Dwelling on Dwell Time - When Is it Time to Remove a Peripheral Intravenous Catheter?

Dwelling on Dwell Time - When Is it Time to Remove a Peripheral Intravenous Catheter? James Davis, MSN RN CCRN CIC HEM Senior Infection Prevention Analyst Pennsylvania Patient Safety Authority and Marcia Ryder, PhD MS RN Research Scientist Ryder Science, Inc. 2015 Pennsylvania Patient Safety Authority Objectives Identify the gaps in research related to infection prevention and leaving peripheral intravenous catheters in place longer than 72 hours Comprehend the risks of peripheral intravenous line infection Examine the risks versus benefits of the clinically indicated replacement standard Identify a clinical process model for the implementation of clinically indicated PIV replacement 2015 Pennsylvania Patient Safety Authority 2 1

Centers for Disease Control and Prevention (CDC) The CDC guidelines for prevention of peripheral vascular catheter related infection (PVCRI) state the following: 1. There is no need to replace peripheral catheters more frequently than every 72 96 hours...category IB* 2. No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated. Unresolved issue * Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence. Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular-related infections, 2011[online]. 2011 [cited 2013 Nov 1] http://www.cdc.gov/hicpac/pdf/guidelines/bsiguidelines-011.pdf 2015 Pennsylvania Patient Safety Authority 3 Caution from the CDC Some studies have suggested that planned removal at 72 hours vs. removing as needed resulted in similar rates of phlebitis and catheter failure. However, these studies did not address the issue of [PVCRI], and the risk of [PVCRI] with this strategy is not well studied. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular-related infections, 2011[online]. 2011 [cited 2013 Nov 1] http://www.cdc.gov/hicpac/pdf/guidelines/bsiguidelines-011.pdf 2015 Pennsylvania Patient Safety Authority 4 2

The Infusion Nurses Society (INS) In 2006, recommended IV site rotation at least every 72 hours. In 2011, recommend that site rotation of the short peripheral catheter be based on clinical indication. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs 2011;34(1 Suppl):S1-S110. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs 2006 Jan-Feb;29(1 Suppl):S1-92. 2015 Pennsylvania Patient Safety Authority 5 INS s Rationale INS identified the primary reference for the change in recommendations to be a meta-analysis of five trials that showed changing the catheter every three days did not reduce the risk of infection. Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 2010 Mar 17;(3):CD007798. 2015 Pennsylvania Patient Safety Authority 6 3

The Opposition Collignon: in 90% of all PVC sepsis cases, the catheter was in place for three days or more. Trinh et al.: stressed that PVC-related bacteremia due to S. aureus is an unrecognized complication of PVC use over time. Maki: abandoning scheduled replacements may not greatly increase the incidence of phlebitis and infiltration, it would probably increase the risk of catheter related bacteremia with Staphylococcus aureus. Collignon PJ. Intravascular catheter associated sepsis: a common problem. Med J Aust 1994 Sep 19;161(6):374-8. Trinh TT, Chan PA, Edwards O, et al. Peripheral venous catheter-related Staphylococcus aureus bacteremia. Infect Control Hosp Epidemol 2011 Jun;32(6):579-83. Maki DG. Improving the safety of peripheral intravenous catheters. BMJ 2008 Jul 8;337:a630. 2015 Pennsylvania Patient Safety Authority 7 We Have Some Questions Is it safe to leave a PVC in place until there is a clinical indication for removal? Is there a time in hours that a PVC could be resited that would likely reduce the risk of PVCRI? 2015 Pennsylvania Patient Safety Authority 8 4

Looking for a Surrogate Measure The National Healthcare Safety Network (NHSN) has no bacteremia criterion for PVCRI. Primary bloodstream infection criteria is not specific in terms of source when compared to central line infection criteria. S. aureus is the second most common cause of hospital-acquired BSI. Hidron AI, Edwards JR, Patel J, et al.; National Healthcare Safety Network Team; Participating National Healthcare Safety Network Facilities. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of the data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol 2008 Nov;29(11):996-1011. 2015 Pennsylvania Patient Safety Authority 9 Looking for a Surrogate Measure PVCRI related to Staphylococcus aureus (S. aureus) may be as high as 23.5% 45.2% of PVCRIs related to S. aureus were found in patients for which the PVC had a dwell time of 4 days. In the United States, almost 200 million PVCs are used each year. Stuart RL, Cameron DR, Scott C, et al. Peripheral intravenous catheter-associated Staphylococcus aureus bacteremia: more than 5 years of prospective data from two tertiary health services. Med J Aust 2013 Jun 3;198(10):551-3. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006 Sep;81(9):1159-71. 2015 Pennsylvania Patient Safety Authority 10 5

Davis, J. Peripheral Vascular Catheter Related Infection: Dwelling on Dwell Time Pa Patient Saf Advis 2014 Mar;11[1]:30-5. 2015 Pennsylvania Patient Safety Authority 11 Davis, J. Peripheral Vascular Catheter Related Infection: Dwelling on Dwell Time Pa Patient Saf Advis 2014 Mar;11[1]:30-5. 2015 Pennsylvania Patient Safety Authority 12 6

Davis, J. Peripheral Vascular Catheter Related Infection: Dwelling on Dwell Time Pa Patient Saf Advis 2014 Mar;11[1]:30-5. 2015 Pennsylvania Patient Safety Authority 13 Pennsylvania Patient Safety Reporting System (PA-PSRS) Narratives A patient was admitted with a diagnosis of inflammatory bowel disease and an IV [intravenous] catheter inserted into the left antecubital. Routine restart of the IV line was waived per physician order. The patient developed a fever. The IV line was discontinued, and the catheter tip was cultured and was positive. 2015 Pennsylvania Patient Safety Authority 14 7

PA-PSRS Narratives Blood cultures were identified with Staphylococcus epidermidis and Staphylococcus aureus. Phlebitis was noted on left forearm from old IV catheters. 2015 Pennsylvania Patient Safety Authority 15 PA-PSRS Narratives Forearm IV line was in for five days; [when it was] removed, [there were]no signs of infection at that time. The next day, the site was red and had a small pocket of pus. Site and blood cultures were positive for staph. 2015 Pennsylvania Patient Safety Authority 16 8

PA-PSRS Narratives The patient with chronic ESRD [end-stage renal disease] was on hemodialysis. The patient developed respiratory failure prior to cardiac catheterization and was febrile with positive blood cultures. [The patient was]diagnosed with peripheral IV catheter bacteremia. 2015 Pennsylvania Patient Safety Authority 17 PA-PSRS Narratives A patient was admitted with A-Fib [atrial fibrillation]. IV catheter #18 inserted at left antecubital space. Four days later, the site was found to be red and tender. The IV line was removed. The patient was started on antibiotics. The IV catheter tip was sent for culture. The culture tip and blood were positive for Staphylococcus. Patient was for pacemaker insertion. The infectious-disease physician was consulted. Antibiotics were started, and pacemaker insertion was put on hold for three days. 2015 Pennsylvania Patient Safety Authority 18 9

In Reality Waiting for a clinical indication of infection to re-site a PVC may place the patient in a position for the development of bacteremia due to prolonged dwell times. 2015 Pennsylvania Patient Safety Authority 19 A Consideration Conduct focused surveillance for PVCRI to determine if re-siting peripheral catheters in adult patients every 72 hours is advantageous to re-siting when clinically indicated. 2015 Pennsylvania Patient Safety Authority 20 10

Moving to Clinically Indicated PIV Replacement vs. Scheduled Replacement thinking it through! Marcia Ryder PhD MS RN RYDER SCIENCE, Inc..medical biofilm research ryder1234@aol.com 21 CDC Guidelines (USA 2011) There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce the risk of infection and phlebitis in adults IB No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated unresolved issue Replace peripheral catheters In children only when clinically indicated IB Infusion Nursing Standards of Practice (USA 2011) The nurse should consider replacement of the short peripheral catheter when clinically indicated and when infusion treatment does not include peripheral parenteral nutrition The nurse should not routinely replace short peripheral catheters in pediatric patients I IV Epic3: National Evidence-Based Guidelines (England 2014) IVAD 28: Peripheral vascular catheter insertion sites should be re-sited when clinically indicated and not routinely, unless device-specific recommendations from the manufacturer indicate otherwise. Class B 22 11

the goal of this session is to to assist the clinician to critically evaluate the risks and benefits of the clinically indicated PIV replacement standard before implementation to present a process model for a safe and effective transition of practice 23 evidence-based practice evidence-based practice is a problem-solving approach to the delivery of health care that integrates: the best evidence from studies and.. patient care data with.. clinician expertise and.. patient preferences and values. Stillwell SB, et al. AJN. 2010;110:58 24 12

what does the evidence tell us? objective: to assess the effects of removing peripheral IV catheters when clinically indicated (CIR) compared to removing and re-siting the catheter routinely (RR) method: review randomized controlled trials (7) that compared RR to CIR of PIV catheters in hospitalized or community dwelling patients receiving continuous or intermittent infusions Webster J, et al. Cochrane Database of Systematic Reviews. 2015;8:1-43 25 what does the evidence tell us? conclusions: the review found no evidence to support changing catheters every 72-96 hours this would provide significant cost savings would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications to minimize PIV-related complications, the insertion site should be inspected at each shift change and catheter removed if signs of inflammation, infiltration, or blockage are present consequently, healthcare organizations may consider changing to a policy whereby catheters are changed only if clinically indicated 26 13

sample setting single center hospital Webster Webster Rickard 2007 2008 2010 community Van Donk 2009 multicenter Rickard 2012 Royal Brisbane and Women s Hospital Queensland Royal Brisbane and Women s Hospital Queensland Launceton General Hospital Tasmania Latrobe Regional Hospital Homecare Victoria Royal Brisbane and Women s Hospital Queensland Princess Alexandra Hospital Queensland Gold Coast Hospital Queensland 27 methods insertions, assessments, decisions single center hospital community multicenter Webster Webster Rickard Van Donk Rickard 2007 2008 2010 2009 2012 Insertions by IV Team (100%) Insertions by IV Team (75%) Sites inspected daily by IV Team Insertions by RNs MDs Assessments, decisions by staff Insertions by RNs MDs Assessments, decisions by homecare RN and PI Insertions by RNs MDs and IV Team (2 hosp) (40%) 28 14

methodological considerations randomization in all studies insertions by same IV team in 3 studies non-blinding of research nurses / bias in assessment assessments and decisions primarily by primary care generalist nurses vs MDs, highly skilled infusion nurses or researchers variability in the definitions of complications variability in the definition for CRBSI and local infection diagnostics: CLABSI not CRBSI colonization cultures only extraluminal 29 29 outcomes 30 15

outcomes: phlebitis risk ratio statistical likelihood of having the event confidence interval range of value for the population mean phlebitis Forest Plot p value probably that the null hypothesis is true p = 0.20 Total events CISC RR 186 166 31 outcomes: infiltration total events CISC RR 186 166 518 452 p = 0.004 32 16

outcomes: catheter blockage total events CISC RR 186 166 518 452 398 377 1102 990 p = 0.16 33 outcomes: local infections confidence interval range of value for the population mean p = 0.30 34 17

outcomes underpowered non-blinding diagnosis generalizability? 0.06 % 35 generalizability 72 hospitals no iv teams Wischnewski N, et al. Zent.bl. Bakteriol. 1998;287:93-103 36 18

Wischnewski N, et al. Zent.bl. Bakteriol. 1998;287:93-103 37 staphylococcus aureus PIV bloodstream infection SA is the second most common cause of hospital-acquired bloodstream infection SA (including MSSA and MRSA) is the primary causative organism for PIV-CRBSI pathogenesis is the same as CVC-CRBSI diagnosis & treatment is lengthy and very costly high risk for disseminated infection $$$$ complicated bacteremia endocarditis prosthetic joint infection ascitic fluid infection empyema arthritis $$ $$ $$ $$ $$ $$ mortality 27% $$ $$ $$ Gosbell IB. Internal Med J. 2005;35:S45-S62 38 19

author country dates % SA-CRBSI PIV CVC PICC rate PIV CVC time to Infection (range) ER placed IV team PIV Δ Collignon Australia 1998-7% 38% 6% 90% > 3 days no 2007 2005 Pujol Spain 2001-65% 0.19 0.18 mean 4.9 days 42% no CISC 2007 2003 per 1000 pt days (1.3-8.9) Boyd UK 2007-10% 72h 2011 2008 Heinrich Germany 2012 26% medical 2013 students Stuart Australia 2007-24% 8% 10% MRSA mean 3.5 days 39% 2013 2012 23% (0.25-9) median 3 days 45% > 4 days 39 author country dates % SA-CRBSI PIV CVC PICC rate PIV CVC time to Infection (range) ER placed IV team Trinh USA 2005-12% 0.07 mean 3 days 67% no 2011 2008 per 1000 (2-6 days) cath days 42% median 4 days complicated (2-7 days) 46% > 3 days multicenter Rickard 2012 all patients except catheters inserted in ER Δ p 24h Collignon PJ, et al. MJA. 2007;10:551-4 Trinh TT, et al. ICHE. 2011;32:579-83. Pujol M, et al. J Hosp Infect. 2007;67:22-9. Stuart RL, et al. MJA. June 2013.10:551 Boyd S, et al. J Hosp Infect. 2011;72:37-41. Heinrich I, et al. GMS Hygiene Infectt Control. 2013;8:2196-5226 40 20

Germany Germany Spain Spain UK UK USA USA 2006-2011 3395 patients 20 tertiary care centers Kaasch AJ, et al. J Infect. 2014;68:242-51 41 sample size: 1,890 events conclusion when the epidemiological links of time to infection are combined with the definition of primary BSI, and when the sheer prevalence of the PIV is considered, it is likely that the majority of acute care adult primary BSIs are due to PIV-CRI Davis J. Pa Patient Saf Advis. March 2014;11(1):30-5 42 21

definitions purpose identify the measures used in infusion phlebitis assessment and evaluate evidence regarding their reliability, validity, responsiveness and feasibility conclusion many scales exist, but none has been thoroughly validated for use in clinical practice a lack of consensus on phlebitis measures has likely contributed to disparities in reported phlebitis incidence, precluding meaningful comparison of phlebitis rates Ray-Barruel G, et al. J Eval Clin Practice. 2014;20:191-202. 43 diagnosis Helm RE, et al. JIN. 2015;38:189-203 Mermel LA. Clin Infect Disease. 2009;49:1-45 44 22

clinical diagnosis phlebitis erythema pain tenderness edema warmth streak formation palpable venous cord purulent drainage infection erythema edema pain warmth purulent drainage Mermel LA. Clin Infect Disease. 2009;49:1-45 Sanchez KT. Scand J Infect Disease. 2012;44:551-4 45 conclusion this would provide significant cost savings cost of time & materials cost of complication p = 0.00001 Stuart: PIV-SAB total cost $4.04 million Helm RE, et al. JIN. 2015;38:189-203 Stuart RL, et al. MJA. June 2013.10:551 46 23

conclusion would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications neither pain nor satisfaction were measured in any of the reviewed studies.patient preferences and values patient dissatisfaction with the venipunture skill level 1996-18% 2003-58% 40% success rate with first canulation attempt 27% patients suffer 3 or more attempts on average, each peripheral catheter requires 2.1 catheters quality improvement: vascular access team Kokotis K. JIN. 2005;28:522-32 Wolosin RJ. Press Ganey Satisfaction Report. 2003;VII:2-4 Barton A, et al. J Nurs Care Quality. 1998;13:77-85 Robinson-Reilly M, et al. Support Care Cancer. 2015;1-7 47 conclusion consequently, healthcare organizations may consider changing to a policy whereby catheters are changed only if clinically indicated up to 90% of catheters fail before completion of therapy Helm RE, et al. JIN. 2015;38:189-203 48 24

conclusion to minimize PIV-related complications, the insertion site should be inspected at each shift change and catheter removed if signs of inflammation, infiltration, or blockage are present this policy most likely will not reduce the incidence of catheter failure 49 thinking points: from the Cochrane review. there is considerable imprecision around the measures for local infection, CRBSI and mortality outcomes giving a high level of uncertainty in the measures from the literature.. the incidence and rate of catheter failure is unacceptably high on-going PIV surveillance is needed PIV infection diagnostics (intra and extraluminal) need definition and protocol multidisciplinary vascular access teams need professional development sound theoretical rationale.. sterile technique for PIV insertion must be considered and evaluated 50 25

clinically indicated site change or not. quality improvement in peripheral vascular access is the challenge! evidence-based practice is a problem-solving approach to the delivery of health care that integrates: the best evidence from studies and.. patient care data with.. clinician expertise and.. patient preferences and values. reduce peripheral IV catheter failure through a patient focused quality improvement initiative how can we do this? Stillwell SB, et al. AJN. 2010;110:58 51 Bennett B, Provost L. QP. July 2015;110:36-43 www.qualityprogress.com 52 26

quality improvement in vascular access outcome primary secondary specific change change model for drivers drivers ideas concepts improvement provide patient focused quality care in vascular access patient focused quality Improvement program professional organization, administration recognition and support establish quality improvement project by vascular access team vascular access patient safety initiative key leverage points in the system specific ideas, concepts and bundles that could generate the desired state Ryder M. AVA 2015 53 outcome primary secondary specific change change model for drivers drivers ideas concepts improvement reduce PIV failure focused surveillance professional competency pathogenesisbased protocols/proc edures technology assessment diagnosis/treat ment protocols vascular access team infection prevention collaboration specialist vs. generalist generalist competency revision insertion protocols/technol ogy revision postinsertion protocols /technology revision complication diagnostic/trea tment criteria 1.Standardize surveillance definitions 2.Conduct point prevalence survey 3 Establish surveillance/reporting/feedback system 4 Revise documentation form 5. Establish surveillance/reporting system 6. Establish VAT serving all VAD patients 7. Staff education program 8. Staff competency assessment Create formal process Establish focused quality improvement program 9 Early assessment/device selection program Focus on outcomes 10. Pain management protocols 11. Insertion checklist 12. Surgical site antisepsis 13. Aseptic (sterile) technique 14. Ultrasound-guided insertion 15. Insertion site CHG-containing dressing 16. Liquid adhesive/adhesive remover 23. Revision diagnostic criteria 24. Phlebitis/infection protocols Investment in quality, patient satisfaction, cost reduction 17. Post-insertion site care/dressing protocol 18. IV filtration 19. Antimicrobial/anticoagulant lock/flush 20. Antireflux/low bacteria transfer connector 21. Access site disinfection/scrubbing 22. Daily check for necessity Ryder M. AVA 2015 54 27

Questions? Like the Authority on Facebook 2015 Pennsylvania Patient Safety Authority 55 28