1. Assess Peripheral Intravenous Catheters
Phlebitis Scale or Preset Intervals
Catherine Rasmussen, RN
Fort Hays State University, Department of Nursing
Introduction
Nurses routinely place, assess, and monitor peripheral intravenous catheters (PIVCs) daily. Phlebitis associated with PIVCs is significant to nursing practice. Inflammation of the vein or phlebitis is a complication that can occur with PIVCs that may cause pain, lead to failure of the catheter, and interruption of treatment. Worldwide PIVC assessment has no evidenced based definitions or assessment scale. To provide best patient outcomes the need for a standardized PIVC phlebitis assessment scale is essential for evidence based nursing practice.
There are 71 phlebitis scales used today and not one is validated (Mihala et al., 2018, p. 261).
A standardized PIVC Phlebitis assessment tool is not in use today (Mihala et al., 2018, p. 261).
Global guidelines recommends removal of PIVCs only for clinical reasons, not set intervals (Mihala et al., 2018, p. 261).
Multiple restarts are costly: supplies/nurse time (Mihala et al., 2018, p. 261).
Phlebitis scales and the definitions of phlebitis are used internationally, yet no existing scale has been proven valid and reliable (Marsh et al. 2015, p. 893).
Centers of Disease Control (CDC) requires PIVCs to be replaced every hours to prevent phlebitis in adults (Morrison & Holt, 2015, p. 187).
Consumers demand affordable health care accountability, efforts to minimize cost is needed by not performing unnecessary procedures” (Helton, Hines, & Best, 2016, p. 44).
Phlebitis can occur up to 48hrs after removal of PIVC (Ray-Burruel, Polit, Murfield, & Rickard, 2014, p. 191).
What assessment tools for phlebitis are: reliable, valid, responsive and feasible?
(Ray-Burruel et al,, 2014, p. 191).
Research Question
For patients with peripheral intravenous catheters, does the use of a phlebitis assessment scale to determine the need for removal reduce the future risk of unnecessary peripheral intravenous catheter replacement compared to removal of peripheral intravenous catheter at preset intervals?
Purpose
The purpose of this systematic review is the determine if using phlebitis assessment scales for PIVCs compared to preset intervals decreases unnecessary PIVC removal and replacement.
Inclusion Criteria:
Phlebitis Scale Example
Adults with PIVCs.
Use of phlebitis scales and or preset removal and replacement of PIVC.
Expected to have PIVC in greater than 72 hours.
A literature search was conducted through the Forsyth Library using the search terms: phlebitis, scale, 72 hours peripheral intravenous catheter, in English, with the search dates of The search engines found and used were: EBSCO CINAHL, Medline, and PubMed. Eleven articles were considered, and it was determined that five focused on the use of phlebitis scales and or preset removal and replacement of PIVCs in 72 to 96 hours. The articles used for the systematic review are four incidence and correlation studies and one systematic review with meta-analysis study.
Implications for Nursing
Figure 2
Visual Infusion Phlebitis Scale
Significance and Interventions
Inconsistent phlebitis assessment and documentation.
Cost: supply use and nurse time.
Need improved phlebitis assessment skills.
Nursing Responsibility to establish and maintain venous access.
Collaboration with nurses/team building.
No standardized PIVC phlebitis assessment scale.
Risk for serious consequences: infection, prolonged hospital stay,
interruption in treatment, and future loss of a vein access.
Need improved documentation: consult informatics team.
Best Patient Outcomes
Leave PIVC in place unless clinically indicated.
Decrease pain for patient.
Decrease invasive procedures.
Increase patient satisfaction.
Decrease interruption in treatment.
Nurse to palpate site for tenderness, no just ask if patient.
is having pain.
Develop audit process to monitor outcomes.
Decrease cost
IV site appears healthy
No signs of phlebitis
OBSERVE CANNULA
One of the following signs is evident:
Slight pain near the IV site
Slight redness near IV site 1
Possibly first signs of phlebitis
Two of the following are evident:
Pain at IV site
Redness 2
Early stage of phlebitis
RESITE CANNULA
ALL of the following are evident:
Pain along path of cannula
Redness around site
Swelling 3
Medium stage of phlebitis
CONSIDER TREATMENT
ALL of the following are evident and extensive:
Palpable venous cord 4
Advanced stage of phlebitis
Or the start of thrombophlebitis
All of the following are evident and extensive:
Pyrexia 5
Advanced stage thrombophlebitis
INITIATE TREATMENT
Systematic Review
Table 1
Question?
Determine the need to remove PIVC: Phlebitis scale or preset intervals?
Determine Inclusion criteria: PIVC, phlebitis scale, 72 hours
Systematic Review: search for key works at Library
Gather all studies keep those that fit inclusion criteria: 11 articles considered, 5 met criteria
Data Abstraction:
PIVC removal using phlebitis scale vs preset intervals
Analyze Data/Result Scales available, preset intervals hrs.
Results: highest correlation: warmth, tenderness, swelling, redness
PIVC intact after
96 hrs.
Scales: inconsistent nurse assessment
Answer Question
Scales not reliable
Phlebitis scale does not determine need for PIVC removal
Assess nursing implications
Nursing education and further research needed
Adapted with permission from Andrew Jackson IV nurse consultant, The Rotherham NHS Foundation Trust, UK. Andrew Jackson 1997
Figure 2 Visual Infusion Phlebitis scale. (From Gallant, P., & Schultz, A.A. (2006). Adapted from Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing, 29(6), Retrieved from:
Combined subjects: 23,262
Most Significant sign/symptom finding: Warmth/tenderness, swelling and erythema
10 Different Phlebitis Scales compared:
Scales are inconsistant and not reliable
Experience Nurse Clinician: level of agreement inconsistent
Need more research to predict PIVC complications
Must palpate, not just as patient if have pain or discomfort
Need more research to determine scale that is predictable, reliable and valid
Most PIVC sites are intact after 96 hours
Preset removal of PIVCs, is an unnecessary procedure
Scales have no uniformity what needs to be present for PIVC removal
Nurses need education on phlebitis assessment
Significant Review Outcomes
Table 2
a,b,c,d,e b c
Conceptual Framework c
References:
Helton, J., Hines, A., Best, J. (2016). Peripheral IV site rotation based on clinical
assessment vs. length of time since insertion. MEDSURG Nursing. Jan/Feb 25,
44-49.
Marsh, N., Gabor, M., Ray-Burruel, G., Webster, J., Wallis, M.C., Richard, C. M.
(2015). Inter-rater agreement on PIVC-associated phlebitis signs, symptoms and
scales. Journal of Evaluation in Clinical Practice, Oct; 21(5)
Mihala, G., Ray-Barruel, G., Chopra, V., Webster, J., Wallis, M., Marsh, N., McGrail,
M., Rickard, C. M. (2018). Phlebitis signs and symptoms with peripheral intravenous
catheters. Journal of Infusion Nursing, 41,
Morrison, K., & Holt, K. E. (2015). The effectiveness of clinically indicated replacement
of peripheral intravenous catheters: an evidence review with implications for clinical
practice. Worldviews on Evidence-Based Nursing, 12(4),
doi: /wvn
Petiprin, A. (2016). Jean Watson-nursing theorist. Nursing Theory. Retrieved from:
Ray-Barruel, G., Polit, D. F., Murfield, J. E., & Rickard, C. M. (2014). Infusion phlebitis
assessment measures: a systematic review. Journal of Evaluation in Clinical Practice,
20(2), 191–202. doi.org/ /jep
Visual Infusion Phlebitis scale. (From Gallant, P., & Schultz, A.A. (2006). Evaluation of
a visual infusion phlebitis scale for determining appropriate discontinuation of
peripheral intravenous catheters. Journal of Infusion Nursing, 29(6),
Retrieved from: d b
Results
Jean Watson’s Caring and Nursing Process
Core to Nursing
Caring:10 carative factors
Foundation for evidence based practice, provide best care, best outcomes
Nursing process is similar to process of scientific research
Assessment: Observe, identify, review, formulate hypothesis
Care Plan: examine variables, what data to collect and how
Evaluation
Data results, intervention, interpretation
Can be applied to a variety of patients and situations
Patient is the focus
Figure 1
The data included 22,789 daily observations on 5907 PIVCs from a total of 3283 subjects.
The maximum of 23 days PIVC duration (Mihala, et al., 2018, p. 260).
Total of 210 patients with total of 247 observations.
Even with experienced nurse clinicians’ level of agreement were inconsistent.
Ten different phlebitis scales were compared, with the Rittenberg (68%) and Catney (63%) performing the best.
The phlebitis scales compared found a significant difference in scales.
Based on current research none of the phlebitis scales can be recommended.
None of the scales contained directions of action according to scores (Marsh, et al. 2015, p. 898).
Total of 71 patients with 81 PIVCs remain healthy over 96 hrs.
Preset intervals are an unnecessary procedure (Helton, et al., 2016 p. 48).
Total 155 patients found no evidence to support reset removal of PIVCs.
No statistical significance of replacing PIVCs compared to clinically indicated.
PIVC replacement only when clinically indicated with current research dose not increase patient risk for phlebitis (Morrison & Holt, 2015, p. 187).
180 studies with a total of 71 phlebitis scales.
Wide variation in assessment techniques and evaluation of the scales.
Scales: No definition of phlebitis.
Scales: No uniformity determining what needs to be present to warrant PIVC removal.
Scales: No strong reliability.
Phlebitis scales were reported differently by the authors.
Many scales were modified resulting in serval versions of each scale.
Nursing assessment skills: Needs evaluation, wide range of education on phlebitis assessment (Ray-Barruel et al., 2014, p. 198). a c e e d e a
Helton, et al., (2016, p.48). Marsh, et al., (2015, p. 898). Mihala, et al., (2015 p 260). Morrison & Holt, (2015, p. 187). Ray-Barruel et al., (2014, p. 198). b c d e
Answer to Question
For patients with peripheral intravenous catheters, the use of a phlebitis assessment scales to determine the need for removal does not reduce the future risk of unnecessary peripheral intravenous catheter replacement compared to removal of peripheral intravenous catheter at preset intervals.
Future Research
The results of this review concluded the urgent need to continue research to determine the best means of diagnosing phlebitis. The current systematic review reveals there is no standardized system world wide.
To provide evidence based practice and provide best patient outcomes a reliable, valid and predictable phlebitis scale must be obtained.
PIVC
Figure 1 Petiprin, A. (2016). Jean Watson-nursing theorist. Nursing Theory