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Cancer Nursing:
doi: 10.1097/NCC.0b013e318277b1fb
DEPARTMENTS: Guest Editorial

Intravascular Device-Related Research: Future Priority Areas for Cancer Nursing

Chan, Raymond Javan PhD(c), MAppSc(Research), BN, RN, FACN

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Editorial Board Member, Cancer Nursing: An International Journal of Cancer Care Cancer Care Services, Royal Brisbane and Women’s Hospital Herston, Queensland Research Centre for Clinical Practice Innovation Griffith University Nathan, QueenslandSchool of Nursing and Midwifery University of Queensland Herston, Queensland, Australia

The author has no funding or conflicts of interest to disclose.

The majority of cancer nurses have to manage intravascular devices (IVDs) on a daily basis, thus placing nurses in the strongest position to generate and use best available evidence to inform this area of practice and to ensure that patients are receiving the best care available. Our literature clearly reflects that cancer nurses are concerned about complications associated with IVDs (eg, extravasation,1 IVD-related bloodstream infection [IVD-BSI],2,3 and thrombosis4). Although enormous attention is given to this area, a number of nursing practices are not sufficiently based on empirical evidence.5,6 Nurses need to set goals and priorities for future research and investments. Priority areas for future research are suggested here for your consideration.

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Safety and Other Patient-Centered Outcomes

Effectiveness IVD-related research should include, but not be limited to, reducing adverse effects associated with IVDs and infusion practices7 and improving patient experiences. For example, IVD-BSI is increasingly recognized as a nurse-sensitive patient outcome.7 Intravascular device–related BSI is associated with increased mortality and increased hospital stays (up to 20 days) and treatment costs (approximately US $56 000/episode).8,9 It is crucial for nurses to recognize that our practices impact this important outcome. Our recent meta-analysis reported that the routine use of chlorhexidine-impregnated dressings on central venous access devices (CVADs) can prevent 1 IVD-BSI in every 62 patients.10 There are now a number of available effective strategies for preventing IVD-BSI.11 However, further evidence is still required to answer some important clinically relevant questions: what dressings are the most effective for preventing IVD-BSI?3 How often do the dressings require changing for preventing IVD-BSI?2

Future effectiveness research also needs to address patient-centered outcomes. For example, patients receiving chemotherapy could experience up to 8 failed attempts of peripheral venous cannulations before being successfully cannulated so that they can receive their chemotherapy.6 In such cases, nurse-led interventions can be designed and tested to address issues that are unpleasant or important to patients. Future IVD research should focus on what appears to be important from the lens of the health professionals and of the patients and carers/families.12

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Efficiency and/or Cost of Care

Nurses have the responsibility to examine the efficiency and costs of care. Are we spending resources in care that are not based on evidence? Can we spend less to achieve the same or better patient outcomes? For example, a finding from a large nurse-led randomized controlled trial involving 3283 hospitalized patients13 was that peripheral intravenous catheters can be removed as clinically indicated, rather than every 72 to 96 hours. There is no difference in the phlebitis rates between groups.13 The cost-saving implication of practice change is expected to be enormous, considering the costs associated with the devices and personnel involved.13 Another example is that recommendation in a clinical guideline that patients with a previous venous puncture proximal to the administration site should not receive chemotherapy for at least 24 hours to prevent extravasation.14,15 However, this guideline is not based on evidence. Our recent prospective study6 followed up 77 patients who had more than 1 venous puncture proximal to the chemotherapy administration site; findings indicated that the 24-hour delay of treatment is unnecessary in the majority of patients and can reduce the efficiency of care capacity of the cancer center.

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Advancing Nursing Roles

Future research of IVD care should also focus on generating evidence that advances the nursing role in managing IVDs. For example, the emerging clinical role of nurse-led CVAD placement is exciting. A recent Australian study of 760 vascular access device placements in 3 intensive care units reported that nurse-led CVAD insertion is safe with low complications, as compared with previously published data.16 These results indicated that nurses who are formally trained and credentialed to insert CVADs can improve organizational efficiencies.16

In summary, future IVD research should focus on effectiveness, efficiency of care, and advancing nursing roles. Some of the examples provided above are based on indirect evidence. Where indirect evidence is the best available evidence, guideline developers and nurse researchers should examine the evidence critically and carefully, to determine whether further replication studies are required with cancer patients and nurses. It is an exciting time for cancer nurses to fully demonstrate that we can indeed make a difference in patient care outcomes by generating and utilizing best-evidence IVD care to patients.

My very best,

– Raymond Javan Chan, PhD(c), MAppSc(Research),

BN, RN, FACN

Editorial Board Member, Cancer Nursing:

An International Journal of Cancer Care

Cancer Care Services, Royal Brisbane and Women’s Hospital

Herston, Queensland

Research Centre for Clinical Practice Innovation

Griffith University

Nathan, Queensland

School of Nursing and Midwifery

University of Queensland

Herston, Queensland, Australia

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References

1. Wengstrom Y, Margulies A. European Oncology Nursing Society extravasation guidelines. Eur J Oncol Nurs. 2008; 12 (4): 357–361.

2. Gavin N, Webster J, Chan RJ, Rickard C. Frequency of dressing changes for central venous access devices on catheter-related infections. Cochrane Database Syst Rev. 2011; (7): CD009213.

3. Webster J, Gillies D, O’Riordan E, Sherriff KL, Rickard CM. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database Syst Rev. 2011; (11): CD003827.

4. Kuter DJ. Thrombotic complications of central venous catheters in cancer patients. Oncologist. 2004; 9 (2): 207–216.

5. Cancer Nurses Society of Australia. Central Venous Access Devices: Principles for Nursing Practice and Education. Australia: Cancer Nurses Society of Australia; 2007.

6. Chan RJ, Alexander A, Bransdon M, et al.. Challenging the distal-to-proximal cannulation technique for administration of anticancer therapies: a prospective cohort study. Cancer Nurs. 2012; 35 (5): E35–E40.

7. Oncology Nursing Society. Oncology Nursing Society 2009–2013 Research Agenda. Oncology Nursing Society; 2009.

8. Collignon PJ. Intravascular catheter associated sepsis: a common problem. The Australian Study on Intravascular Catheter Associated Sepsis. Med J Aust. 1994; 161 (6): 374–378.

9. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006; 81 (9): 1159–1171.

10. Chan RJ, Northfield S, Alexander A, Rickard C. Using the collaborative evidence based practice model: a systematic review and uptake of chlorhexidine-impregnated sponge dressings on central venous access devices in a tertiary cancer centre. Aust J Cancer Nurs. 2012; 13 (2): 10–15.

11. Centers for Disease Control and Prevention (CDC). Guidelines for the Prevention of Intravascular Catheter–Related Infections. Centers for Disease Control and Prevention; 2011.

12. Goossens GA, Vrebos M, Stas M, De Wever I, Frederickx L. Central vascular access devices in oncology and hematology considered from a different point of view: how do patients experience their vascular access ports? J Infus Nurs. 2005; 28 (1): 61–67.

13. Rickard C, Webster J, Wallis M, et al.. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012; 380: 1066–1074.

14. Ener RA, Meglathery SB, Styler M. Extravasation of systemic hemato-oncological therapies. Ann Oncol. 2004; 15 (6): 858–862.

15. Kahn MS. Reducing the morbidity from extravasation injuries. Ann Plast Surg. 2002; 48: 628–632.

16. Alexandrou E, Murgo M, Calabria E, et al.. Nurse-led central venous catheter insertion—procedural characteristics and outcomes of three intensive care based catheter placement services. Int J Nurs Stud. 2012; 49 (2): 162–168.

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