenous catheter (PIVC) insertion and maintenance in Portugal. We sought to derive an international consensus on a PIVC bundle that could guide Portuguese nurses' clinical decision-making in this scope.

METHODS

Two international vascular access specialist groups participated in an online Delphi panel. During the first round, specialists (n = 7) were sent a summary report from a previous observational study conducted in a surgical ward in Portugal. Based on the report findings, specialists were asked to provide five to eight PIVC insertion and maintenance interventions. Then, another set of specialists (n = 7) scored and revised the recommendations until a consensus was reached (≥70% agreement). The PIVC bundle was made available and discussed with the surgical ward's nurses.

RESULTS

After three rounds, a consensus was achieved for five evidence-informed interventions: (i) involve the person and assess the peripheral venous network; (ii) maintain an aseptic no-touch technique; (iii) ensure proper catheter dressing and fixation; (iv) perform catheter flush & lock; (v) test the peripheral venous catheter's functionality and performance at each shift.

CONCLUSION

The final version of the PIVC bundle achieved consensus among international experts. Despite the positive feedback provided by the ward nurses, future studies are warranted to assess its effectiveness in standardizing PIVC care delivery and its potential implications for care outcomes in Portuguese clinical settings.

Peripheral intravenous catheter insertion and use of ultrasound in patients with difficult intravenous access: Australian patient and practitioner perspectives to inform future implementation strategies

Objective

To understand healthcare worker and patient experience with peripheral intravenous catheter (PIVC) insertion in patients with difficult intravenous access (DIVA) including the use of ultrasound (US).

Methods

Descriptive study using 1-on-1 semi-structured interviews conducted between August 2020 and January 2021. Purposeful sampling was used to recruit healthcare practitioners (HCPs) and patients with DIVA who had PIVC experience. Data were analysed using inductive thematic analysis. Interview data were than mapped to the implementation theory Behaviour Change Wheel to inform implementation strategies.

Results

In total 78 interviews (13 patients; 65 HCPs) were completed with respondents from metropolitan (60%), regional (25%) and rural/remote (15%) settings across Australia. Thematic analysis revealed 4 major themes: i) Harmful patient experiences persist, with patient insights not leveraged to effect change; ii) ‘Escalation’ is just a word on the front lines; iii) Heightened risk of insertion failure without resources and training; and iv) Paving the way forward–‘measures need to be in place to prevent failed insertion attempts. Themes were mapped to the behaviour change wheel and implementation strategies developed, these included: staff education, e-health record for DIVA identification, DIVA standard of care and DIVA guidelines to support escalation and ultrasound use.

Conclusion(s)

DIVA patients continue to have poor healthcare experiences with PIVC insertion. There is poor standardisation of DIVA assessment, escalation, US use and clinician education across hospitals. Quality, safety, and education improvement opportunities exist to improve the patient with DIVA experience and prevent traumatic insertions. We identified a number of implementation strategies to support future ultrasound and DIVA pathway implementation.

Nursing minimum data sets: Findings from an umbrella review

OBJECTIVES

This study explores the evidence available on Nursing Minimum Data Sets (NMDSs) by summarising: (a) the main methodological and reporting features of the reviews published in this field to date; (b) the recommendations developed and published in such reviews regarding the NMDSs, and (c) the categories and items that should be included in the NMDSs according to the available reviews.

METHODS

An Umbrella Review was performed. A search of secondary studies published up to November 2021 that were focused on NMDSs for adult hospitalised patients was conducted using MEDLINE (via PubMed), CINAHL and Scopus databases. The included studies were critically evaluated by using the Checklist for Systematic Review and Research Syntheses. The full review process was performed according to the Preferred Reporting Items for Systematic reviews and the Meta-Analyses statement.

RESULTS

From the initial 1311 studies that were retrieved, a total of eight reviews published from 1995 to 2018 were included. Their methodological quality was variable; these reviews offered four types of recommendations, namely at the overall, clinical, research and management levels. Additionally, seven NMDSs emerged with different purposes, elements, target populations and taxonomies. A list of categories and items that should be included in NMDSs have been summarised.

CONCLUSIONS

Nurses are daily involved in the nursing care documentation; however, which elements are recorded is mainly defined at the local levels and relies on paper and pencil. NMDS might provide a point of reference, specifically in the time of health digitalisation. Alongside other priorities as underlined in available recommendations, and the need to improve the quality of the reviews in this field, there is a need to develop a common NMDS by establishing its core elements, deciding on a standardised language and identifying linkages with other datasets.

Nurses' Practices in the Peripheral Intravenous Catheterization of Adult Oncology Patients: A Mix-Method Study

A significant number of adult oncology patients require at least one peripheral intravenous catheter to fulfill their therapeutic plan. Recent evidence indicates that catheter failure rates are high in this cohort, impacting care outcomes and patient experience during cancer treatment. This reality represents a challenge to nurses worldwide since in most international settings they are responsible for delivering quality care during the insertion and maintenance of such devices. This study aims to explore current nursing practices regarding the insertion, maintenance, and surveillance of peripheral intravenous catheters in oncology patients. A two-phase mix-method study was conducted with the nursing team from the surgical ward of a large oncology hospital in Portugal. In phase one (observational prospective study), nurses' practices during catheter insertion and maintenance were observed by the research team and recorded using standardized instruments and validated scales. In phase two, three online focus groups were conducted with the nursing team to present the results observed in phase one and explore their perceptions of current practices. All ethical principles were assured throughout the study. Significant divergent practices were observed and identified by the nurses, especially concerning patient involvement, nurses' adherence to the aseptic, non-touch technique, catheter stabilization and dressing, and catheter flushing and locking. Such practices may partially explain the high complication rate found (26%) and substantiate the need for future intervention in this field.

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.