Timothy R. Spencer

Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates : a report from 13 years of service

Objectives:To report procedural characteristics and outcomes from a central venous catheter placement service operated by advanced practice nurses. Design:Single-center observational study. Setting:A tertiary care university hospital in Sydney, Australia. Patients:Adult patients from the general wards and from critical care areas receiving a central venous catheter, peripherally inserted central catheter, high-flow dialysis catheter, or midline catheter for parenteral therapy between November 1996 and December 2009. Interventions:None. Measurements and Main Results:Prevalence rates by indication, site, and catheter type were assessed. Nonparametric tests were used to calculate differences in outcomes for categorical data. Catheter infection rates were determined per 1,000 catheter days after derivation of the denominator. A total of 4,560 catheters were placed in 3,447 patients. The most common catheters inserted were single-lumen peripherally inserted central catheters (n = 1,653; 36.3%) and single-lumen central venous catheters (n = 1,233; 27.0%). A small proportion of high-flow dialysis catheters were also inserted over the reporting period (n = 150; 3.5%). Sixty-one percent of all catheters placed were for antibiotic administration. The median device dwell time (in d) differed across cannulation sites (p < 0.001). Subclavian catheter placement had the longest dwell time with a median of 16 days (interquartile range, 8–26 d). Overall catheter dwell was reported at a cumulative 63,071 catheter days. The overall catheter-related bloodstream infection rate was 0.2 per 1,000 catheter days. The prevalence rate of pneumothorax recorded was 0.4%, and accidental arterial puncture (simple puncture—with no dilation or cannulation) was 1.3% using the subclavian vein. Conclusions:This report has demonstrated low complication rates for a hospital-wide service delivered by advance practice nurses. The results suggest that a centrally based service with specifically trained operators can be beneficial by potentially improving patient safety and promoting organizational efficiencies.

Nurse-led central venous catheter insertion—Procedural characteristics and outcomes of three intensive care based catheter placement services

BACKGROUND Nurse-led central venous catheter placement is an emerging clinical role internationally. Procedural characteristics and clinical outcomes is an important consideration in appraisal of such advanced nursing roles. OBJECTIVES To review characteristics and outcomes of three nurse-led central venous catheter insertion services based in intensive care units in New South Wales, Australia. DESIGN Using data from the Central Line Associated Bacteraemia project in New South Wales intensive care units. Descriptive statistical techniques were used to ascertain comparison rates and proportions. PARTICIPANTS De-identified outcome data of patients who had a central venous catheter inserted as part of their therapy by one of the four advanced practice nurses working in three separate hospitals in New South Wales. RESULTS Between March 2007 and June 2009, 760 vascular access devices were placed by the three nurse-led central venous catheter placement services. Hospital A inserted 520 catheters; Hospital C with 164; and Hospital B with 76. Over the study period, insertion outcomes were favourable with only 1 pneumothorax (1%), 1 arterial puncture (1%) and 1 CLAB (1%) being recorded across the three groups. The CLAB rate was lower in comparison to the aggregated CLAB data set [1.3 per 1000 catheters (95% CI=0.03-7.3) vs. 7.2 per 1000 catheters (95% CI=5.9-8.7)]. CONCLUSION This study has demonstrated safe patient outcomes with nurse led CVC insertion as compared with published data. Nurses who are formally trained and credentialed to insert CVCs can improve organisational efficiencies. This study adds to emerging data that developing clinical roles that focus on skills, procedural volume and competency can be a viable option in health care facilities.

A review of the nursing role in central venous cannulation: implications for practice policy and research

AIMS AND OBJECTIVES The aim of this article is to review published studies about central vein cannulation to identify implications for policy, practice and research in an advanced practice nursing role. DESIGN Modified integrative literature review. METHODS Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Medline, Embase, and the World Wide Web were undertaken using MeSH key words. Hand searching for relevant articles was also undertaken. All studies relating to the nurses role inserting central venous cannulae in adult populations met the search criteria and were reviewed by three authors using a critical appraisal tool. RESULTS Ten studies met the inclusion criteria for the review, all reported data were from the UK. There were disparate models of service delivery and study populations and the studies were predominantly non experimental in design. The results of this review need to be considered within the methodological caveats associated with this approach. The studies identified did not demonstrate differences in rates of adverse events between a specialist nurse and a medical officer. CONCLUSIONS There were only a small number of studies found in the literature review and the limited availability of clinical outcome data precluded formal analysis from being generated. RELEVANCE TO CLINICAL PRACTICE Central vein cannulation is potentially an emerging practice area with important considerations for policy practice and research. Training specialist nurses to provide such a service may facilitate standardising of practice and improving surveillance of lines, and possibly improve the training and accreditation process for CVC insertions for junior medical officers. For this to occur, there is a need to undertake well-conducted clinical studies to clearly document the value and efficacy of this advanced practice nursing role.

Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio

In vascular access practices, the internal vessel size is considered important, and a catheter to vessel ratio (CVR) is recommended to assist clinicians in selecting the most appropriate-sized device for the vessel. In 2016, new practice recommendations stated that the CVR can increase from 33 to 45% of the vessels diameter. There has been evidence on larger diameter catheters and increased thrombosis risk in recent literature, while insufficient information established on what relationship to vessel size is appropriate for any intra-vascular device. Earlier references to clinical standards and guidelines did not clearly address vessel size in relation to the area consumed or external catheter diameter. The aim of this manuscript is to present catheter-related thrombosis evidence and develop a standardized process of ultrasound-guided vessel assessment, integrating CVR, Virchow’s triad phenomenon and vessel health and preservation strategies, empowering an evidence-based approach to device placement. Through review, calculation and assessment on the areas of the 33 and 45% rule, a preliminary clinical tool was developed to assist clinicians make cognizant decisions when placing intravascular devices relating to target vessel size, focusing on potential reduction in catheter-related thrombosis. Increasing the understanding and utilization of CVRs will lead to a safer, more consistent approach to device placement, with potential thrombosis reduction strategies. The future of evidence-based data relies on the clinician to capture accurate vessel measurements and device-related outcomes. This will lead to a more dependable data pool, driving the relationship of catheter-related thrombosis and vascular assessment.

Preventing contamination at the time of central venous catheter insertion: a literature review and recommendations for clinical practice.

AIMS AND OBJECTIVES To evaluate the evidence base and rationale underpinning the various infections control strategies during central venous catheter insertion and to promote discussion about the key, recurring concepts and recommendations in the literature. Logistical and organisational factors relating to central venous catheter insertion are also examined. BACKGROUND Catheter-related bloodstream infections following the insertion of central venous catheters are associated with significant patient mortality and morbidity, prolonged hospital stays and increased economic costs. Limited published literature specifically examines microbial contamination during the peri-insertion process. METHODS An integrative literature review supervised by a health informatics librarian was undertaken. On the basis of these data, considerations for clinical practice are provided. Retrieved articles were categorised under the following themes: risk of contamination at insertion; clinical and organisational impact of contamination; strategies for reducing contamination; controversies and challenges with decontamination strategies; recommendations for practice and implications for further research and organisational practice. RESULTS Specific recommendations for reducing catheter-related bloodstream infections based on recurring themes include the following: reducing microbial burden on skin prior to the central venous catheter insertion; decreasing contact of gloves and insertion equipment with the patients skin; using specifically trained staff to prepare and maintain a sterile field; and ensuring a sterile technique is adhered to throughout the central venous catheter insertion process. The need for organisational, procedural and clinical practices to support better healthcare outcomes is demonstrated. Highlighting the importance of executive support and regular review of policy and guidelines are necessary to improve patient outcomes. CONCLUSIONS Preventing infections related to central venous catheters requires the integration of clinical, organisational and workforce factors.

Comment on: Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial

We recently read the article ‘Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial’ by Caparas and Hu (1), which raised a number of concerns in this limited-sized patient sample study (n = 54), which we would like to address. The authors did not consider ‘leak’ from the insertion site as potential thrombosis development, which is an early precursor of thrombus formation and compromised venous outflow, which has been clearly documented in literature over the last decade. It could also be due to advanced fibrin sheath development around the catheter body and lumen tip, allowing retrograde flow of an infused solution (irritant or not). The above clinical situations can be caused by both chemical (medication) and mechanical (physical) processes occurring within the vessel. The paper stated if vancomycin therapy was extended beyond 5 days, physicians were advised to administer subsequent doses via a peripherally inserted central catheter (PICC) – so patients were subjected to a secondary device insertion and these numbers were not documented. If blood return could not be demonstrated, the line was assessed with ultrasound to determine its position (which only described intraluminal position) – a catheter position change would be unlikely (unless withdrawn); however, ultrasound assessment was not mentioned or performed to observe/assess for potential thrombus development. Assessment of the device and site was performed daily; however, it is documented that some patients also received a twice-daily dose of vancomycin, but there was failure to mention if the device or site was assessed during the second administration of the drug. Three (10.0%) Grade 1 infiltrations (INS Infiltration Scale) occurred in the midline group. Twenty-nine percent (29%) of midline patients received intravenous vancomycin for greater than 5 days – how many of these patients had a device changed to a PICC (as recommendation in the paper) – this was also not addressed. The reported thrombosis and phlebitis rates were zero (0) in both groups; however, it did not describe which phlebitis tool was used for assessment. The article by Ray-Barruel and colleagues (2), found that there are dozens of phlebitis assessment scales in use, but none have been thoroughly validated for use in the clinical setting and that there are broad disparities in measuring and reporting phlebitis, which have led to enormous variations in reported phlebitis prevalence rates. The lack of addition of AlteplaseTM (Genentech, USA) costs into the PICC group skews the economical comparison between the midline and PICC group. It was not addressed if AlteplaseTM was used in the midline patient population to restore patency of the device. Although the authors showed a significant cost difference between the two groups (~US

Rapid Central Vein Assessment (RaCeVA): A systematic, standardized approach for ultrasound assessment before central venous catheterization

90), it highlights vastly different types of devices in regard to overall costs and the insertion-related expenses. However, if the patient required an extension of therapy beyond the 5-day limit, then costs dramatically increased. If a PICC was initially placed for therapy, and was functional for the duration of infusion, then costs would be more accurate. Two of the three infiltrations clearly occurred days after vancomycin administration had ceased – this cannot be contributed directly to vancomycin as there are other possible reasons for infiltration – power injection or other vesicant/ irritant medication administration could have been a possible cause. Central line-associated blood-stream infection (CLABSI) should not be combated with increased midline use, as this hides the real and underlying issues within an institution if there is a strong CLABSI-related problem. This area of research does need further high level, stringent clinical investigation, which has recently been achieved successfully by Klungboonkrong and colleagues (unpublished data), whose large 2522 midline catheter study investigating deep vein thrombosis (DVT) related to vesicant or irritant medication use through a midline, showed that there was a 56% increase after each successive dose of vesicant or irritant medication when administered, with an increased risk of DVT by a factor of 3.5. The authors’ recommendations were to use a central venous catheter for vesicant or irritant medication administration. This in-press publication requires careful consideration for guideline developers, policy writers, educators and researchers focusing on recommendations for clinical practice changes, which can have significant effects on patientand device-related outcomes.

Repositioning of Central Venous Access Devices using a High-Flow Flush Technique - a Clinical Practice and Cost Review:

Ultrasound technology has revolutionized the practice of safer vascular access, for both venous and arterial cannulation. The ability to visualize underlying structures of the chest, neck, and upper/lower extremities provides for greater success, speed, and safety with all vascular access procedures. Ultrasound not only yields superior procedural advantages but also provides a platform to perform a thorough assessment of the vascular structures to evaluate vessel health, viability, size, and patency, including the location of other important and best avoided anatomical structures—prior to performing any procedures. Such assessment is best performed using a systematic and standardized approach, as the Rapid Central Vein Assessment, described in this study.

The Use of Midline Catheters in the Adult Acute Care Setting - Clinical Implications and Recommendations for Practice

Background Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions. The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. Methods This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia. 7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. Results There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. Conclusions Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.