DART 3: A pragmatic stepped wedge cluster randomised trial of ultrasound guidance to reducing multiple PIVC insertions in hospitalised patients

DART 3: A pragmatic stepped wedge cluster randomised trial of ultrasound guidance to reducing multiple PIVC insertions in hospitalised patients

Jessica Schults^1,2,3,4,6, Nicole Marsh^2,3,4, Amanda Ullman^2,3,4,5,6, Tricia Kleidon^2,3,4,5, Robert Ware⁷, Joshua Byrnes^7,8, Emily Young⁷, Lisa Hall^1,9, Gerben Keijzers^7,10,11, Louise Cullen¹², Pauline Calleja^4,13, Steven McTaggart^5,6, Nathan Peters^14,15, Stuart Watkins¹⁰, Amanda Corley^2,3,4, Christine Brown², Zhen, Lin, 2,14, Frances, Williamson, 12,14,16, Luke, Burgess, 3, Fiona, Macfarlane, 5, Marie, Cooke, 4, Callan, Battley, 5,6, Claire, Rickard, 1,2,3,4

¹Metro North Health Herston Infectious Disease Institute, Herston, QLD, Aus
²The University of Queensland, School of Nursing, Midwifery and Social Work, St Lucia, QLD, Aus
³Nursing Midwifery Research Centre, Royal Brisbane and Women’s Hospital, Herston, QLD, Aus
⁴School of Nursing and Midwifery, Alliance for Vascular Access Teaching and Research, Griffith University, Nathan, QLD, Australia
⁵Children’s Health Queensland Hospital and Health Service, Brisbane, QLD, Australia
⁶Children’s Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
⁷School of Medicine and Dentistry, and Menzies Health Institute Queensland, Southport, QLD, Australia
⁸Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia
⁹School of Public Health, The University of Queensland, Brisbane, QLD, Australia
¹⁰Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
¹¹Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
¹²Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
¹³School of Nursing, Midwifery & Social Science, Central Queensland University, Cairns, QLD, Australia
¹⁴Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
¹⁵Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
¹⁶Jamieson Trauma Institute, Herston, QLD, Australia

Introduction
Approximately half of patients requiring peripheral intravenous catheter (PIVC) insertion have difficult intravenous access (DIVA) requiring multiple insertion attempts. Ultrasound-guided PIVC insertion increases first-attempt success, but widespread implementation has not been evaluated.

Methods
Stepped wedge cluster randomised controlled trial to evaluate the implementation and effectiveness of a co-designed DIVA identification and escalation tool across three Queensland hospitals (12 clusters/wards). Hospital-based assessments, readiness surveys and key informant interviews were conducted during the trial. Outcome measures included patient outcomes (primary endpoint: first-time PIVC insertion success for both all and high-risk of DIVA patients; secondary: ultrasound use and time to insert), implementation outcomes (e.g., readiness for change) and service outcomes (e.g., cluster level blood stream infection rates).

Results
A total of 1,354 patients were enrolled (679 usual care [baseline], 675 DIVA intervention). Sustainability is ongoing (anticipated completion July 2023). Early analysis shows a non-significant change in first attempt PIVC insertion in high-risk DIVA patients (42% to 54%; odds ratio [OR] 1.59, 95% CI [confidence interval] 0.78, 3.22), all patients (61% to 65%; OR 1.22, 95%CI 0.86, 1.75), and use of ultrasound in high-risk DIVA patients (for first attempt; 43% to 57%; OR 2.05, 95%CI 0.90, 4.70). Average time to insertion improved for high-risk DIVAs (-0.55 hours, 95%CI -0.89 to 0.21, p=0.002). No blood stream infections were reported.

Conclusions
Preliminary findings indicate ultrasound use increases first-time PIVC insertion success in high-risk DIVA patients. However, achieving ultrasound adoption requires organisation wide implementation strategies to maximise the impact for all patients.

Biography

Jessica is a conjoint senior research fellow with Metro North Health, Herston Infectious Disease Institute and The University of Queensland School of Nursing Midwifery and Social Work. Jessica is interested in advances in infectious disease surveillance and tracking, using a combination of mature platforms and new electronic platforms. Jessica is leading the process evaluation of the DART 3 trial to determine factors which optimise the implementation of ultrasound guided PIVC insertion.