Phlebitis Assessment Scales: So many scales, so little value?

Gillian Ray-Barruel Senior Research Assistant Griffith Health Institute, Griffith University

ICN 25th Quadrennial Congress Melbourne, May 2013

Background

Methods

Cochrane Library Medline CINAHL

COSMIN guidelines (COnsensus-based Standards for the selection of health Measurement Instruments) •  Reliability (inter-rater, intra-rater, test-retest) •  Validity (content, face, criterion, construct) •  Responsiveness (the ability of a scale to detect

a true change in symptoms) •  Feasibility (time to complete, ease of

completion, clarity of items, etc.)

Results

v  233 studies reported infusion phlebitis as the primary outcome measure

v  Of these, 53 provided no actual definition of phlebitis, despite the study measuring phlebitis

v  180 studies reported measuring phlebitis incidence or severity and gave a definition

v  Of these, 101 used an assessment scale v  79 used a definition only

Results continued

•  Pain •  Tenderness •  Erythema or redness •  Oedema or swelling •  Palpable venous cord •  Induration or hardness •  Frank thrombosis •  Streak formation or red line

•  Purulence or exudate •  Inflammation not specified •  Local warmth •  Local coolness •  Infusion slowed or stopped •  Fever or pyrexia •  Tissue damage •  Impaired function

We found 71 different phlebitis assessment scales in use! 16 symptoms were assessed by the various scales or tools:

Results

Reported phlebitis prevalence §  0-91% for studies using a scale §  0-100% for studies using a definition alone §  Reporting measures varied widely

(per PIVC, per patient, per catheter day)

Results

Reported psychometric assessment §  Many phlebitis scales and tools exist, but

none has been properly validated for use in the clinical setting.

§  Studies that reported testing the psychometric properties of scales (VIP, INS, PVC ASSESS, etc.) all had several major limitations.

Limitations?

Name of scale Limitations INS scale Groll et al, 2010

Inter-rater reliability kappa .45 (moderate) Criterion (concurrent) validity was assessed by comparing assessment to documentation (? ‘gold standard’). Correlation between observation and documentation 0.39. Did not assess intra-rater and test-retest reliability, or responsiveness. Sample size was only 6 nurses.

Documentation in the patient’s chart cannot be considered the gold standard!

Limitations continued

The psychometric properties of Baxter, Maddox, Lipman, Dinley and many other scales have never been reported.

Name of scale Limitations VIP score Gallant & Schultz, 2006

Reported to have good inter-rater reliability (0.85) & content validity. Inter-rater reliability was assessed by comparing each nurse’s assessment to an expert’s opinion (gold standard). Did not compute inter-rater reliability between nurses. No report of intra-rater reliability, test-retest reliability, responsiveness, feasibility, or construct validity.

Conclusions

No existing phlebitis scale or definition can be recommended

XINS Phlebitis Scale Grade 0 – No symptoms Grade 1 – Erythema at access site with or without pain Grade 2 – Pain at access site with erythema and/or edema Grade 3 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord. Grade 4 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord greater than 1 in in length; purulent drainage. X

Final thoughts for assessing an IV cannula

Use clinical judgement! •  Is it needed?

Ø  If not, remove it. Don’t leave it there, just in case. •  Is it working?

Ø  If not, remove it. Resite IV or insert PICC. •  Is it tolerated by the patient?

Ø  If not, remove it. Consider other access (e.g. oral, PICC) •  Is there any evidence of infection from an unknown source?

Ø  If so, remove the cannula.

Thanks for listening!

Infusion phlebitis assessment techniques: A systematic review of their use and psychometric adequacy Gillian Ray-Barruel, Denise F. Polit, Jenny E. Murfield, Claire M. Rickard

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