Volume 29: Issue 1

Highlights

Catheter failure is a serious matter challenging the delivery of high-quality care for pediatric patients.
Insertion modality, patient race, and an intensive care unit or emergency department setting are predictive of catheter failure and removal.
Peripheral intravenous catheter insertion under ultrasound guidance had an estimated dwell time of 6.5 days compared to 4.0 days when transillumination was used.

Abstract

Background:

Peripheral intravenous catheter (PIVC) insertion is one of the most common medical procedures experienced by pediatric patients. A high incidence of catheter failure (CF) and associated sequelae are widely documented.

Methods:

This single-center retrospective study was conducted at a freestanding pediatric academic center. Electronic health records were reviewed to identify variables predictive of PIVC dwell time. PIVCs inserted by the vascular access team using either ultrasound guidance (USG) or transillumination during an inpatient admission in October–December 2019 were analyzed.

Results:

The sample included 743 PIVCs. Survival time, or dwell time, was estimated with the Kaplan-Meier survival curve. PIVCs inserted with USG demonstrated an estimated median dwell time of 6.5 days (95% CI: 5.8, 8.0); those inserted with transillumination had an estimated median dwell time of 4.0 days (95% CI: 3.1, 5.2). Factors predictive of dwell time were insertion modality, race, and patient care setting. Catheter removal associated with failure is 1.87 (95% CI = [1.24, 2.8], P = 0.003) times more likely when the PIVC insertion modality is transillumination compared to USG. Odds of CF are 1.76 (95% CI = [1.19, 2.6], P = 0.004) times more likely in a Black/African American patient than a White patient. Odds of patients in an intensive care unit or emergency department setting are 1.34 (95% CI = [1.03, 1.7], P = 0.029) times more likely to have catheter removal due to failure than in a floor/nonemergency unit.

Conclusions:

Understanding factors contributing to CF gives clinicians the knowledge to improve practice and mitigate harm in pediatric patients.

Highlights

Our project implementing a VAST produced these improved outcomes.
There were 31% fewer IV devices.
There were 22% fewer needle sticks.
There were 49% reduction in delays.

Abstract

Background:

Vascular access is essential in the care of hospitalized pediatric patients. Planning and device selection are important for optimal patient outcomes. Vessel preservation is critical for pediatric patients.

Purpose:

To determine and evaluate the impact of a vascular access team on pediatric patient care.

Methods:

A vascular access specialist team (VAST) was implemented on one medical unit at a tertiary children’s hospital, 16 hours a day for 4 weeks.

Data Analysis:

Descriptive statistics were used, including (a) first-stick success rates, (b) number of needle sticks and vascular access devices per hospital stay, (c) delays in therapy, and (d) frequency of topical analgesic use. Preintervention data were compared with postintervention data. Qualitatively, nursing and medical staff were surveyed to evaluate their perception of project experiences.

Results:

Compared with preintervention data, 56% fewer peripheral intravenous lines were initiated, and 31% fewer total vascular access devices were used during the hospital stay. There were 22% fewer needle sticks per peripheral intravenous line attempt. The first-stick success rate of the VAST was 71% compared with the bedside nurse rate of 52%. There was a 78% reduction in time between devices/1000 patient-days/week, representing reduced interruptions in therapy. The use of topical anesthetics for intravenous device placement increased 333%.

Conclusion:

This project provided clarity regarding the value of the VAST for pediatric hospitalized patients. The VAST model is evidence based, follows best-practice guidelines, is fiscally sound, and optimizes nursing practice and quality patient care.

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.

Use of Central Venous Access Devices in Hospitalized Children outside of the ICU—A Multisite Retrospective Study

Alina G. Burek, MD

aburek@mcw.edu

Purpose: The aims of this study were to (1) identify national trends and variation in CVAD (PICC and non-PICC) use outside of the intensive care unit (CVADs/total encounters); (2) describe the population of children with CVADs; (3) Determine the rate of central line-associated blood stream infections (CLABSI) and venous thromboembolism (VTE) in this population.

Background: Central venous access devices (CVADs) such as peripherally inserted central catheters (PICCs) must be used judiciously due to serious complications (CLABSI and