Time for a Change: The Case for Changing Peripheral IV Catheters When Clinically Indicated

Spencer Jones, Registered Nurse and CTO/Founder of Lineus Medical

Spencer Jones, Registered Nurse and CTO/Founder of Lineus Medical

Administration of fluids using a peripheral intravenous catheter (PIVC) is an extremely common occurrence in hospitals across the nation. Between 60-90% of all patients in the hospital receive a PIVC during their stay (1). Over the past decade, there has been growing debate about how frequently these devices need to be changed. The status quo has been to routinely change these devices every 72-96 hours, even if the PIVC was still functioning appropriately with no signs of complications. In recent years, many clinical studies have been performed to compare outcomes of PIVCs that were changed routinely against those that were only changed when clinically indicated (presence of a complication, infection, device malfunction, etc.). With over 300 million PIVCs sold in the US every year, the economic and clinical outcomes of such a policy change could be vast (2). In this post we will review current literature on this topic and discuss current recommendations for the changing of PIVCs in an inpatient setting. 

The 2006 Infusion Nursing Standard Practice manual stated that “Peripheral short catheter sites should be changed every 72 hours in the adult population. Catheters placed in pre-hospital or external institutions are to be replaced within 24 hours of admission unless contraindicated” (3). The routine replacement of these catheters was meant to prevent complications from occurring, such as infections, phlebitis, dislodgement, and other mechanical complications. The average dwell time for PIVCs varies greatly based on a number of patient characteristics and other clinical factors. A study of 592 patients in 2015 found an average dwell time of 62.21 hours, but noted that dwell times ranged from 10 minutes to 184.8 hours (4). Similar to the wide-ranging dwell times seen with PIVCs, complication rates with PIVCs are notoriously varied. According to a 2015 study in the Journal of Infusion Nursing, PIVC failure rates were reported to be as high as 63% (1). With these abysmal complication rates, one can see why routine replacement was a viable policy. However, many clinicians saw the inherent inefficiency with removing perfectly good PIVCs based on an arbitrary time limit and sought to investigate if the routine replacement really contributed to significant improvement in clinical outcomes. 

A group from Cochrane Systematic Review has been looking into this very issue since 2010. They provided their third update on this topic through a meta-analysis of peer reviewed, randomized controlled trials in January 2019. All together, they reviewed nine studies with a total of 7,412 participants and analyzed the outcomes of PIVCs changed routinely versus those changed when clinically indicated. They found no clear difference in rates of catheter-related blood stream infection, phlebitis, blood stream infection from any cause, local infection, mortality, or pain between the two groups. However, they noted that infiltration and catheter blockage are possibly reduced when catheters are changed routinely. They also found that cost was reduced when catheters were replaced when there was a clinical indication to do so. The studies they reviewed did not report on patient satisfaction rates between the groups (5). The authors of the Cochrane review also noted that “Healthcare organizations may consider changing to a policy whereby catheters are changed only if there is a clinical indication to do so, for example, if there were signs of infection, blockage or infiltration. This would provide significant cost savings, spare patients the unnecessary pain of routine re-sites in the absence of clinical indications and would reduce time spent by busy clinicians on this intervention” (5). 

A 2014 study from Queensland Health in Australia investigated the cost-effectiveness of this policy change and found that the clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60, or roughly $5.43 USD (6). This same study estimated that the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5M over 5 years for their facility, or roughly $3.57M USD (6). No serious adverse events related to the study interventions occurred. Although these studies did not monitor changes in patient satisfaction, it is relatively safe to say that the fewer times a patient experiences a needle stick, the happier they will be. 

Implementation of this of this policy, backed by the clinical literature, should be seriously considered by hospitals all over the world. There are clear benefits to the patient, the nurse, and the hospital facility when a well performing IV line can be kept in place. 

References 

1. Helm, R. E., Klausner, J. D., Klemperer, J. D., Flint, L. M., & Huang, E. (2015). Accepted but Unacceptable: Peripheral IV Catheter Failure. Journal of Infusion Nursing, 38(3), 189-203. 

2. Keleekai, N. L., Schuster, C. A., Murray, C. L., King, M. A., Stahl, B. R., Labrozzi, L. J., Glover, K. R. (2016). Improving Nurses’ Peripheral Intravenous Catheter Insertion Knowledge, Confidence, and Skills Using a Simulation-Based Blended Learning Program. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 11(6), 376-384. 

3. Benbow, M. (2008). Clinically indicated and routine replacement of peripheral intravenous catheters did not differ for catheter failure Commentary. Evidence Based Nursing, 12(1), 19-19. 

4. Miles, G., Newcomb, P., & Spear, D. (2015). Comparison of Dwell-Times of Two Commonly Placed Peripheral Intravenous Catheters: Traditional vs. Ultrasound-Guided. Open Journal of Nursing, 05(12), 1082-1088. 

5. Webster, J., Osborne, S., Rickard, C., & Hall, J. (2019). Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews. 

6. Tuffaha, H. W., Rickard, C. M., Webster, J., Marsh, N., Gordon, L., Wallis, M., & Scuffham, P. A. (2014). Cost-Effectiveness Analysis of Clinically Indicated versus Routine Replacement of Peripheral Intravenous Catheters. Applied Health Economics and Health Policy, 12(1), 51-58. 

MKG-0060 04/19 Rev 00