AVAS Conference Abstracts

Volume 3 Issue 2

AVAS Conference Abstracts

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A QUALITY IMPROVEMENT INITIATIVE ON MIDLINE CATHETERS AS A VIABLE DEVICE FOR DIFFICULT INTRAVASCULAR PATIENTS WITHIN AN ADULT TERTIARY HOSPITAL

Ms Alexandra Pickup, Dr James Rippey, Ms Bobby Kemp
Sir Charles Gairdner Hospital, Nedlands, Western Australia

Introduction: Difficult intravenous access (DIVA) patients continue to challenge clinicians within the acute health care setting. Commonly this relies upon ultrasound guidance for standard peripheral vascular catheter (PVC) insertion following multiple failed attempts. This subgroup frequently experience early complications leading to shorter PVC indwelling time than expected. It is proposed that the use of midlines may help manage these challenges.

Objectives: Assess reliability, safety, complications and utilisation of Midlines for DIVA patients.

Methods: 34 DIVA patients with expected protracted IV therapy were identified on presentation to a tertiary hospital emergency department. A midline was inserted by 1 of 6 trained, highly experienced ultrasound emergency physicians under ultrasound guidance and a questionnaire about the insertion was completed by the physician. The midlines inserted were then regularly audited via questionnaire by the Intravascular Nursing Service until removal.

Summary of Results: Average days indwelling 6.09 (Range 0-19 days). PIVAS score 0 for all midlines at all audit times. Average vein diameter (Range 3 to 8mm). Average vein depth 16.4 (Range = 6 to 35mm). Average failed PVC attempts prior to midline 2.45 (Range 0 to 10). 69.6% did not require further intravenous access during inpatient stay. One potential incident (midline mistaken for PICC, nil adverse outcome to patient recorded).

Discussion: The study supported that midline insertion in a DIVA cohort was reliable, safe, efficient and improved patients’ experiences with intravenous therapy. The QI also showed the importance of multidisciplinary collaboration and hospital wide education when instituting the use of a new intravascular device.

TEACHING SELF ADMINISTRATION OF IV ANTIBIOTICS – AN EFFICIENT, COST EFFECTIVE AND PATIENT CENTRED MODALITY

Beverley-Anne Hopper
Waitemata District Health Board

Abstract

Outpatient IV antibiotics (OPIVA) are increasingly used in today’s healthcare for patients who require long courses of IV antibiotics. OPIVA services allow for patient-centered, home based care and have been shown to improve patient satisfaction and reduce hospital length of stay (LOS). The Waitemata DHB OPIVA service discharges patients on Elastomeric Infusors, District Nurse daily infusions and administering their own IV antibiotics. This presentation will focus on the improvements made by the inclusion of an OPIVA Clinical Nurse Specialist to the team.

One of the remits of the new OPIVA Clinical Nurse Specialist was to teach suitable patients to self-administer their own IV antibiotics. The OPIVA CNS has implemented new self-management modalities, creating instructional resources and has reduced inconsistencies in follow up and transition of care leading to improved patient satisfaction.

Over the last 18 months there has been proven bed days saved and positive patient satisfaction has been noted from a Patient Survey. Patients now have standardised education and counselling and the option to self-administer their antibiotics. An audit of the service supported the inclusion of a Clinical Nurse Specialist to the OPIVA team. The number of patients referred through to the OPIVA service and being taught self-administration continues to grow.

With the appointment of the OPIVA CNS, Waitemata DHB now has a high quality efficient home based IV antibiotic service with optimized transition of patient care, improved patient satisfaction, safety and reduced length of stay.

INTRAVENOUS CARE AND MAINTENANCE OBSERVATION STUDY

Prof, Samantha Keogh ^1,2,3, Ms, Caroline Shelverton^1, ², Ms, Julie Flynn ², Karen Davies²,
Ms, Nicole Marsh ^1,2 , Prof, Claire Rickard C ^1,2
¹AVATARGriffith University
²Royal Brisbane and Women’s Hospital
³Queensland University of Technology

Abstract

Introduction: The aim of this study was to gain a ‘real world’ overview of current intravenous care and maintenance practice by nursing staff. Research has quantified the unacceptably high failure rate of peripherally inserted venous catheters (PIVCs) prior to completion of prescribed treatment (ranging from 26%-44%).

Methods: This was a single center prospective, observational study, of intravenous (IV) medication and flush administration on surgical and medical wards of a tertiary metropolitan hospital. Participants included Registered Nurses and Endorsed Enrolled Nurses from 2 wards, experience ranging from new graduate to >20 years. Consenting nurses were observed over an 8 hour shift whilst administering IV medications or flushes.

Results: Most PIVCs were in for a reason i.e. antibiotic administration. It was identified that IV drugs were administered by infusion or bolus. Poor adherence to infection control was evident with a third of nurses not following aseptic non-touch technique (ANTT), half not fully observing hand hygiene and limited decontamination of the needless connector. Flushing practice was found to be inconsistent with bag and burette delivery.

Conclusion: The implications for practice are that the importance of hand hygiene and ANTT principles need to be highlighted to improve compliance. This includes the use of personal protective equipment. Further evidence on needleless connector decontamination, including scrubbing & drying times is required. We need to re-educate the value of flushing for all PIVCs with a focus on, maintaining patency, prevent mixing of incompatible drugs and early detection of failure.

PERIPHERALLY INSERTED CENTRAL CATHETER Associated THROMBUS (PICCAT) – DOES THE TYPE OF CATHETER MATERIAL AFFECT UPPER LIMB DVT RATES?

Cathy Biles – Clinical Nurse Consultant
Department of Diagnostic Radiology, Princess Alexandra Hospital, Ipswich Road, Woollongabba QLD 4102, Australia

Abstract

Upper limb Deep Vein Thrombosis (DVT) is a common complication in patients who have a Peripherally Inserted Central Catheter (PICC). The BioFlo PICC is made from a material that claims to reduce the thrombus accumulation on it’s surface by 87%, when compared to other standard PICCs. This is thought to reduce the risk of upper limb DVT.

The objective of the PICCAT study is to randomise patients requiring a PICC, to have either a BioFlo PICC or the standard polyurethane PICC. The rate of upper limb DVT in either arm of the study is monitored and analysed, to determine if the catheter material does affect the upper limb DVT rate.

The PICCAT study is a prospective randomised trial designed to compare the rate of symptomatic upper limb DVT in patients with either the BioFlo PICC or the standard polyurethane PICC. Baseline upper limb DVT rates were used to calculate the sample size required. Data collection intervals for symptomatic DVT were determined from onset of symptoms in the baseline DVT data.

An interim analysis guided us to modify the study to concentrate on the Oncology cohort of patients, who consistently demonstrate a higher incidence of upper limb DVT. The sample size was recalculated and randomisation for the study is now in Oncology patients only.

Randomisation for the study continues, and is currently 30% of the revised sample size, as prompted by the interim analysis. At this stage results are inconclusive.

THE IMPORTANCE OF CONFIRMING PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) TIP POSITION FOR COMPUTED TOMOGRAPHY (CT) SCAN CONTRAST PRESSURE INJECTION

Cathy Biles – Clinical Nurse Consultant
Department of Diagnostic Radiology, Princess Alexandra Hospital, Ipswich Road, Woollongabba QLD 4102, Australia

Abstract

A recent patient incident with harm, as a result of the use of a malpositioned PICC for CT contrast pressure injection, prompted a review of protocol when PICCs are used for this purpose.

To prevent a recurrence of a similar incident, a clear and strict checking protocol needed to be formulated to ensure that the tip of the PICC is checked before and after the CT contrast pressure injection, and that steps are taken to rectify any issues or problems that are identified.

A flowchart was designed to guide clinical practice when Radiology staff use PICCs for the CT contrast pressure injection. Concise instructions were important, so that staff had clear direction at each step of the process, and that a consistent and uniform outcome was achieved.

The use of the designated flowchart has been embedded into practice, and has identified further malpositioned PICCs prior to CT pressure injection of contrast. This resulted in alternative intravenous (IV) access being used, and this consistent ongoing monitoring is essential for preventing patient harm.

Confirmation of PICC tip position is now mandatory when a patient is undergoing a CT scan with contrast via a pressure injector. Migration of the PICC tip is not uncommon, and extravasation of contrast through a PICC is a very real risk to patient safety, and needs to be continually monitored through the use of standardised protocol.

CHLORHEXIDINE GLUCONATE OR POLYHEXAMETHYLENE BIGUANIDE DISC DRESSING TO REDUCE THE INCIDENCE OF CENTRAL-LINE-ASSOCIATED BLOOD STREAM INFECTION: A FEASIBILITY RANDOMISED CONTROLLED TRIAL (THE CLABSI TRIAL)

Joan Webster ^1,2,3, Emily Larsen E ^1,2 , Nicole Marsh N^1,2, Md Abu Choudhury ², Patrick Harris¹, Claire M Rickard C^1,2,3, David Paterson⁴
¹Royal Brisbane and Women’s Hospital, Herston, QLD 4006, Australia
²Alliance for Vascular Access Teaching and Research (AVATAR), Griffith University, Brisbane, Australia
³National Centre of Research Excellence in Nursing, Griffith University, Nathan QLD 411, Australia
⁴University of Queensland, UQ Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Herston, Australia

Abstract

Introduction: A number of antimicrobial impregnated discs to prevent central-line associated blood stream infection (CLABSI) are marketed but it is unclear which disc is most effective.

Objective: To investigate the feasibility and safety of comparing two antimicrobial impregnated discs to prevent CLABSI.

Methods: We conducted a single-centre, parallel group, randomised controlled trial in a 929-bed, tertiary referral hospital. Hospital in-patients requiring a peripherally inserted central catheter were randomised to chlorhexidine gluconate (CHG) or polyhexamethylene biguanide (PHMB) disc dressing group. Dressings were replaced every 7-days, or earlier, if clinically required. Participants were followed until device removal or hospital discharge. Feasibility outcomes included: proportion of potentially eligible participants who were enrolled; proportion of protocol violations; and proportion of patients lost to follow-up. Clinical outcomes were: CLABSI incidence, diagnosed by a blinded infection control practitioner; all cause BSI; and product-related adverse events.

Results: Of 143 patients screened, 101 (42%) were eligible. Five (3.5%) declined participation. There was one post-randomisation exclusion. Two (2%) protocol violations occurred in the CHG group. No patients were lost to follow-up. Three (3%) blood stream infections occurred; two (2%) were confirmed CLABSIs (one in each group) and one a mucosal barrier injury-related BSI. 1217 device days were studied; resulting in 1.64 CLABSI/1000 catheter days. One (1%) disc-related adverse events occurred in the CHG group.

Conclusion: Disc dressings containg PHMB are safe to use for infection prevention at catheter insertion sites. An adequately powered trial to compare PHMB and CHG discs is feasible.

A SURVEY OF PATIENT'S EXPERIENCE OF CARE DELIVERED BY THE OUTPATIENT INTRAVENOUS ANTIBIOTIC SERVICE AT AUCKLAND CITY HOSPITAL

Poonam Kumari

Abstract

Background: A review of the literature found limited information on patients’ experience of outpatient intravenous antibiotic (OPIVA) services, suggesting a need for a survey of patients’ experience of the care provided by an OPIVA service.

Objective: To survey patients’ experience of the care provided by the OPIVA service at Auckland City Hospital.

Methods: A cross-sectional survey of consecutive patients aged ≥ 15 years who had received usual care under the OPIVA service at Auckland City Hospital was undertaken. Patients were provided with a patient information sheet and invited to complete a self-administered patient experience questionnaire immediately following their last OPIVA clinic appointment. A patient questionnaire and patient information sheet was posted with a prepaid envelope to patients who had a short course of OPIVA therapy and did not attend the clinic for follow-up.

Results: Of 101 patients approached, 75 (74%) completed the survey questionnaire. Most respondents were male, identified as NZ European, and had received OPIVA initially on an inpatient basis in hospital and completed their treatment in the community. The survey responses were mostly positive towards provision of OPIVA (99%), communication with nurses (97%) and doctors (96%), provision of antibiotic administration training (90%) and information provision (99%), and the convenience of the clinic (87%). Two themes were identified for improvement: respondents reported experiencing difficulty with the medical devices required and a lack of consistency in nursing practice.

Conclusion: Overall, the patient experience of the OPIVA service was rated as positive. Recommended actions to improvement meeting the needs of patients included: better patient discharge information, better collaboration between medical and nursing staff, training sessions for staff and patients, and on-call support services for patients receiving OPIVA.

SAFETY AND QUALITY STANDARDS FOR INVASIVE MEDICAL DEVICES

Sue Greig^{1, 2}
¹Senior Project Officer, National HAI Prevention Program, Australian Commission on Safety and Quality in Health Care
² Adjunct Lecturer, Griffith University

Abstract

What does it mean to have a quality and safety system to support the safe use of invasive medical devices?

Any organisation large or small that uses invasive medical devices or provides care to patients with invasive medical devices in place has the responsibility to ensure that the invasive medical devices are inserted, managed and removed appropriately to minimise risk of healthcare related complications and in a manner consistent with current evidence based principles. This responsibility applies regardless of the complexity of the invasive medical device or the frequency of use.

The safe use of invasive medical devices involves the governance of the organisation utilising quality and safety principles to identify gaps in current practices, assess compliance with policy as well as determine and make available appropriate training and assessment of competence of the workforce.

In January 2013, the Australian Commission on Safety and Quality in Health Care released National Safety and Quality Health Service (NSQHS) Standard 3: Preventing and Controlling Healthcare Associated Infection protect the public from harm and to improve the quality of health care provided by organisations. Invasive medical devices were included in the NSQHS Standard 3 as it was identified there was a significant gap between what should happen and want was actually occurring in health service organisations.

From January 2013 to December 2016 more than 3000 organisations have met the requirements of the NSQHS Standard 3 criterion relating to implementing protocols for invasive device procedures and having competency based training for the workforce who perform procedures with invasive devices.

A RABBIT VENOUS MODEL OF INFUSION INFILTRATION TO STUDY THE EFFECT OF A HYPEROSMOTIC SOLUTION

Hidenori Tanabe^1,2, Naoto Takemura², Ryoko Murayama¹, Makoto Oe¹, Hiromi Sanada³
¹University of Tokyo, Graduate School of Medicine, Department of Advanced Nursing Technology, Tokyo, Japan
²Terumo Corporation, Tokyo, Japan
³University of Tokyo, Graduate School of Medicine, Department of Gerontological Nursing/Wound Care Management, Tokyo, Japan

Abstract

Peripheral intravenous catheters (PIVCs), used to deliver peripheral parenteral nutrition (PPN) in hospitalized patients, are frequently removed due to infiltration, one of the most common complications in intravenous therapy. High osmolality is a risk factor associated with PPN; however, the reason why high osmolality induces infiltration is unclear, and conflicting clinical results have been reported regarding the tolerance to osmolality. Moreover, there is no clear criterion for safe PPN administration. To investigate the mechanism of infiltration induced by a hyperosmotic solution, a rabbit was administered with such a solution. This solution was administered via the rabbit’s left ear vein and normal saline was infused via the rabbit’s right ear vein using PIVCs. The total infusion duration was 1 h; infusion comprised 10 cyclic infusions with 1-min infusion each, and the solution in the vessel was clipped by clamps for 5 min. After administering the solutions, ear vein tissues were sampled and fixed with phosphate-buffered 10% formalin. Cross-sections of the ear vein tissues were stained with CD31 antibody, hematoxylin, and eosin. Immunostaining and a histopathologic examination were performed blindly. Herein infiltration was defined as the presence of subcutaneous edema, which was observed in the left ear that received the hyperosmotic solution. Compared to the right ear vein that received normal saline, the left ear vein showed loss of venous endothelial cells. This suggests that hyperosmotic solutions lead to infiltration due to the loss of endothelial cells. Therefore, this model can be useful in establishing safe administration routes and adequate PPN osmolality.

“HE CRIES, HE SAYS THAT IT HURTS”:

CHILD AND CARE-GIVERS PERSPECTIVE OF PAEDIATRIC PERIPHERAL INTRAVENOUS ACCESS

Ms. Paula Cattanach¹, Ms. Tricia Kleidon^1,2, Dr. Amanda J Ullman^2,3
¹Vascular Access Management Service, Lady Cilento Children’s Hospital, Brisbane, Australia
² Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Australia
³School of Nursing and Midwifery, Griffith University, Nathan, Australia.

Abstract

Aim: Peripheral intravascular catheters (PIVCs) are the most commonly used medical device, but their insertion and management within the paediatric setting can be difficult. This study aimed to explore the patients and care-givers perspectives of the experience of PIVCs in the paediatric acute care setting to inform the development of innovations and practice improvements.

Methods: A prospective, explorative study was undertaken at the Lady Cilento Children’s Hospital, Queensland. Care-givers of children who had recently had a PIVC inserted were invited to participate. Semi-structured interviews were conducted via phone or in person. Interviews were transcribed verbatim and thematic analysis was conducted, with codes developed inductively using an iterative process and agreement on themes negotiated by all team members.

Results: Fifteen care-givers participated in the interviews, prior to data saturation. Care-givers raised similar themes, although with a diverse range of experience related to each aspect of PIVC insertion, use, management and removal. Themes centred on: communication with healthcare staff; apprehension due to previous insertion experiences; fear regarding accidental dislodgement; difficulty with activities of daily living; appreciation for skilled clinicians and technology; and the care-giver role in facilitating insertion.

Conclusion: The development and promotion of effective paediatric PIVC insertion and management practices should take into consideration the expressed needs of patients and care-givers.

A PILOT OBSERVATIONAL SURVEY OF CVAD EXPERIENCES BY AUSTRALASIAN HPN PATIENTS

Karen Winterbourn¹, Gillian Anderson¹, Gil Hardy¹, Rachel Healy¹
¹Parenteral Nutrition Down Under Inc. (PNDU)

Abstract

Introduction: PNDU, the support group for Australian and New Zealand members receiving Home Parenteral Nutrition (HPN) for intestinal failure, appreciates some studies indicate that implanted ports have lower infectious complications than other central venous access devices (CVAD) but the small number of published studies specific to HPN indicate the opposite.

Objectives: To survey PNDU members on practical and historical experiences of catheter-related infections (CRI) with CVAD.

Methods: An on-line questionnaire was circulated to 42 members. Results were analysed by an independent carer.

Results: There was a 74% response (19 adults, 12 carers of children) . All Australian states were represented, with 41.9% in NSW and 3.2% in New Zealand. Time on HPN ranged from <12mo (16.1%) to 20+yrs (6.5%). Hickman/Broviac that had been in place for 12mo-3yrs (42%) were most used (67.7%) and with single lumen (81%). Some had implanted ports (29.0%) or Arterio-Venous Fistulas (AVF)(3.2%). All Hickman/Broviac and 66.7% implanted ports were accessed nightly with Hickman/Broviac dressing changes weekly (81.0%) by themselves (28.6%) or by carers. Heparinised saline (45.2%) or TauroLock™ (35.5%) were the principal locking solutions. CRI were common (67.7%), notably in children (83.3%), with single lumen CVAD (71.4%) and uncapped CVAD (75%). There were no CRI in CVAD using TauroLock™.

Conclusions: This pilot survey describes Australasian HPN practices and although not sufficiently robust to make conclusive statements regarding the type of CVAD, or catheter care procedures and CRI, it is a starting point for further investigation into the contributing factors to CRI in HPN. [247 words]

PERIPHERALLY INSERTED CENTRAL CATHETER OUTCOMES POLYURETHANE VERSUS ENDEXO: PIC COMPARE A RANDOMISED CONTROLLED FEASIBILITY TRIAL

Ms Julieta Woosley¹, Ms. Tricia Kleidon^1,2, Dr. Amanda Ullman^2,3, Dr. Brett Chaseling¹, Dr. Jason Schoutrop¹, Mr Gabor Mihalia², Dr. Li Zhang², Professor Claire Rickard^2,3
¹Vascular Access Management Service, Lady Cilento Children’s Hospital, Brisbane, Australia
² Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Australia
³School of Nursing and Midwifery, Griffith University, Nathan, Australia.

Abstract

Introduction: Peripherally inserted central catheter (PICC) failure causes discomfort, interruption to treatment and prolonged hospital stays. PICCs fail due to infection (local or systemic), and mechanical (blockage due to thrombosis or occlusion). Microbial biofilm complicates treatment of infections. BioFlo™ PICC claims novel technology is resistant to blood products and biofilm development. Independent testing has not yet been undertaken.

Objectives: To establish the feasibility of a definitive randomised control trial (RCT) examining the efficacy and cost effectiveness of new technology BioFlo™ PICC to reduce failure.

Method: Single centre parallel group, pragmatic pilot RCT comparing the effectiveness of BioFlo™ PICC in a tertiary paediatric facility for 150 patients admitted to Lady Cilento Children’s Hospital, Brisbane.

Intervention arms:

Polyurethane PICC: 3fr, 4fr Polyurethane Cook PICC;
New generation polyurethane PICC: 3fr, 4fr Angiodynamics BioFlo™

Primary outcomes: Feasibility (including effect size estimates);

Secondary outcomes: All cause PICC complication (catheter-related bloodstream infection, thrombosis, occlusion, breakage); PICC failure; patient, family and staff satisfaction.

Children’s Health Service District, Queensland provided ethics and governance approval and the trial was prospectively registered on the Australian and New Zealand Clinical Trial Registry (ANZCTR CTRN12614000280606).

Results: Pre-determined feasibility criteria were achieved. The desired cohort was successfully recruited over a suitable time period; low rates of attrition, and good protocol adherence. PICC failure occurred in 22% (n=16/74) standard care and 11% (n=8/72) in BioFlo™.

Conclusions: It is feasible to conduct an efficacy RCT to establish the effectiveness of new catheter technology to reduce PICC failure. Further research is required to definitively identify clinical, cost-effective methods to prevent PICC failure due to infection, occlusion and thrombosis.

IMPROVING PERIPHERAL INTRAVENOUS CATHETER SAFETY AND PERFORMANCE IN PAEDIATRICS: A PROSPECTIVE COHORT STUDY

Ms Victoria Gibson^2,3, Ms Tricia Kleidon^1,2, , Ms. Paula Cattanach¹, Dr. Amanda J Ullman^2,3
¹Vascular Access Management Service, Lady Cilento Children’s Hospital, Brisbane, Australia
² Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Australia
³School of Nursing and Midwifery, Griffith University, Nathan, Australia

Abstract

Background: The insertion and care of peripheral intravenous catheters (PIVC’s) are a complex interdisciplinary responsibility. PIVC’s are associated with a high rate of failure and dysfunction. Practice audits and benchmarking are necessary to drive improvement strategies.

Objectives: To determine current practice, management and complications associated with PIVCs within a tertiary paediatric hospital to provide direction for clinicians to focus education relating to knowledge/practice gaps.

Method: A prospective audit of PIVC inserted at Lady Cilento Children’s Hospital, Brisbane (excluding emergency, operating room suites, intensive care) between January and April 2016 was undertaken. Healthcare workers who insert PIVCs completed an online survey and one-on-one parent interviews were undertaken to understand the patient experience.

Results: One hundred and three PIVC’s were audited. Almost half of PIVCs (50/103; 48%) failed prior to completion of treatment. Almost 40% of PIVCs (19/50; 38%) failed within 24 hours and re-insertion took an average of three hours. Ninety percent (93/103) of PIVCs had no documentation. One in two PIVCs (45/103; 45%) required more than two attempts to insert, fifty percent of PIVC inserters (59/117) wanted to receive more training, and one third (38/117; 32%) had no formal paediatric PIVC training. Parents and children report PIVC experience to be one of the most stressful and painful inpatient experience.

Conclusion: PIVC failure is unacceptably high. Areas identified for improvement were PIVC insertion training, prompt removal when no longer required, regular review of PIVC site and increased compliance with documentation. The next phase of this project will implement PIVC care bundles based on knowledge/practice gaps over three months followed by a post implementation audit to assess implementation success.

MIDLINE CATHETERS FOR PROLONGED ANTIBIOTIC THERAPY

Nicholas Mifflin ^1,Evan Alexandrou^1,2,Craig McManus ^1,3
¹ Central Venous Access Service, Liverpool Hospital New South Wales
²School of Nursing and Midwifery, Western Sydney University New South Wales Australia.
³ After Hours Clinical Nurse Consultant Service, Liverpool Hospital New South Wales

Abstract

Introduction: Recent evidence suggests that peripheral intravenous catheters (PIVC) can remain insitu until clinically indicated for removal. For a multitude of reasons, a significant number of these devices do not last the expected duration of therapy. Midline catheters by design extend further into the vessel and may provide more definitive venous access than traditional peripheral intravenous catheters. They are increasingly being used as an alternative to central venous access devices when prolonged intravenous access is required.

Objectives: To review the effectiveness of polyurethane midline catheters inserted for antibiotic therapy

Methods: Clinical Audit of midlines inserted with ultrasound guidance

Results: Ninety three midlines were audited between June 2016 and January 2017. Nearly all (n=91) midlines were placed in the basilic vein. Dwell time ranged from 1-55 days with a mean dwell of 12 days. Antibiotic therapy and long term access were the primary indications for these devices. Catheters remained insitu until no longer required in 63 patients (67.7 %). Devices were prematurely removed because of dislodgement (n= 16, 17.2%), occlusion (n=3, 3.3 %), leaking at insertion site (n=2, 2.2%), thrombophlebitis (n=3, 3.3%) and asymptomatic thrombosis (n=1, 1.1%).

Conclusion: Midlines may be appropriate for prolonged antibiotic therapy however more research is required on specific antibiotic suitability, dose, dilution and rate of administration.

REDUCING PIVC RELATED BACTERAEIMA WITH EFFECTIVE FEEDBACK

Davidson, M.
¹Infection Prevention and Control, Townsville Hospital and Health Service, Townsville, Australia

Abstract

Introduction: Peripheral Intra-venous Catheter (PIVC) related bacteraemia represent preventable Healthcare Associated infections (HAI). The Infection Prevention & Control (IPAC) department identified recurring themes in PIVC related Staphylococcus aureus bacteraemia (SAB). The potential preventable causes continued to surface despite up to date PIVC policy and procedures.

Objectives: To reduce the number of PIVC related SAB, by using short, case study style, and timely feedback of events as they occurred to the ward/unit that contributed to the event.

Methods: When a PIVC related SAB was confirmed, the IPAC nurse developed a feedback document. A minimum of 2 feedback sessions were run at hand over times for each affected ward/unit. The sessions were no more than 10 minutes duration. Staff were provided with a summary of the event, the effect on the patient and 2 recommendations to prevent future events. Questions were encouraged.

Results: Over a 12 month period, a 30% reduction in PIVC related bacteraemia occurred across the organisation.

Conclusions: A personalised patient story, including photographs of their infected PIVC site, provided meaningful feedback for staff. Coupled with direction for improvement, staff were able to reflect on their practices and implement simple changes. This feedback method resulted in a reduction of PIVC related bacteraemia for the organisation.

IMPROVING BLOOD STREAM SURVEILLANCE: ONE ORGANISATIONS JOURNEY

Davidson, M.
¹Infection Prevention and Control, Townsville Hospital and Health Service, Townsville, Australia

Abstract

Introduction: Surveillance of potential healthcare associated bacteraemia is an important indicator of the quality of healthcare. In 2013, Queensland Health introduced an incentive to reduce adverse events in the form of a financial penalty to Hospital and Health Services that exceeded the agreed upon limit. Therefore a robust system of surveillance is necessary, as without confidence in the numbers of potentially preventable infections, the impetus to make improvements to the delivery of healthcare will be impeded.

Objectives: To improve the quality of data collected for blood stream surveillance at a northern Australian teaching hospital to ensure that such data complies with current Australian data definitions for Staphylococcus aureus bacteraemia (SAB) and Central line associated blood stream infections (CLABSI) as per the Australian Commission for Safety & Quality in Healthcare (ACSQHC).

Methods: In August 2014 the Infection Prevention and Control department introduced a multidisciplinary meeting to discuss all potential health care associated blood stream infections. This team consisted of Infection Control practitioners, Microbiology and Infectious diseases Medical officers plus other invited members. This supported a robust investigative and feedback process.

Results: Increase confidence in numbers with a robust application of nationally agreed definitions. Decrease in CLABSI rates by 60%. 67% of SAB now identified as attributable to vascular access. 45% of all HCAI relating to vascular access.

Conclusions: Guidelines require that organisations implement a validation process for bacteraemia’s related to the provision of healthcare. The implementation of a multidisciplinary meeting has improved the quality of data collected at our organisation.

IS YOUR PICC DRESSED FOR SUCCESS? A RANDOMISED CONTROLLED PILOT TRIAL OF NOVEL DRESSING AND SECUREMENT TECHNIQUES FOR PICC IN 101 PEDIATRIC PATIENTS

Ms Tricia Kleidon^1,2Dr. Amanda Ullman^2,3, Ms. Victoria Gibson^2,3, Dr. Brett Chaseling¹, Dr. Jason Schoutrop¹, Mr Gabor Mihalia², Professor Claire Rickard^2,3
¹Vascular Access Management Service, Lady Cilento Children’s Hospital, Brisbane, Australia
² Alliance for Vascular Access Teaching and Research (AVATAR) group, Menzies Health Institute Queensland, Australia
³School of Nursing and Midwifery, Griffith University, Nathan, Australia.

Abstract

Introduction: Complications and failure of peripherally inserted central catheters (PICCs) are multi-factorial.

Objective: We evaluated the feasibility of an efficacy trial comparing PICC securement and dressing in pediatrics through innovative dressing and securement.

Method: A single centre, pilot compared the effectiveness of various dressing and securement methods for 101 paediatric patients admitted to the Royal Children’s Hospital and Lady Cilento Children’s Hospital, Brisbane; with a PICC and randomised to:

Standard care: Bordered Polyurethane(BPU) Sutureless Securement Device (SSD) (BPU + SSD; StatLock^®; Bard),
Tissue adhesive (TA; Histoacryl^®; Ethicon & BPU)
Integrated dressing and securement product (IDS; SorbaView Shield^®; Centurion)

Primary outcomes: Feasibility (including effect size estimates); Secondary outcomes: All cause PICC complication and failure; patient, family and staff satisfaction.

Ethics and governance approval was provided by the Children’s Health Service District, Queensland and Australian and New Zealand Clinical Trial Registry respectively.

Results: Protocol feasibility was established. PICC failure was: standard care, 6% (2/32); integrated securement dressing, 6% (2/31); and tissue adhesive 3% (1/32). PICC complications were 16% across all groups. Tissue adhesive provided immediate postoperative hemostasis prolonging the first dressing change to 5.5 days compared to 3.5 and 2.5 days in standard care and integrated securement device respectively. Bleeding was the most common reason for first dressing change: standard care (n=18; 75%) and integrated securement device (n=11; 69%) compared to tissue adhesive, (n=4; 27%). Parental satisfaction and staff feedback was most positive for integrated securement dressing.

Conclusions: This research suggests the safety and acceptability of novel securement devices when compared to standard care; it may also reduce post insertion dressing changes. Further research is required to confirm clinical cost effective methods in preventing early PICC failure.

DEVELOPMENT OF AN INTRAVENOUS ACCESS TEAM CREDENTIALING PACKAGE

RN Kerry Taliaferro
Canberra Hospital & Health Services, ACT, Australia

Abstract

Introduction: Establishing a successful nurse led Intravenous Access Team (IVAT) requires training RN’s to achieve competency in all aspects of vascular access care. Theoretical knowledge, clinical insertion skills, critical thinking, and patient centered care are vital to reduce potential complications and provide best evidence based care.

Objectives: To achieve this desired skill set in IVAT RN’s a robust education package was developed addressing all aspects involved in the insertion, care and maintenance of PICC lines according to National standards, international consensus and local hospital polices.

Methods: A variety of training methods were utilised to facilitate teaching the required knowledge, skills and competency components to allow for independent practice.

These included:

In house elearning packages focused upon: Central Venous Access Devices (CVAD’s), surgical aseptic technique, infection control and anatomy and physiology.

External elearning and face to face courses on PICC line insertion under Ultrasound and using ECG Tip Confirmation systems.
Hands on Ultrasound training and simulation sessions with an ultrasonographer.
Insertions under close supervision until a level of competency achieved.
Passing a practical credentialing process and theoretical exam.

Results: Six IVAT RN’s have achieved and maintained competence in PICC insertion and troubleshooting skills. Endorsement during Hospital Accreditation provided external validation of the package. RN’s valued the inclusion of multiple components and teaching methods delivered by a variety of clinicians and educators in achieving and maintaining competency. Developing a peer group to enhance and maintain knowledge allows for reinforcement, continued education and successful annual re credentialing.

BRIDGING THE GAP IN VASCULAR ACCESS – CANCER NURSES TAKE CONTROL

Tanya Flynn

Abstract

Cancer Services has a dedicated nurse-led PICC team responsible for the assessment, insertion and management of vascular access in all cancer patients.

Historically PICCs were inserted without a clear indication, mainly attempting to avoid multiple peripheral ‘sticks’. Powerglide^® Midline was introduced as an intermediate option for these patients and those with difficult vascular access.

The purpose of the Powerglide^® trial was to evaluate a product to determine if it could meet the needs of patients requiring intermediate vascular access undergoing cancer treatment.

Patient’s suitability for Powerglide^® was assessed using a revised vascular assessment form. Patients needing IV therapy > 3 days, with no visible or palpable veins were the predominate cohort. The trial ran for 3 months with 46 Powerglides^® inserted into 43 patients.

A data collection tool captured patient and treatment demographics, blood-draw capability, dwell time and reason for removal.

Three adverse events were noted - two infiltrations, one occlusion. These incidents were reviewed, de-escalated and accepted as a potential risk of cannulation requiring no further investigation. No incidences of thrombophlebitis were seen.

The trial use of Powerglide^® was successful. A longer dwell time was expected (range 2 - 28 days; average 7.5 days), possibly due to delayed referral by medical staff and initial hesitation about a new access device. The Powerglide^® was well received by patients.

Outcomes presented to the executive committee deemed Powerglide® an essential access device and a cost-effective option with regard to time and resources. Implementation throughout the wider organisation has now been rolled out.

STAPHYLOCOCCUS AUREUS BLOODSTREAM INFECTION ASSOCIATED WITH INTRAVASCULAR DEVICES IN WESTERN AUSTRALIAN HOSPITALS

Rebecca McCann¹, Allison Peterson¹, Simone Tempone¹
¹Healthcare Associated Infection Unit, Communicable Disease Control Directorate, Department of Health Western Australia.

Abstract

Introduction: Staphylococcus aureus bloodstream infection (SABSI) is associated with significant morbidity and mortality. All Australian states and territories are required to monitor and report healthcare- associated SABSI (HA-SABSI). The Healthcare Associated Infection Unit (HAIU) within the Western Australian (WA) Department of Health is responsible for the collation and validation of HA-SABSI data from 46 public hospitals. Infection prevention teams in WA hospitals identify, review and submit data to the HAIU that includes identifying the source of the HA-SABSI.

Objectives: To analyse HA-SABSI events and identify those attributed to intravascular devices (IVDs) in WA hospitals for the period 1 January 2010 to 31 December 2016.

Methods: The HAIU reviews all S.aureus positive blood cultures collected within the public hospital system via a comprehensive list obtained from the state-wide laboratory service. This involves clinical review of data available on the WA health patient management system and identification of IVD type. Data is cross-checked with submitted data and any non-congruent data is then reviewed with infection prevention staff at the hospitals.

Results: For the five year reporting period 2011-16, there has been an upward trend in the HA-SABSI rate from 0.57 to 0.70 per 10,000 bed days (p<0.01). The majority (72%) of all HA-SABSI are attributable to IVDs.

Conclusions: HA-SABSI attributed to IVDs are considered preventable adverse events. Identifying these episodes through surveillance that includes sound validation processes is an important component of infection prevention and control programs. These data can be used to formulate policy to improve patient safety outcomes.

IMPLEMENTATION OF A DIFFICULT VENOUS ACESS (DIVA) PATHWAY

Evan Alexandrou¹, Vanno Sou^2,3, Craig McManus^2,3, Nicholas Mifflin¹
¹Central Venous Access Service, Liverpool Hospital New South Wales Australia &School of Nursing and Midwifery, Western Sydney University, New South Wales Australia.
² Central Venous Access Service, Liverpool Hospital New South Wales
³ After Hours Nurse Consultant, Liverpool Hospital New South Wales

Abstract

Introduction: Successful insertion of a peripheral intravenous catheter (PIVC) is crucial for administration of intravenous fluids and medications. Many patients present to hospital with non-visible or palpable veins and ultrasound guidance can increase the likelihood of successful first time insertion. This reduces delays in the commencement of treatment and decreases the risk of device failure.

Objectives: Describe the outcomes of a nurse led DIVA pathway for hospitalised patients.

Methods: Review of protocol development and characteristics of PIVC placement using ultrasound (US) for DIVA patients by trained clinical nurse consultants (CNCs).

Results: Between February 2015 to November 2016, 379 patients were referred to the afterhours CNCs for US guided PIVC insertion due to difficult venous access. More males (56%) than females were referred with a mean age of 66 (SD-16.5) years. The mean BMI was 29.19 (SD 9.25) with a range of 14.69 – 80.56. When referred for ultrasound guidance, 92% (n=350) were cannulated 1^stattempt with remaining (n=29) on 2^nd attempt. Mean number of attempts by other clinicians prior to referral was 3.1[SD 1.6, compared to 1.1 (SD 0.69) by CNCs, p<0.001]. 12% of patients had 5 or more attempts by other clinicians prior to referral. 62% of patients recorded a pain score of 2/10 or less with US insertion compared to 43% of patients rating 8/10 pain score without ultrasound and by other clinicians (p<0.001).

Conclusion: The DiVa pathway at our hospital has significantly improved cannulation success rates for patients with difficult venous access, as has patient and clinician satisfaction.

INDEPENDENT PREDICTORS OF SUCCESSFUL ARTERIOVENOUS VASCULAR ACCESS CANNULATION IN HAEMODIALYSIS PATIENTS

Dr Linda Coventry^1,2, Jon Hosking³, Dr Doris Chan², Professor Di Twigg^1,2, Dr Amanda Towell^1,2, Dr Wai Lim², Evelyn Coral², Professor Claire Rickard⁴
¹Edith Cowan University, WA, Australia
² Sir Charles Gairdner Hospital, WA, Australia
³Diaverum, Toto Oro Dialysis Clinic, New Zealand
⁴ Griffith University, Qld, Australia

Abstract

Introduction: A well-functioning arteriovenous (AV) access (fistula or graft) is required to achieve adequate haemodialysis (HD). Problems with cannulation can lead to infection, haematoma, or aneurysm formation resulting in a need for access revision, central line placement, or loss of vascular access. Identifying factors related to successful AV cannulation may minimize these complications.

Objectives: To identify independent predictors of successful AV access cannulation.

Methods: A prospective cohort study was conducted in three HD units. Patient and nurse demographics were collected. For each episode of cannulation, data on nurse confidence, AV history, access assessment, and cannulation technique were collected. Primary outcome measure was first-time cannulation success, defined as insertion of two (arterial and venous) needles. Repeated measures logistic regression was used to determine the odds of cannulation success.

Results: Data were collected on 1,946 episodes of cannulation (83.9% fistula) in 175 patients by 63 nurses (17.5% male). Cannulation included use of tourniquet (62.9%), ultrasound (4.1%) and the rope-ladder (73.8%) or area (24.7%) technique was used. The missed cannulation rate was 4.3%. Extravasation (n=17, 0.9%) and use of an existing central line (n=6, 0.6%) rarely occurred. Multivariate predictors of cannulation success included fistula compared with graft (OR 2.40; 95%CI 1.32-4.36), older access (OR 1.31; 95%CI 1.07-1.60), no stent (OR 3.09; 95%CI 1.30-7.37), no ultrasound (OR 10.1; 95%CI 4.62-22.3), male nurse gender (OR 58.9; 95%CI 8.9-390), and female nurse gender*confidence interaction (OR 1.34; 95%CI 1.15-1.56).

Conclusions: This study demonstrated few missed cannulations and predictors associated with successful AV access cannulation were identified.

VENOUS THROMBOEMBOLISM AND CENTRAL VENOUS CATHETERS: FRIEND OR FOE?

Kwok Ho
Royal Perth Hospital

Abstract

Central venous catheterization is often used in many critically ill and trauma patients, but at the same time, the incidence of venous thromboembolism (VTE), including pulmonary embolism (PE), in such patients is very high despite anticoagulant prophylaxis. In one cohort study, up to 10% of the patients already had unsuspected deep vein thrombosis (DVT) at the time of ICU admission. Theoretically, the Virchow’s triad suggests that any reduction in venous blood flow can contribute to an increased risk of venous thromboembolism. Clinical evidence confirms that central venous catheterization can increase the risk of VTE. Because VTE is often silent and asymptomatic, prevention is pivotal to reduce its associated morbidity and mortality. Retrievable inferior vena cava filters are increasingly used for primary VTE prophylaxis in patients with contraindications to anticoagulants, especially those after major trauma. IVC filters are, however, expensive, invasive, associated with significant complications and, most importantly, often not removed in a timely fashion. Recently, a new commercial femoral venous catheter incorporated with an inferior vena cava filter has been trialed with some success. This talk will discuss the predictions and prevention of VTE, and the possible roles of femoral venous catheter incorporated with an inferior vena cava filter.

VASCULAR ACCESS DEVICE CHOICE IN CANCER PATIENT

Sam Gibson
Chief Executive Officer, Cancer Nurses Society of Australia

Abstract:

The need for appropriate venous access is multi-factorial for patients with cancer. Many cancer patients are living longer and are offered multiple lines of therapy, often over protracted periods of time. Veno-toxicity is well established with anti-neoplastic therapy and the impact of poor venous access and inappropriate venous access selection can have wide ranging impacts. Additionally, with cancer treatment comes the very real issue of unplanned presentation, often requiring urgent venous access. A clear decision making process in device selection is essential to optimize patient outcomes and to minimise the impact that poor venous access selection can cause.

‘PICCING’ THE RIGHT VESSEL FOR OPTIMAL VASCULAR ACCESS

Evan Alexandrou^1,2, Nicholas Mifflin², Craig McManus^2,3
¹ School of Nursing and Midwifery, Western Sydney University New South Wales Australia.
² Central Venous Access Service, Liverpool Hospital New South Wales
³ After Hours Clinical Nurse Consultant Service, Liverpool Hospital New South Wales

Abstract

Introduction: Ultrasound (US) guidance has significantly increased the use of Peripherally Inserted Central Catheters (PICCs). However, with increasing chronicity and acuity, PICCs can be difficult to place with US in sicker patients because of thrombosis, venous depletion or tortuous vascular pathways. These cohorts are typically referred to anaesthesia or interventional radiology for the placement of a central venous catheter (CVC). The percutaneous insertion of the CVC typically requires accessing the vessel with an 18G needle directly through the skin, then feeding a large guide wire through the needle. This traditional procedure (even with ultrasound) can have significant procedural risks.

Objectives: To describe procedural characteristics of PICC placement outside of the arm to gain vascular access.

Methods: Retrospective review of a PICC placement in the internal jugular, axillary and femoral veins, as both percutaneous and tunnelled techniques.

Results: Between January 2014 to December 2016, 85 PICCs were inserted outside of the arm including 39 axillary, 10 femoral and 36 internal jugular approaches. We observed an arterial puncture rate of 2.4% (n=2) and failed access on 3 occasions (3.5%) requiring another anatomical site attempt. Two (2.4%) axillary approaches required manipulation after insertion with tips in the internal jugular vein. No pneumothoracies were observed and all complications were managed conservatively.

Conclusion: PICCs can be an alternative to CVCs when procedural risk factors are high with the use of a micro puncture (modified Seldinger) technique. They can be trimmed to length and can be tunnelled with relative ease for patients requiring long term access.

TRANSPARENT SEMI-PERMEABLE MEMBRANE (TSM) DRESSINGS ON CENTRAL VENOUS ACCESS DEVICES (CVAD) - DOES CHLORHEXIDINE GLUCONATE (CHG) TSM OR BARRIER FILM MAKE A DIFFERENCE TO ADHESION AND LONGJEVITY OF THE DRESSING?

Jenkins, R.¹ & Maher, L. ² (¹ ICU Liaison CNC; ²CNC Cancer Care, Nepean Blue Mountains Local Health District)

Introduction

Clinicians at a Sydney Teaching Hospital identified perceived adherence issues with current TSM on CVAD dressings not remaining ‘intact’ for the planned 7 days. The infection risks associated with CVAD manipulation following numerous re-dressings as well as increased clinician workload led to this study being undertaken.

Objective

Phase 1 compares the current TSM dressing with the use of a barrier film to substantiate the ‘dressing’ challenges identified in clinical practice.

Phase 2 includes the introduction of a second dressing with absorbent CHG as a comparator using the same patient populations and clinical settings.

Method

The highest number of CVAD’s in clinical practice were identified to provide a convenience sample.

The trial was divided into 2 phases extending over an 8 week period.

Phase 1 Trial – 4 Weeks.

Trial Location / Unit	Dressing Type	Additional Control
Cancer Care (Inpatients) and ICU #1	TSM Dressing	Barrier Film
Cancer Care (Outpatients) and ICU #2	TSM Dressing	No Barrier Film

Phase 2 – 4 weeks.

Trial Location / Unit	Dressing Type	Additional Control
Cancer Care (In Patients) / ICU #1	CHG Dressing	Barrier Film
Cancer Care (Out Patients) / ICU #2	CHD Dressing	No Barrier Film

Clinical staff completed a specifically designed questionnaire each shift in the designated clinical areas.

Results

Trial results are pending (data collection to be completed by 04/04/17).

Conclusions

The comparison of the two Phases of the study.

BLOOD DONATION ABORTED DONATIONS DETER DONORS:
TIME TO DOCUMENT VEIN QUALITY

Authors

Phillip Mondy¹, Amanda Thijsen¹
¹Clinical Services and Research, Australian Red Cross Blood Service, Sydney, Australia

Abstract:

Blood collection agencies rely on people returning to maintain the blood supply. Adverse events significantly reduce the likelihood of returning to donate. However, it remains unknown whether this effect is influenced by the experience of an aborted phlebotomy. This study aims to assess the impact of an aborted donation on donor return.

Adverse events are routinely captured following standard operating procedures nationally. One month, November 2015 from the National Blood Management System was reviewed. Return to donation by end November 2016 for blood donors where the donation was aborted was compared against those instances when any blood donation complication was recorded. A total of 461 (0.08%) of 55790 whole blood donations were aborted, the primary associated reason noted was a slight reaction. Including aborted donations adverse events were noted in 3482 donations, 6.2%. Among whole blood donors return rate following uncomplicated donation was 79%. The return rate was 38.6% following an aborted donation and with any complication noted 56.5% (1968/3482). A chi-square test indicated rate of return differed significantly between donors with “donation aborted” and those with “any complication” (²(1) =130.54, p<0.01).

Aborted whole blood donation is associated with reduced donor return and presumably in part a reflection of vein quality. Donor veins are not formally measured; such data could determine how predictive vein quality is for donation success. In an attempt to reduce the number of aborted donations it also seems timely to routinely document vein quality. Vein scoring would focus senior staff onto donors with more difficult veins.

Introduction of the Visual Infusion Phlebitis Scale at RPAH

Ms Kathleen O’Connor (CNS)
Vascular Access Team, Royal Prince Alfred Hospital, Sydney NSW, Australia

Abstract

A peripheral Intravenous catheter is a tubing inserted into the patients arm to allow for administration of Intravenous medications or fluids. The NSW Health dept states that “Nursing staff should assess the PIVC at each shift for patency, erythema, tenderness, pain, swelling and dressing integrity. Any actions taken should be documented in the Patients health record each shift”.

The aim of this project is to improve the way Nurses report and document on peripheral intravenous cannulation (PIVC) sites. A pre audit of PIVC’s was carried out on inpatients in the general wards in RPAH. Women’s and babies unit and the paediatric wards were excluded.

Education was then completed on 4wards during in-service time. The Vascular Access Team (VAT) presented a Visual Infusion Phlebitis Score (VIP) which is a tool used to guide the Nursing staff on assessing and reporting the cannulation site. On each shift the PIVC will be reviewed and the VIP scale will be used to record the findings. The VIP scale scores the PIVC site 0-5 depending on the condition and integrity of the cannula. This score will then assist the Nurses on deciding if the PIVC needs removal or the Medical staff needs to be contacted.

Approximately 6 weeks post implementation; an audit will again be carried out on the four wards. The VAT will check each PIVC site and review the relevant documentation. .

The pre audit showed very poor documentation on when the PIVC was inserted. There was almost no documentation on the condition of the PIVC site. The post audit will show an increase in documentation of insertion, condition of the PIVC with use of the VIP scale.

We have concluded that having a clinically descriptive tool accessible to staff, will assist nurses in assessing and reporting on PIVC sites. If PIVC’s are monitored each shift we aim to see a reduction in the complications associated with PIVC’s and PIVC’s that are not needed removed promptly.

Author(s)

Pages 14-24

Volume 3 Issue 2

AVAS Conference Abstracts

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