A novel integrated dressing to secure peripheral intravenous catheters in an adult acute hospital: a pilot randomised controlled trial

Using Implementation Science to Improve Short Peripheral Intravenous Catheter Outcomes

Short peripheral intravenous catheters (short PIVCs) are commonly used in acute care, guided by evidence-based policy with interventions to limit premature failure. Research on how nurses use evidence and change processes to optimize outcomes is needed. The study objective was to use a theory-based implementation science approach to evaluate and improve short PIVC insertion and care processes and reduce removals for adverse outcomes in acute care. This mixed-methods study was conducted with inpatient nursing units (n = 23) at a large urban quaternary medical center. Units identified and implemented one PIVC care intervention that could lower catheter removals for adverse outcomes over 3 months. Data from multiple sources were convergently analyzed to evaluate process and outcomes postintervention. Although overall frequency of PIVC removals for adverse outcomes was unchanged, several units improved their outcomes using implementation strategies. The determinant framework provides a plausible explanation for the study results. While adverse outcome rates remained below published rates, some units had limited success improving outcomes with traditional change strategies. Implementation strategies and readily accessible data can offer nursing units a new approach to effectively deploy, monitor, and maintain interventions to achieve improved outcomes.

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.

Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous catheters are the most frequently used invasive device in nursing practice, yet are commonly associated with complications. We performed a systematic review to determine the prevalence of peripheral intravenous catheter infection and all-cause failure.

METHODS

The Cochrane Library, PubMed, CINAHL, and EMBASE were searched for observational studies and randomised controlled trials that reported peripheral intravenous catheter related infections or failure. The review was limited to English language and articles published from the year 2000. Pooled estimates were calculated with random-effects models. Meta-analysis of observation studies in epidemiology guidelines and the Cochrane process for randomised controlled trials were used to guide the review. Prospero registration number: CRD42022349956.

FINDINGS

Our search retrieved 34,725 studies. Of these, 41 observational studies and 28 randomised controlled trials (478,586 peripheral intravenous catheters) met inclusion criteria. The pooled proportion of catheter-associated bloodstream infections was 0.028 % (95 % confidence interval (CI): 0.009-0.081; 38 studies), or 4.40 catheter-associated bloodstream infections per 100,000 catheter-days (20 studies, 95 % CI: 3.47-5.58). Local infection was reported in 0.150 % of peripheral intravenous catheters (95 % CI: 0.047-0.479, 30 studies) with an incidence rate of 65.1 per 100,000 catheter-days (16 studies; 95 % CI: 49.2-86.2). All cause peripheral intravenous catheter failure before treatment completion occurred in 36.4 % of catheters (95 % CI: 31.7-41.3, 53 studies) with an overall incidence rate of 4.42 per 100 catheter days (78,891 catheter days; 19 studies; 95 % CI: 4.27-4.57).

INTERPRETATION

Peripheral intravenous catheter failure is a significant worldwide problem, affecting one in three catheters. Per peripheral intravenous catheter, infection occurrence was low, however, with over two billion catheters used globally each year, the absolute number of infections and associated burden remains high. Substantial and systemwide efforts are needed to address peripheral intravenous catheter infection and failure and the sequelae of treatment disruption, increased health costs and poor patient outcomes.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study

BACKGROUND

Peripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks.

OBJECTIVE

To determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions.

DESIGN

Prospective, interrupted time-series study.

SETTINGS

Seven adult inpatient wards in three Australian hospitals.

PARTICIPANTS

825 adults with 867 peripheral intravenous catheters.

METHODS

Between August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections.

RESULTS

Of 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD -4.4%, 95% CI -8.5, -0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD -5.2%, 95% CI -9.7, -0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD -5.2%, 95% CI -10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention).

CONCLUSIONS

Implementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter.

ANZCTR TRIAL REGISTRATION

ACTRN12617000067370. Date of registration 13 January 2017. Date of first data collection 3rd August 2017.

TWEETABLE ABSTRACT

#IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

Implementation of Evidence-Based Practice in Peripheral Intravenous Catheter Care

BACKGROUND

Inserting a peripheral intravenous (PIV) catheter is a common health care procedure; however, risks include phlebitis, extravasation, and accidental dislodgement. Using evidence-based practices (EBPs) can reduce these risks.

PURPOSE

The purpose of this study was to implement an evidence-based PIV catheter care bundle and a decision-making algorithm.

METHODS

A quasi-experimental study design was used. A care bundle and an evidence-based decision-making algorithm were implemented on a medical unit. Outcomes included length of PIV catheter dwell time, phlebitis and other complications, and health professionals' adherence to the interventions.

RESULTS

A total of 364 PIV catheters were assessed. PIV catheter dwell time decreased from 3.6 to 2.9 days ( P < .001), and phlebitis rates decreased from 14.8% to 4.9% ( P < .05). Health professionals' adherence increased from 84.3% to 91.8%.

CONCLUSIONS

Implementing EBPs can improve care provided to patients with PIV catheters.

Does longer peripheral intravenous catheter length optimise antimicrobial delivery? Protocol for the LEADER study

BACKGROUND

Hospitalised patients receiving intravenous antimicrobial therapy require a reliable device through which this is delivered. Short peripheral intravenous catheters (PIVCs) are the default device for antimicrobial therapy but up to half fail before therapy completion, leading to suboptimal drug dosing, patient distress from repeated insertions, and increased healthcare costs. This study will investigate the use of long PIVCs to determine if they are more reliable at delivering antimicrobial therapy.

METHODS

A two-arm, parallel randomised controlled trial of hospitalised adults requiring at least 3 days of peripherally compatible intravenous antimicrobials. Participants will be randomised to a short (<4 cm) or long (4.5-6.4 cm) PIVC. After interim analysis ( n=70) for feasibility and safety, 192 participants will be recruited. Primary outcome is disruption to antimicrobial administration from all-cause PIVC failure. Secondary outcomes include: number of devices to complete therapy, patient-reported pain and satisfaction, and a cost analysis. Ethical and regulatory approvals have been received.

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

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

A pilot randomized controlled trial of securement bundles to reduce peripheral intravenous catheter failure

BACKGROUND

Peripheral intravenous catheters (PIVCs) are ubiquitous in acute care settings however failure rates are unacceptably high, with around half failing before prescribed treatment is complete. The most effective dressing and securement option to prolong PIVC longevity is unclear.

OBJECTIVES

To determine feasibility of conducting a definitive randomized controlled trial (RCT) investigating evidence-based securement bundles (medical adhesive tapes and supplementary securement products) to reduce PIVC failure.

METHODS

In this pilot non-masked 3-group RCT, adults requiring a PIVC for >24 hrs were randomized to Standard care (bordered polyurethane dressing plus non-sterile tape over extension tubing), Securement Bundle 1 (two sterile tape strips over PIVC hub plus Standard care) or Securement Bundle 2 (Bundle 1 plus tubular bandage) with allocation concealed until study entry.

EXCLUSIONS

laboratory-confirmed positive blood culture, current/high-risk of skin tear, or study product allergy.

PRIMARY OUTCOME

feasibility (eligibility, recruitment, retention, protocol fidelity, participant/staff satisfaction).

SECONDARY OUTCOMES

PIVC failure, PIVC dwell time, adverse skin events, PIVC colonization and cost.

RESULTS

Of 109 randomized participants, 104 were included in final analyses. Feasibility outcomes were met, except eligibility criterion (79%). Absolute PIVC failure was 38.2% (13/34) for Bundle 2, 25% (9/36) for Bundle 1 and 23.5% (8/34) for Standard care. Incidence rate ratio for PIVC failure/1000 catheter days, compared to Standard care, was 1.1 (95% confidence interval [CI] 0.4-2.7) and 2.1 (95% CI 0.9-5.1) for Bundles 1 and 2, respectively.

CONCLUSIONS

A large RCT testing securement bundles is feasible, with adjustment to screening processes. Innovative dressing and securement solutions are needed to reduce unacceptable PIVC failure rates. Trial registration ACTRN12619000026123.

Effectiveness of reinforcement program on adherence toward short peripheral catheter (SPC) care guidelines among registered nurses working in pediatric wards of a tertiary care hospital

BACKGROUND

Short peripheral catheterization is the common procedure performed in every hospital with patients' admittance. It becomes challenging when it comes to children and requires more knowledge and skills. The aim of the current study was to assess the effectiveness of the reinforcement program on adherence to short peripheral catheter (SPC) care guidelines among registered nurses.

MATERIALS AND METHODS

A quasi-experimental study was conducted among 44 registered nurses by observing 96 SPC care events before and after the reinforcement program in pediatric wards of a tertiary care hospital in Eastern India. The study was conducted in a tertiary care public hospital in Eastern India in 2019, and the data collection tool included children's and nurses' socio-demographic data and an observation checklist on intravenous catheterization care. Descriptive statistics were used to explain the participant characteristics, and McNemar's test was used to identify the adherence to SPC care guidelines.

RESULTS

There was a statistically significant improvement in most steps, such as hand washing, gloving, tray preparation, documentation initiation, maintenance, and removal (P = 0.001). A statistically significant reduction in the early stage of phlebitis was found from 66.7% in pre-intervention to 37.5% in post-intervention (P = 0.027).

CONCLUSIONS

The majority of nurses adhered to SPC care guidelines after the reinforcement program. From the study findings, it is recommended that regular reinforcement related to peripheral catheter care acts as a stimulant to adhere to SPC care guidelines. The nursing administration should take initiative by conducting in-service training for the nurses, which motivates them toward practicing quality nursing care.

Peripheral intravenous catheters in the care of oncology and haematology patients

Aim

To determine peripheral intravenous catheter (PIVC) characteristics, complications and risk factors among patients in cancer units.

Methods

A secondary analysis of a global, cross-sectional study (127 hospitals in 24 countries). Participants (≥18 years) admitted to cancer units were assessed once for PIVC characteristics and the presence of complications. Variables included patient demographics, device characteristics, treatment details, and device and/or site complications. PIVC characteristics were presented using qualitative descriptors; mixed-effects logistic regression models determined risk factors for PIVC complications.

Results

In total, 1,807 participants (1,812 PIVCs) were included; 12% (n=215) of PIVCs presented with complications. Risk factors included: insertion by doctors; insertion in ED and ambulance/other locations; poor PIVC dressing integrity; dwell time ≥49 hours; and administration of colloids/blood products and antiemetics.

Conclusions

At least one in ten PIVCs in cancer units present with complications; regular PIVC assessment and improved dressing integrity is likely to reduce risk and improve outcomes.

Preventing radial arterial catheter failure in critical care - Factoring updated clinical strategies and techniques

Radial artery catheterization is a frequently performed procedure for critically ill patients. The correct function of arterial catheters is essential to provide accurate and continuous hemodynamic monitoring, facilitating intermittent blood sampling and helping to optimize the workload for critical care nurses and physicians. However, they are not without their own problems. This narrative practice review discusses several clinical aspects that are not frequently considered but may contribute to enhanced catheter functionality, less device-related failure and more acceptable dwell times. Ultrasound has demonstrated unequivocal efficacies and safety with the procedure, improving first attempt success rates with children, the obese or patients with unstable clinical vital signs and shock. Moreover, anatomic variations of the radial artery are not rare, and ultrasound-guided catheterization reduces the incidence of insertion-related complications such as hematoma, posterior wall puncture, intimal dissection, and radial nerve injury. Ultrasound guidance offers several immediate benefits by enhancing the most appropriate insertion techniques, allows for the correct catheter to vessel ratio measurements to be performed and reduces the angle of insertion, which may affect catheter failure due to inappropriate catheter length. A deeper and more proximal cannulation site at least 4 cm from wrist joint, avoiding the area of wrist flexion, reduces mechanical complications related to patient movements and may improve catheter functionality and dwell along with a better area for stabilization and securement.

Intravenous antimicrobial administration through peripheral venous catheters - establishing risk profiles from an analysis of 5252 devices

INTRODUCTION

Peripheral venous catheters (PVCs) are used to administer antimicrobials, but many fail prior to completion of therapy. While some antimicrobials are known to increase the PVC failure rate, risk profiles for many are unclear.

OBJECTIVE

To synthesize data from prospective PVC studies conducted between 2013 and 2019 to determine associations between common antimicrobials and PVC failure.

METHODS

A secondary analysis was undertaken of seven randomized controlled trials and two prospective cohort studies from three quaternary hospitals (two adult and one paediatric) in Australia between 2013 and 2019. The primary outcome was PVC failure due to vessel injury (occlusion, infiltration or extravasation) or irritation (pain or phlebitis). Associations between antimicrobial use and PVC failure were explored using multi-variable Cox regression.

RESULTS

In total, 5252 PVCs (4478 patients) were analysed; vessel injury and irritations occurred in 19% and 11% of all PVCs, respectively. Vessel injury was significantly associated with cefepime hydrochloride [hazard ratio (HR) 2.50; 95% confidence interval (CI) 1.44-4.34], ceftazidime pentahydrate (HR 1.91, 95% CI 1.11-3.31), flucloxacillin sodium (HR 1.84, 95% CI 1.45-2.33), lincomycin hydrochloride (HR 1.67, 95% CI 1.10-2.52) and vancomycin hydrochloride (HR 1.73, 95% CI 1.25-2.40). Irritation was significantly associated with flucloxacillin sodium (HR 2.58, 95% CI 1.96-3.40).

CONCLUSIONS

This study identified several antimicrobials associated with increased PVC failure, including some that were already known to be associated and some that had not been identified previously. Research is needed urgently to determine superior modes of delivery (e.g. dilution, infusion time, device type) that may prevent PVC failure.

Current practices of peripheral intravenous catheter fixation in pediatric patients and factors influencing pediatric nurses' knowledge, attitude and practice concerning peripheral intravenous catheter fixation: a cross-sectional study

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most widely used intravenous treatment tools for hospitalized patients. Compared to adult patients, PIVC fixation issues are more likely to occur in pediatric patients and can be more complex. However, research on PIVC fixation in pediatric patients is rare. This study aimed to investigate the pass rate for PIVC fixation in pediatric patients and the factors that influence pediatric nurses' knowledge, attitude, and practice (KAP) concerning PIVC fixation.

METHODS

An on-site investigation using a self-designed PIVC fixation standard inspection checklist for first insertion and routine maintenance in pediatric patients and a follow-up questionnaire survey investigating pediatric nurses' KAP concerning PIVC fixation was conducted in a hospital in China between November 1 and December 31, 2019. Data were analyzed using SPSS 21.0.

RESULTS

The pass rate for PIVC fixation in pediatric patients was 52.02%. The pediatric nurses' knowledge, attitude and practice scores on PIVC fixation were 7.2 ± 1.36, 28.03 ± 2.42, and 31.73 ± 2.94, respectively. The multivariate linear regression analysis results show that department (where nurses are working in) and job position are the factors that influence knowledge score (B > 0, P < 0.05); department is also a factor that influences attitude score (B > 0, P < 0.05); and department and nursing hierarchy are the factors that influence practice score (B > 0, P < 0.05).

CONCLUSION

PIVC fixation in pediatric patients is affected by multiple factors. The level of pediatric nurses' KAP on PIVC fixation needs to be improved. It is suggested that guidelines for PIVC fixation in pediatric patients be formulated and that training on PIVC fixation in pediatric patients be provided for pediatric nurses in an effort to raise the pass rate in terms of PIVC fixation in pediatric patients.

Peripheral intravenous catheter failure: A secondary analysis of risks from 11,830 catheters

BACKGROUND

Peripheral intravenous catheters are an essential medical device which are prone to complications and failure.

OBJECTIVES

Identify patient, provider and device risk factors associated with all-cause peripheral intravenous catheter failure as well as individual complications: phlebitis, infiltration/occlusion, and dislodgement to improve patient outcomes.

DESIGN

Secondary analysis of twelve prospective studies performed between 2008 and 2020.

SETTINGS

Australian metropolitan and regional hospitals including one paediatric hospital.

PARTICIPANTS

Participants were from medical, surgical, haematology, and oncology units.

METHODS

Multilevel mixed-effects parametric survival regression was used to identify factors associated with all-cause peripheral intravenous catheter failure, phlebitis, occlusion/infiltration, and dislodgement. We studied patient (e.g., age, gender), device (e.g., gauge), and provider (e.g., inserting clinician) variables. Stepwise regression involved clinically and p<0.20 significant variables entered into the multivariable model. Results were expressed as hazard ratios (HRs) and 95% confidence intervals (CI); p<0.01 was considered statistically significant.

RESULTS

Of 11,830 peripheral intravenous catheters (8,200 participants) failure occurred in 36% (n = 4,263). Occlusion/infiltration incidence was 23% (n = 2,767), phlebitis 12% (n = 1,421), and dislodgement 7% (n = 779) of catheters. Patient factors significantly associated with failure and complications were: female gender (phlebitis; (HR 1.98, 95% CI 1.72-2.27), (infiltration/occlusion; HR 1.45, 95% CI 1.33-1.58), (failure; HR 1.36, 95% CI 1.26-1.46); and each year increase in age (phlebitis; 0.99 HR, 95% CI 0.98-0.99), (failure; 0.99 HR, 95% CI 0.99-0.99). The strongest provider risk factor was intravenous antibiotics (infiltration/occlusion; HR 1.40, 95% CI 1.27-1.53), (phlebitis; HR 1.36, 95% CI 1.18-1.56), (failure; HR 1.26, 95% CI 1.17-1.36). Catheters inserted by vascular access teams were less likely to dislodge (HR 0.53, 95% CI 0.42-0.67). Device risk factors most associated with all-cause failure were wrist/hand (HR 1.34, 95% CI 1.23-1.46), antecubital fossa peripheral intravenous catheters (HR 1.29, 95% CI 1.16-1.44) and 22/24 gauge (HR 1.27, 95% CI 1.12-1.45) catheters.

CONCLUSION

Factors identified, including the protective aspect of vascular access team insertion, and high catheter failure associated with intravenous antibiotic administration, will allow targeted updates of peripheral intravenous catheter guidelines and models of care.

Hiding in Plain Sight: Peripheral Intravenous Catheter Infections

TOPIC

This article presents an overview of the burden of peripheral intravenous catheter infections and current evidence-based recommendations for prevention.

CLINICAL RELEVANCE

Peripheral intravenous catheters are ubiquitous in most health care settings, fostering an acceptance of the peripheral intravenous catheter as benign and inevitable. This device, however, is far from benign, with reported failure rates as high as 90% from complications such as infection and phlebitis. Although reported rates of bloodstream infection related to peripheral intravenous catheters are much lower than those attributed to central venous catheters, the exponentially higher use of peripheral intravenous catheters indicates that the absolute number of peripheral venous catheter-related bloodstream infections is likely as high as and may surpass the number of central venous catheter-related bloodstream infections, with significant associated morbidity and mortality.

PURPOSE OF PAPER

Sustained improvements in outcomes related to peripheral intravenous catheters will depend on recognition of the root causes of failure and increased commitment to practice patterns consistent with infusion therapy standards of practice, effective education about peripheral intravenous catheters, accurate documentation of all aspects of peripheral intravenous catheter management, and consistent surveillance of patient outcomes related to peripheral intravenous catheters.

CONTENT COVERED

This article reviews the significant burden of peripheral intravenous catheter infections, barriers to effective peripheral intravenous catheter management, and current evidence-based recommendations to prevent this source of patient harm.

Care of peripheral intravenous catheters in three hospitals in Spain: Mapping clinical outcomes and implementation of clinical practice guidelines

Background

Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices worldwide. Up to 42% of PIVCs are prematurely removed during intravenous therapy due to failure. To date, there have been few systematic attempts in European hospitals to measure adherence to recommendations to mitigate PIVC failures.

Aim

To analyse the clinical outcomes from clinical practice guideline recommendations for PIVC care on different hospital types and environments.

Methods

We conducted an observational study in three hospitals in Spain from December 2017 to April 2018. The adherence to recommendations was monitored via visual inspection in situ evaluations of all PIVCs inserted in adults admitted. Context and clinical characteristics were collected by an evaluation tool, analysing data descriptively.

Results

646 PIVCs inserted in 624 patients were monitored, which only 52.7% knew about their PIVC. Regarding PIVC insertion, 3.4% (22/646) patients had at least 2 PIVCs simultaneously. The majority of PIVCs were 20G (319/646; 49.4%) and were secured with transparent polyurethane dressing (605/646; 93.7%). Most PIVCs (357/646; 55.3%) had a free insertion site during the visual inspection at first sight. We identified 342/646 (53%) transparent dressings in optimal conditions (clean, dry, and intact dressing). PIVC dressings in medical wards were much more likely to be in intact conditions than those in surgical wards (234/399, 58.7% vs. 108/247, 43.7%). We identified 55/646 (8.5%) PIVCs without infusion in the last 24 hours and 58/646 (9.0%) PIVCs without infusion for more than 24 hours. Regarding PIVC failure, 74 (11.5%) adverse events were identified, all of them reflecting clinical manifestation of phlebitis.

Conclusions

Our findings indicate that the clinical outcome indicators from CPG for PIVC care were moderate, highlighting differences between hospital environments and types. Also, we observed that nearly 50% of patients did not know what a PIVC is.

Global Pediatric Peripheral Intravenous Catheter Practice and Performance: A Secondary Analysis of 4206 Catheters

PURPOSE

To describe worldwide characteristics, performance and risk factors of peripheral intravenous catheters (PIVCs), in pediatrics.

DESIGN

A secondary, subgroup analysis of pediatric (<18 years) data was undertaken, using a global, cross-sectional study of PIVCs. Practice characteristics included: demographic, diagnostic, utility, management, performance and resources. Multivariate regression identified complication risks factors.

RESULTS

Data from 4206 children in 278 hospitals across 47 countries. Most PIVCs (outside of Australia, New Zealand) were inserted by nurses (71%; n = 2950), with dedicated teams only common in North America (23.2%; n = 85). Large gauges (≤18G) were mostly used in South America, Europe and Africa. Regions predominantly placed 24G (49%; n = 2060) except in Australia and New Zealand, who more commonly placed 22G (38.7%; n = 192). The most common placement was the hand (51%; n = 2143), however North America, Australia and New Zealand frequently utilised the antecubital fossa (24.5%, n = 90; 21.4%; n = 106). Polyurethane dressings were most used (67.1%; 2822), and many were not clean, dry and intact (17.1%; n = 715). Over 8% of PIVCs were idle, with the highest rates in North America (21.2%; n = 78). PIVC local complication risk factors included: >2 years age (odds ratio [OR] > 1.58; 1.2-2.1); ambulance/emergency insertion (OR 1.65; 1.2-2.3); upper arm/antecubital placement (OR 1.44; 1.1-2.0); poor dressing integrity (OR 5.4; 4.2-6.9); and 24-72 h dwell (OR > 1.9; 1.3-2.6).

CONCLUSIONS

There is global inconsistency in pediatric PIVC practice, which may be causing harm.

CLINICAL IMPLICATIONS

Improvements in pediatric PIVC placement, dressings, and gauge selection are needed.

Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative

AIM

To improve paediatric peripheral intravenous catheter (PIVC) care through the implementation of care bundles.

METHODS

A pre-post study using mixed methods (clinical audit, staff survey, parent interviews) in 2016 at a tertiary paediatric hospital in Brisbane was conducted to evaluate the effectiveness of a PIVC insertion and maintenance bundle to improve PIVC insertion, promote function and support practice. Participants included children with PIVC, parents and staff inserting and managing PIVCs. A mnemonic care bundle, SUCCESS PIVCS (At insertion: Skills, Understand and prepare, Consent, Clean site, Escalate, Secure, Sign and document. During management: Prompt removal, Inspect hourly, Vein patency, Clean hands and Scrub the hub), was developed and implemented via visual aids, workshops and change champions. During audit, PIVC first-attempt insertion success, PIVC failure, PIVC dwell, escalation to senior clinicians and insertion and management procedures were measured.

RESULTS

Pre-implementation audit (n = 102) and survey (n = 117) data described high rates of PIVC failure (n = 50; 49%), difficulty obtaining equipment (n = 64; 55%) and pressure to insert (n = 50; 43%). Parent interviews (n = 15) identified lack of communication, fear, appreciation of skilled technicians and technology and care giver roles as key to improving the experience. After implementation first-attempt insertion success (45 vs. 62%; risk ratio 1.37, 95% confidence interval 1.05-1.78), first-attempt escalation to senior clinicians (junior doctor 72 vs. 41%; P = <0.001) and median PIVC dwell (40 vs. 52 h; P = 0.021) improved.

CONCLUSION

This multi-level care bundle demonstrated improvements in the insertion and management of PIVCs; however, PIVC failure remained high.

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

Background

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

Methods

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

Results

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

Conclusions

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

Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices

BACKGROUND

Vascular access devices are widely used in healthcare settings worldwide. The insertion of a vascular access device creates a wound, vulnerable to irritation, injury and infection. Vascular access-associated skin complications are frequently reported in the literature, however very little evidence is available regarding the incidence and risk factors of these conditions to inform practice and technology development.

OBJECTIVES

To estimate the incidence of vascular access-associated skin complications, and to identify patient, catheter and healthcare-related characteristics associated with skin complication development.

DESIGN

Secondary data analysis from 13 multi-centre randomised controlled trials and observational studies evaluating technologies and performance of vascular access devices in clinical settings between 2008 and 2017.

SETTINGS

Six hospitals (metropolitan and regional) in Queensland, Australia.

PARTICIPANTS

The 13 studies involved paediatric and adult participants, across oncology, emergency, intensive care, and general hospital settings. A total of 7669 participants with 10,859 devices were included, involving peripheral venous (n = 9933), peripheral arterial (n = 341), and central venous access (n = 585) devices.

ANALYSIS

Standardised study data were extracted into a single database. Clinical and demographic data were descriptively reported. Cox proportional hazards regression models (stratified by peripheral vs central) were used for time-to-event, per-device analyses to examine risk factors. Univariate associations were undertaken due to complexities with missing data in both outcomes and covariates, with p < 0.01 to reduce the effect of multiple comparisons.

RESULTS

Over 12% of devices were associated with skin complication, at 46.2 per 1000 catheter days for peripheral venous and arterial devices (95% confidence interval, CI 42.1-50.7), and 22.5 per 1000 catheter days for central devices (95% CI 16.5-306). The most common skin complications were bruising (peripheral n = 134, 3.7%; central n = 33, 6.8%), and swelling due to infiltration for peripheral devices (n = 296; 2.9%), and dermatitis for central devices (n = 13; 2.2%). The significant risk factors for these complications were predominantly related to device (e.g., skin tears associated with peripheral arterial catheters [hazard ratio, HR 16.0], radial insertion [HR 18.0] basilic insertion [HR 26.0])) and patient characteristics (e.g., poor skin integrity associated with increased risk of peripheral device bruising [HR 4.12], infiltration [HR 1.98], and skin tear [HR 48.4]), rather than management approaches.

CONCLUSIONS

Significant skin complications can develop during the life of peripheral and central vascular access devices, and these are associated with several modifiable and non-modifiable risk factors. Further research is needed to evaluate effectiveness technologies to prevent and treat skin complications associated with vascular access devices.