french medical institute for children (fmic) - IUPUI

FRENCH MEDICAL INSTITUTE
FOR CHILDREN (FMIC)
A study on Incidences of Phlebitis
and Causes in Pediatric Patients at
FMIC, Afghanistan
Rosemin Premji
Nursing Division
1

Team Members
MEMBERS:
Ms. Hamidah Ismail
Ms. Maria Muradi
Ms. Doulat Hirani
(Infection Control Nurse)
(Infection Control Nurse)
(Head of Quality Assurance Program)
FACILITATORS:
Ms.Rosemin Premji
Dr. Alexander Lies
(Administrator, Nursing Division)
(Medical Director)
2

Objectives of the study
• To identify the occurrence and incidences of
phlebitis at French Medical Institute for Children
(FMIC).
• To analyze the causes of phlebitis.
• To present the strategy to minimizes the phlebitis
in the future.
3

Background of the Study
• Peripherally inserted catheters are essential for infants &
children in the neonatal intensive care unit and medical
surgical unit for medication administration, parenteral
nutrition and blood transfusions.
• An observational prospective study was carried out to
identify the incidences of PIVCs infection, causes and
recognize the strategies for its prevention in inpatient
pediatric wards including ICU and medical surgical area
of French Medical Institute for Children (FMIC) ,
Afghanistan.

Background of the Study (…cont)
• More than 250,000 IVD-related BSI occur in the
United States each year, each associated with
prolongation of hospital stay, a 12% to 25%
attributable mortality, and an added cost to health
care of $35000 (Maki, 2002).

Definition
Phlebitis
It is a condition in which inflammation of
the intima of the vein occurs. It is
characterized by pain and tenderness along
the course of the vein, erythema, and
inflammatory swelling with a feeling of
warmth at the site.

Causes of Phlebitis:
Causes of Phlebitis
There are many causes of phlebitis. It could be chemical,
mechanical or bacterial.
• Chemical Phlebitis: The phlebitis occurs after
administration of antibiotics or any infusion
• Mechanical Phlebitis: Phlebitis occurs due to
misplacement of PIVC
• Bacterial Phlebitis: Phlebitis occurs due to proliferation
of Bacteria. (Lynelle.F, 2002)

Stages of Phlebitis
Stages of Phlebitis:
There are four stages of phlebitis.
• Stage I: Ertheyma ( redness at IV site) with or with out
pain.
• Stage II: Ertheyma(redness) with pain on IV site with
or with out Edema.
• Stage III: Redness, pain, swelling along with Streak
formation and palpable venous cord.
• Stage IV: redness, pain, swelling along with Streak
formation and palpable venous cord >1 inch and
Purulent discharge, and fever. (Lynelle.F, 2002)

Method for the study
• A prospective quantitative study was done. A PIVC infection
identification form was developed to identify the occurrence.
• 303 PIVCs placed in 150 pediatric patients from September
2007 until November 2007 at French Medical Institute for
Children (FMIC) in Kabul, Afghanistan.
• During this period all PIVCs inserted for treatment and
hydration purpose were included, these PIVC were in place
until infiltration, and phlebitis is observed or dislodge occurred
or treatment is finished and cannula is removed.
• Technique for inserting, securing and maintaining PIVC was
observed. Knowledge related to the causes, stages of phlebitis
and IV site care was also assessed.

Instrument
For data collection, a form was developed which consist of
• Definition of phlebitis
• Demographic data
• Patient diagnosis
• Lab results
• Stages of phlebitis
• Insertion date
• Site of PIVC
• Frequency to change the PIVC and
• Antibiotics received by patients via PIVC.
Note: 01 form is used for one PIVCs associated phlebitis for
detailed analysis.

Data Analysis
Data Analysis:
• Descriptive analysis was done. Data was entered in
excel sheet and percentages were calculated for
phlebitis in patients in different location i.e. medical
surgical wards and intensive care units. Unit wise
comparison was made for rate of phlebitis. Causes were
studied in all phlebitis and relate with diagnosis, length
of stay, unit and stages of phlebitis. Comparison of
Independent variables, such as causes, numbers of
PIVC inserted in specific units, stages was done. The
dependent Variables such as age and demographic
information was not analyzed.

Results
• There were total of 303 PIVCs were inserted in 150
pediatric patients from which 212 (69.9%) PIVCs
were identified having infection (Phlebitis).
• Among these 212 PIVCs, 81(38%) were from ICU
and 131(62%) were from medical surgical unit.
• The risk of phlebitis increased after 24 hrs of the
PIVCs insertion. In ICU 76% PIVCs developed
infection whereas 67% in medical surgical unit.
• 77.8% PIVCs were identified as developing redness &
swelling.
• The most common reasons of phlebitis were
improper dilution of antibiotics, quality of PIVC and
patient diseases status.

Comparison of Units
Phlebitis in ICU and Wards
13

Phlebitis Categorize in Stages

Causes of phlebitis
15

Conclusion
• Incidence of PIVCs related infections in pediatric patients are
high as compare to the adult patients. The common causes
identified were improper use of antibiotic dilutions, quality of
cannula material and the critical illness of patients.
• Upon investigation few interventions were implemented to
improve the care and decrease the occurrence of PIVCs
infection. Such as:
‣ Ongoing In-services session of staff related to causes, stages of
phlebitis and the IV site care.
‣ Close observation of staff practices by head nurse and infection control
nurse

Conclusion (…Cont)
• Working with material management for changing the
quality of cannula.
• Introduction of transparent dressings.

Limitation of Study:
• In literature it is recommended that after
developing phlebitis the catheter tips should be
sent but due to financial constraints we did not
send the tips.
18

Recommendations
• Awareness sessions for the health care staff regarding the
indication of PIVC use, proper procedure for insertion and
maintenance and the infection control guideline to prevent
infections.
• Periodically assess the adherence to guidelines for proper
insertion and maintenance of PIVC.
• Encourage the attendants to report any changes observed at
the insertion site.
• Work collaboratively with physician and pharmacy for proper
antibiotic dilutions.
• Use single-dose vials for parenteral additives or medications
when possible. Do not combine the leftover content of singleuse
vials for later use.

Recommendations (cont)
• If multi-dose vials are used
1. Refrigerate multi-dose vials after they are opened if
recommended by the manufacturer.
2. Cleanse the access diaphragm of multi-dose vials with
70% alcohol before inserting a device into the vial.
3. Use a sterile device to access a vial and avoid touch
contamination of the device before penetrating the access
diaphragm.
4. Discard multi-dose vial if sterility is compromised.
• Strict compliance to IC protocols. i.e. following hand hygiene
and aseptic techniques at all levels.
• Clean injection port with 70% alcohol before accessing the
system

Recommendations (cont)
• Replacement of IV sets and tubings according to CDC
guidelines. i.e. no more frequently than 72 hours.
• In pediatric population, leave peripheral venous catheters in
place until IV therapy is completed, unless complications
(e.g., phlebitis and infiltration) occur.
• Dissemination of information to the other staff.
• Initiation of the role of IC member in each unit for
monitoring and compliance of IC practices.
• Accept criticism and improve the system

References
• Maki,(2002),The Hospital Infection Control Practices
Advisory Committee Centers for Disease Control and
Prevention Guideline for Prevention of Intravascular
Device-Related Infection (PEDIATRICS) Vol. 110 No.
5 November 2002, pp. 1009-1013
• Paula.L,Maura,M(2004) Troubleshooting Pediatric
Peripheral IVs: Phlebitis and Infiltration. Nursing
Spectrum.
• Lynelle,F;Wallis,M,et.all;(2002), A Descriptive Study of
Peripheral Intravenous Catheters in Patients Admitted
to a Pediatric Unit in One Australian Hospital. Journal of
Infusion Nursing. Pg159-169

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