Complications from i.v. therapy: results from field-started and emergency department-started i.v.'s compared

Emergency inserted peripheral intravenous catheters: a quality improvement project

Vascular access devices are common and necessary in healthcare provision but their use poses a significant risk of acquiring an infection. Ambulance/emergency inserted peripheral intravenous catheters (PIVCs) potentially have higher risks of catheter-related bloodstream infection (CRBSI) because of the inability to maintain asepsis during the insertion procedure. Local guidelines (Queensland, Australia) recommend the removal or replacement of PIVCs inserted in these situations within 24 hours. Routine clinical audits performed within the authors' health service demonstrated a delay in removing ambulance/emergency inserted PIVCs beyond acceptable dwell times. Ambulance/emergency inserted PIVCs were not being recognised as requiring removal by ward staff. A quality improvement project involving key stakeholder engagement, the roll out of a sticker to readily identify ambulance/emergency inserted PIVCs and education of ward staff was introduced to enable identification of this high-risk group. Post-implementation audits demonstrated a significant reduction in numbers of ambulance/emergency PIVCs remaining in situ for longer than 24 hours.

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

INTRODUCTION

Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters.

METHODS

Three non-blinded investigators abstracted EMS and hospital records of children 0-18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission).

RESULTS

We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated.

CONCLUSIONS

Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.

Effects of a Systematic Quality Improvement Process to Decrease Complications in Trauma Patients With Prehospital Peripheral Intravenous Access

Peripheral intravenous (PIV) catheterization is commonly performed, and its complications are costly, may result in serious health issues, and may adversely affect patient satisfaction. At our large urban Level I trauma center, we identified a cluster of 7 PIV complications from prehospital insertions in a 5-month period. Several of the patients developed noninfectious as well as infectious, limb-threatening complications requiring aggressive operative intervention. A performance improvement project was chartered to identify the cause of PIV complications and review current nursing practice. The FOCUS-Plan Do Check Act methodology was used to measure and improve practice. With implementation of interventions and outcomes monitoring, no PIV complications were reported for the subsequent 39 consecutive months. Our findings have implications for more controlled studies to establish best practice at other Level I trauma centers across the country.

Prehospital peripheral venous catheters: a prospective study of patient complications

PURPOSE

To investigate prehospital peripheral venous catheters (PVCs) in relation to the frequency of thrombophlebitis.

METHOD

Data in this prospective study were collated using three types of data source: a study-specific questionnaire, a PVC observation instrument (PVC assess), and electronic patient records. The questionnaire was distributed to ambulance crews who had inserted a PVC before bringing the patient to an emergency department at a level one trauma centre in Sweden during 10 weeks in 2008-2009. Patients admitted to hospital ward were followed-up daily by registered nurses using the PVC assess until the PVC was removed. Patient record data were collected by means of auditing.

RESULTS

Of the 83 patients available for follow-up, 45 (54%) developed thrombophlebitis. Quick PVC removal was performed in 32 (71%) of these patients while 13 (29%) PVCs were left in situ for 1-8 days. No association was found between the occurrence of thrombophlebitis and potential risk factors.

CONCLUSIONS

Although thrombophlebitis frequently occurred in PVCs inserted in a prehospital setting, early removal of the device with complication was common. Further studies are warranted to identify the optimal in situ time for PVCs inserted by prehospital emergency teams.

A Survey of Advanced Life Support Practices in the United States

Study Objective:

A national survey was conducted to determine the sponsorship of emergency medical services (EMS) projects, composition of EMS advanced life support (ALS) teams, types of medications and equipment carried, and procedures approved for use by EMS systems in the United States.

Methods:

A mail survey was sent to 211 training supervisors of EMS services across the United States in 1989. The survey requested demographic and service-related information, including types of EMS sponsorship, composition of ALS teams, medications and equipment carried, and procedures which personnel have been trained to use. Medications carried were correlated with advanced cardiac life support (ACLS), the American College of Emergency Physicians (ACEP) recommended drug lists, and with the sponsoring agency.

Results:

One-hundred seventy (70%) survey forms were returned. The major providers of ALS in the United States are fire departments (36%), followed by private providers (26%), hospitals (22%), and local governments (16%). The most common ALS team composition was two paramedics followed by one paramedic and one emergency medical technician (EMT). Most ALS services carry all of the recommended ACLS medications; a much smaller percentage carry all of the drugs recommended by ACEP. Fire department based ALS units carried the least number of medications; hospital-based ALS units carried the highest number of medications. Combined, over 80 different medications were carried by the services responding to the survey.

Conclusion:

The use of ACLS drugs and procedures are well-established nation-wide; less accepted are the medications recommended by ACEP. While over 80 different medications are carried by the EMS systems that responded to this survey, only a small fraction have been investigated in the prehospital setting.

Management of prehospital seizure patients by paramedics

BACKGROUND

Seizure patients are frequently encountered in the prehospital environment and have the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven.

OBJECTIVE

Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol and to assess characteristics and short-term outcomes that may aid in addressing the utility of specific ALS interventions.

METHODS

This was a retrospective study of 97 EMS cases with the chief complaint of seizure. Prehospital records were reviewed for patient and event characteristics, including past seizure history, seizure timing, level of consciousness, on-scene and transport times, and EMS interventions. Emergency department (ED) records were reviewed for recurrence of seizure activity, ED evaluation, and disposition. Data were analyzed using descriptive statistics and Student t-test.

RESULTS

Of 87 patients meeting the protocol inclusion criteria for all ALS interventions, 11 (12.6%) received cardiac monitoring, 55 (63.2%) had intravenous (IV) access attempted, and 56 (64.4%) had blood glucose determination. Average on-scene time was 5.9 minutes longer if IV access was attempted (p = 0.001), though transport times were not significantly different (11.6 versus 11.3 minutes, respectively; p = 0.851). Additional seizure activity occurred in the prehospital and/or ED settings in 28 patients (28.9% of all cases), including 17 in the prehospital setting and 15 in the ED. Diazepam was administered by EMS for half of the eight (8.2%) patients who had seizures lasting more than 1 minute, while the remainder had seizures that were focal or spontaneously resolved.

CONCLUSION

This study showed a lower-than-anticipated level of compliance with an ALS-based prehospital seizure protocol, though patient-specific care appeared appropriate. Prehospital seizure patients have the potential for seizure recurrence and may benefit from focused ALS interventions, but their heterogeneity makes uniform protocols difficult to develop and follow.

Indication and Usage of Peripheral Venous Catheters Inserted in Adult Patients during Emergency Care

Purpose

The aim of this study was to identify the underlying decisions taken regarding the insertion of prehospital peripheral venous catheters in adult patients and, additionally, to ascertain peripheral venous catheter insertion rate and explore prehospital and hospital (within 24 hours of insertion) pharmaceutical treatment via peripheral venous catheters.

Method

This cross-sectional study gathered data through a study-specific questionnaire and patient record auditing. We distributed a study-specific questionnaire to be completed by ambulance crews, and carried out patient record auditing for 345 patients (median age 64 years, range 18–97 years) arriving at the emergency department at a Swedish level-1 trauma center in October 2008.

Results

Of 135 patients (39%) arriving at the emergency department with a peripheral venous catheter, 94 (70%) had received the device because the ambulance crews intended to use it for intravenous therapeutics (of which analgesics, intravenous fluids, and psycholeptics were most frequently used). In 30 patients (22%), the prehospital inserted device was not used by the ambulance crews or at hospital within 24 hours. The corresponding rate of unused peripheral venous catheters inserted in patients after arrival at the hospital was 35%.

Conclusions

We found that the main reason for the ambulance staff to insert a peripheral venous catheter in a prehospital setting was that they intended to use the device. Further, the rate of unused peripheral venous catheters was lower among prehospital peripheral venous catheters than hospital.

Intravenous catheter complications in the hand and forearm

BACKGROUND

We studied the complications of peripheral intravenous (i.v.) catheters in the hand and forearm in a teaching hospital over a 3-year period.

METHODS

The records of 67 patients who developed i.v. catheter-related complications were reviewed.

RESULTS

The most common sites for developing complications in order of frequency were the forearm, hand, wrist, and antecubital fossa. There were 56 minor and 11 major complications. More than 50% of minor complications occurred in the hand and wrist, and more than 50% of major complications occurred in the hand. In 68% of minor complications, the patients were aged 50 years or older and 68% were women. Minor complications comprised 26 intravenous infiltrations, 23 cases of thrombophlebitis, and 7 cases of cellulitis. Ninety percent of major complication patients were aged 50 or older and 82% were women. Major complications included septic thrombophlebitis in three; hematomas resulting in skin necrosis in two; and infiltration related complications in six, resulting in skin necrosis in two, compressive nerve lesions in two, digital stiffness in one, and compartment syndrome in one. Ten patients with major complications were over the age of 50 years and nine were women. Two patients receiving anticoagulation developed large dorsal subcutaneous space hematomas. Chemotherapeutic agents contributed to two minor complications and one major complication.

CONCLUSION

The hand is a common site for minor and major i.v. catheter complications. Women and older patients are more susceptible to these complications. Peripheral i.v. line complications are not uncommon and can result in morbidity and increased health care costs from prolonged hospitalization, extended use of i.v. antibiotic therapy, and surgical intervention.

"Don't just do something, stand there!": to teach or not to teach, that is the question--intravenous fluid resuscitation training for Combat Lifesavers

Good Level I scientific evidence supporting the efficacy (decreased morbidity and mortality) of prehospital fluid administration by civilian Emergency Medical Services personnel is lacking. The efficacy of this procedure in the hands of army Combat Lifesavers is even less well substantiated. The purpose of this article is to look critically at the skill of intravenous fluid administration that is taught to army Combat Lifesavers and to consider whether or not the application of that skill is actually beneficial to the majority of patients who are recipients of this procedure. A method is described to assist medical educators in making decisions as to which skills should be taught to health care providers, and this method is loosely applied in the following discussion about whether Combat Lifesavers should receive training to start and administer intravenous fluids. Good scientific studies, based on valid data, need to be performed to determine the efficacy of intravenous fluid administration and other combat medical skills.

Advanced or basic life support for trauma: meta-analysis and critical review of the literature

BACKGROUND

The question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversy

METHODS

A total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems.

RESULTS

Six studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92.

CONCLUSION

The aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach.

Appropriateness of intravenous cannulation by paramedics: a London study

INTRODUCTION

The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions.

OBJECTIVES

To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings.

METHODS

Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness.

RESULTS

Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (kappa = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05).

CONCLUSION

Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.

Out-of-hospital intravenous cannulation: the perspective of patients treated by London Ambulance Service paramedics

OBJECTIVES

Previous research has highlighted concern about infection rates in field-placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages-pain, discomfort, distress, and infection-which may be unacceptable to patients.

METHODS

This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three-week period in December 1996. Patients were excluded if they had a self-inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out-of-hospital cannula use were all ascertained and analyzed with chi-square analysis.

RESULTS

Thirty-nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (chi2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care.

CONCLUSIONS

Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, "costs" to the patient are considerable.

Paramedic decisions with placement of out-of-hospital intravenous lines

To determine the incidence of unused out-of-hospital intravenous line (IV) placements, we prospectively studied IV placement in emergency medical services (EMS) patients. Unused IV placement was defined as any patient having an EMS initiated IV that was not used for fluid bolus or medication administration in the field or in the emergency department (ED). Data were analyzed on placement and use of IV lines in the field and in the ED, transport time, years of paramedic practice, and paramedic student presence. Of 290 patients, 165 had an IV initiated (147) or attempted (18). Twenty-nine percent (84 of 290) of the patients received an unused EMS IV. One hundred twenty-five patients had no IV initiated by EMS. Seven subsequently had an IV started and used in the ED, for an undertreatment rate of 2.4% (7 of 290). The presence of a paramedic student increased the odds of an unused IV 1.4 (95% CI, 1.1 to 2.0). IVs are frequently started and not used.

Unnecessary intravenous access in the emergency setting

OBJECTIVE

To determine the rate of unnecessary intravenous (IV) access in the emergency setting.

METHODS

Retrospective chart review of all patients who presented to a rural, academic emergency department (ED) for the study period of June 1 through June 10, 1997. Categorical data and elapsed time to treatment are reported significant at p < 0.05.

RESULTS

1,342 charts were reviewed; of these, 940 patients were enrolled. 402 patients were excluded for: age <18 years, direct admission, or inadequate charting. Emergency medical services (EMS) transported 278 patients and initiated 84 IVs in the field (30%). 90 of the remaining EMS patients had IV access initiated in the ED (32%). 662 patients presented by other means and 175 were given IVs (26%). Of the IVs initiated in the field, 32 (38%) were used, whereas 122 (46%) of the ED-initiated IVs were used. When all data were combined, only 154 (44.0%) of the 349 patients who had IV access obtained received treatment through the IV. The elapsed time to treatment for patients with IVs initiated by EMS but treatment in the ED was 25.9 minutes, which was not different from that for patients who received both IV and treatment in the ED (28.3 minutes).

CONCLUSIONS

A significant percentage of IVs initiated in the emergency setting are used inappropriately. IV access without treatment in the field did not improve elapsed time to treatment once patients arrived to the ED. In an era of diminishing health care budgets, further study and strict examination of the cost-benefit ratio ensure maximal utilization of emergent IV access.

Comparison of clinically significant infection rates among prehospital-versus in-hospital-initiated i.v. lines

STUDY OBJECTIVE

To compare the risk of infection for i.v. lines placed in the prehospital versus in the in-hospital setting in a midsized emergency medical service system.

DESIGN

A retrospective analysis was made of all i.v. line site infections among patients admitted to ward beds from a university hospital emergency department in 1992.

METHODS

The hospital's infection control team conducted daily ward rounds and a surveillance of all wound and blood cultures. Patients with signs and/or symptoms consistent with Centers for Disease Control and Prevention guidelines for skin and soft tissue infection were reported to the responsible medical team. Infections were documented based on consensus opinion between the infection control team and the physicians responsible for the care of the patient. IV lines placed in the prehospital phase of care were identified by electronic retrieval from the prehospital database.

RESULTS

Three thousand one hundred eighty-five patients who had a prehospital or an in-hospital i.v. line placed were admitted from the ED. Eight hundred fifty-nine i.v. lines were prehospital placed (27%), and 2,326 were in-hospital placed (73%). There was one infection in the prehospital group and four in the in-hospital group (infection rate: .0012 for prehospital patients and .0017 for in-hospital patients; P = .591 by Fisher's exact test).

CONCLUSION

Both cohorts had exceptionally low infection rates. No clinically or statistically significant increase in the risk of infection among prehospital- or in-hospital-initiated i.v. lines was identified.

Prehospital care by EMTs and EMT-Is in a rural setting: prolongation of scene times by ALS procedures

Because the initiation of IV lines by emergency medical technicians-Intermediates (EMT-Is) appeared to delay the patient's transport to the hospital, we undertook a retrospective study of 370 patients to compare prehospital care rendered by EMTs (EMT-A equivalent) and EMT-Is in a rural setting. Our study was limited to acute medical conditions in which protocols called for IV lines (124 patients with chest pain, 122 with acute respiratory distress, 99 with seizures, and only 25 with cardiac arrest) (the cardiac arrest cases were too few for statistical significance). We found that the difference in scene times for EMTs and EMT-Is not attempting IV lines was 6.1 and 6.9 minutes, respectively. The average scene time of EMT-Is attempting an IV line was 19.6 minutes (P less than .001) compared with EMT times, or times for EMT-Is not attempting an IV line. One hundred twenty-eight of 370 patients received IV medication within ten minutes of arrival in the emergency department, and ten of these patients had their IV lines initiated successfully in the field. Thirty-nine percent of patients with ED IV lines received IV medication within ten minutes of arrival, while only 21% of patients with a field IV line received medication in this period (P less than .05). We conclude that initiating a field IV line in this specific patient population significantly increased scene time and did not improve the chances of these patients receiving IV medication within ten minutes of arrival in the emergency department.

On-line medical command in theory and practice

Paramedics are often required to use on-line medical command (OLMC) when they provide advanced life support. We evaluated the efficacy of OLMC use under this broad patient inclusion rule and limited paramedic discretion. OLMC was associated with an average of an eight-minute longer on-scene time, and an infrequent rate of physician-directed deviation from written treatment protocols (3.7% of all OLMC calls). Of the system's advanced life support patients, 6.1% experienced changes in their prehospital health status, reflected in changes in the patient's level of consciousness. OLMC use was associated with improved health status in 5.5% of patients compared with 3.2% for those treated without OLMC (P = .1). The health status of 1.3% of the patients treated with OLMC deteriorated. This was not significantly different from the 1.1% of patients treated without OLMC whose status deteriorated. We suggest that targeted OLMC use with expanded paramedic discretion may improve the efficacy of OLMC. Further controlled comparative studies of OLMC efficacy under targeted OLMC use versus broad patient inclusion rules are needed.