Proceeding of Mayapada International Nursing Conference.
Vol.
No.
ISSN:x https://jurnal.
id/index.
php/minc INTEGRATING
FLUSHING
INTO
PHLEBITIS
PREVENTION BUNDLES: IMPLICATIONS FOR NURSING
PRACTICE AND PATIENT SAFETY Ae A LITERATURE
REVIEW
Dwi Praptiwi Wulansari Nursing Department.
Mayapada Hospital Kuningan.
Jakarta.
Indonesia Corresponding author: dwi.
praptiwi@mayapadahospital.
ABSTRACT
Background: The peripheral intravenous catheter (PIVC) is the most commonly used invasive device in hospitals.
However, complications such as phlebitis, infiltration, and catheter failure remain frequent and have significant implications for patient safety.
Recent evidence indicates that implementing a standardized phlebitis prevention bundle including the flushing practice with 0.
9% NaCl can significantly reduce the incidence of phlebitis and improve the quality of nursing practice.
Purpose: This literature review aims to analyze the most recent scientific evidence .
2Ae2.
regarding the integration of flushing practices into phlebitis prevention bundles and their implications for nursing practice and patient Methods: A narrative literature review approach was employed by searching international Scopus-indexed articles from databases including ScienceDirect.
PubMed.
SAGE.
MDPI.
Wiley.
BMJ Open, and JAMA Network.
A total of 15 articles met the inclusion criteria: intervention or implementation studies evaluating PIVC care, phlebitis prevention bundles, or flushing practices with outcomes related to phlebitis reduction.
Results: Most studies reported a reduction in phlebitis rates following the implementation of PIVC care bundles that included routine flushing using the pushAepause technique.
This practice was shown to maintain catheter patency, reduce venous irritation, and prevent drug residue within the lumen.
Furthermore, nursing education, the use of prefilled syringes, and integrated PIVC systems enhanced adherence to patient safety standards.
Conclusion: The integration of flushing into phlebitis prevention bundles is an evidence-based intervention proven to reduce catheter-related complications and strengthen the quality of nursing care.
Sustainable implementation, regular training, and organizational support are key factors in maintaining success and ensuring patient safety.
Keywords: Flushing.
peripheral intravenous catheter.
care bundle, nursing patient safety Introduction Peripheral intravenous catheters (PIVC.
are the most frequently used invasive devices in healthcare facilities.
Approximately 60Ae80% of hospitalized patients receive intravenous therapy through PIVCs for the administration of fluids, medications, or parenteral nutrition (Zanella et al.
, 2.
Despite their widespread use, complications such as phlebitis, infiltration, occlusion, and catheter-related bloodstream infections remain common and pose significant challenges for nurses in various hospital settings (Cernuda-Martynez et al.
, 2.
Proceeding of Mayapada International Nursing Conference Phlebitis is the most prevalent complication, characterized by pain, redness, and inflammation along the vein, which can prolong hospitalization and reduce patient Furthermore, the phlebitis rate is often used as an indicator of nursing care quality and patient safety (Amble et al.
, 2025.
Llady Maura et al.
, 2.
One of the key interventions in catheter care to prevent phlebitis is flushing with 0.
NaCl solution.
Flushing serves to maintain catheter lumen patency, remove residual medication, and prevent chemical irritation of the venous wall (Devrim et al.
, 2.
Several studies have demonstrated that the pushAepause technique using 5Ae10 mL of 0.
9% NaCl creates effective turbulent flow to clear residual drugs and reduce the risk of obstruction and inflammation (Rickard et al.
, 2023.
Piriz-Marabajan et al.
, 2.
However, flushing practices are often inconsistently performed due to insufficient training, heavy workloads, and the lack of integration of this procedure into routine hospital policies (Teixeira et al.
Erdoan & Baykara, 2.
Such inconsistency increases the risk of vascular complications, shortens catheter lifespan, and undermines the effectiveness of intravenous To address these challenges, several studies have developed phlebitis prevention bundles that integrate flushing as a core component of comprehensive PIVC care.
These bundles typically include appropriate vein selection, aseptic insertion technique, use of integrated devices, daily catheter assessment, and routine flushing (Llady Maura et al.
, 2023.
Amble et , 2.
Implementation of such bundles has been shown to significantly reduce the incidence of phlebitis.
For example.
Dramowski et al.
reported decreased PIVC complications among neonates, while Amble et al.
found that the phlebitis rate decreased from 15.
1% to 9.
4% following the adoption of an infection prevention bundle in adult care units.
These studies highlight that successful phlebitis control depends not only on proper insertion techniques but also on sustained catheter maintenance through consistent flushing practices.
Beyond procedural aspects, the successful integration of flushing into phlebitis prevention bundles also relies heavily on behavioral and systemic factors within nursing Education and training play a crucial role in improving compliance with proper flushing practices.
Erdoan and Baykara .
found that algorithm-based PIVC care training reduced phlebitis rates by up to 50%.
Similarly.
Teixeira et al.
emphasized the importance of establishing vascular access teams and clinical supervision to ensure adherence to care standards.
Moreover.
Mimoz et al.
, through an international consensus, stressed that flushing should be recognized as a core nursing competency in vascular access management.
Managerial support, regular audits, and a strong safety culture are key elements in maintaining the effectiveness of this intervention.
Integrating flushing into the phlebitis prevention bundle is not merely a technical refinement but represents a transformation of nursing practice toward evidence-based care focused on patient safety.
Findings from various studies (Cernuda-Martynez et al.
, 2025.
Kaplan et al.
, 2025.
Rickard et al.
, 2.
demonstrate that a multifactorial approach combining education, device innovation, and daily assessment can reduce phlebitis rates and strengthen the quality of nursing care.
Therefore, the systematic implementation of a phlebitis prevention bundle that incorporates flushing can serve as an effective strategy to enhance nursing performance, prevent vascular complications, and ensure patient safety within modern hospital settings.
Methods Research design This study employed a narrative literature review design with a thematic synthesis The purpose of this design was to identify, evaluate, and synthesize empirical research findings related to the implementation of flushing within phlebitis prevention bundles and its implications for nursing practice and patient safety.
This design was chosen because it enables a comprehensive understanding of intervention effectiveness across various contexts and clinical populations, including adult, pediatric, and intensive care units.
Setting and Samples This review included international literature published between 2022 and 2025, retrieved from Scopus-indexed and reputable academic databases such as ScienceDirect.
PubMed.
SAGE.
MDPI.
BMJ Open.
Wiley Online Library, and JAMA Network.
The inclusion criteria were as follows:
Research articles with experimental, quasi-experimental, or implementation study designs evaluating flushing interventions or PIVC care bundles.
Peer-reviewed.
English-language articles with measurable outcomes related to phlebitis or vascular complications.
Studies involving hospitalized patients with Peripheral Intravenous Catheters (PIVC.
The exclusion criteria included: systematic reviews without intervention, studies focusing on central lines, and individual case reports.
A total of 15 articles met the inclusion criteria and were analyzed in depth.
Applies to Experimental Studies The primary focus of the interventions reviewed was the implementation of flushing with 9% NaCl solution as part of a phlebitis prevention bundle.
Several studies applied the pushAe pause flushing technique using 5Ae10 mL of 0.
9% NaCl before and after medication administration, while others conducted flushing every 8 hours as part of routine catheter Within the bundle framework, flushing was integrated with other elements such as appropriate vein selection, aseptic insertion technique, daily catheter assessment, and nurse training on vascular access management (Llady Maura et al.
, 2023.
Amble et al.
, 2025.
Dramowski et al.
, 2.
Measurement and Data Collection Article identification was conducted using a combination of keywords: Auflushing,Ay Auphlebitis prevention bundle,Ay AuPIVC care,Ay Aunursing practice,Ay and Aupatient safety.
Ay The search process included the following steps:
Initial identification and screening based on titles and abstracts.
Full-text review to determine relevance to inclusion criteria.
Data extraction, including research design, setting, sample size, type of intervention, main outcomes .
hlebitis rate, catheter dwell time, nurse complianc.
, and practical Each article was manually analyzed using a thematic summary table mapping the relationship between flushing implementation and clinical outcomes.
Data Analysis Data were analyzed using a descriptive thematic analysis approach.
The first step involved grouping study findings into major themes:
Effectiveness of care bundles in reducing phlebitis.
The role of flushing in chemical and mechanical prevention.
Nurse compliance and education.
Device and system innovations.
Subsequently, a narrative synthesis was conducted to identify patterns of similarity and divergence among study results.
This approach allowed the researcher to draw evidence-based conclusions regarding the benefits of integrating flushing into nursing quality and patient safety practices.
Trustworthiness / Rigor To ensure the rigor and reliability of the findings, the review process adhered to the principles of transparency and replicability.
Each stage of article selection and analysis was systematically documented following Lincoln and GubaAos .
framework of confirmability and dependability.
Content validity was maintained by focusing solely on peer-reviewed empirical studies.
Moreover, source triangulation and cross-study comparison were performed to minimize interpretation bias and strengthen analytical validity.
Ethical Considerations Since this study was a literature review that did not involve direct human participation, formal ethical approval from an institutional review board was not required.
However, all included studies were published scientific works that had obtained ethical clearance from their respective institutions.
Academic integrity was maintained by accurately citing all sources following APA 7th edition format and ensuring that no copyright infringement or plagiarism occurred throughout manuscript preparation.
Table 1.
Summary of Included Studies N Author / Study Title Objective Year Design Sample Method Analysis Key Findings Care bundle Significant To evaluate for the reduction in prevention of QuasiInpatients Llady s of a threeDescriptiv experimental with (BSI) and Maura phase care e analysis .
-phase et al.
bundle in & trend implementati PIVCs .
OO .
PVC-BSI Implementati on of the on and PIVC care Implementati To assess Phlebitis on of an the impact Infection of a quality Amble QuasiNA test and Prevention improveme 2 K.
et al.
time-trend Care Bundle nt (QI) .
reAepos.
program on Peripheral phlebitis with flushing IV Catheters.
To assess Impact of a Complicatio the effect of ns decreased an SPC Descriptiv Dramow peripheral from 21% to care bundle PreAepost 3 ski A.
et catheter care on vascular study neonates inferential .
bundle in a ns in N Author / Study Title Objective Year Design Sample Method Analysis Key Findings To analyze the impact Implementati of a PIVC on of a care bundle Peripheral Implementati 400 on phlebitis Intravenous on study Catheter Care Bundle.
The bundle incidence by Logistic .
up to 45% months of Distal site To compare .
orsal vei.
Comparison catheter of PIVC with higher Kaplan Observationa anatomical sites ANOVA phlebitis et al.
l comparative sites: Pain, regarding inpatients and NA test risk.
vein site pain and d as part of To evaluate the effect of Drawing increase in Davies blood from a sampling Randomized Independe et al.
PIVC vs when proper inpatients nt t-test venepunctur PIVCs on trial (RCT) post-blood e: RCT.
flushing was To examine Phlebitis the impact Training Erdoan with a PIVC algorithm- PreAepost 85 nurses Wilcoxon to 8.
Gyymen based PIVC .
raining & NA tests flushing Baykara interventio.
patients BeforeAeafter .
training on increased by Impact on To evaluate Integrated peripheral the system with Pirizcatheter KaplanAe routine Prospective Marabaj failure with s of an Meier an M.
et an patients survival reduced .
integrated catheter analysis catheter PIVC system in failure by N Author / Study Title Objective Year Design To compare Integrated vs Rickard s of PIVC Multicenter 9 C.
RCT
Clinical & costal catheter Sample Method Analysis 1,000 Integrated Costsystem effectiven reduced care costs by 23% analysis and phlebitis by 37%.
Key Findings BSI risk To analyze Dwell Time association Zanella and Risk of between Cox Prospective 500 10 M.
et Bloodstream catheter cohort study inpatients .
Infection dwell time with PIVCs.
patency and Chemical .
rug Clinicalresidu.
and Cernuda epidemiologi To identify Analytical factors were clinical risk Multivaria 11 Martynez predictors of factors for patients te analysis et al.
PIVCstudy .
d every 8 Prefilled vs To compare Prefilled the safety of prefilled Devrim vs manually Randomized 200 FisherAos microbial 12 .
et al.
syringes for prepared clinical trial children exact test colonization .
PIVC flushing in and phlebitis by up to .
To assess Significant Protect reduction in Rickard PIVC (ProP) KaplanAe effectivenes Multicenter 850 vascular and 13 C.
et trial Meier s of RCT .
Antimicrobia al dressings N Author / Study Title Objective Year Design Sample Method Analysis Key Findings l dressing vs within of integrated care bundles.
Best practice Flushing To develop in the use of identified as Mimoz peripheral International Delphi & a core 14 O.
et al.
consensus nursing .
analysis competency for PIVC Consensus for phlebitis Training and To evaluate Adherence to nursesAo Teixeira PIVC compliance Descriptive Spearman 15 J.
et al.
guidelines by with .
healthcare catheter to 82%.
phlebitis rate reduced by Results and Discussion A review of fifteen international Scopus-indexed studies demonstrated that the integration of flushing practices into the phlebitis prevention bundle consistently produced positive outcomes, including a reduction in phlebitis rates, improved nurse compliance with standard procedures, and a strengthened culture of patient safety.
Effectiveness of Bundles in Reducing Phlebitis Several studies showed that the implementation of Peripheral Intravenous Catheter (PIVC) care bundles that included routine flushing effectively reduced phlebitis incidence.
Llady Maura et al.
reported significant improvements following the implementation of a three-phase care bundle encompassing appropriate vein selection, aseptic technique, and maintenance flushing with 0.
9% NaCl.
The intervention led to decreased rates of bloodstream infection and phlebitis in multiple hospital wards in Spain.
The authors concluded that a comprehensive evidence-based intervention had a major impact on patient safety and nursing care quality.
Similarly.
Mimoz et al.
emphasized that PIVC care cannot be separated from the flushing component, which is essential in preventing vascular complications.
Supporting these findings.
Amble et al.
reported a decrease in phlebitis from 1% to 9.
4% after implementing an infection prevention care bundle in a Norwegian This bundle included the Aseptic Non-Touch Technique (ANTT), 8-hourly catheter evaluations, and pushAepause flushing with 0.
9% NaCl.
Consistent implementation combined with compliance audits significantly improved PIVC-miniQ quality scores.
The authors highlighted that structured bundles supported by ongoing nurse training and organizational commitment significantly reduce complications and enhance nursing care quality.
Similarly.
Rickard et al.
found that standardizing PIVC management practices, including flushing, clinically reduced catheter failure and phlebitis.
In a specialized population.
Dramowski et al.
evaluated a short peripheral catheter (SPC) care bundle in a neonatal unit and observed a substantial decrease in complications such as infiltration, dislodgement, and phlebitis.
The bundle included aseptic practice, use of appropriate securement devices, and post-medication flushing.
These findings confirmed that standardized bundles are effective even among vulnerable populations, such as neonates, without adverse effects.
A related study published in the International Journal of Nursing Studies Advances .
also found reduced phlebitis among adults following similar bundle These results underscore the universal adaptability of flushing integration across various populations and care settings, from general wards to intensive and pediatric Overall, these findings affirm that the success of PIVC care bundles in reducing phlebitis relies on a combination of preventive interventions, rather than a single isolated action.
Appropriate site selection, controlled dwell time, and routine flushing work synergistically to prevent venous inflammation and maintain catheter patency (Cernuda-Martynez et al.
Zanella et al.
, 2.
Integrating flushing into care bundles provides dual benefits extending catheter lifespan and minimizing vascular complications that prolong Hence, care bundles that incorporate flushing represent evidence-based nursing strategies critical to improving nursing care quality and patient safety in modern hospitals (Teixeira et al.
, 2025.
Piriz-Marabajan et al.
, 2.
Role of Flushing in Preventing Mechanical and Chemical Phlebitis The literature highlights that flushing is one of the most essential components in the maintenance of PIVCs, preventing both chemical irritation from drug residues and ensuring optimal venous flow.
Flushing clears residual drugs from the catheter lumen and prevents clot formation that could obstruct blood flow.
Devrim et al.
found that prefilled syringes were more effective than manually prepared syringes, significantly reducing microbial contamination and catheter tip colonization due to less handling and lower environmental exposure.
These findings emphasize that technical aspects of the flushing procedure, including device type, contribute substantially to preventing phlebitis and catheter-related infection.
From an etiological standpoint.
Cernuda-Martynez et al.
identified chemical factors, particularly irritant drug residues, as primary causes of phlebitis.
Inadequate flushing allows irritants to adhere to venous walls, triggering local inflammation.
Thus, performing flushing before and after medication administration is crucial for preventing chemical Zanella et al.
further noted that catheters left in place for more than 72 hours carry a higher risk of bloodstream infection.
hence, 8-hourly flushing and daily evaluation are necessary to maintain patency and prevent bacterial colonization.
Physiologically, the pushAepause technique using 5Ae10 mL of 0.
9% NaCl is the most recommended practice in modern nursing.
This technique creates turbulent flow, effectively clearing residual drugs without exerting excessive intravascular pressure that could damage vein walls (Mimoz et al.
, 2.
This approach not only prevents occlusion and chemical phlebitis but also ensures stable IV flow, maintaining medication dosage and duration Rickard et al.
supported these findings, emphasizing proper flushing as a critical determinant in reducing catheter failure.
Piriz-Marabajan et al.
added that consistent flushing within an integrated PIVC system significantly prolongs catheter lifespan by preventing biofilm formation and lumen Thus, integrating flushing into phlebitis prevention bundles addresses both chemical and mechanical factorsAireducing risks such as negative pressure, occlusion, and vein wall friction.
Overall, current evidence confirms that flushing is a simple yet vital intervention reflecting a patient safetyAeoriented nursing practice.
Nurse Education and Compliance with Flushing Procedures Nurse adherence to flushing protocols is a key factor in phlebitis prevention.
Studies consistently demonstrate that nurse competence and consistency in catheter care directly affect vascular complication rates.
Erdoan and Baykara .
reported that after implementing PIVC care algorithm training, phlebitis incidence dropped from 16.
1% to The training emphasized the pushAepause technique, aseptic procedures, and early recognition of phlebitis signs.
The decrease in phlebitis rates underscores that technical training combined with clinical supervision improves nursesAo practical skills and adherence to standards.
In addition to training, collaborative team approaches enhance implementation success.
Teixeira et al.
highlighted the importance of establishing Vascular Access Teams (VAT.
to ensure compliance with flushing guidelines and infection prevention protocols.
These teams oversee education, quality monitoring, and clinical audits, resulting in reduced phlebitis and improved nurse satisfaction through expert support.
Amble et al.
also found that routine training and feedback-based monitoring enhanced compliance across all bundle components, including flushing.
From a professional standpoint.
Mimoz et al.
, through an international consensus statement, identified flushing as a core nursing competency in vascular access management.
The consensus emphasized incorporating flushing into nursing curricula and institutional Standardized training and certification not only ensure procedural quality but also foster a culture of evidence-based practice in clinical settings.
Rickard et al.
, through the Protect-PIVC (ProP) Trial, further demonstrated that structured education and updated clinical guidelines significantly reduced catheter failure and phlebitis across participating The success of flushing interventions depends not only on protocols and equipment but also on human resource quality and leadership.
Technical skills, clinical leadership, and a strong patient safety culture reinforce safe and effective nursing practice.
Hospitals that include flushing training in continuous nursing education programs report lower vascular complication rates compared to those without such programs (Teixeira et al.
, 2025.
Erdoan & Baykara, 2.
Continuous education and clinical audits should thus be central to phlebitis control strategies and nursing quality improvement initiatives.
Integration of Device Innovation and Flushing Practice Technological advancements in medical devices have greatly contributed to preventing catheter-related complications, including phlebitis.
Recent studies reveal that integrated PIVC systems with safety valves and negative-pressure connectors significantly lower infection risk and extend catheter lifespan.
Rickard et al.
compared integrated and conventional systems and found significant reductions in catheter failure and phlebitis.
Features such as closed valves and sterile connectors minimize cross-contamination during flushing and medication administration.
Similarly.
Piriz-Marabajan et al.
demonstrated that combining device innovation with maintenance flushing yielded lower complication rates and better cost-efficiency in high-risk inpatient settings.
Ergonomic and anatomical factors also affect flushing effectiveness.
Kaplan et al.
compared catheter insertion sites and found that proximal sites, such as the basilic or cephalic veins, posed a lower phlebitis risk compared to distal ones due to reduced mechanical stress during flushing.
This finding shows that flushing effectiveness depends not only on nursing technique but also on device design and anatomical placement.
Procedural innovations also improve clinical efficiency.
Davies et al.
found that blood sampling through closed PIVC systems did not increase phlebitis rates when proper post-procedure flushing was performed.
This suggests that consistent adherence to flushing protocols maintains catheter function without added risk, even in multipurpose PIVC use.
Zanella et al.
further highlighted that daily catheter evaluation combined with regular flushing reduces bloodstream infection risk, a common cause of secondary phlebitis.
Overall, empirical evidence underscores that device innovation, proper flushing technique, and ongoing clinical evaluation are key to preventing phlebitis.
Modern PIVC systems featuring anti-retrograde flow valves and sterile connectors enhance procedural safety, while the pushAepause flushing technique ensures optimal lumen clearance.
Collaboration among medical device manufacturers, nursing professionals, and hospital management is essential for widespread adoption of these innovations, aligned with patient safety standards.
General Analysis and Implications for Nursing Practice Overall, this literature review reveals that integrating flushing practices within the phlebitis prevention bundle consistently yields positive outcomesAireducing phlebitis rates, enhancing nurse compliance, and strengthening the patient safety culture in hospitals.
Multiple studies (Amble et al.
, 2025.
Llady Maura et al.
, 2023.
Dramowski et al.
, 2.
confirmed that structured bundle implementation led to a 30Ae50% reduction in catheterrelated complications within three to six months.
This reinforces that flushing is not merely a routine technical task but an evidence-based nursing intervention critical for maintaining catheter patency, preventing venous inflammation, and ensuring continuity of intravenous The successful implementation of PIVC care bundles depends heavily on institutional policies and system support.
Teixeira et al.
demonstrated that managerial support such as providing adequate equipment, budgeting for prefilled syringes, and quality audits raised procedural compliance to 80%.
Hospital management should ensure that standard operating procedures (SOP.
are accessible, evidence-based, and regularly updated.
Nurse leaders play a vital role in monitoring and providing feedback to sustain adherence to flushing standards (Mimoz et al.
, 2.
Education and certification also determine success.
Erdoan and Baykara .
found that algorithm-based PIVC care training reduced phlebitis by nearly 50%.
Continuous professional education enhances nursesAo technical proficiency and awareness of evidencebased care in preventing vascular complications.
Establishing vascular access team certification programs (Teixeira et al.
, 2.
further improves professionalism and clinical Finally, bundle implementation success should be viewed through the lens of organizational culture, particularly Just Culture and Patient Safety principles.
A fair, learning-oriented nursing culture encourages staff to report errors and procedural deviations without fear of punishment, facilitating continuous improvement (Rickard et al.
, 2024.
Amble et al.
, 2.
Thus, integrating flushing into the phlebitis prevention bundle is not only an effective intervention to reduce phlebitis but also a strategic step toward strengthening patient safety, organizational efficiency, and nursing practice quality in modern healthcare Conclusion This literature review demonstrates that the integration of flushing practices using 0.
NaCl into the phlebitis prevention bundle is an evidence-based nursing intervention proven effective in reducing both the incidence and severity of phlebitis.
Flushing has been shown to maintain catheter patency, minimize the risk of chemical and mechanical irritation, and extend the lifespan of peripheral intravenous catheters.
Various international studies indicate that the implementation of standardized bundles that include flushing makes a significant contribution to improving patient safety and the quality of nursing care.
Beyond its clinical effectiveness, the success of this intervention largely depends on supportive systems and organizational culture.
Hospitals must ensure that flushing is integrated into operational policies and standard procedures for PIVC management, supported by adequate resources such as the use of prefilled syringes, availability of sterile equipment, and sufficient staffing time to enable proper implementation.
This systemic approach ensures the sustainability and consistency of best practices across all care units.
From a human resource perspective, regular training, competency certification, and clinical supervision for nurses are essential to maintaining technical skills and adherence to flushing protocols.
Continuing education should focus not only on procedural aspects but also on strengthening nursesAo understanding of patient safety, evidence-based nursing practice, and just culture, enabling them to perform interventions with a full awareness of their impact on patient outcomes.
The integration of flushing within the phlebitis prevention bundle not only reduces catheter-related complications but also reflects the essence of modern nursing professionalism, which prioritizes patient safety, accountability, and quality of care.
Consistent implementation of this strategy can serve as a benchmark for hospitals in building a culture of safe, effective, and evidence-based nursing practice.
References