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New Publications
Ray-Barruel G. Challenging the status quo: Time to adopt the “80% sure” principle? (Editorial). Vascular Access. 2019;5(1):2. Doi.org/10.33235/va.5.1.2
In this issue, we feature an article on the use of large-bore peripheral intravenous catheters (PIVCs) in women giving birth. Customary practice in many countries, including Australia, sees large-bore PIVCs placed in obstetric patients for the possibility that some will encounter a post-partum haemorrhage and need a blood transfusion. And it is time we questioned the need for cannulation at all for some patients and, in particular, the use of ‘just-in-case’ large-bore devices. Perhaps it’s time to embrace the “80% sure” criteria reported by Hawkins et al.5. Unless we’re 80% sure the haemodynamically stable obstetric patient is likely to need a large-bore catheter, maybe we should pause and weigh the risks and benefits.
Schults J, Long D, Pearson K, Takashima M, Baveas T, Schlapbach L, Macfarlane F, Ullman AJ: Insertion, management and complications associated with arterial catheters in paediatric intensive care: A clinical audit. Australian Critical Care IF 1.93 (accepted March 2019). doi.org/10.1016/j.aucc.2019.05.003
Peripheral arterial catheters (PAC) are used for haemodynamic monitoring and blood sampling in paediatric critical care. Limited data are available regarding PAC insertion and management practices, and how they relate to device function and failure. A total of 100 catheters in 89 children were examined capturing 472 device days. PACs were primarily inserted for blood sampling (78%) in the radial artery (78%) using ultrasound guidance (67%), with 31% inserted on first attempt. Heparin saline solution was used in 82% of devices. Median catheter dwell was 50.6 hours (IQR 24.0 – 158.0), with PAC failure occurring in 19 devices (20%), at a rate of 40.2 per 1000 catheter days (95% CI 25.7 - 63.1). Arm board immobilisation (HR 2.9; 95% CI 1.02-8.02; p = 0.05), higher PIM3 score (HR 1.06; 95% CI 1.03-1.09; p < 0.01) was associated with an increased the risk of PAC failure, and non-2% chlorhexidine antisepsis was associated with a decrease in PAC failure (HR 0.32; 95% CI 0.11-0.96; p = 0.04), in univariate analysis. PAC insertion is challenging, and failure is common. Prospective clinical trial data is needed to identify high risk patient groups and to develop interventions which optimise practices, thereby reducing failure.
Kleidon T, Cattanagh P, Mihala G, Ullman AJ: Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative. Journal of Paediatric and Child Health IF 1.572 (accepted January 2019)
The aim of this study is to improve paediatric peripheral intravenous catheter (PIVC) care through the implementation of care bundles. Pre-implementation audit (n = 102) and survey (n = 117) data described high rates of PIVC failure (n = 50; 49%), difficulty obtaining equipment (n = 64; 55%) and pressure to insert (n = 50; 43%). Parent interviews (n = 15) identified lack of communication, fear, appreciation of skilled technicians and technology and care giver roles as key to improving the experience. After implementation first-attempt insertion success (45 vs. 62%; risk ratio 1.37, 95% confidence interval 1.05–1.78), first-attempt escalation to senior clinicians (junior doctor 72 vs. 41%; P=<0.001) and median PIVC dwell (40 vs. 52 h; P = 0.021) improved. In conclusion, this multi-level care bundle demonstrated improvements in the insertion and management of PIVCs; however, PIVC failure remained high.
Schults JA, Rickard CM, Kleidon T, Paterson R, Macfarlane F, Ullman AJ: Difficult peripheral venous access in children: An international survey and critical appraisal of assessment tools and escalation pathways. Journal of Nursing Scholarship. Aug 2019; 0;0:1-10. doi:10.1111/jnu.12505
Peripheral venous cannulation is considered a routine procedure, yet 50% of first attempt insertions fail, necessitating repeat insertion attempts. Identification of children with difficult intravenous access (DIVA) can help promote prompt escalation to an appropriately skilled clinician. A total of 148 clinicians from eight countries completed the survey. The majority were nurses (n = 92; 62%), practicing as vascular access specialists (n = 27; 18%). Twenty‐three respondents (16%) reported using a DIVA tool, of which the DIVA Score was most common (n = 5; 22%). Five clinical pathways were identified from the survey and review. Based on the AGREE II domains, pathways generally scored well for scope and purpose, and for clarity of presentation areas. Information on the rigor of development and editorial independence was infrequently detailed. Based on AGREE II findings, one pathway was recommended for clinical practice, and four were recommended for use with modification. Resources for the identification and escalation of children with DIVA are not standardized or consistently used. Further work is needed to streamline processes for DIVA identification and escalation to the appropriate clinician, with technology‐assisted insertion capability.
Ullman AJ, Long D, Williams T, Pearson K, Mihala G, Mattke A, Macfarlane F, Rickard CM. Innovation in central venous access device security: A pilot randomized controlled trial in pediatric critical care. Pediatric Critical Care Medicine. July 2019: 1-9. doi: 10.1097/PCC.0000000000002059
Central venous access devices enable many treatments during critical illness; however, 25% of pediatric central venous access devices fail before completion of treatment due to infection, thrombosis, dislodgement, and occlusion. This is frequently
attributed to inadequate securement and dressing of the device; however, high-quality research evaluating pediatric central venous access device securement innovation to prevent central venous access device failure is scarce. This study aimed to establish the feasibility of a definitive randomized control trial examining the effectiveness of current and new technologies to secure central venous access devices in pediatrics. In conclusion, it is feasible to conduct an efficacy randomized control trial of the studied interventions. Further research is required to definitively identify clinical, cost-effective methods to prevent central venous access device failure by examining new dressing and securement technologies and techniques.
Larsen E, Gavin N, Marsh N, Rickard CM. A systematic review of Central Line-Associated Bloodstream Infection (CLABSI) diagnostic reliability and error. Infection Control and Hospital Epidemiology. July 2019:1-7 doi:10.1017/ice.2019.205
The objective to establish the reliability of the application of National Health and Safety Network (NHSN) central-line–associated bloodstream infection (CLABSI) criteria within established reporting systems internationally. A systematic search identified 1,259 publications; 9 studies were eligible for inclusion (n = 7,160 central lines). Publicly reported CLABSI rates were more likely to be underestimated (7 studies) than overestimated (2 studies). Specificity ranged from 0.70 (95% confidence interval [CI], 0.58–0.81) to 0.99 (95% CI, 0.99–1.00) and sensitivity ranged from 0.42 (95% CI, 0.15–0.72) to 0.88 (95% CI, 0.77–0.95). Four studies, which included a consecutive series of patients (whole cohort), reported CLABSI incidence between 9.8% and 20.9%, and absolute CLABSI rates were underestimated by 3.3%–4.4%. The risk of bias was low to moderate in most included studies. Our findings suggest consistent underestimation of true CLABSI incidence within publicly reported rates, weakening the validity and reliability of surveillance measures. Auditing, education, and adequate resource allocation is necessary to ensure that surveillance data are accurate and suitable for benchmarking and quality improvement measures over time.
Choudhury MA, Sidjabat HE, Zowawi HM, Marsh N, Larsen E, Runnegar N, Paterson DL, McMillan DJ, Rickard CM. (2019). Skin colonization at peripheral intravenous catheter insertion sites increases the risk of catheter colonization and infection. American Journal of Infection Control. July 2019. doi.org/10.1016/j.ajic.2019.06.002
Peripheral intravenous catheters (PIVCs) break the skin barrier, and preinsertion antiseptic disinfection and sterile dressings are used to reduce risk of catheter-related bloodstream infection (CRBSI). Of 137 patients, 45 (33%) had colonized skin sites and/or PIVC tips. Of 16 patients with paired colonization of both the skin site and PIVC tips, 11 (69%) were colonized with the same bacterial species. Of these, 77% were clonally related, including 1 identical clone of Pseudomonas aeruginosa in a patient with systemic infection and the same organism identified in blood culture. The results demonstrate that opportunistic pathogen colonization at the skin site poses a significant risk for PIVC colonization and CRBSI. Further research is needed to improve current preinsertion antiseptic disinfection of PIVC skin site and the sterile insertion procedure to potentially reduce PIVC colonization and infection risk.
Kleidon TM, Rickard CM, Schults JA, Mihala G, Rudkin J, Chaseling B, McBride C, Ullman AJ. (2019). Development of a paediatric CVAD database: A retrospective cohort study of practice evolution and risk factors for device failure. Journal of Paediatrics and Child Health (in press, accepted August 2019)
A paediatric retrospective cohort study using prospectively collected data from CVAD database 2012–2014. This study aims to describe practice evolution, complications and risk factors for multiple insertion attempts and device failure in paediatric central venous access devices (CVADs). A total of 1308 CVADs were observed over 273 467 catheter‐days in 863 patients. While advancement in CVAD practices improved overall CVAD insertion and failure outcomes, further improvements and innovation are necessary to ensure improved vessel health and preservation for children requiring CVAD.
Schults JA, Kleidon T, Petsky HL, Stone R, Schoutrop J, Ullman AJ. (2019). Peripherally inserted central catheter design and material for reducing catheter failure and complications (protocol). Cochrane Database of Systematic Reviews(7). doi:10.1002/14651858.CD013366
Peripherally inserted central catheters (PICCs) are routinely inserted in adults and children who require intermediate intravascular therapy such as total parenteral nutrition (Russell 2014; Ullman 2017). However, despite these perceived benefits, PICC complications are common, with 30% of PICCs failing prior to the completion of therapy (Shen 2009; Ullman 2015). The objective of this study is to assess the effectiveness of PICC material and design in reducing catheter failure and complications.
Corley A, Ullman AJ, Mihala G, Ray-Barruel G, Alexandrou E, Rickard CM: Peripheral intravenous catheter dressing and securement practice is associated with site complications and suboptimal dressing integrity: a secondary analysis of 40,637 catheters. International Journal of Nursing Studies. Accepted Aug 2019. Doi.org/10.1016/j.ijnurstu.2019.103409
With over 2 billion peripheral intravenous catheters used globally each year, avoiding complications is crucial for patients and healthcare organisations. Effective catheter dressing and securement is a key nursing strategy to reduce catheter failure and resultant patient harm. Dressing and securement practices, and local hospital policy regarding dressing change frequency varied. One fifth of dressings (21%, n=8519) were not clean, dry and intact. The prevalence of catheter insertion site complications was 16% (n=6503), with signs of phlebitis commonly observed (11.5%, n=4,587). Compared to non-bordered polyurethane dressings, sterile gauze and tape dressings were associated with fewer insertion site complications (odds ratio 0.58, 95% confidence interval 0.50-0.68) and better dressing integrity (odds ratio 0.68; 95% confidence interval 0.59-0.77); whereas, compared with no securement, non-sterile tape at the insertion site was associated with more site complications (odds ratio 2.39, 95% confidence interval 2.22-2.57) and poorer dressing integrity (odds ratio 1.64, 95% confidence interval 1.51-1.75). Modifiable risk factors for peripheral intravenous catheter site and dressing complications were identified and are amendable to further interventional testing.
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