CVAA Vascular Access, Volume 16, Issue 2, Summer 2022

Volume 16, Issue 2 • Summer 2022

In this issue / DANS CE NUMÉRO : Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen Pratiques de verrouillage du dispositif d’accès veineux central dans les services de prestation de soins intensifs aux adultes : Une étude d’observation menée dans un seul centre et visant à établir la durée de verrouillage selon la lumière de cathéter Implementation of a midline catheter service in a regional setting Service de pose d’un cathéter mi-long dans un contexte régional Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation Appuyer le développement de la compétence clinique dans la prise en charge des cathéters centraux insérés par voie périphérique pendant la pandémie de COVID-19 : évaluation d’une formation

Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimise first-insertion success for patients with Difficult IntraVenous Access in the emergency department (LOVE-DIVA): A study protocol for a randomised controlled trial L’utilisation d’un cathéter intraveineux périphérique long avec un fil-guide rétractable afin d’optimiser la probabilité de réussite de la première insertion chez les patients dont l’abord intraveineux est difficile au service des urgences (LOVE-DIVA) : Un protocole de recherche pour un essai contrôlé à répartition aléatoire Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children Complications associées à l’utilisation des cathéters intraveineux périphériques et facteurs de risque d’infiltration ou de phlébite chez les enfants COLLABORATING FOR BEST PRACTICE Beware its twin: Intrathecal implanted ports – Part 2: Safety considerations

BD Max needle-free connector technology Others claim to reduce catheter-related complications.

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The BD MaxPlus™ Needle-free Connector was shown to reduce the risk of CLABSI by 63%, compared to other needle-free connectors, in a 2014 meta-analysis published in the American Journal of Infection Control 1

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reduction in occlusions2

PICC: Peripherally Inserted Central Catheter

References: 1. Tabak YP, Jarvis WR, Sun X, Crosby CT, Johannes RS. Meta-analysis on central line-associated bloodstream infections associated with a needleless intravenous connector with a new engineering design. Am J Infect Control. 2014;42(12):1278–1284. doi: 10.1016/j.ajic.2014.08.018. 2. Williams A. Catheter Occlusion in Home Infusion: The Influence of Needleless Connector Design on Central Catheter Occlusion. J Infus Nurs. 2018;41(1):52–57. doi: 10.1097/NAN.0000000000000259.

BD, the BD Logo, MaxPlus, and MaxZero are trademarks of Becton, Dickinson and Company or its affiliates. © 2022 BD. All rights reserved.

Publications Agreement Number 43332020 ISSN 1913-6692 ISSN (Online) 2563-7193 PUBLICATIONS COMMITTEE Janny Proba (Chair) Leanne Tremain Kerry McDonald EDITOR-IN-CHIEF Linda M. Verde CVAA EXECUTIVE DIRECTOR Melissa Stark

Volume 16, Issue 2 • Summer 2022

Contents

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Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen

MANAGING EDITOR Heather Coughlin

Marlena Ornowska, BSc (Hons), Jessica Wittmann, CRC, and Steven Reynolds, BA, MD, FRCPC

ART DIRECTOR Sherri Keller

Pratiques de verrouillage du dispositif d’accès veineux central dans les services de prestation de soins intensifs aux adultes : Une étude d’observation menée dans un seul centre et visant à établir la durée de verrouillage selon la lumière de cathéter

______________

Vascular Access is published three times per year.

We welcome editorial submissions but cannot assume responsibility or commitment for unsolicited material.

Any editorial material, including photographs that are accepted from an unsolicited contributor, will become the property of the Canadian Vascular Access Association.

The Canadian Vascular Access Association shall not be liable for any of the views expressed by the authors published in Vascular Access, nor shall these opinions necessarily reflect those of the publisher.

Authors are responsible for ensuring the originality of their articles.

Permission and Licensing Vascular Access, the journal of the Canadian Vascular Access Association (CVAA), offers open access to its articles under Creative Commons Attribution Licence CC-BY-SA 4.0. CVAA is First Publisher of the articles herein, unless otherwise specified. Copyright of the articles is retained by the author(s). Any use of the journal content in sharing, adapting, republishing, transmission, storing in a repository or retrieval system, or any other kind of reproduction must acknowledge CVAA as First Publisher, and give appropriate credit to the author(s).

Any changes made must be noted and no added restrictions may be imposed when the material is used or republished. For permission to link to or republish an article, please contact the designated corresponding author or copyright holder. CVAA holds copyright to Association material as identified. Find more information on the allowances and restrictions of CC-BY-SA 4.0 Licences et permissions Vascular Access, la revue de l’Association canadienne d’accès vasculaire (ACAV), offre un accès libre à ses articles en vertu de la licence d’attribution Creative Commons CC-BY-SA 4.0. L’ACAV détient le droit de première publication des articles de la revue, sauf indication contraire. Les auteurs des articles demeurent titulaires du droit d’auteur sur ces derniers. Tout utilisateur qui utilise le contenu de la revue à des fins de partage, d’adaptation, de republication, de transmission, de conservation dans un système d’archivage ou de recherche documentaire, ou de reproduction par quelque moyen que ce soit doit reconnaître le droit de première publication de l’ACAV et mentionner adéquatement les auteurs. Toutes les modifications doivent être indiquées et aucune autre restriction ne peut être imposée lors de l’utilisation ou de la republication du matériel. Pour obtenir la permission de republier ou de créer un lien vers un article, veuillez communiquer avec l’auteur correspondant désigné ou le titulaire du droit d’auteur. L’ACAV est titulaire du droit d’auteur sur le matériel désigné par l’association. Cliquez sur le lien suivant pour de plus amples renseignements sur les permissions et restrictions de la licence CC-BY-SA 4.0.

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Marlena Ornowska, B. Sc. (avec distinction), Jessica Wittmann, coordonnatrice á la recherche clinique, et Steven Reynolds, B.A., M.D., FRCSC

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Implementation of a midline catheter service in a regional setting Paul Jones, NP, BN, MN

Service de pose d’un cathéter mi-long dans un contexte régional Paul Jones, IPS, B. Sc. inf., M. Sc. inf.

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Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation Jennifer Reguindin, MScN, RN, GNC(c), Angel Wang, RN, MN, Kim Capoccitti, MSN, RN, Shevaun Lai, RN, BScN, MN, Christine Saby, MN, RN, Natalie Sakin, MN, RNHSLA, PANC(c), Wesley Woods, RN, CCRN, Christine Ortiz, RN, CON(c), Karen Velasco, RN, Parisa Alvand, MN, RN, Ahmed Ullah Sayed, RN, Marilyn Lee, MN, RN, Donna Rothery, BScN, RN, CNCC(c), and Mikki Layton, MN, NP-Adult, CON(C), CHPCN(C)

Appuyer le développement de la compétence clinique dans la prise en charge des cathéters centraux insérés par voie périphérique pendant la pandémie de COVID-19 : évaluation d’une formation Jennifer Reguindin, M. Sc. inf., inf. aut., CSIG(C), Angel Wang, inf. aut., M. Sc. inf., Kim Capoccitti, M. Sc. inf., inf. aut., Shevaun Lai, inf. aut., B. Sc. inf., candidate à la M. Sc inf., Christine Saby, M. Sc. inf., inf. aut., Natalie Sakin, M. Sc. inf., inf. aut. (Health Systems Leadership and Administration Program), ICPA(C), Wesley Woods, inf. aut., inf. aut. en soins intensifs, Christine Ortiz, inf. aut., CSIO(C), Karen Velasco, inf. aut., Parisa Alvand, M. Sc. inf., inf. aut., Ahmed Ullah Sayed, inf. aut., Marilyn Lee, M. Sc. inf., inf. aut., Donna Rothery, B. Sc. inf., inf. aut., CSI(C) et Mikki Layton, M. Sc. inf., IPS (soins aux adultes), CSIO(C), ICSP(C)

Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 3

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Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimize first-insertion success for patients with Difficult IntraVenous Access in the emergency department (LOVE-DIVA): A study protocol for a randomized controlled trial Hui (Grace) Xu, RN, NP, MN, MNP, PhD candidate, Amanda Corley, RN, MAdvPrac, PhD, Robert S. Ware, BSc (Hons), PhD, Son Nghiem, PhD, Scott Stirling, MBBS, FACEM, FAAEM, Carrie Wang, MBBS, FACEM, and Nicole Marsh, RN, PhD

L’utilisation d’un cathéter intraveineux périphérique long avec un fil-guide rétractable afin d’optimiser la probabilité de réussite de la première insertion chez les patients dont l’abord intraveineux est difficile au service des urgences (LOVE-DIVA) : Un protocole de recherche pour un essai contrôlé à répartition aléatoire Hui (Grace) Xu, inf. aut., IPS, M. Sc. inf., Amanda Corley, inf. aut., maîtrise en pratiques infirmières avancées, Ph. D., Robert S. Ware, B. Sc. (avec distinction), Ph. D., Son Nghiem, Ph. D., Scott Stirling, MBBS, FACEM, FAAEM, Carrie Wang, MBBS, FACEM, et Nicole Marsh, inf. aut., Ph. D.

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Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children Nalan Karaoğlan, Hatice Yıldırım Sarı, and İlker Devrim

Complications associées à l’utilisation des cathéters intraveineux périphériques et facteurs de risque d’infiltration ou de phlébite chez les enfants Nalan Karaoğlan, Hatice Yıldırım Sarı et İlker Devrim

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COLLABORATING FOR BEST PRACTICE Beware its twin: Intrathecal implanted ports – Part 2: Safety considerations Janny Proba, RN, BScN, MEd, EdD(c), CON(C), CHPCN(C), CVAA(c)

Vascular Access Peer Reviewers Astride Bazile, RN, MSc Angele Caporicci, RN, CVAA(c), DipAdEd Julia Casey, RN, BScN, CVAA(c) Melanie Cates, RN, MSc, CVAA(c) Carmen Cernusca, RN, BScN, MScN, CPN(C), CVAA(c) Annie Chaput, RN, BScN, CVAA(c) Mikhail Cherkashin, MD Nicole Daniel, Inf, BScN Jane DeBoer, RN, MSc Celine Dupont, BPharm, MSc Serena Engler, BScN, RN, CVAA(c) Moataz Fatthy, MD Francesca Frati, MLIM, MA, BFA Alberto Galase, RN, MN, CVAA(c) Brendan Smith Hanratty, BSc (Hons), PgCert, RN Paula Harvalik, RN, BScN, MN Chad Johnson, RN, MSc(N) Karen Laforet, RN, MClSc, IIWCC, VA-BC™, CVAA(c) Jessica Lamont, RN, CVAA(c)

Page 4 • Vascular Access • Volume 16, Issue 2, Summer 2022

Luisa Luciani Castiglia, RN, MSc(A) Caroline Marchionni, RN, MSc(N), MSc(A) Amy McClocklin, RN, BN Sheryl McDiarmid, RN, BScN, MEd, MBA, AOCN, ACNP, CVAA(c), CRNI® Megan McQuirter, RN, MSc(N), CCN(C) Pragathi Mulgabal, RN, BScN Kristie Naayer, RN, BScN, CVAA(c), VA-BC™ Kim Newcombe, RN, BScN, CRNI® Diana Pearson, RN, MSN, BScN Janny Proba, RN, BScN, CON(C), CHPCN(C), CVAA(c) Gillian Ray-Barruel, RN, BSN, BA(Hons, English), Grad Cert ICU Nursing, PhD Andrea Raynak, RN, BScN, CVAA(c) Jithin Sagan Sebastian, MCh(VascSurg), MRCS, MS(GenSurg), MBBS Michel Sergerie, RN, MSc Lucie Tardif, RN, MSc(N) Sonja Ozalea Walton, MSN, BSN, RN, CVAA(c)

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Message from the Editor-in-Chief

I

t is summer and I am loving the heat. You might wonder at that because I am sure I have mentioned, in previous editorials, how much I like snow. It is all the messiness in between that I appreciate less than the extremes. Now, I am extremely pleased to offer you an issue that draws from vascular access expertise around the globe presented in a variety of article categories.

We have two observational studies. In the first, Marlena Ornowska and colleagues write from Simon Fraser University and the Royal Columbian Hospital in Canada’s far west. Due to the problem of complications in central venous access devices in an adult critical care population, they studied central line locking practices to see if they offered enough time to be effective. Some locking solutions that are effective in other areas, may not work in a critical care setting. Since the COVID pandemic amplified the number of high-acuity patients, they incorporated the specific concerns of critical care to determine the best locking solutions for preventing line complications in this population. This is valuable information for anyone working in a critical care setting.

The second observational study comes to us from Wangaratta, Australia. Believing midlines, where warranted, offer a better patient experience, Paul Jones wanted to establish a way to ensure midlines were safely and effectively inserted. A framework for a midline catheter service was developed and implemented in a regional hospital and in the community. The service would help reduce cannulation attempts by training nurses in midline insertion and improve the overall experience for patients and staff. After implementation, first-time insertion rates increased to 86%.

Read how, in spite of limited resources, the midline service was a success.

An education evaluation was done by Jennifer Reguindin and colleagues who range from Toronto, Ontario to Athabasca, Alberta. Their study, done at the Michael Garron Hospital in East York, Ontario, responded to the increased need for development of vascular access practices and training in the wake of the COVID pandemic. The increased acuity of inpatients spurred the need for peripheral intravenous central catheters (PICCs), usually inserted and managed by the vascular access team. By the second wave of the pandemic, the demand for the team was becoming cvaa.info

© CVAA 2022

overwhelming. More nurses, RNs and RPNs, needed to be trained to insert and manage PICCs. This article outlines the development of their training plan, how it was implemented across the hospital, and shows how it was evaluated. Success included fewer calls to the busy vascular access team and improved nursing competency. This is a must-read for nursing leaders or anyone involved in establishing policy, clarifying nursing roles, and supporting successful practice.

Hui Xu and colleagues offer a study protocol for a two-armed, randomized controlled trial to be done in the emergency departments (ED) of two hospitals in Brisbane, Australia.

Calling it LOVE-DIVA, the study looks at using a retractable guidewire for inserting a long peripheral vascular access device (PVAD) to improve first-time insertion rates in patients with difficult vascular access (DIVA). Insertion failure negatively impacts the patient’s experience, while adding to staff stress and workload and organizational costs. By comparing guidewire-led long PVADS with standard PVADS, they examined the first-insertion success rate, along with other contributing factors, such as dwell time, the time it takes to insert, number of attempts needed, patient experience, allcause failure, complications, and cost effectiveness of each.

Getting a view of upcoming research trials, like this one, is a great way to get those innovative juices flowing.

We have a prospective study for our reprinted article from the British Journal of Nursing IV Supplement. Karaoğlan and colleagues conducted their study in the largest children’s hospital in a region in Turkey. The authors looked at peripheral intravenous catheter complications and what components contributed to developing infiltration, extravasation, or phlebitis in hospitalized children. We receive few manuscripts about vascular access in pediatrics and are pleased to share this in-depth look at risk factors of such a vulnerable population.

Our feature column, Collaborating for Best Practice, carries the follow-up article from our Spring 2022 Issue, “Beware the Twin: Intrathecal Implanted Ports—Part 2: Safety considerations.” In Part 1, Janny Proba shared her expertise in outlining the challenges to identifying and caring for these special vascular access devices. Here she offers 11 safety considerations and a table that compares the care and management differences between vascular access ports and intrathecal implanted ports. Best practice Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 5

means having the knowledge and skill to provide safe and competent care, even in areas that may be uncommon in your practice. Read up and add this important information to your knowledge arsenal.

And now for some exciting news! In our efforts to continue to expand and educate through collaboration, CVAA has partnered with the Australian Vascular Access Society (AVAS). More than ever, as a planet, we are aware that growth and expansion require working together as individuals, as organizations, and as fields of study. Both CVAA and AVAS are working toward improving the practice of vascular access, and part of that is sharing knowledge through writing and publishing. Our first article from AVAS is the study protocol from Xu et al. For more information about the partnership, check out our announcement below.

I hope you get time to enjoy the good weather, whatever your definition of that is. My many editorial projects will keep me pleasantly occupied, but I will be sure to take time to sit on my balcony with a good cup of tea and something good to read – like a journal.

Have a good summer, Linda M. Verde Editor-in-Chief

Continuing to Partner in Publishing Excellence The Canadian Vascular Access Association and The Australian Vascular Access Society The Australian Vascular Access Society (AVAS) shares CVAA’s commitment to improving and setting standards for vascular access and infusion therapy and promoting best practice in this specialized field. In keeping with our dedication to disseminating knowledge and excellence through our journal, CVAA will receive manuscripts from AVAS that will then be subject to our regular peer review and publication process, and published in our journal, Vascular Access. This partnership expands the pool of authors and manuscript submissions, offering our journal readers, and CVAA and AVAS members, access to a broader range of leading-edge theories, developments, research, and practices. With open access to our publication, this partnership also raises our organizations’ profiles on a global scale.

We continue to enjoy our partnership with the British Journal of Nursing and know that adding AVAS will widen our window on the world of vascular access and infusion therapy. Welcome AVAS. We look forward to a valuable partnership.

Watch for the AVAS logo to find articles from this partnership. Our first AVAS article is a study protocol for a randomized controlled trial by Xu et al. and is published in this issue (see page 41). For more information about the Society, see AVAS’ website.

Page 6 • Vascular Access • Volume 16, Issue 2, Summer 2022

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Message de la rédactrice en chef

C

’est l’été et je profite de la chaleur. Ça pourrait vous surprendre, parce que je suis certaine d’avoir mentionné mon amour pour la neige dans d’anciens numéros. C’est plutôt le chaos entre ces deux extrêmes que j’apprécie moins. Aujourd’hui, je suis extrêmement ravie de vous offrir un numéro qui s’appuie sur une expertise internationale en matière d’accès vasculaire, présentée dans des articles de différentes catégories.

Nous avons deux études d’observation. Tout d’abord, Marlena Ornowska et ses collègues écrivent en direct de l’ouest du Canada, de l’Université Simon Fraser et de l’Hôpital Royal Columbian. À cause du problème des complications associées aux dispositifs d’accès veineux central chez la population d’adultes recevant des soins intensifs, ils ont étudié les pratiques de verrouillage des cathéters centraux afin de déterminer si elles offraient assez de temps pour être efficaces. Certaines solutions de verrouillage jugées efficaces chez d’autres populations peuvent ne pas fonctionner dans un contexte de prestation de soins intensifs. Depuis que la pandémie de COVID a largement augmenté le nombre de patients dont l’état est critique, ils ont pris en considération les craintes particulières liées au contexte des soins intensifs afin de déterminer les meilleures solutions de verrouillage pour prévenir les complications d’insertion des cathéters chez cette population. Ces renseignements sont précieux pour toutes les personnes qui travaillent dans un service de soins intensifs.

La deuxième étude d’observation arrive de Wangaratta en Australie. Convaincu que les cathéters mi-longs offrent une meilleure expérience aux patients, lorsque la situation justifie leur utilisation, Paul Jones voulait établir un moyen sécuritaire et efficace pour leur insertion. Un service d’insertion de cathéters mi-long a été pensé et mis en place dans un hôpital régional et dans un cadre communautaire. Ce service aiderait à réduire le nombre de tentatives d’insertion des cathéters mi-longs par les infirmières en formation et à améliorer l’expérience globale des patients et du personnel.

Après sa mise en œuvre, le taux d’insertions à la première tentative a augmenté jusqu’à atteindre 86 %. Lisez l’histoire de réussite de ce service d’insertion de cathéters mi-longs malgré un contexte où les ressources étaient limitées.

L’évaluation d’une formation a été faite par Jennifer Reguindin et ses collègues de Toronto (Ontario) et d’Athabasca (Alberta). Leur étude, effectuée à l’Hôpital cvaa.info

© CVAA 2022

Michael Garron d’East York (Ontario), a répondu au besoin accru d’élaboration de pratiques et de formations sur l’accès vasculaire pendant la pandémie de COVID. L’état critique croissant des patients hospitalisés a augmenté le besoin d’avoir recours à des cathéters centraux intraveineux périphériques, habituellement insérés et pris en charge par l’équipe de l’accès vasculaire. Lorsque la deuxième vague de la pandémie est arrivée, la charge de l’équipe était en train de devenir accablante. Il fallait former plus d’infirmières, plus d’infirmières autorisées et plus d’infirmières auxiliaires autorisées sur l’insertion et la prise en charge des cathéters centraux intraveineux périphériques. Cet article décrit l’élaboration de leur plan de formation et sa mise en œuvre dans tous les services de l’hôpital. De plus, il présente la façon dont la formation a été évaluée. Parmi les indicateurs de réussite de ce projet figurent la diminution de la sollicitation de l’équipe de l’accès vasculaire qui était très occupée et l’amélioration des compétences en soins infirmiers. Cet article est d’un intérêt essentiel pour les cadres en soins infirmiers et pour toutes les personnes impliquées dans l’établissement de politiques, la clarification des rôles en soins infirmiers et le soutien des pratiques réussies.

Hui Xu et ses collègues présentent un protocole de recherche pour un essai contrôlé à répartition aléatoire et comportant deux groupes qui sera mené dans les services des urgences de deux hôpitaux de Brisbane, en Australie.

Intitulée LOVE-DIVA, cette étude examine l’utilisation d’un fil-guide rétractable pour l’insertion d’un cathéter intraveineux périphérique long afin d’améliorer le taux de réussite de la première insertion chez les patients dont l’abord vasculaire est difficile. L’échec d’insertion a des répercussions négatives sur l’expérience du patient, sur l’augmentation du niveau de stress et de la charge de travail du personnel, ainsi que sur les coûts pour l’organisation.

En comparant l’utilisation des dispositifs d’accès vasculaire périphérique longs avec un fil-guide et l’utilisation des dispositifs traditionnels, ils ont examiné le taux de réussite de l’insertion à la première tentative ainsi que d’autres facteurs comme la durée de séjour, la durée d’insertion du dispositif, le nombre de tentatives d’insertion, l’expérience du patient, l’échec toutes causes, les complications et le rapport coûts-efficacité dans les deux cas. Avoir un aperçu des essais de recherche à venir est un excellent moyen pour stimuler l’innovation.

Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 7

Nous avons également une étude prospective de notre article repris du British Journal of Nursing IV Supplement. Karaoğlan et ses collègues ont mené leur étude dans le plus grand hôpital pour enfants dans une région de la Turquie. Les auteurs ont examiné les complications associées au cathéter veineux périphérique et aux facteurs qui ont contribué aux cas d’infiltration, d’extravasation et de phlébite chez les enfants hospitalisés. Nous avons reçu peu d’articles sur l’accès vasculaire chez les enfants et nous sommes ravis de partager cette analyse en profondeur des facteurs de risque d’une population aussi vulnérable.

Notre rubrique vedette « Collaborating for Best Practice » (Collaborer pour une pratique exemplaire) présente la suite d’un article publié dans notre numéro du printemps 2022 intitulé « Beware the Twin: Intrathecal Implanted Ports—Part 2: Safety considerations ». Dans la première partie, Janny Proba a partagé son expérience en présentant les défis de l’identification et de la prise en charge de ces dispositifs spéciaux d’accès vasculaire.

Dans cette deuxième partie, elle présente 11 mesures de sécurité ainsi qu’un tableau qui compare les différences en matière de soins et de prise en charge des dispositifs d’accès vasculaire et des dispositifs intrathécaux à chambre implantable. Respecter les pratiques exemplaires signifie avoir les connaissances et les compétences nécessaires pour offrir des soins sécuritaires et professionnels, même dans des domaines qui pourraient être rares dans le cadre de votre pratique. Lisez et enrichissez vos connaissances de ces renseignements importants.

Page 8 • Vascular Access • Volume 16, Issue 2, Summer 2022

Il est temps de partager de bonnes nouvelles! Dans le cadre de nos efforts visant à accroître notre portée et à informer par l’intermédiaire de différentes collaborations, l’ACAV s’est associée à l’Australian Vascular Access Society (AVAS). Plus que jamais, les habitants de notre planète savent que la croissance et l’expansion exigent la collaboration entre individus, organisations et domaines d’étude. L’ACAV et l’AVAS travaillent pour l’amélioration des pratiques en matière d’accès vasculaire, y compris le partage des connaissances par l’intermédiaire de l’écriture et la publication. Notre premier article avec l’AVAS porte sur le protocole de recherche de la chercheuse Xu et de ses collègues. Pour obtenir plus de renseignements sur ce partenariat, lisez l’annonce incluse dans ce numéro.

J’espère que vous aurez tous le temps de profiter de ce beau temps, que vous soyez amateur de chaleur ou de froid. Mes nombreux projets éditoriaux m’occuperont avec plaisir, mais je vais m’assurer de prendre le temps de m’asseoir sur mon balcon pour prendre un bon thé et lire... une revue, par exemple.

Je vous souhaite un bel été!

Linda M. Verde Rédactrice en chef

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Poursuite des partenariats visant l’excellence éditoriale L’Association Canadienne d’Accès Vasculaire et l’Australian Vascular Access Society L’Australian Vascular Access Society (AVAS) partage l’engagement de l’ACAV envers l’amélioration et l’établissement de normes pour l’accès vasculaire et la perfusion ainsi qu’envers la promotion des pratiques exemplaires dans ce domaine spécialisé. Conformément à son engagement envers la diffusion des connaissances et de l’excellence par l’entremise de sa revue, l’ACAV recevra des articles de la part de l’AVAS qui feront l’objet de notre processus régulier d’examen par les pairs et de publication, avant d’être publiés dans notre revue Vascular Access. Ce partenariat augmente le nombre d’auteurs et d’articles soumis, ce qui permet aux lecteurs de notre revue, ainsi qu’aux membres de l’ACAV et de l’AVAS, d’avoir accès à un éventail plus large de théories, de développements, de recherches et de pratiques de pointe. Grâce au libre accès à notre publication, ce partenariat accroît aussi la visibilité de nos organisations à l’échelle mondiale.

Nous continuons de profiter de notre partenariat avec le British Journal of Nursing et nous savons que l’ajout de l’AVAS à nos partenaires nous ouvrira une nouvelle fenêtre sur le monde de l’accès vasculaire et de la perfusion.

Bienvenue à l’AVAS! Nous avons hâte de bâtir ce partenariat précieux.

Surveillez le logo de l'AVAS pour indiquer les articles issus de ce partenariat. Notre premier article avec l’AVAS est un protocole de recherche d’un essai contrôlé à répartition aléatoire par Xu et al. qui est publié dans ce numéro (voir page 41). Pour plus d'informations sur la société, consultez le site Web de l’AVAS.

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Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 9

Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen Marlena Ornowska1*, BSc (Hons.), Jessica Wittmann2, CRC, and Steven Reynolds1,2, BA, MD, FRCPC

Pratiques de verrouillage du dispositif d’accès veineux central dans les services de prestation de soins intensifs aux adultes : Une étude d’observation menée dans un seul centre et visant à établir la durée de verrouillage selon la lumière de cathéter Marlena Ornowska1*, B. Sc. (avec distinction), Jessica Wittmann, coordonnatrice á la recherche clinique, et Steven Reynolds, B.A., M.D., FRCSC 1 2

Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada Department of Critical Care, Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada

Corresponding author: Marlena Ornowska, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6; marlena_ornowska@sfu.ca This is an Open Journal Systems article, distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited and it is not for commercial purposes, and is distributed under the same licence as the original.

Il s’agit d’un article d’Open Journal Systems distribué en vertu du contrat de la licence d’attribution Creative Commons (https://creativecommons. org/licenses/by-nc-sa/4.0) qui permet d’utiliser, de distribuer et de reproduire sans restriction son contenu dans tout support, pourvu que l’œuvre original soit adéquatement citée, ne soit pas utilisée pour des fins commerciales et soit distribuée sous la même licence que l’original.

Suggested citation: Ornowska, M., Wittman, J., & Reynolds, S. (2022). Vascular Access – Journal of the Canadian Vascular Access Association, 16(2), 10–21.

Abstract Purpose: Central line complications remain a problem in critical care patient populations. Various interventions to prevent or treat complications, such as central line-associated bloodstream infection and occlusion, have been the focus of recent research.

Although alternative catheter locking solutions have been shown to be effective in other patient populations, their applicability to the critical care setting remains unclear. Due to the high acuity of critical care patients, it is uncertain whether their central lines remain locked for a duration long enough for alternative locking solutions to provide any effect.

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Methods: This single-centre, prospective, observational study aimed to gather information about the length of time central line lumens remain in a locked state in the average critical care patient. Baseline rates of various central line complications were also tracked.

Results: Results of this study indicate that the majority of central lines will have at least one lumen locked for an average of 36.6% of their time in situ.

Conclusions: It is anticipated that this study provides enough exposure for alternative locking solutions to potentially make a © 2022 Ornowska et al.

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Ornowska, M., Wittman, J., & Reynolds, S.

difference in central line complications in this patient population.

Results of this study can be used for planning future multi-centre, randomized controlled trials investigating the efficacy of novel central line locking solutions to prevent central line complications in critically ill patients.

Keywords: critical care, central venous catheters, catheter locking, catheter related infection, catheter obstruction, observational study

Résumé Objectif : Les complications associées aux cathéters centraux demeurent problématiques dans la prestation de soins intensifs aux populations de patients. Diverses interventions pour prévenir ou traiter les complications, comme l’infection sanguine et l’occlusion liées aux cathéters centraux, ont récemment fait l’objet de recherches. Même si d’autres solutions de verrouillage des cathéters se sont avérées efficaces chez d’autres populations de patients, leur applicabilité dans un contexte de prestation de soins intensifs demeure incertaine. À cause de l’état critique des patients recevant des soins intensifs, on ignore si les cathéters centraux restent verrouillés assez longtemps pour que les autres solutions de verrouillage soient efficaces.

Méthodologie : Cette étude d’observation prospective menée dans un seul centre visait à recueillir des renseignements sur la durée pendant laquelle la lumière du cathéter central reste verrouillée chez le patient moyen recevant des soins intensifs.

Les taux initiaux de diverses complications liées aux cathéters centraux ont également été suivis.

Résultats : Les résultats de cette étude indiquent que la majorité des cathéters centraux auront au moins une lumière verrouillée pour une moyenne de 36,6 % de leur durée in situ.

Conclusions : On s’attend à ce que cette étude offre assez de visibilité aux autres solutions de verrouillage afin d’avoir une incidence potentielle sur les complications liées aux cathéters centraux chez cette population particulière de patients. Les résultats de cette étude peuvent être utilisés pour planifier de futurs essais multicentriques, à répartition aléatoire et contrôlés visant à évaluer l’efficacité des nouvelles solutions de verrouillage des cathéters centraux afin de prévenir les complications associées chez les patients gravement malades.

Introduction

I

nsertion of a central venous access device (CVAD) facilitates easy access to a patient’s circulation, enables administration of irritant medications, parenteral cvaa.info

nutrition, antibiotics, and facilitates frequent bloodwork.

Central venous access is also used to deliver lifesaving measures including renal replacement therapy, extracorporeal membrane oxygenation, and rapid delivery of fluids during hypovolemic shock (O’Grady et al., 2011).

As such, a CVAD is placed frequently among intensive care unit (ICU) patients. Although they are essential to care, complications such as central line infection and occlusion may develop. These complications may become life threatening and serve to increase morbidity and mortality of ICU patients (Ziegler et al., 2015). Preventing complications associated with central venous access is imperative to ensuring the best possible care for patients experiencing critical illness.

Many interventions to prevent complications, such as central line-associated bloodstream infection (CLABSI), catheter occlusion, and premature removal, have been implemented into ICU standards of care. Examples include the use of catheter insertion bundles and checklists (Lee et al., 2018), hub decontamination, or ‘scrub the hub’ procedures (Caspari et al., 2017), regular dressing changes and flushing (O’Grady et al., 2011), daily chlorhexidine bathing (Shah et al., 2016), quality improvement projects relating to adequate staff training (Coopersmith et al., 2002; Warren et al., 2004), and maintenance of appropriate staffing of units (Holder et al., 2020; Stone et al., 2008). Many modifications to catheters themselves are also available including silver impregnation and antibiotic coating (Lorente et al., 2016). Despite these efforts, CVAD complications remain a problem in the ICU setting. According to the Canadian Nosocomial Infection Surveillance Program, the rate of CLABSI was reported to be 1.2 per 1,000 catheter days in the adult mixed ICU in 2018 (Canadian Nosocomial Infection Surveillance Program1*, 2020). Recent changes to practice caused by the COVID-19 pandemic have been shown to increase rates of CLABSI by as much as 325% (Assi et al., 2021; LeRose et al., 2021).

The use of alternative catheter locking solutions with additional antimicrobial and anticoagulant properties presents an enticing option to clinicians, as a means of complication prevention. Catheter locking is already part of standard catheter maintenance, thus requiring no additional effort from nursing staff. As the catheter lock stays in the internal lumen of the catheter only when the patient is not receiving any medication or fluids, there is no need to worry about incompatibilities. Further, the use of highly concentrated fluids as a lock is possible, as catheter locks Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 11

Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen

are aspirated and do not enter the patient’s circulation.

These high concentrations may be more effective at killing microorganisms and preventing occlusions, as compared to lower systemic doses ( Justo & Bookstaver, 2014).

Although there may be benefits to using alternative catheter locking fluids, the potential for them to make a difference in the adult critical care population is unclear. Due to the high acuity of these patients, CVADs may be in use for the majority of a patient’s stay, without the possibility of being locked for a long enough duration for the fluid to be effective.

The purpose of this observational study is to determine the amount of time CVAD lumens in the ICU remain in use versus in a locked state. Baseline rates of CVAD complications potentially modifiable by a change in locking practices were also tracked, although they have previously been well documented in the literature in larger studies.

Results of this study will serve to inform the protocol, enrollment timeline, and power calculations of a future randomized controlled trial investigating the effect of 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) as a catheter-locking fluid in the prevention of central line complications in the adult critical care population (NCT04548713).

Materials and methods Study design This was a single-centre observational study that utilized a combination of prospective and retrospective data collection techniques.

Setting The setting of this study included a 30-bed adult intensive care unit (ICU) and high acuity unit (HAU) located in a tertiary care hospital in New Westminster, British Columbia, Canada. The observation period began on December 8, 2020, and ended on January 5, 2021. As there was no intervention in this study, there was no follow-up. Standard protocol for HAU and ICU CVAD care at this hospital is included in the Appendix.

Participants and enrolment Participants of this study included adult patients (18 years or older), admitted to the ICU or HAU during the observation period and who met inclusion and exclusion criteria. Patients were eligible to be enrolled in the study if they were admitted to the ICU or HAU and had a central venous access device Page 12 • Vascular Access • Volume 16, Issue 2, Summer 2022

that required locking. This included central venous catheters (CVCs), peripherally inserted central catheters (PICCs), and hemodialysis catheters. Patients were excluded from the study if they had a confirmed or suspected pregnancy, declined to receive blood products, declined to participate, or were currently enrolled in any other research study that could confound outcome measures.

The inclusion and exclusion criteria used for this observational study were the same that will be used in the future randomized controlled trial. The decision to keep the inclusion and exclusion criteria the same was made to determine the enrolment rate during the observational study, to inform the estimated recruitment timelines of the future trial.

Outcome measures and diagnostic criteria Patient baseline characteristics collected during this study included patient age, sex at birth, APACHE IV score upon admission, any immunodeficiency, and if they had previously experienced a case of CLABSI or CVAD occlusion prior to their enrolment in the study. Information about pre-ICU and ICU length of stay was also collected.

Members of the research team gathered information used to calculate the proportion of time that a patient’s CVAD spent in a locked state during the entirety of its ICU lifecycle.

Other outcome measures included incidence rates of CLABSI, catheter colonization, catheter occlusion requiring alteplase use, catheter occlusion requiring replacement, extravasation/local infection/phlebitis at the site of catheter insertion, and catheter-related venous thrombosis.

Diagnostic criteria were based on national guidelines.

Reasons for CVAD removal were also tracked and recorded.

Data sources and measurement Sources of data collection include routine records kept in patient charts, medical imaging records, laboratory results, and microbiology results, as well as results from an in-person data gathering discussion with the nursing staff.

Ethics approval Permission to conduct this study protocol was provided by the Fraser Health Research Ethics Board. This protocol was also reviewed and approved by the University of British Columbia Clinical Ethics and Simon Fraser University Ethics Boards. As this was not an interventional study, there was no need for informed consent. Study procedures began promptly following ethics and institutional approval. cvaa.info

Ornowska, M., Wittman, J., & Reynolds, S.

Data collection Data collection for this study took place in two parts.

First, between December 8, 2020, and January 5, 2021, eligible patients in the ICU were enrolled prospectively by members of the research team according to inclusion and exclusion criteria. Upon enrolment, paper case report forms (CRFs) containing details about patient baseline characteristics, dates of hospital stay, CVAD type, and date of CVAD insertion were completed by reviewing patient charts. Following enrolment, data regarding locking status was obtained through engaging in daily discussions with nursing staff about the status of their patients’ CVADs. Data related to central line complications and reasons and dates of removal were collected via a combination of review of patient charts, as well as in-person discussions with nursing staff to gain additional details or clarifications.

Information about whether each catheter lumen in the ICU was in use or locked was collected twice daily (AM shift and PM shift) during the above-mentioned in-person discussions with nurses by the Research Coordinator ( JW).

The percentage of time each catheter was in a locked state was calculated by determining the percentage of data points recorded as ‘locked’ as compared to the total data points, per catheter and per individual lumen.

The second part of data collection occurred between March 15 and April 9, 2021. This portion of data collection included a retrospective chart review of HAU patients admitted to the unit between December 8, 2020, and January 5, 2021, and the continued follow-up of ICU patients who were transferred to the HAU within that same time period.

Due to administrative delays in obtaining relevant ethics board approval to include HAU patients prior to the start of ICU in-person data collection, these data were collected retrospectively and were limited to information found only in patients’ charts, without information provided by nursing staff. As such, only data regarding CVAD type, insertion date, removal date, reason for removal, and complications were collected. These were combined with data from the ICU patients enroled previously.

Locking data for the HAU patients were also gathered via retrospective chart review. However, upon assessment of the quality and completeness of data gained prospectively versus retrospectively, we opted not to combine HAU locking data with that obtained from ICU patients. This review process served to inform future data collection procedures for future trials. cvaa.info

The patients were followed by members of the research team until their discharge or end of the observational period, whichever happened first. All CVAD care and maintenance procedures remained the same throughout the observation period. The standard protocol included flushing locked lumens every 12 hours for CVCs and PICCs, and every 48 hours for hemodialysis catheters, as described in the Appendix.

Results Participants A total of 75 patients were enrolled in the study during the observation period. All patients who were confirmed eligible completed the study. Data from all 75 patients were included in the analysis. A total of 46 (61.3%) were male. The mean (±SD) age of patients enrolled in our study was 60 (±15) years old, with an APACHE IV score of 112 (±29). The youngest patient was 18 years old, and the oldest was 85.

On average, patients had a pre-ICU/HAU hospital stay of 4 (±12) days (n = 29 patients), and an ICU and HAU length of stay of 9 (±10) days. One patient had a pre-ICU hospital stay of 86 days. Of all patients, two (2.7%) had previously experienced CLABSI and CVAD occlusion during their hospital stay. Two patients were immunocompromised (summarized in Table 1).

Table 1 Baseline Characteristics of Patients Enrolled During the Observation Period in the ICU and HAU Population Characteristic

Mean ± SD

Age (years)

60 ± 15

APACHE IV score

112 ± 29

Pre-ICU hospital LOS (days)

4 ± 12

ICU LOS (days)

9 ± 10

Sex, male

N (%)

46 (61.3)

Immunocompromised

2 (2.7)

Previous CLABSI

2 (2.7)

Previous CVAD occlusion

2 (2.7)

Types of CVADs recorded in ICU and HAU Patients A total of 125 CVADs were observed during the study period. Of these, the majority were non-tunneled, triplelumen catheters, single-lumen hemodialysis lines, and triplelumen PICCs (n = 77, 17 and 17, respectively). The next most common type observed was the double-lumen PICC (n = 9; summarized in Table 2).

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Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen

Table 2 Count of CVAD Types Inserted into Patients Enrolled During the Observation Period in the ICU and HAU Population CVAD Type

N = 125

Non-tunneled CVC (3 lumen)

77

Hemodialysis catheter (1 lumen)

18

PICC (3 lumen)

17

PICC (2 lumen)

9

PICC (1 lumen)

1

Cordis single lumen

1

9 French introducer sheath central line

1

8.5 French introducer sheath central line

1

CVAD days and Locking Data The average number of days that a CVAD was in place in ICU and HAU patients was 7 (±6) days. The minimum number of days observed was 1 day, and the longest a CVAD was observed to be in place for was for 31 days. The total number of catheter-days of CVADs tracked in this study was 871 catheter-days.

Out of the 77 triple-lumen, non-tunneled catheters tracked, results indicate the medial and proximal lumens were locked for 24.1% and 36.6% of their lifespan, respectively. The distal lumen was found to be locked for an average of 3.2% of its time in situ. A separate analysis was also performed

to determine whether there was a difference in percentage of locked time depending on type of lumen (distal, medial, or proximal). Results of a Kruskal-Wallis test showed significant differences in percentage of locked time between lumens (p = 0.000). Follow-up post hoc testing, using a Dunn’s Multiple Comparisons test, revealed significant differences between the distal and medial (p = 0.000), and distal and proximal lumens (p = 0.000), but not between medial and proximal lumens (p = 0.095). All analyses were performed at alpha = 0.05 (see Figure 1).

For all CVADs tracked in ICU patients (including triplelumen catheters, PICCs, and hemodialysis catheters), it was found that each catheter had at least one lumen locked for an average of 22.4% (± 21.0) of its time in situ.

Complication rates The most common complications recorded during the observation period were CVAD occlusions (23 cases, or 18.4%) and associated alteplase use (also 23 cases, or 18.4%). This equates to an event rate of 26.41 cases per 1,000 catheter days (as shown in Table 3). One CVAD experienced occlusion of all three lumens and was consequently replaced (0.8%, or 1.15 cases per 1,000 catheter days). A catheterrelated venous thrombosis was observed in one catheter.

With regards to infectious complications, one case of CLABSI and one case of colonization were observed.

Figure 1 Proportion of Time CVCs “In-Use” vs “Locked”

Note: Data was gathered from 67 CVCs tracked during the study. The distal lumen was locked for an average of 3.2% of its time in situ. The medial and distal lumens were locked for 24.1% and 36.6% of their lifespans, respectively. Significant difference (p < 0.05) is denoted by an asterisk. *CVC = central venous catheter Page 14 • Vascular Access • Volume 16, Issue 2, Summer 2022

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Discussion

Table 3 CVAD Complications During the Observation Period in the ICU and HAU Population Complication

# Cases

Event Rate%

Event Rate (per 1,000 catheter days)

Confirmed CLABSI

1

0.8

1.2

Occlusion

23

18.4

26.4

Replacement due to occlusion

1

0.8

1.2

Catheter-related venous thrombosis

1

0.8

1.2

Doses of alteplase

23

18.4

26.4

Extravasation/local phlebitis

0

0

0

Catheter colonization

1

0.8

1.2

The organism that was responsible for the CLABSI case was Staphylococcus epidermidis. This patient was only in the ICU for a few hours for end-of-life care and acquired this infection in their previous unit.

Reasons for CVAD removal A summary of reasons for CVAD removal can be found in Table 4. Thirty-nine patients were discharged from the ICU with either their CVC or PICC line still in place.

Aside from patient death, the most common reason for CVAD removal was due to an investigation of an infection.

Nine CVADs were observed to be removed for this reason, even though only one was determined to be a confirmed case of CLABSI. Table 4 Reasons for CVAD Removal or Loss to Follow-up During the Observation Period in the ICU and HAU Population Reason for Removal

N = 125

Removed due to investigation for infection

10

Removed due to occlusion of all 3 lumens

1

Removed due to presence of a clot

1

Change from CVC to PICC for long-term access

10

Patient left unit with CVAD in place (loss to follow-up)

42

Reduced clinical need

3

Patient death

22

Still in place at study end

19

Accidentally removed during patient manipulation

2

Unknown (reasons not listed in HAU patient chart)

15

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Results reveal that at least one lumen of the majority of central lines in the ICU is locked for longer than a third of the total time in situ. This is a much larger proportion of time than initially expected and the first time that this has been reported in the literature, to our knowledge. This is an important finding as it indicates that the lumen of a catheter has a locking solution in situ for a significant proportion of time, allowing it to have a local effect on biofilm and thrombus production. This emphasizes the importance of using effective CVAD locking solutions and performing appropriate clinical testing powered to detect differences in complication rates (Pérez-Granda et al., 2014; Quenot et al., 2019; Souweine et al., 2015).

These baseline rates of CVAD complications during this observation period are comparable to the incidence rates in Canada previously reported in the literature (Canadian Nosocomial Infection Surveillance Program1*, 2020). With regards to global comparisons rates, a 2018 meta-analysis

by Takashima et al. (2018) revealed the incidence rates for CLABSI to be 4.59 per 1,000 catheter days. The results of this study put the pooled percentage of occlusion or blockage of the catheter at 11%, which is lower than the 18.4% observed in our study (Takashima et al., 2018). This large meta-analysis compiled the outcomes of more than 50,000 CVADs and 396,951 catheter days in 63 international studies, which can help explain discrepancies with our own results. Occlusion rates at our centre also were found to be higher than those reported by Takashima et al. (2018). This may be due to nursing culture at our unit, to lock central line catheters when not in use, as compared to other units where the standard may be to keep all catheter lumens open with patency maintenance fluid infusion. Although potentially appealing as a method to reduce CVAD complication rates, ongoing additional fluid administration has well recognized consequences.

Even a low amount of fluid administration can accumulate over a long period of time and lead to fluid overload, which has been shown to be positively associated with increased complications and mortality (Bouchard et al., 2009; ClaureDel Granado & Mehta, 2016; Gillespie et al., 2004).

Results of baseline characteristics of patients enrolled in this study are representative of the typical ICU patient. These baseline characteristics were of interest to us, as previous literature has shown them to be related to the development of CVAD complications (Baskin et al., 2009; Hermite et al., 2012; Lissauer et al., 2012; van Rooden et al., 2005).

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Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen

One interesting observation made during the study was the presence of a few patients who contributed multiple incidents to the complication count. One patient experienced six occlusions that were resolved with six doses of alteplase to one of their CVADs. Similarly, another patient experienced three CVAD occlusions, required four doses of alteplase, and one colonization incident in one of their CVADs. This patient then experienced a subsequent five occlusions that were resolved with six doses of alteplase in the next CVAD they had inserted during their ICU stay. The medical charts of these patients warrant further investigation for the identification of potential risk factors that could have contributed to their high complication rates. These cases also provide evidence to support the notion that CVAD infections and occlusions are related, and that the development of one of these complications increases the risk for the development of another (Timsit et al., 1998; Baskin et al., 2009; Ryder, 2005). Ideally, locking interventions aimed at preventing the development of catheter complications should possess antimicrobial, antibiofilm, and either anticoagulant or antithrombotic properties.

Examples of alternative locking solutions studied to date include ethanol, taurolidine, various antibiotics, and ethylenediaminetetraacetic acid (EDTA). Efficacy of these alternatives has been compared to current standard of care saline, heparin, and citrate. Although potentially protective, benefits must be weighed against risks of use.

For example, ethanol has been shown to damage industrystandard polyurethane and silicone catheters (Mermel & Alang 2014), stimulate S. aureus and S. epidermidis biofilm formation (Luther et al., 2015; Redelman et al., 2012), and cause adverse events (Wolf et al., 2018; PérezGranda et al., 2014) in patients. In terms of risks to the global healthcare system, use of antibiotic locks has been discouraged with the emergence of antibiotic-resistant bacteria and subsequent shift toward antibiotic stewardship initiatives (Laxminarayan et al., 2013). Further, many of the locking fluid alternatives studied are effective at preventing only certain avenues of complication. For example, while taurolidine has been shown to be effective in eradicating gram-negative bacteria (Liu et al., 2013), complications may still arise due to gram-positive infection. Additionally, ethanol, antibiotic, and taurolidine locks lack significant antithrombotic or anticoagulant activity.

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In contrast, chemical chelators, such as EDTA, exhibit potent antimicrobial, antibiofilm, and anticoagulant properties (Percival & Salisbury, 2017). Although promising for use as a locking fluid in the critical care setting, evidence for its efficacy in the literature is limited to a few randomizedcontrolled trials in other patient populations (Campos et al., 2011; Ferreira Chacon et al., 2011; Kanaa et al., 2015; Luiz et al., 2017; Rijnders et al., 2019) and in vivo analysis (Liu et al., 2018), highlighting the need for further investigation and premise for our future trial.

Another important finding of this study includes that one of the most common reasons for CVAD removal in the ICU is due to suspicion of a potential infection. This reflects standard practice in the ICU to remove all lines out of an abundance of caution when the patient begins showing signs of unexplained infection. The majority of CVADs removed for this reason were either not sent for microbiological testing, or not found to be the cause of infection. Although protective for the patient, this results in added utilization of healthcare resources and cost to the system (Pearse et al., 2021). The use of alternative locking solutions could potentially reduce the number of CVADs replaced unnecessarily by reducing the probability of the CVAD causing an infection.

Limitations The significant limitation of this study includes the lack of quality locking data for part of the study population. Due to the reduced acuity of HAU patients, it is likely that rates of CVAD locking are higher in this unit, contributing further cause for the usefulness of a locking intervention.

Further, this study was performed only at a single centre.

This limits generalizability, and is reflective only of nursing culture at our site. Nevertheless, we feel patients and standard CVAD care procedures at our centre are consistent with international guidelines and may be representative of many ICUs. Due to the limited generalizability and level of evidence of this study, results should be interpreted as descriptive and hypothesis-generating only.

Another limitation of the study includes not systematically investigating each CVAD for presence of colonization following removal. According to standard practice at our unit, CVADs in the ICU are only removed for testing at the discretion of the treating physician based on patients’ infection symptomatology. As such, it is likely that the true rate of CVAD colonization was under-represented by the cvaa.info

Ornowska, M., Wittman, J., & Reynolds, S.

results of this study. However, as this is standard practice in most ICUs, the rate of catheter colonization was still in line with previously published literature (Takashima et al., 2018).

Lastly, a limitation of this study includes potential bias caused by nurses being unblinded to study procedures and subsequent effect on the CVAD complication rate. As the inperson data component was essential to gathering important information about CVAD locking status, there was no way to prevent this unblinding.

Conclusions Although the results from this study should be generalized with caution, it is a reasonable assumption that duration of CVAD lumen locking is under-utilized as a tool to help protect against CVAD complications. The critical care population is a good candidate for investigations of alternative locking fluids due to adequate exposure to the locking intervention and high rates of CVAD occlusions potentially modifiable by locking practices. Prevention of CVAD complications in this population is essential to reduce morbidity and mortality and improve patient outcomes.

About the authors Marlena Ornowska, BSc (Hons), is a PhD Student at Simon Fraser University, under the supervision of Dr. Steven Reynolds. The topic of her thesis involves reduction of complications associated with central venous access devices.

Alongside Dr. Reynolds, Marlena is co-investigator of an ongoing multicentre clinical trial examining the effects of locking with EDTA on infection and occlusion rates in the critical care population. Marlena had previously completed her Bachelor of Science (Hons) at Simon Fraser University, majoring in Biomedical Physiology.

Jessica Wittmann, CRC, is a Clinical Research Coordinator in the Critical Care Unit at Royal Columbian Hospital. Throughout her time as a coordinator, she has contributed to protocol development and data collection of a variety of research projects related to reducing risk associated with ICU stay. Her research interests include improvement of mechanical ventilation practices, non-pharmacologic delirium management technology, and reduction of complications associated with central venous access.

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Dr. Steven Reynolds, BA, MD, FRCPC, is a researcher and critical care physician at Royal Columbian Hospital. He is the recipient of the TB Vets Charitable Foundation Professorship in Critical Care, through which he is able to support his research surrounding development of novel solutions to clinical problems. Dr. Reynolds’ research interests include novel central venous access device technology, nonpharmacologic delirium management, as well as prevention of ventilator-induced organ injury. He has previously been awarded two CIHR grants as Principal Investigator, and holds an Associate Professor position in the Biomedical Physiology and Kinesiology Department at Simon Fraser University. He has also recently completed his term as a Wall Institute Scholar, and is looking forward to growing his research portfolio as the Executive Lead at the Institute for Advancing Innovations in Medicine at Royal Columbian Hospital.

À propos des auteurs Marlena Ornowska, B. Sc. (avec distinction), doctorante est doctorante à l’Université Simon Fraser, sous la direction du Dr Steven Reynolds. Sa thèse porte sur la réduction des complications associées aux dispositifs d’accès veineux central.

En collaboration avec le Dr Reynolds, Marlena est co-chercheuse dans un essai clinique multicentrique en cours visant à examiner les effets du verrouillage par l’acide éthylènediaminetétraacétique (EDTA) sur les taux d’infections et d’occlusions chez la population recevant des soins intensifs. Elle a obtenu son baccalauréat ès sciences spécialisé en physiologie biomédicale (avec distinction) de l’Université Simon Fraser.

Jessica Wittmann, coordonnatrice à la recherche clinique, est coordonnatrice à la recherche clinique au sein de l’unité des soins intensifs de l’Hôpital Royal Columbian. Dans le cadre de son rôle de coordonnatrice, elle a contribué à l’élaboration de protocoles et à la collecte de données pour différents projets de recherche portant sur la réduction des risques associés au séjour à l’unité des soins intensifs. Ses recherches portent notamment sur l’amélioration des pratiques de ventilation artificielle, la technologie de prise en charge non pharmacologique du delirium et la réduction des complications associées à l’accès veineux central.

Dr Steven Reynolds, B.A., M.D., FRCSC, est chercheur et médecin aux soins intensifs à l’Hôpital Royal Columbian. Il a reçu la chaire de recherche en soins intensifs de la fondation caritative TB Vets qui lui permet de soutenir ses recherches sur l’élaboration de nouvelles solutions aux problèmes cliniques.

Ses recherches portent notamment sur les nouvelles technologies Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 17

Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen

des dispositifs d’accès veineux central, la prise en charge non pharmacologique du delirium ainsi que la prévention des lésions aux organes causées par les ventilateurs. Il a précédemment reçu deux subventions des IRSC à titre de chercheur principal.

De plus, il est professeur agrégé au département de physiologie et de kinésiologie biomédicales de l’Université Simon Fraser.

Il a récemment terminé son mandat comme érudit au Wall Institute et il a hâte d’agrandir son portefeuille de recherches à titre de responsable de la direction à l’Institute for Advancing Innovations in Medicine de l’Hôpital Royal Columbian.

Funding Statement This research was funded through the Royal Columbian Hospital Foundation Research Fund 2020. The funder had no role in study design, the collection, analysis, and interpretation of data, in writing the report, nor in the decision to submit the article for publication.

Conflicts of Interest Authors declare no conflicts of interest.

Acknowledgments The investigators would like to extend their sincere gratitude to the entire ICU nursing staff at Royal Columbian Hospital, for their incredible efforts in contributing to data acquisition.

In particular, we thank ICU Nurse Educators, Kerri Johnston and Tanis Kohlen, for their invaluable insight into CVAD care procedures and support of this study. We also thank Michelle Nicholas for contributing her knowledge of charting to aid with patient chart review.

References Assi, M. A., Doll, M., Pryor, R., Cooper, K., Bearman, G., & Stevens, M. P. (2021). Impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections: An update and perspective. Infection Control & Hospital Epidemiology, 1–2. https://doi.org/10.1017/ice.2021.92 Baskin, J. L., Pui, C.-H., Reiss, U., Wilimas, J. A., Metzger, M. L., Ribeiro, R. C., & Howard, S. C. (2009). Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. The Lancet, 374(9684), 159–169. https://doi.org/10.1016/S0140-6736(09)60220-8 Bouchard, J., Soroko, S. B., Chertow, G. M., Himmelfarb, J., Ikizler, T. A., Paganini, E. P., & Mehta, R. L. (2009). Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney International, 76(4), 422–427. https://doi.org/10.1038/ ki.2009.159

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Campos, R. P., do Nascimento, M. M., Chula, D. C., & Riella, M. C. (2011). Minocycline-EDTA lock solution prevents catheter-related bacteremia in hemodialysis. Journal of the American Society of Nephrology: JASN, 22(10), 1939–1945. https://doi.org/10.1681/ASN.2010121306 Canadian Nosocomial Infection Surveillance Program1* (2020).

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The impact of coronavirus disease 2019 (COVID-19) response on central-line-associated bloodstream infections and blood culture contamination rates at a tertiary-care centre in the Greater Detroit area. Infection Control & Hospital Epidemiology, 42(8), 997–1000. https://doi.org/10.1017/ice.2020.1335 Lissauer, M. E., Leekha, S., Preas, M. A., Thom, K. A., & Johnson, S. B. (2012). Risk factors for central line-associated bloodstream infections in the era of best practice. Journal of Trauma and Acute Care Surgery, 72(5), 1174–1180. https:// doi.org/10.1097/TA.0b013e31824d1085 Liu, Y., Zhang, A.-Q., Cao, L., Xia, H.-T., & Ma, J.-J. (2013).

Taurolidine lock solutions for the prevention of catheterrelated bloodstream infections: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE, 8(11), e79417. https://doi.org/10.1371/journal. pone.0079417 Luiz, M. V. S. J., Scavone, C., & Tzanno, C. (2017). The CLOCK trial, a double-blinded randomized controlled trial: Trisodium citrate 30% and minocycline 3 mg/mL plus EDTA 30 mg/ mL are effective and safe for catheter patency maintenance among CKD 5D patients on hemodialysis. Hemodialysis International. International Symposium on Home Hemodialysis, 21(2), 294–304. https://doi.org/10.1111/hdi.12492 Lorente, L., Lecuona, M., Jiménez, A., Raja, L., Cabrera, J., Gonzalez, O., Diosdado, S., Marca, L., & Mora, M. L. (2016).

Chlorhexidine-silver sulfadiazine- or rifampicin-miconazoleimpregnated venous catheters decrease the risk of catheterrelated bloodstream infection similarly. American Journal of Infection Control, 44(1), 50–53. https://doi.org/10.1016/j. ajic.2015.08.014 Luther, M. K., Bilida, S., Mermel, L. A., & LaPlante, K. L. (2015).

Ethanol and isopropyl alcohol exposure increases biofilm formation in Staphylococcus aureus and Staphylococcus epidermidis. Infectious Diseases and Therapy, 4(2), 219–226. https://doi.org/10.1007/s40121-015-0065-y Mermel, L. A., & Alang, N. (2014). Adverse effects associated with ethanol catheter lock solutions: A systematic review. The Journal of Antimicrobial Chemotherapy, 69(10), 2611–2619. https://doi.org/10.1093/jac/dku182 cvaa.info

O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., Lipsett, P. A., Masur, H., Mermel, L. A., Pearson, M. L., Raad, I. I., Randolph, A. G., Rupp, M. E., Saint, S., & the Healthcare Infection Control Practices Advisory Committee (HICPAC) (Appendix 1). (2011).

Guidelines for the prevention of intravascular catheterrelated infections. Clinical Infectious Diseases, 52(9), e162– e193. https://doi.org/10.1093/cid/cir257 Pearse, I., Corley, A., Rickard, C. M., & Marsh, N. (2021).

Unnecessary removal of vascular access devices due to suspected infection in Australian intensive care units.

Australian Critical Care, S1036731421001417. https://doi. org/10.1016/j.aucc.2021.09.005 Percival, S. L., & Salisbury, A.-M. (2017). The efficacy of tetrasodium EDTA on biofilms. In G. Donelli (Ed.), Advances in microbiology, infectious diseases and public health (Vol. 1057, pp. 101–110). Springer International Publishing. https://doi. org/10.1007/5584_2017_134 Pérez-Granda, M. J., Barrio, J. M., Muñoz, P., Hortal, J., Rincón, C., Rabadán, P. M., Pernia, M. S., & Bouza, E. (2014). Ethanol lock therapy (E-Lock) in the prevention of catheter-related bloodstream infections (CR-BSI) after major heart surgery (MHS): A randomized clinical trial. PLoS ONE, 9(3), e91838. https://doi.org/10.1371/journal.pone.0091838 Quenot, J.-P., Helms, J., Bourredjem, A., Dargent, A., Meziani, F., Badie, J., Blasco, G., Piton, G., Capellier, G., Mezher, C., Rebibou, J.-M., Nadji, A., Crepin, T., Barbar, S. D., Fleck, C., Cransac, A., Boulin, M., Binquet, C., Soudry-Faure, A., & Bruyère, R. (2019). Trisodium citrate 4% versus heparin as a catheter lock for non-tunneled hemodialysis catheters in critically ill patients: A multicenter, randomized clinical trial.

Annals of Intensive Care, 9(1), 75. https://doi.org/10.1186/ s13613-019-0553-4 Redelman, C. V., Maduakolam, C., & Anderson, G. G. (2012).

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Central venous access device locking practices in the adult critical care setting: A single-centre, observational study establishing duration of locking per catheter lumen

Boyer, A., … Timsit, J.-F. (2015). Ethanol lock and risk of hemodialysis catheter infection in critically ill patients. A randomized controlled trial. American Journal of Respiratory and Critical Care Medicine, 191(9), 1024–1032. https://doi. org/10.1164/rccm.201408-1431OC Stone, P. W., Pogorzelska, M., Kunches, L., & Hirschhorn, L. R. (2008). Hospital staffing and health care-associated infections: A systematic review of the literature. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 47(7), 937–944. https://doi. org/10.1086/591696 Takashima, M., Schults, J., Mihala, G., Corley, A., & Ullman, A. (2018). Complication and failures of central vascular access device in adult critical care settings. Critical Care Medicine, 46(12), 1998–2009. https://doi.org/10.1097/ CCM.0000000000003370 Timsit, J. F., Farkas, J. C., Boyer, J. M., Martin, J. B., Misset, B., Renaud, B., & Carlet, J. (1998). Central vein catheter-related thrombosis in intensive care patients: Incidence, risks factors, and relationship with catheter-related sepsis. Chest, 114(1), 207–213. https://doi.org/10.1378/chest.114.1.207 van Rooden, C. J., Schippers, E. F., Barge, R. M. Y., Rosendaal, F. R., Guiot, H. F. L., van der Meer, F. J. M., Meinders, A. E., & Huisman, M. V. (2005). Infectious complications of central venous catheters increase the risk of catheter-related

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thrombosis in hematology patients: A prospective study.

Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 23(12), 2655–2660. https://doi. org/10.1200/JCO.2005.05.002 Warren, D. K., Zack, J. E., Mayfield, J. L., Chen, A., Prentice, D., Fraser, V. J., & Kollef, M. H. (2004). The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest, 126(5), 1612– 1618. https://doi.org/10.1378/chest.126.5.1612 Wolf, J., Connell, T. G., Allison, K. J., Tang, L., Richardson, J., Branum, K., Borello, E., Rubnitz, J. E., Gaur, A. H., Hakim, H., Su, Y., Federico, S. M., Mechinaud, F., Hayden, R. T., Monagle, P., Worth, L. J., Curtis, N., & Flynn, P. M. (2018).

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Appendix Standard Protocol for HAU and ICU CVAD Care in Royal Columbia Hospital, New Westminster, BC

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Implementation of a midline catheter service in a regional setting Paul Jones, NP, BN, MN

Service de pose d’un cathéter mi-long dans un contexte régional Paul Jones, IPS, B. Sc. inf., M. Sc. inf.

Intensive Care Unit, Northeast Health Wangaratta Correspondence to: paul.jones@nhw.org.au 0409 526 017 This is an Open Journal Systems article, distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited and it is not for commercial purposes, and is distributed under the same licence as the original.

Il s’agit d’un article d’Open Journal Systems distribué en vertu du contrat de la licence d’attribution Creative Commons (https://creativecommons. org/licenses/by-nc-sa/4.0) qui permet d’utiliser, de distribuer et de reproduire sans restriction son contenu dans tout support, pourvu que l’œuvre original soit adéquatement citée, ne soit pas utilisée pour des fins commerciales et soit distribuée sous la même licence que l’original.

Suggested citation: Jones, P. (2022). Implementation of a midline catheter service in a regional setting. Vascular Access – Journal of the Canadian Vascular Access Association, 16(2), 22–29.

Abstract Introduction: Midline catheters have been reported to be an effective and safe means of providing patients with intravenous access within the hospital and community setting. With minimal experience in the introduction of a midline service across the local health network, a regional hospital pursued this task.

This observational study assesses the provision of a safe clinical framework for midline insertion, and the improvement of patient care and experiences by avoiding treatment interruptions and unnecessary cannulation attempts from failed traditional peripheral vascular access devices.

Methods: From the introduction of the midline service in June 2018, outcome measures of all patients who received a midline over the following two-year period were documented including rate of line success, complication rates, dwell time, and the number of insertion attempts.

Results: The midline service provided 207 lines over a twoyear period with a total dwell time of 1,585 days. Project goals were achieved with 85% (Aim ≥ 85%) of all lines completing treatment prior to removal. First attempt insertion was 86% (Aim ≥ 80%) with a maximum insertion attempt of two.

Rates of line-related complications were less than 8%, with Page 22 • Vascular Access • Volume 16, Issue 2, Summer 2022

five documented cases of phlebitis (2.5%) and one deep vein thrombosis with no infections documented.

Conclusion: Despite limited resources, a successful midline service was introduced. Future expansion will see an increase in insertor numbers providing improved access to the service.

Keywords: midline, ultrasound, nursing, phlebitis, DIVA

Résumé Introduction : On a déterminé que les cathéters mi-longs étaient un moyen efficace et sécuritaire offrant aux patients une méthode d’accès intraveineux en milieu hospitalier et communautaire. À cause du peu d’expérience en matière d’insertion des cathéters mi-longs dans l’ensemble du réseau de santé local, un hôpital régional a entrepris la tâche d’explorer le sujet. Cette étude d’observation évalue la mise à disposition d’un cadre clinique sécuritaire pour l’insertion des cathéters mi-longs ainsi que l’amélioration des soins et des expériences des patients, en évitant les interruptions de traitement et les tentatives d’insertion infructueuses à cause des dispositifs traditionnels d’accès vasculaire périphérique défaillants.

Méthodologie : Depuis l’introduction du service de pose des cathéters mi-longs en juin 2018, les critères d’évaluation de tous © 2022 Jones

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les patients chez qui un cathéter mi-long a été inséré au cours des deux années suivantes ont été documentés, y compris le taux de succès de la pose, le taux de complications, la durée de séjour et le nombre de tentatives d’insertion.

Incorporating midlines into hospital vascular access options can be successfully achieved, delivering an opportunity to provide a single line for the entirety of treatment from the hospital and into the community setting (Owen, 2014).

Résultats : Le service de pose des cathéters mi-longs a procédé à l’insertion de 207 cathéters sur une période de deux ans, avec une durée de séjour totale de 1585 jours. Les objectifs du projet ont été atteints : 85 % (l’objectif était de ≥ 85 %) des cathéters ont été retirés après la fin du traitement. Le taux d’insertions à la première tentative a atteint 86 % (l’objectif était de ≥ 80 %) et le nombre maximal de tentatives d’insertion était de deux.

Le taux de complications associées à l’insertion des cathéters était de moins de 8 % : cinq cas de phlébite (2,5 %) et un cas de thrombose veineuse profonde sans infection ont été documentés.

Objective The study aims to assess the safe, effective, and efficient introduction of a midline insertion team in regions without dedicated vascular access specialists, targeting one attempt per line with low rates of complications.

Conclusion : Malgré des ressources limitées, il a été possible de mettre en place un service efficace de pose de cathéters milongs. La future croissance du projet augmentera le nombre de cathéters insérés et améliorera l’accès au service.

Introduction

P

roviding a single intravenous access for the course of a patient’s admission is a challenging and difficult task. For a large cohort of patients, numerous unsuccessful attempts precede achieving intravenous access (Sabri et al., 2013). Insufficient access to skilled and qualified vascular access specialists, unsuccessful attempts are often repeated throughout a single admission, particularly when prolonged access is required. These costly interruptions to treatment have the potential to lengthen hospital admissions and greatly impact patient and staff satisfaction with a higher risk of vascular access complications, such as infection, phlebitis, and pain (Anderson, 2004; Tagalakis et al., 2002; Uslusoy & Mete, 2008).

The introduction of midlines has provided vascular access teams with a safe, efficient and reliable means of establishing access in a population where central access is not indicated and traditional peripheral intravenous cannulation (PIVC) is difficult to establish, unreliable, or will require multiple insertions to achieve treatment goals (Anderson, 2004; Alexandrou et al., 2011; Moreau et al., 2015; Cummings et al., 2011). Midlines are recognized as an option to reduce the incidence of phlebitis, a substantial contributor to PIVC failure, and catheter-associated blood stream infections (Anderson, 2004; O’Grady et al., 2011; Salgueiro-Oliveira et al., 2013; Warrington et al., 2012).

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Methods Study design The introduction of the midline service was developed as a quality improvement project. The framework consisted of specialized training in midline insertion for a cohort of staff, the referral pathway, the documentation, and a set of parameters or goals against which to assess the safe clinical implementation.

A retrospective observational study of all adult patients who had a midline inserted during the study period, from June 2018 to June 2020, was undertaken.

Setting Northeast Health Wangaratta is a 228-bed, rural regional hospital with approximately 20,000 admissions per year.

Without a designated vascular access team, the task of obtaining peripheral vascular access in challenging situations across the organization lies with ultrasound-trained critical care nurses. Anecdotal evidence suggested an increase in complications prior to referral, including multiple failed access attempts, premature PIVC failure, inappropriate site and vessel selection, and multiple PIVC referrals per patients. This was particularly the case for patients identified as difficult intravenous access (DIVA). The introduction of a midline service planned to address these issues, while aiming to provide one line per referral from a single attempt early in the admission process.

Three Critical Care Unit (CCU) nurses, an effective full-time (EFT) equivalent of 2.4 (96 nursing hours per week), with expertise in the use of ultrasound-guided PIVC insertion were trained by BARD Access Specialists (Becton-Dickson, BD [the supplier]) using Powerglide Pro midlines. It was estimated that an EFT of 2.4 would be sufficient to provide the health service with access to the midline team within 24–48 hours from referral,

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Implementation of a midline catheter service in a regional setting

while providing sufficient exposure to insertion practice to maintain a high level of competence. Insertor training included ultrasound theory, best practice for insertion, care, troubleshooting and maintenance of midlines, and insertion practice utilizing phantom limbs and ultrasound.

Once the BARD Access Specialists were confident with the insertor’s technique, supervised practice was commenced on patients throughout the organization.

Medical physicians with high expertise in ultrasoundguided central line insertion, in addition to the BARD Specialists, supervised insertions until competence and independent practice was awarded. This was achieved through a minimum of five successful insertions with minimal assistance and prompting from supervisors.

The supplier’s specialists provided the organization’s nurses with initial care, maintenance and troubleshooting, education, and training. To ensure line success and high rates of referrals, the primary midline team member provided multiple education sessions across the organization over the study period. Nursing staff were encouraged to communicate with members of the midline team should a complication arise or assistance be required.

Participants All adult patients who consented to a midline insertion were included in the study. Due to the retrospective design, ethics approval was gained to permit data collection. No patients for whom a midline was inserted were excluded or removed. For the first six months of the midline service, no lines were inserted into Hospital in the Home (HITH) patients, while baseline safety and effectiveness were established.

Any clinician, nurse or doctor, could refer to the midline team. At the earliest opportunity, a member of the midline team undertook a vascular assessment to ensure appropriateness of midline insertion. Assessment included indication and estimated length of treatment for intravenous access, vascular access history – previous lines and attempts, relevant medical history (e.g., chemotherapy, steroid use), and vessel integrity – size, depth, options for site rotation, and presence of contraindications for insertion.

All midlines were inserted using ultrasound via the cephalic, basilic, or brachial veins above the antecubital fossa. Lines were 20-gauge with either 8 or 10cm length and utilized based on vessel depth and anatomical features.

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Indications for midline insertion according to best practice recommendations included the following: • intravenous access required for 5 to 30 days; • identified as a difficult intravenous access (DIVA), as locally defined by greater than or equal to two attempts, a history of difficult access and/or requiring ultrasound guidance; • insufficient options for intravenous site rotation; and • pH range of medication 5–9 and osmolality < 600mOsmol/L (Anderson, 2004, 2005; Alexandrou et al., 2011; Gorski et al., 2016; Griffiths, 2007; Moreau et al., 2015; Moreau & Chopra, 2016; Warrington et al., 2012).

To optimize the early identification (within 48hr of admission) of patients for referral by nursing or medical staff, admission diagnosis was included in the indications for midline insertion. Diagnosis-related group (DRG) codes, combined with electronic medication dispensing, provided a list of diagnoses that frequently require intravenous access for greater than five days. The top five diagnoses were pneumonia, cellulitis, exacerbation of congestive cardiac failure, sepsis, and exacerbation of chronic obstructive pulmonary disease.

The presence of the diagnosis was used to identify potential patients, while insertion remained at the discretion of the midline team member following assessment.

Indications for midline insertion and the referral process were included in organization-wide education, including posters, prior to service commencement.

Outcome variables Prior to the commencement of the midline service, primary goals were established to ensure patient safety, risk reduction, and appropriate quality control practice.

Complications were referred back to the midline team for investigation and recommendation.

Goals included the following and reflect targets and results from previous successful studies: • successful treatment ≥ 85%, as defined by intravenous access no longer required at time of removal; • first attempt insertion success ≥ 80% to ensure patient safety and satisfaction, while preserving vessel integrity and midline rate of success; • a rate of phlebitis of ≤ 2%; and • rate of infection ≤1 per 1,000 line-days (Anderson, 2004; Moreau & Chopra, 2016; Warrington et al., 2012). cvaa.info

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Data sources Data were collected through the use of a midline insertion and care document commenced by a member of the midline team at insertion. The document served as a tool for medical and nursing staff to monitor the midline including the organization’s visual infusion phlebitis (VIP) scores (see Table 1), dressing changes, and line health, and as an aid to prompt allied health staff to its presence. This form was photocopied and returned to the Critical Care Unit to facilitate the tracking of patients with ward staff encouraged to supply documentation on the removal of the midline. If insufficient information was provided, patient histories were audited.

Results

Time required to insert, including time out of CCU, was documented and served to track midline team demand for potential future expansion.

The rate of phlebitis was slightly higher than the preestablished goal at 2.5% (n = 5). Two catheters were removed due to chemical phlebitis with VIP scores greater than or equal to two. Remaining catheter VIP scores did not progress and treatment was completed prior to removal.

Collected data were collated and analyzed in a Microsoft Excel spreadsheet. Statistical analysis comprised descriptive statistics with categorical variables summarized using number (count) and percentage, and continuous variables summarized using mean. There was no pre-determined sample size, as the sampling was determined by the number of eligible cases presenting over the study period. To promote integrity, a consultant physician who was not a member of the midline team reviewed the data.

Organisation Visual Infusion Phlebitis Score (VIP)

Slight pain, light redness (<2cm) at cannula site

Pain and redness, heat or swelling at cannula site Pain, redness, heat or swelling with exudate, hardening, a palpable venous cord or tissue damage at cannula site

The primary study goals were attained with the exception of the rate of phlebitis. Eighty-five percent (n = 178) of inserted midlines completed treatment successfully, while first attempt insertion was 89% (207 midlines, 232 attempts).

Only one catheter required more than the recommended two attempts.

Thirteen midlines were removed prior to treatment completion when a change in patient condition required an escalation of care. These were not listed as failed due to the requirements for infusions outside the accepted indications for peripheral administration (e.g., total parenteral nutrition or inotropic/vasopressor support). Central venous access was established and the midline removed.

Table 2

Table 1 No pain, heat, redness or swelling

During the two-year study period, 207 midlines were placed, delivering 1,585 dwell days. Table 2 highlights the primary study goals and the outcomes. For one line, the removal date was not recorded. The average dwell time was eight days with a maximum of 38 days.

0

1

2

3

Remove cannula if not required. Monitor cannula site every shift and when accessing line.

Remove cannula if not required or consider replacement. Monitor cannula site every shift and when accessing site.

PHLEBITIS Remove cannula. Notify Medical team.

SEVERE PHLEBITIS Remove cannula. Notify Medical Team.

Send swab of exudate & blood cultures, if febrile.

The Primary Study Goals and Results Results

N (%)

Total midlines inserted

207

Total dwell days

1585

Average dwell time – days

8

Maximum dwell time – days

38

Primary goals Successful treatment ≥ 85%

178 (85%)

First attempt success ≥ 80%

207/232 (89%)*

Phlebitis ≤ 2.0% Infection 0%

5 (2.5%) 0%

Vessel accessed Basilic

108 (52%)

Cephalic

58 (28%)

Brachial

41 (20%)

Midline length 8 Centimetre 10 Centimetre

110 (53%) 97 (47)

*207 midlines inserted from 232 attempts.

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Implementation of a midline catheter service in a regional setting

The most common indication for insertion (see Table 3) was intravenous access required for less than two weeks (47%, n = 97), followed by patients identified as DIVA (36%, n = 75) and intravenous access required for greater than two weeks (16%, n = 32).

Incorporating a diagnosis for improved identification of patients for midline insertion, highlighted an accurate prediction. The top five diagnoses of patients who received a midline are shown in Table 4. However, with a higher than desired average of approximately 4.7 days to insertion, it is unclear if the predicted diagnosis improved the time to identification and referral.

Hospital in the Home patients received 6% (n = 13) of midlines, allowing treatment to be completed in the community. Two lines failed, one a result of accidental removal, the other through kinking. The line accidentally removed was replaced and community treatment completed.

Complications occurred in 14% (n = 29) of midlines, which failed the primary study goal and were removed prior to completion of treatment (see Table 5). Adjusting for insertor and patient error, i.e., failure to insert (improper insertion technique leading to failure) and accidental patient removal, reduces the complication rate to 9% (n = 18).

Two cases of catheter migration were observed, where the cannula migrated out of the vessel leading to failure. This complication was not able to be explained by patient factors, e.g., excessive movement.

One deep vein thrombosis (DVT) was diagnosed sonographically, following the development of localized upper-limb edema post-midline failure.

No infections were attributed to midlines during the study period. This was supported through independent local infection control auditing practices, including Staphlococcus aureus bacteremia (SAB) monitoring.

Discussion

Table 3 Indications for Midline Insertion Indication

No. (%)

IVA <2/52

97 (47%)

DIVA

75 (36%)

IVA >2/52

35 (17%)

Total

207

IVA < 2/52 = Intravenous access required less than two weeks.

DIVA = Difficult Intravenous Access and/or insufficient sites for rotation.

IVA >2/52 = Intravenous access required for greater than two weeks.

The aim of the study, through a retrospective observation model, was to establish a safe and effective midline service in an institution without a specialist vascular access team.

The midline service was able to achieve a total of 207 lines during the study period with near complete achievement in the pre-established goals. Eighty-nine percent of lines were inserted from a single attempt with 85% achieving treatment goals. No infections were recorded and rates of phlebitis were mildly higher than the goal, 2.5% vs. 2%. Adjusting for patient and insertor factor, the rate of total line-related Table 5

Table 4

Type and Number of Midline Complications

Number of Midlines Inserted per Diagnosis Predicted Diagnosis Actual Diagnosis with Requiring Midline Midline Insertion

No. Midlines per Diagnosis

Pneumonia

Pneumonia

32

Cellulitis

Sepsis

31

Congestive cardiac failure

Cellulitis

24

Sepsis

Bacteraemia

16

Exacerbation COPD

Congestive cardiac failure

12

Exacerbation COPD

(8th)

7

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Midline Complications

No. (%)

Accidental removal by patient

9 (4.3%)

Kinked catheter

6 (2.8%)

Phlebitis

5 (2.4%)

Infiltration

3 (1.4%)

Failed insertion *

2 (1%)

Catheter migration**

2 (1%)

DVT

1 (0.5%)

Blocked catheter

1 (0.5%)

Total

29

*Failed insertion – improper insertion technique or tip location resulting in line failure in less than 24hr **Catheter migration – migration of the catheter extraluminaly, leading to line failure.

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Jones, P.

complications was less than 10%. The progression of treatment to the community setting was achieved in a lessthan-expected number of patients. This was largely attributed to understandable safety concerns surrounding elastomeric infusion devices use with midlines in the community setting and the initial six-month delay.

It was reassuring that the results of the study are reflective of the literature, particularly those where the goals and objectives were established (Anderson, 2004; Alexandrou et al., 2011; Cummings et al., 2011; Moreau et al., 2015).

The implementation of the midline service was safe, effective, and provided uninterrupted treatment with low rates of complications seen more commonly with traditional peripheral access devices (Salgueiro-Oliveira et al., 2013). Allowing for a dwell time of approximately 3 and 14 days respectively, it is estimated that a total 519 PIVCs and 34 PICCs were potentially prevented through the implementation of the midline service (Moreau & Chopra, 2016; O’Grady et al., 2011). With up to 26% of PIVC first attempts failing, the removal of these traditional short-term devices has significant implications for patient safety, comfort and satisfaction in addition to the potential reduction in central line-associated complications (Fields et al., 2014; Maki et al., 2006; Pathak et al., 2015; Sabri et al., 2013).

A major strength to this model was the use of nurses well experienced in the use of ultrasound for peripheral access.

This was noted by the BARD team in the quick progression of the nurses in their training. The high rate of first-time success was largely attributed to this and may highlight the importance of establishing systems that promote skill attainment and development prior to progression, including competence in PIVC insertion using ultrasound prior to midline insertion requiring ultrasound.

Limitations The identification of patients and the referral process was a noted limitation within this model. Using a modified version of a system presented within the literature, the predicted diagnosis appeared an accurate means for early identification (Anderson, 2004). However, it is estimated, through the monitoring of the DRG system, that approximately 30% of patients meeting criteria for potential insertion were not referred. In addition, an average delay of 4.7 days to insertion highlights an area for development, with this population likely undergoing unnecessary PIVCs and attempts prior to midline placement.

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The small team size with an EFT of 2.4 and the competing responsibilities of insertors, due to an increase in CCU acuity, was insufficient and contributed to delays.

It is considered possible that assessment of phlebitis may have been inaccurate. Due to the insufficient resources and competing commitments of the midline team, VIP monitoring of individual lines on removal relied on general clinical staff. If concerns were raised, midline team members would investigate with recommendation for practice, if required. However, it was reassuring that the auditing of patient records failed to identify any documentation or escalation in treatment for phlebitis for midlines not previously recording a complication.

At commencement of the midline service, we had planned to include the number of PIVCs and attempts prior to midline insertion referral in the data collection. However, due to time limitations on insertors, the team elected to focus on the pre-established goals. Adoption of these factors into future works could provide valuable insight into vascular access practice and complications.

Noting these limitations, a number of forthcoming advances are currently being developed and implemented. No longer hindered by the global pandemic, the expansion of the team is underway and includes ultrasound-trained emergency department nurses. This expansion aims to reduce delays to insertion by promoting early patient identification at the point of admission and greater availability to insertors.

Anecdotal evidence, provided by the midline team and nurses caring for patients, suggested that the patient experience was enhanced with the inclusion of a midline into their care delivery when compared to traditional PIVCs. In addition, medical and nursing staff reported reduced frustration and greater satisfaction. With a larger sample size, future qualitative research to include these experiences would be an area of interest.

Conclusion The aim of this study was to assess the provision of a safe framework for midline insertion, in regions with limited resources. Despite limitations in early identification and delays to insertion, a successful service was introduced. The introduction of the midline team enabled the achievement of one line per referral, providing successful treatment, with low rates of complications, within its pre-established goals.

Expansion of the team is underway in an attempt to improve Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 27

Implementation of a midline catheter service in a regional setting

early recognition and reduce delays to insertion. Aiming to remove unnecessary cannulations and their attempts, the organization endeavours to improve its service and patient care delivery.

About the author Paul Jones, NP, BN, MN, is currently an Associate Nurse Unit Manager of the Intensive Care Unit at Northeast Health Wangaratta, a regional 220-bed hospital in Victoria, the Southeast of Australia.

With 17 years of ICU experience, he accomplished a Masters of Advanced Nursing Practice and in 2020 was successfully endorsed as a Nurse Practitioner.

A strong passion in vascular access has led him to the implementation of numerous quality improvement initiatives across the organization; most recently, the development of a midline service and formal peripheral intravenous cannulation insertion using ultrasound training for medical and nursing colleagues.

Professional undertakings have included working with Victoria’s healthcare and safety regulators – Safer Care Victoria – in the research and development of guidelines and recommendations to improve the provision of care including, pain agitation and delirium in ICU, the statewide standardization of inotropes, and the improvement of the local recognition and response team.

Since 2020, he has held the position of National Safety and Quality Health Service – Recognizing and Responding to Acute Deterioration Standard lead for the organization.

À propos de l’auteur Paul Jones, IPS, B. Sc. inf., M. Sc. inf. : Il est actuellement infirmier et gestionnaire associé de l’unité de soins intensifs du Northeast Health Wangaratta, un hôpital régional de 220 lits à Victoria, dans le sud-est de l’Australie. Riche de 17 ans d’expérience au sein de l’unité de soins intensifs, il a obtenu une maîtrise en pratiques infirmières avancées et il a obtenu avec succès son titre d’infirmier praticien en 2020.

Sa grande passion pour l’accès vasculaire l’a motivé à mettre en œuvre de nombreuses initiatives d’amélioration de la qualité dans toute l’organisation, la plus récente étant l’introduction d’un service de pose de cathéters mi-longs et d’insertion normalisée de cathéters intraveineux périphériques, en formant les collègues du personnel médical et infirmier sur les techniques d’échographie.

Page 28 • Vascular Access • Volume 16, Issue 2, Summer 2022

Parmi ses projets professionnels figurent son travail avec Safer Care Victoria, un organisme de réglementation en soins de santé et en sécurité à Victoria, en matière de recherche et d’élaboration de lignes directrices et de recommandations visant à améliorer la prestation de soins, y compris la prise en charge de l’agitation et du delirium causés par la douleur au sein de l’unité de soins intensifs, la normalisation du recours aux inotropes à l’échelle de l’état et l’amélioration de l’équipe locale de reconnaissance des risques et d’intervention.

Disclosure BARD Medical was selected for its comprehensive training, support and education assistance package for insertors and the organization. BARD Medical supplied no financial assistance to the organization, midline team members, or project and were not involved in the audit process nor have been provided with the results. Purchase of the Powerglide midline and disposables was at the sole expense of the organization.

References Alexandrou, E., Ramjan, L., Spencer, T., Frost, S., Salamonson, Y., & Davidson, P. (2011). The use of midline catheters in the adult acute care setting – Clinical implications and recommendations for practice. The Journal of the Association for Vascular Access (JAVA), 16(1), 35–41.

Anderson, R. (2004). Midline catheters: The middle ground for intravenous therapy administration. Journal of Infusion Nursing, 25(5), 313–321.

Anderson, R. (2005). When to use a midline catheter. Nursing, 35(4), 68.

Cummings, M., Hears, N., McCuthcheon, H., & Deuter, K. (2011). Improving antibiotic treatment outcomes through the implementation of a midline: Piloting a change in practice for cystic fibrosis patients. Journal of Vascular Nursing, 29(1), 11–15.

Fields, J. M., Piela, N. E., & Ku, B. S. (2014). Association between multiple IV attempts and perceived pain levels in the emergency department. Journal of Vascualr Access, 15(6), 514–518.

Gorski, L. Hadaway, L. Hagle, M. E. McGoldrick, M. Orr, M. Doellman, D. (2016). Infusion therapy standard of practice – Revised 2016. Journal of Infusion Nursing, (39) 1S. Griffiths, V. (2007). Midline catheters: Indications, complications and maintenance. Nursing Standard, 22(11), 48–57.

Maki, D. G., Kluger, D. M., & Crnich, C. J. (2006). The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clinic Proceedings, 81(9), 1159–1171 Moureau, N., & Chopra, V. (2016). Indications for peripheral, midline and central catheters: Summary of the MAGIC recommendations. British Journal of Nursing , 25(8), S15– S24. cvaa.info

Jones, P.

Moureau, N., Sigl, G., & HIll, M. (2015). How to establish an effective midline service: A case study of 2 hospitals. JAVA, 20(3), 179–188.

O’Grady, N. P., Alexander, M., Burns, L. A., Delligen, P., Garland, J., Heard, S. O., Lipsett, P. A., Masur, H., Mermel, L. A., Pearson, M. L., Raad, I. I., Randolph, A., Rupp, M. E., Saint, S., & Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). Guidlines for the prevention of intravascular catheter-related infections. Centre for Disease Control. https://www.cdc.gov/infectioncontrol/pdf/ guidelines/bsi-guidelines-H.pdf Owen, K. (2014). The use of 8cm midlines in community IV therapy. British Journal of Nursing, 23(19), S18–S20.

Pathak, R., Patel, A., Enuh, H., Adekunle, O., Shrisgantharajah, V., & Diaz, K. (2015) The incidence of central line–associated bacteremia after the introduction of midline catheters in a ventilator unit population. Infectious Diseases in Clinical Practice, 23(3), 131–134.

Sabri, A., Sizalas, J., Holmes, K. S., Labib, L., & Musslvand, T. (2013). Failed attempts and improvement strategies in peripheral intravenous catheterization. Biomedical Materials and Engineering, 23(1–2), 93–108.

Salgueiro-Oliveira, A., Veiga, P., & Parreira, P. (2013). Incidence of phlebitis in patients with peripheral intravenous catheters: The influence of some risk factors. Australian Journal of Advanced Nursing, 30(2), 32–39.

Tagalakis, V., Kahn, S., Libman, M., & Blostein, M. (2002). The epidemiology of peripheral vein infusion thrombophlebitis: A critical review. The American Journal of Medicine, 113(2), 146 –151.

Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients with peripheral intravenous catheters: A descriptive study. Journal of the American Academy of Nurse Practitioners, 20(4), 172–180.

Warrington, W., Jr., Penoyer, D., Kamps, T., & Van Hoeck, E. (2012). Outcomes for using a Modified Seldinger Technique for long term intravenous therapy in hospitalised patients with difficult venous access. JAVA, 17(1), 24–31.

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Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 29

Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation Jennifer Reguindin*, MScN, RN, GNC(c), Angel Wang, RN, MN, Kim Capoccitti, MSN, RN, Shevaun Lai, RN, BScN, MN, Christine Saby, MN, RN, Natalie Sakin, MN, RNHSLA, PANC(c), Wesley Woods, RN, CCRN, Christine Ortiz, RN, CON(c), Karen Velasco, RN, Parisa Alvand, MN, RN, Ahmed Ullah Sayed, RN, Marilyn Lee, MN, RN, Donna Rothery, BScN, RN, CNCC(c), and Mikki Layton, MN, NP-Adult, CON(C), CHPCN(C)

Appuyer le développement de la compétence clinique dans la prise en charge des cathéters centraux insérés par voie périphérique pendant la pandémie de COVID-19 : évaluation d’une formation Jennifer Reguindin*, M. Sc. inf., inf. aut., CSIG(C), Angel Wang, inf. aut., M. Sc. inf., Kim Capoccitti, M. Sc. inf., inf. aut., Shevaun Lai, inf. aut., B. Sc. inf., candidate à la M. Sc inf., Christine Saby, M. Sc. inf., inf. aut., Natalie Sakin, M. Sc. inf., inf. aut. (Health Systems Leadership and Administration Program), ICPA(C), Wesley Woods, inf. aut., inf. aut. en soins intensifs, Christine Ortiz, inf. aut., CSIO(C), Karen Velasco, inf. aut., Parisa Alvand, M. Sc. inf., inf. aut., Ahmed Ullah Sayed, inf. aut., Marilyn Lee, M. Sc. inf., inf. aut., Donna Rothery, B. Sc. inf., inf. aut., CSI(C) et Mikki Layton, M. Sc. inf., IPS (soins aux adultes), CSIO(C), ICSP(C) *Corresponding author: Jennifer Reguindin, Jennifer.Reguindin@tehn.ca This is an Open Journal Systems article, distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited and it is not for commercial purposes, and is distributed under the same licence as the original.

Il s’agit d’un article d’Open Journal Systems distribué en vertu du contrat de la licence d’attribution Creative Commons (https://creativecommons. org/licenses/by-nc-sa/4.0) qui permet d’utiliser, de distribuer et de reproduire sans restriction son contenu dans tout support, pourvu que l’œuvre original soit adéquatement citée, ne soit pas utilisée pour les fins commerciales et soit distribuée sous la même licence que l'original.

Suggested citation: Reguindin, J., Wang, A., Capoccitti, K., Lai, S., Saby, C., Sakin, N., Woods, W., Ortiz, C., Velasco, K., Alvand, P., Sayed, A., Lee, M., Rothery, D., & Layton, M. (2022). Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation. Vascular Access – Journal of the Canadian Vascular Access Association, 16(2), 30–40.

Abstract Introduction: Hospitals had to create new practices and training due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. An increase in patient acuity and the need for peripherally inserted central catheters (PICC) across the hospital required an urban community hospital to educate and support in-patient nurses to manage PICCs in acute and complex care units. Traditionally, these skills were performed by specialized registered nurses (RNs) from the Vascular Access Team (VAT). This paper highlights the education plan, implementation, and evaluation of a hospital-wide training for Page 30 • Vascular Access • Volume 16, Issue 2, Summer 2022

RNs and registered practical nurses (RPNs) in in-patient areas units during the SARS-CoV-2 pandemic.

Methods: Clinical Resource Leaders (CRLs) created a modular approach to upskill existing nurses and train new hires. Various education strategies, such as the use of competency assessments, creating practice supports, and incorporating specialists as a resource, were utilized to ensure knowledge transfer, application, and guidance of evidence-informed clinical practices. Vascular Access Team documentation was utilized to obtain Kirkpatrick’s (2021) level 4 evaluation. © 2022 Reguindin et al.

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Reguindin, J., Wang, A., Capoccitti, K., Lai, S., Saby, C., Sakin, N., Woods, W., Ortiz, C., Velasco, K., Alvand, P., Sayed, A., Lee, M., Rothery, D., & Layton, M.

Results: This training program was implemented after the second wave of the pandemic and was also embedded into nursing orientation. This structured approach ensured that nurses were competent to support the increased acuity and needs of patients. Eighty percent of full-time and part-time nurses were trained to manage PICC lines.

Conclusion: Education evaluation results show a decrease in PICC-related VAT assistance requests with a baseline of 570 calls down to 149 six months after education was implemented.

Leaders are encouraged to ensure teams have role clarity, policies, and practice supports to be successful.

Résumé Objectif : La pandémie de coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) a forcé les hôpitaux à élaborer et mettre en place de nouvelles pratiques et formations.

L’augmentation des cas de patients dont l’état était jugé critique et la nécessité de procéder à l’insertion de cathéters centraux par voie périphérique (CCIP) dans tous les services hospitaliers a mené un hôpital communautaire d’un centre urbain à former et à soutenir ses infirmières sur la manière de prendre en charge les CCIP chez les patients hospitalisés au sein des unités de soins de courte durée et complexes. Traditionnellement, ce sont les infirmières autorisées spécialisées de l’équipe de l’accès vasculaire qui étaient responsables de ces tâches. Cet article décrit le plan pédagogique, la mise en œuvre et l’évaluation de la formation donnée aux infirmières autorisées et aux infirmières auxiliaires autorisées qui ont travaillé au sein de toutes les unités des malades hospitalisés de l’hôpital pendant la pandémie de SRASCoV-2.

Méthodologie : Les responsables des ressources cliniques ont créé une approche modulaire pour améliorer les compétences des infirmières en fonction et pour former les nouvelles infirmières.

Différentes stratégies de formation, y compris l’utilisation de méthodes d’évaluation des compétences, la création d’outils de soutien en pratique et l’intégration de spécialistes comme ressources supplémentaires, ont été utilisées afin d’assurer le transfert et la mise en œuvre des connaissances et d’offrir de l’orientation en pratique clinique fondée sur les données probantes. La documentation de l’équipe de l’accès vasculaire a été utilisée pour obtenir l’évaluation de niveau 4 du modèle de Kirkpatrick (2021).

Résultats : Ce programme de formation a été mis en œuvre après la deuxième vague de la pandémie. Il a également été intégré au programme d’orientation du personnel infirmier.

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Cette approche structurée a permis d’offrir aux infirmières les compétences nécessaires pour soutenir l’augmentation du niveau de gravité de l’état des patients et de leurs besoins. Quatre-vingts pour cent des infirmières à temps plein ou à temps partiel ont été formées à l’insertion des CCIP. Conclusion : Les résultats de l’évaluation de la formation indiquent la baisse du nombre de demandes d’aide liées aux CCIP faites à l’équipe de l’accès vasculaire. Six mois après la mise en œuvre de la formation, le nombre de demandes faites auprès de l’équipe est passé de 570 demandes à 149 demandes.

Les responsables sont invités à s’assurer de la clarté des rôles au sein des équipes et de l’accès aux politiques et aux outils de soutien en pratique nécessaires pour réussir.

Introduction

H

ospitals had to create new practices and training due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. During the second wave of the pandemic (at the end of 2020), there was an increase in patient acuity and the need for peripherally inserted central catheters (PICCs), a central vascular access device (CVAD), across Michael Garron Hospital (MGH). This required Clinical Resource Leaders (CRLs), who are similar to advanced practice nurse educators, to create a training program to support in-patient nurses in acute and complex care units to manage PICCs. Traditionally, these skills were performed by the specialized registered nurses (RNs) from the Vascular Access Team (VAT), Intensive Care Unit (ICU), Cardiac Integrated Units (CIU), and Emergency Room (ER) nurses. Rapid Response Nurses usually supported clinical units when VAT was not available, however, their focus shifted to supporting deteriorating patients during this pandemic.

Michael Garron Hospital provides services to 400,000 patients a year. This hospital is committed to improvement and to adapting to the needs of a diverse community. With an aging population and being in the middle of a pandemic, the complexity of the patients cared for by interprofessional teams is increasing.

Formed in 2019, the VAT is composed of RNs who are accountable for inserting, troubleshooting, caring for, and managing the care for PICCs in in-patient adults. Managing PICCs is comprised of dressing changes, needleless connector changes, blood draw, and troubleshooting. In addition, they are the resource for any difficult intravenous

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Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation

device insertions and any other vascular access concerns.

There are three regular RNs who support the hospital every day from 0800 to 1600 hours. Since the creation of the team, the VAT has been accountable for all nursing procedures associated with PICCs across the organization: assessment, insertion, care and maintenance, administration, monitoring, complications, and removal (Canadian Vascular Access Association [CVAA], 2019) outside of the specialty areas. With the increasing complexity of the patient population and an increase in the number of PICCs in the organization, it was necessary to plan the transition of the care of PICCs from the VAT to the nurses who work on the units. This aligns with education and competency practice guidelines (CVAA, 2019; Gorski et al., 2021).

The PICC insertion data were collected since program inception and are shown in Figure 1. The VAT nurses had to insert and maintain anywhere from 15 when they started to more than 40 PICC lines in the first two waves of the pandemic. The increase in the number of PICCs across the units, outside of ICU and CIU, comes with significant risks to quality care if the hospital does not extend the skill and competency to other RNs and registered practical nurses (RPNs), for example, blood work results that are required

for specific medications or planning for patient discharge/ transition. Vascular access team workload issues caused delays to treatment, intervention and/or bed flow. Another risk to quality is in accessing and de-accessing a PICC. A nurse may be required to start or end an infusion or medication that requires a PICC and VAT nurses are only available until 4 pm. Waiting for the VAT nurses to arrive may be as long as 16 hours resulting in delayed patient care.

Additionally, consistently relying on the VAT can delay timely discharges. Understanding how to de-access IV fluids and/or medications safely is essential for nurses to decrease the risk of developing central line infections. Note that Figure 1 has peaks and valleys, which represent either training and vacation days of the three nurses trained in the program. Figure 1 also highlights the influenza season in January 2020, an anticipated “surge” time or a surge in patient numbers that exceed hospital bed capacity. All of these factors signalled the need to train more nurses to support complex and acute care patients with PICCs. This paper highlights the education plan, implementation, and evaluation of a hospital-wide training program for RNs and RPNs in the medicine, surgery, and complex continuing care units during a pandemic. Kirkpatrick’s

Figure 1 PICC Insertions at MGH

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Reguindin, J., Wang, A., Capoccitti, K., Lai, S., Saby, C., Sakin, N., Woods, W., Ortiz, C., Velasco, K., Alvand, P., Sayed, A., Lee, M., Rothery, D., & Layton, M.

Model was utilized to guide evaluation, as this model creates a chain of evidence demonstrating the effectiveness of an educational intervention. The model is divided into four levels describing different aspects of learning evaluation: (1) learner reaction; (2) learning; (3) behavioural changes after the educational intervention; and (4) the impact of the educational intervention on the organization’s perspective (Kirkpatrick & Kirkpatrick, 2021).

Overview of education program Target learners Peripherally inserted central catheter care for this hospital, then, is a new expectation of RNs and RPNs working in the various in-patient units for our local urban community hospital. Several programs are affected: • Inpatient Medicine; • Surgery Services that include inpatient surgery and the recovery room; • Complex Continuing Care (also known as Transitional Care); and • Nursing Resource Team.

Nurses from six inpatient medicine units, two inpatient surgery units, two complex continuing care units, and the nursing resource team (NRT) were the target learners.

The NRT nurses traditionally spans multiple units, which included all the units listed above. In addition, this program was also open to untrained nurses from the emergency department, perianesthesia care unit, and cardiac integrated units. A PICC education program was essential to ensure that the care provided was safe and standardized across the hospital (CVAA, 2019; Gorski et al., 2021). The educational intervention of the inpatient unit nurses included instruction on the importance of PICC care, support of new knowledge, providing opportunity to learn and practice skills, and working with certified nurses to support safe practice. In addition, the many manufacturers and types of PICC led to nuances in training nurses.

Education program development Policies, procedures, and education development were based on current best practices and evidence (CVAA, 2019; Gorski, 2017; Gorski et al., 2021). According to the CVAA (2019) best practice guidelines, various education strategies should be utilized to ensure knowledge transfer into practice.

Training goals and objectives, as well as learner activities, covered various domains of learning, including cognitive, affective and psychomotor. cvaa.info

Training Goal #1: To obtain the knowledge and competencies associated with nursing care and management of PICC lines in adult patients (CVAA, 2019).

Objectives: Upon completion of the PICC education program, learners would be able to • outline the components and anatomical placement of PICC lines, list the indications and contraindications for a PICC line, as well as describe the nursing care and management of PICC lines; • compare and contrast central and peripheral venous access catheters; • describe potential complications and safety considerations associated with PICC lines as well as nursing actions to prevent and treat these complications; • create individualized nursing care plans for patients with PICC lines; and • adhere to hospital policies on nursing responsibilities related to care and maintenance of PICC lines.

Training Goal 2: To learn and apply the skills to perform nursing care and management of PICC lines in adult patients.

Objectives: By the end of the PICC education program, learners will be able to • perform procedures related to care and management of PICC lines, including dressing change, cap change, flushing, and blood withdrawal; • perform nursing assessment and documentation of PICC line care and management; and • consider and perform appropriate nursing interventions to address PICC line issues or complications.

PICC education Clinical Resource Leaders created a modular approach to upskill existing nurses and train new hires. The PICC education was informed by Kirkpatrick’s (2021) four-level evaluation model. Various education strategies were used to support learners (CVAA, 2019), such as: • the development of a learning package, inclusive of learning resources and practice support materials; • the use of competency assessments; • in-person training using low-fidelity simulations and hands-on practice; • the incorporation of specialists as a resource; and • the development of videos to use for teaching as well as a resource.

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Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation

The PICC education program was developed to meet the aforementioned goals and objectives using the following teaching-learning strategies: A learning package was implemented to meet the first goal and its objectives while low-fidelity simulations and hands-on practice was used to address the second goal and its objectives. These strategies were also utilized to ensure knowledge transfer, application, and guidance of evidence-informed clinical practices (CVAA, 2019; Gorski et al., 2021).

These strategies were informed by the philosophical framework of social constructivism, which posits that the learners cognitively and socially engage in the learning environment to gain new understandings (Handwerker, 2012). By becoming active in learning, learners are able to develop metacognition and are more prepared to transfer knowledge and skills to new situations (Handwerker, 2012).

The literature has found that educational activities aligned with this philosophy, such as simulations, are effective in developing learners to be critical thinkers, gain clinical reasoning, and foster a sense of salience (Handwerker, 2012; Peters, 2000).

Learning package Benefits of this approach were two-fold. For the organization, having a learning package was cost-effective and each staff member had the same education resources, resulting in standardization of the information (CVAA, 2019). The content also highlighted procedures found in the revised organizational policies. For a staff member, the learning package encouraged self-directed learning and allowed easy accessibility of resources.

The learning package covered the content discussed in the objectives outlined in the first goal: (1) components and anatomical placement of PICC lines; (2) the indications and contraindications for a PICC line; (3) the differences between central and peripheral venous access catheters; (4) potential complications and safety considerations associated with PICC lines, as well as nursing actions to prevent and treat these complications; (5) nursing responsibilities related to care and maintenance of PICC lines and skills checklists; and (6) nursing care plans related to PICC lines.

Included in the learning package also were skills checklists, which were created to outline all the steps required in the skills and the learner was evaluated based on the checklist to ensure consistency (CVAA, 2019).

To align with level 2 of Kirkpatrick’s Model (2021), staff were required to take a 20-question multiple-choice test Page 34 • Vascular Access • Volume 16, Issue 2, Summer 2022

at the end of completing the learning package to measure the degree of the learner’s acquisition of the intended knowledge. Staff required 80% to pass and move to the next part of the curriculum. If staff did not receive 80%, each CRL had to follow up with the staff member to address knowledge gaps before moving forward to in-person training.

In-person training The second goal and its objectives predominantly focused on the psychomotor domain and technical skills; thus, lowfidelity simulations (Kiker et al., 2020; Kim et al., 2016) and hands-on practice opportunities were chosen.

Low-fidelity simulations. Simulation allows the educator to evaluate, via direct observation, if the learners are able to apply concepts learned in the learning package.

Growing research has shown that simulations have a variety of benefits, such as the ability to make errors in a safe environment; improve confidence, critical thinking, and decision-making skills; provide standardized patient situations; provide immediate feedback; and improve psychomotor and technical skills (Nehring & Lashley, 2009). As a constructivist-based strategy, simulations promote the construction of knowledge by learners, as educators create experiences that resemble the real healthcare setting (Handwerker, 2012).

Learners participated in a one-hour in-service where they practised nursing assessment and care hands-on with lowfidelity manikin arms with a PICC line in place. The inservice was designed to mirror the experiential learning that would occur in the clinical setting when they perform the skill independently. Nurses who attended low-fidelity simulations • demonstrated safe techniques related to PICC care in adults, such as: infection control positive patient identification aseptic non-touch techniques; • demonstrated PICC skills: dressing changes accessing flushing and locking (without heparin) blood procurement; and • received feedback from the educators.

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Hands-On training and competency validation. As the last part of the education program, learners were given the opportunity to perform the skills learned in the low-fidelity cvaa.info

Reguindin, J., Wang, A., Capoccitti, K., Lai, S., Saby, C., Sakin, N., Woods, W., Ortiz, C., Velasco, K., Alvand, P., Sayed, A., Lee, M., Rothery, D., & Layton, M.

simulations on real patients under the supervision of the CRL or a VAT nurse. A learner completed all modules after they were able to perform the skills accurately and were “signed off ”. This strategy further bridged the gap between theory and practice as clinical experiences in real-life settings are the best form of experiential learning (Handwerker, 2012). Additionally, this part of the curriculum is aligned with level 3 of Kirkpatrick’s Model, wherein the handson training measures the degree to which learners apply learning from the education program.

Practice supports Vascular access device policies were accessible through the policy repository used by the hospital. Learning resources were available on the intranet practice pages. In addition to the learning package, skills videos were created by the CRLs using the supplies and equipment utilized in the hospital. This job aid was available for nurses who may need a refresher on the skill and expectations. It serves to standardize the resources available within the hospital rather than performing an internet search.

Methods Setting Michael Garron Hospital had a steady increase in patients requiring PICC lines so training was prioritized (Figure 2).

The training occurred in this urban community hospital.

Initial training of existing nurses occurred in a phased approach and in between pandemic waves. With infection control in mind, small group activities were scheduled in February 2021 (Quarter 4, 2020) and the beginning of April 2021 (Quarter 1, 2021). As noted previously, inpatient nurses, both RNs and RPNs, were included. In addition, any nurses from specialty areas like ER and CIU were also included in this phased approach. This training was included in the new hire nurse orientation in March 2021. The training intervention started with the distribution of learning packages two to three weeks prior to a nurse’s scheduled hands-on training session. Passing marks were required to confirm attendance. The hands-on training portion was facilitated by the CRLs. Competency validation occurred after this training event.

Data collection Information to validate the performance gap was obtained through the daily documentation submitted by the VAT. These documents include 1. PICC insertion data; 2. pages received from switchboard and documentation of tasks in which they called to perform; and 3. planned bloodwork schedules.

Data found in Figure 1, Figure 2, and Table 1 were derived from the data listed above.

Figure 2 PICC Insertions by Programs

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Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation

Baseline data were collected in February 2020, prior to launching the training program. This table shows that there were 512 calls related to PICC care, maintenance, and troubleshooting.

Training completion rates were collected for each program to ensure that the goal of 80% of full-time and part-time nurses were trained to care for and manage PICC lines was obtained. Only nurses who successfully achieved the four modules were counted.

Results Evaluation results Table 2 lists training completion rates by program between February to August 2021, which shows the range of trained nurses across programs. The number of clinical units counted within a program is listed in parentheses. Minimum values represent the lowest training rate within a program and maximum values represent the unit with the highest completion rates.

Level 4 Evaluation (Kirkpatrick & Kirkpatrick, 2021) shows the impact of an educational intervention from the organization’s perspective. At MGH, this was evident; as more nurses were trained to care for PICC lines over the months, there were less calls to the VAT nurses (see Table 3). The significant drop in VAT requests for blood draws and resource calls (from 214 requests for blood draws from PICCs in February of 2021 for 44 inserted PICCs, compared to 16 requests for help to 41 PICCs in August 2022) showed the effectiveness of the training program. In addition, resource calls that include VAD assessments and weekly line flushing for dormant lines, decreased by 57% from February to August.

In addition to the educational effectiveness, there were minimal clinical complications associated to the upskilling of inpatient unit nurses out of 1,000 requests for bedside insertions between 2019 to October 2021. The tracked complications followed by the VAT were

Table 1

Table 2

February 2021 Data

Program Data

Number of PICCs in hospital for the month

41

Request for flushing, troubleshooting, and assessment

278

Request for bloodwork

214

Request for PICC needleless connector change

15

Request for PICC dressing change

3

Request for access and PICC disconnection

2

Total calls VAT received in relation to PICC

512

Overall calls to VAT in relation to PICC and VAD-related tasks

673

Program

Min

Max

August 2021 Completion

Emergency and Critical Care, and Clinical Strategy (3 patient units)

61%

100%

65%

Transitional Care (2 patient units)

84%

90%

93%

Medicine Program (6 patient units)

21%

100%

69%

Surgical Program (2 patient units)

76%

80%

77%

Nursing Resource Team (supports multiple units)

81%

Table 3 VAT Activity by Month VAT actions (2021)

Feb

March

April

May

Jun

July

Aug

Sep

Number of PICCs in hospital

44

42

54

36

54

42

41

32

PICC needleless connector change

15

2

6

1

2

2

1

0

Resource call

277

172

154

149

106

143

117

102

Bloodwork

214

164

46

82

49

29

16

17

PICC salvage

0

0

4

3

3

11

3

7

PICC dressing

3

3

11

6

8

6

4

3

PICC rescue PICC-related calls

0

0

4

3

3

11

3

7

509

344

223

259

179

200

149

141

Page 36 • Vascular Access • Volume 16, Issue 2, Summer 2022

cvaa.info

Reguindin, J., Wang, A., Capoccitti, K., Lai, S., Saby, C., Sakin, N., Woods, W., Ortiz, C., Velasco, K., Alvand, P., Sayed, A., Lee, M., Rothery, D., & Layton, M.

• • • •

1 site infection; 1 reverse migration; 3 thrombi; 1 septic/thrombophlebitis (transitioned from a different hospital); and • PICC salvage – 31 counts from April to September 2021.

Table 3 shows that PICC rescues were minimal when the training program started in February and March of 2021. As more nurses were trained, there was a fluctuating number of phone calls to VAT nurses when the patency of PICC lines were compromised. These lines were salvaged through proper assessment and interventions by the VAT nurses (CVAA, 2019; Gorski et al., 2021).

Despite the increase in salvaging PICCs, what can be commended is the decrease in resource calls, requests for blood work support, needleless access, and de-accessing PICCs.

Discussion Design and implementation considerations There were two key anticipated operational issues that included resources and staffing. Due to the pandemic, CRLs often had many competing priorities. Since it was an organization-wide rollout, working collaboratively across all programs helped ensure that in-services were standardized and consistent across the organization. Given massive staffing shortages and increased acuity of patients, it was difficult for staff to leave the unit to be trained. With this in mind, the in-services were split into manageable sessions that were one hour in length to reduce the length of time nurses would be off the unit and away from patient care tasks. The modular approach to learning decreased the risk of overwhelming staff with new information. Furthermore, policies, the learning package, and job aids were made accessible to staff whenever they were available to alleviate this potential issue.

Organization-wide approaches were implemented to promote sustainability. The education program was integrated into corporate orientation. This change also was incorporated into hospital policy (e.g., indicating that nurses who are certified can now perform these skills rather than relying on VAT nurses) and into the electronic health records (e.g., nurses will have access to document these new skills).

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Conclusions The goal of evaluation for training programs is to show that there is a shift from knowledge to practice. With this initial evaluation, results show a significant decrease in requests for PICC assistance from the VAT (more than 512 calls in one month down to 149) from implementation to six months post-implementation, as noted in Table 3. Clinical complications from increasing trained staff were also minimal. From our results, further evaluation or research may be completed to understand the root cause of the fluctuating PICC salvage incidences.

Disclosures No monies have been received from BD outside of our standard contract for our purchase of consumables, which qualifies us for the ultrasound machine used for PICC line insertion.

About the authors Jennifer Reguindin, MScN, RN, GNC(c), is the clinical resource leader for nursing practice and education at Michael Garron Hospital. Jennifer leads and coordinates hospital training rollouts. She also trains and supports the practice of the nursing resource team, extern mentors, externs, and the supervised practice experience partnership internationally educated nurses (IENs). She holds an Adjunct Lecturer Appointment with the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

Angel Wang, RN, MN, is the Clinical Resource Leader for the Complex Continuing Care Department at Michael Garron Hospital. She completed her Master of Nursing degree in the thesis stream at Toronto Metropolitan University, focusing on nursing leadership, education and research. Angel is committed to nursing scholarship, with research interests in professional practice, the nursing workforce, and gerontology. She is deeply passionate about elevating nurses and the nursing profession to further benefit patient care as well as to enhance nursing and organizational outcomes and the healthcare system as a whole.

Kim Capoccitti, MSN, RN, held a previous role as the clinical resource leader for the intensive care unit and the vascular access team at Michael Garron Hospital in Toronto, ON. She is currently the advanced practice nurse for the critical care unit and the cardiovascular intensive care unit at Sunnybrook Health Sciences Centre. Kim supports quality improvement initiatives across critical care in the Tory Trauma Program.

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Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation

Shevaun Lai, RN, BScN, MN Candidate, is a final year Master of Nursing student at Athabasca University. She received a Bachelor of Science in Nursing degree at Ontario Tech University in Ontario, Canada. She has experience working in critical care, clinical teaching and education. She is passionate about advancing nursing practice by utilizing evidence-based research to improve clinical practice and patient outcomes. She is a strong advocate for speaking up for safety through a mix of transformational and servant leadership. She is committed to lifelong learning, continuing education, and professional development.

Christine Saby, MN, RN, is the clinical resource leader for the perianaesthesia care unit, preoperative assessment clinic, and ambulatory clinics. She completed a Master of Nursing degree with a teaching focus at Athabasca University. Her career experience includes paediatrics, critical care, inpatient surgery and perianaesthesia care nursing and education. Christine has a passion for learning, best practice, and supporting nursing teams.

Natalie Sakin, MN, RNHSLA, PANC(c), is the interim manager for the general internal medicine units. She was the clinical resource leader for these units.

Wesley Woods, RN, CCRN, is a highly skilled vascular access nurse. His background as a critical care nurse has enabled him to perfect his vascular access skills. Within his role on the Vascular Access Team, he has led process improvements around workflow, documentation and growing the Nurse-Led PICC Line insertion program at Michael Garron Hospital.

He is passionate about enhancing the skills, specifically around vascular access, of RNs and RPNs throughout the organization.

Christine Ortiz, RN, CON(c), is a full-time vascular access team nurse.

Karen Velasco, RN, is a part-time vascular access team nurse. She advocates for quality patient care and empowering nurses through skills development and training. Her career experience includes working in the emergency department, resource team, and community nursing.

Page 38 • Vascular Access • Volume 16, Issue 2, Summer 2022

Parisa Alvand, MN, RN, is the Interim Clinical Manager for the Inpatient Respiratory Unit, Progressive Weaning Centre, and Internal Medicine. She was the Clinical Resource Leader for these units. She holds an Adjunct Lecturer Appointment with the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.

Ahmed Ullah Sayed, RN, is the Clinical Resource Leader for the emergency department (ED) at Michael Garron Hospital. He is a certified Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), and Canadian Triage & Acuity Scale (CTAS) instructor. He also teaches the Crisis Prevention Institute method of verbal de-escalation and crisis management in ED. He is certified and works toward improving practice in emergency medicine for inter-professional team members via in-person and virtual simulation. He is involved in numerous quality improvement projects within the organization and with other stakeholders in the community.

He is the Continuing Professional Development nursing lead for the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) with the passion to build capacity and improve care in emergency medicine globally.

Marilyn Lee, MN, RN, is the Manager of Critical Care, Vascular Access and the Co-Lead for the Rapid Response Team at the Michael Garron Hospital. She completed an undergraduate degree at the University of Windsor and a Master of Nursing degree with a management focus at the University of Toronto. Her career experience includes inpatient surgery, perianaesthesia care and critical care nursing education and management. Marilyn has a passion for advocating for highquality and safe family-centred care.

Donna Rothery, BScN, RN, CNCC(c) is the supervisor of the intensive care unit and vascular access team. Donna is a partial load clinical facilitator with the Centennial College Paramedic program, and partial load faculty for the Centennial College Nursing Bridging program. Donna’s focus on education and best practice standards has led to improvement initiatives within both the vascular access and intensive care units.

Mikki Layton, MN, NP-Adult, CON(C), CHPCN(C), is the chief nursing executive at Michael Garron Hospital and a practising nurse practitioner. Mikki holds an undergraduate degree from Ryerson University and a Master of cvaa.info

Reguindin, J., Wang, A., Capoccitti, K., Lai, S., Saby, C., Sakin, N., Woods, W., Ortiz, C., Velasco, K., Alvand, P., Sayed, A., Lee, M., Rothery, D., & Layton, M.

Nursing from the University of Toronto. She holds an Adjunct Clinical Appointment with the Lawrence S. Bloomberg Faculty of Nursing University of Toronto, and is on faculty with Centennial College nursing bridging program. Mikki’s career has been dedicated to advancing nursing practice and advocating for high-quality and safe person and family-centred care.

À propos des auteurs Jennifer Reguindin, M. Sc. inf., inf. aut., CSIG(C), Responsable des ressources cliniques pour la pratique et la formation en soins infirmiers à l’Hôpital Michael Garron. Elle dirige et coordonne l’implémentation des formations à l’hôpital. De plus, elle forme et soutient les membres de l’équipe de ressources infirmières, les mentors externes, les stagiaires et les membres du personnel infirmier formé à l’étranger dans le cadre du partenariat encadré en expérience pratique. Elle est chargée de cours associée à la Faculté des sciences infirmières Lawrence S. Bloomberg de l’Université de Toronto.

Angel Wang, inf. aut., M. Sc. inf., Responsable des ressources cliniques au service des soins continus complexes de l’Hôpital Michael Garron. Elle a complété sa thèse et obtenu sa maîtrise en sciences infirmières à l’Université Toronto Metropolitan.

Sa recherche était axée sur le leadership, la formation et la recherche en soins infirmiers. Elle a une bourse en soins infirmiers et ses domaines de prédilection en recherche sont la pratique professionnelle, la main-d’œuvre en soins infirmiers et la gérontologie. Elle est extrêmement passionnée par la valorisation des infirmières et de leur métier, et par la façon d’améliorer les soins aux patients ainsi que les résultats relatifs aux soins infirmiers, aux organisations et au système de santé dans l’ensemble.

Kim Capoccitti, M. Sc. inf., inf. aut., Auparavant responsable des ressources cliniques à l’unité de soins intensifs et au sein de l’équipe de l’accès vasculaire à l’Hôpital Michael Garron à Toronto (Ontario). Elle est actuellement infirmière en pratique avancée à l’unité des soins intensifs et à l’unité de soins intensifs cardiovasculaires au Sunnybrook Health Sciences Centre. Elle soutient les initiatives d’amélioration de la qualité dans toutes les unités de soins intensifs du programme Tory Trauma.

Shevaun Lai, inf. aut., B. Sc. inf., candidate à la M. Sc inf., Étudiante en dernière année de maîtrise en sciences infirmières à l’Université Athabasca. Elle a obtenu son baccalauréat en sciences infirmières à l’Université Ontario Tech (Ontario, Canada). Elle a de l’expérience de travail en soins intensifs ainsi qu’en enseignement et éducation clinique. Elle est passionnée par

cvaa.info

la valorisation de la pratique des soins infirmiers – elle utilise les recherches fondées sur les données probantes pour améliorer la pratique clinique et les résultats pour les patients. Elle est une grande défenseuse de la promotion de la sécurité à l’aide de stratégies mixtes de leadership transformationnel et relationnel.

L’apprentissage tout au long de la vie, la formation continue et le perfectionnement professionnel lui tiennent à cœur.

Christine Saby, M. Sc. inf., inf. aut., Responsable des ressources cliniques à l’unité de soins périanesthésiques, à la clinique d’évaluation préopératoire et aux cliniques de soins ambulatoires. Elle a obtenu sa maîtrise en sciences infirmières (spécialité : enseignement) de l’Université Athabasca. Elle a de l’expérience professionnelle en soins pédiatriques, en soins intensifs, en chirurgie avec hospitalisation, en soins infirmiers périanesthésiques et en éducation. Elle est passionnée par l’apprentissage, par les pratiques exemplaires et par le soutien des équipes en soins infirmiers.

Natalie Sakin, M. Sc. inf., inf. aut. (Health Systems Leadership and Administration Program), ICPA(C), Gestionnaire intérimaire des unités de médecine interne générale. Elle était la responsable des ressources cliniques de ces unités.

Wesley Woods, inf. aut., inf. aut. en soins intensifs, Infirmier hautement compétent en accès vasculaire. Son expérience en tant qu’infirmier aux soins intensifs lui a permis de perfectionner ses compétences en accès vasculaire. Dans le cadre de ses responsabilités au sein de l’équipe de l’accès vasculaire, il a été responsable de l’amélioration des processus relatifs au flux de travail, à la documentation et au programme en pleine croissance d’insertion des CCIP par les infirmières à l’Hôpital Michael Garron. Il est passionné par l’amélioration des compétences, notamment celles liées à l’accès vasculaire, des infirmières autorisées et des infirmières auxiliaires autorisées dans l’ensemble de l’organisation.

Christine Ortiz, inf. aut., CSIO(C), Infirmière à temps plein au sein de l’équipe de l’accès vasculaire.

Karen Velasco, inf. aut., Infirmière à temps partiel au sein de l’équipe de l’accès vasculaire.

Parisa Alvand, M. Sc. inf., inf. aut., Gestionnaire clinique intérimaire de l’unité des soins respiratoires des patients hospitalisés, du centre de sevrage progressif et de l’unité de médecine interne. Elle a été la responsable des ressources cliniques de ces unités. Elle est chargée de cours associée à la Faculté des sciences infirmières Lawrence S. Bloomberg de l’Université de Toronto.

Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 39

Supporting clinical competency in managing peripherally inserted central catheters during the COVID-19 pandemic: An education evaluation

Ahmed Ullah Sayed, inf. aut., Responsable des ressources cliniques du service des urgences de l’Hôpital Michael Garron.

Il est formateur certifié pour les certifications Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS) et Canadian Triage & Acuity Scale (CTAS). Il enseigne également la méthode du Crisis Prevention Institute de désescalade verbale et de gestion de crise dans le service des urgences. Il est certifié et travaille pour l’amélioration de la pratique des membres des équipes interprofessionnelles en médecine d’urgence au moyen de la simulation en personne et virtuelle. Il est impliqué dans de nombreux projets d’amélioration de la qualité au sein de l’organisation et avec d’autres intervenants de la communauté. Passionné par le renforcement des capacités et l’amélioration des soins en médecine d’urgence à l’échelle mondiale, il est responsable du perfectionnement professionnel continu en soins infirmiers au sein de la Toronto Addis-Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM).

Marilyn Lee, M. Sc. inf., inf. aut., Gestionnaire des soins intensifs au sein de l’équipe de l’accès vasculaire et coresponsable de l’équipe d’intervention rapide à l’Hôpital Michael Garron.

Elle a obtenu un diplôme de premier cycle de l’Université de Windsor et une maîtrise en sciences infirmières (spécialité : gestion) de l’Université de Toronto. Elle a de l’expérience professionnelle en chirurgie avec hospitalisation, en soins périanesthésiques, et en éducation et gestion infirmière des soins intensifs. Marilyn est passionnée par la promotion des soins de grande qualité, sécuritaires et centrés sur la famille.

Donna Rothery, B. Sc. inf., inf. aut., CSI(C), Superviseuse de l’unité de soins intensifs et de l’équipe de l’accès vasculaire. Elle est animatrice clinique à temps partiel auprès du programme paramédical du Centennial College et professeure à temps partiel dans le programme de transition en soins infirmiers du Centennial College. Ses domaines de prédilection en éducation et en pratiques exemplaires lui ont permis de mener des initiatives d’amélioration au sein de l’équipe de l’accès vasculaire et de l’unité de soins intensifs.

Page 40 • Vascular Access • Volume 16, Issue 2, Summer 2022

Mikki Layton, M. Sc. inf., IPS (soins aux adultes), CSIO(C), ICSP(C), Chef de direction, soins infirmiers, à l’Hôpital Michael Garron et infirmière praticienne spécialisée. Elle a obtenu un diplôme de premier cycle de l’Université Ryerson et une maîtrise en sciences infirmières de l’Université de Toronto.

Elle est chargée de cours associée à la Faculté des sciences infirmières Lawrence S. Bloomberg de l’Université de Toronto.

De plus, elle fait partie du corps professoral du programme de transition en soins infirmiers du Centennial College.

Elle a consacré sa carrière à la valorisation de la pratique des soins infirmiers et à la promotion de soins de grande qualité, sécuritaires et centrés sur la famille.

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Peters, M. (2000). Does constructivist epistemology have a place in nurse education? Journal of Nursing Education, 39(4), 166– 172.

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Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimise first-insertion success for patients with Difficult IntraVenous Access in the emergency department (LOVE-DIVA): A study protocol for a randomised controlled trial Hui (Grace) Xu1,2*, RN, NP, MN, MNP, PhD candidate, Amanda Corley1,3, RN, MAdvPrac, PhD, Robert S. Ware4,5, BSc (Hons), PhD, Son Nghiem4,5, PhD, Scott Stirling6, MBBS, FACEM, FAAEM, Carrie Wang2, MBBS, FACEM, and Nicole Marsh1,3, RN, PhD

L’utilisation d’un cathéter intraveineux périphérique long avec un fil-guide rétractable afin d’optimiser la probabilité de réussite de la première insertion chez les patients dont l’abord intraveineux est difficile au service des urgences (LOVE-DIVA) : Un protocole de recherche pour un essai contrôlé à répartition aléatoire Hui (Grace) Xu1,2*, inf. aut., IPS, M. Sc. inf., Amanda Corley1,3, inf. aut., maîtrise en pratiques infirmières avancées, Ph. D., Robert S. Ware4,5, B. Sc. (avec distinction), Ph. D., Son Nghiem4,5, Ph. D., Scott Stirling6, MBBS, FACEM, FAAEM, Carrie Wang2, MBBS, FACEM et Nicole Marsh1,3, inf. aut., Ph. D. School of Nursing and Midwifery, Griffith University, Brisbane Australia Department of Emergency Medicine, QEII Hospital, Brisbane, Australia 3 Nursing and Midwifery Research Centre, Royal Brisbane and Women’s Hospital, Brisbane, Australia 4 Menzies Health Institute Queensland, Griffith University, Brisbane, Australia 5 School of Medicine and Dentistry, Griffith University, Brisbane, Australia 6 Department of Emergency Medicine, Logan Hospital, Brisbane, Australia *Corresponding author: Hui (Grace) Xu, E: g.xu@griffith.edu.au 1 2

This is an Open Journal Systems article, distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited and it is not for commercial purposes, and is distributed under the same licence as the original.

Il s’agit d’un article d’Open Journal Systems distribué en vertu du contrat de la licence d’attribution Creative Commons (https://creativecommons. org/licenses/by-nc-sa/4.0) qui permet d’utiliser, de distribuer et de reproduire sans restriction son contenu dans tout support, pourvu que l’œuvre original soit adéquatement citée, ne soit pas utilisée pour des fins commerciales et soit distribuée sous la même licence que l’original.

Suggested citation: Xu, H., Corley, A., Ware, R. S., Nghiem, S., Stirling, S., Wang, C., & Marsh, N. (2022). Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimize first-insertion success for patients with Difficult Intra-Venous Access in the emergency department (LOVE-DIVA): study protocol for a randomized controlled trial. Vascular Access – Journal of the Canadian Vascular Access Association, 16(2), 41–49.

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© 2022 Xu et al.

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Using a LOng peripheral intraVEnous catheter with retractable guidewire to optimize first-insertion success for patients with Difficult IntraVenous Access in the emergency department (LOVE-DIVA): A study protocol for a randomized controlled trial

Abstract Introduction: First-insertion success rates for peripheral vascular access devices (PVADs) in patients with difficult venous access (DIVA) are low, which negatively affects staff workload, patient experience, and organizational cost. There is mixed evidence regarding the impact of a peripheral vascular access device with retractable coiled tip guidewire (GW; AccuCath™, BD) on the first-insertion success rate. The aim of this study is to investigate whether the use of long GW-PVADs, compared with standard PVADs, reduces the risk of first-time insertion failure, in patients admitted to emergency departments (EDs).

admis aux services des urgences réduit les risques d’échec de la première tentative d’insertion par rapport aux dispositifs traditionnels.

Methods and analysis: A parallel-group, two-arm, randomized controlled trial will be carried out in two Australian EDs to compare long GW-PVADs (5.8cm length) against standard care PVADs (short or long). Patients ≥18 years of age meeting DIVA criteria will be eligible for the trial. The sample size is 203 participants for each arm. Web-based central randomization will be used to ensure allocation concealment. Neither clinicians nor patients can be blinded to treatment allocation. Primary outcome is the first-insertion success rate. Secondary outcomes include the number of insertion attempts, time to insert PVAD, all-cause failure, dwell-time, patient-reported pain, serious adverse events, complications, subsequent vascular access devices required, patient satisfaction, staff satisfaction, and healthcare costs. Differences between the two groups will be analyzed using Cox proportional hazards regression. Cost-effectiveness analysis will also be conducted. Intention-to-treat analysis will be used.

Méthodologie et analyse : Un essai contrôlé à répartition aléatoire et comportant deux groupes parallèles sera mené dans deux services des urgences en Australie afin de comparer les effets de l’utilisation des dispositifs d’accès vasculaire périphérique longs avec un fil-guide (longueur : 5,8 cm) aux effets de l’utilisation des dispositifs de référence (courts ou longs). Les patients de 18 ans ou plus qui remplissent les critères de difficulté de l’abord intraveineux seront admissibles à participer à l’essai. L’échantillon est de 203 participants par groupe. La répartition aléatoire centralisée à l’aide d’un système en ligne assurera la dissimulation de l’attribution. L’attribution du traitement ne pourra pas être à l’insu des cliniciens ou des patients. Le critère d’évaluation principal est le taux de réussite de la première tentative d’insertion. Les critères d’évaluation secondaires comprennent le nombre de tentatives d’insertion, la durée d’insertion du dispositif d’accès vasculaire périphérique, l’échec toutes causes, la durée de séjour, la douleur signalée par le patient, les manifestations indésirables graves, les complications, les dispositifs d’accès vasculaire subséquents exigés, la satisfaction du patient, la satisfaction du personnel et les coûts liés aux soins de santé. Les différences entre les deux groupes seront analysées au moyen du modèle de régression à risques proportionnels de Cox. Une analyse du rapport coût-efficacité sera également effectuée. Une analyse de l’intention de traiter sera menée.

Ethics and dissemination: The study is approved by Metro South Ethics Committee (HREC/2022/QMS/82264) and Griffith University (2022/077). The findings will be published in a peer-reviewed journal.

Éthique et diffusion : L’étude est approuvée par le Metro South Ethics Committee (HREC/2022/QMS/82264) et l’Université Griffith (2022/077). Les résultats seront publiés dans une revue évaluée par des pairs.

Trial registration: ACTRN12622000299707

Numéro de l’essai : ACTRN12622000299707

Résumé

Introduction

Introduction : Le taux de réussite de la première tentative d’insertion des dispositifs d’accès vasculaire périphérique chez les patients dont l’abord intraveineux est difficile est bas, ce qui entraîne des répercussions négatives sur la charge de travail du personnel, l’expérience du patient et les coûts à l’échelle de l’organisation. Les données concernant les effets de l’utilisation des cathéters intraveineux périphériques avec un fil-guide à embout enroulé (AccuCath™ de l’entreprise BD) sur le taux de réussite de la première tentative d’insertion sont contradictoires.

Cette étude vise à déterminer si l’utilisation des dispositifs d’accès vasculaire périphérique longs avec un fil-guide chez les patients

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I

nserting a peripheral vascular access device (PVAD) promptly to administer drugs and fluids is crucial for the treatment of patients in emergency departments (ED).

Failing to secure reliable vascular access could contribute to ED crowding, as well as delays in patient treatments and diagnostic testing (Witting, 2012). Despite PVAD insertion being one of the most common tasks for ED clinicians, the task remains challenging when considering one in three patients present with difficult venous access (DIVA; Rippey et al., 2016; Whalen et al., 2017). Patients with DIVA are often individuals who are overweight,

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without visible or palpable veins, IV drug users, receiving recent chemotherapy, or have medical conditions (e.g., sickle cell disease; Fields, Piela, Au, et al., 2014; Rippey et al., 2016).

First PVAD insertion failure in DIVA patients is as high as 58% (Farrell et al., 2017; Kleidon et al., 2019; Larsen, 2010; Reigart et al., 2012). Repeated PVAD insertion not only causes patient distress, pain and dissatisfaction (Fields, Piela, & Ku, 2014), but also increases staff workload and organizational costs (Tuffaha et al., 2014). Failure to secure a PVAD in ED patients who are unstable or critically unwell can lead to a more invasive procedure, such as insertion of a central vascular access device (CVAD) (Schoenfeld et al., 2011). To increase insertion success, ultrasound is widely utilized to assess vein location and characteristics during PVAD insertion, to avoid ‘blind puncture’ (Bahl et al., 2016; van Loon et al., 2018). Findings from a systematic review suggest that ultrasound-guided insertion has a higher success rate compared with landmark insertion (81% versus 70%; van Loon et al., 2018).

Traditionally, short PVADs (length < 4 cm) are the first line device choice by clinicians, including for DIVA patients.

Research demonstrates that long PVADs (4.5 to 6.4 cms) allow access to deeper veins and a larger proportion of catheters to reside within the vein. This significantly improves PVAD stability and increases the longevity of the device dwell (Bahl et al., 2019). Indeed, as there are more choices of various types of PVADs on the market, clinicians are becoming more conscious of selecting the right devices for the challenging DIVA population, to enhance firstinsertion success.

New PVAD devices using advanced technology are promising in enhancing first-time insertion success. An example is a guidewire (GW) PVAD with a retractable coiled tip, designed to reduce damage to the endothelial layer of blood vessels. However, current evidence about its effectiveness in increasing first-insertion success and reducing complications is mixed. Results of a randomized controlled trial (RCT) showed using a long GW-PVAD was associated with higher first-insertion success (89% GWPVAD versus 47% standard PVAD), increased dwell time (4.4 days GW-PVAD versus 1.5 days standard PVAD) and fewer complications (8% GW-PVAD versus 52% standard PVAD) compared with standard PVADs in a medical ward (Idemoto et al., 2014). Similarly, two observational studies

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found that using GW-PVAD is associated with a lower insertion failure rate and better patient satisfaction in ED settings (Chiricolo et al., 2015; Raio et al., 2018). In contrast, a small RCT (n = 93) conducted in prehospital settings compared insertion time and found a small difference (42 seconds longer, p < 0.0001) to insert GW-PVAD compared with standard PVADs ( Jin et al., 2018). Furthermore, a single-site RCT conducted in an interventional radiology outpatient population found no difference between the GW-PVAD and standard PVADs in the first-time insertion success (77% GW-PVAD versus 82% standard PVAD; Chick et al., 2017). Previous research has been conducted as either small single-site RCTs (Chick et al., 2017; Idemoto et al., 2014) or observation studies (Chiricolo et al., 2015; Raio et al., 2018). Rigorous evidence from a large multi-site RCT is needed to determine the effectiveness of long GW-PVADs in an ED setting. This study aims to determine whether a GW-PVAD, compared to a standard PVAD, is clinically and cost-effective in the ED setting.

Methods and analysis Design A prospective, two-arm, multi-site RCT will be conducted to compare long GW-PVADs (intervention) with standard care PVADs (control). The design and reporting of the trial is informed by the CONSORT guideline (Moher et al., 2010). The trial was prospectively registered with the Australian New Zealand Clinical Trial Registry ACTRN12622000299707).

Hypotheses Primary hypothesis: • Patients with long GW-PVADs will have a higher firstinsertion success rate, compared with patients receiving standard care PVADs. Secondary hypothesis: • Compared with patients receiving standard care PVADs, patients with long GW-PVADs will have lower all-cause PVAD failure and longer dwell-time.

Setting and participants This RCT will be undertaken in two metropolitan secondary level hospital EDs in Queensland, Australia. All patients presenting to the EDs who are ≥18 years old requiring a PVAD and identified as DIVA patients will be eligible for trial entry (Table 1).

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Table 1 Inclusion and Exclusion Criteria Inclusion criteria

Exclusion criteria

• >18 years • Require PIVC as part of treatment • Identified as difficult PIVC insertion by meeting at least one of the criteria: (1) lack of visible or palpable vein; (2) history of DIVA or medical history (e.g., end-stage renal disease and receiving dialysis, IV drug user, sickle cell disease) suggesting DIVA; (3) failed one PVAD insertion attempt (Hallam et al., 2016) • Informed written consent

• Presence of a co-existent, or requiring a central vascular access device (CVAD) or midline • Patients with upper arm limitations (e.g., mastectomy, renal patients) • Non-English-speaking patients without an interpreter • Patients requiring urgent care (e.g., triage category one) • Patients receiving end-of-life care • Previous enrolment in the study

Study interventions Participants will be randomized to either the standard care PVAD (control) arm or the GW-PVAD (intervention) arm.

• Control: either a short PVAD (< 4 cm length, e.g., BD Insyte™ Autoguard™ BC, Introcan Safety®3 catheter, B Braun) or long PVAD catheter (4.5–6.4 cm length, e.g., BD Insyte™ Autoguard™ BC, Introcan Safety®Deep Access, B Braun), inserted by a registered nurse or doctor with established PVAD insertion skills, with or without ultrasound guidance as per clinical judgement. The choice of long or short will be based on clinician judgement.

• Intervention arm: a long GW-PVAD, inserted in the upper arm or forearm vein, (5.8 cm length, AccuCath Ace™ Intravascular Cannula, BD, Salt lake City, UT, USA), by a registered nurse or doctor competent to insert GWPVAD, with ultrasound guidance.

Outcomes Primary outcome • First-time insertion success: on the first-insertion attempt there is a visible presence of blood at the PVAD hub after piercing through the skin into the vein, and a successful flush of normal saline into the vein is achieved (Carr et al., 2016).

Secondary outcomes • Number of PVAD insertion attempts (needle punctures to insert PVAD) • Time to insert PVAD (time from randomization to successful insertion)

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• PVAD failure rate: any causes of ‘failure’ (unintentional cessation of PVAD function before treatment is complete), a composite of infiltration or extravasation (Doellman et al., 2009), blockage or occlusion (with/ without leakage; Helm et al., 2015), dislodgement (partial/complete), infection (laboratory-confirmed local or bloodstream infection as per NHSN 2021; National Healthcare Safety Network, 2021), phlebitis (2 or more of pain/tenderness, erythema and/or swelling > 1 cm, palpable cord and/or vein streak > 2 cm; Rickard et al., 2018), and thrombosis (confirmed by ultrasound) PVAD dwell-time (time from PVAD insertion to removal, in hours) • Patient reported pain from the insertion procedure (0–10 Verbal Rating Scale) • Serious adverse events (e.g., ICU admission) • Individual complications: extravasation or infiltration, occlusion or blockage (with or without leakage), venous thrombosis, catheter dislodgement (complete or partial), phlebitis (vessel wall irritation), or infection (laboratoryconfirmed bloodstream infection NHSN 2021 criteria: positive blood culture from the peripheral vein, clinical signs of infection with no other apparent source except the PVAD, and localized PVAD site infection without bloodstream infection; NHSN CVS-VASC criteria; Marsh et al., 2020) • Subsequent vascular devices required to complete required treatment (until discharge, insertion of CVAD) • Satisfaction: patient satisfaction (10-point Likert scale) and staff satisfaction (10-point Likert scale) will be collected after PVAD insertion • Cost data will be collected in both arms for the costeffectiveness analysis. This sub-study will focus on collecting direct variable costs (includes cost and number of products used and staff for PVAD insertion; costs of treating any complications, including PVAD reinsertions) in a subset of 30 per arm, assuming fixed costs (e.g., buildings, overhead) are similar in both arms (Tuffaha et al., 2014).

Sample size Assuming a 40% first-insertion failure rate in DIVA patients based on previous studies (Farrell et al., 2017; Kleidon et al., 2019; Larsen, 2010; Reigart et al., 2012), we hypothesize an absolute reduction of 15% with the novel catheters (Chiricolo et al., 2015; Idemoto et al., 2014). With twosided alpha of 0.05 and 90% power, 203 participants in each group (406 total) are required. We do not expect significant attrition or missing outcome data given the study design.

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Recruitment, randomization, allocation concealment, and blinding Hospital-based research nurses (ReNs) will screen the EDs’ patients who meet the inclusion criteria on a daily basis (Monday to Friday). These patients will be approached by the ReN, who will explain the trial and give ample opportunity for the patients to ask questions. The participants who sign the consent form will be randomized 1:1 to the GW-PVAD and standard care PVAD groups with varied block sizes of 4 and 6 using a central randomization service (https://www151.griffith.edu.au/). Allocation concealment will be maintained.

Blinding of ReNs, clinicians, and patients to treatment allocation is not possible due to the type of intervention.

However, the infectious disease physician who allocates infection outcomes and the statistician will be blinded to treatment allocation.

Data collection Dedicated ReNs will collect and enter de-identified data into the Research Electronic Data Capture (REDCap, Vanderbilt) (Harris et al., 2009). All patients will be followed

by ReNs daily until 48 hours after removal of their PVADs. Clinical data will be collected from inserters, patients, treating clinicians, clinical notes and pathology records. All data will be collected by using a unique study identification number. Quality checks for allocation integrity and 100% data validation for the initial five patients, consent forms, primary outcomes, and a random 5% other data for all patients will be undertaken by the principal investigator.

At study enrolment/insertion Data including demographic variables (e.g., age, gender), clinical factors (e.g., comorbidities, diagnosis), catheter/ vessel variables (e.g., catheter size/length, insertion site, catheterized vein condition, used for blood collection or not, number of PVAD insertion attempts, time to insertion between first needle stick to catheter secured by dressing, need for rescue inserter), number of concurrent PVADs, patient satisfaction score, and staff satisfaction score will be collected by ReNs. Daily check ReNs will perform daily checks from Monday to Friday to assess patients for site complications. Weekend daily data will be completed based on the information in patients’ clinical notes; an attempt to contact the relevant nurse will be made where missing data exists. cvaa.info

Within 24 hours of PVAD removal Data regarding PVAD removal time, removal reason, insertion site assessment, completion of treatment, and needs for other vascular access device(s) will be collected.

4 8 hours post PVAD removal Microbiological results from blood cultures, catheter tips, or insertion site swabs collected, as per the treating clinical team, will be allocated to our infection outcomes by an independent blinded infectious disease physician (not part of the research team). Additional information about patient outcomes (e.g., discharge, dead) before 48 hours will also be collected.

Data collection for cost analysis ReNs will collect direct cost (e.g., staff time, materials) of a convenience sample of 60 participants in both control and treatment groups (30 in each group). ReNs will observe the length of each insertion time, the number of PVAD insertion attempts, and the materials during insertion (e.g., PVAD/ GW-PVAD, dressing pack, sterile probe for ultrasound guided PVAD insertions, dressings, or securements used to secure the PVAD). The unit costs of required materials will be collected from the most recent Queensland Health purchase prices. Labour costs will be calculated using directly measured time for procedures and estimated hourly salary for Queensland Health staff. Likewise, the total cost of materials will be calculated by multiplying the number of resources used and their unit costs. Costs associated with complications will be estimated using both observed data from the study and literature synthesis. The cost of complications from literature (Tuffaha et al., 2014) will be used, because with the relatively small sample size of 30 and that the risk of complication is low, data from the sample with complications may not be sufficient to generate reliable statistics for the costs of complications.

Validity and reliability A range of strategies was utilized in the design phase to minimize bias and enhance the internal validity of the trial, including using a randomization website, varied block sizes, allocation concealment, blinding during data analysis, and intention-to-treat analysis method. Sampling from two metropolitan EDs ensures the external validity of the trial and the findings will be generalizable to other metropolitan EDs. Additionally, ReNs and a vascular access specialist will perform inter-rater reliability testing of 5% daily site inspections to assess outcome assessment reliability.

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Statistical analysis Data will be transferred from the REDCap database to Stata (StataCorp, College Station, TX, USA) for analysis.

Data will be analyzed according to the intention-to-treat (ITT) principle. A statistical significance level will be set at p ≤ 0.05. The primary outcome, first-insertion success, will be assessed using logistic regression. Secondary outcomes measured with interval data will be assessed using linear regression analyses, while outcomes with count data will be analyzed using Poisson regression models. Time-toevent data will be analyzed using Cox proportional hazards methods and displayed using Kaplan-Meier curves. Missing data will be modelled for best- and worst-case outcomes and the sensitivity of results to missing data will be investigated using multiple imputation or pattern-mixture methods.

Sensitivity analysis will be performed to observe any difference in outcomes related to inserters’ skill levels, as well as comparing long GW-PVAD with various types of standard care PVADs. Cost-effectiveness analysis A decision tree model will be used to conduct the costeffectiveness of the trial. Particularly, costs and selected outcomes of the control and intervention groups will be compared to generate an incremental cost-effectiveness ratio (ICER). Statistical properties of costs, outcomes, and the ICER will be generated using Monte Carlo simulations.

The estimated ICER will be compared to the willingnessto-pay (WTP) for the selected outcome to determine the cost-effectiveness of the trial. One-way and probabilistic sensitivity analyses will be conducted to determine the robustness of cost-effectiveness results to changes in factors affecting costs and outcomes. The WTP for the primary outcome will be estimated using two options.

First, the WTP is proxied by observed costs associated with successful catheter insertion using the usual care approach.

This includes costs of staff time and materials required for successful insertion. Second, literature synthesis and consultation with expert clinicians in the research team will be conducted to ensure the robustness of the findings.

Trial status Recruitment is scheduled to commence in June 2022.

Data collection is anticipated to be completed within six months.

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Discussion Establishing vascular access for DIVA patients is an ongoing challenge for ED clinicians. This RCT is the first trial investigating whether a novel GW-PVAD makes a difference in the first-insertion success rate and PVAD complications in an ED setting. This study will generate new evidence to fill the current knowledge gap and assist ED clinicians to make safe, evidence-based decisions in managing this challenging clinical task.

Strengths and limitations • This study is a multisite, fully powered RCT that will provide rigorous evidence regarding the clinical and costeffectiveness of an innovative GW-PVAD. • A range of strategies was utilized in the planning to ensure the rigour of the design including internal and external validity and inter-rater reliability.

• Blinding will not be possible due to the nature of the intervention. However, independent infectious disease physicians, and the statistician, will be blinded to treatment allocation.

• The study will be conducted in a single region in Australia with an adult cohort, which might restrict the generalizability of the findings.

Ethics and dissemination The trial has obtained ethical approval from Metro South Ethics Committee (HREC/2022/QMS/82264). The trial will be conducted in compliance with the Australian Government National Health and Medical Research Council (NHMRC) National Statement on Ethical Conduct in Human Research (National Health and Medical Research Council, 2018). Written consent will be obtained from all participants before randomization. Participants can withdraw from the study at any stage. Patient confidentiality will be maintained as no individual patient data will be presented in publications and conference presentations.

Serious adverse events (e.g., death, unplanned admission to intensive care unit) will be reported to the ethics committee.

The findings of the trial will be published in a peer-reviewed journal.

Funding statement The trial was funded by the Emergency Medicine Foundation Grant (EMLE-201R36-2021-XU).

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Disclosures

À propos des auteurs

NM reports investigator-initiated research grants or speaker fees provided to Griffith University or University of Queensland on her behalf from Becton Dickinson, 3M, and Cardinal Health and Eloquest.

Hui (Grace) Xu, inf. aut., IPS, M. Sc. inf., infirmière praticienne médicale, doctorante : Infirmière praticienne possédant une solide expérience clinique dans les soins d’urgence. Elle est également adjointe principale de recherche au sein du groupe CRE Wiser Wound care du NHMRC à l’Université Griffith et chercheuse universitaire associée au sein du groupe AVATAR. Dans le cadre de ses fonctions, ses recherches ont porté sur la prévention des complications associées aux patients admis au service des urgences.

About the authors Hui (Grace) Xu, RN, NP, MN, MNP, PhD candidate, is a Nurse Practitioner with extensive clinical experience in emergency care. She also works as Senior Research Assistant at the NHMRC CRE Wiser Wound care group at Griffith University and Adjunct Research Fellow with the AVATAR group. Across these roles, her research focuses on preventing complications associated with patients in emergency department.

Amanda Corley, RN, MAdvPrac, PhD, is an experienced intensive care nurse with 25 years’ experience and specialities in cardiac surgical and respiratory critical care. Amanda has particular expertise and interest in the management and care of vascular access devices, particularly ECMO (Extra Corporeal Membrane Oxygenation) cannula.

Robert S. Ware, BSC (Hons), PhD, is a biostatistician and clinical epidemiologist with more than 15 years’ experience as a consulting academic statistician.

Robert S. Ware, B. Sc. (avec distinction), Ph. D. : Biostatisticien et épidémiologiste clinique possédant plus de 15 ans d’expérience comme statisticien-conseil universitaire.

Son Nghiem, Ph. D. : Économiste de la santé possédant plus de 10 ans d’expérience en économie de la santé et en recherche sur les services de santé.

Son Nghiem, PhD, is a health economist with more than 10 years’ experience in health economics and health service research.

Scott Stirling, MBBS, FACEM, FAAEM : Urgentologue possédant une solide expérience en formation sur les techniques d’échographie et en éducation clinique aux États-Unis et en Australie.

Scott Stirling, MBBS, FACEM, FAAEM, is an emergency physician with extensive experience in ultrasound training and clinical education in both USA and Australia.

Carrie Wang, MBBS, FACEM : Urgentologue avec une passion pour l’éducation, les interventions et l’utilisation de l’échographie dans la prestation de soins sécuritaires et rapides aux patients.

Carrie Wang, MBBS, FACEM, is an emergency physician with a passion for education, procedures, and the incorporation of ultrasound use to deliver safe and timely care to patients.

Nicole Marsh, RN, PhD, is the Nursing Director, Research, at the Royal Brisbane and Women’s Hospital, and is an inaugural member of the AVATAR group. She has been a Project Manager on single- and multi-centre clinical trials related to vascular access devices since 2007. Her research focus is on preventing peripheral intravenous catheter complications. cvaa.info

Amanda Corley, inf. aut., maîtrise en pratiques infirmières avancées, Ph. D. : Infirmière cumulant une vaste expérience de 25 ans en soins intensifs, avec des spécialités en chirurgie cardiaque et en soins respiratoires intensifs. Son expertise et son intérêt portent surtout sur la prise en charge et la prestation des soins par l’entremise des dispositifs d’accès vasculaire, notamment la canule ECMO (oxygénation par circulation extracorporelle).

Nicole Marsh, inf. aut., Ph. D. : Directrice de la recherche en soins infirmiers à l’Hôpital Royal Brisbane and Women’s et membre fondatrice du groupe AVATAR. Depuis 2007, en tant que chargée de projet, elle dirige des essais cliniques multicentriques et menés dans un seul centre portant sur les dispositifs d’accès vasculaire. Ses recherches portent principalement sur la prévention des complications associées au cathéter veineux périphérique.

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Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival. American Journal of Emergency Medicine, 37(4), 715–721. https://doi.org/10.1016/j.ajem.2018.07.031 Bahl, A., Pandurangadu, A. V., Tucker, J., & Bagan, M. (2016). A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients. American Journal of Emergency Medicine, 34(10), 1950–1954. https://doi.org/10.1016/j.ajem.2016.06.098 Carr, P. J., Rippey, J. C., Cooke, M. L., Bharat, C., Murray, K., Higgins, N. S., Foale, A., & Rickard, C. M. (2016).

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: The Vascular Access Decisions in the Emergency Room (VADER) study protocol. BMJ Open, 6(2), e009196. https://doi.org/10.1136/bmjopen-2015-009196 Chick, J. F. B., Reddy, S. N., Chen, J. X., Sammarco, T., Chittams, J., & Trerotola, S. O. (2017). A randomized comparison between an intravenous catheter system with a retractable guidewire and conventional intravenous catheters. The Journal of Vascular Access, 18(6), 530–534. https://doi. org/10.5301/jva.5000763 Chiricolo, G., Balk, A., Raio, C., Wen, W., Mihailos, A., & Ayala, S. (2015). Higher success rates and satisfaction in difficult venous access patients with a guide wire-associated peripheral venous catheter. American Journal of Emergency Medicine, 33(12), 1742–1744. https://doi.org/10.1016/j. ajem.2015.08.005 Doellman, D., Hadaway, L., Bowe-Geddes, L. A., Franklin, M., LeDonne, J., Papke-O’Donnell, L., Pettit, J., Schulmesister, L., & Stranz, M. (2009). Infiltration and extravasation: Update on prevention and management. Journal of Infusion Nursing, 32(4), 203–211. https://doi.org/https://doi. org/10.1097/NAN.0b013e3181aac042 Farrell, C., McCulloch, E., Bellhouse, S., Delahoyde, M.-K., Hill, S., Rickard, C., & Yorke, J. (2017). Peripheral cannulae in oncology: Nurses’ confidence and patients’ experiences.

Cancer Nursing Practice, 16(3), 32–38. https://doi. org/10.7748/cnp.2017.e1408 Fields, J. M., Piela, N. E., Au, A. K., & Ku, B. S. (2014). Risk factors associated with difficult venous access in adult ED patients. American Journal of Emergency Medicine, 32(10), 1179–1182. https://doi.org/10.1016/j.ajem.2014.07.008 Fields, J. M., Piela, N. E., & Ku, B. S. (2014). Association between multiple IV attempts and perceived pain levels in the emergency department. The Journal of Vascular Access, 15(6), 514–518. https://doi.org/10.5301/jva.5000282

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Hallam, C., Weston, V., Denton, A., Hill, S., Bodenham, A., Dunn, H., & Jackson, T. (2016). Development of the UK Vessel Health and Preservation (VHP) framework: A multi-organisational collaborative. Journal of Infection Prevention, 17(2), 65–72. https://doi. org/10.1177/1757177415624752 Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010 Helm, R. E., Klausner, J. D., Klemperer, J. D., Flint, L. M., & Huang, E. (2015). Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing, 38(3), 189–203. https://doi.org/10.1097/NAN.0000000000000100 Idemoto, B. K., Rowbottom, J. R., Reynolds, J. D., & Hickman, R. L. (2014). The AccuCath intravenous catheter system with retractable coiled tip guidewire and conventional peripheral intravenous catheters: A prospective, randomized, controlled comparison. Journal of the Association for Vascular Access, 19(2), 94–102. https://doi.org/10.1016/j.java.2014.03.001 Jin, L. M., Medeck, S., Ruley, J., Riddle, M., & Aden, J. (2018).

“Guidewire intravenous catheter systems do not improve first-pass success rates for peripheral access when placed by army combat medics (68W) in a pre-hospital setting.” A prospective, randomized controlled trial with crossover study design. Military Medicine, 183(11–12), e730–e734. https:// doi.org/10.1093/milmed/usy110 Kleidon, T. M., Cattanach, P., Mihala, G., & Ullman, A. J. (2019).

Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative.

Journal of Paediatrics and Child Health, 55(10), 1214–1223. https://doi.org/10.1111/jpc.14384 Larsen, P., Eldridge, D., Brinkley, J., Newton, D., Goff, D., Hartzog, T., Saad, N. D., Perkin, R. (2010). Pediatric peripheral intravenous access: Does nursing experience and competence really make a difference? Journal of Infusion Nursing, 33(4), 226–235.

Marsh, N., Webster, J., Ullman, A. J., Mihala, G., Cooke, M., Chopra, V., & Rickard, C. M. (2020). Peripheral intravenous catheter non-infectious complications in adults: A systematic review and meta-analysis. Journal of Advanced Nursing, 76(12), 3346–3362. https://doi.org/10.1111/jan.14565 Moher, D., Hopewell, S., Schulz, K. F., Montori, V., Gotzsche, P. C., Devereaux, P. J., Elbourne, D., Egger, M., & Altman, D. G. (2010). CONSORT 2010 explanation and elaboration: Updated guidelines for reporting parallel group randomised trials. The BMJ, 340, c869. https://doi.org/10.1136/bmj.c869 National Health and Medical Research Council. (2018). National statement on ethical conduct in human research: 2007 (updated 2018). Commonwealth of Australia. www.nhmrc.gov.au/ guidelines/publications/e72 cvaa.info

Xu, H., Corley, A., Ware, R. S., Nghiem, S., Stirling, S., Wang, C., & Marsh, N.

National Healthcare Safety Network. (2021). National Healthcare Safety Network (NHSN) patient safety component manual https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_ current.pdf Raio, C., Elspermann, R., Kittisarapong, N., Stankard, B., Bajaj, T., Modayil, V., Nelson, M., Chiricolo, G., Wie, B., Snock, A., Mackay, M., & Ash, A. (2018). A prospective feasibility trial of a novel intravascular catheter system with retractable coiled tip guidewire placed in difficult intravascular access (DIVA) patients in the Emergency Department. Internal and Emergency Medicine, 13(5), 757–764. https://doi. org/10.1007/s11739-017-1747-0 Reigart, J. R., Chamberlain, K. H., Eldridge, D., O’Brien, E. S., Freeland, K. D., Larsen, P., Goff, D., & Hartzog, T. H. (2012). Peripheral intravenous access in pediatric inpatients. Clinical Pediatrics, 51(5), 468–472. https://doi. org/10.1177/0009922811435164 Rickard, C. M., Marsh, N., Webster, J., Runnegar, N., Larsen, E., McGrail, M. R., Fullerton, F., Bettington, E., Whitty, J. A., Choudhury, M. A., Tuffaha, H., Corley, A., McMillan, D. J., Fraser, J. F., Marshall, A. P., & Playford, E. G. (2018).

Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): A pragmatic, randomised controlled, superiority trial. The Lancet, 392(10145), 419–430. https://doi.org/10.1016/s01406736(18)31380-1 Rippey, J. C., Carr, P. J., Cooke, M., Higgins, N., & Rickard, C. M. (2016). Predicting and preventing peripheral intravenous cannula insertion failure in the emergency department: Clinician ‘gestalt’ wins again. Emergency Medicine Australasia, 28(6), 658–665. https://doi.org/10.1111/1742-6723.12695

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Schoenfeld, E. M., Shokoohi, H., & Boniface, K. (2011).

Ultrasound-guided peripheral intravenous access in the emergency department: Patient-centered survey. Western Journal of Emergency Medicine, XII(4), 475–477.

Tuffaha, H. W., Rickard, C. M., Webster, J., Marsh, N., Gordon, L., Wallis, M., & Scuffham, P. A. (2014). Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters. Applied Health Economics and Health Policy, 12(1), 51–58. https://doi.org/10.1007/ s40258-013-0077-2 van Loon, F. H. J., Buise, M. P., Claassen, J. J. F., Dierick-van Daele, A. T. M., & Bouwman, A. R. A. (2018). Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: A systematic review and meta-analysis. British Journal of Anaesthesia, 121(2), 358–366. https://doi.org/10.1016/j. bja.2018.04.047 W halen, M., Maliszewski, B., & Baptiste, D. L. (2017).

Establishing a dedicated difficult vascular access team in the emergency department: A needs assessment. Journal of Infusion Nursing, 40(3), 149–154. https://doi.org/10.1097/ NAN.0000000000000218 Witting, M. D. (2012). IV access difficulty: Incidence and delays in an urban emergency department. The Journal of Emergency Medicine, 42(4), 483–487. https://doi.org/10.1016/j. jemermed.2011.07.030

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This article is reprinted with permission from the British Journal of Nursing, 2022, Vol. 31, No. 8 (IV and Vascular Access Supplement). © MA Healthcare Ltd. Le Présent article est reproduit avec l’autorisation du British Journal of Nursing, 2022, Vol. 31, No. 8, (IV and Vascular Access Supplement). © MA Healthcare Ltd.

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children Nalan Karaoğlan, Hatice Yıldırım Sarı, and İlker Devrim

Complications associées à l’utilisation des cathéters intraveineux périphériques et facteurs de risque d’infiltration ou de phlébite chez les enfants Nalan Karaoğlan, Hatice Yıldırım Sarı et İlker Devrim This is an Open Journal Systems article, distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited, not used for commercial purposes, and is distributed under the same license as the original.

Il s’agit d’un article d’Open Journal Systems distribué en vertu du contrat de la licence d’attribution Creative Commons (https://creativecommons. org/licenses/by-nc-sa/4.0) qui permet d’utiliser, de distribuer et de reproduire sans restriction son contenu dans tout support, pourvu que l’œuvre originale soit adéquatement citée, ne soit pas utilisée pour des fins commerciales et soit distribuée sous la même licence que l’original.

Suggested Citation: Karaoğlan, N., Sari, H. Y., & Devrim, I. (2022). Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children. Vascular Access – Journal of the Canadian Vascular Access Association, 16(2), 50–60. (Reprinted from “Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children,” 2021, British Journal of Nursing, 31[8; IV and Vascular Access Supplement], S14–S23.)

Abstract Aim: This study aimed to identify the types of complications of peripheral intravenous catheters (PIVCs) in hospitalized children and possible risk factors for the development of extravasation, infiltration, and phlebitis.

Method: The study was conducted in the largest children’s hospital in a region of Turkey, with a bed capacity of 354 and 1,400 employees, which provides care only to pediatric patients aged from newborn to 18 years old. In this five-month prospective study, the complications of PIVCs in hospitalized children and risk factors leading to the development of extravasation, infiltration, and phlebitis were recorded. During morning and Page 50 • Vascular Access • Volume 16, Issue 2, Summer 2022

afternoon daily visits, the researcher examined catheter sites for complications and indications for removal.

Results: The study covered 244 patients aged from 1 month to 17 years, 575 PIVCs and 1,600 catheter days. The rates of infiltration and phlebitis observed in children with PIVCs were 8.7% and 15.8%, respectively. Logistic regression revealed that using 22- and 24-gauge catheters, hospitalization in the surgery ward, and continuous infusion were significant independent risk factors for the development of infiltration (P < 0.001). Direct logistic regression revealed that age in months, hospitalization in a surgery ward, and placement of the catheter in the veins of the antecubital fossa were significant independent risk factors for the development of phlebitis (P < 0.001). © 2022 MA Healthcare Ltd.

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Karaoğlan, N., Sarı, H. Y., & Devrim, I.

Conclusion: Catheter size, hospitalization in the surgery ward, and continuous infusion contributed to the development of infiltration. Age, hospitalization in the surgery ward, and catheter placement in the antecubital vein contributed to the development of phlebitis.

Keywords: peripheral intravenous catheter, infusion phlebitis, infusion complications, paediatric peripheral intravenous infiltration

Résumé Objectif : Cette étude visait à déterminer les types de complications associées à l’utilisation des cathéters intraveineux périphériques chez les enfants hospitalisés et les facteurs de risque possibles d’extravasation, d’infiltration et de phlébite.

Méthodologie : L’étude a été menée dans le plus grand hôpital pour enfants dans une région de la Turquie. Comptant 354 lits et 1400 employés, l’hôpital fournit uniquement des soins aux nouveau-nés, aux enfants et aux adolescents âgés de 18 ans ou moins. Dans cette étude prospective de 5 mois, les complications associées à l’utilisation des cathéters intraveineux périphériques chez les enfants hospitalisés et les facteurs de risque entraînant l’extravasation, l’infiltration et la phlébite ont été consignés.

Dans le cadre de visites quotidiennes en matinée ou en aprèsmidi, le chercheur a vérifié les points d’insertion des cathéters pour constater la présence ou non de complications et la nécessité de procéder au retrait.

Résultats : L’étude a porté sur 244 patients âgés d’un mois à 17 ans, sur 575 cathéters intraveineux périphériques et sur 1600 jours-cathéters. Les taux d’infiltrations et de phlébites observés chez les enfants ayant des cathéters intraveineux périphériques étaient de 8,7 % et 15,8 %, respectivement. La régression logistique a révélé que l’utilisation de cathéters avec une taille de 22 et de 24 gauges, l’hospitalisation dans l’unité de chirurgie et la perfusion continue étaient des facteurs de risque indépendants importants d’infiltration (p < 0,001). La régression logistique directe a révélé que l’âge en mois, l’hospitalisation dans l’unité de chirurgie et l’insertion du cathéter dans les veines de la fosse antécubitale étaient des facteurs de risque indépendants importants de phlébite (p < 0,001).

Conclusion : La taille des cathéters, l’hospitalisation dans l’unité de chirurgie et la perfusion continue ont contribué aux cas d’infiltration. L’âge, l’hospitalisation dans l’unité de chirurgie et l’insertion du cathéter dans les veines de la fosse antécubitale ont contribué aux cas de phlébite.

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Key points • The use of peripheral intravenous catheters (PIVCs) has a range of complications, including clotting, occlusion, leakage, infiltration, extravasation, phlebitis, dislodgement, accidental removal and infection • PIVC complications cause pain to patients and increase healthcare costs because of repeated dressing changes and prolonged hospital stays • Catheter size, hospitalisation in the surgery ward and continuous infusion contributed to the development of infiltration • Age, hospitalisation in the surgery ward and catheter placement in the antecubital vein contributed to the development for phlebitis.

• Being aware of PIVC complications and of what causes them should lead to better care bundles

P

eripheral intravenous (IV) catheterization is one of the most frequently carried out procedures in paediatric patients, and up to 50% of the hospitalized children are estimated to undergo this procedure (Ullman et al., 2020). These are not only critically ill children who require immediate IV antimicrobial treatment or rehydration therapy, such as patients suffering from sepsis, but also healthy children who need diagnostic tests.

Like many invasive procedures, the use of peripheral intravenous catheters (PIVCs) has a broad range of complications, including clotting, occlusion, leakage, infiltration, extravasation, phlebitis, partial dislodgement, accidental removal, and infections (Lee et al., 2009; Rickard et al., 2012; Abolfotouh et al., 2014; Marsh et al., 2015, 2018; Webster et al., 2019).

Catheter-related complications are an important patient safety problem. Drug treatment may be postponed because of catheterrelated complications, and catheters may need to be inserted repeatedly to continue treatment. These negative outcomes cause pain to patients and increase healthcare costs because of repeated procedures and prolonged hospital stays (Ullman et al., 2020). Approximately 30%–50% of PIVCs are removed early because of various complications (Helm et al., 2015).

In neonatal intensive care units, high complication rates of up to 97% of PIVCs have been reported (Legemaat et al., 2016; Marsh et al., 2021), while studies in older children reported lower rates (de Lima et al, 2011; Malyon et al., 2014). In a

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Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

global study of paediatric peripheral IV catheter practice and performance conducted with 4,206 children in 278 hospitals across 47 countries, PIVC complication risk factors were found to be age > 2 years; ambulance/emergency insertion; upper arm/antecubital placement; poor dressing integrity; and 24–72 hours dwell time (Ullman et al., 2020).

Although research has examined the incidence of infiltration, extravasation, and phlebitis in children and neonates from different countries, to the authors’ knowledge, no prospective study has focused on what the most common PIVC complications are in children in Turkey.

This five-month prospective study aimed to identify the types of complications of PIVCs in hospitalized children and possible risk factors for the development of extravasation, infiltration and phlebitis.

Methods Study design and settings A descriptive, observational study was conducted over five months, from 1 July 2018 to 30 November 2018. It was carried out in the region’s largest children’s hospital, established in 1947, which has a bed capacity of 354, with 1,400 employees providing care only to paediatric patients ranging from newborns to those aged 18 years.

The study included patients hospitalized in pediatric medical wards and cardiology, infectious disease and surgery wards.

Any intensive care setting, including paediatric, neonatal, burn, or cardiovascular units, was not included in the study.

During the study period, the departments included had a 160-bed capacity altogether and the total number of patients hospitalized in them per year was 2,300.

Sampling The incidence of catheter-related complications varies from one study to another. The infiltration/extravasation (I/E) rate was 5.5% in Özalp Gerçeker’s et al. (2018) study, and the phlebitis rate was 5% in Ben Abdelaziz’s et al. (2017) research. Using a calculation based on these rates, the sample size was determined to be 490 catheters to reach significance (type 1 error and 95% power; Ben Abdelaziz et al., 2017; Özalp Gerçeker et al., 2018).

This study included 244 patients, 575 PIVCs and 1,600 catheter days. The inclusion criteria were: being older than neonatal (4 weeks), being hospitalized, and undergoing PIVC insertion from the first day of the study.

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The exclusion criteria were: having undergone PIVC insertion before the study began, having a central venous catheter inserted, being transferred from an intensive care unit, and having a PIVC inserted in the emergency department.

Data collection After written consent had been obtained from the parents of children who had PIVCs, the patients were followed during their hospitalization. Study participation was initiated by a member of the research team during routine morning visits.

Each patient had a case number, and each catheter was recorded on a form with no information that could have identified the patient.

The first author, who performed the observations, was a nurse trained in catheter-related complications who had worked in pediatric wards for 25 years. The visits were performed daily by the same researcher to prevent possible observer bias.

Every day, the researcher examined the catheter site for symptoms of PIVC complications and, if the PIVC was not in place, she noted the indication for removal. If infiltration/ extravasation had occurred, the researcher also recorded the infiltrated fluid or drug and the flow rate.

The researchers were not involved in the patients’ medical care, or decisions to remove PIVCs, or shift to central venous catheters.

Demographic and catheter characteristics were determined by the researchers using the ‘PIVC insertion site in pediatric patients’ evaluation form. If infiltration/extravasation (I/E) developed, researchers noted the location with the ‘PIVC complications’ form. Both forms were developed by the researchers.

Data collection forms PIVC insertion site in paediatric patients form This form included the following possible risk factors (independent variables): sex; age; diagnosis; ward name and type; PIVC location (left or right, hand, arm and foot, or upper or lower extremity; Lee et al., 2009; Malyon et al., 2014); time of PIVC insertion (by nursing shifts: 08.00– 16.00; 16.00–23.59; 00.00–07.59); catheter gauge; presence of continuous IV fluid; and presence of IV drug therapy (Lee et al., 2009; Malyon et al., 2014; Gorski et al., 2016).

Continuous infusion was defined as the infusion of fluids to patients who needed to undergo continuous 24-hour fluid therapy for various reasons. Intravenous drug therapy cvaa.info

Karaoğlan, N., Sarı, H. Y., & Devrim, I.

was defined as the administration of an antibiotic or other medication once or more times a day. These drugs were diluted and given over a short period (ranging from a few minutes to 30 minutes depending on the properties of the drug) by an IV fluid treatment pump.

No special technology was used to assist catheter insertion in any clinic participating in this study. All catheters were inserted by nurses working in those wards. The hospital where this study was conducted had no vascular access team.

PIVC complications form This form, developed by the researchers, included questions about the location of I/E, PIVC insertion day, when I/E occurred, time I/E was noticed (time elapsed until the I/E), infiltrated or extravasated intravenous fluid(s) and medication, and interventions for I/E provided by nurses at the bedside.

The dependent variable was the occurrence of at least one PIVC complication, including extravasation, infiltration and phlebitis. Phlebitis was identified if pain or tenderness, erythema, warmth, swelling, induration, purulence, or a palpable venous cord was present at the location of the PIVC. The researcher used the Phlebitis Scale and Visual Infusion Phlebitis Scale for grading phlebitis (Gorski et al., 2016).

Diagnosis of infiltration and extravasation was performed in accordance with the Infusion Nurses Society’s (INS) Infusion Therapy Standards of Practice (INS, 2006). Among the symptoms of infiltration/extravasation are pain, edema, fluid leakage from the puncture site, changes in colour including blanching from nonvesicant solutions (vesicants can produce redness; however, colour changes may not be visible if there is extravasation into deep tissue), and blister formation (Gorski et al., 2016).

The infiltration rate was calculated by dividing the number of infiltration incidents by the total number of peripheral catheter days in the study cohort. The infiltration percentage was calculated by dividing the number of infiltration incidents by the total number of peripheral catheters in the study cohort. The peripheral phlebitis percentage was calculated by dividing the number of phlebitis incidents by the total number of peripheral catheter days in the study cohort (INS, 2006; Gorski et al., 2016).

Statistics The study data was analysed using IBM SPSS Statistics 17.0.

The quantitative data were described using arithmetic mean and standard deviation, or median with interquartile range, if they followed a non-normal distribution. cvaa.info

For categorical variables, percentages and frequencies were calculated, and the chi-squared test or Fisher’s exact test was used for intergroup comparisons. The Holm-Bonferroni correction method was used to overcome familywise errors, and the Student’s t-test or the non-parametric MannWhitney U test was used for the quantitative variables.

A multiple logistic regression test was calculated to predict the development of infiltration according to age, catheter size, whether the patient was hospitalised in the surgery or the pediatric ward, and whether or not the patient had a continuous infusion. The direct logistic regression was performed to assess the impact of several factors on the likelihood of phlebitis developing, and three independent variables (age in months, whether the patient was hospitalised in the surgery or the paediatric ward, and whether the catheter was placed in the antecubital fossa, hand or foot).

For the multivariate analysis, the authors included variables with a P value of < 0.05 in the univariate analysis, as well as any other variable predicted to be a potential risk factor for the outcome variables.

Research ethics Before the study was conducted, written permission was obtained from the ethics committee and hospital management. Written consent was obtained from the mothers of the children whose catheters were monitored.

Results Patient demographics and characteristics of peripheral venous catheters The study included 244 patients, 575 PIVCs and 1,600 peripheral venous catheter days. Of the 244 patients, 147 (60.2%) were male. The median age was 2 years (in a range of 1 month to 17 years). Nearly half of the patients (n = 108; 44.3%) were aged <1 year, and 178 (66.0%) were aged <6 years.

One hundred and eighty-three patients (75.0%) were hospitalized on the pediatric medical ward, and 61 (25.0%) were on the pediatric surgery ward. The patients were admitted for conditions affecting the respiratory system (57 patients; 23.3%), cardiovascular system (50 patients; 20.4%), and gastrointestinal system (49 patients; 20.8%).

During the study period, 575 PIVCs were inserted. Of these, 292 (50.8%) were inserted on the right side of the body. The Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 53

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

most used locations were veins in the upper extremities (n = 410; 71.3%). The most used sites were the veins of the dorsum of the hand (n = 240; 41.7%), the dorsum of the foot (n = 103; 17.9%) the antecubital fossa (n = 90; 15.7%), followed by other sites (Table 1).

Of the PIVCs, 71.0% (n = 408) were 24-gauge in size.

The length of the PIVCs was 19 mm (24- and 26-gauge) in 98.1% (n = 564). Nearly 60.3% of the PIVCs (n = 347) were inserted by nurses working on the daytime shift. Of the PIVCs, 83.0% were attached to infusion sets, 10.0% to serum sets, and 7.0% to perfusion chamber sets.

Catheter mean survival time was 56.36±35.51 hours (ranging from 2 hours to 274 hours). During the study, 207 (36%) PIVCs were removed because of IV therapy completion, 305 (53.0%) owing to occlusion, and 48 (8.3%) because they had become dislodged. The remaining indications for catheter removal were patient transfer to the pediatric intensive care unit and shifting to central venous catheters (nine PIVCs; 1.5%); phlebitis (one PIVC; 0.17%); the nurse observing problems with the line Table 1 Characteristics of peripheral intravenous catheters (PIVCs))

Upper or lower extremities

The shift that the PIVC was inserted PIVC size

PIVC length

Comparison of patients with and without infiltration Infiltration developed in 50 of 575 of the PIVCs (8.6%).

There were 25 (50.0%) boys in the infiltration group and 297 (56.6%) in the non-infiltration group; there was no significant difference between these two groups (P > 0.05; Table 3). The mean age of the patients with infiltration or without infiltration was 6.5 years and 4 years respectively, significantly higher in the infiltration group (P < 0.05).

There was no significant difference in rates between the group that developed infiltration and the group that was free of infiltration by location (right or left; upper versus lower extremities; veins at the dorsum of the hand, foot and antecubital fossa; P > 0.05 for each variable). The mean numbers of catheter days were 2.46±1.2 and 2.81±1.54 days in the infiltration group and non-infiltration group respectively, and there was no significant difference between the two groups (P > 0.05).

%

Right

292

50.8

Left

283

49.2

Table 2

Upper extremity

410

71.3

Peripheral intravenous catheters complications during the study period

Lower extremity

146

25.3

Scalp

10

1.7

Complications

n

%

Infiltration

5

0.8

Yes

50

8.7

Dorsum of the hand

240

41.7

Grade 1

42

84.0

Neck Anatomical site of PIVC insertion

Infiltration was observed at 8.7% (50) of the PIVCs, extravasation was observed at 0.2% (one) and phlebitis was observed at 15.8% (91). Most infiltrations were evaluated as grade I (84%) and phlebitis cases as grade I (54.9%; Table 2) according to the INS infiltration scale (INS, 2006). The infiltration rate was calculated as 31.25 per 1000 catheter days.

n Site Right or left side

(two PIVCs; 0.34%); and patients or caregivers refusing treatment (three PIVCs; 0.51%).

Dorsum of the foot

103

17.9

Grade 2

7

14.0

Antecubital fossa

90

15.7

Grade 3

1

2.0

Wrist

67

11.7

525

91.3

Ankle

38

6.6

No Extravasation

Other*

37

6.4

Yes

1

0.2

08:00–16:00

347

60.3

No

574

99.8

16:00–23.59

190

33.0

Total

575

100.0

00:00–07:59

38

6.6

Phlebitis

22 gauge

11

1.9

Yes

91

15.8

24 gauge

408

71.0

Grade 1

50

54.9

26 gauge

156

27.1

Grade 2

31

34.1

19 mm

564

98.1

Grade 3

10

11.0

25 mm

11

1.9

No

484

84.2

575

100.0

*Other sites included ankle, toes, scalp, neck, fingers, abdomen, armpit, shoulder

Page 54 • Vascular Access • Volume 16, Issue 2, Summer 2022

Total

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Karaoğlan, N., Sarı, H. Y., & Devrim, I.

Table 3 Univariate analysis of risk factors for infiltration observed in peripheral intravenous catheters (PIVCs) during follow-up PIVCs with infiltration n=50 (%)

PIVCs without infiltration n=525 (%)

Sex

P value

>0.05

PIVCs with infiltration n=50 (%)

PIVCs without infiltration n=525 (%)

Ward speciality

<0.001

Male

25 (50)

297 (56.5)

Paediatrics

31 (62)

444 (84.5)

Female

25 (50)

228 (43.4)

Surgery

19 (38)

81 (15.4)

Right side

23 (46)

269 (51.2)

22 gauge and 24 gauge

44 (88)

375 (71.5)

Left side

27 (54)

256 (48.8)

26 gauge

6 (12)

150 (28.5)

25 mm

0

11 (2.0)

19 mm

50 (100)

514 (98.0)

Site of catheter by side

>0.05

Site of catheter by extremity

>0.05

Upper extremities

34 (68)

394 (75.0)

Lower extremities

16 (32)

131 (25.0)

Specific preferred PIVC insertion (veins used) Dorsum of the hand Hand or wrist Feet

>0.05

Catheter size

0.012

Catheter length

>0.05

Infusion fluid

>0.05

26 (52.0)

214 (40.7)

Yes

32(64)

269 (51.2)

4 (8)

63 (12.0)

No

18(36)

256 (48.8)

Yes

48 (96)

492 (93.7)

No

2 (4)

33 (6.3)

13 (26)

128 (24.3)

Antecubital fossa

4 (8)

86 (16.3)

Others

3 (6)

34 (6.4)

Shifts when the catheters were inserted

IV drug therapy

>0.05

Presence of continous infusion

0.002

Morning

30 (60)

317 (60.3)

Yes

33 (66)

227 (43.2)

Afternoon

16 (32)

174 (33.1)

No

17 (34)

298 (56.7)

4 (8)

34 (6.4)

Night

The infiltration rate was significantly higher in the 22- and 24-gauge catheters (10.5%) than in the 26-gauge catheters (2.8.%; P = 0.0012). It was also significantly higher in the catheters with continuous infusions (12.7%) than in those in which continuous infusion was not applied (5.4%; P < 0.05).

The Hosmer-Lemeshow goodness of fit test indicated that the initial model, which included age, was a poor fit (P = 0.016), so the age variable was eliminated from the final logistic regression analysis.

Direct logistic regression was performed to assess the impact of several factors on the likelihood of the catheters developing infiltration in the new model, which considered three independent variables (catheter size, whether the patient was in the surgery or pediatric ward, and whether the patient had continuous infusion or not). The full model containing all predictors was statistically significant (chisquared: [3, n = 575] = 91.3; P < 0.001).

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P value

Three of the independent variables made a statistically significant contribution to the outcome (catheter size, whether the patient was hospitalized at the surgery or pediatric ward, and whether the patient had continuous infusion or not) (Table 4). The strongest predictor of developing infiltration was catheter size. Study findings indicate that 22and 24-gauge catheters would be 2.693 times more likely to develop infiltration than larger catheters. Being admitted to the surgical ward and having continuous infusion were also associated with nearly twice the risk of infiltration (Table 4).

Comparison of patients with and without phlebitis During the study, phlebitis developed in 91 (15.8%) of the 575 PIVCs. There were 59 (18.3%) male and 32 (12.6%) female patients in the phlebitis group, and there was no significant difference in terms of the variable of sex (P > 0.05; Table 5). The average age of the patients with PIVCs who developed phlebitis was 5 years 6 months and the average age of those who did not develop phlebitis was 4 years; age was significantly higher in the infiltration group (P < 0.005).

Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 55

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

Table 4

Table 5. Univariable analysis of risk factors for phlebitis in peripheral venous catheters (PIVCs)

Logistic regression model of risk factors for infiltration and phlebitis OR (95% CI)

P value

2.693 (1.107–6.550)

0.029

PIVCs with phlebitis n = 91 (percentage)

PIVCs without infiltration n = 484 (percentage)

Male

59 (64.8)

263 (54.3)

Female

32 (35.2)

221 (45.6)

Infiltration Catheter size 26 gauge 22–24 gauge Ward specialty Paediatric medical ward Paediatric surgery ward

2.312 (1.192–4.484)

0.013

Having continuous infusion No Yes

2.095 (1.093–4.015)

0,026

1.004 (1.001–1.008)

0,026

Phlebitis Age Ward specialty

Specific preferred PIVC insertion site

0.510 (0.278–0.935)

0.029

0.027

Antecubital fossa Dorsum of the hand Veins of the feet

0.424 (0.227–0.794) 0.612 (0.266–1.407)

0.007 0.248

There was no significant difference in the rates between the catheter group that developed phlebitis and the catheter group that was free of phlebitis in terms of catheter location (right or left; upper versus lower extremities; P > 0.05 for each variable). The rate of phlebitis from catheters placed in the antecubital veins was significantly higher (25/90; 27.8%) than in the hands (38/320; 11.9%) or feet (22/141; 15.6%; P = 0.002). The phlebitis rate was significantly higher in the surgery ward (24/100; 24%) than in the pediatric ward (67/475; 14.0%; P = 0.014). The mean numbers of catheter days were 3.09±1.8 and 2.73±1.45 in the phlebitis group and the non-infiltration group respectively, and there were no significant differences between the two groups (P > 0.05).

The full model of logistic regression containing all predictors (age in months, whether the patient was hospitalized in the surgery or pediatric ward, and whether the catheter was placed in the antecubital fossa, hand or foot) was statistically significant (chi-squared: [5, n = 433] = 23.56, P < 0.001).

As Table 4 shows, three of the independent variables made a statistically significant contribution to the model (age, administration to the surgery ward and placing the catheter in the antecubital vein).

Page 56 • Vascular Access • Volume 16, Issue 2, Summer 2022

>0.05

Location of the catheter

>0.05

Right side

38 (41.7)

254 (52.5)

Left side

53 (58.3)

230 (47.5)

Extremity (upper and lower)

>0.05

Upper extremities

63 (69.4)

347 (71.7)

Lower extremities

26 (28.6)

120 (24.8)

2 (1.0)

17 (3,5)

Dorsum of the hand

38 (41.8)

282 (58.2)

Veins found at the feet

22 (24.2)

119 (24.6)

Antecubital fossa

25 (26,4)

65 (13.5)

6 (6.6)

18 (3.7)

Others

Paediatric surgery ward Paediatric medical ward

Sex

Site of PIVC insertion

Others

0.002

Shifts that the catheters were inserted

>0.05

Morning

52 (57.1)

295 (61.0)

Afternoon

36 (39,6)

154 (31.8)

3 (3.3)

35 (7.2)

Paediatrics

67 (73.6)

408 (84.3)

Surgery

24 (26.4)

76 (15.7)

Night Ward speciality

0.014

Catheter size

>0.05

22 and 24 gauge

73 (80.2)

346 (71.5)

26 gauge

18 (19.8)

138 (28.5)

25 mm

4 (4.4)

7 (1.4)

19 mm

87 (95,6)

477 (98,6)

Catheter length

>0.05

Infusion fluid

>0.05

Yes

62 (68.1)

239 (49.4)

No

29 (31.9)

245 (50.6)

Intravenous drug therapy

P value

>0.05

Yes

89 (97.8)

451 (93.2)

No

2 (2.2)

33 (6.8)

Presence of continuous infusion

0.002

Yes

48 (52.8)

212 (43.8)

No

43 (47.2)

272 (56.2) cvaa.info

Karaoğlan, N., Sarı, H. Y., & Devrim, I.

Logistic regression revealed that PIVCs in the pediatric surgery wards were associated with a significantly higher risk of phlebitis than those in medical wards. In addition, logistic regression revealed that phlebitis was less likely to develop when PIVCs were inserted in the dorsum of the hand and foot rather than the antecubital fossa (Table 4).

Discussion This five-month prospective study investigated the complications and risk factors of PIVCs, including extravasation, infiltration and phlebitis in a tertiary pediatric centre. To the authors’ knowledge, this study is one of the few long-term studies examining peripheral line complications in Turkey. During the study, infiltration was observed with 8.7% of the 575 PIVCs, extravasation was observed in 0.2% of patients, and phlebitis occurred in 15.8% of patients. The infiltration rate was calculated as 31.25 per 1000 catheter days.

In this study, infiltration and extravasation were observed with 8.7% and 0.2% of the PIVCs respectively, with the infiltration rate being 31.25 per 1,000 catheter days. In one descriptive study from Turkey, which included 297 peripheral catheters, the infiltration rate was lower (2.9%) and the extravasation rate was higher (2.3%) than in our study (Temizsoy et al., 2017). The differences between the rates of infiltration and extravasation in these two studies might be because of their design and setting, differences between the institutions, and health professional characteristics (such as the number of nurses per shift and the presence of an intravenous team).

In the present study, infiltration and extravasation rates were lower than in other studies (Taylor, 2015; Major and Huey, 2016; Park et al., 2016). Moreover, the results of these studies were measured as either percentages or infiltration numbers per patient or catheter days, which makes them hard to compare (Taylor, 2015; Major and Huey, 2016; Park et al., 2016; Temizsoy et al., 2017; Özalp Gerçeker et al., 2018). The infiltration rates were reported to vary between 0.2 and 25.2% (Taylor, 2015; Major and Huey, 2016; Park et al., 2016; Ben Abdelaziz et al., 2017; Özalp Gerçeker et al., 2018) while, according to a number of studies, lower rates were mostly achieved with quality improvement interventions (Tofani et al., 2012; Sriupayo et al., 2014; Duncan et al., 2018; Ray-Barruel et al., 2019).

In some studies, infiltration rates were reported to range from 5.5 to 59.7/1000 catheter days (Tofani et al., 2012; cvaa.info

Miliani et al., 2017; Braga et al., 2018; Özalp Gerçeker et al., 2018). The variety in infiltration rates reported in different studies (Tripathi et al., 2008; Tofani et al., 2012; Miliani et al., 2017; Braga et al., 2018; Özalp Gerçeker et al., 2018) show that the infiltration and extravasation rates can vary from country to country, from state to state, from hospital to hospital, and even between wards in the same hospital.

In this study, the main dependent predictors for the development of infiltration were catheter size (22 and 24 gauge versus 26 gauge), being in the surgical ward, and having continuous infusion via PIVC. The 22- and 24-gauge PIVCs were used mostly in older children, and had a higher flow rate (20–36 ml/minute) than 26-gauge PIVCs (13 ml/minute). De Lima Jacinto et al. (2011) reported that the peripheral catheter size was not a risk factor for PIVC complications. However, a recent multicentre prospective study from Tunisia reported that the use of 24-gauge catheters was associated with PIVC complications (Ben Abdelaziz et al., 2017).

Although age was excluded from the multiple regression analysis because of poor fit, the mean age was significantly higher in the infiltration group, suggesting that it may play a role in the development of infiltration.

Being in the surgical department was an independent factor for the development of infiltration. Major and Huey (2016) reported that infiltration rates were higher in surgical than in medical paediatric wards (12.3 versus 9.6 per 1,000 per catheter days), supporting the findings of the present study.

Park et al. (2016) reported that infiltration rates were higher in pediatric medical than in surgical wards (9.4 versus 2.8).

These reports suggested that not only the age, but also other associated risk factors might affect PIVC complications between hospitals.

In this study, phlebitis developed in 91 PIVCs (15.8%).

Phlebitis rates have been reported in a range of 2–53% in different paediatric studies (Sriupayo et al., 2014; MonasorOrtolá et al., 2019; Suliman et al., 2020).

In this study, the most important independent factors contributing to the development of phlebitis were hospitalization in the surgery ward and age. One study found that catheter complications increased with age (Tripathi et al., 2008). This finding may be owing to the selection of the patients because 66.0% of patients were aged under six years, and the catheters movement depends on how well the fixation (securement) was performed.

Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 57

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

Moreover, although no study has compared phlebitis rates in surgical and medical pediatric wards, the risk of developing phlebitis can be a marker for patient care and can vary between settings.

management, it was decided to build a catheter team to standardize PIVC use. The nurses working at the hospital were trained in vascular access to achieve standardisation in their approach to catheterization and complications.

The present study found PIVC insertion at the antecubital fossa was a risk factor for developing phlebitis. This supports a previous study including adults, in which 815 PIVCs were reviewed (Miliani et al., 2017), although another multicentre study reported that PIVCs inserted in the antecubital fossa and forearm had a lower risk of phlebitis (Cicolini et al., 2014).

A study is planned to determine the prevalence of PIVC catheter complications in different pediatric clinics and hospitals in Turkey. Quality improvement studies on PIVC insertion to prevent and reduce complications will continue. BJN

Limitations There are some limitations to the present study.

First, it did not take into account some possible risk factors during insertion, such as the number of unsuccessful attempts before insertion, and the experience of the nurse.

Second, it was performed in a single children’s hospital so there is a limitation to generalizability, reflected by the variety of the risk factors and the rate of PIVC complications.

However, to the authors’ knowledge, this study is one of the limited number of prospective long-term studies focusing on PIVCs inserted in the children and gives additional useful data on PIVCs.

Conclusion The results of this study demonstrated that the university hospital had relatively high rates of phlebitis and infiltration compared to those previously reported in the literature.

Older age and hospitalisation in the surgery department are common risk factors for developing infiltration and phlebitis.

The findings suggest that risk factors for PIVCs might vary, depending on individual inpatient wards, hospitals, and countries. Awareness of potential risks is essential, because knowing about the present situation may lead to the development of care bundles that improve PIVC use. For the future, an international, user-friendly registry system for PIVC complications should be developed.

Because of the results of this research, another study was carried out to determine how the nurses working in the same hospital inserted PIVCs, what difficulties they experienced during insertion and how they approached complications.

PIVC complications were considered as a patient safety problem; under plans drawn up by the hospital’s quality Page 58 • Vascular Access • Volume 16, Issue 2, Summer 2022

CPD reflective questions • What interventions do you implement in your clinic to prevent and reduce peripheral intravenous catheter (PIVC) complications?

• Which site for peripheral venous catheterisation do you prefer? Does your hospital have a written protocol for this?

• Do you monitor peripheral venous catheters in your hospital for complications such as phlebitis and infiltration?

About the authors Nalan Karaoğlan, Nurse, Division of Pediatric Infectious Disease, Dr Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey Hatice Yıldırım Sarı, Professor, Nursing Department, Health Sciences Faculty, Izmir Katip Celebi University, Izmir, Turkey İlker Devrim, Professor, Division of Pediatric Infectious Disease, Dr Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey, ilkerdevrim2003@yahoo.com

À propos des auteurs Nalan Karaoğlan : Infirmière, Département des maladies infectieuses pédiatriques, Hôpital Dr Behcet Uz pour la formation et la recherche sur les maladies et la chirurgie pédiatriques, Izmir, Turquie Hatice Yıldırım Sarı : Professeure, Département de soins infirmiers, Faculté des sciences de la santé, Université Izmir Katip Celebi, Izmir, Turquie İlker Devrim : Professeur, Département des maladies infectieuses pédiatriques, Hôpital Dr Behcet Uz pour la formation et la recherche sur les maladies et la chirurgie pédiatriques, Izmir, Turquie, ilkerdevrim2003@yahoo.com cvaa.info

Karaoğlan, N., Sarı, H. Y., & Devrim, I.

Declaration of interest None Accepted for publication February 2022

References Abolfotouh, M. A., Salam, M., Bani Mustafa, A., White, D., & Balkhy, H. (2014). Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications. Therapeutics and Clinical Risk Management, 10(10), 993–1001. https://doi.org/10.2147/TCRM. S74685 Ben Abdelaziz, R., Hafsi, H., Hajji, H., Boudabous, H., Ben Chehida, A., Mrabet, A., Boussetta, K., Barsaoui, S., Sammoud, A., Hamzaoui, M., Azzouz, H., & Tebib, N. (2017). Peripheral venous catheter complications in children: Predisposing factors in a multicenter prospective cohort study. BMC Pediatrics, 17(1), 208. https://doi.org/10.1186/ s12887-017-0965-y Braga, L. M., Parreira, P. M., Oliveira, A. S. S., Mónico, L. S. M., Arreguy-Sena, C., & Henriques, M. A. (2018). Phlebitis and infiltration: Vascular trauma associated with the peripheral venous catheter. Revista Latina-Americana de Enfermagem, 26(0), e3002. https://doi.org/10.1590/15188345.2377.3002 Cicolini, G., Manzoli, L., Simonetti, V., Flacco, M. E., Comparcini, D., Capasso, L., Di Baldassarre, A., & Elfarouki, G. E. (2014).

Phlebitis risk varies by peripheral venous catheter site and increases after 96 hours: A large multi‐centre prospective study. Journal of Advanced Nursing , 70(11), 2539–2549. https://doi. org/10.1111/jan.12403 de Lima Jacinto, A. K., Avelar, A. F. M., & Pedreira, M. L. G. (2011). Predisposing factors for infiltration in children submitted to peripheral venous catheterization. Journal of Infusion Nursing, 34(6), 391–398. https://doi.org/10.1097/ NAN. 0b013e3182306491 Duncan, M., Warden, P., Bernatchez, S. F., & Morse, D. (2018).

A bundled approach to decrease the rate of primary bloodstream infections related to peripheral intravenous catheters. Journal of the Association for Vascular Access, 23(1), 15–22. https://doi. org/10.1016/j.java.2017.07.004 Gorski, L., Hadaway, L., Hagle, M. E., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy standards of practice.

Journal of Infusion Nursing, 39(Suppl 1), S1–S159 Helm, R. E., Klausner, J. D., Klemperer, J. D., Flint, L. M., & Huang, E. (2015). Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing, 38(3), 189–203. https://doi.org/10.1097/NAN.0000000000000100 Infusion Nurses Society. (2006). Standards: Infusion-related complication. 54. Infiltration. Journal of Infusion Nursing , 29(1), 59–60.

Lee, W.-L., Chen, H.-L., Tsai, T.-Y., Lai, I.-C., Chang, W.-C., Huang, C.-H., & Fang, C.-T. (2009). Risk factors for peripheral intravenous catheter infection in hospitalized cvaa.info

patients: A prospective study of 3165 patients. American Journal of Infection Control, 37(8), 683–686. https://doi. org/10.1016/j.ajic.2009.02.009 Legemaat, M., Carr, P. J., van Rens, R. M., van Dijk, M., Poslawsky, I. E., & van den Hoogen, A. (2016). Peripheral intravenous cannulation: Complication rates in the neonatal population: A multicenter observational study. The Journal of Vascular Access, 17(4), 360–365. https://doi.org/10.5301/jva.5000558 Major, T. W., & Huey, T. K. (2016). Decreasing IV infiltrates in the pediatric patient—System-based improvement project.

Pediatric Nursing, 42(1), 14–49.

Malyon, L., Ullman, A. J., Phillips, N., Young, J., Kleidon, T., Murfield, J., & Rickard, C. M. (2014). Peripheral intravenous catheter duration and failure in paediatric acute care: A prospective cohort study. Emergency Medicine Australasia, 26(6), 602–608. https://doi.org/10.1111/1742-6723.12305 Marsh, N., Webster, J., Mihala, G., & Rickard, C. M. (2015).

Devices and dressings to secure peripheral venous catheters to prevent complications. Cochrane Database of Systematic Reviews, 12(6), CD011070. https://doi. org/10.1002/14651858. CD011070.pub2 Marsh, N., Webster, J., Ullman, A., Mihala, G., Cooke, M., & Rickard, C. (2018). How often are patients experiencing local and catheter-related bloodstream infections within an adult population? A systematic review of peripheral venous catheter complications and failure. Infection, Disease & Health, 23(S1), S12. https:// doi.org/10.1016/j.idh.2018.09.046 Marsh, N., Larsen, E. N., Takashima, M., Kleidon, T., Keogh, S., Ullman, A. J., Mihala, G., Chopra, V., & Rickard, C. M. (2021). Peripheral intravenous catheter failure: A secondary analysis of risks from 11,830 catheters. International Journal of Nursing Studies, 124, 104095. https://doi.org/10.1016/j. ijnurstu.2021.104095 Miliani, K., Taravella, R., Thillard, D., Chauvin, V., Martin, E., Edouard, S., Astagneau, P., & CATHEVAL Study Group.

(2017). Peripheral venous catheter-related adverse events: Evaluation from a multicentre epidemiological study in France (the CATHEVAL Project). PLoS One, 12(1), e0168637. https://doi.org/10.1371/journal.pone.0168637 Monasor-Ortolá, D., Cortés-Castell, E., Martínez-Pascual, C., Esteve-Ríos, A., & Rizo-Baeza, M. M. (2019). Factors influencing the success of peripheral venous access in neonates. Journal of Pediatric Nursing, 47, e30–e35. https:// doi.org/10.1016/j.pedn.2019.04.017 Özalp Gerçeker, G., Kahraman, A., Yardimci, F., Bilsin, E., Binay, S., Cevik Özdemir, H. M., Karakul, A., Zengin, D., Ardahan Sevgili, S., Gümüs, M., Başbakkal, Z., & Akpinar, S. (2018). Infiltration and extravasation in pediatric patients: A prevalence study in a children’s hospital. The Journal of Vascular Access, 19(3), 266–271. https://doi. org/10.1177/1129729817747532 Park, S. M., Jeong, I. S., Kim, K. L., Park, K. J., Jung, M. J., & Jun, S. S. (2016). The effect of intravenous infiltration management program for hospitalized children. Journal of Pediatric Nursing , 31(2), 172–178. https://doi.org/10.1016/j. pedn.2015.10.013 Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 59

Complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children

Ray-Barruel, G., Xu, H., Marsh, N., Cooke, M., & Rickard, C. M. (2019). Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: A systematic review. Infection, Disease & Health, 24(3), 152– 168. https://doi.org/10.1016/j.idh.2019.03.001 Rickard, C. M., Webster, J., Wallis, M. C., Marsh, N., McGrail, M. R., French, V., Foster, L., Gallagher, P., Gowardman, J. R., Zhang, L., McClymont, A., & Whitby, M. (2012).

Routine versus clinically indicated replacement of peripheral intravenous catheters: A randomised controlled equivalence trial. The Lancet, 380(9847), 1066–1074. https://doi. org/10.1016/S0140-6736(12)61082-4 Sriupayo, A., Inta, N., Boonkongrat, S., Kaphran, K., Uttama, J., Budsabongphiwan, S., Prasertwittayakij, C., & Oberdorfer, P. (2014). Effectiveness of peripheral vascular catheter care bundle in the Pediatric Nursing Service, Chiang Mai University Hospital, Thailand. Chiang Mai Medical Journal, 53(2), 63–73.

Suliman, M., Saleh, W., Al-shiekh, H., Taan, W., & AlBashtawy, M. (2020). The incidence of peripheral intravenous catheter phlebitis and risk factors among pediatric patients. Journal of Pediatric Nursing, 50, 89–93. https://doi.org/10.1016/j. pedn.2019.11.006 Taylor, J. T. (2015). Implementing an evidence-based practice project in the prevention of peripheral intravenous site infiltrations in children. Journal of Infusion Nursing, 38(6), 430– 435. https://doi.org/10.1097/ NAN.0000000000000131

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Temizsoy, E., Eris, Ö., Karakoç, A., Cangür, S., Karatekin, G., & Ovalı, F. (2017). Turkish validity reliability of the Pediatric Peripheral Intravenous Infiltration Scale and its adaptation to newborns. Journal of Pediatric Research, 4, 232–238. https:// doi.org/10.4274/jpr.78055 Tofani, B. F., Rineair, S. A., Gosdin, C. H., Pilcher, P. M., McGee, S., Varadarajan, K. R., & Schoettker, P. J. (2012). Quality improvement project to reduce infiltration and extravasation events in a pediatric hospital. Journal of Pediatric Nursing, 27(6), 682–689. https://doi.org/10.1016/j.pedn.2012.01.005 Tripathi, S., Kaushik, V., & Singh, V. (2008). Peripheral IVs. Journal of Infusion Nursing , 31(3), 182–188. https://doi. org/10.1097/01.NAN.0000317704.03415.b9 Ullman, A. J., Takashima, M., Kleidon, T., Ray-Barruel, G., Alexandrou, E., & Rickard, C. M. (2020). Global pediatric peripheral intravenous catheter practice and performance: A secondary analysis of 4206 catheters. Journal of Pediatric Nursing , 50, e18–e25. https://doi.org/10.1016/j. pedn.2019.09.023 Webster, J., Osborne, S., Rickard, C. M., & Marsh, N. (2019).

Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews, 2019(1), D007798. https://doi. org/10.1002/14651858.CD007798.pub5

cvaa.info

This is the second part of a two-part article. Part 1: Challenges was published in the Spring 2022 issue of Vascular Access, Journal of the Canadian Vascular Access Association.

Beware its twin: Intrathecal implanted ports – Part 2: Safety considerations Janny Proba, RN, BScN, MEd, EdD(c), CON(C), CHPCN(C), CVAA(c)

B

ecause of the obvious similarities that exist between an intrathecal (IT) implanted port compared to an implanted venous port, clinicians need to be aware of a few differences to ensure continued safety of delivery via this route.

6) Non-coring needle length: Typical lengths to access port septum can range from 0.75” to 2” depending on the body composition of the patient. Length must be a sufficient length to seat the needle in the septum properly to allow for the proper delivery of infusates.

1) Care and maintenance: There are distinct differences between an IT and implanted venous ports (Table 1).

7) Advocate for a higher profile port reservoir: If possible, this can aid in easier identification and palpation of the septum.

2) Easy identification: Extra care must be used when identifying IT routes for other clinicians. This includes clear labelling of the dressing to indicate the IT route, as well as distinct tubing to alert the clinician of the unconventional route of administration. This also includes terminology, as the term ‘implanted port’ should be further specified as ‘implanted venous port’ or ‘intrathecal implanted port.’

These terms are not interchangeable.

3) Location: Implanted IT ports are typically located in the abdomen but, with palpation, can be easily mistaken for an epigastric or umbilical port (also located in abdomen for bariatric weight loss indications) or a venous port (typically located on the upper chest). There have been cases reported where an IT port is moved from the usual abdominal location to the upper chest (usually as a result of close proximity to an ostomy to reduce infective risk).

4) Infusions: Accidental infusions of IV fluid (due to incorrect identification of port) have resulted in permanent cord damage or death.

5) Medication: Medications must be preservative-free and sterile for IT delivery.

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8) Securement: Semi-occlusive, transparent dressings should be used.

9) Comfort: Patients typically prefer gauze under the transparent dressing to cushion and protect fragile skin against the wings of the non-coring needle. Due to the location, this also may protect against friction from repeated movements. Similar to a central line, the practice of using gauze under the dressing is not advised and should be avoided, as it creates a moisture pocket that encourages bacterial growth over a short period of time. An alternative would be to use a skin barrier protectant.

10) Assessment and monitoring: To reduce risk, assessment and monitoring are done similarly to epidural administration of medications. Refer to your organization’s policy. This typically includes vital sign monitoring, pain assessment, sedation score, nausea, urinary retention, sensory and motor block, site assessment.

11) Contraindications: Contraindications include increased intracranial pressure, coagulopathy, allergy or sensitivity to medication, and larger body composition.

Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 61

Beware its twin: Intrathecal implanted ports – Part 2: Safety considerations

Table 1 Differences Between Care and Maintenance of Vascular Ports Versus Intrathecal Ports Comparing Care & Maintenance Implanted Port

Indications

Antiseptic

Non-Coring Needle

Dressing

Tubing

Access

Intrathecal (IT)

- for IT delivery of opioids and/ or local anesthetic for management of intractable pain

- use of chlorhexidine to cleanse skin prior to access and all connections - avoid alcohol swabs to reduce risk of neurotoxicity

- range from 0.75” to 2” in length - longer needles required to penetrate through adipose & subcutaneous tissue in abdomen - typically changed Q7 days and prn

- semi-occlusive, transparent dressing - clearly label INTRATHECAL with date and DO NOT FLUSH - change with every needle exchange or prn - no gauze under dressing

- easily identifiable tubing (i.e., yellow-stripe tubing) - clearly label INTRATHECAL with date

- no aspiration needed; - no saline flush required - medication is primed to end of tubing - sterile technique required

- no final flush or locking solution needed

Vascular Access

- for delivery of fluids, medications, or blood products via intravenous route

- range from 0.5” to 1” in length on average - shorter needles required due to upper chest wall placement - typically changed Q7 days & prn

- semi-occlusive, transparent dressing

- IV tubing according to organization’s products and stock

- aspirate for blood return to verify placement - flush with saline and lock according to organization’s policy - sterile technique required

- flush & lock according to organization’s policy

Knowledge of the differences between these implanted ports is vital for numerous settings, including in-patient, out-patient, or community ones. Since these implanted ports can be used for acute, chronic, or palliative indications, clinicians can expect to utilize these devices for all stages of the healthcare trajectory. Since these devices are not

Page 62 • Vascular Access • Volume 16, Issue 2, Summer 2022

De-Access

commonly seen in most patients, clinicians may feel illequipped to provide care for these patients. Thus, the ability to distinguish between these devices can greatly impact the delivery of high-quality patient care and skillful care can directly influence the likelihood of positive clinical outcomes.

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Call for Manuscripts THE DEADLINE FOR SUBMISSIONS FOR THE Winter 2022 ISSUE IS August 30, 2022 Vascular Access welcomes unsolicited manuscripts. We are the peer-reviewed, open access journal published three times a year by the Canadian Vascular Access Association. Dedicated to disseminating information to improve vascular access, we give voice to international scholars and practitioners in this specialized field. Get the most from your publishing experience. Retain copyright of your article, so you can upload it to national and international repositories, get a chance to be featured in an issue of the British Journal of Nursing: IV and Vascular Access Supplement, and get added exposure being part of our journal that is featured on the Australian Vascular Access Society’s website.

We welcome quantitative and qualitative research, including the following and more: prospective, randomized control trials (RCTs); retrospectives; literature and systematic reviews; data analyses; survey results and analyses; and RCT protocols. We are also looking for brief papers about best practice implementation or knowledge translation. Send any enquiries or manuscripts to CVAA at publications@cvaa.info. Author guidelines can be accessed through https://cvaa.info/en/publications/vascular-access-journal or contact Linda Verde, Editor, at editor@cvaa.info.

Appel à contributions LA DATE LIMITE DE RÉCEPTION DES PROPOSITIONS D’ARTICLES POUR LE NUMÉRO D’Hiver 2022 EST LE 30 août 2022 Vascular Access accepte les manuscrits non sollicités. Publiée trois fois par année par l’A ssociation canadienne d’accès vasculaire, notre revue est révisée par des pairs. Visant la diffusion d’information pour améliorer l’accès vasculaire, nous donnons une voix aux chercheurs et aux professionnels de ce domaine spécialisé de partout dans le monde. Nous offrons une expérience de publication hors pair. Vous conserverez les droits d’auteur de votre article, ce qui vous permettra de le téléverser dans des référentiels nationaux et internationaux, et pourrait mener à sa publication dans un numéro du British Journal of Nursing: IV and Vascular Access Supplement. Obtenez aussi plus de visibilité en publiant dans notre revue qui est accessible sur le site Web de la Australian Vascular Access Society.

Nous acceptons les articles sur des études quantitatives et qualitatives, y compris les suivantes : études contrôlées randomisées (ECR) prospectives; revues rétrospectives, systématiques et de la littérature; analyses de données; résultats et analyses de sondage; protocoles d’ECR. Nous acceptons également de courts articles sur la mise en œuvre de pratiques exemplaires ou l’application des connaissances. Veuillez transmettre toute demande d’information ou proposition d’article à l’ACAV à publications@cvaa.info. Pour connaître les lignes directrices à l’intention des auteurs, visitez le https://cvaa.info/en/publications/vascular-access-journal ou communiquez avec Linda Verde, rédactrice en chef, à editor@cvaa.info.

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Volume 16, Issue 2, Summer 2022 • Vascular Access • Page 63

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