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