Care Bundles and Peripheral Arterial Catheters: A Scoping Review^CE

Background and Significance

A frequently performed practice in anesthesia, critical care, and emergency medicine is insertion of a peripheral arterial catheter (AC) for hemodynamic monitoring and frequent blood sampling. With millions inserted annually in the United States, peripheral AC associated complications include dislodgement, mechanical failure, and infection.¹ The risk of AC related infection has been known for over a decade to be comparable with short-term, noncuffed central venous catheters (CVCs).^1–6 ACs have been described as the most manipulated intravascular device in Intensive Care Units and the operating room increasing risk factors, with the need for an AC bundle described in 2008 and 2010^1,5–8 to decrease risk and improve patient safety. The literature also shows that guidelines recommended by the Centers for Disease Control for AC insertion have often not been followed.⁹ Such evidence indicates a need for a standardized approach for insertion and care of peripheral ACs to improve practice by featuring the specified interventions of patient assessment, an appropriate aseptic technique, and correct insertion and/or securement methods. A standardized safe insertion bundle incorporating ultrasound-guidance for ACs has recently been published to promote procedural excellence.¹⁰ Standardization with a structured framework has been achieved using insertion and care bundles, initially with CVCs, incorporating specified interventions that improve practice, effectiveness, and patient safety in an efficient and cost-effective manner to minimize complications.¹¹ To clarify, the key features of a care bundle are collective, reliable, and continuous performance to improve care.^12,13 Many bundles focus on hospital-acquired infections,^14–18 particularly central line associated blood stream infections (CLABSIs). The landmark Michigan Keystone Intensive Care Unit Patient Safety Program in 2006 resulted in the large (66%) and sustained decreased rate of catheter related blood stream infections (CRBSIs).¹⁹ However, audit processes report improved care in many aspects of care delivery following implementation of care bundles.²⁰ An AC care bundle to facilitate best practice for AC insertion and care is overdue.

This scoping review will map the existing literature about care bundles for all intravascular devices, with a focus on peripheral ACs. Such a review is a useful tool for evidence reconnaissance by providing a broad topic overview.²¹ Conceptual analysis will describe and interpret aspects of the care bundle, as developed by the Institute for Healthcare Improvement, to inform about future research about ACs.^22–24 The extent of available research and research methodologies will be examined. Analysis of the range of research literature will provide conceptual clarity about the topic, as well as providing an overview of the field and breadth of evidence. We will incorporate the key concept of scoping by clarifying definitions and providing a narrative overview of the literature. This will outline what is already known, and thus identify important clinical practice concerns that exist for ACs. Thus, gaps in the research will be identified.

Aims and Objectives

The aim of this scoping review is to identify the features of bundled interventions for vascular access devices that determine care outcomes and to highlight research gaps about care bundles for peripheral ACs. The objectives are to examine and map an overview of the research.

We focused our review on the following research questions:

What types of care bundles for vascular access devices have been reported?

What are the bundle components of existing vascular access device bundles?

What are the outcomes of the introduction of care bundles for specific intravascular access devices?

Design and Methods

A review design was selected and a scoping review of literature was performed, modelled on the frameworks of Arksey and O'Malley²⁵ and the Cochrane Health Group,²² and carried out according to the Methodology for Joanna Briggs Institute Scoping Reviews.²¹

Literature about “care bundles” and “arterial catheters” published in English with no time limit was included, with the following broad criteria of intervention type, population, and geographical location: (1) all intravascular devices; (2) adult and pediatric populations; and (3) all operating rooms and critical care units.

The investigators adopted a consultative approach to the scoping framework, to ensure a consistent application of the inclusion criteria.

Reporting of Results

Tables were created to demonstrate the flow of inclusion/exclusion for study selection, characteristics, and study outcomes, as follows. The search results were collated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method,²⁶ an evidence-based minimum set of items that may be applied to scoping reviews. Our literature search was summarized in the PRISMA Flow Diagram (Figure). Characteristics of included studies are presented in Table 1, and study outcomes are listed in Table 2.

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Table 1. Characteristics of Included Studies, N = 84 (100%)

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Table 2. Outcomes of Included Studies, N = 84 (100%)

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Results

Limitations

This scoping review has the following limitations. It did not assess the risk of bias, as in systematic reviews. Studies in a language other than English were excluded.

Discussion

This scoping review identifies the available evidence, which strongly supports the use of care bundles to reduce infection in several intravascular devices. The highest prevalence of improvement for all infection types across all devices was reported for adult CVCs, with a significant decrease of CLABSI by 21.4% (P > 0.0001 to P = 0.043) in 18 observational studies. Thus, the emphasis in reporting outcomes for use of care bundles in all intravascular devices was a reduction in the incidence of infection. This important outcome was the primary discussion, with the features of care bundles and their significant role in insertion and care of the different intravascular devices for improved practice was generally not addressed. The components of bundles were infrequently specified and explained (4.7%), and this data was not provided for ACs. The important evidence gap is the lack of studies about use of care bundles for improved practice regarding insertion and care of ACs. The review identified only 1 study (1.2%) that included ACs in a study of CVCs. This study provided randomized controlled trial data that focused on infection reduction and was 1 of only 2 randomized controlled trials reviewed for all devices. The lack of research about ACs does not reflect the historical evidence of the equivalent risks for infection in ACs as in nontunnelled CVCs,^7,8 or the need for study of the components of care bundles for insertion and care to address practice concerns about patient assessment, aseptic technique, and insertion and securement methods.

Conclusion

The lack of randomized controlled trial evidence is highlighted for all device types in this review of care bundles and importantly identifies the lack of studies of ACs. Such a lack of research of ACs shows a need for study of best practice techniques involving the implementation of care bundles to minimize infection risk in line with all intravascular devices, as well as promoting the use of bundled strategies for insertion and care. The need for high quality evidence is a priority for studying ACs. This will inform a process to provide procedural excellence for optimal care of ACs using the bundled approach to minimize the complications of dislodgement and mechanical failure, as well as infection.