Determinants of the optimal selection of vascular access devices: A systematic review underpinned by the COM-B behavioural model.

BACKGROUND: Optimal selection of vascular access devices is based on multiple factors and is the first strategy to reduce vascular access device-related complications. This process is dependent on behavioural and human factors. The COM-B (Capability, Opportunity, Motivation, Behaviour) model was used as a theoretical framework to organize the findings of this systematic review. METHODS/AIMS: To synthesize the evidence on determinants shaping the optimal selection of vascular access devices, using the COM-B behavioural model as the theoretical framework. DESIGN: Systematic review of studies which explore decision-making at the time of selecting vascular access devices. DATA SOURCES: The Medline, Web of Science, Scopus and EbscoHost databases were interrogated to extract manuscripts published up to 31 December 2021, in English or Spanish. RESULTS: Among 16 studies included in the review, 8/16 (50%) focused on physical capability, 8/16 (50%) psychological capability, 15/16 (94%) physical opportunity, 12/16 (75%) social opportunity, 1/16 (6%) reflective motivation and 0/16 (0%) automatic motivation. This distribution represents a large gap in terms of interpersonal and motivational influences and cultural and social environments. Specialist teams (teams created for the insertion or maintenance of vascular access devices) are core for the optimal selection of vascular access devices (75% physical capability, 62% psychological capability, 80% physical opportunity and 100% social opportunity). CONCLUSION: Specialist teams predominantly lead all actions undertaken towards the optimal selection of vascular access devices. These actions primarily centre on assessing opportunity and capability, often overlooking motivational influences and social environments. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: A more implementation-focused professional approach could decrease inequity among patients and complications associated with vascular access devices. IMPACT: Optimal selection of vascular access devices is the primary strategy in mitigating complications associated with these devices. There is a significant disparity between interpersonal and motivational influences and the cultural and social environments. Furthermore, specialized teams play a pivotal role in facilitating the optimal selection of vascular access devices. The study can benefit institutions concerned about vascular access devices and their complications. REPORTING METHOD: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. WHAT DOES THIS ARTICLE CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Optimal selection of vascular devices remains a growing yet unresolved issue with costly clinical and patient experience impact. Interventions to improve the optimal selection of vascular devices have focused on training, education, algorithms and implementation of specialist vascular teams; alas, these approaches do not seem to have substantially addressed the problem. Specialist vascular teams should evolve and pivot towards leading the implementation of quality improvement interventions, optimizing resource use and enhancing their role.

Interventions to reduce peripheral intravenous catheter failure: An international e-Delphi consensus on relevance and feasibility of implementation.

BACKGROUND: Around 1 billion peripheral intravenous catheters (PIVC) fail annually worldwide before prescribed intravenous therapy is completed, resulting in avoidable complications, dissatisfaction, and avoidable costs surging to ∼€4bn. We aimed to provide an international consensus on relevance and feasibility of clinical practice guideline recommendations to reduce PIVC failure. METHODS: e-Delphi study with three rounds through an online questionnaire from March-September 2020 recruiting a multispecialty panel formed by clinicians, managers, academic researchers, and experts in implementation from seven developed and three developing countries, reflecting on experience in PIVC care and implementation of evidence. Further, we included a panel of chronic patients with previous experience in the insert, maintenance, and management of PIVC and intravenous therapy from Ireland and Spain as public and patient involvement (PPI) panel. All experts and patients scored each item on a 4-point Likert scale to assess the relevance and feasibility. We considered consensus descriptor in which the median was 4 with less than or equal to 1,5 interquartile intervals. FINDINGS: Over 90% participants (16 experts) completed the questionnaire on all rounds and 100% PPI (5 patients) completed round 1 due to high consensus they achieved. Our Delphi approach included 49 descriptors, which resulted in an agreed 30 across six domains emerged from the related to (i) general asepsis and cutaneous antisepsis (n = 4), (ii) catheter adequacy and insertion (n = 3), (iii) catheter and catheter site care (n = 6), (iv) catheter removal and replacement strategies (n = 4), (v) general principles for catheter management (n = 10), and (vi) organisational environment (n = 3). CONCLUSION: We provide an international consensus of relevant recommendations for PIVC, deemed feasible to implement in clinical settings. In addition, this methodological approach included substantial representation from clinical experts, academic experts, patient and public expertise, mitigating uncertainty during the implementation process with high-value recommendations to prevent PIVC failure based contextual and individual features, and economic resources worldwide.

What fuels suboptimal care of peripheral intravenous catheter-related infections in hospitals? A qualitative study of decision-making among Spanish nurses.

BACKGROUND: Peripheral intravenous catheters (PIVC) are commonly used in hospital worldwide. However, PIVC are not exempt from complications. Catheter-related bloodstream infections (CRBSI) increase morbidity and mortality rates, and costs for the healthcare organization. PIVC care is shaped by the complex mix of professional and organizational culture, such as knowledge gaps, low perception of impact of PIVCs on patient safety, or lack of hospital guidelines. AIM: To explore determinants of decision-making about the prevention of PIVC-BSI among nurses in Spanish hospitals. METHODS: We conducted a descriptive qualitative study with semi-structured interviews in three public hospitals, the Balearic Islands Health Care Service in Spain. We considered hospital ward nurses working routinely with inpatients at any of the three hospitals for enrolment in the study. We approached relevant informants to identify suitable participants who recruited other participants through a 'snowball' technique. Fourteen inpatient nurses from the hospital took part in this study between September and November 2018. We employed several triangulation strategies to underpin the methodological rigour of our analysis and conducted the member checking, showing the information and codes applied in the recording of the interviews to identify the coherence and any discrepancies of the discourse by participants. We used the COREQ checklist for this study. FINDINGS: We identified four major themes in the analysis related to determinants of care: The fog of decision-making in PIVC; The taskification of PIVC care; PIVC care is accepted to be suboptimal, yet irrelevant; and chasms between perceived determinants of poor PIVC care and its solutions. CONCLUSION: The clinical management of PIVCs appear ambiguous, unclear, and fragmented, with no clear professional responsibility and no nurse leadership, causing a gap in preventing infections. Furthermore, the perception of low risk on PIVC care impact can cause a relevant lack of adherence to the best evidence and patient safety. Implementing facilitation strategies could improve the fidelity of the best available evidence regarding PIVC care and raise awareness among nurses of impact that excellence of care.

Validity of a catheter exit site clinical assessment scale for the early detection of exit site infections in patients on haemodialysis with a central venous catheter: protocol for a multicentre validation study in Spain (EXITA Study).

INTRODUCTION: Haemodialysis patients with central venous catheter (HD-CVC) are at increased risk of exit site infections (ESIs) and catheter-related bloodstream infections, causing an increase of hospitalisation, morbidity and mortality rates. The main aim of the EXITA Study is to develop and validate an instrument for the early detection of HD-CVC ESIs. METHODS AND ANALYSIS: EXITA is a multicentre prospective cohort study to validate the proposed instrument with a sample of 457 HD-CVCs: 92 in the ESI group and 365 in the non-ESI group. Sample size was calculated using Epidat V.4.2 software, with 95% and 90% expected sensitivity and specificity, respectively, an ESI incidence around 20% and 5%-10% precision range. During each haemodialysis session, the absence or presence of each item will be assessed by nurses. If any item is present, a microbiological study of pericatheter skin smears and/or exit site exudate will be carried out. HD-CVC ESI will be diagnosed when the pericatheter skin smears and/or exit site exudate culture are positive (≥15 CFU/mL by semiquantitative Maki's technique or ≥1000 CFU/mL by Cleri's technique). To validate the scale, a logistic regression analysis will be performed: the ß coefficients of each of the signs/symptoms of the scale to be validated will be estimated. We will use logit function and calculate ESI probability=elogit ESI/1+elogit ESI. ETHICS AND DISSEMINATION: The study has been approved by the Research Ethics Committee with Medical Products of Cantabria (approval code 2019.146). We will obtain informed consent from all participants before data collection. We will publish the study results in a peer-reviewed scientific journal.

Multimodal intervention for preventing peripheral intravenous catheter failure in adults (PREBACP): a multicentre, cluster-randomised, controlled trial.

BACKGROUND: 2 billion peripheral intravenous catheters (PIVC) are inserted into inpatients worldwide each year. Almost one in two PIVCs fail before completion of intravenous therapy. We aimed to determine the efficacy and costs of a multimodal intervention to reduce PIVC failure among hospitalised patients. METHODS: PREBACP was a cluster-randomised, controlled trial done at seven public hospitals in Spain. Clusters (hospital wards) had at least 70% permanent staff and data were collected from patients aged 18 years and older with one or more PIVCs at the start of intravenous therapy. Clusters were randomly assigned (1:1) to the multimodal intervention or control group using a centralised, web-based randomisation software, and stratified by type of setting. We concealed randomisation to allocation, without masking patients or professionals to the intervention. An intervention using a multimodal model and dissemination of protocols, education for health-care professionals and patients, and feedback on performance was implemented for 12 months in the intervention group. The control group received usual care. The primary outcome was all-cause PIVC failure at 12 months (phlebitis, extravasation, obstruction, or infections). Subsequently, through an amendment to the protocol approved on July 25, 2021, we included dislodgement as part of PIVC failure. Analysis was by modified intention to treat, which included all randomly assigned hospital wards for whom data on the primary endpoint were available. This trial is registered with the ISRCTN Registry, ISRCTN10438530. FINDINGS: Between Jan 1, 2019, and March 1, 2020, we randomly assigned 22 eligible clusters to receive the multimodal intervention (n=11 clusters; 2196 patients, 2235 PIVCs, and 131 nurses) or usual practice in the control group (n=11 clusters; 2282 patients, 2330 PIVCs, and 138 nurses). At 12 months, the proportion of PIVC failures was lower in the intervention group than in the control group (37·10% [SD 1·32], HR 0·81 [95% CI 0·72 to 0·92] vs 46·49% [2·59], HR 1·23 [1·04 to 1·39]; mean difference -9·39% [95% CI -11·22 to -7·57]; p<0·0001). Per-protocol-prespecified analysis of the primary outcome excluding dislodgement also showed the intervention significantly reduced PIVC failure compared with the control group at 12 months (33·47% [SD 2·98], HR 0·85 [95% CI 0·75 to 0·96] vs 41·06% [4·62], HR 1·18 [1·04 to 1·33]; mean difference -7·59% [95% CI -11·05 to -4·13]; p<0·0001). INTERPRETATION: A multimodal intervention reduced PIVC failure, thereby reducing potentially serious complications for hospitalised patients. The findings of PREBACP enabled a deeper understanding of decision making, knowledge mobilisation, and sense making in routine clinical practice. FUNDING: The College of Nurses of the Balearic Islands. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Care of peripheral intravenous catheters in three hospitals in Spain: Mapping clinical outcomes and implementation of clinical practice guidelines.

BACKGROUND: Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices worldwide. Up to 42% of PIVCs are prematurely removed during intravenous therapy due to failure. To date, there have been few systematic attempts in European hospitals to measure adherence to recommendations to mitigate PIVC failures. AIM: To analyse the clinical outcomes from clinical practice guideline recommendations for PIVC care on different hospital types and environments. METHODS: We conducted an observational study in three hospitals in Spain from December 2017 to April 2018. The adherence to recommendations was monitored via visual inspection in situ evaluations of all PIVCs inserted in adults admitted. Context and clinical characteristics were collected by an evaluation tool, analysing data descriptively. RESULTS: 646 PIVCs inserted in 624 patients were monitored, which only 52.7% knew about their PIVC. Regarding PIVC insertion, 3.4% (22/646) patients had at least 2 PIVCs simultaneously. The majority of PIVCs were 20G (319/646; 49.4%) and were secured with transparent polyurethane dressing (605/646; 93.7%). Most PIVCs (357/646; 55.3%) had a free insertion site during the visual inspection at first sight. We identified 342/646 (53%) transparent dressings in optimal conditions (clean, dry, and intact dressing). PIVC dressings in medical wards were much more likely to be in intact conditions than those in surgical wards (234/399, 58.7% vs. 108/247, 43.7%). We identified 55/646 (8.5%) PIVCs without infusion in the last 24 hours and 58/646 (9.0%) PIVCs without infusion for more than 24 hours. Regarding PIVC failure, 74 (11.5%) adverse events were identified, all of them reflecting clinical manifestation of phlebitis. CONCLUSIONS: Our findings indicate that the clinical outcome indicators from CPG for PIVC care were moderate, highlighting differences between hospital environments and types. Also, we observed that nearly 50% of patients did not know what a PIVC is.

Risk Factors for Difficult Peripheral Intravenous Cannulation. The PIVV2 Multicentre Case-Control Study.

BACKGROUND: Difficult peripheral intravenous cannulation (DPIVC) is associated with serious complications related to vascular access. These complications might be avoided if the risk factors were identified previously, enabling the detection of potentially difficult situations at an early stage. The aim of this study is to consider these risk factors, to determine the influence of the hospital setting, to examine the association between DPIVC and the different techniques of catheter insertion and to analyse the importance of the clinician's experience in this context. METHODS: Case-control study following a previously published protocol, conducted in 48 units of eight public hospitals in Spain. Adult patients requiring a peripheral intravenous cannula were prospectively included in the study population during their hospital stay. Over a period of 11 months, for consecutive eligible patients, nurses in each participating unit recorded data on their assessment of the vascular access performed and the technique used. Variables related to these medical personnel were also recorded. One of the researchers reviewed the patients' clinical history to compile the relevant health variables and to characterise the healthcare process. The statistical analysis included association tests among the main study variables. The risk factors were analysed using bivariate logistic regression. The variables found to be statistically significant were included in a multivariate logistic regression model incorporating each of the healthcare environments identified. RESULTS: The study population was composed of 2662 patients, of whom 221 (8.3%) presented with DPIVC. A previous history of difficulty, the presence of non-palpable veins, acute upper limb alterations and punctures in the ante-cubital fossa were found to be independent risk factors for DPIVC. Differences were found in the frequency of occurrence of DPIVC and in some risk factors, according to the healthcare context. The variables related to the characteristics of the hospital personnel did not influence the study event. CONCLUSION: The present study identifies four independent risk factors for DPIVC that can be incorporated into algorithms aimed at preventing its occurrence and facilitating the referral of patients to vascular access specialist teams.

Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis.

Peripheral venous catheterization is a common technique in hospitals which is not always successful, resulting in multiple punctures and degradation of the vessels. This scenario, which we have termed 'difficult peripheral venous access', is associated to delays in care, obtention of samples or diagnosis, as well as a higher use of central catheters. This study intends to identify risk factors associated to the incidence of 'difficult peripheral venous access' in adults at hospital. We designed a systematic review of published studies (protocol PROSPERO 2018 CRD42018089160). We conducted structured electronic searches using key words and specific vocabulary, as well as directed searches in several databases. After validity analysis, we selected 7 studies with observational methodology. We found great variability in the definition of 'difficult peripheral venous access' and in the variables proposed as risk factors. Statistically significant factors through studies include demographic and anthropometric variables (gender, Body Mass Index), as well as medical and health conditions (diabetes, renal insufficiency, parenteral drug abuse, cancer chemotherapy), together with variables related to the vein or vascular access (vein visibility and palpability, vessel diameter, previous history of difficulty). Some studies have also considered variables related to the professional performing the technique. Meta-analyses were carried out for gender and obesity as potential risk factors. Only obesity appeared as a statistically significant risk factor with OR of 1.48; 95% CI (1.03 to 1.93; p = 0.016). Methodological heterogeneity prevented the development of further meta-analyses. It is essential to design future studies with diverse hospital populations, in which a wide selection of potential risk factors can be studied in a unique analysis. Our work identifies the most relevant variables that should be included in those studies.

Incidence of peripheral intravenous catheter failure among inpatients: variability between microbiological data and clinical signs and symptoms.

Background: Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices among inpatients. Catheter-related bloodstream infections (CRBSI) are serious yet preventable events for patients. Although the contribution of PIVCs towards these infections is gradually being recognised, its role in the Spanish setting is yet to be determined. We aimed to estimate the rate and incidence of PIVC failure at Manacor hospital (Spain) as baseline within a wider quality improvement initiative. Methods: Tips from all PIVC removed during December 2017 and January 2018 in hospital wards were cultured semiquantitatively. The study population included all PIVCs inserted in adult patients admitted to any of three medical and one surgical wards, emergency department, critical care unit and operating rooms. Clinical, microbiological and ward information was collected by clinical researchers for each PIVC from insertion to removal on the study sites. CRBSI was defined per international guidelines (i.e., Centers for Disease Control and Prevention, USA). Data was analysed descriptively. Results: Seven hundred and eleven tips were cultured, with 41.8% (297/711) reported as PIVC failure. The PIVC failure rate density-adjusted incidence for hospital length of stay (HLOS) was 226.2 PIVC failure/1000 HLOS. 5.8% (41/711) tips yielded positive isolates, with most frequent microorganisms Staphylococcus spp (S. epidermidis 29/41, 70.7%, S. aureus 2/41, 4.9%, S. hominis 2/41, 4.9%), and Acinetobacter baumannii (1/41, 2.4%). One S. aureus isolate was methicillin-resistant. 53.6% (22/41) positive cultures were obtained from patients with local signs and symptoms compatible with catheter-related infection (CRI), 2.4% (1/41) were compatible with CRBSI type 2 and that clinical signs improve within 48 h of catheter removal (density-adjusted incidence for hospital stays of 16.7 PIVC-CRI/1000 hospital-stays and 0.76 PVC-BSI/1000 hospital-stays respectively) and no patients were diagnosed CRBSI type 3 with a bacterial growth concordant in tip and blood cultures. Most cases responded favourably to catheter removal and management. Conclusions: Our findings show that almost 42% PIVCs resulted in unplanned removal, amplifying the importance in terms of morbidity, mortality and patient safety. A high number of positive tip cultures without clinical signs and symptoms was observed. We underpin the importance to remove unnecessary PIVCs for the prevention of CRBSI.

Risk factors for difficult peripheral venous cannulation in hospitalised patients. Protocol for a multicentre case-control study in 48 units of eight public hospitals in Spain.

INTRODUCTION: Patients with difficult venous access experience undesirable effects during healthcare, such as delayed diagnosis and initiation of treatment, stress and pain related to the technique and reduced satisfaction. This study aims to identify risk factors with which to model the appearance of difficulty in achieving peripheral venous puncture in hospital treatment. METHODS AND ANALYSIS: Case-control study. We will include adult patients requiring peripheral venous cannulation in eight public hospitals, excluding those in emergency situations and women in childbirth or during puerperium. The nurse who performs the technique will record in an anonymised register variables related to the intervention. Subsequently, a researcher will extract the health variables from the patient's medical history. Patients who present one of the following conditions will be assigned to the case group: two or more failed punctures, need for puncture support, need for central access after failure to achieve peripheral access, or decision to reject the technique. The control group will be obtained from records of patients who do not meet the above conditions. It has been stated a minimum sample size of 2070 patients, 207 cases and 1863 controls.A descriptive analysis will be made of the distribution of the phenomenon. The variables hypothesised to be risk factors for the appearance of difficult venous cannulation will be studied using a logistic regression model. ETHICS AND DISSEMINATION: The study was funded in January 2017 and obtained ethical approval from the Research Ethics Committee of the Balearic Islands. Informed consent will be obtained prior to data collection. Results will be published in a peer-reviewed scientific journal.

Canalización de vías venosas periféricas difíciles y utilidad de técnicas ecográficas en un Servicio de Urgencias / Catheterization in cases with difficult peripheral venous access, and the utility of ultrasound techniques in an Emergency Unit

Objetivo: averiguar los factores asociados con «vía venosa difícil» (VVD) en pacientes adultos atendidos en el servicio de urgencias, así como describir el uso que las enfermeras hacen de las técnicas de punción asistidas por ultrasonido (técnica eco-facilitada -EF- y técnica eco-guiada -EG-) y el grado de éxito de cada una frente a la técnica de canalización tradicional. Método: estudio descriptivo transversal realizado en pacientes adultos con «vía venosa difícil» atendidos en el servicio de urgencias del Hospital de Manacor (Mallorca). La enfermera que realizaba la canalización cumplimentaba un registro anónimo con variables relacionadas con su intervención, con la salud del paciente y con el éxito en cada una de las técnicas. Las pruebas de contraste de hipótesis utilizadas para determinar la asociación fueron la U de Mann-Whitney para variables cuantitativas y Chi cuadrado para categóricas. Resultados: se analizaron 51 casos. Las variables vinculadas a VVD fueron: no encontrar venas a la palpación (72,6%), no encontrar venas visibles (66,7%), historia previa de dificultad (66,7%) y más de dos intentos fallidos de canalización (49%). el factor agudo más común fue la hipotensión (29,4%), los factores crónicos más habituales fueron la obesidad (45,1%), tratamiento con quimioterapia (29,4%) y diabetes (23,5%). En 40 pacientes se utilizó la técnica «ciega» y en 39 casos se usaron técnicas asistidas por ecografía, que resultaron más eficaces que el abordaje habitual (p<0.05). Conclusiones: hay indicios de la existencia de factores asociados a la dificultad en la función periférica, las técnicas ecográficas permiten solucionar eficazmente estos casos provocando menor número de punciones (AU)

Objective: to find out the factors associated with «difficult venous access» (DVA) in adult patients managed at the Emergency Unit, as well as to describe the use by nurses of ultrasound-assisted puncture techniques (ultrasound-assisted (UA) technique and ultrasound-guided (UG) technique), and the degree of success of each one vs. the traditional catheterisation technique. Method: a descriptive transversal study conducted in adult patients with «difficult venous access» seen at the Emergency Unit of the Hospital de Manacor (Majorca). The nurse conducting the catheterization completed an anonymous record with variables associated with their intervention, the health of the patient, and success in each one of the techniques. the contrast hypothesis tests used to determine association were Mann-Whitney’s U for quantitative variables and Square Chi for categorical variables. Results: dirty-one (51) cases were studied. The DVA-associated variables were: not finding veins at palpation (72.6%), not finding visible veins (66.7%), previous history of difficulty (66.7%) and >2 failed catheterization attempts (49%). The most common acute factor was hypotension (29.4%), the most usual chronic factors were obesity (45.1%), chemotherapy treatment (29.4%) and diabetes (23.5%). The «blind» technique was used in 40 patients, and ultrasound-assisted techniques were used in 39 cases, which were more effective than the usual approach (p<0.05). Conclusions: there are signs of the presence of factors associated with difficulty in peripheral puncture; ultrasound techniques offer an effective solution for these cases, leading to a lower number of punctures (AU)