Jurnal Phlebitis
Jurnal Phlebitis
Jurnal Phlebitis
Keywords Abstract
assessment, measurement, peripheral
intravenous catheter, phlebitis, Rationale, aims and objectives Phlebitis is a common and painful complication of periph-
psychometric assessment, scales eral intravenous cannulation. The aim of this review was to identify the measures used in
infusion phlebitis assessment and evaluate evidence regarding their reliability, validity,
Correspondence responsiveness and feasibility.
Ms Gillian Ray-Barruel Method We conducted a systematic literature review of the Cochrane library, Ovid
Centre for Health Practice Innovation MEDLINE and EBSCO CINAHL until September 2013. All English-language studies
Griffith Health Institute (randomized controlled trials, prospective cohort and cross-sectional) that used an infusion
Griffith University phlebitis scale were retrieved and analysed to determine which symptoms were included in
Bldg N48 each scale and how these were measured. We evaluated studies that reported testing the
Kessels Road psychometric properties of phlebitis assessment scales using the COnsensus-based Stand-
Nathan ards for the selection of health Measurement INstruments (COSMIN) guidelines.
Qld 4111 Results Infusion phlebitis was the primary outcome measure in 233 studies. Fifty-three
Australia (23%) of these provided no actual definition of phlebitis. Of the 180 studies that reported
E-mail: g.ray-barruel@griffith.edu.au
measuring phlebitis incidence and/or severity, 101 (56%) used a scale and 79 (44%) used
a definition alone. We identified 71 different phlebitis assessment scales. Three scales had
Accepted for publication: 22 November 2013
undergone some psychometric analyses, but no scale had been rigorously tested.
Conclusion Many phlebitis scales exist, but none has been thoroughly validated for use
doi:10.1111/jep.12107
in clinical practice. A lack of consensus on phlebitis measures has likely contributed to
disparities in reported phlebitis incidence, precluding meaningful comparison of phlebitis
rates.
Journal of Evaluation in Clinical Practice 20 (2014) 191202 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd. 191
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Infusion phlebitis assessment measures G. Ray-Barruel et al.
included. No date limitations were applied, with citations pub- based Standards for the selection of health Measurement
lished until September 2013 included. Titles and abstracts were INstruments (COSMIN) [8,9]. Relevant measurement properties
initially screened for relevance. Full texts of potentially relevant for phlebitis assessment include reliability (inter-rater, intra-rater,
articles were obtained and evaluated for inclusion. The reference testretest), validity (content, face, criterion, construct) and
lists of these articles were checked for other studies of potential responsiveness. Because phlebitis scales are formative indexes
relevance, and these were also retrieved. rather than reflective scales [10,11], neither internal consistency
All articles that examined infusion phlebitis assessment in nor structural validity is relevant.
adults as a primary outcome measure were retrieved, but only In addition, our review also considered attributes associated
those that used a phlebitis assessment scale were included in the with excellence in clinimetrics. Feinsteins [12] approach to
final review. Each scale was examined to identify which signs and developing clinical assessment tools, especially relevant for
symptoms were included in the measurement of phlebitis. Figure 1 formative indexes like phlebitis scales, was taken, including
illustrates the study selection process. The role of the phlebitis evaluation of the sensibility of clinical instruments. Sensibility
assessor, how often assessment was performed and if training in includes several properties covered in COSMIN (e.g. content
phlebitis assessment had been provided were noted. Information validity, responsiveness), but also includes acceptability and fea-
regarding each scales psychometric properties, if provided, was sibility, that is, ease of practical application of clinical instru-
also recorded. ments. Feasibility takes into consideration such issues as length
This review used definitions of measurement properties and of time to complete the scale, ease of administration and clarity
parameters consistent with those provided by the COnsensus- of the items and instructions [12].
192 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
G. Ray-Barruel et al. Infusion phlebitis assessment measures
2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd. 193
Infusion phlebitis assessment measures G. Ray-Barruel et al.
194 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
Table 1 Studies that reported measuring some psychometric properties of a phlebitis assessment scale
Ahlqvist et al., 2001: 107 PIVC in Effect of introducing Scale 03 Lundgren et al., Redness % PIVC 7 nurses not Second daily Reliability, validity,
2006 [44] 67 medical and guidelines for Phlebitis defined 1993 [48] Tenderness 2001 survey: employed on feasibility
Cross-sectional surgical patients; PIVC care on as 1 Pain 39% grade 1 study wards assessed in pilot
survey (pre/post) 2002: 99 PIVC in 63 incidence of Swelling 7% grade 2 study. No data
Sweden medical and thrombophlebitis, Increased 2002 survey: provided.
surgical patients nurses care, temperature 27% grade 1
handling and Palpable cord 0% grade 2
documentation Pus
Ahlqvist et al., 67 PIVC Inter-rater reliability PVC ASSESS Hershey et al., Pain N/A Nurses trained in Group A (3 RNs) Inter-rater and
2010 [86] of phlebitis Points per symptom 1984 [7] Tenderness phlebitis assessed at intra-rater
Cross-sectional assessment using 1 or more Erythema assessment bedside reliability
Sweden PIVC assessment symptom(s) Oedema Group B (3 RNs) assessed; content
tool Induration assessed photos validity informally
Purulent exudate of same PIVCs 4 assessed;
Streak formation weeks later acceptability and
Palpable cord feasibility
assessed
Bostrom-Ezrati 514 medical and Incidence of IV site Maddox scale 05 Maddox, 1983 [20] Erythema % patients Nurse data Twice daily Inter-rater reliability
et al., 1990 [53] surgical patients symptoms, and Swelling 22.6% grade 1 collectors assessed
Prospective cohort at 4 hospitals associated patient Induration 17.3% grade 2
United States and practice Pain
factors Palpable venous
cord
Boyce & Yee, 24 PIVC in 12 Incidence and Modified INS scale INS, 2006 [16] Pain % PIVC Staff nurses Every 4 hours until Content validity and
2012 [24] patients severity of 04+ Erythema 50% grade 0+ 24 hours after feasibility
Prospective cohort phlebitis in Phlebitis defined as Oedema infusion ceased assessed. No
United States patients given 0+ (pain) Streak formation data provided.
2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
peripherally Palpable venous
infused cord
amiodarone Purulent drainage
Campbell, 1998 [31] 90 medical patients Incidence and Baxter scale 05 Baxter, 1988 [18] Pain % patients Staff nurses None stated Testretest reliability
Prospective cohort from 13 wards severity of Erythema 26% grade 13 reported as being
Northern Ireland phlebitis, Swelling assessed. No
contributing Induration data provided.
factors, extended Palpable venous
length of stay, IV cord
complications
Catney et al., 411 medical and Relationship of Authors scale 13 None stated Pain or tenderness % patients 6 IV team staff Twice daily Inter-rater reliability,
2001 [40] surgical patients dwell time to Phlebitis defined as Erythema 7.3% grade 2 construct validity
Prospective cohort phlebitis and 2 Swelling and feasibility
United States infiltration Palpable venous reportedly
cord assessed in pilot
study. No data
provided.
Dibble et al., 514 patients in 4 Frequency of IV site Modified DeLuca DeLuca et al., 1975 Pain % patients 66 research Twice daily Inter-rater reliability
1991 [54]* hospitals symptoms and Maddox [101]; Maddox Redness 39.9% assistants (nurse assessed
Prospective cohort scale 15 used et al., 1977 [19] Swelling educators, RNs,
United States Induration nursing students)
Palpable cord
Infusion phlebitis assessment measures
195
196
Table 1 Continued
Dryburgh & Imlah, 38 outpatients Incidence and Modified Phlebitis American IV Nursing Erythema % patients Community nurses Daily Testretest, face
2002 [77] receiving IV severity of Rating Scale 14 Standards, 1982 Tenderness 27% cefazolin validity and
RCT antibiotics for phlebitis with two Pain 59% cloxacillin construct validity
Canada cellulitis antibiotics Swelling assessed. No
Induration data provided.
Purulence
Gallant & Schultz, 851 PIVC in 513 Reliability of a VIP scale 05 Jackson, 1998 [14] Pain % PIVC Research IV team Daily Authors reported
2006 [13] adult cardiac phlebitis scale Phlebitis defined as Redness 6.2% VIP 2 nurses trained in testing inter-rater
Prospective cohort surgical and VIP 2 Warmth VIP scale reliability, but
Infusion phlebitis assessment measures
*Bostrom-Ezrati et al., 1990 and Dibble et al., 1991 reported on the same study.
No reference given by authors and unable to locate reference.
Measurement property values are shown in the text of the paper.
Number of patients not stated.
Number of PIVC not stated.
2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
G. Ray-Barruel et al. Infusion phlebitis assessment measures
the most recent (2006) version of the INS phlebitis scale [16]. In reported in inter-rater reliability studies [84,85] because the focus
the study, adults with a PIVC were recruited from a community is on how close the reliability coefficient is to 1.00, not whether it
hospital and a visiting home nursing agency. Pairs of independent is different from 0.00.
research nurses who were not providing direct patient care under- Although the researchers provided initial data on the psycho-
took 392 observations of 176 patients. No information regarding metric properties of the widely used INS scale, the research did not
the training of the research nurses was provided, nor did the report comprehensively examine reliability and validity. There were no
state how many pairs of nurses performed ratings. The study aimed assessments of reliability over time (testretest and inter-rater),
to yield evidence regarding the INS scales reliability (inter-rater), and the validation efforts did not generate sufficient evidence of
validity, acceptability and feasibility. validity. Furthermore, the scales responsiveness was not evalu-
For inter-rater reliability, two nurses simultaneously scored the ated. The assessments of feasibility and acceptability were the
INS scale for each patient. The kappa statistic was used for the most comprehensive published to date, but the findings would have
reliability index; proportion in agreement was not reported. It was been of greater value with a larger sample than six nurses. It would
not reported whether the kappa statistic was calculated based on be advantageous to replicate this research in additional centres and
agreement for the full scales 04 range (i.e. a weighted kappa), or with a better gold standard phlebitis criterion, such as evaluation
on a simpler dichotomous rating of phlebitis presence (1) or of patients by an infusion expert.
absence (0). Furthermore, although different pairs of raters
assessed different sets of patients (i.e. the design was not fully
PVC ASSESS
crossed), it is unclear whether the appropriate statistic Fleisss
kappa [78,79] rather than Cohens kappa [80] was used. In any Ahlqvist and a team of Swedish co-researchers [86] developed a
event, the reported kappa was 0.45, which is considered moder- 45-item tool called PVC ASSESS to assess the management, docu-
ate using Landis and Kochs [81] standards (kappas of 0.210.40 mentation, signs and symptoms associated with PIVC use and
are fair, 0.410.60 are moderate, 0.610.80 are substantial, and complications. Only 11 of the items measure phlebitis symptoms
0.81 and greater are almost perfect). Standards for kappa are 5 based on patient reports (pain, tenderness, communicating) and
controversial [82,83], but few would argue that a kappa of 0.45 6 based on nurse observation. All observation items are dichoto-
offers strong evidence of assessor agreement. mous, indicating presence or absence of erythema, oedema, puru-
In terms of validity, Groll and colleagues assessed what they lent exudate, induration at insertion site, streak formation and
called concurrent validity. Concurrent validity, a form of criterion palpable cord. In the methodological paper describing the instru-
validity, requires a gold standard, which in this case was docu- ment, there were no guidelines for combining scores from the 11
mentation of phlebitis in the patients charts. The Spearman corre- symptom items into an overall score, nor any discussion about a
lation between the number of times observers said phlebitis discrete cut-off score for phlebitis.
occurred based on the INS scale and the number of times phlebitis Reliability was assessed at the item level and only for the six
was documented in the chart was a modest 0.39. Research nurses items that required nurses observations. Inter-rater reliability was
using the scales identified more than twice as many cases of estimated with 3 nurses and 66 patients. The researchers calculated
phlebitis as were recorded in patient charts. An entry in a patients proportion of agreement and kappa, using multi-rater kappa. Pro-
chart is a questionable choice for a gold standard. Indeed, the portion of agreement ranged from 0.77 (erythema) to 0.95
authors noted that the discrepancy between the charts and the scale (exudate and palpable cord). Because of low prevalence of most
underscores the need for the use of validated tools(p. 389). Within symptoms, kappa was computed only for one item (erythema), a
COSMINs classification, the procedure would best be described as modest 0.40 [95% confidence interval (CI) = 0.180.62]. Inter-
convergent validation (i.e. evidence that two separate measures of a rater reliability was assessed for three items that could be evalu-
construct are correlated) rather than criterion validation. ated via colour photographs for 67 patients, using a different set of
The INS scale was also assessed for acceptability and feasibil- three nurse assessors. Proportion of agreement ranged from 0.76 to
ity. The nurses completed the instruments relatively quickly, with 0.89, and the only kappa value again for erythema was 0.58
a mean completion time of 1.3 minutes (range 115 minutes, SD (95% CI = 0.440.72).
0.9 minutes) to complete both the phlebitis scale and the INS The researchers also assessed intra-rater reliability (which they
infiltration scale (the INS infiltration scale is not covered in this incorrectly called testretest reliability) using photographs. Three
review). Feedback from six research nurses indicated that the nurses examined colour photographs of 67 patients. They rated the
phlebitis scale was acceptable for the purpose of identification and presence or absence of three signs (erythema, exudate and streak
measurement of phlebitis, the instructions were clear, and the scale formation) on two occasions, 4 weeks apart. Commendably, the
was deemed easy to use and clinically appropriate. Acceptability order of presentation of the photos was altered at the second
was further supported by the fact that there were only limited viewing. Across the three raters, intra-rater kappas ranged from
amounts of missing data. 0.49 (nurse 1, streak formation) to 0.76 (nurse 2, purulent
The researchers concluded that the scale was valid and reliable exudate). The median intra-rater kappa was 0.59. This study was
in both the acute care and community settings (p. 390). However, the only one in which intra-rater reliability (constancy of assess-
the values of both kappa for inter-rater reliability (0.45) and the ment by the same rater over time) was evaluated.
correlation coefficient for the validity evaluation (0.39) are In terms of validity, only content validity was considered.
modest. The researchers perhaps interpreted statistically signifi- The report indicates that the research group confirmed content
cant differences as evidence of the scales good properties. validity . . . through comparisons with guidelines and published
However, statistical significance is of limited interest in assess- scientific literature in the field (p. 1109). It does not appear that a
ments of measurement properties, and indeed they are seldom formal content validity assessment was performed. The team did
2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd. 197
Infusion phlebitis assessment measures G. Ray-Barruel et al.
undertake an assessment of acceptability and feasibility. A sample bitis should be calculated as the number of phlebitis incidents per
of 27 nurses and 93 nursing students informally used the instru- total number of PIVC multiplied by 100 [15,17,18], but this review
ment with nearly 600 patients, and then provided feedback about found that reporting methods varied considerably: per patient, per
the clarity and content of items, and the usefulness and layout of PIVC and per 1000 catheter days.
the tool. A few changes were made after this feedback, but results The regular clinical use of a phlebitis tool is believed to provide
of the feasibility assessments were not provided. a trigger, alerting nurses to take action if problems occur [92]. The
Although the researchers considered their tool as reliable, review found that the most commonly used tools were the INS,
kappa values for the inter-rater and intra-reliability of nurse- VIP, Jackson, Baxter and Maddox scales; however, all of these
observed phlebitis items were modest. No information about the have been modified by various authors and several versions of each
reliability for the five patient-reported items was provided, and one scale exist, with some researchers continuing to use older versions.
of these items (Communicating) was not defined. Testretest Typical modifications include the addition or removal of phlebitis
reliability (short-term stability of scores across different assess- symptoms and variations in the scoring process, including the
ments) was not evaluated. In terms of validity, no evidence was number of symptoms required for diagnosis and changes to the
offered regarding the criterion validity (e.g. comparison to a gold numerical scale. The INS phlebitis scale is a popular tool, but
standard) or construct validity, nor was responsiveness of the several variations exist [1518], and we found that many authors
index evaluated. Feasibility information was limited. Gransson further modified the tool for their own purposes. The UK Royal
and Johansson [87] also used the PVC ASSESS tool, but did not College of Nursing recommends the VIP scale [93] because spe-
report any psychometric evaluation. cific actions, such as PIVC removal, are given as severity of
phlebitis increases. However, the VIP scale exists and continues to
be used in multiple modified versions. In the United States, the
Discussion INS currently recommends using either the INS tool [15,16], as
In this systematic review of research studies using phlebitis as the evaluated by Groll and colleagues [29], or the VIP scale, as per
primary endpoint, we found numerous definitions of phlebitis, 71 Gallant and Schultz [13].
different phlebitis assessment scales, a wide variation in assess- Frequency of phlebitis assessment ranged from every cannula
ment techniques and reported phlebitis rates, and very little psy- access, to twice daily, daily or even second daily assessment.
chometric evaluation of the existing scales. While it was surprising Accessibility or visibility of the PIVC site was not mentioned in
to find such an array of confounding factors in phlebitis assess- the majority of studies, although presumably some used gauze and
ment, of even greater concern was the fact that many studies tape dressings, which are acceptable [94] but preclude visual
reported phlebitis as a primary endpoint without providing any inspection of some symptoms.
definition of phlebitis at all. Assessors ranged from student nurses and ward nurses to
Among the 180 studies that explained how they determined experienced IV teams, and medical and nursing researchers.
phlebitis, either by scale or definition alone, we found a broad range Although some authors reported providing education on phlebitis
of definitions. The Centers for Disease Control and Prevention [88] assessment, the majority did not. Inter-rater reliability of phlebitis
defines phlebitis as warmth, tenderness, erythema or palpable assessment has proved to be problematic. A 2002 epidemiological
venous cord, citing Maki and Ringer [89], although this is not the literature review [60] reported that no diagnostic criteria for phle-
definition used by those authors. Other commonly used descriptors bitis had been proven valid or reproducible. Since then, several
include pain, swelling, induration and purulent drainage. authors have reported measuring inter-rater reliability, but none
With cumulative scales, no uniformity exists as to how many has addressed the full psychometric properties of the scale used, as
signs must be present to qualify as phlebitis and/or warrant the discussed earlier. The studies reviewed suggest that it is extremely
removal of the PIVC. Many tools consider the presence of two or difficult to use existing scales with confidence, given the modest
more symptoms as phlebitis, with others requiring only one sign, inter-rater reliability values.
and others several signs. Furthermore, differentiating phlebitis With the current state of knowledge about scale quality, we
from extravasation may be difficult when tenderness and oedema cannot recommend a particular phlebitis assessment scale. None of
are the predominant signs [90]. the existing scales has been subjected to rigorous and thorough
Numerous progressive scales with grading according to psychometric testing. For example, sensitivity and specificity have
symptom severity have been developed over the past 40 years, but not been calculated for any scale. With the current evidence, no
persistent limitations include the following: (1) not all required scale stands out as being of particularly high quality. In particular,
symptoms may be present, yet the PIVC is not working properly inter-rater reliability estimates tend to be quite modest.
[91]; and (2) a patient may not develop the signs in the particular This review highlights priorities for future psychometric evalu-
sequence outlined by the scale, and thus does not meet the thresh- ations of phlebitis scales. The most critical measurement proper-
old for phlebitis despite patient/staff concerns that trigger PIVC ties to assess are inter-rater and intra-rater reliability, as well as
removal [60,91]. criterion validity (although other properties, such as responsive-
Phlebitis rates ranged widely in this review. This can be attrib- ness, would be of interest). With respect to inter- and intra-rater
uted in part to the absence of a universally accepted scale with reliability, it is statistically unlikely that any scale will show high
strong demonstrated reliability. The INS [16,17] recommends a kappa values due to the generally low prevalence of phlebitis
phlebitis rate of 5% or less as acceptable, but differences in defi- among a group of hospital patients at one moment in time. Future
nition and assessment procedures, study design (prevalence versus evaluations of reliability should provide the actual proportions
incidence), casemix of research trials and rate calculation methods of phlebitis assessments with positive agreement and negative
make comparison difficult. The INS also recommends that phle- agreement [95], to assist in interpretation of kappa estimates. Byrt
198 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
G. Ray-Barruel et al. Infusion phlebitis assessment measures
2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd. 199
Infusion phlebitis assessment measures G. Ray-Barruel et al.
22. Lipman, A. G. (1974) Effect of buffering on the incidence and sever- 40. Catney, M. R., Hillis, S., Wakefield, B., Simpson, L., Domino, L.,
ity of cephalothin-induced phlebitis. American Journal of Hospital Keller, S., Connelly, T., White, M., Price, D. & Wagner, K. (2001)
Pharmacology, 31 (3), 266268. Relationship between peripheral intravenous catheter dwell time and
23. Dinley, J. (1976) Venous reactions related to in-dwelling plastic the development of phlebitis and infiltration. Journal of Infusion
cannulae: a prospective clinical trial. Current Medical Research and Nursing, 24 (5), 332341.
Opinion, 3 (9), 607617. 41. Nichols, E. G., Barstow, R. E. & Cooper, D. (1983) Relationship
24. Boyce, B. A. & Yee, B. H. (2012) Incidence and severity of phlebitis between incidence of phlebitis and frequency of changing IV tubing
in patients receiving peripherally infused amiodarone. Critical Care and percutaneous site. Nursing Research, 32 (4), 247252.
Nurse, 32 (4), 2734. 42. Madan, M., Alexander, D. J. & McMahon, M. J. (1992) Influence of
25. Kelsey, M. C. & Gosling, M. (1984) A comparison of the morbidity catheter type on occurrence of thrombophlebitis during peripheral
associated with occlusive and non-occlusive dressings applied to intravenous nutrition. Lancet, 339 (8785), 101103.
peripheral intravenous devices. Journal of Hospital Infection, 5 (3), 43. Madan, M., Alexander, D. J., Mellor, E., Cooke, J. & McMahon, M.
313321. J. (1991) A randomised study of the effects of osmolality and heparin
26. May, J., Murchan, P., MacFie, J., Sedman, P., Donat, R., Palmer, D. with hydrocortisone on thrombophlebitis in peripheral intravenous
& Mitchell, C. J. (1996) Prospective study of the aetiology of infu- nutrition. Clinical Nutrition, 10 (6), 309314.
sion phlebitis and line failure during peripheral parenteral nutrition. 44. Ahlqvist, M., Bogren, A., Hagman, S., Nazar, I., Nilsson, K., Nordin,
British Journal of Surgery, 83 (8), 10911094. K., Valfridsson, B. S., Sderlund, M. & Nordstrm, G. (2006) Han-
27. Nordenstrom, J., Jeppsson, B., Loven, L. & Larsson, J. (1991) dling of peripheral intravenous cannulae: effects of evidence-based
Peripheral parenteral nutrition: effect of a standardized compounded clinical guidelines. Journal of Clinical Nursing, 15 (11), 13541361.
mixture on infusion phlebitis. British Journal of Surgery, 78 (11), 45. Bergeron, M. G., Brusch, J. L., Barza, M. & Weinstein, L. (1976)
13911394. Significant reduction in the incidence of phlebitis with buffered
28. Scalley, R. D., Van, C. S. & Cochran, R. S. (1992) The impact of an versus unbuffered cephalothin. Antimicrobial Agents and Chemo-
i.v. team on the occurrence of intravenous-related phlebitis. A therapy, 9 (4), 646648.
30-month study. Journal of Intravenous Nursing, 15 (2), 100109. 46. Rickard, C. M., Webster, J., Wallis, M. C., et al. (2012) Routine
29. Groll, D. L., Davies, B., MacDonald, J., Nelson, S. & Virani, T. versus clinically indicated replacement of peripheral intravenous
(2010) Evaluation of the psychometric properties of the phlebitis and catheters: a randomised controlled equivalence trial. Lancet, 380
infiltration scales for the assessment of complications of peripheral (9847), 10661074.
vascular access devices. Journal of Infusion Nursing, 33 (6), 385 47. Kerin, M. J., Pickford, I. R., Jaeger, H., Couse, N. F., Mitchell, C. J.
390. & Macfie, J. (1991) A prospective and randomised study comparing
30. Powell, J., Tarnow, K. G. & Perucca, R. (2008) The relationship the incidence of infusion phlebitis during continuous and cyclic
between peripheral intravenous catheter indwell time and the inci- peripheral parenteral nutrition. Clinical Nutrition, 10 (6), 315319.
dence of phlebitis. Journal of Infusion Nursing, 31 (1), 3945. 48. Lundgren, A., Jorfeldt, L. & Ek, A. C. (1993) The care and handling
31. Campbell, L. (1998) I.v.-related phlebitis, complications and length of peripheral intravenous cannulae on 60 surgery and internal medi-
of hospital stay: part 2. British Journal of Nursing, 7 (22), 1364 cine patients: an observation study. Journal of Advanced Nursing, 18
1366, 13681370, 13721363. (6), 963971.
32. do Rego Furtado, L. C. (2011a) Maintenance of peripheral venous 49. Fujita, M., Hatori, N., Shimizu, M., Yoshizu, H., Segawa, D.,
access and its impact on the development of phlebitis: a survey of 186 Kimura, T., Iizuka, Y. & Tanaka, S. (2000) Neutralization of prosta-
catheters in a general surgery department in Portugal. Journal of glandin E1 intravenous solution reduces infusion phlebitis.
Infusion Nursing, 34 (6), 382390. Angiology, 51 (9), 719723.
33. Panadero, A., Iohom, G., Taj, J., Mackay, N. & Shorten, G. (2002) A 50. Gupta, A., Mehta, Y., Juneja, R. & Trehan, N. (2007) The effect of
dedicated intravenous cannula for postoperative use effect on inci- cannula material on the incidence of peripheral venous thrombophle-
dence and severity of phlebitis. Anaesthesia, 57 (9), 921925. bitis. Anaesthesia, 62 (11), 11391142.
34. Uslusoy, E. & Mete, S. (2008) Predisposing factors to phlebitis in 51. Bayer-Berger, M., Chiolero, R., Freeman, J. & Hirschi, B. (1989)
patients with peripheral intravenous catheters: a descriptive study. Incidence of phlebitis in peripheral parenteral nutrition: effect of the
Journal of the American Academy of Nurse Practitioners, 20 (4), different nutrient solutions. Clinical Nutrition, 8 (4), 181186.
172180. 52. Falchuk, K. H., Peterson, L. & McNeil, B. J. (1985)
35. Khawaja, H. T., Campbell, M. J. & Weaver, P. C. (1988) Effect of Microparticulate-induced phlebitis. Its prevention by in-line filtra-
transdermal glyceryl trinitrate on the survival of peripheral intra- tion. New England Journal of Medicine, 312 (2), 7882.
venous infusions: a double-blind prospective clinical study. British 53. Bostrom-Ezrati, J., Dibble, S. & Rizzuto, C. (1990) Intravenous
Journal of Surgery, 75 (12), 12121215. therapy management: who will develop insertion site symptoms.
36. Monreal, M., Oller, B., Rodriguez, N., Vega, J., Torres, T., Valero, P., Applied Nursing Research, 3, 146152.
Mach, G., Ruiz, A. E. & Roca, J. (1999a) Infusion phlebitis in 54. Dibble, S. L., Bostrom-Ezrati, J. & Rizzuto, C. (1991) Clinical pre-
post-operative patients: when and why. Haemostasis, 29 (5), 247254. dictors of intravenous site symptoms. Research in Nursing and
37. Monreal, M., Quilez, F., Rey-Joly, C., Rodriguez, S., Sopena, N., Health, 14 (6), 413420.
Neira, C. & Roca, J. (1999b) Infusion phlebitis in patients with acute 55. Everitt, N. J. & McMahon, M. J. (1997) Influence of fine-bore cath-
pneumonia: a prospective study. Chest, 115 (6), 15761580. eter length on infusion thrombophlebitis in peripheral intravenous
38. Rypins, E. B., Johnson, B. H., Reder, B., Sarfeh, I. J. & Shimoda, K. nutrition: a randomised controlled trial. Annals of the Royal College
(1990) Three-phase study of phlebitis in patients receiving peripheral of Surgeons of England, 79 (3), 221224.
intravenous hyperalimentation. American Journal of Surgery, 159 56. Harrigan, C. A. (1984) A cost-effective guide for the prevention of
(2), 222225. chemical phlebitis caused by the pH of the pharmaceutical agent.
39. Sherertz, R. J., Stephens, J. L., Marosok, R. D., et al. (1997) The risk National Intravenous Therapy Association, 7 (6), 478479.
of peripheral vein phlebitis associated with chlorhexidine-coated 57. Jarrard, C., Goodner, W., Piazza, J. A. & Bomar, W. L. (1987) The
catheters: a randomized, double-blind trial. Infection Control and syringe infusion pump system its effect on phlebitis rates. National
Hospital Epidemiology, 18 (4), 230236. Intravenous Therapy Association, 10 (1), 2933.
200 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.
G. Ray-Barruel et al. Infusion phlebitis assessment measures
58. Larson, E. & Hargiss, C. (1984) A decentralized approach to main- on phlebitis in a neurological intensive care unit: a case-control
tenance of intravenous therapy. American Journal of Infection study. Journal of Internal Medicine Research, 40 (6), 23212326.
Control, 12 (3), 177186. 77. Dryburgh, L. & Imlah, T. (2002) A comparison study: incidence and
59. Popovsky, M. A. & Ilstrup, D. M. (1986) Randomized clinical trial of severity of clients diagnosed with severe cellulitis who develop phle-
transparent polyurethane i.v. dressings. National Intravenous bitis receiving cloxacillin vs. cefazolin in the community setting.
Therapy Association, 9 (2), 107110. CINA: Official Journal of the Canadian Intravenous Nurses Asso-
60. Tagalakis, V., Kahn, S. R., Libman, M. & Blostein, M. (2002) The ciation, 18, 2231.
epidemiology of peripheral vein infusion thrombophlebitis: a critical 78. Fleiss, J. L. (1971) Measuring nominal scale agreement among many
review. American Journal of Medicine, 113 (2), 146151. raters. Psychological Bulletin, 76, 378382.
61. Williams, D. N., Gibson, J., Vos, J. & Kind, A. C. (1982) Infusion 79. Fleiss, J. L., Nee, J. & Landis, J. (1979) Large sample variance of
thrombophlebitis and infiltration associated with intravenous cannu- kappa in the case of different sets of raters. Psychological Bulletin,
lae: a controlled study comparing three different cannula types. 86, 974977.
National Intravenous Therapy Association, 5 (6), 379382. 80. Cohen, J. (1960) A coefficient of agreement for nominal scales.
62. do Rego Furtado, L. C. (2011b) Incidence and predisposing factors of Educational and Psychological Measurement, 20, 3746.
phlebitis in a surgery department. British Journal of Nursing, 20 (14), 81. Landis, J. R. & Koch, G. G. (1977) The measurement of observer
S16S18, S20, S22 passim. agreement for categorical data. Biometrics, 33, 159174.
63. Trinh, T. T., Chan, P. A., Edwards, O., Hollenbeck, B., Huang, B., 82. DeVet, H. C. W., Terwee, C., Mokkink, L. B. & Knol, D. L. (2011)
Burdick, N., Jefferson, J. A. & Mermel, L. A. (2011) Peripheral Measurement in Medicine: A Practical Guide. Cambridge, UK: Cam-
venous catheter-related Staphylococcus aureus bacteremia. Infection bridge University Press.
Control and Hospital Epidemiology, 32 (6), 579583. 83. Gwet, K. (2012) Handbook of Inter-Rater Reliability. Gaithersburg,
64. Bertolino, G., Pitassi, A., Tinelli, C., Staniscia, A., Guglielmana, B., MD: Advanced Analytics.
Scudeller, L. & Luigi Balduini, C. (2012) Intermittent flushing 84. Davies, M. & Fleiss, J. (1982) Measuring agreement for multinomial
with heparin versus saline for maintenance of peripheral intravenous data. Biometrics, 38, 10471051.
catheters in a medical department: a pragmatic cluster-randomized 85. Hallgren, K. (2012) Computing inter-rater reliability for observa-
controlled study. Worldviews on Evidence-Based Nursing, 9 (4), tional data. Tutorials in Quantitative Methods for Psychology, 8,
221226. 2334.
65. Biswas, J. (2007) IV nursing care. Clinical audit documenting inser- 86. Ahlqvist, M., Berglund, B., Nordstrom, G., Kland, B., Wirn, M. &
tion date of peripheral intravenous cannulae. British Journal of Johansson, E. (2010) A new reliable tool (PVC ASSESS) for assess-
Nursing, 16 (5), 281283. ment of peripheral venous catheters. Journal of Evaluation in Clini-
66. Nagata, K., Egashira, N., Yamada, T., Watanabe, H., Yamauchi, Y. & cal Practice, 16, 11081115.
Oishi, R. (2012) Change of formulation decreases venous irritation in 87. Gransson, K. E. & Johansson, E. (2012) Prehospital peripheral
breast cancer patients receiving epirubicin. Supportive Care in venous catheters: a prospective study of patient complications.
Cancer, 20 (5), 951955. Journal of Vascular Access, 13 (1), 1621.
67. Yamada, T., Egashira, N., Watanabe, H., Nagata, K., Yano, T., 88. OGrady, N. P., Alexander, M., Burns, L. A., et al. (2011) Guidelines
Nonaka, T. & Oishi, R. (2012) Decrease in the vinorelbine-induced for the prevention of intravascular catheter-related infections. Clini-
venous irritation by pharmaceutical intervention. Supportive Care in cal Infectious Diseases, 52 (9), e162e193.
Cancer, 20 (7), 15491553. 89. Maki, D. G. & Ringer, M. (1991) Risk factors for infusion-
68. Polit, D. & Beck, C. (2006) The content validity index: are you sure related phlebitis with small peripheral venous catheters. A
you know whats being reported? Research in Nursing and Health, randomized controlled trial. Annals of Internal Medicine, 114 (10),
29 (5), 489497. 845854.
69. Polit, D., Beck, C. & Owens, S. (2007) Is the CVI an acceptable 90. Curran, E. T., Coia, J. E., Gilmour, H., McNamee, S. & Hood, J.
indicator of content validity? Appraisal and recommendations. (2000) Multi-centre research surveillance project to reduce
Research in Nursing and Health, 30 (4), 459467. infections/phlebitis associated with peripheral vascular catheters.
70. Chee, S. & Tan, W. (2002) Reducing infusion phlebitis in Singapore Journal of Hospital Infection, 46 (3), 194202.
hospitals using extended life end-line filters. Journal of Infusion 91. Webster, J., Osborne, S., Rickard, C. & Hall, J. (2010) Clinically-
Nursing, 25 (2), 95104. indicated replacement versus routine replacement of peripheral
71. Gouping, Z., Wan-Er, T., Xue-Ling, W., Min-Qian, X., Kun, F., venous catheters. Cochrane Database of Systematic Reviews, (3),
Turale, S. & Fisher, J. W. (2003) Notoginseny cream in the treatment CD007798.
of phlebitis. Journal of Infusion Nursing, 26 (1), 4954. 92. Goddard, L., Clayton, S., Peto, T. E. & Bowler, I. C. (2006) The
72. Mestre, G., Berbel, C., Tortajada, P., et al. (2012) Successful multi- just-in-case venflon: effect of surveillance and feedback on preva-
faceted intervention aimed to reduce short peripheral venous lence of peripherally inserted intravascular devices. Journal of Hos-
catheter-related adverse events: a quasiexperimental cohort study. pital Infection, 64 (4), 401402.
American Journal of Infection Control, 41, 520526. 93. Dougherty, L., Bravery, K., Gabriel, J., et al. (2010) Standards for
73. Palefski, S. S. & Stoddard, G. J. (2001) The infusion nurse and Infusion Therapy: The RCN IV Therapy Forum. London: Royal
patient complication rates of peripheral-short catheters. A pro- College of Nursing.
spective evaluation. Journal of Intravenous Nursing, 24 (2), 113 94. Gillies, D., ORiordan, L., Carr, D., Frost, J., Gunning, R. & OBrien,
123. I. (2003) Gauze and tape and transparent polyurethane dressings for
74. Washington, G. T. & Barrett, R. (2012) Peripheral phlebitis: a point- central venous catheters. Cochrane Database of Systematic Reviews,
prevalence study. Journal of Infusion Nursing, 35 (4), 252258. (4), CD003827.
75. White, S. A. (2001) Peripheral intravenous therapy-related phlebitis 95. Cicchetti, D. V. & Feinstein, A. R. (1990) High agreement but low
rates in an adult population. Journal of Intravenous Nursing, 24 (1), kappa: II. Resolving the paradoxes. Journal of Clinical Epidemiol-
1924. ogy, 43 (6), 551558.
76. Liu, F., Chen, D., Liao, Y., Diao, L., Liu, Y., Wu, M., Xue, X., You, 96. Byrt, T., Bishop, J. & Carlin, J. B. (1993) Bias, prevalence and kappa.
C. & Kang, Y. (2012) Effect of Intrafix SafeSet infusion apparatus Journal of Clinical Epidemiology, 46 (5), 423429.
2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd. 201
Infusion phlebitis assessment measures G. Ray-Barruel et al.
97. Hoehler, F. K. (2000) Bias and prevalence effects on kappa viewed in 100. Glinas, C., Loiselle, C. G., LeMay, S., Ranger, M., Bouchard, E. &
terms of sensitivity and specificity. Journal of Clinical Epidemiol- McCormack, D. (2008) Theoretical, psychometric, and pragmatic
ogy, 53 (5), 499503. issues in pain measurement. Pain Management Nursing, 9, 120
98. Sim, J. & Wright, C. C. (2005) The kappa statistic in reliability 130.
studies: use, interpretation, and sample size requirements. Physical 101. DeLuca, P. P., Rapp, R. P., Bivins, B., McKean, H. E. & Griffen, W.
Therapy, 85 (3), 257268. O. (1975) Filtration and infusion phlebitis: a double-blind prospec-
99. Dychter, S. S., Gold, D. A., Carson, D. & Haller, M. (2012) tive clinical study. American Journal of Hospital Pharmacology, 32
Intravenous therapy: a review of complications and economic con- (10), 10011007.
siderations of peripheral access. Journal of Infusion Nursing, 35 (2),
8491.
202 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.