Central venous access device terminologies, complications, and reason for removal in oncology: a scoping review.

BACKGROUND: Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation. METHODS: A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data. RESULTS: From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies (n = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies. CONCLUSION: Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

Assessment of Barriers, Supports, and Context to Implement Best Practice Pain Management in the Emergency Department: The IMPAINED Study.

AIM: To assess the emergency department practice context and identify strategies to improve outcomes of patients with acute pain. BACKGROUND: Effective treatment of acute pain in the emergency department depends upon clinicians adopting pain interventions into practice. However, it is well-recognized that acute pain is often undertreated. The local practice context strongly influences clinicians' adoption of interventions into their clinical practice. An assessment of this practice context can inform implementation interventions and strategies to improve outcomes for patients with acute pain. METHODS: Chart audit, staff survey, and staff working groups were conducted from June 2020 to May 2021 Data were analyzed and synthesized across sources informed by assessment elements of the Ottawa model of research use (OMRU) implementation model and expert recommendations for implementing change strategies. RESULTS: The OMRU facilitated contextual assessment of pain treatment practice in the emergency department and the development of implementation strategies. Adoption of evidence-based pain interventions was low in the sample studied. Workflow and workload were the primary barriers to evidence-based pain practices by potential adopters, while positive beliefs and high awareness of evidence-based pain interventions were supportive factors. Implementation strategies were informed by assessment findings and mapped to the Ottawa model and expert recommendations for implementing change elements. CONCLUSION: The adoption of evidence into practice in the emergency department relies upon a comprehensive assessment of the local context. The use of the OMRU assessment process resulted in meaningful engagement with staff and a deeper understanding of local pain management practices. Clinicians view evidence-based pain management as important, however, there are competing priorities within the emergency department, such as patient flow and triage. This study provides an exemplar of utilizing an implementation framework to identify pain practices within the emergency department. CLINICAL IMPLICATIONS: Achieving impactful change in clinical practice to improve patient outcomes should start with the application of implementation methods that enable comprehensive analysis of the local practice context. The assessment should begin with collaboration with local clinicians that persist throughout the life of the study to ensure change is sustainable.

Implementation frameworks, strategies and outcomes in optimizing central venous access device practice in paediatrics: A scoping review.

Paediatric patients with complex or acute conditions may require a central venous access device, however, almost one-third of these devices have associated complications (e.g. infections). Implementation of evidence-based practices regarding central venous access devices can reduce and potentially prevent complications. AIMS: This scoping review aimed to explore recent interventional research in CVAD management through an implementation lens. DESIGN: This scoping review used the Arksey and O'Malley framework. Studies were included if they were written in English, published in 2012 to July 2023, involved children and were relevant to the study aims. Risk of bias was appraised by the Mixed Methods Appraisal Tool. DATA SOURCES: Searches were undertaken in EMBASE, CINAHL (Ebsco), PubMed, Web of Science and Cochrane Library (CENTRAL). RESULTS: Of the 1769 studies identified in a systematic search, 46 studies were included. Studies mostly focused on health professionals and central venous access device maintenance and had quantitative pre-post study designs. Adherence to implementation frameworks was lacking, with many studies employing quality improvement approaches. Implementation strategies were typically multipronged, using health-professional education, bundles and working groups. Bundle compliance and reductions in central line-associated bloodstream infections were the most featured outcomes, with most studies primarily focusing on effectiveness outcomes. CONCLUSION: Translation of evidence-based practices to the clinical setting is difficult and current adoption of implementation frameworks (apart from 'quality improvement') is limited. Implementation strategies are diverse and dependent on the local context, and study outcomes typically focus on the effectiveness of the physical intervention, rather than measuring the implementation effort itself. IMPLICATIONS FOR PATIENTS: Future intervention research requires a more uniform and deliberate application of implementation frameworks and strategies. IMPACT: Greater exploration of relationships between frameworks and strategies and implementation and service outcomes is required to increase understanding of their role in maximizing resources to improve health care. Adhered to best reporting guidelines as per PRISMA-ScR (Tricco et al., 2018). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Implementation contexts and strategies for alternative peripherally inserted central catheter material and design selection: A qualitative exploration using CFIR/ERIC approach.

AIM: To explore the implementation contexts and strategies that influence the uptake and selection of alternative peripherally inserted central catheter (PICC) materials and design. DESIGN: Qualitative evaluation of end user perspectives within a randomized control trial of different PICC materials and design. METHODS: Semi-structured interviews with key stakeholders were undertaken via an adapted, rapid-analytic approach using the Consolidated Framework for Implementation Research. Outcomes were mapped against the Expert Recommendations for Implementing Change (ERIC) tool for strategies to guide innovation in PICC practice. RESULTS: Participants (n = 23) represented a combination of users and inserters/purchasers, from adult and paediatric settings. Dominant themes included intervention characteristics (intervention source), inner setting (structural characteristics) and individuals involved (self-efficacy). Strategies emerging to support a change from ERIC mapping (n = 16) included promotion of intervention adaptability, inclusion of staff and consumer perspectives and sufficient funding. Implementation contexts such as inner setting and individuals involved equally impacted PICC success and implementation effectiveness and enabled a greater understanding of barriers and facilitators to intervention implementation in this trial. CONCLUSION: Trial evidence is important, but healthcare decision-making requires consideration of local contexts especially resourcing. Implementation contexts for Australian healthcare settings include a practical, strategic toolkit for the implementation of alternative PICC materials and designs. REPORTING METHOD: This study adhered to COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Barriers and facilitators to evidence-based perioperative hypothermia management for orthopaedic patients: A systematic review.

AIM: To assess barriers and facilitators to the implementation of guidelines for the prevention of inadvertent perioperative hypothermia in orthopaedic patients. DESIGN: Systematic review. DATA SOURCES: Nine databases: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, ProQuest Dissertations and Theses, Scopus, Web of Science and Trip Clinical Evidence Database. METHODS: Primary studies published in English between January 2008 to July 2022 were screened. Study selection, quality assessment, and data extraction were completed independently by researchers. Data were extracted using the Consolidated Framework for Implementation Research and mapped to the Expert Recommendations for Implementing Change strategies. RESULTS: Eighty-seven studies were included in the review. The most frequently reported barriers and facilitators related to evidence strength, relative advantage, and cost of implementing perioperative hypothermia prevention guidelines. The top four ERIC strategies were: Identify and prepare champions; Conduct educational meetings; Assess for readiness and identify barriers and facilitators; and Inform local opinion leaders. CONCLUSION: This review provides synthesized evidence regarding barriers and facilitators to perioperative hypothermia guidelines for patients undergoing orthopaedic surgery. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Our work provides theory guided strategies to promote implementation of perioperative hypothermia prevention to assist nurses caring for patients undergoing orthopaedic surgery. IMPACT: Findings provide professionals caring for patients undergoing orthopaedic surgery with theory-informed strategies to improve perioperative hypothermia prevention. Reducing perioperative hypothermia will improve outcomes for patients undergoing orthopaedic surgery. REPORTING METHOD: The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. NO PATIENT OR PUBLIC CONSULTATION: Due to the study design, no patient or public consultation took place.

Long-term outcomes after paediatric sepsis (LOTUS)-A protocol for an Australian cohort study.

BACKGROUND: Globally, sepsis has been identified as one of the leading causes of preventable childhood mortality and morbidity. Previous studies on intensive care patients estimated that approximately 30% of children with sepsis experience some form of disability at discharge. Development of care has seen growing numbers of children treated for sepsis not requiring a PICU admission; however, outcomes in this population are yet to be understood. Further focus is required to understand sepsis survivorship across the wider population to address knowledge gaps and morbidity burden in the broader surviving population. AIMS: To assess the cognitive, physical, emotional and social health of children surviving sepsis 2 years after hospital discharge. STUDY DESIGN: A prospective, observational cohort study. RESULTS: Two hundred and thirty-two children will be screened, 2 years after their hospital admission, and approached for participation in this study. Children who are <18 years of age at follow-up, treated for sepsis-related organ dysfunction or septic shock in Queensland between October 2018 and December 2019, will be included. Children who are deceased at follow-up, under care of the state, or require English interpreters will be excluded from participation. Data will be collected through an online follow-up survey comprising validated caregiver-reported questionnaires covering the four Post Intensive Care Syndrome-paediatrics (PICS-p) domains (cognitive, physical, emotional and social health; Manning et al. Pediatr Crit Care Med, 2018, 19, 298-300). The primary outcome is an adaptive behaviour of the participants assessed using the Vinelands-3 tool. Secondary outcomes will include neurodevelopment, quality of life, child distress, overall function, executive function, caregiver's distress and caregiver's stress. Analysis of variance (ANOVA), Kruskal-Wallis and Fisher's exact test/chi-squared tests will be used for statistical analyses. No adjustments will be made for multiple comparisons but it is acknowledged that comparisons made in this study are exploratory. RELEVANCE TO CLINICAL PRACTICE: With more children surviving sepsis, there is a need for a more comprehensive assessment of patient and family outcomes to allow support structures for families leaving the hospital after sepsis. This study is expected to inform clinicians and stakeholders of patient and family well-being after sepsis survivorship.

Long-term outcomes after paediatric sepsis: A narrative review.

OBJECTIVES: Sepsis is one of the leading causes of mortality in the paediatric population. However, knowledge is limited around morbidity in childhood sepsis survivors. The aim of this review is to identify and critically appraise the evidence for long-term outcomes in paediatric survivors of sepsis using the Post Intensive Care Syndrome - paediatrics (PICS-p) framework. METHODS: A search for studies was undertaken in the electronic databases PubMed and Cumulative Index to Nursing and Allied Health Literature from 2010. Criteria for inclusion are as follows: participants >28 d adjusted age, diagnosed with sepsis, and follow-up after hospital discharge using a validated outcome measure. The PICS-p subdomains (cognitive, physical, emotional, and social) guided thematic synthesis of current literature. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: In total, nine studies, involving 2136 children, using 13 different outcome measures were included in the review. Mean follow-up time was 28 d after hospital discharge with a range of 7 d to 12 m across the PICS-p domains. Physical functioning was the most examined domain explored in six studies that used four outcome measures. Morbidity in physical, cognitive, and emotional domains was still evident at 9-12 m. No literature identified explored social health. CONCLUSION(S): Overall, we identified a wide range of measures, administered at various time points in studies of sepsis survivorship in childhood. Variation in follow-up timepoints, validated tools, and restricted outcome measures highlighted the lack in understanding of this priority area. Furthermore, long-term outcome research and a cohesive understanding across all the PICS-p domains are needed to better understand this population. REGISTRATION: Not registered.

Proactive debriefing to promote wellbeing in intensive care nurses: A protocol.

BACKGROUND: The dynamic, rewarding, yet challenging environment of the intensive care unit is experienced in extremes by intensive care nurses. To ensure intensive care nurses can continue to fulfil their professional roles and responsibilities, careful consideration and promotion of collective and individual wellbeing is required. Regular proactive debriefing provides an opportunity to commune, connect, and reflect on the challenging nature of clinical work and is a potential intervention to aid in the promotion of wellbeing. AIM/OBJECTIVE: This study aims to collaboratively develop, implement, and evaluate a proactive debriefing intervention, which will target the promotion of nurses' wellbeing. STUDY PLAN: This hybrid effectiveness-implementation study will use a pretest/post-test design to test a codesigned proactive debriefing intervention on the wellbeing of nurses working in a large quaternary intensive care unit. This research will be conducted in two phases. Phase one will consist of focus groups and a codesign workshop. Phase two surrounds the implementation and analysis of the codesigned intervention.

Adult pain and anticipatory anxiety assessment in the emergency department: An integrative literature review.

INTRODUCTION: Patients presenting to the emergency departments in pain often experience co-occurring symptoms. Anticipatory anxiety in the emergency department may be currently under-recognised. Clinical tools to facilitate the assessment of co-occurring symptoms aligns with providing more patient centred care and improved outcomes and experience. AIMS: This integrative review aimed to identify and examine the psychometric properties of tools currently used for pain and anticipatory anxiety assessment in adult patients presenting to the emergency department. This study also aimed to identify the current clinical practice used to assess adult pain and anticipatory anxiety. METHODS: Whittemore and Knafl's methodology guided the review process, and it is reported according to relevant items from PRISMA checklist. Studies were included if they focused on tools for pain or anxiety assessment of adults in emergency departments in English language publications since 2010. Quality of studies was evaluated using the Mixed Methods Appraisal Tool (MMAT). The results were summarised through narrative synthesis. RESULTS: A total of 15 studies were identified for narrative synthesis. Six tools for pain, and four tools for anticipative anxiety were found. All currently used clinical tools assess symptoms in isolation. There was limited discussion of the clinical context of identified tools within the included studies. CONCLUSION: Pain and anxiety assessment are currently performed in symptom isolation with a variety of tools with varying degrees of reliability. There exists a lack of clinical tools able to assess co-occurring symptoms of pain and anticipatory anxiety in the clinical setting of the emergency department. No studies discussed clinical tool use in current practice. RELEVANCE TO CLINICAL PRACTICE: The reconstruction of available pain and anxiety assessment tools into one validated and holistic tool for assessment in the ED clinical setting, would provide a contextually appropriate guide to clinical assessment and treatment. Acknowledging and measuring these symptoms may facilitate future rigorous testing of experimental studies of novel methods to reduce pain and anxiety in the ED. NO PATIENT OR PUBLIC CONTRIBUTION: Patient or public contribution does not apply to this Integrative Review. CLINICAL TRIAL REGISTRATION NUMBER: Not applicable.

A scoping review of nurse-led randomised controlled trials.

BACKGROUND: Nurses comprise the largest portion of the healthcare workforce worldwide. However, nurse representation in the leadership of clinical research and research funding is largely unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established to provide a coordinated network, focussed on building research capacity in nursing and midwifery. To support this work, this scoping review of nurse-led randomised controlled trials was conducted to summarise research activity, as well as highlight future research directions, gaps and resources. Midwife-led trials will be reported elsewhere. AIM: To quantify number, type and quality of nurse-led randomised controlled trials registered between 2000-2021. DESIGN: A scoping review of RCTs. DATA SOURCES: Medline, Emcare and Scopus were searched from 2000 to August 2021. ANZCTR, NHMRC, MRFF and HRC (NZ) registries were searched from inception to July 2021. REVIEW METHODS: This review was informed by the JBI scoping review framework using the PRISMA-ScR. RESULTS: Our search yielded 188 nurse-led publications and 279 registered randomised controlled trials. Multiple trials had the same nurse leaders. There were more registrations than publications. Publications were predominantly of high methodological quality; however, there was a reliance on active controls and blinding was low. Trial registrations indicate that universities and hospital/healthcare organisations were the major sources of funding, while publications indicate that Governments and the National Health and Medical Research Council were the main funding bodies. CONCLUSION: A small number of high-quality, large-scale, nationally funded randomised controlled trials were identified, with a larger number of locally funded small trials. There was a disparity between the number of registered trials and those published. Additional infrastructure, funding and career frameworks are needed to enable nurses to design, conduct and publish clinical trials that inform the health system and improve health outcomes. RELEVANCE TO CLINICAL PRACTICE: Research initiated and led by nurses has the potential to improve the health and well-being of individuals and communities, and current nurse-led research is of high methodological quality; however, there were very few nurse-led RCTs, conducted by a small pool of nurse researchers. This gap highlights the need for support in the design, conduct and publishing of nurse-led RCTs. PATIENT OR PUBLIC CONTRIBUTION: This is a scoping review; therefore, patient or public contribution is not applicable.

Implementation frameworks, strategies and outcomes used in peripheral intravenous catheter studies: A systematic review.

AIMS: The aim of this study was to critically evaluate implementation frameworks, strategies and/or outcomes used to optimise peripheral intravenous catheter (PIVC) care and/or promote guideline adherence. BACKGROUND: Although a considerable volume of research has investigated the effectiveness of PIVC interventions and treatments to promote performance and prevent harm, how to best implement this evidence into dynamic clinical settings and populations is not well understood. Implementation science is central to translating evidence-based knowledge to the bedside; however, there is a gap in identifying the best implementation framework, strategies and/or outcomes to optimise PIVC care and/or guideline adherence. DESIGN: A systematic review. METHOD: The review was conducted using innovative automation tools. Five databases and clinical trial registries were searched on 14 October 2021. Qualitative and quantitative PIVC intervention studies reporting implementation strategies were included in the review. Data were extracted independently by experienced researchers in pairs. The Mixed Method Appraisal tool was used to assess the quality of individual studies. Narrative synthesis was used to present the findings. The systematic review was reported following the PRISMA checklist. RESULTS: Of 2189 references identified, 27 studies were included in the review. Implementation frameworks were used in 30% (n = 8) of studies, with most used during the preparation (n = 7, 26%) and delivery phase (n = 7, 26%) and then evaluation phase (n = 4, 15%). Multifaceted strategies were commonly adopted (n = 24, 89%) to promote PIVC care or study interventions which were clinician (n = 25, 93%) and patient-targeted (n = 15, 56%). The most commonly reported implementation outcomes were fidelity (n = 13, 48%) and adoption (n = 6, 22%). Most studies were scored as low quality (n = 18, 67%). CONCLUSION: We call for researchers and clinicians to work together and use implementation science frameworks to guide study design, implementation and evaluation in future PIVC studies, to improve evidence translation and thereby improve patient outcomes.

Controlling peripheral intravenous catheter failure by needleless connector design: A pilot randomised controlled trial.

AIM: To test the feasibility of a study protocol that compared the efficacy of neutral- and negative-pressure needleless connectors (NCs). DESIGN: A single-centre, parallel-group, pilot randomised control trial. METHODS: Our study compared neutral-(intervention) and negative-pressure (control) NCs among adult patients in an Australian hospital. The primary feasibility outcome was measured against predetermined criteria (e.g. eligibility, attrition). The primary efficacy outcome was all-cause peripheral intravenous catheter failure, analysed as time-to-event data. RESULTS: In total, 201 (100 control; 101 intervention) participants were enrolled between March 2020 and September 2020. All feasibility criteria were met except eligibility, which was lower (78%) than the 90% criterion. All-cause peripheral intravenous catheter failure was significantly higher in the intervention group (39%) compared to control (19%). CONCLUSION: With minor modifications to participant screening for eligibility, this randomised control trial is feasible for a large multicentre randomised control trial. The neutral NC was associated with an increased risk of peripheral intravenous catheter failure. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: There are several NC designs available, often identified by their mechanism of pressure (positive, negative and neutral). However, NCs can contribute to peripheral intravenous catheter failure. This is the first randomised controlled trial to compare neutral and negative NC designs. Negative pressure NCs had lower PIVC failure compared to neutral NCs, however the results might not be generalisable to other brands or treatment settings. Further high-quality research is needed to explore NC design. REPORTING METHOD: Study methods and results reported in adherence to the CONSORT Statement. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Peripheral intravenous catheter insertion, maintenance and outcomes in Indonesian paediatric hospital settings: A point prevalence study.

PURPOSE: This study aimed to assess peripheral intravenous catheter use, maintenance practices, and outcomes of paediatric patients in a developing country setting. DESIGN AND METHODS: A point prevalence survey using validated checklist was conducted between March and April 2022 in ten hospitals in Indonesia. A total number of 478 participants were approached during the audit. Data were obtained from site observation and medical records. RESULTS: Of the 386 patients surveyed, >90% (362) had one catheter in-situ. The catheters were mostly inserted by nurses (331, 86%), primarily in the dorsum of the hand (207, 54%) with the purpose of delivering intravenous infusions and medications (367, 95%). Simple transparent dressings (176, 46%) with splint and bandage (295, 76%) were predominantly used for securement methods. Insertion sites were not visible for 182 (47%) patients, and 151 (40%) of daily care practices were poorly documented. Complications were documented in the medical record for 166 (43%) catheters. Adjusted analysis indicated that patient diagnosis, ward, catheter size, location, dressings, infusate, and flushing administration were significantly associated with complications. CONCLUSIONS: Findings indicate that issues related to paediatric intravenous catheter complications in Indonesia are comparable to developed country settings. Ongoing surveillance is important to evaluate the management practices to benchmark against guidelines, optimise patient safety, and improve outcomes. PRACTICE IMPLICATIONS: Results demonstrate low and middle-income countries face similar challenges with catheter insertion and care. The study indicates the importance of applying vascular access needs assessments, providing training for inserters, identifying optimum dressing methods, and optimising documentation.

The relationship between practice environment, job satisfaction and intention to leave in critical care nurses.

BACKGROUND: Recent studies in the Kingdom of Saudi Arabia (KSA) have shown that the increasing nursing turnover in the health care industry has become a great source of concern. The overdependence on the supply of expatriate nurses (74%) and coronavirus disease 2019 (COVID-19) travel restrictions have exacerbated this staffing issue. AIMS: To examine the relationship between perception of nursing practice environment (NPE), job satisfaction and intention to leave (ITL) among critical care nurses working in the state of Ha'il in KSA. DESIGN: Cross-sectional correlational (observational) design. METHODS: Data were collected via electronic online survey distributed to registered critical care nurses working in King Khalid Hospital (KKH), Ha'il, KSA, between July and August 2020. Participant demographics and key variables data related to NPE, job satisfaction and ITL respectively were collected from the participants using existing and validated questionnaires. Descriptive statistics and correlational analysis and multivariable analyses were conducted. RESULTS: A response rate of 98% was achieved (152/160) for the study. Findings showed that the NPE was largely favourable (M = 2.89, SD = 0.44); however, nurse participation in hospital affairs (M = 2.83, SD = 0.47) and staffing and resource adequacy (M = 2.88, SD = 0.47) scored lowest. NPE was found to be significantly correlated with job satisfaction (rs = .287, P < .01). A significant negative relationship was found between NPE and ITL (rs = -0.277**, P < .01). However, job satisfaction was associated with ITL (rs = -.007, P = .930). CONCLUSIONS: Maintaining a healthy work environment and job satisfaction levels in critical care units is key to improving, recruitment and retention of nursing staff. RELEVANCE TO CLINICAL PRACTICE: Critical care and hospital leaders should implement programs that enhance the quality of the practice environment. This will improve nurse participation in unit and hospital affairs, job satisfaction and intention to stay.

What blood conservation practices are effective at reducing blood sampling volumes and other clinical sequelae in intensive care? A systematic review.

OBJECTIVES: The objective of this study was to critically appraise and synthesise evidence for blood conservation strategies in intensive care. Blood sampling is a critical aspect of intensive care to guide clinical decision-making. Repeated blood sampling can result in blood waste and contamination, leading to iatrogenic anaemia and systemic infection. REVIEW METHOD USED: Cochrane systematic review methods were used including meta-analysis, and independent reviewers. DATA SOURCES: A systematic search was conducted in Medline, CINAHL, PUBMED and EMBASE databases. The search was limited to randomised controlled trials (RCTs) and cluster RCTs, published in English between 2000 and 2021. REVIEW METHODS: Paired authors independently assessed database search results and identified eligible studies. Trials comparing any blood conservation practice or product in intensive care were included. Primary outcomes were blood sample volumes and haemoglobin change. Secondary outcomes included proportion of patients receiving transfusions and infection outcomes. Quality appraisal employed the Cochrane Risk of Bias tool. Meta-analysis using random effects approach and narrative synthesis summarised findings. RESULTS: Eight studies (n = 1027 patients), all RCTs were eligible. Six studies included adults, one studied paediatrics and one studied preterm infants. Seven studies evaluated a closed loop blood sampling system, and one studied a conservative phlebotomy protocol. Studies were of low to moderate quality. Meta-analysis was not possible for interventions targeting blood sample volumes or haemoglobin. Decreased blood sample volumes reported in four studies were attributable to a closed loop system or conservative phlebotomy. No study reported a significant change in haemoglobin. Meta-analysis demonstrated that use of a closed system (compared to open system) reduced the proportion of patients receiving transfusion [Risk Ratio (RR) 0.65, 95% CI 0.46-0.92; 287 patients] and reduced intraluminal fluid colonisation [RR 0.25, 95% CI 0.07-0.58; 500 patients]. CONCLUSIONS: Limited evidence demonstrates closed loop blood sampling systems reduced transfusion use and fluid colonisation. Simultaneous effectiveness-implementation evaluation of these systems and blood conservation strategies is urgently required. PROSPERO PROTOCOL REGISTRATION REFERENCE: CRD42019137227.

Patient blood management in critically ill children undergoing cardiac surgery: A cohort study.

OBJECTIVE: The objective of this study was to audit current patient blood management practice in children throughout cardiac surgery and paediatric intensive care unit (PICU) admission. DESIGN: This was a prospective observational cohort study. SETTING: This was a single-centre study in the cardiac operating room (OR) and PICU in a major tertiary children's hospital in Australia. PATIENTS: Children undergoing corrective cardiac surgery and requiring admission to PICU for postoperative recovery were included in the study. MEASUREMENTS AND MAIN RESULTS: Fifty-six patients and 1779 blood sampling episodes were audited over a 7-month period. The median age was 9 months (interquartile range [IQR] = 1-102), with the majority (n = 30 [54%]) younger than 12 months. The median number of blood sampling episodes per patient per day was 6.6 (IQR = 5.8-8.0) in total, with a median of 5.0 (IQR = 4.0-7.5) episodes in the OR and 5.0 (IQR = 3.4-6.2) episodes per day throughout PICU admission. The most common reason for blood tests across both OR and PICU settings was arterial blood gas analysis (total median = 86%, IQR = 79-96). The overall median blood sampling volume per kg of bodyweight, patient, and day was 0.63 mL (IQR = 0.20-1.14) in total. Median blood loss for each patient was 3.5 mL/kg per patient per day (IQR = 1.7-5.6) with negligible amounts in the OR and a median of 3.6 mL/kg (IQR = 1.7-5.7) in the PICU. The median Cell Saver® transfusion volume was 9.9 mL/kg per patient per day (IQR = 4.0-19.1) in the OR. The overall median volume of other infusion products (albumin 4%, albumin 20%, packed red blood cells) received by each patient was 20.1 mL/kg (IQR = 10.7-36.4) per day. Sampling events and blood loss were positively associated with PICU stay. CONCLUSIONS: Patient blood management practices observed in this study largely conform to National Blood Authority guidelines. Further implementation projects and research are needed to accelerate implementation of known effective blood conservation strategies within paediatric critical care environments.

Building effective engagement for implementation with i-PARIHS: a collaborative enquiry into paediatric pain care in the emergency department.

BACKGROUND: Pain is a central and distressing experience for children in the emergency department (ED). Despite the harmful effects of pain, ED care often falls short of providing timely and effective pain relief. Knowledge translation research targeting systems of care holds potential to transform paediatric pain care. This article reports on the first stages of an implementation project aimed at embedding effective and sustainable practice change in an Australian children's hospital ED. METHODS: The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework underpinned a cooperative process of engagement to establish a practitioner-led, interprofessional research collaborative. The Kids Pain Collaborative (KPC) aimed to co-design innovation in paediatric ED pain care, facilitating an extensive reconnaissance of research evidence, clinician and family experiences, and local evaluation data. This critical appraisal of the context and culture of pain management generated foci for innovation and facilitation of implementation action cycles. RESULTS: Engaging in a complex process of facilitated critical reflection, the KPC unpacked deeply embedded assumptions and organisational practices for pain care that worked against what they wanted to achieve as a team. A culture of rules-based pain management and command and control leadership produced self-defeating practices and ultimately breakdowns in pain care. By raising a critical awareness of context, and building consensus on the evidence for change, the KPC has established a whole of ED shared vision for prioritising pain care. CONCLUSIONS: In-depth key stakeholder collaboration and appraisal of context is the first step in innovation of practice change. The KPC provided a space for collaborative enquiry where ED clinicians and researchers could develop context-specific innovation and implementation strategy. We provide an example of the prospective application of i-PARIHS in transforming ED pain care, using a collaborative and participatory approach that has successfully enabled high levels of departmental engagement, motivation and ownership of KPC implementation as the facilitation journey unfolds.

Nurse knowledge and confidence on peripheral intravenous catheter insertion and maintenance in pediatric patients: A multicentre cross-sectional study.

PURPOSE: To examine nursing knowledge and confidence of peripheral intravenous catheter insertion and maintenance in pediatric patients. DESIGN AND METHODS: An online survey using validated questionnaires was conducted in ten (tertiary and district) hospitals in Indonesia from May to September 2020. Multivariable general linear models were used to investigate associations between nurses' characteristics and knowledge and confidence on the catheter insertion and maintenance score. RESULTS: A total of 413 out of 458 pediatric nurses completed the survey (a response rate of 90%). The mean score of the nurse knowledge on insertion was 18.9(±3.3) (maximum score: 21), and the maintenance score was 6.5(±2.0) (maximum score: 12). The median score of the nurse insertion and maintenance confidence was quite high: 44 (IQR = 7) out of 50 and 37 (IQR = 4) out of 45, respectively. Initial patient assessment, catheter securement, site assessment and management of complications are areas where nurse knowledge and confidence are still lacking. Adjusted analysis indicates that training and work experience were significantly associated with the knowledge and confidence score (p < 0.05). CONCLUSION: Pediatric nurses were largely confident in their skills but this was not reflected in their knowledge scores. Training and experience were important predictors for nursing knowledge and confidence in catheter insertion and maintenance. PRACTICE IMPLICATIONS: The results provide nursing and hospital managers and educational institutions to understand areas of intravenous catheter insertion and maintenance in which nurses lack of knowledge and confidence as well as to formulate tailored and ongoing training to improve nurse knowledge, confidence, practices and optimize patients' care.

Barriers and facilitators to implementing evidence based bleeding management in Australian Cardiac Surgery Units: a qualitative interview study analysed with the theoretical domains framework and COM-B model.

BACKGROUND: Bleeding during cardiac surgery is a common complication that often requires the transfusion of blood products. The combination of bleeding and blood product transfusion incrementally increases adverse outcomes including infection and mortality. Following bleeding management guideline recommendations could assist with minimising risk but adherence is not high, and the cause for lack of adherence is not well understood. This study aimed to identify barriers and facilitators to practicing and implementing evidenced-based intra-operative, bleeding management in Australian cardiac surgery units. METHODS: We used a qualitative descriptive design to conduct semi-structured interviews with Australian cardiac surgeons, anaesthetists and perfusionists. The Theoretical Domains Framework (TDF) was utilised to guide interviews and thematically analyse the data. Categorised data were then linked with the three key domains of the COM-B model (capability, opportunity, motivation - behaviour) to explore and understand behaviour. RESULTS: Seventeen interviews were completed. Nine of the 14 TDF domains emerged as significant. Analysis revealed key themes to improving capability included, standardisation, monitoring, auditing and feedback of data and cross discipline training. Opportunity for change was improved with interpersonal and interdepartmental collaboration through shared goals, and more efficient and supportive processes allowing clinicians to navigate unfamiliar business and financial models of health care. Results suggest as individuals, clinicians had the motivation to make change and healthcare organisations have an obligation and a responsibility to partner with clinicians to support change and improve goal directed best practice. CONCLUSION: Using a theory-based approach it was possible to identify factors which may be positively or negatively influence clinicians ability to implement best practice bleeding management in Australian cardiac surgical units.

Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial.

BACKGROUND: Peripheral intravenous catheters (PIVCs) are ubiquitous medical devices, crucial to providing essential fluids and drugs. However, post-insertion PIVC failure occurs frequently, likely due to inconsistent maintenance practice such as flushing. The aim of this implementation study was to evaluate the impact a multifaceted intervention centred on short PIVC maintenance had on patient outcomes. METHODS: This single-centre, incomplete, stepped wedge, cluster randomised trial with an implementation period was undertaken at a quaternary hospital in Queensland, Australia. Eligible patients were from general medical and surgical wards, aged ≥ 18 years, and requiring a PIVC for > 24 h. Wards were the unit of randomisation and allocation was concealed until the time of crossover to the implementation phase. Patients, clinicians, and researchers were not masked but infections were adjudicated by a physician masked to allocation. Practice during the control period was standard care (variable practice with manually prepared flushes of 0.9% sodium chloride). The intervention group received education reinforcing practice guidelines (including administration with manufacturer-prepared pre-filled flush syringes). The primary outcome was all-cause PIVC failure (as a composite of occlusion, infiltration, dislodgement, phlebitis, and primary bloodstream or local infection). Analysis was by intention-to-treat. RESULTS: Between July 2016 and February 2017, 619 patients from 9 clusters (wards) were enrolled (control n = 306, intervention n = 313), with 617 patients comprising the intention-to-treat population. PIVC failure was 91 (30%) in the control and 69 (22%) in the intervention group (risk difference - 8%, 95% CI - 14 to - 1, p = 0.032). Total costs were lower in the intervention group. No serious adverse events related to study intervention occurred. CONCLUSIONS: This study demonstrated the effectiveness of post-insertion PIVC flushing according to recommended guidelines. Evidence-based education, surveillance and products for post-insertion PIVC management are vital to improve patient outcomes. TRIAL REGISTRATION: Trial submitted for registration on 25 January 2016. Approved and retrospectively registered on 4 August 2016. Ref: ACTRN12616001035415 .