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Care bundles and prevention of vascular access complications
June 22, 2020
Vascular access (IV) devices are widely used in different patient settings in hospitals all over the world. 90% of all patients admitted to a hospital receive an IV catheter1, a testament to the relevance and effectiveness of this mode of medication infusion. However, the placement, maintenance and use of vascular access devices and catheters are not without risk. Vascular access devices are implicated in several healthcare-associated infections (HAIs), with as many as 40% of the healthcare-associated bloodstream infections (BSIs) in Europe being attributed to IV catheters.2 Catheter failures are also a frequent occurrence in hospitals. Worldwide, 35-50% of the peripheral IVs are reported to fail, usually due to unnecessary and avoidable complications.1
Complications that cause vascular access device failures can occur either during placement, due to mechanical problems during insertion, or long placement durations.3 The common reasons for the failure of catheters are infiltration and extravasation, blockage, dislodgement, and phlebitis.3
Some types of vascular access complications begin even before a needle is inserted into the patient. In aged patients with comorbidities and severe functional limitations, finding venous access sites for inserting catheters can be a challenge due to a lack of visible and palpable veins. The prevalence of difficult venous access in such patients can be as high as 59.3%. 4
Dealing with IV catheter complications – The care bundle approach
A care bundle is a set of interventions that, when used together, significantly improve patient outcomes. 5 The set of interventions are often delivered by multidisciplinary teams working together, supported by evidence-based research and approved practices.
In the specific context of vascular access, several care bundle projects have resulted in improved patient outcomes. Examples of successful vascular access related care bundles include the HANDS project6 and a few others that were devised to reduce BSIs during insertion and maintenance of central venous access devices (CVAD).7-9 A recent systematic review on insertion and maintenance care bundles to reduce peripheral intravenous catheter (PIVC) BSIs analysed the efficacy of different interventions in preventing adverse events.3 The key results of this systematic review are summarised here.
Insertion and maintenance bundles for PIVC related BSI
Ray-Barruel et. al 3 analysed 13 selected studies based on inclusion/exclusion criteria. Studies from 8 countries were analysed, with sample sizes ranging from centres with 200 patients a day, to those with over 2 million patient days. Outcome assessors were infection control professionals, nurse researchers, nurse anaesthetics, study centre coordination staff, and others which were ‘not stated’.
A total of 21 insertion and 22 maintenance care bundle components were reported across the studies analysed.3 Implementation strategies mostly involved education, audits and feedback. BSI, phlebitis and Staphylococcus aureus infection rates were the reported outcomes in most studies. Some studies also reported auditing of bundle compliance.
Of the studies analysed, 12 reported a reduction in phlebitis and BSI, while one reported no reduction in BSI and an increase in phlebitis.
The systematic review reveals that standardisation and consistency are less evident in PIVC care bundles. Several intervention strategies have been reported, but the large variations in bundle elements and time periods make it difficult to compare and identify the most effective ones. The studies also did not report contextual factors like leadership support and sustainability, which are often crucial for the success of care bundle interventions.
To conclude, the authors state that the standardisation of care bundle interventions is necessary for a meaningful comparison between studies. Although the effects of care bundles on PIVC related BSI appear encouraging, more rigorous studies are needed to get a clearer picture.
Read the systematic review on care bundles for preventing peripheral intravenous catheter-related complications
#BSI #CLABSI. #dislodgement #extravasation #infiltration #occlusion #phlebitis. care bundles #PIVC #thrombosis #Vascular access
2. Surveillance report. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals Accessed on 10 April 2019, at https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/healthcare-associated-infections-antimicrobial-use-PPS.pdf.
3. Ray-Barruel G, Xu H, Marsh N, Cooke M, Rickard CM. Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: A systematic review. Infect Dis Health 2019; 24(3): 152-68. DOI: 10.1016/j.idh.2019.03.001
4. Armenteros-Yeguas V, Gárate-Echenique L, Tomás-López MA, et al. Prevalence of difficult venous access and associated risk factors in highly complex hospitalised patients. Journal of clinical nursing, 2017; 26(23-24): 4267–75. DOI: 10.1111/jocn.13750
5. McCarron K. Understanding care bundles. Nursing Made Incredibly Easy Journal 2011; 9(2): 30-3. doi: 10.1097/01.NME.0000394024.85792.42
6. Caguioa J, Pilpil F, Greensitt C, Carnan D. HANDS: standardised intravascular practice based on evidence. Br J Nurs 2012; 21(14): S4, S6, S8-11. DOI: 10.12968/bjon.2012.21.Sup14.S4
7. Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D. Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clin Infect Dis 2014; 59(1): 96-105. DOI: 10.1093/cid/ciu239
8. Ista E, van der Hoven B, Kornelisse RF, et al. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis 2016; 16(6): 724-34. DOI: 10.1093/cid/ciu239
9. Zingg W, Pittet D. Central-line bundles need a multimodal implementation strategy. Lancet Infect Dis 2016; 16(6): 631-2. DOI: 10.1016/S1473-3099(15)00480-6
Approbation number : BD-17832