As end-stage renal disease (ESRD) prevalence escalates globally, hemodialysis remains a pivotal kidney replacement therapy, necessitating reliable vascular access. This paper examines transhepatic tunneled catheter placement as a non-conventional vascular access method for ESRD patients with exhausted typical sites. We discuss the clinical imperative for alternative access options due to the frequent complications associated with central venous catheters (CVCs), such as infection, stenosis, and thrombosis, which often necessitate relocation and can exhaust conventional sites. Highlighting the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for CVC placement hierarchy and the evolution of placement techniques, we emphasize ultrasound or fluoroscopy guidance to mitigate complications. Our experience with three ESRD cases demonstrates the efficacy of transhepatic catheter placement under imaging guidance, showing good clinical outcomes and patency to date. This technique offers a viable access route with fewer complications and is presented as part of an algorithm for urgent dialysis access in patients with vascular exhaustion. We advocate for pre-dialysis kidney care and peritoneal dialysis or urgent kidney transplantation as preferable treatments, but acknowledge the reality for many patients where hemodialysis is the only short-term option. Transhepatic tunneled catheters can serve as a safe and reproducible vascular access alternative, potentially improving patient survival in hemodialysis-dependent individuals with limited vascular access options.
Background: Peripheral intravenous catheter (PIVC) failures remain common, hindering patient care. Ultrasound-guided PIVC (USG-PIVC) placement offers improved first-time and overall insertion success rates, reduced complications, and enhanced patient satisfaction. Yet, in our adult intensive care unit (ICU), most USG-PIVCs were placed by physicians, a skill that nursing staff could also benefit from acquiring. Purpose: Our aim was to select the most appropriate handheld ultrasound device and develop a comprehensive USG-PIVC nursing education program to improve PIVC success rates and enhance patient care. Methods: This quality improvement initiative's literature review guided development of an education model and evaluation of three handheld ultrasound devices. Nurses received two hours of didactic training, two hours of classroom simulation, and supervised clinical practice. Outcomes were analyzed by the lead ICU clinical educator. Results: Five ICU nurses performed 76 USG-PIVC placements with 70%–90% overall insertion success rates, ie within two attempts. The preferred of three ultrasound devices was selected for its highest success rate, portability, transducer probe, and screen integration lending to ease of use, quick start-up, and clinical support. Nurses were overwhelmingly positive about the education program, as evidenced by informal qualitative feedback collected at each end of session. Conclusion: Our comprehensive USG-PIVC insertion program empowers nurses to improve vascular access through a structured approach, combining online learning, simulation, and supervised clinical practice, with effective ultrasound technology selection. This approach provides other organizations with insight to equip nurses and leverage ultrasound technology toward meeting the 2024 Canadian Vascular Access Association guidelines' (in press) recommendations for ultrasound guidance and product selection.
BACKGROUND:Palliative care patients often require frequent, resource-intensive, intermittent subcutaneous injections or complex infusion pumps for end-of-life symptom management. PURPOSE:We aimed to explore the feasibility of using non-electronic elastomeric infusion devices for continuous subcutaneous medication delivery in hospice and home care. METHODS:A quality improvement initiative included an environmental scan to evaluate elastomeric devices and treatment protocols, followed by a stepwise implementation of elastomeric infusion devices for symptom management of palliative care patients. RESULTS:During five years, 4,754 elastomeric devices were dispensed with non-narcotic medication mixtures to 265 patients in hospice and home care and 585 devices with narcotic mixtures for 62 patients during a 12-month period. No adverse events were reported. A total of 110 unique medication combinations involving 11 symptom management medications were dispensed. Qualitative feedback revealed strong nursing, physician, patient, and caregiver support. The acceptability of elastomeric subcutaneous infusions of symptom management medications was supported by the reported simplicity, safety, efficacy, and efficiency of this treatment modality. The protocol was adopted in hospice and is in the pilot phase for home care. CONCLUSION:Our findings suggest that continuous subcutaneous infusions via elastomeric infusion pumps offer a promising and feasible approach to end-of-life symptom management in hospice and home care. Elastomeric infusions may enhance simplicity, acceptability, safety, efficacy, and efficiency of care, compared to traditional routine subcutaneous injections. While results lay a foundation for treatment protocols that reduce care complexity, further research is warranted to optimize medication combinations and evaluate outcomes.
With a lack of standard processes in first parenteral dose medication administration in the home and community setting, a quality improvement initiative was undertaken by provincial home and community care service provider organizations (SPOs) in Ontario to support an evidence-based practice approach for administering the first dose of an intravenous (IV) medication. The project group, consisting of clinical leaders and business competitors, united to collaborate and support evidence-based, safe patient care. The group developed an evidence-based approach to screening patients for safe administration of the first dose of a parenteral medication within the home and community setting. Aligning the practice of administering the first dose of a parenteral medication is critical to providing safe, consistent, equitable, and timely care for all patients requiring a first dose in the home and community setting. From the SPO perspective, this improvement initiative has achieved the primary goal of aligning on a consistent patient safety screening tool used to support determining if first dose administration of a parenteral medication in the community is safe for the patient. Outputs of this work include collaborating with the provincial government funder and with SPOs who are competing for the same contracts within this sector, and the development of evidence-based resources to support patient screening. An exciting outcome was the opportunity to align with the Canadian Vascular Access Association (CVAA) and their mission statement of advocating for safe, quality patient care across the healthcare system (CVAA, n.d.). By developing an evidence-based approach to administering the first dose of a parenteral medication, this group has advocated for CVAA to include elements of the quality improvement (QI) initiative within the newly updated 2024 CVAA guidelines. This manuscript outlines the continued and thorough process undertaken by SPOs and the provincial government funder for home and community care to standardize best practices for administering a first dose of a parenteral medication in this unique sector. The successes and challenges encountered in aligning all those with a vested interest are highlighted.
Ultrasound is commonly used to assist with peripheral vascular access and there is growing evidence that there is an advantage to using guidewires to aid insertion. This prospective observational study compares outcomes in ultrasound-guided peripheral cannulation using either standard catheter-over-needle devices or a single lumen arterial catheter inserted using the Seldinger technique. Analysis of results demonstrated a clear advantage in terms of device survival to completion of therapy in the guidewire group.
Purpose: Haemato-oncology patients who require treatment for infections in the hospital receive intravenous antibiotics (IVABs) and intravenous therapy (IVT) via an infusion pump attached to a pole on wheels. This IV pole can hinder a patient’s mobility and ability to perform activities of daily living. A computerized ambulatory delivery device (CADD), often used in the outpatient or home setting, is a portable infusion pump that delivers IVABs and IVT without the need of a wheel-based pole. This study will investigate the use of portable CADDs in the inpatient setting to determine if they improve patients’ mobility when compared with using the IV pole. Methods: A randomized controlled trial of patients requiring IVABs or IVT, of two haemato-oncology wards in a large, quaternary hospital, will recruit 110 adults randomized on a 1:1 basis into either a CADD arm or an IV pole arm. The primary outcome is mobility as assessed by number of steps per day (recorded via accelerometer). Secondary outcomes include sleep disturbance, quality of life, and hospital-acquired complications. All randomized patients will be analyzed by intention to treat.
Aims: To assess the feasibility of a randomized controlled trial using virtual reality (VR) intervention to manage anxiety in adult patients during painful needle-related procedures in an emergency department (ED). Background: The often overlooked or insufficiently managed needle-related anxiety in adults negatively impacts patient satisfaction and experience, necessitating innovative solutions. While VR has shown potential benefits for children, its efficacy has yet to be evaluated within the adult population. Design: A pilot randomized controlled trial. Methods: A single-site, two-arm, parallel randomized controlled trial will be conducted in an Australian ED. Eligible adult patients (n = 60) needing painful needle-related procedures will be randomly assigned to either a VR intervention group (wearing a VR headset) or a standard care group. Anxiety, stress, and pain levels will be measured during three time points, pre-, during, and post-interventions. It is expected to see a reduction in anxiety, stress, and pain levels in the VR intervention group. Discussion: The findings will demonstrate the feasibility of conducting a fully powered trial. Conclusion: This study will provide insights into the potential of VR intervention as a management strategy for anxiety in ED patients undergoing painful needle-related procedures.
Background: Insertion of peripheral vascular access devices (PVADs) is the most commonly performed invasive medical procedure worldwide. Peripheral vascular access devices pose a significant risk of complications, especially in older adults, who experience age-related changes in skin, connective tissue, and veins. Adults older than 65 years old have the highest rate of hospital admissions, and a higher prevalence of co-morbid conditions than do younger adults. Despite the risks, PVADs in this population have not been well-explored. Aim: To identify the available evidence on PVADs in older adult populations, including patient experience. This scoping review protocol will function as a framework for a review, using a systematic process of published and grey literature. The population is adults 65 years of age and over. Methods: The Johanna Briggs Institute methodology, built on the Arksey and O’Malley framework, will guide this scoping review. A search of electronic medical databases will be conducted. Grey literature searches will supplement the electronic database searches. A data extraction tool will be employed for screening and data extraction. The PRISMA-ScR flow chart will be used to present the methodological process, and the extracted data will be tabulated with a narrative summary. Conclusion: This scoping review protocol provides the framework that underpins the scoping review, which will explore the existing evidence to inform future research.
Peripheral intravenous catheter (PIVC) insertion is a frequent procedure for hospitalized pediatric and neonatal patients. Timely and successful PIVC insertion can be challenging in pediatric and neonatal patients due to small or fragile veins, younger age, obesity, and patient activity (Alberto et al., 2023; Ben Abdelaziz et al., 2017; Girotto et al., 2020; Schults et al., 2019, 2022). First attempt insertion success ranges from 64% to 74%, with an average of 2.1 attempts prior to insertion of a functional PIVC (Kleidon et al., 2022). In children with difficult intravenous access (DIVA), the average number of attempts increases to four prior to an insertion of a functional PIVC (Kleidon et al., 2019; Schults et al., 2019). In addition to insertion difficulty, once a functional PIVC is successfully inserted, it is reported that 34% to 56% will fail prior to treatment completion, often necessitating the need for additional attempts to replace the failed PIVC (Indarwati et al., 2020; Kleidon et al, 2019; Kleidon, Rickard et al., 2020; van Rens, 2021).
Purpose: This study aimed to determine the incidence of peripheral intravenous catheter (PIVC)-induced phlebitis and its predictors among adult patients hospitalized at Dow University Hospital, Karachi, Pakistan. Methods: A sample of 258 adult patients admitted in the selected wards and planned for peripheral intravenous catheter insertion were recruited through consecutive sampling during March to May 2019. Daily follow-ups were performed to observe signs of phlebitis using a validated tool. The cohort was followed until discharge, removal of peripheral intravenous catheter, or study conclusion. Results: Of 258 patients studied, 139 (53.9%) were females. A significant number of the participants 104 (40.3%) were young adults of age 20–40 years. The incidence of phlebitis was 39.1%. Tuberculosis (TB), peripheral intravenous catheter dwell time before initial assessment, administration of IV fluids, and dissatisfactory nursing care at Day 1 were associated significantly with the development of phlebitis. There was a doseresponse relationship between the catheter dwell time in hours before initial assessment and the development of phlebitis. Conclusion: This study found an increased incidence (39.1%) in three months of PIVC-induced phlebitis among adult patients. In addition to patient-related and PIVC-related risk factors considered in this study, PIVC-induced phlebitis is found to be significantly associated with the level of PIVC care provided by nurses. Continuous nursing education, developing standard care plans for PIVCs, and proper documentation of care are recommended.
Aim: This study will evaluate the most effective peripheral intravenous catheter securement in paediatric emergency departments to reduce catheter failure, healthcare costs, patient distress, and improve satisfaction. Design: A multisite, three-arm, parallel, superiority, randomized controlled trial of 506 children requiring peripheral intravenous catheter in the emergency department. The trial will be reported following CONSORT guidelines, is registered on the Australian New Zealand Clinical Trials Registry (ACTRN12619001026112) and ethics is approved via Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/19/QCHQ/45567). Methods: Staff screen patients, six months to eight years old, requiring peripheral intravenous catheters and inpatient stay of more than 24 hours. Written informed consent is obtained from the legal guardian with 1:1:1 randomization ratio allocation: 1. Standard care: Bordered polyurethane dressing (Tegaderm Advanced®; 3M) 2. Integrated dressing and securement: SorbaView SHIELD® (Centurion Medical Products) 3. Integrated dressing and securement with tissue adhesive: SorbaView SHIELD® (Centurion Medical Products) and Tissue Adhesive Secureport IVTM (Adhezion Biomedical) Primary outcome is peripheral intravenous catheter failure; secondary outcomes are peripheral intravenous catheter complications, pain and distress, healthcare costs, and staff satisfaction or acceptability. Intention-to-treat analysis of timeto-event data will be completed using adjusted Cox regression. Direct costs calculated from the hospital perspective and costeffectiveness analysis will estimate the incremental cost of each treatment option. Discussion: Most hospitalized children require a peripheral intravenous catheter, although persistent high rates of failure are recognized as a patient safety concern. The outcomes of this trial will directly inform clinical care for peripheral intravenous catheter securement in children in emergency departments. Charters1,2, RN, PG Paed Acute Care, Kelly Foster2 , MNRS, RN, Dip HS, PG Crit Care, PhD Candidate, Benjamin Lawton1 , BSc, MBCHB, FRACP, Mph, Corey Cassidy3 , BSc (Hons), MBBS (Hons), FACEM, Joshua Byrnes4 , BEcon, BComm, MEcon, MHealth Econ, PhD, Gabor Mihala4,5, MEng (Mech), Gcert (Biostat), PhD, Jessica Schults5-8, RN, PhD, Tricia Kleidon5,6,8, RN, MNSci (Nurse Prac.), PhD candidate, Ruth McCaffery3 , RN, Kristy Van9 , RN, MNrs, and Amanda Ullman5-8, RN, PhD
PURPOSE:Intensive care unit (ICU) patients are at risk for central line-associated bloodstream infection (CLABSI) with significant attributable mortality and increased hospital length of stay, readmissions, and costs. Chlorhexidine (di)gluconate (CHG) is used as a disinfectant for central line insertion; however, the feasibility and efficacy of using CHG as a locking solution is unknown.METHODS:Patients with a central venous access device (CVAD) in situ were randomized to standard care or a CHG lock solution (CHGLS) within 72 hours of ICU admission. The CHG solution was instilled in the lumen of venous catheters not actively infusing. CVAD blood cultures were taken at baseline and every 48 hours. The primary outcome was feasibility including recruitment rate, consent rate, protocol adherence, and staff uptake. Secondary outcomes included CVAD colonization, bacteraemia, and clinical endpoints.RESULTS:Of 3,848 patients screened, 122 were eligible for the study and consent was obtained from 82.0% of the patients or substitute decision makers approached. Fifty participants were allocated to each group. Tracking logs indicated that the CHGLS was used per protocol 408 times. Most nurses felt comfortable using the CHGLS. The proportion of central line colonization was significantly higher in the standard care group with 40 (29%) versus 26 (18.7%) in the CHGLS group (P=0.009).CONCLUSIONS:Using a device that delivers CHG into CVADs was feasible in the ICU. Findings from this trial will inform a full-scale randomized controlled trial and provide preliminary data on the effectiveness of CHGLS.TRIAL REGISTRATION:ClinicalTrials.gov Identifier NCT03309137, registered on October 13, 2017.
Central venous access devices (CVADs) are a mainstay for many patients receiving mid-to-long-term intravenous therapy. Cancer Institute of NSW programs, eviQ and eviQ Education, provide free online cancer treatment protocols and resources for clinicians, patients and carers. In 2021, the complete suite of eviQ CVAD resources were updated via extensive consultation with vascular access experts and the evidence-based literature to reflect the latest evidence for CVAD management. Resources include eLearning modules, clinical procedures, complication management algorithms, assessment and documentation tools, quizzes, and patient education materials. We encourage readers to explore and promote eviQ and eviQ Education for CVADs and share these resources with nursing, interventional radiology, or medical colleagues caring for patients with a CVAD, as well as patients and carers.
The Australian Commission on Safety and Quality in Health Care launched the long-awaited Management of Peripheral Intravenous Catheters (PIVCs) Clinical Care Standard (CCS) in May 2021. This national standard for short PIVC insertion and management is based on a review of national and international evidence-based practice guidelines and has been endorsed by a panel of vascular access and infection control experts from across Australia. Using the PIVC CCS to monitor and improve PIVC insertion and management at a local level helps organisations meet some of the accreditation requirements of the National Safety and Quality Health Service (NSQHS) Standards.
Background Billions of peripheral intravenous catheters (PIVCs) are used globally each year, with 44-58% of first attempts failing. Ultrasound use for PIVC insertion has demonstrated improved first pass success, reduced attempts, and improved satisfaction. With the expansion of point-of-care and hand-held ultrasound units, there is a need to identify and explore options for clinical use. Aim We aim to conduct a scoping review of peer-reviewed and non-peer-reviewed literature to identify articles that explore the nature and distribution of research activity and current state of evidence in the adoption and use of point-of-care and hand-held ultrasound for PIVC insertion. Methods A search using keywords and Medical Subject Headings for published and unpublished literature in English between the years 2000 to 2021 will be undertaken in electronic databases and clinical trial registry sites. Two independent reviewers will screen all titles and abstracts for eligibility and extract data from relevant articles into a standardised electronic data collection form. Quantitative studies will be classified into groups investigating similar interventions, strategies and outcomes, and data presented as descriptive statistics, as appropriate. A thematic analysis will be conducted on the information extracted from qualitative studies and findings presented using narrative synthesis. Ethics and dissemination Ethics approval is not required for this review. The findings will be published and presented to audiences invested in peripheral intravenous cannulation success.
Strengths and limitations of this study• PIVC insertion is challenging in the austere or combat setting, and catheter failure is common.Data from this study will reveal securement techniques that optimise practice in high threat/ disaster settings and enhance patient safety and quality.• This study will not be conducted in a real-life disaster or combat settings; however, high-fidelity simulations present an alternative option. BackgroundThe insertion of a peripheral intravenous catheter (PIVC) is one of the most common clinical procedures performed.About 30 million are used in Australia each year, with up to 70% of hospitalised patients requiring a PIVC at some point during their hospital stay. 1 However, it is well documented that PIVCs often fail before the completion of intravenous (IV) treatment, 2,3 with an incidence as high as 69%. 3 Researchers have shown that this failure is, in part, a result of inadequate stabilisation AbstractIntroduction Haemorrhage is the leading cause of preventable death in combat settings.Pre-hospital practice guidelines advocate for the rapid delivery of blood products and intravenous access to deliver adjunct treatments.However, peripheral intravenous catheter (PIVC) insertion is challenging in the austere setting, and catheter failure is common.This study aims to investigate dressing and securement methods to prevent catheter dislodgement and explore participants' experiences with these methods within an Australian Defence Force Tactical Combat Casualty Care (TCCC) training course.Methods and analysis A two-phase mixed-method design will be used to compare the Ruggedised Field (Ranger) method with the S-Wrap technique to reduce PIVC dislodgement rates during TCCC simulations.The study will be undertaken at the Australian Army School of Health in Victoria, Australia.In Phase 1, we will examine the pull-out force of each dressing securement method in vitro.Phase 2 will involve (i) an observational audit (n=30 participants) of TCCC training to assess the quality and safety of PIVC securement practices and (ii) focus groups with participating healthcare professionals (HCPs) (n<15 participants) to understand their lived experiences of PIVC insertion and securement practices.Associations between pull-out forces will be assessed using analysis of variance, and descriptive statistics will be used to summarise audit data.Focus group data will be analysed using content analysis.
By now, many of you probably have heard about Marie Kondo’s KonMari method and her books Spark joy and The life-changing magic of tidying. I haven’t yet read these books (by the look of my desk, I probably need to!), but the catchy titles made me ponder how we could create some life-changing magic and spark joy in the vascular access world. We hear so many times about what goes wrong in our hospitals. I thought it would be fun to imagine a perfect world of vascular access, one that would spark joy.
Indwelling medical devices, including vascular access and urinary catheters, pose a risk for infection, and therefore daily assessment and consideration of their continued need is a patient safety priority. The I-DECIDED® device assessment and decision tool is an evidence-based checklist, designed to improve the assessment, care and timely removal of invasive devices in acute hospitalized patients. This paper explains each step of the tool, with rationale for inclusion.
