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Your paraphrasing of INS SOP on removal is not the same meaning as the actual statement. A clinical indication is the signs or symptoms listed in that same SOP. So pain is an indication to remove, etc. This is the standard now and it is based on many well-conducted reseach studies showing that the outcome of changing based on a defined number of hours or days is no better than changing when clinically indicated. CDC guidelines from 2011 are the final version of that document in that format as they will not be updating the whole thing again. They will be issuing short new guidelines based on available evidence such as the one in 2017 on chlorhexidine gluconate use. They have not issued anything on any VAD removal. Their 2011 statement said removal was not a strategy to decrease infection risk. Also for dozens of years now, the standard for removal of PIVs in peds was when clinically indicated and a number of hours was not used. There has not been a major outbreak of infectious problems in the peds population with this policy. Also, PIVs are still reported for the majority to fail within the first 48 h, so this change in policy does not automatically mean that the dwell time will be greatly extended. It does mean that staff must be taught these clinical indications that mandate immediate removal. In other words, leaving a site in place when there is redness, pain, leaking, etc is not acceptable practice and can lead to far greater complications. I have read far too many depositions in legal cases where the nurse testified to the idea that she could not take it out because the patient had no other other catheter in place. This practice is definitely below the standard of care. So there is no other recommendation for removal of any VAD, including PIVs, based on a number of hours or days. You can use the studies listed in the INS SOP, plus there have been others published since then supporting the clinically indicated change.