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AVATAR Newsletter October 2018   

AVA 2018 Columbus, Ohio, USA

Association for Vascular Access Meeting, September 2018

The AVATAR team got their annual fix of inspiration, fun and friendship at the AVA Meeting, held this year in Columbus, Ohio. AVATAR researchers contributed to the pre-meeting workshop, invited speaker sessions, poster and oral sessions on topics including Neonatal and Paediatric Ultrasound Guided PICCs, Skin Health and Device Security, Value Frameworks for Vascular Access, The I-DECIDED Device Assessment and Decision Tool, Pediatric Vascular Access Journeys, State of the Art Ultrasound, PIVC Associated Bloodstream Infections, Expert vs Generalist PIVC Insertion, Vascular Access Teams, and PEDISIG Grand Rounds. We were moved by the Keynote presentation from Marcus Engel and loved seeing our friend Dr Jack LeDonne honoured as a Herbst Awardee. On the final day, yes we were all very tired by then after working and socialising hard, but we brought our best Oscar entering performances to “Lunch and Learn with the Experts”, dressing up to debate “CVAD Materials matter: Or do they?”. We continued arguing about this amongst ourselves for a few of the many hours on the long plane ride back home!


New collaboration

A 5-year Memorandum of Understanding (MOU) for academic and scientific cooperation has been signed between the Griffith University and the University of Michigan. The MOU will facilitate further the existing highly successful international collaboration between researchers from Menzies Health Institute Queensland’s AVATAR Group, and the University of Michigan’s Medical School, and extend opportunities for collaboration to other researchers in both universities.

A Griffith University delegation of researchers from AVATAR, School of Nursing and Midwifery, Centre for Applied Health Economics and Patient Centred Health Services attended the University of Michigan for a signing ceremony on 20 September by Prof Bonnie Barber, Dean-Research(Health), Griffith University, and Dr Joseph Kolars, Senior Associate Dean for Education and Global Initiatives, University of Michigan.

The visit involved three days of meetings and presentations between the Griffith University delegation, and researchers from Michigan’s Patient Safety Enhancement Program, Hospital Medicine Safety Consortium, Vascular Access Service Team, School of Nursing, Health Economics, Implementation Science, TACTICAL (ICU), and Institute for Healthcare Policy and Innovation.

Don't Forget the Bubbles

On Sunday the 26th of August Amanda Ullman and Tricia Kleidon led a vascular access masterclass for Don’t Forget the Bubbles in beautiful but chilly Melbourne. The aim of the class was to help participants (around 37 doctors and nurses) identify and trouble shoot common problems with central venous access devices and to introduce ultrasound-guided peripheral intravenous access. The class was run in partnership with medical officers from around Australia and involved a mix of hands on sessions with phantoms and ultrasound machines, vein mapping and expert presentations. Overall feedback from the day was that it was a cracking success and participants were keen to head back to their hospital sites and develop their PIVC ultrasound insertion skills.
Bronwyn Pearse, AVATAR PhD student, presenting at "Blood Management in 2019", Plenary Session at Australian Society of Anaesthetists National Scientific Congress


Grant News

Cooke M, Broadhurst D. Vascular Access Device Planning in the Alternate Care Setting. BD (Canada) unrestricted grant. $20,000 CAD


Dr Evan Alexandrou, Dr Nicolas Mifflin, Mr Vanno Sou, Mr Craig McManus, Dr Stephen Frost, Dr Ritesh Sanghavi, Prof Kenny Lawson, Prof Anders Aneman, Prof Claire Rickard. Comparing traditional Placement With ElectrocArdiography for central Vascular access dEvices trial (P-WAVE Trial). Finished recruitment (350 patients) and are now in data collation/ analysis phase. Investigator Initiated Grant through BARD.


S Keogh, M Totsika, K Alexander. AI: N Gavin $10,000 IHBI Collaboration Scheme. An evaluation of biofilm formation in Standard versUs peRForated peripheral intravenous catheters. Micro-SURF: an in vitro study.


Australian College of Nursing (ACN) Project Grant. Managing Intravenous Devices among patients with Limited vascular access or prolonged therapy: InvestigatiNg the Efficacy of midline catheters- the MIDLINE study. $30,000. Nicole Marsh, Julie Flynn, Claire Rickard.


Awards Received


2018 Menzies Health Institute Queensland, Excellence in Publication Awards for the articles below:

Claire Rickard, Gillian Ray-Barruel. Peripheral intravenous catheter assessment: beyond phlebitis. Lancet Haematology 2017;4(9):e402-e403.

Nicole Marsh. Devices and dressings to secure peripheral venous catheters: A Cochrane systematic review and meta-analysis. International Journal of Nursing Studies, 2017

Amanda Ullman. Dressing and Securement for central venous access devices (CVADs): A Cochrane sytematic review. International Journal of Nursing Studies, 2016.



At the 27th Annual RBWH Healthcare Symposium Nicole Marsh was awarded The Cecilia Brazil Nursing Research Award for Peripheral intravenous catheter failure and complications within the adult population: a systematic review.

At The Prince Charles Hospital Amanda Corley (right) won the TPCH Rising Star of Research Award, while India Lye (left) received The Prince Charles Hospital Foundation Paul Zimmerman Best New Investigator Award for her 3-minute thesis presentation on “In vitro testing of cyanoacrylate tissue adhesives for ECMO cannula securement” (I Lye, A Corley, N Bartnikowski, Y Qu, J Fraser)

Australasian College for Infection Prevention and Control 2018 Conference
19-21 November 2018
Brisbane Convention and Exhibition Center
Brisbane, QLD, Australia

11th Hospital in the Home (HITH) Society Annual Scientific Meeting
21-23 November 2018
Stamford Plaza
Brisbane, QLD, Australia

AVAS 2019 Scientific Meeting- Walk the Line
12-14 May 2019
Parkroyal Parramatta, Sydney, Australia

ICPIC 2019 International Conference on Prevention and Infection Control
10-13 September 2019
Geneva, Switzerland

AVA 2019 Association for Vascular Access Annual Scientific Meeting
4-7 October 2019
Caesars Palace
Las Vegas, NV, USA

New Publications

Please, find the articles under Our Publications on the AVATAR website

Tuffaha H, Marsh N, Byrnes J, Gavin N, Webster J, Cooke M, Rickard CM. The cost of vascular access devices in public hospitals in Queensland. Australian Health Review. Sept 2018. DOI: 10.1071/AH18102
Approximately 2.75 million vascular access devices were used in public hospitals in Queensland in 2016, at a total cost of A$59.14 million. This comprised a total equipment cost of around A$10.17 million and a total labour cost of A$48.85 million. Vascular access is an important component of healthcare expenditure. The present study is the first to characterise and cost vascular access devices in Queensland. Further research is needed on the costs of maintaining device function and of treating complications associated with vascular access.

Carr PJ, Rippey JCR, Cooke ML, Higgins NS, Trevenen M, Foale A, Rickard CM. From insertion to removal: A multicentre survival analysis of an admitted cohort with peripheral intravenous catheters inserted in the emergency department. Infection Control and Hospital Epidemiology. September 2018 DOI:10.1017/ice.2018.190
The following variables were associated with increased risk of PIF: being an older patient (for a 1-year increase, hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P=.0001); having an Australian Triage Scale score of 1 or 2 compared to a score of 3, 4, or 5 (HR, 2.04; 95% CI, 1.39-3.01; P=.0003); having an ultrasound-guided PIVC (HR, 6.52; 95% CI, 2.11-20.1; P=.0011); having the PIVC inserted by a medical student (P=.0095); infection prevention breaches at insertion (P=.0326); and PIVC inserted in the ante cubital fossa or the back of hand compared to the upper arm (P=.0337). PIF remains at an unacceptable level in both traditionally inserted and ultrasound-inserted PIVCs

Rickard CM, Ullman AJ. Bloodstream infection and occlusion of central venous catheters in children. Lancet Infectious Diseases. Invited comment. 2018 Aug;18(8):815-817.
Both infectious and occlusive complications are unacceptably common across CVC types and paediatric populations, causing many devices to fail prematurely. Ongoing efforts are needed to find effective flush and lock solutions for CVCs that lead to fewer infected and occluded devices being replaced.

Slater K, Snell S, Cooke M, Fullerton F, Rickard CM. Needleless connector drying time – How long does it take? American Journal of Infection Control. July 2018. DOI: 10.1016/j.ajic.2018.05.007.
Allowing needleless connectors (NCs) on vascular catheters adequate drying time after cleaning with antiseptic is essential. Drying time instructions on antiseptic pads/wipes relate to skin use, not inanimate objects. Needleless connector drying times after a 15-second scrub with isopropyl-alcohol, isopropyl alcohol/chlorhexidine, or povidone-iodine varied from 5 seconds to >6 minutes.

Rickard CM, Marsh N, Webster J, Runnegar N, Larsen E, McGrail MR, Fullerton F, Bettington E, Whitty JA, Choudhury MA, Tuffaha H, Corley A, McMillan D, Fraser JF, Marshall A, Playford EG. Dressings and securements for the prevention of peripheral intravenous catheter failure (SAVE): a pragmatic, randomised, controlled, superiority trial. The Lancet. 2018 Jul 26. pii: S0140-6736(18)31380-1
163 (38%) of 427 patients in the tissue adhesive with polyurethane group (absolute risk difference –4∙5% [95% CI –11∙1 to 2∙1%], p=0∙19), 169 (40% of 423 of patients in the bordered polyurethane group (–2∙7% [–9∙3 to 3∙9%] p=0∙44), 176 (41%) of 425 patients in the securement device with polyurethane group (–1∙2% [–7∙9% to 5∙4%], p=0∙73), and 180 (43%) of 422 patients in the polyurethane group had PIVC failure. Current dressing and securement methods are commonly associated with PIVC failure and poor durability, with simultaneous use of multiple products commonly required. Cost is currently the main factor that determines product choice. Innovations to achieve effective, durable dressings and securements, and randomised controlled trials assessing their effectiveness are urgently needed.

Mihala G, Ray-Barruel G, McGrail M, Marsh N, Webster J, Wallis M, Chopra V, Rickard CM. Phlebitis signs and symptoms in peripheral intravenous catheters: incidence and correlation study. Journal of Infusion Nursing. 2018 Jul/Aug;41(4):260-263
A total of 22 789 daily observations of 6 signs (swelling, erythema, leakage, palpable venous cord, purulent discharge, and warmth) and 2 symptoms ( pain and tenderness ) were analyzed of 5907 catheter insertion sites. Most signs and symptoms of phlebitis occurred only occasionally or rarely; the incidence of tenderness was highest (5.7%). Correlations were mostly low; warmth correlated strongly with tenderness , swelling , and erythema.

Choden J, Carr PJ, Brock AR, Esterman A. Factors associated with difficult peripheral intravenous cannulation among pediatric patients at tertiary hospitals in Bhutan. A multi-centre study. Journal of Vascular Access. 2018 DOI: 10.1177/1129729818792826
Our first time successful cannulation rate is substantially lower than that found in similar studies in other countries. Considering the impact a peripheral intravenous catheter has on patients’ clinical outcomes and cost implications, reducing the number of failed attempts should be of high importance. Better education and simulation, combined with the adoption of vessel locating technology, are required to improve insertion practice in Bhutan. This could lead to greater efficiency of the health facilities in Bhutan.

Moureau NL, Carr PJ. Vessel Health and Preservation: a model and clinical pathway for using vascular access devices. British Journal of Nursing. 2018 Apr 26;27(8):S28-35
Vessel Health and Preservation (VHP) represents a systematic approach
to initiating and managing vascular access for the purpose of intravenous
patient medication treatments. The application of VHP quadrant components is designed to improve the quality of acute care and patient outcomes by reducing infection, thrombosis and phlebitis through selection of the most appropriate
cannulae, inserter and management through trained staff. A systematic approach to vascular access incorporates guidelines and recommendations while ensuring that clinical staff receive the education and training necessary to provide the safest level of patient car. The evaluation quadrant of VHP includes audits and monitoring of outcomes to pinpoint the required education and establish evidence of the need for specialty products that may reduce negative outcomes. Without intravenous cannulae treatment is impossible in acute care today, and yet vascular access devices carry a high level of risk requiring vigilance in the application of evidence provided to clinicians in the form of updated training and education.   

Piper., R, Carr PJ., Kelsey L., Bulmer A., Keogh S., Doyle B. Towards a better understanding of the mechanistic causes of peripheral intravenous catheter failure: a parametric computational study. Scientific Reports- Nature. 2018 8(1)
Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet up to 50% fail. Many pathways to failure are mechanistic and related to fuid mechanics, thus can be investigated using computational fuid dynamics (CFD). Here we used CFD to investigate typical PIVC parameters (infusion rate, catheter size, insertion angle and tip position) and report the hemodynamic environment (wall shear stress (WSS), blood damage, particle residence time and venous stasis volumes) within the vein and catheter, and show the effect of each PIVC parameter on each hemodynamic measure. Catheter infusion rate has the greatest impact on our measures, with catheter orientation also playing a significant role. In some PIVC configurations WSS was 3254 times higher than the patent vein, and blood damage was 512 times greater, when compared to control conditions. Residence time is geometry-dependent and decreases exponentially with increasing insertion angle. Stasis volume decreased with increasing infusion rate and, to a lesser degree, insertion angle. Even without infusion, the presence of the catheter changes the fow feld, causing low velocity recirculation at the catheter tip. This research demonstrates how several controllable factors impact important mechanisms of PIVC failure. These data, the first of their kind, suggest limiting excessive infusion rates in PIVC.


Alliance for Vascular Access Teaching and Research Group
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