5921d8c7645f6c7fdc7dcb00753f85ff 304078.pdf b6c4916c850bf9dcfb0c89a0588e68ca0db9dc5b 304078.pdf 70ee1364325f973b4a1459fffa42a85060048f831ed0f634ffa02554bcf85bda 304078.pdf Title: Assessment, Treatment, and Follow-Up of Phlebitis Related to Peripheral Venous Catheterisation: A Delphi Study in Spain Subject: Background: Phlebitis related to peripheral venous catheters (PVCs) is a common complication in patients who require these devices and can have important consequences for the patients and the healthcare system. The management and control of the PVC-associated complications is related to nursing competency. The present study aims to determine, at the national level in Spain, the consensus on the assessment, treatment, and follow-up of PVC-related phlebitis and the importance of the actions taken. Method: A three-round Delphi technique was used with clinical care nurses who are experts in the field of in-hospital intravenous treatment in Spain. For this, an online questionnaire was developed with three open-ended questions on the dimensions of phlebitis assessment, treatment, and follow-up. For the statistical analysis of the results, frequencies and percentages were used to determine consensus, and the measures of central tendency (mean, standard deviation, and the coefficient of variation) were used to rank importance. The coefficient of variation was set as acceptable at 30%. Results: The final sample was 27 expert nurses. At the conclusion of round 3, actions were ranked according to their importance, with six items included in the PVC-related phlebitis assessment (symptomatology/observation, redness, the Maddox scale, induration, temperature, and pain), two in treatment (catheter removal, pentosan polysulphate sodium ointment + application of cold), and just one in follow-up (general monitoring + temperature control). Conclusions: There is a major disparity in relation to the PVC-related phlebitis assessment, treatment, and follow-up actions. More clinical studies are therefore needed to minimise the complications associated with the use of PVCs, given their impact on the quality of care and patient safety and their economic cost. Keywords: Delphi technique; intravenous infusion; nursing; peripheral venous catheter; phlebitis Author: Alba Torné-Ruiz, Mercedes Reguant, Montserrat Sanromà-Ortiz, Marta Piriz, Judith Roca and Judith García-Expósito Creator: LaTeX with hyperref Producer: pdfTeX-1.40.25 CreationDate: Thu Feb 1 11:08:48 2024 CET ModDate: Thu Feb 1 11:12:32 2024 CET Custom Metadata: no Metadata Stream: no Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 14 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 597056 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- ZSBPMM+VnURWPalladioL-Bold Type 1 Custom yes yes yes 10 0 MMTIAM+VnURWPalladioL Type 1 Custom yes yes yes 16 0 BPWVHR+URWPalladioL-Bold Type 1 Custom yes yes yes 21 0 LIGNZB+URWPalladioL-Roma Type 1 Custom yes yes yes 27 0 PFHEFX+URWPalladioL-Ital Type 1 Custom yes yes yes 32 0 LAXKRU+CMSY10 Type 1 Builtin yes yes yes 37 0 XAOEUN+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 53 0 AMGEIJ+PalatinoLinotype-Bold CID TrueType Identity-H yes yes yes 78 0 AMGFNK+ArialMT TrueType WinAnsi yes yes no 84 0 AMGEIK+PalatinoLinotype-Roman CID TrueType Identity-H yes yes yes 87 0 AMGEJK+PalatinoLinotype-Italic CID TrueType Identity-H yes yes yes 93 0 AMGEJL+PalatinoLinotype-Italic TrueType WinAnsi yes yes no 99 0 AMGEJM+PalatinoLinotype-Bold TrueType WinAnsi yes yes no 102 0 AMGEJN+PalatinoLinotype-Roman TrueType WinAnsi yes yes no 105 0 AMGFAM+PalatinoLinotype-Roman TrueType MacRoman yes yes no 108 0 AMGFNI+SymbolMT CID TrueType Identity-H yes yes yes 111 0 LWALTY+VnURWPalladioL-Italic Type 1 Custom yes yes yes 149 0 Jhove (Rel. 1.28.0, 2023-05-18) Date: 2025-01-13 02:36:02 CET RepresentationInformation: 304078.pdf ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16) LastModified: 2025-01-09 16:31:20 CET Size: 597056 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 352 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: section.1 Item: Title: Materials and Methods Destination: section.2 Children: Item: Title: Design Destination: subsection.2.1 Item: Title: Stages and Tools Destination: subsection.2.2 Item: Title: Preparation Stage: Selection of Experts Destination: subsection.2.3 Item: Title: Preparation Stage: Preparation of Tool Destination: subsection.2.4 Item: Title: Consultation Stage and Data Collection Destination: subsection.2.5 Item: Title: Consensus Stage: Statistical Analysis Destination: subsection.2.6 Item: Title: Methodological Quality of the Study Destination: subsection.2.7 Item: Title: Ethical Considerations Destination: subsection.2.8 Item: Title: Results Destination: section.3 Children: Item: Title: Participant Characteristics by Round Destination: subsection.3.1 Item: Title: Results by Round Destination: subsection.3.2 Item: Title: Discussion Destination: section.4 Children: Item: Title: Assessment Dimension Destination: subsection.4.1 Item: Title: Treatment Dimension Destination: subsection.4.2 Item: Title: Follow-Up Dimension Destination: subsection.4.3 Item: Title: Limitations of the Study Destination: subsection.4.4 Item: Title: Implications for Clinical Practice and Future Research Destination: subsection.4.5 Item: Title: Conclusions Destination: section.5 Item: Title: References Destination: appendix.A. Info: Title: Assessment, Treatment, and Follow-Up of Phlebitis Related to Peripheral Venous Catheterisation: A Delphi Study in Spain Author: Alba Torné-Ruiz, Mercedes Reguant, Montserrat Sanromà-Ortiz, Marta Piriz, Judith Roca and Judith García-Expósito Subject: Background: Phlebitis related to peripheral venous catheters (PVCs) is a common complication in patients who require these devices and can have important consequences for the patients and the healthcare system. The management and control of the PVC-associated complications is related to nursing competency. The present study aims to determine, at the national level in Spain, the consensus on the assessment, treatment, and follow-up of PVC-related phlebitis and the importance of the actions taken. Method: A three-round Delphi technique was used with clinical care nurses who are experts in the field of in-hospital intravenous treatment in Spain. For this, an online questionnaire was developed with three open-ended questions on the dimensions of phlebitis assessment, treatment, and follow-up. For the statistical analysis of the results, frequencies and percentages were used to determine consensus, and the measures of central tendency (mean, standard deviation, and the coefficient of variation) were used to rank importance. The coefficient of variation was set as acceptable at 30%. Results: The final sample was 27 expert nurses. At the conclusion of round 3, actions were ranked according to their importance, with six items included in the PVC-related phlebitis assessment (symptomatology/observation, redness, the Maddox scale, induration, temperature, and pain), two in treatment (catheter removal, pentosan polysulphate sodium ointment + application of cold), and just one in follow-up (general monitoring + temperature control). Conclusions: There is a major disparity in relation to the PVC-related phlebitis assessment, treatment, and follow-up actions. More clinical studies are therefore needed to minimise the complications associated with the use of PVCs, given their impact on the quality of care and patient safety and their economic cost. Keywords: Delphi technique; intravenous infusion; nursing; peripheral venous catheter; phlebitis Creator: LaTeX with hyperref Producer: pdfTeX-1.40.25 CreationDate: Thu Feb 01 11:08:48 CET 2024 ModDate: Thu Feb 01 11:12:32 CET 2024 ID: 0xe43395439a58ccfb20dd5506c9e36fbd, 0xe43395439a58ccfb20dd5506c9e36fbd Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: PFHEFX+URWPalladioL-Ital FontSubset: true FirstChar: 45 LastChar: 252 FontDescriptor: FontName: PFHEFX+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: MMTIAM+VnURWPalladioL FontSubset: true FirstChar: 129 LastChar: 243 FontDescriptor: FontName: MMTIAM+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: BPWVHR+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 122 FontDescriptor: FontName: BPWVHR+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: LAXKRU+CMSY10 FontSubset: true FirstChar: 1 LastChar: 20 FontDescriptor: FontName: LAXKRU+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true ToUnicode: true Font: BaseFont: LWALTY+VnURWPalladioL-Italic FontSubset: true FirstChar: 161 LastChar: 243 FontDescriptor: FontName: LWALTY+VnURWPalladioL-Italic Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: ZSBPMM+VnURWPalladioL-Bold FontSubset: true FirstChar: 160 LastChar: 226 FontDescriptor: FontName: ZSBPMM+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Font: BaseFont: LIGNZB+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 248 FontDescriptor: FontName: LIGNZB+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true ToUnicode: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 34, 281, 152, 290 Annotation: Subtype: Link Rect: 34, 271, 96, 278 Annotation: Subtype: Link Rect: 34, 164, 96, 186 Annotation: Subtype: Link Rect: 125, 90, 154, 99 Annotation: Subtype: Link Rect: 34, 78, 149, 87 Annotation: Subtype: Link Rect: 34, 756, 175, 792 Annotation: Subtype: Link Rect: 515, 756, 560, 792 Annotation: Subtype: Link Rect: 123, 660, 134, 674 Annotation: Subtype: Link Rect: 228, 660, 239, 674 Annotation: Subtype: Link Rect: 376, 660, 387, 674 Annotation: Subtype: Link Rect: 454, 660, 465, 674 Annotation: Subtype: Link Rect: 549, 660, 560, 674 Annotation: Subtype: Link Rect: 171, 648, 182, 661 Annotation: Subtype: Link Rect: 529, 139, 536, 148 ActionDest: 143 Annotation: Subtype: Link Rect: 276, 101, 283, 110 ActionDest: 143 Annotation: Subtype: Link Rect: 334, 76, 341, 85 ActionDest: 143 Annotation: Subtype: Link Rect: 119, 17, 279, 28 Annotation: Subtype: Link Rect: 400, 17, 560, 28 Annotation: Subtype: Link Rect: 34, 378, 87, 397 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 368, 744, 375, 752 ActionDest: 143 Annotation: Subtype: Link Rect: 276, 706, 283, 715 ActionDest: 143 Annotation: Subtype: Link Rect: 255, 693, 262, 702 ActionDest: 143 Annotation: Subtype: Link Rect: 334, 693, 341, 702 ActionDest: 143 Annotation: Subtype: Link Rect: 391, 655, 398, 665 ActionDest: 143 Annotation: Subtype: Link Rect: 386, 643, 393, 652 ActionDest: 143 Annotation: Subtype: Link Rect: 393, 643, 400, 652 ActionDest: 143 Annotation: Subtype: Link Rect: 544, 630, 556, 639 ActionDest: 143 Annotation: Subtype: Link Rect: 544, 618, 556, 627 ActionDest: 143 Annotation: Subtype: Link Rect: 358, 593, 370, 602 ActionDest: 143 Annotation: Subtype: Link Rect: 315, 530, 322, 539 ActionDest: 143 Annotation: Subtype: Link Rect: 323, 530, 330, 539 ActionDest: 143 Annotation: Subtype: Link Rect: 330, 530, 342, 539 ActionDest: 143 Annotation: Subtype: Link Rect: 345, 530, 357, 539 ActionDest: 143 Annotation: Subtype: Link Rect: 410, 530, 422, 539 ActionDest: 143 Annotation: Subtype: Link Rect: 490, 467, 497, 476 ActionDest: 143 Annotation: Subtype: Link Rect: 498, 467, 509, 476 ActionDest: 143 Annotation: Subtype: Link Rect: 510, 467, 522, 476 ActionDest: 143 Annotation: Subtype: Link Rect: 236, 203, 248, 211 ActionDest: 143 Annotation: Subtype: Link Rect: 249, 202, 261, 211 ActionDest: 146 Annotation: Subtype: Link Rect: 348, 190, 360, 199 ActionDest: 146 Annotation: Subtype: Link Rect: 364, 177, 376, 186 ActionDest: 146 Annotation: Subtype: Link Rect: 465, 139, 477, 148 ActionDest: 146 Annotation: Subtype: Link Rect: 207, 124, 214, 136 ActionDest: 70 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 544, 510, 556, 519 ActionDest: 143 Annotation: Subtype: Link Rect: 475, 391, 560, 403 Annotation: Subtype: Link Rect: 186, 378, 236, 390 Annotation: Subtype: Link Rect: 202, 228, 214, 236 ActionDest: 146 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 390, 653, 543, 665 Annotation: Subtype: Link Rect: 207, 630, 219, 639 ActionDest: 143 Annotation: Subtype: Link Rect: 412, 323, 424, 332 ActionDest: 146 Annotation: Subtype: Link Rect: 390, 235, 402, 244 ActionDest: 146 Annotation: Subtype: Link Rect: 403, 235, 415, 244 ActionDest: 146 Annotation: Subtype: Link Rect: 306, 197, 318, 206 ActionDest: 143 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 199, 728, 213, 740 ActionDest: 70 Annotation: Subtype: Link Rect: 450, 630, 462, 639 ActionDest: 146 Annotation: Subtype: Link Rect: 226, 580, 238, 589 ActionDest: 146 Annotation: Subtype: Link Rect: 328, 250, 335, 262 ActionDest: 121 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 404, 195, 411, 207 ActionDest: 127 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 442, 402, 449, 414 ActionDest: 130 Annotation: Subtype: Link Rect: 235, 214, 242, 226 ActionDest: 130 Page: Sequence: 8 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 543, 615, 555, 624 ActionDest: 146 Annotation: Subtype: Link Rect: 191, 577, 203, 586 ActionDest: 146 Annotation: Subtype: Link Rect: 425, 539, 432, 548 ActionDest: 143 Annotation: Subtype: Link Rect: 432, 539, 444, 548 ActionDest: 146 Annotation: Subtype: Link Rect: 447, 539, 459, 548 ActionDest: 146 Annotation: Subtype: Link Rect: 192, 514, 204, 523 ActionDest: 146 Annotation: Subtype: Link Rect: 389, 464, 401, 473 ActionDest: 146 Annotation: Subtype: Link Rect: 404, 464, 416, 473 ActionDest: 146 Annotation: Subtype: Link Rect: 327, 439, 339, 448 ActionDest: 143 Annotation: Subtype: Link Rect: 196, 389, 208, 398 ActionDest: 146 Annotation: Subtype: Link Rect: 209, 389, 221, 398 ActionDest: 146 Annotation: Subtype: Link Rect: 487, 351, 494, 360 ActionDest: 143 Annotation: Subtype: Link Rect: 304, 313, 316, 322 ActionDest: 143 Annotation: Subtype: Link Rect: 496, 276, 508, 285 ActionDest: 143 Annotation: Subtype: Link Rect: 337, 250, 344, 260 ActionDest: 143 Annotation: Subtype: Link Rect: 443, 187, 455, 197 ActionDest: 146 Annotation: Subtype: Link Rect: 346, 137, 353, 146 ActionDest: 143 Annotation: Subtype: Link Rect: 232, 125, 239, 134 ActionDest: 143 Annotation: Subtype: Link Rect: 387, 87, 399, 96 ActionDest: 146 Annotation: Subtype: Link Rect: 469, 87, 481, 96 ActionDest: 146 Annotation: Subtype: Link Rect: 482, 87, 494, 96 ActionDest: 146 Annotation: Subtype: Link Rect: 497, 87, 509, 96 ActionDest: 146 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 531, 681, 543, 690 ActionDest: 146 Annotation: Subtype: Link Rect: 198, 605, 210, 614 ActionDest: 154 Annotation: Subtype: Link Rect: 211, 605, 223, 614 ActionDest: 154 Annotation: Subtype: Link Rect: 519, 593, 531, 602 ActionDest: 154 Annotation: Subtype: Link Rect: 450, 542, 462, 552 ActionDest: 143 Annotation: Subtype: Link Rect: 237, 492, 249, 501 ActionDest: 154 Annotation: Subtype: Link Rect: 252, 492, 264, 501 ActionDest: 154 Annotation: Subtype: Link Rect: 204, 379, 216, 388 ActionDest: 143 Annotation: Subtype: Link Rect: 217, 379, 229, 388 ActionDest: 154 Annotation: Subtype: Link Rect: 529, 379, 541, 388 ActionDest: 154 Annotation: Subtype: Link Rect: 544, 379, 556, 388 ActionDest: 154 Annotation: Subtype: Link Rect: 452, 367, 464, 376 ActionDest: 143 Annotation: Subtype: Link Rect: 453, 354, 465, 363 ActionDest: 143 Annotation: Subtype: Link Rect: 465, 354, 477, 363 ActionDest: 154 Annotation: Subtype: Link Rect: 478, 354, 490, 363 ActionDest: 154 Annotation: Subtype: Link Rect: 354, 329, 366, 338 ActionDest: 154 Annotation: Subtype: Link Rect: 369, 329, 381, 338 ActionDest: 154 Annotation: Subtype: Link Rect: 232, 266, 244, 275 ActionDest: 146 Annotation: Subtype: Link Rect: 286, 253, 298, 263 ActionDest: 146 Annotation: Subtype: Link Rect: 402, 216, 414, 225 ActionDest: 143 Annotation: Subtype: Link Rect: 280, 166, 292, 175 ActionDest: 154 Annotation: Subtype: Link Rect: 545, 153, 557, 162 ActionDest: 154 Annotation: Subtype: Link Rect: 477, 78, 489, 87 ActionDest: 146 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 536, 189, 560, 200 Annotation: Subtype: Link Rect: 165, 177, 401, 188 Page: Sequence: 12 Annotations: Annotation: Subtype: Link Rect: 298, 482, 335, 492 Annotation: Subtype: Link Rect: 441, 435, 479, 446 Annotation: Subtype: Link Rect: 236, 401, 273, 412 Annotation: Subtype: Link Rect: 352, 366, 390, 377 Annotation: Subtype: Link Rect: 367, 343, 404, 354 Annotation: Subtype: Link Rect: 410, 343, 446, 354 Annotation: Subtype: Link Rect: 155, 321, 193, 331 Annotation: Subtype: Link Rect: 199, 321, 235, 331 Annotation: Subtype: Link Rect: 192, 297, 230, 308 Annotation: Subtype: Link Rect: 236, 297, 272, 308 Annotation: Subtype: Link Rect: 511, 274, 549, 285 Annotation: Subtype: Link Rect: 179, 251, 216, 262 Annotation: Subtype: Link Rect: 176, 229, 214, 239 Annotation: Subtype: Link Rect: 395, 205, 433, 216 Annotation: Subtype: Link Rect: 361, 171, 398, 182 Annotation: Subtype: Link Rect: 404, 171, 440, 182 Annotation: Subtype: Link Rect: 458, 148, 495, 159 Annotation: Subtype: Link Rect: 402, 125, 440, 136 Annotation: Subtype: Link Rect: 498, 102, 536, 113 Annotation: Subtype: Link Rect: 500, 90, 538, 101 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 172, 719, 210, 729 Annotation: Subtype: Link Rect: 216, 719, 252, 729 Annotation: Subtype: Link Rect: 418, 706, 456, 718 Annotation: Subtype: Link Rect: 417, 683, 455, 694 Annotation: Subtype: Link Rect: 59, 627, 96, 637 Annotation: Subtype: Link Rect: 520, 614, 557, 625 Annotation: Subtype: Link Rect: 59, 546, 96, 556 Annotation: Subtype: Link Rect: 279, 522, 316, 533 Annotation: Subtype: Link Rect: 519, 499, 557, 510 Annotation: Subtype: Link Rect: 59, 489, 95, 499 Annotation: Subtype: Link Rect: 257, 453, 295, 464 Annotation: Subtype: Link Rect: 511, 430, 548, 441 Annotation: Subtype: Link Rect: 185, 408, 221, 418 Annotation: Subtype: Link Rect: 156, 384, 194, 395 Annotation: Subtype: Link Rect: 200, 384, 236, 395 Annotation: Subtype: Link Rect: 519, 361, 557, 372 Annotation: Subtype: Link Rect: 498, 338, 536, 349 Annotation: Subtype: Link Rect: 394, 327, 432, 338 Annotation: Subtype: Link Rect: 403, 281, 441, 292 Annotation: Subtype: Link Rect: 264, 258, 302, 269 Annotation: Subtype: Link Rect: 267, 235, 304, 246 Annotation: Subtype: Link Rect: 310, 235, 346, 246 Annotation: Subtype: Link Rect: 59, 213, 96, 223 Annotation: Subtype: Link Rect: 188, 190, 225, 200 Annotation: Subtype: Link Rect: 231, 190, 267, 200 Annotation: Subtype: Link Rect: 294, 154, 331, 165 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 373, 672, 411, 683 Annotation: Subtype: Link Rect: 417, 672, 453, 683 Annotation: Subtype: Link Rect: 59, 569, 96, 579 Annotation: Subtype: Link Rect: 156, 500, 194, 510 Annotation: Subtype: Link Rect: 200, 500, 236, 510 Annotation: Subtype: Link Rect: 205, 477, 243, 487 Annotation: Subtype: Link Rect: 59, 454, 96, 464 Annotation: Subtype: Link Rect: 349, 430, 386, 441 Annotation: Subtype: Link Rect: 169, 396, 207, 407 Annotation: Subtype: Link Rect: 213, 396, 249, 407 Annotation: Subtype: Link Rect: 288, 373, 326, 384 Annotation: Subtype: Link Rect: 149, 339, 186, 349 Annotation: Subtype: Link Rect: 193, 339, 229, 349 Annotation: Subtype: Link Rect: 132, 316, 169, 326 Annotation: Subtype: Link Rect: 95, 282, 133, 292 Annotation: Subtype: Link Rect: 519, 258, 556, 269 Checksum: 98e24f03 Type: CRC32 Checksum: 5921d8c7645f6c7fdc7dcb00753f85ff Type: MD5 Checksum: b6c4916c850bf9dcfb0c89a0588e68ca0db9dc5b Type: SHA-1 Checksum: 70ee1364325f973b4a1459fffa42a85060048f831ed0f634ffa02554bcf85bda Type: SHA-256