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Reduction of hospital acquired Staphylococcus aureus bacteraemia by routine replacement of peripheral intravenous catheters at 72 hours
- Judith A. Bowley, Martin A. Kiernan, Cecilia M. Jukka, Bridget Lees, Andrew Chalmers, Nicola Gilbert (23 July 2008)
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Realities about intravenous catheters in hospital NHS trusts in England
- KAI SUN TSANG (24 July 2008)
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Potential Consequences of Routine Peripheral Intravenous Catheter Replacement
- Jeremy A Stone (27 July 2008)
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Reducing The Number Of Attempts Taken To Introduce Intravenous Catheter Must Be Our Priliminary Goal To Stop Spreading Hospital Infections.
- Kadiyali M Srivatsa (28 July 2008)
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Catheter associated thrombophlebitis and endothelium.
- Fernando Martins do Vale (29 July 2008)
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A frustrating response to our clinical frustration.
- Jonathan Armitage (21 August 2008)
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Judith A. Bowley, Consultant Medical Microbiologist Southport and Ormskirk NHS Trust, Southport and Formby DGH, Southport. PR8 6PN, Martin A. Kiernan, Cecilia M. Jukka, Bridget Lees, Andrew Chalmers, Nicola Gilbert
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Webster et al1 report that replacement of intravenous peripheral catheters only when clinically indicated has no effect on the incidence of phlebitis and infiltration when compared with routine replacement at 72 hours. Southport and Ormskirk NHS Trust is a District General Hospital with approximately 550 beds. A policy for routine replacement, with enhanced documentation, of peripheral intravenous catheters at 72 hours was introduced in accordance with Department of Health guidelines2 in April 2007. Prior to this, catheter change was according to clinical need. There is no dedicated nurse intravenous therapy team at our hospital but a service exists for the placement of peripherally inserted central catheters (PICC lines). This is provided by three Nurse Consultants in General Medicine and Surgery and is utilized for any patient likely to require a more prolonged course of intravenous therapy. In the twenty seven months between January 2005 and March 2007 there were 42 cases of hospital acquired Staphylococcus aureus bacteraemia (methicillin sensitive and methicillin resistant). 15 (35%) of the cases were associated with peripheral intravenous catheter phlebitis. Since introducing the policy for routine peripheral intravenous catheter change at 72 hours there have been 26 cases of hospital acquired Staphylococcus aureus bacteraemia, only one (4%) of which has been associated with an infected peripheral cannula or PICC line. The incidence of phlebitis has also decreased but detailed analysis of the data has not yet been carried out. Routine catheter change at 72 hours is supported by a Trust-wide peripheral intravenous catheter care plan that requires completion by the health care professional inserting the catheter, along with documentation recording the need for continued catheterisation and observation of the catheter site by using the Visual Infusion Phlebitis3 score at each change of nursing shift. The catheter is removed by nursing staff after a 72-hour placement. Compliance with the care plan across the Trust has been achieved in a majority of cases. We acknowledge that moderate cost savings could be made if intravenous peripheral catheters were changed according to clinical need but we believe the costs of treating severe infections, including bacteraemia, considerably outweigh the savings made. We also support the views of Maki4 that the risks of longer catheter dwell time may become more apparent in an adequately powered study and that it is unlikely that the results of Webster et al1 can be generalized to the majority of hospitals without a dedicated nurse intravenous therapy team. We intend to continue using our peripheral intravenous catheter care plan, routinely changing catheters at 72 hours, as we believe this approach has been a successful intervention with respect to reducing hospital acquired Staphylococcus aureus bacteraemia within our Trust. 1. Webster J, Clarke S, Paterson D, Hutton A, van Dyk S, Gale C, Hopkins T. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomized controlled trial. BMJ 2008;337:a339. (19 July.) 2. Saving Lives: reducing infection, delivering clean and safe care. High impact intervention No 2. Peripheral intravenous cannula care bundle. Department of Health. November 2006. 3. Gallant P and Schultz AA. Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing 2006;29(6):338-45. 4. Maki DG. Improving the safety of peripheral intravenous catheters. BMJ 2008;337:a630. (19 July.) Competing interests: None declared |
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KAI SUN TSANG, PLASTIC SHO SALISBURY DISTRICT HOSPITAL, SP2 8BJ
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After reading the Joan Webster research article (BMJ 208;337:a339) and the editorial comment (BMJ 2008;337:a630) by professor Maki, I can only say their findings would not be useful in England according to my personal experience. First, the task of intravenous catheters insertion in England is rested mainly on the shoulder of junior doctors, particularly the most junior ones. Due to various reasons, there is no specialised team for standard intravenous catheter insertion in most hospitals. Often, it would be lucky to get one sited in the first attempt. It would be a serious drain on manpower if a regular re-siting regime is adopted, not to mention the cost. This would include not just the replacement, but those discarded catheter due to failure of insertion. In a well constructed trial, the cost of wasted material should be included as well. This could well tip the balance against the more frequently changed group. Second, documentation about the loss of catheters and their reasons is not a common practise in England. A retrospective study like this one would not be useful at all. It is partly a staffing issue, but it is also a ‘cultural’ issue here. This would take a lot more of a few forms to rectify it. Third, the real risk of complications is also affected by how many catheter one has. That is having 2 catheters changed at regular interval means the patient will have double the risk to one catheter. This is something that Webster research has not specify. The risk may be lower per catheter, but the overall total sum could be different. It would be nice to know the proportion of complications in the intervention group arise from the first catheter sited. If one knows the catheter is only required for 4 days, it would be more sensible to leave the first one in under observation for another 24 hours. On the whole, it would be easier for the clinician to decide if we know more about the natural progress of the survival of the intravenous catheter in use. Bregenzer from Switzerland showed that the difference of the rate of complications does not vary much between regular changed catheter and those staying more than 3 days. [1] This is why I think it is better to base the decision of removal of intravenous catheter on clinical judgement, rather than following a guideline blindly. I agree the 72 hours suggestion is an important factor in the decision making but that is not all. Lastly, it may be better off to spend more effort on improving the catheter care. This could involve using regular heparin flush to prolong the patency of the catheter. [2] Or using new catheter design which has improved polymer characteristics or anti-septic impregnated catheter [3] if the cost or technology is available. References: 1: Bregenzer T, Conen D, Sakmann P, Widmer AF. Is routine replacement of peripheral intravenous catheters necessary? Arch Intern Med. 1998 Jan 26;158(2):151-6. 2: Nieto-Rodriguez JA, Garcìa-Martìn MA, Barreda-Hernandez MD, Hervàs MJ, Cano-Real O. Heparin and infusion phlebitis: a prospective study. Ann Pharmacother. 1992 Oct;26(10):1211-4. 3: Veenstra DL, Saint S, Sullivan SD. Cost-effectiveness of antiseptic- impregnated central venous catheters for the prevention of catheter- related bloodstream infection. JAMA. 1999 Aug 11;282(6):554-60. Competing interests: None declared |
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Jeremy A Stone, SpR Anaesthetics Leicester LE1 5WW, Leicester Royal Infirmary
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The research by Webster et al was very interesting indeed. Infection control is a very important issue and any strategy which could reduce this risk is most welcome. It was interesting to see therefore that routine replacement of peripheral intravenous cannulae in this study did not correspond with a reduction in the incidence of phlebitis. I would like to consider the potential consequences of adopting a more aggressive routine replacement policy. We have all looked after the 'difficult veins' patient requiring i.v. treatment of some kind. If a routine replacement policy demanded a cannula be removed whilst it was still functioning followed by unsuccessful attempts at recannulation then it is highly likely that central access be required. A higher rate of referral to the anaesthetic department for central lines may ensue with all the (possibly avoidable) complications of that procedure. Additionally if a cannula is removed and there is a delay in placing the subsequent one doses of important drugs could be missed (antibiotics, B blockers) with avoidable sequalae for the patient. Patient satisfaction is an increasingly important and measured variable in healthcare these days. If they see 'another needle' in a situation where, in their eyes at least, there is no need the clearly their satisfaction will drop. If specialist teams of nurses do develop to look after iv devices then it is another step in eroding the skills of junior doctors. Who else will the specialist team turn to when they fail? The very same junior doctors who have not been allowed to learn this vital skill. After all who is the expert at doing the 'ticky ones'? Why, the person who also does all of the 'easy ones'. Competing interests: None declared |
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Kadiyali M Srivatsa, Gp College Road Surgery, Woking, Surrey GU22 8BT
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Since 1989, we have been warning cannula manufacturers about the danger of multiple attempts and its association with spreading hospital infections. The incidence of Staphylococcus aureus infections acquired in hospitals has risen in tandem with increased use of cannulation since the Braunule (cannula) was introduced in 1962 (1). When working as a Registrar in Neonatal units, we noticed babies who were difficult to introduce cannula were getting MRSA infections. To over come this problem, we studied the technique and developed a spring loaded- device to help us introduce the cannula with ease. Our hypothesis was tested and the results were published in Anastasia Analgesia (2) Cannula manufacturers were enthusiastic and so asked senior consultants if they find cannula introduction technique difficult. Based on their response, they were not keen to bring in changes because they were told our technique will de-skill doctors and the seniors felt they did not have any problem. Intravenous cannulation – as well as the word ‘Venflon’ – is hated by all, especially patients and house officers. The former dislike it because it is painful, whereas the latter are repulsed more by the fact that inserting cannula on a regular basis is such a sub-cortical job. I successfully inserted about 60% of Venflons at the first attempt. My success rate improved rapidly, and, during my SHO year, I managed to lift this further 30% to 90%, (3). We feel our main task must be to help junior inexperienced doctors & nurse to introduce cannula in the first attempt. It is often complicated in patients who are afraid, as fear activates the sympathetic nervous system, provoking peripheral vasoconstriction. Once an initial attempt at cannulation has failed, nearly all patients experience a degree of sympathetic activation that makes subsequent attempts increasingly difficult (4). We conducted observational studies and presented our finding to cannula manufacturers (5). Our study show experienced doctors take on average 2-3 attempts to introduce cannula unlike the junior in-experienced ones are told to abandon the procedure if they fail twice. Failure to introduce cannula was not due to difficulty to locate a vein because blood was noted in the blood chamber of these failed attempts. The success rate of seniors is not better but they are more confident and continue the procedure. We do not have enough data to prove cannula insertion is a safe procedure because the guidelines published in the past were all based on central venous catheter introduction and not based on peripheral intravenous catheters. This technique introducing intravenous catheters has not been properly assessed since they were introduced. Cannula manufacturers are now competing with Asian cannula manufacturers and so are pressing on and promoting their safety cannula. They have not showed any enthusiasm in altering the technique of introduction to help us and protect patients from these spreading hospital infections. The suggestion of bringing in better technique to ease insertion is likely to remain a dream in the future. Using specialized team as recommended for standard intravenous catheter insertion in most hospitals is not a safe practice as junior doctors will be de-skilled. Article published in British Journal of Nursing state “Cannulation can be complicated by preexisting disease, prolonged hospital admission and multiple vascular access attempts. Nurses must be aware of their own limitations in relation to experience and skill (Nursing and Midwifery Council 2004). There may be times when the nurse should decline to attempt cannulation if patient history or assessment suggests that cannulation is too complex (6) Phlebitis occurring early (<48 hours) is often due to traumatic insertion which damage veins associated with inadequately prepared skin and drying time is not observed. Replacing cannula in 72 hours may be beneficial in some hospitals but we feel this will not be necessary if the cannula is introduced in the first attempt with very strict a septic technique. Reference: (1) Martina Benzing, MRCPCH (UK), PhD, and Kadiyali M. Srivatsa, MD. Alternative method of cannulation could reduce needlestick injuries and the spread of hospital-acquired infections. Managing Infection Control (March 2006), 54-60. (2) Srivatsa KM. Cannulation of vessels using a spring-loaded device; Anesth Analg 1992; 75: 867b-868b. (3) Painless intravenous cannulation for 16p. Lilantha Wedisinghe; Issue 11 January 2007) (4) Johnstone M. The effect of lorazepam on the vasoconstriction of fear. Anaesthesia 1976, 31: 868-872.7. Cleary M. Peripheral intravenous (5) Srivatsa KM. http://www.scribd.com/doc/452088/Peripheral-Venous- Cannula-Introducing-Technique-and-MRSA-infection (6) Jackson A (2003) Reflecting on the nursing contribution to vascular access. British Journal of Nursing. 12, 11, 657- 665. (7) Katie Scales (Scales K (2005) Vascular access: a guide to peripheral venous cannulation. Nursing Standard. 19, 49, 48-52. Competing interests: Inventor of Spring-loaded cannula & U-Cannula |
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Fernando Martins do Vale, Prof. Pharmacology Inst. Farmacologia e Neurociências - Faculdade Medicina Lisboa. 1649-028 Lisboa. Portugal
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Peripheral intravenous catheterisation is a common invasive procedure among inpatients, and to prevent phlebitis and infection is accepted as standard procedure the changing of catheters every three days, but this practice has not been rigorously tested. Webster and colleagues comparing routine replacement of intravenous peripheral catheters with replacement only when clinically indicated, found no significant difference in catheter failure (phlebitis or infiltration) per 1000 device hours, but the costs were 25% higher with routine replacement. Maki refers that the low incidence of phlebitis in the Webster’s trial may be explained by the highly experienced team that have inserted and provided care of the catheters. Maki’s commentary seems very pertinent, because vascular endothelium, which has antithrombotic properties, is very friable which is illustrated in the lab by its easy removal from the vascular wall with simple passage of cotton. Vascular endothelium may be injured by the catheter when the diameter of catheter and vein are similar, or when it is placed on mobile zones producing movements inside the vessel, or by some drugs (diazepam, iv anaesthetics, antibiotics, anticancer drugs) especially when the venous flow is small to dilute drugs. Experienced teams avoid factors that may easily damage vascular endothelium. Webster’s trial refers collected baseline personal, clinical, and catheter related data (type of infusate, drugs injected and their pH level, type and size of catheter used, and the site of insertion). It could be interesting to study a possible relation of the catheter location, or drugs infused with the phlebitis incidence. It is possible that the catheters placed on antecubital veins have fewer incidence of phlebitis than those placed on flexor zones. Some caustic drugs must be administered diluted or in veins with greater blood flow. I have seen many cases of phlebitis from catheters placed on hand’s veins (low blood flow) after administration of diazepam. Finally, it is also important to have in mind, not only the dangers and economical costs, but also the PAIN elicited by catheter introduction in certain places like the hands, which are one of the most sensitive areas of our body. Fernando Martins do Vale, MD, PhD
Competing interests: None declared |
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Jonathan Armitage, clinical fellow christchurch colorectal unit, christchurch, private bag 4710
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We read with interest the article by Webster et al. concerning the need for routine replacement of peripheral intravenous catheters. As busy clinicians we have often been frustrated by the need to recannulate patients whose peripheral access was removed when apparently working well due to infection control policies. Therefore we welcome any attempt to uncover a poor scientific basis to this policy. Despite this we feel that this article cannot be given merit. The methodology was suspect, with poor compliance to study protocol and a high degree of patient exclusion. The data presentation is confusing with the most clear results appearing to be that only 26% of cannulae stayed in long enough to meet the 72hr cut off for replacement and that phlebitis and infiltration occurred in > 3rd of patients in both groups. Finally the conclusions are nonsensical and at odds with the author’s discussion. This paper goes to great length to criticize the original Scarborough data, however its own findings seem only to support that papers conclusion that leaving peripheral cannulae in-situ greater than 48hrs leads to high levels of failure and phlebitis. 1: Randomised clinical trial of elective re-siting of intravenous cannulae. Barker P, Anderson AD, MacFie J. Ann R Coll Surg Engl. 2004 Jul;86(4):281-3. Competing interests: None declared |
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