Vascular access and clinical competency: Which elements matter? The development of three bottom-up and evidence-grounded self-assessment tools.

BACKGROUND: Assessing competency in the speciality of vascular access is still limited, and few valid and reliable tools are available. Therefore, this study aimed to develop and validate three different tools for assessing competency in managing the care of short peripheral cannulas (SPCs), midlines, peripherally inserted central catheters (PICCs), centrally inserted central catheters (CICCs), and arterial catheters (ACs) (tool one), placing SPCs (tool two), placing PICCs and midlines (tool three). METHODS: A two-phase and multi-method design was adopted. Phase one was implemented to develop the initial pool of items for each tool, starting from a literature overview. Panel discussions were adopted for developing the items. In phase two, the developed items were tested for content and face validity, involving a panel of 10 experts. Once obtained adequate content validity, a cross-sectional data collection was implemented to enroll three samples of healthcare workers who had to assess their competency through the developed tools. Dimensionality was assessed by performing a principal component analysis (PCA) and assessing internal consistency (Cronbach's α). RESULTS: Tool one had 26 items, and the dimensionality was given by placement, risk assessment, procedure conformity and traceability, and patient education to self-care. Tool two had 35 items; its principal components were: risk evaluation, identification, clinical assessment and orientation to self-care, placement, and procedure registration shaped the competency of placing SPCs. Tool three had 31 items; its principal components were: risk assessment, placement, conformity to standards and procedure traceability, education, and orientation to self-care were the essential elements for adequately placing midlines and PICCs. Cronbach's α values ranged between 0.806 and 0.959. CONCLUSIONS: The three developed tools reflected the core elements of competency in each application area, representing an initial framework that could be useful in future research and educational projects. Cross-national investigations are required to corroborate the described results.

GAVeCeLT-WoCoVA Consensus on subcutaneously anchored securement devices for the securement of venous catheters: Current evidence and recommendations for future research.

BACKGROUND: Subcutaneously anchored securement devices (or subcutaneous engineered securement devices) have been introduced recently into the clinical practice, but the number of published studies is still scarce. The Italian Group of Long-Term Central Venous Access Devices (GAVeCeLT)-in collaboration with WoCoVA (World Congress on Vascular Access)-has developed a Consensus about the effectiveness, safety, and cost-effectiveness of such devices. METHODS: After the definition of a panel of experts, a systematic collection and review of the literature on subcutaneously anchored securement devices was performed. The panel has been divided in two working groups, one focusing on adult patients and the other on children and neonates. RESULTS: Although the quality of evidence is generally poor, since it is based mainly on non-controlled prospective studies, the panel has concluded that subcutaneously anchored securement devices are overall effective in reducing the risk of dislodgment and they appear to be safe in all categories of patients, being associated only with rare and negligible local adverse effects; cost-effectiveness is demonstrated-or highly likely-in specific populations of patients with long-term venous access and/or at high risk of dislodgment. CONCLUSION: Subcutaneously anchored securement is a very promising strategy for avoiding dislodgment. Further studies are warranted, in particular for the purpose of defining (a) the best management of the anchoring device so to avoid local problems, (b) the patient populations in which it may be considered highly cost-effective and even mandatory, (c) the possible benefit in terms of reduction of other catheter-related complications such as venous thrombosis and/or infection, and-last but not least-(d) their impact on the workload and stress level of nurses taking care of the devices.

Axillary vein thrombosis in COVID positive patient with midline and continuous positive airway pressure Helmet.

We describe the case of a coronavirus disease patient with midline who, during ventilation with continuous positive airway pressure helmet with underarm fastening straps, presented thrombosis of the axillary vein in the armpit. The tip of the midline ended in the armpit. The thrombosis has been resolved with anticoagulant therapy with low molecular weight heparin of 100 IU/kg bid without giving pulmonary embolism. In an emergency context like this, the need to resort to ventilation strategies even in departments generally not accustomed to the use of these devices and to the management of this type of patients, the need to use and adapt the available material (e.g. being unable to renounce to use underarm fastening straps) obliges us to consider the use of alternative strategies also in the field of vascular access. After this case, we began to consider techniques that allow us to prevent the catheter from ending in the armpit, with benefit. It is essential to continue to observe this patient.

A retrospective study of the safety of over 100,000 peripherally-inserted central catheters days for parenteral supportive treatments.

The type of central vascular access device providers chosen for providing parenteral supportive treatments has evolved over the past years, going from routinely used centrally inserted catheters to a more recent trend of peripherally-inserted central catheters (PICCs) when expected treatment duration is less than 6 months. This multicenter retrospective study aimed to provide a comprehensive assessment of the safety of PICCs in administering parenteral supportive treatments. All adult inpatients and outpatients who had a PICC inserted for the administration of parenteral supportive treatments (i.e., parenteral nutrition, intravenous fluids, blood products, or antibiotics) between September 2007 and December 2014 in four public Italian hospitals were included. The primary outcome was PICC removal because of an adverse event (AE, defined as occlusion, exit-site infection, or symptomatic thrombosis). Among the 1,250 included patients, 178 PICC-related removals because of AEs (14.2%; 1.62 AEs per 1,000 PICC days) were reported. Rates of PICC removal because of occlusion, exit-site infection, and symptomatic thrombosis were 1.08, 0.32, and 0.23 per 1,000 PICC days, respectively. The median dwell-time between PICC insertion and its removal because of an AE was 67 days (interquartile range 28-180 days). Risk of PICC removal due to AE was higher with open-system PICCs [hazard ratio = 2.75, 95% confidence interval 1.52-4.96]. In this study, we found preliminary evidence that PICCs can be safely used to administer parenteral supportive treatments lasting up to 6 months. PICCs may be a relevant alternative to centrally inserted catheters for medium-term parenteral supportive treatments.

Can Peripherally Inserted Central Catheters Be Safely Placed in Patients with Cancer Receiving Chemotherapy? A Retrospective Study of Almost 400,000 Catheter-Days.

BACKGROUND: Peripherally inserted central catheters (PICCs) are central venous catheters (CVCs) that are commonly used in onco-hematologic settings for chemotherapy administration. As there is insufficient evidence to recommend a specific CVC for chemotherapy administration, we aimed to ascertain PICC-related adverse events (AEs) and identify independent predictors of PICC removal in patients with cancer receiving chemotherapy. MATERIALS AND METHODS: Information on adult patients with cancer with a PICC inserted for chemotherapy administration between September 2007 and December 2014 was extracted from six hospital databases. The primary outcome was PICC removal due to PICC-related AEs (occlusion, infection, or symptomatic thrombosis). Independent predictors of PICC removal were identified using a multivariate Cox regression model. RESULTS: Among the 2,477 included patients, 419 PICC-related AEs (16.9%; 1.09 AEs per 1,000 PICC-days) were reported. AEs increased when PICC was inserted at the brachial site (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.02-1.84) and with open systems (HR, 1.89; 95% CI, 1.24-2.88) and decreased in older men (HR, 0.63; 95% CI, 0.49-0.81). CONCLUSION: Use of PICC for chemotherapy administration was associated with a low all-AEs rate. The basilic vein was the safer site, and valved systems had fewer AEs than open systems. More research is needed to explore the interaction between AEs, sex, and age. IMPLICATIONS FOR PRACTICE: These findings provide clinicians with evidence that peripherally inserted central catheters (PICCs) are safe for chemotherapy administration. They also suggest that clinicians should limit the use of open systems when long chemotherapy regimens are scheduled. Moreover, alternatives to PICCs should be considered when administering chemotherapy to young men.

The Risk of Adverse Events Related to Extended-Dwell Peripheral Intravenous Access.

Midline catheters (MCs) may be useful to avoid repeated venipuncture in patients requiring prolonged intravenous infusions with limited adverse events (AEs). We analyzed 2 Italian hospital databases to ascertain the safety of MCs. Among 1,538 adult patients, 154 MC-related AEs (10%; 2.49 AEs per 1,000 MC days) were reported.Infect Control Hosp Epidemiol 2018;875-877.

Evaluating safety, efficacy, and cost-effectiveness of PICC securement by subcutaneously anchored stabilization device.

PURPOSE: In recent years, a large variety of medical devices has become available. Every device must be efficient, safe and cost effective, but it is not enough to use it properly without considering the environment in which it will be employed. We applied this kind of analysis to subcutaneously anchored sutureless devices (SAS). METHODS: This is a one-center prospective observational study on safety, effectiveness and cost effectiveness of an SAS device (SecurAcath, Interrad) for securement of peripherally inserted central catheter (PICC) in 30 adult cancer patients with treatment expected to be >60 days. RESULTS: During 4963 catheter days and after 709 dressing changes (documented by 373 pictures), the use of SAS was associated with no episode of PICC dislodgement and a lower incidence of complications if compared to traditional securement devices. Insertion, management and removal of SAS were not associated with an increased pain perception by the patients. Cost effectiveness was particularly evident for long dwelling PICCs. CONCLUSIONS: Our study suggests that SAS is a highly effective and cost-effective method for securement of medium- to long-term PICCs with expected duration longer than 30 days. The introduction of SAS had a positive impact on our healthcare organization.