Background
US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) no more frequently than every 72 to 96 hours. Routine replacement is thought to ...reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation or infection. Costs associated with routine replacement may be considerable. This is the third update of a review first published in 2010.
Objectives
To assess the effects of removing peripheral intravenous catheters when clinically indicated compared with removing and re‐siting the catheter routinely.
Search methods
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 18 April 2018. We also undertook reference checking, and contacted researchers and manufacturers to identify additional studies.
Selection criteria
We included randomised controlled trials that compared routine removal of PIVC with removal only when clinically indicated, in hospitalised or community‐dwelling patients receiving continuous or intermittent infusions.
Data collection and analysis
Three review authors independently reviewed trials for inclusion, extracted data, and assessed risk of bias using Cochrane methods. We used GRADE to assess the overall evidence certainty.
Main results
This update contains two new trials, taking the total to nine included studies with 7412 participants. Eight trials were conducted in acute hospitals and one in a community setting. We rated the overall certainty of evidence as moderate for most outcomes, due to serious risk of bias for unblinded outcome assessment or imprecision, or both. Because outcome assessment was unblinded in all of the trials, none met our criteria for high methodological quality.
Primary outcomes
Seven trials (7323 participants), assessed catheter‐related bloodstream infection (CRBSI). There is no clear difference in the incidence of CRBSI between the clinically indicated (1/3590) and routine change (2/3733) groups (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.08 to 4.68), low‐certainty evidence (downgraded twice for serious imprecision).
All trials reported incidence of thrombophlebitis and we combined the results from seven of these in the analysis (7323 participants). We excluded two studies in the meta‐analysis because they contributed to high heterogeneity. There is no clear difference in the incidence of thrombophlebitis whether catheters were changed according to clinical indication or routinely (RR 1.07, 95% CI 0.93 to 1.25; clinically indicated 317/3590; 3‐day change 307/3733, moderate‐certainty evidence, downgraded once for serious risk of bias). The result was unaffected by whether the infusion was continuous or intermittent. Six trials provided thrombophlebitis rates by number of device days (32,709 device days). There is no clear difference between groups (RR 0.90, 95% CI 0.76 to 1.08; clinically indicated 248/17,251; 3‐day change 236/15,458; moderate‐certainty evidence, downgraded once for serious risk of bias).
One trial (3283 participants), assessed all‐cause blood stream infection (BSI). We found no clear difference in the all‐cause BSI rate between the two groups (RR 0.47, 95% CI 0.15 to 1.53; clinically indicated: 4/1593 (0.02%); routine change 9/1690 (0.05%); moderate‐certainty evidence, downgraded one level for serious imprecision).
Three trials (4244 participants), investigated costs; clinically indicated removal probably reduces device‐related costs by approximately AUD 7.00 compared with routine removal (MD −6.96, 95% CI −9.05 to −4.86; moderate‐certainty evidence, downgraded once for serious risk of bias).
Secondary outcomes
Six trials assessed infiltration (7123 participants). Routine replacement probably reduces infiltration of fluid into surrounding tissues compared with a clinically indicated change (RR 1.16 (95% CI 1.06 to 1.26; routine replacement 747/3638 (20.5%); clinically indicated 834/3485 (23.9%); moderate‐certainty evidence, downgraded once for serious risk of bias).
Meta‐analysis of seven trials (7323 participants), found that rates of catheter failure due to blockage were probably lower in the routine‐replacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.01 to 1.29; routine‐replacement 519/3733 (13.9%); clinically indicated 560/3590 (15.6%); moderate‐certainty evidence, downgraded once for serious risk of bias).
Four studies (4606 participants), reported local infection rates. It is uncertain if there are differences between groups (RR 4.96, 95% CI 0.24 to 102.98; clinically indicated 2/2260 (0.09%); routine replacement 0/2346 (0.0%); very low‐certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision).
One trial (3283 participants), found no clear difference in the incidence of mortality when clinically indicated removal was compared with routine removal (RR 1.06, 95% CI 0.27 to 4.23; low‐certainty evidence, downgraded two levels for very serious imprecision).
One small trial (198 participants) reported no clear difference in device‐related pain between clinically indicated and routine removal groups (MD −0.60, 95% CI −1.44 to 0.24; low‐certainty evidence, downgraded one level for serious risk of bias and one level for serious imprecision).
The pre‐planned outcomes 'number of catheter re‐sites per patient', and 'satisfaction' were not reported by any studies included in this review.
Authors' conclusions
There is moderate‐certainty evidence of no clear difference in rates of CRBSI, thrombophlebitis, all‐cause BSI, mortality and pain between clinically indicated or routine replacement of PIVC. We are uncertain if local infection is reduced or increased when catheters are changed when clinically indicated. There is moderate‐certainty evidence that infiltration and catheter blockage is probably lower when PIVC are changed routinely; and moderate‐certainty evidence that clinically indicated removal probably reduces device‐related costs. The addition of two new trials for this update found no further evidence to support changing catheters every 72 to 96 hours. Healthcare organisations may consider changing to a policy whereby catheters are changed only if there is a clinical indication to do so, for example, if there were signs of infection, blockage or infiltration. This would provide significant cost savings, spare patients the unnecessary pain of routine re‐sites in the absence of clinical indications and would reduce time spent by busy clinicians on this intervention. To minimise PIVC‐related complications, staff should inspect the insertion site at each shift change and remove the catheter if signs of inflammation, infiltration, occlusion, infection or blockage are present, or if the catheter is no longer needed for therapy.
Background
Pressure ulcers, localised injuries to the skin or underlying tissue, or both, occur when people cannot reposition themselves to relieve pressure on bony prominences. These wounds are ...difficult to heal, painful, expensive to manage and have a negative impact on quality of life. Prevention strategies include nutritional support and pressure redistribution. Dressing and topical agents aimed at prevention are also widely used, however, it remains unclear which, if any, are most effective. This is the first update of this review, which was originally published in 2013.
Objectives
To evaluate the effects of dressings and topical agents on pressure ulcer prevention, in people of any age, without existing pressure ulcers, but considered to be at risk of developing one, in any healthcare setting.
Search methods
In March 2017 we searched the Cochrane Wounds Group Specialised Register, CENTRAL, MEDLINE, MEDLINE (In‐Process & Other Non‐Indexed Citations), Embase, and EBSCO CINAHL Plus. We searched clinical trials registries for ongoing trials, and bibliographies of relevant publications to identify further eligible trials. There was no restriction on language, date of trial or setting. In May 2018 we updated this search; as a result several trials are awaiting classification.
Selection criteria
We included randomised controlled trials that enrolled people at risk of pressure ulcers.
Data collection and analysis
Two review authors independently selected trials, assessed risk of bias and extracted data.
Main results
The original search identified nine trials; the updated searches identified a further nine trials meeting our inclusion criteria. Of the 18 trials (3629 participants), nine involved dressings; eight involved topical agents; and one included dressings and topical agents. All trials reported the primary outcome of pressure ulcer incidence.
Topical agents
There were five trials comparing fatty acid interventions to different treatments. Two trials compared fatty acid to olive oil. Pooled evidence shows that there is no clear difference in pressure ulcer incidence between groups, fatty acid versus olive oil (2 trials, n=1060; RR 1.28, 95% CI 0.76 to 2.17; low‐certainty evidence, downgraded for very serious imprecision; or fatty acid versus standard care (2 trials, n=187; RR 0.70, 95% CI 0.41 to 1.18; low‐certainty evidence, downgraded for serious risk of bias and serious imprecision). Trials reported that pressure ulcer incidence was lower with fatty acid‐containing‐treatment compared with a control compound of trisostearin and perfume (1 trial, n=331; RR 0.42, 95% CI 0.22 to 0.80; low‐certainty evidence, downgraded for serious risk of bias and serious imprecision). Pooled evidence shows that there is no clear difference in incidence of adverse events between fatty acids and olive oil (1 trial, n=831; RR 2.22 95% CI 0.20 to 24.37; low‐certainty evidence, downgraded for very serious imprecision).
Four trials compared further different topical agents with placebo. Dimethyl sulfoxide (DMSO) cream may increase the risk of pressure ulcer incidence compared with placebo (1 trial, n=61; RR 1.99, 95% CI 1.10 to 3.57; low‐certainty evidence; downgraded for serious risk of bias and serious imprecision). The other three trials reported no clear difference in pressure ulcer incidence between active topical agents and control/placebo; active lotion (1 trial, n=167; RR 0.73, 95% CI 0.45 to 1.19), Conotrane (1 trial, n=258; RR 0.74, 95% CI 0.52 to 1.07), Prevasore (1 trial, n=120; RR 0.33, 95% CI 0.04 to 3.11) (very low‐certainty evidence, downgraded for very serious risk of bias and very serious imprecision). There was limited evidence from one trial to determine whether the application of a topical agent may delay or prevent the development of a pressure ulcer (DermalexTM 9.8 days vs placebo 8.7 days). Further, two out of 76 reactions occurred in the DermalexTM group compared with none out of 91 in the placebo group (RR 6.14, 95% CI 0.29 to 129.89; very low‐certainty evidence; downgraded for very serious risk of bias and very serious imprecision).
Dressings
Six trials (n = 1247) compared a silicone dressing with no dressing. Silicone dressings may reduce pressure ulcer incidence (any stage) (RR 0.25, 95% CI 0.16 to 0.41; low‐certainty evidence; downgraded for very serious risk of bias). In the one trial (n=77) we rated as being at low risk of bias, there was no clear difference in pressure ulcer incidence between silicone dressing and placebo‐treated groups (RR 1.95, 95% CI 0.18 to 20.61; low‐certainty evidence, downgraded for very serious imprecision).
One trial (n=74) reported no clear difference in pressure ulcer incidence when a thin polyurethane dressing was compared with no dressing (RR 1.31, 95% CI 0.83 to 2.07). In the same trial pressure ulcer incidence was reported to be higher in an adhesive foam dressing compared with no dressing (RR 1.65, 95% CI 1.10 to 2.48). We rated evidence from this trial as very low certainty (downgraded for very serious risk of bias and serious imprecision).
Four trials compared other dressings with different controls. Trials reported that there was no clear difference in pressure ulcer incidence between the following comparisons: polyurethane film and hydrocolloid dressing (n=160, RR 0.58, 95% CI 0.24 to 1.41); Kang’ huier versus routine care n=100; RR 0.42, 95% CI 0.08 to 2.05); 'pressure ulcer preventive dressing' (PPD) versus no dressing (n=74; RR 0.18, 95% CI 0.04 to 0.76) We rated the evidence as very low certainty (downgraded for very serious risk of bias and serious or very serious imprecision).
Authors' conclusions
Most of the trials exploring the impact of topical applications on pressure ulcer incidence showed no clear benefit or harm. Use of fatty acid versus a control compound (a cream that does not include fatty acid) may reduce the incidence of pressure ulcers. Silicone dressings may reduce pressure ulcer incidence (any stage). However the low level of evidence certainty means that additional research is required to confirm these results.
In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans which detail essential steps in caring for patients with specific clinical problems. ...Particularly, care pathways for the dying have been developed as a model to improve the end-of-life care of all patients. They aim to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. Therefore, there is a significant need for clinicians to be informed about the utilisation of end-of-life care pathways with a systematic review.
To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).
The Cochrane Register of controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in September 2009.
All randomised controlled trials (RCTs), quasi-randomised trial or high quality controlled before and after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.
Results of searches were reviewed against the pre-determined criteria for inclusion by two review authors.
The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review.
Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people.
Aims
The aim of this systematic review and meta‐analysis was to summarize and quantify peripheral intravenous catheter‐related complications.
Design
This systematic review is reported by means of the ...Cochrane process for randomized controlled trials and the Meta‐analysis of Observation Studies in Epidemiology for cohort studies.
Data sources
The Cochrane Central Register of Controlled Trials, PubMed, CINAHL and EMBASE databases, clinical trial registries such as ClinicalTrials.gov and the reference list of included studies were searched from 2000 ‐April 2019.
Review Methods
Using a purpose designed data extraction tool, two authors independently identified studies for full review, data extraction and quality assessment. Dichotomous outcomes were pooled after Freeman–Tukey double arcsine transformation using random‐effects meta‐analysis; estimates of heterogeneity were taken from inverse‐variance fixed‐effect models.
Results
Seventy observational studies and 33 randomized controlled trials were included (76,977 catheters). Peripheral intravenous catheter‐related complications were as follows: phlebitis (with definition) 19.3%, phlebitis (without definition) 4.5%, infiltration/extravasation 13.7%, occlusion 8%, leakage 7.3%, pain 6.4% and dislodgement 6.0%. Subgroup analysis found infiltration/extravasation for emergency department‐inserted catheters was significantly higher (25.2%; p = .022) than for those inserted in other departments and pain was significantly higher (p < .001) in countries with developing economies compared with developed economies.
Conclusion
Peripheral intravenous catheter complications are unacceptably common worldwide. This review suggests substantial and multi‐specialty efforts are needed to address the sequalae associated with complications. The potential benefits for patients and health services are considerable if complications are reduced.
Impact
Peripheral intravenous complications interrupt important treatment which can be distressing for patients and result in longer hospital stays with increased healthcare costs. This review found phlebitis and infiltration are the most prevalent reason for catheter failure. These results provide nurses with a strong evidence base for the development of effective interventions for practice which are vital for preventing poor outcomes for patients with peripheral intravenous catheters.
摘要
目的
本系统评价和荟萃分析旨在概述和量化外周静脉导管相关并发症。
设计
本系统评价是通过随机对照试验用Cochrane程序和队列研究用荟萃分析流行病观察研究来报告的。
数据来源
2000年至2019年4月期间,检索了Cochrane对照试验中央缓存器、PubMed、CINAHL和EMBASE数据库、ClinicalTrials.gov等临床试验缓存器和纳入研究的参考文献清单。
审查方法
两位作者使用专门设计的数据提取工具,独立确定了全面审查、数据提取和质量评估方面的研究。在Freeman‐Tukey双重反正弦转化后,使用随机效应荟萃分析对二元结果进行汇总;异质性的估计是基于逆方差固定效应模型。
结果
纳入了70项观察性研究和33项随机对照试验(76977例导管)。外周静脉导管相关并发症如下:静脉炎(有定义)19.3%、静脉炎(无定义)4.5%、浸润/外渗13.7%、闭塞8%,渗漏7.3%、疼痛6.4%和移位6.0%。亚组分析发现,急诊科插入的导管的浸润/外渗明显高于其他科室插入的导管的浸润/外渗(25.2%;p=.022),发展中经济体国家的疼痛明显高于发达经济体国家(p <.001)。
结论
外周静脉导管并发症在全球范围内是不可接受的常见病症。本项审查表明,需要做出大量的多专业工作来解决与并发症相关的后遗症问题。减少并发症将对患者和医疗服务产生巨大的潜在益处。
影响
外周静脉并发症使得重要治疗中断,这可能会给患者带来痛苦,并导致住院时间延长,医疗费用增加。本项审查发现静脉炎和浸润是导管失败的最主要原因。这些结果为护士制定有效的实践干预措施提供了有力的证据基础,这对预防外周静脉导管患者的预后不良至关重要。
Background
Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). While existing evidence for the effectiveness of ...NPWT remains uncertain, new trials necessitated an updated review of the evidence for the effects of NPWT on postoperative wounds healing by primary closure.
Objectives
To assess the effects of negative pressure wound therapy for preventing surgical site infection in wounds healing through primary closure.
Search methods
We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in February 2018. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta‐analyses, and health technology reports to identify additional studies. There were no restrictions on language, publication date, or setting.
Selection criteria
We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.
Data collection and analysis
Four review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to GRADE methodology.
Main results
In this second update we added 25 intervention trials, resulting in a total of 30 intervention trials (2957 participants), and two economic studies nested in trials. Surgeries included abdominal and colorectal (n = 5); caesarean section (n = 5); knee or hip arthroplasties (n = 5); groin surgery (n = 5); fractures (n = 5); laparotomy (n = 1); vascular surgery (n = 1); sternotomy (n = 1); breast reduction mammoplasty (n = 1); and mixed (n = 1). In three key domains four studies were at low risk of bias; six studies were at high risk of bias; and 20 studies were at unclear risk of bias. We judged the evidence to be of low or very low certainty for all outcomes, downgrading the level of the evidence on the basis of risk of bias and imprecision.
Primary outcomes
Three studies reported mortality (416 participants; follow‐up 30 to 90 days or unspecified). It is uncertain whether NPWT has an impact on risk of death compared with standard dressings (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.25 to 1.56; very low‐certainty evidence, downgraded once for serious risk of bias and twice for very serious imprecision).
Twenty‐five studies reported on SSI. The evidence from 23 studies (2533 participants; 2547 wounds; follow‐up 30 days to 12 months or unspecified) showed that NPWT may reduce the rate of SSIs (RR 0.67, 95% CI 0.53 to 0.85; low‐certainty evidence, downgraded twice for very serious risk of bias).
Fourteen studies reported dehiscence. We combined results from 12 studies (1507 wounds; 1475 participants; follow‐up 30 days to an average of 113 days or unspecified) that compared NPWT with standard dressings. It is uncertain whether NPWT reduces the risk of wound dehiscence compared with standard dressings (RR 0.80, 95% CI 0.55 to 1.18; very low‐certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision).
Secondary outcomes
We are uncertain whether NPWT increases or decreases reoperation rates when compared with a standard dressing (RR 1.09, 95% CI 0.73 to 1.63; 6 trials; 1021 participants; very low‐certainty evidence, downgraded for very serious risk of bias and serious imprecision) or if there is any clinical benefit associated with NPWT for reducing wound‐related readmission to hospital within 30 days (RR 0.86, 95% CI 0.47 to 1.57; 7 studies; 1271 participants; very low‐certainty evidence, downgraded for very serious risk of bias and serious imprecision). It is also uncertain whether NPWT reduces incidence of seroma compared with standard dressings (RR 0.67, 95% CI 0.45 to 1.00; 6 studies; 568 participants; very low‐certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). It is uncertain if NPWT reduces or increases the risk of haematoma when compared with a standard dressing (RR 1.05, 95% CI 0.32 to 3.42; 6 trials; 831 participants; very low‐certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision. It is uncertain if there is a higher risk of developing blisters when NPWT is compared with a standard dressing (RR 6.64, 95% CI 3.16 to 13.95; 6 studies; 597 participants; very low‐certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision).
Quality of life was not reported separately by group but was used in two economic evaluations to calculate quality‐adjusted life years (QALYs). There was no clear difference in incremental QALYs for NPWT relative to standard dressing when results from the two trials were combined (mean difference 0.00, 95% CI −0.00 to 0.00; moderate‐certainty evidence).
One trial concluded that NPWT may be more cost‐effective than standard care, estimating an incremental cost‐effectiveness ratio (ICER) value of GBP 20.65 per QALY gained. A second cost‐effectiveness study estimated that when compared with standard dressings NPWT was cost saving and improved QALYs. We rated the overall quality of the reports as very good; we did not grade the evidence beyond this as it was based on modelling assumptions.
Authors' conclusions
Despite the addition of 25 trials, results are consistent with our earlier review, with the evidence judged to be of low or very low certainty for all outcomes. Consequently, uncertainty remains about whether NPWT compared with a standard dressing reduces or increases the incidence of important outcomes such as mortality, dehiscence, seroma, or if it increases costs. Given the cost and widespread use of NPWT for SSI prophylaxis, there is an urgent need for larger, well‐designed and well‐conducted trials to evaluate the effects of newer NPWT products designed for use on clean, closed surgical incisions. Such trials should initially focus on wounds that may be difficult to heal, such as sternal wounds or incisions on obese patients.
US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the ...risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010.
To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.
For this update the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Search Co-ordinator searched the PVD Specialised Register (December 2012) and CENTRAL (2012, Issue 11). We also searched MEDLINE (last searched October 2012) and clinical trials registries.
Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.
Two review authors independently assessed trial quality and extracted data.
Seven trials with a total of 4895 patients were included in the review. Catheter-related bloodstream infection (CRBSI) was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 but the confidence interval (CI) was wide, creating uncertainty around the estimate (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001).
The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.
This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary ...care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review.
To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles. We conducted the original search in September 2009, and the updated search in June 2013.
All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.
Two review authors assessed the results of the searches against the predetermined criteria for inclusion.
The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update.
With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.
To assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure.
Secondary data analysis from a randomized controlled trial of PIVC dwell time. The ...Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal.
Three acute care hospitals in Queensland, Australia.
The trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use.
Modifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio HR, 1.47 95% confidence interval (CI), 1.28-1.68, 1.27 95% CI, 1.08-1.49, and 1.25 95% CI, 1.04-1.50, respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 95% CI, 1.08-2.03). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 95% CI, 0.67-0.94). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 95% CI, 1.93-3.10 and 1.65 95% CI, 1.23-2.22, respectively), clinical staff insertion compared with intravenous service (HR, 1.69 95% CI, 1.30-2.20); and smaller PIVC diameter (HR, 1.29 95% CI, 1.02-1.61). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 95% CI, 1.28-2.09) and occlusion (HR, 1.44 95% CI, 1.30-1.61).
PIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists.
The original randomized controlled trial on which this secondary analysis is based is registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12608000445370).
BACKGROUND
Almost 70% of hospitalized patients require a peripheral intravenous catheter (PIV), yet up to 69% of PIVs fail prior to completion of therapy.
OBJECTIVE
To identify risk factors ...associated with PIV failure.
DESIGN
A single center, prospective, cohort study.
SETTING
Medical and surgical wards of a tertiary hospital located in Queensland, Australia.
PARTICIPANTS
Adult patients requiring a PIV.
MEASUREMENTS
Demographic, clinical, and potential PIV risk factors were collected. Failure occurred if the catheter had complications at removal.
RESULTS
We recruited 1000 patients. Catheter failure occurred in 512 (32%) of 1578 PIVs. Occlusion/infiltration risk factors included intravenous (IV) flucloxacillin (hazard ratio HR, 1.98; 95% confidence interval CI, 1.19‐3.31), 22‐gauge PIVs (HR, 1.43; 95% CI, 1.02‐2.00), and female patients (HR, 1.48; 95% CI, 1.10‐2.00). Phlebitis was associated with female patients (HR, 1.81; 95% CI, 1.40‐2.35), bruised insertion sites (HR, 2.16; 95% CI, 1.26‐3.71), IV flucloxacillin (HR, 2.01; 95% CI, 1.26‐3.21), and dominant side insertion (HR, 1.39; 95% CI, 1.09‐1.77). Dislodgement risks were a paramedic insertion (HR, 1.78; 95% CI, 1.03‐3.06). Each increase by 1 in the average number of daily PIV accesses was associated (HR 1.11, 95% CI 1.03‐1.20)–(HR 1.14, 95% CI 1.08‐1.21) with occlusion/infiltration, phlebitis and dislodgement. Additional securement products were associated with less (HR 0.32, 95% CI 0.22‐0.46)–(HR 0.63, 95% CI 0.48‐0.82) occlusion/infiltration, phlebitis and dislodgement.
CONCLUSION
Modifiable risk factors should inform education and inserter skill development to reduce the currently high rate of PIV failure.
Summary Background The millions of peripheral intravenous catheters used each year are recommended for 72–96 h replacement in adults. This routine replacement increases health-care costs and staff ...workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement. Methods This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370. Findings All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI −1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred. Interpretation Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications. Funding Australian National Health and Medical Research Council.
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