Infection Control & Hospital Epidemiology
the ED. Because the reason for removal (including PIF) is poorly recorded in the medical record in routine practice,9 we pro- spectively followed admitted patients who had had a PIVC inserted in 2 EDs.
Methods
We published the protocol and methods for this study as sec- ondary outcomes in an open access journal.10 Our study has been registered with the Australian and New Zealand Trials Registry (ANZCTRN12615000588594). We used the STROBE checklist to assist with the reporting of this observational study.11
Study design and setting
A prospective multicenter observational cohort of admitted patients from ED who had their PIVC insertion observed by trained data collectors were followed up to identify whether PIF occurred. The researchers were predominantly present during the day shift on weekdays but were intermittently present on week- ends. They were not present during night shifts. The study was performed in Sir Charles Gairdner Hospital and Fiona Stanley Hospital, 2 large academically affiliated hospitals in Perth, Western Australia. The former is a 650-bed hospital with approximately 65,000 ED patients assessed annually; the latter is a 783-bed hospital with ~80,000 adult ED presentations annually.
Data collection variables of interest
We collected data from June 2015 to May 2016 using a case report form with a content validity index score >0.78 (reflecting good content validity12) and an initial Fleiss κ of 0.90 (suggesting almost perfect agreement when used for data collection13). As defined in our published protocol,10 patient variables included gender, age, skin condition (good, fair, poor),14 skin shade using the Fitzpatrick skin shade index,15 the venous international assessment scale (number of visible veins),16 vein palpability (with and without a tourniquet, and never palpable), and insertion site (back of hand, wrist, forearm, ante cubital fossa upper arm). Clinical presentations associated with the following characteristics were recorded: confu- sion, sepsis, chemotherapy, diabetes, and difficult intravenous access. We collected the patient’s Australasian Triage Scale (ATS) score of 1 to 5: patients with an ATS score of 1 are patients with immediately life threatening events, and patients with an ATS of 5 are less urgent.17 Clinician variables included role (phlebotomist, nurse, medical student, intern, registered medical officer, registrar, consultant); insertion experience (as a numerical category (0 to >1,000 PIVCs inserted); number of needle redirections; whether PIVC was inserted on the first attempt; and the use of ultrasound. Data on the PIVC gauge 14–22g, type of add-on device (J-Loop, 3- way stopcock, or needlefree connector), the indication for the PIVC (eg, contrast CT scan, crystalloid and/or colloid intravenous fluids), and intravenous medications (eg, antibiotics, steroids, analgesia, antipyretics, cardiac medication) were also collected. Additionally, we observed any infection prevention breach defined as a com- promise of an aseptic nontouch technique (ANTT) during the PIVC insertion.18 We defined PIF per our protocol: PIVC removal owing to failure defined as a composite of the following: infiltration, occlusion, pain and/or peripheral intravenous assessment score >2 (the hospital’s assessment tool for PIVC phlebitis), or dislodgement (ie, accidental-securement device failure or purposeful removal).
Sample
A convenience sample of ED presentations who were subse- quently admitted a hospital ward was used to measure rates of PIVC insertion failure.
Statistical analysis
The primary outcome was to establish the reasons for removal of the PIVC to identify rates of PIF and dwell times. Summary statistics for all variables of interest were performed, including means and stan- dard deviations (SD) for normally distributed continuous variables, medians, and interquartile ranges (IQRs) for nonnormally distributed continuous variables and counts (N) and percentages (%) for cate- gorical variables. Cox proportional hazards regression was used to model the time from PIVC insertion to failure, where the PIVCs that didnot fail arecensoredattheir date of removal. Forwardstepwise model selection was performed where all variables (as described in the Data collection variables of interest section) were considered for inclusion, and the significance level for variable entry and exit was set at 5%. The proportional hazards assumption was tested by including the time-dependent covariates in the model and checking for sig- nificance. This assumption was met as no variables were found to depend on time (all P>.9). Hazard ratios (HR), 95% confidence intervals (CIs), and P values were calculated. Data were analyzed using the R environment for statistical computing (version 3.4.4).19
Ethical approval
Full ethical approval for this study was obtained from Sir Charles Gairdner Hospital, Human Research Ethics (office ref. HR 2015- 149) and reciprocated at Fiona Stanley Hospital, and Griffith University. This approval included a waiver of consent for the inclusion of the patients receiving a PIVC.
Results General characteristics
Having observed the insertion of their PIVC in the ED, we followed 391 patients to measure dwell time and reason(s) for removal. Table 1 displays characteristics of variables associated with PIF for all 391 patients with and without PIVC failure. Supplementary Table S1 displays baseline clinical characteristics of all patient, clinician, environment, product, technology, and infusate factors with sum- mary statistics influencing PIVC failure. The characteristics of our sample included female gender
(N=203; 52%) and mean age of 63.3 years (SD, 21.3 years). Also, 137 patients (35%) had an Australasian Triage Scale score of 1 or 2, that is, these patients were in an immediately or imminently life-threatening condition. The percentage of PIVCs not used for any intravenous therapy, intravenous medications and intrave- nous contrast scans was 25%. The first attempt insertion success rate in this admitted cohort was 79%. The median hospital length of stay for 385 patients (6 obser-
vations missing due to transfer to others healthcare facilities) was 2 days (IQR, 1–5 days), and the median PIVC dwell time was 28.5 hours (IQR, 17.4–50.8 hours). The rate of PIVC failure was 30% (N=118), and patients with PIVC failure had a median PIVC dwell time of 24.1 hours (IQR, 11.7–50.8 hours). Patients without PIVC failure had a median PIVC dwell time of 29.9 hours (IQR, 20.7–49.8 hours) (Table 2). Infiltration and occlusion accounted for 15% of all reasons for removal (Table 3) with zero PIVC related blood stream infections identified.
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