Evidence for elective replacement of peripheral intravenous catheter to prevent thrombophlebitis: a systematic review

The impact of flushing with pre-filled saline syringes on the incidence of peripheral venous catheter failure: A quasi-experimental study

BACKGROUND

Short peripheral venous catheters are one of the most frequently used devices in hospitals. Peripheral venous catheter failure, defined as the unscheduled dysfunction of peripheral venous catheter, is common and frequently entails a new invasive procedure. Flushing the catheter maintains patency and could prolong peripheral venous catheter dwell time. The introduction of pre-filled saline flushing syringes as compared to manually filled saline flushing syringes could facilitate the frequency of catheter flushing, and subsequently it could reduce peripheral venous catheter failure rate.

OBJECTIVE

To demonstrate differences in overall peripheral venous catheter failure rates before and after the introduction of pre-filled saline flushing syringes and to assess the risk factors for peripheral venous catheter failure.

METHODS

Quasi-experimental design, before-and-after intervention study. Intervention: introduction of pre-filled saline syringes for flushing. Multicenter study conducted in medical and surgical wards of three European hospitals during a 9-month period (4 months pre-intervention, 5 months intervention). A multivariate Cox proportional model was used to identify factors associated with the occurrence of peripheral venous catheter failure.

RESULTS

Data from 3853 peripheral venous catheters in 1915 patients were analyzed. Compared to pre-intervention period, a significant decrease in peripheral venous catheter failure rate was observed in the intervention period (57% vs 43.4%, p < 0.001). Independent factors associated with peripheral venous catheter failure were as follows: Charlson score ⩾4 (hazard ratio: 1.648; 95% confidence interval: 1.069-2.527), days of hospital stay ⩾10 (hazard ratio: 1.468; 95% confidence interval: 1.172-1.837), and catheter "D" (hazard ratio: 1.758; 95% confidence interval: 1.058-2.919).

CONCLUSION

The use of pre-filled saline syringes significantly reduced peripheral venous catheter failure and increased catheter dwell time. Thus, it is important to reinforce the use of the pre-filled syringes for flushing to reduce the incidence of peripheral venous catheters' failure.

Accepted but Unacceptable: Peripheral IV Catheter Failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Peripheral intravenous catheter difficulty - A clinical survey of registered nurse and critical care nurse performance

OBJECTIVES

To describe the characteristics, problems and interventions associated with performing peripheral intravenous catheterisation in difficult situations when registered nurses need support from critical care nurses.

BACKGROUND

Only a few studies have focused on peripheral intravenous catheterisation problems or interventions to promote success. There is limited research on the education, knowledge, confidence and skills of registered nurses associated with successful peripheral intravenous catheterisations.

DESIGN

A descriptive cross-sectional survey design was used.

RESULTS

A total of 101 questionnaires were completed by critical care nurses (n = 32) and 92 by registered nurses (n = 83); the total number of participants was 115. The same critical care nurses and registered nurses could participate several times on different occasions. Statistical analyses were performed using descriptive statistics. The patterns differed in part between the registered nurses who needed support and the critical care nurses who provided the support. Both registered nurses and critical care nurses used ultrasound to a very low extent (2.2% vs. 1.0%). The registered nurses indicated to a significantly higher extent (p = 0.02) that the veins were invisible and that they had performed the optional interventions. The success rate for critical care nurses was considerably high (86.1%). The most common place for successful insertion was the wrist. Critical care nurses performed fewer interventions, and they informed the patients and assessed that the veins were fragile to a higher extent.

CONCLUSIONS

Superior nursing skills are required in order to adapt and assess specific situations related to peripheral intravenous catheterisation difficulties and to choose the adequate interventions. Young and newly graduated registered nurses should be offered individualised training during the post-educational period on how to assess problems and perform peripheral intravenous catheterisations in specific difficult situations.

RELEVANCE TO CLINICAL PRACTICE

Simulation is suggested for practical training in order to increase patient safety related to the performance of technical skills such as peripheral intravenous catheterisation.

Problems associated with performance of peripheral intravenous catheterization in relation to working experience

The aim of this study was to explore general registered nurses' (RNs) assessments of problems associated with difficult peripheral intravenous catheterization (PIVC) depending on their years of working experience, that is, those who had worked 3 years or less and those who had worked more than 3 years. The design was a quantitative, nonexperimental, descriptive, and analytic survey. The participating RNs (n = 83) were divided into two groups according to the length of their working experience, and the analysis was performed using the SPSS, version 24, software. The RNs also had the opportunity to answer a free-text question related to the aim. The results showed that less experienced RNs assessed to a significantly higher extent that they lacked time, experience, and ability and that there was no blood return; however, they assessed that the peripheral venous catheters were in the vein. If critical care nurses had been requested for support earlier, this request was seen as a reason not to try PIVC at all because critical care nurses were assessed as more experienced and skilled. To develop the kind of effective problem-solving and clinical reasoning needed for practice, a supportive setting must be created throughout nursing education as well as after graduation. Further research should focus on the education needs associated with PIVC and seek to understand to what extent learning in clinical skill simulation laboratories is transferred to actions in the clinical setting.

Effects of the Smartphone Application "Safe Patients" on Knowledge of Patient Safety Issues Among Surgical Patients

Recently, the patient's role in preventing adverse events has been emphasized. Patients who are more knowledgeable about safety issues are more likely to engage in safety initiatives. Therefore, nurses need to develop techniques and tools that increase patients' knowledge in preventing adverse events. For this reason, an educational smartphone application for patient safety called "Safe Patients" was developed through an iterative process involving a literature review, expert consultations, and pilot testing of the application. To determine the effect of "Safe Patients," it was implemented for patients in surgical units in a tertiary hospital in South Korea. The change in patients' knowledge about patient safety was measured using seven true/false questions developed in this study. A one-group pretest and posttest design was used, and a total of 123 of 190 possible participants were tested. The percentage of correct answers significantly increased from 64.5% to 75.8% (P < .001) after implementation of the "Safe Patients" application. This study demonstrated that the application "Safe Patients" could effectively improve patients' knowledge of safety issues. This will ultimately empower patients to engage in safe practices and prevent adverse events related to surgery.

Accepted but unacceptable: peripheral IV catheter failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Are parents of children hospitalized with severe community-acquired pneumonia more satisfied with care when physicians allow them to share decisions on the antibiotic route?

CONTEXT AND OBJECTIVE

Despite convincing evidence that oral and injected amoxicillin have equal efficacy in children with severe community-acquired pneumonia (CAP), hospitalized children often receive injected antibiotics. To investigate whether shared decision-making (choosing the antibiotic route) influences parental satisfaction.

DESIGN, SETTING AND PARTICIPANTS

In a one-year questionnaire-based study, we enrolled consecutive children hospitalized for CAP. At admission, all children's parents received a leaflet on CAP. Parents arriving during the daytime were assigned to a shared group and could choose the antibiotic route, those admitted at other times were assigned to an unshared group for whom physicians chose the antibiotic route. Shared group parents answered anonymous questionnaire investigating why they chose a specific route. Parents in both groups answered another anonymous questionnaire at discharge assessing perceived satisfaction with care.

MAIN OUTCOME MEASURE

Parents' satisfaction with perceived medical information as assessed by data from a questionnaire.

RESULTS

Of the 95 children enrolled, more children's parents were assigned to the unshared than the shared group (77 vs. 18). Of the 18 children's parents in the shared group, 14 chose the oral antibiotic route mainly to avoid painful injections. Doctors explanations were considered better in the shared than in the unshared group (P = 0.02).

DISCUSSION AND CONCLUSIONS

The larger number of children's parents assigned to the unshared group reflects paediatricians' reluctance to offer shared-decision making. Well-informed parents prefer oral antibiotic therapy for children with severe CAP. Allowing parents choose the antibiotic route respects parents' wishes, reduces children's pain and improves satisfaction.

Phlebitis risk varies by peripheral venous catheter site and increases after 96 hours: a large multi-centre prospective study

AIMS

This multi-centre prospective field study evaluated whether peripheral venous catheter site of insertion influences the risk of catheter-related phlebitis. Potential predictors of phlebitis were also investigated.

BACKGROUND

Millions of patients worldwide use peripheral venous catheters, which frequently cause local complications including phlebitis, infection and obstruction. Although phlebitis predictors have been broadly investigated, uncertainties remain on the potential effect of cannulation anatomical site, duration and the appropriate time for catheter removal.

DESIGN

A prospective cohort design was carried out from January-June 2012.

METHODS

The clinical course of each patient who received a new peripheral venous catheter for any cause in five Italian hospitals was followed by trained nurses until catheter removal. The presence of phlebitis was assessed every 24 hours using the Visual Infusion Phlebitis score. Analyses were based upon multilevel mixed-effects regression.

RESULTS

The final sample consisted of 1498 patients. The average time for catheters in situ was 65·6 hours and 23·6% of the catheters were in place beyond 96 hours. Overall phlebitis incidence was 15·4%, 94·4% of which were grade 1. The likelihood of phlebitis independently increased with increasing catheter duration, being highest after 96 hours. Compared with patients with catheter placed in the dorsum of the hand (22·8% of the sample), those with the catheter located in the antecubital fossa (34·1%) or forearm were less likely to have a phlebitis of any grade.

CONCLUSIONS

Antecubital fossa and forearm veins may be preferential sites for peripheral venous cannulation. Our results support Centers for Disease Control and Prevention recommendations to replace catheters in adults no later than 96 hours. A relevant proportion of healthcare personnel did not adhere to such guidelines - more attention to this issue is required.

Management, clinical outcomes, and complications of acute cannula-related peripheral vein phlebitis of the upper extremity: A retrospective study

OBJECTIVE

Acute phlebitis due to peripheral vein catheter use is frequently observed in clinical practice, and requires surgical therapy in severe cases. In this retrospective study, we aimed to increase awareness, evaluate current treatment options, and develop recommendations to optimize treatment outcomes.

METHODS

A total of 240 hospitalized patients with a diagnosis of upper extremity phlebitis from 2006 to 2011 were evaluated in terms of initial clinical features, parameters, co-morbidities and treatment regimes. Severity of phlebitis was graded according to the Baxter scale by assessing clinical symptoms such as pain, erythema, induration, swelling, or palpable venous cord (grade 0-5). Patients were divided in two subgroups: conservative (n = 132) and operative (n = 108) treatment.

RESULTS

Surgical intervention rates and severity were higher for cannula insertion in the cubital fossa region than for cannula insertion in the forearm and hand region (p < 0.05). Baxter scale grades were higher in the surgical treatment group than in the conservative treatment group (4.47 vs. 2.67, respectively).

CONCLUSIONS

The cubital fossa region is vulnerable to severe phlebitis and is not recommended as the first site of choice for cannulation. Phlebitis of Baxter scale grade 4 or 5 should be considered for early surgical intervention.

Prehospital peripheral venous catheters: a prospective study of patient complications

PURPOSE

To investigate prehospital peripheral venous catheters (PVCs) in relation to the frequency of thrombophlebitis.

METHOD

Data in this prospective study were collated using three types of data source: a study-specific questionnaire, a PVC observation instrument (PVC assess), and electronic patient records. The questionnaire was distributed to ambulance crews who had inserted a PVC before bringing the patient to an emergency department at a level one trauma centre in Sweden during 10 weeks in 2008-2009. Patients admitted to hospital ward were followed-up daily by registered nurses using the PVC assess until the PVC was removed. Patient record data were collected by means of auditing.

RESULTS

Of the 83 patients available for follow-up, 45 (54%) developed thrombophlebitis. Quick PVC removal was performed in 32 (71%) of these patients while 13 (29%) PVCs were left in situ for 1-8 days. No association was found between the occurrence of thrombophlebitis and potential risk factors.

CONCLUSIONS

Although thrombophlebitis frequently occurred in PVCs inserted in a prehospital setting, early removal of the device with complication was common. Further studies are warranted to identify the optimal in situ time for PVCs inserted by prehospital emergency teams.

Associação entre flebite e retirada de cateteres intravenosos periféricos

Estudo de coorte prospectivo, com objetivo de verificar a incidência de flebite em pacientes com cateter intravenoso periférico e identificar possíveis associações dessa complicação com variáveis relativas a estes cateteres. Foram avaliados 76 pacientes adultos internados em enfermaria de um hospital universitário, utilizando-se de uma ficha contendo variáveis relativas aos pacientes, ao cateter intravenoso periférico e à terapia farmacológica. A flebite foi avaliada segundo classificação proposta pela Infusion Nurses Society. Utilizou-se estatística descritiva e inferencial. Observou-se incidência de 25,8% de flebite, das quais 40% apresentaram manifestações clínicas de dor, com eritema e ou edema. Dentre os pacientes com flebite, 60% desenvolveram um episódio da complicação, e o tempo de permanência médio dos cateteres intravenosos periféricos com flebite foi de 3,10 dias. Constatou-se associação da flebite à retirada do cateter intravenoso periférico por ocorrência adversa (p<0,001). São necessárias ações educativas e capacitação da equipe de enfermagem para o manejo da terapia intravenosa, principalmente no que tange à detecção precoce da flebite.

Analysis of computer alerts suggesting oral medication use during computerized order entry of i.v. medications

PURPOSE

Compliance with computer alerts suggesting oral medication use during computerized order entry of i.v. medications was analyzed.

SUMMARY

Using automated computerized clinical decision support (CDS) to suggest converting i.v. medications to oral alternatives can reduce medication costs for hospitalized patients, but prescriber noncompliance limits the effectiveness of such interventions. Clearer understanding of the factors associated with noncompliance to alerts may facilitate the design of more effective CDS systems. Electronic medical record data were retrospectively analyzed to measure the rate of compliance with a CDS alert that suggested converting to an equivalent oral form of a drug at the time of ordering the i.v. formulation. Multiple logistic regression was used to examine the associations among medication type, clinician characteristics, hospital service type, time of order, and compliance with the i.v.-to-oral conversion recommendation. The main outcome was compliance with the alert, measured at the level of the individual medication order. The mean +/- S.E. overall compliance rate was 18.7% +/- 0.6%. Compliance varied among the medications, with methyl-prednisolone having the lowest (8%) and famotidine the highest (32%) (p < 0.05). Nurses had the highest compliance rate (35%) while pharmacists had the lowest (10%) (p < 0.05). Medical house staff (19%) and medical faculty (21%) complied at similar rates. The intensive care units had lower compliance rates than did the medical-surgical ward (15% versus 21%, p < 0.05).

CONCLUSION

CDS alerts to convert 12 i.v. medications to oral alternatives were developed and implemented in an urban tertiary hospital. Compliance rates for the alerts were relatively low and varied by medication, location, and clinician type.

Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial

BACKGROUND

Peripheral intravenous device (IVD) complications were traditionally thought to be reduced by limiting dwell time. Current recommendations are to resite IVDs by 96 hours with the exception of children and patients with poor veins. Recent evidence suggests routine resite is unnecessary, at least if devices are inserted by a specialised IV team. The aim of this study was to compare the impact of peripheral IVD 'routine resite' with 'removal on clinical indication' on IVD complications in a general hospital without an IV team.

METHODS

A randomised, controlled trial was conducted in a regional teaching hospital. After ethics approval, 362 patients (603 IVDs) were randomised to have IVDs replaced on clinical indication (185 patients) or routine change every 3 days (177 patients). IVDs were inserted and managed by the general hospital medical and nursing staff; there was no IV team. The primary endpoint was a composite of IVD complications: phlebitis, infiltration, occlusion, accidental removal, local infection, and device-related bloodstream infection.

RESULTS

IVD complication rates were 68 per 1,000 IVD days (clinically indicated) and 66 per 1,000 IVD days (routine replacement) (P = 0.86; HR 1.03; 95% CI, 0.74-1.43). Time to first complication per patient did not differ between groups (KM with log rank, P = 0.53). There were no local infections or IVD-related bloodstream infections in either group. IV therapy duration did not differ between groups (P = 0.22), but more (P = 0.004) IVDs were placed per patient in the routine replacement (mean, 1.8) than the clinical indication group (mean, 1.5), with significantly higher hospital costs per patient (P < 0.001).

CONCLUSIONS

Resite on clinical indication would allow one in two patients to have a single cannula per course of IV treatment, as opposed to one in five patients managed with routine resite; overall complication rates appear similar. Clinically indicated resite would achieve savings in equipment, staff time and patient discomfort. There is growing evidence to support the extended use of peripheral IVDs with removal only on clinical indication.

REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) Number ACTRN12608000421336.

Indication and Usage of Peripheral Venous Catheters Inserted in Adult Patients during Emergency Care

Purpose

The aim of this study was to identify the underlying decisions taken regarding the insertion of prehospital peripheral venous catheters in adult patients and, additionally, to ascertain peripheral venous catheter insertion rate and explore prehospital and hospital (within 24 hours of insertion) pharmaceutical treatment via peripheral venous catheters.

Method

This cross-sectional study gathered data through a study-specific questionnaire and patient record auditing. We distributed a study-specific questionnaire to be completed by ambulance crews, and carried out patient record auditing for 345 patients (median age 64 years, range 18–97 years) arriving at the emergency department at a Swedish level-1 trauma center in October 2008.

Results

Of 135 patients (39%) arriving at the emergency department with a peripheral venous catheter, 94 (70%) had received the device because the ambulance crews intended to use it for intravenous therapeutics (of which analgesics, intravenous fluids, and psycholeptics were most frequently used). In 30 patients (22%), the prehospital inserted device was not used by the ambulance crews or at hospital within 24 hours. The corresponding rate of unused peripheral venous catheters inserted in patients after arrival at the hospital was 35%.

Conclusions

We found that the main reason for the ambulance staff to insert a peripheral venous catheter in a prehospital setting was that they intended to use the device. Further, the rate of unused peripheral venous catheters was lower among prehospital peripheral venous catheters than hospital.

[Incidence of phlebitis due to peripherally inserted venous catheters: impact of a catheter management protocol]

OBJECTIVE

To assess the impact on the incidence of PPIVC by implementing a catheter management protocol and to determine risk factors for PPIVC development in hospitalized patients.

METHOD

A total of 3978 episodes of venous catheterization were prospectively included from September 2002 to December 2007. A catheter management protocol was implemented during this period of time. The incidence and variables associated to the occurrence of PPIVC were determined.

RESULTS

The incidence of PPIVC from 2002 to 2007 was 4.8%, 4.3%, 3.6%, 2.5%, 1.3% and 1.8% (p<0.001). Perfusion of amiodarone [adjusted OR (AOR) 25.97; 95% CI=7.29-92.55, p=0.0001] and cefotaxime (AOR 2.90; 95% CI=1.29-6.52, p=0.01) and the shift when the catheters were placed (AOR for morning vs. night shift 0.60; 95% CI=0.35-1.02, p=0.063) were independently associated to the development of PPIVC. A history of phlebitis was the only factor independently associated to phlebitis due to peripherally inserted central venous catheters (AOR 3.24; CI at 95% CI= 1.05-9.98, p=0.04).

CONCLUSIONS

A catheter management protocol decreases the incidence of PPIVC in hospitalized patients. The risk of PPIVC increases for peripherally inserted central venous catheters when the patients have a history of phlebitis and for peripheral venous catheters when amiodarone or cefotaxime are infused. Catheterization of peripheral veins performed during morning shifts is associated with a lower incidence of PPIVC when compared with night shift catheterizations.

Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial

OBJECTIVE

To compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated.

DESIGN

Randomised controlled trial.

SETTING

Tertiary hospital in Australia.

PARTICIPANTS

755 medical and surgical patients: 379 allocated to catheter replacement only when clinically indicated and 376 allocated to routine care of catheter (control group).

MAIN OUTCOME MEASURE

A composite measure of catheter failure resulting from phlebitis or infiltration.

RESULTS

Catheters were removed because of phlebitis or infiltration from 123 of 376 (33%) patients in the control group compared with 143 of 379 (38%) patients in the intervention group; the difference was not significant (relative risk 1.15, 95% confidence interval 0.95 to 1.40). When the analysis was based on failure per 1000 device days (number of failures divided by number of days catheterised, divided by 1000), no difference could be detected between the groups (relative risk 0.98, 0.78 to 1.24). Infusion related costs were higher in the control group (mean $A41.02; pound19.71; euro24.80; $38.55) than intervention group ($A36.40). The rate of phlebitis in both groups was low (4% in intervention group, 3% in control group).

CONCLUSION

Replacing peripheral intravenous catheters when clinically indicated has no effect on the incidence of failure, based on a composite measure of phlebitis or infiltration. Larger trials are needed to test this finding using phlebitis alone as a more clinically meaningful outcome.

REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12605000147684.

Use and complications of peripheral vascular catheters: a prospective study

Peripheral vascular catheters (PVCs) are important medical devices but their insertion and usage are associated with discomfort and potential complications such as thrombophlebitis. This article looks into the various aspects of the practice of using PVCs, especially their complications and ways of avoiding them.

AIMS

to determine the complications (and their associated factors) related to PVCs.

DESIGN

prospective.

SETTING

District General Hospital.

PATIENTS

a study was undertaken of 86 of the 106 patients consecutively admitted as an emergency over a period of two weeks who had a PVC inserted.

METHODS AND INTERVENTIONS

the admitting doctors inserted the PVCs at their discretion. PVC sites were inspected daily.

ANALYSIS AND RESULTS

of the 86 PVCs inserted, 42 were never used, while 43 were of large gauge and 29 were left in situ for over 72 hours. Eight patients developed thrombophlebitis, of which four had a large gauge PVC, two were never used and two were left in situ for over 72 hours (P=0.016).

CONCLUSIONS

incidence of thrombophlebitis may be reduced by re-siting or removing PVCs within 72 hours. PVC gauge and whether it was used, were not associated with this complication.