Intradermal Injections: Traditional Bevel Up Versus Bevel Down

Intradermal s: Traditional Bevel Up Versus Bevel Down Karen Tarnow and Naomi King This study used qualitative and quantitative methods to examine differences regarding correct placement of injectate, leaking or bleeding, time to administer injection, and comfort of person administering, and receiving an intradermal injection. Each (N 98) administered and received two injections. Subjects evaluated their comfort on a Likert scale. After second injection, each reported which was better. Most of the time (82%), a wheal was produced. Leaking or bleeding occurred a fourth of the time. Subjects rated the first injection better (p 0.05) with no preference regarding technique. Subjects administering injections reported bevel up more comfortable (p 0.01). Bevel up was significantly faster. 2004 Elsevier Inc. All rights reserved. S OME NURSING PRACTICE has been based on tradition. A push for evidence-based practice and research drives nursing practice. Nursing is challenged daily to keep current with various aspects of practice, so the importance for nursing to periodically check tradition becomes vital to the growth of the profession. To enhance patient outcomes, nursing must continually question its practice and ask why the technical skills or techniques are performed in a certain manner. Nurses are taught to give intradermal injections using a bevel-up technique as described in standard fundamental nursing textbooks (Potter & Perry, 2001). The accuracy of intradermal injections is dependent on the health care provider s ability to administer the injectate in the upper layer of the dermis. Annual literature reviews are performed to ensure current knowledge and skills and technique accuracy. Intradermal injections are administered to health care providers all across the United States each year for mandated tuberculosis screening. The intradermal skin test is the most reliable screening test for tuberculosis for people who are not immunocompromised (CDC, 1999). Many others also participate in tuberculosis skin testing, including at-risk populations such as the homeless, immigrants, and migrant workers. The intradermal route is also used for allergy testing, which is done on thousands of people annually. The current health care environment requires health care professionals to be proficient, to use time efficiently, and to provide care that is sensitive to the comfort of the client. REVIEW OF LITERATURE Fundamental nursing texts are consistent in describing an intradermal injection as the injection of a small amount of medication (0.01-0.1 ml) using a 1-mL syringe with one-hundredth ml calibration and a 25- to 27-gauge needle that is 1/4 to 5/8 inch long with the bevel of the needle up, that is, the bevel is facing away from the skin surface before skin piercing. The needle is inserted at a 5 to 15 angle to the skin surface to a depth of 0.5 to 0.15 millimeters. Medication is injected into a superficial layer of upper dermis or epidermis to form a wheal. Preferred sites of injection are ventral forearm, upper chest, or upper back (Beecroft, 1999; Craven & Hirnle, 2000; Elkin, Perry, & Potter, 2000; Hogan, 2000; Kozier, Erb, Berman, & Burke, 2000; Lilleby, 2000; Potter & Perry, 2001; Taylor, Lillis, & LeMone, 1997). These references are all nursing fundamentals textbooks, and none of them cite any research on intradermal technique. Howard et al. (1997) describe a similar technique except the injection is administered with the bevel of the needle down, that is, the bevel is facing the skin surface before the skin is pierced. Karen Tarnow, RN, PhD, Clinical Assistant Professor, The University of Kansas School of Nursing, Kansas City, KS; and Naomi King, RN, C, MS, Clinical Assistant Professor, The University of Kansas School of Nursing, Kansas City, KS. Address reprint requests to Karen Tarnow, RN, PhD, The University of Kansas School of Nursing, 3901 Rainbow Blvd, Kansas City, KS 66160. E-mail: ktarnow@kumc.edu 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1704-0008$30.00/0 doi:10.1016/j.apnr.2004.09.009 Applied Nursing Research, Vol. 17, No. 4 (November), 2004: pp 275-282 275

276 TARNOW AND KING The accuracy of intradermal injections is dependent on the health care provider s ability to administer the injectate in the upper layer of the dermis. The subjects administering the intradermal injections were three medical students with no experience in skin testing. Instruction and demonstration were provided, but no details were reported. The subjects were allowed to practice four times before collecting the data. Howard et al. did not specify if the practice was a simulation or on a person. The three subjects each administered 20 intradermal injections into one of the three unidentified volunteers with 10 injections being administered in one arm using one technique and the other technique in the other arm. It was not reported if attention was given to the order of bevel up or bevel down. One volunteer received two tests, so four sets of 10 intradermal injections were administered using both techniques. These investigators found the bevel-down technique to be superior to the bevel-up technique. They found that administering the injections via the bevel-down technique was faster to perform than using the bevel-up technique. The timing interval was not defined. In addition, the bevel-down technique was reportedly more likely to produce a wheal and less likely to squirt or leak. The Howard et al. study was the only research found on intradermal technique. The methodological limitations and small sample size of the previous study along with results that were in contrast to traditional techniques led the authors to replicate the study with tighter control and improved research methods. METHODS The Howard et al. (1997) study prompted our own study involving beginning nursing students in a baccalaureate program at a public medical center. These students were enrolled in a junior-level nursing techniques course. Student participation in this study was not a course requirement. They had never before administered an intradermal injection, so they had not yet acquired this psychomotor skill. Differences in the bevel-up versus bevel-down technique relative to correct placement of the injectate as evidenced by wheal formation, time required administering the injection, comfort level of the person receiving the injection, and comfort level of the person administering the injection were evaluated. Correct placement of the injectate refers to the full dose being administered directly into the intradermal tissue producing a wheal and no leaking. The research proposal was submitted to the medical center internal review board, and permission was received to conduct the study. Research Questions The research questions were as follows: (1) Is there a difference in correct placement of the injectate between the bevel-up and bevel-down technique for intradermal injections? (2) Is there a difference in the time required for administering an intradermal injection between the bevel-up and bevel-down technique? (3) Is there a difference in the comfort level of the person receiving an intradermal injection between the bevel-up and beveldown technique? And (4) Is there a difference in the comfort level of the person administering an intradermal injection between the bevel-up and bevel-down technique? Research Design The case-companion design was used whereby subjects served as their own control. Specifically, each student rated each injection administered and received. Each student administered and received two intradermal injections, one bevel up and the other bevel down. Sample and Setting Subjects were students enrolled in the junior year of a baccalaureate nursing program at a large Midwest public medical center campus. They were taking a beginning clinical nursing course during which parental injections were taught. The injections were administered in one of the 10 examination rooms of the Clinical Learning Laboratory in the School of Nursing building to control for differences in environmental conditions. Four clinical nursing faculty members were involved with student evaluation and data collection. The student receiving the injection sat behind a privacy screen placing an arm through the curtain. Both students were seated (Fig 1).

INTRADERMAL INJECTIONS 277 Procedures The study was reviewed and approved by the School of Nursing Research Committee and the Medical Center Human Subjects Committee. After an explanation of the study, students who wished to participate signed consent forms. Individual confidentiality was maintained. Names were not identified on the data collection sheets. An identification number was assigned to each student on the consent form, and this number was used on the data collection sheets. Only aggregate data were reported. Failure to participate in the study had no effect on a student s progression in the course or in the School of Nursing. A competency demonstration checklist for intradermal injections (Appendix 1) from the techniques course was followed. An investigator-developed tool was used to record data regarding time and results concerning the critical elements of wheal, leaking, and bleeding. The students evaluated their comfort in administering and in receiving a bevel-up injection and a bevel-down injection using investigator-developed tools with a scale of 1 to 5. After both injections and evaluations were completed, students rated whether the first or second injection was better. Better was not defined for the student. Student preparation included several components. A 90-minute class presented information about parental injections. All students later participated in a 1-hour practice session supervised by their clinical instructor. During the practice session, they manipulated needles and syringes, filling them and injecting into simulation devises. Specifically, hot dogs were used to practice intradermal injections. Pairs of students signed up to demonstrate competency performing intradermal injections at times when the investigators were available to evaluate student performance. All students enrolled were offered the opportunity to participate in the study. If they chose not to participate, they received the same instruction using the same procedure for bevel-up injections. They did not perform a beveldown intradermal injection, and no data were collected. Of the 120 students in the class, 98 provided signed informed consent. The students used 0.09 ml of sterile bacteriostatic normal saline drawn from a 30-mL multidose vial to fill the syringes they used to administer the injections. The pair volunteered for the role each would fill first. The investigator flipped a coin, a penny, to determine the order of injections. Heads indicated bevel-up technique was used first. Tails indicated bevel-down technique was used first. The student acting as the client was not aware of the order of injections. After the administration of the first injection, students evaluated their comfort level with the injection and the investigator evaluated student technique and recorded time required for the injection. Then, the second intradermal injection was administered and the students evaluated their comfort level with this injection and also indicated which injection was better and the investigator evaluated student technique and recorded time required for the injection. The student playing the role of the nurse then played the client role and the procedure was repeated. Instruments The syringe used was a Becton Dickinson & Co (Franklin Lakes, NJ) latex-free syringe having 1-mL capacity calibrated in hundredths with a 27- gauge 1/2-inch Precision Glide needle having a tuberculin Slip Tip bevel. The investigators used a Bollinger (Grand Prairie, TX) Electronic Alarm StopWatch that calculated seconds to hundredths. Investigator-developed evaluation forms were used to document results. Critical elements studied for each injection were correct placement of injectate (presence of wheal, no leaking, or no bleeding), self-reported comfort of person in client role, selfreported comfort of person in nurse role, and time to administer the injection. Four clinical nursing faculty members supervised the students and recorded the data. Before the actual data collection, the four faculty investigators held a training session. To ensure consistency when recording time, the stop watch was started when the needle cap was removed from the syringe and stopped when the needle was pulled out of the skin. The syringes were filled before this step, and time to draw up was not part of the recorded time. Wheal was evaluated only on presence or absence; the size of the wheal was not measured. The researchers developed forms for recording data; there were forms for the investigator, the subject in the nurse role, and the subject in the client role. The investigator s form had two columns. Each column had a space for recording the time. Up or down was circled to indicate

278 TARNOW AND KING one. A similar form was developed for subjects in the nurse role. This form asked Please rate on a scale of 1 to 5 your comfort level when administering the intradermal injection, with one (1) being very comfortable and five (5) being I never want to do it again. Separate forms were used for the first and the second injection with the additional question of Which injection was better? added to the second form. Figure 1. Subjects during data collection. which direction the bevel was pointing before insertion. Yes and no were in each column and each line to indicate appropriately the presence or absence of a wheal, leaking, and bleeding. Subjects in the role of client were given a form that asked Please rate on a scale of 1 to 5 your comfort when receiving the intradermal injection, with one (1) being no discomfort and five (5) being hurts a lot. Below this sentence was a row of five numbers with no discomfort above the 1 and hurts a lot above the 5. The subject circled a number. The form was then taken by the investigator, and the subject was given a second form with the same content for the second injection. In addition, it asked Which injection was better? followed by 1st and 2nd. The subject was asked to circle RESULTS Of the 98 subjects participating in the study, 45 administered the intradermal injection bevel up the first time and 53 of them used the bevel-down technique the first time. Several types of data were collected. Time is interval data; the Likert scale produced ordinal data, and the other questions yielded nominal data. Subjects receiving the injection did not know which technique was used when they were asked which was better, the first or second injection. The instructor s sheet identified which technique, the bevel-up or bevel-down, was used first and which was used second. McNemar chi-square binomial exact test was used to examine the nominal data regarding presence or absence of a wheal to determine if there was a difference in correct placement of the injectate between the first and second injection for paired samples. The critical elements related to order, first or second injection, showed a very slight improvement with the second injection but no statistically significant difference. Most of the time (82.14%), a wheal was produced and the site neither leaked (73.98%) nor bled (74.49%). The same critical elements were examined based on whether the injection was administered using the bevel-up or bevel-down technique. A mixed model analysis using SPSS 11.0 analyzed the data revealing no statistical difference between the bevel-up and bevel-down technique Table 1. Presence of a Wheal Bevel Up or Bevel Down Technique Total Wheal Bevel Down Total Wheal Bevel Up Wheal Bevel Down, 1 st Wheal Bevel Up 1 st Wheal Bevel Down, 2 nd Wheal Bevel Up 2 nd None 19 16 12 9 7 7 9.39% 6.33% Yes 79 82 41 36 38 46 80.61% 83.67% N 196 N 98 N 98 2.313, p.576 2.101, p.751 2.110, p.741 Fisher s p.474 Fisher s p.481

INTRADERMAL INJECTIONS 279 Table 2. Presence of Leaking Bevel-Up or Bevel-Down Technique Total Leak Bevel Down Total Leak Bevel Up Leak Bevel Down, 1 st Leak Bevel Up 1 st Leak Bevel Down, 2 nd Leak Bevel Up 2 nd None 70 75 36 35 34 40 71.43% 76.53% Yes 28 23 17 10 11 13 28.57% 23.47% N 196 N 98 N 98 2.663, p.416 2 1.184, p.277 2.00, p.992 Fisher s p.195 Fisher s p.590 with either Pearson chi-square (wheal, p.751 first injection, p.741 second injection; leakage, p.277 first injection, p.992; bleeding p.277 first injection and p.272 second injection) or Fisher Exact Test (wheal, p.474 first injection, p 0.481 second injection; leakage, p.195 first injection, p 0.590 second injection; bleeding p.195 first injection, p.199 second injection). Again, most of the time there was a wheal and it neither leaked nor bled (Tables 1 through 3). All 98 subjects/students in the study administered both an injection using the bevel-up technique and an injection using the bevel-down technique. A wheal was produced 80.6% of the time bevel down and 85.4% of the time bevel up. The site did not leak 72.9% of the time bevel down and 78.1% of the time bevel up. There was no bleeding 77.1% of the time bevel down and 78.1% of the time bevel up. Time to administer the injection was recorded. Students filled the syringes for administration and recapped. The timing started when the cap was removed from the filled syringe, continued during the injection, and ended when the needle was removed from the skin. SAS 8.02 (SAS Institute, Inc., Cary, NC) and SPSS 11.0 (SPSS, Inc., Chicago, IL) software were used to analyze both first and second injection and also bevel up or down with time as the dependent variable. A linear mixed model was used which analyzed all data and did not throw out the subject if any data were missing. Eight subjects had one time missing; four were the first time and four were the second time. Analysis of variance revealed that the second injection was significantly faster than the first injection regardless of technique (F 24.99, p.001). Means of 46.28 and 37.59 seconds were recorded for the first and second injection respectfully with standard deviations of 20.56 and 19.92. The difference in time needed for the first and the second injection was 8.2 2 seconds with a 95% confidence interval of 4.9 to 11.4. The longest time for the first injection was 115.30 seconds and for the second 103.84 seconds. This was the same subject and the fourth participant, so this extreme outlier was not noted as being particularly different. The shortest time for the first injection was 11.08 seconds. The shortest time for the second injection was 10.41 seconds. Standard deviations for both were about 20 seconds (Table 4). Subjects administered the bevel-up injections faster than the bevel-down injections by 4.64 seconds 1.9. (F 8, p.0058). The 95% confi- Table 3. Presence of Bleeding Bevel up or Bevel Down Total Bleed Bevel Down Total Bleed Bevel Up Bleed Bevel Down, 1 st Bleed Bevel Up, 1 st Bleed Bevel Down, 2 nd Bleed Bevel Up, 2 nd None 74 75 36 35 38 40 75.51% 76.53% Yes 24 23 17 10 7 13 24.49% 23.47% N 196 N 98 N 98 2.028, p.867 2 1.184, p.277 2 1.206, p.272 Fisher s p.195 Fisher s p.199

280 TARNOW AND KING Table 4. Time to Administer 1st 2nd Bevel Up Bevel Down Mean time in seconds 46.28 s 37.59 s 38.97 s 44.90 s Mean time in seconds Longest time (s) 115.30 s 103.85 s 95.02 s 115.3 s Longest time (s) Shortest time (s) 11.08 s 10.41 s 10.41 s 11.08 s Shortest time (s) Standard deviation 20.56 19.92 17.51 23.09 Standard deviation F 24.99, p.001 F 8, p.0058 dence interval was 1.42 to 7.85. The means for bevel up were 42.13 seconds (SD, 16.85) for the first injection and 35.95 seconds (SD, 17.83) for the second. Means for bevel down were 48.57 seconds (SD, 21.88) for the first injection and 38.35 (SD, 21.23) for the second injection (Fig 2). Analysis of variance was used to compare comfort ratings on a scale of 1 to 5. For those in the client role, 1 meant no discomfort and 5 indicated hurts a lot. There was no significant difference related to comfort for client preference for bevel up or bevel down. There was a significant difference in comfort (F 7.284, p.02) regarding first or second injection with the first having a lower score, meaning less discomfort, regardless of technique. In the nurse role, the results were different. With this scale 1 meant very comfortable and 5 meant I never want to do it again. There was no significant difference between first or second injection regarding nurse comfort. The subjects in the nurse role report a statistically significant difference (F 9.002, p 0.003) in comfort with bevel up being closer to very comfortable than bevel down. DISCUSSION Intradermal injections are administered throughout the world when tuberculosis testing or allergy testing is done. Tradition has been that bevel up has been the recommended technique, but only one research article on intradermal injections was found and it contradicted that. Based on the current study in which the bevel-up technique was more comfortable for the subject in the nurse role and was faster to administer, this study suggests that the traditional bevel-up technique is the preferred way to administer intradermal injections. Patient outcomes (wheal, leakage, and bleeding) with regard to bevel-up or bevel-down technique were equivalent. Intradermal injections are administered throughout the world when tuberculosis testing or allergy testing is done. Further research on nursing procedures including intradermal technique is needed. Both patient outcomes and comfort and nurse comfort need to be included as variables to study. Time was relevant both in this study and the Howard et al. (1997) study but may be a significant variable only during the initial learning process. Further study of time after proficiency has been developed could be explored. Figure 2. Mean times 1st and 2nd injections bevel up and bevel down. LIMITATIONS This study is limited to only one class in the School of Nursing. All subjects were young to middle-aged adults; there were no children or elderly subjects. Students only had the opportunity to practice their technique on hot dogs before they

INTRADERMAL INJECTIONS 281 administered an intradermal injection to a subject. Standard procedure for this assignment is to practice manipulating needle and syringe and practicing administration on hot dogs. Students are not permitted to practice any invasive procedure unless their practice is supervised by licensed professional nurses. In this study, a wheal was evaluated merely as present or not. A more controlled study could measure the size of the wheal as a means to evaluate how much of the injectate was administered into the intradermal layer versus surrounding tissue. Measuring the size of the wheal would be a more accurate indication of accurate placement and correct technique for administering an intradermal injection. Each student only administered and received one injection bevel up and one injection bevel down. It is possible that the second injection, whether it was bevel up or bevel down, was faster because the student had less anxiety and fear administering the second injection. Anticipating a new skill may have caused the novice student to take more time administering the first injection. With repeated practice, proficiency at administering intradermal injections is expected to become faster and more accurate regarding placement of the injectate in intradermal space. CONCLUSIONS The critical elements of accuracy, comfort, and time were studied with regards to administering intradermal injections. The bevel-up technique was more comfortable for the subject in the nurse role and was faster to administer than bevel down. The variables, related to accuracy of placement as measured by presence of wheal and no leakage or bleeding and client comfort, that were studied showed no difference with technique. The results suggest that nurses continue to use bevel-up technique as the preferred way to administer intradermal injections because of increased comfort for the person in the nurse role and because it was faster to administer. More research needs to be done regarding technique for intradermal injections because the only two studies completed have differing results. The critical elements of accuracy, comfort, and time were studied with regards to administering intradermal injections. One way for nursing knowledge to remain current is for nurses to question our traditional ways of performing techniques, such as parental injections, tracheostomy care, urinary catheter insertion and management, or phlebotomy. Nursing professionals should refrain from saying statements such as, That s how I was taught. or It s always been done that way. Failure to question tradition can lead to stagnation in practice. The current focus on patient outcomes will enhance professional nursing practice. Clinical research can validate or improve patient outcomes and contribute to the art and the science that is professional nursing. Acknowledgments We greatly appreciate the work and effort of Elizabeth Lounds, RN, MS, Joyce Neal Lasseter, RN, MS, Byron Gajewski, PhD, and Marge Bott, RN, PhD. Elizabeth and Joyce helped with data collection. Joyce, Marge, and Byron did the computer work for data analysis. We could not have accomplished this without them. APPENDIX 1. NURS 301: TECHNIQUES FOR THERAPEUTIC NURSING INTERVENTIONS Intradermal s YES NO IMPLEMENTATION *1. Verify order and check for allergies or incompatibilities *2. Wash hands 3. Provide for client s privacy *4. Identify client and introduce self 5. Inform client of medication *6. Put on disposable gloves 7. Identify possible sites for ID injections 8. Inspect forearm for lesions or discoloration

282 TARNOW AND KING YES NO IMPLEMENTATION 9. Choose appropriate injection site along ventral aspect of forearm 10. Have client flex elbow and support it on flat surface 11. Cleanse injection site 12. Hold swab correctly 13. Remove needle cap correctly 14. Hold syringe comfortably with bevel of needle pointing up 15. Stretch skin over injection site 16. With needle at 5 15 degree angle, insert slowly through epidermis just below skin surface *17. Do not aspirate before injecting 18. Inject medication slowly and feel resistance 19. Notice wheal appear on skin 20. Withdraw needle at same angle as inserted. 21. Do not massage site. Gently remove blood by lightly dabbing w/alcohol. 22. Assist client to comfortable position *23. Discard needles and syringes properly without recapping *24. Wash hands 25. Explain possible reactions to client 26. Document *27. Answer rationale questions 28. Complete in allotted time 90% 25 All critical elements must be met Time allotted: 10 minutes Critical Elements: 1. Maintain asepsis 2. Correct syringe and needle size for type of injection 3. Correct dose Rationale Questions: 1. Why is the needle inserted with the bevel up? 2. Why not massage after an intradermal injection? 3. What do you do if you do not get a wheal, or if it leaks? Beecroft, P. (1999). Administering intradermal injections. In Lindeman C. A. & McAthie M., (Eds.). Fundamentals of contemporary nursing practice. (pp. 367-370). Philadelphia: Saunders. Center for Disease Control (CDC), National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination, Public Health Practice Program Office, Division of Media and Training Services. ((1999)). Self-Study Modules on Tuberculosis. Retrieved November 5, 2003, from http://www.phppo.cdc.gov/phtn/tbmodules/modules1-5/default.htm. Craven, R. F., & Hirnle, C. J. (2003). Fundamentals of nursing: Human health and function (4th ed.) (pp. 546, 548, 551). Philadelphia: Lippincott Williams & Wilkins. Elkin, M. K., Perry, A. G., & Potter, P. A. (2000). Nursing interventions & clinical skills. (2nd ed.) (pp. 469-472). St. Louis: Mosby. Hogan, M. A. (2000). Administering an intradermal medication. In Harkreader H., (Ed.). Fundamentals of nursing: Caring and clinical judgment. (pp. 564-566). Philadelphia: Saunders. REFERENCES Howard, A., Mercer, P., Nataraj, H. C., & Kang, B. C. (1997). Bevel-down superior to bevel-up in intradermal skin testing. Annals of Allergy, Asthma, & Immunology, 78, 594-596. Kozier, B., Erb, G., Berman, A. J., & Burke, K. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.) (pp. 793, 794, 820-822, 1455). Upper Saddle River, NJ: Prentice Hall Health. Lilleby, K. (2000). Administering an intradermal injection. In G. B. Altman, P. Buchsel, & V. Coxon (Eds.). Delmar s fundamental & advanced nursing skills (pp. 547-551). Canada: Delmar. Potter, P. A., & Perry, A. G. (2005). Administering subcutaneous, intramuscular, and intradermal injections. In Fundamentals of nursing. (6th ed.) (pp. 831, 832, 884-885, 887, 890-891). St. Louis: Mosby. Taylor, C., Lillis, C., & LeMone, P. (2005). Fundamentals of nursing: The art and science of nursing care (5th ed.) (pp. 734, 737-738, 748). Philadelphia: Lippincott.