Claire M. Rickard

Publish or Perish: A Systematic Review of Interventions to Increase Academic Publication Rates.

Academics are expected to publish. In Australia universities receive extra funding based on their academic publication rates and academic promotion is difficult without a good publication record. However, the reality is that only a small percentage of academics are actively publishing. To fix this problem, a number of international universities and other higher education institutions have implemented interventions with the main aim being to increase the number of publications. A comprehensive literature search identified 17 studies published between 1984 and 2004, which examined the effects of these interventions. Three key types of interventions were identified: writing courses, writing support groups and writing coaches. The resulting publication output varied, but all interventions led to an increase in average publication rates for the participants.

Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage.

OBJECTIVES We studied the incidence of myocardial injury in aneurysmal subarachnoid hemorrhage (SAH) using the more sensitive cardiac troponin I (cTnI) assay, correlated changes in cTnI with creatine kinase, MB fraction (CK-MB), myoglobin, and catecholamine metabolite assays, and examined the predictive value of changes in cTnI for myocardial dysfunction. BACKGROUND Myocardial injury in aneurysmal SAH as evidenced by elevated CK-MB fraction has been reported. Little published data exist on the value of cTnI measurements in aneurysmal SAH. METHODS Thirty-nine patients were studied for seven days. Clinical cardiovascular assessment, electrocardiographic (ECG), echocardiography, cTnI, CK, CK-MB and CK-MB index, myoglobin and 24-h urinary catecholamine assays were performed in all patients. The ECG abnormalities were defined by the presence of ST-T changes, prolonged QT intervals, and arrhythmias. An abnormal echocardiogram was defined by the presence of wall-motion abnormalities and a reduced ejection fraction. The severity of SAH was graded clinically and radiologically. RESULTS Eight patients demonstrated elevations in cTnI (upper limit of normal is 0.1 microg/liter with the immunoenzymatic assay and 0.4 microg/liter with the sandwich immunoassay), while five had abnormal CK-MB levels (upper limit of normal is 8 microg/liter). Patients with more severe grades of SAH were more likely to develop a cTnI leak (p < 0.05). Patients with cTnI elevations were more likely to demonstrate ECG abnormalities (p < 0.01) and manifest clinical myocardial dysfunction (p < 0.01) as evidenced by the presence of a gallop rhythm on auscultation and clinical or radiological evidence of pulmonary edema as compared to those with CK-MB elevations. The sensitivity and specificity of cTnI to predict myocardial dysfunction were 100% and 91%, respectively, whereas the corresponding figures for CK-MB were 60% and 94%, respectively. Elevations in myoglobin levels (upper limit of normal <70 microg/liter) and urinary catecholamine metabolites (urinary vanilmandelate/creatinine ratio upper limit of normal, 2.6) are a nonspecific finding. CONCLUSIONS Measurements of cTnI reveal a higher incidence of myocardial injury than predicted by CK-MB in aneurysmal SAH, and elevations of cTnI are associated with a higher incidence of myocardial dysfunction. Thus, cTnI is a highly sensitive and specific indicator of myocardial dysfunction in aneurysmal SAH.

Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial

BACKGROUND The millions of peripheral intravenous catheters used each year are recommended for 72-96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement. METHODS This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370. FINDINGS All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI -1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred. INTERPRETATION Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications. FUNDING Australian National Health and Medical Research Council.

Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters.

Objective: Peripheral arterial catheters are perceived as having low infective potential compared with other catheters and may be overlooked as a cause of catheter-related bloodstream infection. We aimed to measure colonization and rates of catheter-related bloodstream infection in arterial catheters, to investigate risk factors for arterial catheter colonization, and to compare arterial catheter infection rates with those in concurrently sited and managed central venous catheters. Design: Prospective 24-month cohort study. Setting: Eight-bed combined general intensive care and high-dependency unit of a 350-bed Australian teaching hospital. Patients: Three hundred twenty-one arterial catheters in 252 adult and pediatric patients were observed for 1,082 catheter days, and 618 central venous catheters in 410 patients were observed for 4,040 catheter days. All catheters were inserted in, or presented to, the intensive care unit. Both arterial catheters and central venous catheters were inserted by trained personnel under aseptic conditions, and management was standardized. Interventions: None. Measurements and Main Results: The incidence per 1,000 (95% confidence interval) catheter days of colonization (≥15 colonies) and catheter-related bloodstream infection was 15.7 (9.5–25.9) and 0.92 (0.13–6.44) for arterial catheters and 16.8 (13.3–21.3) and 2.23 (1.12–4.44) for central venous catheters. Arterial catheter colonization was not significantly different than that in central venous catheters (hazard ratio, 1.17; 95% confidence interval, 0.41–3.36; p = .77). Arterial catheter colonization increased with dwell time and was similar to central venous catheters over time. Femoral arterial catheters were colonized more often than radial arterial catheters (hazard ratio, 5.08; 95% confidence interval, 0.85, 30.3; p = .075), and colonization was significantly higher when the catheter was inserted in the operating theater or emergency department (hazard ratio, 4.45; 95% confidence interval, 1.42–13.9; p = .01) compared with the intensive care unit. Conclusions: The incidence of catheter-related bloodstream infection from arterial catheters was low. However, both arterial catheter colonization and rates of catheter-related bloodstream infection were similar to those in concurrently sited and identically managed central venous catheters. By inference, the arterial catheter should be accorded the same degree of importance as the central venous catheter as a potential source of sepsis.

Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomized controlled trial.

OBJECTIVE To assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure. METHODS Secondary data analysis from a randomized controlled trial of PIVC dwell time. The Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal. SETTING Three acute care hospitals in Queensland, Australia. PARTICIPANTS The trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use. RESULTS Modifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio [HR], 1.47 [95% confidence interval (CI), 1.28-1.68], 1.27 [95% CI, 1.08-1.49], and 1.25 [95% CI, 1.04-1.50], respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 [95% CI, 1.08-2.03]). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 [95% CI, 0.67-0.94]). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 [95% CI, 1.93-3.10] and 1.65 [95% CI, 1.23-2.22], respectively), clinical staff insertion compared with intravenous service (HR, 1.69 [95% CI, 1.30-2.20]); and smaller PIVC diameter (HR, 1.29 [95% CI, 1.02-1.61]). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 [95% CI, 1.28-2.09]) and occlusion (HR, 1.44 [95% CI, 1.30-1.61]). CONCLUSIONS PIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists. TRIAL REGISTRATION The original randomized controlled trial on which this secondary analysis is based is registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12608000445370).

Multicentre study of delirium in ICU patients using a simple screening tool.

Traditionally, intensive care unit (ICU) delirium was viewed as benign and was under-diagnosed in the absence of ICU-appropriate screening tools. Research suggests that up to half of all ICU patients experiencing delirium will continue to do so after discharge to the ward, and half of those experiencing delirium in the ward will die within 1 year of delirium diagnosis. ICU-specific screening tools are now available. The purpose of this study was to identify the incidence of delirium in ICU and explore its associations to clinical factors and outcomes. A secondary aim was to evaluate the usefulness of the intensive care delirium screening checklist (ICDSC). A total of 185 patients in six ICUs in Australia and New Zealand were screened for delirium using the ICDSC over two 12-hour periods per day for the duration of their ICU admission. Some 84 patients (45%) developed delirium. Development of delirium was associated with increased severity of illness (acute physiology and chronic health evaluation--APACHE II--and sequential organ failure assessment--SOFA), ICU length of stay (LOS), and use of psycho-active drugs. Delirious patients showed no statistically significant difference in ICU and hospital mortality rates, nor prolonged hospital LOS. The ICDSC was found to be user-friendly. The incidence of delirium, observed characteristics and outcomes for patients admitted to Australian and New Zealand ICUs for > 36 hours without any history of altered mental state fell in the mid-range and were generally consistent with previous literature. An ICU-specific delirium assessment, such as the ICDSC, should be included in routine ICU observations to minimise under-diagnosis of this serious phenomenon.

Complications of Central Venous Access Devices: A Systematic Review.

CONTEXT: The failure and complications of central venous access devices (CVADs) result in interrupted medical treatment, morbidity, and mortality for the patient. The resulting insertion of a new CVAD further contributes to risk and consumes extra resources. OBJECTIVE: To systematically review existing evidence of the incidence of CVAD failure and complications across CVAD types within pediatrics. DATA SOURCES: Central Register of Controlled Trials, PubMed, and Cumulative Index to Nursing and Allied Health databases were systematically searched up to January 2015. STUDY SELECTION: Included studies were of cohort design and examined the incidence of CVAD failure and complications across CVAD type in pediatrics within the last 10 years. CVAD failure was defined as CVAD loss of function before the completion of necessary treatment, and complications were defined as CVAD-associated bloodstream infection, CVAD local infection, dislodgement, occlusion, thrombosis, and breakage. DATA EXTRACTION: Data were independently extracted and critiqued for quality by 2 authors. RESULTS: Seventy-four cohort studies met the inclusion criteria, with mixed quality of reporting and methods. Overall, 25% of CVADs failed before completion of therapy (95% confidence interval [CI] 20.9%–29.2%) at a rate of 1.97 per 1000 catheter days (95% CI 1.71–2.23). The failure per CVAD device was highest proportionally in hemodialysis catheters (46.4% [95% CI 29.6%–63.6%]) and per 1000 catheter days in umbilical catheters (28.6 per 1000 catheter days [95% CI 17.4–39.8]). Totally implanted devices had the lowest rate of failure per 1000 catheter days (0.15 [95% CI 0.09–0.20]). LIMITATIONS: The inclusion of nonrandomized and noncomparator studies may have affected the robustness of the research. CONCLUSIONS: CVAD failure and complications in pediatrics are a significant burden on the health care system internationally.

Routine Replacement versus Clinical Monitoring of Peripheral Intravenous Catheters in a Regional Hospital in the Home Program: A Randomized Controlled Trial

This randomized, controlled trial involving 316 patients in the home setting found no difference in the rate of phlebitis and/or occlusion among patients for whom a peripheral intravenous catheter was routinely resited at 72-96 hours and those for whom it was replaced only on clinical indication (76.8 events per 1,000 device-days vs 87.3 events per 1,000 device-days; P = .71). There were no bloodstream infections.

Routine changing of intravenous administration sets does not reduce colonization or infection in central venous catheters.

OBJECTIVE To determine the effect of routine intravenous (IV) administration set changes on central venous catheter (CVC) colonization and catheter-related bacteremia. DESIGN Prospective, randomized, controlled trial. SETTING Eighteen-bed intensive care unit (ICU) in a large metropolitan hospital. PARTICIPANTS Two hundred fifty-one patients with 404 chlorhexidine gluconate and silver sulfadiazine-coated multi-lumen CVCs. INTERVENTIONS CVCs inserted in the ICU and in situ on day 4 were randomized to have their IV administration sets changed on day 4 (n = 203) or not at all (n = 201). Use of fluid containers and blood product administration sets was limited to 24 hours. CVCs were removed when not required, infection was suspected, or in place on day 7. Catheter cultures were performed on removal by blinded laboratory staff. Catheter-related bacteremia was diagnosed by a blinded intensivist using strict definitions. Data were collected regarding catheter duration, site, Acute Physiology and Chronic Health Evaluation (APACHE) II score, patient age, diagnosis, hyperglycemia, hypoalbuminemia, immune status, number of fluid containers and IV injections, and administration of propofol, blood, total parenteral nutrition, or lipid infusion. RESULTS There were 10 colonized CVCs in the group receiving a set change and 19 in the group not receiving one. This difference was not statistically significant on Kaplan-Meier survival analysis. There were 3 cases of catheter-related bacteremia per group. Logistic regression found that burns diagnosis and increased ICU stay significantly predicted colonization. CONCLUSION IV administration sets can be used for 7 days in patients with short-term, antiseptic-coated CVCs.

Infusion phlebitis assessment measures: a systematic review

Rationale, aims and objectives Phlebitis is a common and painful complication of peripheral intravenous cannulation. The aim of this review was to identify the measures used in infusion phlebitis assessment and evaluate evidence regarding their reliability, validity, responsiveness and feasibility. Method We conducted a systematic literature review of the Cochrane library, Ovid MEDLINE and EBSCO CINAHL until September 2013. All English-language studies (randomized controlled trials, prospective cohort and cross-sectional) that used an infusion phlebitis scale were retrieved and analysed to determine which symptoms were included in each scale and how these were measured. We evaluated studies that reported testing the psychometric properties of phlebitis assessment scales using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. Results Infusion phlebitis was the primary outcome measure in 233 studies. Fifty-three (23%) of these provided no actual definition of phlebitis. Of the 180 studies that reported measuring phlebitis incidence and/or severity, 101 (56%) used a scale and 79 (44%) used a definition alone. We identified 71 different phlebitis assessment scales. Three scales had undergone some psychometric analyses, but no scale had been rigorously tested. Conclusion Many phlebitis scales exist, but none has been thoroughly validated for use in clinical practice. A lack of consensus on phlebitis measures has likely contributed to disparities in reported phlebitis incidence, precluding meaningful comparison of phlebitis rates.