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Informing Practice of Dressing and Securement of Peripheral Arterial Catheters: Back to the Future
scrubbing and disinfecting the hub (as recommended by the 2014 EPIC guidelines); (c) adoption of new devices e so-called ’port protectors’ - for chronic disinfection of the hub (as recommended by the 2014 SHEA/IDSA guidelines). Results and implications: We believe these new approach focused on both ELC and ILC prevention will have a positive impact on the overall risk of CRBSI in our hospitals. Conclusion: As current evidence suggests that today the prevalent route of bacterial contamination of VAD is intra-luminal, rather than extra-luminal, new policies and new strategies are necessary, so to minimize the risk of infection and getting closer to the ’targeting zero’.
Use of a Transparent Dressing With Integrated Securement Device for Peripheral i.v. Cannulas: A Pilot Study Mauro Pittiruti Purpose: Recently, new transparent semipermeable membranes integrated with a securement device have become available on the European market. We have tested one of this membranes (SorbaView Shield Peripheral, Carefusion) (SVSP) in a small series of patients candidate to peripheral i.v. lines (PIV). Methods: We recruited adult patients candidate to peripheral intravenous therapy with expected duration < 9 days. All PIVs (20G and 22G short cannulas) were inserted according to a standardized protocol including preferred insertion site at forearm, proper hand washing policy and skin antisepsis with 2% chlorhexidine. Each PIV was covered and secured by SVSP. The connection between cannula and extension tube was covered by the SVSP; the extension and the membrane were left in place for 7 days and replaced earlier only if the dressing became damp, loosened or soiled. Results: We studied 20 PIVs in 18 patients: 16 PIVs were inserted at forearm. Placement and removal of SVSP were easy, painless and free of complications. PIV duration was 2.95 days (mean) and 4 days (median). Unscheduled removal of the PIV occurred only in two cases (one fluid leakage from the exit site with loosening of the dressing; one local inflammation): in all other cases, PIV was removed because end of therapy and/or need for a central line. There was no episode of dislocation. No SVSP needed to be replaced. Nurses and patients compliance were optimal. Limitations: Our results should be confirmed by a larger series of cases and by prospective randomized studies comparing SVSP vs. standard transparent membranes. Conclusions: The SVSP device was associated with an optimal securement of the PIV, while allowing a proper daily inspection of the exit site.
Use of PICCs in Hematopoietic Stem Cell Transplantation: A Retrospective Analysis of 285 Cases Mauro Pittiruti Purpose: Peripherally inserted central catheters (PICCs) may play a role also in patients undergoing hematopoietic stem
cell transplantation (HSCT). We have retrospectively reviewed our experience with silicon Groshong closed-ended valved PICCs (S-PICC) and polyurethane power injectable openended non-valved PICCs (P-PICC) in this patient population. Methods: All PICCs were positioned by our PICC team (adopting a standardized insertion bundle) and utilized by specifically trained nurses of our hematology unit (adopting standardized maintenance bundles). Results: In seven years, 285 PICCs were inserted in 280 patients (115 females and 165 males; mean age 49 years): 185 PICCs in 183 autologous HSCT patients and 100 PICCs in 97 allogeneic HSCT patients. No relevant insertion-related complication occurred. Mean duration was 25 days in autologous vs. 52 days in allogeneic HSCT. Most PICCs were removed electively: 14.6% were removed accidentally (1%) or because of proven catheter complication (3.8%) or suspected PICC infection (9.8%). Symptomatic thrombosis occurred in 5.26%. Catheter-related bloodstream infection (CRBSI) was proven in 8 cases (2.8%, 0.8 episodes per 1000 PICC days), PICC colonization in 14 cases (4.9%), non-catheter related bacteremia in 43 cases (15.1%). There was no difference between autologous and allogeneic HSCT. Incidence of thrombotic or infective complications was similar in S-PICCs and P-PICCs. Though, S-PICCs were associated with some mechanical complications (primary tip malposition, 2.2 %; malfunction due to lumen occlusion, 6%), which did not occur with P-PICCs. Limitations: The differences between P-PICCs vs. S-PICCs should be confirmed by a prospective randomized study. Conclusions: PICCs are safe and effective in the management HSCT patients: insertion complications are negligible, while the incidence of venous thrombosis and of CRBSI is very low. P-PICCs have some advantages over S-PICCs in terms of incidence of mechanical complications.
Informing Practice of Dressing and Securement of Peripheral Arterial Catheters: Back to the Future Heather Reynolds Title: Informing Practice of Dressing and Securement of Peripheral Arterial Catheters: Back to the Future. Background: Annual global use of peripheral arterial catheters (ACs) for BP monitoring and blood sampling in critical care is extensive: Australia 160,000, USA 8 million, & Europe 2.5 million. Catheter complications associated with catheter dressing/securement lead to failure from accidental dislodgement, occlusion, thrombosis or bloodstream infection. Up to 25% of ACs fail during treatment and cause significant morbidity, patient suffering, prolong hospitalization and increase costs. Purpose: To perform a review of the literature about dressing/ securement of peripheral arterial catheters. Methods: A literature search of the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL, as well as Google and Google Scholar was performed. A systematic review and meta-analysis was performed with the scarce literature.
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Results: Only two pilot randomized controlled trials were suitable for inclusion. These studied 123/195 surgical patients with arterial catheters, with the same four interventions: control standard polyurethane, integrated device TegadermÔ Advanced, the securement device StatLockÒ and tissue adhesive HistoacrylÒ. All methods were superior to control standard care polyurethane and the processes were feasible. Incidence of catheter failure overall was: occlusion 12%, dislodgement 2% and thrombosis 1%. Pooled intervention group failure was 27/241 (11%). Pilot economic analyses indicated the newer products were more cost-effective, and the most economical way for further testing was a large fourarm trial. Discussion: Both trials had robust methodology. The observed effect sizes supported the necessity for future research. Overall 11% catheter failure rate was unacceptably high. Limitations: The pilot trials were intentionally underpowered to test statistical difference. Conclusions: Both trials showed standard care dressings were inadequate. Thus, we plan a future multicenter randomized trial which will definitively test these dressing/securement interventions to prevent arterial catheter failure, with the intention to inform future practice.
Tracking PICC Data Sarah Robinson Background: An understanding of PICC complications, dwell time, and insertion data was difficult to obtain without extensive chart audits. Without this information, tracking of complication data was not conducted. Purpose: The purpose was to create a database that easily compiled data for every PICC insert in the facility. This data can then be formatted into monthly reports. Project Description: An Access database was created by the writer’s facilities IT department. The PICC line information for each PICC placed is entered into the PICC QA database during insertion, any pertinent information during the length of stay is also entered, and the removal date and reason is entered when the line is removed. The information is than compiled into monthly reports. Results: The database began in September 2008. It now contains over 7994 PICC lines information. Each patient’s PICC information can be sorted by patient medical record number allowing the inserting clinician to look up the patient’s information prior to insert to access any PICC history prior to insert attempt. Implications: The data gained from the database has resulted in process changes for the facility, including the implementation of a chlorehexidine impregnated disc at the insert site, the use of chlorehexidine impregnated catheters for the prevention of deep vein thrombosis, and the elimination of routine chest xrays by the implementation of a tip locating device. Conclusion: The PICC QA Database has improved the care of the patients who receive a PICC at the writer’s facility. The information gained from the database has resulted in process changes and an understanding of complication issues.
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A Nurse Driven Strategy to Significantly Decrease PICC Insertion Delays Through the Design and Execution of a Pre-PICC Procedure Process Kristine Sadlek Background: The PICC team places approximately 200 PICC lines per month. The mean time from room arrival to start of procedure was 15 minutes. The previous process was fragmented with subsequent delays. The delays encountered when entering the patient’s room resulted in an average of 50 hours per month. Purpose: By decreasing the number of delays the PICC team encounters for each patient there was an opportunity to place more lines, decrease length of stay (LOS), increase patient throughput, decrease ED boarding, and increase patient and nurse satisfaction. Project or Case Description: The team developed and implemented a Pre-PICC Procedure Process (P4) tool for the nursing staff. Four main components reminded them to assess for patient needs and prepare the patient and room adequately for the PICC team. The process included the PICC team calling ahead to the bedside nurse with an approximate time of arrival for the PICC line placement so prep and education could be initiated. A second call to the nurse was made by the PICC team about 20 minutes prior to arrival to the patient’s room. Results: Total procedure delays decreased from 15 to nine minutes per case. Total PICC placement prep time delays decreased from 50 hours to 30 hours per month. Implications: Measurable patient outcomes included decreased LOS, increased patient throughput, and decreased ED boarding. Additional benefits included increased patient satisfaction due to improved communication amongst the interdisciplinary health care team; increased overall nurse satisfaction with teamwork; increased the number of PICC lines placed per day; decreased delays in patient discharge times. Conclusions: The P4 check list items allow the bedside nurse to adequately prepare the patient, family and the room for the procedure. In addition to improving the patient’s plan of care the P4 improved operational flow resulting in a positive ripple effect for the entire organization. The P4 strategy may be replicated in other organizations to yield similar positive outcomes.
A Prospective Study of Placement and Confirmation of Peripheral Inserted Central Catheters (PICC) Tip Position Using a New Tracking and Electrographic Method Herve Rosay Background/Purpose: Atrio-cava junction is the best position for central venous catheters (CVC). Fluoroscopy is still the reference to place PICC in France. The endocavitary ECG
2015
Use of a Transparent Dressing With Integrated Securement Device for Peripheral i.v. Cannulas: A Pilot Study Mauro Pittiruti Purpose: Recently, new transparent semipermeable membranes integrated with a securement device have become available on the European market. We have tested one of this membranes (SorbaView Shield Peripheral, Carefusion) (SVSP) in a small series of patients candidate to peripheral i.v. lines (PIV). Methods: We recruited adult patients candidate to peripheral intravenous therapy with expected duration < 9 days. All PIVs (20G and 22G short cannulas) were inserted according to a standardized protocol including preferred insertion site at forearm, proper hand washing policy and skin antisepsis with 2% chlorhexidine. Each PIV was covered and secured by SVSP. The connection between cannula and extension tube was covered by the SVSP; the extension and the membrane were left in place for 7 days and replaced earlier only if the dressing became damp, loosened or soiled. Results: We studied 20 PIVs in 18 patients: 16 PIVs were inserted at forearm. Placement and removal of SVSP were easy, painless and free of complications. PIV duration was 2.95 days (mean) and 4 days (median). Unscheduled removal of the PIV occurred only in two cases (one fluid leakage from the exit site with loosening of the dressing; one local inflammation): in all other cases, PIV was removed because end of therapy and/or need for a central line. There was no episode of dislocation. No SVSP needed to be replaced. Nurses and patients compliance were optimal. Limitations: Our results should be confirmed by a larger series of cases and by prospective randomized studies comparing SVSP vs. standard transparent membranes. Conclusions: The SVSP device was associated with an optimal securement of the PIV, while allowing a proper daily inspection of the exit site.
Use of PICCs in Hematopoietic Stem Cell Transplantation: A Retrospective Analysis of 285 Cases Mauro Pittiruti Purpose: Peripherally inserted central catheters (PICCs) may play a role also in patients undergoing hematopoietic stem
cell transplantation (HSCT). We have retrospectively reviewed our experience with silicon Groshong closed-ended valved PICCs (S-PICC) and polyurethane power injectable openended non-valved PICCs (P-PICC) in this patient population. Methods: All PICCs were positioned by our PICC team (adopting a standardized insertion bundle) and utilized by specifically trained nurses of our hematology unit (adopting standardized maintenance bundles). Results: In seven years, 285 PICCs were inserted in 280 patients (115 females and 165 males; mean age 49 years): 185 PICCs in 183 autologous HSCT patients and 100 PICCs in 97 allogeneic HSCT patients. No relevant insertion-related complication occurred. Mean duration was 25 days in autologous vs. 52 days in allogeneic HSCT. Most PICCs were removed electively: 14.6% were removed accidentally (1%) or because of proven catheter complication (3.8%) or suspected PICC infection (9.8%). Symptomatic thrombosis occurred in 5.26%. Catheter-related bloodstream infection (CRBSI) was proven in 8 cases (2.8%, 0.8 episodes per 1000 PICC days), PICC colonization in 14 cases (4.9%), non-catheter related bacteremia in 43 cases (15.1%). There was no difference between autologous and allogeneic HSCT. Incidence of thrombotic or infective complications was similar in S-PICCs and P-PICCs. Though, S-PICCs were associated with some mechanical complications (primary tip malposition, 2.2 %; malfunction due to lumen occlusion, 6%), which did not occur with P-PICCs. Limitations: The differences between P-PICCs vs. S-PICCs should be confirmed by a prospective randomized study. Conclusions: PICCs are safe and effective in the management HSCT patients: insertion complications are negligible, while the incidence of venous thrombosis and of CRBSI is very low. P-PICCs have some advantages over S-PICCs in terms of incidence of mechanical complications.
Informing Practice of Dressing and Securement of Peripheral Arterial Catheters: Back to the Future Heather Reynolds Title: Informing Practice of Dressing and Securement of Peripheral Arterial Catheters: Back to the Future. Background: Annual global use of peripheral arterial catheters (ACs) for BP monitoring and blood sampling in critical care is extensive: Australia 160,000, USA 8 million, & Europe 2.5 million. Catheter complications associated with catheter dressing/securement lead to failure from accidental dislodgement, occlusion, thrombosis or bloodstream infection. Up to 25% of ACs fail during treatment and cause significant morbidity, patient suffering, prolong hospitalization and increase costs. Purpose: To perform a review of the literature about dressing/ securement of peripheral arterial catheters. Methods: A literature search of the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL, as well as Google and Google Scholar was performed. A systematic review and meta-analysis was performed with the scarce literature.
2015
j
Vol 20 No 4
j
JAVA
j
243
Results: Only two pilot randomized controlled trials were suitable for inclusion. These studied 123/195 surgical patients with arterial catheters, with the same four interventions: control standard polyurethane, integrated device TegadermÔ Advanced, the securement device StatLockÒ and tissue adhesive HistoacrylÒ. All methods were superior to control standard care polyurethane and the processes were feasible. Incidence of catheter failure overall was: occlusion 12%, dislodgement 2% and thrombosis 1%. Pooled intervention group failure was 27/241 (11%). Pilot economic analyses indicated the newer products were more cost-effective, and the most economical way for further testing was a large fourarm trial. Discussion: Both trials had robust methodology. The observed effect sizes supported the necessity for future research. Overall 11% catheter failure rate was unacceptably high. Limitations: The pilot trials were intentionally underpowered to test statistical difference. Conclusions: Both trials showed standard care dressings were inadequate. Thus, we plan a future multicenter randomized trial which will definitively test these dressing/securement interventions to prevent arterial catheter failure, with the intention to inform future practice.
Tracking PICC Data Sarah Robinson Background: An understanding of PICC complications, dwell time, and insertion data was difficult to obtain without extensive chart audits. Without this information, tracking of complication data was not conducted. Purpose: The purpose was to create a database that easily compiled data for every PICC insert in the facility. This data can then be formatted into monthly reports. Project Description: An Access database was created by the writer’s facilities IT department. The PICC line information for each PICC placed is entered into the PICC QA database during insertion, any pertinent information during the length of stay is also entered, and the removal date and reason is entered when the line is removed. The information is than compiled into monthly reports. Results: The database began in September 2008. It now contains over 7994 PICC lines information. Each patient’s PICC information can be sorted by patient medical record number allowing the inserting clinician to look up the patient’s information prior to insert to access any PICC history prior to insert attempt. Implications: The data gained from the database has resulted in process changes for the facility, including the implementation of a chlorehexidine impregnated disc at the insert site, the use of chlorehexidine impregnated catheters for the prevention of deep vein thrombosis, and the elimination of routine chest xrays by the implementation of a tip locating device. Conclusion: The PICC QA Database has improved the care of the patients who receive a PICC at the writer’s facility. The information gained from the database has resulted in process changes and an understanding of complication issues.
244
j
JAVA
j
Vol 20 No 4
j
A Nurse Driven Strategy to Significantly Decrease PICC Insertion Delays Through the Design and Execution of a Pre-PICC Procedure Process Kristine Sadlek Background: The PICC team places approximately 200 PICC lines per month. The mean time from room arrival to start of procedure was 15 minutes. The previous process was fragmented with subsequent delays. The delays encountered when entering the patient’s room resulted in an average of 50 hours per month. Purpose: By decreasing the number of delays the PICC team encounters for each patient there was an opportunity to place more lines, decrease length of stay (LOS), increase patient throughput, decrease ED boarding, and increase patient and nurse satisfaction. Project or Case Description: The team developed and implemented a Pre-PICC Procedure Process (P4) tool for the nursing staff. Four main components reminded them to assess for patient needs and prepare the patient and room adequately for the PICC team. The process included the PICC team calling ahead to the bedside nurse with an approximate time of arrival for the PICC line placement so prep and education could be initiated. A second call to the nurse was made by the PICC team about 20 minutes prior to arrival to the patient’s room. Results: Total procedure delays decreased from 15 to nine minutes per case. Total PICC placement prep time delays decreased from 50 hours to 30 hours per month. Implications: Measurable patient outcomes included decreased LOS, increased patient throughput, and decreased ED boarding. Additional benefits included increased patient satisfaction due to improved communication amongst the interdisciplinary health care team; increased overall nurse satisfaction with teamwork; increased the number of PICC lines placed per day; decreased delays in patient discharge times. Conclusions: The P4 check list items allow the bedside nurse to adequately prepare the patient, family and the room for the procedure. In addition to improving the patient’s plan of care the P4 improved operational flow resulting in a positive ripple effect for the entire organization. The P4 strategy may be replicated in other organizations to yield similar positive outcomes.
A Prospective Study of Placement and Confirmation of Peripheral Inserted Central Catheters (PICC) Tip Position Using a New Tracking and Electrographic Method Herve Rosay Background/Purpose: Atrio-cava junction is the best position for central venous catheters (CVC). Fluoroscopy is still the reference to place PICC in France. The endocavitary ECG
2015