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Innovative Solutions and Insights to Phlebitis Prevention

      Eighty percent of hospitalized patients receive an intravenous cannula, which is a routine clinical procedure performed in hospitals that is essential to deliver medications and fluids for therapeutic purposes.
      • Zheng G.
      • Yang L.
      • Chen H.
      • Chu J.
      • Mei L.
      For prevention and treatment of infusion phlebitis.
      The incidence of phlebitis has been reported to range from 20% to 80%, and has far exceeded the acceptable incidence of 5% or less recommended by the Intravenous Nurses Society guidelines.
      • Zheng G.
      • Yang L.
      • Chen H.
      • Chu J.
      • Mei L.
      For prevention and treatment of infusion phlebitis.
      The consequences include increased duration of hospitalization by 7 to 14 days, and increased morbidity and mortality.
      • Raad I.
      • Hanna H.
      • Maki D.
      Intravascular catheter-related infections: advances in diagnosis, prevention, and management.
      The additional cost ranged from $3000 to $56,167 for each episode of infection.
      • Raad I.
      • Hanna H.
      • Maki D.
      Intravascular catheter-related infections: advances in diagnosis, prevention, and management.
      It can be complicated by septic thrombophlebitis, which can result in life-threatening consequences such as metastatic infection, leading to septic pulmonary emboli and acute endocarditis.
      • Mermel L.A.
      • Allon M.
      • Bouza E.
      • et al.
      Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: update by the Infectious Diseases Society of America.
      As an under-evaluated area in the realm of health care-associated infections, the call for more effective prophylaxis strategies is urgent. The purpose of this Commentary is to provide insights and revisit current strategies in the prevention of phlebitis.
      Firstly, we present a simple and innovative solution of splinting. Splinting of the joints with intravenous cannulation is a firmly established practice in pediatric patients and decreases the risk of phlebitis.
      • Ben Abdelaziz R.
      • Hafsi H.
      • Hajji H.
      • et al.
      Peripheral venous catheter complications in children: predisposing factors in a multicenter prospective cohort study.
      However, studies have yet to be performed in adults to explore this.
      A review of the literature reveals that intravenous cannulation at the joints is a risk factor for phlebitis.
      • Cicolini G.
      • Bonghi A.P.
      • Di Labio L.
      • Di Mascio R.
      Position of peripheral venous cannulae and the incidence of thrombophlebitis: an observational study.
      • Maki D.G.
      • Ringer M.
      Risk factors for infusion-related phlebitis with small peripheral venous catheters.
      • Lanbeck P.
      • Odenholt I.
      • Paulsen O.
      Antibiotics differ in their tendency to cause infusion phlebitis: a prospective observational study.
      • Furtado C.
      Incidence and predisposing factors of phlebitis in a surgery department.
      Motion at the wrist or antecubital fossa is postulated to traumatize the veins.
      • Furtado C.
      Incidence and predisposing factors of phlebitis in a surgery department.
      Mechanical irritation of the vascular wall by the catheter tip damages the endothelium. This process induces inflammation of the vascular wall, with fibrin deposition and thrombus formation.
      • Zingg W.
      • Pittet D.
      Peripheral venous catheters: an under-evaluated problem.
      To illustrate the role of splinting in the prevention of phlebitis in adults, we conducted a preliminary study. With wrist flexion and extension, a volunteer study noted a 6.7-mm excursion despite fixation by a transparent dressing. The trauma caused to the veins is evidenced by the horizontal pistoning of the intravenous catheter at the wrist joint, which is illustrated in Figure 1. Given that patients with a cannula at the wrist are subjected to repeated wrist flexion and extension, it is considered that this continual excursion must predispose to infection. Figure 2 shows an example of a wrist splint.
      Figure 1
      Figure 1Pictorial demonstration of the horizontal pistoning of the intravenous cannula of the wrist with motion. (A) Splinted wrist in neutral position and the catheter of the intravenous cannula visible at 0.26 cm from the site of insertion. (B) Unsplinted wrist in flexion and the catheter of the intravenous cannula visible at 0.41 cm from the site of insertion. (C) Unsplinted wrist in extension and the corresponding disappearance of the catheter of the intravenous cannula.
      Figure 2
      Figure 2Photos of the right wrist that has an intravenous cannula with and without splint in the neutral position. (A) Side view of the splinted right wrist. (B) Bird’s eye view of the nonsplinted right wrist. (C) Bird’s eye view of the splinted right wrist.
      While splinting demonstrates great potential in the prophylaxis of phlebitis, it has yet to be established in current clinical practice guidelines on phlebitis prevention in adults by the Centers for Disease Control and Prevention.
      • O'Grady N.P.
      • Alexander M.
      • Burns L.A.
      • et al.
      Guidelines for the prevention of intravascular catheter-related infections.
      The practice of splinting may be met with resistance, as health care is a complex adaptive system involving many stakeholders and regulations.
      • Braithwaite J.
      Changing how we think about healthcare improvement.
      Only 50% to 60% of care has been delivered in line with level 1 evidence or consensus-based guidelines for at least a decade and a half.
      • Braithwaite J.
      Changing how we think about healthcare improvement.
      Implementing new changes will require hospitals to amend their protocols, as well as education and collaborative efforts by physicians, nurses, and administrators.
      Secondly, we challenge the standard practice of changing intravenous cannula routinely as a preventive strategy for phlebitis. According to the Centers for Disease Control and Prevention, it is recommended to change the catheter site every 72 to 96 hours.
      • O'Grady N.P.
      • Alexander M.
      • Burns L.A.
      • et al.
      Guidelines for the prevention of intravascular catheter-related infections.
      However, whether catheters should be replaced based on clinical indications remains unresolved. This is despite increasing convincing evidence that clinically indicated catheter replacement may not increase the risk of phlebitis compared with routine replacement of catheters.
      • Rickard C.M.
      • Webster J.
      • Wallis M.C.
      • et al.
      Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.
      • Webster J.
      • Clarke S.
      • Paterson D.
      • et al.
      Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial.
      • Rickard C.M.
      • McCann D.
      • Munnings J.
      • McGrail M.R.
      Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial.
      • Webster J.
      • Osborne S.
      • Rickard C.
      • Hall J.
      Clinically-indicated replacement versus routine replacement of peripheral venous catheters.
      • Chang W.P.
      • Peng Y.X.
      Occurrence of phlebitis: a systematic review and meta-analysis.
      In a multicentered, nonblinded randomized equivalence trial, the incidence of phlebitis was 7% in both the routine group, whereby catheters were replaced every 72 to 96 hours, and also the clinically indicated group, whereby catheters were replaced in the event of phlebitis, infiltration, occlusion, accidental removal, or suspected infection related to the catheter.
      • Rickard C.M.
      • Webster J.
      • Wallis M.C.
      • et al.
      Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.
      This is in good agreement with previous randomized controlled trials,
      • Webster J.
      • Clarke S.
      • Paterson D.
      • et al.
      Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial.
      • Rickard C.M.
      • McCann D.
      • Munnings J.
      • McGrail M.R.
      Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial.
      a Cochrane review,
      • Webster J.
      • Osborne S.
      • Rickard C.
      • Hall J.
      Clinically-indicated replacement versus routine replacement of peripheral venous catheters.
      and a systematic review.
      • Chang W.P.
      • Peng Y.X.
      Occurrence of phlebitis: a systematic review and meta-analysis.
      Catheters replaced based on clinical indication remained intact longer and had fewer complications.
      • Maier D.
      To replace or not to replace? Replacing short peripheral catheters based on clinical indication.
      It can increase patient satisfaction and decrease equipment requirements and staff time by 40%. It is projected to result in $203,380.80 in annual savings. This is similarly demonstrated in a cost-effectiveness analysis performed alongside a randomized controlled trial.
      • Tuffaha H.W.
      • Rickard C.M.
      • Webster J.
      • et al.
      Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters.
      Given that there are no significant differences between clinically indicated, as compared with routine, replacement of catheters, it would be recommended to modify current guidelines for catheters to be changed when clinically indicated.
      The implementation of this change is predicated on the basis that the clinical manifestations of phlebitis can be recognized in a standardized manner. However, change may be difficult in view of the fact that current assessment tools for phlebitis are highly observer dependent according to a systematic review.
      • Ray-Barruel G.
      • Polit D.F.
      • Murfield J.E.
      • Rickard C.M.
      Infusion phlebitis assessment measures: a systematic review.
      It would be necessary to revise current tools to include objective pictorial correlation illustrating the different stages of phlebitis.
      The prevalence of phlebitis may be the reflection of a problem in infection control, which is invariably linked to patient safety.
      • Burke J.P.
      Infection control – a problem for patient safety.
      It is concerning, as publications have reported that the average compliance to hand hygiene has varied among hospitals from 16% to 81%.
      • Burke J.P.
      Infection control – a problem for patient safety.
      As Staphylococcus aureus, which is a common skin flora, is the predominant causative organism in phlebitis, the compliance to aseptic technique should be emphasized.
      • O'Grady N.P.
      • Alexander M.
      • Burns L.A.
      • et al.
      Guidelines for the prevention of intravascular catheter-related infections.
      In summary, the provision of effective prevention strategies is a barrier to minimizing the occurrence of this nosocomial infection. The stepping stone to the implementation of the prevention strategies would be changing the hospital protocols, and effectiveness can be achieved only with collaborative effort involving all rungs of the health care system. Priorities for future research may include the elucidation of the role of splinting or the optimal duration for catheter change to provide for more compelling evidence upon which effective prophylaxis and management should be based.

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