Nicole Marsh

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.

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).

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.

Securement methods for peripheral venous catheters to prevent failure: a randomised controlled pilot trial

Purpose To assess the effectiveness of four securement methods to prevent peripheral intravenous catheter (PIVC) failure. Methods A single-centre, four-arm, randomised, controlled, non-blinded, superiority pilot trial was conducted in a tertiary referral hospital in Queensland (Australia), between November 2012 and January 2013. Adult patients, with a PIVC expected to remain in situ for ≥24 hours and admitted to general medical or surgical wards, were randomly allocated to standard polyurethane dressing (control, SPU), tissue adhesive (TA) with an SPU, bordered polyurethane dressing (BPU) or sutureless securement device (SSD) with an SPU, experimental groups. The primary endpoint was PIVC failure, defined as premature device removal before the end of therapy because of pain, blockage, leaking, accidental removal and local or catheter-related bloodstream infection. Results PIVCs were used for an average of 2.6 days across all study groups (n = 85). Catheter failure was lowest in the TA group (3/21, 14%) and highest in the control group (8/21, 38%), with BPU and SSD failure at 5/20 (25%) and 5/23 (22%), respectively. The adjusted hazard ratio of catheter failure was lowest in the TA group (0.50, 95% CI: 0.13-1.98), and then the BPU (0.52, 95% CI: 0.15-1.78) and SSD (0.61, 95% CI: 0.20-1.91) groups. No patient was suspected of a local or catheter-related bloodstream infection. Conclusions Current SPU dressings alone do not prevent many cases of PIVC failure. TA appears promising as an innovative solution, but may not be suitable for all patients. A larger Australian National Health and Medical Research Council (NHMRC)-funded trial has commenced.

Intravascular Device Use,management, Documentation and Complications: A Point Prevalence Survey

OBJECTIVE To examine the use, management, documentation and complications for intravascular devices in cardiac, medical and surgical inpatients. METHODS A point prevalence survey was undertaken in a large tertiary hospital in Queensland. Descriptive statistics were used to analyse data. RESULTS Of the 327 patients assessed, 192 (58.7%) had one or more devices in situ. Of the 220 devices, 190 (86.4%) were peripheral venous catheters, 25 (11.4%) were peripherally inserted central catheters and five (2.3%) were central venous catheters. Sixty-two of 220 devices (28.2%) were in situ without a clear purpose, whereas 54 (24.7%) had one or more complications, such as redness, pain, tracking, oedema or oozing. There was no documentation on the daily patient care record to indicate that a site assessment had occurred within the past 8h for 25% of the devices in situ. CONCLUSIONS The present study identified several problems and highlighted areas for improvement in the management and documentation for intravascular devices. Ongoing education, promoting good clinical practice and reauditing, can be applied to improve the management of devices.

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.

A point prevalence study of cancer nursing practices for managing intravascular devices in an Australian tertiary cancer center

PURPOSE The use of intravascular devices is associated with a number of potential complications. Despite a number of evidence-based clinical guidelines in this area, there continues to be nursing practice discrepancies. This study aims to examine nursing practice in a cancer care setting to identify nursing practice and areas for improvement respective to best available evidence. METHODS A point prevalence survey was undertaken in a tertiary cancer care centre in Queensland, Australia. On a randomly selected day, four nurses assessed intravascular device related nursing practices and collected data using a standardized survey tool. RESULTS 58 inpatients (100%) were assessed. Forty-eight (83%) had a device in situ, comprising 14 Peripheral Intravenous Catheters (29.2%), 14 Peripherally Inserted Central Catheters (29.2%), 14 Hickman catheters (29.2%) and six Port-a-Caths (12.4%). Suboptimal outcomes such as incidences of local site complications, incorrect/inadequate documentation, lack of flushing orders, and unclean/non intact dressings were observed. CONCLUSIONS This study has highlighted a number of intravascular device related nursing practice discrepancies compared with current hospital policy. Education and other implementation strategies can be applied to improve nursing practice. Following education strategies, it will be valuable to repeat this survey on a regular basis to provide feedback to nursing staff and implement strategies to improve practice. More research is required to provide evidence to clinical practice with regards to intravascular device related consumables, flushing technique and protocols.

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.

Securing All intraVenous devices Effectively in hospitalised patients— the SAVE trial: study protocol for a multicentre randomised controlled trial

Introduction Over 70% of all hospital admissions have a peripheral intravenous device (PIV) inserted; however, the failure rate of PIVs is unacceptably high, with up to 69% of these devices failing before treatment is complete. Failure can be due to dislodgement, phlebitis, occlusion/infiltration and/or infection. This results in interrupted medical therapy; painful phlebitis and reinsertions; increased hospital length of stay, morbidity and mortality from infections; and wasted medical/nursing time. Appropriate PIV dressing and securement may prevent many cases of PIV failure, but little comparative data exist regarding the efficacy of various PIV dressing and securement methods. This trial will investigate the clinical and cost-effectiveness of 4 methods of PIV dressing and securement in preventing PIV failure. Methods and analysis A multicentre, parallel group, superiority randomised controlled trial with 4 arms, 3 experimental groups (tissue adhesive, bordered polyurethane dressing, sutureless securement device) and 1 control (standard polyurethane dressing) is planned. There will be a 3-year recruitment of 1708 adult patients, with allocation concealment until randomisation by a centralised web-based service. The primary outcome is PIV failure which includes any of: dislodgement, occlusion/infiltration, phlebitis and infection. Secondary outcomes include: types of PIV failure, PIV dwell time, costs, device colonisation, skin colonisation, patient and staff satisfaction. Relative incidence rates of device failure per 100 devices and per 1000 device days with 95% CIs will summarise the impact of each dressing, and test differences between groups. Kaplan-Meier survival curves (with log-rank Mantel-Cox test) will compare device failure over time. p Values of <0.05 will be considered significant. Secondary end points will be compared between groups using parametric or non-parametric techniques appropriate to level of measurement. Ethics and dissemination Ethical approval has been received from Queensland Health (HREC/11/QRCH/152) and Griffith University (NRS/46/11/HREC). Results will be published according to the CONSORT statement and presented at relevant conferences. Trial registration number Australian New Zealand Clinical Trial Registry (ACTRN); 12611000769987.