Joan Webster

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.

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

Objective To compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated. Design Randomised controlled trial. Setting Tertiary hospital in Australia. Participants 755 medical and surgical patients: 379 allocated to catheter replacement only when clinically indicated and 376 allocated to routine care of catheter (control group). Main outcome measure A composite measure of catheter failure resulting from phlebitis or infiltration. Results Catheters were removed because of phlebitis or infiltration from 123 of 376 (33%) patients in the control group compared with 143 of 379 (38%) patients in the intervention group; the difference was not significant (relative risk 1.15, 95% confidence interval 0.95 to 1.40). When the analysis was based on failure per 1000 device days (number of failures divided by number of days catheterised, divided by 1000), no difference could be detected between the groups (relative risk 0.98, 0.78 to 1.24). Infusion related costs were higher in the control group (mean

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

A41.02; £19.71; €24.80;

Quality of life and depression following childbirth: impact of social support

38.55) than intervention group (

Prevention and treatment of acute radiation-induced skin reactions: a systematic review and meta-analysis of randomized controlled trials

A36.40). The rate of phlebitis in both groups was low (4% in intervention group, 3% in control group). Conclusion Replacing peripheral intravenous catheters when clinically indicated has no effect on the incidence of failure, based on a composite measure of phlebitis or infiltration. Larger trials are needed to test this finding using phlebitis alone as a more clinically meaningful outcome. Registration number Australian New Zealand Clinical Trials Registry ACTRN12605000147684.

Improving antenatal recognition of women at risk for postnatal depression

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).

IDentify, Educate and Alert (IDEA) trial: an intervention to reduce postnatal depression

OBJECTIVE to evaluate the impact of social support on postnatal depression and health-related quality of life. DESIGN prospective cohort study. Data were collected at baseline and at six weeks post discharge using a postal survey. SETTING AND PARTICIPANTS between August and December 2008, 320 women from a large tertiary hospital were recruited following the birth of their infant. MEASUREMENTS Edinburgh Postnatal Depression Scale (EPDS), Maternity Social Support Scale and World Health Organization Quality of Life assessment questionnaire. FINDINGS of the 320 women recruited, 222 (69.4%) returned their six-week questionnaire. Women with low social support had significantly higher scores on the EPDS than women who reported adequate support (p = 0.007). There was also a significant effect of social support on health-related quality of life. Women with low family or partner support scored lower in all domains, with the greatest mean difference in the social health domain (p = 0.000). Of those scoring >10 on the EPDS, 75.5% had sought professional help. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE women with low social support are more likely to report postnatal depression and lower quality of life than well-supported women. Careful assessment of a womans level of support following the birth, particularly from her partner and family, may provide useful information for possible interventions.

Post-Caesarean Wound Infection: A Review of the Risk Factors.

BackgroundRadiation-induced skin reaction (RISR) is a common side effect that affects the majority of cancer patients receiving radiation treatment. RISR is often characterised by swelling, redness, pigmentation, fibrosis, and ulceration, pain, warmth, burning, and itching of the skin. The aim of this systematic review was to assess the effects of interventions which aim to prevent or manage RISR in people with cancer.MethodsWe searched the following databases up to November 2012: Cochrane Skin Group Specialised Register, CENTRAL (2012, Issue 11), MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1806), CINAHL (from 1981) and LILACS (from 1982). Randomized controlled trials evaluating interventions for preventing or managing RISR in cancer patients were included. The primary outcomes were development of RISR, and levels of RISR and symptom severity. Secondary outcomes were time taken to develop erythema or dry desquamation; quality of life; time taken to heal, a number of skin reaction and symptom severity measures; cost, participant satisfaction; ease of use and adverse effects. Where appropriate, we pooled results of randomized controlled trials using mean differences (MD) or odd ratios (OR) with 95% confidence intervals (CI).ResultsForty-seven studies were included in this review. These evaluated six types of interventions (oral systemic medications; skin care practices; steroidal topical therapies; non-steroidal topical therapies; dressings and other). Findings from two meta-analyses demonstrated significant benefits of oral Wobe-Mugos E for preventing RISR (OR 0.13 (95% CI 0.05 to 0.38)) and limiting the maximal level of RISR (MD -0.92 (95% CI -1.36 to -0.48)). Another meta-analysis reported that wearing deodorant does not influence the development of RISR (OR 0.80 (95% CI 0.47 to 1.37)).ConclusionsDespite the high number of trials in this area, there is limited good, comparative research that provides definitive results suggesting the effectiveness of any single intervention for reducing RISR. More research is required to demonstrate the usefulness of a wide range of products that are being used for reducing RISR. Future efforts for reducing RISR severity should focus on promising interventions, such as Wobe-Mugos E and oral zinc.

The Effects of a Multimodal Intervention Trial to Promote Lifestyle Factors Associated With the Prevention of Cardiovascular Disease in Menopausal and Postmenopausal Australian Women

Summary: The purpose of this study was to assess the effectiveness of a practical antenatal screen used at the Royal Womens Hospital, Brisbane, to identify women at risk for postnatal depression. It was a prospective, hospital‐based, cohort study of 901 women (600 with and 301 without prenatal risk factors for postnatal depression). Depression was measured 16 weeks after the birth using the Edinburgh Postnatal Depression Scale. More of the women with a prenatal risk factor for depression (25.9%) scored above 12 on the Edinburgh Postnatal Depression Scale than those without any risk (10.9%) (p ≤ 0.001). Low social support (p ≤ 0.001), a personal history of mood disorder (p ≤ 0.001) and a past history of postnatal depression (p = 0.002) were all strongly associated with postnatal depression in this sample. Results indicate that an objective, psychosocial assessment during pregnancy improves recognition of women at risk for postnatal depression.

Screening for partner violence: direct questioning or self-report?

Objective To test the effectiveness of a prenatal intervention in reducing the incidence of postnatal depression.