S1(1818 Keogh S, Flynn J, Marsh N, Mihala G, Davies K, Rickard C. Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomised controlled trial in adult medical-surgical hospital patients. Trials. 2016;17(1):348. https://doi.org/10.1186/s13063-016-1470-6
https://doi.org/10.1186/s13063-016-1470-...
) |
Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomized controlled trial in adult medical-surgical hospital patients
2016/Australia
CINAHL
PubMed
Cochrane
Embase |
Controlled randomized clinical trial
n: 160 patients using PVC |
Test the effect of varying volumes of solution and flushing frequencies on PVC failure. |
Device failure rates per 1,000 hours were not significantly different for 3 ml and 10 ml volume intervention (p = 0.06). Regarding the frequency of 24 hours versus 6 hours (p = 0.05) for the interval for performing flushing in PVC without continuous perfusion, there was also no difference.
The catheter handling rate per day (flushing combined with medication administration) significantly predicted peripheral catheter failure. |
Increased volume and frequency of flushing did not significantly alter the risk of PVC failure. Being female, catheter insertion site on the dorsum of the hand and a greater number of episodes of access manipulation (for flushing and medication) increase the risk of PVC failure. |
S2(1919 Klein J, Jepsen A, Patterson A, Reich RR, Mason TM. Heparin versus normal saline: flushing effectiveness in managing Central Venous Catheters in patients undergoing Blood and marrow transplantation. Clin J Oncol Nurs. 2018;22(2):199-202. https://doi.org/10.1188/18.CJON.199-202
https://doi.org/10.1188/18.CJON.199-202...
) |
Heparin versus normal saline: flushing effectiveness in managing Central Venous Catheters in patients undergoing Blood and marrow transplantation
2018/ USA
CINAHL
PubMed
Cochrane |
Controlled randomized clinical trial
n: 30 patients chosen for convenience submitted to Bone Marrow Transplantation (BMT). Each patient with a new CVC was randomized to receive either heparinized solution or normal saline alone for washing. |
Determine if there is a difference in line patency when using only normal saline versus heparin and saline and check the incidence of Central Venous Catheter-Associated Blood Stream Infection (CLABSI) when releasing central lines in patients undergoing BMT. |
Among the 698 events observed, line problem rates were similar between washing with heparin and normal saline (8.8%) and with normal saline (8.5%) (p = 0.88).
For patients with baseline problems, plasminogen activator was administered at similar rates for heparin flushing (25%) and flushing using normal saline (27%) (p = 0.02).
A CLABSI occurred in the saline group, however it did not represent a deviation from the historical CLABSI rates of the study site. |
The study did not show conclusive differences in heparin efficacy and safety with normal saline versus washing with normal saline only for CVC treatment, which requires caution, due to the risks of heparin. |
S3(2020 Oliveira ASS, Costa PJS, Graveto JMGN, Costa FJG, Osório NIA, Cosme ASTC, et al. Nurses’ peripheral intravenous catheter-related practices: a descriptive study. Rev Enf Ref. 2019;IV(21):111-20. https://doi.org/10.12707/RIV19006
https://doi.org/10.12707/RIV19006...
) |
Práticas dos enfermeiros na cateterização intravenosaperiférica: um estudo descritivo
2019/ Portugal
CINAHL |
Cross-sectional and descriptive study
n: observation of 26 nurses during insertion of 38 catheters and 66 times of PVC maintenance |
Know nurses’ practice during PVC insertion and maintenance |
Regarding PVC maintenance, nurses tested catheter patency using 0.9% sodium chloride for flushing (78.8%) and 21.2% of participants did not verify catheter patency before administering intravenous medication. There was a variation in the volume and technique used for maintenance.
In 35 cases, PVC was used to administer medication intravenously, occurring multiple administrations in 15 patients. Overall, PVC flushing was performed between multiple medication administration in 53.3% of the moments observed, while in one fifth of the cases a final flushing moment was not performed. |
Nursing practices during PVC insertion and maintenance are not consistent and do not always respect current standards of care recommendations. |
S4(2121 Di Fine G, Centini G, Gavetti D, Lemma P, Cavallo F, Pici A, et al. Best practices in the management of Central Vascular Access devices: an observational study in areas with a high prevalence of trained nurses. J Infus Nurs. 2018;41(5):319-25. https://doi.org/10.1097/NAN.0000000000000297
https://doi.org/10.1097/NAN.000000000000...
) |
Best practices in the management of central vascular access devices: an observational study in areas with a high prevalence of trained nurses
(2018)/Italy
CINAHL
PubMed
Embase |
Observational study
n:148 nurses from nine medical-surgical wards; 171 observations (53 dressing procedures and 118 flushing procedures). |
Determine the level of good practice in areas with a high prevalence of nurses trained in the management of central vascular access devices. |
Of the 118 flushing procedures observed, 76% were performed in accordance with good practices.
The most frequent errors were related to incorrect use of needleless connectors. Thirteen of 28 incorrect procedures (46%) involved failure to disinfect needleless connectors.
Specifically regarding flushing, there were no considerable differences between nurses who participated in the course and those who did not. |
Overall, the variables that influenced the best management practices for central vascular access devices were related to nurses with less than five years of professional experience and who recently participated in a training program. |
S5(2222 Nyika ML, Mukona D, Zvinavashe M. Factors contributing to phlebitis among adult patients admitted in the medical-surgical units of a central hospital in Harare, Zimbabwe. J Infus Nurs. 2018;41(2):96-102. https://doi.org/10.1097/NAN.0000000000000265
https://doi.org/10.1097/NAN.000000000000...
) |
Factors contributing to phlebitis among adult patients admitted in the medical-surgical units of a central hospital in Harare, Zimbabwe
2018/Zimbabwe
CINAHL
PubMed
Embase |
Quantitative, analytical study
n: 46 hospitalized patients |
Assess the factors that contribute to phlebitis after PVC insertion among adult patients admitted to the medical-surgical units of a Central Hospital in Harare, Zimbabwe. |
The findings of this study showed that in no catheter was flushing performed as regularly as expected. Only 13.0% performed flushing, however, the practice took place irregularly according to INS guidelines;
72.7% of PVC that were never washed developed advanced stages of phlebitis (grades 4 and 5). |
Among the contributing factors for phlebitis, irregularity in catheter flushing was highlighted. It was recommended that procedural guidelines on catheter maintenance care be disseminated at the study site. |
S6(2323 Parreira P, Vicente R, Bernardes RA, Sousa LB, Serambeque B, Costa P, et al. The flushing procedure in nursing practices: a cross-sectional study with Portuguese and Brazilian nurses. Heliyon. 2020;6(8):e04579. https://doi.org/10.12707/RIV19006
https://doi.org/10.12707/RIV19006...
) |
The flushing procedure in nursing practices: A cross-sectional study with Portuguese and Brazilian nurses
2020/Portugal and Brazil
PubMed
Embase |
Cross-sectional and descriptive study
n: 76 Brazilian and Portuguese nurses answered an online questionnaire. |
Identify nursing practices related to flushing procedure in PVC, namely: times of performance; size of syringe used; the solution of choice, volume and technique applied; knowledge and compliance with the recommended rules on flushing by nurses. |
Most nurses (84.2%) reported performing flushing. The most used technique was continuous pressure with the syringe plunger (31.2%), followed by the push-pause technique (23.4%). Although most perform flushing at four different times (after device insertion, before, between and after drug administration), there were inconsistencies in flushing solution, volume and syringe size. The volume most used for washing was 5 ml, filled with normal solution. There was recognition of the omission of this procedure due to time limitations, lack of familiarity with material procedure and unavailability. |
The study concluded that flushing procedure is not always performed by nurses in their clinical approach. Moreover, several inconsistencies were observed between the practice developed by nurses in performing flushing, reflecting the lack of empirical evidence in this area of research. |
S7(2424 Liu F, Liao T, Wang Q, Tao Y. Evaluation of a novel flushing protocol for a peripherally inserted central catheter (PICC) in the neurological intensive care unit: a prospective randomized study. Natl Med J India. 2018;31(1):5-7. https://doi.org/10.4103/0970-258X.243419
https://doi.org/10.4103/0970-258X.243419...
) |
Evaluation of a novel flushing protocol for a peripherally inserted central catheter (PICC) in the neurological intensive care unit: A prospective randomized study
2018/China
PubMed
Cochrane
Embase |
Prospective randomized clinical trial
n: 360 patients from a neurointensive unit using PICC. The experimental group used the VAMP system (Closed system device with a 5 ml reservoir used to store 0.9% SF) for flushing. Control group: conventional method |
Investigate whether a new flushing method using the VAMP system for PICC could decrease the risk of venous thromboembolism and bloodstream infections compared to the traditional flushing method. |
The occurrence of infection and mean time to perform flushing were statistically lower in the experimental group (VAMP). The PICC occlusion rate, proportion of males, age, APACHE II score and length of hospital stay did not show significant differences between the two groups. |
The VAMP system as a method for flushing is simple to use and may be more beneficial for patients with PICC, as it allows for a decrease in the risk of infections related to the bloodstream. |
S8(2525 Huang V. Effect of a patency bundle on central venous catheter complications among hospitalized adult patients: a best practice implementation project. JBI Database System Rev Implement Rep. 2018;16(2):565-86. https://doi.org/10.11124/JBISRIR-2016-003340
https://doi.org/10.11124/JBISRIR-2016-00...
) |
Effect of a patency bundle on central venous catheter complications among hospitalized adult patients: a best practice implementation project
2018/Australia
CINAHL
PubMed
Embase |
Observational, quantitative
n: 20 nurses in two Intensive Care Units |
Improve continuity of care, reducing central catheter occlusions from training to apply a bundle of good practices in CVC maintenance. |
In a preliminary observation, the selection of appropriate syringe size (100%), flushing volume (80%), solution and sequence (90%) was rated as excellent. Nurses’ compliance with the aspiration and assessment of blood return (40%) and the use of the push-pause technique (25%) were insufficient and exposed a significant knowledge gap and need for education.
After performing a multimodal education model, there was a significant improvement in nurses’ flushing technique. Twice as many nurses remembered to aspirate for blood return and apply the push-pause technique. However, catheter patency/occlusion documentation did not improve. |
Multimodal education reached all nurses and contributed to significantly improve compliance with best maintenance practices. Nurses were trained to solve occlusion problems using thrombolytics.
However, after three months of multimodal training the data did not demonstrate a continuous downward trend in occlusion rates. |
S9(2626 Zhong L, Wang HL, Xu B, Yuan Y, Wang X, Zhang YY, et al. Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis. Crit Care. 2017;21(1):5. https://doi.org/10.1186/s13054-016-1585-x
https://doi.org/10.1186/s13054-016-1585-...
) |
Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis
2017/China
PubMed
Embase |
Systematic review with meta-analysis
n: 10 clinical trials involving 7,875 individuals |
Assess the effectiveness of normal saline (NS) versus heparinized solution (HS) in maintaining CVC permeability in adult patients. |
NS can be equally, if not more effective, in keeping CVC functioning. Of the studies that reported secondary outcomes (heparin-induced thrombocytopenia, hemorrhage, central venous thrombosis, and catheter-related bloodstream infection), heparinized saline was not shown to be superior to non-HS. However, in short-term use (<30 days), flushing with HS is slightly superior to NS. |
HS is not superior to NS in reducing CVC occlusion. However, in the short term, the use of HS is slightly superior to NS for flushing catheters, from a statistical point of view. |
S10(2727 Saliba P, Cuervo G, Hornero A, De Carli G, Marani A, Puro V, et al. The impact of flushing with pre-filled saline syringes on the incidence of peripheral venous catheter failure: a quasi-experimental study. J Vasc Access. 2020; 21(4):490-496. https://doi.org/10.1177/1129729819888423
https://doi.org/10.1177/1129729819888423...
) |
The impact of flushing with pre-filled saline syringes on the incidence of PVC failure: A quasi-experimental study
(2019)/Spain
PubMed
Embase |
Quasi-experimental design, before and after intervention study.
n:3,853 PVC in 1,915 patients analyzed. |
Demonstrate the differences in overall PVC failure rates before and after the introduction of pre-filled saline syringes for flushing. |
Compared with the pre-intervention period, a significant decrease in the PVC failure rate was observed in the intervention period (57% vs 43.4%, p<0.001). |
The use of saline pre-filled syringes significantly reduced PVC failure and increased catheter dwell time. It was concluded that the use of pre-filled syringes is important to perform flushing and to reduce the incidence of PVC failure. |
S11(2828 Oliveira LB, Fava YR, Rodrigues ARB, Franulovic AC, Ferreira NT, Püschel VAA. Management of peripherally inserted central catheter use in an intensive care unit of a teaching hospital in Brazil: a best practice implementation project. JBI Database System Rev Implement Rep. 2018;16(9):1874-86. https://doi.org/10.11124/JBISRIR-2017-003577
https://doi.org/10.11124/JBISRIR-2017-00...
) |
Management of peripherally inserted central catheter use in an intensive care unit of a teaching hospital in Brazil: a best practice implementation project
2018/Brazil
PubMed |
Evidence implementation project with pre- and post-test
n: pre: 22 patients and 180 nursing staff. After an educational program: 14 patients and 180 nursing staff |
Conduct an audit to assess compliance with best practices in PICC management in the Intensive Care Unit and implementation of evidence-based practices recommended by the Joanna Briggs Institute (JBI) |
The initial audit indicated that PICC maintenance in relation to flushing had low compliance of 2 to 20%, especially for the criteria related to PICC permeability assessment with a 10 ml syringe or carrying out before and after drug administration, blood product infusion, lipid infusion and blood collection.
After the implementation of best practices by JBI for PICC management, a new follow-up audit was carried out, which showed improvement in all 10 criteria. Criteria related to flushing achieved 83% to 89% compliance. |
Greater compliance with evidence-based best practices was achieved on all audit criteria assessed after an educational program The criteria that achieved the greatest compliance with best practice recommendations were related to prevention of bloodstream infection and PICC loss due to obstruction. |
S12(2929 Keogh S, Shelverton C, Flynn J, Mihala G, Mathew S, Davies M, et al Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomised trial. BMC Med. 2020;18(1):252. https://doi.org/10.1186/s12916-020-01728-1
https://doi.org/10.1186/s12916-020-01728...
) |
Implementation and evaluation of short peripheral intravenous catheter flushing guidelines: a stepped wedge cluster randomized trial
2020/Australia
PubMed
Embase |
Cross-sectional, randomized, cluster study
n: 619 patients (control n = 306, intervention n = 313) |
Assess the effect of a bundle to enforce PVC flushing guidelines with pre-filled flush syringes. |
Practice in the control group was standard treatment (variable practice with manually prepared flushing with 0.9% sodium chloride). The intervention group received practice guidance on bundled reinforcement education (including administration with a pre-filled syringe prepared by the manufacturer).
PVC failure was 91 (30%) in the control and 69 (22%) in the intervention group. Total costs were lower in the intervention group. No serious adverse events related to the study intervention occurred. |
This study demonstrated the effectiveness and lower cost of flushing PVC with a pre-filled syringe according to recommended guidelines. Evidence-based education, use of bundles, surveillance, and post-PVC maintenance materials are vital to improving patient outcomes. |
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