Happy 2017 from AVATAR!

We hope you are having a great year and your patients are doing even better, with comfortable, complication-free vascular access devices and infusion therapy.

A few bits of news from AVATAR to you:

  • Professor Claire Rickard returns as Principal Director in 2017 and retains Directorship of Dressing and Securement
  • Professor Samantha Keogh returns as Director of Flushing and Blood Sampling. We owe a debt of thanks to Samantha for Principal Directing in 2016 and are excited to watch her research group growing each year, now based at the Queensland University of Technology
  • Professor Marie Cooke, Professor Marianne Wallis and Dr Li Zhang return as Directors of Education and Evidence Based Practice; Devices and Therapy; and Infection Prevention and Microbiology respectively
  • We welcome Dr Amanda Ullman RN PhD as the inaugural Director of Paediatrics and Neonates for AVATAR. This has been one of our fastest growing research areas within AVATAR and we are so proud of Amanda, and her colleagues especially Tricia Kleidon, Nurse Practitioner, in getting us to this point in our history. Check out our new Paediatrics tab at avatargroup.org.au

Peripheral IV Catheter monitoring - Prestigious Postdoctoral Fellowship

The talented Dr Gillian Ray-Barruel is now funded for 2 years by Griffith University to improve the current systems of peripheral intravenous catheter (PIVC) monitoring and decision making. Following on from her work with phlebitis scales and the OMG study, Gillian is tackling IV assessment and prompt removal of redundant PIVCs. The I-DECIDED Study will test the effectiveness of a decision-making tool (I-DECIDED) in improving PIVC assessment and care in 3 Brisbane hospitals. Stay tuned to hear more about this exciting study!

Other recent research funding - congratulations to the following researchers

2017 The Western Australia Nursing and Midwifery Academic Support Grant.

Development of a clinical prediction model for appropriate PIVC insertion success.

Carr P $20,000

2017 American Society for Parenteral and Enteral Nutrition (ASPEN) Rhoads Foundation.

Improving central-line associated bloodstream infection diagnosis in allogeneic haematopoietic stem cell transplant patients with parenteral nutrition (The Improving CLABSI Trial). 

Gavin N, Rickard C, Hill G, Harris P, Zhang L, Markey K, Andersen S, Larsen E. US$25,000

2017 Princess Alexandra Hospital Research Foundation Grant.

Central venous Access device SeCurement And Dressing Effectiveness: the CASCADE pilot trial.

Mitchell M, Rickard CM, Playford G, Zhang L, Davis C, Ullman A $75,000

2017-2018 Queensland Health Nursing & Midwifery Senior Research Fellowship.

Controlling device Occlusion and infection by ConnectOr design And decontamination: COCOA pilot trial

Rickard C, McCarthy A, Kleidon P, Larsen E, Zhang L, Ullman A, Marsh N, Edwards R. $120,000

2017 Royal Brisbane and Women's Hospital (RBWH) and RBWH Foundation Research Project Grant.

RELiable Intravenous Access By Line Experts: RELIABLE Study

Marsh N, Webster J, Rickard C, Cooke M, Larsen E, Cadigan C.  $31,429.18

2017 RBWH and RBWH Foundation Research Project Grant.

Cancer care: The risK factors of vEnous access failure (CARETaKER Study)

Larsen E, Marsh N, Gavin N, Flynn J, Webster J. $37,926

2017 RBWH and RBWH Foundation Research Project Grant.

Estimating Prevalence of Impaired Skin surrOunding DevicEs: The EPISODE Study. 

Gavin N, Kleidon T, Marsh N, Ullman A, Rickard CM, Larsen E, Campbell J.  $40,000

2017 RBWH and RBWH Foundation Patricia Dukes Fellowship 

Improving central-line associated bloodstream infection diagnosis in allogeneic haematopoietic stem cell transplant patients with parenteral nutrition.

Gavin N. $50,000

2017 RBWH and RBWH Foundation Postgraduate Scholarship 2017.

Evaluating current and new methods for effective decontamination of needleless connectors: A pilot randomised control trial.  

Flynn J. $19,716

2017 RBWH and RBWH Foundation Postgraduate Scholarship.

Identifying potential risk factors that predict peripheral intravenous catheter failure.  

Marsh N $19,716


Blog Posts

Missed these? Click on the links below for recent blog posts

- State of the Art in Vascular Access Management Seminar


- How to Assess an Intravenous Cannula


- Scoping the Evidence for Central Venous Access Devices


- Is it Time for a Protocol for Long term Central Venous Access? A Caregiver's Perspective


- Welcome to Brisbane Maria Paula Nurse Researcher from Brazil


- A Survivalist Guide to paediatric Central Venous Access Device Dysfunction


- Thank You AVATAR Group



The WA AVATAR group are busy getting ready for WoCoVA / AVAS May 10-12 and to welcome all to beautiful Perth.  Make sure you follow #AVAS17 for updates and check out the very exciting vascular access scientific program http://avasasm.org.au/program/program-outline.html

Pete Carr and Gavin Jackson recently presented at a Grand Round session at Fiona Stanley Hospital; They were invited to discuss "72hrs or what". Great to see some vascular access exposure in unique hospital grand round sessions.  Suffice to say the WA gang continue (the most remote AVATAR chapter in Australia) continues to fly the AVATAR flag.



The NSW group continues to work on a number of projects.
The results and publication manuscript of the One Million Global Peripheral Intravenous Catheter (OMG PIVC) study is in its final draft and to be submitted shortly to a medical journal. This landmark study reviewed over 40,000 PIVCs across 51 countries. Many clinicians are eager to see the results and we can't wait to have the study finally published. 

The Difficult Intravenous Access (DiVa) Study has been completed at Liverpool hospital, 379 patients had PIVCs inserted by the after-hours CNCs who have been trained in ultrasound guidance. The project has been very successful with over 92% of cannulas inserted first attempt (many of these patients had previously experienced multiple attempts at cannulation by other clinicians). The results and manuscript are currently being prepared congratulations to Vanno Sou, Craig McManus, Julie Ale and Nicholas Mifflin for their great work. Results of this study will be presented in Perth at the AVAS ASM.  A follow  study is currently being prepared for ethics: DiVa 2-The patient experience. This study aims to interview patients to gain insight into their experience of being a DiVa patient.

We continue our audit of the MIdLIne CatheTers for ANtibiotic Therapy study  (MILITANT Study)- to date we have followed up over 150 midlines preliminary results will be presented at the AVAS ASM in Perth. These devices have been inserted for a number of antibiotics where previously PICCs were used.

Our study: Comparing traditional Placement With electrocArdiography for central Vascular access dEvices trial (P-WAVE Trial) is going strong. This randomised trial is assessing and comparing CVAD insertion between two methods: traditional anthropometric and ECG guided. Our outcomes of interest are catheter tip position, malposition rates, procedural time and cost benefit. So far we have recruited 100 patients of the 345 required for the study. We estimate to have final numbers in a few months.

Congratulations also goes to Nicholas Mifflin for his case study publication in the Journal of the Association for Vascular Access: Paradoxical Electrocardiographic Rhythm During Peripherally Inserted Central Catheter Insertion from Persistent Left Superior Vena Cava.



Second Victorian Vascular Access Education and Discussion Forum - AVATAR Victorian Chapter, AVAS and CNSA.

The second Victorian Education and Discussion forum was held on March 30, 2017.

The topic was "Everything dressings! Evidence, gaps and the future. Education and discussion." It was fabulous to welcome metropolitan Melbourne participants as well as being teleconferenced to six hubs across the state and one from Queensland.

The presentation by Dr Amanda Ullman, AVATAR/Griffith University (Brisbane) was titled 'Sticky solutions: Vascular access securement and dressings.' Amanda presented current evidence on dressings and securement as well as the paediatric component of vascular access for peripheral and central devices. Amanda made a stellar performance originally planned to be via teleconference which was amended due to Cyclone Debbie to sitting in the dark and via mobile phone. Both a fabulous and professional performance by Amanda in challenging conditions!!

Kerrie Curtis presented evidence-based alternatives to recommended practice for patient cohorts who develop complications to dressings and securement. Questions and discussion ensued where participants discussed the application of evidence in the clinical setting in regards to vascular access dressing and securement.

In May 2017, we look forward to the next meeting which will focus on patency and occlusion management.


2017 Publications (links on our website)

1. Randomized controlled trials in central vascular access devices: A scoping review. Takashima M, Ray-Barruel G, Ullman A, Keogh S, Rickard CM. PLoS One. 2017 Mar 21;12(3):e0174164. doi: 10.1371/journal.pone.0174164. eCollection 2017.

More high quality randomized trials across central venous access device management are necessary, especially in dressing and securement and patency. These can be encouraged by having more studies with multidisciplinary team involvement and consumer engagement. Additionally, there were extensive gaps within population sub-groups, particularly in tunneled devices, and in pediatrics and neonates. Finally, outcome definitions need to be unified for results to be meaningful and comparable across studies.

2. Road map for improvement: Point prevalence audit and survey of central venous access devices in paediatric acute care. Ullman AJ, Cooke M, Kleidon T, Rickard CM. J Paediatr Child Health. 2017 Feb;53(2):123-130. doi: 10.1111/jpc.13347. Epub 2016 Oct 6.

CVADs are prevalent and essential for paediatric health care; however, complications remain a significant problem. Areas identified for improvement were local CVAD guidelines, regular documentation of CVAD site assessment and review of dressing products to improve integrity.

3. Microorganisms present on peripheral intravenous needleless connectors in the clinical environment. Slater K, Cooke M, Whitby M, Fullerton F, Douglas J, Hay J, Rickard C. Am J Infect Control. 2017 Mar 20. pii: S0196-6553(17)30108-6. doi: 10.1016/j.ajic.2017.02.008.

The aim of this study was to quantify culturable microorganisms on needleless connectors (NCs) attached to peripheral intravenous catheters in hospitalized adult medical patients. Half (50%) of 40 NCs were contaminated with microorganisms commonly found on the skin or mouth. Staphylococcus capitis and Staphylococcus epidermidis were most commonly isolated. Emergency department insertion and higher patient dependency were statistically associated with positive NC microorganism growth. These results reaffirm the need for NC decontamination prior to access.

4. Can hand hygiene observation and reporting be improved through a risk-based targeted approach? Slater K, Cooke M, Rickard C, Whitby M. Am J Infect Control. 2017 Feb 1;45(2):212-213. doi: 10.1016/j.ajic.2016.09.012.

A more focused approach to monitoring hand hygiene in a cost-effective, reproducible manner, without inherent bias, focusing on critical sites (often indwelling medical devices) and with realistic targets, is surely a topic which requires more broad discussion to achieve a practical and realistic, consensus approach.

5. Alcohol Caps or Alcohol Swabs With and Without Chlorhexidine: An In Vitro Study of 648 Episodes of Intravenous Device Needleless Connector Decontamination. Flynn J, Keogh S, Rickard C, Zhang L. Infection Control and Hospital Epidemiology. 2017. Jan 31:1-3. doi: 10.1017/ice.2016.330. Early on-line.

Our data suggest that the ideal method of needleless connector decontamination is 30 seconds with CHG swabs,
although even 5-second CHG swabbing outperformed other methods. However, poor compliance with active decontamination method may negate the effectiveness of CHG swabbing. CHG swabbing also leaves a residue on the external surface of the needleless connector, and it is unclear whether this residue has ongoing antimicrobial benefit, degrades the connector material, or even leads to CHG injection into the bloodstream. Further research is needed to elucidate these issues.

6. Non-culture based diagnostics for intravascular catheter related bloodstream infections. Zhang L, Rickard CM. Expert Review of Molecular Diagnostics. Invited review paper. 2017 Feb;17(2):181-188. doi: 10.1080/14737159.2017.1275964.

The development of additional diagnostic methods has potential to beneficially supplement conventional culture diagnosis, and molecular techniques have particular potential to fulfil this need. They would also contribute significant new knowledge on the bacterial species present on catheters that are generally missed by diagnosis using traditionally culture-dependent methods. Advances in molecular strategies, together with new biomarkers, might lead to the development of faster, more sensitive and cheaper technologies and instruments. This review aims to provide a platform for the further development of IVCBSI diagnostic techniques.

7. Devices and dressings to secure peripheral venous catheters: A Cochrane systematic review and meta-analysis. Marsh N, Webster J, Mihala G, Rickard CM. Int J Nurs Stud. 2017 Feb;67:12-19. doi: 10.1016/j.ijnurstu.2016.11.007. Epub 2016 Nov 16.

There is no strong evidence to suggest that any one dressing or securement product for preventing peripheral venous catheter failure is more effective than any other product. All of the included trials were small, had high or unclear risk of bias for one or more of the quality elements we assessed, and wide confidence intervals, indicating that further randomised controlled trials are necessary. There is a need for suitably powered, high quality trials to evaluate the newer, high use products and novel - but expensive - securement methods, such as surgical grade glue.

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