The Use of Tissue Adhesive for Peripheral Intravenous and Arterial Catheters: A Survey of Clinician Experience

Lori Kaczmarek, MSN, RN, VA-BC™ | Vascular Access Clinical Specialist, Adhezion Biomedical, LLC

INTRODUCTION

Recent editions of Intravascular Quarterly (IQ) included reports about the clinician experience and patient outcomes using tissue adhesive (TA) in the neonatal population and another described TA use to manage post device insertion bleeding and oozing in adults. 1, 2 This report seeks to understand the impact of TA on peripheral intravenous (PIV) and arterial catheters (AC).

PERIPHERAL AND ARTERIAL CATHETER FAILURE

Attention to the care and management of peripheral intravenous (PIV) catheters has grown over the past several years. Organizations like Emergency Care Research Institute (ECRI), Association for Vascular Access (AVA) and Infusion Nurses Society (INS) have raised awareness about vascular access complications, failure rates and the need for better clinical education. They also serve to educate consumers and improve their understanding about the risk these devices pose. 3-6 Helm, Steere, Jones, and others have contributed to the body of knowledge about PIV failure, along with the human and economic impact. 7-12

By contrast, fewer studies exist about arterial catheters (AC), their associated complications, and failure rates. Arterial catheters, however, are known to contribute to bloodstream infections (BSI) and also fail in the same manner other vascular access devices do. 13, 14 In fact, Timsit et al., report that AC BSI is similar to that observed with central venous catheters (CVC) prompting the call to employ similar prevention bundles for care and maintenance for AC’s. 15 There is growing momentum to disclose all hospital onset bacteremia (HOB) over central line associated bloodstream infection (CLABSI) as a quality indicator for public reporting in the United States (US). 16, 17 This change would certainly draw more attention to PIV and AC care and maintenance. Pay-for performance initiatives have, after all, been effective in reducing CVC CLABSI by 50% from 2008 to 2014.18 The true impact of the pandemic on CLABSI rates has yet to be appreciated, but early reporting suggests an increase in catheter-associated bacteremia. 19

INNOVATIVE TECHNOLOGY

In 2019, Dr. Robert Helm provided a classic article update to “Accepted but Unacceptable: Peripheral IV Failure”. In it, he affirms that more awareness exists about the problem of PIV failure since his 2015 report, yet the problem remains unsolved.

While clinical experts and industry are striving to make improvements, the impact of trauma and contamination are fundamental components of PIV care that must be improved. The “simple transparent dressing is inadequate to fully stabilize and secure” our catheters, said Helm. Perhaps the most noteworthy statement in this article relates to the CONTINUED ON NEXT PAGE

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need to “…introduce catheter care and management practices in a way that is clinically simple, highly reproducible, and cost-effective.” 8 This is where TA comes in: an innovative technology which is simple, highly reproducible and is cost-effective. The only TA approved and labeled for vascular access use is SecurePortIV® (Adhezion Biomedical, LLC, Wyomissing, PA, USA). SecurePortIV® (SPIV) is a highly purified medical cyanoacrylate (CA) approved for all vascular access devices and comes with no age limits. 20 In vitro testing of polyurethane and silicone to assess long-term exposure of tissue adhesive on catheters found no chemico-physical changes. 21

SURVEY DEMOGRAPHICS

A questionnaire sent to twelve (12) clinicians was completed in June 2021. The inquiry targeted a cross-section of hospitals that use TA for care and maintenance of vascular access devices including AC and PIV catheters. The hospitals surveyed include 11 within the United States (US) and 1 from Qatar (QA). The responses represent adult, pediatric, and/or neonatal inpatient populations. Fifty percent (50%) report using TA on both PIV and AC’s. on clinical judgement, ultrasound guided PIVs, or a Vascular Access Team (VAT) member may apply. ARTERIAL CATHETERS (AC)

Care and maintenance of ACs prior to implementing TA was widely variable among the clinicians’ responses: • “They are sutured and then secured with a CHG impregnated dressing.” • “Sterile insertion, CHG disk, sutured.” • “Integrated securement device and clear occlusive dressing.” • “Same as venous (PIV) catheters.” • “Adhesive tape, CHG disk, transparent dressing.” • “Just a simple PIV dressing with tape for securement (this is what the Certified Registered Nurse Anesthetists [CRNA] used. Our VAT would use an adhesive securement device under the CHG dressing.”

Like PIV catheters, it is equally distributed as to who applies TA to ACs and when. Forty-three percent (43%) report applying TA on all AC’s and the same report only those ACs placed by a designated team. Fourteen (14%) apply TA to ACs based on clinical judgement.

PERIPHERAL INTRAVENOUS CATHETERS (PIV)

Prior to using TA on PIV catheters, respondents report a variety of securement methods in use. The majority (55%) report no additional infection prevention modalities in use. Some (27%) use CHG gel dressings and others (18%) apply a CHG disk. Fifty percent (50%) use TA on all PIV catheters regardless of who inserts them while others add TA to the PIV based

TA IMPACT ON PIV AND AC CARE AND MAINTENANCE

When asked to summarize the impact TA has made on PIV and AC care and maintenance in their CONTINUED ON NEXT PAGE

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organization, clinicians shared this feedback: • “Reduced line migration” (PIV and AC) • “We simply glue the insertion site and eliminate sutures and CHG disk.” (AC) • “My team uses it in all types of access. We provide vascular access services to all areas [including]

NICU where you may find a 300gm patient to our oncology, cardiac and pediatric intensive care. The team feels strongly about using it in all various lines the team places and helps with.

Lines include PICC’s, Midlines, EDC, USGPIVs, arterial lines, tunnel and non-tunnel lines.” (PIV and AC)”

• “Catheter is no longer pistoning, maintaining the best waveform to monitor the patient.” (AC) • “Decreased the number of dressing changes and catheter manipulation that could contribute to early failure.” (AC and PIV) • “Once applied correctly the lines do not re-bleed causing dressing adherence issues.” (AC) • “This product provided two important functions for PIVs. It seals the insertion site and stabilizes the device. Sealing the site can reduce the risk of tissue and blood stream infections. Stabilizing the device can reduce movement that contributes to phlebitis and can help reduce accidental removals.” (PIV) • “We are so satisfied with this products ability to anchor the site and reduce bleeding, infection, and loss of site. The overall patients appreciate it, so our satisfaction levels are up.” (PIV) • “Our CVOR and Cath lab team absolutely praise this product.” (PIV) • “Once I brought this product to our Infection

Prevention team it was immediately approved for purchase. There is no question we all need to use this product, when I explain to the patient the reason for its use, they get excited and are happy to know we use the most up to date products protecting them from infection. Our ICU physicians LOVE this product as well.” (SPIV)

SUMMARY

The changing healthcare landscape demands attention on all vascular access device care and management, beyond central lines. When considering options for VAD care and management, heed the words of Dr. Helm, “…simple, highly reproducible and cost-effective.” 8 TA has demonstrated positive outcomes across all ages and devices and is simple to use. Innovative technology like this allows organizations to simplify care and maintenance across the spectrum of VADs and among all caregivers. Finally, streamlining care gives clinicians the opportunity to maintain a high level of competency regardless of the device they are caring for.

SUMMARY

1. Kaczmarek L. Tissue Adhesive Bleeding and Oozing Practice Summary. Intravascular Quarterly. 2021;XI(2):9-13. Accessed May 15, 2021. https://issuu.com/avainfo/docs/published_-_iq_-_ may_2021

2. Kaczmarek L. A survey of clinicians: Bringing tissue adhesive to the neonatal population. Intravascular Quarterly. 2021;XI(1):2-5. Accessed Feb 20, 2021. https://cdn.ymaws.com/www.avainfo.org/ resource/resmgr/images/iq/iq_-_february_2021-final.pdf

3. Association for Vascular Access (AVA). Resource Guide for Vascular Access: Recommended Study Guide for Vascular Access Board Certification. vol 3. 2019:148.

4. ECRI Institute. Top 10 Patient Safety Concerns for 2019: Executive Brief. 2019. Accessed March 15, 2019. https://www.ecri.org/ landing-top-10-patient-safety-concerns-2019

5. 2021 Infusion Therapy Standards of Practice Updates. J Infus Nurs. Jul-Aug 01 2021;44(4):189-190. doi:10.1097/ NAN.0000000000000436

6. ECRI Institute. Top 10 Patient Safety Concerns for 2021: Executive Brief. 2021. https://www.ecri.org/

7. Carr PJ, Rippey JCR, Cooke ML, et al. Derivation of a clinical decisionmaking aid to improve the insertion of clinically indicated peripheral intravenous catheters and promote vessel health preservation. An observational study. PLoS One. 2019;14(3):e0213923. doi:10.1371/ journal.pone.0213923

8. Helm RE. Accepted but Unacceptable: Peripheral IV Catheter Failure: 2019 Follow-up. J Infus Nurs. May/Jun 2019;42(3):149150. doi:10.1097/NAN.0000000000000324

CORE VALUES

RESPECT

AVA believes treating others with respect will ensure a safe and healthy environment.

ACCOUNTABILITY

AVA believes in setting and meeting timely deadlines and working together with our members, volunteers and other partners to pursue outcomes that help patients.

INTEGRITY

AVA aspires to have a foundation of honesty and integrity in everything we do.

TEAMWORK

AVA believes working together to unleash everyone’s potential will achieve exceptional results.

EXCELLENCE

AVA creates a lasting and positive impact within vascular access through excellence in all endeavors.

MISSION To lead healthcare by protecting patients and providers to improve lives VISION A world with safe vascular access USE OF TISSUE ADHESIVE, CONTINUED FROM PREVIOUS PAGE

9. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. MayJun 2015;38(3):189-203. doi:10.1097/NAN.0000000000000100

10. Jones RK. Short Peripheral Catheter Quality and Economics: The Intravenous Quotient. J Infus Nurs. Nov/Dec 2018;41(6):365-371. doi:10.1097/NAN.0000000000000303

11. Pires ABM, Lima AFC. Direct cost of peripheral catheterization by nurses. Rev Bras Enferm. Jan-Feb 2019;72(1):88-94. doi:10.1590/0034-7167-2018-0250

12. Steere L, Ficara C, Davis M, Moureau N. Reaching One Peripheral Intravenous Catheter (PIVC) Per Patient Visit With Lean Multimodal Strategy: the PIV5Rights™ Bundle. Journal of the Association for Vascular Access. 2019;24(3):31-43. doi:10.2309/j. java.2019.003.004

13. Greer MR, Carney S, McPheeters RA, Aguiniga P, Rubio S, Lee J. Radial Arterial Lines Have a Higher Failure Rate than Femoral. West J Emerg Med. Mar 2018;19(2):364-371. doi:10.5811/ westjem.2017.11.34727

14. O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of bloodstream infection: a systematic review and metaanalysis. Crit Care Med. Jun 2014;42(6):1334-9. doi:10.1097/ CCM.0000000000000166

15. Timsit JF, Ruppe E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med. Feb 2020;46(2):266-284. doi:10.1007/s00134-020-059506 16. Rock C, Thom KA, Harris AD, et al. A Multicenter Longitudinal Study of Hospital-Onset Bacteremia: Time for a New Quality Outcome Measure? Infect Control Hosp Epidemiol. Feb 2016;37(2):143-8. doi:10.1017/ice.2015.261

17. Dantes RB, Abbo LM, Anderson D, et al. Hospital epidemiologists’ and infection preventionists’ opinions regarding hospital-onset bacteremia and fungemia as a potential healthcare-associated infection metric. Infect Control Hosp Epidemiol. May 2019;40(5):536540. doi:10.1017/ice.2019.40

18. Centers for Disease Control and Prevention website. National and state healthcare associated infections progress report. Published 2016. Accessed July 06, 2021, https://www.cdc.gov/hai/pdfs/ progress-report/hai-progress-report.pdf

19. Fakih MG, Bufalino A, Sturm L, et al. COVID-19 Pandemic, CLABSI, and CAUTI: The Urgent Need to Refocus on Hardwiring Prevention Efforts. Infect Control Hosp Epidemiol. Feb 19 2021:122. doi:10.1017/ice.2021.70

20. Adhezion Biomedical LLC. SecurePortIV: Indication for Use (IFU). SPI-IFU01-1903. June 2019. Accessed April 14, 2021. www. SPIVTraining.com

21. Di Puccio F, Giacomarro D, Mattei L, Pittiruti M, Scoppettuolo G. Experimental study on the chemico-physical interaction between a two-component cyanoacrylate glue and the material of PICCs. J Vasc Access. Jan 2018;19(1):58-62. doi:10.5301/jva.5000816