The Development and Implementation of a Venous

The Development and Implementation of a
Venous Extravasation Assessment System
Sylvia Rineair, BSN, MSHA, RN, VA-BC Clinical Director and Julie Stalf, MSN, RN, VA-BC Education Specialist II
Vascular Access Team
Our interdisciplinary working group developed and
implemented an intravenous extravasation
assessment and documentation tool for use in our
patient population, which includes neonates through
adults. The tool contains a scale for estimating the
volume of fluid extravasated, the level of infusate
risk and documentation. Validation results suggest
unit nurses were quickly able to learn the scale and
measure percentages of extravasations similar to
those obtained by vascular access team (VAT)
nurses. Extravasation Data
Identify the components of a Venous
Extravasation Assessment System based on
patient size and infusate
Tools and Staff Support Systems
All Grades Will Have Two Symbols
1. Percent of extravasation-reported as a number
2. Type of infusate-reported as a letter
The tool contains a continuous scale
for estimating the volume of fluid
extravasated, a three-category
estimation of the potential local
chemical and physical toxicity of the
extravasated medication or agent,
and a volume measurement that can
be used for estimating the size of an
extravasation anywhere on the body.
INS Infiltration Scale:
Did not differentiate between drug and volume
 Any blood product, irritant or vesicant
extravasation was an automatic grade 4 even if
it resulted in no harm to patient
What did we need?
• Simple, easy, clear extravasation grading scale
• No subjectivity
• Extravasations to be graded based on patient
 Once documentation of an extravasation is entered
into the EMR, if the extravasation is 30% or greater
and/or a Red list medication, a page is automatically
generated to the VAT RN to report to the point of
care and assess the site. If indicated, a treatment of
the extravasation can occur quickly.
 VAT RNs are also available to assist the unit staff
with questions or follow up regarding venous
 A policy specific to the treatment and management of
venous extravasations was also developed at
Cincinnati Children’s. This policy can be used as a
tool in decision making about treating a venous
extravasation and is based on the size of the
extravasation and the infusate.
An evidence-based
table of medications
stratified by their
relative risk of causing
harm if extravasated
was developed at
Cincinnati Children’s
Hospital Medical
VAT RNs and Leaders are available to review Touch,
Look and Compare (TLC )poster and PIV assessment
techniques TLC poster
The Venous Extravasation Assessment System has
been expanded to include central venous catheters
Our goal is to eliminate PIV extravasations and prevent
serious harm to our patients.
Neil D. Johnson, MD, Medical Director, Vascular
Access Team
Peggy Hopkins, Education Technical Associate
Click to return to Poster
Assessment/Grading of Extravasation
PIV Extravasation Scenario
RN palpates the swelling at the
widest dimension. It measures
3cm. X = 3cm
RN measures length from
longest fingertip to axilla. It
measures 30 cm. Y = 30cm
Click to return to poster
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