Running head: PERIPHERAL INTRAVENOUS CATHETERS

Incidence of Infection and Phlebitis in Peripheral Intravenous Catheters:

Routine Versus Clinically Indicated Replacement
Amber Jones Radcliffe, Kathryn Lewandowsky and Tina Hoxie
Western Washington University

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Abstract
Purpose: To examine current findings and recommendations regarding the replacement of
peripheral intravenous catheters (PIVs) within the hospitalized adult population. Specifically, we
wanted to compare the rates of phlebitis and infection in PIVs that are routinely changed every
seventy- two to ninety- six hours versus those that are changed only when clinically indicated.
Rationale: Insertion of a PIV is the most common invasive procedure performed in hospitals
worldwide. Through the last several decades, it has been generally accepted as standard practice
to replace PIVs every seventy- two to ninety- six hours, regardless if the PIV is patent, securely
in place, and asymptomatic of signs of phlebitis or infection. If research indicates that the rates of
phlebitis or infection are the same or lower in PIVs that are changed only when clinically
indicated, compared to those that are changed routinely regardless of their status, then the
evidence should dictate PIVs only be replaced when clinically necessary.
Methods: The thirteen research articles we reviewed included systematic reviews, integrative
analysis, meta-analysis, as well as clinical practice guidelines from the Centers for Disease
Control and Prevention (CDC).
Results: Overwhelmingly, the studies revealed that there is no difference in the rates of phlebitis
and infection in routinely replaced PIVs than in those that are replaced only when clinically
indicated. The CDC claims there is no need to replace PIVs more frequently than seventy- two
to ninety- six hours, but makes no formal recommendation on changing them only when
clinically needed. The research also contained recommendations from randomized controlled

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studies for helping PIVs remain securely in place and patent (which then leads to less
complications and decreases the need for PIVs to be replaced).
Implications: Based on our analysis of the research, PIVs replaced only when clinically indicated
compared to those replaced on a routine basis have the same rates of phlebitis and infection.
Therefore, it would benefit patients, nurses and hospitals to adopt the practice of changing PIVs
only when clinically indicated. The cost savings in nursing labor, supply costs, and overall health
care costs would be significant. (It is our understanding that currently Skagit Valley Hospital
does replace PIVs only when clinically indicated, though no official policy or report from Deb
Fisher, manager of the Intravenous Therapy team at Skagit, was obtained to verify this.)
Keywords: peripheral vascular access, phlebitis, infection, infusion therapy,
documentation, clinical practice guidelines

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Introduction
Currently, the Centers for Disease control and Prevention (CDC) states that adult
peripheral intravenous catheters do not need to be replaced more frequently than every seventytwo hours, in order to minimize the risk for phlebitis and infection (CDC, 2011). It does not
specify a recommended time frame for replacement, which leaves room for interpretation for
clinical practice guidelines. It is estimated that over 200 million PIV catheters are placed in the
United States each year. Of the 200 million catheters, seventy percent of all adult admissions in
the acute care setting require IV therapy for approximately seven to ten days (Morrison & Holt,
2015). Consider that most of those catheters are being routinely replaced every seventy- two to
ninety -six hours, as is common policy amongst hospitals. If instead those PIVs were being
replaced only when clinically indicated, that would quickly add up to saving millions of hours in
staffing, millions of dollars in health care costs, as well as limit exposure to possible infection
that comes with replacing PIVs. Please note that by replacing only when clinically indicated is
defined as the PIV site or area around it as having erythema, pain, tenderness, induration, or
other signs of phlebitis or possible infection, as well as not being patent (Fang, 2012).
According to studies cited by Morrison & Holt (2015), the most common problems with
PIVs is phlebitis. Phlebitis is inflammation of the catheterized vein and is characterized by pain,
tenderness, erythema, warmth, swelling and induration. Phlebitis is typically associated with
mechanical irritation from catheter placement, rather than as a result of infection. The rate of
infection from PIVs is rare and is typically around 0.1% of all catheters placed. Though

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infections associated with PIVs are rare, nurses can play an important part in preventing
infection by increasing vigilance of patients with PIVs who have predisposing factors, such as
age, gender, patient diagnosis and infection at another site. Also, studies show that using an IV
team has been associated with reduced rates of phlebitis and other complications (Clarke, 2016).
Synthesis of Literature
Looking first at the conclusions derived on PIV site infection, a comprehensive study by
Ullman, Keogh, Marsh and Rickard (2015) looked at the difference in infection and phlebitis
rates with routine replacement of PIVs versus replacement when clinically indicated. The
researchers found that none of the patients in either group experienced local venous infection and
only one patient had a catheter related bloodstream infection. The one infection reported was
from the routinely replaced group. A literature review analyzing differences between routine and
clinically indicated PIV replacement, concluded that routine replacement was better supported by
the evidence reviewed. The author noted that while PIV related infection is low, bacteremia from
a PIV tends to be life-threatening in nature, particularly for the immunocompromised patient
population (Clarke, 2016). But another Systematic review by Morrison & Holt (2015),
referenced the same study, and concluded that the sample size used for the study was too small to
produce statistically significant results, making conclusions unsupported. The Morrison & Holt
literature review looked at the evidence to date and found that there was clear support for the
conclusion that PIVs can be changed only when clinically indicated without increasing risk for
infection.

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Another literature review on the same topic looked at seven trials with a total of 4895
patients. The quality of the evidence was rated as high for most outcomes but was downgraded to
moderate specifically for the outcome catheter-related bloodstream infection (CRBSI). Five trials
with 4806 patients found no significant difference between the routine and clinical replacement
groups in regards to CRBSI rate (Webster, Osborne, Rickard, and New, 2015).
A large multicenter, non-blinded, randomized equivalence trial compared routine versus
clinically necessary PIV replacement. Of the 3283 participants, all were inpatients with PIVs
estimated to be required for treatment lasting at least ninety -six hours. The article went on to
mention that in the routine replacement group, the average participant had an IV catheter dwell
time of seventy hours and the clinically replaced group averaged ninety-nine hours. The study
found nine participants in the routine group developed bloodstream infections, compared to just
four patients in the clinically indicated group. Also noted in the study was that one patient in the
routine placement group had a catheter-related bloodstream infection but no one in the clinically
indicated replacement group did (Brown & Rowland, 2013).
Phlebitis incidence was also considered in the studies we reviewed. Of the three large
studies previously described (Ullman et al., 2015; Morrison & Holt, 2015; Webster et al., 2015),
all unanimously concluded that both the routine and clinical replacement groups had the same
rates of phlebitis, which averaged approximately 7%, overall. In fact, Brown & Rowland (2013)
explained that the incidence of phlebitis is nearly identical between the two groups, because after
the vein sustains mechanical trauma from catheterization, the body mounts a biological response,
peaking within twenty- four and forty -eight hours and then resolves. Therefore, both groups

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demonstrate the same rates of phlebitis, because both groups have an average catheter dwell time
greater than forty- eight hours, or the peak of symptoms.
Clinical Practice Recommendations
To decrease the current failure rate of PIVs which averages between 35-50% (Helm,
Klausner, Klemperer, Flint, & Huang, 2015), there are certain clinical practice recommendations
that need to be more widely adopted. One recommendation would be standardizing
documentation of phlebitis. A common theme of frustration found in the research was regarding
adequate assessment of IV site complications, and the lack of consistent assessment scales used
for evaluating and grading phlebitis. In Ray-Barruel, Polit, Murfield & Rickards 2014 study,
they found that there was a poor correlation between documentation and phlebitis rates. Nor
could they find that there has been development of any gold standard (p. 193) with which to be
able to standardize assessment and documentation. Further research was recommended to find
the best assessment tool. By encouraging consistent documentation among hospitals, more
accurate incidence rates of phlebitis in the adult population can be obtained. The most current
recommendation of the Infusion Nurses Society (2011) states that nurses can reliably use one of
two available phlebitis scales (see Appendix A).
Another area of clinical recommendation involves the use of PIV securement devices. An
Integrative review by Alekseyev et al., (2012), described current research on the effectiveness of
IV securement devices. Overwhelmingly, their results demonstrated that the use of IV
securement devices decreased all complications associated with peripheral IV catheters, and
prolonged their longevity and patency.

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Studies have also support the recommendation of having designated IV teams with
specialty training insert and maintain IV catheters (known as vascular access team, IV therapists,
infusion nurses, or STAT nurses). The research shows that PIV placement by IV teams can
significantly reduce the incidence of PIV complications such as phlebitis, catheter-related
bacteremia and local inflammation via increased knowledge of proper securement techniques,
choice of site placement, and consistent follow through of protocols (Sabri et al., 2013; Santolim
et al., 2012; Arbique et al., 2012; CDC, 2011). Its important to note that all nurses at a facility
that place PIVs, whether or not they are on a designated IV therapy team, be given consistent
training on EBP techniques for best PIV insertion; this helps to not only improve insertion
success, but also helps to maintain the integrity of the PIV once it is in place (Helm et al., 2015.)
(Also see Appendix B for algorithm for the replacement of PIV catheters).
Also recommended is the practice of ultrasound guidance technology for placement, as it
is quickly being shown to improve success rates and decrease the number of insertions in veins
that are not easily visible. This improves patient satisfaction, reduces delays, reduces supply
costs and helps to preserve veins. This is a technique that is becoming more standardized and is
showing great promise in improved outcomes regarding PIV placement and usage (Arbique,
Bordelon, Dragoo & Huckaby, 2014; Meerm, Jehangir, Euerle, & Hsu, 2016).
Lastly, it is generally understood that the longer a PIV is left in the body, the greater the
risk of developing complications. This knowledge leads to the clinical recommendation of
documentation each shift of the clinical necessity of the PIV. This practice helps ensure saline or
heparin locked PIVs dont remain in place longer than necessary, thereby becoming a potential
source of phlebitis or infection. Documentation each shift of the clinical necessity of the PIV is

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commonly built into part of the Registered Nurse IV assessment section in facilities that use
EPIC as their electronic medical record. Some of the institutions in western Washington that
have this required documentation section of their EPIC programs include University of
Washington, Harborview Medical Center, Providence Medical Centers, Swedish Hospital, and
all Peace Health Medical Centers.
Conclusion
In summary, the research concludes that there is no difference in phlebitis or infection
rates in PIVs that are replaced only when clinically indicated versus those that are replaced
routinely. Yet the benefits of clinically indicated replacement are many, and are important to the
foundation of EBP. These benefits positively impact patients, nurses, as well as hospitals and
our health care system at large. Benefits include improved patient satisfaction, reduced pain and
potential complications, vein preservation, as well as saved nursing labor and decreased supply
costs.
Given the strength of the evidence currently available from these studies, it was
concluded that placing a PIV is not only staff intensive, but the costs involved in routine
replacements of venous catheters are an unnecessary expense. The resources that would be saved
by following the guidelines for clinically indicated replacement could be redirected or saved to
reduce the overall cost of healthcare. Time saved from routine restarts may also have the added
benefit of improved compliance in assessing and documenting the insertion site each shift, with
the catheter being removed if signs of complication, inflammation, infiltration, or blockage

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develop (Webster, et al., 2015). (See also Appendix B for assessment and replacement
algorithm).
Acute care organizations should consider changing policy to reflect the most current
evidence-based practice of clinically indicated PIV replacement, as well as providing in-service
training for all nurses who place PIV catheters. Cumulatively, the cost savings of time and
resources, reduced discomfort and pain for patients, and practice guided by sound research
should be the goal. All of these benefits encompass the foundations of evidence based practice.
As nurses, we must embrace as well as implement EBP throughout the inpatient settings where
PIVs are inserted. By doing so, outcomes for all stakeholders will continue to improve.

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Reference List
Alekseyev, S., Byrne, M., Carpenter, A., Franker, C., Kidd, C., & Hulton, L. (2012). Prolonging
the life of a patients IV: An integrative review of intravenous securement devices.
MEDSURG Nursing, 21(5), 285292.
Arbique, D., Bordelon, M., Dragoo, R., & Huckaby, S. (2014). Ultrasound-guided access for
peripheral intravenous therapy. MEDSURG Nursing, 115.
Brown, D., and Rowland, K. Optimal Timing for Peripheral IV Replacement? The Journal of
Family Practice 62, no. 4 (April 2013): 200202.
Centers for Disease Control and Prevention. (2011) Guidelines for the prevention of
intravascular catheter-related infections, 2011. 10-16. Retrieved from
https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Clarke, M., Randle, J. The care and maintenance of peripheral intravenous catheters. Nursing
Times. Accessed June 25, 2016. http://www.nursingtimes.net/
the-care-and-maintenance-of-peripheral-intravenous-catheters/201769.fullarticle.
Fang, Chi-Tai. (2012, September). Peripheral IV in Too Long | AHRQ Patient Safety Network.
Retrieved July 21, 2016, from https://psnet.ahrq.gov/webmm/case/278/peripheral-iv-intoo-long

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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), 189203.
http://doi.org/10.1097/NAN.0000000000000100
Ho, K. HM, and Cheung, D. SK. Guidelines on timing in replacing peripheral intravenous
catheters. Journal of Clinical Nursing 21, no. 11/12 (June 2012): 14991506 8p.
doi:10.1111/j.1365-2702.2011.03974.x.
Meerm, Jehangir M, Euerle, Brian, MD, & Hsu, Sam, MD. (2016). Ultrasonography
assisted peripheral line placement: Overview, indications, contraindications. Retrieved
from http://emedicine.medscape.com/article/1433943-overview
Morrison, K., and Holt, K. The effectiveness of clinically indicated replacement of peripheral
intravenous catheters: An evidence review with implications for clinical practice.
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doi:10.1111/wvn.12102

Ray-Barruel, G., Polit, D. F., Murfield, J. E., & Rickard, C. M. (2014). Infusion phlebitis
assessment measures: A systematic review. Journal of Evaluation in Clinical Practice,
20(2), 191202. http://doi.org/10.1111/jep.12107
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improvement strategies in peripheral intravenous catheterization. Bio-Medical Materials

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& Engineering, 23(1/2), 93108.

Ullman, A. J., Keogh, S., Marsh, N., and Rickard. C. M. Routine versus clinically indicated
replacement of peripheral catheters. British Journal of Nursing 24 (January 16, 2015):
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Webster, J., Osborne, S., Rickard, C. M., and New, K. Clinically-indicated replacement versus
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http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007798.pub4/abstract.

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Appendix A
Retrieved from: https://infusionnurse.org/2011/02/21/the-phlebitis-scale-does-mean-something/

Phlebitis Scale (from the Infusion Nursing Standards of Practice 2011 S47)
Grade 0 No symptoms
Grade 1 Erythema at access site with or without pain
Grade 2 Pain at access site with erythema and/or edema
Grade 3 Pain at access site with erythema and/or edema, streak formation, palpable venous cord.
Grade 4 Pain at access site with erythema and/or edema, streak formation, palpable venous
cord greater than 1 in in length; purulent drainage.

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Appendix B

(Ho et al., 2011)

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