Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis.

BACKGROUND: Peripherally inserted central catheters (PICCs) are associated with an increased risk of venous thromboembolism. However, the size of this risk relative to that associated with other central venous catheters (CVCs) is unknown. We did a systematic review and meta-analysis to compare the risk of venous thromboembolism associated with PICCs versus that associated with other CVCs. METHODS: We searched several databases, including Medline, Embase, Biosis, Cochrane Central Register of Controlled Trials, Conference Papers Index, and Scopus. Additional studies were identified through hand searches of bibliographies and internet searches, and we contacted study authors to obtain unpublished data. All human studies published in full text, abstract, or poster form were eligible for inclusion. All studies were of adult patients aged at least 18 years who underwent insertion of a PICC. Studies were assessed with the Newcastle-Ottawa risk of bias scale. In studies without a comparison group, the pooled frequency of venous thromboembolism was calculated for patients receiving PICCs. In studies comparing PICCs with other CVCs, summary odds ratios (ORs) were calculated with a random effects meta-analysis. FINDINGS: Of the 533 citations identified, 64 studies (12 with a comparison group and 52 without) including 29 503 patients met the eligibility criteria. In the non-comparison studies, the weighted frequency of PICC-related deep vein thrombosis was highest in patients who were critically ill (13·91%, 95% CI 7·68-20·14) and those with cancer (6·67%, 4·69-8·64). Our meta-analysis of 11 studies comparing the risk of deep vein thrombosis related to PICCs with that related to CVCs showed that PICCs were associated with an increased risk of deep vein thrombosis (OR 2·55, 1·54-4·23, p<0·0001) but not pulmonary embolism (no events). With the baseline PICC-related deep vein thrombosis rate of 2·7% and pooled OR of 2·55, the number needed to harm relative to CVCs was 26 (95% CI 13-71). INTERPRETATION: PICCs are associated with a higher risk of deep vein thrombosis than are CVCs, especially in patients who are critically ill or those with a malignancy. The decision to insert PICCs should be guided by weighing of the risk of thrombosis against the benefit provided by these devices. FUNDING: None.

What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.

OBJECTIVE: To explore the causes of failure to activate the rapid response system (RRS). The organisation has a recognised incidence of staff failing to act when confronted with a deteriorating patient and leading to adverse outcomes. DESIGN: A multi-method study using the following: a point prevalence survey to determine the incidence of abnormal simple bedside observations and activation of the rapid response team by clinical staff; a prospective audit of all patients experiencing a cardiac arrest, unplanned intensive care unit admission or death over an 8-week period; structured interviews of staff to explore cognitive and sociocultural barriers to activating the RRS. SETTING: Southern Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne. MEASUREMENTS: Frequency of physiological instability and outcomes within the in-patient hospital population. Qualitative data from staff interviews were thematically coded. RESULTS: The incidence of physiological instability in the acute adult population was 4.04%. Nearly half of these patients (42%) did not receive an appropriate clinical response from the staff, despite most (69.2%) recognising their patient met physiological criteria for activating the RRS, and being 'quite', or 'very' concerned about their patient (75.8%). Structured interviews with 91 staff members identified predominantly sociocultural reasons for failure to activate the RRS. CONCLUSIONS: Despite an organisational commitment to the RRS, clinical staff act on local cultural rules within the clinical environment that are usually not explicit. Better understanding of these informal rules may lead to more appropriate activation of the RRS.

How I nearly MET my maker: a story of clinical futile cycles and survival.

In this series, the articles have highlighted a variety of implementation methods and uses of rapid response systems (RRSs). They have described how RRSs have been uniquely tailored to the organizations' culture and clinical environments, with largely positive results following implementation. In this article, Dr. Buist tells a somewhat different story, a highly personal one, which focuses on his own critical decompensation after surgery at his own hospital. The RRS (in this case, a medical emergency team was the efferent arm) at first successfully intervened, only to make a near-tragic error. Yet, as Dr. Buist, one of the leading proponents of RRSs worldwide, argues, the RRS-like any system-has the potential to err. He reminds us that even safety nets can require safety nets. So this story is also a cautionary tale: Just because your hospital has implemented an RRS, it does not mean (1) that the system is perfect or (2) that all preventable deaths are averted. To meet the goal of eliminating all preventable deaths in hospitals, an RRS requires continuous surveillance and adjustment. Furthermore, it must be implemented and operated in the context of the hospital's organizational culture. Although the administrative and quality improvement arms of the RRS are often underemphasized, this story exemplifies their importance--not just for RRSs but indeed for all hospital systems. The author, one of the leading proponents of rapid response systems worldwide, recounts his own close-call experience, in which he found himself in what he terms a clinical futile cycle.

Documentation of clinical review and vital signs after major surgery.

OBJECTIVE: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation. DESIGN, SETTING AND PARTICIPANTS: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003--July 2005. MAIN OUTCOME MEASURES: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors. RESULTS: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends. CONCLUSION: Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.