Is use of a secondary IV, or piggyback system, reduce the rate of central line-associated bloodstream infections?

A search of Joanna Briggs for the term piggyback identified several evidence summaries and recommendations.  Each of them cited the 2002 CDC guidelines as evidence in discussing piggyback systems.

MMWR Recomm Rep. 2002 Aug 9;51(RR-10):1-29.
O’Grady NP, et al.  Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention.

On p. 11, the guidelines state that “modified piggyback systems have the potential to prevent contamination…” and cite this single study:

JPEN J Parenter Enteral Nutr. 1992 Nov-Dec;16(6):581-5.
Inoue Y, et al.  Prevention of catheter-related sepsis during parenteral nutrition: effect of a new connection device.

A search of PubMed was conducted using the following terms:
(piggyback OR secondary iv OR (secondary AND infusion)) AND infections AND prevention AND central venous catheters

The results include the Inoue study.  No other studies focus on prevention of catheter-associated bloodstream infections, but may report data on infection rates, which may also be useful.  However, the populations for most of the other studies were neonates.

jkn 3/14

Nursing care for a patient with externalized shunt

Hill, Michelle A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. Journal of Neuroscience Nursing, 2012 Aug; 44 (4): 188-93.

Henman, Lita Checklists and Bundles-Not Just for Central Lines Anymore: Using a Standardized Insertion and Maintenance Approach to Eliminate External Ventricular Drain Infections. American Journal of Infection Control, 2011 Jun; 39 (5): E195.

Orsi GB Hospital-acquired infection surveillance in a neurosurgical intensive care unit. Journal of Hospital Infection, 2006 Sep; 64 (1): 23-9.

Cummings R Understanding external ventricular drainage. Journal of Neuroscience Nursing (J NEUROSCI NURS), 1992 Apr; 24 (2): 84-7.

Lwin, Sein, et al. “External ventricular drain infections: successful implementation of strategies to reduce infection rate.” Singapore medical journal 53.4 (2012):255-259.

Littlejohns, Linda R, and BrettTrimble. “Our policy on external ventricular drainage systems includes the procedure for priming the system. Does it really have to be primed?.” Critical care nurse 25.3 (2005):57-59.

Criddle, Laura M. “Is it an expected practice for critical care nurses to irrigate an external ventriculostomy drainage (EVD) system with tissue plasminogen activator (tPA) to break up blood clots in the tubing to facilitate drainage, thereby preventing increased intracranial pressure?.” Critical care nurse 27.3 (2007):78-78, 81.

Searched PubMed & CINAHL. Keywords: external shunt, externalized shunt, (nursing or nurse)

Does hourly rounding reduce the risk of accidental falls in a cardiovascular surgical unit?

A CINAHL search for (rounds OR rounding) AND falls AND (cardiac OR coronary OR cardiovascular) did not retrieve any results.

A search for (rounds OR rounding) AND falls AND (surgical OR surgery OR postoperative) retrieved 13 references, including these studies in medical-surgical units:

Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Woodward JL; Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 2009 Jul-Aug; 23 (4): 200-6.

Hourly Rounding: A Replication Study. Olrich, Todd; Kalman, Melanie; Nigolian, Cindy; MEDSURG Nursing, 2012 Jan-Feb; 21 (1): 23-36.

A search in PubMed found these two additional articles.

Krepper, Rebecca, et al. “Evaluation of a Standardized Hourly Rounding Process (SHaRP).” Journal for healthcare quality 36.2 (2014):62-69.
The first took place in two 32-bed cardiovascular surgery nursing units.

Ciccu Moore, Rita, et al. “Care and comfort rounds: improving standards.” Nursing management 20.9 (2014):18-23.
This study took place in an orthopaedic and surgical rehabilitation ward.

See also Does hourly or intentional rounding reduce the rate of accidental falls in acute care facilities?

See also Are inpatients with cardiac conditions or on diuretic therapy at risk for falls and is there any evidence of interventions to reduce falls in this population?
This blog entry references a couple of papers in the search  results that include patients with cardiac conditions in their populations.  You might be able to extrapolate strategies to your population.

Reviewed and updated 4/8/2014 ldt

Is capnography or end tidal CO2 assessment effective for monitoring adult patients in emergency departments or intensive care units who are undergoing moderate sedation or mechanical ventilation?

Bottom line:  There is evidence that associates capnography with improved detection of respiratory depression during procedural sedation and in management of mechanical ventilation.

Monitoring during moderate sedation:

PubMed search: (capnography OR end tidal carbon dioxide) AND sedation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Includes prospective studies, a systematic review and some lower quality comparative studies.

Higher quality study (Randomized controlled trial and prospective studies)
Proehl J, et al. J Emerg Nurs. 2011 Nov;37(6):533-6. Emergency Nursing Resource: the use of capnography during procedural sedation/analgesia in the emergency department.
Systematic review describes evidence from research studies, meta-analyses, systematic
reviews, and existing guidelines. Rates evidence using Appraisal of Guidelines Research & Evaluation methodology.

Deitch K, et al. Ann Emerg Med. 2010 Mar;55(3):258-64. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial.
Patients (n=132) in the ED who received propofol sedation received standard monitoring plus capnography and were randomized so that physicians administering care either had access to capnography readings or were blinded to capnography readings.  RESULTS:  Hypoxia was observed in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%).  Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds)

Burton JH, et al. Acad Emerg Med. 2006 May;13(5):500-4. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?
60 patients (enrollment stopped after review of 20 acute respiratory events) underwent capnographic monitoring while under procedural sedation. Abnormal end tidal CO2 findings were documented in 36 patients (60%). Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events.

Monitoring during mechanical ventilation

PubMed:  (capnography OR end tidal carbon dioxide) AND mechanical ventilation AND (emergency department OR intensive care OR critical care) AND humans[mesh]
Filters:  Systematic reviews

Walsh BK, Crotwell DN, Restrepo RD. Capnography/Capnometry during mechanical ventilation: 2011.  Respir Care. 2011 Apr;56(4):503-9.
Applied GRADE criteria to 200+ identified studies and guidelines. Includes several recommendations for use of capnography in monitoring patients on mechanical ventilation.

Indwelling urinary catheter removal protocols for reducing CAUTI rates

A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections. Moola Sandeep Konno R.

Removal of short term indwelling urethral catheters. [Best practice information sheets]

Urethral Catheter: Removal. [Evidence Summaries]

Clinical practical procedures. Urinary catheters: part 4 — removing an indwelling urinary catheter. Nursing Times 2008 vol:104 iss:42 pg:26

Fink, Regina; Gilmartin, Heather; Richard, Angela; Capezuti, Elizabeth; Boltz, Marie; Wald, Heidi; Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Health system Elders hospitals. Detail American Journal of Infection Control, 2012 Oct; 40 (8): 715-20

Prevention of catheter-associated urinary tract infections in patients with hip fractures through education of nurses to specific catheter protocols. Orthopedic Nursing. 2012 vol:31 iss:1 pg:12

Dailly, Sue; Prevention of indwelling catheter-associated urinary tract infections. Nursing Older People, 2011 Mar; 23 (2): 14-9

Reviewed JKN 4/14

Does trimming peripherally inserted central catheters (PICC) increase the incidence of thrombosis?

Bottom line: There is not much published evidence addressing this question.

Summary:
Joanna Briggs: Peripherally Inserted Central Catheters: Occlusion
Reviews evidence associated with risk associated with misplacement or movement of the catheter tip and location of insertion site.  I checked the references cited, but did not find any discussion of modifying or trimming the catheter.

PubMed:
peripherally inserted catheter AND thrombosis AND (trimmed OR trimming OR modif* OR cutting)

Evidence that specifically discusses trimming includes
Parvez. Thrombosis Research (2004) 113, 175—177:  A comparison of changes in surface of catheter at site of trimming.  Authors hypothesize that roughness introduced by trimming line can contribute to thrombosis.

EMBASE:
To view search click on the EMBASE link and then copy this search statement into the search box:

‘peripherally inserted central catheter’ AND thrombosis  AND (trimming OR trimmed OR modif*)

Additional evidence that specifically discusses trimming includes:

Trimming of peripherally inserted central catheters: The end result
Pettit J.  JAVA – Journal of the Association for Vascular Access 2006 11:4 (209-214)
This paper references a study showing how trimming affects the catheter tip.  Possibly this reference is to the Parvez article from the PubMed results above.  We do not have access to this Pettit paper, but you can request through interlibrary loan link in the Find It @ Emory menu for this article

Other papers in both the PubMed and EMBASE searches seem to mention trimming or cutting the catheter, but only as part of the procedures and not as a risk factor.

SEARCH METHODS
Resources searched:
Evidence summary resources:  Joanna Briggs JBI+Connect
Large literature databases: PubMed, EMBASE

Search included combinations of these terms:
Peripherally inserted central catheter, catheter
trimming, trimmed, modif* (for modify, modified, modification, etc.)
thrombosis