Factors associated with peripheral intravenous cannulation first-time insertion success in the emergency department. A multicentre prospective cohort analysis of patient, clinician and product characteristics.

OBJECTIVES: This study aimed to identify the incidence of and factors associated with peripheral intravenous catheter/cannula (PIVC) first time insertion success (FTIS) in the emergency department (ED). DESIGN: Prospective cohort study. SETTING: Two tertiary EDs in Western Australia. PARTICIPANTS: 879 ED patients. PRIMARY OUTCOME: To identify factors affecting FTIS using univariate and multivariate logistic regression modelling. We created four models: patient factors only; clinician factors only; products and technology factors only and all factors model. We assessed each model's performance using area under the receiver operating characteristic curve. RESULTS: A total of 1201 PIVCs were inserted in 879 patients. The mean age was 60.3 (SD 22) years with slightly more females (52%). The FTIS rate was 73%, with 128 (15%) requiring a second attempt and 83 (9%) requiring three or more attempts. A small percentage (3%) had no recorded number of subsequent attempts. FTIS was related to the following patient factors: age (for a 1-year increase in age: OR 0.99, 95% CI 0.983 to 0.998; p=0.0097); and target vein palpability: (always palpable vs never palpable: OR 3.53 95% CI 1.64 to 7.60; only palpable with tourniquet vs never palpable: OR 2.20, 95% CI 1.06 to 4.57; p=0.0014). Clinician factors related to FTIS include: clinicians with greater confidence (p<0.0001) and insertion experience (301-1000 vs <301: OR 1.54, 95% CI 1.02 to 2.34; >1000 vs <301: OR 2.07, 95% CI 1.41 to 3.04; p=0.0011). The final all factors model combining patient factors; clinician factors and product and technology factors has greater discriminative ability than specific factors models. It has a sensitivity of 74.26%, specificity of 57.69%, positive predictive value of 82.87% and negative predictive value of 44.85%. CONCLUSION: A clinical decision, matching patients who have no palpable veins and are older, with clinicians with greater confidence and experience, will likely improve FTIS. TRIALREGISTRATION NUMBER: ANZCTRN12615000588594; Results.

Derivation of a clinical decision-making aid to improve the insertion of clinically indicated peripheral intravenous catheters and promote vessel health preservation. An observational study.

BACKGROUND: It is well established that the idle peripheral intravenous catheter (PIVC) provides no therapeutic value and is a clinical, economic and above all, patient concern. This study aimed to develop a decision aid to assist with clinical decision making to promote clinically indicated peripheral intravenous catheter (CIPIVC) insertion in the emergency department (ED) setting. Providing evidence for a uniform process could assist clinicians in a decision-making process for PIVC insertion. This could enable patients receive appropriate vascular access healthcare. METHODS: We performed a secondary analysis of data from a multicentre cohort of emergency department clinicians who performed PIVC insertion. We defined CIPIVC a priori as one used for a specific clinical treatment and or procedure such as prescribed intravenous (IV) fluids; prescribed IV medication; or IV contrast (for computerized tomography scans). We sought to refute or validate an assumption if the clinician performing or requesting the insertion decided the patient was >80% likely to need a PIVC. Using logistic regression, we derived a decision aid for CIPIVCs. RESULTS: In 817 patients undergoing PIVC insertion, we observed 68% of these to be CIPIVCs. Admitted patients were significantly more likely to have a CIPIVC, Odds Ratio (OR) = 3.05, 95% confidence interval (CI) = 2.17-4.30, p = <0.0001. Before insertion, patients who definitely needed IV fluids/medicines OR = 3.30, 95% CI = 2.02-5.39, p = <0.0001 and who definitely needed a contrast scan OR = 3.04, 95% CI = 1.15-8.03, p = 0.0250 were significantly more likely to have a device inserted for a clinical indication. Patients who presented with an existing vascular access device were more likely to have a new CIPIVC inserted for use OR = 4.35, 95% CI = 1.58-11.95, p = 0.0043. The clinician's pre-procedural judgment of the likelihood of therapeutic use >80% was independently associated with CIPIVC; OR 3.16, 95% CI = 2.06-4.87, p<0.0001. The area under the receiver operating characteristic curve was 0.81, and at the best cut-off, the model had a specificity of 0.81, sensitivity of 0.71, a positive predictive value of 0.89 and negative predictive value of 0.57. CONCLUSIONS: Using the derived decision aid, clinicians could ask:- "Does this patient need A-PIVC?" Clinicians can decide to insert a CIPIVCs when: (i) Admission to hospital is anticipated and when (ii) a Procedure requires a PIVC, e.g., computerised tomography scans and where an existing suitable vascular access device is not present and or; (iii) there is an indication for IV fluids and or medicines that cannot be tolerated enterally and are suitable for dilution in peripheral veins; and, (iv) the Clinician's perceived likelihood of use is greater than 80%.

From insertion to removal: A multicenter survival analysis of an admitted cohort with peripheral intravenous catheters inserted in the emergency department.

BACKGROUND: Most patients admitted to the hospital via the emergency department (ED) do so with a peripheral intravenous catheter/cannula (PIVC). Many PIVCs develop postinsertion failure (PIF). OBJECTIVE: To determine the independent factors predicting PIF after PIVC insertion in the ED. METHODS: We analyzed data from a prospective clinical cohort study of ED-inserted PIVCs admitted to the hospital wards. Independent predictors of PIF were identified using Cox proportional hazards regression modeling. RESULTS: In 391 patients admitted from 2 EDs, the rate of PIF was 31% (n=118). The types of PIF identified were infiltration, occlusion, pain and/or peripheral intravenous assessment score >2 (ie, the hospital's assessment of PIVC phlebitis), and dislodgement (ie, accidental securement device failure or purposeful removal). Of the PIVCs that failed, infiltration and occlusion combined were the most common causes of PIF (n=55, 47%). The median PIVC dwell time was 28.5 hours (interquartile range [IQR], 17.4-50.8 hours). The following variables were associated with increased risk of PIF: being an older patient (for a 1-year increase, hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P=.0001); having an Australian Triage Scale score of 1 or 2 compared to a score of 3, 4, or 5 (HR, 2.04; 95% CI, 1.39-3.01; P=.0003); having an ultrasound-guided PIVC (HR, 6.52; 95% CI, 2.11-20.1; P=.0011); having the PIVC inserted by a medical student (P=.0095); infection prevention breaches at insertion (P=.0326); and PIVC inserted in the ante cubital fossa or the back of hand compared to the upper arm (P=.0337). CONCLUSION: PIF remains at an unacceptable level in both traditionally inserted and ultrasound-inserted PIVCs.Clinical trial registrationAustralian and New Zealand Trials Registry (ANZCTRN12615000588594).

Vascular access specialist teams for device insertion and prevention of failure.

BACKGROUND: Most people admitted to hospitals worldwide require a vascular access device (VAD). Hundreds of millions of VADs are inserted annually in the USA with reports of over a billion peripheral intravenous catheters used annually worldwide. Numerous reports suggest that a team approach for the assessment, insertion, and maintenance of VADs improves clinical outcomes, the patient experience, and healthcare processes. OBJECTIVES: To compare the use of the vascular access specialist team (VAST) for VAD insertion and care to a generalist model approach for hospital or community participants requiring a VAD in terms of insertion success, device failure, and cost-effectiveness. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1); Ovid MEDLINE (1950 to 7 February 2018); Ovid Embase (1980 to 7 February 2018); EBSCO CINAHL (1982 to 7 February 2018); Web of Science Conference Proceedings Citation Index - Science and Social Science and Humanities (1990 to 7 February 2018); and Google Scholar. We searched the following trial registries: Australian and New Zealand Clinical Trials Register (www.anzctr.org.au); ClinicalTrials.gov (www.clinicaltrials.gov); Current Controlled Trials (www.controlled-trials.com/mrct); HKU Clinical Trials Registry (www.hkclinicaltrials.com); Clinical Trials Registry - India (ctri.nic.in/Clinicaltrials/login.php); UK Clinical Trials Gateway (www.controlled-trials.com/ukctr/); and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (www.who.int/trialsearch). We searched all databases on 7 February 2018. SELECTION CRITERIA: We planned to include randomized controlled trials (RCTs) that evaluated the effectiveness of VAST or specialist inserters for their impact on clinical outcomes. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane and used Covidence software to assist with file management. MAIN RESULTS: We retrieved 2398 citations: 30 studies were eligible for further examination of their full text, and we found one registered clinical trial in progress. No studies could be included in the analysis or review. We assigned one study as awaiting classification, as it has not been accepted for publication. AUTHORS' CONCLUSIONS: This systematic review failed to locate relevant published RCTs to support or refute the assertion that vascular access specialist teams are superior to the generalist model. A vascular access specialist team has advanced knowledge with regard to insertion techniques, clinical care, and management of vascular access devices, whereas a generalist model comprises nurses, doctors, or other designated healthcare professionals in the healthcare facility who may have less advanced insertion techniques and who care for vascular access devices amongst other competing clinical tasks. However, this conclusion may change once the one study awaiting classification and one ongoing study are published. There is a need for good-quality RCTs to evaluate the efficacy of a vascular access specialist team approach for vascular access device insertion and care for the prevention of failure.

Tools, Clinical Prediction Rules, and Algorithms for the Insertion of Peripheral Intravenous Catheters in Adult Hospitalized Patients: A Systematic Scoping Review of Literature.

BACKGROUND: First-time peripheral intravenous catheter (PIVC) insertion success is dependent on patient, clinician, and product factors. Failed PIVC insertion are an under-recognized clinical phenomenon. OBJECTIVE: To provide a scoping review of decision aids for PIVC insertion including tools, clinical prediction rules, and algorithms (TRAs) and their findings on factors associated with insertion success. METHODS: In June 2016, a systematic literature search was performed using the medical subject heading of peripheral catheterization and tool* or rule* or algorithm*. Data extraction included clinician, patient, and/or product variables associated with PIVC insertion success. Information about TRA reliability, validity, responsiveness, and utility was also extracted. RESULTS: We screened 36 studies, and included 13 for review. Seven papers reported insertion success ranging from 61%-90% (4030 insertion attempts), 6 on validity, and 5 on reliability, with none reporting on responsiveness and utility. Failed insertions were associated with obesity (odds ratio [OR], 0.71-1.7; 2 studies) and smaller gauge PIVCs (OR, 6.4; 95% Confidence Interval [CI}, 3.4-11.9). Successful inser tions were associated with visible veins (OR, 0.87-3.63; 3 studies) or palpable veins (OR, 0.79-5.05; 3 studies) and inserters with greater procedural volume (OR, 4.4; 95% CI, 1.6-12.1) or who predicted that insertion would be successful (OR, 1.06; 95% CI, 1.04-1.07). Definitions of insertion difficulty are heterogeneous such as time to insert to a number of failed attempts. CONCLUSIONS: Few well-validated reliable TRAs exist for PIVC insertion. Patients would benefit from a validated, clinically pragmatic TRA that matches insertion difficulty with clinician competency.

Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review.

OBJECTIVES: To compare the available dressing and securement devices for central venous access devices (CVADs). DESIGN: Systematic review of randomised controlled trials. DATA SOURCES: Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews and of Effects, NHS Economic Evaluation Database, Ovid MEDLINE, CINAHL, EMBASE, clinical trial registries and reference lists of identified trials. REVIEW METHODS: Studies evaluated the effects of dressing and securement devices for CVADs. All types of CVADs were included. Outcome measures were CVAD-related bloodstream infection, CVAD tip colonisation, entry and exit site infection, skin colonisation, skin irritation, failed CVAD securement, dressing condition and mortality. We used standard methodological approaches as expected by The Cochrane Collaboration. RESULTS: We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. It is unclear whether there is a difference in the rate of CVAD-related bloodstream infection between securement with gauze and tape and standard polyurethane (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated dressings and standard polyurethane (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93). There is moderate quality evidence that chlorhexidine gluconate-impregnated dressings reduce the frequency of CVAD-related bloodstream infection per 1000 patient days compared with standard polyurethane dressings (RR 0.51, 95% CI 0.33 to 0.78). There is moderate quality evidence that catheter tip colonisation is reduced with chlorhexidine gluconate-impregnated dressings compared with standard polyurethane dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and standard polyurethane are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). CONCLUSIONS: Medication-impregnated dressing products reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types. There is some evidence that chlorhexidine gluconate-impregnated dressings, relative to standard polyurethane dressings, reduce CVAD-related bloodstream infection for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of CVAD-related bloodstream infection. Most studies were conducted in intensive care unit settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVADs.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol.

INTRODUCTION: Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency. METHODS AND ANALYSIS: We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule. ETHICS AND DISSEMINATION: The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used. TRIAL REGISTRATION NUMBER: ACTRN12615000588594; Pre-results.

In ICU state anxiety is not associated with posttraumatic stress symptoms over six months after ICU discharge: A prospective study.

BACKGROUND: Posttraumatic stress symptoms are common after intensive care treatment. The influence of anxiety during critical illness on the development of posttraumatic stress symptoms needs to be investigated. OBJECTIVE: To determine the association between anxiety during critical illness (state and trait components) and posttraumatic stress symptoms over six months after ICU discharge. METHODS: Prospective study including 141 patients admitted ≥24h to a closed mixed adult ICU in a tertiary hospital. State anxiety was assessed with the Faces Anxiety Scale during ICU stay. Trait anxiety was measured with the State-Trait Anxiety Inventory Form Y-2. Posttraumatic stress symptoms were measured at three and six months after ICU discharge using the Post-Traumatic Stress Symptoms 10-Question Inventory. Clinical and demographical data were also collected. Mixed effect regression models were used to determine if state and trait anxiety were factors significantly associated with posttraumatic stress symptoms over time. RESULTS: Moderate to severe levels of state anxiety in ICU were reported by 81 (57%) participants. Levels of trait anxiety (median 36 IQR: 29-47) were similar to the Australian population. High levels of posttraumatic stress symptoms occurred at three (n=19, 19%) and six months (n=15, 17%). Factors independently associated with posttraumatic stress symptoms were trait anxiety (2.2; 95% CI, 0.3-4.1; p=0.02), symptoms of anxiety after ICU discharge (0.6; 95% CI, 0.2-1.1; p=0.005), younger age (-1.4; 95% CI, -2.6 to -0.2; p=0.02) and evidence of mental health treatment prior to the ICU admission (5.2; 95% CI, 1.5-8.9; p=0.006). CONCLUSIONS: Posttraumatic stress symptoms occurred in a significant proportion of ICU survivors and were significantly associated with higher levels of trait anxiety, younger age, mental health treatment prior to the ICU admission and more symptoms of anxiety after ICU discharge. Early assessment and interventions directed to reduce state and trait anxiety in ICU survivors may be of benefit.

Trait Anxiety But Not State Anxiety During Critical Illness Was Associated With Anxiety and Depression Over 6 Months After ICU.

OBJECTIVE: To determine the association between anxiety during critical illness and symptoms of anxiety and depression over 6 months after ICU discharge in survivors of intensive care treatment. DESIGN: Longitudinal study. SETTING: One closed mixed ICU in an adult tertiary hospital in Brisbane, Australia. PATIENTS: Participants (n = 141) were adults (≥ 8 yr), admitted to ICU for at least 24 hours, able to communicate either verbally or nonverbally, understand English, and open their eyes spontaneously or in response to voice. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The outcomes of symptoms of anxiety and depression over 6 months after ICU discharge were assessed using the Hospital Anxiety Depression Scale. The primary variable of interest was anxiety during critical illness. Two components of anxiety (state and trait) were assessed during critical illness using the Faces Anxiety Scale and the trait component of the State-Trait Anxiety Inventory. Perceived social support, cognitive functioning, and posttraumatic stress symptoms were also assessed using standardized instruments. Clinical and demographic data were obtained from patients and medical records. Participants were followed up in hospital wards and at 3 and 6 months after ICU discharge. During ICU treatment, 81 of the 141 participants (57%) reported moderate to severe levels of state anxiety. Of the 92 participants who completed the surveys at the 6-month follow-up, 26 participants (28%) reported symptoms of anxiety and 21 (23%) symptoms of depression. Symptoms of anxiety and depression were strongly correlated in this cohort of survivors. Trait anxiety was significantly associated with both anxiety and depression symptoms over time; however, state anxiety was not associated with either outcome. Participants who reported post-ICU memories of intra-ICU anxiety were significantly more anxious during recovery over 6 months. Cognitive functioning and posttraumatic stress symptoms were both significantly associated with anxiety and depression symptoms over time. CONCLUSION: Symptoms of anxiety and depression are a significant issue for general ICU survivors. Trait anxiety was significantly associated with adverse emotional outcomes over 6 months after ICU discharge. There was also a significant relationship between post-ICU memories of intra-ICU anxiety and anxiety during recovery. Interventions to reduce anxiety during critical illness need to be considered and evaluated for their longer term benefits for survivors of critical illness.

Insertion of peripheral intravenous cannulae in the Emergency Department: factors associated with first-time insertion success.

BACKGROUND: We sought to identify the reasons for peripheral intravenous cannulae insertion in the emergency department (ED), and the first-time insertion success rate, along with patient and clinician factors influencing this phenomenon. METHODS: A prospective cohort study of patients requiring peripheral cannulae insertion in a tertiary ED. Clinical and clinician data were obtained. RESULTS: A total 734 peripheral intravenous cannula (PIVC) insertions were included in the study where 460 insertions were analysed. The first-time insertion success incidence was 86%. The antecubital fossa (ACF) site accounted for over 50% of insertions. Multivariate logistic regression modelling to predict first-time insertion success for patient factors found: age <40 versus 80+ years, emaciated versus normal patient size, having a visible or palpable vein/s, and ACF versus forearm insertion site to be statistically significant. Statistically significant clinician factors predicting success were: higher number of prior cannulation procedures performed, and increased clinician perception of the likelihood of a successful insertion. When patient and clinician factors were combined in a logistic regression model, emaciated versus normal, visible vein/s, ACF versus forearm site, higher number of prior PIVC procedures performed and increased clinician perceived likelihood of success were statistically associated with first-time insertion success. CONCLUSIONS: Peripheral intravenous cannulation insertion success could be improved if performed by clinicians with greater procedural experience and increased perception of the likelihood of success. Some patient factors predict cannulation success: 'normal' body weight, visible vein/s and cubital fossa placement; venepuncture may be a cheaper alternative for others if intravenous therapy is not imperative.

Dressings and securement devices for central venous catheters (CVC).

BACKGROUND: Central venous catheters (CVCs) play a vital role in the management of acute and chronic illness. Dressings and securement devices must ensure CVCs do not dislodge or fall out, provide a barrier protection from microbial colonisation and infection, and be comfortable for the patient. There is a large range of dressing and securement products available for clinicians to use. OBJECTIVES: To compare the available dressing and securement devices for CVCs, in terms of catheter-related bloodstream infection (BSI), catheter colonisation, entry- and exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing condition and mortality. SEARCH METHODS: In June 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); The Database of Abstracts of Reviews of Effects (DARE); NHS Economic Evaluation Database (NHSEED); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; six clinical trial registries and reference lists of identified trials. There were no restrictions based on language or date of publication or study setting. SELECTION CRITERIA: We included randomised controlled trials that evaluated the effects of dressing and securement devices for CVCs. All types of CVCs were included, i.e. short- and long-term CVCs, tunnelled and non-tunnelled, port-a-caths, haemodialysis catheters, and peripherally-inserted central catheters (PICCs). DATA COLLECTION AND ANALYSIS: We used standard Cochrane Collaboration methods including independent review of titles and abstracts for relevance, data extraction, and risk of bias assessment of the included studies by two review authors. Results are expressed using risk ratio (RR) for categorical data with 95% confidence intervals (CIs). For outcomes best presented as a rate-per-time-period, rate ratios and standard errors have been used. We performed multiple treatment meta-analyses to rank the effectiveness of each intervention for each outcome. MAIN RESULTS: We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. The extent of blinding of outcome assessment was unclear in most studies. The quality of evidence varied between different comparisons and outcomes. We mainly downgraded the quality of evidence for imprecision, indirectness, risk of bias and inconsistency.It is unclear whether there is a difference in the rate of catheter-related BSI between securement with gauze and tape and standard polyurethane (SPU) (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated (CGI) dressings and SPU (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of catheter-related BSI relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93).There is moderate quality evidence that CGI dressings reduce the frequency of catheter-related BSI per 1000 patient days compared with SPU dressings (RR 0.51, 95% CI 0.33 to 0.78).There is moderate quality evidence that catheter tip colonisation is reduced with CGI dressings compared with SPU dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and SPU are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). It is unclear if there is a difference in rates of skin irritation or damage when CGI dressings are compared with SPU dressings (moderate quality evidence) (RR 11.17, 95% CI 0.84 to 149.48).A multiple treatment meta-analysis found sutureless securement devices as likely to be the most effective at reducing the incidence of catheter-related BSI (low quality evidence), with CGI dressings ranked second (low quality evidence). AUTHORS' CONCLUSIONS: Medication-impregnated dressing products reduce the incidence of catheter-related BSI relative to all other dressing types. There is some evidence that CGI dressings, relative to SPU dressings, reduce catheter-related BSI for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of catheter-related BSI. A multiple treatment meta-analysis found that sutureless securement devices are likely to be the most effective at reducing catheter-related BSI though this is low quality evidence. Most studies were conducted in intensive care unit (ICU) settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVCs. Future research may adjust the estimates of effect for the products included in this review and is needed to assess the effectiveness of new products.

Optimal timing for intravascular administration set replacement.

BACKGROUND: The tubing (administration set) attached to both venous and arterial catheters may contribute to bacteraemia and other infections. The rate of infection may be increased or decreased by routine replacement of administration sets. This review was originally published in 2005 and was updated in 2012. OBJECTIVES: The objective of this review was to identify any relationship between the frequency with which administration sets are replaced and rates of microbial colonization, infection and death. SEARCH METHODS: We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1950 to June 2012), CINAHL (1982 to June 2012), EMBASE (1980 to June 2012), reference lists of identified trials and bibliographies of published reviews. The original search was performed in February 2004. We also contacted researchers in the field. We applied no language restriction. SELECTION CRITERIA: We included all randomized or controlled clinical trials on the frequency of venous or arterial catheter administration set replacement in hospitalized participants. DATA COLLECTION AND ANALYSIS: Two review authors assessed all potentially relevant studies. We resolved disagreements between the two review authors by discussion with a third review author. We collected data for seven outcomes: catheter-related infection; infusate-related infection; infusate microbial colonization; catheter microbial colonization; all-cause bloodstream infection; mortality; and cost. We pooled results from studies that compared different frequencies of administration set replacement, for instance, we pooled studies that compared replacement ≥ every 96 hours versus every 72 hours with studies that compared replacement ≥ every 48 hours versus every 24 hours. MAIN RESULTS: We identified 26 studies for this updated review, 10 of which we excluded; six did not fulfil the inclusion criteria and four did not report usable data. We extracted data from the remaining 18 references (16 studies) with 5001 participants: study designs included neonate and adult populations, arterial and venous administration sets, parenteral nutrition, lipid emulsions and crystalloid infusions. Most studies were at moderate to high risk of bias or did not adequately describe the methods that they used to minimize bias. All included trials were unable to blind personnel because of the nature of the intervention.No evidence was found for differences in catheter-related or infusate-related bacteraemia or fungaemia with more frequent administration set replacement overall or at any time interval comparison (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.67 to 1.69; RR 0.67, 95% CI 0.27 to 1.70). Infrequent administration set replacement reduced the rate of bloodstream infection (RR 0.73, 95% CI 0.54 to 0.98). No evidence revealed differences in catheter colonization or infusate colonization with more frequent administration set replacement (RR 1.08, 95% CI 0.94 to 1.24; RR 1.15, 95% CI 0.70 to 1.86, respectively). Borderline evidence suggested that infrequent administration set replacement increased the mortality rate only within the neonatal population (RR 1.84, 95% CI 1.00 to 3.36). No evidence revealed interactions between the (lack of) effects of frequency of administration set replacement and the subgroups analysed: parenteral nutrition and/or fat emulsions versus infusates not involving parenteral nutrition or fat emulsions; adult versus neonatal participants; and arterial versus venous catheters. AUTHORS' CONCLUSIONS: Some evidence indicates that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the risk of infection. Other evidence suggests that mortality increased within the neonatal population with infrequent administration set replacement. However, much the evidence obtained was derived from studies of low to moderate quality.

Study protocol: Intensive Care Anxiety and Emotional Recovery (Icare)-a prospective study.

BACKGROUND: Survivors of intensive care units (ICUs) commonly present with symptoms of anxiety, depression and post-traumatic stress disorder (PTSD) during recovery. A number of factors have been identified as predictors of these adverse emotional outcomes, but the role of state anxiety during critical illness in the development of these emotional problems remains unknown. PURPOSE: The Intensive Care Anxiety and Emotional Recovery (ICARe) study protocol proposes the development of a statistical model to determine the relationship between state anxiety during ICU stay and symptoms of anxiety, depression and PTSD at three occasions; after ICU discharge but prior to hospital discharge and at the third and sixth months post ICU discharge. METHODS: Prospective study including adult patients admitted to the ICU of a tertiary metropolitan Australian hospital for ≥24 h who are able to: (1) communicate verbally or nonverbally; (2) understand English and (3) open their eyes spontaneously or in response to voice to respond to the Faces Anxiety Scale (state anxiety assessment). One hundred and seventy patients will be assessed for their levels of state anxiety during their ICU stay to achieve a sample size of about 104 patients six months after discharge. The outcomes of the ICARe study will include symptoms of anxiety, depression and PTSD assessed by standardised questionnaires widely used in intensive care research. Demographic, clinical, and social support information will also be collected. RESULTS: The projected sample size will provide sufficient power to evaluate the association between state anxiety and adverse emotional outcomes, as well as a variety of variables that will be entered into a multivariate regression analysis. CONCLUSION: This study will provide new evidence to improve care during critical illness and reduce adverse outcomes during recovery with the potential to decrease unnecessary suffering, promote comfort and improve long-term recovery.

Information transfer for multi-trauma patients on discharge from the emergency department: mixed-method narrative review.

AIM: This paper is a report of a review conducted to identify (a) best practice in information transfer from the emergency department for multi-trauma patients; (b) conduits and barriers to information transfer in trauma care and related settings; and (c) interventions that have an impact on information communication at handover and beyond. BACKGROUND: Information transfer is integral to effective trauma care, and communication breakdown results in important challenges to this. However, evidence of adequacy of structures and processes to ensure transfer of patient information through the acute phase of trauma care is limited. DATA SOURCES: Papers were sourced from a search of 12 online databases and scanning references from relevant papers for 1990-2009. REVIEW METHODS: The review was conducted according to the University of York's Centre for Reviews and Dissemination guidelines. Studies were included if they concerned issues that influenced information transfer for patients in healthcare settings. RESULTS: Forty-five research papers, four literature reviews and one policy statement were found to be relevant to parts of the topic, but not all of it. The main issues emerging concerned the impact of communication breakdown in some form, and included communication issues within trauma team processes, lack of structure and clarity during handovers including missing, irrelevant and inaccurate information, distractions and poorly documented care. CONCLUSION: Many factors influence information transfer but are poorly identified in relation to trauma care. The measurement of information transfer, which is integral to patient handover, has not been the focus of research to date. Nonetheless, documented patient information is considered evidence of care and a resource that affects continuing care.

A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia.

OBJECTIVES: This study, as part of a larger programme of research, sought to investigate the effect that participation in a 40-min live group music programme, involving facilitated engagement with song-singing and listening, three times a week for eight weeks, had on agitation and anxiety in older people with dementia. METHODS: A randomized cross-over design, with music and reading control groups, was employed. Forty-seven participants with mild-moderate dementia, from two aged care facilities in Queensland, Australia, were recruited. Participants were assessed three times on the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) and the Rating Anxiety in Dementia Scale (RAID). RESULTS: A sub-analysis of 24 participants attending ≥50% of music sessions found a significant increase in the frequency of verbal aggression over time, regardless of group (F(2,46) = 3.534, p < 0.05). A series of multiple regressions found cognitive impairment, length of time living in the facility and gender to be predictors of agitation overall and by subtype. CONCLUSION: Participation in the music programme did not significantly affect agitation and anxiety in older people with dementia. Both the music and reading group activities, however, gave some participants a 'voice' and increased their verbalization behaviour. Agitation was found to be predicted by a number of background factors (namely level of cognitive impairment, length of time in the facility and gender). Future studies would benefit more from in-depth participant assessment prior to study commencement, helping to moderate the influence of low scores, and by undertaking interventions at times when assessed symptoms are most prevalent.