Extended Dwell Catheters in the NICU

Most infants in the newborn intensive care unit (NICU) require insertion of a device to acquire vascular access during hospitalization and this is the most common procedure in the NICU. New devices are met with uncertainty due to lack of evidence for their use. Extended dwell catheters (EDC) are new devices that offer long-term vascular access for infants. An EDC is a deep line that is inserted peripherally, terminating in the upper arm or leg and is designed to stay in place for up to 29 days. The product is intended to decrease multiple intravenous entries. The purpose of this project was to analyze data on EDC use in infants as a quality improvement project. The objectives included, 1) analyzing 4 years of data about various vascular devices' longevity and reasons for termination, 2) analyze the data to determine the effectiveness of EDC use in infants, 3) present the results to clinicians using the devices so that they can decide about future use, 4) disseminate the findings to other institutions where use of EDCs is limited. Peripherally inserted venous catheters (PIV) have poor longevity in the NICU. Approximately 95% of PIVs in the NICU are removed prior to the completion of therapy and the average PIV in the NICU stays in for 37 hours before various complications require replacement. Peripherally inserted central catheters (PICC) are also used in the NICU, and although they remain in place longer then PIVs and have less complications, PICCs are expensive and the complications can be life threatening. Limited research points to the benefit of EDCs over conventional PIVs for infants because of the increased dwell time and efficacy. Extended dwell catheters have advantages over PICCs because they are less expensive and avoid the life-threatening complications associated with PICCs. The project was implemented after IRB approval and began with a thorough literature review that compared various devices. Extended dwell catheter data from 432 NICU charts was collected and analyzed statistically using independent T-tests and chi-square tests. Results showed that 71.70% of EDC remained in place until therapy was no longer needed and the average line days were 4.02 +/- 2. Analysis also revealed that the reasons for discontinuation of EDCs prior to the end of treatment were similar to those of PIVs and PICCs. During the same time PICC data from 202 NICU charts was collected and analyzed using T-tests and chi-square tests. Results showed that 84% of PICCs remained in place until therapy was no longer needed and the average line days were 7.31 +/-4.35. Although the PICCs remained in place longer and were more reliable, there were 4 potentially life-threatening complications recorded. A cost analysis also showed EDCs to be the least expensive option. The findings were presented locally and feedback from attendees was used to modify and improve the presentation for the NICU Developmental Meeting, which is attended by the NICU and special care nursery directors and managers from 8 different hospitals throughout Utah. The information was also prepared for future publication in a peer-reviewed journal. This project has achieved the goal of presenting EDC data so that local clinicians have findings on which to base their practice. The results indicated that EDCs offer a safe, effective, and cost saving alternative to PIVs and PICCs for infants. The benefits of using this device will decrease interventions to the patient, while saving staff time and resources.

Running head: EXTENDED DWELL CATHETERS IN THE NICU Extended Dwell Catheters in the NICU Kimberlee Chenoweth RN, BSN University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 EXTENDED DWELL CATHETERS IN THE NICU 2 Executive Summary Most infants in the newborn intensive care unit (NICU) require insertion of a device to acquire vascular access during hospitalization and this is the most common procedure in the NICU. New devices are met with uncertainty due to lack of evidence for their use. Extended dwell catheters (EDC) are new devices that offer long-term vascular access for infants. An EDC is a deep line that is inserted peripherally, terminating in the upper arm or leg and is designed to stay in place for up to 29 days. The product is intended to decrease multiple intravenous entries. The purpose of this project was to analyze data on EDC use in infants as a quality improvement project. The objectives included, 1) analyzing 4 years of data about various vascular devices' longevity and reasons for termination, 2) analyze the data to determine the effectiveness of EDC use in infants, 3) present the results to clinicians using the devices so that they can decide about future use, 4) disseminate the findings to other institutions where use of EDCs is limited. Peripherally inserted venous catheters (PIV) have poor longevity in the NICU. Approximately 95% of PIVs in the NICU are removed prior to the completion of therapy and the average PIV in the NICU stays in for 37 hours before various complications require replacement. Peripherally inserted central catheters (PICC) are also used in the NICU, and although they remain in place longer then PIVs and have less complications, PICCs are expensive and the complications can be life threatening. Limited research points to the benefit of EDCs over conventional PIVs for infants because of the increased dwell time and efficacy. Extended dwell catheters have advantages over PICCs because they are less expensive and avoid the lifethreatening complications associated with PICCs. The project was implemented after IRB approval and began with a thorough literature review that compared various devices. Extended dwell catheter data from 432 NICU charts was collected and analyzed statistically using independent T-tests and chi-square tests. Results showed that 71.70% of EDC remained in place until therapy was no longer needed and the average line days were 4.02 +/- 2. Analysis also revealed that the reasons for discontinuation of EDCs prior to the end of treatment were similar to those of PIVs and PICCs. During the same time PICC data from 202 NICU charts was collected and analyzed using T-tests and chi-square tests. Results showed that 84% of PICCs remained in place until therapy was no longer needed and the average line days were 7.31 +/-4.35. Although the PICCs remained in place longer and were more reliable, there were 4 potentially life-threatening complications recorded. A cost analysis also showed EDCs to be the least expensive option. The findings were presented locally and feedback from attendees was used to modify and improve the presentation for the NICU Developmental Meeting, which is attended by the NICU and special care nursery directors and managers from 8 different hospitals throughout Utah. The information was also prepared for future publication in a peer-reviewed journal. This project has achieved the goal of presenting EDC data so that local clinicians have findings on which to base their practice. The results indicated that EDCs offer a safe, effective, and cost saving alternative to PIVs and PICCs for infants. The benefits of using this device will decrease interventions to the patient, while saving staff time and resources. The project committee included, Deb Penney, PhD, CNM, MPH-Project advisor, Kim Friddle PhD, APRN, NNP-BC-Program Director, Pam Hardin, PhD, RN-Assistant Dean for MS & DNP programs. EXTENDED DWELL CATHETERS IN THE NICU Table of Contents Executive Summary………….......…………………………………..…...…...................…2 Acknowledgements………..……………………………………………………………......5 Problem Statement………..………………………………………………………………...6 Clinical Significance……..………………...…………………………………………….....6 Purpose and Objectives…..……………………………………………………….………...8 Implementation and Evaluation………………………………………………….....……..9 Literature Review…………………………………………………………….…………........9 Theoretical Framework…………………………………………………….………………..13 Implementation Plan and Evaluation......................................................................................16 Objectives...............................................................................................................................16 Results.................………………………………………………..……………….....……....16 Future Recommendations.......................................................................................................18 DNP Essentials.......................................................................................................................18 Conclusion………………………………………………………………………….......…...19 References..............................................................................................................................21 Appendix A: Data sheet used for EDCs.................................................................................25 Appendix B: Data sheet used for PICCs................................................................................26 Appendix C: PAS Abstract....................................................................................................27 Appendix D: Article Placed in NICU Newsletter..................................................................29 Appendix E: Presentation Evaluation Form...........................................................................30 Appendix F: Final PowerPoint Presentation..........................................................................31 Appendix G: IRB Approval For Extended Dwell Catheter Data...........................................35 Appendix H: IRB Approval For PICC Line Data..................................................................36 Appendix I: IRB Agreement Letter From the University of Utah to Defer IRB to IHC.......37 Appendix J: Project Presentation............................................................................................38 Appendix K: Poster Presentation............................................................................................41 3 EXTENDED DWELL CATHETERS IN THE NICU Acknowledgements This project would never have happened had it not been for my project chair, Debra Penney, my content expert Belinda Chan, and my statistician, Jia-Wen Guo. Their guidance and support have been invaluable. I would also like to thank the University of Utah's Neonatal Nurse Practitioner program staff members who have been a constant support during my project process and throughout my entire program. Not only have they helped me to succeed, they have made the process fun and memorable. Lastly, I would like to thank my husband, Mike, and children, Jaycee and Ethan, who have provided the love and support I needed in order to thrive during the most challenging process of my life. 4 EXTENDED DWELL CATHETERS IN THE NICU 5 Problem Statement Vascular access, defined as the ability to enter the vascular system to administer therapy or obtain blood (Vascular Access Device, 2009), is a challenge in infants within the newborn intensive care unit (NICU) for many reasons including small and extremely fragile veins (Wyckoff, 1999). The majority of NICU infants will require vascular access during their stay (Dawson, 2002). As technology and innovation improve, different options have become available to aid in neonatal vascular access, including the extended dwell catheter (EDC) (also known as a midline catheter), which is a hybrid between a peripherally intravenous catheter (PIV) and a central line (Wyckoff, 1999). An EDC is 6 to 8 cm long and is designed to remain in a vein in for up to 29 days. Insertion of the catheter is limited to peripheral veins in the legs, the forearms or in the head. The design of the product is intended to decrease multiple entries of intravenous sites in the neonate and improve outcomes when a peripherally inserted central catheter (PICC) line is not necessary or ideal (Neo Medical Inc., 2011b). Both PIVs and central lines come with complications and an EDC may be a better option for many infants requiring vascular access for an extended time. In a tertiary hospital in Utah, the use of EDC began on a trial basis in 2012 and since that time, data has been gathered regarding the success and complications with its use. Analysis of this data along with other evidence from the literature will provide important information for clinical decisions regarding the use of EDCs within the NICU setting. This information will likely allow NICUs to make informed decisions about use. Clinical Significance Vascular access devices are often lifelines for patient therapies and the insertion of such devices is the most common procedure within the NICU (Ramasethu, 2008). The most frequently used vascular access devices include the PICC line, the umbilical venous catheter (UVC), and the EXTENDED DWELL CATHETERS IN THE NICU 6 PIV. A PICC is a central line, meaning a venous catheter that is inserted peripherally and threads into the central venous circulation (Seton, 2011), and x-rays confirm its correct placement. It can remain in place for months at a time (Pettit, 2006). A UVC is a central line that is placed at birth or shortly thereafter. The catheter is inserted via the umbilical vein and is thread into the inferior vena cava where it remains for 7-10 days (Pettit, 2006) then removed to prevent the risk of infection. A PIV catheter is shorter than a central line catheter, generally 2 cm, and is inserted peripherally; for example, in the hand or foot. These vascular access devices are easier to place than a central line, but do not last as long and can often take multiple attempts to successfully place (Pettit, 2006). The EDC may be a good alternative to these widely accepted vascular access devices and alleviate many of the complications associated with PIVs and central lines but information about its use in NICU patients is lacking. Without good information on comparative use of these devices, it is difficult to recommend one use over another and to individualize patient care based on anticipated vascular access time and patient condition. The NICU's treatment standards are built on evidenced-based practice so new devices that may lack sufficient research are met with uncertainty. Such is the case with EDCs. A NICU in a tertiary hospital in Utah has been using EDC since 2012 and data has been gathered from 432 infants. According to the manufacturer (Neo Medical Inc., 2011a), the goal of the extended dwell product is to provide the smallest gauge catheter for treatment. The dwell time for extended dwell catheters is up to 29 days (Neo Medical Inc., 2011b). This provides an additional option for infants that may likely be superior. It is likely that the EDC is superior to other devices and this may benefit several stakeholders. The EDC provides an additional option for infants that require lengthier vascular access without having to insert a central line, decreasing the number of vascular access restarts, risk of infection, and nursing time needed with a PIV or PICC (Neo Medical Inc., 2011a). Also, EXTENDED DWELL CATHETERS IN THE NICU 7 in many instances EDC are a feasible alternative to a central line allowing infants to stay in smaller community hospitals where central lines aren't an available option. This allows the infant to stay with the mother rather than being transferred to a more acute facility for central line placement. The EDC is a benefit for several reasons. For the neonate because it does not require serial x-rays to confirm placement, as do central lines; this saves the neonate from radiation exposure. Avoiding the need for x-ray confirmation also saves NICU staff time with insertion and subsequent surveillance saves hospital costs. Other savings to the hospital include equipment because the extended time that the catheter can remain in place compared to the multiple new placements needed for other devices in the same timeframe. A cost analysis was done using equipment and nursing time associated with insertion (See Appendix J) Purpose The purpose of this scholarly project was to analyze data on EDCs and PICCs and present the findings as a quality improvement project, to aid personnel in NICUs to have evidence in their decision making process when selecting vascular access devices for patient care. Objectives The following objectives were implemented to complete the project: • Analyze the data regarding previous use of EDCs in the infant population and compare variables of use (problems) with standard intravenous devices used in the same population. • Inform users of EDCs about the findings from the data so that they can determine the future use of these devices in their settings. • Disseminate the findings about EDC use in newborns to a broader audience. Literature Review EXTENDED DWELL CATHETERS IN THE NICU 8 Vascular Access in Infants The use of vascular access devices began decades ago in NICUs and are used for nutritional support and medications (Franck, Hummel, Connell, Quinn, & Montgomery, 2001). It is often difficult for NICU staff members to know what device is best for certain infants. The difficulty lies in the lack of literature in this small population. Types of Vascular Access Within the NICU, there are many different venous vascular access devices. The main four include: PIVs, UVCs, PICCs, and EDCs. Each comes with advantages and disadvantages. The most widely used vascular access device used in the NICU is a PIV, which is commonly a 22-or 24-gauge Teflon radiopaque over-the needle catheter (Franck et al., 2001). Most NICU nurses are competent at inserting a PIV, which is usually placed in the extremities or the scalp (Franck et al., 2001), but despite the high rate of use and long history, PIVs still have a poor record. Approximately 95% of PIVs are removed before the completion of therapy, generally due to complications such as infiltration, infection, clotting, or other problems (Frank et al., 2001). One study (n=72) among the neonatal population showed the average length of time a PIV was in place before complications required removal was 30 hours (Tobin, 1988), while another larger study (n=250) among the neonatal population showed 37 hours to be the average length of time (Smith & Wilkinson-Faulk, 1994). This is an extremely short period compared to the length of nutritional supplementation and/or medication needed in most newborn and infant cases. Peripherally Inserted Central Catheters. Peripherally inserted central catheters are made of silicone, polyurethane, or polyethylene (Ramasethu, 2008) and are generally inserted by bedside nurses who have completed additional central line placement training (Davis & Kokotis, 2004). They are intended for long-term nutrition and medication therapies and are not a good EXTENDED DWELL CATHETERS IN THE NICU 9 option for short-term vascular access. Peripherally inserted central catheters have fewer complications than PIVs, but the complications they have are much more serious. One serious but rare complication is a pericardial effusion; this occurs when the walls of the atrium or superior vena cava become irritated causing fluid from the PICC to leak into the pericardial sac. This can lead to pericardial tamponade (Bansal, & Snyder, 2015). Another risk of a PICC is deep vein thrombosis. The placement of a PICC causes endothelial trauma, stasis, and platelet adhesion. These conditions can lead to thrombus formation (Nyberg, 2013). Peripherally inserted central catheters are designed to stay in longer than PIVs making them more vulnerable to infection. These infections are caused by skin flora when there is a break in sterile field during placement or dressing change, contaminated infusion, or infection spread by the blood from an unrelated site (Kornbau, Lee, Hughes & Firstenberg, 2015). Umbilical Venous Catheters. Umbilical venous catheters are inserted in the umbilical vein up to 48 hours after birth after which the site is not accessible (Federal Drug Administration [FDA], 2006) and these require additional training for nurses, advanced practice nurses and physicians who place them (FDA, 2006). A UVC can only stay in for a limited amount of time due to the increased risk of infection with prolonged use (Centers for Disease Control [CDC], 2011). According to the CDC (2011), a UVC should be removed when it is no longer needed, and should not exceed 14 days. The risks involved with a UVC are similar to those of a PICC with the addition of hepatic necrosis where the line migrates into the portal vein and fluids and medication cause liver damage (FDA, 2006). Extended Dwell Catheters. An EDC is a short-term, peripheral intravenous catheter designed to dwell for up to 29 days (Neo Medical Inc., 2011b). In infants, the terms, midline catheter and an extended dwell catheter, are interchangeable. Midline catheters are defined as venous access catheters where the insertion site is peripheral (in the forearms or lower legs) but EXTENDED DWELL CATHETERS IN THE NICU 10 the tip of the catheter is not central, meaning the tip is not in the thoracic vasculature. Specifically, the tip is below the axilla of the arm or groin of the leg (Neo Medical Inc., 2015). In adults, the length of the midline catheter can be inserted up to 20 cm. The extended dwell catheter for infants, is only 6-8 cm long offering a wide range of peripheral placement options in an infant. For an adult, this would generally not be midline just below the axilla, but in an infant, it is. Thus, an extended dwell catheter is a midline catheter in an infant (Neo Medical Inc., 2015). The CDC defines those that can insert peripheral intravascular catheters as trained personnel who have achieved and demonstrated competency in the insertion procedure and maintenance of such lines (2011). Extended dwell catheters fall under the umbrella of short-term catheters. The manufacturer of the product (Neo Medical Inc., 2011a) recommends the same placement guidelines as PIVs as stated by the CDC for those placing an EDC and trained associates are available to assist with the required training and education. Generally, each hospital unit that uses the catheters decides who will be able to place them. Though new to NICUs, EDCs are showing great promise in their role in vascular access of the infant. According to the manufacturer, Neo Medical Inc. (2011a), the advantages of an extended dwell include: • Decreased complications associated with multiple needle sticks (including pain and infection) that are often required for standard PIVs to complete therapy. • Reducing the risk of infection associated with frequently having to replace traditional PIVs. • The material used in extended dwell catheters shows a reduction in vein erosion that is associated with traditional PIVs. • Reliable access for an extended period of time (up to 29 days) without the need for a central line. (pg. 7) EXTENDED DWELL CATHETERS IN THE NICU 11 Research on midline catheters focuses on use in adults and the use in infants is limited. In a retrospective study by Wood (2015) with 142 infants, 83% of the 142 participants finished the IV nutrition and/or medication therapy before complications set in using an EDC and the average dwell time was 5.7 days. In a non-randomized prospective study of 1,130 infants the average dwelling times for EDCs was 7-10 days, with 43% of the catheters staying in until the end of treatment (Leick-Rude & Haney, 2006). Both studies show a vast improvement in EDCs over PIVs in overall dwell times and the number of catheters that remained in place with no complications until the end of treatment. Limited research points to the benefit of EDCs over conventional PIVs for infants because of the increased percentage of EDCs staying in until the end of treatment and their comparative increased dwell time. If the research data collected during this quality improvement project shows EDCs to be a beneficial alternative to PIVs for many infants, the benefits to the patient, the staff, and the healthcare cooperation would provide compelling evidence for utilizing EDCs within the NICU setting. Theoretical Framework The Diffusion of Innovation theory has been used to explain the process of diffusion of knowledge and/or innovation through the social systems in which it pertains (Orr, 2003). According to Orr (2003), Everett Rogers developed this theory as a way to explain how innovations spread and whether the population accepts or rejects them. The theory explains how the decisions of individuals affect those around them and eventually a domino effect may be seen where the innovation is either accepted or rejected by the entire social system. The constructs of the theory include knowledge, persuasion, decision, implementation and confirmation. This cycle repeats itself through many different user segments if the innovation proves beneficial. It begins with the early innovators that recognize the benefit of the innovation. As they gain knowledge EXTENDED DWELL CATHETERS IN THE NICU 12 and spread the word, the next cycle is the early adopters, followed by the early majority, the late majority and the laggards who tend to resist change (Robinson, 2009). Extended dwell catheters show a lot of promise in the infant population, but are a relatively new innovation having been available for distribution for less than 10 years. They are not widely used in Utah, making Roger's Diffusion of innovation theory applicable to this project. The collection of data on extended dwell catheter use in a NICU applies the first construct of the theory, knowledge. With the knowledge gained through the literature review and data collected, in the NICU it will be possible to make a case for using these catheters, or persuade other facilities to use the device in their NICUs. Persuasion is the second theoretical construct, which promotes innovation. According to Robinson (2009) observable results and peer-to-peer networking of trusted colleagues drives the adoption of innovation. The knowledge that is shared with colleagues and others along with the author's trust in these relationships aids in their decisionmaking; this is the third construct. They will then move on to the fourth construct and chose whether on not to implement the device. Eventually they will be able to confirm whether on not the decision was a good one, which is the final construct. The EDC is a new device that is used by early adopters among hospital clinicians. As more data is gathered and published on the benefits of using extended dwell catheters popularity for the using the device will increase and cycle through various hospitals until it reaches the laggards. The extended dwell catheter is currently an innovation in NICUs and it is yet to be seen if it will gain widespread acceptance. Implementation Plan and Evaluation Objective #1 Implementation Evaluation EXTENDED DWELL CATHETERS IN THE NICU Determine the effectiveness of EDC use in newborns. 1. Conducted an extensive literature review regarding EDC and other vascular access devices available to NICU infants. 13 1. Literature review done and confirmed as complete by project chair and content expert. 2. Submitted applications to the hospital and the University Institutional Review boards 2. IRB applications (IRB). reviewed by chair and submitted with approval 3. Collected EDC and PICC data gathered obtained. over the last 4 years at the project hospital NICU 3. All EDC and PICC data gathered and verified by 4. Defined variables with EDC and PICC the central line use that impact use (complications, line management team lead. days, gestation and weight, etc.). 4. Variables defined and 5. Statistician ran data about use and approved by content variables. experts and statistician. 6. Analyzed data with the statistician and 5. Data analyzed by the compare hospital data with what is currently statistician and conclusions published on alternative devices. were drawn. Objective #2 Inform users of EDCs about the findings from the data so that they can determine the future use of these devices in their setting. Implementation 1. Developed a PowerPoint presentation to share the analysis of data. 2. Created an evaluation form for participants that gave feedback for improving the presentation. 6. Hospital data gathered and compared to data found in the literature. Evaluation 1. PowerPoint reviewed by content expert and approved for dissemination. 3. Confirmed the dates for informing the hospital central NICU line team and NP group about the findings. 2. PowerPoint presentation successfully presented to the neonatal nurse practitioner group in their November staff meeting. 4. Presented the findings by a power point presentation to the hospital's Urban Central Region neonatal nurse practitioner group staff meeting on November 22nd, 2016. 3. Article placed in the January 2017 edition of the NICU's monthly newsletter. 5. Wrote an article for the unit's January monthly newsletter. 6. Gathered feedback on the presentation EXTENDED DWELL CATHETERS IN THE NICU Objective #3 Disseminate the findings about EDC use in newborns to a broader audience. and article from the two groups and revised the power point based on the feedback. Implementation 1. A final PowerPoint presentation developed after changes were made based on input from NP group 2. The PowerPoint was presented at Utah Valley Medical Center's Neonatology meeting on January 30th, 2017 and the NICU Developmental Team Meeting on February 16th, 2017 (this meeting is attended by the NICU and special care nursery directors and managers from 8 different hospitals throughout Utah). 14 Evaluation 1. Final presentation successfully disseminated to a broader NICU audience. 2. Publish findings in a neonatal/pediatric journal. 3. Conference call with Cleveland Clinic Children's Hospital Pediatric Vascular Access Team on February 20, 2017 regarding the introduction of EDCs. Team lead and contact was Christine FlechlerMahoney, BSN, RNC-NIC, VA-BC. 4. Abstract for a poster presentation was submitted and accepted by the Pediatric Academic Society for the May 2017 conference. Objectives The purpose of this project was to organize and present data regarding EDCs as a quality improvement project, in order to aid infant intensive care units in their decision making regarding whether or not to use the catheters. The following objectives were implemented to complete this project: • Determine the percentage of EDCs that remain in place until therapy is complete as well as reasons EDC are discontinued prior to the completion of therapy in infants. Compare this data to PIVs and PICC lines. EXTENDED DWELL CATHETERS IN THE NICU • 15 Inform users of EDCs about the findings from the data so that they can determine the future use of these devices in their setting. • Disseminate the findings about EDC use in infants to a broader audience. Implementation and Evaluation The first objective was to collect and analyze data on EDC use and this was implemented by conducting a literature review, submitting IRB applications, collecting data using data sheets on device initiation, use and termination (See Appendix A and B), and then analyzing the data by comparing the EDC with other commonly used devices. Each step was reviewed and approved by the content expert and project chair. The data collection included a retrospective review that was completed on all infants who had an EDC or PICC placed during hospitalization in a 48-bed level IIIB NICU in Utah between August 2012 and December 2016. Inclusion criteria were infants > 32 weeks gestational age at birth and a weight of > 1500 gm at birth. Data collected included the infant's name, date of birth, birth weight, gestational age, type of intravascular device, reason for insertion and removal, insertion site and indwell days (See Appendix A and B). A statistician was found to analyze the collected data and analysis included an independent t-test and Chi-square test. The second objective was to share the information about EDC use with clinicians who use the device. A PowerPoint was developed as well as an evaluation form, and these were reviewed by the content expert and project chair prior to the presentation. The preliminary results were presented by PowerPoint to the Urban Central Region neonatal nurse practitioner group in their November 2016 staff meeting. Those in attendance (23) filled out evaluations (See Appendix E). Changes were made to the final presentation based on the feedback from attendees. By mid January 2017 the finalized data was gathered and analysed. EXTENDED DWELL CATHETERS IN THE NICU 16 The third objective included revision of the presentation based on the neonatal nurse practitioner feedback and incorporation of the final data analysis. The presentation was reviewed by the content expert, then presented to the Utah Valley Hospital's NICU team (18 in attendance) on January 30th, 2017 and the NICU Developmental Meeting on Feb. 16th, 2017 (See Appendix F). Also, a conference call was done with Cleveland Clinic Children's Hospital Pediatric Vascular Access Team on February 20, 2017 regarding the introduction of EDCs to their facility. Total attendees at these two venues were approximately 60 people. A poster was made that conveyed the project process and results and will presented at the Pediatric Academic Society's annual conference on May 5th, 2017 in San Francisco, California (See Appendix K). In December of 2016 an abstract was submitted to the Pediatric Academic Society's conference (See Appendix C). The abstract was accepted and the poster will be presented May 5, 2017 in San Francisco, California. Due to the compelling evidence of the project a manuscript for publication is being written for submission to The Journal of Perinatology and co-authored by Belinda Chan MD and Jia-Wen Guo PhD, RN. Results The data included EDCs for 432 infants between 32-41 weeks gestational age (mean 35 5/7 + 2.65; P=0.002) and 1.5-4.4 kg birth weight (2.69 ± 0.73; P=0.35). Total catheter days were 1,735 with an average indwell time of 4.02 ± 2.29 days (p<0.001). This data was compared to previously published data on PIVs in the NICU. Extended dwell catheters were shown to have a longer dwell time of 4.02 + 2.29 than the average PIV indwell time of 1.5 days (Smith et al, 1994). In those infants with an EDC, 71.7% remained functional until they were no longer needed. The majority of early EDC line removals were due to leaking (n=37, 8.6%), infiltration EXTENDED DWELL CATHETERS IN THE NICU 17 (n=29, 6.7%), cording (n=18, 4.2%), clotting (n=15, 3.5%), or accidental dislodgement (n=14, 3.2%). There was no association between EDC failure and birth weight or gestational age. In addition, EDCs were compared to PICC lines. Data was compared from these neonates at the same time as the EDC data. During the study, PICCs were inserted in 202 infants between 32-41 weeks gestational age (mean 36 3/7 + 2.68 p=0.002) and 1.5-4.5 kg birth weight (2.82 ± 0.76; p=0.35). Total catheter days were 1,476 with an average indwell time of 7.31 ± 4.35 days (p<0.001). In those infants with a PICC, 84.20% remained functional until no longer needed, which was a significantly higher success rate than EDC. However, in this population, PICCs were associated with 1 case of each of the following: Central line-associated blood stream infection (CLABSI), premature ventricular contractions, decreased venous return to the head, and possible abdominal infiltration of a saphenous line; all can be considered life-threatening complications. No life-threatening complications were seen in 1,735 EDC line days. A cost analysis was conducted to compare the EDC to PIVs and PICCs. Two aspect of cost were taken into account, supplies and nursing time. Cost analysis was based on Intermountain Health Care's supply costs, which were gathered using the NICU supply liaison. Nursing time was based on an average nursing wage of $30.00 an hour; 10 min. x 2 nurses for PIVs assuming the PIV will require replacing every 37 hours based on previously published literature (Smith & Wilkinson-Faulk, 1994), 30 min. x 2 nurses for EDCs and 1 hour x 2 nurses for PICCs. The time frames used were an estimate based on experience. The analysis showed that for 1 week a PIV cost was $100.17, a PICC cost was $590.38 and an EDC cost was $73.15. A cost saving is evident when using an EDC over both PIVs and PICCs. Elevated costs for both PIVs and PICCs include increased staff time and supply costs. Peripheral inserted central catheter costs also include the need for x-rays to confirm placement. Recommendations EXTENDED DWELL CATHETERS IN THE NICU 18 Extended dwell catheters are new devices in NICUs and sufficient data about their use is lacking. This project adds to the data and gives health providers more information in selecting intravascular devices that meet the needs of their fragile patients. If EDCs continue to show promise, the infants that use them will benefit the most. A great deal of knowledge regarding EDCs has been gathered and analysed during this project, but there is more to be done. As a result of the project multiple local NICUs and special care nurseries have begun using EDCs and are being encouraged to keep data similar to that used for this project. Rather than using previously published data to compare EDCs to PIVs, data from actual patients in the same setting can be used. In this project, if similar data on PIVs had been collected simultaneously from this patient population the variables would have been reduced by using the same setting and population for comparison. This posed a weakness to the retrospective project that may be avoided in similar projects in the future. Collection and analysis data that includes all types of vascular devices (PIVs, EDCs, PICCs and UVCs), would provide more reliable data for comparison and increasing. Diversifying the settings for collection would make the data more generalizable.. An additional future recommendation that would provide stronger research for EDCs would be randomized control trials utilizing PIVs, PICCs, and EDCs. DNP Essentials The DNP Essentials (American Association of Colleges of Nursing, 2006) provide a framework of goals, as projects are being thought out and assessed for relevance and importance. This project addressed Essential I, Essential III and IV from this document and are explained below. Essential I, Scientific Underpinnings for Practice describes the need for an understanding of science in its most basic form and translate it into actions that benefit patients. Through a literature review, collection of data and its analysis, scientific findings of EDC use were generated EXTENDED DWELL CATHETERS IN THE NICU 19 and disseminated which will likely improve patient care within NICUs. Without science, the nursing field would not explore, realize and justify the advances that have provided continued improvements in the field. This leads into the implementation of science using evidence-based practice. Essential III is Clinical Scholarship and Analytical Methods for Evidence-Based Practice. This Essential describes the need for new evidence, how to evaluate existing evidence and decide if there is a need for change. In this project, a gap was noted in vascular access within the specific patient population. This gap was being met through use of a new device at one NICU, but was rarely used at other related NICUs. This DNP project included a comprehensive literature search to investigate the existing evidence and to identify a gap in care regarding vascular access in NICU patients. From there data was gathered and disseminated as outline by DNP essential III. Having gained knowledge in many technologies utilized by healthcare, the project findings have been disseminated to a larger audience with proficiency. This aspect of the DNP program is discussed in essential IV. This knowledge allows the work that is put in to a doctoral project to benefit a larger audience and benefit more patients in a shorter period of time. Essential VI, Interprofessional Collaboration for Improving Patient and Population Health Outcomes discusses how best outcomes can be obtained more efficiently and with more success with a highly collaborative team, utilizing the strengths of those involved. By learning and utilizing what is discussed in this DNP essential the benefits gained by the research done have been implemented using the proper channels, making the project run smoother and more efficiently. This skill is invaluable to any professional, but in the nursing profession it can make a difference in the efficacy of innovation, patient care, and the long-term outcomes of our patients. Conclusion EXTENDED DWELL CATHETERS IN THE NICU 20 Extended dwell catheters appear to have advantages over PIVs and PICCs for vascular access in infants within the studied population. Extended dwell catheters have greater longevity than PIVs but less longevity than PICCS. They are more cost effective than both PIVs and PICCs over a one-week time frame, and have no recorded life threatening complications. This information leads to the conclusion that EDCs are an effective vascular access device for infants in the NICU setting that are > 32 weeks gestation at birth and > 1500 gm. at birth. The use of an EDC should be considered when evaluating vascular access needs. This is a small study with one site. More studies with different populations are needed to confirm these findings. In addition, control for variables such as standardizing the technique of insertion is needed to decrease bias. EXTENDED DWELL CATHETERS IN THE NICU 21 References American Association of Colleges of Nursing (2006). The Essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/dnp/Essentials.pdf Bansal, M. & Snyder, C. (2015). 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Sparks, NV: n.p. 22 EXTENDED DWELL CATHETERS IN THE NICU 23 Nyberg, K. (2013). Upper extremity DVT no longer a rarity-what to know. Retrieved from http://www.medpagetoday.com/resource-center/DVT-and-PE/upper-extremitydvt/a/41454 Pettit, J. (2006). Fostering a New Era of Vascular Access Device Selection in Neonates. Newborn and Infant Nursing Reviews, 6(4), 186-192. http://doi.org/10.1053/j.nainr.2006.09.004 Ramasethu, J. (2008). Complications of Vascular Catheters in the Neonatal Intensive Care Unit. Clinics in Perinatology, 35(1), 199-222. http://doi.org/10.1016/j.clp.2007.11.007 Romesberg, Tricia L., "Midline Catheter Use in the Newborn Intensive Care Unit" (2014). UNF Theses and Dissertations. Paper 544. http://digitalcommons.unf.edu/etd/544 Smith, A. B., & Wilkinson-Faulk, D. (1994). Factors affecting the life span of peripheral intravenous lines in hospitalized infants. Pediatric Nursing, 20(6), 543-547. Tobin, C. R. (1988). 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Journal of Vascular Access Devices, 4(3), 26-29. http://doi.org/10.2309/108300899775970737 EXTENDED DWELL CATHETERS IN THE NICU Appendix A: Data sheet used for Extended Dwell Catheters 24 EXTENDED DWELL CATHETERS IN THE NICU Appendix B: Data sheet used for PICCs. 25 EXTENDED DWELL CATHETERS IN THE NICU 26 EXTENDED DWELL CATHETERS IN THE NICU 27 Appendix C: PAS Abstract 1 Division of Neonatology, University of Utah, Salt Lake City, UT. 2 College of Nursing, University of Utah, Salt Lake City, UT 2017 PAS Abstract Evaluating Extended Dwell Catheters as an alternative form of intravenous access for NICU patients. Kimberlee Chenoweth1, Jia-Wen Guo2, Belinda Chan1 BACKGROUND: Establishing vascular access is a common and sometimes vital NICU procedure. However, peripheral intravenous catheters (PIV) typically lack longevity, and peripherally inserted central catheters (PICC) can be associated with critical complications. Extended Dwell Catheters (EDC) are 8cm silicone catheters inserted into peripheral veins, which have been safely used in adults, but have not gained popularity in neonates due to a lack of evidence. OBJECTIVE: We performed a quality improvement evaluation of the safety, efficacy, and cost-effectiveness of EDC use in neonates. DESIGN/METHODS: We retrospectively reviewed all neonates who an EDC placed during their hospitalization in a 48-bed level IIIB NICU at Intermountain Medical Center in Murray, Utah between 2012 and 2015. Inclusion criteria were > 32 weeks gestation age (GA) and > 1500 gm birth weight (BW). Data collected included demographics, reason for insertion and removal, insertion site and indwell days. Data was analyzed using a T-test. RESULTS: EDC were inserted in 310 neonates between 32-41 weeks GA and 1.5-4.4 kg BW. Total catheter days were 1235 with an average indwell of 4.0±2.4 (mean±SD) days; longer than our average PIV indwell of 1.5 days (Smith et al, 1994). 69% of EDC remained functional until they were no longer needed. Early line removal was due to leaking (9%), infiltration (6.5%), EXTENDED DWELL CATHETERS IN THE NICU 28 cording (4.6%), clotting (4.2%), or accidental dislodgement (3.2%). There was no association between EDC failure and BW or GA. During the period studied, 84% of PICC remained functional until no longer needed, which was a higher success rate than EDC (p<0.02). However, our PICCs were associated with CLABSI (0.87/1000 line days), pleural effusion (0.87/1000 line days) and cardiac tamponade (0.17/1000 line days). All the life-threatening PICC complications occurred in neonates <32 weeks GA except two cases; none of these complications were seen in 1235 EDC line days. Cost analysis revealed that EDC cost $45 less than PIV for insertion and supplies; furthermore, the EDC is $753 less expensive than a PICC, as EDC placement does not require x-ray confirmation. CONCLUSION: EDC appear to have advantages over PIV and PICC for intravenous access in neonates. They have greater longevity than PIVs, likely more cost effective and might have a lower complication rate. The latter conclusion must await additional testing. Appendix D: Article Placed in NICU Newsletter. EXTENDED DWELL CATHETERS IN THE NICU 29 Extended Dwell Catheters By: Kim Chenoweth The majority of infants in the NICU require vascular access during hospitalization and the insertion of a vascular access device is the most common procedure in the NICU. Extended dwell catheters are a new device that our NICU has been utilizing for four years. They offer an additional option for infants that require lengthier vascular access without the need of a central line. Our goal, when using extended dwell catheters, is to minimize painful PIV sticks and offer an alternative to central lines in infants > 1500 grams and > 32 weeks who require multiple days of IV fluids and/or IV medication. By utilizing extended dwell catheters we have the opportunity to: • Increase patient comfort • Preserve peripheral veins • Decrease clinician time • Have more reliable venous access • Decrease the rate of infection • Decrease costs Approximately 95% of PIVs in the NICU are removed prior to the completion of therapy and the average PIV in the NICU stays in only 30 hours before various complications require replacing. Compared to PIV data, we have had great success with extended dwell catheters. Between Aug. 2012-2016, 432 extended dwell catheters have been placed at Intermountain Medical Center's NICU and between March and Aug. 2016, 21 catheters have been placed at LDS hospital's level 2 nursery. Overall 72% of extended dwell catheters remained in place until the therapy was no longer needed. The problems that did arise are comparable to those of a PIV and included leaking, infiltration, accidentally dislodged, cording, clotted, possible phlebitis, redness, broken catheter, sluggish when flushing, and mild hand edema. As we continue to offer these catheters as an alternative method of vascular access, please always be vigilant of the babies in your care and if they will benefit from an extended dwell catheter. If an infant requires frequent PIVs, multiple pokes per PIV start, or multiple days of fluid and/or medications such as antibiotics, they may be the perfect candidate for an extended dwell catheter. Our unit is paving the way for many other NICUs and level 2 nurseries throughout Utah to begin using extended dwell catheters, due in large part to the nurses on our unit. Thank you for your diligence and hard work advocating for our precious patients. Appendix E: Presentation Evaluation Form EXTENDED DWELL CATHETERS IN THE NICU 30 EXTENDED DWELL CATHETERS IN THE NICU Appendix E: Final PowerPoint Presentation 31 EXTENDED DWELL CATHETERS IN THE NICU 32 EXTENDED DWELL CATHETERS IN THE NICU 33 EXTENDED DWELL CATHETERS IN THE NICU 34 EXTENDED DWELL CATHETERS IN THE NICU Appendix G: IRB Approval for Extended Dwell Catheters Data 35 EXTENDED DWELL CATHETERS IN THE NICU Appendix H: IRB Approval for PICC Line Data 36 EXTENDED DWELL CATHETERS IN THE NICU 37 Appendix I: IRB Agreement Letter From the University of Utah to Defer IRB to IHC EXTENDED DWELL CATHETERS IN THE NICU Appendix J: Project PowerPoint Presentation 38 EXTENDED DWELL CATHETERS IN THE NICU 39 EXTENDED DWELL CATHETERS IN THE NICU 40 EXTENDED DWELL CATHETERS IN THE NICU Appendix K: Poster Presentation 41