Prevention of peripheral intravenous catheter-related ...

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Editorials rationale, through consideration of data on students’ early career intentions, to make changes to educational programs and provision of incentives to meet these shortages. Over time, the linked data will also allow evaluation of such initiatives. Linkages with the Australian Rural Clinical Schools Program Survey and the Undergraduate Medical and Health Sciences Admission Test Longitudinal Study are planned. These will assist in analyses of medical school selection processes and further curriculum development. The MSOD dataset provides mechanisms for evaluating and comparing outcomes of different medical programs (eg, graduate and undergraduate entry; shorter and longer programs) and alignment with national workforce needs. So what does the future hold? The success of workforce research lies in its contribution to resolving medical workforce shortages and maldistribution. With close engagement between policymakers and researchers, the MSOD Project provides evidence that will continue to underpin innovative approaches to teaching and training, inform appropriate internship and specialty training placements, and contribute to further development of assessment tools and measurement of the quality of clinical training. The outcomes of these developments should provide the medical workforce required to meet the future needs of Australia and New Zealand. Acknowledgements: We are grateful to the medical schools, stakeholder organisations, medical students, graduates and doctors who participated in the MSOD Project. The project was possible due to funding made available by Health Workforce Australia (2011 onwards) and the Australian Government Department of Health and Ageing (2004–2011). Competing interests: As well as being employed by the Australian National University as Dean of Medicine and Health Sciences and Dean of the Medical School, Nicholas Glasgow is Chair of the MSOD Project Board and Treasurer of Medical Deans Australia and New Zealand Inc. Provenance: Commissioned; externally peer reviewed.

1 Health Workforce Australia. Health Workforce 2025: doctors, nurses and

midwives — Volume 1. Adelaide: HWA, 2012. 2 Australian National Audit Office. Rural and Remote Health Workforce Capacity

3 4



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– the contribution made by programs administered by the Department of Health and Ageing. Canberra: Commonwealth of Australia, 2009. Australian Institute of Health and Welfare. Medical workforce 2011. Canberra: AIHW, 2013. (AIHW Cat. No. HWL 49; National Health Workforce Series No. 3.) Buykx P, Humphreys JS, Wakerman J, Pashen D. A systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy. Aust J Rural Health 2010; 18: 102-109. Medical Deans Australia and New Zealand. Medical Schools Outcomes Database [project website]. (accessed Feb 2013). Humphreys JS, Prideaux D, Beilby J, Glasgow NJ. From medical school to medical practice — a national tracking system to underpin planning for a sustainable medical workforce in Australia. Med J Aust 2009; 191: 244-245. Medical Training Review Panel. Fifteenth report. Canberra: Australian Government Department of Health and Ageing, 2012. Medical Deans Australia and New Zealand. Minister praises project. Outcomes: Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project 2012; Issue 7. 2012_12_-Issue_7.pdf (accessed May 2013). Gerber JP, Landau LI. Driving change in rural workforce planning: the Medical Schools Outcomes Database. Aust J Prim Health 2010; 16: 36-39. Medical Deans Australia and New Zealand. MSOD Project: inaugural research forum. Forum report. Sydney: MDANZ, 2012. au/wp-content/uploads/2011-Inaugural-Research-Forum-Report-FINAL.pdf (accessed Feb 2013). Jones M, Humphreys J, Prideaux D. Predicting medical students’ intentions to take up rural practice after graduation. Med Educ 2009; 43: 1001-1009. Hays R. The utilisation of the health care system for authentic early experience placements. Rural Remote Health 2013. In press. Jones M, Humphreys J, Prideaux D, MacGrail M. Why does a rural background make medical students more likely to intend to work in rural areas and how consistent is the effect? A study of the rural background effect. Aust J Rural Health 2012; 20: 29-34. Royal College of Physicians and Surgeons of Canada. 14th International Health Workforce Collaborative 2013. Poster abstracts. publicpolicy/imwc/conference14.php (accessed May 2013). Medical Deans Australia and New Zealand. MSOD report: spatial mapping medical schools and student origins. (accessed Feb 2013). ❏

Prevention of peripheral intravenous catheter-related bloodstream infections: the need for a new focus Careful insertion and maintenance technique on every occasion is important — not routine replacement


ntravascular access device-related bloodstream infections, including Staphylococcus aureus bacteraemias (SABs), cause substantial clinical harm and waste scarce health care resources. And yet, many, if not most, are preventable. We are belatedly realising that to eliminate these complications we must conduct research, implement evidence-based interventions and reduce the clinical practice variation that leads to their occurrence. Public reporting and the financial disincentives associated with apparent poor performance are also pulling us along this path. In this issue of the Journal, Stuart and colleagues provide yet another wake-up call by describing a case series of 137 peripheral intravenous catheter (PIVC)-associated SABs.1 They highlight some important failings in our processes for managing

PIVCs that allow devastating complications to occur and which require our urgent attention. Infections can occur at any time after PIVC insertion, but early infections typically reflect the insertion procedure.2 More than half of the SAB episodes in Stuart et al’s study (55%) occurred within 96 hours of insertion, suggesting suboptimal practice. Aseptic insertion is difficult in emergency situations, and SAB episodes were predominantly associated with insertion by the ambulance service or in the emergency department (ED) (21% and 40% of SABs, respectively). In addition, ambulance or ED insertions accounted for 61% of early infections (up to 96 hours). PIVCs inserted in the ED have been reported to have a sixfold higher incidence of SAB than lines inserted in

Claire M Rickard

BN, GradDipN(CriticalCare), PhD, Professor of Nursing, 1,3 and Honorary Fellow 2,4

Joan Webster

RN, RM, BA, Nursing Director — Research, 2 and Professor of Nursing 1,3

E Geoffrey Playford

MB BS(Hons), MMed(ClinEpi), PhD, Director, 4 Infection Management Services, and Associate Professor 5

Research p 554

MJA 198 (10) · 3 June 2013


Editorials 1 NHMRC Centre for Research Excellence in Nursing, Interventions for Hospitalised Patients Griffith Health Institute, Griffith University, Brisbane, QLD. 2 Research and Development Unit, Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Brisbane, QLD. 3 School of Nursing and Midwifery, Griffith University, Brisbane, QLD. 4 Princess Alexandra Hospital, Metro South Health, Brisbane, QLD. 5 University of Queensland, Brisbane, QLD.

[email protected]

doi: 10.5694/mja13.10428


wards.3 Hospital-wide data including PIVC insertions that did not result in SAB were not available, but Stuart and colleagues’ series suggests institutional reliance on the prehospital and ED settings for PIVC insertion as well as increased SAB risk associated with these settings. Treating all PIVCs inserted by the ambulance service and in the ED as “guilty” of non-aseptic insertion is one avenue for potentially avoiding complications. At our hospitals, we try to remove such PIVCs within 24 hours. This may explain why we found just two PIVC-associated SABs in our study — only 10% of 5907 PIVCs were inserted in the ED.4 However, “routine replacement” of PIVCs inserted by the ambulance service or in the ED increases workload in the wards, compromises vessel health and fails to address the root cause of the problem — non-aseptic insertion technique. It would be preferable to get it right the first, and every, time we perform an insertion. Achieving consistent aseptic insertion across the prehospital, emergency and inpatient spectrum, in addition to flagging and removing PIVCs inserted in true emergencies, requires a coordinated, disciplined approach, but we should demand nothing less. Not all PIVC-related infections will be prevented with a focus on catheters inserted in prehospital and ED settings; indeed, Stuart et al found that most PIVC-associated SAB episodes (65%) occurring within 72 hours of insertion were among patients whose PIVCs were inserted in a ward. This rate demands close attention be paid to practices throughout the hospital; specifically, preinsertion skin preparation with alcoholic chlorhexidine ⭓ 0.5%, hand hygiene and aseptic, non-touch technique using a sterile field and clean or sterile gloves. Correct insertion will prevent many infections — but not all, unless clean, intact dressings and aseptic technique when accessing the PIVC are also used. Careful daily assessment is required; of need, and for inflammation or infection, with prompt removal of clinically suspect or redundant lines. Amazingly, we do a poor job at identifying PIVCs that have no purpose and should be removed. New strategies to reduce complications could include chlorhexidine-impregnated dressings and bundles of care, both of which have been shown to be effective in reducing infections associated with central venous catheters (CVCs) and potentially also with PIVCs.5,6 Our hospitals have moved from using “IV teams” to perform insertions to leadership by key individuals who champion policies and drive change to ensure PIVC care is evidence-based and standardised. Stuart and colleagues found 24% of SABs (137/583) to be PIVC-associated, which was higher than the 4% (24/544) found in a recent US study.3 Further, they found more SABs were associated with PIVCs than with CVCs (24% compared with 18%). In contrast, a review of 491 bloodstream infections, of which 31% were SABs, found many more were CVC-associated (38%) than PIVC-associated (7%).7 Stuart et al’s definition of PIVC-associated SAB allowed for up to 7 days between the presence of a PIVC and a positive blood culture for SAB, which is likely to have increased PIVCassociated SAB incidence; a more restrictive 48-hour time frame is more common.8 This incidence rate may also have been increased by the use of site symptoms (redness, tenderness, phlebitis or induration) as confirmation of the PIVC

MJA 198 (10) · 3 June 2013

source, rather than microbiological catheter-tip or site cultures. We observed that PIVCs frequently developed site symptoms, and these had poor positive predictive value for bloodstream infections.4 Regardless of definitions, the overall incidence of PIVC-related bloodstream infection is very low — ⭐ 1 in 1000 patients;4,9 randomised controlled trials of interventions would require logistically impossible sample sizes to prove efficacy using this end point. The SAB episodes described by Stuart and colleagues occurred despite institutional policies already being in place for PIVC removal in 96 hours or less. Dwell times for episodes of PIVC-associated SAB averaged 3.5 days — within the recommended time frame — further suggesting that dwell time was not a factor. Some SABs occurred up to 9 days after insertion, but it is often impossible to resite catheters routinely, owing to patients’ poor veins or clinical condition, or staff unavailability.10 Undoubtedly, microbes increase over time, and longer overall dwell time holds greater risk than a shorter period, but strong data have indicated that two 3-day PIVCs hold the same risk as a PIVC with a dwell time of 6 days.4,11 Stuart et al’s data confirm that SAB remains a problem with PIVCs and that, rather than relying on the “3 day rule” to prevent complications, strict attention to insertion and maintenance practice is required. This complements the message from our recent large trial published in The Lancet — PIVCs can be safely used beyond 96 hours, but they must also be aseptically inserted, carefully maintained, assessed daily and removed as soon as possible.4 It is time to stop watching the clock and instead focus on our own practices — for our patients’ benefit. Competing interests: No relevant disclosures. Provenance: Commissioned; externally peer reviewed. 1 Stuart RL, Cameron DRM, Scott C, et al. Peripheral intravenous catheter-







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associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services. Med J Aust 2013; 198: 554-556. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49: 1-45. Trinh TT, Chan PA, Edwards O, et al. Peripheral venous catheter-related Staphylococcus aureus bacteremia. Infect Control Hosp Epidemiol 2011; 32: 579-583. Rickard CM, Webster J, Wallis MC, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012; 380: 1066-1074. Timsit J, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter related sepsis in critically ill adults: a randomized controlled trial. JAMA 2009; 301: 1231-1241. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-2733. Collignon PJ, Dreimanis DE, Beckingham WD, et al. Intravascular catheter bloodstream infections: an effective and sustained hospital-wide prevention program over 8 years. Med J Aust 2007; 187: 551-554. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52: e162-e193. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81: 1159-1171. Palese A, Cassone A, Kulla A, et al. Factors influencing nurses’ decision-making process on leaving in the peripheral intravascular catheter after 96 hours: a longitudinal study. J Infus Nurs 2011; 34: 319-326. 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.

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