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Gina Ward
Do we need permission to utlize Grading tools ; infiltration, phlebitis

 We do not use a Grading tool for Infiltration/extravasation, nor phlebitis.    I have reviewed the standards and feel that it is a necessary component of our assessment.    I am finding many infiltrates that are not handled properly and the doctors are not even being made aware.    

I have seen the Infiltration/Extravasation grading tool that is in the INS  Policy and Procedure book as well as the one included for Phlebitis in the Standards. 

My question is ;    can we utlize them in our documentation , policy etc....or do we need permission to use them from a particular source??? 

what grading tools are you utilizing?    I would love to see any policies that incorporate the use of a tool .  I will try to attach a copy of the ones I am referring to.

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Image icon Infiltration-chart.png682.73 KB
Image icon phlebitis grading tool.jpg15.41 KB
lynncrni
Permission would be an issue

Permission would be an issue of copyright use. I think most people use those scales without requesting permission, but you should ask request permission from the INS office if you are concerned about it. 

The infiltration scale you posted is not a good one and is not evidence based. It was removed from the INS SOP in 2011. It is only found in an old edition of the policy and procedure book. The are several problems with it, including the fact that blood is not a vesicant as it appears on this scale. It is designed only for adults and only focuses on peripheral infiltration. There is no consideration for extravasation on it either. In 2016 there was only 1 infiltration scale for peds that has been tested for reliability and validity. It is mentioned in the 2016 SOP but the scale was not included. 

 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
Lynn,  

Lynn,  

Thanks for your response .   Could you help me understand better your responses;   I know you made mention of blood not being a vessicant, but I dont read that staement that way on that list.  I dont believe its saying blood is a vessicant, but .........

  I read it as   any infiltration of  blood products, irritants , or vessicants are  to be graded a Grade 4 infiltrate, not that blood is a vessicant.   

You also made mention that it doesnt cover extravasation on there but it does ( without saying it) ;   under the Grade 4 infiltrate, where it says infiltration of any vessicant or irritant, ( that is an extravasation) and that would fall under Grade 4. 

However, I certainly value your expert input.......   so......if the recommendations are for a standardized tool or definition for assessing and documenting infiltration/extravastion ............   which ones should we use?????     why do they recommend using a grading tool  but it seems there is not one out there that has proven effective or valid?? 

Is it then up to the facility to select one they feel would be best utilized???

What is everyone else doing????

Thanks,   Gina Ward RN , VA-BC

 

 

 

Gina Ward R.N., VA-BC

lynncrni
Yes, it is a facility based

Yes, it is a facility based decision as to which grading scale you use and INS has not made a recommendation. As I mentioned there are no scales except for the pediatric one in the study by Pop that has been tested for reliability and validity. There are several scales published and it is important to use a scale, but the decision as to which one is based on what your facility wishes to use. I don't remember the exact wording in the original scale used in the old SOP versions. When I started working on this, the one that was used at that time was similar to the one you attached. But I thought it had stronger language indicating that blood was a vesicant. you are right, this one does not indicate that. I researched this question and spoke with pathologists. We could not find any literature that would indicate that blood was a vesicant or that it would be considered to be at the high end of this scale. Extravasation is the escape of a vesicant medication. Vesicants do their harm in the subq tissue. Irritants do their harm inside the vein. So why would an irritant always be considered to be a grade 4? Does not make sense to me. Clinically one should know if they are working with a vesicant with the potential for subq damage, but the actual clinical picture will be the same except for burning. This scale also does not include absence of blood return, an important point for assessment. The numbers listed in this scale are for adults and do not apply to children whose arms would be smaller. Now that I look at the scale you posted again, it may not be the very same original that appeared in the SOP. We may have made some changes before it went into the P &P book, I just don't remember. Also I have not done a recent literature search so I don't know if there is now a scale that has been tested except for the peds one. There could be something new that  I am not aware of. So, yes a scale of some kind is a valuable tool to guide your staff. When reviewing legal cases, I always wish they had used some type of scale to grade it but very few do. This decision is made by the facility about which one to use. 

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Judybeth
Hi Gina, we do use the scales

Hi Gina, we do use the scales you attached. I have no idea if the hospital asked INS for permission. I think they have been in use at my facility since there inception, which was long before my time. We are also aware the infiltration scale as written is no longer part of the SOP, and both scales weren’t tested. I seem to remember Cochrane review, I think, that ripped one or both scales apart in terms of validity. However, as Lynn stated, it is at least something to help us document what we saw at the time and gives the next nurse something to go by. In our documentation we have a separate area to address blood return assessment ( none, sluggish, brisk) and pain when obvious signs of phlebitis or infiltration aren’t present and may be coming from some other cause. 

Judybeth

Gina Ward
Thank you both for your feed

Thank you both for your feed back.   That does help me alot.

Judybeth,   is there any way you could share your policy with me?      [email protected]

thanks in advance!!   Gina

Gina Ward R.N., VA-BC

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