Inclusion of the European Portuguese Version of the Visual Infusion Phlebitis Scale in a Health Information System

Citation: Ventura, D., DaSilva Freitas, J., & Simoes, J. (2023). Inclusion of the European Portuguese version of the visual infusion phlebitis scale in a health information system. Online Journal of Nursing Informatics (OJNI), 26(3), https://www.himss.org/resources/online-journal-nursing-informatics

Abstract

Background: Phlebitis is the most frequent complication associated with the use of peripheral venous catheters (PVCs). Nurses are responsible for the adequate introduction, maintenance, and removal of PVCs. Therefore, nursing teams need reliable and valid tools to prevent phlebitis and other complications with the use of PVCs. The Visual Infusion Phlebitis (VIP) score is the principal tool recognized by the international scientific community used for this purpose. This scale evaluated the presence of phlebitis through the observation and classification of six symptoms: pain, edema, erythema, induration, palpable venous cord, and venous thrombosis. The use of assessment tools inserted in Health Information Systems (HIS) has potential benefits, namely in terms of organizational efficiency, improved communication, improved quality of care and patient safety.

Aim and Method: This study aimed to create a proposal for the inclusion of the VIP PT-PT (European Portuguese version) in a HIS to assess the presence of phlebitis in patients with a PVC. A quantitative research methodology was used where inter-observer reliability studies of the scale were performed. Later, use cases and activity diagrams were created in UML (Unified Modeling Language). All ethical requirements were fulfilled.

Findings: Results demonstrate that the VIP PT-PT scale is a reliable tool to be applied in the context of Portuguese healthcare. A proposal was developed in UML that allows the implementation of this scale in the most used HIS in Portugal (SClínico), which can improve the monitoring of the PVC catheterization site and continuity of care by health professionals.

Introduction

The peripheral venous catheterization (PVC) procedure is one of the most invasive procedures performed in hospitals around the world. In the United States, over 300 million catheters are sold annually, and approximately 60–90 % of all hospitalized patients require peripheral venous access during hospitalization (Høvik et al., 2019; Lv & Zhang, 2020; Marsh et al., 2017; Suliman et al., 2020) .

The introduction of a PVC is done with the aim of infusing a patient with therapy, fluids, nutrients, and replacement of blood products which is one of the preferred routes for medication administration, as it ensures that the concentration of the active ingredient that enters the blood stream is always constant (Schettini et al., 2022). Choosing this route avoids problems such as drug inactivation or malabsorption by the viscera and is therefore a preferred route when the oral route is unavailable (Borello & Nichols, 2022) .

The use of a PVC has the main advantage of being a minimally invasive procedure, insertion and maintenance is easy to learn, and serves a wide range of uses. It does not require diagnostic and therapeutic means to confirm its positioning, and it has a relatively low risk of bloodstream infection compared to other more invasive procedures, such as central venous catheters (Marsh, Webster, et al., 2020). PVCs exhibit a risk of bloodstream infection that is about 40-fold lower than more invasive, longer-dwelling vascular access devices (0.06 bacteremia per 1000 catheter-days) (Simonov et al. 2015).

Despite its usefulness, the introduction of a PVC may cause complications. Whenever a new PVC is inserted, there is a risk of extra-lumen infection, since the catheter perforates the skin surface, thus potentially allowing pathogens to enter the bloodstream (Marsh et al., 2017; Marsh, Larsen, et al., 2020; Marsh, Webster, et al., 2020). Factors such as poor asepsis in access handling increase the risk of endo-lumen infection. An infection with a PVC starting point increases a patient's hospital stay by an average of seven to 20 days, in addition to substantial economic costs for the institution that can reach up to 16.540 million euros in Hungary (Endrei et al., 2019).

It has been verified that up to a quarter of inserted PVCs become obstructed or are removed accidentally, which may lead to extravasation of the perfused solution with edema formation (Marsh et al., 2017). The presence of a PVC predisposes the patient to the appearance of phlebitis and venous stasis with the formation of thrombi that can migrate into the bloodstream and result in thrombophlebitis (Mandal & Raghu, 2019; Marsh et al., 2017).

In Portugal, a systematic review carried out by Oliveira & Parreira (2010) analyzed 19 studies related to the incidence of phlebitis and the extent of its occurrence, concluding that the incidence of phlebitis ranged from 3.7% to 64.6%. The authors justified that these different incidence values may be related to the length of stay of the catheter, its diameter, the anatomical puncture site, the type of dressing protecting the catheter insertion site, the fixation method, the clinical context where the catheter is inserted, the material of manufacture, the use of infusion extension tube between the catheter and the medical stopcock, the type and characteristics of the therapy administered, the manipulation and optimization of the catheter, the use of infusion pumps, the frequency of surveillance of the insertion site and the specific training of nurses on this topic. Also, in this regard, the results of the National Infection Prevalence Survey indicated that PVCs are the most relevant extrinsic factor for the occurrence of Nosocomial Bloodstream Infections (NBIs) (Direção Geral de Saúde, 2017).

In a survey conducted in 2012 in one Portuguese health institution, PVCs were the most relevant extrinsic risk factor, increasing the prevalence of NBIs to 11.7% (Pina et al., 2013). In another investigation, in 170 registered NBIs, 66.1% were due to the presence of a PVC (Oliveira, 2014). Another study reported that with 221 observations of 78 PVCs performed in 58 patients, an incidence rate of 36.7% was recorded for phlebitis (Nobre & Martins, 2018).

At an international level, in Japan a prospective cohort study with a sample of 2741 patients and 7118 PVCs inserted, phlebitis rate was 7.5% (Yasuda et al., 2021). In other studies, such as the research carried out by Urbanetto et al. (2011) 231 patients presented a phlebitis rate of 24.7%. In the study by Magerote et al. (2011), a rate of 25.8% was found in 155 introduced PVCs. According to the Infusion Nurses Society, the recommended percentage of occurrence of phlebitis in hospitals should be equal to or less than 5%  (Gorski et al., 2021).

A systematic review conducted by Ray-Barruel et al. (2014), whose objective focused on the identification of instruments to assess phlebitis, found the existence of 71 worldwide instruments for recording and parameterizing PVC introduction-related phlebitis. Of these, not all are original, with numerous disparities between them (Marsh et al., 2015). Among these instruments, the most frequently mentioned in the literature are: Visual Infusion Phlebitis (VIP) (Jackson, 1998); Infusion Nurse Society Standards (Journal of Infusion Nursing, 2006); Maddox (Maddox et al., 1983); and Baxter (Baxter, 1988).

According to Marsh et al. (2020),  the nurse is the health professional responsible for peripheral venous catheterization and is assigned functions ranging from PVC insertion to maintenance of access, as well as its replacement and removal. Nurses are also responsible for administering the intravenous therapy and monitoring the patient during administration. In the face of any change that makes it impossible to continue the treatment, accidental removal of the access, infiltration, or the presence of inflammatory signs, the nurse is autonomous in making the clinical decision to withdraw the access (Høvik et al., 2019; McGowan, 2014; Oliveira, 2014; Santos-Costa et al., 2022).

It is important to sensitize nurses to correct surveillance of the catheter insertion site and its daily optimization, through palpation of the surrounding area and visualization of the PVC insertion site (Høvik et al., 2019). Urbanetto et al. (2011) agree and reinforce the idea that nurses should be able to identify the factors that may be at the origin of the development of phlebitis, to prevent not only its appearance but also worsening of the health status of the patient (Høvik et al., 2019; Oliveira, 2014).

The national recommendations of the Portuguese health regulatory institution indicate that the prevention of infections associated with PVCs is based on six points: selection of the type of catheter, selection of the puncture site, adequate skin disinfection before puncture, maintenance and optimization of the puncture catheter, catheter replacement strategies, and antibiotic prophylaxis (Direção Geral da Saúde, 2017). Other recommendations refer to the use of phlebitis assessment scales, with frequent surveillance, bringing gains in the prevention of phlebitis or in its early identification with the implementation of measures appropriate to the identified changes (Gorski et al., 2021). It is, therefore, necessary to train nurses in the use of these instruments for the prevention and identification of phlebitis.

In terms of the use of the International Classification for Nursing Practice (ICNP®), (International Council of Nurses, 2019) peripheral catheterization is positioned as a therapeutic attitude, with associated nursing interventions, and serves as the basis for planning care and implementing these interventions. However, in Portugal, there is little documentation of information related to monitoring, surveillance, and evaluation of PVCs that are inserted, and subsequent interventions.

In the opinion of Ahlqvist et al. (2006) and Groot et al. (2022), adequate documentation and improved care enable health gains. Numerous international recommendations reinforce the need to use documentation standards, including recommending judicious use of parameters registration: PVC caliber, anatomical place of the puncture, number of attempts, type of fixation used, teaching performed, appearance and place of insertion, and clinical reason for the PVC (Gorski et al., 2021).

Health information systems (HISs) are tools for collecting, processing, analyzing, and transmitting information necessary for the various health services to organize and operate. An HIS allows for an interrelationship between the various actors in the system, which leads to all data collected and introduced being decisive for the patient's health process (Torab-Miandoab et al., 2023).

Electronic health records (EHRs), which are an integral part of a health information system, were developed with the aim of recording observations, informing, acquiring knowledge, monitoring performance, and, above all, justifying the interventions to be performed on the patient (Shortliffe & Cimino, 2014; Torab-Miandoab et al., 2023).

The World Health Organization stated that investment in EHRs brings gains in the detection of health problems, namely healthcare-associated infections (HAIs), facilitates communication and exchange of data among health institutions, and is preponderant in helping clinical decision support in monitoring the established objectives of each institution, and in promoting the quality of care provided and equity of access to the health system (Shortliffe & Cimino, 2014; Torab-Miandoab et al., 2023; World Health Organization, 2008). The development of a tool that allows the recording and consultation of information, and aids in clinical decision support, brings gains in health and contributes to the improvement of healthcare provided and patient safety (Torab-Miandoab et al., 2023).

The main objective of this work focused on the creation of a proposal to improve nursing documentation in patients with phlebitis. More specifically, it was intended to translate and culturally adapt the VIP to European Portuguese (VIP PT-PT), to study the inter-observer reliability of the VIP PT-PT, to create diagnoses and interventions in nursing directed to the score obtained on the scale, and finally to create a representation in Unified Modeling Language (UML) diagrams of the evaluation instrument to be applied in a health information system.

Materials and Methods

Visual Infusion Phlebitis Scale Translation and Adaptation

To perform the translation and cultural adaptation process to the European Portuguese language, the authors followed the ISIS – Outcomes Translation and Linguistic Validation Process provided by the ISPOR Task Force for Translation and Cultural Adaptation – Oxford University Innovation (Wild et al., 2005). This translation method is a structured methodology that allows researchers to translate foreign language documentation into their mother language in a phased, concise, and clear way, ensuring integrity throughout all translation stages (Wild et al., 2005). The choice of this procedure was based on previous similar studies  (Haragus et al., 2018; Padovani et al., 2021; Simões et al., 2011; Yosmaoglu et al., 2016).

In the initial phase, the document was translated by two bilingual specialists, fluent in European Portuguese and English. The two translators were chosen based on their training and according to the following criteria: Translator one – should be aware of the concepts to be translated, and his focus is on bringing clinical terms closer to the reality of the mother language, so that the translation is as reliable as possible; Translator two – should not have any training in the field of study, nor be informed of the concepts to be translated, should use a more common language, without being influenced by the academic field of study.

At the end of the translation process, a report was prepared with the translation done, highlighting the doubts and uncertainties. The final document is a combination of the two works carried out by the translators, namely the researchers of this study, who had the function of compiling the translations, and the notes that show how the consensus was generated between the two evaluators. Possible discrepancies and errors that occurred during the translation process were detected and corrected by the authors (Wild et al., 2005).

Then the authors carried out an adaptation of the initial translation using ICNP® (International Council of Nursing, 2019) terminology. ICNP® terminology was used to facilitate cross-mapping amongst local terms and existing terminologies. We believe that this adaptation using ICNP® terminology can establish an international standard to facilitate the description and comparison of nursing practice. At a health information system's level, standardized and universal terminology, such as ICNP®, is the core of any electronic health record, providing a consistent and systematic method that defines concepts and translates knowledge of the clinical practice of nurses. Ali & Sieloff (2017) gave an account of this type of language's role, from the collection process to the computerization of data. From the point of view of care provided to the patient, it brings advantages in terms of safety in the process of individualizing care through diagnoses and interventions suited to the patient's actual needs.

Using the final document, in an impartial way, it was translated back into English, in a process called ‘retroversion.’ This process serves to confirm that the translated version fully represents the meaning that the original document aims to produce (Wild et al., 2005). Once this process was completed, the produced version was sent to the original author of the scale (Andrew Jackson, Consultant Nurse Intravenous Therapy and Care, Rotherham General Hospitals, NHS Trust), obtaining proper approval for use.

Visual Infusion Phlebitis Scale Reliability Study

The reliability study was conducted in a surgical inpatient unit at a hospital in the Central Region of Portugal. The hospital’s Ethics Committee gave full ethical approval, and the study was registered with the hospital’s Research Office, thus fulfilling local research governance requirements (process number 084608). The study was conducted in accordance with the principles stated in the Declaration of Helsinki. All data were confidential and kept securely in locked filing cabinets and on password-protected computers.

A convenience sample of 23 patients was included in the reliability study. A similar sample was used in a previous study performed by Simões et al. (2011), and the inclusion criteria were: (1) patients aged 18 years or over; (2) patients who had a blocked peripheral intravenous catheter (PVC); and (3) patients with a PVC who were receiving intravenous therapy. The exclusion criteria were: (1) patients whose PVC had already been removed; and (2) patients with a PVC for less than 24 hours.

All data were collected by two nurses with ten years of work experience between April and May 2018. Prior to data collection, informed consent to participate in the research was obtained from the patients. The VIP PT-PT scale was applied by the same two nurses to all the patients at two consecutive points with a minimal interval of 24 hours and a maximum of 48 hours. At the first point, each patient was independently assessed by nurse A (A1) and nurse B (B1). On the second day, nurse A (A2) and nurse B (B2) completed a second examination. Nurses did not discuss assessment results at any time during the data collection period. In addition to the VIP scale, a questionnaire was used to collect socio-demographic characterization data of the patients.

The collection data procedure produced four data sets referred to here as A1, B1, A2, and B2. Descriptive statistics were used for the analysis of sociodemographic data, such as frequencies, percentages, means, and standard deviation. Cohen's kappa, Spearman's correlation coefficient, and Kendall's correlation coefficient were used to analyze reliability and inter-observer agreement.

Cohen's kappa is considered the gold standard for evaluating inter-observer reliability, as stated by Santiago (2016). It can only be applied to nominal and ordinal data, and when used in the presence of two evaluators or two moments of data collection. The results assume values ​​between -1 and 1, where kappa=1 means perfect agreement, kappa=0 means no agreement other than what would be expected by chance and kappa=-1 means perfect disagreement in the sense that the raters give opposite/differing ratings.

Spearman's Rho and Kendall's Tau are measures of association between two variables. For their application, the variables must be on a scale with ordinal values ​​and in the presence of two evaluators who will apply the evaluation instrument. These coefficients were used to quantify the degree of agreement between the ratings of the two evaluators and both vary between -1 and 1. Spearman’s Rho is a correlation coefficient with the usual interpretation of the range of possible values: perfect positive correlation gives Rho=1, perfect negative correlation gives Rho=-1 and independence gives Rho=0. Kendall's Tau measures the degree of agreement with Tau=1 representing total agreement, Tau=-1 representing perfect disagreement and Tau=0 represents independent ratings (Santiago 2016). Since both measures can be used to assess the agreement between raters, we have used both to enforce our conclusions. For Spearman's Rho, obtaining a score between 0.00 and 0.19 means a very weak agreement, while between 0.20 and 0.39 means weak, between 0.40 and 0.59 means moderate, between 0.60 and 0.79 means strong, and between 0.80 and 1.00 means very strong agreement (Santiago 2016).

All statistical analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS) 25.0 for Windows (Armonk, NY: IBM Corp.), and the level of significance used was 0.05.

Proposal for the Inclusion of the VIP PT-PT Scale in a Health Informatics System

To transcribe the VIP PT-PT scale into a programming language, for later integration into a nursing information system, the Unified Modeling Language (UML) was used in version 2.0, using Microsoft Visio Professional 2016 (Kimmel, 2005).

UML is an expressive programming language that describes all the scenarios and points of view necessary for the development of a system. This language provides a set of useful tools for documenting and analyzing systems and gathering their prerequisites for their operation. It is used to visualize, specify, build, and document all elements of a software system. It is a tool acclaimed by the scientific community to facilitate communication between developers and end-users as it allows the system to be analyzed in detail. It has the advantage of a posteriori quickly mapping to a programming language, such as Java or C++.

UML version 2.0 offers 13 diagram shapes that can be categorized into four main categories: structure diagrams for a representation of the system components to be modeled, such as class, composite, implementation, and object diagrams; behavior diagrams, which simulate what will happen once the modeled system is active with the use case diagrams implemented; and finally, interaction diagrams, that are a subrepresentation of behavior diagrams, which allow control of the data flow of the system's elements that are being modeled (Pecoraro & Luzi, 2022). In the VIP PT-PT computerization proposal, only use case diagrams and activity diagrams describing the user's interaction with the computer system will be represented  (Pecoraro & Luzi, 2022) .

The use case diagrams aim to focus on the dynamic aspect of the system, identify internal and external influences, and provide an ‘outside’ view of the system, showing the interactions between the various actors. In the process of elaboration and implementation of a new software or elements, the use of use case diagrams has as its main function to collect the main functional requirements of a system. Each user/actor provides the different scenarios that specify how the interaction with the system will take place. This type of diagram not only provides clarification in terms of actors and sequences of events but also indicates the logical sequence of actors' progress during their actions in the system. Actors are represented by a human figure and use cases by oval structures. The associations between users and use cases are demonstrated using arrows. There is also the use of the ‘include’ and ‘expand’ functions when we want to illustrate a condition.

Activity diagrams depict the sequence of system operation, from one activity to another, to capture dynamic and behavioral activity. The purpose of activity diagrams is to represent the flow of actions from the particular to the general, giving a notion of hierarchy and parallelism with the reality of what the system is. The use of this type of diagram has the main function of detailing and deepening the level of specificity of each function (Pecoraro & Luzi, 2022) .

Graphically, activity diagrams are represented by rectangles with rounded corners and the transitions between them by an arrow. The arrow also has the function of controlling the transition, which needs to be true to start the sequence. The diamonds that are represented refer to the multiple decisions that can be taken, under the conditions presented in the rectangles above the arrows. The beginning is defined by a single circle, and the end by two circles, one being more interior than the other.

Results

European Portuguese Version of the Visual Infusion Phlebitis Scale (VIP PT-PT)

After the VIP translation process into European Portuguese, we obtained the first version represented in Figure 1, which is in accordance with the original scale, both in terms of content and aesthetics.

Considering this first version, the color system was changed to a more gradual system of traffic lights (green, yellow, orange, and red) to alert the nurse to the level of severity of the result obtained. In addition, using the ICNP®, the scale was developed and adapted so that, after observing the venous catheter insertion site and the surrounding area, a nursing diagnosis and associated nursing interventions could be formulated (Figure 2). Thus, the possible results to be obtained vary from 0 to 5 points, and each diagnosis is associated with a set of nursing interventions, for a concrete action on the part of the nurse that must be selected considering the specificity of the situation. Five main diagnoses were established, using the ICNP® language: without the involvement of the venous catheter (0 points – green); risk of venous catheter compromise (1 point – yellow); low degree of venous catheter compromise (2 points – orange); moderate degree of venous catheter compromise (3 points – orange); high degree of venous catheter compromise (4 points – orange); venous catheter infection (5 points – red).

Reliability Study

The reliability tests were applied to a sample of 23 patients with the sociodemographic and clinical characteristics presented in Table 1. Thus, the sample is mostly composed of female patients, with an average age of 58.9 years, mostly represented by patients between 51 and 80 years old. As for chronic comorbidities, patients mostly presented with arterial hypertension (48%), diabetes mellitus (43%), and hypercholesterolemia (30%). Regarding the characteristics of the PVCs, the predominant insertion site was the veins on the back of the hands and the most frequently used PVC caliber was 18G. About 48% of PVCs were filled at the time of evaluation and 52% had some type of perfusion. Catheter fixation was performed in 70% of situations with transparent dressing and in 30% with hypoallergenic opaque adhesive.

As regards the application of the VIP PT-PT scale, the scores obtained ranged between 0 and 2, with a score of 0 – “Sem comprometimento do cateter venoso” (“No venous catheter compromise”) being the most prevalent (Table 2).

As for the reliability test applied to the assessments of the two nurses to verify the reliability of the results obtained, a Cohen's kappa value of 0.918 was obtained, which according to Santiago (2016) means almost perfect reliability between two observers for a nominal data category.

Kendall's Tau and Spearman's Rho statistical tests were also calculated to determine whether the two different evaluating nurses had the same interpretation on similar days, applying the scale to the same patient. The results for Kendall's Tau test were 0.772 for day 1 and 0.925 for day 2, which represents a strong and very strong correlation, respectively (Table 3) (Santiago, 2016). With regard to Spearman's Rho test, values of 0.772 were obtained for day 1 and 0.926 for day 2, which represents an almost total agreement between the two nurses (Santiago, 2016).

Proposal for the Inclusion of the VIP PT-PT Scale in a Health Informatics System

For the presentation of use case diagrams in UML, four system actors were defined: nurse, patient, head nurse, and assistant physician. As shown in Figure 3, the interactions between them are represented by arrows and each use case refers to its function. The patient is an actor in the system, but in a passive way, since they are the bearer of the PVC and, consequently, the target of the evaluation. The nurse is responsible for monitoring the venous catheter and surveillance of the access insertion site and must apply the VIP PT-PT scale and record according to what was observed in the nursing information system. For the management and supervision functions she/he performs, the head nurse monitors the actions of nurses and ensures that the assessment instrument is being applied correctly. The patient's physician is also an actor in the perspective of developing multidisciplinary teamwork. It is to him/her that the nurse should turn when the performing assessments score is 5, requesting his collaboration in the systemic treatment of the infection.

The proposed activity diagram, represented in Figures 4 and 5, includes the operation sequence of the VIP PT-PT scale in a computer environment, from one activity to the other. We chose to create two activity diagrams for a better representation of the flow of activities and understanding of the items, to ensure dynamic and behavioral activity. The nurse in the provision of care and maintenance of venous access applies the scale to the patient. When observing the venous catheter insertion site, the nurse is faced with an option node that, according to the signs and symptoms, will lead to the correct diagnosis and nursing interventions. At the end of the observation, the diagram leads the user to a termination node, ending the activity. Figures 4.1 and 5.1 show these activity diagrams in English.

Discussion

The study of the occurrence of phlebitis associated with the introduction of a PVC is a topic that has been intriguing and worrying the scientific community for decades. The first references to the use of instruments to assess the PVC insertion site for the prevention of phlebitis were made by Maddox et al. (1983). Since then, numerous tools have been created, some original, others with slight variations, totaling 71 existing tools, as Ray-Barruel et al. (2014) described in their systematic review.

What nurses and physicians have been questioning is that, despite the high number of assessment instruments, there is still no consensus on a definition of phlebitis that is widely accepted, according to the signs and symptoms that make up this definition. This is the variance observed in the different scales produced (Ray-Barruel et al., 2014)

The choice of the VIP scale, originally by Jackson (1998) and modified by Gallant & Schultz (2006), is justified since it is the assessment instrument that gathers the most significant consensus among the community. For some authors, for instance Marsh et al. (2015), it is even considered the current gold standard for assessing the risk of phlebitis, as it is the only instrument that suggests an action based on the outcome of the assessment. It is also the scale recommended by the Royal College of Nursing of the United Kingdom and is widely used in the United States of America with recognition by the INS (Gorski et al. 2021).

In terms of the reliability of the VIP PT-PT scale, the data obtained demonstrate the reliability that this instrument imposes when applied. This ‘almost perfect’ reliability that two observers obtained under the same scenario is in line with what Gallant & Schultz (2006) wrote, while studying the evaluation of the clinical use of VIP, when they found an inter-observer reliability greater than 0.85.

In Portugal, several studies have been conducted focusing on the nursing care to be provided related to the introduction of a PVC. The recommendations and protocols are well defined in the literature for the Portuguese community, according to the studies by Oliveira & Parreira (2010), Oliveira (2014), Reis (2016) and Santos-Costa et al. (2022), although in the comparison between health institutions there is no uniformity and there is still interprofessional variability. However, with the application in the surgical service specialties of this study, good practices regarding the maintenance of the PVC were demonstrated.

Internationally, it should be noted that the last systematic review conducted by Ray-Barruel et al. (2019) mentioned that in 13 protocols for the insertion and monitoring of PVCs, only three contemplated the use of some scale to assess the risk of phlebitis.

This study aimed to fill the gap caused by the lack of a diagnostic standard and nursing interventions regarding PVCs in Portugal since the interventions associated with the therapeutic approach ‘peripheral venous catheterization’ reveal some fragility in detecting and preventing infections associated with PVC (phlebitis).

The use of classification systems and terminology that lead to uniformity of terms makes it possible for health professionals to convey the same meaning and facilitate effective communication between them. The choice of ICNP® to define the diagnostic and interventional standard of the scale reflects this intention.

ICNP® (International Council of Nurses, 2019) is one global terminology classification system that helps nurses in their practice. It classifies nursing phenomena, actions, and outcomes. It is undoubtedly a key instrument in the production of focused and user-oriented nursing records, with a view to satisfying their fundamental human needs. We share the same opinion as Simões et al. (2011) when stating that the use of an international classification allows nurses to solidify their autonomy in the provision of care, as elements of the multidisciplinary team, and to assist in the research and improvement of healthcare by providing more consistent data that meet the real needs of the user.

For each result produced by applying the VIP PT-PT scale, dedicated diagnoses were developed together with targeted interventions corresponding to each sign and symptom identified in each stage of the assessment instrument. We believe that this approach leads the nurse to the individualization of care, allowing a more effective and complementary action regarding the maintenance of the PVC and the prevention of infections. The introduction of assessment instruments in electronic health records revolutionized the way registrations have been made so far, which contributes to an ease of access to the documentation of the patient's clinical process, brings gains in the quality and safety of care provided and numerous advantages for health research, especially in the speed with which data can be accessed  (Hardiker et al., 2019).

The paradigm of the use of electronic health records in nursing practice, at an international level, is facing a change, as there are reports that the systems implemented in health units are not keeping up with the dynamics that some services require, as well as the enormous complexity that some systems impose on the user, ending up absorbing a large portion of the nurse's time in completing nursing records (Hardiker et al., 2019).

The suggestion of computer implementation of the VIP PT-PT scale in the most widely used hospital information system in Portugal (SClínico) emphasizes the need to create adequate, reliable, and valid diagnostic standards for clinical use. We believe that the existence of a model of how the scale will operate and how the user will interact with the computing environment is an added value. In an era in which there are still some barriers regarding the use by the end user of the product, the simplification of the menus and the items to be presented to the nurse who is performing the registration are extremely important.

There were some limitations during this study. Some difficulties were felt from the point of view of obtaining the sample, given that the established inclusion and exclusion criteria, as well as the working hours of the two nurses who collaborated in the study, did not allow for a broader sampling. The place where the questionnaire was applied has some specificities, as it is a surgery service, with a high surgical volume, so obtaining the sample was not difficult. Some difficulties were found in the defined inclusion and exclusion criteria, and in the nurses' availability to collaborate with the study and to fulfill all the defined prerequisites.

Conclusions

From the point of view of translating the scale into European Portuguese, we consider that the final version is translated and culturally adapted to the reality of healthcare provided by Portuguese nurses. The inter-observer reliability assessment was first calculated by using Cohen's kappa, which concludes that the scale has almost perfect reliability and inter-observer agreement was guaranteed by Spearman's Rho and Kendall's Tau.

Nursing diagnoses and interventions were also created in a systematized and standardized language, ICNP®, which provides nurses with more targeted and specific tools for preventing phlebitis and maintaining PVCs. Modelling the scale in UML is undoubtedly an asset, as its inclusion in an informatic health system, such as the Hospital SClínico, allows a quick completion by the nurse, and a contribution to the creation of indicators directed to this theme.

We believe that with this tool and with the set of diagnoses created, there is a positive impact on what healthcare is provided by nurses, as they are equipped with reliable tools that produce indicators that prove the excellence of their care. Thus, the use of the VIP PT-PT scale inserted in EHRs/HISs means an easy access to patient data, better cost effectiveness, improved efficiency, and quality of care, reduced scope of error, increased data security and retrievability of these data, improved patient care and outcomes achieved, constituting an important support in the clinical decision-making process.