We have been at 96 hours for several years now, and we are debating on taking a time limit out of our policy completely. We would like to see the policy state to remove for signs and/or symptoms or phlebitis and/or infection. I have always thought it very mean to remove a perfectly good PIV (especially on a patient with limited access) for no good reason. There are more and more studies being done in this area. It's kinda like pulling a PICC or central catheter for the "possibility" of it causing an infection. We PICC nurses gripe at the doc's all the time for that.
May be a good thing you don't work Ped's. Since the current CDC recommendation is; a child's peripheral catheter should stay in place until the I.V. therapy is complete or a complication develops.
Isn't this a "double standard"?
[quote=karrenberg]I have a really hard time understanding the concept of removing a PIV only for s/s of phlebitis and or infiltration. [/quote]
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
Not so fast Heather. Short peripheral catheters are the only catheters that have the research to support this removal recommendation. The statistics are analyzed using the Kaplan Meier Product Limit Estimator or the point in time when 50% of the catheters have failed from a catheter related reason. So this process eliminates those catheters that were removed for other reasons such as therapy D/C'd that have nothing to do with how well the catheter performs. Now the point in time when 50% of catheters fail has been reported to be 96 hours with a polyurethane catheter studied by Dr. Maki. This figure gets translated into a guideline from CDC and a standard from INS. The INS standards committee chose not to extend the standard to 96 h with the last revision because there were not enough studies so that this could be applied to all hospitals in all settings (remember we are writing standards to the lowest common denominator or the nurses in small facilities that do not have IV teams, etc.)
I am not aware of any studies that have examined the length of dwell time for any CVC using this same statistical method. So don't through the baby out with the bathwater. Just because we do not have this data for CVCs, I do not believe it is appropriate to ignore it for the PIVs.
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
I do work peds and I can tell you elective site changes do not keep a vein a perfectly good vein. In many cases the damage is done in the first 24 hours even though there is no obvious evidence. I have removed many an IV at or before 24 hours and those veins have thickened inflamed walls and do develop some variable damage that may or may not improve to the point that the vein can be used again in the future. Ultimately the more PIVs the patient has the less veins they have left regardless of the dwell time. Ask any chronically ill patient who is dependent on a CVC because of vein depletion (Cystic Fibrosis patients are a good example). It is interesting that patients receiving regular transfusions (e.g. sickle cell patient) can actually have the same vein used on a monthly basis--they get skin scarring and vein entry scarring but the integrity of the vein itself remains good. The infusates are the culprit which is why I think of it as vein failure rather than catheter failure. One dose of Phenergan demonstrates that.
Angela is one of those rare experts - pediatric infusion therapy/vascular access. She has been working in this specialized area for at least the ~20 years that I have known her. I would put what she says about pediatric IV therapy in the same level as Ann Marie Frey and Darcy Doellman. Research also supports what she is saying about the greatest risk of vein damage occurs within the first 24- 48 hours after insertion. And there is a huge impact from drugs and promethazine (Phenergan) is one of the worst!
Do you have an IV Team? What hours do they cover? Sounds like you need one. It sounds as if you need a system-wide approach to solving what sounds like major quality issues. I read medical records every day where the nurse told the patient the site was fine or was "watching" the edema get larger. So it sounds like some of your staff might be headed for legal trouble if they do not improve. I would definitely agree that extending the policy to 96 hours in this case is not the best thing to do. It is also important to emphasize that the time limit is not the only thing they should be concerned about. Any PIV site with any signs or symptoms of any complication requires immediate removal, regardless of the length of dwell time. Also remember the Hawthorne effect - what gets studied gets improved. So maybe any amount of effort you can focus on this problem will make some improvements.
Personally I salute Heather for making an effort to overcome the PIV dwell time double standard. As a society do we feel that adults need to suffer more than children, not sure of the rational? As for sickler phanominom, I assure you, by the time they make 25, there in the same boat as the CF Pt.'s
As for I.V. teams..... Well, let's just say that the primary R.N. is still responsible to assess the I.V. site after the I.V team places it. Not to mention that vanco, nafcilllian,etc... is ordered by M.D.'s, dispensed by pharmacists and done with knowledge of hospital administrators and policy.
Thank you, Lynn, for your kind words.
Inadequate care of PIVs (and other VADs) and lack of recognition/management of complications happens everywhere and we all beat our heads against a wall trying to educate and stay ahead of it. It is a multi level problem.
I have been forced to shorten my orientation time to such a length that it is impossible to get all the information in that needs to be provided. Orientees are filled so full of information the first two weeks that they cannot retain it all. Because nursing schools provide a pitiful education on infusion therapy and it is not unlikely that a graduate may never have placed an IV in school, they learn OTJ training. Because my role has changed, new hires no longer have an opportunity to have a clinical experience with me. So they learn anyway they can and sometimes it is passed on by those that also did not learn --the blind leading the blind, if you will.
I do a lot of informal one on one education everywhere I go--it is amazing to see the reactions, I get, and the statement "I never knew that" or "I was told" (something completely different). Still, one on one is better than nothing and that one person can then educate the other staff--I have seen it happen. And the staff often come to me for clarification of something they've heard. It is an uphill battle but I love when a nurse comes to me and says "I did this..."(the right way) or "You were right--it is better..." (whatever).
Another thing that I think is important is to empower the patient/family with education and an insistance for action if they believe something to be wrong. Listen to the patient ( or the parent, in my case), I tell the staff. I've had kids ask me for a new PIV when I could not see anything wrong except they had pain---good enough for me--no one likes getting stuck so if they're asking there's a good reason.
And, lastly, I changed our sentinal report form to reflect data such as who placed to PIV, if and what with it was wrapped, where it was, etc. so that degree of complication can be correlated to practices. Now just to get folks to be complete with filling it out-LOL.
There is always something you can do--even if it's a little thing-- that can make a big difference. We never have enough staff, enough time or enough resources--right now I am a team of one and I can't tell you how frustrated I get with what I want to do versus what I can do ---then again, I'm sure you all already know.
As far as the "double standard", I'm not sure that is really what's going on. Kids have about half the number of usable veins than adults (not less veins but less accessible veins). You can quickly exhaust their supply. And yes, sicklers suffer vein depletion sometimes before the age of 5 but it's from medication infusion and not transfusions. We see sicklers beyond the age of 30 if they stroked during their childhood but sometimes it's the toddlers who have been the sickest who are the hardest to stick.