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Journal of Hospital Infection 92 (2016) 280e286

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Nursing care as a predictor of phlebitis related to

insertion of a peripheral venous cannula in emergency
departments: findings from a prospective study
A. Palese a, *, E. Ambrosi b, F. Fabris a, A. Guarnier c, P. Barelli c, P. Zambiasi c,
E. Allegrini d, L. Bazoli e, P. Casson f, M. Marin g, M. Padovan h, M. Picogna i,
P. Taddia j, D. Salmaso k, P. Chiari l, O. Marognolli b, F. Canzan b, L. Saiani b
on behalf of the ESAMED Group
Udine University, Udine, Italy
Verona University, Verona, Italy
Azienda per i Servizi Sanitari Provincia, Trento, Italy
Azienda Ospedaliera Verona, Verona, Italy
Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
Azienda ULSS n. 9, Treviso, Italy
Azienda per i Servizi Sanitari n. 2 ‘Isontina’, Gorizia, Italy
Azienda ULSS n. 6, Vicenza, Italy
Azienda per i Servizi Sanitari n. 4 ‘Medio Friuli’, Udine, Italy
Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy
Fondazione Zancan, Padua, Italy
Bologna University, Italy


Article history: Background: To date, few studies have investigated the occurrence of phlebitis related to
Received 24 March 2015 insertion of a peripheral venous cannula (PVC) in an emergency department (ED).
Accepted 19 October 2015 Aim: To describe the natural history of ED-inserted PVC site use; the occurrence and
Available online 24 November severity of PVC-related phlebitis; and associations with patient, PVC and nursing care
2015 factors.
Methods: A prospective study was undertaken of 1262 patients treated as urgent cases in
Keywords: EDs who remained in a medical unit for at least 24 h. The first PVC inserted was observed
Phlebitis daily until its removal; phlebitis was measured using the Visual Infusion Phlebitis Scale.
Vascular access devices Data on patient, PVC, nursing care and organizational variables were collected, and a
Catheterization time-to-event analysis was performed.
Peripheral Findings: The prevalence of PVC-related phlebitis was 31%. The cumulative incidence (78/
Survival analysis 391) was almost 20% three days after insertion, and reached >50% (231/391) five days
Missed nursing care after insertion. Being in a specialized hospital [hazard ratio (HR) 0.583, 95% confidence
Emergency departments interval (CI) 0.366e0.928] and receiving more nursing care (HR 0.988, 95% CI 0.983e0.993)
Medical units were protective against PVC-related phlebitis at all time points. Missed nursing care

* Corresponding author. Address: Viale Ungheria 20, 33100 Udine University, Udine, Italy. Tel.: þ39 9 432 590926, þ39 3338276621.
E-mail address: (A. Palese).
0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
A. Palese et al. / Journal of Hospital Infection 92 (2016) 280e286 281
increased the incidence of PVC-related phlebitis by approximately 4% (HR 1.038, 95% CI
Conclusions: Missed nursing care and expertise of the nurses caring for the patient after
PVC insertion affected the incidence of phlebitis; receiving more nursing care and being in
a specialized hospital were associated with lower risk of PVC-related phlebitis. These are
modifiable risk factors of phlebitis, suggesting areas for intervention at both hospital and
unit level.
ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction dressing materials).16 However, the abovementioned factors

determining missed nursing care (defined as unfinished,
Peripheral venous cannulae (PVC) are commonly used by delayed or omitted nursing tasks16) have not been studied to
nurses to provide medications or infusions.1 The use of PVC date in relation to their association with PVC-related phlebitis.
among hospital inpatients increased significantly from 11% in In addition, the amount of nursing care given to patients on a
1992 to 33% in 2002.2 More recently, 30e80% of patients were daily basis, the proportion of care offered by graduate nurses
reported to have had at least one PVC inserted during their educated to university level, and the skills mix of the nursing
hospital stay.3 With the increased use of PVC, concerns have staff have been largely associated with negative clinical out-
arisen regarding the incidence of PVC-related phlebitis, which comes,17 but no studies to date have explored their role in
can result in discomfort, pain and increased morbidity, mor- predicting PVC-related phlebitis.
tality and healthcare costs.4e6 Moreover, only a few studies1,18 have investigated the
PVC-related phlebitis is inflammation of the tunica intima of occurrence of phlebitis in PVC inserted in emergency de-
a superficial vein caused by the presence and use of a PVC. It partments (EDs), despite the fact that a large proportion are
can be diagnosed clinically on the basis of at least two of the positioned in this context.19 Although PVC insertion should be
following signs: pain; erythema; swelling; induration; or a performed under aseptic conditions in all contexts, the urgent
palpable venous cord near the site of the PVC.1 The incidence need to cannulate a vein in critically ill patients, the over-
of PVC-related phlebitis has been documented to occur in crowded ED setting or other concerns can conflict with strict
10.9e25% of cases,4e7 with great variability in the literature compliance with asepsis guidelines.20 Therefore, PVC inserted
due to lack of agreement on a definition of PVC-related phle- in EDs that remain in situ in patients subsequently admitted to
bitis; the use of different measurement tools;8 and the inclu- a ward can incur an higher risk of phlebitis due to the initial
sion of various clinical contexts, populations7 and sample sizes substandard conditions of insertion, if nursing care offered at
(from 38 to 1498).4 the ward level is substandard.
Factors related to patients and to the PVC itself influence This study aimed to develop knowledge on the natural his-
the occurrence of phlebitis. Some studies6,9 found that pa- tory of PVC inserted in EDs and then managed in medical wards;
tients aged 65 years were more likely to develop phlebitis, assess the prevalence, cumulative incidence and severity of
but other studies did not.5 Some studies6 found that phlebitis PVC-related phlebitis; and determine patient, PVC and nursing
was more common in women, other studies9 found it was more care predictors.
common in men, and others5 did not find any association be-
tween sex and the incidence of phlebitis. Neutropenia, Methods
immunosuppression, circulatory impairments and malnutrition
have been shown to increase the risk of phlebitis.5,9 At the PVC Study design and setting
level, cannula material and size,5,6 insertion site and place-
ment technique,4,5,10 duration of site use4,5,10,11 and type of A prospective explanatory pragmatic study was undertaken
infusion solution6,12 have been identified as factors influencing over a seven-month period (2012e2013) in 12 medical units
the occurrence of phlebitis. located in 12 hospitals in northern Italy.
More recently, the relationship between nursing care and
the incidence of PVC-related phlebitis has attracted the Participants
attention of researchers. The risk of PVC-related phlebitis has
been reported to be lower when patients are cared for by Urgent cases who received PVC in EDs and were subse-
experienced nurses,13 and when nurses follow evidence-based quently admitted to a medical unit for at least 24 h, who were
guidelines.13 Registered nurses’ (RNs) perceptions of working willing to participate in the study, were included. In all pa-
under suboptimal conditions affecting daily PVC management tients included, the first PVC inserted in the ED was considered.
have also been associated with increased risk of phlebitis.9,14 This PVC was observed and followed until it was removed for
Nevertheless, ensuring compliance with the available guide- clinical reasons (such as phlebitis), or because, based on the
lines15 and offering the care required by each patient is not RN’s clinical judgement, it was no longer needed (completion
often possible due to high workloads in the wards (e.g. an in- of the treatment or patient discharge).10
crease in the number of patients that a nurse is required to care Patients who did not wish to participate in the study, and
for), communication failures within the healthcare team, and those admitted to the ward as scheduled cases or transferred
shortages of resources at the bedside (e.g. appropriate from other hospitals were excluded. Other secondary PVC
282 A. Palese et al. / Journal of Hospital Infection 92 (2016) 280e286
inserted in EDs, or in medical wards where patients were in this situation, the PVC was monitored frequently. Grade II
admitted, were also excluded. phlebitis was classified as the presence of two of the following
signs: pain, erythaema or swelling. Under these circumstances,
Dependent and independent variables the PVC was generally removed. In the case of Grade III or
higher phlebitis, the PVC was generally removed. The same
Dependent variables were the duration of PVC site use and researchers collected the other patient-level data at ward
the appearance of phlebitis [assessed using the Visual Infusion admission through a physical assessment and interview (with
Phlebitis Scale (VIPS)].21 Independent variables were as the reference caregiver, when appropriate).
follows. Nursing care and organizational-level data were collected
by interview from the RNs and the chief nurse by the RN re-
e Patient factors: demographic (e.g. sex) and clinical data, searchers assigned to the unit. The total amount of nursing
such as the reason for urgent hospital admission; number of care, the proportion of care delivered by graduate RNs, and the
comorbidities; daily medication(s); degree of dependency skills mix were documented by the RN researchers using a
for activities of daily living (Barthel Index); cognitive structured data collection grid when interviewing the chief
problems (agitation or confusion); and number of ED visits nurse.
during the last three months.22 Data on the amount of care missed during the last shift were
e PVC factors: arm used for the PVC (right or left); insertion based on a MISSCARE survey23 completed by the clinical RNs
site; number of days for which the PVC remained in place; responsible for the patients included in this study.
and reason for removal.
e Nursing care factors: amount of daily care received from Ethical issues
RNs (min/patient); skills mix as the proportion of care given
by RNs (RN care/RN care þ nursing assistant care); pro- The study was approved by the Ethical Committee of the
portion of care offered by graduate RNs; and missed care University Hospital of Verona, Italy (coordinating centre). Po-
(amount of planned care omitted or delayed).16 tential participants or their reference caregivers were given
e Organizational factors: teaching status of the hospital (e.g. appropriate information about the aims of the study, and their
whether it offered clinical placements for nursing stu- written consent was obtained before they were enrolled in the
dents), and level of specialism of the hospital (general: study. Patients and caregivers were assured that they could
general medical and surgical units only; medium: addi- withdraw from the study at any time, and that this would have
tional medical and surgical specialties; high: with a trauma no impact on the care they received. The confidentiality of the
centre, cardiac surgery and neurosurgery units). participating patients and RNs was guaranteed.
When the researchers detected phlebitis on the basis of
VIPS,21 this was reported immediately to the RN responsible for
Data collection instruments the patient, with the aim of assuring patient safety and timely
decision-making with respect to PVC removal.
VIPS21 is a valid and reliable instrument to assess the pres-
ence and severity of PVC-related phlebitis, and to determine
whether or not a PVC should be removed.7 Scores range from Statistical methods
0 (no signs of phlebitis) to 5 (advanced thrombophlebitis).
The MISSCARE Survey16 documents gaps in nursing care and Data analysis was performed using Statistical Package for
the reasons for their occurrence. This tool is based on a list of Social Sciences Version 22 (IBM Corp., Armonk, NY, USA). As a
24 nursing interventions, and respondents use a five-point preliminary step, changes, if any, in the amount of nursing care
Likert scale [1 (never) to 5 (always)] to indicate how often received each day by participating patients in each medical
each intervention was missed during the last shift. The total unit were assessed. As no differences were found, indicating
score can range from 24 (no interventions omitted) to 120 (all stability in daily care received, the subsequent statistical
interventions omitted), and provides a global assessment of the analysis was undertaken. Averages and 95% confidence in-
amount of care that was missed during a shift. Psychometric tervals (95% CI) were calculated for continuous variables, and
evaluations of the instrument have confirmed the underlying sums and percentages were calculated for categorical
construct through a confirmatory factor analysis, and found an variables.
acceptable degree of internal consistency.16 This study used a Time-to-event analyses based on Cox regression analysis
recently validated Italian version of the MISSCARE Survey.23 [hazard ratios (HR) and 95% CI] were performed to examine the
relationship between time since PVC insertion and the occur-
rence of phlebitis; and the predictive role of patient, PVC,
Data collection process
nursing care and organizational variables. In the time-to-event
analysis, the outcome was the occurrence of PVC-related
Two RN researchers were identified at each unit level (total
phlebitis, and predictors were introduced as continuous or
of 24 researchers) to perform data collection; they were not
categorical variables in accordance with their nature
involved in the care of patients included in this study. They
(P < 0.05).
attended a one-day training session on PVC-related phlebitis
assessment using VIPS.21 These RN researchers evaluated the
presence of phlebitis daily by direct observation of the PVC site Results
using VIPS.
According to VIPS,21 the presence of slight pain or redness Overall, 1262 out of 2080 eligible patients (60.6%) were
near the PVC insertion site was considered as Grade I phlebitis; included in this study. Among the excluded patients, 351
A. Palese et al. / Journal of Hospital Infection 92 (2016) 280e286 283
(42.8%) were transferred from other hospitals/units, 310 Table I
(37.7%) did not wish to participate in the study, and 159 (19.5%) Patient (N ¼ 1262), peripheral intravenous cannula (PVC) and
were admitted as scheduled cases or not received the PVC in nursing care factors
the ED. The characteristics of the participants, the PVC
N (%) or mean (95% CI)
observed and the nursing care received are shown in Table I.
Patient factors
Age (years) 74.7 (73.9e75.4)
Rate of phlebitis Sex (female) 641 (50.8)
Primary reason for urgent admission (37.7%)a
There were 391 cases of PVC-related phlebitis among the Heart failure 176 (13.9)
1262 PVC inserted, representing an incidence of 31%. Of these, Pneumonia 77 (6.1)
317 (81.1%) patients had a VIPS score of 1, 63 (16.1%) patients COPD 47 (3.7)
had a VIPS score of 2, and 11 (2.8%) patients had a VIPS score of Pulmonary oedema and respiratory 43 (3.2)
3. No VIPS scores >3 were reported. The incidence of PVC- distress
related phlebitis was calculated as the total number of Sepsis 42 (3.3)
cases/days observed, giving a rate of 6.9 per 1000 PVC-days Acute renal failure 23 (18.2)
(391 cases/5606 days observed). Pulmonary cancer 23 (18.2)
Pulmonary embolism 23 (18.2)
Gastroenteric cancer 23 (18.2)
Time-to-event analysis and predictors Barthel Index (0, dependent; 100, 51.09 (49.01e53.16)
Figure 1 shows the results of the time-to-event analysis for Confused or agitated 213 (16.9)
planned PVC removal (no longer needed) and removals due to Comorbidities
phlebitis. Three days after PVC insertion, the cumulative 2 683 (54.1)
incidence of phlebitis (78/391) was almost 20%, and this 3e5 471 (37.3)
reached >50% (231/391) by five days after insertion. >5 108 (8.6)
Approximately 30, 48 and 78 cases of phlebitis were re- Medications (number of medications/day)
ported on the second, third and fourth days after PVC inser- 2 290 (22.9)
tion, respectively, indicating a daily phlebitis rate of 2.4%, 4.8% 3e5 392 (31.1)
and 10.6%, respectively (Table II). >5 580 (46.0)
As reported in Table III, only nursing care and Previous ED visits during the last three months
organizational-level variables affected the incidence of phle- 0 802 (63.6)
bitis. Being treated in a highly specialized hospital (HR 0.583, 1 316 (25.0)
95% CI 0.366e0.928) and receiving more nursing care (HR 2 105 (8.3)
0.988, 95% CI 0.983e0.993) were protective against PVC- >2 39 (3.1)
related phlebitis. Each unit of missed care increased the risk PVC factors
of PVC-related phlebitis by approximately 4% (HR 1.038, 95% CI Duration of PVC placement (days) 4.44 (4.31e4.57)
1.001e1.077), and a similar effect was observed for each 1% Site of PVC
increase in the amount of nursing care delivered by graduate Right forearm 645 (51.1)
RNs (HR 1.021, 95% CI 1.010e1.033). Cephalic vein 333 (26.4)
Radial vein 302 (23.9)
Dorsal metacarpal veins 262 (20.8)
Discussion Medial antebrachial vein 146 (11.6)
Basilic vein 124 (9.8)
This study investigated 1262 patients treated as urgent Arm veins 39 (3.1)
cases in EDs for a variety of conditions and subsequently Other sites 56 (4.4)
transferred to a medical unit for at least 24 h. Previous Nursing care factors
studies1,18 have included smaller samples of patients admitted Amount of care received by each patient 129.4 (128.2e130.6)
as urgent cases. The sex distribution in these studies was (min/day)
similar to that observed in the present study (approximately Proportion of care delivered by RNs (%) 63.7 (62.5e63.6)
50:50), but the average age of participants was lower than in Proportion of care delivered by graduate 2.1 (51.3e52.8)
the present study. The causes of admission were not reported RNs (%)
in these earlier studies.1,18 Missed care (24, no nursing care was 52.6 (51.3e52.9)
The maximum time that a PVC remained in place was 16 missed; 120, all interventions were
days, and at least 57 PVC (4.5%) were left in situ for 10 days. omitted)
The most recent recommendations11,24 state that it is unnec- Organizational factors
essary to replace PVC more often than every 72e96 h to reduce Teaching status 937 (74.2)
risk of infection and phlebitis in adults, suggesting that removal High level of specialization of hospital 613 (48.6)
should only take place when clinically necessary. Future N, number; %, relative frequency; CI, confidence interval; ED, emer-
research should explore the reasons why PVC remain in place gency department; COPD, chronic obstructive pulmonary disease; RN,
for longer periods in order to elucidate the clinical decision- registered nurse.
making process guiding PVC removal. Other clinical conditions (e.g. gastrointestinal haemorrhage, type 1
and type 2 diabetes, stroke etc.) accounted for 4% of cases.
284 A. Palese et al. / Journal of Hospital Infection 92 (2016) 280e286

Table III
Factors affecting the incidence of peripheral intravenous cannula
0.9 (PVC)-related phlebitis over time: Cox regression analysis
b SE P HR Lower Upper
Patient factors
Cumulative - event free

0.7 Age (years) 0.003 0.004 0.542 0.997 0.989 1.006

Sex (female) 0.161 0.109 0.137 0.851 0.688 1.053
Comorbidities (N) 0.105 0.095 0.267 0.900 0.748 1.084
0.5 Medication 0.100 0.074 0.178 0.905 0.782 1.047
molecules/day (N)
0.4 Barthel Index (0, 0.002 0.002 0.256 0.998 0.995 1.001
0.3 independent; 100,
0.2 Confusion or 0.004 0.135 0.976 0.996 0.764 1.299
agitation (yes)
0.1 PVC factors
0.0 Arm (right) 0.100 0.105 0.344 1.105 0.899 1.359
PVC insertion site
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Median cubital 0.030 0.151 0.844 1.030 0.767 1.384
Time (days) vein
Cephalic vein 0.084 0.153 0.581 1.088 0.807 1.467
Figure 1. Time to occurrence of peripheral venous cannula (PVC)- Radial vein 0.207 0.201 0.303 1.230 0.829 1.826
related phlebitis. Blue line, PVC removed for clinical reasons; Dorsal metacarpal 0.194 0.198 0.329 1.214 0.823 1.790
green line, PVC removed due to phlebitis. veins
Medial 0.006 0.397 0.989 0.994 0.457 2.164
antebrachial vein
Rate of phlebitis Basilic vein 1.026 0.720 0.154 0.358 0.087 1.468
Arm veins 0.351 1.024 0.732 1.420 0.191 10.572
The incidence of PVC-related phlebitis in the study sample Nursing care factors
was 31%; this was in line with previous studies using VIPS21 or Proportion of care 0.028 0.014 0.054 0.973 0.946 1.001
similar tools. Studies of phlebitis associated with PVC inserted delivered by RNs
in EDs have reported lower rates (9%1 and 13.6%18). However, (%)
only one1 of these studies reported how phlebitis was defined, Missed care (24, no 0.037 0.019 0.046 1.038 1.001 1.077
and neither of them used a validated tool for the assessment of nursing care was
phlebitis. missed; 120, all
interventions were
Time-to-event analysis and predictors omitted)
Care delivered by 0.021 0.006 0.000 1.021 1.010 1.033
PVC-related phlebitis appeared two days after insertion of graduate RNs (%)
the device in the ED, and the cumulative incidence of phlebitis Total delivered care 0.012 0.002 0.000 0.988 0.983 0.993
increased dramatically from three days after insertion. Maki (min/day)
and Ringer25 reported that the incidence of phlebitis increased Organizational factors
from 48 h after catheterization, but other studies4,5 have re- Teaching status (yes) 0.580 0.315 0.065 0.560 0.302 1.037
ported that phlebitis started to appear from 24 h after PVC Level of 0.540 0.237 0.023 0.583 0.366 0.928
insertion, as in the present study. specialization of
Unlike previous studies showing that the incidence of hospital (high)
phlebitis was related to patient factors such as age or sex,5,6,9
number of medications or comorbidities,5,9,12 or PVC factors CI, confidence interval; b, coefficient; SE, standard error; HR, hazard
ratio; RN, registered nurse.
such as insertion site,4,25 this study found that neither patient
Where relevant, the reference category is given in parentheses.
nor PVC factors were related to the incidence of phlebitis.

Table II
Daily incidence of peripheral intravenous cannula (PVC)-related phlebitis
Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Total
PVC removed due to Ph (N) 0 30 48 78 75 63 28 25 12 14 6 5 3 2 1 1 391
Planned PVC removala (N) 28 211 210 159 91 69 35 27 16 10 8 4 1 1 0 1 871
PVC remaining (N) 1234 993 735 498 332 200 137 85 57 33 19 10 6 3 2 0 0
Incidence of Ph (%) 0 2.4 4.8 10.6 15.1 18.9 14.0 29.4 14.1 24.5 18.1 26.3 33.0 33.3 33.3 50.0
Ph, PVC-related phlebitis.
PVC no longer needed.
A. Palese et al. / Journal of Hospital Infection 92 (2016) 280e286 285
In this study, the only factors found to affect the incidence In addition, comparing phlebitis rates in PVC inserted in
of phlebitis were related to nursing care and organizational contexts other than EDs may help in identifying the role of the
factors. The amount of missed care16 was a predictor of PVC- ED setting in increasing the occurrence of phlebitis.
related phlebitis; for each unit increase in missed care, there
was a 3.8% increase in risk of developing phlebitis over the
lifetime of the PVC. When assessment of the PVC insertion site Conclusions
is missed, and/or other nursing interventions are missed,
recognition of phlebitis might be delayed. No previous studies According to the findings, three days after the insertion of
investigating the association between missed care and phle- PVC in EDs, the cumulative incidence of phlebitis was almost
bitis have been documented to date, therefore preventing 20%, and this reached >50% five days after PVC insertion. The
comparisons. amount of missed nursing care and the expertise of the nurses
Another predictor of PVC-related phlebitis was the propor- caring for the patient after PVC insertion affected the inci-
tion of care delivered by graduate RNs. For a 1% increase in the dence of phlebitis; receiving more nursing care and being in a
proportion of graduate RNs on the team, there was a 2.1% in- specialized hospital were associated with lower risk of devel-
crease in the risk of developing phlebitis over the lifetime of oping phlebitis. This study identified some modifiable risk
the PVC. Graduate RNs are likely to be less experienced nurses, factors of PVC-related phlebitis, suggesting areas for inter-
particularly in the Italian context where the university degree vention at hospital and unit level.
has been introduced recently, therefore confirming previous Findings suggest that emergency nurses should document
findings with regard to the role of limited clinical experience in precisely when and how the patient’s PVC has been inserted,
increasing the risk of phlebitis.9,15 and that PVC inserted in EDs should be assessed regularly,
The risk of developing phlebitis, measured as the HR for a particularly from three days post insertion, to ensure early
given period of time, was reduced by 1% for each 1 min/day identification of possible signs of phlebitis. Attention should be
increase in total care received. When nurses have more time to given by managers to monitoring the nursing care offered and
dedicate to patient care, there is an increase in patient sur- the possible causes of missed nursing care, which could include
veillance and safety.13 The HR associated with phlebitis was increased nurse-to-patient ratio, poor quality teamwork or
also lower for patients admitted to highly specialized hospitals. poor use of existing staff resources. Moreover, specific educa-
In these hospitals, PVC insertion is likely to be a more common tional interventions may be of value in alerting clinical nurses
procedure. Moreover, patients admitted to highly specialized to PVC-related complications, particularly with regard to
settings are likely to be more critical and therefore exposed to novice nurses and general hospitals.
more nursing care, and/or submitted to closer monitoring,
leading to earlier identification of adverse events. Further- Conflict of interest statement
more, previous studies9,14 have reported that the incidence of None declared.
PVC-related phlebitis is lower when staff are more skilled and
have greater expertise; this is more likely to be the case in Funding source
high-volume hospital centres. None.

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