Tools, Clinical Prediction Rules, and Algorithms for the Insertion of Peripheral Intravenous Catheters in Adult Hospitalized Patients: A Systematic Scoping Review of Literature

In June 2016, a systematic search of the Cochrane library, Ovid Medline® In-process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1946 to Present>, EBSCO CINAHL databases, and Google Scholar with specific keywords to identify publications that identified or defined TRAs was undertaken. Medical subject headings were created with assistance from a research librarian using tailored functions within individual databases. With key search terms, we limited studies to those related to our inclusion criteria. See Appendix 1 for our search strategy for Medline and CINAHL.

We used Covidence, a web-based application specifically designed for systematic reviews to screen and evaluate eligible publications.¹⁷ Two authors (PJC and NSH) screened the initial retrieved searches based upon the predetermined inclusion and exclusion criteria.

Data Extraction

A paper template was developed and used by 2 reviewers (P.J.C. and N.S.H.). Data included the following: study sample, aim(s), design, setting and country in which the study took place, clinical and patient variables, and how the TRAs were developed and tested. Studies were categorized by TRA type. We also sought to identify if clinical trial registration (where appropriate) was evidenced, in addition to evidence of protocol publication and what standardized reporting guidelines were used (such as those outlined by the EQUATOR Network).¹⁸

Data Synthesis

Formal meta-analysis was beyond the scope and intention of this review. However, we provide the FTIS rate and the ranges of odds ratios (ORs) with 95% confidence intervals (CIs) for certain independent predictors.

Thirty-six references were imported for screening against title and abstract content, with 11 studies excluded and 25 studies assessed for full-text eligibility (see Figure, PRISMA Flowchart). We then excluded a further 12 studies (6 did not meet inclusion criteria, 2 were focused on the prehospital setting, 2 were personal correspondence and focused on another type of VAD, 1 was a protocol to establish a TRA, and 1 was a framework for all device types), leaving 13 studies included in the final review (see Figure). These studies presented data on 4 tools,^19-22 4 predictive models^3,23-25 (of which 3 present receiver operating characteristic/area under the curve scores),^3,23,24 2 framed as risk factor studies,^26,27 and 1 of each of the following: a scale,²⁸ a score,²⁹ and an estimation of the incidence report rate (Table 1).³⁰ Seven studies had “difficult” or “difficulty” in their title as a term to use to describe insertion failure.^{3,19,24-27,30} One study was titled exclusively for the nursing profession,²⁰ 5 studies were reported in medical journals,^{3,24,26,29,30} and 6 were reported in nursing journals,^19-22,25,27 with the remainder published in a vascular access journal.^23,28

General Characteristics of Included Studies

One TRA which was registered as a clinical trial²⁴ involved a standardized reporting tool as is recommended by the EQUATOR Network.¹⁸

Nine of the 13 papers reported that TRA components were chosen based on identified predictors of successful insertion from observational data^{3,19,23-28,30}, with 5 papers using multivariate logistic regression to identify independent predictors.^3,23,24,26,2 At least 4330 insertion attempts on patients were reported. Seven papers reported FTIS, which ranged from 61%-90%.^3,23-27,30

Two clinical settings accounted for 10 of the 13 included studies. We identified 5 papers from the ED setting^{3,23,26,29,30} and 5 studies specific to cancer settings.^19-22,28 Two ED papers identified clinical predictors of insertion difficulty, with 1 identifying an existing medical diagnosis (such as sickle cell disease, diabetes, or intravenous drug abuse) and the other reporting a pragmatic patient self-report of difficulty.^26,30 Three studies focused on patient-exclusive variables (such as vein characteristics)^19,21,28 and some with a combined clinician and patient focus.^{3,23-25,27,30}Relatively few studies reported interobserver measurements to describe the reliability of clinical assessments made.^3,19,21,28 Webster et al. in Australia assessed interrater reliability of a vein assessment tool (VAT) and found high agreement (kappa 0.83 for medical imaging nurses and 0.93 for oncology nurses).²¹ Wells compared reliability with Altman’s K scores obtained from a different VAT when compared with the Deciding on Intravenous Access tool and found good agreement.²² Vein deterioration was proposed as a variable for inclusion when developing an assessment tool within an oncological context.³¹ In Spain, de la Torre and colleagues²⁸ demonstrated good interrater agreement (with kappa, 0.77) for the Venous International Assessment (VIA) tool. The VIA offers a grading system scale to predict the patient’s declining vessel size while undergoing chemotherapy via peripheral veins with PIVCs. Grade I suggests little or no insertion failure, whereas a Grade V should predict insertion failure.