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.

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.

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.

Mapeo de variabilidad sobre prácticas enfermeras relacionadas con el acceso vascular en el entorno de hemodiálisis. Estudio transversal / Mapping of variability on nursing practices in the hemodialysis environment. Cross-sectional study

Introducción: La Variabilidad de la Práctica Asistencial se define como "aquella situación en la cual pacientes con una clínica similar no son cuidados ni tratados de la misma forma en diferentes niveles de atención, sin que exista una base sólida en conocimientos derivados del cumplimiento de guías de práctica clínica". Objetivo: Analizar la adherencia de las enfermeras a recomendaciones basadas en evidencias, comparar la adherencia respecto a las características sociodemográficas e identificar intervenciones con mayor variabilidad en el manejo del acceso vascular. Material y Método: Estudio observacional transversal. Los sujetos de estudio fueron enfermeras de hemodiálisis que contestaron un cuestionario online ad hoc formado por 33 preguntas a través de GoogleForm, difundido por correo electrónico a nivel nacional durante los meses de octubre y noviembre de 2017. El cuestionario se organizó para dar respuesta a las variables del perfil sociodemográfico y a la adherencia a recomendaciones basadas en las guías KDOQI, detectando 7 dominios fundamentales para la práctica enfermera en hemodiálisis. Resultados: Se obtuvieron 217 encuestas válidas procedentes de 17 comunidades autónomas, lo que supone una tasa de respuesta del 16,69%. La adherencia a las recomendaciones resultó moderada, un 53,24% de las respuestas coincidieron con la evidencia emitida en las guías de práctica clínica. Las intervenciones con mayor incertidumbre y variabilidad están relacionadas con el uso del antiséptico, tipo y tiempo de apósitos y técnica de punción. Conclusión: Se obtuvo una adherencia moderada sobre las áreas de conocimiento que están produciendo mayor incertidumbre en los entornos de hemodiálisis, siendo el mapeo de variabilidad un instrumento útil para su detección

Introduction: The Variability of the Care Practice is defined as "that situation in which patients with a similar clinical situation are not cared for or treated in the same way in different levels of care, without a solid base in knowledge derived from the compliance with clinical practice guidelines". Objective: To analyze the adherence of nurses to recommendations based on evidence, to compare adherence in relation to sociodemographic characteristics and to identify interventions with greater variability in the management of vascular access. Material and Method: Cross-sectional observational study. The study subjects were hemodialysis nurses who answered an ad hoc online questionnaire formed by 33 questions through GoogleForm, disseminated by email at national level, during October and November 2017. The questionnaire was organized to respond the variable of the sociodemographic profile and adherence to recommendations based on the KDOQI guidelines, detecting 7 fundamental domains for nursing practice in hemodialysis. Results: 217 valid surveys were obtained from 17 autonomous communities, which implies a response rate of 16.69%. Adherence to the recommendations was moderate, 53.24% of respondents agreed with the evidence issued in clinical practice guidelines. Interventions with greater uncertainty and variability are related to the use of the antiseptic, type and time of wound dressings, and puncture technique. Conclusion: A moderate adherence was obtained related to the areas of knowledge that are producing greater uncertainty in hemodialysis environments, being the mapping of variability a useful instrument for such detection

Implementation of a knowledge mobilization model to prevent peripheral venous catheter-related adverse events: PREBACP study-a multicenter cluster-randomized trial protocol.

BACKGROUND: Peripheral venous catheters are the most commonly used invasive devices in hospitals worldwide. Patients can experience multiple adverse events during the insertion, maintenance, and management of these devices. Health professionals aim to resolve the challenges of care variability in the use of peripheral venous catheter through adherence to clinical practice guidelines. The aim of this cluster-randomized controlled trial is to determine the efficacy of a multimodal intervention on incidence of adverse events associated with the use of peripheral venous catheters in adult hospital patients. Additional aims are to analyze the fidelity of nurses and the relationship between contextual factors on the use of best available and the outcomes of the intervention. METHODS: Five public hospitals in the Spanish National Health System, with diverse profiles, including one university hospital and four second-level hospitals, will be included. In total, 20 hospitalization wards will be randomized for this study by ward to one of two groups. Those in the first group receive an intervention that lasts 12 months implementing evidence-based practice in healthcare related to peripheral catheters through a multimodal strategy, which will contain updated and poster protocols insertion, maintenance and removal of peripheral venous catheters, technologies applied to e-learning, feedback on the results, user and family information related to peripheral catheter, and facilitation of the best evidence by face-to-face training session. PRIMARY OUTCOME MEASURES: Incidence of adverse events associated with the use of peripheral venous catheters is measured by assessing hospital records. SECONDARY OUTCOME MEASURES: Nurses' adherence to clinical practice guidelines, clinical outcomes, and the cost of implementing the multimodal intervention. DISCUSSION: Clinical implementation is a complex, multifaceted phenomenon which requires a deep understanding of decision-making, knowledge mobilization, and sense making in routine clinical practice. Likewise, the inclusion of strategies that promote fidelity to recommendations through multicomponent and multimodal intervention must be encouraged. The use of a transfer model could counterbalance one of the greatest challenges for organizations, the evaluation of the impact of the implementation of evidence in the professional context through quality indicators associated with prevention and control of infections. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10438530 . Registered 20 March 2018.