PHLEBITIS NEW INDICATOR FOR NURSES TEACHING SLIDE

phlebitis

1. (INDIKATOR QAP BAHARU)
UNIT PEMBANGUNAN PIAWAIAN
KUALITI
BAHAGIAN KEJURURAWATAN

2. 1.Terms of Reference for the Phlebitis Coordinator 2023
2.Technical Specification
3. Assessment of Phlebitis with Visual Infusion Phlebitis (VIP)
Scores
4. Assessment forms
5. Nursing Responsibilities
6. Reference

3. Phlebitis has a direct/indirect impact on the patient health as it
can cause discomfort, and pain and prolongs in-patient stays
that may lead to the patient suffering.
The Nursing Division has been monitoring the indicator of
Thrombophlebitis(advanced level of phlebitis)since 2010 at the
national level under the Quality Assurance Program with a
standard of incidents of < 0.5%.
Over the years of monitoring there was no shortfall in quality
and the standard has been achieved. Any PIVC that causes
discomfort will be removed immediately, hence there was no
incidence of Thrombophlebitis reported.

4. From 2023 onwards, the Nursing Division will focus on a new
indicator; PHLEBITIS as early detection of vein inflammation to replace
the old indicator; Thrombophlebitis.
The assessment tool remains which is the Visual Infusion Phlebitis
Score(VIP). The new standard set is incidence must be less than 35%.
In order to monitor this indicator each state has to appoint a
coordinator to ensure the compliance of this indicator in the
respective states.

5. Senior Clinical Matrons who are well versed with
this indicator. Preferably from GredU36 and above.
Must have at least 5-10 years of relevant
experience and have detailed working knowledge
in one or more of the wards in the clinical fields.

6. 1.Ensure that the nurses are well informed, trained, and adhere to the
assessment of the indicator
Strict adherence to the principles of the Aseptic Technique when
inserting, administering or providing care management to intra-vascular
devices (IVD).
Healthcare workers who insert, use/manage and remove intra-vascular
devices must strictly implement standard precautions during the insertion,
management, and removal of all IVDs.
Documentation of insertion date and time and relevant forms.
Each dressing change or direct observation should also be documented in
the patient progress notes.

7. 2.Submit quarterly before 10
th
of(April,July,October&
January)-monitoring progress reports, based on the
monthly ward reports to Nursing Division, Ministry
of Health Malaysia.
3.Conduct updated courses from time to time and
attend meetings at State Health Department Level
and Nursing Division, Ministry of Health Malaysia.

8. Indicator: Incidence of Phlebitis among inpatients with intravenous
(IV) cannulation
Criteria :
Inclusion :All admitted patients with a peripheral
venous cannula.
Exclusion :
1.“Double counting” i.ethe complication during the
previous admission.
2.Psychiatry patient.
3.Patient under chemotherapy.

9. Type of indicator
:
Rate-based outcome indicator
Numerator
:
Total Number Phlebitis incidences
Denominator
:
Total Number of inserted peripheral venous cannulas
Formula
:
Numerator x 100%
Denominator
Standard
:
≤ 35 %
Data Collection
:
1.Where: data will be collected from every ward of the hospital.
2.Who: data will be collected by the ward manager/staff nurse/ personnel in
charge of the ward.
3. How frequent: Monthly data collection.
4. Who Should verify: All performance data must be verified by the matronarea
/ Head of Unit.
5. How to collect: Data will be collected from the record book/ patient’s case
notes.
Remarks
:
Phlebitis Chart (BKJ-BOR-PPK-QAP 1)-Will be used for Phlebitis monitoring.
Report must be sent to State matron (KPJN) for Nursing Division compilation
All peripheral venous cannula must be counted.
Any Transfer In /Transfer Out with Healthy Cannula is considered new case
for receiving hospital.

10. NOITEMS OLD NEW
1 Indicator Incidence of Thrombophlebitis among
inpatients with intravenous (IV)
cannulation
Incidence of Phlebitisamong inpatients with
intravenous(IV) cannulation
2 Exclusion
criteria
1’“Double counting” i.ethe complication
during the previous admission.
2.Psychiatry patient.
3.Neonates patient.
4.Paediatric patient.
5.Unconscious patient.
1’“Double counting” i.ethe complication
during the previous admission.
2.Psychiatry patient.
3.Patient under chemotherapy
3 Standard ≤ 0.5 % ≤ 35 %
4 Remarks 1. Thrombophlebitis Chart (10
Pind.2/2018)-Will be used for Phlebitis
monitoring.
2.Report must be sent to State matron
(KPJN) for Nursing Division compilation
3.All peripheral venous cannula must be
counted.
1.Phlebitis Chart (BKJ-BOR-PPK-QAP 1)-Will
be used for Phlebitis monitoring.
2.Report must be sent to State matron
(KPJN) for Nursing Division compilation
3.All peripheral venous cannula must be
counted.
4.Any Transfer In /Transfer Out with
Healthy Cannula is considered new case for
receiving hospital
CHANGES IN TECHNICAL SPECIFICATION

12. VISUAL INFUSION PHLEBITIS (VIP) SCORES
Site Observation Score Action
IV site appears healthy 0 No sign of phlebitis
OBSERVE CANNULA
One of the following signs evident:
Pain near IV site (pain score of (1-3)
May not require analgesics
Slight redness near IV site
1 FIRST signs of phlebitis
OBSERVE / RESITE CANNULA
Two of the following signs evident:
Pain at IV site(pain score of (4-6)
Interfere with activities
Redness around site
Swelling
2 Early stage of phlebitis
RESITE CANNULA
ALL of the following signs evident:
Pain at IV site(pain score of (4-6)
Interfere with concentration
Redness around site
Swelling
3 Medium stage of phlebitis
RESITE CANNULA
CONSIDER TREATMENT
ALL of the following signs evident and extensive:
Pain along path of cannula(pain score of (7-9)
Interferes with basic needs
Redness around site
Swelling
Palpable venous cord
4 Advanced stage of phlebitis or the start of
thrombophlebitis
RESITE CANNULA CONSIDER TREATMENT
ALL of the following signs evident and extensive:
Pain along path of cannula (pain score of 10) . Bed rest required
Redness around site
Swelling
Palpable venous cord
Pyrexia
5 Advanced stage of thrombophlebitis
INITIATE TREATMENT
RESITE CANNULA

20. PROSES PENGURUSAN BORANG PHLEBITIS

Mula
Kemasukan pesakit ke wad dengan IVD/ Cannula
Jururawat
Mengisi borang BKJ-BOR-PPK-QAP 1
Setiap 4 jam pemerhatian
Ketua Jururawat/ Jururawat Incaj
Mengisi borang BKJ-BOR-PPK-QAP 2
Setiap hari dan diverifikasi oleh Penyelia Jururawat kawasan
Penyelaras Phlebitis Hospital
Mengumpul data dan mengisi borang BKJ-BOR-PPK-QAP 3
Data mesti disemak dan diverifikasi oleh KPJH
Data dan shortfall summary perlu hantar ke Penyelaras Phlebitis Negeri
setiap 3 bulan
Penyelaras Phlebitis Negeri
Mengisi borang BKJ-BOR-PPK-QAP 4 dan BKJ-BOR-PPK-QAP 5
Data dan shortfall summary disemak dan verifikasi oleh KPJN
Perlu hantar ke Unit Kualiti Bahagian Kejururawatan setiap 3 bulan.
Tamat

21. DateTime
Site
of
IV
Cannulation
Additive
Plain
IV
drip
IV
Branula
only
Pain
Score
(At
IV
Site)
Slight
Redness
Redness Swelling
Palpable
Venous
cord
pyrexia
VIPScore
Phlebitis
*Unconscious
patient
(√ )
Yes (
-
) No
Name&Initial
Medication
Blood
TX
01234 5
YES NO
(√)YES
(-)NO
(√)YES
(-)NO
(√)YES(-)NO (√)YES(-)NO
(√)YES
(-)NO
# This format should be filled by Staff Nurse. # ( √ ) YES ( –) NO
BKJ-BOR-PPK-QAP 1
BAHAGIAN KEJURURAWATAN KEMENTERIAN KESIHATAN MALAYSIA
4 HOURLY OBSERVATION CHART FOR PHLEBITIS
Name: _____________ RN : _____________ Ward : ____________
Side Of IV Cannulation: *Right / Left *Hand / Leg
*Scalp

22. VISUAL INFUSION PHLEBITIS SCORE (V.I.P SCORE)

SITE OBSERVATION

SCORE

SIGNS OF PHLEBITIS

ACTION
IV Site appears healthy 0 No signs of phlebitis OBSERVE CANNULA
One of the following signs is evident:
1. Pain near IV site (Pain score 1-3). May not require analgesic.
2. Slight redness near IV site

1

Possibly first signs of
phlebitis

OBSERVE / RESITE
CANNULA
Two of the following signs are evident:
1. Pain at IV site - Moderate pain (Pain Score 4-6)
Interferes with activities.
2. Redness near IV site
3. Swelling


2


Early stage of phlebitis


RESITE CANNULA
ALL of the following signs evident:
1. Pain along path of cannula (Pain Score 4-6)
Interferes with concentration.
2. Redness around site
3. Swelling


3

Medium stage of
phlebitis

RESITE CANNULA
CONSIDER TREATMENT
ALL of the following signs evident and extensive:
1. Pain along path of cannula (Pain Score 7-9) Interferes with basic
needs.
2. Redness around site
3. Swelling
4. Palpable Venous Cord


4

Advanced stage of
phlebitis the start of
thrombophlebitis


RESITE CANNULA
CONSIDER TREATMENT
ALL of the following signs evident and extensive:
1. Pain along path of cannula (Pain Score 10) Bedrest required.
2 .Redness around site
3. Swelling
4. Palpable venous cord
5 .Pyrexia



5


Advanced stage of
thrombophlebitis


INITIATE TREATMENT
RESITE CANNULA

23. COMMON VEINS USE FOR SETTING IV LINES
ABBREVIATION
HAND
LEG
HEAD
A Antebrachial GSVGreat Saphenous Vein STVSuperficial Temporal Vein
B Basilic LSVLesser Saphenous VeinPAVPosterior Auricular Vein
C Cephalic DVADorsal Venous Arch FV Frontal Vein
MC Median Cubital
DVADorsal Vein Arch
(C)
(MC)
(B)
(A)
(B)
(C)
(DVA)
(DVA)
(LSV)
(GSV)
(FV)
(STV)
(PAV)

24. BKJ-BOR-PPK-QAP 1
BAHAGIAN KEJURURAWATAN KEMENTERIAN KESIHATAN MALAYSIA
4 HOURLY OBSERVATION CHART FOR PHLEBITIS
Name: ___MADAM W__________ RN : ____00789_________ Ward : __5 SURCIGAL__________
Side Of IV Cannulation: *Right / Left *Hand / Leg
*Scalp
Date Time
Site
of
IV
Canulation
Additive
Plain
IV
drip
IV
Branula
only
Pain
Score
(At
IV
Site)
Slight
Redness
Redness Swelling
Palpable
Venous
cord
Pyrexia
VIPScore Phlebitis
*Unconscious
patient
(√ )
Yes (
-
) No
Name&Initial
Medication
Blood
TX
012345 YES NO
(√)YES
(-)NO
(√)YES
(-)NO
(√)YES(-)NO (√)YES(-)NO
( √ )YES
(-) NO
21.12.224 AM B √ - √-0-----√----- - - - JT A
21.12.228 AM B - - √-3------√---- √ - - JT B
# Continue observation for 48 Hours after the cannula was removed.

25. BKJ-BOR-PPK-QAP 2
BAHAGIAN KEJURURAWATAN
KEMENTERIAN KESIHATAN MALAYSIA
CUMULATIVE DATA COLLECTION FOR PHLEBITIS , BY WARD SISTER U32/ KUP U32
Ward : Year:
SN RN
Total Site of IV
Canulation
Additive
Plain IV drip
IV Branula
Pain Score ( At IV
Site)
Slight
Redness Redness Swelling Palpable
Venous cord
Pyrexia
VIP Score Phlebitis
Unconscious
patient
( √ )
Conscious Patient
( √ )
Medicati
on
Blood TX
0 1 2 3 4 5YESNO
( √ ) YES
( -) NO
( √ ) YES
( -) NO
( √ ) YES ( -) NO ( √ ) YES ( -) NO TOTAL
TOTAL
Prepared By: Verified By:
(Ward Sister) (Matron)
Date : Date:

26. BKJ-BOR-PPK-QAP 3
BAHAGIAN KEJURURAWATAN
KEMENTERIAN KESIHATAN MALAYSIA
CUMULATIVE DATA COLLECTION FOR PHLEBITIS ,FILLED BY COORDINATOR
HOSPITAL : JAN-MARCH: JULY-SEPT:
YEAR : APR-JUNE: OCT-DEC:
No Ward
Total cannulation
( %) Phlebitis
Adult
(Conscious Patient)
Adult
(Unconscious Patient)
Paediatrics Neonates
N D % N D % N D % N D %
Total
Note: (N) -Numerator -Total number phlebitis incidences. (D) -Denominator -Total number of inserted peripheral venous cannulas.
Prepared by: Verified by:
_____________________________
_______________________
___________
(Coordinator) (Hospital Chief Matron)
Date : Date :

27. BKJ-BOR-PPK-QAP 4
BAHAGIAN KEJURURAWATAN
KEMENTERIAN KESIHATAN MALAYSIA
PHLEBITIS REPORT BY JKN COORDINATOR
STATE : JAN-MARCH: JULY-SEPT
YEAR : APR-JUNE OCT-DEC
No Hospital
Adult Adult
Paediatrics Neonates ( %)
Phlebitis
(Conscious Patient) (Unconscious Patient)
N D % N D % N D % N D %
Total
Note: (N) -Numerator -Total number phlebitis incidences. (D) -Denominator -Total number of inserted peripheral venous cannulas.
Prepared by: Verified by:
(JKN Coordinator) (State Matron)
Date : Date :

28. BIL
LAPORAN
INSIDEN
SEBAB-SEBAB
(MASALAH YANG
DIHADAPI)
TINDAKAN PEMBETULAN
YANG PERLU DILAKUKAN
SEGERA
(CORRECTIVE ACTION)
TARIKH
PELAKSANAAN
TINDAKAN
PENAMBAHBAIKAN
(PREVENTIVE ACTION)
TARIKH
TINDAKAN
SUSULAN
(3 Bulan)
CATATAN
BKJ-BOR-PPK-QAP 5
RUMUSAN LAPORAN INSIDEN PHLEBITIS
NEGERI: _______________ HOSPITAL / JABATAN _______________________Disediakan oleh: ____________________ Disemak oleh: _____________________
(Penyelaras Hospital) (Ketua Penyelia Hospital)

Tarikh: Tarikh:

29. BKJ-BOR-PPK-QAP 6
BAHAGIAN KEJURURAWATAN KKM
SENARAI SEMAK PENYELARAS AKTIVITI PHLEBITIS UNTUK PEMANTAUAN AUDIT PHLEBITIS
NEGERI:____________ HOSPITAL: __________ TARIKH: _____
Tandatangan Pegawai Audit Tandatangan Pegawai yang di audit
_________________________________ _________________________________
(Nama & Chop) (Nama & Chop)
BIL.PERKARAYANGDI SEMAK YA TIDAK TINDAKAN
YANG
DIAMBIL
1.Surat perlantikan seorang Coordinator untuk institusimasing-masingoleh
KPJH/KPJK
2.MenyediakanPanduanRujukan(Spesifikasi)
3.MenyediakanTermsofReference/tanggungjawabPenyelaras
4.AdabuktiLatihandanTaklimatuntukpastikansemuajururawatkenalkan
denganformatdanproseskutipandata.
5 AdabuktimenjalankanPEER Auditdiantarawad/Unit.
(Audit IVD dan Phlebitis)
6.AdaFlowChart untukpengurusanThrpmbophlebitis.
7.
Borang-borangdigunakan:-
7.1-4 hlyObservationChart
BKJ-BOR-PPK-QAP 1
7.2–CumulativeDataCollectionbywardKJ/KUPBKJ-BOR-PPK-QAP
2
7.2 –Cumulative Data Collection byHospitalCoordinator
BKJ-BOR-PPK-QAP 3
7.4–LaporanPhlebitisSukuTahun (KPJNkepada BKJ)
BKJ-BOR-PPK-QAP 4

30. BKJ-BOR-PPK-QAP 7
BAHAGIAN KEJURURAWATAN KKM
SENARAI SEMAK KETUA JURURAWAT WAD/UNIT/ONCALL UNTUK PEMANTAUAN AUDIT PHLEBITIS
Hospital / Wad / Unit:
Nama Pegawaiyang dipantau: Tarikh:
Bil. Perkarayang di semak YaTidakUlasan
1.Penggunaancarta pemantauanphlebitis
(BKJ-BOR-PPK-QAP 1) (mengikutbilangancannulation)
2.Kefahamanstafdalammemberigrading phlebitis(BKJ-BOR-PPK-QAP 1)
3.Penjagaanpesakit
3.1 Tarikhdanmasa IVD / cannuladi pasang
3.2 Plaster dilekat dengan sempurna
3.3 Tiada ’Back flow’dalam tubing *
3.4 Tiadaudaradalamtubing *
3.5 Tiadakesandarahdalamtubing danchamber *
4.Tiada Tanda-tanda phlebitis:
4.1 Sakit
4.2 Kemerahan
4.3 Suam
4.4 Bengkak
4.5 Palpable venous cord
5.5.1 Pengumpulan data (BKJ-BOR-PPK-QAP 2)
5.2 Reten dilakukan setiap bulan.( BKJ-BOR-PPK-QAP 3)
6.MelakukanRCA (jikaadainsiden)*Untuk Kegunaan Ketua Jururawat Wad/Unit/Oncall

Tandatangan Pegawai Pemantau Jumlah Skor: ........ x 100 = ............%

(Nama & Chop) 15

32. NURSING RESPONSIBILITIES :-
1.Hand Hygiene :-
Hands are decontaminated immediately
before and after each episode of patient
contact using the correct hand hygiene
technique. (5 moments of hand hygiene)

33. 2. Observe the aseptic technique:-
Alcohol wipes are used to decontaminate
port and surrounding area, and allowed to dry
prior to the administration of fluid or injections
via the cannula.
Patency is maintained.

34. 3. Monitoring:-
Monitor intravenous therapy
Check the infusion and the IV cannulation
site at least every 4 hours or when necessary
Flow of fluid
IV site: erythema, warmth, and edema
Cannula should be removed where it is no
longer indicated.

35. 4. Dressings :-
A sterile, semi-permeable, transparent
dressing is used to allow observation of
insertion site made accessible.
Ensure that the IV line is anchored & secured
properly.

36. 5. Cannula replacement :-
Resitecannula after 72 hours or as clinically
indicated.
eg. blood transfusion eg. Size 18G
Document each time after a change of IV site.

37. 6. Documentation:-
Document in phlebitis observation chart and
in the Patient’s case notes the dateand
time of removal of the cannula and the signature
of the nurse undertaking the task.
Continue observation for 48 Hours –after the
cannula was removed.

38. 6. REFERENCE

39. 1.Reducing the High Incidence of Phlebitis among Children in General Pediatric Ward
Hospital PulauPinang, Lim VC, Geraldine C, SivamaghesvariS, Ling KL, StatilaMD, Fazliana
A(2022)
2. Incidence of Phlebitis among Adult Patients with Peripheral Intravenous Catheter in an East Cost
Hospital Malaysia, AzlinaDaud, Fatimah Mohamad, Siti NoorkhairinaSowtali(2018)
3. AIMI Bundle: Early Phase in Implementing an Intravenous Line Care Bundle in s Tirtiary
PaediatricHospital, PeriakaruppanPW, Chan MF, Cher LH, DimatatacDMA, HooiYY, NadesonV,
Lau GM, Lee SK, Sim MH, Yap SS, Yeo SH (2022)
4. Incidence of Peripheral Intravenous Catheter Phlebitis and its associated factors among patients
admitted to University of Gondar Hospital, Northwest Ethiopia: A prospective, observational
study,MulugetaLulie, AbiloTadesse, TewodrosTsegaye, TesfayeYesuf, Mezgebu
Silamsaw(2021)
5.The incidence and risk of infusionphlebitis with peripheral intravenouscatheters: A meta-analysis,
LuyuLV and JiaqianZhang(2019)