implementation of a protocol for the prevention and management of extravasation injuries in the...

E V I D E N C E U T I L I S A T I O N

Implementation of a protocol for the prevention andmanagement of extravasation injuries in the neonatalintensive care patientjbr_213 165..171

Diane Warren RGON Grad Cert (neonatal) NNP (hospital cert)Auckland City Hospital, Auckland, New Zealand

AbstractAim This project sought to determine nurses’ understanding and management of infants with intravenous (IV)therapy. There were three specific aims:• To improve identification and management of extravasation injuries in neonates• To ensure management of extravasation injuries in neonates is classified according to IV extravasation staging

guidelines• To develop a protocol that outlined actions required to manage extravasation injuries

Methods This project utilised a pre- and post-implementation audit strategy using the Joanna Briggs Institute (JBI)Getting Research into Practice (GRIP) program. This method has been used to improve clinical practice by utilisingan audit, feedback and re-audit sequence. The project was implemented in four stages over a 7-month period from21 October 2009 to 30 May 2010.

Results Initially, there was poor compliance with all four criteria, ranging from zero to 63%. The GRIP phase of theproject identified five barriers which were addressed throughout this project. These related to education of staff andthe development of a protocol for the prevention and management of extravasation injuries in the neonatalpopulation. Following implementation of best practice, the second audit showed a marked improvement in all fourcriteria, ranging from 70 to 100% compliance.

Conclusions Overall, this project has led to improvements in clinical practice in line with current evidence. Thishas resulted in enhanced awareness of the risks associated with IV therapy and of measures to prevent an injuryoccurring within this clinical setting.

Key words: extravasation, intravenous, management, neonatal patient, prevention.

Background

The Neonatal Critical Care Unit (NCCU) is a unique envi-ronment that provides a high level of intensive care to thepremature and critically ill neonate. Over the years, neonatalcare has significantly increased the survival of very low birth-weight and extremely premature infants. Intravenous (IV)therapy has become an essential and routine treatment forthe neonatal intensive care patient. It is required for theadministration of fluids, nutrition, blood products and medi-cations. Despite the overall benefits, IV therapy can be asso-

ciated with a variety of local and systemic complications,such as catheter-related infections, phlebitis and extravasa-tion.1 Many of the solutions used to treat neonates have thepotential to cause ischaemia, necrosis and skin loss.1,2

Examples of these solutions include but are not limited to:Total Parental Nutrition, 10–15% dextrose solutions, antibi-otics, sodium bicarbonate infusions or blood products.Additionally, the use of some medications, such as dopam-ine or adrenaline, can generate tissue ischaemia secondaryto vasoconstriction.1–3 Extravasation is a common complica-tion of neonatal infusion therapy. The incidence of somedegree of extravasation, within this population, has beenreported to range between 23% and 63%.4 Extravasationinjuries are more commonly associated with peripherallyinserted venous catheters than central venous catheters.1,5 A

Correspondence: RGON Diane Warren, Auckland City Hospital,2 Park Road, Grafton, Auckland 1010, New Zealand. Email:[email protected], [email protected]

doi:10.1111/j.1744-1609.2011.00213.x Int J Evid Based Healthc 2011; 9: 165–171

© 2011 The AuthorInternational Journal of Evidence-Based Healthcare © 2011 The Joanna Briggs Institute

UK survey undertaken in 2004 identified 38 per 1000infants had recorded extravasation injury and skin loss whilein an NCCU. An important aspect to consider is that 70% ofthese injuries occurred in neonates of 26 weeks gestation orless.6–8 Newborn babies are particularly at risk for extrava-sation injury due to the delicate nature and small diameterof their peripheral veins. Additionally, infants are unable toarticulate pain, which may allow infusions to continueunnoticed.9,10 Once an extravasation injury has occurred itcan be difficult to predict whether or not there will besignificant soft tissue damage.11 However, these types ofinjuries can create significant morbidity such as secondaryinfections, skin loss, nerve and tendon damage. Any of thesecomplications can potentially require surgical interventionand, depending on the extent of the injury, ongoing painmanagement may be necessary.1,6,12 One of the barriers topreventing IV injury is the failure of healthcare professionalsto assess and document injuries, accurately, and in a timelymanner.9,13–15 Additionally, all staff members may not havean understanding of, or apply, best practice in relation to IVcare. The use of a staging tool has been employed in somepaediatric settings, enabling staff to objectively grade IVextravasation.3,5 The assessment of IV catheters requiresexperienced nurses, who are methodical, and cautious intheir observation of catheter sites.16 Well-informed nursesact as patient advocates and are key factors in the preven-tion, detection and management of these injuries.16 Extrava-sation is defined as the ‘inadvertent administration of avesicant (or blistering) solution into the surrounding tis-sue’.13 Infiltration is defined as the ‘inadvertent administra-tion of a nonvesicant (or non blistering) solution into thesurrounding tissue’.13 Within the literature, the termsextravasation and infiltration are often used interchange-ably. In the neonatal population, there is a lack of distinctionbetween vesicant and nonvesicant solution injuries due tothe potential of both types of solutions to cause skin lossand necrosis. Throughout this article, I will use the termextravasation to describe both phenomena.

Audit question

Are we using best practice in the prevention and manage-ment of extravasation injuries in the neonatal critical careunit?

Aims of the project

This project sought to determine nurses understanding andmanagement of infants with IV therapy. There were threespecific aims:• To improve identification and management of extravasa-

tion injuries in neonates10

• To ensure management of extravasation injuries in neo-nates is classified according to IV extravasation stagingguidelines5

• To develop a protocol that outlined actions required tomanage extravasation injuries

Methods

This project utilised a pre- and post-implementation auditstrategy using the Joanna Briggs Institute (JBI) GettingResearch into Practice (GRIP) program.17 Utilising the audit,feedback and re-audit sequence has been shown to enhancechange and improve clinical practice.17 The project wasimplemented in four stages over a 7-month period from 21October 2009 to 30 May 2010.

Stage 1: preparation for auditThis involved the identification of an audit topic, develop-ment of a proposal, forming a project team, defining auditcriteria, defining the setting and sample size, and then con-ducting a pre-implementation audit.

Identification of the audit topicThe topic chosen for the project was the ‘Prevention andManagement of Extravasation Injuries in the Neonatal Inten-sive Care Patient’. This topic was chosen as there was noprotocol in place, within the service, which outlined specificbest practice management for IV care. When an extravasa-tion injury occurred, the documentation and managementof these events was reactive. There were no strategies uti-lised to limit damage and mitigate any associated morbidity.Many infants receiving neonatal care require prolonged IVtherapy; consequently, if safeguards are ignored, complica-tions can occur.

Development of a proposalLiterature was searched using CINAHL, Medline andCochrane databases using the MeSH headings: infant,newborn, neonate, preterm infant, extravasation, infiltra-tion; this was limited to English articles. There were 205articles found. The reference lists from these articles werealso reviewed. No systematic reviews or randomised controltrials in humans were found to determine if one form ofintervention was superior to another in reducing the associ-ated morbidity. Most trials were empirical and based onsmall uncontrolled trials, case reviews or animal studies.Minimal research exists on neonatal IV therapy and thereforeresearch on adults and animals models is considered asevidence to guide practice.18 Many different approacheswere identified regarding the management of extravasationinjuries, with no current consensus identifying a standard-ised treatment regime. However, within the literature, thereis a consensus that when providing IV therapy the aim is toprevent an injury occurring and that early intervention andappropriate management is essential to limit damage shouldan extravasation occur.13

Forming a project teamBefore the project commenced, the Deputy Director ofNeonatology/Maternal Fetal Medicine and Mater MothersHospital Research Centre (MMHRC) agreed that the projectwould be approved as there was minimal risk existing to thepatient population. There was awareness that when iatro-genic injuries of this nature occur, there is the potential forconsiderable morbidity.

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Key stakeholders were identified and included in theproject. The Staff Specialist Neonatology, Nurse UnitManager Intensive Care Nursery 2 (ICN2), Clinical Facilitator(ICN2), Research Nurse (MMHRC) and members of the‘Neonatal Practice Development Team’ (NPDT) formed thechange management team. The project leader was the clini-cal facilitator, who was participating in the ‘Translating Evi-dence into Practice’ program at the MMHRC. All the auditswere conducted by the project leader who then consultedwith team members directly and at team meetings. Regularcommunication with all project members was maintained atall times.

Defining audit criteriaEvidence-based guidelines, relating to IV line management,were sourced from the ‘Infusion Nursing Standards of Prac-tice’13 and JBI best practice guidelines for the ‘Manage-ment of Peripheral Intravascular Devices’.19 Audit criteriawere then developed from these sources. Three key areaswere identified as essential for limiting the risk associatedwith IV therapy: assessment, prevention and managementof IV injuries. Four criteria were chosen to audit these keyareas:

Criterion 1: All babies with IV catheters have the sitechecked and documented hourly for signs of extravasation.

A retrospective review of the observation records fromneonates in the ICN1 and ICN2 area was undertaken. Thesecharts were from patients receiving IV therapy.

The gestational ages of the reviewed patients ranged from25–34 weeks; IV therapy was indicated for prematurityand/or sepsis.

Compliance required the following conditions being met:• There was documented evidence on the patient record

that the IV site had been checked hourly to indicatepatency

• There were no periods missing documentation within a24-h periodCriterion 2: The peripheral IV catheter site is secured with

transparent adhesive and limb clearly visible at all times.The peripheral IV sites of babies in the ICN1 and ICN2

areas were observed.Compliance required the following conditions being met:

• At the time of assessment the infants IV site is securedwith transparent dressing

• At the time of assessment the limb, with the IV catheter,is clearly visibleCriterion 3: A protocol is in place for the assessment,

grading and management of extravasation injuries in theneonate.

Compliance required the following condition being met:• The policy and procedures site at the Mater Mothers’

Hospital (MMH) is searched for a protocol, which includesthe assessment, grading and management of extravasa-tion injuries in the neonateCriterion 4: Nursing staff have received education on the

management of neonatal extravasation injuries within thelast year. All staff audited were either full-time or part-timeemployees working rostered shifts; no permanent night staff

were surveyed. The staff were either registered nurses orregistered nurses/registered midwives with more than halfthose surveyed having over 6 years’ nursing experience inneonatal intensive care.

Compliance required the following conditions being met:• Staff training records indicated they had received educa-

tion on this topic within the last 12 months• Staff stated they had received training on this topic within

the last 12 months

Defining setting and sample sizeThe project was undertaken at the NCCU, MMH, Brisbane,Queensland, Australia. This is a level six tertiary unit whichspecialises in the care and management of premature andsick newborns. The NCCU has a 79-cot nursery, comprising25 ICN1 cots, 22 ICN2 cots and 32 special care nursery cots.There are approximately 2100 newborns admitted to theNCCU annually. The service manages all varieties of neonatalconditions including extreme prematurity, congenitalanomalies, cardiac and surgical conditions. The majority ofall infants admitted to the service require some IV therapy.The service employs approximately 300 nursing staff, whodemonstrate a range of clinical skills and experience.

Inclusion and exclusion criteriaFor this project two audits were undertaken with the follow-ing sample sizes:• Sixty newborns (pre-implementation 30, post-

implementation 30) admitted to the NCCU who requiredIV therapy

• Sixty neonatal nurses (pre-implementation 30, post-implementation 30) working within the NCCUData for the audits were collected consecutively over a

2-week period pre- and post-implementation.

Pre-implementation auditAn initial audit was undertaken in December 2009 to evalu-ate the degree to which current policy and practice werereflective of best practice recommendations for IV care. Theaudit was undertaken in the ICN1 and ICN2 areas of theNCCU. Audit criteria were assessed with a grade – Yes, No ornot applicable.• Data for criterion 1 were collected from the babies’ health

record• Data for criterion 2 were collected from observing babies

with IV lines in situ• Data for criterion 3 involved searching the policy and

procedures site at the MMH• Data for criterion 4 were collected by verbally asking

nurses if they have received any education on the man-agement of extravasation injuries and reviewing stafftraining records for evidence of related educationThis process was undertaken by the project leader. The

audit utilised the MMHRC evidence-based audit form anddata were gathered against best practice criteria. Theresults of the audit were then entered manually into anMMHRC program which calculated percentages and dis-played results on a bar graph. In general, the results of the

Extravasation: prevention and management 167


pre-implementation indicated a poor compliance with allfour criteria (Fig. 1). These are expanded on in the Discus-sion section of this article. The results were presented tostaff at ward meetings and via email. IV workshops andClinical Nurse study days were forums where PowerPointpresentations and group discussion of results facilitatedlearning about the subject. Opportunities for participantsto identify challenges within their practice, which impactedon their ability to adhere with best practice, were identi-fied. Project members had the audit results discussed withthem directly, via email and at team meetings.

Stage 2: protocol developmentThere was no organisational protocol outlining the preven-tion and management of extravasation injuries in thenewborn. The need for a protocol to define the accountabil-ity of nursing, in the participation and delivery of infusiontherapy, was identified as essential by the project team. Theprotocol was initially developed by the project leader andreviewed by the project team. The Neonatal Clinical Gover-nance and Action Committee then reviewed the protocoland it was accepted for inclusion on the MMH policy andprocedure website.

The protocol detailed three phases: prevention, recogni-tion and management. Best practice recommendations forthe prevention of an injury included: hourly assessmentand documentation of IV patency, visibility of the IV site,specific requirements for securing the catheter and thecorrect use of tapes to limit obstruction to venous return.A recommendation to avoid sites of flexion was included,as these areas are particularly vulnerable to injury due todifficulty securing the catheter and a reduction in subcu-taneous tissue.20,21

Recognition of an injury was facilitated by incorporatinga staging tool which enabled staff to grade extravasation

events (Table 1).5,7 These tools have been shown to stan-dardise descriptions. They utilise the assessment of differ-ent criteria such as pain, swelling or colour, and assignthem a grade.2,3 The stages range from one to four, withfour being the most severe. Laminated cue cards were pro-vided for each work area to assist nurses in rememberingto evaluate and document IV patency according to thestaging scale.

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Figure 1 Results of the pre-implementation audit.

Table 1 Extravasation Grading Scale5,7

Stage Characteristic

1 Pain at siteFlushes with difficultyNo erythemaNo swelling

2 Pain at siteMild erythemaSlight swelling at siteNo blanchingGood pulse below site1–2 s capillary refill below site

3 Pain at siteModerate swelling above and/or below siteBlanchingSkin cool to touchGood pulse below site1–2 s capillary refill below site

4 Pain at siteSevere swelling above and/or below siteBlanchingSkin cool to touchDecreased or absent pulse†

Capillary refill >4 s†

Skin breakdown or necrosis†

†The presence of any of these signs indicates a stage 4 injury.

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Within the protocol different management options wereoutlined dependent upon the stage of injury. There weretwo options for the management of stage 3 or 4 injuries;both were at the discretion of the Consultant Neonatologist.One option was a saline flush-out. This is a sterile procedureused to flush the infusate out of the affected tissue.11 Thesecond option involved the use of Phentolamine or 2%Nitro-glycerine; this can be used to reverse the ischaemiathat occurs as a result of some medications.22,23 All extrava-sations identified as stages 3 or 4 required compulsory inci-dent reporting and were tracked for risk managementpurposes. The protocol places additional emphasis on pro-tecting parental rights by mandating the need to consultparents and gain consent for photographing of all stage 3and 4 injuries.

Stage 3: implementation of best practiceThis involved analysis of audit results, dissemination ofresults to staff and implementation of strategies to improvepractice (GRIP). Five barriers for getting evidence into prac-tice were identified and strategies to improve practice weredeveloped.

Barrier 1: Lack of education for nurses to increase theawareness of potential hazards of IV therapy.

Strategy: It was felt there was a need to increase theawareness of the potential hazards of IV therapy. IV therapyis a routine practice within neonatal care; hence many stafffelt they were very familiar with IV care for this population.Feedback and discussion of audit results was provided atward meetings and via email to all staff. The discussioncentred not only on the results of the audits but on strat-egies which could be used to improve clinical practice.Understanding perceptions and experiences of staff withinthe service was essential to achieve positive staff attitudesand maintain integration of practice change.24 Discussionof reported extravasation injuries within the service wasincluded on the agenda for ward meetings. Maintainingthe confidentiality of staff involved in any incident wascrucial, and therefore discussions centred on constructivelyidentifying areas where improvements could be made,rather than specific details of individual events.

Barrier 2: Lack of knowledge about the risk factors andstaging of extravasation injuries.

Strategy: Educational in-service sessions were provided fornursing staff. These were held at a variety of times over amonth period. An IV workshop covering a variety of topicson fluid therapy, including a session relating to the preven-tion, recognition and management of extravasation injury,was held. Two Clinical Nurse study days provided the oppor-tunity to discuss the new IV protocol with the senior nursingteam. This group of nurses would be instrumental in theimplementation of the protocol within the service. Noticeboards, displayed at various locations throughout the unit,were utilised to exhibit educational posters which focusedon strategies to prevent an injury occurring. Posters wereparticularly effective when using pictures addressing specificcare issues. The posters displayed different stages of IV injuryand images pre- and post-extravasation treatments. A

staging tool, to assess and document an IV injury, was not inplace within the service. An essential component of theproject was the development of a protocol which incorpo-rated a staging tool and outlined specific managementoptions to consider in the event of an injury.

Barrier 3: Time constraints to attend education sessions.Strategy: Short sessions, which focused on the fundamen-

tals, were provided at a variety of times. Busy nursing staffwere targeted at change of shift to attend sessions whichwere limited to 15-min duration.25 The aim was to facilitateincremental change and enhance implementation.

Barrier 4: Dissemination of information to a large numberof staff.

Strategy: Team leaders, Clinical Nurses and the NPDT wereidentified, by the project team, as key personnel to influenceorganisational change. This group of change championswould be influential in providing leadership, support andconsistent communication with the multidisciplinary team.24

Leadership support has been closely linked with positive staffattitudes and successful implementation of change.26,27 Allnew staff were targeted to receive education, whichaddressed any knowledge deficits relating to the prevention,assessment and documentation of IV therapy.

Barrier 5: Staff rotation and skill mix.Strategy: It is well documented that experienced, edu-

cated nurses are a key factor in the prevention of IV compli-cation.28 Due to the size of the service and the variance inskill level within the nursing team, it was essential that lessexperienced team members were supported by staff whoworked across the service.29

Stage 4: post-implementation auditThis was an audit using the same methodology as the pre-implementation audit with comparative analysis of theresults. The second audit was undertaken 3 months afterimplementation of best practice, in April 2010. The resultsshowed a marked improvement in all four criteria and thiswas disseminated to key stakeholders via the same methodsas the pre-implementation audit. These results are presentedin the Discussion section of this article.

Results

Pre-implementation auditAll four criteria indicated poor compliance with best prac-tice. Hourly checking and documentation of IV sites had acompliance rate of 43% (criterion 1). Of the 30 patientsaudited the IV site was secured correctly with transparentadhesive and the line visible 63% of the time (criterion 2).For criteria 3 and 4 the grade was zero. There was noprotocol in place (criterion 3), and of the 30 staff audited inthe ICN1 or ICN2 areas, no education had been receivedwithin the last 12 months relating to extravasation manage-ment (criterion 4).

Post-implementation auditThere was marked improvement in all four criteria. Criterion1 (site checking) had a 27% improvement reaching 70%



compliance. Criterion 2 (site securing) achieved 73% com-pared with 63% in the initial audit. A 100% compliance wasnoted in criterion 3 (protocol) due to the developmentand implementation of a protocol and lastly a significantimprovement was shown in criterion 4 (staff education)which improved from zero to 75% on the second audit(Fig. 2).

Conclusion

Overall, this project has led to improvements in clinicalpractice in line with current evidence. This has resulted inimproved awareness of the risks associated with IV therapyand of measures to prevent an injury occurring within thisclinical setting. Criterion 1, which focused on the documen-tation and checking of IV sites, required hourly documenta-tion on patient bedside charts to indicate IV patency. Whenauditing the charts, if there was 1 h missed within a 24-hperiod, the patient received a no for this criterion. Followingthe first audit, it was noted that several patients had extendedperiods (6–18 h) without documentation. Within part of theservice, the area for documenting IV patency was not clearlyobvious to all staff, and after clarifying this, there was amarked improvement in compliance. Educational boards inthe work areas and nurses’ stations were used to displayexamples of accurate documentation, highlighting thesection to record patency. The feedback and discussion ofaudit results focused on strategies that could be used toimprove clinical practice. Approaches included: checking anddocumenting the status of all IV sites with two nurses athandover; ensuring the IV is flushed with saline, prior toadministering medication and the importance of close obser-vation of an IV site during medication administration. It wasnoted that some staff were documenting checking of the site,but were neglectful in actually observing the IV site. This

finding was addressed with staff on an individual basis. Fol-lowing the second audit, there was a marked improvement incompliance, and the periods that were missing documenta-tion were significantly shorter (1–2 h). This still resulted in a‘no’ and consequently this improvement is not shown in theresults. The second criterion required the IV sites to becompletely visible when audited. This required not only thesite to be secured with transparent adhesive but also the limbhad to be positioned to permit clear observation. Onlymodest improvement from 63 to 73% was achieved. Thelines were all secured with clear adhesive; however, swad-dling impaired easy viewing of the IV site. This is a develop-mentally supportive intervention, but requires modificationto support best practice.30 The development of a protocolrated 100% compliance for the second audit (criterion 3);however, it was beyond the scope of this project to assesscompliance with the new protocol. This document contains astrong focus on prevention and, appraising the incidence ofcomplications following adherence with best practice isrequired. When the project commenced it was not the prac-tice to routinely report IV injuries. Staff tended to only reportevents that required further treatment of a skin lesion orinjuries that developed necrosis. Greater awareness of theneed to grade all IV extravasations and mandatory reportingof grade 3 and 4 injuries should facilitate accurate follow up inthe future. Should an injury occur, there is now a protocol inplace to guide management which should limit the amountof tissue damage in this group of iatrogenic injuries. It hasbeen identified that further monitoring is warranted in theevaluation of different management options on morbidity.Additionally, there was no plan put in place to disseminate theinformation beyond our unit; however, the protocol is now inuse elsewhere within the Mater Health Service. I believe a planshould have been identified at the time of completion of theproject.

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Figure 2 Results of the pre- and post-implementation audit.

170 D Warren


As a result of this project, there has been significant edu-cation (criterion 4) provided to staff. This resulted in 75% ofstaff in the second audit stating they had received educationon the topic. The need to provide ongoing education hasbeen recognised by the project team as crucial to ensurepractice change is maintained.

In summary, this project has shown the value in utilising thepre- and post-implementation audit sequence as a methodfor translating evidence into practice. Although there wasclear evidence of improvement in practice, the project timeframe limited the achievement of longer term outcomes. Oneof the barriers that had been identified at the start of theproject was the need to support junior staff by ensuring seniornurses rotated across the service. It was felt this would aid inthe early identification of extravasation as many junior staffhad never seen this type of injury in a neonatal patient.Consistent senior staff support could have facilitated earlyrecognition of subtle changes to IV patency. Unfortunately,many senior members of the service were very resistant torotations out of the ICN1 area, and this remained a persistentbarrier. The need to review the sustainability of the practiceimprovement will be re-examined by undertaking 6 monthlyaudits using similar criteria. Ensuring the results are fed backand discussed with relevant staff will increase adherence withbest practice recommendations. Surveying medical staffworking within the unit would have provided a more com-plete picture of the impact of this project.

Lastly, the development of an on-line training modulerelating to IV therapy and a video demonstrating the treat-ment options for stage 3 and 4 injuries is planned. This willprovide an educational tool to assist medical and nursingstaff who have never performed these procedures in neo-natal care.

Acknowledgements

The author would like to acknowledge the support of LynneElliott, Dr M Dingwall, A Warren and K Kynoch for theirsupport and contribution to this project. This project couldnot have been undertaken without the support of the MaterMothers’ Hospital NCCU.

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