Standard 53.2: An incidence of phlebitis shall be reported as an adverse patient outcome.
Standard 53.3: Statistics on incidence, degree, cause, and corrective action taken for phlebitis shall be maintained and readily retrievable.
Standard 53.4: The nurse shall be competent to assess the access site and determine the need for intervention and treatment in the event of phlebitis.
Standard 53.5: All information related to the event shall be documented in the patient's permanent medical record.
Standard 53.6: Phlebitis shall be documented using a uniform standard scale for measuring grade or severity of phlebitis.
In my role as a homecare clinical nurse specialist, I provide a substantial orientation to home infusion therapy for all newly hired nurses, most of whom come to home healthcare with acute care and infusion nursing experience. As part of the orientation, I give the nurses a written test that includes some scenarios of infusion-related complications. I have found that it is not uncommon for nurses to lack understanding about the difference between phlebitis and infiltration and the significance of these complications-an observation shared by many of my colleagues in the Infusion Nurses Society (INS). Over the next 2 issues, I will address the standards of phlebitis and infiltration in relation to peripheral IV catheters.
Standard 53.1 defines phlebitis as an inflammation of the vein. Signs and symptoms include pain, erythema, edema, streak formation, and/or a palpable cord. The consequences of phlebitis include pain, discomfort, and limitation of vascular access. Phlebitis may result in more serious complications, such as purulent thrombophlebitis, sepsis, and thrombosis formation, which lead to increased length of hospitalization, need for antibiotics, and possible surgical intervention. Several factors contribute to the development of phlebitis, including administration of irritating IV fluids or medications, injury to the inner lining of the vein by the catheter, and infection. It is important to implement strategies to reduce the risk of phlebitis, monitor the IV site closely for evidence of phlebitis, and remove the IV catheter when signs and symptoms such as pain and erythema occur. Knowledge of contributing factors and application of associated INS standards help to reduce the risk of phlebitis.
Avoid administering irritating infusion therapies through a peripheral IV catheter. Infusions not appropriate for peripheral administration include parenteral nutrition, continuous vesicant drug infusions, infusates with a pH of less than 5 or more than 9, and infusates with osmolality of more than 600 mOsm/L (see INS Standard 37). A centrally placed catheter is indicated for irritating infusates. Remember that midline catheters are peripheral catheters and that these same guidelines apply. Antiseptic solutions used to prepare the site should be allowed to completely air-dry before placing the catheter (see INS Standard 41). This practice avoids tracking the antiseptic into the vein and potentially causing irritation that leads to phlebitis.
Minimize the risk for phlebitis caused by vein trauma. Use the smallest size catheter and the shortest length to accommodate the infusion therapy (see INS Standard 38). Avoid areas of flexion and lower extremities (exception: infants) when placing peripheral catheters (see INS Standard 37). Ensure that the catheter is stabilized in place (see INS Standard 43). Catheter stabilization is now recognized as an important intervention in reducing the risk for phlebitis, infection, catheter migration, and catheter dislodgment. When the catheter is stabilized, there is less movement of the catheter in and out of the insertion site and less irritation of the vein by the catheter (see the "Speaking of Standards column" in the January/February 2007 issue).
Minimize the risk for phlebitis caused by introduction of bacteria. Prepare the site with an antiseptic before venipuncture. Wash your hands and use aseptic technique during all infusion procedures. Monitor the site carefully and instruct patients to report any pain or discomfort at the site. The practice criteria under the Phlebitis Standard also recommend that sites be observed for 48 hours after removal to detect postinfusion phlebitis and that patients be given written instructions about signs and symptoms to report. Phlebitis is rated using a scale. The scale cited in the Standards is as follows:
* Grade 0 = No symptoms
* Grade 1 = Erythema at access site with or without pain
* Grade 2 = Pain at access site with erythema and/or edema
* Grade 3 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord
* Grade 4 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord > 1 inch in length, purulent drainage
Standard 53.4 addresses competence in assessment and intervention related to phlebitis. Expertise in infusion therapy matters!! The Centers for Disease Control and Prevention states that specialized IV teams have shown unequivocal effectiveness in reducing the incidence of catheter-related infections and associated complications and costs.2 In one example of a randomized, prospective controlled trial, patients whose peripheral IV catheters were started by and maintained by a dedicated IV team of nurses had significantly fewer local and bacteremic complications than patients whose IV catheters were started by medical house staff and maintained by floor nurses.3Infusion Nursing Standards of Practice (see Standard 49) states that peripheral IV catheters are removed and replaced every 72 hours (adults) and upon evidence of complications, discontinuation of therapy, or suspected contamination. There is no recommendation for a routine removal and replacement time interval for neonatal and pediatric patients. Some research supports longer dwell times in adults, but the research primarily involves IV specialists inserting and maintaining the catheters. For example, in one study that examined extending peripheral IV catheter dwell time, researchers found that if nonirritating medications were administered and a dedicated team of IV specialists inserted and evaluated the catheters, catheter dwell time may be extended beyond 72 hours.4 There is clearly a need for more well-designed research studies to guide clinical practice in frequency of peripheral catheter replacement.
The practice criteria for the standard recommend that any incident of phlebitis at Grade 2 or more be reported as an unusual occurrence. In the absence of specialty teams and certified infusion nurses, it is not uncommon for organizations to lack mechanisms for monitoring infusion-related complications. It is important that organizations recognize phlebitis as an adverse outcome and monitor its incidence. INS practice guidelines state that an acceptable rate for short peripheral IV catheter phlebitis should be 5% or less. When higher rates occur, the data should be analyzed for degree of phlebitis and potential causes to develop a performance improvement plan.
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