Remove safely and replace if needed

Quality statement 10

A patient with a PIVC will have it removed when it is no longer needed or at the first sign of malfunction or local site complications. A new PIVC will be inserted only if ongoing peripheral vascular access is necessary, consistent with the replacement recommendations in the current version of the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Purpose

To minimise complications by ensuring that PIVCs are removed safely when they are no longer needed, when they malfunction or when complications develop. Replacement with a new device only occurs when IV therapy needs to continue.

What the quality statement means

For patients

Your PIVC will be removed when it is no longer needed. If you are unsure when it will be removed, ask your clinician.

If your PIVC has malfunctioned or there are signs of problems such as pain, redness or swelling, and your treatment is not finished yet, your clinician will need to remove your PIVC and replace it with a new one. Your clinician will also make sure that your PIVC is replaced as often as current Australian guidelines recommend.

If you are going home and your PIVC is still in place, ask your clinician if it can be removed.

For clinicians

Remove PIVCs as soon as they are no longer needed – for example, if a patient can tolerate oral therapy – or if complications occur. Signs and symptoms that indicate that the PIVC should be removed include:

  • Pain and tenderness at the insertion site, with or without palpation
  • Warmth, redness or swelling
  • Leakage of fluid from the insertion site
  • Resistance when flushing or absence of blood return.

Ensure removal and replacement of PIVCs is in accordance with the current version of the Australian Guidelines for the Prevention and Control of Infection in Healthcare (see Box 6).

Box 6: Recommendations for replacement of PIVCs – from the Australian Guidelines for the Prevention and Control of Infection in Healthcare

Do not routinely replace PIVCs in neonates and children.

For adults, there are two options for the replacement of PIVCs. Policies on the replacement of PIVCs should be based on a formal risk assessment that takes into account:

  • The availability of staff appropriately trained in the insertion, monitoring, assessment and maintenance of PIVCs on each shift

  • The quality of PIVC surveillance in the healthcare facility, including surveillance of regular inspection of the site and device, and of PIVC-related Staphylococcus aureus bacteraemia (SAB)

  • The need for robust documentation and reporting processes on device insertion, maintenance and removal that is supported by the results of audits.

In considering the above factors, healthcare facilities may routinely follow one of the following two options:

Option 1: Replace a PIVC every 72 hours

This practice is based on observational studies that show an increased risk of bloodstream infection with PIVCs left in place for more than 72 hours.

Option 2: Replace a PIVC based on clinical indication

A strategy of replacing a PIVC when a clinical indication for replacement is identified (rather than routinely at 72 hours) may be considered only when there is:

  • Surveillance of PIVC-related bloodstream infection performed at the facility

  • Comprehensive documentation of insertion, maintenance and removal of PIVCs (audit results demonstrate a sustained compliance with daily PIVC assessment documentation)

  • Compliance with competency requirements for insertion and management.

This option is informed by a systematic review, first published in 2011 and updated most recently in 2015, which concluded that rates of bloodstream infection and thrombophlebitis were not significantly different when PIVCs were changed based on clinical indication rather than routinely replaced.

Replacing a PIVC based on clinical indication can be cost saving and may reduce the discomfort for patients associated with regular replacement.

Document the reason for removal of the PIVC and the condition of the site. Observe the insertion site for 48 hours after the PIVC is removed for signs of post-infusion pain, redness or swelling. If the patient is discharged from hospital, explain what signs they should look out for after the PIVC is removed and who they should contact if signs of infection develop.

Replace with a new PIVC if ongoing vascular access is required. If extended IV therapy is anticipated, consider whether an alternative device, such as a peripherally inserted central catheter or central line, should be inserted (see Quality statement 1).

Consider re-siting PIVCs, within 24 hours, when adherence to aseptic technique is uncertain or unknown, such as insertion during a medical emergency.

For hospitalised patients, ensure that PIVCs are removed before discharge, unless the PIVC is intended to continue beyond discharge as part of the patient’s care plan.

For health service organisations

Ensure that systems are in place that state the considerations for when a PIVC should be removed and replaced, and monitor adherence to guideline recommendations for ongoing quality improvement. These systems should be based on a formal risk assessment that takes into account:

  • The availability of staff appropriately trained in the insertion, monitoring, assessment and maintenance of PIVCs on each shift
  • The quality of PIVC surveillance in the healthcare facility, including surveillance of regular inspection of the site and device, and of PIVC-related Staphylococcus aureus bacteraemia (SAB)

The need for robust documentation and reporting processes on device insertion, maintenance and removal that is supported by the results of audits.

For patients

Your PIVC will be removed when it is no longer needed. If you are unsure when it will be removed, ask your clinician.

If your PIVC has malfunctioned or there are signs of problems such as pain, redness or swelling, and your treatment is not finished yet, your clinician will need to remove your PIVC and replace it with a new one. Your clinician will also make sure that your PIVC is replaced as often as current Australian guidelines recommend.

If you are going home and your PIVC is still in place, ask your clinician if it can be removed.

For clinicians

Remove PIVCs as soon as they are no longer needed – for example, if a patient can tolerate oral therapy – or if complications occur. Signs and symptoms that indicate that the PIVC should be removed include:

  • Pain and tenderness at the insertion site, with or without palpation
  • Warmth, redness or swelling
  • Leakage of fluid from the insertion site
  • Resistance when flushing or absence of blood return.

Ensure removal and replacement of PIVCs is in accordance with the current version of the Australian Guidelines for the Prevention and Control of Infection in Healthcare (see Box 6).

Box 6: Recommendations for replacement of PIVCs – from the Australian Guidelines for the Prevention and Control of Infection in Healthcare

Do not routinely replace PIVCs in neonates and children.

For adults, there are two options for the replacement of PIVCs. Policies on the replacement of PIVCs should be based on a formal risk assessment that takes into account:

  • The availability of staff appropriately trained in the insertion, monitoring, assessment and maintenance of PIVCs on each shift

  • The quality of PIVC surveillance in the healthcare facility, including surveillance of regular inspection of the site and device, and of PIVC-related Staphylococcus aureus bacteraemia (SAB)

  • The need for robust documentation and reporting processes on device insertion, maintenance and removal that is supported by the results of audits.

In considering the above factors, healthcare facilities may routinely follow one of the following two options:

Option 1: Replace a PIVC every 72 hours

This practice is based on observational studies that show an increased risk of bloodstream infection with PIVCs left in place for more than 72 hours.

Option 2: Replace a PIVC based on clinical indication

A strategy of replacing a PIVC when a clinical indication for replacement is identified (rather than routinely at 72 hours) may be considered only when there is:

  • Surveillance of PIVC-related bloodstream infection performed at the facility

  • Comprehensive documentation of insertion, maintenance and removal of PIVCs (audit results demonstrate a sustained compliance with daily PIVC assessment documentation)

  • Compliance with competency requirements for insertion and management.

This option is informed by a systematic review, first published in 2011 and updated most recently in 2015, which concluded that rates of bloodstream infection and thrombophlebitis were not significantly different when PIVCs were changed based on clinical indication rather than routinely replaced.

Replacing a PIVC based on clinical indication can be cost saving and may reduce the discomfort for patients associated with regular replacement.

Document the reason for removal of the PIVC and the condition of the site. Observe the insertion site for 48 hours after the PIVC is removed for signs of post-infusion pain, redness or swelling. If the patient is discharged from hospital, explain what signs they should look out for after the PIVC is removed and who they should contact if signs of infection develop.

Replace with a new PIVC if ongoing vascular access is required. If extended IV therapy is anticipated, consider whether an alternative device, such as a peripherally inserted central catheter or central line, should be inserted (see Quality statement 1).

Consider re-siting PIVCs, within 24 hours, when adherence to aseptic technique is uncertain or unknown, such as insertion during a medical emergency.

For hospitalised patients, ensure that PIVCs are removed before discharge, unless the PIVC is intended to continue beyond discharge as part of the patient’s care plan.

For health service organisations

Ensure that systems are in place that state the considerations for when a PIVC should be removed and replaced, and monitor adherence to guideline recommendations for ongoing quality improvement. These systems should be based on a formal risk assessment that takes into account:

  • The availability of staff appropriately trained in the insertion, monitoring, assessment and maintenance of PIVCs on each shift
  • The quality of PIVC surveillance in the healthcare facility, including surveillance of regular inspection of the site and device, and of PIVC-related Staphylococcus aureus bacteraemia (SAB)

The need for robust documentation and reporting processes on device insertion, maintenance and removal that is supported by the results of audits.