Volume 201 - Issue 4
Preventing peripheral intravenous catheter-associated bloodstream infection: the randomised controlled trial versus the real world
Authors: Diana Egerton-Warburton, George Braitberg and Anthony Kambourakis
Med J Aust 2014; 201 (4): 197-198. || doi: 10.5694/mja14.00363
Published online: 18 August 2014
Published online: 18 August 2014
Consider all the evidence to ensure safe stewardship of PIVCs
To the Editor: Debate regarding the prevention of peripheral intravenous catheter (PIVC)-associated bloodstream infection has been enriched by research and letters published in the Journal.1-3 Stuart and colleagues and Collignon and colleagues highlighted an association of long dwell times with PIVC-associated bloodstream infection.1,2 Rickard and colleagues refer to contrasting high-level evidence in a Cochrane review.3,4 We would suggest that important lessons can be learnt from both perspectives.
The Hawthorne effect and strict inclusion and exclusion criteria mean that, while largely free of bias, the outcomes of clinical trials are not generalisable. The retrospective data on PIVC-associated bloodstream infections reported by Stuart et al and Collignon et al, while methodologically limited, demonstrate the real-world experience of hundreds of patients.1,2
We believe that clinicians should consider all forms of evidence when designing processes to ensure safe stewardship of PIVCs. In health services with independent “line teams” and a comprehensive PIVC insertion bundle, a “replace as clinically indicated” approach may be appropriate. Other health care services may be better suited to a mandatory replacement policy.
Given evidence that half of PIVCs inserted in our tertiary emergency department (ED) were unused,5 along with the evidence of PIVC-associated infection,1 Monash Health introduced a comprehensive multimodal change process to reduce unused PIVCs and subsequent bloodstream infections. Clinicians in Monash Health EDs are asked to only insert a PIVC if they feel it is at least 80% likely it will be used in the following 4 hours. An accompanying education campaign provides guidance in cases where a precautionary PIVC may be required, such as for patients who present after a seizure. The aim of the intervention is to avoid insertion of unnecessary PIVCs, while ensuring appropriate insertion, and to improve insertion methods. Four months after the intervention began, we demonstrated a reduction in total monthly PIVCs from 1413 to 928 and an unused PIVC rate of 19.3% (unpublished data). This change process has been offered to EDs throughout Victoria by the Department of Health.6
We would support the establishment of a specific national standard regarding the stewardship of PIVCs, which should include the need to carefully evaluate whether insertion of the PIVC is necessary.
Competing interests
No relevant disclosures.
References
- Stuart RL, Cameron DRM, Scott C, et al. Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services. Med J Aust 2013; 198: 551-553. 1
- Collignon PJ, Kimber FJ, Beckingham WD, Roberts JL. Prevention of peripheral intravenous catheter-related bloodstream infections: the need for routine replacement [letter]. Med J Aust 2013; 199: 750-751. 2
- Rickard CM, Webster J, Playford EG. Prevention of peripheral intravenous catheter-related bloodstream infections: the need for routine replacement [letter]. Med J Aust 2013; 199: 751-752. 3
- Webster J, Osborne S, Rickard C, Hall J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 2010; (3): CD007798. lefthere
- Limm EI, Fang X, Dendle C, et al. Half of all peripheral intravenous lines in an Australian tertiary emergency department are unused: pain with no gain? Ann Emerg Med 2013; 62: 521-525. doi: 10.1016/j.annemergmed.2013.02.022. 5
- Emergency Care Improvement and Innovation Clinical Network, Department of Health, Victoria. Evidence-based care in emergency departments 2014. http://health.vic.gov.au/clinicalnetworks/emergency/em2014-activities.htm (accessed Mar 2014).