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TRAINING OF THE NURSING TEAM IN AN INTENSIVE CARE UNIT TO

REDUCE THE INCIDENCE OF PHLEBITIS IN A PRIVATE HOSPITAL IN

SÃO PAULO

Ana Clara Santos De Lima1

Gabriel Dos Santos Bin2

Jaqueline Alves Gomes3

Milena Beatriz Duarte4

Nicolly Da Silva Nunes5

Patrycia Stuart 6

Abstract: Phlebitis is an acute inﬂ ammatory process affecting a vein where a vascular device has

been inserted, which may cause edema, discomfort, pain, hyperemia at the insertion site, and the

presence of a palpable ﬁ brous cord along the venous pathway, with or without purulent secretion. Its

main causes are related to mechanical, chemical, and bacterial factors. This study aims to develop a

training project for the nursing staff of the Intensive Care Unit (ICU) focused on peripheral venous

access care and phlebitis prevention, with the objective of reducing its incidence, whether mechanical,

chemical, bacterial, or post-infusion, as well as promoting awareness regarding appropriate conduct

in the presence of phlebitis according to the institutional protocol. A qualitative approach based on the

observational method was used for data collection, enabling the identiﬁ cation of failures in phlebitis

prevention processes. In addition, improvements to nursing care practices were proposed through

the application of the PDCA cyclical method, using interactive games and slide-based training. The

1 Graduandos em enfermagem pela Umc universidade de Mogi das Cruzes

2 Graduandos em enfermagem pela Umc universidade de Mogi das Cruzes

3 Graduandos em enfermagem pela Umc universidade de Mogi das Cruzes

4 Graduandos em enfermagem pela Umc universidade de Mogi das Cruzes

5 Graduandos em enfermagem pela Umc universidade de Mogi das Cruzes

6 Graduandos em enfermagem pela Umc universidade de Mogi das Cruzes

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study also presents a quantitative approach, as it aims to reduce the incidence of phlebitis in the

ICU by monitoring unit indicators for up to three months after the implementation of the project.

During the years 2019 and 2020, adverse events related to phlebitis were reported in the ICU, with

an accumulated median of 11.8 and a total of 94 reported cases. With the implementation of this

project, the expectation is to reduce the current median from 11.8 to 8. Through the PDCA tool,

the study proposes implementing actions such as staff training, educational cards, and the Tasy®

alert window, measures expected to optimize safe patient care and reduce phlebitis rates in the unit,

contributing to improvements in healthcare assistance. The implementation of this project involves

ﬁ nancial and human resources from the institution, especially the nursing team, requiring important

internal changes and the engagement of the multidisciplinary healthcare team, supported by the unit

coordination. Continuous reassessment of care practices and unit indicators is recommended in order

to ensure ongoing education and professional training.

Keywords: Patient Care, Catheters, Phlebitis, Clinical Protocols, Intensive Care Unit.

INTRODUCTION

During the supervised internship and assisted practices in the intensive care unit, provided in

the nursing course, a case of chemical phlebitis in the upper limbs was observed, in which amiodarone

(ancoron®), an antiarrhythmic, was being administered, indicated when there is an arrhythmic heart

disorder that is capable of aggravating the patient’s clinical pathology. This drug is among the drugs

that cause a high incidence of phlebitis; The therapy was being performed through a peripheral

venous catheter in which it was observed that in less than 48 hours the two upper limbs had evolved

to phlebitis, so that it was almost impossible for him to move his arms. This event impacted the group

and became a trigger for the development of this work.

The peripheral venous catheter is a device used to access the patient’s venous network, it

is an invasive procedure because it causes the disruption of the natural barrier of the human body.

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Through it, it is possible to directly access the veins, it can be used for the administration of nutrients,

ﬂ uids, blood products, enabling the infusion of volumes and medications, in addition to enabling

biological sample collection. It is extremely important for the installation of intravenous therapy,

especially in cases of patients in severe condition, thus enabling the administration of volume and

several other medications to maintain the hemodynamic and vital status of the patient submitted to it

(PHILLIPS, et al, 2001).

Peripheral venous access is most often introduced by the nursing team, although it is a

common procedure in the hospital routine, it requires speciﬁ c skills and care from its insertion to

its maintenance, since it is associated with several complications, such as phlebitis, extravasations

and inﬁ ltrations (Infusion Nurses Society et al, 2011). The site of choice of venous network puncture

is of paramount importance, regions such as the arm and forearm should be prioritized, avoiding

regions of folds and joints, in addition to the preparation of the insertion site, the technique used in the

puncture, the type of dressing, the time of permanence of the access, the type of infusion and the care

in handling and maintaining the patency of the catheter are fundamental for the prevention of these

events (Machado AF, Pedreira MD, Chaud MN et al, 2008).

Phlebitis is an acute inﬂ ammatory process in a vein in which the device has been introduced,

which can cause edema, discomfort, pain, hyperemia at the site, and also a palpable ﬁ brous cord along

the vein path, with or without the presence of purulent secretion at the insertion site. Its main causes

are mechanical, chemical, and bacterial processes (Royal College of Nursing, 2015). Mechanical

processes occur when there is movement of the catheter cannula inside the vein, whether it is due

to incorrect ﬁ xation or not, causing friction in the venous wall or also when the chosen catheter has

a larger caliber than the vein in question can support. Chemical processes occur when the infused

medication or solution is irritating, when the medication is diluted inappropriately, when small

particles are present in the solution, or when it is infused quickly. Bacterial processes occur when

there is an infection in the insertion, causing the bacterium to come into contact with the interior of

the vein, either due to a failure in handling or also due to a failure of the aseptic technique at the time

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of puncture. And ﬁ nally, post-infusion phlebitis that occurs after the end of the medication infusion

and even after the removal of the device, usually identiﬁ ed within 48 to 96 hours after its removal

(Machado AF, Pedreira MD, Chaud MN, 2008).

The nursing team is responsible for the maintenance, care and daily observation of the

insertion of the venous access, intervening quickly and effectively when one of the symptoms is

found. Phlebitis can be classiﬁ ed as a grade from 1 to 5 according to the Maddox scale, a scale that

measures signs, symptoms and pain, thus directing the best conduct for treatment, according to the

protocol of each institution (DE SOUZA et al, 2014).

Figure 1. Phlebitis assessment scale – Maddox scale.

Source: https://enfermagemcuidadosintensivos.blogspot.com/2016/12/escala-visual-evaluation-of-

the-ﬂ ebite.html.

There are contributing factors to the development of phlebitis in a patient undergoing

intravenous therapy in an intensive care unit, such as the catheter insertion technique, the anatomy

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of the site, size and type of device, vein caliber incompatible with the catheter, number of puncture

attempts at the same site, catheter permanence for more than 72 hours, the severity of the disease,

pre-existing infections, irritating and vesicant drugs such as the concentration of the infusions, the

patient’s clinical condition, the tonicity and pH of the drug or solution, incompatibility between drugs

and ineffective ﬁ ltration (FAVORETTO et al, 2016).

Phlebitis can generate other complications and damage, as well as necrosis of the local tissue,

thrombophlebitis, where the thrombus can migrate to the lung, causing a pulmonary embolism and

also bloodstream infections. When not treated early and adequately, it can increase the patient’s stay

in hospitalization, postponing hospital discharge, and can even cause psychological trauma and death,

and for the institution it can generate a considerable increase in the cost of hospital care (Machado AF,

Pedreira MD, Chaud MN et al, 2008).

The World Health Organization (WHO) by Ordinance No. 529, of April 1, 2013, implemented

the National Patient Safety program, one of the main objectives is to propose measures to reduce risks

and adverse events, ensuring greater quality and safety in the care provided. An adverse event is

characterized by any damage that occurs to the patient directly or indirectly, occurring during care in

a health institution, which may result in temporary or permanent disability in his or her life. (Ministry

of Health, 2013).

Regardless of its classiﬁ cation, phlebitis is considered an adverse event and can be reported

to the Patient Safety Center in the quality and safety department of the Institution, however, grade 5

phlebitis is mandatory to be immediately reported to the responsible medical team and to the Hospital

Infection Control Service (SCIH).

That said, the guiding question of this study is: Why is it that after numerous disclosures of

phlebitis prevention in institutions, there are still signiﬁ cant complications in intensive care units?

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OBJECTIVE

The present study aims to develop and train the nursing staff of the intensive care unit on

care with peripheral venous access and prevention of phlebitis, aiming to reduce its incidence, whether

mechanical, chemical, bacterial or post-infusion, in addition to making them aware of how to proceed

in the presence of phlebitis based on the institutional protocol.

METHODOLOGY

From 06/23/2021 to 06/30/2021 we monitored the care practices of nursing professionals

in the afternoon, which consists of 6 nursing technicians, 3 nurses and 2 doctors on duty in the

temporary intensive care unit (ICU) due to COVID-19, installed on the third ﬂ oor of a private hospital

in São Paulo, consisting of 15 private beds. A qualitative approach based on the observational method

was used for data collection, where it was possible to identify failures in the phlebitis prevention

processes. This project aims to suggest improvements to the practice of professionals, according to

the institutional protocol, using the cyclical PDCA method, through an interactive game and slide

training, carried out simultaneously, for the team of nursing technicians in this unit, to be applied

in September 2021. The study also presents a quantitative approach because it aims to reduce the

incidence of Phlebitis in the ICU, we will monitor the unit’s indicator up to three months after the

implementation of the project.

PDCA

PDCA was created in the 1920s by Walter Andrew Shewhart, an American physicist,

renowned in the area of statistical quality control, but it was only in the 1950s that the method was

popularized, by Professor William Edwards Deming, another scholar dedicated to the improvement

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of production processes in the United States.

The PDCA method is a management tool with the objective of promoting the continuous

improvement of processes through four actions, which are:

• plan;

• to do (do);

• check;

• act.

Actions are carried out in cycles of simple understanding, not only to identify the emergence

of the problem, but also the solution. When improvement is identiﬁ ed, the next step is to take the

necessary actions to promote changes and achieve results with greater effectiveness and quality. It

is important to note that PDCA happens at the beginning of the planning of actions, but it is not

something that happens only once and can change throughout the project, according to the need

for a new adaptation. Thus, the PDCA methodology contributes precisely to this control, as it is a

continuous method (AGUIAR et al, 2002).

PLAN

Phlebitis is the inﬂ ammation of a vein, caused by mechanical, chemical, bacterial factors

or after infusion. Its complication is venous involvement, evolving to deep vein thrombosis and

consequently to pulmonary embolism and in some cases death. In addition to compromising the

patient’s recovery, affecting temporarily or temporarily, extending his stay in the intensive care unit

and his hospitalization in general. With the intention of reinforcing the knowledge already acquired in

a theoretical or practical way by the nursing team, in addition to resuming the importance of avoiding

this adverse event, a project was developed by the nursing students, focused on a temporary intensive

care unit installed on the third ﬂ oor of a Private Hospital in São Paulo, with the objective of testing

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knowledge in a relaxed way and thus carrying out a survey of the points to be worked on to improve

the care provided and reinforcing the importance of applying the Phlebitis protocol established by the

institution itself. The tool used to develop the game allows slides to be presented simultaneously, to

apply theoretical training along with it, aiming at a better ﬁ xation of knowledge, and consequently

improvements in care practice and feasibility of protocol information in a fast and safe way, making

the actions a routine in the unit.

It will be proposed the implementation of a new window in the Tasy® system, a system

currently used in the institution to record nursing notes, in order to evaluate the catheter regardless of

its condition, aiming to stimulate the observation of the insertion site frequently during the shift and

thus prevent complications or identify them early in order to start the appropriate treatment as soon

as possible.

It will also be proposed the delivery of cards (Appendix D), to be used by the professional

with the badge, with information about phlebitis, how to identify it, degree of internship and how to

proceed, aiming at easy access to information.

EXECUTE (DO)

To identify the points to be worked on, aiming at improving the prevention of Phlebitis, a

“Quiz” was developed by the students of the technical nursing course, to be applied to the unit’s nursing

team, using the Kahoot Creator® website (Appendix E), with knowledge questions on the subject in

question (Appendix A), in addition to the Quiz, slides from the program itself will be presented

simultaneously in order to raise awareness and ﬁ x the knowledge (Appendix B). Participation gifts

will be distributed, regardless of the grade or assertive questions, as a form of incentive to participate

in the action. And for the ﬁ rst place in the Quiz, a prize time off will be offered to be agreed with the

unit manager.

It will be proposed the implementation of a window in the Tasy® system with the new nursing

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care routine, aimed at patients with peripheral venous access, in which the catheter will be evaluated,

regardless of its status, with questions pertinent to Phlebitis, such as risk of the injected drug, change

of access, conduct taken by the nursing technician and which nurse was notiﬁ ed (Appendix C).

Figure 2. Example of the Tasy® system where the new “tab” can be inserted to evaluate the catheter

at risk of phlebitis.

Source: Image taken from the internal system used by the institution as a support tool – TASY.

A card will be delivered that should be used with the employee’s identiﬁ cation badge with

information contained in the institutional phlebitis protocol (Appendix D), on how to recognize the

complication, degree of internship and how to proceed, aiming at immediate access to the protocol,

since it was perceived by the students that the path of the ofﬁ cial document is complex and the ﬁ le

is heavy, generating a certain delay to access it. The use of this card does not exempt access to the

document, later it will be proposed to the Human Resources team that these cards be delivered at the

time of integration.

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CHECK

In order to verify the results obtained after the Quiz, awareness training and guidance on

the Phlebitis prevention and treatment protocol to the nursing team, after three months a survey of

the intensive care unit indices will be carried out, with the purpose of evaluating the improvements

achieved. If the objective is achieved, which is to raise awareness and reduce the Phlebitis index, a

Coffee Breack will be offered to the sector’s care team as a way of recognizing improvements in care

practices and the team’s commitment focused on the institution’s protocol.

ACT/ENHANCE (ACT)

In order to verify the changes achieved in the long term, it will be proposed to ﬁ x an acrylic

in the nursing station or in the comfort space of the collaborators with information on how long the

intensive care unit has been without the occurrence of phlebitis notiﬁ cation, regardless of the degree

on the Maddox scale, and with each recorded notiﬁ cation “zero” this statistic, in addition to updating

the unit’s monthly phlebitis indexes in “Gestão a Vista”. And also after a year, we would do a new

study to evaluate the results obtained before and after the reorientation on the Phlebitis prevention and

treatment protocol for nursing professionals.

DISCUSSION AND RESULTS

According to the project schedule (Appendix F) it would be applied in the period from

09/06/2021 to 09/10/2021, in its ﬁ rst two days, the practice and technique of the employee assigned to

take care of the beds of patients who are receiving pharmacological treatment by peripheral intravenous

route will be observed. In the following days, a Quiz and training would be applied simultaneously

on the topic of Phlebitis to employees, reinforcing the importance of the institutional protocol and the

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improvement of care practices.

As previously discussed, an adverse event such as phlebitis can prolong the length of

hospitalization, increase costs for the patient and the hospital, and also cause traumas, whether

psychological or physiological (FAVORETTO et al, 2016), with this it becomes necessary to use a

quantitative instrument that aims to evaluate the quality and performance of the service provided by

the nursing team, through a management tool called quality indicator, which aims to understand the

work process and the objectives to be achieved, in order to improve the service provided (HADDAD

et al, 2011). It is worth emphasizing the importance of reporting such an adverse event and reporting

it, not with a punitive but an educational character, as this is a marker of practice that allows us to

evaluate the current scenario and make corrections when necessary, later monitoring how effective

the improvement actions were in reducing cases. The continuous use of this instrument improves

practice in order to avoid damage and complications to the patient.

In the last 2 years (2019/2020) reports of adverse events related to phlebitis were recorded in

the ICU, with a cumulative median of 11.8, out of a total of 94 cases reported between the years cited.

Figure 3. Accumulated database for the years 2019/2020/2021 on phlebitis indicator in ICU and

Inpatient Unit, Private Hospital.

Source: Private Hospital Database, 2026

However, for the application of this project, it is necessary to have the support of the

coordination, the interest and availability of the professionals of the nursing team in the sector and the

ﬁ nancial resources raised, aiming at the training of the individuals involved and better practices in the

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care of peripheral venous catheter within the Intensive Care Unit, consequently reducing its phlebitis

rates. With this project we hope to reduce the current median of the ICU from 11.8 to 8.

CONCLUSION

By choosing to develop this ﬁ nal project on the topic of Phlebitis within the Intensive

Care Unit, we aimed to identify the points of improvement in the care practice related to the care

with peripheral venous catheters, especially in the prevention of the occurrence of Phlebitis and its

Institutional protocol, making professionals aware of the importance of caring for the device, from its

insertion to maintenance, its daily evaluation, identifying early warning signs so that the treatment

can be started in a timely manner. faster and more effective, preventing other complications that

generate longer hospitalization time and worsening of the patient’s condition and higher costs for the

Health Institution. Through the PDCA tool, we aim to implement actions in the unit such as training,

the card, the Tasy® window, measures that would contribute to optimizing safe care with the objective

of reducing phlebitis rates in the unit, with improvement in the care provided.

The application of this project involves ﬁ nancial and human resources of the Institution,

especially of the nursing team, which implies important internal changes with the involvement of the

entire care team with the support of the unit’s coordination, which is fundamental for this project to

have applicability and reach the expected results.

Due to the relevance of the theme, we suggest a continuous reassessment of the unit’s care

and indexes, ensuring permanent recycling and education to employees periodically and whenever

necessary, in order to provide best practices based on scientiﬁ c evidence, in a humanized way, avoiding

causing other damage to patients related to care, ensuring their recovery, well-being and safety.

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