Assess Peripheral Intravenous Catheters Phlebitis Scale or Preset

Assess Peripheral Intravenous Catheters Phlebitis Scale or Preset Intervals Catherine Rasmussen, RN Fort Hays State University, Department of Nursing Inclusion Criteria: 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 72 -96 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 48 hrs 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). 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. IV site appears healthy One of the following signs is evident: • Slight pain near the IV site • Slight redness near IV site Two of the following are evident: • Pain at IV site • Redness Systematic Review ALL of the following are evident: • Pain along path of cannula • Redness around site • Swelling Table 1 Determine the need to remove PIVC: Phlebitis scale or preset intervals? Analyze Data/Result Scales available, preset intervals 72 -96 hrs. Results: highest correlation: warmth, tenderness, swelling, redness Determine Inclusion criteria: PIVC, phlebitis scale, 72 hours Data Abstraction: PIVC removal using phlebitis scale vs preset intervals Systematic Review: search for key works at Library ALL of the following are evident and extensive: • Pain along path of cannula • Redness around site • Swelling • Palpable venous cord Gather all studies keep those that fit inclusion criteria: 11 articles considered, 5 met criteria All of the following are evident and extensive: • Pain along path of cannula • Redness around site • Swelling • Palpable venous cord • Pyrexia 0 No signs of phlebitis OBSERVE CANNULA 1 Possibly first signs of phlebitis OBSERVE CANNULA 2 3 4 5 Early stage of phlebitis RESITE CANNULA Medium stage of phlebitis RESITE CANNULA CONSIDER TREATMENT Advanced stage of phlebitis Or the start of thrombophlebitis RESITE CANNULA CONSIDER TREATMENT PIVC intact after 96 hrs. Scales: inconsistent nurse assessment Scales not reliable 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), 338 -345. Retrieved from: https: //nursekey. com/complications-and-nursing-interventions/ Assess nursing implications Nursing education and further research needed Answer Question Combined subjects: 23, 262 a, b, c, d, e 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 Significant Review Outcomes Table 2 Phlebitis scale does not determine need for PIVC removal Significance and Interventions Advanced stage thrombophlebitis INITIATE TREATMENT RESITE CANNULA Adapted with permission from Andrew Jackson IV nurse consultant, The Rotherham NHS Foundation Trust, UK. Andrew Jackson 1997 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? Figure 2 Visual Infusion Phlebitis Scale 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 2013 -2018. The search engines found and used were: EBSCO CINAHL, Medline, and Pub. Med. 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. Question? Implications for Nursing Most Significant sign/symptom finding: Warmth/tenderness, swelling and erythemac 10 Different Phlebitis Scales compared: b Experience Nurse Clinician: level of agreement inconsistent b Need more research to predict PIVC complications d 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. Conceptual Framework Results • 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). Figure 1 Caring: 10 carative factors Foundation for evidence based practice, provide best care, best outcomes Patient is the focus Can be applied to a variety of patients and situations Scales are inconsistant c and not reliable Jean Watson’s Caring and Nursing Process Core to Nursing Data results, intervention, interpretation Evaluation Care Plan: examine variables, what data to collect and how Figure 1 Petiprin, A. (2016). Jean Watson-nursing theorist. Nursing Theory Nursing process is similar to process of scientific research Assessment: Observe, identify, review, formulate hypothesis • 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). • • Must palpate, not just as patient if have pain or c discomfort Need more research to determine scale that is predictable, reliable and e valid Most PIVC sites are a intact after 96 hours Preset removal of PIVCs, is an unnecessary d procedure Scales have no uniformity what needs to be present for PIVC e removal Nurses need education e on phlebitis assessment a Helton, et al. , (2016, p. 48). b. Marsh, et al. , (2015, p. 898). c Mihala, et al. , (2015 p 260). d. Morrison & Holt, (2015, p. 187). e. Ray-Barruel et al. , (2014, p. 198). 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). 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. 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) 893 -899. http: //doi: 10. 1111/jep. 12396. Mihala, G. , Ray-Barruel, G. , Chopra, V. , Webster, J. , Wallis, M. , Marsh, N. , Mc. Grail, M. , Rickard, C. M. (2018). Phlebitis signs and symptoms with peripheral intravenous catheters. Journal of Infusion Nursing, 41, 260 - 263. 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), 187 -198 doi: 10. 1111/wvn. 12102. Petiprin, A. (2016). Jean Watson-nursing theorist. Nursing Theory. Retrieved from: http: //www. nursing-theory. org/nursing-theorists/Jean-Watson. php. 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/10. 1111/jep. 12107. 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), 338 -345. Retrieved from: https: //nursekey. com/complications-and-nursing-interventions/. PIVC