Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial.

OBJECTIVES: In children, intravenous therapy (IVT) is generally administered via peripheral intravenous catheters (PIVCs) (2-6 cm in length). There is evidence that PIVCs are unreliable after 2 days. Long peripheral catheters (LPCs) (6-15 cm in length) could improve the delivery of IVT. The aim of this trial was to determine if LPCs could decrease catheter failure and the number of catheters in children receiving multiday IVT. METHODS: This was an open-label randomized controlled trial conducted at Monash Children's Hospital in Melbourne, Australia. Participants were from the ages of 1 to 17 years, undergoing surgery and requiring >48 hours of postoperative IVT. Participants were randomly assigned to a 2.5-cm 22G PIVC or an 8-cm 22G LPC. RESULTS: Seventy-two children were randomly assigned, 36 received PIVCs, and 36 received LPCs. The median duration of IVT was 5.1 days and was similar between groups (P = .9). Catheter failure was higher for PIVCs than LPCs (66.7% vs 19.4%; relative risk [RR]: 3.4; P = .0001 or 187.9 vs 41.0 failures per 1000 catheter-days). Infiltration was the most common reason for PIVC failure (33.3% vs 2.8%; RR: 12.0; P = .001). LPCs exhibited superior life span (4.7 vs 3.5 days [median]; P = .01). Children with LPCs were twice as likely to complete therapy with a single catheter (80.6% vs 38.9%; RR: 2.1; P = .0006). CONCLUSIONS: LPCs reduce catheter failure and total catheters in children. They should be considered as the first-line device for peripheral access in any child receiving prolonged IVT.

Use of catheter maintenance solutions by community nursing staff: an assessment.

This article discusses catheter maintenance solutions, the way they are supposed to be used and the way they actually are being used in primary and community care in the UK. It discusses the knowledge that community nursing staff have regarding these solutions and the need for further education. Appropriate assessment from a suitably trained individual is recommended, resulting in both usage and cost being dramatically decreased, offering more appropriate management and the likelihood of decreasing the incidence of catheter-associated urinary tract infections (CAUTI). The literature surrounding catheter maintenance solutions is investigated, and the lack of available evidence is highlighted. Preliminary research exploring primary and community care nurses' knowledge of catheter maintenance solutions is also discussed.

A Randomized Trial Comparing Outcomes of 3 Types of Peripheral Intravenous Catheters.

BACKGROUND: There was an increase in peripheral intravenous catheter (PIVC) complications and adverse patient events after product conversion during the merger between a rural hospital and a larger hospital system. A review of the existing literature identified a gap in evidence evaluating 2 closed PIVC systems compared with an open PIVC system. PURPOSE: The purpose of the current project was to ascertain whether open or closed PIVCs are best for patients, staff, and the health care system in terms of 3 main criteria: quality, safety, and cost. METHODS: A prospective, 2-site randomized controlled trial was used to compare outcomes. RESULTS: There were no differences in the complication rates between catheter types. There was a statistically significant increase in blood leakage and a decrease in clinician satisfaction with the open-system catheter. CONCLUSIONS: Our project supports current clinical recommendation that a closed PIVC system, regardless of type, is not only safer and cost-effective but also preferred by patients and clinicians.

Intrathecal Baclofen Therapy in Patients With Multiple Sclerosis: Improved Outcomes and Reduced Costs Through Identification of Catheter Malfunction.

INTRODUCTION: Two patients previously implanted with intrathecal Baclofen (ITB) pumps for management of intractable spasticity due to multiple sclerosis (MS) were referred to our center for ongoing management of their spasticity. Initial evaluation of these patients revealed high levels of spasticity in the presence of ITB doses 10 times the average daily dose of our other MS patients. CLINICAL FACTS: High doses of ITB required frequent clinical visits and result in high drug and procedure costs. Both patients' daily doses were greater than 1000 mcg/day resulting in clinical visits every 1-2 months with drug and procedure costs ranging from 16 to 23 thousand dollars annually based on Medicare national average pricing for physician's office. Of the 59 MS patients receiving ITB therapy at our institution, the mean, median, and mode daily doses for ITB are 184, 115, and 159 mcg/day, respectively. The high ITB doses in these patients and poor spasticity control raised suspicion for pump/catheter malfunction and prompted immediate troubleshooting. FINDINGS: One patient's catheter was found to be disconnected from the pump and the other's catheter tip was outside the intrathecal space. In both cases, the patients were not receiving the therapy. After pump/catheter replacement, both patients received excellent clinical benefits from ITB at significantly lower daily doses. This reduction in dose resulted in decreased frequency of medication refills (twice annually) which resulted in decreased cost of care (12-19 thousand dollars savings annually per patient). DISCUSSION: These cases illustrate the need for early ITB pump troubleshooting to identify catheter problems, improve efficacy, and avoid unnecessary healthcare costs.

[10 years of external quality assurance in dialysis in Germany: Results and future prospects]. / 10 Jahre Qualitätssicherung Dialyse in Deutschland ­ Bilanz und Ausblick.

BACKGROUND: In 2006, the Federal Joint Committee introduced a quality assurance programme for ambulatory dialysis treatment in Germany. Regarding the impact of chronic dialysis treatment on the quality of life of patients and on health care costs, quality assurance in dialysis is considered highly relevant. The directive on Quality Assurance in Dialysis (QSD-RL) established an external quality assurance programme on the basis of the assessment of certain quality parameters combined with an internal quality management system based on benchmarking parameters in all dialysis practices and centres. Data on quality parameters are collected and analysed quarterly. Regional associations of statutory health insurance physicians take responsibility for quality improvement measures and sanctions. This article aims to provide an overview of the development of quality parameters from 2008 to 2015. METHODS: We analysed the summarised annual quality reports published on the website of the Federal Joint Committee between 2009 and 2016. We present results on the so-called core quality parameters duration and frequency of dialysis sessions (both for haemodialysis patients), wKt/V for peritoneal dialysis patients, and percentage of haemodialysis patients with central venous catheters which has only been measured since 2014. RESULTS AND CONCLUSIONS: In 2015, 92,000 patients received outpatient dialysis. Between 2008 and 2015, the results for the core quality parameters duration and frequency of haemodialysis improved while the results for wKt/V seemingly show an unfavourable trend. The percentage of patients with central venous catheters appears to be quite high, and thus indicates that there is potential for quality improvement. FUTURE PERSPECTIVES: For the future, the Federal Joint Committee has resolved to merge the quality assurance programmes in dialysis and in kidney transplantation into a newly designed programme that has the potential to follow patients through all stages and kinds of renal replacement therapy and to focus on further aspects of treatment quality.

Innovation in catheter securement devices: minimising risk of infection, trauma and pain.

Urinary catheters are one of the most common invasive devices used in the NHS. The risks are well-documented and the practice of catheterisation of the bladder has been around for years. Traditionally catheter fixation devices have not been widely used, despite many best practice guidelines advising on their use as a standard within catheter care and maintenance. This article considers some of the evidence around urinary catheterisation and the benefits and limitations of fixation devices. There will be a product focus on the Optimum Medical Ugo Fix Gentle catheter fixation device, with case histories to demonstrate patient satisfaction with the product.

Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults.

BACKGROUND: Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death. OBJECTIVES: To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles. SELECTION CRITERIA: We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults. DATA COLLECTION AND ANALYSIS: At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required. MAIN RESULTS: In this systematic review, we included 42 trials.Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis. AUTHORS' CONCLUSIONS: Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.

Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters.

BACKGROUND: Millions of peripheral intravenous catheters are used worldwide. The current guidelines recommend routine catheter replacement every 72-96 h. This practice requires increasing healthcare resource use. The clinically indicated catheter replacement strategy is proposed as an alternative. OBJECTIVES: To assess the cost effectiveness of clinically indicated versus routine replacement of peripheral intravenous catheters. METHODS: A cost-effectiveness analysis from the perspective of Queensland Health, Australia, was conducted alongside a randomized controlled trial. Adult patients with an intravenous catheter of expected use for longer than 4 days were randomly assigned to receive either clinically indicated replacement or third-day routine replacement. The primary outcome was phlebitis during catheterization or within 48 h after catheter removal. Resource use data were prospectively collected and valued (2010 prices). The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations. Additionally, value of information (VOI) and value of implementation analyses were performed. RESULTS: The clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60 (95% confidence interval [CI] 4.96-10.62) and a non-significant difference in the phlebitis rate of 0.41% (95% CI -1.33 to 2.15). The incremental net monetary benefit was AU$7.60 (95% CI 4.96-10.62). The expected VOI was zero, whereas the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5 million over 5 years. CONCLUSION: The clinically indicated catheter replacement strategy is cost saving compared with routine replacement. It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinically indicated.

Preventing catheter-associated urinary tract infections in the intensive care unit.

Urinary tract infection remains one of the most common healthcare-associated infections in the intensive care unit and predominantly occurs in patients with indwelling urinary catheters. Duration of catheterization is the most important risk factor for developing catheter-associated urinary tract infection (CAUTI). General strategies for preventing CAUTI include measures such as adherence to hand hygiene. Targeted strategies for preventing CAUTI include limiting the use and duration of urinary catheters, using aseptic technique for catheter insertion, and adhering to proper catheter care. Anti-infective catheters may be considered in some settings. Successful implementation of these measures has decreased urinary catheter use and CAUTI.

PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites: a NICE Medical Technology Guidance.

The PleurX peritoneal drainage catheter for drainage of malignant ascites in a community setting has been evaluated by the NICE Medical Technologies Evaluation Programme. This article outlines the evidence included in the Sponsor's submission, the independent critique by the External Assessment Centre (EAC) and the recommendations made by the Medical Technologies Advisory Committee (MTAC). In accordance with the scope issued by NICE, the intervention technology was the indwelling PleurX peritoneal catheter drainage system, the comparator was large-volume paracentesis (LVP; inpatient or outpatient) and the population was patients with treatment-resistant, recurrent malignant ascites. Nine studies (ten papers) were identified with a total of 180 PleurX-treated patients; six were case series with more than four patients that, despite being low in the hierarchy of evidence, provided useful safety information. Technical success of the initial PleurX placement procedure was 100% across five studies which reported this outcome. One study reported equal complication rates between patients treated with indwelling PleurX catheters (40 patients and 40 catheters) and those receiving repeated LVPs (67 patients and 392 procedures), 7.5% (3/40; 95% CI 1.6, 20) and 7.5% (5/67; 95% CI 2.2, 15), respectively. All remaining studies were single-arm and reported complication rates of between 0% and 59%; this wide range was largely due to variation in the definition of complications and adverse events. Using validated tools, one case series reported improvements in several ascites-related symptoms after placement of the PleurX catheter; however, an overall quality-of-life improvement at 12 weeks was not demonstrated. Positive patient opinions relating to improved symptom control and convenience were reported in a qualitative study. Cost analysis demonstrated that PleurX offered savings to the NHS when compared with repeated LVPs performed in an inpatient setting. This saving of £679 per patient was driven primarily by reducing hospital bed days (year 2009-2010 values), but would require 23.5 additional community nurse visits. Advice from clinical experts was that additional home visits were overestimated as many patients would receive such visits regardless of whether a PleurX drain had been fitted. The model demonstrated that PleurX would be more expensive than LVP procedures performed in a setting where one or less hospital bed days were used (e.g. day case or outpatient). There was uncertainty surrounding the number of patients for whom insertion of a PleurX drain would be appropriate as well as the point in the care pathway at which such treatment should be administered. MTAC supported the case for adoption and considered that the available evidence showed PleurX was clinically effective, has low complication rates, can improve quality of life and is less costly than inpatient LVP. In Medical Technology Guidance 9 (MTG9), NICE recommended that PleurX peritoneal catheter drainage system be considered for use in patients with treatment-resistant, recurrent malignant ascites.

Draping and associated equipment for indwelling catheter manipulation by hospital staff: an assessment of attitudes and adequacy.

OBJECTIVE: To address the usability and safety aspects of current equipment for indwelling urinary catheter (IDC) manipulation, by assessing the attitudes of doctors and nurses to infection control, occupational health and environmental waste, and the perceived adequacy of available catheter packs, particularly drapes, when performing such manipulations. SUBJECTS AND METHODS: A self-administered survey instrument was created using an online database and completed by doctors and nurses. The survey covered basic demographics and experience with IDC, attitudes to infection control, occupational health and safety, and the environment, as well as adequacy of current equipment in containing spillage of urine and/or blood. RESULTS: In all, 87 doctors and 228 nurses completed 315 of 350 (90%) surveys. Doctors and nurses were concerned about infection control, occupational health and safety issues, and environmental waste. Incidents involving spillage of urine and/or blood often go unreported. There were no differences between nurses and doctors having specialist training in urology or experience (P > 0.05). The second major finding is that available catheter packs, particularly drapes, when manipulating IDCs, are inadequate and spillage is likely. These findings were more pronounced in doctors and those with urology training (P < 0.05). CONCLUSION: The attitudes of health professionals involved with IDC manipulations are consistent with other fields, as is the under-reporting of episodes of contamination by bodily fluids. The current equipment, particularly drapes, are inadequate for containing urine and blood, leading to infection control, occupational health, environmental and cost implications.

Comparison of three peripherally-inserted central catheters: pilot study.

Peripherally-inserted central catheters (PICCS) are non-tunnelled, central catheters inserted through a peripheral vein of the arm. They are 50-60 cm long and are usually made of either silicone or second-third generation polyurethane. PICCs can be used for prolonged, continuous or intermittent infusion therapies (up to 3 months) both in hospitalized patients and in patients treated as outpatients, in a hospice, or at home. When establishing a vascular service it is key to select a PICC that meets the requirements of safety, cost-effectiveness, high resistance (ability to take increasing fluid volumes with high pressure devices) and durability, and low complications rate. The complications and dwell times of three different PICCs were studied: coated polyurethane, valved silicone and power-injectable. The study was conducted at the chemotherapy suite at the author's hospital with the aim of selecting the right PICC based on low incidence of complications, resistance and enhanced dwell time. Results show a low incidence of complications and long dwell time among patients with the power-injectable PICC. Furthermore, this study demonstrated a reduction on the rate of occlusion and rupture with power-injectable PICCs, which makes them safer to use for administration of chemotherapy and other vesicant agents, as well as for the management of patients in critical care.

Pain control in augmentation mammaplasty: safety and efficacy of indwelling catheters in 644 consecutive patients.

BACKGROUND: In an effort to give patients an additional effective form of analgesia, indwelling catheters for the instillation of a long-acting local anesthetic have been used to alleviate postoperative pain in patients undergoing augmentation mammaplasty. OBJECTIVE: This prospective study analyzes the safety and efficacy of this form of pain control in a consecutive series of 644 patients. METHODS: Patients were given a choice of intermittent bolus or continuous flow catheters for pain control. Prior to discharge, 20 mL of 0.25% bupivicaine with 1:400,000 epinephrine was instilled by a nurse into catheters for those patients receiving bolus self-administration. Pain scores for each side were recorded both before and 30 minutes after instillation. Patients then instilled 1 to 2 additional doses of bupivicaine during the first 24 hours and continued to record pain scores in the evening and following morning. For patients using continuous flow catheters, 0.25% bupivicaine without epinephrine was used to fill pumps that allowed up to 2 days of continuous flow at a rate of 2 mL per hour per side. Patients recorded pain at time intervals similar to those of patients using bolus self-administration. Questionnaires were given to all patients to determine the extent of pain reduction following the instillation of local anesthesia. More than 200 complete questionnaires were gathered, and pain scores from each of these were analyzed to gauge the efficacy of the instillation regimen. RESULTS: Eighty-nine percent of the patients who self-administered a bolus of bupivacaine reported pain reduction on the evening of surgery, and 78% reported a reduction on the following morning, before implant mobility exercises. Catheters were maintained for 1 day postoperatively by 544 patients (84%) and for 2 days by 100 patients (16%). One patient developed an infection of unknown etiology that ultimately resulted in the loss of a unilateral implant. CONCLUSIONS: A prospective study of 644 consecutive augmentation mammaplasty patients shows that indwelling catheters for the postoperative instillation of bupivacaine are both safe and effective in the management of postoperative pain. This gives the patient an additional form of analgesia, limited to the operative site, which is helpful in a multimodal pain management program. Both continuous flow and intermittent bolus self-administration systems are effective and their patient ratings are indistinguishable.

A novel catheter system for totally implantable intravenous drug therapy: assessment of catheter function and patency with trepostinil therapy.

BACKGROUND: Catheter failure, either due to dislodgment, occlusion or infection is the leading complication of chronic intravenous drug therapy. Better drug delivery techniques are required to advance life saving therapies that require this delivery method. This study evaluated the chronic performance of a fully implantable drug delivery system that incorporates a novel intravenous catheter. The system was designed to reduce complications associated with intravascular drug delivery including catheter occlusion, breakage, migration, and infection. METHODS: Twelve canines were implanted with a novel central venous catheter (Model 10642; Medtronic, Minneapolis, MN) connected to a totally implanted programmable drug pump (Model 8637 SynchroMed II, Medtronic). The drug delivery systems infused saline (n=6) or treprostinil (n=6) (Remodulin; United Therapeutics, Research Triangle Park, NC) for either 12 or 26 weeks at a continuous flow rate of 540 microL/day. Catheter performance was assessed at 0 (implant), 2, 4, 8, 12, 16, 20, and 24 weeks by quantifying delivery pressure, delivery volume and steady state Treprostinil concentrations. RESULTS: All catheters remained patent and free of complications for the duration of the study. Analysis of pressure waveforms during bolus delivery showed low and unchanged catheter resistance throughout the study. Measurement of pump delivery volume accuracy showed that the delivered volume was statistically similar to the calculated delivery (product of flow rate and elapsed time). Measurement of plasma treprostinil levels showed stable concentrations over the study period. There were no catheter dislodgments or breakage. Pathology showed all catheters free from fibrosis and thrombus and minimal changes to the vascular endothelium. CONCLUSIONS: The Model 10642 vascular catheter along with the SynchroMed II implantable drug delivery system showed promising performance in a chronic animal model.

Removal of short-term indwelling urethral catheters.

This information on best practice discusses the evidence for the removal of short-term indwelling urethral catheters. The article has been reproduced with the permission of the Joanna Briggs Institute (JBI). The article is derived from a systematic review of research published by the JBI,'Comparison of late night and early morning removal of short-term urethral catheters: a systematic review' (Fernandez et ol 2003), and another published in the Cochrane Library 'Policies for the removal of short-term indwelling urethral catheters' (Griffiths and Fernandez 2005). The primary references on which this information is based are available in the systematic review reports to members of the JBI via the website: www.joannabriggs.edu.au and the Cochrane Library.