PREVENTING INTRAVENOUS SITE INFECTIONS AND

Preventing Intravenous Site Infections and Phlebitis
Betina McCrosky
WGU
Evidence-Based Nursing Research
WZT Task 1
Dec. 27, 2014

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PREVENTING INTRAVENOUS SITE INFECTIONS AND

Article

A 1-2
Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. Journal Of The American Academy Of Nurse
Practitioners, 20(4), 172-180. doi:10.1111/j.17457599.2008.00305.x

Introduction

Authors of this investigative review wanted to research the predisposing factors in peripheral intravenous (IV) catheters causing phlebitis. Millions of patients hospitalized in the U.S. each year have had an IV or IVs’. The patients in this study received a variety of IV drugs and IV infusion solutions.

Review of Literature

Phlebitis rates from previous studies range from 41.8% to 68.8%.
These studies also looked into consideration of predisposing factors such as age, gender, immunosuppression, aseptic techniques, medications and high osmolality solutions. The authors found conflicting correlations with age, gender and infusion rates being a cause for phlebitis.
Catheter size, length of time it was in place, location (site) and the drugs infused had not been studied.

Discussion of
Methodology

This is a descriptive comparative study. Standard protocol for this hospital: Sites are assessed and cared for with povidone iodine 10% every 24 h. PIVs are changed routinely every 72 hrs.
A new IV is inserted when symptoms such as tenderness or pain develop. The data was collected by, developing a questionnaire and direct observation using the Scale of Phlebitis to diagnose phlebitis.
91% of the data collected was by the author, Esin Uslusoy, BSN,
MS. The remaining 9% of data was reported by the nurses taking care of the patients.

Data Analysis

568 catheters were studied. 309 developed 1st. degree phlebitis
(redness and pain). Age and gender had no effect. The location

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of the catheter when place in the elbow (antecubital) and the use of infusion pumps did show a higher rate of phlebitis. Chi-square and logistic regression analyses were performed. The results showed, that time (catheter left in place), type of infusions and the frequency of drugs being administered were major factors in causing phlebitis. Catheters place in the OR also had a lower rate of phlebitis than the IVs inserted in the ED.
Researcher’s conclusion

The sample was large enough. Most of the data was collected by one person thus increasing the confidence level with the results.
The data shows that by placing the IV in the elbow area does increase the rate of phlebitis along with certain solutions and/or drugs being given IV route. There is conflicting literature on age, gender and the use of infusion pumps increases the rates of phlebitis. Further studies need to be done.
It is important for nurses to learn and know the risk factor and be proactive in preventing phlebitis.

A3
The evidence presented in this research article I have chosen, does support the researchers ‘conclusion. The time, location, medication and the use of pumps are all factors needed to be considered when inserting a peripheral intravenous catheter.
A4
The only ethical issue that may have arisen for the researcher would be not having the consent of the patients or the hospital that allowed the study to be performed. In this case they did. PREVENTING INTRAVENOUS SITE INFECTIONS AND

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A5
This research study was a descriptive comparative study of older studies results and this study which was performed in 2008. The way in which data was collected was observational. I do not believe there is a better way to conduct this kind of research.

SECTION B 1
Peripheral intravenous catheters are inserted into just about every patient that is admitted into the hospital. Having IV access is crucial in saving lives. Medications, fluids and blood products are infused through peripheral intravenous catheters. The process of inserting catheters aseptically and correctly is a nursing care problem at times. There are nurses who are skilled at placing IVs and then there are not so skilled nurses or techs placing IVs. Nursing documentation of the IV is also a problem. Assessment of the IV every shift and during your shift is important to keep the IV patent and or removing it due to pain or infiltration. Phlebitis is serious and can lead to blood stream infections and permanent damage to the vein.
A 2 See Attached Matrix
B 3 Annotation Bibliography
Ahlqvist, M., Bogren, A., Hagman, S., Nazar, I., Nilsson, K., Nordin, K., &
…Nordstrom, G. (2006). Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines. Journal of Clinical Nursing. 15(11), 1354-1361. doi:10.1111/j.1365-2702.2006.01403.x PREVENTING INTRAVENOUS SITE INFECTIONS AND

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This cross-sectional study was on the handling of peripheral intravenous cannulae
(catheters in US). 107 and 99 cannulae were studied. The following guides were used: Indication of treatment, problems that might arise, time in place, site appearance, how to use skin disinfectant, care and handling. PIVC size, using the smallest gauge in respect to the treatment being given. Conclusion: putting these guidelines into practice made significant improvements. A decreased frequency of signs of thrombophlebitis. Other factors associated with less complications was nursing knowledge, risks, insertion techniques and how to care for PIVCs’ along with accurate documentation. Hospital practice reviews and educating patients about their IVs would involve them with the care of their PIVC. The evidence collected in this article is adequate and does support best nursing practice. Biswas J. IV nursing care. Clinical audit documenting insertion date of peripheral intravenous cannulae. British Journal of Nursing [serial online]. March 8, 2007;
16(5):281283. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed
January 27, 2015.
This study was performed on three random days in the month of April 2006. All
PIVs, dressings, sites and intravenous fluids or medications were examined. The nursing staff was also interviewed. 123 IVs were placed during the 3 days of the study. 53 out of 123 IVs had the date of insertion documented on the dressing. 17 out of the 123 IVs were in place longer than 72 hours. 28 of the patients had inflammation at the site. This study used a Visual Phlebitis Scale (0-5). 19 patients

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scored a 1 (slight redness at the site), and 9 scored 2 (pain at site with erythema).
The nursing staff was aware of the 72 hour guidelines. Isopropyl alcohol 70% was used for most PIV insertions and the use of clear dressings versus gauze and tape dressings have lowered infection rates.
This study shows me that with inconsistent documentation by the nursing staff makes it difficult to assess the time duration of the PIV. Good aseptic techniques and frequent hand washing also reduces the rates of hospital acquired bloodstream infections. Assessing the PIV site every shift is imperative and good nursing practice. Fujita, T., & Namiki, N. (2008). Replacement of peripheral intravenous catheters. Journal of Clinical Nursing, 17(18), 2509-2510. doi:10.1111/j.1365-2702.2008.02358.x
This study was a prospective observational study of adults. 180 men and 167 women that required peripheral IV therapy. This hospital’s policy at the time of this study was to leave the peripheral intravenous catheter
(PIC) in until it become clotted or inflamed. Extravasation occurred in 108 of the patients. Phlebitis occurred in 26 patients and clotting in 10. No catheter related bloodstream infections occurred.
This study also agrees with the CDC for removal of the PIC in 96 hours but the clinical practice and study results showed that 25% of the PICs showed no signs or symptoms of phlebitis at the 96 hour dwelling time. In certain patient populations this study suggests that PICs can be left in place for up 120 hours. The researchers’ conclusion is adequate for making a practice change in the time a PIC in left in place. PREVENTING INTRAVENOUS SITE INFECTIONS AND

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Grune, F., Schrappe, M., Basten, J., Wenchel, H., Tual, E., & Stuszer, H. (2004).
Phlebitis rate and time kinetics of short peripheral intravenous catheters. Infection, 32(1),
30-32.
This observational cohort study was conducted on complication rates and time kinetics of peripheral intravenous catheters (PIVCs) in four hospitals. 1582 patients with 2495 PIVCs’ were observed daily using standard questionnaires.
Phlebitis was defined by modified CDC guidelines. The phlebitis occurrences’ were 27 in 100 patients and 104 per 1,000 PIV days. Most IVs were in for 2 days.
Time kinetics (Kaplan-Meier) were linear. The results of this study show that time kinetics of PIVC phlebitis does not support the recommendation of removal or replacement of the catheter in 72 hours, provided the insertion site is monitored daily. PIVC complications include obstruction, extravasation, thrombus, phlebitis, and venous trauma.
This study shows that by assessing the IV site daily is the best way to prevent phlebitis or other complications. The researchers’ evidence in this study is adequate in supporting good nursing practice.
Idvall, E., & Gunningberg, L. (2006). Evidence for elective replacement of peripheral intravenous catheter to prevent thrombophlebitis: a systematic review. Journal of
Advanced Nursing, 55(6), 715-722. doi:10.1111/j.1365-2648.2006.03962.x
A systematic literature review of three randomized studies performed by:
Barker et al. (2004), Kerin et al. (1991), May et al. (1996)

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These studies suggested that having the option to replace the peripheral intravenous catheters would reduce the prevalence and complications of thrombophlebitis developing.
This article also states there is limited scientific information (studies) in the management of PIC’s. Replacing the PIV with no evidence of complication is unnecessary and costly to the patients?
I feel this article is interesting and an important subject. More clinical trials need to be performed. The type of medications, IV fluids and time the PIC is left in place are all factors in causing/preventing thrombophlebitis or phlebitis.
Johannson, M. E., Pilhammar, E., Khalaf, A., & Willman, A. (2008). Registered nurses’
Adherence to clinical guidelines regarding peripheral venous catheters: a structured observational study. Worldviews on Evidence-Based Nursing / Sigma Theta Tau
International, Honor Society of Nursing, 5(3), 148-159. doi:10.1111/j.17416787.2008.00105.x
This observational study was conducted using data of 343 PIV catheters. To examine the national and local clinical guidelines of PIVCs’. The type of dressing, the size of the catheter, time in place and location. This article also explores the frequency of thrombophlebitis and nurses’ non-adherence to the guidelines of documentation. The data was collected at a university hospital with
(1030 beds). Then at one rural hospital (170 beds). Nursing documentation of the
Insertion date was more prevalent than documenting the time and dressing.

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Best practice suggests PIVCs’ should be replaced every 72 hours. Signs and symptoms of swelling, pain or infection were measured with the catheter in place, not when the catheter was removed. Thrombophlebitis can occur after the removal of the PIVC. The results for thrombophlebitis was 7.0% of the studied PVC sites.
Nurses only partly adhere to clinical guidelines of PIVCs’. The nurses in this study did however remove or replace PIVCs before any severe problems arose.
Documentation of PIVC is essential for determining the length of time the PIVC has been in place. Clinical guidelines exist on the national and local levels but vary in how explicit the rationale is presented, despite the attention to evidencebased guidelines.
There is a reason why we have clinical guidelines and evidence based practice guidelines. Randomized controlled trials are important to conduct so as to establish the best time duration, site location and size of the catheter. This will help to reduce the complications and increase cost effectiveness. This study’s results are adequate and relevant to nursing practice today.
Rickard, C. M., McCann, D., Munnings, J., & McGrail, M. R. (2010). Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomized controlled trial. BMC Medicine, 853. doi:10.1186/1741-7015-8-53 Within this article and authors show that routine peripheral IVs don’t need to be replaced in 96 hours of placement. The randomized study was of 603 IVs inserted in the hospital setting. Open (non-blinded), parallel group RCT. The results were

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that 68 (PIVs) per 1,000 IV days had to be removed or restarted due to problems.
66 (PIVs) per 1,000 IV days for routine replacement. Changing the IV site when no inflammation, pain or evident problems caused higher hospital costs per patient.
Clinically needing to replace the IV to a new site would achieve savings in equipment, patient discomfort and staff time.
The evidence collected in this research article is adequate for making a policy/practice change. In my practice, I will not replace the PIV if the site and dressing is clean, dry and intact. It also has to flush easily and cause no pain to my patient. Tohid, H., Sim, N., & Lin, L. (2005). Extending the use of peripheral intravenous catheter and administration sets from 72 hours to 96 hours. Singapore Nursing Journal,
32(2), 51-56.
An observational study was conducted to examine the rate of PIV (catheter) site infections and bloodstream infections when the peripheral catheter was left in place for 96 hours. 212 samples were examined over 16 months. Five samples of 166 exhibited presence of phlebitis. The phlebitis rate was 3%. The infection rate of PIVs left in for 96 hours had a confidence interval of 0% 10 1.8%.
The results agrees with the CDC’s recommendation of discontinuing the IV or replacing at new site every 96 hours for continuous infusions.
I feel this was a small study. It also did not take into consideration the type of IV fluid, medications and anatomical placement of the PIV.

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Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. Journal of the American Academy of Nurse
Practitioners, 20(4), 172-180. doi:10.1111/j.1745-7599.2008.00305.x
A descriptive comparative study to look at any predisposing factors that may contribute to patients developing phlebitis from their peripheral intravenous catheters. The factors being IV solutions and IV drugs being administered and location of the PIV. Using systematic observations of 568 IV sites in 355 patients during treatments and 48 hours after discontinuing the PIV. The placement of PIV in the antecubital vein (elbow) resulted in an increased risk of phlebitis. The movement of the elbow joint can cause trauma to the vein. Phlebitis was more prevalent in patients receiving a number of IV drugs and hypertonic solutions frequently. 309 out of 568 IV sites developed phlebitis with the catheters were in place. Post infusion phlebitis appeared in 25 sites after the removal of the PIV. This study showed no differences between gender, patient age or catheter size. PIVs inserted in the operating room versus in the ED had a lower rate of phlebitis.
This study is adequate to make recommendations for IV practice protocols. The use of medications that are harmful to our veins is a serious problem that increases phlebitis cases.
Zarate, L., Mandelco, B., Wilshaw, R., & Ravert, P. (2008). Peripheral intravenous catheters started in prehospital and emergency department settings. Journal of Trauma
Nursing. 15(2), 47-52.

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This research article looked into the rate of phlebitis in peripheral intravenous catheters that were inserted into trauma patients out in the field by Emergency
Medical personnel versus catheters being inserted in the hospital emergency department. Variables measured were where the PIV was placed anatomically, size (gauge) and the patients’ Injury Severity Score (ISS). The results showed phlebitis in 5.79% of the 432 patients studied. Trauma patients who had a high
ISS also had a higher rate of phlebitis. The findings also indicate that the anatomical site and gauge of the catheter did not increase the phlebitis rates. The evidence collected in this study shows there is a lower rate of phlebitis, due to a lack of statistically significant findings from studies performed close to 20 years ago. The decrease in phlebitis today in trauma patients is from better techniques and catheters. The use of gloves in the field and in the hospital along with improved dressings that protect IV catheter sites. Better training of EMT’s and
Paramedics has also improved over the years.
This was a small sample study conducted in one hospital. The authors’ did not look at the bore size (gauge) or the medications being put through the IV that may be irritating to veins. The length of time in which the catheter was left in was not evaluated. PIVs place under emergency situations, the CDC suggest that the PIV be removed after 48 hrs. This policy by the CDC may need to be re-evaluated.
The removal and replacement of IV catheters when not indicated can lead to increased costs and patient discomfort especially if the patient has poor veins.
This research is adequate to make a nursing change.

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This observational group examination was conducted on the time that complications happened to peripheral intravenous catheters (PIVCs’) of 15 hospital wards in four hospitals.
1582 patients with 2495 PIVCs’ were observed following a standard questionnaire. Using a modified CDC guideline, the rate of phlebitis was 27 in
100 patients and 104 per 1,000 catheter days. The time involved was 2 days.
Time kinetics (Kaplan-Meier) were linear. The results of this study are that time kinetics of PIVC phlebitis does not agree with the recommendation to remove or replace the catheter at 72 hours, provided the insertion site is monitored daily.
PIVC complications include obstruction, extravasation, thrombus, phlebitis, and venous trauma.
This study shows that by assessing the IV site daily is the best way to prevent phlebitis or other complications. The researchers’ evidence in this study is adequate in supporting good nursing practice.
SECTION B
4, 5, 6
The criteria I used to research these articles was that they had to be peer reviewed and published in a medical journal or nursing journal. The articles are similar in their content and results. Information taken from such articles are used to make evidence based practice guidelines or protocols to improve patient care and outcomes.
A nursing strategy would be to prevent IV site infections and phlebitis from ever happening. Nurses and other health care professionals who place IVs need to be diligent in their

PREVENTING INTRAVENOUS SITE INFECTIONS AND practice of aseptic techniques, care of the IVs, documentation of placement and removal of IV catheters. The elective replacement of the IV catheter when there is no sign of problems, still needs to be studied. The implementation of BD Nexia Closed IV catheter system from the BD
Insyte peripheral catheters makes it impossible for the catheter hub to come apart. The tubing comes already attached to the catheter hub keeping the catheter clean and secure. It is important to use a theoretical nursing model for research so there is structure, rationales for the variables and a frame of reference. It also helps to direct the research in a systematic and orderly fashion allowing progress. Furthermore, assessing the design, applicability of the information and having actual value to the nursing profession.

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References
Biswas, J. (2007, March 8). Clinical Audit documenting insertion date of peripheral intravenous cannulae. British Journal of Nursing, 16(2), 281-283. Retrieved from info.britishjournalofnursing.com DeGuzman, P., & McCaskill, C. (2008). Evaluating peripheral IV guidelines for the outpatient setting. AAACN Viewpoint, 30, 4. Retrieved from http://www.aaacn.org
Fujita, T., & Namiki, N. (2008). Replacement of peripheral intravenous catheters. Journal of
Clinical Nursing, 17(18), 2509-2510. http://dx.doi.org/10.1111/j.13652702.2008.02358.x
Grune, F., Schrappe, M., Basten, J., Wenchel, H., Tual, E., & Stutzer, H. (2004). Phlebitis rate and time kinetics of short peripheral intravenous catheters. Infection, 32(1), 30-32.
Retrieved from www.springerlink.com.wgu.idm.oclc.org/home/main.mpx
Houser, J. (2007). Theoretical frameworks. In Barlett, & James (Eds.), Nursing research:
Reading, Using, and Creating Evidence (p. 165). Retrieved from http://online.vitalsource.com/books/9781284024234/id/pg165 Idvall, E., & Gunningberg, L. (2006). Evidence for elective replacement of peripheral intravenous catheter to prevent thrombophlebitis. Journal of Advanced Nursing, 55(2),
715-722. http://dx.doi.org/10.1111/j.1365-2648.2006.03962.x
Johansson, M., Pihammar, E., Khalaf, A., & Willman, A. (2008). Registered Nurses’ adherence to clinical guidelines regarding peripheral venous catheters: a structured observational

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study. Worldviews on Evidence-Based Nursing, 5(3), 148-159. Retrieved from www.nursingsociety.org/Publications/Worldviews/Pages/Worldviews.aspx/index.html Rickard, C. M., McCann, D., Munnings, J., & McGrail, M. R. (2010). Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomized controlled trial. . BMC Medicine, 853. http://dx.doi.org/10.1186/1741-7015-8-53 Tohid, H., Sim, N., & Lin, L. (2005). Extending the use of peripheral intravenous catheter and administration sets from 72 hours to 96 hours. Singapore Nursing Journal, 32(2), 51-56.
Retrieved from http://issuu.com/singaporenursesassociation/docs/snj_octdec2011_dd_21_nov Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. Journal of the American Academy of Nurse
Practitioners, 20(4), 172-180. http://dx.doi.org/10.1111/j.1745-7599.2008.00305.x
Zarate, L., Mandleco, B., Wilshaw, R., & Ravert, P. (2008). Peripheral intravenous catheters started in prehospital and emergency department settings. Journal of Trauma Nursing,
15(2), 47-52. Retrieved from http://www.traumanurses.org/journal-of-trauma-nursing
References Biswas, J. (2007, March 8). Clinical Audit documenting insertion date of peripheral intravenous cannulae. British Journal of Nursing, 16(2), 281-283. Retrieved from info.britishjournalofnursing.com
DeGuzman, P., & McCaskill, C. (2008). Evaluating peripheral IV guidelines for the outpatient setting. AAACN Viewpoint, 30, 4. Retrieved from http://www.aaacn.org
Fujita, T., & Namiki, N. (2008). Replacement of peripheral intravenous catheters. Journal of

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Clinical Nursing, 17(18), 2509-2510. http://dx.doi.org/10.1111/j.13652702.2008.02358.x
Grune, F., Schrappe, M., Basten, J., Wenchel, H., Tual, E., & Stutzer, H. (2004). Phlebitis rate and time kinetics of short peripheral intravenous catheters. Infection, 32(1), 30-32.
Retrieved from www.springerlink.com.wgu.idm.oclc.org/home/main.mpx
Houser, J. (2007). Theoretical frameworks. In Barlett, & James (Eds.), Nursing research:
Reading, Using, and Creating Evidence (p. 165). Retrieved from http://online.vitalsource.com/books/9781284024234/id/pg165 Idvall, E., & Gunningberg, L. (2006). Evidence for elective replacement of peripheral intravenous catheter to prevent thrombophlebitis. Journal of Advanced Nursing, 55(2),
715-722. http://dx.doi.org/10.1111/j.1365-2648.2006.03962.x
Johansson, M., Pihammar, E., Khalaf, A., & Willman, A. (2008). Registered Nurses’ adherence to clinical guidelines regarding peripheral venous catheters: a structured observational study. Worldviews on Evidence-Based Nursing, 5(3), 148-159. Retrieved from www.nursingsociety.org/Publications/Worldviews/Pages/Worldviews.aspx/index.html Rickard, C. M., McCann, D., Munnings, J., & McGrail, M. R. (2010). Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomized controlled trial. . BMC Medicine, 853. http://dx.doi.org/10.1186/1741-7015-8-53 Tohid, H., Sim, N., & Lin, L. (2005). Extending the use of peripheral intravenous catheter and administration sets from 72 hours to 96 hours. Singapore Nursing Journal, 32(2), 51-56.

PREVENTING INTRAVENOUS SITE INFECTIONS AND
Retrieved from http://issuu.com/singaporenursesassociation/docs/snj_octdec2011_dd_21_nov Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. Journal of the American Academy of Nurse
Practitioners, 20(4), 172-180. http://dx.doi.org/10.1111/j.1745-7599.2008.00305.x
Zarate, L., Mandleco, B., Wilshaw, R., & Ravert, P. (2008). Peripheral intravenous catheters started in prehospital and emergency department settings. Journal of Trauma Nursing,
15(2), 47-52. Retrieved from http://www.traumanurses.org/journal-of-trauma-nursing

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