Experts consider whether replacing intravenous devices every three days is clinically indicatedBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4952 (Published 10 September 2010) Cite this as: BMJ 2010;341:c4952
US experts in infection control are reviewing advice issued in 2002 that intravenous devices should be replaced every 72 to 96 hours as a matter of routine.
Updated guidance from the Centers for Disease Control infection control advisory group (HICPAC) is expected to be published this winter. A draft says that peripheral intravenous devices should be replaced “no more frequently than every 72-96 hours” but that evidence for leaving catheters in place unless clinically indicated was an “unresolved issue.”
The 2002 guidelines are based on findings from early small studies that suggested routine replacement might limit complications such as phlebitis. But the proposed change comes as evidence mounts that replacing intravenous devices every three days is not clinically indicated. A Cochrane review published earlier this year suggested the policy of automatic replacement has no benefits in terms of reducing complications.
The results of a small study published on 10 September support the findings of the review. They suggest that replacing an intravenous cannula only when there is a clinical problem would free up hundreds of thousands of nursing and medical staff hours and result in no more complications than the recommended policy of routine replacement.
The study found no more complications in patients whose peripheral intravenous devices were replaced only when clinically indicated than in a control group whose devices were replaced every 72 to 96 hours, whether or not they were still working effectively without complications (BMC Medicine 2010;8:53; doi:10.1186/1741-7015-8-53).
Because it causes discomfort to the patient, and takes about 20 minutes for a nurse or doctor to carry out, the routine replacement policy should be scrapped, the Australian researchers say.
Researcher, Claire Rickard, from the Research Centre for Clinical and Community Practice Innovation at Griffith University, Queensland, Australia, said, “Recommended timelines for routine resite have been extended over the past three decades from 24 to 72 hours. Currently, 72 to 96 hour resite is recommended.
“Even with these extended durations, such policies still cause increased workload in hospitals, where the task of removing and replacing well functioning IVDs [intravenous devices] generally falls to busy nursing and junior medical staff. Our results indicate that the average duration of IV [intravenous] therapy is 5 to 6 days and that many catheters can remain complication free for this period, or even longer.”
A change in policy would mean that every other patient receiving intravenous treatment in hospital would not need to have a replacement cannula, the researchers estimate. Under current guidelines four out of five patients who have a cannula are likely to have it replaced while they are having intravenous treatment, they say.
The researchers randomly allocated 177 patients who needed a cannula to a policy of routine replacement every 72 to 96 hours, and 185 to a policy of replacement when clinically indicated. Clinical indications for replacement included failure of the device and phlebitis.
In the study there were 66 complications every 1000 patient days for patients fitted with intravenous devices in those where the devices were routinely replaced, and 67.8 complications where the devices were only replaced when clinically necessary. No significant differences were seen in the proportion of individual types of complications—phlebitis, infiltration, or blockage—between the two groups. No cases of infection were seen in either group in the study. The lack of difference between the two policies was seen in both intention to treat and per protocol analyses that the researchers carried out.
The researchers estimate that in Australia alone a policy of switching cannulas only when clinically indicated, rather than routinely, could avoid the unnecessary insertion of 660 000 intravenous devices, free up 280 000 hours of nursing and medical staff time, and save up to $A24m a year (£14.2m, €17.3m, $22m).
Cite this as: BMJ 2010;341:c4952