NCS1202: Evidence-Based Practice in Health Care - Case study Assessment Answers

In the given case study, nursing staff did not follow the hospital policy of changing IVCs daily. It was also find out that no particular complications occur during this time period which means that routine replacement does not have significant impact on reducing phlebitis or other infections. The following evidences have been mentioned to support the extended use of IVCs in hospitals. The Intravenous cannulation is done frequently to avoid any kinds of infection and phlebitis. But, avoiding them to be changed frequently does not provide any kind harm for the patient. With the use of Phlebitis scale it can be seen if there is any kind of complication. This scale is clinically approved and feasible to use. If the scale shows 0, than there is no harm. Thus the paper will discuss that how this scale is useful and why it is not important to change IVC daily.

Description

The identified problem is related with routine replacement of IVC in hospital setting would probably help to reduce phlebitis rate. It has become an important issue that changing IVC on daily basis can reduce the chances of infection. Intravenous cannulas are the most preferred medical devices these days. These devices are generally used for administration of fluids, medicines, blood sampling etc. It has been found that use of these devices is associated with pain, phlebitis, hematoma and other related infections. Specialized teams performed Intravenous cannulation function (Webster, et al, 2008).

Re-cannulation has become an important aspect of healthcare delivery system as this leave patient under heavy stress. From the patient’s point of view, it is not a comfortable condition for them and prolong their hospital stay. Patient centered care must be provided by the hospital staff to develop good patient-hospital relation. Also delays the whole medical treatment (Dillon et al, 2008). A cannula may remain for several days so there is no time limit for it. Routine or daily replacement of cannulas creates psychological and financial pressure on patient and the family. It is recommended to replace a cannula during phlebitis, occlusionor infection (Dillon, et al, 2008). There could be various types of complications associated with insertion of a cannula. Infection can appear due to entry on bacteria through insertion site.

Phlebitis

IV induced phlebitis is the most common problem. A number of clinical research articles has indicated that approximately 25-60% of the patient face phlebitis problem. It is denoted by inflammation of internal lining of a vein and a patient feels pain at the insertion site (Hankins et al, 2001). It can be classified into three different categories – bacterial, mechanical, and infusion. In the research library of the CINAHL are available the data related to qualitative studies. The biomedical research literature available at Medline also provides the qualitative analysis. The qualitative analysis of Thrombophlebitis of Medline research library states the causes, symptoms and effects of the problem.Use of contaminated devices often give raise to mechanical phlebitis. It occurs due to use of bigger size of cannula. Initial assessment of patient is the key factor to avoid any kind of friction on lining of the vein. It can be avoided by using an appropriate size of the cannula and following less manipulation at the insertion site will decrease the infection rate.

Skin born bacteria can enter into IV system causing infection. Aseptic practices, improper use of device use can increase the chances of bacterial infection. Infusion related phlebitis occurs due to irritation of internal lining of vessel wall associated with medicines. So medicines which are not properly mixed can cause infusion phlebitis.

Phlebitis scale must be used in clinical practice by all healthcare professionals. It is noted on a scale of 0 to 4. No symptoms are visible at scale 0 while oedema or erythema with pain are observed along with streak formation at scale 4.

Guidelines are available recommending use of peripheral intravenous cannulation for not longer than 72 hours. Trained medical personal has to review it closely after insertion. Risk-benefit analysis is required before making decision of its replacement. It is stated that if there is no sign of infection then peripheral intravenous cannula should not be replaced which means that phlebitis score is 0. (Ministry of Health, 2013).

Several research studies have been conducted to identify the chances of infection rate by changing IVC daily. It is evident that intravenous cannulas are changed after every 72 to 96 hours. Hospitals follow different policies for the same. IVC is replaced if patient has been observed with some unresolved clinical issue. It is recommended to replace it after 96 hours in adults while clinical symptoms are taken into consideration for children (Brown & Rowland, 2013).

The recommendation for the practice is that cannula should be observed regularly. Slight pain with scale showing 0 displays no signs of phlebitis. The slight pain and redness at the IV site shows first sign of phlebitis, under such circumstance cannula should be observed. In the case of phlebitis the recommendations are as follows:

• Regular exercising is the best way to improve blood circulation and blood vessels.
• The ideal weight should be maintained.
• Intake of anti-inflammatory diet.
• Sitting or standing for long time should be avoided (Brown & Rowland, 2013).

In 2008, a comparative randomized clinical trial of 755 inpatients were made to observe for differences between routine IVC replacements and based upon clinical symptoms. No significant differences was found between two groups with relative risk of 1.15 at 95% confidence interval. The infection rate was noted almost same within these groups - 38% for replacement of IVC depending upon clinical symptoms while 33% for routine replacement of IVC practice (Webster et al, 2008).

A randomized trial of approximately 362 inpatients was conducted to measure the effectiveness of routine replacement of IVC. The median time of replacement was taken 70 to 80 hours. The rate of phlebitis was found similar in both the study groups which was merely 7% for routine replacement and 10% for the other group with a relative ratio of 1.44.No particular infections were noted in these groups (Rickard et al, 2010).

In another study including more than 3000 hospitals patients, similar pattern was followed as in the previous research studies. Reviewers found out that both the study groups (routine replacement versus clinically based symptoms) have same phlebitis chances (Webster et al., 2010).

Clinically indicated replacement of IVC is recommended based upon the findings of the above discussed research studies. It does not increase the phlebitis rate in comparison with routine IVC replacement practice (Brown & Rowland, 2013). One of the important benefits associated with clinically indicated replacement is that this will improve patient satisfaction by decreasing hospital cost. The fact is that people are afraid of changing of IVC in routine and do not perceive the importance of routine IVC replacement. The use of IVC has become very frequent in the hospitals these days. At the IV site, swelling, redness, phlebitis can occur but the rate of infection is 0.5 per 1000 cases (Brown & Rowland, 2013). Indicating importance of clinically indicated replacement without putting financial burden on patient’s pocket.

There are evidences to support to use intravenous cannula for an extended time period until appearance of clinical symptoms. Unnecessary use of cannulas will increase hospital cost, patient stress, and staff time. IVCs are vital for administration of medicines. Early research studies have shown an association between phlebitis rate and prolonged use of IVCs. So hospitals adopted policy of routine replacement of IVCs. (Ministry of Health, 2013) Late on, it was recommended to use IVCs for 72 hours and now 96 hours of time period. Currently, 72 to 96 hours of ICVs are generally in practice to reduce phlebitis. Patients including children and adults are exempted from this recommendation. The risk of complications is similar whether IVCs are used for 96 hours or 24 hours. Despite the fact, routine replacement of IVCs has been widely accepted by stating that infection chances are reduced at larger extent (Rickard et al, 2010). Phlebitis score must be taken into consideration to take a decision of replacement. Zero score does not indicate presence of infection hence not require action of replacement.

Previously studies have been conducted to show the efficacy rate of prolonged use of IVCs. It is safe to leave ICVs for a longer time period till they are functioning well as analyzed in a 3 day routine resite randomized study in Australia. The study results indicate use of ICVs for 5-6 days without noticing any complication (Ministry of Health, 2013). Re cannulation is associated with additional inconvenience and pain. The study results are consistent with other research studies and no benefits have been observed for routine replacement. Hospital policy to replace IVCs routine is based upon few observational research studies. Research data also supports use of IVCs for a longer duration as phlebitis or other infections stabilize after 24-36 hours. It is the main reason behind similar infection rate after 3 and 6 days of cannulation (Rickard et al, 2010).

Summary

Use of device for peripheral cannulation requires skilled medical team. Staff must be aware of the possible infections related with IVCs. Replacement should be performed only for clinical indications but not very frequently. Insertion and reinsertion procedure must be effective and safe for patient’s health. Patients should be satisfied with the hospital service provided at affordable cost. Multicenter studies are needed to evident the importance of routine replacement of IVCs as it is involved with high healthcare cost and patient stress.

The skin born bacteria or the other bacteria’s can enter through IV, but by keeping the regular check, such issues can be resolved. Replacement of IVCs based upon clinical indication can save approximately AUS$25 million each year followed by saving of unnecessary use of 60,000 IVCs. Consistent results have been obtained in favor of extended use of IVCs rather than adopting policy of routine replacement.

According to the above research it is very important that Phlebitis scale should be used by the healthcare professionals. If the scale displays 0, it means there are no symptoms of infection, still the healthcare professionals and the nurses should regularly observe cannula.

The challenge is to train our resource pool especially nursing staff to combat with any obstacle related with health system. They must be involved for daily review and monitoring to analyze the need of IV device replacement. Planning and proper framework for effective implementation of hospital rules and policies is the demand of healthcare sector to improve health outcomes.