Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key.

OBJECTIVE: To develop and validate a difficult intravenous access risk assessment and escalation pathway, to increase first time intravenous insertion success in paediatrics. METHODS: Mixed methods underpinned by literature and co-production principles. Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia. RESULTS: Interview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February-April 2020) involving 21 stakeholders culminating in the co-production of the "DIVA Key". The DIVA Key was evaluated between May-December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range = 81.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa = 0.71, 95% CI 0.63-0.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2-27.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR) = 10 [8-10]; 8 [8-10 respectively). CONCLUSION: The DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.

Inherent and modifiable risk factors for peripheral venous catheter failure during cancer treatment: a prospective cohort study.

PURPOSE: To identify modifiable and non-modifiable risk factors for peripheral intravenous catheter (PIV) failure among patients requiring intravenous treatment for oncology and haematology conditions. METHODS: A single-centre prospective cohort study was conducted between October 2017 and February 2019. Adult in-patients requiring a PIV for therapy were prospectively recruited from two cancer units at a tertiary hospital in Queensland, Australia. The primary outcome was a composite of complications leading to PIV failure (local and bloodstream infection; occlusion; infiltration/extravasation; leakage; dislodgement; and/or phlebitis). Secondary outcomes were (i) PIV dwell time; (ii) insertion and (iii) failure of a CVAD; (iv) adverse events; (v) length of hospital stay. Outcomes were investigated using Bayesian multivariable linear regression modelling and survival analysis. RESULTS: Of 200 participants, 396 PIVs were included. PIV failure incidence was 34.9%; the most common failure type was occlusion/infiltration (n = 74, 18.7%), then dislodgement (n = 33, 8.3%), and phlebitis (n = 30, 7.6%). While several patient and treatment risk factors were significant in univariable modelling, in the final multivariable model, only the use of non-sterile tape (external to the primary dressing) was significantly associated with decreased PIV dislodgement (hazard ratio 0.06, 95% confidence interval 0.01, 0.48; p = 0.008). CONCLUSION: PIV failure rates among patients receiving cancer treatment are high, the sequelae of which may include delayed treatment and infection. Larger studies on risk factors and interventions to prevent PIV failure in this population are needed; however, the use of secondary securements (such as non-sterile tape) to provide further securement to the primary PIV dressing is particularly important. TRIAL REGISTRATION: Study methods were registered prospectively with the Australian New Zealand Clinical Trials Registry on the 27th March 2017 (ACTRN12617000438358); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372191&isReview=true.

PRE-scripted debriefing for Paediatric simulation Associated with Resuscitation EDucation (PREPARED): A multicentre, cluster randomised controlled trial.

Aim: Scripted debriefing tools may improve the performance of novices debriefing in resuscitation courses, but this has not previously been measured. The aim of this study was to determine the impact of a script on the quality of debriefs in a statewide paediatric resuscitation course. Methods: This cluster-randomised controlled trial compared scripted debriefing (intervention) versus non-scripted debriefing (control) for participants in a paediatric resuscitation course. The trial was conducted across participating sites in Queensland, Australia, from November 2017 to February 2020. Debriefing quality was measured using the Observational Structured Assessment of Debriefing (OSAD) tool. The OSAD tool rates 8 domains that comprise the elements of an ideal debrief. OSAD scores between scripted and non-scripted groups were compared, overall and after stratification by debriefer experience and site size. Results: Seventy debriefings occurred across 19 sites (intervention, n = 34, control n = 36). There was a statistically significant increase in total OSAD scores in the scripted group, compared to non-scripted (mean difference (MD) = 3.5, 95% confidence interval (CI) 0.7-6.2, p = 0.01). The categories of 'reflection' and 'analysis' had the greatest difference in OSAD scores in the scripted group (MD = 0.8, 95%CI 0.2-1.3, p = 0.005; MD = 0.6, 95%CI 0.2-1.0, p = 0.007). After stratification, overall OSAD scores improved for novices (MD = 4.1, 95%CI 0.5-7.7, p = 0.03) and large centres (MD = 5.2, 95%CI 1.1-9.2, p = 0.01). Conclusion: Providing debriefing scripts to faculty facilitating simulated paediatric resuscitation scenarios improved the quality of debriefing, especially for novices and those at large sites. The development and provision of debriefing scripts for large-scale paediatric resuscitation courses should be considered.

'How many audits do you really need?': Learnings from 5-years of peripheral intravenous catheter audits.

BACKGROUND: Peripheral intravenous catheters (PIVCs) are medical devices used to administer intravenous therapy but can be complicated by soft tissue or bloodstream infection. Monitoring PIVC safety and quality through clinical auditing supports quality infection prevention however is labour intensive. We sought to determine the optimal patient 'number' for clinical audits to inform evidence-based surveillance. METHODS: We studied a dataset of cross-sectional PIVC clinical audits collected over five years (2015-2019) in a large Australian metropolitan hospital. Audits included adult medical, surgical, women's, cancer, emergency and critical care patients, with audit sizes of 69-220 PIVCs. The primary outcome was PIVC complications for one or more patient reported symptom/auditor observed sign of infection or other complications. Complication prevalence and 95% confidence interval (CI) were calculated. We modelled scenarios of low (10%), medium (20%) and high (50%) prevalence estimates against audit sizes of 20, 50, 100, 150, 200, 250, and 300. This was used to develop a decision-making tool to guide audit size. RESULTS: Of 2274 PIVCs evaluated, 475 (21%) had a complication. Complication prevalence per round varied from 7.8% (95% CI, 4.2-12.9) to 39% (95% CI, 32.0-46.4). Precision improved with larger audit size and lower complication rates. However, precision was not meaningfully improved by auditing >150 patients at a complication rate of 20% (95% CI 13.9%-27.3%), nor >200 patients at a complication rate of 50% (95% CI 42.9%-57.1%). CONCLUSION: Audit sizes should be 100 to 250 PIVCs per audit round depending on complication prevalence.