Catheter-to-Vessel Ratio and Catheter-Related Thrombosis in Peripherally Inserted Central Catheters: A Retrospective Review of Records

Catheter-related thrombosis (CRT) is a potential complication of peripherally inserted central catheters (PICCs). With PICC use becoming more common, it is important to minimize this complication. Selection of an appropriately sized vessel can reduce the risk of catheter-related thrombosis. Research suggests that using a catheter-to-vessel-ratio (CVR) of 45% or less can minimize this risk. This quality improvement project was implemented to evaluate the impact of utilizing an ultrasound device that can measure catheter-to vessel ratio with peripherally inserted central catheter insertion by the vascular access team. Data was collected using a retrospective chart review looking at CRT rates before and after implementation of an ultrasound device that measures CVR to identify and use vessels with a CVR of 45% or less to insert PICCs. While there was no statistically significant difference, data suggests that using a CVR of 45% or less decreases the incidence of CRT. Results also reinforce previous research that cancer diagnosis as well as insertion of larger gauge PICCs were associated with deep vein thrombosis. Future studies that include larger sample sizes to validate this measurement are recommended. Keywords: Catheter-to-Vessel-Ratio (CVR), Peripherally Inserted Central Catheter (PICC), Catheter-Related-Thrombosis (CRT), Deep Vein Thrombosis (DVT

The Impact of an Online Educational Course on Vascular Nurses’ Knowledge, Self-Confidence and Competence

In the United States, approximately 8 to 10% of patients admitted to an acute care facility receive venous access. Nurses that specialize in vascular access place approximately 3 million peripherally inserted central catheter (PICC) lines annually. There is a lack of standard minimum requirements for educating PICC nurses, especially on insertion techniques and maintenance. The goal of the project was to enhance the preparation of nurses who place PICC lines in different healthcare settings in order to improve quality metrics such as CLABSI, UE DVT, and LOS, with a subsequent decrease in cost of care. A pilot study that utilized a quasi-experimental, one-group pre-posttest design with a convenience sample was performed using an online educational PICC course and certification process as the independent variable. The dependent variable, improved vascular access nurse’s knowledge, competence and self-confidence, was measured by a pre-post intervention test and self-efficacy assessment. Collected data were analyzed to determine if a correlation existed between the intervention and dependent variables. The pretest and posttest results were statistically significant (t = -6.069, p = .000), indicating that the participants had improved knowledge/competence post intervention. Results of the pre-post self-efficacy assessment showed that the nurses felt more confident following the program (t = - 2.591, p = .011). The primary investigator of this study recommends future implementation of a formal standardized orientation program, as well as a standardized validation/certification process for all vascular access nurses

Foreign Intravascular Object Embolization and Migration: Bullets, Catheters, Wires, Stents, Filters, and More

Foreign intravascular object embolization (FIOE) is an important, yet underreported occurrence that has been described in a variety of settings, from penetrating trauma to intravascular procedures. In this chapter, the authors will review the most common types of FIOEs, including bullet or “projectile” embolism (BPE), followed by intravascular catheter or wire embolization (ICWE), and conclude with intravascular noncatheter object (e.g., coil, gelatin, stent, and venous filter) migration (INCOM). In addition to detailed topic-based summaries, tables highlighting selected references and case scenarios are also presented to provide the reader with a resource for future research in this clinical area

An Observational Study of Peripherally Inserted Central Cather(PICC)-Related Complications Amongst Oncology Patients

This thesis reports on a retrospective observational study that examined the complication rate of peripherally inserted central catheters (PICCs) within a regional cancer centre. PICCs are increasingly used for delivery of chemotherapy and other intravenous therapies in oncology patients. A literature review revealed that almost all published research on PICC complications reported on silicone (Groshong(TM)) catheter use, rather than the polyurethane (Arrow(TM)) PICCs used at Christchurch Hospital. Also, much literature referred to PICCs being inserted by non-nurses, whereas the Christchurch service uses specially-trained nurses to insert them. The purpose of the study was to identify the nature, incidence and rates of polyurethane (Arrow(TM)) PICC complications in an adult oncology cohort. Ethics Committee approval was gained to retrospectively follow all PICCs inserted in adult oncology patients at Christchurch Hospital over a 13-month period from 1st March 2006 until 31st March 2007. Data collected were analysed utilising the statistical computer package SPSS. One hundred and sixty-four PICCs were inserted into 156 individual oncology patients over this period. The median dwell time was 68 days (range 6-412, IQR 39-126) for a total of 14,276 catheter-days. Complications occurred in 25 (15%) out of 164 PICC lines, in 22 (15%) of the 156 patients for an overall complication rate of 1.75 per 1000 catheter-days. However, only 16 of the 25 PICCs with complications required early removal (9.75% of the cohort) for a favourably low serious complication rate of 1.12 per 1000 catheter-days. The three commonest complications were infection at 4.3% (7/164) or 0.49 infection complications/1000 PICC-days, PICC migration at 3% (5/164) or 0.35/1000 catheter days, and thrombosis at 2.4% (4/164) or 0.28/1000 catheter days. The median time to complication was 41 days (range 2-160, IQR 25-77). Those with complications were more likely to have a gastro-intestinal or an ovarian cancer diagnosis, and less likely to have colorectal cancer (p=0.001). These findings provide support for the safe and effective use of polyurethane (Arrow(TM)) PICCs for venous access within the adult oncology context. Furthermore, it suggests that cost effective nurse-led (Arrow(TM)) PICC insertions can contribute to a low complication rate. This benchmark study should be followed by further prospective studies examining the relationship of cancer diagnosis to PICC complication rates in oncology patients

A Multi-Method Evaluation Of A Guideline Based Clinical Decision Support Intervention On Provider Ordering Behavior, System Acceptance And Inter-Professional Communication

Background and aims: Unnecessary variation in the delivery of patient care is well documented in the medical literature; evidence-based clinical practice is critical for improving the quality of care. Clinical decision support systems (CDSS) are promising tools for improving the systematic integration of evidence into clinical practice. This study evaluated a CDSS in a domain of care that had not yet been explored—namely, decision support for venous catheter selection. This dissertation study aimed to (1) evaluate the effect of this CDSS on provider ordering behavior before and after implementation and explore the differential impact of this tool by provider type and service and (2) identify organizational, individual, usability, and workflow factors that impact CDSS acceptance by physicians and advanced practice nurses and to elicit information about the impact of this system on communication between providers and the nurse-led vascular access team. Methods: This was a multi-method study. Aim one was single group pre-post analysis of longitudinal data. Variables included those related to patient and provider level factors. The main analysis was conducted with linear regression models with random effects to account for clustering of data. We conducted semi-structured interviews for aim two and use conventional qualitative content analysis to identify themes. Results: We found mixed results in the impact of the CDSS on provider ordering behavior. While the CDSS did not have an impact on the number of venous catheters ordered, we saw a statistically and clinically significant decrease in the proportion of double lumen catheters ordered. Findings for the qualitative aim showed that the CDSS improved process efficiency and inter-professional communication. We found that it also facilitated education for evidence based practice for novice providers. Discussion: This dissertation study showed a clear impact of the CDSS on double lumen catheter ordering, which has implications for patient outcomes. Furthermore, we found impacts by provider type. Additional work is needed to evaluate this CDSS in other settings and to further assess differential impacts by provider type

Rate of colonization of Internal Jugular and Femoral Central Venous Catheters in Medical Intensive Care Unit and Medical High Dependency Unit

OBJECTIVES: To assess the colonization rate and catheter related bloodstream infection rate of internal jugular and femoral central venous catheters in Medical Intensive Care Unit and Medical High Dependency Unit. METHODS: Single blinded randomized controlled trial where the site of central venous catheter insertion was determined by randomization. There were 2 arms with equal allocation – internal jugular and femoral. Inclusion criteria: All patients in Medical Intensive Care Unit / Medical High Dependency Unit who require insertion of a central venous catheter. Exclusion criteria: 1. Deep vein thrombosis, 2. Cardiac arrest in the last 24 hours, 3. Patients who do not give consent, 4. Pregnant women, 5. Immunocompromised patients, 6. Severe coagulopathy, 7. Skin lesion, 8. Profound volume overload. Primary Outcome: Colonization rate of central venous catheter tip in the jugular and femoral group. Secondary outcome: Catheter Related Bloodstream Infection rate in patients with jugular and femoral central venous catheters. RESULTS: The colonization rate in the internal jugular and the femoral group was 20.5% and 23.9% respectively. This difference was not statistically significant. More patients need to be included in the study to draw clinical implications. There were 3 catheter related bloodstream infections among the patients included in the study. All 3 infections were in the femoral group. There is a trend towards higher number of catheter related bloodstream infections in the femoral group in spite of similar colonization rates

Risk Prediction and New Prophylaxis Strategies for Thromboembolism in Cancer

Thromboembolism is a compelling challenge in cancer care because of its life-threatening nature as well as its impact on specific treatments. Current guidelines do not generally recommend antithrombotic prophylaxis, except in selected categories of patients at high risk of thrombosis. Accordingly, several clinical decision models have been developed to guide the oncologist in thromboembolic risk assessment and targeted prophylaxis. Low-molecular-weight heparins (LMWH) are currently considered as the standard approach in clinical practice guidelines, but recent randomized controlled trials (RCT) indicate that direct oral anticoagulants (DOACs) are effective for the treatment/prophylaxis of cancer-associated thromboembolism. However, many unanswered questions remain on the efficacy and safety of anticoagulants in selected cancer subgroups, and in primary and secondary prevention settings, where anticoagulation needs to be balanced on the risk of bleeding complications. Presently, patient selection remains the main challenge. Improvement in existing VTE risk models or the construction of alternative risk assessment tools are needed in order to ameliorate the risk stratification of cancer patients. This reprint will cover the current clinical evidence supporting the standard of care and emerging treatment/prophylactic options for cancer-associated thromboembolism during both active treatment and simultaneous/palliative care. Tailored approaches based on the use of individualized factors to stratify the thrombotic/bleeding risk in each individual patient are discussed