Running Header: IMPLICATIONS FOR PIVC DISCONTINUATION
Implications for Clinically Indicated Discontinuation of Peripheral Intravenous Catheters
Andrew Bierman
Azusa Pacific University
Diana Amaya Rodriguez, PhD, MS, CNS, RN
GNRS 507 – Scientific Writing
April 4th, 2015
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The most recent research of peripheral intravenous catheter (PIVC) discontinuation is
based on clinical indication rather than on routine. The purpose of this literature review is to
provide a detailed analysis and discussion of PIVC discontinuation intervention research. This
literature review will incorporate the most pertinent research that has addressed PIVC
discontinuing interventions, specifically when clinically indicated.
Background
CDC recommendations support the removal of peripheral intravenous catheters (PIVCs)
on a routine schedule. The CDC recommendations were based upon three studies completed
between the years of 1983 and 1998 (CDC, 2011). Although the incidence of phlebitis and blood
stream infections associated with PIVCs was usually low, serious complications can lead to
death due to the frequency at which such catheters are used (CDC, 2011). Phlebitis is identified
as the leading cause of sepsis and infection associated with PIVC usage (Ho & Cheung, 2012).
Discontinuation of the PIVC based on clinical indications rather than routine can allow for
longer PIVC indwell times without an increase in phlebitis and infection. This would lead to
decreased PIVC insertions, discomfort, and pain when PIVC’s are used throughout the patient's
hospital stay. In hospitalized adult patients with Peripheral Intravenous Catheters (PIVCs) that
are used throughout the patients' hospital stay, does PIVC discontinuation when clinically
indicated extend PIVC indwell time with no increase in incidences of phlebitis, versus PIVC
discontinuation based on routine schedule?
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Current Guidelines and their Challenges
Each year, millions of peripheral intravenous catheters are discontinued 72-96 hours after
insertion (Rickard, Webster et al., 2012). Early studies showed a correlation between indwell
times and incidence of phlebitis (Rickard, McCann et al., 2014). As a result, the CDC
recommend that PIVCs be discontinued based upon a routine schedule in order to decrease the
incidence of phlebitis (CDC, 2011). CDC recommendations are adopted by hospitals across the
world, however, research is finding no clinical preferences for discontinuing PIVCs based on
routine against discontinuing PIVCs when clinically indicated (Ho & Cheung, 2012).
Furthermore, Clemen et al. (2012) pointed out that, of the articles utilized by the CDC to support
their recommendation, all but one article focused on the use of central venous catheters (CVCs)
instead of PIVCs. Van Donk, Rickard, Doolan, and McGrail (2009) concluded that routine
discontinuation of PIVCs is only more beneficial than clinically indicated discontinuation when
the discontinuation occurs every 24 hours. However, the study highlighted how unfeasible that
would be, as the cost, patient discomfort, and time expenditure by the nurses would dramatically
increase. It is clear from these varied indications that a review of current guidelines is necessary.
Clinically Indicated Discontinuation
The need for the CDC to review the standards for discontinuing PIVCs is apparent.
While currently, PIVCs are being discontinued on a routine schedule, clinically indicated
discontinuation focuses on removing the catheter only when necessary. Discontinuing PIVCs
when clinically indicated can allow for longer indwell times (Rickard & Webster et al., 2012).
These longer indwell times will lead to less insertions of PIVCs, less catheters used, cost savings
to the hospital and patient, and less discomfort for the patient (Gonzalez Lopez et al., 2014). It is
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important to mention that the most current CDC guidelines released in 2011 do mention PIVC
discontinuation when clinically indicated twice in their guideline recommendations. The CDC
recommends clinically indicated discontinuation of PIVCs for pediatric patients (CDC, 2011).
For adults, they consider PIVC discontinuation by clinical indication as “unresolved,” a term
Rickard and Webster et al. (2012) defines as needing more research. Ho and Cheung (2012)
highlight this as nothing more than confusing for healthcare workers as the CDC recommends an
intervention while at the same time claiming that not enough research has been done on that very
same intervention.
Current Research
Of the ten articles discussed within this literature review, five research articles relate
directly to the relationship between incidence of phlebitis and discontinuing a PIVC based on
clinical indications rather than by routine (Benbow, 2009, Gonzalez Lopez, 2012, Rickard, 2010,
Rickard & Webster 2012, Van Donk, 2009). Other research compared open and closed PIVC
systems being discontinued when clinically indicated and others evaluated nurses' perceptions
and decision making processes for clinically indicated discontinuation of PIVCs. Overall, the
research trends implicate discontinuation of PIVCs when clinically indicated rather than by a
routine.
Variables
Though overall findings show a consensus recommendation for clinical indication,
individual variables play a vital role in determining the findings. Exploring these variables can
further evidence the factors recommending this consensus. Trends found within the research
focused on aspects of PIVC usage such as incidence if phlebitis and indwell times. Additional
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considerations such as nursing assessment and current practices and technology of PIVCs were
also briefly discussed by a few of the research articles, and can contribute to the consensus.
Phlebitis. Phlebitis is an irritation of the vein that causes pain, erythema, swelling, and
heat (Rickard, McCann, Munnings, and McGrail, 2010). Phlebitis was the main variable used to
establish the CDC recommendation, with the purpose to decrease its incidence. Though, not all
of the research studies individually define phlebitis, the previously discussed definition closely
matches the CDC definition. Within the research studies, phlebitis is used as the primary
determinate for catheter failure. The goal of the research was to show that incidence of phlebitis
will not increase when discontinuing the PIVC only when clinically indicated, even if indwell
times prolong. The Rickard et al. (2012) study found that 7% of PIVCs failed due to phlebitis in
both the routine and clinically indicated sample populations, while accounting for longer indwell
times with the clinically indicated group. Benbow (2009) found that only 4% of PIVCs failed
due to phlebitis in the clinically indicated sample group, while 3% of PIVCs failed due to
phlebitis in the routine replacement group. Though the routine replacement group had a 1%
decrease in incidence of phlebitis, Benbow (2009) consider that to be statistically insignificant.
The other research articles (Rickard, 2010, Rickard & Webster 2012, Van Donk, 2009) that
compare routine and clinically indicated PIVC discontinuation had similar findings.
Indwell times. Phlebitis and other catheter related complications are directly associated
with catheter indwell times (Gonzalez Lopes et al., 2013). Indwell times refer to the duration for
which the PIVC catheter remains inserted into the patients vessel. According to research
associated with the CDC guidelines, as catheter indwell times increase, so to do the incidence of
phlebitis (DHHS, 2011). Therefore, the CDC recommended indwell times of no greater than 96
IMPLICATIONS FOR PIVC DISCONTINUATION
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hours. Other research, however, found that indwell times up to 137 hours can be reached without
any statistically significant increase in incidence of phlebitis. In the study by Rickard et al.
(2012), clinically indicated discontinuation allowed for average indwell times of 99 hours
without any increase in phlebitis cases. Furthermore, the study conducted by Van Donk, Rickard,
McGrail, and Doolan (2009) found that PIVC indwell times can increase to 108 hours without
increase in incidence of phlebitis when discontinuing the PIVC based on clinical indication.
Gonzalez Lopez et al. (2012) took the study a step further and found that by utilizing closed
PIVC systems, indwell times can increase to 137 hours when discontinuing only when indicated.
Increasing indwell times can have secondary benefits that include improvements in
patient comfort and cost savings to both the hospital and the patient (Lee et al., 2009). Gonzalez
Lopez (2012) found there to be a nearly $100,000.00 in cost savings overall, when utilizing
closed PIVC systems for up to 137 hours. This cost savings is a shared finding in most of the
other research articles due to increased indwell times and less PIVC insertions. Clemen et al.
(2012) concluded immediate benefits would be that the patients pain and discomfort levels
would decrease due to less PIVC insertions, which would also lend to time savings for the nurses
not having to insert more PIVCs.
Additional considerations. While clinically indicated PIVC discontinuation was
consistently recommended as a superior method for PIVC discontinuation, other factors and
variables may also play important roles in efficacy. Lee et al. (2009) indicate that the utilization
of well-trained IV specialist may be the key to success. Though IV specialist may be an
important factor in the prevention of phlebitis, Benbow (2009) made a point to highlight the
importance of regular nursing assessments of the PIVC sites when changing to a non-routine
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approach for discontinuation, especially in the absence of IV specialists. Though IV specialist
would be ideal for any PIVC usage, the reality is that most hospitals do not have the benefit of
these specialists at all times. The importance of nurses making clinical decisions about PIVC
usage and whether to keep the PIVC indwelling for longer periods of time, is paramount (Palese
et al., 2010). Education and comprehensive training is necessary to ensure the most informed
healthcare professionals, and it is essential to equip them with the tools to adequately care for
PIVCs (Ho & Cheung, 2014).
Another consideration for PIVC discontinuation is the advancement of technology. Since
the 1998 research, there have been PIVC technology advancements. Rickard et al. (2012)
highlighted that the most current PIVCs are made with low-irritant materials that can allow for
longer indwell times without adverse reactions. Gonzalez Lopez (2013) compared closed PIVC
systems in their research and have identified that these systems have lower rates of microbial
contamination. With the inception of new materials and new PIVC systems, indwell times can
increase without the incidence of phlebitis also increasing.
Findings, Strengths, and Limitations.
The most significant strengths found in the research is the overwhelming unanimity and
consensus of the findings. Of the research that compared the incidence of catheter failure, all
found no statistically significant difference in incidences of phlebitis between routine
replacement of PIVCs and clinically indicated replacement of PIVCs. Of the research comparing
indwell times between the two interventions, all research articles found an increase in PIVC
indwell times.
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Though the research articles demonstrate strong evidence towards affirming clinically
indicated replacement of PIVCs, they don’t go without limitations in the research. Sample size
and location diversity were limiting factors in a few of the research studies. The Rickard,
McCann, Munnings, and McGrail (2010) research had only 362 participants from one regional
hospital in Australia. With the Pales et al. (2011) study only 269 PIVCs were observed during
the study. Data accuracy can decline with a low sampling census and poor variability in the
sampling population. The CDC indicates in their guidelines that more research is necessary
before clinically indicated discontinuation of PIVCs is adopted as a recommendation for adults.
Further research to increase the accuracy of the data, is essential especially when working with
interventions that can harm the patient.
Conclusion
Discontinuing a PIVC based on a routine schedule might seem like the best way to
decrease infection in patients, however, the research shows that this may not be the case. The
most current research seems to find no increase in incidence of phlebitis when PIVC indwell
times exceed routine replacement timeframes. Successful implementation of standards based on
clinical indication will rely heavily on comprehensive nursing assessments of the PIVC site,
something nurses already do now Replacing PIVCs when clinically indicated can prolong the life
of PIVCs without an increase in incidence of phlebitis. This can lead to less PIVC insertions, less
patient discomfort, and less costly medical expenditures. Overall, the research supports clinically
indicated discontinuation versus routine. It is clear there are benefits to clinically indicated
discontinuation of PIVCs over routine replacement, and is recommended that the CDC seriously
evaluate current research for adoption as a recommendation into their guidelines.
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Clinical Implications
Clinically indicated discontinuation of Peripheral Intravenous Catheters (PIVCs) provides
benefits beyond just extending indwell times. The key findings of the research implicate the need
for change and create a framework for which a plan for change can be built. The purpose of this
segment is to create that plan for change along with evaluating the question, in hospitalized adult
patients with Peripheral Intravenous Catheters (PIVCs) that are used throughout the patients'
hospital stay, does PIVC discontinuation when clinically indicated extend PIVC indwell time
with no increase in incidences of phlebitis, versus PIVC discontinuation based on routine
schedule?
Key findings and Research Grading
PIVC systems are currently discontinued based upon CDC guidelines which recommends
discontinuation every 72-96 hours. These guidelines were established to decrease incidence of
phlebitis and infection. The most current research finds that the healthcare system and its patients
can benefit from discontinuing a PIVC only when clinically indicated (Rickard et al.,
2012). Current research finds that clinically indicated discontinuation of PIVCs can be
implemented without significant increases in the incidence of phlebitis compared to routine
replacement (Benbow, 2009, Rickard and McCann et al. 2010, Rickard et al. 2012, Van Donk et
al., 2009). Clinically indicated discontinuation can increase PIVC indwell times (Gonzalez
Lopez et al, 2014, Rickard and McCann et al. 2010, Rickard et al. 2012, Van Donk et al., 2009).
The usage of closed PIVC systems versus open systems, has been found to extend indwell times
to 137 hours when clinically indicated (Gonzalez Lopez et al, 2014). The extension of PIVC
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indwell times can lead to a decrease in the number used on patients. Less PIVC insertion may
decrease the incidence of patient anxiety and discomfort associated with their use.
For all research, the Melnyk and Fineout-Overholt scale was used to grade the research
quality. Benbow (2009), Gonzalez Lopez et al. (2014), Rickard and McCann et al. (2010),
Rickard et al. (2012), Van Donk et al. (2009) were all graded as level two studies, as their study
designs were all randomized controlled trials. Clemen et al. (2012), and Palese et al. (2011) were
graded as level four studies, as their design was a case controlled study and longitudinal
observational study, respectively. Ho and Cheung (2011) is graded as a level five study, as their
article was a systematic review and guideline recommendation based on other research.
Implications
CDC guidelines on PIVCs are based upon outdated research and requires an analysis for
possible revision. Currently, PIVCs are discontinued on a routine basis, clinically indicated
discontinuation focuses instead on removing the catheter only when necessary. Discontinuing
PIVCs when clinically indicated allow for longer indwell times (Rickard et al., 2012). These
longer indwell times will lead to less insertions of PIVCs, less catheters used, cost savings to the
hospital and patient, and less discomfort for the patient (Gonzalez Lopez et al., 2014).
Plan for Implementation
Considering that a vast majority of hospitals operate within CDC guidelines, a change
would need to be made at that level. The CDC would need to adopt clinically indicated
discontinuation of PIVCs as a recommendation for adult patients. These recommendations
should include guidelines for assessments as well as maximum thresholds. Ho and Cheung
(2011) recommend the nurse to assess the PIVC site at least two times per shift. If phlebitis,
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blockage, infiltration, or local infection is found, the PIVC should be replaced immediately (Ho,
& Cheung, 2011).
Education is an important factor within the PIVC intervention plan. The nurse is the first
line of defense against phlebitis. By implementing training and education associated with site
assessments, nurses can dramatically increase the efficacy of clinically indicated PIVC
discontinuation. Education of the nurse should focus on identifying early signs of phlebitis, as
well as higher levels of aseptic insertion techniques. Scales are used for many assessments to
assist the nurse in level of care. Creation of a phlebitis scale can be a method in establishing
consistent assessments.
Having the nurse educate the patient on what the PIVC is, what its function is, along with
signs and symptoms of phlebitis, can prove to be invaluable. Equipping the patient with
necessary information can help to prevent phlebitis and bacterial infection. Creating and
implementing training for the nurses and other healthcare professionals is important. It is equally
important to evaluate efficacy of the training and implementations of learned processes. Ho and
Cheung (2011) suggest that clinical guidelines be reviewed every five years and should involve:
re-educating on current implementation guidelines, carrying out reviews of those guidelines, and
conducting audits that review outcomes along with new research,. These reviews can benefit
nurses, along with any staff involved with the PIVC. Potential barriers can be staffing levels
along with the workload of the nurse. These may lead to the nurse being unable to assess the
PIVC site adequately. Oversight and accountability will be key.
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Ethical, Cultural, and Spiritual Considerations
Choosing to implement PIVC discontinuation when clinically indicated shouldn’t happen
without considering the ethical implications. First, these studies are conducted on human
subjects. It’s important to recognize that this intervention can have adverse health effects if not
done properly. If the nurse fails to assess or fails to correctly assess the PIVC site, phlebitis can
lead to sepsis which is a serious health concern (Ho and Cheung, 2011). The study methodology
adopted by the researchers was sound. The researchers only chose healthy adult participants to
study, considering the possible adverse outcomes. Overall, the benefits of this study outweigh the
possible consequences. Though some participants did develop phlebitis in the experimental
group, the researchers found no statistically significant increase in the incidences of phlebitis
between the routine method and clinically indicated method.
Cultural and spiritual sensitivity within the healthcare system has become more important
now than ever before. Its relevance has especially been emphasized as countries around the
world become more culturally and spiritually diverse. It is the responsibility of the healthcare
professional to practice culturally sensitive care and to recognize when certain standard practices
may not be normal to others, particularly minority groups or recent immigrants.
The process of inserting a PIVC can be traumatic, painful, and discomforting. Though its
use is viewed as necessary in a lot of cases, not all patients may understand its purpose. It is
important that healthcare providers take the time to explain the purpose and process of using
PIVCs to everyone, especially those that may be new to its usage. If language barriers exist, it is
important to use a certified hospital translator to ensure that PIVC information is fully
understood. This can allow for an informed decision on its use. It is also important to recognize
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that some religions and beliefs may also have reservations or even completely forbid the use of
PIVCs. Incorporating patient education into aspects of PIVC use, can ensure an adequately
informed patient.
Gaps in the Literature
While the findings of the research found benefits of discontinuing PIVCs based on
clinical indication, there are gaps within the literature. The CDC makes it apparent that more
research is needed with clinically indicated PIVC discontinuation. With a few of the research
studies falling short in population and variability, continuing the current research with larger and
more varied patient populations would have a benefit. Further research should focus on nursing
assessment of PIVC sites, and aseptic insertion techniques. They can bring further benefit to
clinically indicated discontinuation by providing insight into best practices. Another area to
consider research would be patient satisfaction along with cost savings, which can further
emphasize the benefits of the PIVC intervention.
Conclusion
Research shows that discontinuing a PIVC only when clinically indicated is more
beneficial than by routine. The research finds no increase in incidence of phlebitis when PIVC
indwell times exceed routine replacement timeframes. Successful implementation of standards
based on clinical indication will rely heavily on nursing assessments, education of both the nurse
and patient, and the implementation of a review process. While some gaps in the literature find a
need for larger, more varied participant samples, it is clear there are benefits to clinically
indicated discontinuation of PIVCs over routine replacement. It is recommended that the CDC
evaluate current research for adoption as a recommendation into their guidelines.
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References
Benbow, M. (2009, January). Clinically indicated and routine replacement of peripheral
intravenous catheter did not differ for catheter failure [Electronic version]. Evidence
Based Nursing, 12(1), 19.
Centers for Disease Control, United States Department of Health and Human Services.
(2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections,
2011. Retrieved from http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html
Clemen, L. J., Heldt, K. A., Jones, K., Baker, L. L., Pacha, J., Hurm, L., & Renner, C. H. (2012,
January). Assessing Guidelines for the Discontinuation of Prehospital Peripheral
Intravenous Catheters [Electronic version]. Journal of Trauma Nursing, 19(1), 46-49.
Fineout-Overholt, E., Melnyk, B.M., Stillwell, S.B., Williamson, K.M. (2010). Crtical appraisal
of the evidence: Part I. AJN, 110(7). 47 – 52.
Gonzalez Lopez, J., Arribi Vilela, A., Fernandez del Palacio, E., Olivares Corral, J., Benedicto
Martı, C., & Herrera Portal, P. (2014). Indwell times, complications and costs of open vs
closed safety peripheral intravenous catheters: a randomized study [Electronic
version]. Journal of Hospital Infection, 84, 117-126. doi: 10.1016/j.jhin.2013.10.008
Ho, K. H., & Cheung, D. S. (2011, September). Guidelines on timing in replacing peripheral
intravenous catheters [Electronic version]. Journal of Clinical Nursing, 21, 1499-1506.
Palese, A., Cassone, A., Kulla, A., Dorigo, S., Magee, J., Artico, M., & Camero, F. (2011,
October). Factors influencing Nurses Decision-Making Process on Leaving in the
Peripheral Intravenous Catheter After 96 hours [Electronic version]. Journal of Infusion
Nursing, 34(5), 319-326.
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Rickard, C. M., McCann, D., Munnings, J., & McGrail, M. R. (2010, September 10). Routine
resite of peripheral intravenous devices every 3 days did not reduce complications
compared with clinically indicated resite: a randomised controlled trial.BMC
Medicine, 8(53), 1-10. Retrieved from EbscoHost. doi: 10.1186/1741-7015-8-53
Rickard, C. M., Webster, J., Wallis, M. C., Marsh, N., McGrail, M. R., French, V., & Foster, L.
(2012, September 22). Routine versus clinically indicated replacement of peripheral
intravenous catheters: A randomized controlled equivalence trial [Electronic
version].thelancet, 380, 1066-1074. doi: 10.1016/S0140-6736(12)61082-4
Van Donk, P., Rickard, C. M., McGrail, M. R., & Doolan, G. (2009, September). Routine
Replacement versus Clinical Monitoring of Peripheral Intravenous Catheters in a
Regional Hospital in the Home Program: A Randomized Controlled Trial [Electronic
version]. Infection Control and Hospital Epidemiology, 30(09), 915-917.
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Grading Rubric for Clinical Project: Clinical Implications Paper:
Category
Transition
Section
Maximum
10 points
Body – Plan for
change
Maximum
35 points
Grading of
Evidence,
Barriers/Facilitat
ors to change,
spiritual/cultural
and ethical
considerations
15 points
Exemplary
Problem clearly
identified.
Thesis statement and
focus of the paper clear
to reader.
Significance to nursing
discussed.
PICOT question
included
Appropriate findings
from your literature
review identified and
discussed.
Uses inference and
reason to draw logical
conclusions about
implications and
consequences.
Identifies a strategy and
potential problems.
Provides support for
change or innovation.
Transitions link sections
and paragraphs well.
Content vocabulary
appropriate, used well.
Evaluation outcome
clearly discussed and
supported
Clear plan developed
to implement change
in practice.
Barriers/Facilitators to
change identified and
addressed, considered
possible ethical
implications,
demonstrates insight
and depth in discussion.
Cultural/Spiritual
Considerations included.
Summary statement of
grading of evidence with
citation.
Meets
Requirements
Needs
Improvement
Problem identified.
Thesis statement clear
to reader
Significance to nursing
identified.
PICOT question
included
Problem unclear.
Thesis statement
unclear or missing.
Significance to
nursing not
addressed.
PICOT question not
included
Literature review
incorporated adequately.
Draws logical
conclusions.
Identifies a strategy and
potential problems.
Proposed change is
understandable and has
support in literature.
Evaluation outcomes
included.
Minor problems with
transition and order of
paragraphs or sections.
Content vocabulary
generally accurate.
Plan developed to
implement change in
practice, but not clear.
Literature review
not incorporated
adequately.
Findings unclear.
Strategies unclear
or not logical.
No support for
proposed changes.
No evaluation
outcome or
evaluation outcome
not clearly
supported.
Many or significant
problems with
transition and order
of paragraphs or
sections.
Significant errors in
content vocabulary.
Plan unclear for
change in practice
Minimal discussion of
possible
barriers/facilitators,
minimal insight and/or
depth.
Ethical, spiritual or
cultural considerations
not all included.
Summary statement of
grading of evidence with
citation.
No discussion of
possible
barriers/facilitators,
no ethical
considerations, no
spiritual/cultural
considerations, no
insight/depth
demonstrated.
No summary
statement of
grading of evidence
with citation.
Points
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Conclusion
Maximum
15 points
Clear, thorough
summary.
Relevance to nursing
clearly stated.
Recommendations clear
and supported.
Problem and findings
summarized.
Relevance to nursing
appropriate.
Recommendations
supported.
Assignment
Max. 5 points
Addresses all required
elements of assignment
& expands them.
No grammar or spelling
errors.
Addresses all required
elements of assignment.
Citations include all
elements of APA
formatting, according
examples in APA 7.01.
No more than two minor
errors in APA style
formatting in all citations.
Follows examples in
APA 7.01.
Follows all APA
formatting guidelines;
uses Word functions
appropriately,
introduction and
conclusion included
Follows all formatting
guidelines; minor
problems with Word
functions.
Grammar &
Spelling
Max. 10 points
APA Format for
Citations
Max. 5 points
*Formatting
Max.5 points
1-2 minor errors per
page.
17
Summary
inadequate.
Relevance to
nursing unclear or
missing.
Recommendations
unclear or
unconnected.
Fails to address all
required elements
of assignment
3 or more errors
per page.
More than two
minor errors or one
significant error in
formatting in all
citations. Does not
follow examples in
APA 7.01.
Formatting errors;
page length
incorrect; poor use
of Word functions.