Clinically Indicated Replacement Versus Routine Replacement of Peripheral Venous Catheters

What are the effects of removing a peripheral intravenous catheter when clinically indicated versus routinely removing and inserting a new catheter?Obtaining vascular access, including through the use of peripheral intravenous catheters (PIVs), is one of the most common, invasive procedures for hospitalized patients. On average, 2 vascular access devices are placed per patient per hospital stay.1 Although they are common, several risks are associated with PIVs, including phlebitis, infiltation, extravasation, and infection.2 Over the last decade, growing evidence has changed how PIVs are managed and has influenced the published guidelines from leading organizations such as the Centers for Disease Control and Prevention3 and the Infusion Nurses Society.2 However, practice guidelines do not always align internationally, so continued evaluation of the evidence is necessary.Most hospitals have practice protocols that call for careful assessment of PIVs and placement only when clinically indicated.3 That stated, with continued improvements in product design and improved nursing practice, results of recent studies support the potential benefit for keeping PIVs in place unless complications are present. For example, the latest standards from the Infusion Nurses Society indicate that PIVs “are not removed based solely on length of dwell time because there is no known optimum dwell time.”2A thorough review of the evidence is needed on a periodic basis to fully understand the body of evidence on the differences between clinically indicated replacement and routine replacement of PIVs. This systematic review is the third update on this topic by the authors: the first occurred in 2010 and the second occurred in 2015.4This summary is based on the updated, systematic review by Webster and colleagues4 that included data from 9 randomized controlled trials, with a total of 7392 participants. The authors explored the following main outcomes:The authors independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication bias. They resolved any disagreements by reviewing the data together and through discussion.Risk ratio (RR) and mean difference with confidence intervals (CIs) were used as the measures of treatment effect between different comparisons and outcomes. The internationally approved Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of evidence for each outcome.5The following points summarize the main results of this systematic review:The main outcomes reported in this systematic review suggest that patients are not adversely affected if PIV catheters are changed on the basis of clinical indications rather than on a routine basis. The reviewers found moderate- to low-quality evidence that there is no clear difference in rates of CRBSI, thrombophlebitis, or all-cause bloodstream infection between clinically indicated and routine replacement of PIV catheters. The reviewers also found moderate-quality evidence that infitration and catheter blockage is probably lower when PIV catheters are changed routinely, and moderate-quality evidence shows that clinically indicated removal probably reduces device-related costs.Based on the findings of this systematic review, health care organizations should consider policies in which PIV catheters are changed only in the presence of clinical indication (eg, signs of infection, occlusion, infiltation). Such policies could potentially lead to cost savings and better patient experiences, because patients would not need to endure the pain of routine changes. The overall time spent by nursing staff on PIV insertion could also be reduced. Cornerstones to moving away from routine PIV changes are regular and frequent catheter site assessments and guidelines to remove the PIV catheter if signs of inflammation, infiltation, or occlusion are present or as soon as it is safe to do so.It is important that nurses who care for critically ill patients advocate for the best, evidence-based treatment. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine if it is best to implement in an individual context.