An Improved Definition and SAFE Rule for Predicting Difficult Intravascular Access (DIVA) in Hospitalized Adults

Patients with difficult intravascular access (DIVA) are common, yet the condition is often ignored or poorly managed, leading to patient dissatisfaction and misuse of health care resources. This study sought to assess all published risk factors associated with DIVA in order to promote prospective identification and improved management of patients with DIVA. A systematic literature review on risk factors associated with DIVA was conducted. Risk factors published in ≥4 eligible studies underwent a multivariate meta-analysis of multiple factors (MVMA-MF) using the Bayesian framework. Of 2535 unique publications identified, 20 studies were eligible for review. In total, 82 unique DIVA risk factors were identified, with the 10 factors found in ≥4 studies undergoing MVMA-MF. Significant predictors of DIVA included vein visibility, vein palpability, history of DIVA, obesity (body mass index [BMI] >30), and history of intravenous (IV) drug abuse, which were combined to create the mnemonic guideline, SAFE: See, Ask (about a history of DIVA or IV drug abuse), Feel, and Evaluate BMI. By recognizing patients with DIVA before the first insertion attempt and treating them from the outset with advanced vein visualization techniques, patients with DIVA could be subject to less frequent painful venipunctures, fewer delays in treatment, and a reduction in other DIVA-associated burdens.

Comparison of Clinical, Economic, and Humanistic Outcomes Between Blood Collection Approaches: A Systematic Literature Review

BACKGROUND

A systematic literature review was performed to understand the prevalence, advantages, and disadvantages of blood collection using different approaches (direct venipuncture or vascular access devices), and interventions used to mitigate the disadvantages.

METHODS

The review included a broad range of study designs and outcomes. Database searches (Embase, MEDLINE, Cochrane library, and Centre for Reviews and Dissemination) were conducted in March 2021 and supplemented by hand searching.

RESULTS

One hundred forty-one publications were included. The data indicate that blood sampling from vascular access devices is common in emergency departments, trauma centers, and intensive care units. Studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals. Significant cost savings could be made through enforcing strict aseptic technique, or using the initial specimen diversion technique.

CONCLUSIONS

Hemolysis and sample contamination are far from inevitable in vascular access device-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the initial specimen diversion technique. Needle-free blood collection devices offer further hope for reducing hemolysis. No publication focused on the difficult venous access population; insertion success rates are likely to be lower (and the benefits of vascular access devices higher) in these patients.

Clinician satisfaction and preference for central venous catheter systems promoting patient safety, ease-of-use and reduced clinician error

OBJECTIVES

Central venous catheters (CVC) are frequently utilized with limited data on user preferences. A simulation/survey-based study was conducted among anesthesia providers to evaluate attitudes toward general CVC system attributes, and satisfaction with elements of the most-commonly used and a novel CVC system.

METHODS

Forty providers completed a simulation using both CVC systems and a 29-item questionnaire, including multiple-choice, free-text, ranking, and Likert-like questions. Ranking scores were reported using a scale of 0 (least important/satisfactory) to 100 (most important/satisfactory). Statistical significances were evaluated via Wilcoxon signed-rank sum test.

RESULTS

Participants chose (mean±SD) patient safety (83.9 ± 25.3), ease-of-use (64.6 ± 26.1), and reduced risk for error (61.1 ± 26.7) as the most important attributes when considering a CVC system. Satisfaction levels were significantly higher for the novel system: overall (p < 0.001), its ease-of-use (p < 0.001), tray layout/design (p < 0.001), and safety (p = 0.012). Mean satisfaction scores were significantly higher for the novel system's potential to reduce 5 of 7 common issues, including clinician error (p < 0.001), and contamination/infection (p < 0.001).

CONCLUSION

Anesthesia providers preferred CVC systems promoting patient safety, ease-of-use and reduce clinician error. Significantly higher (p < 0.05) satisfaction scores were awarded to a novel system featuring a sequentially organized tray, enhanced labeling, and a guidewire funnel.

Emergency provider preference for powered intraosseous devices and satisfaction with features improving safety, reliability, and ease-of-use

BACKGROUND

Powered intraosseous (IO) systems are valuable devices for emergent situations, with limited data on user preferences. A simulation/survey-based study was conducted among emergency medical service (EMS) providers to evaluate attitudes toward general powered IO system features to measure preferences/satisfaction for the most-commonly used and a novel powered IO system (with a passive safety needle, battery life indicator, and snap-securement/dressing).

RESEARCH DESIGN AND METHODS

Forty-two EMS providers completed a simulated activity using both powered IO systems and a 30-item questionnaire, including multiple choice, free-text, ranking, and Likert-like questions. Ranking scores were reported using a scale of 0 (least important/satisfactory) to 100 (most important/satisfactory). Statistical significances were evaluated via Wilcoxon signed-rank sum test.

RESULTS

Providers indicated driver performance (mean score ± SD; 77.8 ± 27.5) and IO needle safety mechanism (63.1 ± 27.9) as the most important features. Participants reported significantly higher (p < 0.001) satisfaction with the novel IO system overall, and its needle safety, battery life indicator, securement/dressing, and ease-of-use. Powered driver performance satisfaction was similar and favorable for the novel (88.1 ± 18.2) and traditional (87.1 ± 15.3) systems.

CONCLUSIONS

These findings highlight the value of clinician/user input and demonstrate EMS providers are more satisfied with a powered IO system featuring design elements intended to enhance safety and ease-of-use.

Comparative Effectiveness, Efficiency, and ED Nurse Preference Between Two Methods of Visualization for Midline Catheter Insertion: A Pilot Study

Introduction

Rapid and reliable peripheral IV access is essential for many patients admitted to the emergency department (ED) to ensure administration of life-saving medications, and successful intravenous cannulation can significantly affect patient care.

Objective

The objective of this study was to assess the impact of a continuous needle tracking system on the accuracy, speed, and quality of ultrasound-guided peripheral venous catheter insertions.

Methods

A convenient sample study based on the study setting using simulated tissue was conducted with 49 US-based ED nurses to compare the insertion of a midline catheter using traditional ultrasound guidance versus an advanced needle-tracking technology along with ultrasound guidance. The purpose of this evaluation was to assess the impact of continuous needle tracking system. Informed consent was obtained from all individual participants involved in this study. All participants were made aware that the results may be published. There was no IRB approval for this study. All sources were properly disclosed within the text.

Results

The addition of the advanced needle-tracking technology significantly reduced total insertion attempts, insertion time, backwall penetrations, and redirects (probes to hit the target vein), while improving image clarity and confidence for participants.

Conclusion

The innovative needle-tracking system evaluated in this pilot study has the potential to improve emergent difficult vascular access. EDs should assess the value of this technology to potentially improve the management of difficult intravenous access patients in their settings.

The Association Between Catheter Type and Dialysis Treatment: A Retrospective Data Analysis at Two U.S.-Based ICUs

Dialysis catheter type may be associated with differences in continuous renal replacement therapy (CRRT) treatment in the critically ill, with potential implications for patient outcomes and healthcare costs.

OBJECTIVES

To evaluate the association between the catheter type and multiple dialysis treatment outcomes among the critically ill.

DESIGN

Retrospective, observational study.

SETTING

Two U.S.-based ICUs.

PARTICIPANTS

Critically ill patients receiving CRRT between April 1, 2018, and July 1, 2020. A total of 1,037 CRRT sessions were analyzed.

MAIN OUTCOMES AND MEASURES

Circuit life, alarm interruption frequency (including a subset of vascular access [VA]-related alarms), termination type (elective vs nonelective), and blood flow rates. Pre- (n = 530) and post-catheter change (n = 507) periods were assessed, and the post-change period was further divided into intervals of pre-COVID (n = 167) and COVID contemporaneous (n = 340) to account for the pandemic's impact.

RESULTS

Compared with pre-change sessions, post-change sessions had 31% longer circuit life (95% CI, 1.14-1.49; p < 0.001), 3% higher blood flow rate (1.01-1.05; p < 0.01), and lower proportion of nonelective terminations (adjusted odds ratio [OR], 0.42 [0.28-0.62]; p < 0.001). There were fewer interruptions for all alarms (adjusted count ratio, 0.95 [0.87-1.05]; p = 0.31) and VA-related alarms (0.80 [0.66-0.96]; p = 0.014). The sessions during COVID period were statistically similar to pre-COVID sessions for all outcomes except a lower proportion of nonelective terminations (adjusted OR, 0.39 [0.22-0.70]; p < 0.01).

CONCLUSIONS

A change in catheter type was associated with longer CRRT sessions with fewer interruptions and unexpected terminations in a population of critical patients.

Symptomatic Deep Vein Thrombosis Associated With Peripherally Inserted Central Catheters of Different Diameters: A Systematic Review and Meta-Analysis

We assessed the relationship between peripherally inserted central catheter (PICC) diameters and symptomatic deep vein thrombosis (DVT) rates. We conducted a systematic search for articles published between 2010 and 2021 reporting DVT incidence by catheter diameter in patients who had a PICC, followed by meta-analyses for DVT risk in each diameter group. Pooled DVT rates were incorporated into an economic model. Of 1627 abstracts screened, 47 studies were included. The primary meta-analysis of 40 studies demonstrated the incidence of DVT was 0.89%, 3.26%, 5.46%, and 10.66% for 3, 4, 5, and 6 French (Fr) PICCs (P  =  .01 between 4 and 5 Fr). Rates of DVT were not significantly different between oncology and nononcology patients (P  =  .065 for 4 Fr and P  =  .99 for 5 Fr). The DVT rate was 5.08% for ICU patients and 4.58% for non-ICU patients (P  =  .65). The economic model demonstrated an annual, incremental cost savings of US$114 053 for every 5% absolute reduction in 6 Fr PICCs use. Using the smallest PICC that meets the patients' clinical needs may help to mitigate risks and confer savings.

Prevalence, causes, impacts, and management of needle phobia: An international survey of a general adult population

Needle phobia is an overlooked condition that affects virtually all medical procedures. Our study aimed to identify how commonly needle phobia is experienced, its underlying reasons, impacts, and potential mitigation strategies. A global survey was conducted in a general adult population using a questionnaire based on a targeted literature review that identified under-researched areas. The 21-item questionnaire was completed on a secure, web-based survey platform. Statistical analyses and models were utilized to identify relationships between participant characteristics and needle phobia. Of the 2,098 participants enrolled in the study, 63.2% (n = 1,325) reported experiencing needle phobia, and rated the intensity of their fear as 5.7 (±2.6) on average on a scale from 0 (no fear) to 10 (very strong/unreasonable fear or avoidance). According to the logistic regression model, other medical fears (odds coefficient = 2.14) and family history (1.67) were the most important factors associated with needle phobia. General anxiety (96.1%) and pain (95.5%) were the most common reasons for needle fear. Of the participants experiencing needle phobia, 52.2% stated avoiding blood draws, followed by 49.0% for blood donations, and 33.1% for vaccinations. While 24.3% of participants have seen a therapist, most have never sought help. The majority have shared their fear with nurses (61.1%) or physicians (44.4%); however, the provider helpfulness was rated as 4.9 (±3.1) on average on a scale from 0 (unhelpful) to 10 (extremely helpful). Utilizing non-invasive alternatives (94.1%) and smaller needles (91.1%) were most commonly identified as potential device-related solutions to alleviate fear; distractions (92.1%) and relaxation techniques (91.7%) were the top non-device-related approaches. Our findings highlight the prevalent nature of needle phobia and provide insights into its etiology and effects on patient care. Clinician responses were not perceived as helpful, emphasizing the need to address needle phobia, and improve patient experience.

Vascular access teams: a global outlook on challenges, benefits, opportunities, and future perspectives

BACKGROUND

Specialized vascular access training for medical professionals organized into vascular access teams (VATs) was shown to improve patient outcomes, clinical efficiency, and cost savings. Professional perspectives on VAT benefits, organization, challenges, and opportunities on a global scale remain inadequately explored. Using detailed perspectives, in this study, we explored the global VAT landscape, including challenges faced, clinical and clinico-economic impacts of VATs, with emphasis on underresearched facets of VAT initiation, data dissemination, and metrics or benchmarks for VAT success.

METHODS

Semistructured in-depth interviews of 14 VAT professionals from 9 countries and 5 continents were used to elicit qualitative and quantitative information.

RESULTS

Catheter insertions (100%) and training (86%) were the most performed VAT functions. Based on a 1-7 scale evaluating observed impacts of VATs, patient satisfaction (6.5) and institutional costs (6.2) were ranked the highest. VAT co-initiatives, advanced technology utilization (6.6), and ongoing member training (6.3) distinctly impacted VAT endeavors. Most institutions (64%) did not have routine mechanisms for recording VAT-related data; however, all participants (100%) stated the importance of sharing data to demonstrate VAT impacts. Time constraints (57%) emerged as one of the major deterrents to data collection or dissemination. The majority (64%) experienced an increased demand or workload for VAT services during the COVID-19 pandemic.

CONCLUSIONS

Despite the global variances in VATs and gaps in VAT-related data, all participants unanimously endorsed the benefits of VAT programs. Evaluating the impact of VATs, disseminating VAT-related data, and forging specialized institutional partnerships for data sharing and training are potential strategies to tackle the hurdles surrounding VAT formation and sustenance.

A narrative review of historic and current approaches for patients with difficult venous access: considerations for the emergency department

INTRODUCTION

Timely placement of vascular access devices is critical during emergent clinical situations; however, challenges in peripheral access can be a common occurrence. Historically, emergency teams have used various approaches to gain peripheral vascular access in situations where traditional means were not feasible; these options have included peripheral venous cutdown, ultrasound-guided peripheral intravenous catheters (PIVs), longer PIVs, central catheters, and intraosseous devices. Each of these options have associated strengths and limitations depending on the clinical situation.

AREAS COVERED

This narrative review reports on the burden of difficult venous access situations and discusses the evidence, and strengths and limitations of vascular access options to help address this challenge. Although first puncture success rates can be high when using alternative methods, significant challenges can include increased procedure time and greater risk of complications. The Easy-Internal Jugular (Easy-IJ) technique is a newer alternative option for patients with difficult venous access that is demonstrated to be safe and effective in emergency care.

EXPERT OPINION

Moving forward, additional clinical studies are required to fully characterize the outcomes associated with the Easy-IJ technique and guidewire-assisted intravenous catheters, as well as to inform guideline development for more comprehensive recommendations on managing challenging or difficult peripheral access situations.

Procedure Code Utilization for Vascular Access Device Placement in the Inpatient Setting: A Retrospective Analysis

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in adult inpatients (2015 to 2020) using Cerner Real World Data™ to evaluate the utilization of CPT codes for VAD placement/replacement procedures. A total of 14,253,584 patient encounters were analyzed, 0.111 percent (n=15,833) of which received at least one VAD procedure code. Non-tunneled CVC procedures had the highest code rate (0.067 percent), while PIV/midline procedures were the least likely to be coded (0.004 percent). The annual proportion of code utilization increased from 10.9 percent in 2015 to 19.7 percent in 2020 (p<0.0001). Despite widespread use of VADs in the inpatient setting, the procedure coding rate was found to be remarkably low. Appropriate coding/documentation practices may ensure proper care by capturing VA-related patient history, and improve research quality and resource/staff allocation.

Physician preferences associated with powered intraosseous access systems: Safety features, reliability, and ease of use

Objective

This study evaluated physician preferences and values related to the most commonly used (traditional) powered intraosseous (IO) system and a novel powered IO system featuring a passive safety needle, battery life indicator, and snap‐securement/skin attachment.

Methods

Emergency physicians participated in an IO simulation using both the traditional and novel IO systems. Participants completed a 27‐item postsimulation questionnaire to state their preferences toward each IO system and values related to the novel IO system features using a multiple choice, 11‐point value ranking scale (0 = no value, 10 = extremely valuable) and free‐text answer questions.

Results

Among the 22 study participants, 90.9% (95% confidence interval [CI]: 70.8%, 98.9%) preferred the novel IO system; top reasons for this preference were the novel IO system's passive safety needle and snap‐securement/skin attachment. Participants who preferred the traditional IO system (9.1%) noted its ease of use and familiarity. Many physicians preferred the novel IO system's needle (81.8%; 95% CI: 59.7%, 94.8%), powered driver (77.3%; 95% CI: 54.6%, 92.2%), and snap‐securement/skin attachment (100%; 95% CI: 84.6%, 100%) compared with the traditional IO system. Safety and ease of use were the most common preference explanations. Of the participants, 100% provided a value score ≥7 for the novel IO system's passive safety needle (mean score, 9.45), whereas fewer participants (59.1%) gave a value score ≥7 for the multilight battery life indicator (mean score, 6.68).

Conclusion

This study demonstrates that emergency physicians prefer and value a novel IO system with features that enhance safety and ease of use. These results provide insight into important factors related to IO systems for emergency physicians.

Defining difficult intravenous access (DIVA): A systematic review

BACKGROUND

The term "difficult intravenous access" (DIVA) is commonly used but not clearly defined. Repeated attempts at peripheral intravenous catheter (PIVC) insertion can be a traumatic experience for patients, leading to sub-optimal clinical and economic outcomes. We conducted a systematic literature review (SLR) to collate literature definitions of DIVA, with the aim of arriving at an evidence-driven definition.

METHODS

The SLR was designed to identify clinical, cost, and quality of life publications in patients requiring the insertion of a PIVC in any setting, including studies on US-guidance and/or guidewire, and studies with no specific intervention. The search was restricted to English language studies published between 1st January 2010 and 30th July 2020, and the Ovid platform was used to search several electronic databases, in addition to hand searching of clinical trial registries.

RESULTS

About 121 studies were included in the SLR, of which 64 reported on the objectives relevant to this manuscript. Prevalence estimates varied widely from 6% to 87.7% across 19 publications, reflecting differences in definitions used. Of 43 publications which provided a definition of DIVA, six key themes emerged. Of these, themes 1-3 (failed attempts at PIV access using traditional technique; based on physical examination findings for example no visible or palpable veins; and personal history of DIVA) were covered by all but one publication. Following a failed insertion attempt, the most common number of subsequent attempts was 3, and it was frequently reported that a more experienced clinician would attempt to gain access after multiple failed attempts.

CONCLUSIONS

Considering the themes identified, an evidence-driven definition of DIVA is proposed: "when a clinician has two or more failed attempts at PIV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA."

Peripherally inserted central catheters inserted with current best practices have low deep vein thrombosis and central line–associated bloodstream infection risk compared with centrally inserted central catheters: A contemporary meta-analysis

Background:

Peripherally inserted central catheters and centrally inserted central catheters have numerous benefits but can be associated with risks. This meta-analysis compared central catheters for relevant clinical outcomes using recent studies more likely to coincide with practice guidelines.

Methods:

Several databases, Ovid MEDLINE, Embase, and EBM Reviews were searched for articles (2006–2018) that compared central catheters. Analyses were limited to peer-reviewed studies comparing peripherally inserted central catheters to centrally inserted central catheters for deep vein thrombosis and/or central line–associated bloodstream infections. Subgroup, sensitivity analyses, and patient-reported measures were included. Risk ratios, incidence rate ratios, and weighted event risks were reported. Study quality assessment was conducted using Newcastle–Ottawa and Cochrane Risk of Bias scales.

Results:

Of 4609 screened abstracts, 31 studies were included in these meta-analyses. Across studies, peripherally inserted central catheters were protective for central line–associated bloodstream infection (incidence rate ratio = 0.52, 95% confidence interval: 0.30–0.92), with consistent results across subgroups. Peripherally inserted central catheters were associated with an increased risk of deep vein thrombosis (risk ratio = 2.08, 95% confidence interval: 1.47–2.94); however, smaller diameter and single-lumen peripherally inserted central catheters were no longer associated with increased risk. The absolute risk of deep vein thrombosis was calculated to 2.3% and 3.9% for smaller diameter peripherally inserted central catheters and centrally inserted central catheters, respectively. On average, peripherally inserted central catheter patients had 11.6 more catheter days than centrally inserted central catheter patients ( p = 0.064). Patient outcomes favored peripherally inserted central catheters.

Conclusion:

When adhering to best practices, this study demonstrated that concerns related to peripherally inserted central catheters and deep vein thrombosis risk are minimized. Dramatic changes to clinical practice over the last 10 years have helped to address past issues with central catheters and complication risk. Given the lower rate of complications when following current guidelines, clinicians should prioritize central line choice based on patient therapeutic needs, rather than fear of complications. Future research should continue to consider contemporary literature over antiquated data, such that it recognizes the implications of best practices in modern central catheterization.