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Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review
ARTICLE IN PRESS American Journal of Infection Control ■■ (2016) ■■-■■
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American Journal of Infection Control
American Journal of Infection Control
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Major Article
Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review Monideepa B. Becerra DrPH, MPH a, Daniel Shirley MD, MS b, Nasia Safdar MD, PhD b,c,* a
Department of Health Science and Human Ecology, California State University, San Bernardino, CA Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI c William S. Middleton Memorial Veterans Hospital, Madison, WI b
Key Words: Bloodstream infection Patient outcomes Idle lines CLABSI
Objective: Complications of intravenous catheters remain a major contributor to health care costs and are a patient safety problem. An intravenous catheter not actively in use—an idle catheter—may increase the risk of infectious and noninfectious complications. We conducted an integrative review of the available literature to evaluate the prevalence, risk factors, and outcomes associated with idle intravenous catheters. Methods: Searches of multiple computerized databases were conducted to identify studies on idle intravenous catheters. Data on definitions of idle catheter, type of catheter, prevalence, risk factors, and patient outcomes were extracted. Results: Thirteen studies met inclusion criteria and were included in the review. The location and setting of the studies were diverse, including cross-sectional, retrospective, and prospective, and were conducted in varied geographic locations. The definition of an idle catheter was variable across studies. Although studies varied in terms of line-days or number of catheters placed, the primary definition of idle device was based on number of days or percent of devices left in situ without use. Four studies evaluated patient outcomes associated with idle catheters and found increased risk of infection, intensive care unit admission, and phlebitis. Conclusions: Idle intravenous catheters are common and are associated with adverse outcomes. Prospective studies incorporating uniform definitions of idle catheters to test interventions to reduce idle catheter use are urgently needed. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Intravenous catheters (ICs), both peripheral and central, are common in medical practice for both in-hospital care and in ambulatory care settings,1 with an estimated 150 million peripheral and 5 million central ICs used each year in the United States.2-4 Although critical for medical care, ICs increase the risk of local and systemic infectious complications such as bloodstream infections,5 endocarditis,6 and thrombophlebitis.7 Current estimates of attributable mortality and cost due to central IC complications range from
* Address correspondence to Nasia Safdar, MD, PhD, Department of Medicine, University of Wisconsin-Madison, 1685 Highland Ave, Madison, WI 53792. E-mail address: [email protected] (N. Safdar). NS is supported by a VA MERIT award and by the VA Patient Safety Center. The project reported here was also supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service Quality Enhancement Research Initiative (project No. PEC 15-248). The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs. Conflicts of Interest: None to report.
12%-25% and $35,000-$56,000 per episode, respectively, leading to an annual cost of patient care due to central line-associated bloodstream infections estimated to be as high as $2.3 billion in the United States.8-10 Prevention of complications must focus on optimizing use of these devices, such as insertion only when medically necessary and ensuring removal according to recommended guidelines.11 Despite evidence-based recommendations to remove ICs when no longer needed, studies show that ICs often remain in situ unnecessarily and these idle catheters lead to adverse patient consequences.12-14 However, the magnitude of this risk is unknown. We undertook an integrative review to examine the prevalence, risk factors, and outcomes of idle ICs.
REVIEW PROCESS Following recommended guidelines, an integrative review was conducted to evaluate the available literature on this topic.15 Queries
0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2016.03.073
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Records identified through database searching (n = 23)
Additional records identified through other sources (n = 2)
Records after duplicates removed (n = 0)
Records screened (n = 25)
Records excluded (n = 10)
Full-text articles assessed for eligibility (n = 15)
Full-text articles excluded, with reasons (n = 2) Zingg and Pittet, 2009 was a literature review. Marschall et al., 2008 was a recommendation
Studies included in qualitative synthesis (n = 13)
Fig 1. Literature identification procedure.
were carried out using MEDLINE (including PubMed) and EBSCOhost (including Cumulative Index to Nursing and Allied Health Literature) using the following combinations of search terms within titles and abstracts of published articles: idle OR unused OR unnecessary OR inappropriate AND catheter. The search was conducted March through September 2015. All queries were limited to studies published in English during the past 10 years to focus on the most recent literature, although no restriction on country of research was placed. Reviews, commentaries, editorials, dissertations, single-patient case studies, and abstracts were excluded. Studies that defined the inappropriate use of a catheter as the wrong device without discussion of unused days and those including catheters other than intravascular were excluded from this review. For the identified studies following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses guidelines (Fig 1), we collected information on study characteristics such as the unit of analysis, definition of idle catheter, type of catheter used, risk factors, prevalence, and patient outcomes. Consensus was reached among evaluators to finalize the identified studies for assessment. RESULTS Overall study characteristics As shown in Table 1, we identified 13 studies that met inclusion criteria: 3 retrospective studies, 13,18,24 4 prospective studies,14,16,20,21 and 6 cross-sectional analyses,17,19,22,23,25,26 with a total of 38,940 patients. We also included a qualitative study by Zingg et al21 that described interviews with health care workers to assess agreement on indications for IC use. Four of the 13 studies reported use of peripheral ICs,13,16,19,26 4 specified central venous catheters,14,21,24,25 1 study included ICs with unspecified site,18 and 4 additional studies reported on both peripheral and central ICs.17,20,22,23 Four of the 13 identified studies were conducted in the United States,18,20,24,25 whereas others were completed in Australia,13,14
Canada,22 New Zealand,17 United Kingdom,16 Spain,23 Sweden,19 and Switzerland.21 One study included data from 13 countries.26 The study sites varied, including emergency departments,16,18,19 medicalsurgical ward,20 intensive care units,14,22 or entire facilities.13,17,21,23-25 Definition of idle catheter The definition of an idle catheter was heterogeneous in the reviewed literature (Table 1). Seventy-seven percent13,14,16-18,20,21,23-26 of studies defined an idle catheter as a catheter through which no medication or fluid was being administered at the time of evaluation or a catheter was not needed for monitoring of patient hemodynamic status. Other studies used the following criteria for defining an idle catheter: IC left in situ for longer than recommended duration of 72 hours (for peripheral intravenous line),17 IC not used within 24 hours of insertion,19 or IC used for medication delivery that could have been combined with an already-existing device.22 The unit of analysis in the studies varied, including number of patients, number of catheters, and catheter-days. All but 3 studies21,24,25 evaluated percentage of patients with idle catheters, whereas 2 studies assessed the number of days of idle catheters21,25 and 1 assessed both percentage of patients and number of idle days.24 Among studies that focused on central venous catheters only, percentage of patients with idle catheter days was consistently used, whereas among studies that only evaluated peripheral intravenous lines, the common measure was percentage of patients with idle catheters without regard to catheter-days. In studies that included both peripheral and central devices, reported measures varied between number of excess catheters, time left in place beyond 72 hours, and percent of patients with idle devices. For studies that focused on central venous catheters only, the percentage of patients with IC days was consistently used as the unit of analysis, whereas among studies that evaluated peripheral intravenous lines, a frequently employed measure was percentage of patients with ICs. In studies that included both peripheral and central devices, reported measures varied between number of excess
Table 1 Study characteristics Author, year
Study design
Study setting, country
Ritchie et al 200717
Cross-section
Emergency department, United Kingdom Tertiary care hospital, New Zealand
Kuzma et al 200918
Retrospective
Ambulance transport, United States
Göransson and Johansson 201119 Tiwari et al 201120
Cross-section
Zingg et al 201121
Unit of analysis
Catheter type
86 patients
Peripheral intravenous
830 total inpatients 376 patients with devices in situ 90 devices 34,585 patients
Peripheral cannula: 70% Tunneled/non-tunneled central: 13% Peripherally inserted central catheter: 5% Other: 10% Intravenous (unspecified)
Level 1 trauma emergency department, Sweden Adult medical-surgical ward, United States
345 patients
Peripheral intravenous
436 patients
Central and peripheral
Prospective and interviews
University-affiliated primary and tertiary care center, Switzerland
2,704 catheter-days (378 catheters used for 292 patients)
Central venous
Limm et al 201313
Retrospective
Tertiary care hospital, Australia
570 patients
Peripheral intravenous cannulas
Kanji et al 201322
Cross-section
Intensive care unit, Canada
434 patients
Burdeu et al 201414
Prospective
Intensive care unit, Australia
340 patients
Y-site infusion and intravenous catheters (central and peripheral) Central venous
Fernández-Ruiz et al 201423
Cross-section
1,368-bed tertiary-care hospital, Spain
834 patients
Prospective
Vascular catheters 80.6% peripheral 15.8% central 3.6% arterial catheter Central venous
• • • Tejedor et al 201424
Retrospective
Acute care, academic tertiary care facility, United States
89 patients 1,433 wards central venous catheter-days
Trick et al 200425
Cross-section
Public teaching hospital, United States
945 catheter-days (74 patients)
Central venous
Alexandrou et al 201526
Cross-section
13 countries
479 patients
Peripheral intravenous
Definition of idle catheter Catheter left in situ without any medication or infusion Number of catheters and number of days left in situ
Lack of catheter use for medication, or at least 250 cc normal saline, or documented wideopen run No use of catheter by ambulance crew/hospital staff within 24 h of placement No use of catheter at least once in 24 h for delivery of fluids, blood products, medications, parenteral nutrition, or need for hemodynamic status monitoring, or hemodialysis, or access for cardiac dysthymia, or expectant intravenous access (no use in 48 h) Use of central venous catheter for convenience and not used for prolonged (> 7 d) antibiotic therapy, chemotherapy, parenteral nutrition, hemodynamic monitoring, dialysis, and intropic drugs, or lack of peripheral access Cannulas not used for delivering fluids or drugs, including intravenous contrast, until discharge from emergency department Excess catheter used for medication A day of catheter use without any documented or observed medical need More than medically needed number of catheters placed
A day in which the catheter was not used for infusion, medications, comfort care, lack of peripheral access, antimicrobial administration, pre-admission or discharge day placement, or needed in case of patient instability (respiratory care, oxygen saturation, heart rate, blood pressure) Catheter not used for: hemodynamic monitoring, parenteral nutrition/ vasopressors, medications, hemodialysis, plasmapheresis, hemodynamic instability, or lack of peripheral access Catheter not used for medication or fluid delivery
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catheters, time left in place beyond 72 hours, and percent of patients with idle devices. Prevalence of idle catheters Table 2 displays the prevalence, risk factors, and outcomes associated with idle catheters. Among those studies evaluating peripheral ICs only, the percent of patients with idle catheters ranged from 16%26-50%,13 with Limm et al13 further noting that 44% remained unused after 72 hours of device insertion. Studies that evaluated central devices only found that the lowest prevalence was 2.7% among intensive care unit patients, although the same researchers found a higher (6.6%) prevalence of idle days among patients not in intensive care.21 The prevalence of 1 versus at least 2 days of having an idle catheter also varied by study population. For instance, Tejedor et al,24 using data from a tertiary care facility, reported that 46% of patients had at least 2 idle catheter days (25% with 1 idle day), whereas Burdeu et al14 reported the prevalence of having at least 2 days of an idle catheter to be 25% (50% had 1 idle day). In studies that evaluated both peripheral and central devices, the percent of patients with idle catheters was noted to be higher among intensive care unit patients compared with medical and surgical ward patients.23 One study observed idle catheter days in 31% of surgicalward patients,20 whereas another study showed that 33% of tertiary care hospital patients had devices left in situ for more than 72 hours.17 Studies also showed that 18%22-39%17 of patients had at least 1 device in excess. One study that did not specify the site of IC insertion reported 83% of devices to be idle.18 Such a wide range in the prevalence of idle catheters is likely related to the diverse study design, settings, and choice of definitions. Risk factors for idle catheters Eight of the studies in this review evaluated factors associated with idle catheter presence (Table 2). One study noted that convenience was the reason for nearly 12% of idle catheters in ICU patients,21 whereas another study attributed 22% of idle devices to intention to provide medications.19 Patient age and other demographic factors were not consistently found to be important risk factors.18,20 Kanji et al22 and Ritchie et al17 found that inappropriate medication delivery resulted in excess ICs being used. In interviewing health care workers on the agreement of central venous catheter use, Zingg et al21 found that in 8.3% of site visit interviews, nurses and physicians did not know why the IC was in place. Further studies are needed to examine risk factors for idle catheters and to better understand the “just in case” reasoning for leaving the IC in place when not in use. Assessment of the influence of idle catheters As shown in Table 2, approximately 30% (n = 4) of the included studies assessed patient outcomes related to idle catheter use.16,17,20,26 Phlebitis or thrombophlebitis was reported in 12% of patients with idle peripheral catheters in a cross-sectional multination analysis26 and in 9% of patients in a prospective study in United Kingdom evaluating peripheral catheters as well.16 Among 436 adult medicalsurgical ward admissions in 1 hospital, idle central and peripheral catheter-days were associated with a > 7-fold increased likelihood of intensive care unit admission, although reasons for this increase were left unexplained.20 In another study, 12% of patients with an idle catheter (including central and peripheral devices) had either confirmed infection or signs of infection in a cross-sectional analysis.27 The bulk of the existing literature, although sparse, indicates that idle catheters (central or peripheral) are associated with
negative patient outcomes. The limited number of studies that undertook such assessments highlights the need for more research to comprehensively characterize patient outcomes related to idle catheters and the burden that the unnecessary use of ICs place on health care use and cost.
DISCUSSION For best medical care, it is essential that ICs be used only when and for as long as necessary. The consequences of idle ICs are an increased risk of infectious and noninfectious complications. Prevention of idle catheters may be an effective strategy in decreasing IC-associated complications, including bloodstream infection. The existing literature does not provide a comprehensive assessment of the prevalence, risk factors, and resulting influence of idle catheters on health and health care systems. Our findings suggest that this is an important area for future research and, in this integrative review we evaluated the existing data to synthesize current knowledge and highlight important gaps in the field that must be addressed. Our review highlights 4 major emergent themes: idle catheter use was not measured or defined uniformly across studies, the prevalence of idle catheters is varied but generally high across a range of health care settings, knowledge of risk factors related to idle catheters and patient outcomes related to ICs is limited, and limited data exist on the patient outcomes of idle catheters. All of these make the true burden on the health care system difficult to estimate. Although all 4 prospective studies defined idle catheters as those left in without any use, the number of days after which a device was considered idle varied, with some defining idle as 24 hours, whereas another study identified idle when a device was left in situ without use for more than 7 days.21 Such lack of uniformity in the definition of idle catheter in the literature is a unique finding that merits attention because it may mask the true burden and result in underreporting of prevalence. Without a clear definition of how health care facilities define idle devices, national guidelines may not be effectively implemented. The importance of a common vocabulary has been further identified as a priority by the National Committee on Vital and Health Statistics,28 demonstrating a significant gap in the literature in ensuring the heterogeneous definition of idle catheter is standardized across facilities. Although most of the current HAI prevention efforts have focused on central lines, assessing idle catheter days for peripheral catheters is also important given the number of such devices used in medical care. An assessment of necessity, indication, and appropriateness should be a key part of regular assessment of all ICs in health care institutions. The use of an insertion checklist has been shown to markedly reduce central line-associated bloodstream infections and an indication for the line could be incorporated into such a checklist for initial insertion and into a similar maintenance checklist for subsequent monitoring. For example, in a multisite collaborative project to reduce central venous catheterassociated bloodstream infection, Jeffries et al29 demonstrated the feasibility of a daily review of necessity of catheters and care goals, which in turn resulted in nearly $3 million in health care cost savings and prevention of 198 infections. Lederle et al12 further noted that noncompliance with recommendations to remove unnecessary devices and “in case of need” placement as potential risk factors for the presence of idle catheters, and as further noted in our review, a limited number of studies have evaluated the risk factors of idle catheter use. Among the 4 prospective studies, only half (n = 2) assessed at-risk patients. For studies that did conduct such an assessment, the identified risk factors were diverse, including patient demographic
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Table 2 Prevalence, risk factors, and outcomes associated with idle catheters Author, year
Prevalence
Abbas et al 200716 Ritchie et al 200717
Peripheral vascular catheter never used • 49% of patients > 1 Catheter inserted when not needed • 39% of patients (95% CI, 23%-58%) Left for > 72 h • 33% of patients (95% CI, 18%-52%)
Kuzma et al 200918
Intravenous catheter not used • 83% of those with catheter inserted
Göransson and Johannson 201119
Percent of patients with unused catheters during ambulance transport • 22% Percent of patients with unused catheters after emergency department admission • 35% Inappropriate days • n = 1,179 out of 3,806 catheter-days, 31% • Mean ± standard deviation inappropriate days per patient, 2.7 ± 4.9 Unnecessary catheter-days • Total: n = 130, 4.8% (95% CI, 4.0%-5.7%) • ICU: n = 34, 2.7% (95% CI, 1.9%-3.8%) • Non-ICU: n = 96 non-ICU, 6.6% (95% CI, 5.4%-8.0%) Unused cannulas among ED admission • n = 284, 50% (95% CI, 45.6%-54.0%) Unused cannulas 72 h post-ED admission • n = 27 out of 62 patients discharged to wards, 44% (95% CI, 31.0%-59.7%)
Tiwari et al 201120
Zingg et al 201121
Limm et al 201313
Trick et al 200425
Median and rage of central and peripheral catheters • 17.89% patients had 1 idle catheter Idle central venous catheter- days • n = 208 of 794 patients, 26.2% Number of idle central venous catheter-days • 1 d: 50% • ≥ 2 d: 25% 21.9% of patients had inappropriate number of catheters • Medical wards: 20.0% • Surgical wards: 23.9% • Intensive care units: 26.3% Idle central venous catheter-days • n = 361, 25.2% • At least 1 d idle: 63% • ≥ 2 d idle: 46% • Mean, 4.1 d Central venous and peripheral venous idle days • Mean, 3.4 d Unjustified catheter-days • 43 d (from 11 patients), 4.6%
Alexandrou et al 201526
Percent of patients with idle catheters • 16%
Kanji et al 201322 Burdeu et al 201414
Fernández-Ruiz et al 201423
Tejedor et al 201424
Risk factors None assessed Reasons for device insertion and retention: Antibiotics (32%) Hydration (27%) Other intravenous medication (22%) Surgery/anesthesia (13%) Total parenteral nutrition (5%) Transfusion (5%) Chemotherapy (3%) Other (3%) No reason (7%) Asian vs white (OR, 1.20; P = .008) Hispanic vs white (OR, 1.16; P = .020) Unknown/other race vs white (OR, 1.19; P < .0001) Transport level code 3 vs code 2 (OR, 0.49; P < .0001) Low BP vs normal BP (OR, 0.31; P < .0001) High BP vs normal BP (OR, 1.07; P < .0001) Bradycardia vs normal (OR, 0.68; P < .0001) Bradypnea vs normal (OR, 0.26; P < .0001) Tachypnea vs normal (OR, 0.80; P = .001) Abnormal skin color vs normal (OR, 0.63; P < .0001) > 2 second cap refill vs ≤ 2 seconds (OR, 0.70; P < .0001) Primary prehospital catheter insertion reason: Intention to provide therapeutic agents
• • • • • • • • • • • • • • • • • • • •
• • •
Age (y): OR, 1.02 (95% CI, 1.01-1.03) Total catheter number: OR, 3.66 (95% CI, 2.43-5.51) Duration of catheterization (d): OR, 1.19 (95% CI, 1.10-1.29)
Outcomes Developed thrombophlebitis • 9% of patients Confirmed infection or signs of infection • 12% (95% CI, 4%-28%) of patients with intravenous devices • 3% (95% CI, 2%-4%) per total inpatients • 5% (95% CI, 3%-7%) per device • 7% (95% CI, 4%-10%) per patient with device in situ None assessed
None assessed
•
ICU admission: OR, 7.80 (95% CI, 2.33-26.11)
Catheter use for convenience was higher toward end of dwell time Overall: +5.6% per time-point (95% CI, 3.6%-7.6%), P < .001 ICU: +11.9% per time-point (95% CI, 4.1%-9.6%), P = .003 Non-ICU: +4.2% per time-point (95% CI, 1.8%-6.6%), P = .001
None assessed
Odds of unused cannulas Discharged to home: OR, 3.8 (95% CI, 2.7-5.4) Discharged to ward: OR, 0.27 (95% CI, 0.18-0.38) Discharged to theatre/coronary care/catheterization lab: OR, 0.17 (95% CI, 0.05-0.58) • Presenting complaint gastrointestinal: OR, 0.50 (95% CI, 0.33-0.75) • Presenting complaint of shortness of breath: OR, 0.28 (95% CI, 0.12-0.62) Primary reason for idle catheter: Lack of medication rearrangement
None assessed
None assessed
None assessed
None assessed
None assessed
None assessed
None assessed
Higher for non-ICU patients Non-ICUL: n = 33 of 388, 8.5% (95% CI, 6.0%-11.9%) ICU: n = 10 of 557, 1.8% (95% CI, 0.9%-3.4%) None assessed
None assessed
• • • • • •
None assessed
• •
BP, blood pressure; CI, confidence interval; emergency department; ICU, intensive care unit; OR, odds ratio.
12% developed phlebitis
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characteristics, presence of other illness, provider-stated intention to treat, or convenience reasons. Although few studies have assessed barriers to IC removal, the themes of convenience for health care workers and the “just in case” approach that impedes prompt removal of ICs are major barriers that must be addressed to reduce idle catheter prevalence. Even among the 4 prospective studies, which provide longitudinal assessment, only 2 made such assessments and found increased infection rates. One possible reason for idle catheters may be ambiguity regarding indications for particular types of ICs and perceived risk of complications. A recent publication on indications for ICs provides valuable data in this regard by using a consensus-building approach to generate appropriate indications for IC use in a multitude of different settings.30 Furthermore, the recent Choosing Wisely initiative31 emphasizes the importance of reducing unnecessary procedures and practices to optimize patient care. Idle ICs clearly fall within the category of unnecessary procedures. This is an opportune time to capitalize on the momentum generated by Choosing Wisely as well as the increased scrutiny by regulatory agencies and clinical medicine societies on IC-related complications. The results of this review should be interpreted in the context of its limitations. Due to recent intensive efforts for the prevention of central line-associated bloodstream infection, we hypothesized that recent literature would be most relevant and limited our studies to the past 10 years. Our literature search was limited to English-language articles only. The heterogeneity in the study design, measures, and populations precluded a meta-analysis. Publication bias also is a concern. We attempted to undertake a comprehensive search to identify all relevant articles but did not include abstracts or gray literature, which may have influenced the findings. Furthermore, whereas sicker patients are more likely to report higher prevalence of devices, and thus could influence the prevalence rates noted in our study findings, the practice of unused devices, especially among such ill patients, should not be prevalent; thus, our study further demonstrates the need for vigilance in ensuring efficacy in device use among at-risk patients. CONCLUSIONS This integrative review highlights several key areas of inquiry that should be addressed in future studies. Prospective interventional studies with uniform definitions of idle catheters and rigorous assessment of patient outcomes, such as infectious complications, coupled with a deeper understanding of the barriers to IC removal are essential. References 1. Cheung E, Baerlocher MO, Asch M, Myers A. Venous access. Can Fam Physician 2009;55:494-6. 2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33. doi:10.1056/NEJMra011883. 3. American College of Surgeons. Revised statement on recommendations for use of real-time ultrasound guidance for placement of central venous catheters. American College of Surgeons; 2011. Available from: https://www.facs.org/ about-acs/statements/60-real-time-ultrasound#note1. Accessed September 9, 2015. 4. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:S89-107. 5. Chopra V, O’Horo JC, Rogers MAM, Maki DG, Safdar N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013;34:908-18. doi:10.1086/671737. 6. Yamashita S, Noma K, Kuwata G, Miyoshi K, Honaga K. Infective endocarditis at the tricuspid valve following central venous catheterization. J Anesth 2005;19:84-7. doi:10.1007/s00540-004-0284-y.
7. Volkow P, Cornejo-Juárez P, Arizpe-Bravo AB, García-Méndez J, Baltazares-Lipp E, Pérez-Padilla R. Catheter-related septic thrombophlebitis of the great central veins successfully treated with low-dose streptokinase thrombolysis and antimicrobials. Thromb J 2005;3:11. doi:10.1186/1477-9560-3-11. 8. Miller DL, O’Grady NP. Guidelines for the prevention of intravascular catheterrelated infections: recommendations relevant to interventional radiology for venous catheter placement and maintenance. J Vasc Interv Radiol 2012;23:9971007. doi:10.1016/j.jvir.2012.04.023. 9. Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg 2001;136:229-34. 10. Rello J, Ochagavia A, Sabanes E, Roque M, Mariscal D, Reynaga E, et al. Evaluation of outcome of intravenous catheter-related infections in critically ill patients. Am J Respir Crit Care Med 2000;162(3 Pt 1):1027-30. doi:10.1164/ ajrccm.162.3.9911093. 11. Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheterrelated infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45. doi:10.1086/599376. 12. Lederle FA, Parenti CM, Berskow LC, Ellingson KJ. The idle intravenous catheter. Ann Intern Med 1992;116:737-8. 13. Limm EI, Fang X, Dendle C, Stuart RL, Egerton Warburton D. Half of all peripheral intravenous lines in an Australian Tertiary Emergency Department are unused: pain with no gain? Ann Emerg Med 2013;62:521-5. doi:10.1016/ j.annemergmed.2013.02.022. 14. Burdeu G, Currey J, Pilcher D. Idle central venous catheter-days pose infection risk for patients after discharge from intensive care. Am J Infect Control 2014;42:453-5. doi:10.1016/j.ajic.2013.11.011. 15. Torraco RJ. Writing integrative literature reviews: guidelines and examples. Hum Resour Dev Rev 2005;4:356-67. doi:10.1177/1534484305278283. 16. Abbas SZ, de Vries TK, Shaw S, Abbas SQ. Use and complications of peripheral vascular catheters: a prospective study. Br J Nurs 2007;16:648, 650, 652. doi:10.12968/bjon.2007.16.11.23675. 17. Ritchie S, Jowitt D, Roberts S, Auckland District Health Board Infection Control Service. The Auckland City Hospital Device Point Prevalence Survey 2005: utilisation and infectious complications of intravascular and urinary devices. N Z Med J 2007;120:U2683. 18. Kuzma K, Sporer KA, Michael GE, Youngblood GM. When are prehospital intravenous catheters used for treatment? J Emerg Med 2009;36:357-62. doi:10.1016/j.jemermed.2007.11.054. 19. Göransson KE, Johansson E. Indication and usage of peripheral venous catheters inserted in adult patients during emergency care. J Vasc Access 2011;12:193-9. 20. Tiwari MM, Hermsen ED, Charlton ME, Anderson JR, Rupp ME. Inappropriate intravascular device use: a prospective study. J Hosp Infect 2011;78:128-32. doi:10.1016/j.jhin.2011.03.004. 21. Zingg W, Sandoz L, Inan C, Cartier V, Clergue F, Pittet D, et al. Hospital-wide survey of the use of central venous catheters. J Hosp Infect 2011;77:304-8. doi:10.1016/j.jhin.2010.11.011. 22. Kanji S, Lam J, Goddard RD, Johanson C, Singh A, Petrin L, et al. Inappropriate medication administration practices in Canadian adult ICUs: a multicenter, cross-sectional observational study. Ann Pharmacother 2013;47:637-43. doi:10.1345/aph.1R414. 23. Fernández-Ruiz M, Carretero A, Díaz D, Fuentes C, González JI, García-Reyne A, et al. Hospital-wide survey of the adequacy in the number of vascular catheters and catheter lumens. J Hosp Med 2014;9:35-41. doi:10.1002/jhm.2130. 24. Tejedor SC, Tong D, Stein J, Payne C, Dressler D, Xue W, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the idle central venous catheter. Infect Control Hosp Epidemiol 2012;33:50-7. doi:10.1086/663645. 25. Trick WE, Vernon MO, Welbel SF, Wisniewski MF, Jernigan JA, Weinstein RA. Unnecessary use of central venous catheters: the need to look outside the intensive care unit. Infect Control Hosp Epidemiol 2004;25:266-8. doi:10.1086/ 502390. 26. Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, et al. International prevalence of the use of peripheral intravenous catheters. J Hosp Med 2015;10:530-3. doi:10.1002/jhm.2389. 27. Ritchie SK, Murphy EC-S, Ice C, Cottrell LA, Minor V, Elliott E, et al. Universal versus targeted blood cholesterol screening among youth: the CARDIAC project. Pediatrics 2010;126:260-5. doi:10.1542/peds.2009-2546. 28. National Committee on Vital and Health Statistics. Toward a national health information infrastructure. ASPE; 2000. Available from: https://aspe.hhs.gov/ legacy-page/toward-national-health-information-infrastructure-148636. Accessed March 28, 2016. 29. Jeffries HE, Mason W, Brewer M, Oakes KL, Muñoz EI, Gornick W, et al. Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units a performance improvement collaborative. Infect Control Hosp Epidemiol 2009;30:645-51. doi:10.1086/599166. 30. Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method Michigan appropriateness guide for intravenous catheters (MAGIC). Ann Intern Med 2015;163(6 Suppl):S1-40. doi:10.7326/M15-0744. 31. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA 2012;307:1801-2. doi:10.1001/jama.2012.476.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major Article
Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review Monideepa B. Becerra DrPH, MPH a, Daniel Shirley MD, MS b, Nasia Safdar MD, PhD b,c,* a
Department of Health Science and Human Ecology, California State University, San Bernardino, CA Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI c William S. Middleton Memorial Veterans Hospital, Madison, WI b
Key Words: Bloodstream infection Patient outcomes Idle lines CLABSI
Objective: Complications of intravenous catheters remain a major contributor to health care costs and are a patient safety problem. An intravenous catheter not actively in use—an idle catheter—may increase the risk of infectious and noninfectious complications. We conducted an integrative review of the available literature to evaluate the prevalence, risk factors, and outcomes associated with idle intravenous catheters. Methods: Searches of multiple computerized databases were conducted to identify studies on idle intravenous catheters. Data on definitions of idle catheter, type of catheter, prevalence, risk factors, and patient outcomes were extracted. Results: Thirteen studies met inclusion criteria and were included in the review. The location and setting of the studies were diverse, including cross-sectional, retrospective, and prospective, and were conducted in varied geographic locations. The definition of an idle catheter was variable across studies. Although studies varied in terms of line-days or number of catheters placed, the primary definition of idle device was based on number of days or percent of devices left in situ without use. Four studies evaluated patient outcomes associated with idle catheters and found increased risk of infection, intensive care unit admission, and phlebitis. Conclusions: Idle intravenous catheters are common and are associated with adverse outcomes. Prospective studies incorporating uniform definitions of idle catheters to test interventions to reduce idle catheter use are urgently needed. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Intravenous catheters (ICs), both peripheral and central, are common in medical practice for both in-hospital care and in ambulatory care settings,1 with an estimated 150 million peripheral and 5 million central ICs used each year in the United States.2-4 Although critical for medical care, ICs increase the risk of local and systemic infectious complications such as bloodstream infections,5 endocarditis,6 and thrombophlebitis.7 Current estimates of attributable mortality and cost due to central IC complications range from
* Address correspondence to Nasia Safdar, MD, PhD, Department of Medicine, University of Wisconsin-Madison, 1685 Highland Ave, Madison, WI 53792. E-mail address: [email protected] (N. Safdar). NS is supported by a VA MERIT award and by the VA Patient Safety Center. The project reported here was also supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service Quality Enhancement Research Initiative (project No. PEC 15-248). The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs. Conflicts of Interest: None to report.
12%-25% and $35,000-$56,000 per episode, respectively, leading to an annual cost of patient care due to central line-associated bloodstream infections estimated to be as high as $2.3 billion in the United States.8-10 Prevention of complications must focus on optimizing use of these devices, such as insertion only when medically necessary and ensuring removal according to recommended guidelines.11 Despite evidence-based recommendations to remove ICs when no longer needed, studies show that ICs often remain in situ unnecessarily and these idle catheters lead to adverse patient consequences.12-14 However, the magnitude of this risk is unknown. We undertook an integrative review to examine the prevalence, risk factors, and outcomes of idle ICs.
REVIEW PROCESS Following recommended guidelines, an integrative review was conducted to evaluate the available literature on this topic.15 Queries
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Records identified through database searching (n = 23)
Additional records identified through other sources (n = 2)
Records after duplicates removed (n = 0)
Records screened (n = 25)
Records excluded (n = 10)
Full-text articles assessed for eligibility (n = 15)
Full-text articles excluded, with reasons (n = 2) Zingg and Pittet, 2009 was a literature review. Marschall et al., 2008 was a recommendation
Studies included in qualitative synthesis (n = 13)
Fig 1. Literature identification procedure.
were carried out using MEDLINE (including PubMed) and EBSCOhost (including Cumulative Index to Nursing and Allied Health Literature) using the following combinations of search terms within titles and abstracts of published articles: idle OR unused OR unnecessary OR inappropriate AND catheter. The search was conducted March through September 2015. All queries were limited to studies published in English during the past 10 years to focus on the most recent literature, although no restriction on country of research was placed. Reviews, commentaries, editorials, dissertations, single-patient case studies, and abstracts were excluded. Studies that defined the inappropriate use of a catheter as the wrong device without discussion of unused days and those including catheters other than intravascular were excluded from this review. For the identified studies following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses guidelines (Fig 1), we collected information on study characteristics such as the unit of analysis, definition of idle catheter, type of catheter used, risk factors, prevalence, and patient outcomes. Consensus was reached among evaluators to finalize the identified studies for assessment. RESULTS Overall study characteristics As shown in Table 1, we identified 13 studies that met inclusion criteria: 3 retrospective studies, 13,18,24 4 prospective studies,14,16,20,21 and 6 cross-sectional analyses,17,19,22,23,25,26 with a total of 38,940 patients. We also included a qualitative study by Zingg et al21 that described interviews with health care workers to assess agreement on indications for IC use. Four of the 13 studies reported use of peripheral ICs,13,16,19,26 4 specified central venous catheters,14,21,24,25 1 study included ICs with unspecified site,18 and 4 additional studies reported on both peripheral and central ICs.17,20,22,23 Four of the 13 identified studies were conducted in the United States,18,20,24,25 whereas others were completed in Australia,13,14
Canada,22 New Zealand,17 United Kingdom,16 Spain,23 Sweden,19 and Switzerland.21 One study included data from 13 countries.26 The study sites varied, including emergency departments,16,18,19 medicalsurgical ward,20 intensive care units,14,22 or entire facilities.13,17,21,23-25 Definition of idle catheter The definition of an idle catheter was heterogeneous in the reviewed literature (Table 1). Seventy-seven percent13,14,16-18,20,21,23-26 of studies defined an idle catheter as a catheter through which no medication or fluid was being administered at the time of evaluation or a catheter was not needed for monitoring of patient hemodynamic status. Other studies used the following criteria for defining an idle catheter: IC left in situ for longer than recommended duration of 72 hours (for peripheral intravenous line),17 IC not used within 24 hours of insertion,19 or IC used for medication delivery that could have been combined with an already-existing device.22 The unit of analysis in the studies varied, including number of patients, number of catheters, and catheter-days. All but 3 studies21,24,25 evaluated percentage of patients with idle catheters, whereas 2 studies assessed the number of days of idle catheters21,25 and 1 assessed both percentage of patients and number of idle days.24 Among studies that focused on central venous catheters only, percentage of patients with idle catheter days was consistently used, whereas among studies that only evaluated peripheral intravenous lines, the common measure was percentage of patients with idle catheters without regard to catheter-days. In studies that included both peripheral and central devices, reported measures varied between number of excess catheters, time left in place beyond 72 hours, and percent of patients with idle devices. For studies that focused on central venous catheters only, the percentage of patients with IC days was consistently used as the unit of analysis, whereas among studies that evaluated peripheral intravenous lines, a frequently employed measure was percentage of patients with ICs. In studies that included both peripheral and central devices, reported measures varied between number of excess
Table 1 Study characteristics Author, year
Study design
Study setting, country
Ritchie et al 200717
Cross-section
Emergency department, United Kingdom Tertiary care hospital, New Zealand
Kuzma et al 200918
Retrospective
Ambulance transport, United States
Göransson and Johansson 201119 Tiwari et al 201120
Cross-section
Zingg et al 201121
Unit of analysis
Catheter type
86 patients
Peripheral intravenous
830 total inpatients 376 patients with devices in situ 90 devices 34,585 patients
Peripheral cannula: 70% Tunneled/non-tunneled central: 13% Peripherally inserted central catheter: 5% Other: 10% Intravenous (unspecified)
Level 1 trauma emergency department, Sweden Adult medical-surgical ward, United States
345 patients
Peripheral intravenous
436 patients
Central and peripheral
Prospective and interviews
University-affiliated primary and tertiary care center, Switzerland
2,704 catheter-days (378 catheters used for 292 patients)
Central venous
Limm et al 201313
Retrospective
Tertiary care hospital, Australia
570 patients
Peripheral intravenous cannulas
Kanji et al 201322
Cross-section
Intensive care unit, Canada
434 patients
Burdeu et al 201414
Prospective
Intensive care unit, Australia
340 patients
Y-site infusion and intravenous catheters (central and peripheral) Central venous
Fernández-Ruiz et al 201423
Cross-section
1,368-bed tertiary-care hospital, Spain
834 patients
Prospective
Vascular catheters 80.6% peripheral 15.8% central 3.6% arterial catheter Central venous
• • • Tejedor et al 201424
Retrospective
Acute care, academic tertiary care facility, United States
89 patients 1,433 wards central venous catheter-days
Trick et al 200425
Cross-section
Public teaching hospital, United States
945 catheter-days (74 patients)
Central venous
Alexandrou et al 201526
Cross-section
13 countries
479 patients
Peripheral intravenous
Definition of idle catheter Catheter left in situ without any medication or infusion Number of catheters and number of days left in situ
Lack of catheter use for medication, or at least 250 cc normal saline, or documented wideopen run No use of catheter by ambulance crew/hospital staff within 24 h of placement No use of catheter at least once in 24 h for delivery of fluids, blood products, medications, parenteral nutrition, or need for hemodynamic status monitoring, or hemodialysis, or access for cardiac dysthymia, or expectant intravenous access (no use in 48 h) Use of central venous catheter for convenience and not used for prolonged (> 7 d) antibiotic therapy, chemotherapy, parenteral nutrition, hemodynamic monitoring, dialysis, and intropic drugs, or lack of peripheral access Cannulas not used for delivering fluids or drugs, including intravenous contrast, until discharge from emergency department Excess catheter used for medication A day of catheter use without any documented or observed medical need More than medically needed number of catheters placed
A day in which the catheter was not used for infusion, medications, comfort care, lack of peripheral access, antimicrobial administration, pre-admission or discharge day placement, or needed in case of patient instability (respiratory care, oxygen saturation, heart rate, blood pressure) Catheter not used for: hemodynamic monitoring, parenteral nutrition/ vasopressors, medications, hemodialysis, plasmapheresis, hemodynamic instability, or lack of peripheral access Catheter not used for medication or fluid delivery
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catheters, time left in place beyond 72 hours, and percent of patients with idle devices. Prevalence of idle catheters Table 2 displays the prevalence, risk factors, and outcomes associated with idle catheters. Among those studies evaluating peripheral ICs only, the percent of patients with idle catheters ranged from 16%26-50%,13 with Limm et al13 further noting that 44% remained unused after 72 hours of device insertion. Studies that evaluated central devices only found that the lowest prevalence was 2.7% among intensive care unit patients, although the same researchers found a higher (6.6%) prevalence of idle days among patients not in intensive care.21 The prevalence of 1 versus at least 2 days of having an idle catheter also varied by study population. For instance, Tejedor et al,24 using data from a tertiary care facility, reported that 46% of patients had at least 2 idle catheter days (25% with 1 idle day), whereas Burdeu et al14 reported the prevalence of having at least 2 days of an idle catheter to be 25% (50% had 1 idle day). In studies that evaluated both peripheral and central devices, the percent of patients with idle catheters was noted to be higher among intensive care unit patients compared with medical and surgical ward patients.23 One study observed idle catheter days in 31% of surgicalward patients,20 whereas another study showed that 33% of tertiary care hospital patients had devices left in situ for more than 72 hours.17 Studies also showed that 18%22-39%17 of patients had at least 1 device in excess. One study that did not specify the site of IC insertion reported 83% of devices to be idle.18 Such a wide range in the prevalence of idle catheters is likely related to the diverse study design, settings, and choice of definitions. Risk factors for idle catheters Eight of the studies in this review evaluated factors associated with idle catheter presence (Table 2). One study noted that convenience was the reason for nearly 12% of idle catheters in ICU patients,21 whereas another study attributed 22% of idle devices to intention to provide medications.19 Patient age and other demographic factors were not consistently found to be important risk factors.18,20 Kanji et al22 and Ritchie et al17 found that inappropriate medication delivery resulted in excess ICs being used. In interviewing health care workers on the agreement of central venous catheter use, Zingg et al21 found that in 8.3% of site visit interviews, nurses and physicians did not know why the IC was in place. Further studies are needed to examine risk factors for idle catheters and to better understand the “just in case” reasoning for leaving the IC in place when not in use. Assessment of the influence of idle catheters As shown in Table 2, approximately 30% (n = 4) of the included studies assessed patient outcomes related to idle catheter use.16,17,20,26 Phlebitis or thrombophlebitis was reported in 12% of patients with idle peripheral catheters in a cross-sectional multination analysis26 and in 9% of patients in a prospective study in United Kingdom evaluating peripheral catheters as well.16 Among 436 adult medicalsurgical ward admissions in 1 hospital, idle central and peripheral catheter-days were associated with a > 7-fold increased likelihood of intensive care unit admission, although reasons for this increase were left unexplained.20 In another study, 12% of patients with an idle catheter (including central and peripheral devices) had either confirmed infection or signs of infection in a cross-sectional analysis.27 The bulk of the existing literature, although sparse, indicates that idle catheters (central or peripheral) are associated with
negative patient outcomes. The limited number of studies that undertook such assessments highlights the need for more research to comprehensively characterize patient outcomes related to idle catheters and the burden that the unnecessary use of ICs place on health care use and cost.
DISCUSSION For best medical care, it is essential that ICs be used only when and for as long as necessary. The consequences of idle ICs are an increased risk of infectious and noninfectious complications. Prevention of idle catheters may be an effective strategy in decreasing IC-associated complications, including bloodstream infection. The existing literature does not provide a comprehensive assessment of the prevalence, risk factors, and resulting influence of idle catheters on health and health care systems. Our findings suggest that this is an important area for future research and, in this integrative review we evaluated the existing data to synthesize current knowledge and highlight important gaps in the field that must be addressed. Our review highlights 4 major emergent themes: idle catheter use was not measured or defined uniformly across studies, the prevalence of idle catheters is varied but generally high across a range of health care settings, knowledge of risk factors related to idle catheters and patient outcomes related to ICs is limited, and limited data exist on the patient outcomes of idle catheters. All of these make the true burden on the health care system difficult to estimate. Although all 4 prospective studies defined idle catheters as those left in without any use, the number of days after which a device was considered idle varied, with some defining idle as 24 hours, whereas another study identified idle when a device was left in situ without use for more than 7 days.21 Such lack of uniformity in the definition of idle catheter in the literature is a unique finding that merits attention because it may mask the true burden and result in underreporting of prevalence. Without a clear definition of how health care facilities define idle devices, national guidelines may not be effectively implemented. The importance of a common vocabulary has been further identified as a priority by the National Committee on Vital and Health Statistics,28 demonstrating a significant gap in the literature in ensuring the heterogeneous definition of idle catheter is standardized across facilities. Although most of the current HAI prevention efforts have focused on central lines, assessing idle catheter days for peripheral catheters is also important given the number of such devices used in medical care. An assessment of necessity, indication, and appropriateness should be a key part of regular assessment of all ICs in health care institutions. The use of an insertion checklist has been shown to markedly reduce central line-associated bloodstream infections and an indication for the line could be incorporated into such a checklist for initial insertion and into a similar maintenance checklist for subsequent monitoring. For example, in a multisite collaborative project to reduce central venous catheterassociated bloodstream infection, Jeffries et al29 demonstrated the feasibility of a daily review of necessity of catheters and care goals, which in turn resulted in nearly $3 million in health care cost savings and prevention of 198 infections. Lederle et al12 further noted that noncompliance with recommendations to remove unnecessary devices and “in case of need” placement as potential risk factors for the presence of idle catheters, and as further noted in our review, a limited number of studies have evaluated the risk factors of idle catheter use. Among the 4 prospective studies, only half (n = 2) assessed at-risk patients. For studies that did conduct such an assessment, the identified risk factors were diverse, including patient demographic
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Table 2 Prevalence, risk factors, and outcomes associated with idle catheters Author, year
Prevalence
Abbas et al 200716 Ritchie et al 200717
Peripheral vascular catheter never used • 49% of patients > 1 Catheter inserted when not needed • 39% of patients (95% CI, 23%-58%) Left for > 72 h • 33% of patients (95% CI, 18%-52%)
Kuzma et al 200918
Intravenous catheter not used • 83% of those with catheter inserted
Göransson and Johannson 201119
Percent of patients with unused catheters during ambulance transport • 22% Percent of patients with unused catheters after emergency department admission • 35% Inappropriate days • n = 1,179 out of 3,806 catheter-days, 31% • Mean ± standard deviation inappropriate days per patient, 2.7 ± 4.9 Unnecessary catheter-days • Total: n = 130, 4.8% (95% CI, 4.0%-5.7%) • ICU: n = 34, 2.7% (95% CI, 1.9%-3.8%) • Non-ICU: n = 96 non-ICU, 6.6% (95% CI, 5.4%-8.0%) Unused cannulas among ED admission • n = 284, 50% (95% CI, 45.6%-54.0%) Unused cannulas 72 h post-ED admission • n = 27 out of 62 patients discharged to wards, 44% (95% CI, 31.0%-59.7%)
Tiwari et al 201120
Zingg et al 201121
Limm et al 201313
Trick et al 200425
Median and rage of central and peripheral catheters • 17.89% patients had 1 idle catheter Idle central venous catheter- days • n = 208 of 794 patients, 26.2% Number of idle central venous catheter-days • 1 d: 50% • ≥ 2 d: 25% 21.9% of patients had inappropriate number of catheters • Medical wards: 20.0% • Surgical wards: 23.9% • Intensive care units: 26.3% Idle central venous catheter-days • n = 361, 25.2% • At least 1 d idle: 63% • ≥ 2 d idle: 46% • Mean, 4.1 d Central venous and peripheral venous idle days • Mean, 3.4 d Unjustified catheter-days • 43 d (from 11 patients), 4.6%
Alexandrou et al 201526
Percent of patients with idle catheters • 16%
Kanji et al 201322 Burdeu et al 201414
Fernández-Ruiz et al 201423
Tejedor et al 201424
Risk factors None assessed Reasons for device insertion and retention: Antibiotics (32%) Hydration (27%) Other intravenous medication (22%) Surgery/anesthesia (13%) Total parenteral nutrition (5%) Transfusion (5%) Chemotherapy (3%) Other (3%) No reason (7%) Asian vs white (OR, 1.20; P = .008) Hispanic vs white (OR, 1.16; P = .020) Unknown/other race vs white (OR, 1.19; P < .0001) Transport level code 3 vs code 2 (OR, 0.49; P < .0001) Low BP vs normal BP (OR, 0.31; P < .0001) High BP vs normal BP (OR, 1.07; P < .0001) Bradycardia vs normal (OR, 0.68; P < .0001) Bradypnea vs normal (OR, 0.26; P < .0001) Tachypnea vs normal (OR, 0.80; P = .001) Abnormal skin color vs normal (OR, 0.63; P < .0001) > 2 second cap refill vs ≤ 2 seconds (OR, 0.70; P < .0001) Primary prehospital catheter insertion reason: Intention to provide therapeutic agents
• • • • • • • • • • • • • • • • • • • •
• • •
Age (y): OR, 1.02 (95% CI, 1.01-1.03) Total catheter number: OR, 3.66 (95% CI, 2.43-5.51) Duration of catheterization (d): OR, 1.19 (95% CI, 1.10-1.29)
Outcomes Developed thrombophlebitis • 9% of patients Confirmed infection or signs of infection • 12% (95% CI, 4%-28%) of patients with intravenous devices • 3% (95% CI, 2%-4%) per total inpatients • 5% (95% CI, 3%-7%) per device • 7% (95% CI, 4%-10%) per patient with device in situ None assessed
None assessed
•
ICU admission: OR, 7.80 (95% CI, 2.33-26.11)
Catheter use for convenience was higher toward end of dwell time Overall: +5.6% per time-point (95% CI, 3.6%-7.6%), P < .001 ICU: +11.9% per time-point (95% CI, 4.1%-9.6%), P = .003 Non-ICU: +4.2% per time-point (95% CI, 1.8%-6.6%), P = .001
None assessed
Odds of unused cannulas Discharged to home: OR, 3.8 (95% CI, 2.7-5.4) Discharged to ward: OR, 0.27 (95% CI, 0.18-0.38) Discharged to theatre/coronary care/catheterization lab: OR, 0.17 (95% CI, 0.05-0.58) • Presenting complaint gastrointestinal: OR, 0.50 (95% CI, 0.33-0.75) • Presenting complaint of shortness of breath: OR, 0.28 (95% CI, 0.12-0.62) Primary reason for idle catheter: Lack of medication rearrangement
None assessed
None assessed
None assessed
None assessed
None assessed
None assessed
None assessed
Higher for non-ICU patients Non-ICUL: n = 33 of 388, 8.5% (95% CI, 6.0%-11.9%) ICU: n = 10 of 557, 1.8% (95% CI, 0.9%-3.4%) None assessed
None assessed
• • • • • •
None assessed
• •
BP, blood pressure; CI, confidence interval; emergency department; ICU, intensive care unit; OR, odds ratio.
12% developed phlebitis
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characteristics, presence of other illness, provider-stated intention to treat, or convenience reasons. Although few studies have assessed barriers to IC removal, the themes of convenience for health care workers and the “just in case” approach that impedes prompt removal of ICs are major barriers that must be addressed to reduce idle catheter prevalence. Even among the 4 prospective studies, which provide longitudinal assessment, only 2 made such assessments and found increased infection rates. One possible reason for idle catheters may be ambiguity regarding indications for particular types of ICs and perceived risk of complications. A recent publication on indications for ICs provides valuable data in this regard by using a consensus-building approach to generate appropriate indications for IC use in a multitude of different settings.30 Furthermore, the recent Choosing Wisely initiative31 emphasizes the importance of reducing unnecessary procedures and practices to optimize patient care. Idle ICs clearly fall within the category of unnecessary procedures. This is an opportune time to capitalize on the momentum generated by Choosing Wisely as well as the increased scrutiny by regulatory agencies and clinical medicine societies on IC-related complications. The results of this review should be interpreted in the context of its limitations. Due to recent intensive efforts for the prevention of central line-associated bloodstream infection, we hypothesized that recent literature would be most relevant and limited our studies to the past 10 years. Our literature search was limited to English-language articles only. The heterogeneity in the study design, measures, and populations precluded a meta-analysis. Publication bias also is a concern. We attempted to undertake a comprehensive search to identify all relevant articles but did not include abstracts or gray literature, which may have influenced the findings. Furthermore, whereas sicker patients are more likely to report higher prevalence of devices, and thus could influence the prevalence rates noted in our study findings, the practice of unused devices, especially among such ill patients, should not be prevalent; thus, our study further demonstrates the need for vigilance in ensuring efficacy in device use among at-risk patients. CONCLUSIONS This integrative review highlights several key areas of inquiry that should be addressed in future studies. Prospective interventional studies with uniform definitions of idle catheters and rigorous assessment of patient outcomes, such as infectious complications, coupled with a deeper understanding of the barriers to IC removal are essential. References 1. Cheung E, Baerlocher MO, Asch M, Myers A. Venous access. Can Fam Physician 2009;55:494-6. 2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33. doi:10.1056/NEJMra011883. 3. American College of Surgeons. Revised statement on recommendations for use of real-time ultrasound guidance for placement of central venous catheters. American College of Surgeons; 2011. Available from: https://www.facs.org/ about-acs/statements/60-real-time-ultrasound#note1. Accessed September 9, 2015. 4. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:S89-107. 5. Chopra V, O’Horo JC, Rogers MAM, Maki DG, Safdar N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013;34:908-18. doi:10.1086/671737. 6. Yamashita S, Noma K, Kuwata G, Miyoshi K, Honaga K. Infective endocarditis at the tricuspid valve following central venous catheterization. J Anesth 2005;19:84-7. doi:10.1007/s00540-004-0284-y.
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Jeffries HE, Mason W, Brewer M, Oakes KL, Muñoz EI, Gornick W, et al. Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units a performance improvement collaborative. Infect Control Hosp Epidemiol 2009;30:645-51. doi:10.1086/599166. 30. Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method Michigan appropriateness guide for intravenous catheters (MAGIC). Ann Intern Med 2015;163(6 Suppl):S1-40. doi:10.7326/M15-0744. 31. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA 2012;307:1801-2. doi:10.1001/jama.2012.476.