Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial

Samantha Keogh, Caroline Shelverton, Julie Flynn, Gabor Mihala, Saira Mathew, Karen M Davies, Nicole Marsh, Claire M Rickard, Samantha Keogh, Caroline Shelverton, Julie Flynn, Gabor Mihala, Saira Mathew, Karen M Davies, Nicole Marsh, Claire M Rickard

Abstract

Background: Peripheral intravenous catheters (PIVCs) are ubiquitous medical devices, crucial to providing essential fluids and drugs. However, post-insertion PIVC failure occurs frequently, likely due to inconsistent maintenance practice such as flushing. The aim of this implementation study was to evaluate the impact a multifaceted intervention centred on short PIVC maintenance had on patient outcomes.

Methods: This single-centre, incomplete, stepped wedge, cluster randomised trial with an implementation period was undertaken at a quaternary hospital in Queensland, Australia. Eligible patients were from general medical and surgical wards, aged ≥ 18 years, and requiring a PIVC for > 24 h. Wards were the unit of randomisation and allocation was concealed until the time of crossover to the implementation phase. Patients, clinicians, and researchers were not masked but infections were adjudicated by a physician masked to allocation. Practice during the control period was standard care (variable practice with manually prepared flushes of 0.9% sodium chloride). The intervention group received education reinforcing practice guidelines (including administration with manufacturer-prepared pre-filled flush syringes). The primary outcome was all-cause PIVC failure (as a composite of occlusion, infiltration, dislodgement, phlebitis, and primary bloodstream or local infection). Analysis was by intention-to-treat.

Results: Between July 2016 and February 2017, 619 patients from 9 clusters (wards) were enrolled (control n = 306, intervention n = 313), with 617 patients comprising the intention-to-treat population. PIVC failure was 91 (30%) in the control and 69 (22%) in the intervention group (risk difference - 8%, 95% CI - 14 to - 1, p = 0.032). Total costs were lower in the intervention group. No serious adverse events related to study intervention occurred.

Conclusions: This study demonstrated the effectiveness of post-insertion PIVC flushing according to recommended guidelines. Evidence-based education, surveillance and products for post-insertion PIVC management are vital to improve patient outcomes.

Trial registration: Trial submitted for registration on 25 January 2016. Approved and retrospectively registered on 4 August 2016. Ref: ACTRN12616001035415 .

Keywords: Catheter-related infection; Evidence-based practice; Flushing; Peripheral intravenous catheter; Randomised trial.

Conflict of interest statement

SK’s current employer (QUT) has received on her behalf education consultancy fees from BD Medical. NM’s previous employer (Griffith University) has received on her behalf investigator-initiated research grants and unrestricted educational grants from BD-Bard and Cardinal Health consultancy fees from BD-Bard. CMR’s employer has received, on her behalf, investigator-initiated research grants and unrestricted educational grants from BD-Bard, Cardinal Health, and consultancy fees from 3 M, BD-Bard, BBraun. All other authors declare no competing interests. BD Medical provided in-kind support for this study through the provision of product education. BD Medical did not design the study protocol, did not collect or analyse data, and were not involved at all in the preparation of the manuscript. There are no non-financial competing interests to declare.

Figures

Fig. 1
Fig. 1
Incomplete stepped wedge cluster randomised trial with an implementation period. Study design and patient flow
Fig. 2
Fig. 2
Staff satisfaction rating of intervention % scored ≥ of 7 (out 10)

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