Gillian Ray-Barruel

Nursing considerations to complement the Surviving Sepsis Campaign guidelines

Objectives:To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. Design:Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. Methods:We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. Results:Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. Conclusion:Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.

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.

Inter‐rater agreement on PIVC‐associated phlebitis signs, symptoms and scales

RATIONALE, AIMS AND OBJECTIVES Many peripheral intravenous catheter (PIVC) infusion phlebitis scales and definitions are used internationally, although no existing scale has demonstrated comprehensive reliability and validity. We examined inter-rater agreement between registered nurses on signs, symptoms and scales commonly used in phlebitis assessment. METHODS Seven PIVC-associated phlebitis signs/symptoms (pain, tenderness, swelling, erythema, palpable venous cord, purulent discharge and warmth) were observed daily by two raters (a research nurse and registered nurse). These data were modelled into phlebitis scores using 10 different tools. Proportions of agreement (e.g. positive, negative), observed and expected agreements, Cohens kappa, the maximum achievable kappa, prevalence- and bias-adjusted kappa were calculated. RESULTS Two hundred ten patients were recruited across three hospitals, with 247 sets of paired observations undertaken. The second rater was blinded to the firsts findings. The Catney and Rittenberg scales were the most sensitive (phlebitis in >20% of observations), whereas the Curran, Lanbeck and Rickard scales were the most restrictive (≤2% phlebitis). Only tenderness and the Catney (one of pain, tenderness, erythema or palpable cord) and Rittenberg scales (one of erythema, swelling, tenderness or pain) had acceptable (more than two-thirds, 66.7%) levels of inter-rater agreement. CONCLUSIONS Inter-rater agreement for phlebitis assessment signs/symptoms and scales is low. This likely contributes to the high degree of variability in phlebitis rates in literature. We recommend further research into assessment of infrequent signs/symptoms and the Catney or Rittenberg scales. New approaches to evaluating vein irritation that are valid, reliable and based on their ability to predict complications need exploration.

Infection risks associated with peripheral vascular catheters

Background: Peripheral vascular catheters (PVC) are the most frequently used invasive medical devices in hospitals, with 330 million sold each year in the USA alone. One in three UK inpatients at any one time has at least one PVC in situ according to the Scottish National Prevalence survey. Method: A narrative review of studies describing the infection risks associated with PVCs. Results: It is estimated that 30–80% of hospitalised patients receive at least one PVC during their hospital stay. Despite their prevalence, PVCs are not benign devices, and the high number of PVCs inserted annually has resulted in serious catheter-related bloodstream infections and significant morbidity, prolonged hospital stay and increased healthcare system costs. To date, PVC infections have been under-evaluated. Most studies focus on central venous catheter rather than PVC-associated bloodstream infections. Risks associated with PVC infection must be addressed to reduce patient morbidity and associated costs of prolonged hospital admission and treatment. Discussion: This article discusses the sources and routes of PVC-associated infection and outlines known effective prevention and intervention strategies.

Postinfusion Phlebitis: Incidence and Risk Factors

Objective. To document the incidence of postinfusion phlebitis and to investigate associated risk factors. Design. Analysis of existing data set from a large randomized controlled trial, the primary purpose of which was to compare routine peripheral intravascular catheter changes with changing catheters only on clinical indication. Participants and Setting. Patients admitted to a large, acute general hospital in Queensland, Australia, and who required a peripheral intravenous catheter. Results. 5,907 PIVCs from 3,283 patients were studied. Postinfusion phlebitis at 48 hours was diagnosed in 59 (1.8%) patients. Fifteen (25.4%) of these patients had phlebitis at removal and also at 48 hours after removal. When data were analyzed per catheter, the rate was lower, 62/5907 (1.1%). The only variable associated with postinfusion phlebitis was placement of the catheter in the emergency room (P = 0.03). Conclusion. Although not a common occurrence, postinfusion phlebitis may be problematic so it is important for health care staff to provide patients with information about what to look for after an intravascular device has been removed. This trial is registered with ACTRN12608000445370.

The relationship between intravenous infusate colonisation and fluid container hang time

AIMS To examine the level of microbial colonisation in intravenous fluids after 24 hours of use in an acute care setting to determine the necessity of changing infusate bags on a time-related basis. BACKGROUND Catheter-related bloodstream infections are a serious and life-threatening complication of intravascular devices. Colonised intravenous fluids are one potential source of infection; however, there is little published literature on incidence rates and few recent studies. Routine intravenous fluid replacement has been advocated as an infection control method, but the effectiveness of this is unknown and the optimal duration for infusate use remains uncertain. DESIGN Cross-sectional study over 18 months in a 257-bed teaching hospital. METHODS Infusate specimens (n = 264) were obtained from crystalloid fluids that had been used for 24 hours or more. Microbiological culture and sensitivity testing was performed and infusate-related bloodstream infection (IRBSI) rates were recorded. Sample testing of previously unopened intravenous solutions acted as a control. RESULTS The infusate colonisation rate was 0.4%, or 0.09 per 1000 infusion hours. The only isolated organism was coagulase-negative Staphylococcus. Infusions had been in use for 24-185 hours (1-8 days). There was no difference in median duration of use for colonised (35.0 hours) and sterile (34.0 hours) specimens (Mann-Whitney test, p = 0.99). There were no cases of IRBSI. CONCLUSION The incidence of intravenous fluid colonisation and the risk of related bloodstream infection are low even after several days of infusate use. Current practice appears to successfully maintain the sterility of intravenous fluids. RELEVANCE TO CLINICAL PRACTICE Routine replacement of intravenous fluids continues in many settings, often 24 hourly, in the belief that this prevents infection. We found no relationship between duration of use and colonisation and routine replacement may be unnecessary. Further research is needed to investigate the effectiveness of routinely replacing intravenous fluids at set time points to prevent colonisation and infection.

Not "just" an intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross-sectional survey of 25 countries

Peripheral intravascular cannula/catheter (PIVC) insertion is a common invasive procedure, but PIVC failure before the end of therapy is unacceptably high. As PIVC failure disrupts treatment and reinsertion can be distressing for the patient, prevention of PIVC failure is an important patient outcome. Consumer participation in PIVC care to prevent failure is an untapped resource. This study aimed to understand consumers’ PIVC experience; establish aspects of PIVC insertion and care relevant to them; and to compare experiences of adult consumers to adult carers of a child. An international, web-based, cross-sectional survey was distributed via social media inviting adult consumers and adult carers of a child under 18 years who had experienced having a PIVC in the last five years (one survey each for adults and adult carers) to complete a 10-item survey. As such, sampling bias is a limitation and results should be carefully considered in light of this. There were 712 respondents from 25 countries, mainly female (87.1%) and adults (80%). A little over 50% of adults described insertion as moderately painful or worse, with level of insertion difficulty (0–10 scale) identified as moderate (median 4, IQR 1, 7). Adult carers reported significantly more pain during insertion and insertion difficulty (both p < 0.001). Rates of first insertion attempt failure were higher in children compared with adults (89/139 [64%] vs 221/554 [40%]; p < 0.001), and 23% of children required ≥ 4 attempts, compared with 9% of adults (p < 0.0001). Three themes from open-ended question emerged: Significance of safe and consistent PIVC care; Importance of staff training and competence; and Value of communication. The PIVC experience can be painful, stressful and frustrating for consumers. Priorities for clinicians and policy makers should include use of pain relief as standard practice to reduce the pain associated with PIVC insertion and developing strategies to increase first PIVC insertion attempt success particularly for children and older consumers.

Peripheral intravenous catheter assessment: beyond phlebitis

Essential across clinical specialties, around 2 billion peripheral venous catheters (PVCs) are sold annually worldwide. As a foreign body, PVCs frequently cause phlebitis, and this inflammation is perhaps also the mechanism underlying other common complications of occlusion, infiltration, and even dislodgement. PVCs frequently fail during treatment, with one third to one half removed prematurely because of complications. This removal constitutes substantial health system waste and increases pain, workload, and procedures for replacement devices. Regular assessment of PVC condition is recommended to detect complications and respond appropriately. Globally, millions of such assessments are documented daily in medical records. Despite its ubiquity, no internationally consistent approach to PVC assessment exists. In fact, one quarter of published studies reporting phlebitis use no instrument or definition at all. By contrast, at least 71 phlebitis scales (and numerous other definitions) exist, but only three have had any psychometric evaluation for validity and reliability, and none comprehensively. Clinically popular approaches, such as the Visual Infusion Phlebitis Score or Infusion Nurses Society Phlebitis Scale, have spawned almost innumerable variants, having been constantly adapted by authors and health services, yet retaining their original names. Phlebitis incidence in individual studies has been reported at 0–100%, a major problem for any haematologist seeking to assess the effectiveness of new products or strategies that prevent or treat phlebitis. In The Lancet Haematology, Katarina Göransson and colleagues clearly show the reason for this inconsistency. In, to our knowledge, the largest study to date, they systematically and prospectively applied various phlebitis instruments to the same large cohort of adult patients in hospital, showing wildly divergent phlebitis incidence, from none to more than a third of the cohort (34%). These findings accord with previous modelling of clinical trial data using ten phlebitis tools, which found prevalence from less than 2% to more than 20% and negligible-to-poor association of most items within these tools. Goransson and colleagues’ PVCs included the typical distribution of sizes and insertion sites, so the results are probably strongly generalisable to most adult patients requiring PVCs. Goransson and colleagues’ work indicates that the energy expended compelling practitioners to assess PVCs and auditing documentation for so-called compliance is largely a waste of resources. They conclude appropriately that the current instruments are almost worthless and argue compellingly that a change is needed. This conclusion aligns well with the knowledge that current monitoring approaches do not prompt health staff to take action on the basis of abnormal assessment findings. A worldwide study highlighted endemic patterns of non-removal of PVCs despite therapy completion, pain, leaking, or other device dysfunction, as well as non-replacement of PVC dressings despite loose, bloodstained, or moist condition. So, is a PVC monitoring tool needed at all? The answer is yes. Meaningful tools would enable health services to strive for safe, quality care and know if they are achieving this care. A major change in PVC management is that removal is now recommended only for clinical (instead of time-based) criteria—ie, when the PVC treatment is complete, does not work, is not tolerated, has fallen out, is suspected of infection, or was inserted with use of non-aseptic technique. Consequently, the goalposts for prevention of PVC complications have substantially moved—we should now prevent complications for the potential maximum 29 days of PVCs’ licensed indication, not simply for a few days. Thus, valid, reliable methods for PVC assessment are more important than ever, and Goransson and colleagues’ work is timely. Should the myriad of existing tools continue to be compared and further developed, or does tool development need to be started again? Since current tools mainly aim to measure phlebitis (but clearly do it badly), ignore the raft of equally common (occlusion, infiltration, and dislodgement) or more serious (infection) complications than phlebitis, do not address important risk factors (redundant PVCs and poor-quality dressings and securements), and do not always prompt appropriate removal even when phlebitis scores are abnormal, nothing less than a total rethink of PVC monitoring seems to be urgently needed. A useful and safe PVC is one that the patient still needs, is tolerated (not painful), is free of all complications C Ri ck ar d

Randomized controlled trials in central vascular access devices: A scoping review

Background Randomized controlled trials evaluate the effectiveness of interventions for central venous access devices, however, high complication rates remain. Scoping reviews map the available evidence and demonstrate evidence deficiencies to focus ongoing research priorities. Method A scoping review (January 2006–December 2015) of randomized controlled trials evaluating the effectiveness of interventions to improve central venous access device outcomes; including peripherally inserted central catheters, non-tunneled, tunneled and totally implanted venous access catheters. MeSH terms were used to undertake a systematic search with data extracted by two independent researchers, using a standardized data extraction form. Results In total, 178 trials were included (78 non-tunneled [44%]; 40 peripherally inserted central catheters [22%]; 20 totally implanted [11%]; 12 tunneled [6%]; 6 non-specified [3%]; and 22 combined device trials [12%]). There were 119 trials (68%) involving adult participants only, with 18 (9%) pediatric and 20 (11%) neonatal trials. Insertion-related themes existed in 38% of trials (67 RCTs), 35 RCTs (20%) related to post-insertion patency, with fewer trials on infection prevention (15 RCTs, 8%), education (14RCTs, 8%), and dressing and securement (12 RCTs, 7%). There were 46 different study outcomes reported, with the most common being infection outcomes (161 outcomes; 37%), with divergent definitions used for catheter-related bloodstream and other infections. Conclusion More high quality randomized trials across central venous access device management are necessary, especially in dressing and securement and patency. These can be encouraged by having more studies with multidisciplinary team involvement and consumer engagement. Additionally, there were extensive gaps within population sub-groups, particularly in tunneled devices, and in pediatrics and neonates. Finally, outcome definitions need to be unified for results to be meaningful and comparable across studies.

Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide

BACKGROUND Peripheral intravenous catheter (PIVC) use in health care is common worldwide. Failure of PIVCs is also common, resulting in premature removal and replacement. OBJECTIVE To investigate the characteristics, management practices, and outcomes of PIVCs internationally. DESIGN SETTING/PATIENTS Cross-sectional study. Hospitalized patients from rural, regional, and metropolitan areas internationally. MEASUREMENTS Hospital, device, and inserter characteristics were collected along with assessment of the catheter insertion site. PIVC use in different geographic regions was compared. RESULTS We reviewed 40,620 PIVCs in 51 countries. PIVCs were used primarily for intravenous medication (n = 28,571, 70%) and predominantly inserted in general wards (n = 22,167, 55%). Two-thirds of all devices were placed in non-recommended sites such as the hand, wrist, or antecubital veins. Nurses inserted most PIVCs (n = 28,575, 71%); although there was wide regional variation (26% to 97%). The prevalence of iIn this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.dle PIVCs was 14% (n = 5,796). Overall, 10% (n = 4,204) of PIVCs were painful to the patient or otherwise symptomatic of phlebitis; a further 10% (n = 3,879) had signs of PIVC malfunction; and 21% of PIVC dressings were suboptimal (n = 8,507). Over one-third of PIVCs (n = 14,787, 36%) had no documented daily site assessment and half (n = 19,768, 49%) had no documented date and time of insertion. CONCLUSIONS In this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.