It’s a common practice — maintaining peripheral intravenous catheters (PIVCs) in stable hospital patients even after the need for IV therapy has been resolved. And the thinking goes, why not? After all, if emergent treatment is needed, PIVCs offer convenient access.

Now, many physicians and other healthcare providers are questioning the practice and contend it’s time for a mindset shift.

“Although peripheral catheters have a relatively low risk of infection, the rate at which we use them is leading to a significant number of consequential infections,” said Brent Kennis, MD, resident physician at The University of Utah, Salt Lake City, and lead author of a review paper in the Journal of Hospital Medicine. “And we should think more carefully about who does and doesn’t need a peripheral catheter.”

The paper is part of a series on “Things We Do for No Reason.” In it, Kennis and his two coauthors summarize the risks and benefits.

Other hospitalists interviewed by Medscape Medical News agreed that a mindset shift is due on the practice of routinely maintaining PIVCs and said they actively discuss appropriate PIVC use and monitoring at their institutions.

“We are overdue on making this change in healthcare systems,” agreed Vineet Chopra, MD, MBBS, professor and chair of medicine at the University of Colorado School of Medicine-Anschutz, Aurora, Colorado. He reviewed the paper for Medscape Medical News but was not involved in its reporting.

PIVCs: Why Routinely Maintaining PIVCs Is Done

PIVCs are ubiquitous in hospitals worldwide. About 70% of hospitalized patients have a PIVC. They’re commonly placed preemptively — just in case IV treatment is needed — and about one third of PIVCs placed in the emergency department are never used. About one quarter of those placed in hospitalized patients in North America are maintained but not actively used, the so-called “idle PIVCs.”

Routinely Maintaining PIVCs: Risks

While PIVCs do offer convenient access for emergent treatment, they are also associated with risks, Kennis and his coauthors wrote, including local infections, phlebitis, and vascular damage. Patient discomfort is also a downside. “Some patients are bothered,” Kennis said, “Some are not bothered at all.”

PIVCs carry a lower risk for bloodstream infections than do central venous catheters, but their widespread use makes them responsible for more than a third of Staphylococcus aureus catheter-related bacteremia.

“Local infections are bad but treatable,” Kennis said. However, “when people get Staphylococcus aureus bloodstream infections, that’s a really big deal.” Those infections can require weeks or months of antibiotics and can cause a lot of damage, he said.

“I think that’s the most convincing point in the paper,” he said. “These catheters, while relatively benign, have a rare chance of causing a very serious complication.”

How often are PIVCs sitting idle after the need for the IV for treatment passes? “I’m not aware of any data on that,” Kennis said, but it is known that many sit idle and unneeded, he said.

“More and more, there is a push to use oral medications,” Kennis told Medscape Medical News.

As an example, he pointed to pain medications, such as opioid pain medicines, and what he terms the rollercoaster of IV vs oral routes. “IV pain medicines work better — they kick in fast, but also wear off more quickly. Oral may take longer to kick in, but last longer.”

Besides the infection risk, pain and phlebitis affect about 10%-20% of patients with PIVCs. There is also the reliability factor, with more than one third of PIVCs failing before treatment is done.

When Routinely Maintaining PIVCs Make Sense

Sometimes, maintaining PIVCs does make sense, the researchers said. IV access remains the preferred route of drug administration for cardiac arrest and “just in case” PIVCs are appropriate in patients at highest risk for decompensation. Other scenarios: those with anticipated diagnostic studies needing IV contrast, expected procedures needing sedation, and those unable to tolerate oral medications.

Second Opinions

The mindset shift is appropriate and in progress, hospitalists and other physicians who reviewed the new report told Medscape Medical News.

“The evidence supporting removal of IVs based on clinical need rather than standardized durations (routine removal) is solid,” said Chopra. “Our hospital has policies to remove devices that are idle and not being used — not just for IVs, but also other indwelling catheters such as urinary catheters.”

“I completely agree that routine ‘keep-the-IV-in-just-in-case’ for clinically stable pediatric inpatients deserves reappraisal,” said Kristina Nazareth-Pidgeon, MD, pediatric hospitalist and inpatient medical director of general pediatrics and complex care at the Duke University Medical Center, Durham, North Carolina.

“Part of the question that comes up in these cases is, should we have put in the IV in the first place,” she said. There is a tendency not to reassess the need for IVs over the course of a patient’s hospitalization, she said.

For pediatric patients, another consideration is the trauma some children experience with IV placement, so maintaining access means the patient won’t have to experience that twice, she said. At Duke, healthcare providers now consider on a daily basis whether the IV is still needed, she said, but acknowledges that this is done more often with central lines than with peripheral lines.

“IVs are important for a lot of patients, but to maintain it in every single patient every single day is likely not needed,” agreed Joseph Caleb McCall, MD, clinical assistant professor and Division Chief of the Neurohospitalist Division at the Thomas Jefferson University, Philadelphia.

At his hospital, conversations often focus on when it’s possible to eliminate the IV. The thinking is to remove IVs when possible and for clinicians to use their best judgment.

His advice: maintain a daily checklist, especially for complicated patients, when it’s easy to overlook the IV questions while focusing on other medical issues, reminding healthcare providers to reassess the IV need.

“Make this something you discuss with a partner in care, such as a nurse,” he said. Nurses often think about the ongoing need. “Partnering with a nurse and making it a regular conversation can be really valuable,” McCall said. “Working with our nurses has really helped us keep a closer eye on this.”

Quality Improvement — Recommendations

As for guidelines, “there seems to be a potpourri of policies and cultural practices when it comes to IV practices,” Kennis said. “No one [specialty or association] seems to own IV peripheral catheters because they are so ubiquitous.”

In 2024, the Association for Vascular Access published standards of care for PIVCs, focusing on assessing the initial and ongoing need, educating patients and clinicians, paying attention to pain reduction, and removing and replacing only if needed.

Industry offered this guide.

Kennis recommends using a validated IVC assessment tool such as I-Decided. Researchers reported its use reduced idle PIVCs and catheter complications.

Kennis offered other recommendations, which he acknowledged may apply more for hospitalists than for other physician practice areas:

• Place PIVCs only in selected patients who need short-term IV treatment or who are likely to need IV therapies emergently.
• Monitor and reassess the need often.
• Consider PIVC removal in stable patients who can tolerate oral medication or who have no anticipated need for IV access in the near future.

Kennis, McCall, Nazareth-Pidgeon, and Chopra reported having no relevant disclosures.

No funding was reported.