Notes to support the presentation 'Introduction to the Visual Infusion Phlebitis (VIP) score'
- 1. IV Care & Management: Site Monitoring Implementing the VIP score Notes: 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%.
- 2. Regular evaluation of the condition of the IV site is essential to ensure and maintain patient safety. “...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) 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.
- 3. 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 “Phlebitis should be documented using a uniform standard scale infection. 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.
- 4. The first approach to managing infusion phlebitis is associated with prevention. Prevention includes utilising the smallest gauge catheter for its intended use and ensuring Infusion phlebitis adequate blood flow past the tip of the catheter. 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 The second requirement associated with maintain patient infusion care is the detection of the earliest safety and comfort. 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.
- 5. 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). Image from: NAVAN (1998) Tip location of peripherally inserted central catheters. Journal of Vascular Access Devices. 3(2), p.8-10. 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.
- 6. 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. "...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). 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.”
- 7. 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. http://www.kennedys-law.com/media/docs/KennedysMedicalLawBriefMarch2010_832010.htm 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.
- 8. VIP score recommendations Gallant and Schultz (2006) state that... “The VIP scale, as evaluated in this study, was In 2006 Paulette considered to be a valid and reliable measure for Gallant and Alyce determining when a PIV catheter should be Schultz completed removed” Galant and Schultz (2006). an evaluation of the The VIP score is the tool recommended by the RCN (2010) VIP score as a tool and the Department of Health (2010) in the UK. that determines the appropriate Also, the VIP score is recommended in the Infusion Nursing Standards of Practice (INS 2011). Stating that... discontinuation of peripheral “The Visual Infusion Phlebitis (VIP) scale has content intravenous validity, inter-rater reliability, and is clinically feasible. catheters. This scale includes suggested actions matched to each scale score” Infusion Nurses Society (2011). 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.
- 9. VIP score incorporated into national bundles The VIP score is accepted as the international tool for the early recognition of infusion phlebitis and appropriate removal of the vascular access device. Notes: Here we have an example of a peripheral IV care bundle for the Department of Health (UK).
- 10. 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) The cannula site must also be observed when: taken (if any) must Bolus injections are administered be documented. 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.
- 11. References Danchaivijitr, 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. Danchaivijitr et al Dutton, W.F. (1924) Intravenous Therapy: Its application in the modern practice of medicine. F.A. Davis Company, Philadelphia. (1995) states 34.1 Gallant P and Schultz AA (2006) Evaluation of a visual infusion phlebitis scale for determining per cent of infusions appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing. vol. 29, no. 6, p. 338-45. are interrupted by INS (2011) Infusion Nursing Standards of Practice. Journal of Infusion Nursing. Supplement. 34(1s). complications of Jackson A. (1998) A battle in vein: infusion phlebitis. Nursing Times. 94 (4), p.68-71. which 6.2 per cent Jackson A. (2003) Reflecting on the nursing contribution to vascular access. British Journal of were infusion Nursing. 12(11), p.657-665. phlebitis. 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.