NHS Tayside has agreed to apologise to the family of a 79-year-old man who died in Ninewells Hospital after knee-replacement surgery.

Scottish Public Services Ombudsman Professor Alice Brown said the man — referred to as Mr A — was admitted to Ninewells on April 20, 2006, and had his operation the following day. He later suffered episodes of diarrhoea and vomiting and then a cardiac arrest and subsequently died on April 26.

The man’s sister — Ms C — complained first to NHS Tayside and then took her case to the Ombudsman, who found there had been a failure to properly monitor Mr A’s fluid levels on April 25 and to accurately control the flow of intravenous fluid as detailed on the prescription chart for April 26.

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The authors completed a meta-analysis of prospective randomized trials that examine the use of Urokinase lock or flush solution for prevention of bloodstream infections associated with central venous catheters for chemotherapy.

Kethireddy, S. and Safdar, N. (2008) Urokinase lock or flush solution for prevention of bloodstream infections associated with central venous catheters for chemotherapy: a meta-analysis of prospective randomized trials. Journal of Vascular Access. 9(1), p.51-57.

Abstract:

Background: Intravascular devices (IVDs) carry significant risk of device-associated bloodstream infection (BSI). Catheter thrombosis increases the likelihood of microbial colonization of the catheter and BSI. Urokinase has been studied for the prevention of BSI associated with IVDs. We undertook a systematic review to determine the efficacy of urokinase-heparin lock or flush solution compared with heparin alone in preventing IVD-associated BSI. Methods: Computerized databases were searched for relevant publications in English from January 1966 to 1 January 2007. We identified randomized controlled trials comparing a urokinase-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term IVDs. Summary effect sizes were calculated with assessment of heterogeneity. Results: Five randomized, controlled trials involving a total of 991 patients being treated with IVDs met the inclusion criteria; all five studies were conducted among patients with cancer; three of these studies were undertaken in children and two in adults. The summary risk ratio with a urokinase-heparin lock solution for IVD-associated BSI was 0.77 (95% confidence interval [CI], 0.60–0.98; p=0.01). Results of the test for heterogeneity were not statistically significant (p=0.53). Conclusions: Use of a urokinase lock solution in high-risk patient populations being treated with long-term central IVDs may reduce the risk of BSI. However, there are few randomized trials and methodologic limitations of these preclude more robust recommendations regarding the use of urokinase to prevent BSI. Further adequately powered studies should seek to evaluate the efficacy of urokinase and optimize dosage and instillation regimen.

Stewart Jessamine, Group Manager, Medsafe in conjunction with the Ministry of Health (NZ)  are continuing to monitor the situation with respect to the global problem of heparin contaminated with over-sulphated chondroitin sulphate (OSCS) entering the market.

Medicines regulators around the world have taken a number of different approaches to managing this issue.  In New Zealand, Medsafe requires all manufacturers of heparin-based products to test for the presence of OSCS in products supplied to the market. To date all of the manufacturers of heparin and low molecular weight heparin products supplied to New Zealand have reported that OSCS has not been detected in the products used by patients.

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Actor Dennis Quaid, whose twins were given an overdose of a blood thinner as newborns at a California hospital, toured a Dallas hospital on Tuesday to learn about a system to prevent such errors.

Officials at Children’s Medical Center Dallas showed Quaid and his wife, Kimberly, the hospital’s system of bar-coding medications to allow the drugs to be tracked electronically from the point of dispensing until being administered to the patient.

“This system here at Children’s Medical Center, I’m really amazed … it’s beyond cutting edge,” Quaid said at a news conference after the tour.

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MedPro Safety Products, has entered into two medical supply manufacturing agreements with Greiner Bio-One International. The two agreements grant Greiner the right to manufacture, market and distribute MedPro’s tube-activated and skin-activated blood collection systems and its winged ‘butterfly’ safety needle system.

MedPro’s Chairman and Chief Executive Officer, Craig Turner, stated: “Greiner is a world-class company, specifically known for its dedication to providing superior product quality and services. We are particularly pleased to expand our relationship with Greiner, which we believe will accelerate global market access for our product, and global exposure for our Company”.

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Irene Lavery and Emma Smith from the Western General Hospital, Edinburgh contrast and compare the skill of venepuncture against the 2008 Nursing and Midwifery Council Code.

Lavery, I. and Smith, E. (2008) Venepuncture practice and the 2008 nursing and Midwifery Council Code. British Journal of Nursing. 17(13), p.824-828.

Abstract:

This article explores the new Nursing and Midwifery Council Code (2008) in relation to venepuncture and, through analysing each clause, will present key considerations for good practice. The skill of venepuncture is discussed and, using a scenario, will review the technique and the impact of the Code on the practitioner. Any clinical skill requires safe and competent practice; it is hoped that this article will aid practitioners involved in undertaking venepuncture to reflect on their skills and knowledge, and to review best practice.

The authors examine issues that impact upon the successful implementation of national guidance such as the NHS better blood transfusion programme and the NPSA safer practice notice 14, right patient, right blood.

Gray, A., Hart, M., Dalrymple, K. and Davies, T. (2008) Promoting safe transfusion practice: right blood, right patient, right time. British Journal of Nursing. 17(13), p.812-817.

Abstract:

Despite an array of initiatives designed to support the delivery of safe and appropriate transfusion practice, incidences of patients receiving the wrong blood continue to be reported. Nurses play a key role in delivering safe and appropriate transfusion care and have a responsibility to support national initiatives, such as the NHS Better Blood Transfusion programme of action and the National Patient Safety Agency Safer Practice Notice 14, Right Patient, Right Blood. This article examines factors, which impact on the successful implementation of a programme aimed at promoting best transfusion practice, such as organizational support, leadership, education and competency assessment, and the role of audit and feedback. By championing the  systematic assessment of transfusion procedures, the implementation of education and guidelines and the use of innovative approaches, such as care bundles, we can ensure that nurses have the appropriate knowledge, skills and understanding to provide the highest standards of transfusion care to our patients.

These two recently published systematic reviews consider the impact of anti-infective-treated central venous access devices on the incidence of catheter-related blood stream infections.

The first is…

Niël-Weise, B.S., Stijnen, T. and van den Broek, P.J. (2008) Anti-infective-treated central venous catheters for total parenteral nutrition or chemotherapy: a systematic review. The Journal of Hospital Infection. 69(2), p.114-23.

Abstract:

This systematic review assesses the effect of anti-infective-treated central venous catheters (CVCs) on catheter-related bloodstream infection (CRBSI) in patients who received a CVC for total parenteral nutrition (TPN) or chemotherapy. Randomised controlled trials were retrieved from Medline and the Cochrane Library up to 14 October 2007. Two reviewers independently assessed trial quality and extracted data. Data for CRBSI were combined where appropriate, using a random effects model, and subgroup meta-analysis was carried out where applicable. The impact of the risk for CRBSI in the control group on the effect of anti-infective CVCs was studied by using meta-regression based on the bivariate meta-analysis model. Nine trials were included in the review. One trial showed that antibiotic-treated CVCs reduced the risk for CRBSI in outpatients with chemotherapy and a CVC in-situ during a period of about nine weeks. Eight trials did not find an overall significant benefit in favour of antiseptic-treated CVCs in patients who had a CVC during a mean of about two weeks. No relationship could be established between the effect of anti-infective-treated CVCs and the underlying risk for CRBSI, although nearly all trials had serious methodological shortcomings. Thus, available scientific evidence to prevent CRBSI by the use of anti-infective-treated CVCs in patients receiving chemotherapy or TPN is not sufficient as a basis to recommend their use. The recommendation of the Centers for Disease Control and Prevention to use antibiotic- or antiseptic-impregnated CVCs, when the risk for CRBSI remains high despite good hygienic practice, should therefore be limited to patients in the intensive care/perioperative setting.

The second…

Hockenhull, J.C., Dwan, K., Boland, A., Smith, G., Bagust, A., Dündar, Y., Gamble, C., McLeod, C., Walley, T. and Dickson, R. (2008) The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation. Health Technology Assessment. 12(12), p.1-154.

Abstract:

OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of central venous catheters (CVCs) treated with anti-infective agents in preventing catheter-related bloodstream infection (CRBSI). DATA SOURCES: Major electronic databases were searched from 1985 to August 2005. REVIEW METHODS: The systematic clinical and economic reviews were conducted according to accepted procedures. Only full economic evaluations (synthesis of costs and benefits) comparing the use of anti-infective central venous catheters (AI-CVCs) with untreated CVCs or other treated catheters were selected for inclusion in the economic review. RESULTS: A total of 32 trials met the clinical inclusion criteria. Seven different types of AI-CVC were identified, with the most frequently tested being chlorhexidine and silver sulfadiazine (CHSS) (externally treated), CHSS (externally and internally treated) and minocycline rifampicin (internally and externally treated). In general, the trials were of a poor quality in terms of reported methodology, microbiological relevance and control of confounding variables. The pooled result suggests a statistically significant advantage for AI-CVCs in comparison to standard catheters in reducing CRBSI [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.34 to 0.60, 24 studies, I-squared = 0%, fixed effects]. Analysis by subgroups of catheters demonstrates that antibiotic-treated catheters and catheters treated internally and externally decrease CRBSI rates significantly (OR 0.26, 95% CI 0.15 to 0.46, six studies, I-squared = 0%, fixed effects, and OR 0.43, 95% CI 0.26 to 0.70, nine studies, I-squared = 0%, fixed effects, respectively). Catheters treated only externally demonstrate a wider CI and non-significant effect (OR 0.67, 95% CI 0.43 to 1.06, nine studies, I-squared = 0%, fixed effects). A treatment effect was also found for trials with an average duration of between 5 and 12 days, and for the one study with a mean duration of over 20 days. There was a statistically significant treatment effect for both femoral and jugular insertion sites and for those studies reporting a mix of insertion sites. The treatment effect was not observed in trials using exclusively subclavian insertion sites. Of the four trials that compared treated catheters, one reported a benefit of antibiotic-treated catheters over catheters treated externally with CHSS. All three sensitivity analyses testing for study design differences reported a statistically significant treatment effect. The review was limited owing to the quality of the trials included, marked differences in the definitions and methods of diagnosis of CRBSI, and inconsistent reporting of risk factors and patient population factors. Furthermore, two-thirds of trials were commercially funded. The economic performance (cost-effectiveness and potential cost-savings) of using AI-CVCs to reduce the number of CRBSIs in patients requiring a CVC was also reviewed. Results show that the use of AI-CVCs instead of standard CVCs can lead to a reduction in CRBSIs and decreased medical costs. To complement the reviews, a basic decision-analytic model was constructed to explore a range of possible scenarios for the NHS in England and Wales. Results show that for every patient who receives an AI-CVC there is an estimated cost-saving of 138.20 pounds. The multivariate sensitivity analyses estimate potentially large cost-savings, depending on the size of the population, under a wide range of cost and clinical assumptions. However, those considering the purchase of AI-CVCs should ensure that their patient populations and the important characteristics of local clinical practice are indeed similar to those described in this economic evaluation. CONCLUSIONS: Overall, AI-CVCs are clinically effective and relatively inexpensive and therefore their integration into clinical practice can be justified. However, the use of these anti-infective catheters without the appropriate use of other practical care initiatives will have only a limited success on the prevention of CRBSIs. Comparative trials are required to determine which, if any, of the treated catheters is the most effective. Pragmatic research related to the effectiveness of bundles of care that may reduce rates of CRBSI is also warranted.

The MHRA have issued  a medical device alert (MDA/2008/051) which concerns the Kimal safety fistula needle. Kimal is aware of the potential for the unintentional retraction of the cannula into the protection sheath, which can result in exsanguination.  As a result, Kimal is recalling all lots of the device. 

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This article reviews the safety of powered intraosseous devices in pediatric patients. The authors state that ”the rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients” (Horton and Beamer 2008).

Horton, M.A. and Beamer, C. (2008) Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatric Emergency Care. 24(6), p.347-350.

Abstract:

OBJECTIVE: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.

METHODS: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.

RESULTS: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 +/- 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 +/- 2.8, and mean infusion pain score was 3.2 +/- 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.

CONCLUSIONS: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.