title: Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.
abstract: BACKGROUND
  The millions of peripheral intravenous catheters used each year are recommended for 72-96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement.
  
  
  METHODS
  This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370.
  
  
  RESULTS
  All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI -1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred.
  
  
  CONCLUSIONS
  Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications.
  
  
  BACKGROUND
  Australian National Health and Medical Research Council.
authors.affiliation: Research Centre for Clinical and Community Practice Innovation, Griffith Health Institute, Griffith University, Nathan, QLD, Australia. c.rickard@griffith.edu.au
authors.forename: Claire M
authors.initials: CM
authors.lastname: Rickard
authors.forename: Joan
authors.initials: J
authors.lastname: Webster
authors.forename: Marianne C
authors.initials: MC
authors.lastname: Wallis
authors.forename: Nicole
authors.initials: N
authors.lastname: Marsh
authors.forename: Matthew R
authors.initials: MR
authors.lastname: McGrail
authors.forename: Venessa
authors.initials: V
authors.lastname: French
authors.forename: Lynelle
authors.initials: L
authors.lastname: Foster
authors.forename: Peter
authors.initials: P
authors.lastname: Gallagher
authors.forename: John R
authors.initials: JR
authors.lastname: Gowardman
authors.forename: Li
authors.initials: L
authors.lastname: Zhang
authors.forename: Alice
authors.initials: A
authors.lastname: McClymont
authors.forename: Michael
authors.initials: M
authors.lastname: Whitby
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D055499:Catheter-Related Infections / Q000191:economics / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation* / Q000379:methods; D020878:Device Removal / Q000191:economics; D004866:Equipment Contamination / Q000191:economics; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010689:Phlebitis / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D011793:Queensland / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult