MADISON MEMORIAL HOSPITAL Version #: version

Title: Peripheral Intravenous (IV) Policy and Intravenous (IV) Care

Process Owner: Ty Cottle, Sara Brubaker, Edgar Montoya, Savannah Bundy, Katie Date Approved:
Doxey, Emily Burden
Approver(s): AP Both Sister Barnhill, Kevin McEwan Effective Date:

Department(s): Labor and Delivery, NICU, Emergency Department, Medical- Next Review
Surgery, ICU, Surgery Unit, Radiology Date:
(This document is confidential and proprietary to Madison Memorial Hospital. Unauthorized use or copying without written consent is strictly prohibited.)

Purpose/Summary:
Purpose: Insert and maintain a peripheral IV safely and in a standardized manner to reduce risk
for infection, usage of extra equipment and patient discomfort.
Summary: This policy outlines the procedure for preparing, inserting, and maintaining a
peripheral intravenous catheter. The procedure includes a step by step explanation on following
evidence based practice to successfully and safely care for an intravenous catheter.

Definitions:
● Peripheral intravenous catheter (PIVC): catheter placed into a peripheral vein for
venous access to administer intravenous therapy such as medication fluids. (JoVE
Science Education Database, 2020).

● Tourniquet: a device for stopping the flow of blood through a vein or artery, typically by
compressing a limb with a cord or tight bandage.

● Needleless connector: device that enables connection between intravenous catheter and
allows access for aspiration and infusion.

Goals and Objectives:

1. Hospital staff will receive yearly standardized training regarding initiating an intravenous
access device and will review this policy once a month.
2. IV will be safely started using evidenced based practice and hospital policy.
3. IV will be maintained properly according to evidence based practice and hospital policy.

The Goals and Objectives of this process interrelate to the hospitals goals and
objectives as follows:

Quality: By providing a yearly standardized training for I.V. initiation, health professionals are
more likely to provide care that is consistent and maintains a high-quality level.

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Providing the Exceptional Experience: Properly starting and maintaining I.V’s Ensures
increased comfort by decreasing errors and therefore decreasing pain that may arise from
infection, impaired skin integrity, and infiltration issues.
Ensuring Our Future: Patient satisfaction and comfort lead to a trusting, comfortable hospital
environment that patients will remember and lean on in the future if needed. It also provides the
staff with a standard of care that is appreciated and easy to follow.

Equipment and Suitable Environment Needed:

● 20- or 22-gauge catheter for intravenous insertion

● IV Extension set
● IV Fluid
● Saline flush
● Waterproof pad or towel
● 2 × 2-in gauze squares
● Tourniquet
● Tape
● Transparent, occlusive dressing
● Clean gloves
● Chlorhexidine swabs
● Sterile field

Procedure:
● Inserting a Peripheral Intravenous Catheter according to evidence based practice
● Proper IV care according to evidence based practice

Overview Details Quality

Records

IV Site
Preparation
Step 1
Preparing Patient
● Check providers orders for details regarding the IV
● Gather the necessary supplies. Make sure the sharps
container is close at hand.
● Prepare insertion as close to procedure needing an IV
as possible.
● Explain the procedure to the patient and the purpose of
the IV catheter. Lack of competence is one of the major
fears patients have with insertion of IVs.
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● Disinfecting supplies readily available at the bedside

enables staff fulfillment of decontamination with
needleless connectors.

(Gorski et al., 2016)

Step 2 Finding an Appropriate Site

● Ask about patients' preferred vein used for past
insertions.
● Apply tourniquet to engorge veins.
● Use veins that are easily palpated using the index and
middle fingers of the dominant hand.
● Carefully select a site that will not cause complications
due to bending or being easily pulled out. Avoiding
sites in the antecubital area has reduced the likelihood
of alarms sounding and catheters being pulled out.
Consider the condition of the veins, size of the cannula
and duration of the catheter. Larger gauges and forearm
placement tend to increase the likelihood of the
duration of the IV.
● For veins that are especially difficult to find, using
ultrasound-guided PIV decreases the likelihood of
central venous access.
● For difficult vein access, use the following
interventions to facilitate vein engorgement...
○ Gently blot or tap the skin overlying the vein
and wiping the area with an antiseptic swab.
○ Apply a warm compress, or soak the limb in
warm water, for a short period before line
placement.
○ Optimize ergonomics for the operator placing
the line, include patient positioning and ambient
lighting.
○ Apply topical aliquots of glyceryl trinitrate.

IV Insertion
Step 1 ● Place tourniquet three to four inches above the intended
site. Double checking that the tourniquet is removed is
key in preventing future complications including
compartment syndrome.
● After swabbing the insertion site briskly in a
horizontal, then vertical, then circular pattern,
performed venipuncture. Anchored the vein below the
site by placing thumb over the vein and gently
stretching the skin against the direction of the insertion

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4 to 5 cm distal to the site. Asked the patient to relax

his or her hand.
● Cautioned the patient that he or she would feel a quick
stick.
● Inserted the vascular access device with the bevel up at
a 10- to 30-degree angle slightly distal to the actual site
of venipuncture in the direction of the vein.
● Observed for blood return through the flashback
chamber of the catheter.
● Lowered the catheter until it was almost flush with the
skin.
● Advanced the catheter 0.6 cm into the vein and
loosened the stylet of the over-the-needle catheter.
Continued to hold the skin taut while stabilizing the
needle. Advanced the catheter off of the needle to
thread just the catheter into the vein until the hub rested
at the venipuncture site. When using a winged needle,
advance the cannula until the hub rests at the
venipuncture site.
● Did not insert the stylet once it had been loosened.
● Release the tourniquet
● Flush IV prior to use to assess catheter function
○ Flush IV before and after IV medications are
pushed
● An extension set should be considered to avoid
catheter manipulation
● After the IV is inserted, apply a securement device.
● Use sterile, transparent dressing
● Do not tape over site
● It is recommended to use engineered stabilization
devices including adhesive devices, devices that hold
the catheter in place using molded technology, or a
Velcro type surface.
● Peripheral intravenous catheters need to be carefully
documented including how they are inserted, when
they become dislodged and other complications occur.

(Gorski et al., 2016)

Monitoring and
Managing
Step 1 Monitoring
● Assess site and surrounding area for redness,
tenderness, swelling, and drainage by visual inspection

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and palpation through the intact dressing and through

patient reports about any discomfort including pain,
paresthesia, numbness, or tingling.
● Assess at least every 4 hours; every 1 to 2 hours for
patients who are critically ill/sedated or have cognitive
deficits; hourly for neonatal/pediatric patients; and
more often for patients receiving infusions of vesicant
medications. Take extra precautions and assess as often
as possible.
● Educate patients on the signs and symptoms of
infections such as redness, swelling, tenderness, or pain
around the insertion site
(Nickels, 2019).

Step 2 IV Site change:

● It is also now recommended by the CDC that catheters
are only to be replaced when clinically indicated.
Randomized trials support the conclusion to leave in
the IV as long as it functions properly instead of the
previous 72 to 96 hours.
● Pediatrics: site will be changed only when
dysfunctional
(Nickels, 2019).

Step 3 IV Tubing and Solutions:

● All tubing will be labeled with the date & time it was
started, date & time to be discarded or changed, and
initials of the caregiver.
● Tubing to be changed with contraindicated solutions or
medications, or with catheter/ site change.
● Continuous use tubing, secondary sets & add-on
devices (ie. medication filters, bridges, adapters) will
be changed every 96 hours, with IV site change or
immediately if contamination or system integrity
suspect.
● Use aseptic, non-touch technique to change the
needleless connector.
● Needleless connectors should be changed no sooner
than 96-hour time periods.
● When in use with continuous infusion, the needleless
connector is changed with the primary infusion set (96
hours).
● Needleless connector should be replaced if:
A. connector is removed for any reason,

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B. residual blood or debris in needleless connector

C. Blood culture from PIVC
D. Contamination
E. Organizational policies
F. Manufacturer’s directions
● Having the same type of needleless connector
everywhere in the organization can lessen the chance of
confusion about the steps.

Note: Certain medications require more frequent tubing/filter

changes. Refer to IV Medication Reference Manual.

● Lipid and all Parenteral Nutrition (PN) solutions, filter,

adapters & tubing will be changed every 24 hours.

● Blood & blood products - as per “Blood, Blood

Components and Plasma Protein Products -
Administration of” policy.
● Use of a needleless connector for fast flow rates of
crystalloid solutions and red blood cells can
significantly decrease flow rates. Avoidance is best
practice.

● Manufacturer steps for sequence of clamping of

catheter and syringe disconnection should be followed
to minimize intraluminal thrombotic occlusion.

● All tubing will be labeled with the date & time it was
started, date & time to be discarded or changed, and
initials of the caregiver.

(Gorski et al., 2016)

Overview Details Quality

Records

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Step 4 Needleless connectors must be disinfected before each

entry into the PIVC

● Execute a strong mechanical scrub for manual

decontamination of the needleless connector
before each access to the PIVC
● Allow PIVC to dry.
● Disinfecting agents: 70% isopropyl alcohol,
iodophors, or > 0.5% chlorhexidine.
● 70% isopropyl alcohol has a scrubbing time of 5
to 60 seconds. Other agents need further
research for best scrubbing time.
● Mechanical scrubbing is needed even with
needleless connectors that have antimicrobial
coats.

(Gorski et al., 2016)

Internal References:
● Madison Memorial Peripheral Intravenous Policy
● Madison Memorial IV Tubing Change Policy
● Madison Memorial IV Site Change Policy
External References:
Keleekai, N. L., Schuster, C. A., Murray, C. L., King, M. A., Stahl, B. R., Labrozzi, L. J.,

Glover, K. R. (2016). Improving Nursesʼ Peripheral Intravenous Catheter Insertion

Knowledge, Confidence, and Skills Using a Simulation-Based Blended Learning

Program. Simulation in Healthcare: The Journal of the Society for Simulation in

Healthcare, 11(6), 376–384. doi: 10.1097/sih.0000000000000186

Gorski, L., Hadaway, L., Hagle, M. E., McGoldrick, M., Orr, M., & Doellman, D. (2016).

Infusion Therapy Standards of Practice (Vol. 39).

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Nickel, B. (2019). Peripheral Intravenous Administration of High-Risk Infusions in Critical

Care: A Risk-Benefit Analysis. Critical Care Nurse, 39(6), 16–28. https://doi-

org.byui.idm.oclc.org/10.4037/ccn2019443

Moureau, N. (2019). Shifting the standard of care in IV dislodgement prevention. Infection

Control Today. Retrieved from https://www.infectioncontroltoday.com/infusion-

vascular-access/shifting-standard-care-iv-dislodgement-prevention

Recommendations. (2015, November 5). Retrieved from

https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

Beecham, G. B., & Tackling, G. (2019). Peripheral line placement. National Center for

Biotechnology Information. 21(7). Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK539795/

The Royal Children's Hospital Melbourne. (2018). Peripheral intravenous (IV) device

management. Retrieved from

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Peripheral_Intravenous

_IV_Device_Management/

JoVE Science Education Database. Nursing Skills. Peripheral Intravenous Catheter Insertion.

JoVE, Cambridge, MA, (2020).

Requirements:

● Peripheral Catheters and midline catheters should be inserted in an upper extremity. The
catheter used should be based on the intended purpose and potential duration of use.
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“Avoid using steel needles for administration of fluids and medication.” use a
peripherally inserted central catheter (PICC), for IV therapy over 6 days. Evaluation of
insertion site should be done daily by palpitation through the dressing for tenderness.
Dressings should not be replaced if there is no sign of infection. If signs of phlebitis
(warmth, tenderness, erythema or palpable venous cord) are present, remove immediately
(Recommendations, 2015).
● Assessments done on a regular basis should include: catheter position, patency/occlusion,
limb symmetry, any signs of phlebitis (erythema, tenderness, swelling, pain etc.) and
infiltration/extravasation” (The Royal Childrens Hospital Melbourne, 2018) Assessment
of dressing should include: checking securement of device and if it is still clean and dry.
Assure that dressings are not too tight or restrictive. During continuous infusion of IV
fluids check the infusion site for any signs of complications and document the
assessments hourly. Infusion lines should be replaced at least every 7 days using standard
aseptic technique. Lines should be changed at the end of fresh blood or fresh blood
product administration. Lipid emulsions require tubing, bag, and line change every 24
hours (The Royal Childrens Hospital Melbourne, 2018).

Replacement of Administration Sets

1. In patients not receiving blood, blood products or fat emulsions, replace administration
sets that are continuously used, including secondary sets and add-on devices, no more
frequently than at 96-hour intervals, but at least every 7 days.
2. No recommendation for rate of replacing intermittently used sets
3. No recommendation for rate of replacing needles to access ports
4. Replace tubing used to administer blood, blood products, or fat emulsions (those
combined with amino acids and glucose in a 3-in-1 admixture or infused separately)
within 24 hours of initiating the infusion.
5. Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial
is changed, per the manufacturer’s recommendation.
6. No recommendation can be made regarding the length of time a needle used to access
implanted ports can remain in place. (Summary of Recommendations, 2015)

Quality Assurance and Sustainability:

In order to maintain and ensure the quality of care given, updated supplies need to be
available, continuing education needs to occur, and clinical practice of peripheral intravenous
insertion and care should be continually monitored. New technologies are being developed
quickly that help prevent complications associated with peripheral IVs. Obtaining these devices
and other necessary supplies required for peripheral IVs is key in promoting usage of the above
policy (Moreau, 2019). In order to promote standardization and reduce the risk of complications,
regular education should be given biannually. Additionally, regular monitoring and encouraged
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documentation will help determine the occurrence with which the above policy is used as well as
the outcomes from following the outlined steps. Through utilizing education, adequate updated
supplies and monitoring, the above quality of the above policy will be maintained and promoted.
Sustainability is dependent on the documentation and management of each PIV. Nurses need to
initial and date the PIV site after each insertion. It is also necessary to monitor signs and
symptoms of infection every 4 hours.

Disclaimer:
This is a resource to assist staff and not all circumstances may apply. Adaptation may be needed
with clarification from health care providers depending on patient needs. Vein troubleshooting
using steps not set forth in this policy may also be needed. This policy does not guarantee safety
of IV administration and does not promise one time or patent vein cannulation.

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