Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial

Background: Peripheral intravenous catheters (PIVCs) are ubiquitous medical devices, crucial to providing essential fluids and drugs. However, post-insertion PIVC failure occurs frequently, likely due to inconsistent maintenance practice such as flushing. The aim of this implementation study was to evaluate the impact a multifaceted intervention centred on short PIVC maintenance had on patient outcomes. Methods: This single-centre, incomplete, stepped wedge, cluster randomised trial with an implementation period was undertaken at a quaternary hospital in Queensland, Australia. Eligible patients were from general medical and surgical wards, aged ≥ 18 years, and requiring a PIVC for > 24 h. Wards were the unit of randomisation and allocation was concealed until the time of crossover to the implementation phase. Patients, clinicians, and researchers were not masked but infections were adjudicated by a physician masked to allocation. Practice during the control period was standard care (variable practice with manually prepared flushes of 0.9% sodium chloride). The intervention group received education reinforcing practice guidelines (including administration with manufacturer-prepared pre-filled flush syringes). The primary outcome was all-cause PIVC failure (as a composite of occlusion, infiltration, dislodgement, phlebitis, and primary bloodstream or local infection). Analysis was by intention-to-treat. Results: Between July 2016 and February 2017, 619 patients from 9 clusters (wards) were enrolled (control n = 306, intervention n = 313), with 617 patients comprising the intention-to-treat population. PIVC failure was 91 (30%) in the control and 69 (22%) in the intervention group (risk difference-8%, 95% CI-14 to-1, p = 0.032). Total costs were lower in the intervention group. No serious adverse events related to study intervention occurred. Conclusions: This study demonstrated the effectiveness of post-insertion PIVC flushing according to recommended guidelines. Evidence-based education, surveillance and products for post-insertion PIVC management are vital to improve patient outcomes

An observational study of nurses’ intravenous flush and medication practice in the clinical setting

Introduction: Research has quantified the unacceptably high failure rate of peripheral intravenous catheters (PIVCs) prior to completion of prescribed treatment. Surveys and audits have highlighted inconsistencies in reported practice and guidelines. Aim: The aim of this study was to gain a 'real world' overview of nurses' intravenous (IV) flushing and medication practice, and compare this to current practice recommendations. Method: This was a single-centre, prospective observational study of IV flush and medication administration by nurses over a range of times on surgical and medical wards of a tertiary metropolitan hospital. Results: Eighty-two nurses were observed in the study, yielding 82 sets of observations. Most observations were for PIVCs (n = 77; 93%) with modes of delivery divided between IV bolus (n = 28; 34%), IV medication in a bag (n = 36; 44%), and IV burette (n = 18; 22%). Pre and post drug administration flushes were delivered in all cases of bolus delivery; however, flushing practice was less consistent with other delivery modes. The majority (n = 56/61; 91%) of flushes used 10 mL syringes with 0.9% sodium chloride. Nearly a third of nurses were not fully compliant with hand hygiene (n = 36/82; 32%) or of aseptic non-touch technique (ANTT) (n = 27/82; 33%) in the preparation phase. However, needleless decontamination was conducted in 99% of cases. Conclusion: Mixed forms of drug delivery were observed, with use of single bags predominating. This has implications for healthcare costs and infection control. Flushing practice was consistent for bolus delivery but inconsistent for bag and burette delivery. Adherence to hand hygiene and ANTT was also sub optimal. The limited studies on flushing practices to date are inhibiting recognition of this important patient quality and safety issue. Practice and guidelines need to be consistent with current best practice recommendations. Future studies need to minimise practice variation in trial protocol and/or acknowledge and account for varied practice with analysis

Design, development and preliminary assessment in a porcine model of a novel peripheral intravenous catheter aimed at reducing early failure rates

Background: Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet despite best efforts by end-users, PIVCs experience unacceptably high early failure rates. We aimed to design a new PIVC that reduces the early failure rate of in-dwelling PIVCs and we conducted preliminary tests to assess its efficacy and safety in a porcine model of intravenous access. Methods: We used computer-aided design and simulation to create a PIVC with a ramped tip geometry, which directs the infused fluid away from the vein wall; we called the design the FloRamp™. We created FloRamp prototypes (test device) and tested them against a market-leading device (BD Insyte™; control device) in a highly-controlled setting with five insertion sites per device in four pigs. We measured resistance to infusion and visual infusion phlebitis (VIP) every 6 h and terminated the experiment at 48 h. Veins were harvested for histology and seven pathological markers were assessed. Results: Computer simulations showed that the optimum FloRamp tip reduced maximum endothelial shear stress by 60%, from 12.7 Pa to 5.1 Pa, compared to a typical PIVC tip and improved the infusion dynamics of saline in the blood stream. In the animal study, we found that 2/5 of the control devices were occluded after 24 h, whereas all test devices remained patent and functional. The FloRamp created less resistance to infusion (0.73 ± 0.81 vs 0.47 ± 0.50, p = 0.06) and lower VIP scores (0.60 ± 0.93 vs 0.31 ± 0.70, p = 0.09) than the control device, although neither findings were significantly different. Histopathology revealed that 5/7 of the assessed markers were lower in veins with the FloRamp. Conclusions: Herein we report preliminary assessment of a novel PIVC design, which could be advantageous in clinical settings through decreased device occlusion and reduced early failure rates.</p