With an emphasis on reducing hospital length of stay and providing care in nonhospital settings, there has been a significant increase in the incidence of patients living at home with a central vascular access device (CVAD) in place. Indications for CVAD placement and outpatient care include the need for reliable access, chemotherapy, outpatient parenteral antimicrobial therapy (OPAT), home parenteral nutrition (HPN), and hydration. Community-based or home intravenous (IV) infusion therapy is convenient and cost-effective, and nearly 3 million CVADs are used each year in both inpatient and outpatient care.1 A variety of devices are used in the transition of a patient's care from hospital to home and outpatient/ambulatory settings, including tunneled CVADs with and without implanted ports, and nontunneled devices such as peripherally inserted central catheters (PICCs).
Patients in any setting with a CVAD in place are at risk for developing complications, especially those with lengthier dwell times. CVAD-associated complications result in a great deal of morbidity and mortality.2 Rates of central line-associated bloodstream infection (CLABSI) that occur in home settings have been reported to range from 0.4 per 1000 patient days in patients receiving OPAT3 to 0.594 per 1000 CVAD days in patients receiving cancer therapies, and to 10.045 per 1000 CVAD days in patients receiving HPN. Receiving infusion therapy in outpatient settings has also been shown to considerably increase patients' risk for CLABSI.6 Rates of CVAD thrombotic complications in patients receiving cancer therapies have been identified as ranging from 0.067 to 1.358 per 1000 CVAD days in pediatric and adolescent populations, and the incidence in adults has been found to be as high as 9.3%.9 Receiving HPN also poses risks for catheter thrombotic complications, which have been found to range from 0.0710 to 0.115,11 as well as other occlusions ranging from 0.0710 to 0.356 per 1000 CVAD days. Patients with a CVAD in place may be followed by home health care providers, may receive care in an outpatient/ambulatory care setting, or may receive care from both entities. In many instances, family members/caregivers and patients themselves are taught to provide CVAD care.6
Despite the complications described in the literature, little is known about the day-to-day characteristics of CVAD care and the factors that may contribute to these complications. The purpose of this exploratory, descriptive study was to examine patients' experiences with receiving CVAD care in nonhospital settings and the extent to which CVADs are accessed, by whom, and for what purposes. This study also sought to gain an understanding of the degree to which patients are exposed to potential inconsistencies in CVAD care practices.
Adult patients were eligible to participate in the study if they were receiving care in 1 of 4 clinical areas at 1 academic medical center in the midwestern United States: 1) inpatients who were being discharged with a CVAD (IP); 2) patients with CVADs receiving outpatient treatment in the intestinal rehabilitation clinic (IR); 3) infectious diseases clinic (ID); or 4) infusion clinic (IC). Recruitment occurred from July 2012 through March 2014. Pediatric patients and adult patients who were under the care of a parent or legal guardian were excluded, as well as patients who did not speak English. The authors attempted to recruit 25 patients from each clinical area. Institutional review board approval was obtained and signed, and informed consent was obtained from patients who agreed to participate.
Patients were given a “Patient Record of CVAD Care” form (Figure 1) and asked to complete the information every time CVAD care was provided over 14 days or until their CVAD was removed—whichever occurred first. The 2-sided form directed patients to record date/time, title of person providing CVAD care, location where care was provided, and purpose of care. Patients were asked to record complications such as occlusion and/or CLABSI. An occlusion was defined as an obstruction in at least 1 lumen that required treatment with a thrombolytic agent. The authors used the criteria for CLABSI in home health care provided by the Association for Professionals in Infection Control and Epidemiology.2 Participants were given stamped, preaddressed envelopes to submit completed diaries. Demographic information collected included age, gender, diagnosis, CVAD type and number of lumens, and date and site of insertion.
Patient characteristics and CVAD access data were analyzed using descriptive statistics. The Fisher exact test was used to compare gender and type of CVAD with responder status. The mean age was compared between the responder groups using the 2-sample t test. The Mann-Whitney test was used to compare the median number of days with CVAD in place between responder groups. All analyses were done using SAS Version 9.4 (SAS Inc; Cary, NC), and a P value <.05 was considered statistically significant.
Seventy-five patients agreed to participate out of a total of 100 patients who were invited. The makeup of the patients with a CVAD in place included OPAT (ID and IP subjects; 31%), chemotherapy and other cancer care-related access needs (IC subjects; 29%), and parenteral nutrition (IR subjects; 40%). Forty-one patients (54.7%) returned completed diaries, reflecting 418 device days. Patients who returned diaries ranged in age from 26 to 81 years and had a CVAD in place from <1 to 3110 days, with a median dwell time of 56 days at the time of study entry (Table 1).
The IR patients had the highest median CVAD days at the time of study entry. All IP patients had PICCs in place for <1 day at the time of study entry. On average, the ID patients had fewer CVAD days at the time of study entry compared with IR and IC patients. One IC patient reported having an implanted port in place for over 8 years at the time of study entry. While PICCs were almost equally present in patients from each of the 4 clinical areas, IR patients were more likely to have tunneled, nonport devices compared with IC patients, who had higher numbers of implanted ports.
The location where CVAD care was provided, title of the person providing care, and the reason for CVAD access are displayed in Tables 2 and 3, respectively. Across all patients, 77% of CVAD care was provided in the patient's home compared with other sites. Home care was provided via self-care (48%), by a family member/caregiver (25%), and/or by a nurse (27%). All ID patients' CVAD care was provided in a clinic by a nurse, as was the case for the majority of IC patients. However, 96% of CVAD care for IR patients was performed in the home, and 93% of that care was provided by the patients themselves (62%) and/or by a family member/caregiver (31%). Diaries reflected 1279 CVAD care episodes with various combinations of recorded reasons for catheter care (N = 1930), ranging from 1 to 4 reasons per episode. Only 16 entries (dressing changes) did not involve CVAD access, representing 1% of all episodes. Flushing the device was the most frequently cited reason for CVAD care (52%), followed by medication administration/infusion (35%), withdrawing blood or locking solution (10%), and changing the dressing (4%). The majority of patients (71%) recorded at least 1 dressing change. IC and ID patients' dressing changes were performed by a nurse during clinic visits, while dressing changes for IR and IP patients were generally performed in the patients' home by a nurse. In a few instances, dressings were changed in both locations for IR and IP patients. Three IR patients (17%) recorded performing their own dressing changes at home. Each patient had a tunneled CVAD in place for >270 days (range 271-503) at the time of study entry.
Patient Diary Completion
Diary entries in which patients recorded details of CVAD care ranged from 1 to 14 days (Table 4). IP patients recorded CVAD care over an average of 10.8 days during the study, whereas IC patients averaged 6.4 days of record keeping. ID and IR patients maintained diaries an average of 11.7 days and 12.7 days, respectively. The average number of diary entries of CVADs being accessed ranged from 12.6 entries in IC patient diaries to 52.2 entries in IR patient diaries. On average, all patients accessed their CVAD more than 1 time per day, ranging from 1.3 times in ID patients to 3.9 times in IR patients. Although patients recorded each date/time their CVAD was accessed, in most instances while administering medications and/or infusions, the device was flushed before and after; therefore, 1 time stamp of the CVAD care episode did not necessarily mean the device was accessed only once at the time recorded. In some instances, especially with IR patients, 1 episode of CVAD care could involve flushing the CVAD 3 times or more. One IR patient recorded that her CVAD was accessed 154 times during the 14-day record-keeping period, averaging 11 times per day. All of this patient's CVAD care was performed via self-care, with the exception of 2 times that a nurse came to her home to access the device and change the dressing.
Although no patients recorded experiencing a CLABSI, 2 patients (5%) recorded a total of 4 CVAD occlusions, yielding an occlusion rate of 9.57 per 1000 device days. One IR patient recorded an occlusion in each of the lumens of her double-lumen PICC occurring on the same date, and each requiring 1 dose of a thrombolytic agent administered during 1 clinic visit. One IC patient recorded 2 episodes of occlusion in his double-lumen tunneled CVAD across a 4-day period within 14 days of record keeping, with both episodes treated by a thrombolytic agent during clinic visits. It is not known whether the same lumen occluded twice or whether each was affected, because the data collection worksheet did not direct patients to record this level of detail. When examining differences between those who returned diaries and those who did not, responders were slightly older than nonresponders, but age, gender, median dwell time, and type of CVAD device were not significantly different. Table 5 displays responder and nonresponder characteristics.
The authors examined the extent to which CVADs are accessed, by whom, and for what purposes in patients living at home with a CVAD in place. Patients were exposed to a variety of care processes performed by multiple, different individuals who accessed the device, often in several different settings (eg, home, clinic) within the same calendar day. The study uncovered important information about the magnitude of CVAD accesses that patients experience within a 14-day period; this is compounded by the mean dwell time of CVADs for home and outpatient therapies, which can range from 56 days12 to greater than 200 days.6 The duration of dwell time is dependent on the type of CVAD used and the patient diagnosis.6,12 Although the recorded percentage of CVAD complications was lower than what is reported in other studies examining adult patients on home infusion therapies,4–6,12 the occlusion rate of 9.57 per 1000 device days shown in this study is exceptionally higher.
Patients' exposure to potential inconsistencies in CVAD care practices is evidenced in this study (Tables 2 and 3) and highlights the need to examine the extent to which care providers' practices are standardized across settings. In addition, it is important to examine the standardization of education and competency validation processes that are provided to patients and family members/caregivers in the home setting. Exploring caregivers' readiness to provide care has been emphasized,5 and the study findings reveal the need to articulate this information to patients who rely on self-care.
The Institute of Medicine highlights the importance of standardizing care to optimize safety and outcomes.13 Evidence-based guidelines aimed at the prevention of CVAD-related infections and other complications provide a framework in which care can effectively become standardized.14–17 Implementing a standardized CVAD care bundle by home care nurses and family caregivers in ambulatory care settings proved successful at decreasing CLABSI rates by 48% over 24 months in a pediatric oncology population.18 Whether health care providers from home health and home infusion agencies, ambulatory clinics, or outpatient infusion centers follow evidence-based guidelines and implement standardized CVAD care practices remains under the purview of individual agency and clinic policy. Policies directing standardized CVAD care processes based on best practice recommendations for CLABSI prevention have been found to be inconsistent in meeting all recommended elements in home health care.19 Further, CVAD care practices differ between settings18,19 and between care providers employed within the same setting, because each institution may interpret and implement evidence-based guidelines according to its own unique attributes and abilities.20
Patients and caregivers are often taught CVAD care by nurses and other care providers upon discharge from hospital or outpatient settings after device insertion. However, education provided may vary depending on who conducts the teaching and is subject to error when care providers themselves are unsure of proper technique.21 Rinke et al18 found that despite a 24-month, intensive quality improvement process, nearly 20% of CVAD care performed by clinic nurses was not in compliance with components of a CVAD care bundle. Educational programs such as the “Central Line Program for Patients,” developed by and made available from the American College of Surgeons, prepare patients and family members/caregivers with what to expect when a CVAD will be inserted and equip them for self-care in the home setting.22 Having the patient/family caregiver perform return demonstrations of CVAD care can effectively evaluate their understanding and ability to adhere with performance.18 Equipping patients and family members/caregivers with CVAD maintenance checklists reinforces knowledge of best practices and can enable an intervention if a nurse, family member, or other caregiver is observed violating appropriate protocols.18 Evidence-based tools, similar to those produced by The Joint Commission and aimed at CLABSI prevention,23 could be developed specifically for medication regimens that patients with CVADs are asked to follow at home. These tools may lessen the impact of information overload, which has been described as a frequent experience among patients with complex medical regimens who are transitioning to home care, especially elderly patients.24
This study had several limitations. It involved a small number of patients. However, a response rate of 54.7% provided a robust dataset, and those patients who returned diaries compared with nonresponders were similar in demographic characteristics, suggesting a lack of response bias. It is unknown whether patients completed their diary entries contemporaneously with catheter care. As a result, the findings may misrepresent the actual times a patient, family member/caregiver, nurse, or other provider accessed the devices, and for what purposes. Only 14 days of recorded CVAD care was collected, which may misrepresent the actual number of complications that patients with a CVAD experienced during the time it was in place. Data beyond CVAD removal from any patients whose CVADs were removed because of completed therapies during the 14-day record-keeping period were not collected. Thus, it is not known whether any of these patients experienced a CLABSI within 48 hours of CVAD removal. Children and adolescents under the age of 19 years were not included in this study, and as a result, findings cannot be generalized to these populations. Data also were not collected on the following: educational or economic status; any CVAD-related education the patient received; or treatment regimes, such as CVAD flushing or locking protocols. As a result, the extent to which flushing practices were done appropriately is not known and may have contributed to the high occlusion rate. Lastly, this study only included patients from 1 academic medical center in the midwestern United States, so findings may not be generalizable to other hospital types or to other states.
It is well understood that variation in care practices introduces increased risk of adverse events.13 The data in this study revealed the extent to which patients with CVADs in place are exposed to factors that increase the potential for care practice variation and, thus, the risk for acquiring complications in the home setting. Findings will support next steps in the authors' subsequent longitudinal project aimed at standardizing education and processes of care for patients with CVADs in a home setting that will positively impact outcomes in other nonhospital settings.
1. The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources; 2012.
3. Barr D, Semple L, Seaton R. Outpatient parenteral antimicrobial therapy (OPAT) in a teaching hospital-based practice: a retrospective cohort study describing experience and evolution over 10 years. Int J Antimicrob Agents. 2012;39(5):407–413.
4. Morano SG, Latagliata R, Girmenia C, et al Catheter-associated bloodstream infections and thrombotic risk in hematologic patients with peripherally inserted central catheters (PICC). Support Care Cancer. 2015;23(11):3289–3295.
5. Shang J, Ma C, Poghosyan L, Dowding D, Stone P. The prevalence of infections and patient risk factors in home health care
: a systematic review. Am J Infect Control. 2014;42(5):479–484.
6. Crispin A, Thul P, Arnold D, Schild S, Weimann A. Central venous catheter complications during home parenteral nutrition: a prospective pilot study of 481 patients with more than 30,000 catheter days. Onkologie. 2008;31(11):605–609.
7. Pinon M, Bezzio S, Tovo PA, et al A prospective 7-year survey on central venous catheter-related complications at a single pediatric hospital. Eur J Pediatr. 2009;168(12):1505–1512.
8. Revel-Vilk S, Yacobovich J, Tamary H, et al Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer. Cancer. 2010;116(17):4197–4205.
9. Beckers MM, Ruven HJ, Seldenrijk CA, Prins MH, Biesma DH. Risk of thrombosis and infections of central venous catheters and totally implanted access ports in patients treated for cancer. Thromb Res. 2010;125(4):318–321.
10. Higuera I, Garcia-Peris P, Camblor M, et al Outcomes of a general hospital-based home parenteral nutrition (HPN) program; report of our experience from a 26-year period. Nutr Hosp. 2014;30(2):359–365.
11. Puiggros C, Cuerda C, Virgili N, et al Catheter occlusion and venous thrombosis prevention and incidence in adult home parenteral nutrition (HPN) programme patients [in Spanish]. Nutr Hosp. 2012;27(1):256–261.
12. Keller SC, Williams D, Gavgani M, et al Environmental exposures and the risk of central venous catheter complications and readmissions in home infusion
therapy patients. Infect Control Hosp Epidemiol. 2017;38(1):68–75.
13. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
14. Nailon R, Rupp ME. A community collaborative to develop consensus guidelines to standardize out-of-hospital maintenance care of central venous catheters. J Infus Nurs. 2015;38(2):115–121.
15. Camp-Sorrell D, Matey L, eds. Access Device Standards of Practice for Oncology Nursing. Pittsburgh, PA: Oncology Nursing Society; 2017.
16. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S1–S159.
17. O'Grady NP, Alexander M, Burns LA, et al Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162–e193.
18. Rinke ML, Bundy DG, Chen AR, et al Central line maintenance bundles and CLABSIs in ambulatory oncology patients. Pediatrics. 2013;132(5):e1403–e1412.
19. Rinke ML, Bundy DG, Milstone AM, et al Bringing central line-associated bloodstream infection prevention home: CLABSI definitions and prevention policies in home health care
agencies. Jt Comm J Qual Patient Saf. 2013;39(8):361–370.
20. Falder-Saeed K, McClain K, Patton L, Langford M, Marusich J, Flom L. Teaming up to take down community-acquired bloodstream infections: a program aimed at educating and training nurses in the community. J Vasc Access. 2016;21(4):217–222.
21. Petroulias PL. Use of electronic tablets for patient education
on flushing peripherally inserted central catheters. J Infus Nurs. 2017;40(5):298–304.
23. The Joint Commission. CLABSI toolkit and monograph: preventing central line–associated bloodstream infections: useful tools, an international perspective. http://www.jointcommission.org/CLABSIToolkit
. Published 2013. Accessed December 2, 2018.
24. Romagnoli KM, Handler SM, Ligons FM, Hochheiser H. Home-care nurses' perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period. BMJ Qual Saf. 2013;22(4):324–332.
Keywords:© Copyright 2019 by Infusion Nurses Society
ambulatory care; central line complications; central line occlusion; central vascular access device; home health care; home infusion; patient education; patient engagement; self-care; standardized care