The Cochrane Review Clinically-indicated replacement versus routine replacement of peripheral venous catheters is an update of a review previously published in April 2013, and first published in 2010 from the Cochrane Vascular Group.
The review found significant evidence that routinely changing or replacing peripheral venous catheters is no better than replacing when clinically indicated. The Group has reported that this evidence has a potential cost saving to the NHS of £40 million over a five-year period. Here’s its story from publication to informing policy. How it began The US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72-96 hours - ie every 3-4 days. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients, and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. The Cochrane researchers wanted to assess the effects of removing peripheral IV catheters when clinically indicated, compared with removing and re-siting the catheter routinely. The Cochrane Review found no evidence of benefit to support the widespread current practice of changing catheters routinely. What’s been the Impact of this Cochrane evidence?Upon assessment of these findings, healthcare organizations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings, and would also spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimize peripheral catheter-related complications in the context this revised procedure, insertions site should be inspected at each shift change and catheters removed if signs of inflammation, infiltration, or blockage are present. This Cochrane Review directly informed two recommendations (IVAD29 and IVAD28) in the UK's National Institute for Health and Clinical Excellence (NICE) accredited national guideline for preventing healthcare-associated infections in National Health Service (NHS) hospitals in England (Epic3). These recommended implementing a clinically indicated strategy rather than routine replacement. A recent cost analysis to asses how much adopting this evidence-based practice would save the NHS came to the following conclusions: “To implement clinically indicated replacement of peripheral catheters, hospitals that currently undertake routine catheter replacement practice will need to update their policy… . [I]f only one-third of the 11.5 million hospital admissions to NHS England hospitals every year required peripheral venous catheterization for more than three days, the expected population for the proposed strategy implementation over five years would be around 20 million patients. Accordingly, we calculate that if the clinically indicated strategy was fully implemented in all NHS hospitals in England, then the cost savings to the system would be around ₤40 million over five years.” Supporting resources Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Browne J, Prieto J, Wilcox M. epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. London: Richard Wells Research Centre, University of West London; 2013. Journal of Hospital Infection 2014; 86S1: S1-70. This update contains two new trials, taking the total to nine included studies with 7412 participants. Eight trials were conducted in acute hospitals and one in a community setting. We rated the overall certainty of evidence as moderate for most outcomes, due to serious risk of bias for unblinded outcome assessment or imprecision, or both. Because outcome assessment was unblinded in all of the trials, none met our criteria for high methodological quality. Primary outcomes Seven trials (7323 participants), assessed catheter-related bloodstream infection (CRBSI). There is no clear difference in the incidence of CRBSI between the clinically indicated (1/3590) and routine change (2/3733) groups (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.08 to 4.68), low-certainty evidence (downgraded twice for serious imprecision). All trials reported incidence of thrombophlebitis and we combined the results from seven of these in the analysis (7323 participants). We excluded two studies in the meta-analysis because they contributed to high heterogeneity. There is no clear difference in the incidence of thrombophlebitis whether catheters were changed according to clinical indication or routinely (RR 1.07, 95% CI 0.93 to 1.25; clinically indicated 317/3590; 3-day change 307/3733, moderate-certainty evidence, downgraded once for serious risk of bias). The result was unaffected by whether the infusion was continuous or intermittent. Six trials provided thrombophlebitis rates by number of device days (32,709 device days). 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). One trial (3283 participants), assessed all-cause blood stream infection (BSI). We found no clear difference in the all-cause BSI 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%); moderate-certainty evidence, downgraded one level for serious imprecision). Three trials (4244 participants), investigated costs; clinically indicated removal probably reduces device-related costs by approximately AUD 7.00 compared with routine removal (MD −6.96, 95% CI −9.05 to −4.86; moderate-certainty evidence, downgraded once for serious risk of bias). Secondary outcomes Six trials assessed infiltration (7123 participants). 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%); moderate-certainty evidence, downgraded once for serious risk of bias). Meta-analysis of seven trials (7323 participants), found that rates of catheter failure due to blockage were probably lower in the routine-replacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.01 to 1.29; routine-replacement 519/3733 (13.9%); clinically indicated 560/3590 (15.6%); moderate-certainty evidence, downgraded once for serious risk of bias). Four studies (4606 participants), reported local infection rates. It is uncertain if there are differences between groups (RR 4.96, 95% CI 0.24 to 102.98; clinically indicated 2/2260 (0.09%); routine replacement 0/2346 (0.0%); very low-certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision). 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; low-certainty evidence, downgraded two levels for very serious imprecision). One small trial (198 participants) reported no clear difference in device-related pain between clinically indicated and routine removal groups (MD −0.60, 95% CI −1.44 to 0.24; low-certainty evidence, downgraded one level for serious risk of bias and one level for serious imprecision). The pre-planned outcomes 'number of catheter re-sites per patient', and 'satisfaction' were not reported by any studies included in this review. This website uses cookies. By continuing to use this website you are giving consent to cookies being used. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. Got it, thanks!
Aladeen Alloubani1, *, Mohammad Awwad2, Laila Akhu-Zaheya3
1 Nursing Research & EBP Unit, King Hussein Cancer Center, Jordan and Harvard Medical School, United States
2 Nursing Administration, King Hussein Cancer Center, Jordan
3 Faculty of Nursing, Jordan University of Science and Technology, and King Hussein Cancer Center, Jordan  Article History:Received Date: 29/6/2018Revision Received Date: 11/12/2018 Acceptance Date: 7/1/2019 Electronic publication date: 23/1/2019 Collection year: 2019
Current literature indicates the optimal replacement time of an intravenous catheter, ranges from when “clinically indicated” (i.e. signs of complications such as infection, occlusion, and/or phlebitis) to three days. The time constraint is designed to prevent infection(s) and phlebitis, as well as to decrease the costs of healthcare, and the time spent by nurses, on patient care.
To evaluate the impact of routine removal and re-siting of the peripheral intravenous catheter removal, compared to removal when “clinically indicated” by adults and/or pediatrics.
A search for literature was conducted via Cochrane Review and Web of Sciences™ Core Collection, MEDLINE, and PubMed to summarise the optimal timing for peripheral intravenous cannula replacement. One reviewer individually evaluated the trial(s), review(s), quality of the guidelines, and then, extracted the data.
Criteria included guideline(s); randomized controlled trial(s); and reviews; all of which matched routine removal of peripheral intravenous cannulation, with re-sited when “clinically indicated”, only in patients in the hospital, partaking in intravenous medication and/or fluids. Articles of relevance to the topic, published in English, French, or Portuguese, prior to 2018, were reviewed.
The effective implementation of evidence-based, guideline-based practice can decrease the catheter-related infection risk. While larger multi-site trials are required, present-day evidence asserts: the repetitive inserting of a peripheral intravenous device may raise the patient’s level of discomfort, increase the costs of healthcare, and does not decrease complications associated with peripheral intravenous devices.
The clinically indicated intravenous catheter replacement procedure is cost-effective, compared with the recurring replacement procedure, which recurs every 72 hours; it has been suggested that healthcare institution(s) and hospital(s) have considered revising the policy, whereby intravenous catheters are replaced, if clinically indicated, only.
Keywords: Cannula replacement, Catheter-related bloodstream infection, Clinically indicated, Infection, Phlebitis, Peripheral intravenous catheter removal.
‘Intravenous Therapy’ is a common, invasive procedure amongst hospitalized patient(s), and relates to the incidence of phlebitis. Several hospitals have protocols in place, wherein replacement of IV catheters should occur between 72 to 96 hours, regardless of clinical indication. This time constraint has been designed to prevent possible complications such as infection, occlusion, and/or phlebitis. According to the Infusion Nurses Society (INS) guidelines (2016) however, there is no need to change the peripheral intravenous cannula for adult patients, after 72 hours [1]. The INS guidelines revealed that the catheter for adult patients should be changed when clinically indicated only. For children, however, the catheter replacement is recommended only when clinically indicated. Interventions have been created to decrease the incidence of phlebitis, including: Changing the catheter material(s) [2], the use of heparinized catheters [3] and innovative techniques for securing the catheters [4]. Registered Nurses are authorized to insert peripheral intravenous cannulation for patients who need intravenous fluid(s) and/or treatment(s). Accordingly, from the time of insertion to the time of the catheter’s removal, Registered Nurses have an essential role in patient care and frequently check the catheter to limit and/or prevent complication(s). This study aimed to evaluate the impact(s) of peripheral intravenous catheters removal and routinely re-siting the catheter, compared with removal when clinically indicated, by pediatrics and adult patients.
All randomized controlled trials, guidelines, and systematic reviews, examining the routine removal of peripheral intravenous and removal only when clinically indicated were included; cross-over trials were not included in this review. However, research involving patients’ needing peripheral intravenous cannulation to be on site, for at least 72 hours, for the administration of the intravenous therapy, was included as well. These involved patients in a healthcare setting(s) such as clinics, hospitals, and/or nursing homes. However, any study comprised of patients receiving nutrition and/or parenteral fluid(s) was excluded. Any duration of routine replacement or clinically indicated replacement were involved; cannulation or catheters formed from any brand of material such as metal or plastic; coated or non-coated with any brand of the treatment(s), such as antibiotic or anticoagulant; or covered by any dressing such as gauze or transparent occlusive were included.
A randomized controlled trial is defined as “a study design which assigns participants (randomly) to a control group or an experimental group. As the study is conducted, the only expected difference between the control and experimental groups in a Randomized Controlled Trial (RCT) is the outcome variable being studied,” [5]. A systematic review “is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review,” [6]. Finally, The Institute of Medicine (IOM) [7] defined clinical practice guidelines as “statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” The references were employed in this systematic review, whereby several references are assessed critically to provide evidence on the topic. The results of retrieving the references were explained and summarised in the tables to provide a clear picture of the issue. Based on such results, it was desirable to make judgments and suggestions [8].
A literature search was conducted between January and February 2018 using the Cochrane Review Database and Web of Sciences™, MEDLINE, and PubMed, to review the optimal timing for replacement of peripheral intravenous cannulation. The search terms were “cannula replacement,” “clinically indicated,” “catheter-related bloodstream infection,” “infection” and “phlebitis.” All the articles for relevance to the topic published in the English, French or Portuguese languages before 2018 were reviewed. Looking for the best evidence, the search was conducted for the last ten years from 2008 to 2018. However, we found some important articles in the literature prior to 2008; thus, it was included in the inclusion criteria. However, the first author individually assessed all the clinical trials, systematic reviews and guidelines quality to extract the data.
According to the Human Subjects Protection guidelines, this review was considered IRB-exempt, since all the studies included in this review were published, available online, and individual patients were not identified. The study was based on ethical guidelines for conducting studies. All the sources included in the study are appropriately cited and referenced.
Twenty-one studies of optimal timing for peripheral IV cannula replacement in adults and paediatrics were identified. These studies included eight randomised, controlled trials, five non-randomized trials, and eight systematic reviews and guidelines. Table 1 summarizes the studies regarding the optimal timing for peripheral IV cannula replacement in adults, while Table 2 summarizes the studies regarding the optimal timing for the replacement of peripheral intravenous cannula in paediatrics.
Despite the fact, most hospitals’ policies indicated routine changes of intravenous catheters every 3 to 4 days, there is no conclusive evidence to support the benefit of that practice [9-15]. One randomised, controlled trial found that the clinically indicated replacement strategy is more cost-effective, compared with the routine replacement strategy [16]. In addition, another randomized, controlled trial found no difference in occlusion and phlebitis rates amongst patients for whom a peripheral intravenous cannula was replaced routinely 3-4 days and those for whom it was re-sited only when clinically needed [17]. Also, another randomized, controlled trial found that re-siting peripheral intravenous catheters when clinically indicated has no impact on the incidence of failure, based on a composite measure of phlebitis or infiltration [18]. Peripheral intravenous cannulas can be removed when clinically indicated. This shift in practice will minimize many catheter insertions, the associated discomfort, and extensive costs in both equipment and staff workload; also it would spare patients the unnecessary pain-related to routine re-sites [12, 16, 19-21]. In addition, clinically indicated intravenous cannula replacement is harmless practice especially for patients who are at low risk for infection and who are not receiving total parenteral nutrition, blood transfusions, or interleukin [12, 14, 22].
Table 1. Summary of optimal timing for peripheral intravenous cannula replacement in adults’ studies.
Table 2. Summary of optimal timing for peripheral intravenous cannula replacement in paediatrics studies.
There is developing evidence to recommend the prolonged use of peripheral intravenous catheters and with removal only when clinically indicated for pediatric patients [12, 14, 19, 23, 24]. Re-sited the cannula should be avoided when possible, as this will affect and distress the child and parents [23]. One study showed that intravenous cannula could be maintained safely with adequate monitoring for up to six days in critically ill children [24]. Also, one randomized clinical trial showed superior clinical indication method, compared with routine catheter replacement [25]. One study suggested that intravenous catheters indicated replacement when there is accidental dislodgement, phlebitis, occlusion and infection [23]. There are factors that also would interfere with catheter replacement among pediatric patients. This includes the duration and frequency of therapy, the infusate’s properties, the condition and patient preferences [26]. Many studies showed that replacing catheters in children every three days would not decrease phlebitis, bacterial colonisation, or catheter-induced sepsis and could increase extravasation risk [27-30].
Intravenous cannulation is one of the most frequent invasive procedures hospitalized patient would have. The optimal timing for peripheral intravenous cannula replacement among adults and pediatrics patients is still an argumentative issue. A growing number of studies supported the replacement decision of intravenous catheters when it is clinically indicated. However, this study aimed to evaluate the impact of peripheral intravenous catheter removal and re-siting the catheter routinely, compared with removal when clinically needed, among pediatrics and adults. Moreover, there is no conclusive evidence to support the benefit of a routine change of intravenous catheters, every 72 to 96 hours. Though it is recommended to inspect the IV catheter insertion site after every 12 hours to minimise peripheral catheter-related complications, and to replace if signs of inflammation, infiltration, or blockage are present. The duration and frequency of therapy, the infusate’s properties, and the condition and preferences of the patient can be used as conditions to decide on the proper time for intravenous catheter replacement. The studies showed that clinically indicated intravenous replacement method is superior as it minimizes several catheter insertions, discomfort associated with catheter insertion, and extensive costs in both equipment and staff workload. Moreover, it would spare patients the unnecessary pain of routine replacements, especially for pediatric patients. In addition, many randomized, clinical trials found no difference in the rate of phlebitis and/or occlusion among patients for whom a peripheral intravenous catheter was routinely re-sited at 72-96 hours and those for whom it was replaced, only as clinically indicated.
Effective implementation of these evidence-based guidelines practice can decrease the catheter-related infection risk. While larger multisite trials are needed, evidence up to the present time recommends that repetitive insertion of peripheral intravenous devices may make patient upset, discomfort and increase healthcare costs as well as it does not decrease peripheral intravenous devices complications. The clinically indicated intravenous catheter replacement procedure is cost-effective compared with replacement after every 72 hours. It is suggested that hospitals and healthcare institutions consider revising the policy whereby intravenous catheters are replaced if clinically indicated only.
The authors declare no conflict of interest, financial or otherwise. We would like to thank Manar Saleh (University of Houston; Teacher, Houston Independent School District) for her valuable assistance and support in editing and revising this manuscript. |
How long is a peripheral IV site good for?
Pos Terkait
Copyright © 2024 ketajaman Inc.
