IV Care & Management: Site Monitoring

Implementing the VIP scoreNotes:

Premature peripheral IV catheter failure poses a significant problem that negatively

affects patient treatment and safety.

One of the contributing factors to premature peripheral IV catheter failure is the issue

of infusion phlebitis.

Phlebitis rates vary in the literature. Mowry and Hartman state that phlebitis rates

can range up to 27%.

“...plunging a

needle directly into

a vein can be

accomplished with

perfect ease and

safety under proper

aseptic

precautions, so that

no scar or mark of

any kind is left to

indicate the site of

injection…”.

Dutton (1924)

Regular evaluation of the condition of the IV site is essential to

ensure and maintain patient safety.

Image from Dutton (1924)

Notes:

IV care has been part of healthcare for more than a century.

Dutton (1924) began the journey to better IV safety in 1924. He talked about safety

reduction in scars and marks associated with the therapy.

Every healthcare worker needs to identify how they can contribute to a reduction in

premature peripheral IV catheter failure.

The VIP score was

developed to reduce

the incidence and

impact of infusion

phlebitis. However,

the added benefits

of site monitoring

include early

recognition of other

issues such as

infiltration or

infection.“Phlebitis should be documented using a uniform standard scale

for measuring degrees or severity of phlebitis” (RCN 2010).

Notes:

The Visual Infusion Phlebitis score is a standardised approach to monitoring

peripheral IV catheter sites.

The fact that it encourages site observation means that it also has an impact on

other peripheral IV catheter problems such as dislodgement, infiltration and

infection.

The innovation of this tool is the recognition of the visual nature of peripheral IV

problems and the subsequent benefits of a visual tool to identify these issues early.

Infusion phlebitis

originates from two

main sources. One

is mechanical the

other is chemical.

By far the most

prevalent cause of

infusion phlebitis is

chemical in origin.

Early recognition of

phlebitis will help to

maintain patient

safety and comfort.

The first approach to managing infusion phlebitis is

associated with prevention. Prevention includes utilising the smallest gauge catheter for its intended use and ensuring

adequate blood flow past the tip of the catheter.

The second requirement associated with

infusion care is the detection of the earliest signs of infusion phlebitis.

Notes:

The insertion of appropriate vascular access devices will make significant

reductions in the incident of infusion phlebitis.

This must be supported by the introduction of a standardised tool for the monitoring

of peripheral IV sites.

Image from:NAVAN (1998) Tip location of peripherally inserted central catheters. Journal of Vascular Access Devices. 3(2), p.8-10.

Blood flow in the

cephalic and basilic

veins in the upper

arms is 40 to 95ml/

min compared to

the superior vena

cava with a blood

flow of 2000 ml/min

(Stranz and

Kastango 2002).

Notes:

As we mentioned earlier prevention of phlebitis is the primary concern.

Consideration of blood flow around the tip of the catheter is important to

understand.

Blood flow in the veins of the arms may be as little as 40ml/min (Stranz and

Kastango 2002).

During the administration of irritant drugs the reduced blood flow may result in an

increased incidence of infusion phlebitis.

"...phlebitis caused

by infusates of

incorrect pH and

osmolarity occurs

frequently... The

degree of cellular

damage from either

low or high pH is

determined by the

type of tissue

exposed to the pH

and the duration of

exposure” (Stranz

and Kastango 2002).

Table from:Stranz, M. and Kastango, E.S. (2002) A review of pH and osmolarity. International Journal of Pharmaceutical Compounding. 6(3), p.216-220.

Notes:

Consideration of blood flow past the tip of the catheter must be viewed in

association with the chemical composition of the drug to be infused.

A pH between 5 and 9 is considered appropriate for safe peripheral administration.

However, Stranz and Kastango (2002) describe how a phlebitic episode depends

upon the type of tissue that the drug is coming into contact with. They further

describe “In vitro experiments have demonstrated that solution pH values of 2.3 and

11 kill venous endothelium cells on contact.”

http://www.kennedys-law.com/media/docs/KennedysMedicalLawBriefMarch2010_832010.htm

Failure to monitor

and document the

condition of a

peripheral

intravenous catheter

site may result in a

claim due to a

breach in duty of

care.

Notes:

As health care workers we have a duty of care to monitor the condition of a patients

IV site.

Failure to monitor IV sites is seen as failure in duty of care. The VIP score is

internationally acknowledged as a proven standardised tool for the monitoring of

peripheral IV catheter sites.

In 2006 Paulette

Gallant and Alyce

Schultz completed

an evaluation of the

VIP score as a tool

that determines the

appropriate

discontinuation of

peripheral

intravenous

catheters.

Gallant and Schultz (2006) state that...

“The VIP scale, as evaluated in this study, was considered to be a valid and reliable measure for determining when a PIV catheter should be removed” Galant and Schultz (2006).

The VIP score is the tool recommended by the RCN (2010) and the Department of Health (2010) in the UK.

Also, the VIP score is recommended in the Infusion Nursing Standards of Practice (INS 2011). Stating that...

“The Visual Infusion Phlebitis (VIP) scale has content validity, inter-rater reliability, and is clinically feasible. This scale includes suggested actions matched to each scale score” Infusion Nurses Society (2011).

VIP score recommendations

Notes:

The VIP score empowers healthcare workers. IV catheters can be removed at the

first indication of phlebitis.

The VIP score is recommended by the Department of Health (UK), INS (US) and RCN

(UK). It is also used in many other countries and has been translated into a number

of languages.

The VIP score is

accepted as the

international tool for

the early recognition

of infusion phlebitis

and appropriate

removal of the

vascular access

device.

VIP score incorporated into national bundles

Notes:

Here we have an example of a peripheral IV care bundle for the Department of

Health (UK).

All patients with a

peripheral

intravenous access

device in place must

have the IV site

checked at least

daily for signs of

infusion phlebitis.

The subsequent

score and action(s)

taken (if any) must

be documented.

The cannula site must also be observed when: Bolus injections are administered IV flow rates are checked or altered

Solution containers are changed

Notes:

The VIP score is based around a traffic light system of site monitoring.

0 = Site is healthy.

1 = Extra vigilance required. Closely monitor the IV site as infusion phlebitis may

soon develop.

2 = First signs of early phlebitis. Remove short peripheral IV device.

3 - 5 = Established phlebitis of increasing degrees of severity.

Removal of vascular access devices at VIP stage 2 should ensure that extreme

levels of phlebitis rarely occur.

Danchaivijitr et al

(1995) states 34.1

per cent of infusions

are interrupted by

complications of

which 6.2 per cent

were infusion

phlebitis.

ReferencesDanchaivijitr, S., Srihapol, N., Pakaworawuth, S., Vaithayapiches, S., Judang, T., Pumsuwan, V. and Kachintorn, K. (1995) Infusion-related phlebitis. Journal of the Medical Association of Thailand. 78, Suppl 2:S85-90.

Department of Health (2010) High impact intervention: Peripheral intravenous cannula care. DH, London.

Dutton, W.F. (1924) Intravenous Therapy: Its application in the modern practice of medicine. F.A. Davis Company, Philadelphia.

Gallant P and Schultz AA (2006) Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing. vol. 29, no. 6, p. 338-45.

INS (2011) Infusion Nursing Standards of Practice. Journal of Infusion Nursing. Supplement. 34(1s).

Jackson A. (1998) A battle in vein: infusion phlebitis. Nursing Times. 94 (4), p.68-71.

Jackson A. (2003) Reflecting on the nursing contribution to vascular access. British Journal of Nursing. 12(11), p.657-665.

Mowry, J.L. and Hartman, L.S. (2011) Intravascular thrombophlebitis related to the peripheral infusion of amiodarone and vancomycin. Western Journal of Nursing Research.33(3), p.457-471

NAVAN (1998) Tip location of peripherally inserted central catheters. Journal of Vascular Access Devices. 3(2), p.8-10.

RCN (2010) Standards for infusion therapy. Royal College of Nursing, London.

Stranz, M. and Kastango, E.S. (2002) A review of pH and osmolarity. International Journal of Pharmaceutical Compounding. 6(3), p.216-220.

Notes:

Every short peripheral IV catheter should be monitored and the findings

documented.

The VIP score essentially facilitates the removal of short peripheral IV catheters at

the earliest signs of infusion phlebitis.