Central Venous Access Device-Associated Skin Complications in Adults with Cancer: A Prospective Observational Study.

OBJECTIVES: To identify the prevalence and type of central venous access device-associated skin complications for adult cancer patients, describe central venous access device management practices, and identify clinical and demographic characteristics associated with risk of central venous access device-associated skin complications. METHODS: A prospective cohort study of 369 patients (626 central venous access devices; 7,682 catheter days) was undertaken between March 2017 and March 2018 across two cancer care in-patient units in a large teaching hospital. RESULTS: Twenty-seven percent (n = 168) of participants had a central venous access device-associated skin complication. In the final multivariable analysis, significant (P < .05) risk factors for skin complications were cutaneous graft versus host disease (2.1 times greater risk) and female sex (1.4 times greater risk), whereas totally implanted vascular access device reduced risk for skin complications by two-thirds (incidence risk ratio 0.37). CONCLUSION: Central venous access device-associated skin complications are a significant, potentially avoidable injury, requiring cancer nurses to be aware of high-risk groups and use evidence-based preventative and treatment strategies. IMPLICATIONS FOR PRACTICE: This study has confirmed how common these potentially preventable injuries are. Therefore, the prevalence of these complications could be reduced by focusing on improvements in skin assessment, reductions in central venous access device dressing variation and improving clinician knowledge of this injury.

Prospective cohort study of an Australian cancer care services-led model of emergent care.

ObjectiveMany cancer care services (CCS) provide pragmatic models of emergent care for their patients as part of 'business as usual' without understanding the scope of this work. We aimed to describe an Australian CCS-led model of emergent care and quantify and profile emergent care provided over a 6-month period to understand scope and demand.MethodsThis prospective cohort study was performed at a large tertiary hospital on the eastern coast of Australia in 2016. The study explored emergent care provided during business hour and after-hours, including telephone advice, unplanned care and unplanned admissions. Data were collected via electronic hospital records and clinical nurses regarding who accessed care, why care was accessed, what care was provided and how the episode of care ended.ResultsBetween March and September 2016, 1412 episodes of unplanned care were provided in the CCS-led model of care, including 307 episodes of telephone advice (237 patients; min max 1-4 episodes per patient; 825 episodes of unplanned care (484 patients; min max 1-9 episodes per patient) and 280 unplanned admissions (233 patients; min max 1-6 episodes per patient). During the same time, an additional 459 unplanned admissions (361 patients) occurred via the emergency department (ED), of which 125 (27.2%) occurred during business hours which could have been managed by the CCS. Most people who received care experienced issues associated with disease or treatment and had received systemic anticancer therapy in the past 30 days.ConclusionsThe data demonstrate that a significant volume of emergent care was provided within the CCS over the study period, in addition to planned cancer treatment. Due to the ever-increasing demands on EDs and the significant need for emergent care for people with cancer, there is need for CCS-led models of care to provide specialist emergent care specifically for people who are receiving systemic anticancer therapy. Such models must be adequately resourced to meet the needs of patients, carers and healthcare professionals.What is known about the topic?There is increasing focus on innovative models of emergent care for people with cancer in the out-patient setting to relieve pressure on EDs and improve patient experiences. Limited literature has focused on such models in the Australian context.What does this paper add?This paper describes, quantifies and profiles care provided in a pragmatic CCS-led model of emergent care in a large tertiary hospital in Australia over 6 months. The data demonstrate significant demand for emergent care within business hours, as well as out of hours, predominantly for people undergoing systemic anticancer therapy.What are the implications for practitioners?The findings of this study highlight the need for CCS to develop pragmatic models of emergent care. Appropriate resources, infrastructure, policies and procedures are required to adequate meet the needs of patients and carers.

A comparison of hydrophobic polyurethane and polyurethane peripherally inserted central catheter: results from a feasibility randomized controlled trial.

BACKGROUND: To evaluate the feasibility of an efficacy trial comparing a hydrophobic polyurethane peripherally inserted central catheter (PICC) with a standard polyurethane PICC. METHODS: This pilot randomised controlled trial (RCT) was conducted between May 2017 and February 2018. Adult participants (n = 111) were assigned to hydrophobic polyurethane PICC with proximal valve (intervention) or a polyurethane PICC with external clamp (standard care). Primary outcome was trial feasibility including PICC failure. Secondary outcomes were central line-associated bloodstream infection, local infection, occlusion, thrombosis, fracture and dislodgement, phlebitis, local or systemic allergic reaction, and PICC dwell time. RESULTS: All feasibility outcomes were achieved, apart from eligibility criteria. In total, 338 patients were screened, 138 were eligible (41%), and of these 111 were randomised (80%). Patients received the allocated PICC in 106 (95%) insertions. No patients withdrew from the study and there was no missing data. PICC failure was 24% (13/55) in the intervention group and 22% (12/55) in the standard care group (p = 0.820). PICC failure per 1000 PICC days was 16.3 in the intervention group and 18.4 in the control group (p = 0.755). The average dwell time was 12 days in the intervention and 8 days in the control group. CONCLUSIONS: This study demonstrates the feasibility of an efficacy trial of PICC materials in an adult population, once adjustments were made to include not only in-patients, but also patients being discharged to the Hospital in the Home service. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12616001578493 . Prospectively registered on 16 November 2016. The trial protocol was published a priori (Kleidon et al., Vasc Access 3:15-21, 2017).

Supporting patients and carers affected by pancreatic cancer: A feasibility study of a counselling intervention.

PURPOSE: Patients with pancreatic cancer have extremely high unmet psychological and physical needs. Family carers of these patients have even higher levels of distress than patients. Our purpose was to assess the feasibility and acceptability of a counselling intervention in patients diagnosed with pancreatic cancer and their carers. METHODS: We conducted a single-arm feasibility study of the PREPARES (Patients and RElatives affected by PAncreatic cancer: Referral, Education and Support) pilot intervention. Patient and carer participants received up to nine counselling sessions delivered by a trained nurse via telephone and/or telehealth technology. The intervention, informed by self-efficacy theory, involved components to assess and address care needs, and provide feedback to clinicians. Feasibility was measured using participation and retention rates. Participants completed semi-structured interviews at the end of the intervention about acceptability. These were analysed using thematic analysis. RESULTS: Twelve people participated: five patients and seven carers (38% and 50% participation rates respectively). Most participants (eight) completed all nine counselling sessions; two chose to receive fewer sessions and two were discontinued requiring more intensive psychiatric support. The intervention was highly acceptable. Participants unanimously preferred the telephone over video-conferencing and to receive counselling separately from their carer/patient. The main perceived benefits were emotional support, the nurse-counsellors' knowledge, care coordination and personalised care. Suggested improvements included a welcome pack about their nurse-counsellor and that sessions should continue beyond nine sessions if required. CONCLUSIONS: The PREPARES intervention was feasible and highly acceptable. This low-cost intervention provided much-needed support to people affected by this devastating disease.

How do cancer care services in Australia take care of their patients when they require emergency care? We need more evidence.

A letter to the editor on cancer patients accessing emergency care.

Current evidence of education and safety requirements for the nursing administration of chemotherapy: An integrative review.

PURPOSE: The administration of chemotherapy is a complex task which has many safety issues. Safe administration of chemotherapy by nurses should be evidence-based. The aim of this integrative review was to synthesise the evidence about education and practice requirements for safe administration of chemotherapy by nurses. METHOD: A systematic search of four databases identified 17 studies for inclusion in this review. Key words: Nurse, chemotherapy, cytotoxic drug, administration, safety, education. Data extracted from the studies included author, year, aims, design, sample, outcome measures and findings. After screening the articles, extracting study data and completing a summary table, critical appraisal of the studies was completed using the Mixed Methods Appraisal Tool (MMAT). RESULTS: All the studies focused on strategies to promote patient and nurse safety during nursing administration of chemotherapy. Content analysis identified five themes: governance, process safeguards, communication, interdisciplinary collaboration and education. Key strategies or interventions that increased patient and/or nurse safety identified were standardised computer-generated chemotherapy orders, barcodes, medication safety procedures, education and simulated learning. CONCLUSIONS: This review found low-level evidence exists about the education and safety requirements for nursing administration of chemotherapy. High-level research is needed to assist healthcare services to select evidence-based educational and safety strategies and provide appropriately resourced work environments to support the safe nursing administration of chemotherapy and deliver the best possible patient outcomes.

Taking care of our own: A narrative review of cancer care services-led models of care providing emergent care to patients with cancer.

PURPOSE: To synthesise available evidence on cancer care services-led models of care in the acute care setting that aim to reduce emergency presentations and/or hospital admissions for patients with cancer. METHODS: A narrative review of studies describing models of care for patients with cancer and emergent healthcare needs was undertaken. Four databases were searched using keywords to identify primary research or quality improvement articles published between January 2005-June 2017. RESULTS: After a systematic search, 22 studies were included in the review. The methodological quality of the included studies was poor when assessed using the Mixed Methods Appraisal Tool. Most studies were retrospective and set in a single centre. The overarching outcomes associated with the most commonly described models of care (telephone advice services and/or unplanned care and assessment units) were improved coordination of care/continuity of care, prompt access to specialist care, reduced utilisation of emergency departments, fewer hospital admissions and reduced cost. At the time of this review, evaluation of Nurse Practitioner-led services and acute oncology services had been limited. CONCLUSIONS: Findings indicate several models of care reduce emergency presentations and/or hospitalisations for those living with cancer and improve patient outcomes. What remains unclear is which underlying mechanisms reduce emergency presentations and/or hospitalisations for patients with cancer and whether successful models of care are uniquely suited to specific contexts of care or applicable across different healthcare settings. More research is needed to assist healthcare services to develop and evaluate models of care to address the emergent needs of people with cancer.

Insertion site assessment of peripherally inserted central catheters: Inter-observer agreement between nurses and inpatients.

INTRODUCTION: Many patients are discharged from hospital with a peripherally inserted central catheter in place. Monitoring the peripherally inserted central catheter insertion site for clinical and research purposes is important for identifying complications, but the extent to which patients can reliably report the condition of their catheter insertion site is uncertain. The aim of this study was to assess the inter-observer agreement between nurses and patients when assessing a peripherally inserted central catheter site. METHODS: The study was based on inpatients who were enrolled in a single-centre, randomised controlled trial comparing four different dressing and securement devices for peripherally inserted central catheter sites. A seven-item peripherally inserted central catheter site assessment tool, containing questions about the condition of the dressing and the insertion site, was developed. Assessment was conducted once by the research nurse and, within a few minutes, independently by the patient. Proportions of agreement and Cohen's kappa were calculated. RESULTS: In total, 73 patients agreed to participate. Overall, percentage agreement ranged from 83% to 100% (kappa = .65-.82). For important clinical signs (redness, swelling, ooze, pus and tracking), there were high levels of percentage agreement (99%-100%). CONCLUSION: The high level of agreement between nurse/patient pairs make the instrument useful for assessing peripherally inserted central catheter-associated signs of localised infection, allergic or irritant dermatitis or dressing dislodgement in a community setting.

Central venous Access device SeCurement And Dressing Effectiveness for peripherally inserted central catheters in adult acute hospital patients (CASCADE): a pilot randomised controlled trial.

BACKGROUND: Peripherally inserted central catheters (PICCs) are commonly used for delivering intravenous therapy. PICC failure is unacceptably high (up to 40%) due to mechanical, infectious and thrombotic complications. Poor securement potentiates all complication types. This randomised controlled trial (RCT) aimed to examine the feasibility of a large RCT of four dressing and securement methods to prevent PICC failure. METHODS: This single-centre pilot RCT included 124 admitted medical/surgical/cancer patients aged ≥ 16 years with a PICC. Interventions were: (i) standard polyurethane dressing and sutureless securement device (SPU + SSD, control); (ii) polyurethane with absorbent lattice pad dressing (PAL + Tape); (iii) combination securement-dressing (CSD); and (iv) tissue adhesive (TA + SPU). All groups except TA + SPU had a chlorhexidine-gluconate (CHG) impregnated disc. Feasibility outcomes were recruitment and safety/acceptability of the interventions. The primary outcome was PICC failure, a composite of PICC removal for local infection, catheter-associated bloodstream infection, dislodgement, occlusion, and/or catheter fracture. Secondary outcomes included individual complications, dressing failure and dwell time, PICC dwell time, skin complications/phlebitis indicators, product costs, and patient and staff satisfaction. Qualitative feedback was also collected. RESULTS: PICC failure incidence was: PAL + CHG + Tape (1/5; 20%; 17.4/1000 days), SPU + SSD + CHG (control) (4/39; 10%; 9.0/1000 days), TA + SPU (3/35; 9%; 9.6/1000 days), and CSD + CHG (3/42; 7%; 9.4/1000 days). Recruitment to PAL + CHG + Tape was ceased after five participants due to concerns of PICC dislodgement when removing the dressing. CSD + CHG, TA + SPU (TA applied only at PICC insertion time), and control treatments were acceptable to patients and health professionals. CONCLUSION: A large RCT of CSD + CHG and TA + SPU (but not PAL + CHG + Tape) versus standard care is feasible. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12616000027415 . Registered on 15 January 2016.

The caregiving journey for family members of relatives with cancer: how do they cope?

Family caregivers need adequate support from healthcare professionals to complete the demands associated with caregiving with minimal impact on their own health and well-being. An optimal balance of provision of care between family and support services has not been achieved; therefore, this literature review investigates how family caregivers endure and cope with the challenges of caring for an adult relative with cancer. This review considered the characteristics of caregivers and their functioning, the external and internal supports that help them cope, the ongoing challenges as they journey along the caregiving trajectory, the personal costs of caregiving, and how caregivers cope with supporting their family members through to the end of their journeys. The literature provides an abundance of research on the numerous challenges encountered by families living with cancer; however, little research has been conducted on the coping strategies used by family caregivers at specific stages along the illness trajectory that either optimize or hinder personal recovery. Even less information is available on interventions nurses can introduce to ease the caregiving burden. Improving nurses' understanding of the stressors and unmet needs associated with caregiving is fundamental to the development of effective family-focused clinical interventions.