This toolkit outlines what is meant by infiltration and extravasation and the scale and impact of these injuries within the NHS. It provides information and further resources shaped around a five-stage approach:

1. Prevention – Safe IV therapy administration and vascular access practice.
2. Recognition – Recognise the early stages of extravasation.
3. Treatment – Early intervention and treatment to reduce or stop tissue damage.
4. Follow up – Ensure the patient is followed up and supported.
5. Reporting – Standardised incident reporting of infiltration and extravasation.

To support the implementation of this approach, NIVAS recommends that:

• All NHS hospitals should have an extravasation lead for non–chemotherapy and chemotherapy practice.
• All NHS hospitals should improve awareness of non–chemotherapy and chemotherapy extravasation and have guidelines in place.
• All NHS hospitals should standardise reporting of infiltration and extravasation incidents.
• National infiltration and extravasation guidelines for chemotherapy and non-chemotherapy practice.
• Support the creation of a vascular access service team in all NHS Hospitals.

Related reading

• National campaign aims to reduce patient harm from infiltration and extravasation (March 2023)
• NHS Resolution presentation: Learning from extravasation claims (6 October 2023)

Can you tell us a bit about yourself and your role?

I am a nurse consultant in vascular access and IV therapy. Essentially this means I specialise in using veins to deliver drugs into patients. My expertise is in placing vascular access devices into veins all over the body; from cannulas in hands and arms to implanted IV ports and PICCs which feed into the central veins. I have been working in this field for 13 years now and my main focus is reducing any complications that can occur with IV therapy and vascular access, such as extravasation.

What is extravasation?

Extravasation is when certain types of drugs (called vesicants) inadvertently infiltrate or leak into the tissue surrounding a vein when they are given to patients through a cannula or other vascular access device.  Extravasation of vesicant drugs can cause a patient serious harm including severe pain, disfigurement, limb loss and disability or, in extreme cases, death.

Above photo is of an extravasation injury.

Who is at risk of harm from extravasation?

Anyone who is receiving an intravenous vesicant drug is at risk of extravasation injury. 

Risk factors for extravasation injuries include

• using small or fragile veins
• cannula insertion sites across joints
• sedated patients who cannot express pain
• poorly secured vascular access devices (VAD),
• VADs placed in difficult IV access patients including children
• bariatric or oedematous limbs.

Patients receiving cancer treatment in the form of intravenous chemotherapy are at high risk of extravasation, , which is why staff working in cancer care are well trained to prevent, recognise, treat and report these injuries.

However, non-chemotherapy  vesicant drugs are used across all healthcare settings. Sadly, training and guidance around the risks and preventative measures is very poor outside of cancer care, in general intravenous practice.  

How widespread is this problem?

One issue is the lack of quality data on number of these sorts of injuries. There is no national standard on reporting extravasation outside of cancer care, so the extent of harm is unclear.

However, NHS resolution recently published data showing that from April 2010-December 2021, claims relating to extravasation injuries cost the NHS a staggering £16million.

Why does it keep happening?

There are several contributing factors. When a patient is given these drugs, a small tube is used (a catheter). If these devices fail,  are used incorrectly, become dislodged or the wrong size is selected it can lead to infiltration of the drug which can cause an extravasation injury.

Staff are often not trained to prevent or recognise an extravasation injury, leading to delays in recognition,  diagnosis and treatment. This can cause very serious complications for the patient. Early recognition and treatment can reduce the severity of tissue damage. Or as we like to say, ‘time is tissue’ when dealing with extravasation.   

As mentioned before, the lack of standardised reporting locally and nationally and data collection has its own part to play. We should be reporting and reviewing all suspected incidents of infiltration and extravasation injuries. Only then will we be able to understand what went wrong and how we can prevent future harm to others.

There is also work to be done to empower the patients receiving these drugs; to recognise when there might be an issue with their catheter, and to feel able to speak up.

Where possible, it is important that patients are made aware of the risks before receiving vesicant drugs. With elective procedures for example, they should be provided with a consent form, so they are informed and able to make a decision that feels best for them.

What needs to happen to keep patients safe from harm?

To improve patient safety and reduce avoidable harm caused by extravasation the campaign is calling for:

• All NHS organisations to appoint clinical leadership for extravasation.
• National standardised guidelines to be applied to all healthcare settings.
• Policies put in place to ensure patients needing vesicant drugs in elective procedures are informed of the risks and able to make decisions accordingly.
• Staff across all healthcare settings to be educated to prevent, recognise, treat and report extravasation.
• Mandatory incident reporting with inclusion of suspected Extravasation as a metric on quality reports and reported at Board level.
• Patients and relatives to be educated to recognise catheter issues and empowered to report these.
• Extravasation injuries to be investigated so learning can be promptly applied and shared to prevent future harm.

Why do you feel so passionately about reducing harm in this area?

The majority of infiltration and extravasation injuries are avoidable. At the very least the severity of these injuries can be reduced if there is an awareness of extravasation in non-chemotherapy IV therapy administration. The national campaign aims to focus on the following actions. I hope these will reduce the risk of infiltration and extravasation and prevent the significant injuries that I commonly see in practice from occurring.

Prevention

Safe IV therapy administration and vascular access practice is essential to preventing infiltration and extravasation occurring in the first instance. All healthcare professionals involved in the delivery of intravenous therapies and the use of vascular access devices should be aware of the preventative measures associated with infiltration and extravasation, vessel health and preservation and the principles of vascular access.

Recognition

Recognising the early stages of extravasation is vital, early diagnosis can reduce the amount of damage done to the patient’s tissue. 

Treatment

Early intervention and treatment to reduce or stop tissue damage. Hot or cold compress, injectable antidotes, tissue wash out and referral to plastics should be considered as part of the treatment pathway for extravasation.

Follow-up

Ensure the patient is followed up and supported by the appropriate department, either IVAS, Plastics or tissue viability. Clinical photography should be used to continuously document the extravasation injury. The patient may need psychological support depending on the extent of the injury. Social support may also be necessary on discharge.

Reporting

Standardised local incident reporting of the infiltration and extravasation should be undertaken.

Who can make a difference and how?

Patient safety managers and clinical leaders can advocate for an extravasation lead within their organisation. That could be in hospitals, social care, the community or care homes.

We envisage this role coordinating a network of staff, trained in extravasation. That person would be accountable for ensuring these ‘local experts’ understand how to prevent, recognise, treat and report extravasation so they are able to support the wider staff group. They would also support the translation of national guidance (due to be published early 2023) into local practice.

This role already exists in chemotherapy care, but we would like to see it created for non-chemotherapy care too.

Patients and relatives can speak up if they see an issue with a catheter; if it becomes dislodged, knocked or uncomfortable for example. Flagging any issues to staff could help encourage prompt action and reduce the chance of an extravasation injury if vesicant drugs are being used.  

Frontline staff who use vesicant drugs (however rarely) can highlight their training needs around extravasation to managers. Sharing articles like this can help put forward a case, alongside the two key documents below.

Did You Know

Extravasation: A patient safety priority (leaflet)

What's next

This year, for the first time, national guidelines on non-chemotherapy extravasation will be published by NIVAS. It is important these are applied across all healthcare settings. NIVAS will also be running webinars to help people understand how to put the guidelines into practice. Please visitwww.nivas.org.uk to keep up to date.

Get involved – help lead the way on extravasation safety

There are various ways to support our campaign so do get in touch if you are interested in this work. We are especially keen to hear from:

• Organisations with an appetite to lead the way in embedding the national guidelines.
• Patients who have experienced an extravasation injury who are willing to share their experience and insights and/or become an advocate for the campaign.
• Frontline staff who have already made improvements to extravasation safety in their settings and are willing to share their experiences. 

You can get in touch with me at andrew.barton@nhs.net

This virtual forum featured a panel discussion with the following speakers:

• Andrew Barton, Chair of NIVAS and IV nurse consutlant (NIVAS and Frimley NHS Trust)
• Alison Macefield, Deputy Head of Midwifery (Royal Devon and Exeter NHS Foundation Trust) 
• Jorge Leon-Villapalos, Consultant in Plastic Surgery and Burns (Chelsea & Westminster)
• Lisa-Marie Musgrave, Senior Claims Manager (NHS Resolution)
• Samantha Thomas, Associate Safety and Learning Lead London (NHS Resolution)

Presentations from this session can be found below:

Extravasation: Learning from claims (NHS Resolution)

NHS Resolution extravasation presentation 2022 PDF.pdf

Extravasation injuries: Recognition and clinical Management (Jorge Leon-Villapalos)

EXTRAVASATION INJURIES JLV PDF.pdf

Complications of IV therapy: Extravasation (Andrew Barton)

NIVAS extravasation presentation 2022 Andrew Barton PDF.pdf

Related reading

• Extravasation: a patient safety priority (28 June 2022)
• NHS Resolution report – Extravasation (15 March 2022)