Getting evidence into nursing practice: replacing the routine

nurse checks patient's IV

The UK’s epic3 Guidelines recommend changing PVCs only when clinically indicated, based on Cochrane evidence

Last week, I wrote a blog summarising reliable Cochrane evidence which supports replacing peripheral venous catheters (PVCs) only when clinically indicated. A previous version of the review informed The UK’s epic3 National Evidence Based Guidelines (2014) which recommend that short peripheral catheters should be replaced when clinically indicated, being both safe and cost-saving. In the UK, at least, I would expect this to be reflected in practice, but I already knew from Twitter conversations that routine replacement of PVCs is not uncommon. This week, I guest hosted a @WeNurses tweetchat to explore what’s happening now, what practitioners think about this evidence and whether it can support a change in practice where routine still rules.

Who joined the chat?

We had 63 contributers to the chat, sharing over 400 tweets, the majority nurses from different specialties and nursing students. It was great that we were also joined by a radiographer, giving us a view from another area of practice, and by Professors of Nursing Claire Rickard and Joan Webster, authors of the Cochrane review. Most were in the UK but we had contributions from Australia too, where Joan is Nursing Director for Research in at the Royal Brisbane and Women’s Hospital and Claire leads the AVATAR (Alliance for Vascular Access Teaching And Research) Group. The word cloud at the top was generated by the chat.

What determined routine PVC replacement policies?

Claire Rickard told us that routine re-siting of PVCs was changed from 24 to 48 hours in the 1980s, based on expert opinion only, and that the Centers for Disease Control changed its recommendation from 48 hourly to every 72-96 hours in the 1990s, based on cohort studies with 2500 people. There are data from many more patients in randomized controlled trials of clinically indicated replacement. Epic3 guidelines are clear that clinically-indicated is the way to go but Claire said many guidelines have not been updated since new evidence came out.

Routine replacement still dominates

Many said that their local policy is to change them at 72 hours. There were some caveats. One said that it could be left longer if access is particularly difficult; another that replacement at 72 hours is usual and that although review to see if the PVC can remain in place is encouraged this doesn’t tend to happen. Adult nursing student Darren said “my placement area tend to change them after 4 days, regardless of need”. Another student, Lee, reported that changing at 72 hours was the norm in his placements, “unless difficult access, then monitor and record”. We were all horrified to hear that in one place the routine replacement policy has been retained ‘so junior doctors can get enough practice!’

But clinical indicators are the drivers for some

Micahel told us that “in the community a pragmatic approach is often adopted using VIP scale”. One contributor expressed concern about the accuracy of recording of VIP (Validated Infusion Phlebitis) scores and another cited this as one of the reasons for impending policy change, but this system was mentioned by several. “All care workers should know signs that should be reported”, commented Anne-Marie.

Boy In Hospital With Tablet

In paediatrics, unnecessary procedures are rightly seen as unacceptable.

Radiographer Janice said she changes the PVC if she is unhappy with it, irrespective of time in situ, noting that some CT exams require high flow rates and that that they have to be mindful of IV contrast extravasation. Her practice is to flush with saline after the exam and check with the ward if the cannula can be left in. “As a cannulating radiographer it is a priority that I work with my nursing colleagues to ensure best practice”.

In paediatrics, re-siting when clinically indicated seems to be the norm and the idea of doing unnecessary procedures rightly regarded as unacceptable. As Claire asked, “why is that seen as safe but not in adults?”

Could it lead to complacency, one asked? Someone else thought it could, but this would be outweighed when balanced against the risks, and could be mitigated by training. The UK-based venepuncture and cannulation training folk, @vipvctraining, said their teaching is firmly based on the guidelines and they advocate replacing when clinically indicated.

According to Joan Webster, it’s “pretty simple really; if the site is red, swollen etc, take the device out. This may be after 10 hours or ten days …”

How long could a PVC remain in situ?

Claire says they are licensed by regulatory authorities for 30 days use and that she has used them for around 20 days. She also notes that most fail by 72 hours. “If they make it to 72 hours, let’s not ruin it!”

What about the patient?

IV insertion

Unnecessary PVC insertion isn’t good for patients

Happily, there was plenty of discussion about consideration for the patient. Several pointed out that it’s important not to site, or re-site, PVCs unless there is a clinical need to do so, and to remove them as soon as no longer required. Comments included that they are painful, that anaesthetic creams can be ineffective and that cannulation skills are variable. Joan Webster said that returning patients who have taken part in their trials now refuse to have their PVCs changed routinely! We liked this! “Patient power! No routine replacement thank you very much!” Patients and carers, it was noted, can be powerful advocates in achieving the implementation of evidence.

The argument should be over

We have good evidence that replacing PVCs when clinically-indicated does not put patients at increased risk of complications of IV therapy and and saves money. So are there any reasons NOT to do this? “Wouldn’t that be poor practice?” asked Charlotte. It seems that there are obstacles to change.

Sometimes tradition trumps evidence…

Kaye said that their policy (in New South Wales) is to replace routinely at 72 hours because blood stream infection (BSI) is a concern. Yet the evidence doesn’t support this. Cochrane author Claire noted that there were half the BSIs in clinically indicated PVCs and that we don’t know whether making holes in skin 72 hourly causes BSI.  Craig thinks that re-siting PVCs ‘just in case’ puts patients at risk.

It seems that culture is an obstacle to change here, with Kaye noting that “their argument is that translation into practice is difficult”.  Depressingly, when asked if this is just a triumph of tradition/culture/habit over evidence, Kaye says “Absolutely! It has always won!” “The weight of tradition and experience of BSI outweighs the evidence for clinical replacement.”

Trusts not trusting?

While Trust policy should be evidence-based, it isn’t always. Several people thought Trusts would be reluctant to change their policies, despite the weight of evidence. Might there be concerns about accusations of neglect? Policies, it’s felt, are not easy to change and it was suggested that it would take a brave Trust to change their policy. Why should this be so, when all the evidence is in favour of clinically-indicated replacement? It was good to hear news of one Trust that has just done this, resulting in “30% less cannula insertions and no increase in VIP scores”.

Evidence into action: what will you do now?

There was a strong sense that the evidence necessitated action where practice isn’t following it, with talk of  professional responsibility to raise concerns and to challenge current practice that has been shown not to be based on the best available evidence. It was agreed that staff are bound by policy but that policy should be challenged. Several people finished the chat determined to take action. Here are some of the intentions and suggestions:

  • “Print off the epic3 Guidelines and take them to the Trust to help argue the case”
  • “If you want to take something away, you have to give something in return. Implement a new PVC removal daily checklist”
  • “If policy doesn’t follow best evidence then identify gatekeepers to change if unsure. Be the patients’ advocate always”
  • “Evidence must be disseminated to IPC teams and policy revisited”
  • “Key to PVC insertion and care is training, education and good audit cycle. So infection control and IVTeams can play a part”
  • “Will share the chat summary with future radiographer @SCoRMembers cannulation course delegates”
  • “I will be bringing this up with the ward sister in the morning!”
  • “EBP must inform Trust policy – so time for a review of it, conversations start tomorrow!”

These last two came from nursing student Darren and from Craig, an Infection Prevention Nurse, and they were as good as their word. Darren was told by the ward sister that “she likes them out after three days” and when Darren told her about the evidence she said replacing after 72 hours is Trust policy. Other nurses there said this policy had been implemented as a knee-jerk reaction to an incident, instead of improving checking of PVCs. Darren is now going to contact infection control about this. Great news Darren and do go clutching epic3! Craig tweeted an update too: “we are on it and will be making change soon based on the latest evidence: tweetchat to action.” Fantastic!

Do share what you’re doing

medical team

Do tell us if you have shared the evidence with colleagues or explored the possibilities for changing practice if it’s not following the evidence

It would be wonderful to hear what other people have done since reading and discussing the evidence. Have you shared it with colleagues or done something towards changing practice where it doesn’t follow this evidence? Do tell us about it here in the comments section. You can also join in the conversation on Twitter with me @SarahChapman30 and @ukcochranecentr, and of course @WeNurses. If you can, use our series hashtag #EENursing as well as #WeNurses.

Another tweetchat?

Thank you everyone for what was an incredibly interesting tweetchat. At the end, Nick Chinn @NRCUK, who had been lurking from #WeNurses HQ, asked “how often is policy driven by best quality care? Are other factors important to them?” while Teresa @AgencyNurse wanted to know “how empowered/supported do clinicians feel to be able to challenge policy?” Interesting questions for another tweetchat surely, and perhaps we can also come back in six months to find out if there have been changes in PVC replacement policy.

Creative Commons License
Getting evidence into nursing practice: replacing the routine by Sarah Chapman is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007798.pub4/abstract.
Permissions beyond the scope of this license may be available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007798.pub4/abstract. The images within the blog are not available for re-se as they have been purchased from istock.com for Evidently Cochrane.

Links:

Chapman S. “Replacing peripheral venous catheters: have you ditched the routine?”. Evidently Cochrane. 6 November 2015. Web. 21 November 2015. http://www.evidentlycochrane.net/replacing-peripheral-venous-catheters-have-you-ditched-the-routine/

You can see the details of the tweetchat here http://wecommunities.org/tweet-chats/chat-details/2581

Webster J, Osborne S, Rickard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD007798. DOI: 10.1002/14651858.CD007798.pub4.

Plain language summary of the review http://www.cochrane.org/CD007798/PVD_replacing-peripheral-venous-catheter-when-clinically-indicated-versus-routine-replacement

Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Browne J, Prieto J, Wilcox M. epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. London: Richard Wells Research Centre, University of West London; 2013. Journal of Hospital Infection 2014; 86S1: S1-70. Available from: http://download.journals.elsevierhealth.com/pdfs/journals/0195-6701/PIIS0195670113600122.pdf

Tuffaha HW, Rickard CM, Inwood S, Gordon L, Scuffham P. The epic3 recommendation that clinically indicated replacement of peripheral venous catheters is safe and cost-saving: how much would the NHS save? J Hosp Infect 2014;87(3):183-4. doi: 10.1016/j.jhin.2014.04.004. Available from: http://www.journalofhospitalinfection.com/article/S0195-6701(14)00124-8/abstract

There is now an NIHR Signal available on this review:

NIHR Dissemination Centre, National Institute for Health Research. “NIHR Signal: Routine replacement of intravenous cannulae is unnecessary and costly”. NIHR Signal, 28 January 2016. Web. 4 February 2016.https://discover.dc.nihr.ac.uk/portal/article/4000096/routine-replacement-of-intravenous-cannulae-is-unnecessary-and-costly

Page last updated 04 February 2016

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Sarah Chapman

About Sarah Chapman

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Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients. A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

3 Comments on this post

  1. […] peripheral venous catheters and whether it is reflected in current practice (catch up on it in this blog if you missed it), I’m turning my attention to central venous catheters […]

  2. […] That last one always made me (inwardly) howl with frustration whenever I heard it, but I know you evidence-seekers won’t have ticked that one. It would be great to tick the first three, but can you? There might be more howling over those. I was rather shocked (ok, call me naïve) to discover that reliable evidence supporting the replacement of peripheral venous catheters only when clinically indicated, duly recommended by the UK’s epic3 National Evidence-Based Guidelines as being both safe and cost-saving, had not translated into practice in some hospitals. This came to light in a lively #WeNurses tweetchat on the evidence and you can catch up with it in this blog. […]

  3. […] another Evidently Cochrane blog, summarizing and reflecting on the […]

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