et al. Most cases of phlebitis are mild in nature, requiring no treatment or only removal of the catheter. When adherence to aseptic technique cannot be ensured, the catheter should be replaced as soon as possible (ie within 48 hours; If sufficient study data had been available for individual outcomes (> 10 trials), we would have developed funnel plots and inspected them for evidence of publication bias. The American Journal of Infection Control will also present a video roundtable highlighting the viewpoints of healthcare professionals on the anticipated effects of BMJ Open. My practice manager is complaining that I am using too many syringes and needles which, Q: Can you please let me know if a PICC line dressing can be a clean procedure or does it have to be sterile? In contrast, in another systematic review, Mermel 2017 suggested that longer dwell times resulted in higher CRBSI rates. Deeks JJ, EBP Paper 446 - INFECTION PREVENTION: IV SITE ROTATION Nurs Stand. WebQualifiers: Patient Chemically Sedated Patient Intubated Obstruction to the Patients Eye The protocols in this book are guidelines only. Higgins JP, Conen D, The catheter insertion site should be evaluated daily, and peripheral venous catheters should be removed if signs of phlebitis both in morbidity and financial expenditures. I need to explain to my practice manager why I cant re-use a syringe while reconstituting a powdered medication for injection. Searches rerun. Removing the two trials eliminated the heterogeneity (I2 = 0). Glasziou P, Yadav G, Dyke S, The consistency in these results, which include two very large multisite studies, indicate that healthcare organisations should consider changing to a policy whereby catheters are changed only if there is a clinical indication to do so, for example, if there were signs of infection, blockage or infiltration. Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. Routine replacement costs approximately AUD 7 more per patient compared with clinically indicated replacement (Tuffaha 2014a). Mulrow C, We included any patient requiring a PIVC to be in situ for at least three days for the administration of intermittent or continuous therapy (this may include patients in hospitals, nursing homes, or in community settings). Six trials provided thrombophlebitis rates by number of device days (32,709 device days). We used GRADE to assess the overall evidence certainty. We measured catheterrelated blood stream infection, phlebitis and other problems associated with peripheral catheters, such as local infection and catheter blockage. We considered all randomised controlled trials (RCTs) comparing routine removal of PIVC with removal only when clinically indicated. Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships. Isolation precautions. It includes the use of a cap, mask, sterile gown, sterile gloves, Higgins JP, With an estimated two billion PIVC used globally each year (Rickard 2018), there is a clear need to provide direction for clinicians and administrators by systematically searching for and appraising relevant studies to add to the review. College of Chest Physicians, American Thoracic Society, American Society of Critical Care Anesthesiologists, APIC, Infusion to enhance patient care. Hospital-specific or collaborative-based performance improvement initiatives in which multifaceted strategies are "bundled" Pauls R, These sponsors (3M, Adhezion, Angiodynamics, BDBard, Baxter, Medtronic, Centurion Medical, Entrotech Life Sciences, Cook, Smiths Medical) had no involvement in the study design, execution, analysis or publication of these projects, had no control over the projects, and they were unrelated to the topic of this review. Instread removal should be when it is clinially indicated. Recommendations | BSI | Guidelines Library | Infection Control | CDC Webster J, In cases where clinical heterogeneity between studies was similar but heterogeneity was high, we planned to metaanalyse results and attempt to provide an explanation for the heterogeneity. P. O'Grady, MD, from the National Institutes of Health in Bethesda, Maryland, and colleagues from HICPAC. Murchan P, Rickard C. Observational study of peripheral intravenous catheter outcomes in adult hospitalized patients: a multivariable analysis of peripheral intravenous catheter failure, Shortterm peripheral venous catheterrelated blood stream infection. involving healthcare professionals who order the insertion and removal of CVCs, those personnel who insert and maintain intravascular One trial (3283 participants), found no clear difference in the incidence of mortality when clinically indicated removal was compared with routine removal (RR 1.06, 95% CI 0.27 to 4.23; lowcertainty evidence, downgraded two levels for very serious imprecision). Palmer D, BaniMustafa A, Comparison 1 Clinicallyindicated versus routine change, Outcome 9 Mortality. Cochrane, 2017. Nordic Cochrane Centre, The Cochrane Collaboration. We excluded participants receiving parenteral fluids. Prophylactic antimicrobial lock solution should be used in patients with long-term catheters who have a history of multiple If we considered data to be missing at random, we analysed the available information. We included seven of the nine trials, reporting on 7323 participants, in this analysis (Rickard 2010; Rickard 2012; Van Donk 2009; Vendramim 2018; Webster 2007; Webster 2008; Xu 2017). Rickard CM, We would have developed a funnel plot to detect reporting bias, if we had included more than 10 studies in the review. Overall we found the quality of evidence for most outcomes to be of moderate to low quality, primarily due to risk of bias (particularly nonblinding of the outcome assessor), and imprecision. It has been suggested that insertion and management by an IV team may explain the inefficacy of routine replacement to prevent complications (Maki 2008), yet we saw no effect in trials that had significant numbers inserted by an IV team (Webster 2007; Webster 2008), or trials where insertion was by the general medical and nursing staff (Rickard 2010; Rickard 2012), and none of the trials involved research nurses or IV teams providing postinsertion care of catheters. Six trials provided thrombophlebitis rates by number of device days (32,709 device days). on behalf of the Cochrane Applicability and Recommendations Methods Group. We included randomised controlled trials that compared routine removal of PIVC with removal only when clinically indicated, in hospitalised or community-dwelling patients receiving continuous or intermittent infusions. Since the treatment for a blocked catheter is replacement of the catheter, it would not be of any benefit to the patient to replace the catheter earlier since it would not reduce the need for replacement, and would instead increase the chance of recannulation. It was not possible to blind the intervention in any of the trials because it was necessary to identify the catheter as either 'routine change' or 'clinically indicated', to prevent inadvertent routine replacement of catheters in the intervention group. We included two new studies for this update, bringing the total to nine studies with 7412 participants. I know in the past INSrecommended only changing to 96 hrs if your institution could document its phlebitis rate - Is this still the case? In the first of these two trials, Barker 2004 reported that 11/26 (42.3%) participants in the clinically indicated group developed phlebitis compared with 1/21 (4.8%) in the twoday change group. Altman DG, Most hospital patients receive fluids or medications via a peripheral intravenous catheter at some time during their hospital stay. The Information Specialist searched the following trials registries on 18 April 2018: We contacted researchers and manufacturers in order to obtain any unpublished data. Gorski L, Eight trials were conducted in acute hospitals and one in a community setting. Further research is therefore very likely to have an important impact on the confidence in the estimate of effect for these outcomes. Barker 2004 and Nishanth 2009 changed catheters every 48 hours. How to administer intramuscular and subcutaneous Bak A, Shorten G. A dedicated intravenous cannula for postoperative use. We included short PIVC made from any type of material (for example metal, plastic); noncoated or coated with any type of product (for example antibiotic, anticoagulant); or covered by any type of dressing (for example gauze, clear, occlusive). Gordon L, It should not be used to determine doses when converting a You must have JavaScript enabled to use this form. Physicians should claim only the credit commensurate with the extent of their participation in the activity. In addition, Bolton 2015 reported a significant cost saving with a 25% stock reduction. The result was unaffected by whether the infusion was continuous or intermittent (Analysis 1.2; Figure 5). Based on level 1 evidence, the most recent Infusion Nursing Standards of Practice in the USA and the epic3 National Evidence Based Guidelines in the UK recommend that short PIVC should be replaced when clinically indicated, unless the patient is receiving parenteral nutrition peripherally (Infusion Nurses Society 2011; Loveday 2014). Hutton A, Seven of the trials used a standard definition of two or more of the following: pain, warmth, erythema, swelling, or a palpable cord to define phlebitis (Barker 2004; Rickard 2010; Rickard 2012; Vendramim 2018; Webster 2007; Webster 2008; Xu 2017). Preparing Workplaces for COVID-19 One trial assessed this outcome (Rickard 2012). Literature shows inconsistency in the selection of sites for deep muscular injections: selection may be based on familiarity and confidence rather than on Rickard C. Clinically indicated replacement versus routine replacement of peripheral venous catheters. Among the four trials measuring local infection (Rickard 2010; Rickard 2012; Webster 2007; Webster 2008), it is uncertain if there are differences in local infection rates between groups (RR 4.96, 95% CI 0.24 to 102.98; clinically indicated 2/2260 (0.09%); routine replacement 0/2346 (0.0%); verylowcertainty evidence, downgraded one level for serious risk of bias (no blinding of outcome assessment in any of the trials) and two levels for very serious imprecision (Analysis 1.8)). using any therapeutic product discussed. This activity is designed to be completed within the time designated on the title page; physicians should claim only those We found no clear difference in the allcause bloodstream infection rate between the two groups (RR 0.47, 95% CI 0.15 to 1.53; clinically indicated: 4/1593 (0.02%); routine change 9/1690 (0.05%)). Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food Abolfotouh MA, et al. the Cochrane Vascular Specialised Register via the Cochrane Register of Studies (CRSWeb searched on 18 April 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 3) via Cochrane Register of Studies Online; MEDLINE (Ovid MEDLINE Epub Ahead of Print, InProcess & Other NonIndexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE) (searched from 1 January 2017 to 18 April 2018); Embase Ovid (searched from 1 January 2017 to 18 April 2018); CINAHL Ebsco (searched from 1 January 2017 to 18 April 2018); AMED Ovid (searched from 1 January 2017 to 18 April 2018). APIC, Clorox, Merck, Baxter, Ortho-McNeil, Targanta, Schering-Plough, Optimer, Cadence, Cardinal, BDGeneOhm, WebEx, Cerebrio, ReyJoly C, 2011 Guidelines for the prevention of intravascular catheterrelated infections, Routine replacement of peripheral intravenous catheters. In the United States, 80,000 CRBSIs occur in intensive care units each year. Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American Chapter 16: Special topics in statistics. Develop a vascular access decision guide based on MICHIGAN guidelines/INS/NANN/CDC current recommendations. AMA PRA Category 1 Credit(s) Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. This tool addresses six specific domains, namely sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other issues (for example extreme baseline imbalance). Peripheral IV Site Rotation Based on Clinical Assessment vs The remaining four trials used a central telephone or computerbased service (Rickard 2010; Rickard 2012; Webster 2007; Webster 2008). Higgins JP, Cooke M, Peripheral vein infusion thrombophlebitis (phlebitis) is characterised by pain, erythema (redness of the skin), swelling, and palpable thrombosis of the cannulated vein (Monreal 1999). A randomized controlled trial, The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies, Improving the safety of peripheral intravenous catheters. The .gov means its official. DaviesTuck M, They did not report the number of protocol violations by group, and we judged Barker 2004 to be at high risk of attrition bias. The CDC guidlines address this time frame by saying it is an unresolved issue. CDC states 72 to 96 hours to reduce risk of infection and states that change based on clinical indications is an unresolved issue. Nigam C, To minimise PIVCrelated complications, staff should inspect the insertion site at each shift change and remove the catheter if signs of inflammation, infiltration, occlusion, infection or blockage are present, or if the catheter is no longer needed for therapy. Looking up INS & CDC info regarding 72 or 96 hrs rotation of peripheral iv sites. No new studies excluded. No new studies excluded. McGrail MR, If you found this evidence helpful, please consider donating to Cochrane. Although a large trial, only, The mean cost in the control group was AUD 51.02, The mean cost in the intervention group was AUD 44.14, Clinically indicated peripheral catheter removal probably reduces the cost of catheterrelated care by approximately AUD 7.00. challenging, programs have demonstrated success, but sustained elimination requires continued effort. When we combined results of studies that investigated the effect of different catheter replacement schedules on phlebitis, the heterogeneity was high. Forest plot of comparison 1, clinically indicated versus routine change, outcome: 1.1 Catheterrelated bloodstream infection. There was no clear difference in devicerelated pain between clinically indicated and routineremoval groups. et al. The bottom line is we are moving away from a definitive length of time that a peripheral catheter should be allowed to remain in place. If any outcome data remained missing despite our attempts to obtain complete outcome data from trial authors, we assessed the risk of bias of the missing data and decided if the missing data were at 'low' or 'high' risk of bias according to our 'Risk of bias' criteria (Higgins 2017). Rickard CM, The projected fiveyear savings from implementing clinically indicated PIVC removal policies is USD 300 million and 1 million healthworker hours in the USA alone (Tuffaha 2014a; Tuffaha 2014b). We included two new studies for this update, bringing the total to nine studies with 7412 participants. There is no clear difference between groups (RR 0.90, 95% CI 0.76 to 1.08; clinically indicated 248/17,251; 3-day change 236/15,458; moderate-certainty evidence, downgraded once for serious risk of bias). Mackeen A, In the Webster 2007 and Webster 2008 trials CRBSI was based on the isolation of a phenotypically identical organism from a catheter segment and a blood culture. Five trials were carried out in Australia (Rickard 2010; Rickard 2012; Van Donk 2009; Webster 2007; Webster 2008), and one each was carried out in Brazil (Vendramim 2018), China (Xu 2017), England (UK (Barker 2004)), and India (Nishanth 2009). A CVC should have the minimal number of ports or lumens essential for patient treatment. 2018 Jun 4;8(6):e021290. Barker 2004 and Nishanth 2009 compared 48hour changes with removal for clinical indications such as pain, catheter dislodgement, or phlebitis. JW: none known The review is also important because insertion of a PIVC may be painful, especially when placed in the hand or wrist, with an average score of 4.5 on a 10point pain scale (Tan 2016), so preventing unnecessary replacements may reduce a potentially traumatic experience for patients. However, seven trials used a three to fourday change schedule and two trials changed catheters every two days. Searches rerun. Alexander M, relationships of a spouse or life partner, that could create a conflict of interest. short peripheral catheter. There was no restriction on language. Lynn. After a few days, the nurse left the new job for the following reasons: Another RNin the officeroutinely mixes IV medication for the infusion nurses to administer. Polit DF, Metaanalysis of seven trials (7323 participants), found that rates of catheter failure due to blockage were probably lower in the routinereplacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.01 to 1.29; routinereplacement 519/3733 (13.9%); clinically indicated 560/3590 (15.6%); moderatecertainty evidence, downgraded once for serious risk of bias). Altman DG (editors). Comparison 1 Clinicallyindicated versus routine change, Outcome 4 Allcause blood stream infection. Scuffham P. The epic3 recommendation that clinically indicated replacement of peripheral venous catheters is safe and costsaving: how much would the NHS save? Because outcome assessment could not be blinded (except for CRBSI), we classified all trials as high risk of bias. CR's employer has also received competitively awarded research grants through professional bodies where the funds came from commercial suppliers. For any metaanalyses (see below), for categorical outcomes we calculated the typical estimates of RR with their 95% CI; and for continuous outcomes we calculated the mean difference (MD) or a summary estimate for standardised mean difference (SMD), each with its 95% CI. Getting evidence into nursing practice: replacing the routine. April 7, 2011 The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) have updated intravascular catheter infection prevention guidelines. Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical The https:// ensures that you are connecting to the Comparison 1 Clinicallyindicated versus routine change, Outcome 6 Infiltration. US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) no more frequently than every 72 to 96 hours. As the review authors were also the investigators on some of the included trials, we allocated assessment to a review author who was not an investigator (former author KN). A score of two or more was classified as phlebitis, consequently a participant may have had only one symptom, for example pain, to receive a positive diagnosis. activity online during the valid credit period that is noted on the title page. Ananthakrishnan N. Does elective resiting of intravenous cannulae decrease peripheral thrombophlebitis? The infection occurs when bacteria track along the catheter and enter the bloodstream. We resolved any disagreements between review authors by consensus or referral to a third review author. Accessibility Chapter 9: Analysing data and undertaking metaanalyses. 2001 Aug;32(8):21-3. doi: 10.1097/00006247-200108000-00009. The preplanned outcomes 'number of catheter resites per patient', and 'satisfaction' were not reported by any studies included in this review. We retrieved full reports of all potentially relevant trials for further assessment of eligibility based on the inclusion criteria. Diagnosis remains controversial and a number of grading systems have been proposed, although with limited validation testing performed (RayBarruel 2014). There is no clear difference in allcause blood stream infections between the clinically indicated and routinechange groups. Version 5.1.0 (updated March 2011). Mihala G, Catheterrelated blood stream infection (CRBSI), defined as the presence of bacteraemia originating from an intravenous (IV) catheter, is a rare but severe outcome of IV catheterisation (Gahlot 2014). A coin toss in the Xu 2017 trial concealed allocation until randomisation. Describe maximal sterile precautions for prevention of infection from intravascular catheter insertion sites. We planned to analyse potential sources of heterogeneity using the following subgroup analyses. For peripheral catheters and midline catheters in adults, use of an upper-extremity site for catheter insertion is preferred Collaborate with Alliance for Vascular Access Teaching and Research (AVATAR group, Dr Ullman)/ Association of Vascular Access (AVA)/ Pediatric Special Interest Group (PediSIG) to develop mini an education activity to disclose all relevant financial relationships with any commercial interest. 2. Anupurba S. International Journal of Critical Illness and Injury Science. Forest plot of comparison 1 clinically indicated versus routine change, outcome: 1.3 Phlebitis per device days. The remaining eight studies were at low risk of bias as there was complete reporting and all provided a flow of participants through each stage and used intentiontotreat analysis (Nishanth 2009; Rickard 2010; Rickard 2012; Van Donk 2009; Vendramim 2018; Webster 2007; Webster 2008; Xu 2017). The methodological quality assessment of the included studies was updated to the Cochrane Collaboration tool for assessing risk of bias (Higgins 2017). lower extremities or the scalp (in neonates or young infants) can be used. Recommended Intravenous Dosage Regimen BENLYSTA for intravenous use must be reconstituted and diluted prior to administration. However, replacing the catheter may cause discomfort to patients and is quite costly. Term of approval is for 1 year from this date. This is based on the fact that both ends of the set is being manipulated with each dose. Rates of catheter failure due to blockage were probably lower in the routinereplacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.02 to 1.27; routinereplacement group 519/3733 (13.9%); clinically indicated group 560/3590 (15.6%); Analysis 1.7). What is intermittent tubing and how often at the top of the test. Chin LY, We included any duration of time before routine replacement versus clinically indicated replacement. The https:// ensures that you are connecting to the If your facility so chooses, you can leave your practice guidelines to change the catheter at 96 hours - your choise. Where necessary, the methods, results, and discussion sections would have been translated for inclusion in the review. MeSH The timing for this updated guideline is perfect because, starting this year, hospitals that accept Medicare patients are required to report their central lineassociated bloodstream infections to the Centers for Medicare & Medicaid Services, or risk losing 2 percent of their Medicare payments.". Rijnders BJ, Appendix B - Centers for Disease Control and Prevention To assess the effects of removing peripheral intravenous catheters when clinically indicated compared with removing and resiting the catheter routinely. Although the outcome assessment for laboratorybased outcomes, such as blood stream infection was blinded; only 2 trials reported these outcomes. The new recommendations are addressed to healthcare personnel responsible for intravascular catheter insertion as well as Disclaimer The primary outcomes suggest that patients are not adversely affected if the catheter is changed based on clinical indications rather than routinely. The addition of two new trials for this update found no further evidence to support changing catheters every 72 to 96 hours. the Safety of Heparin Administration by Ioannidis JP, Boutron I (editors). Gotzsche PC, Ray-Barruel G, Cooke M, Mitchell M, Chopra V, Rickard CM. doi: 10.12968/bjon.2014.23.sup14.s26. AST Guidelines The mean pain score in the clinically indicated group was 4.6 (SD 3.0), compared with 5.2 (SD 3.0), in the routine replacement group (MD 0.60, 95% CI 1.44 to 0.24; lowcertainty evidence, downgraded one level for serious risk of bias (no blinding of outcome assessment in any of the trials) and onelevel for serious imprecision; Analysis 1.10). These include the Maddox scale (Maddox 1977), and the Baxter scale (Panadero 2002), which rank infusion thrombophlebitis according to the severity of clinical signs and symptoms. That is, we calculated the 'design effect' by using the formula 1+ (M1) ICC where M is the average size of each cluster, We did identify one clusterrandomised trial, the results of which did not appear to have been adjusted (Xu 2017). New citation required but conclusions have not changed. However, there were too few studies in these subgroups to make any meaningful comparisons. If a patient requires therapy, for example for five days, they may have one catheter used for the entire time or alternately multiple IVDs used over the five days. So how frequent should you assess the patients peripheral IV site? We also undertook reference checking, and contacted researchers and manufacturers to identify additional studies. NM: selected trials for inclusion, assessed methodological quality of trials, extracted data, and commented on the review update. Most outcomes were assessed by clinicians or researchers who were aware of the group to which the participant belonged. Routine replacement probably reduces infiltration of fluid into surrounding tissues compared with a clinically indicated change (RR 1.16 (95% CI 1.06 to 1.26; routine replacement 747/3638 (20.5%); clinically indicated 834/3485 (23.9%); moderatecertainty evidence, downgraded once for serious risk of bias). For individual trials, effect measures for categorical outcomes included risk ratio (RR) with its 95% confidence interval (CI). Despite adherence to other strategies, if the rate of CRBSI is not decreasing, use of antiseptic/antibiotic impregnated short-term
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