Assessing  phlebi,s:  Cau,on  advised!  

Gillian  Ray-­‐Barruel,  RN,  BSN,  Grad  Cert  ICU  Nursing,  BA(Honours)  Senior  Research  Assistant,  OMG  PIVC  Study  PI  and  Coordinator  AVATAR  Group,  Menzies  Health  Ins,tute  Queensland,  Griffith  University  

4th  SEHA  Interna.onal  Nursing  Conference  Abu  Dhabi,  UAE,  November  24-­‐25,  2015  

Session  objec,ves    1.  Describe  the  current  challenges  for  achieving  excellence  in  the  care  provided  to  the  pa,ent  with  a  PIVC.    2.  Review  the  role  of  nursing  research  in  promo,ng  the  development  of  innova,ve  strategies  to  achieve  excellence  in  healthcare  seZngs.    3.  Propose  steps  for  developing  innova,ve  strategies  to  achieve  excellence  in  pa,ent  care  considering  the  various  challenges  nurses  are  encountering.    

RCTs  

Cochrane  Reviews  

Micro  lab  studies  

Prac,ce  surveys,  Cohort  studies  

Knowledge  transla,on,  Educa,on  

Health  Economics  

Pilot  trials,  Simula,on  

Professor  Claire  Rickard,  AVATAR  Founder  and  Head    

• Over  a  billion  PIVCs  inserted  annually  worldwide  • Most  common  clinical  procedure    

•  Blood  sampling  •  Emergency  admission  /  resuscita,on  •  Parenteral  medica,on  •  IV  fluids  

•  >60%  of  hospital  inpa,ents  have  a  PIVC  during  admission  

• Phlebi,s  significantly  increases  risk  of  future  phlebi,s  (Hadaway  2012;  Gallant  et  al,  2006;  Palefski  et  al,  2001)  

Why  should  we  care  about  PIVCs?  

Examined  phlebi,s  scoring  tools  and  signs/symptoms  for  reliability,  validity,  feasibility,  responsiveness.    

COSMIN  guidelines  (COnsensus-­‐based  Standards  for  the  selec,on  of  health  Measurement  Instruments)  

Phlebi,s  Scales  Systema,c  Review    

Results  v  233  studies  reported  infusion  phlebi,s  as  the  primary  outcome  

measure  v  53  of  these  provided  no  defini,on  of  phlebi,s,  despite  the  study  

measuring  phlebi,s  v  180  studies  reported  measuring  phlebi,s  incidence  or  severity  

and  gave  a  defini,on  v  Of  these,  101  used  an  assessment  scale  v  79  used  a  defini,on  only  

§  71  different  phlebi,s  scales  §  15  different  signs/symptoms  

0

10

20

30

40

50

60

70

80 Frequency of reporting symptoms in 71 phlebitis scales

Reported  phlebi,s  prevalence    •  0-­‐91%  for  studies  using  a  scale  •  0-­‐100%  for  studies  using  a  defini,on  alone  • Repor,ng  measures  varied  widely                    

•  (per  PIVC,  per  pa,ent,  per  catheter  day)    Lack  of  consistency  in  measuring  phlebi6s  likely  contributes  to  the  variability  in  reported  phlebi6s  rates  

Results  

•  Many  phlebi,s  scales  and  tools  exist,  but  none  has  been  properly  validated  for  use  in  the  clinical  seZng.  

•  Studies  that  reported  tes,ng  the  psychometric  proper,es  of  scales  (VIP,  INS,  PVC  ASSESS,  etc.)  all  had  several  major  limita,ons.  

Inter-­‐rater  study  of  phlebi,s  signs  •  Subset  of  a  large  mul,centre  RCT  (3283  pa,ents,  5907  PIVCs)  (Rickard  et  al,  Lancet,  2012)  

•  210  pa,ents,  3  hospitals,  246  sets  of  paired  observa,ons  undertaken  within  a  10  min  ,meframe.    

•  Blinded  observa,on,  2  RN  raters,  5  min  apart  

•  7  signs  &  symptoms  (pain,  tenderness,  erythema,  swelling,  warmth,  purulent  discharge,  and  palpable  cord  

Inter-­‐rater  study  •  The  inter-­‐rater  data  were  modelled  into  phlebi,s  scores  using  10  different  scoring  tools    

•  (Barker,  Baxter,  Catney,  Curran,  Lanbeck,  Maki,  Rickard,  Rinenberg,  Van  Donk,  and  Visual  Infusion  Phlebi,s  [VIP]  scales).    

• Only  published  phlebi,s  tools  that  used  the  7  symptoms  our  nurses  assessed  could  be  included  in  the  modelling.  

• Propor,ons  of  specific  agreement  (e.g.  posi,ve,  nega,ve),  observed  and  expected  agreements,  Cohen’s  kappa,  the  maximum  achievable  kappa,  prevalence-­‐  and  bias-­‐adjusted  kappa  were  calculated.    

•  Barker:  ≥  2  of  pain,  swelling,  erythema,  palpable  cord  &  warmth  •  Baxter:  ≥  1  of  pain,  swelling,  erythema,  palpable  cord  &  purulence  

•  Catney:  ≥  1  of  pain,  tenderness,  erythema  &  palpable  cord  •  Curran:  ≥  1  of  erythema  (≥  2.5cm)  &  purulence  

•  Lanbeck:  erythema  and  swelling  with  either  tenderness  or  pain  

•  Maki:  ≥  2  of  pain,  tenderness,  swelling,  erythema,  palpable  cord  &  purulence  •  Rickard:  ≥  2  of  erythema  (≥  1  cm),  swelling  (≥  1  cm),  palpable  cord,  purulence  &  pain  (≥  2  out  of  10)  or  tenderness  (≥  1  cm)  

•  Ri?enberg:  ≥  1  of  (pain  or  tenderness)  or  (swelling  or  erythema)  

•  Van  Donk:  ≥  1  of  pain  (≥  2  out  of  10),  swelling  (≥  1  cm),  erythema  (≥  1  cm),  or  ≥  2  of  pain,  swelling,  erythema  &  purulence  

•  VIP:  ≥  2  of  pain,  swelling  &/or  erythema.  

Phlebi,s  defini,ons  used  

Findings  

•  The  most  prevalent  symptom  was  tenderness:  47/246  observa,ons  (19.1%).    

•  The  Catney  and  Rinenberg  scales  were  the  most  sensi,ve  (phlebi,s  in  >  20%  of  observa,ons)  

• Barker  and  VIP  scales  were  the  most  restric,ve  (no  phlebi,s  detected).    

• Only  ‘tenderness’  ‘erythema’,  and  the  Catney  and  Rinenberg  scales  had  acceptable  (66.7%)  levels  of  inter-­‐rater  agreement.    

Summary  

•  Inter-­‐rater  agreement  for  phlebi,s  assessment  signs/symptoms  and  scales  is  generally  low.    

• Poor  agreement  likely  contributes  to  the  high  degree  of  variability  in  phlebi,s  rates  in  the  literature.    

•  Further  research  and  new  approaches  to  assessing  vein  irrita,on  are  needed.  

No  exis,ng  phlebi,s  scale  or  defini,on  can  be  recommended    

XINS Phlebitis Scale Grade 0 – No symptoms Grade 1 – Erythema at access site with or without pain Grade 2 – Pain at access site with erythema and/or edema Grade 3 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord. Grade 4 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord greater than 1 in in length; purulent drainage. X

Regular assessment of the PIVC site is key! Use  clinical  judgement!  

• Is it needed? Ø If not, remove it. Don’t leave it there, just in case.

• Is it tolerated by the patient? Ø If not, remove it. Consider other access (e.g. oral, PICC)

• Is it working? Ø If not, remove it. Resite IV or insert PICC.

• Is there any evidence of infection from an unknown source? Ø If so, remove the cannula.

•  5,907  PIVCs  from  3,283  pa,ents    

•  Post-­‐infusion  phlebi,s  at  48  hours  was  diagnosed  in  59  (1.8%)  pa,ents.    

•  Fiteen  (25.4%)  of  these  pa,ents  had  phlebi,s  at  removal  and  also  at  48  hours  ater  removal.  

•  Even  ater  the  catheter  is  removed,  the  site  should  be  checked  daily  for  at  least  48  hours.  

Post-­‐infusion  Phlebi,s  

References      Marsh  N,  Mihala  G,  Ray-­‐Barruel  G,  Webster  J,  Wallis  MC,  Rickard  CM.  Inter-­‐rater  agreement  on  PIVC-­‐associated  phlebi,s  signs,  symptoms  and  scales.  J  Eval  Clin  Pract.  2015;21(5):893-­‐9.    Ray-­‐Barruel  G,  Polit  DF,  Murfield  JE,  Rickard  CM.  Infusion  phlebi,s  assessment  measures:  a  systema,c  review.  J  Eval  Clin  Pract.  2014;20(2):191-­‐202.    Rickard  CM,  Webster  J,  Wallis  MC,  Marsh  N,  McGrail  MR,  French  V,  et  al.  Rou,ne  versus  clinically  indicated  replacement  of  peripheral  intravenous  catheters:  a  randomised  controlled  equivalence  trial.  Lancet.  2012;380(9847):1066-­‐74.    Webster  J,  McGrail  M,  Marsh  N,  Wallis  MC,  Ray-­‐Barruel  G,  Rickard  CM.  Pos,nfusion  Phlebi,s:  Incidence  and  Risk  Factors.  Nurs  Res  Pract.  2015;2015:691934.      

For  more  informa,on  or  to  get  involved  in  IV  research,    please  contact  us:    www.avatargroup.org.au  

Ques,ons?