Developing a venous access guideline in Malta : a modified delphi study

Abstract

Background Venous access (VA) is a common practice, however, locally the process is not guided by a standard operating procedure creating challenges among clinicians on selecting the best venous access device (VAD) for patients. This is the first study aiming to inform local policy by developing an evidence-based VA guideline including peripheral intravenous cannulas (PIVCs), midlines, peripherally inserted central catheters (PICCs), portacaths and Hickman to be used by clinicians. Method Two scoping reviews of the most recent evidence-based literature and guidelines were conducted. Six articles and eight guidelines were retrieved and critically appraised. A prototype VA guideline was formulated based on the World Health Organisation Handbook for Guideline Development. A two-round modified Delphi method was implemented aiming at achieving consensus agreement among clinical experts on the prototype guideline. Round one of the modified Delphi consisted of a focus group discussion (FGD) to discuss and explore the perspectives of local experts on the prototype guideline. This was analysed using thematic analysis. Round 2 consisted of an online questionnaire using the Appraisal of Guidelines for Research & Evaluation Instrument. Analysis was done using formulaic analysis. Findings Five participants representing the Infection Prevention and Control Department, the VA team and the Interventional Radiology Department made up the expert panel during the FGD. Four main themes were identified: referring patients for a VAD insertion, types of VADs, complications and VAD removal. It was concluded that the guideline should be aimed toward inpatients and outpatients and that an early VAD need assessment should be done within the first 24hours of admission by the firm consultant. PIVCs are recommended for infusions lasting up to six days whilst midlines are preferred for infusions lasting up to three weeks. For non-peripherally compatible infusates lasting up to six months, PICCs are preferred, whilst portacaths and Hickman are ideal for the administration of long-term treatment lasting longer than six months. Portacaths are the line of choice for the administration of treatment for solid tumours whilst Hickman are preferred for haematology patients. PIVCs, midlines, PICCs and Hickman can be removed in the ward whilst portacaths are removed in the Angiosuite Unit. From the guideline assessment questionnaire it was concluded that the finalised guideline is of a ‘high quality’. Conclusion Based on the consensus agreement amongst local clinical experts from the FGD and questionnaire, the VAD selection criteria is primarily based on the expected duration of treatment and the type of infusate to be infused. This is presented as a flow diagram to help the VAD selection process.