Management from a multidisciplinary perspective of phlebitis related to peripheral venous catheter insertion: An international Delphi study

Abstract

Aim

To determine the consensus and importance of care practices related to the management of peripheral venous catheter (PVC)‐related phlebitis in hospitalized patients through the views of experts from different disciplines.

Background

PVCs are commonly used in hospitals but are associated with complications such as phlebitis. Their management differs widely, and studies are heterogeneous.

Design

Delphi method.

Methods

Four stages: problem area (with Web of Science bibliometric review in July 2022), panel members, two Delphi rounds and closing criteria. In the Delphi survey, experts answered an online questionnaire based on assessment, treatment and follow‐up dimensions (September 2022–February 2023). Statistical analyses were conducted of frequencies, percentages, measures of central tendency and levels of dispersion (QD). A space for comments was created, and a thematic analysis conducted of them.

Results

Eighteen experts (nurses, doctors and pharmacists) participated in the Delphi rounds. Forty‐five activities were identified: 19 in assessment, 15 in treatment and 11 in follow‐up. A high consensus level (QD ≤ 0.6) was found in five activities (11.12%), moderate level (0.6 < QD < 1.0) in 19 (42.22%) and low level (QD > 1.0) in 21 (46.66%). Seven themes were determined (patient perspective, lack of consensus, low evidence‐based practices, stage‐based treatments, prevention activities, high variability in practice and specialist teams and interdisciplinary work).

Conclusion

The importance of systematic assessment scales is highlighted together with consensus on signs and symptoms (pain, redness, inflammation, palpable cord and induration). Treatment according to severity and daily visual recording and monitoring are emphasized along with the need for patient participation and healthcare literacy. A high level of consensus was obtained in 11% of the activities, showing the large variability of criteria and interventions for phlebitis management. Highlighted needs include working in a team, the use of specialist teams and promoting evidence‐ and prevention‐based activities.

Relevance to Clinical Practice

Clinical variability is noted and, therefore, the importance of consensus on standardized care for PVC phlebitis and evidence‐based practice.

Reporting Method

Delphi studies (CREDES).

Patient or Public Contribution

Experts contribution.

Impact.

• It is noted that despite the importance given by health professionals to scales for the assessment of phlebitis, no gold standard for this has been identified at the international level.

• There is currently a wide variety of interventions for the management of PVC‐related phlebitis, only 11% of which have a high level of expert consensus. High level consensus was obtained in visual exam (signs and symptoms) with scales/instruments (assessment dimension), remove catheter, treatment according to severity and paracetamol (pain control) (treatment dimension) and register and visual control (non‐specific) (follow‐up dimension).

• Greater standardization of phlebitis management and the use of clinical protocols are needed, along with the active involvement and empowerment of patients in their health process.

• The value of specialist teams in vascular access is highlighted, along with the interdisciplinary work of the healthcare team.

1. INTRODUCTION

Peripheral venous catheters (PVCs) are the most commonly used invasive devices in the hospital setting. However, there are discrepancies in how to properly manage them and treat PVC‐associated complications (Xu et al., 2023), the incidence of which is underestimated due to the frequent and daily use of catheters at the point‐of‐care level, the challenge of identifying complications, the inconsistent use of PVC‐associated procedural codes and the voluntary nature of PVC reporting (Lim et al., 2019). One of the most prevalent complications is phlebitis (Marsh et al., 2020). This is associated with endothelial damage of the intimal layer (leading to thrombus formation) and with inflammation of the tunica media of the vein causing oedema, infiltration and possible rupture of the integrity of the wall (Pittiruti et al., 2023). This process causes different symptoms, usually of a local character such as pain, surrounding red swelling, hyperaemia, warmness, redness, tenderness and oedema (García‐Expósito et al., 2021). Establishing assessment elements can help in the diagnosis and follow‐up of phlebitis (Gorski et al., 2021; Mihala et al., 2018). PVC‐related phlebitis increases morbidity, hospitalization and financial costs and decreases the satisfaction of the person affected by this condition (Blanco‐Mavillard et al., 2020; Marsh et al., 2020; Salma et al., 2019). It can result in more serious complications such as blood stream infections like bacteraemia (Drugeon et al., 2023; Marsh et al., 2021) and increase the risk of death (Lim et al., 2019). Phlebitis is classified as an adverse event or unnecessary harm caused by medical care, and its reporting and relevant actions are intended to strengthen the culture of patient safety (Nunes De Almeida et al., 2022).

Different literature reviews (García‐Expósito et al., 2021, 2023; Goulart et al., 2020; Guanche‐Sicilia et al., 2021) have shown that phlebitis treatment and its effectiveness are unresolved issues. There is a high degree of study heterogeneity, with the use of different products with significant diversity in their preparation and application. The products used can be divided into three groups: physical, pharmacological and phytotherapeutic measures (García‐Expósito et al., 2021). Given the high level of variability, the results are inconclusive in terms of the applicability of the products in clinical practice and further research is needed.

It should be noted that the diagnosis and management of post‐insertion phlebitis is usually the direct competence of nursing worldwide, although the relevant scientific production of nursing and other medical disciplines in this specific regard is relatively low (Alkan & Akyüz, 2021). In a study by Marsh et al. (2020), phlebitis was identified as the most prevalent complication and it was proposed that the guidelines for its prevention and for catheter management should consider both infectious and non‐infectious complications in order to improve PVC functionality and patient experience. In the context described above, it is, therefore, essential to explore and agree on elements for the management of post‐PVC phlebitis worldwide.

2. AIMS

The aims of the study are: (1) to establish consensus on care practices related to the management of PVC phlebitis in hospitalized patients worldwide through the views of experts in the field; and (2) to determine the importance of these activities in the care setting.

3. METHODS

The Delphi technique was used in this study. The Delphi method is a systematic process of two or more rounds which aims to achieve consensus among the participants and, in this case, was used to explore a healthcare‐related intervention (Niederberger et al., 2021). The design of this study can be justified given the lack of definition or vagueness regarding associated phlebitis assessment and control activities, and its management at worldwide level through the application of widely diverse topical products (García‐Expósito et al., 2021, 2023; Goulart et al., 2020; Guanche‐Sicilia et al., 2021; Marsh et al., 2020), as well as the possibility offered by Delphi studies of the development of qualitative points of view (Nasa et al., 2021).

The Delphi method is a social research technique which seeks to obtain a reliable collective opinion from a group of experts (Landeta & Lertxundi, 2024). Its main characteristics include it being: (1) an iterative process (minimum of two rounds); (2) with anonymity among the experts (avoiding undesired influences); (3) with controlled feedback and (4) with statistical analysis of the group's answers (Landeta & Lertxundi, 2024).

A structured two‐round process was conducted following the recommended guidelines for Delphi studies: REporting DElphi Studies (CREDES) (Jünger et al., 2017). This methodological process is based on four stages as proposed by Nasa et al. (2021) (Figure 1).

FIGURE 1.

Stages of the Delphi methodological process.

3.1. Problem area

The methodological proposal of Nasa et al. (2021) provides different strategies to address this stage, one of which is a literature review. A bibliometric review was, therefore, conducted by three members of the research team (AT‐R, JR, JG‐E) in July 2022. The generation of a bibliometric review as an initial stage of a Delphi study constitutes an original proposal as no similar proposals have been found in the literature. A bibliometric exploration facilitates the detailed recording of key external (authors, institutions, etc.) and internal elements, such as research foci (Xiao et al., 2021). This initial bibliometric analysis, therefore, allowed, firstly, the systematic identification of relevant experts at global level (institutions and authors), enabling us to contact and invite them onto the panel of experts. Selecting the experts is a crucial aspect in Delphi studies (Landeta & Lertxundi, 2024; Nasa et al., 2021). It secondly allowed us to detail general aspects for investigation on the topic of the management of phlebitis due to vascular access. The Web of Science (WOS) was searched using PubMed MeSH terms (TS = “phlebitis or thrombophlebitis” and “catheter”). The decision to exclusively use WOS data was taken based on the literature (Selva‐Pareja et al., 2022), because of its interconnections, the inclusion of a large number of high impact journals and the possibility of data export for bibliometric analysis. Inclusion criteria were original research articles on the subject and in any language. Studies considered non‐primary (literature reviews, etc.) and other documents (conferences, etc.) were excluded. This initial bibliometric study was repeated and extended in January of 2023 (Torné‐Ruiz et al., 2023). The results obtained reinforced the need for: (1) research at international level; and (2) new studies on the assessment and treatment of PVC‐related phlebitis.

3.2. Panel members

The literature review enabled the determination of bibliometric aspects such as the identification of reputable authors with publications and high citations and leading university or healthcare centres in the field (Supplementary Material S1: Author affiliations and number of articles). With this information, a selection protocol was detailed and the criteria for the suitability of the experts were: experts from health professions (nurses, doctors, pharmacists) with international publications in the last 10 years and from different continents (Europe, Asia, Australia and America). Africa was not represented as no relevant experts had been found according to the data obtained in the bibliometric review described in Section 3.1.

The research team contacted the experts via the corresponding author of the articles. In the initial phase, 40 experts were invited, with an anticipated loss of 40% or more (Martínez‐Jaimez et al., 2022). It should be noted that experts from highly distinguished institutions and authors with numerous scientific publications were among the participants in the study. While it is important to maintain the anonymity of the expert panellists (Nasa et al., 2021), Table 1 shows the main characteristics of the experts who participated in the two rounds.

TABLE 1.

General characteristics of the experts.

Variables	n	%
Age a	43.31	12.59
Sex
Male	4	22.22
Female	14	77.78
Years of experience a	17	12.32
Publications a	18	32.9
Work profession
Nurse	16	88.88
Doctor	1	5.56
Pharmacist	1	5.56
Advanced training (professionals)
Postgraduate diploma	3	16.67
Master	5	27.78
Doctorate	7	38.89
Speciality	1	5.55
None	2	11.11
Work experience (professionals)
Hospital care	1	5.56
Oncology	1	5.56
Geriatrics	1	5.56
Orthopaedics	1	5.56
Research	1	5.56
Vascular access control unit	7	38.89
Infections control unit	1	5.56
Dialysis	1	5.56
Pharmacy	1	5.56
Emergency unit	2	11.11
Intensive care unit	1	5.56
Country
Spain	3	16.67
USA	1	5.56
Italy	2	11.11
Sweden	1	5.56
Norway	1	5.56
Sweden	1	5.56
Chile	1	5.56
UK	2	11.11
France	1	5.56
Brazil	3	16.67
Australia	2	11.11

^a Mean and standard deviation (SD).

3.3. Delphi rounds

For the first round, an electronic questionnaire (e‐Delphi) previously used for a national study in Torné‐Ruiz et al., 2024 was employed given its ease of comprehension and the ability to obtain information in a contrasted way due to its previous use. The questionnaire consisted of two parts: (1) basic identification data of the expert (age, sex, country of origin, initial and advanced training, years of experience and area of expertise, publications); and (2) open questions on three dimensions of PVC‐related phlebitis: assessment (scales/tools/observation of signs and symptoms), treatment (general activities and types of treatment by product) and follow‐up activities (general or specific) (Supplementary Material S2: First round tool. Open questions).

In the second round, the data were presented grouped into three dimensions by items according to the responses of the experts. This was carried out by the research team (A T‐R, M S‐O, A C‐N, JR, JG‐E), who analysed the content of the responses through key concepts given the initial open question. It was ensured that all the opinions expressed were represented, whether similar or diverging (Reguant Alvarez & Torrado Fonseca, 2016), and without questioning their scientific validity. These items were fully in line with the responses of the experts. This format by item according to key concepts facilitated a synthesis of the information and, hence, a better understanding of the information for the subsequent round.

The second survey was, therefore, presented in the format of item by dimension as a brief closed assertion and by frequency according to the responses of the experts in round 1. The experts were asked whether they agreed or not (by marking YES or NO) and to rank the importance of the item on a Likert scale from 1 (not at all) to 4 (very), with a space left open for argumentation and additional comments. In both rounds, the research team controlled the process through an analysis of the responses by three researchers (AT‐R, JR, J G‐E) ensuring the anonymity of the members and their answers.

The means of communication with the experts was by email. In the first message sent, the study and objectives were presented, participation was requested and a link to the questionnaire was provided using the RedCap© 10.7.1 platform. The first round was carried out between September and October 2022 and the second between December and February 2023.

3.4. Closing criteria

The data were analysed by frequencies, percentages, measures of central tendency and level of dispersion [quartile deviation QD = (Q3–Q1)], QD ≤ 0.6 (high level), 0.6 < QD < 1.0 (moderate level), or QD > 1.0 (low level) (Niederberger et al., 2021). Additional comments were analysed and grouped into categories following the methodology of qualitative thematic analysis by two researchers (A T‐R, JR).

In relation to the closure criteria and the stability of the results, the research team had initially planned three Delphi rounds but decided to terminate the study with just two rounds after weighing up the possibility of a high rate of abandonment in a third round and after evaluating the stability of the responses between rounds by calculating the proportion of experts who modified their response (López‐Gómez, 2018). It should be noted that the experts generally maintained their position in rounds 1 and 2 (Supplementary Material S3: Stability of responses of the experts by dimension and round).

3.5. Ethical considerations

This type of study is considered to be low‐risk non‐interventional research (Steel et al., 2021). In this line, the Ethics Committee for Research involving medicinal products (CEIm by its initials in Spanish) of the Hospital Universitari Arnau de Vilanova (Lleida, Spain) responded to the request with an exemption of assessment and approval due to the non‐interventional nature of this research. Informed consent was obtained electronically from each participant via the initial questionnaire. Data were anonymized by the PI of the group.

4. RESULTS

4.1. Synthesis of the bibliometric indicators

The bibliometric indicators are presented according to the thematic coding undertaken in this study based on the three identified dimensions. A total of 836 occurrences were found in relation to the dimension of assessment, 422 in relation to that of treatment and 344 in relation to that of follow‐up (Supplementary Material S4: Occurrences by dimension). For this, an analysis was performed of the most frequent word occurrences, using a minimum of 10. Table 2 shows the main occurrences by frequency.

TABLE 2.

Main words by occurrence and dimension.

Assessment		Treatment		Follow‐up activities
Words	Occurrences	Words	Occurrences	Words	Occurrences
Complications	123	Prevention	90	Guidelines	54
Phlebitis	117	Management	52	Central venous catheters	42
Thrombophlebitis	79	Anti‐inflammatory	43	Care	39
Pain	72	Infection	40	Devices	23
Exam	71	Cold	37	Infusion	22
Scales/scores	70	Therapy	36	Children	21
Risk‐factors	67	Replacement	33	Epidemiology	21
Infections	46	Routine	32	Register	18
Thrombosis	35	Topic	28	Placement	18
Diagnosis	27	Heparin	21	Outcomes	17
Insertion	24	Inserted central catheters	10	Control	17
Failure	21			Cannula	15
Sepsis	20			Safety	15
Experience	18			PICC	12
Vein‐thrombosis	13			Time	10
Surveillance	12
Staphylococcus‐aureus bacteraemia	11
Thromboembolism	10

4.2. Results by round and dimension

In relation to the experts, stage 1 was completed by 22 of the 40 invited experts (55% response rate) and stage 2 by 18 of the participating 22 (81.81% response retention). It is not possible to report the causes of drop‐out (four reminder emails were sent). Thematic coding was carried out by dimensions and responses: 19 activities emerged in the assessment dimension, 15 in the treatment dimension and 11 in the follow‐up dimension. Tables 3, 4, 5 show the results by dimension explored and activities, by rounds (1 and 2), the percentage of agreement and the mean plus standard deviation of the importance assigned by the experts.

TABLE 3.

Assessment dimension (first and second round).

Items	Round 1	Round 2
	Agree	Agree	Importance
	% consensus	% consensus	M	SD	Mdn
A1. Visual exam (signs and symptoms) no scales	45.45	55.56	3.50	0.71	4
A2. Visual exam (signs and symptoms) with scales/instruments	86.36	94.44	3.61	0.78	4
A2.1 Instrument: VIP score	18.18	22.22	2.39	1.14	2
A2.2 Instrument: INS score	18.18	16.67	1.89	1.28	2
A2.3 Instrument: Maddox score	13.64	22.22	2.22	1.44	2
A2.4 Instrument: I‐DECIDED	4.55	11.11	1.94	1.11	2
A2.5 Instrument: Phlebitis score	4.55	11.11	2.61	1.20	3
A2.6 Complementary instrument: Pain score (VAS)	77.27	94.44	3.33	0.91	4
A3. Signs/symptoms (linked to phlebitis)
A3.1 Pain	77.27	94.44	3.61	0.61	4
A3.2 Redness	72.73	94.44	3.50	0.62	4
A3.3 Inflammation	63.64	77.78	3.67	0.49	4
A3.4 Swelling	59.09	66.67	2.94	1.11	3
A3.5 Purulence	31.82	33.33	2.83	1.04	3
A3.6 Tenderness	40.91	44.44	2.89	0.83	3
A3.7 Red streak	59.09	61.11	3.00	1.03	3
A3.8 Obstruction of fluids	22.73	27.78	2.33	1.53	2.5
A3.9 Palpable cord	59.09	72.22	3.61	0.70	4
A3.10 Induration	59.09	77.78	3.56	0.62	4

Abbreviations: I‐DECIDED, I‐DECIDED IV assessment and decision tool; INS, Infusion Nurses Society; M, mean; Mdn, median; SD, standard deviation; VAS, Visual Analogue Scale; VIP, Visual Infusion Phlebitis.

TABLE 4.

Treatment dimension (first and second round).

Items	Round 1	Round 2
	Agree	Agree	Importance
	% consensus	% consensus	M	SD	Mdn
T1. General activities
T1.1 Remove catheter	63.64	83.33	3.78	0.55	4
T1.2 Elevation of extremity	18.18	33.33	2.67	1.08	3
T2. Physical treatments
T2.1 Cold pack	36.36	44.44	2.39	1.04	3
T2.2 Warm compress	18.18	27.78	1.72	1.13	1.5
T3. Pharmacological treatments
T3.1 Burow's solution (aluminium acetate solution)	22.73	33.33	1.94	1.11	2
T3.2 Thrombocid ointment (pentosan polysulphate sodium)	13.64	50.00	2.67	0.77	3
T3.3 Menaven gel (heparinoid)	9.09	11.11	2.17	0.62	2
T3.4 Topical corticosteroid	4.55	5.56	1.00	0.91	1
T3.5 Paracetamol (pain control)	13.64	27.78	2.11	0.58	2
T3.6 Oral anti‐inflammatory (NSAIDs) (advanced level)	13.64	22.22	1.89	0.96	2
T3.7 Oral or iv antibiotic (advanced level)	9.09	27.78	2.89	0.83	3
T3.8 Topical anti‐inflammatory (non‐specific)	18.18	33.33	2.06	1.30	2
T3.9 Treatment according to severity (advanced level)	31.82	66.67	3.22	1.31	4
T4. Phytotherapeutic treatments
T4.1 Chamomile tea (basic level)	9.09	11.11	1.33	1.08	1.5
T4.2 Arnica gel (basic level)	4.55	5.56	1.29	1.16	1
T5. General treatment aspects
T5.1 Treatment prescribed by the doctor (advanced level)	27.27	44.44	2.17	1.42	2

Abbreviations: M, mean; Mdn, median; NSAIDs, non‐steroidal anti‐inflammatory medications; SD, standard deviation.

TABLE 5.

Follow‐up dimension (first and second round).

Items	Round 1	Round 2
	Agree	Agree	Importance
	% consensus	% consensus	Mean importance	SD	Mdn
F1 General activities
F1.1 Register	68.18	83.33	4.00	0.0	4
F1.2 Daily control	45.45	94.44	3.39	0.61	3
F2. Specific activities
F2.1 Visual control (non‐specific)	59.09	88.89	3.89	0.32	4
F2.2 Control protocols and nursing plans	13.64	33.33	3.22	1.00	4
F2.3 Health education	4.55	33.33	3.11	0.90	3
F2.4 Medical review	9.09	22.22	2.22	1.17	2
F2.5 PVC change	4.55	16.67	3.28	0.75	3
F2.6 Collect patient assessment	4.55	16.67	2.39	1.38	2.5
F2.7 Photographic control	4.55	16.67	2.22	1.17	2
F2.8 Echo‐doppler control	9.09	11.11	2.11	1.13	2
F2.9 Symptoms control and medication (according to irritant or vesicant type)	4.55	5.56	2.11	1.28	2

Abbreviations: M, mean; Mdn, median; PVC, peripheral venous catheter; SD, standard deviation.

In relation to the assessment dimension (Table 3), the highest consensus of 94.44% was obtained in A2. Visual exam (signs and symptoms) with scales/instruments, scoring a mean importance of $\overline{X}=3.61$ (SD 0.78, Mdn 4) and A2.6 Complementary instrument: Pain score (VAS) (94.44%, $\overline{X}=3.33$, SD 0.91, Mdn 4). The items considered the least important were the instruments INS score ($\overline{X}=1.89$, SD 1.28, Mdn 2) and I‐DECIDED ($\overline{X}=1.94$, SD 1.11, Mdn 2). In the signs/symptoms category, A3.1 Pain and A3.2 Redness showed the highest consensus (94.44%). The response item A3.8 Obstruction of fluids scored lowest in importance ($\overline{X}=2.33$, SD 1.53, Mdn 2.5) and consensus (27.78%).

With respect to the treatment dimension (Table 4), the highest scores of the experts in terms of importance and consensus were obtained in T1.1 Remove catheter (83.33%, $\overline{X}=3.78$, SD 0.55, Mdn 4) and T3.9 Treatment according to severity (advanced level) (66.67%, $\overline{X}=3.22$, SD 1.31, Mdn 4). The lowest mean importance scores were obtained in Topical corticosteroid ($\overline{X}=1.00$, SD 0.91, Mdn 1) in pharmacological treatments and in Arnica gel (basic level) ($\overline{X}=1.29$, SD 1.26, Mdn 1) in phytotherapeutic treatments, with both items obtaining the lowest consensus score in this dimension of 5.56%.

With respect to the follow‐up dimension (Table 5), the two items in the general activities category obtained high scores (F1.1 Register with 83.33%, $\overline{X}=4$ and SD 0, Mdn 4, and F1.2 Daily control with 94.44%, $\overline{X}=3.39$ and SD 0.61, Mdn 3). For Specific activities, the highest consensus was found in F2.1 Visual control (non‐specific) (88.89%, $\overline{X}=3.89$, SD 0.32). The two lowest scoring items in terms of consensus were F2.9 Symptoms control and medication (according to irritant or vesicant type) (5.56%) and F2.8 Echo‐doppler control (11.11%), with both also having low mean importance scores (2.11).

Finally, Table 6 shows the level of dispersion of the responses given by the experts in relation to the importance of the proposed activities. It should be noted that only five activities out of 45 are classified in the high level, which was the level with the highest agreement but the fewest activities (11.12%), followed by the moderate level with 19 out of 45 (42.22%) and the low level with 21 out of 45 (46.66%). The low level encompassed the highest number of activities but with the lowest agreement on the importance of the proposed activities.

TABLE 6.

Dimension and level of dispersion.

QD	Assessment item	Treatment item	Follow‐up item
Pt
High QD ≤ 0.6	A1. Visual exam (signs and symptoms) with scales/instruments	T1.1 Remove catheter	F1.1 Register
		T3.5 Paracetamol (pain control)	F2.1 Visual control (non‐specific)
Moderate 0.6 < QD < 1.0	A2. Visual exam (signs and symptoms) no scales/instruments	T3.7 Oral or iv antibiotic (if needed) (Advanced level)	F1.2 Daily control
	A2.1 Instrument: VIP score	T3.3 Menaven gel (heparinoid)	F2.5 PVC change
	A2.2 Instrument: INS score	T3.6 Oral anti‐inflammatory (NSAIDs) (advanced level)	F2.3 Health education
	A2.4 Instrument: I‐DECIDED	T3.2 Thrombocid ointment (pentosan polysulphate sodium)
	A3.1 Pain	T3.9 Treatment according to severity (advanced level)
	A3.2 Redness
	A3.3 Inflammation	T5.1 Treatment prescribed by the doctor (advanced level)
	A3.9 Palpable cord
	A3.10 Induration
	A2.6 Complementary instrument: Pain score (VAS)
Low QD > 1.0	A2.5 Instrument: Phlebitis score	T1.2 Elevation of extremity	F2.2 Control protocols and nursing plans
	A2.3 Instrument: Maddox score	T2.1 Cold pack	F2.4 Medical review
	A3.4 Swelling	T2.2 Warm compress	F2.6 Collect patient assessment
	A3.5 Purulence	T3.1 Burow's solution (aluminium acetate solution)	F2.7 Photographic control
	A3.6 Tenderness		F2.8 Echo‐doppler control
	A3.7 Red streak	T3.4 Topical corticosteroid	F2.9 Symptoms control and medication (according to irritant or vesicant type)
	A3.8 Obstruction of fluids	T3.8 Topical anti‐inflammatory (non‐specific)
		T4.1 Chamomile tea (basic level)
		T4.2 Arnica gel (basic level)

Abbreviations: I‐DECIDED, I‐DECIDED IV assessment and decision tool; INS, Infusion Nurses Society; NSAIDs, non‐steroidal anti‐inflammatory medications; PVC, Peripheral Venous Catheter; VAS, Visual Analogue Scale; VIP, Visual Infusion Phlebitis.

4.3. Analysis of the comments of the experts

During the process, an open response space was provided to the participants. The complementary analysis of the comments made by the experts is presented in Table 7.

TABLE 7.

Comments of the experts.

Dimension	Theme	Quotations
Assessment	Patient perspective	I examine the site for signs and symptoms. I also ask the patient about their experience with the PIVC (pain/tenderness, any other concerns). E1R1 Scales are important for grading purposes, However, visual inspection and assessment in partnership with patients is key. E4R2
	Lack of consensus	I consider the most used scale to be the INS… Currently, I want to implement the VIP scale… E5R2 Based on signs and symptoms primarily since there is a lack of sufficient evidence around scales and scores to be used. E3R1 Scores are too subjective. I often find that nurses write a score of 0, but when I assess the site, it should not be 0. E4R1
Treatment	Low evidence‐based practices	Cold compresses, Menaven gel, Burow's solution … they're all topical treatments. Application in general 3 times a day as soon as signs appear of erythema, inflammation. E8R2 I believe we don't have a policy on what treatment to give, it's very patient dependant. E9R2 I follow the most common treatments described in the literature. Alternative treatments (phytotherapeutic) I no longer use due to their unavailability, although the literature is divergent regarding effectiveness. E6R2
	Stage‐based treatments and interdisciplinary approach in advanced stages	We apply cold packs in the area, and we also use an arnica gel two or three times a day. This is normally used in early stages, but in advanced ones we have to assess the plan with a vascular specialist… E1R2 In Grade III the doctor is asked to prescribe an anti‐inflammatory… E13R2
	Prevention activities	In the end, prevention activities are the gold standard in phlebitis treatment. E3R10
Follow‐up	High variability in practice	According to clinical protocol. E4R1 According to clinical routines. E6R1 There is no specific protocol in the centre, they follow the model of a registration sheet and mainly monitor that there is no fever. E7R1
	Specialist teams and interdisciplinary work	Perhaps one of the effective ways to improve is to train and develop specialist and interdisciplinary care teams who… E3R2 Currently, there are specialist teams with expert staff who are responsible for monitoring tasks, interacting with and linking up with different healthcare actors to coordinate actions. E8R2

5. DISCUSSION

A total of 18 international experts participated in this Delphi‐based study to determine key elements of the clinical management of PVC‐related phlebitis in the dimensions of assessment, treatment and follow‐up. These were identified through a bibliometric study of the literature. It should be noted that the configuration of the panel of experts is essential to ensure the quality of the process and of the results (López‐Gómez, 2018; Nasa et al., 2021; Reguant Alvarez & Torrado Fonseca, 2016). In addition, the bibliometric analysis enabled the identification of the occurrences of key concepts according to the three dimensions explored, which indicated elements in concurrence with the findings of the Delphi study. In the assessment dimension, keyword occurrences were identified related to venous catheter complications (complication, phlebitis and pain, among others) and activities (diagnosis, exam, score). In the treatment dimension, keyword occurrences included, among others, therapy, topical, cold and heparin and in the follow‐up dimension guidelines, register, care, outcome and control. These dimensions and concepts coincide with the bibliometric study of Torné‐Ruiz et al. (2023).

5.1. Assessment activities: Observation and the use of instruments

The need to use assessment scales and instruments was confirmed, as opposed to the use of non‐systematized observation, with a high consensus on its importance. This finding is consistent with the results of other studies (García‐Expósito et al., 2021; Gorski et al., 2021; Mihala et al., 2018). However, no specific instrument shows a high consensus of importance. The instruments that appear with moderate consensus are VIP score, INS score, Maddox score, phlebitis score, I‐DECIDED and VAS for pain. The different phlebitis scales share symptoms and signs and allow the degree of severity to be established, although each has its particularities and the vast majority are not clinically validated (Mihala et al., 2018). While there is no gold standard for the assessment of phlebitis (Garcia‐Expósito et al., 2021; Marsh et al., 2015), it is imperative to monitor phlebitis rates using control methods and definitions that are consistent and allow comparison with benchmark data (Pittiruti et al., 2023). It should be noted that one of the experts argued that assessment should be more global in relation to the PVC and not focused on a specific complication. This idea is considered in the I‐DECIDED tool (Ray‐Barruel et al., 2020).

A total of five signs and symptoms linked to phlebitis with moderate consensus of importance were found: pain, redness, inflammation, palpable cord and induration. Pain is a prominent sign in the detection of phlebitis by experts and is consistent with the literature (Garcia‐Expósito et al., 2021, 2023; Gorski et al., 2021; Marsh et al., 2021; Simões et al., 2022) and with the patient's own opinion (Pittiruti et al., 2023). Low consensus was found with respect to five more: swelling, purulence, tenderness, red streak and obstruction of fluids. The confusion in terms of symptomatology could be explained by the lack of pathological evidence to differentiate inflammation of the vein from local venous thrombosis (Pittiruti et al., 2023) and by the overlaying of other local complications (infiltration/extravasation, infection, etc.) (Marsh et al., 2020).

However, two key elements were found as the responses of the experts confirmed, firstly, variability and subjectivity in the assessment of signs and symptoms, and secondly, the importance of the patient's perspective not only in assessment but throughout the entire process. This element is explicitly included in scales such as I‐DECIDED (Ray‐Barruel et al., 2020) where the patient is actively involved in the assessment (symptomatology, aspects of the device, infusion of fluids and/or drugs or treatment plan). The important role of PVC users and the need for healthcare training for good prevention and follow‐up should also be highlighted (Ray‐Barruel et al., 2020). Offering basic knowledge to the patient provides autonomy in care, which can improve patient safety, secondary costs and practitioner time (Ray‐Barruel & Alexander, 2023). Vascular access health literacy, shared decision‐making and patient empowerment should be included in interventions that address complications of PVCs (Blanco‐Mavillard et al., 2020).

In this context, professional training in the identification of signs and symptoms of phlebitis through visual inspection and palpation is key (Gorski et al., 2021), regardless of whether or not an instrument is used. This is because all instruments detail signs and symptoms that the practitioner must assess and identify. In addition, the results show the need for an interdisciplinary approach on the part of the entire healthcare team (nurses, doctors, pharmacists, etc.) and for the creation of hospital‐based teams specializing in vascular access. However, it is not yet possible to determine the clinical impact of such specialist teams as opposed to a more generalist model approach (Carr et al., 2018).

5.2. Treatment activities: General and associated products

In relation to the rest of the treatment products, the results concur with those from other studies (Garcia‐Expósito et al., 2021, 2023) which show high product heterogeneity. Paracetamol, as an analgesic drug, is the only product with a high consensus. However, most of the published studies on analgesics and PVCs focus on pain relief in PVC cannulation (Babaieasl et al., 2019) and not on post‐catheterization as a complication of phlebitis.

The experts concurred and selected catheter removal as an initial priority action, which is consistent with other studies and guidelines (Gorski et al., 2021; Guanche‐Sicilia et al., 2021; Pittiruti et al., 2023). The highest expert consensus regarding treatment concerns the offering of treatment according to phlebitis grade, without specifying the type. It was found that the experts offer symptom‐based treatment mainly for lower grades of phlebitis, which may be attributable to the extent of nursing functions at the clinical level (88.88% of the experts consulted were nurses). It should be noted that grade 1 is the most frequently treated and that, in the study by Miliani et al. (2017), cases graded 1 or 2 are considered suspected phlebitis and those graded 3 or higher (according to the Maddox scale) as manifest phlebitis.

When analysing the results, it emerges that for mild levels the treatment is topical and with local products such as heparins and heparinoids (Menaven Gel® and Thrombocid®), Burow's solution, non‐specific anti‐inflammatories, application of physical measures and phytotherapeutic products such as arnica and chamomile. These products aim for a local anti‐inflammatory, analgesic and anti‐oedematous effect (Guanche‐Sicilia et al., 2021). With respect to physical measures (application of heat or cold), there was no consensus among the experts as indeed occurs in the literature (Garcia‐Expósito et al., 2021). Some studies have reported positive effects through the application of a warm compress three times a day as a treatment (Aksoy & Bayram, 2023), while others support the application of a cold gel pack for prevention purposes (Okyay & Basak, 2024).

At higher levels, other routes of administration such as oral or intravenous administration are introduced, and products such as antibiotics appear which would, therefore, be related to infectious‐type PVC phlebitis (Ray‐Barruel et al., 2020). It should also be noted that the experts highlight the importance of a multidisciplinary approach and that the level of competence shifts from the nurse to the physician in higher degrees of phlebitis. Generally, higher degrees of phlebitis are the least frequent as actions will already have been implemented in the initial levels. However, no treatment application results in an unfavourable evolution and greater tissue damage (Miliani et al., 2017; Nunes De Almeida et al., 2022).

5.3. Follow‐up activities: Documenting and reporting

The element with the most consensus is the need to record phlebitis. This is a key element that is not linked to a purely individual activity of recording an event but should be an act with collective involvement and with an impact on organizational decision‐making. In this line, Marsh et al. (2020) detail a specific attention to phlebitis with definition of standardized results that allow audits and comparable clinical records in relation to PVC in order to advance the quality and safety of health care. It should also be noted that the literature (Gunasundram et al., 2021) describes that correctly documenting phlebitis leads to increased detection. The need for daily assessment is essential not only for prevention (Mandal & Raghu, 2019) but also for early diagnosis of complications and follow‐up (Alexandrou et al., 2023; Berger et al., 2022), and is also an activity that achieves maximum consensus. This daily assessment should be done once per shift and each time the PVC is accessed (Gorski et al., 2021; Pittiruti et al., 2023).

Importantly, a low consensus was found in two aspects that a priori should be considered relevant: the monitoring of protocols and the control of symptoms and medication. In relation to the first (F2.2 Control protocols and nursing plans), this element should be explored in more detail as it seems that the experts do not recognize its link with evidence‐based practice in this activity. The experts' comments reinforce this view, with professionals who do and do not follow protocols in their care work. A priori, the existence of protocols on the placement and maintenance of PVCs should contribute to the incorporation of the most current guidelines and the standardization of care practice (Drugeon et al., 2023). In this context, evidence‐based practice brings increased knowledge, best practices and improved patient care. The implementation of clinical practice guidelines combines the best recommendations with professional experience and patient preferences (Blanco‐Mavillard et al., 2020). The need for the training of professionals has been highlighted, along with the use of clinical strategies and protocols and the implementation of a vascular access team to achieve better control of complications (Paterson et al., 2022; Pittiruti et al., 2023). Studies such as those by Marsh et al. (2021) show an almost 50% reduction in complications, such as risk of dislodgement, when catheters are inserted by the vascular access team and that the use of ultrasound systems improves the insertion of all types of catheters (including peripheral catheters) in more complex cases (Millington et al., 2020). Regarding the second element, F2.9 Symptoms control and medication (according to irritant or vesicant type), the low score may be attributable to the fact that the experts were not asked to assess aspects of phlebitis prevention or infection control and therefore did not consider this or other preventive measures in the follow‐up. There are multiple factors that contribute to the development of complications in relation to prevention, including catheter size, preparation of the insertion site, infusion type, insertion technique, catheter dwell time, dressing type and insertion site (Salma et al., 2019), but these were not addressed in this study as the overall objective exclusively addresses the management of PVC phlebitis.

Finally, the findings show some elements of consensus and a high variability in activities in the three dimensions explored (assessment, treatment and follow‐up). Further research is, therefore, needed to address the management of PVC phlebitis due to its social, clinical and economic implications. Complications of PVCs represent a real burden for the healthcare system and for the patient (Lim et al., 2019).

6. STRENGTHS AND LIMITATIONS OF THE WORK

This study provides an overall perspective of a diverse reality. While the nature of the methodology employed does not offer conclusive results, it does indicate lines of work for further in‐depth exploration through studies that enable the gathering of empirical evidence. It should be noted that the identification and subsequent selection of the experts exclusively through the WOS database can be considered a potential limitation as it may entail an under‐ or over‐representation of a particular geographic region and hence of expert opinions.

The heterogeneity of the experts prevents broader consensus on most of the activities but is nonetheless an accurate reflection of the situation expressed in the literature on the management of PVC phlebitis because of its high variability in healthcare practice. One potential limitation of the study is that Asian researchers who had published on the topic were invited to participate but declined the invitation. However, the results show a basic clinical approach to this highly prevalent complication which has an important impact on the quality of care and patient safety.

7. CONCLUSIONS

Assessment of phlebitis should be performed with validated instruments or scales that allow for systematization. Observation and palpation are key aspects of professional nursing training for the proper assessment of the signs and symptoms of phlebitis. There is high consensus on the symptom of pain and moderate consensus on other symptoms such as redness, inflammation, palpable cord and induration. No single treatment stood out, but there was consensus that the treatment should vary according to the severity of the phlebitis. In mild stages, a local anti‐inflammatory, analgesic and anti‐oedematous effect is sought with different pharmacological and non‐pharmacological products. In more advanced stages, a multidisciplinary approach is required. In relation to follow‐up, the need for daily monitoring and visual assessment was identified. Evidence‐based practice, standardization of care and prevention‐based activities should be promoted, as well as active patient participation and vascular access literacy. The results also showed the importance and relevance of an interdisciplinary approach, with the participation of all the components of the healthcare team, and of the use of specialist teams.

Finally, there is a need to increase consensus on the management of this common complication in hospital settings and to promote evidence‐based practices. Of the activities identified in the management of phlebitis, a high level of consensus among experts was obtained in only 11% of them, demonstrating the large variability of criteria and interventions for the management of phlebitis among professionals at the present time.

8. RELEVANCE TO CLINICAL PRACTICE

The findings of this study provide some elements of consensus for clinical practice in the management of phlebitis in the three dimensions of assessment, treatment and follow‐up of phlebitis, although clinical variability is evident. The need to promote a rigorous assessment that allows for a care plan adapted to the patient is identified.

Nursing competence is key in the management of phlebitis, although strategies that integrate patients throughout the process are also indispensable. The need to work as a team with medical or other professionals must be established, and the importance of specialist vascular access teams cannot be overstated. Therefore, good management of phlebitis should be based on the available evidence and standardized to reduce variability in the same setting.

This is an important healthcare issue which should in no circumstances be underestimated because of its impact on patient safety and the quality of the care given. Scientific progress in this issue is essential based on the performing of implementation and clinical studies that rigorously assess the treatments used to deal with this issue.

AUTHOR CONTRIBUTIONS

All authors meet the criteria for authorship: (1) have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; (2) been involved in drafting the manuscript or revising it critically for important intellectual content; (3) given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content and (4) agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION

Not applicable.

CONFLICT OF INTEREST STATEMENT

The authors do not have any disclosures, conflicts of interest or financial interests to report.

Supporting information

Supplementary Material S1.

Supplementary Material S2.

Supplementary Material S3.

Supplementary Material S4.

Torné‐Ruiz, A. , Sanromà‐Ortiz, M. , Corral‐Nuñez, A. , Medel, D. , Roca, J. , & García‐Expósito, J. (2024). Management from a multidisciplinary perspective of phlebitis related to peripheral venous catheter insertion: An international Delphi study. Nursing Open, 11, e2229. 10.1002/nop2.2229

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.