Peripheral IV Catheters: If clinically indicated replacement doesn t work, what will? Professor Dr Claire Rickard RN PhD Australian Vascular Access Teaching and Research (AVATAR) Group 3M Leadership Summit, May 2014 Financial Disclosures Disclosure of Relevant Financial Relationships: Educational lectures for: 3M, BD, Carefusion, Mayo Consultancy research: Analytica, BD, Zychem Research grants from: Australian College of Critical Care Nurses, Australian National Health and Medical Research Council (NHMRC), BD, Centurion, Griffith University, The Prince Charles Hospital Foundation, The Royal Brisbane Hospital Foundation Objectives 1. To review the evidence for clinically indicated peripheral intravenous (PIV) catheter removal 2. To recognise the serious global problem of PIV catheter failure -due to infiltration, blockage, dislodgement, phlebitis and infection 3. To understand common risk factors for PIV failure and identify key interventions that may avoid complications and improve the patient experience 1
Brisbane, Australia Randomised controlled trials + Plus Microbiology lab Simulation lab Practice surveys Cross sectional studies Cohort studies Pilot RCTs Cochrane systematic reviews & meta-analysis Health economics Knowledge translation Education & training 2
Specialties of: Vascular Access, Intensive Care, Haematology-Oncology, Emergency Department, Paediatrics, Cardiac, Infection Prevention, Infectious Diseases, Microbiology, Anaesthetics, Medical-Surgical Over 100 members: Nurses, Doctors, Scientists, Pharmacists, Health Economists, Statisticians, PhD/Masters students. NH&MRC Centre for Research Excellence in Nursing Interventions NEONATES ADULTS CVADs CHEMO PICCs? CHILDREN VENOUS PORTS TUNNELLED PN PERIPHERAL HOSPITAL HOME ARTERIAL DIALYSIS Our Challenge: to create the highest level evidence Level I Evidence Systematic reviews & metaanalysis Randomized clinical trials Foundation Research Observational cohort study Point prevalence study Practice survey Laboratory experiments AVATAR 3
Peripheral IV catheters and time History of PIV replacement Pre 1970/1971 Clinically indicated replacement 1970/71 US epidemic of catheter related sepsis with over 100 deaths CDC Recommendation for 24 hour PIV replacement Epidemic later traced to manufacturer contaminated fluid 1981 CDC recommends 48-72 hour replacement based on expert opinion 1996 CDC recommends 48-72 hour replacement 2002 CDC recommends at least 72-96 hour replacement 2011 CDC recommends not more frequently than 72-96 hour replacement CDC says clinically indicated replacement is unresolved Rickard CM et al. Lancet 2012; Vol. 380. Pages 1066-74. 4
3,283 patients with 5,907 PIVs Equal risk at baseline for patient risk factors Equal risk at baseline for PIV risk factors Skin prep with 2% chlorhexidine in 70% alcohol BD Insyte Autoguard catheters 3M Tegaderm 1624W dressings Primary endpoint: Phlebitis (2 or more of: pain/tenderness, swelling, purulence, palpable cord) Rickard CM et al. Lancet 2012; 380. 1066-74 Findings No difference in phlebitis: 7% of patients in each group No difference in overall PIVC failure between groups No difference in PIVC colonisation between groups 0 PIVC-BSI in clinically indicated group/ 1 in 72-96 hour group 4 BSIs clinically indicated group/9 BSIs 72-96 hour group All gram negative BSIs in 72-96 hour replacement group Rickard CM et al. Lancet 2012; 380. 1066-74 INS Standards of Practice 2011 Consider replacement of the short peripheral catheter when clinically indicatedand when infusion treatment does not include peripheral parenteral nutrition. The decisionto replace the short PIV should be based on assessmentof the patient s condition; access site; skin and vein integrity; length and type of prescribed therapy; venue of care; integrity and patency of VAD; dressing; and stabilization device Level I evidence* *Idvallet al. 2006 J AdvNursing, & Webster et al. 2010 Cochrane Database of SRs 5
PIVs should be re-sited when clinically indicated and not routinely, unless device-specific recommendations from the manufacturer indicate otherwise Insertion sites should be inspected at a minimum each shift, and a VIP score recorded. The catheter should be removed when complications occur or as soon as it is no longer required Health economic assessment FOR PATIENTS Reduction in cannulation procedures by 20-25% Haitham Tuffaha PhD candidate FOR THE USA Reduction of 2.5million PIV insertions Save 1 million hours of staff time Reduced costs USD $400 million over 5 years Tuffaha H, Rickard CM, et al. Cost-effectiveness analysis of clinicallyindicated versus routine replacement of peripheral intravenous catheters. Applied Health Economics and Health Policy. 2014. A happy ending.? 6
The Dark Side. 26% of PIVs FAILED Of 5,907 PIVs* 25.6% OCCLUSION/INFILTRATION 1512 PIVs 6.4% ACCIDENTAL REMOVAL 4.6% PHLEBITIS 375 PIVs 273 PIVs * Wallis MC.Rickard CM. Risk factors for PIV catheter failure: A multivariate analysis of data from a randomized controlled trial. ICHE. 2014;35(1) 63-68. Note: PIVs could have more than one complication. 26% failure of a medical device? Should 26% of cardiac pacemakers fail? Should 26% of blood glucometers fail? Should 26% of hip prostheses fail? Should 26% of PICCs fail? Why should 26% of PIVs fail? Wallis MC.Rickard CM. Risk factors for PIV catheter failure: A multivariate analysis of data from a randomized controlled trial. ICHE. 2014; 35(1) 63-68. 7
40% of PATIENTS have at least one PIV failure over a course of therapy^ ^1,306/3,283 patients. Rickard CM. 2012. The Lancet. 380. 1066-1074 PIVs are failing around the globe 51% 53% 38% 26% 58% 100% 43% 42% 26% 26% Incidence from published PIV studies are not directly comparable since definitions have varied, but we do seem to have a problem!! 26% PIVs develop occlusion/infiltra tion This effects 37% of patients over 1 episode of IVT 1512/5907 PIVs Wallis et al 2014 ICHE. 1202/3283 patients, Rickard et al 2012 Lancet. 8
6% of PIVs just fall out.this effects 10% of patients 375/5907 PIVs, Wallis et al 2014 ICHE. 325/3283 patients, Rickard et al 2012 Lancet. 4.6% of PIVs develop phlebitis this effects 7% of patients Rickard et al 2012 Lancet One in five PIVs is redundant New K et al. Australian Health Review. 2014. In press. 9
Can we do better? Can we do more? Insertion & removal ANTT & Infection Control Patency & flushing Connectors & cleaning Securement & dressings IV lines & solutions 10
Gonzalez Lopez et al. 2014 J HospInf Risk factors for PIV catheter failure: a multivariate analysis of data from a randomized controlled trial Wallis M, Rickard CM. Infection Control & Hospital Epidemiology 2014;35(1) 63-68. Predictors of Occlusion/Infiltration HR 95%CI p Wallis et al. ICHE 2014 Hand 1.47 1.28-1.68 <0.001 Female 1.44 1.30-1.61 <0.001 IV Antibiotics 1.41 1.25-1.59 <0.001 IV Hydrocortisone 1.36 1.03-1.80 0.028 Any infection 1.27 1.12-1.44 <0.001 Antecubital fossa 1.27 1.08-1.49 0.004 Upper arm 1.25 1.04-1.50 0.016 2 nd or later IV 1.17 1.01-1.35 0.037 OT/Rad insert 0.80 0.67-0.94 0.009 IV Antipyretic 0.76 0.59-0.97 0.030 11
Predictors of Accidental Removal *Cox regression HR* 95%CI p Hand 2.45 1.93-3.10 <0.001 Non-IV Team insert 1.69 1.30-2.20 <0.001 Antecubital fossa 1.65 1.23-2.22 0.001 Smaller than 20G 1.29 1.02-1.61 0.030 BD Insyte Autoguard Wallis et al. ICHE 2014 Predictors of Phlebitis HR* 95%CI p Female 1.64 1.28-2.09 <0.001 Larger than 20G 1.48 1.08-2.03 0.014 Any infection 1.41 1.05-1.89 0.022 Age 0.99 0.98-0.99 <0.001 IV Other Meds 0.72 0.56-0.92 0.009 *Cox regression Each increase in age by 1 year, decreased HR by 1.1% BD Insyte Autoguard Wallis et al. ICHE 2014 What will the New World of Clinically Indicated PIV replacement be like? 12
Change in preferred PIV site placement Distal to proximal CHANGE Forearm INS 2011 Standard 33: Site selection should be initiated routinely in the distal areas of the upper extremities; subsequent cannulation should be made proximal to the previously cannulated site (Level V evidence) Change to preferred PIV size Smaller Bigger Dislodgement Phlebitis The 20 gauge is king Change to PIV Inserter Any inserter CHANGE Expert inserter Specialist versus non-specialist vascular access insertion for the prevention of access device failure. Carr P. Rickard CM. Cochrane Database of Systematic Reviews 2014 (Protocol) Peter Carr 13
Changes to Dressings and Securement Anecdotal reports from our research nurses were that many PIVs in the Lancet study had ineffective dressings & securement Improvements in this area will be vital to prevent PIV failure The evidence base is lacking and dated The SAVE Trial Securing All intravasculardevices Effectively in PIVs Randomized to 4 groups: Standard polyurethane (SP) Bordered polyurethane Sutureless securement device + SP Tissue adhesive + SP 1,880 patients 2013-2014 AUD$ 1 million Australian National Health & Medical Research Council Improved PIV flushing and dilution Flushing & dilution are important, BUT Evidence for most aspects is limited Current flushing practice is highly varied ANTT understanding is low Prefilled syringes reduce risk for contamination & save some RN time Retrospective cohort study in Italy observed lower CRBSI rate with prefilled syringes than with manually filled syringes (6.3% vs 2.7%, p=0.016) Keogh S Rickard CM. J Inf Nursing 2014 Keogh S.Rickard CM. Submitted 2014 BertoglioS et al. J HospInf2013 Dr Samantha Keogh 14
31/07/2014 The FliP trial: Flushing in PIVs Randomize patients to 4 flush groups: Low frequency, low volume High frequency, low volume Low frequency, high volume High frequency, high volume 3 or 10 mls; 1 or 4 times/day Primary outcome: Catheter Failure (occlusion, infiltration, phlebitis, infection) Secondary outcomes: Device life; Costeffectiveness; Dislodgement Investigator-initiated study. BD & university funding Pilot RCT in 2014, larger RCT for 2015-> Longer dwell PIVs will require changes to Infection Prevention Skin preparation pre-insertion CHANGE Weekly reapplication? Clean gloves CHANGE Sterile gloves? One dressing CHANGE Weekly dressing? Plain dressing CHANGE Antimicrobial dressing?.we CAN stop this happening 15
Join us Evan Alexandrou Principal Investigator Worldwide benchmarking study. Join us! Register your interest at the website: www.omgpivc.org Email: omgstudy-group@griffith.edu.au Twitter: @OMGstudy1 Peripheral IV Catheters: If clinically indicated replacement doesn t work, what will? Professor Dr Claire Rickard RN PhD Australian Vascular Access Teaching and Research (AVATAR) Group 3M Leadership Summit, May 2014 Thank you 16