Peripheral Intravenous Catheter Research Articles

Peripheral intravenous catheter failure, nurse staffing levels and care complexity individual factors: A retrospective multicentre cohort study

Introduction Short peripheral intravenous catheter (PIVC) failure is a common complication that is generally underdiagnosed. Some studies have evaluated the factors associated with these complications, but the impact of care complexity individual factors and nurse staffing levels on PIVC failure is still to be assessed. The aim of this study was to determine the incidence and risk factors of PIVC failure in the public hospital system of the Southern Barcelona Metropolitan Area. Methods A retrospective multicentre observational cohort study of hospitalised adult patients was conducted in two public hospitals in Barcelona from 1st January 2016 to 31st December 2017. All adult patients admitted to the hospitalisation ward were included until the day of discharge. Patients were classified according to presence or absence of PIVC failure. The main outcomes were nurse staffing coverage (ATIC patient classification system) and 27-care complexity individual factors. Data were obtained from electronic health records in 2022. Results Of the 44,661 patients with a PIVC, catheter failure was recorded in 2,624 (5.9%) patients (2,577 [5.8%] phlebitis and 55 [0.1%] extravasation). PIVC failure was more frequent in female patients (42%), admitted to medical wards, unscheduled admissions, longer catheter dwell time (median 7.3 vs 2.2 days) and those with lower levels of nurse staffing coverage (mean 60.2 vs 71.5). Multivariate logistic regression analysis revealed that the female gender, medical ward admission, catheter dwell time, haemodynamic instability, uncontrolled pain, communication disorders, a high risk of haemorrhage, mental impairments, and a lack of caregiver support were independent factors associated with PIVC failure. Moreover, higher nurse staffing were a protective factor against PIVC failure (AUC, 0.73; 95% confidence interval [CI]: 0.72–0.74). Conclusion About 6% of patients presented PIVC failure during hospitalisation. Several complexity factors were associated with PIVC failure and lower nurse staffing levels were identified in patients with PIVC failure. Institutions should consider that prior identification of care complexity individual factors and nurse staffing coverage could be associated with a reduced risk of PIVC failure.

Aligning peripheral intravenous catheter quality with nursing culture-A mixed method study.

To explore barriers and facilitators that influence adherence to evidence-based guidelines for peripheral intravenous catheter care in different hospital wards. Sequential explanatory mixedmethod study design, with qualitative data used to elaborate on quantitative findings. Data were collected between March 2021 and March 2022 using the previously validated Peripheral Intravenous Catheter mini questionnaire (PIVC-miniQ) on each ward in a tertiary hospital in Norway. Survey completion was followed by individual interviews with nurses from selected wards. The Pillar Integration Process was used to integrate and analyse the quantitative and qualitative findings. The PIVC-miniQ screening assessed 566 peripheral intravenous catheters in 448 patients in 41 wards, and we found variation between wards in the quality of care. Based on the quantitative variation, we interviewed 24 nurses on wards with either excellent or not as good quality. The integration of the quantitative and qualitative findings in the study enabled an understanding of factors that influence nurses' adherence to the care of peripheral venous catheters. One main theme and four subthemes emerged. The main finding was that ward culture affects education practice, and this was evident from four subthemes: (1) Deviation from best practice, (2) Gaps in education and clinical training, (3) Quality variation between wards and (4) The importance of supportive leadership. This mixed method study is the first study to explore reasons for variability in peripheral intravenous catheter quality across hospital wards. We found that ward culture was central to catheter quality, with evidence of deviations from best practice correlating with observed catheter complications. Ward culture also impacted nursing education, with the main responsibility for learning peripheral intravenous catheter management left to students' clinical training placements. Addressing this educational gap and fostering supportive leadership, including champions, will likely improve peripheral intravenous catheter care and patient safety. Nurses learn good peripheral intravenous catheter care in wards with supportive leaders and champions. This implies that the quality of nursing practice and patient outcomes are situational. Nurses need a strengthened emphasis on peripheral catheter quality in the undergraduate curriculum, and nurse leaders must emphasize the quality of catheter care in their wards. The study findings impact nurse leaders who must commit to quality and safety outcomes by appointing and supporting local ward champions for promoting peripheral intravenous catheter care. This also impacts nursing education providers, as the emphasis on catheter care must be strengthened in the undergraduate nursing curriculum and continually reinforced in the hospital environment, particularly when guidelines are updated. The study adhered to the Good Reporting of A Mixed Method Study (GRAMM). A patient representative has been involved in planning this study.

Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections.

Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

The ultrasound-guided versus standard technique for peripheral intravenous catheter placement by nurses: A systematic review and meta-analysis

AimTo comprehensively evaluate the efficacy of Ultrasound-guided technique for peripheral intravenous catheter placement by nurses in their daily practice. BackgroundPeripheral intravenous catheter insertion is a common clinical procedure in healthcare settings. Ultrasound-guided peripheral intravenous placement has emerged in recent decades and was recognized as particularly useful in some specific patient groups. MethodsStudies that had compared the ultrasound-guided and traditional approaches were eligible for inclusion and further analysis. The primary outcome was the success rate on the first intravenous insertion attempt. The secondary outcomes included the time needed for successful insertion, and the average number of attempts to establish the IV access. We systematically assess all studies using Cochrane Collaboration’s Risk of Bias tool and the Newcastle-Ottawa Scale. We calculated the odds ratio and standardized mean difference with 95% confidence intervals for the outcomes. Data were analyzed and visualized on Review Manager 5.3.4 and Stata 16.0. Results23 studies were included (17 randomized controlled trials and six cohort studies) with a population of 2,051 patients offered ultrasound-assisted technique and 2,479 treated with the conventional approach for comparison. The former approach was associated with a higher success rate on the first attempt in comparison (OR = 2.95, 95% CI: 1.86, 4.69). This technique also took less time and less acupuncture to patients’ skin (SMD = -0.62, 95% CI: -1.01, -0.23; SMD = -0.55, 95% CI: -0.92, -0.18). In the sub-group analyses, children were more likely to benefit from ultrasound guided technique. Ultrasound guided technique demonstrated consistent and significant benefits in emergency clinical settings. Hospitals from different geographical locations exhibited similar trends in the three outcomes. Year of publication and study design revealed inconsistent and insignificant outcomes.. ConclusionsUltrasound-guided technique can be a safer, faster, and more effective alternative to the traditional approach for nurses to establish intravenous access across different clinical settings and age groups.

Smaller-gauge catheters and greater body weights are associated with increased risk of peripheral intravenous catheter complications in cats hospitalized in the critical care unit.

To identify risk factors associated with peripheral intravenous catheter (PIVC) complications in cats hospitalized in the critical care unit (CCU). 120 cats admitted to the CCU between October 2022 and September 2023. This prospective, observational study was performed at a single veterinary teaching hospital. Cats hospitalized in the CCU for ≥ 24 hours were evaluated for enrollment. Peripheral intravenous catheters were placed by trained personnel following a standardized protocol and monitored for complications. PIVC complications were classified as extravasation, phlebitis, dislodgement, occlusion, line breakage, or patient removal. Median PIVC dwell time was 42.25 hours (range, 24.25 to 164.25 hours). Overall PIVC complication rate was 18.3% (22/120), with extravasation (7/120 [5.8%]) and dislodgement (7/120 [5.8%]) being the most frequently recorded complications. Multivariable analysis identified that for each kilogram increase in body weight there is a higher likelihood of a PIVC complication (OR, 1.46; 95% CI, 1.03 to 2.05; P = .03). Additionally, use of a larger-gauge (20-gauge vs 22-gauge) PIVC is associated with a significantly lower likelihood of a PIVC complication (OR, 0.13; 95% CI, 0.03 to 0.56; P = .006). These results suggest that smaller-gauge (22-gauge) PIVCs and greater body weights are associated with an increased risk of complications in cats hospitalized in the CCU. When possible, a larger-gauge (20-gauge) PIVC should be placed in cats admitted to the CCU.

Effectiveness and safety of measures to prevent infections and other complications associated with peripheral intravenous catheters: A systematic review and meta-analysis.

Peripheral intravenous catheters (PIVCs) contribute substantially to the global burden of infections. This systematic review assessed 24 infection prevention and control (IPC) interventions to prevent PIVC-associated infections and other complications. We searched Ovid MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL and reference lists for controlled studies, from January 1, 1980-March 16, 2023. We dually selected studies, assessed risk of bias, extracted data, and rated the certainty of evidence (COE). For outcomes with three or more trials, we conducted Bayesian random-effects meta-analyses. 105 studies met our prespecified eligibility criteria, addressing 16 of the 24 research questions; no studies were identified for eight research questions.Based on findings of low to high COE, wearing gloves reduced the risk for overall adverse events related to insertion compared to no gloves (one non-randomised controlled trial [RCT]; adjusted risk ratio [RR]: 0.52, 95% confidence interval 0.33-0.85), and catheter removal based on defined schedules potentially resulted in a lower phlebitis/thrombophlebitis incidence (10 RCTs; RR: 0.74, 95% credible interval 0.49-1.01) compared to clinically indicated removal in adults. In neonates, chlorhexidine reduced the phlebitis score compared to non-chlorhexidine-containing disinfection (one RCT; 0.14 versus 0.68, p = 0.003). No statistically significant differences were found for other measures. Despite their frequent use and concern about PIVC-associated complications, this review underscores the urgent need for more high-quality studies on effective IPC methods regarding safe PIVC management. In the absence of valid evidence, adherence to standard precaution measures and documentation remain the most important principles to curb PIVC complications.

Introducing an ultrasound-guided longer length peripheral IV catheter for patients with difficult venous access.

Insertion of a peripheral intravenous catheter (PIVC) is one of the most common procedures carried out in hospitals worldwide, but failure rates are unacceptably high. This local quality improvement project aimed to assess improvements in first-stick success rate, dwell time and overall catheter success rate when implementing a longer-length peripheral intravenous catheter (LPIVC) under ultrasound guidance for patients with difficult venous access (DVA). Data were collected from 386 DVA patients requiring a PIVC at one hospital. Number of catheter insertion attempts, catheter dwell time and reason for catheter removal were recorded for each patient. To implement the new DVA catheterisation pathway, registered nurses undertook a training programme comprising workshops and ultrasound-guided cannulation technique practice on phantoms. Costs and waste weights associated with LPIVC insertion, compared with midline insertion, were calculated. First-stick success rate was 95.0% using the LPIVC under ultrasound guidance. Dwell time ranged from 1 to 80 days, with a large proportion of those dwelling <1 day being placed in day-case patients. Treatment success rate with the LPIVCs was 83.6%. Equipment costs for an LPIVC insertion were £89.22 lower than for a midline insertion, and the weight of waste generated per procedure was 1 kg lower for LPIVCs. First-stick success rate of LPIVCs, aided by improved purchase in the vein and visualisation with ultrasound guidance, was very high, superior to rates reported in other studies. The procedure provides a better patient experience as successful first attempts avoid unnecessary further insertion attempts. Other benefits are increased nursing time efficiency, a reduction in clinical waste and the lower cost of the equipment required.

Establishing a plan to improve pediatric patient comfort during PIV insertions and blood specimen collection: a quality improvement effort.

Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased. The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection. The authors met their goals by using quality improvement methodology. Prioritizing patient comfort often requires institutional culture change. Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (eg peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically. The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24 134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change. The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2. From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions. While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.

Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction

Peripheral intravenous catheters (PIVCs) facilitate essential treatment. Failure of these essential devices is frequent and new securement strategies may reduce failure and improve patient outcomes. To evaluate clinical effectiveness of novel PIVC securement technologies for children to reduce catheter failure. A 3-arm, parallel group, superiority randomized clinical trial was conducted at 2 regional Australian hospitals from February 5, 2020, to January 14, 2022. Children aged 6 months to 8 years who were anticipated to require admission with a PIVC for at least 24 hours of in hospital treatment were eligible. Data were analyzed from May 25, 2022, to February 20, 2024. Participants were randomly allocated in a 1:1:1 ratio to standard care, bordered polyurethane (Tegaderm [3M]), integrated securement dressing (SorbaView SHIELD [Medline]), and integrated securement dressing with tissue adhesive (Secureport IV). One catheter was studied per patient. Primary outcome was PIVC failure, defined as premature cessation of PIVC function for any reason prior to completion of planned treatment. Secondary outcomes were PIVC complications (any time dislodgement, occlusion, infiltration, partial dislodgement, extravasation, device leaking, phlebitis, pain), PIVC longevity, intervention acceptability (clinicians, participants, caregivers; 0-10 scale), and pain on removal (participants and caregivers; 0-10 scale relevant to age), adverse events, and health care costs. A total of 383 patients (51% female; median age 36 [25th-75th percentiles, 22-72] months) were randomized 134 to standard care, 118 to integrated securement dressing, and 131 to integrated securement dressing with tissue adhesive. PIVC failure was lowest in integrated securement dressing with tissue adhesive (15 [12%]; adjusted hazard ratio [aHR], 0.47; 95% CI, 0.26-0.84) compared with integrated securement dressing (24 [21%]; aHR, 0.78; 95% CI, 0.47-1.28) and standard care (43 [34%]). Direct costs were significantly lower for integrated securement dressing with tissue adhesive (median, Australian dollars [A$], 312 [A$1 is equal to $0.65 US dollars]; IQR, A$302-A$380) and integrated securement dressing (median, A$303; IQR, A$294-A$465) compared with standard care (median, A$341; IQR, A$297-A$592; P ≤ .002) when considering the economic burden related to failure of devices. PIVC longevity and intervention acceptability were similar across all groups. In this study, PIVCs secured with integrated securement dressings and tissue adhesive, in comparison with standard care, bordered polyurethane dressings, were associated with significantly reduced PIVC failure, for children admitted to hospital via the emergency department. Further research should focus on implementation in inpatient units where prolonged dwell and reliable intravenous access is most needed. Australian New Zealand Clinical Trials Registry Identifier: ACTRN12619001026112.

Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice. To understand how clinicians personalize decisions about resuscitation in practice. This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023. Online Qualtrics clinical vignette survey. Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs. Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%). These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.

Pediatric hemolysis in emergency departments: Prevalence, risk factors, and clinical implications.

This study aimed to analyze the prevalence, risk factors, and clinical implications of hemolyzed laboratory samples in the pediatric emergency department (ED), a subject on which existing data remains scarce. We conducted a multi-site observational cohort analysis of pediatric ED encounters in Metro Detroit, Michigan, United States. The study included participants below 18 years of age who had undergone peripheral intravenous catheter (PIVC) placement and laboratory testing. The primary outcome was the presence of hemolysis, and secondary outcomes included identifying risk factors for hemolysis and assessing the impact of hemolysis on PIVC failure. Between January 2021 and May 2022, 10,462 ED encounters met inclusion criteria, of which 14.0% showed laboratory evidence of hemolysis. The highest proportion of hemolysis occurred in the infant (age 0-1) population (20.1%). Multivariable regression analysis indicated higher odds of hemolysis for PIVCs placed in the hand/wrist in the toddler (age 2-5) and child (age 6-11) subgroups. PIVCs placed in the hand/wrist also demonstrated higher odds of failure in infants. Hemolysis in the pediatric ED population is a frequent complication that occurs at similar rates as in adults. PIVCs placed in the hand/wrist were associated with higher odds of hemolysis compared to those placed in the antecubital fossa. Clinicians should consider alternative locations for PIVC placement if clinically appropriate. Further research is needed to better understand the clinical implications of pediatric hemolysis.

Increased risk of complications in lower versus upper limb peripheral intravenous cannulation in children with severe neurological impairment.

Obtaining peripheral intravenous catheter (PIVC) access in children with severe neurological impairment (SNI) is often challenging and commonly associated with complications, including dislodgement, phlebitis and extravasation. In severe cases, extravasation injury may lead to tissue necrosis, ulceration and long-term morbidity. The aim of this study was to determine the relative incidence of PIVC complications secondary to lower limb cannulation, compared to upper limb, in children with SNI. A single centre, retrospective, observational review was conducted. Patients with SNI, admitted at a tertiary paediatric centre over 6months between July and December 2022, were included. One-hundred fifty-five PIVC procedures were conducted in 110 children over the study period. Complications were more common in lower limb PIVCs (12/16, 75%) compared to upper limb (58/139, 42%), p = 0.01. Upper limb cannulation is preferred in children with SNI.

Exploring Clinicians' insertion experience with a new peripheral intravenous catheter in the emergency department

BackgroundHospitals frequently introduce new medical devices. However, the process of clinicians adapting to these new vascular access devices has not been well explored. The study aims to explore clinicians’ experience with the insertion of a new guidewire peripheral intravenous catheter (PIVC) introduced in the emergency department (ED) setting. MethodsThe study was conducted at two EDs in Queensland, Australia, utilising a qualitative explorative approach. Interviews were conducted with guidewire PIVC inserters, including ED doctors and nurses, and field notes were recorded by research nurses during insertions. Data analysis was performed using inductive content analysis, from which themes emerged. ResultsThe study compiled interviews from 10 participants and field notes from 191 observation episodes. Five key themes emerged, including diverse experience, barriers related to the learning process, factors influencing insertion success, and recommendations to enhance clinicians’ acceptance. These themes suggest that the key to successful adoption by clinicians lies in designing user-friendly devices that align with familiar insertion techniques, facilitating a smooth transfer of learning. ConclusionClinician adaptation to new devices is vital for optimal patient care. Emergency nurses and doctors prefer simplicity, safety, and familiarity when it comes to new devices. Providing comprehensive device training with diverse training resources, hands-on sessions, and continuous expert support, is likely to enhance clinician acceptance and the successful adoption of new devices in ED settings.

Peripheral Intravenous Catheters Are Preferable for Emergency Department Patients With Septic Shock

Peripheral Intravenous Catheters Are Preferable for Emergency Department Patients With Septic Shock

The Prevalence and Associated Factors of Peripheral Intravenous Complications in a Thai Hospital.

Complications of peripheral intravenous catheters (PIVCs) remain a major contributor to health care costs and are a patient safety problem. The objective of this cross-sectional descriptive study was to examine the prevalence of complications and factors associated with complications from peripheral intravenous fluid administration. The study was conducted at a tertiary care hospital in Thailand. The instruments were developed from the literature review. Data were analyzed using SPSS statistics, version 22. The study examined 441 patients with a total of 497 PIVC sites. Phlebitis (level 1 and 2 only) occurred at 2.41% of all sites; infiltration (level 1 and 2 only) occurred at 1.01% of all sites, and extravasation (mild and moderate only) occurred at 0.60% of all sites. Factors associated with the occurrence of infiltration complications included receiving intravenous (IV) crystalloids (P = .03) and receiving IV analgesic drugs (P = .001). Age was statistically significantly related to extravasation complications (P = .001). Nurses should be aware of possible complications from peripheral intravenous fluid administration, especially in older patients and those receiving IV crystalloids or analgesic drugs.

Establishing a Plan to Improve Pediatric Patient Comfort during PIV Insertions and Blood Specimen Collection: A Quality Improvement Effort

Highlights Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased. The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection. The authors met their goals by using quality improvement methodology. Prioritizing patient comfort often requires institutional culture change. Abstract Background: Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (i.e., peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically. Design and Methods: The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24,134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change. Aims and Objectives: The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2. Results: From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions. Conclusions: While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.

Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies.

Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters. A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP. Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6mm Hg after 3% HTS bolus administration (p < 0.001). Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.

Authors' response to “Comment on Marsh et al. (2023) ‘Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis’”

Authors' response to “Comment on Marsh et al. (2023) ‘Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis’”

Efficacy and Durability of Intravenous Ertapenem Therapy for Recalcitrant Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a debilitating follicular skin disorder in which bacterial colonization is typical. Oral antibiotic efficacy can be unreliable; however, selective intravenous antibiotics, specifically ertapenem, may provide favorable clinical outcomes. To explore optimal course duration, efficacy, and patient satisfaction associated with intravenous ertapenem for HS. This retrospective review of the medical records of 98 patients with HS between 2018 and 2022 measured and evaluated patient outcomes before and after treatment with intravenous ertapenem. Participants were followed up in a telephone survey assessing patient perspectives and satisfaction. All of those included in this study received medical care from the Albert Einstein College of Medicine's Montefiore HS Center. Patients were treated with 1 g of ertapenem that was self-administered at home through a peripheral intravenous central catheter using an elastomeric pump for 12 to 16 weeks. Antiandrogens and immunomodulatory biologic therapies initiated prior to ertapenem were maintained throughout the treatment course. The primary outcomes, encompassing clinical severity (evaluated through the HS Physician Global Assessment score [a 6-point scale ranging from clear to very severe] and a numerical rating scale for pain [an 11-point scale in which a score of 0 indicates no pain and a score of 10 indicates the worst possible pain]) and markers of inflammation (such as leukocytes, erythrocyte sedimentation rate, C-reactive protein, and interleukin-6), were measured at baseline, the midcourse of intravenous ertapenem treatment, at the end of the course, and posttherapy. Bacterial abundance was also examined at these 4 points, and patient satisfaction was assessed during follow-up. A total of 98 patients (mean [SD] age, 35.8 [13.0] years; 61 [62.2%] female) with HS were treated with intravenous ertapenem. The self-reported racial distribution included 3 individuals identifying as Asian (3.1%), 59 as Black/African American (60.2%), 13 as White (13.3%), and 23 as either other or unknown (23.5%). Additionally, 24 participants (24.5%) reported Spanish/Hispanic/Latino ethnicity. The mean (SD) treatment duration spanned 13.1 (4.0) weeks, with posttherapy follow-up occurring after 7.8 (3.6) weeks. From baseline to posttherapy follow-up, significant reductions were found in the mean (SD) HS Physician Global Assessment scores (3.9 [1.0] vs 2.7 [1.2]; P < .001) and the numerical rating scale for pain (4.2 [3.3] vs 1.8 [2.7]; P < .001), C-reactive protein (5.4 [11.4] vs 2.4 [2.0] mg/dL; P < .001), interleukin-6 (25.2 [21.1] vs 13.7 [13.9]; P < .001), and leukocytes (11.34 [3.9] vs 10.0 [3.4]; P < .001). At follow-up, 76 patients (78.0%) participated in the telephone survey, where 63 (80.3%) reported medium to high satisfaction; further, 69 (90.8%) would recommend ertapenem to other patients. In this retrospective review of medical records and telephone survey, treating HS with intravenous ertapenem, administered for a mean of 13 weeks, was associated with improvement in clinical and inflammatory markers, as well as heightened patient satisfaction. Nonetheless, this approach should be monitored for the emergence of antimicrobial resistance given a longer than standard treatment course.

Association between peripheral intravenous catheters and clinical characteristics in the development of phlebitis

Background: Serious complications can develop from erroneous insertion of a peripheral intravenous catheter (PIVC). Successful PIVC insertion has a great place in the continuation of IV treatment without causing complications that may require the removal of the PIVC. Methods: The population for this prospective observational study included patients who had undergone PIVC insertion in the surgical, intensive care, and inpatient units of a large teaching and research hospital in Istanbul. Data were collected via a patient information form, a PIVC and treatment information form, the Visual Infusion Phlebitis (VIP) scale, and a PIVC nurse observation form. The SPSS 24 software package was used to analyze the data. Results: Of the 168 patients enrolled, 64.9% ( n = 109) were male, and the mean age was 56.71 ± 17.97 years. The mean PIVC dwell time was 73.46 ± 21.57 h, and 32.7% ( n = 55) of the catheters were removed due to discharge from hospital. Overall, 29.2% ( n = 49) of the cases developed phlebitis, with half of the cases (51%, n = 25) developing grade 2 phlebitis and developed within 48 h in 38.8% of cases ( n = 19). The mean PIVC dwell time was significantly lower in patients with phlebitis than in those with no phlebitis ( p &lt; 0.05). Conclusions: It was determined that PIVC dwell time could be increased by routine surveillance to monitor for phlebitis regularly. It is recommended that education programs for nurses be developed to prevent PIVC-related complications.