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

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.

Peripheral intravenous catheter insertion in the Emergency Department

BACKGROUND

Growing research suggests that a large number of peripheral intravenous catheters (PIVCs) inserted in the Emergency Department (ED) are unused. The aim of this study was to assess the proportion of unused ED inserted PIVCs in a before-and-after interventional study. Additional aims were to ascertain indications for PIVC insertion in the ED and to increase the appropriateness of PIVC insertion.

METHOD

A prospective interventional study was conducted. Data were collected on 150 cases in the pre- and a further 150 cases in the post-intervention phase. During the intervention phase strategies were implemented to increase appropriate PIVC insertion in the ED. Interventions included introduction of insertion and removal stickers, new venepuncture devices, changing the intravenous (IV) trolley layout, and an educational campaign.

RESULTS

Results from this study demonstrate that the number of PIVCs used (50 vs. 28) remained unchanged, however the number of PIVC insertions initiated by nursing staff reduced significantly (p=0.049). With regard to the indication for PIVC insertion, the implementation of the interventions was associated with significantly fewer PIVCs being inserted for routine blood collection (p=0.006) and for PIVCs inserted for a potential need of medication and intravenous fluid administration (p=0.03). There was a significant reduction in the number of PIVCs inserted following the intervention (74 vs. 50: p=0.005).

CONCLUSION

This study demonstrated a high proportion of unused PIVCs in the ED. A composite intervention strategy was developed and significantly reduced the "just-in-case" PIVCs inserted.

Assessing guidelines for the discontinuation of prehospital peripheral intravenous catheters

Insertion of prehospital peripheral intravenous (PIV) catheters frequently occurs under suboptimal conditions. Timely replacement of prehospital PIV catheters may minimize the risk of inhospital catheter-related infections. Inconsistent recommendations exist concerning when prehospital PIV catheters should be replaced. The following study assessed compliance with hospital order sets for the discontinuation of prehospital PIV catheters in trauma patients and their associated complications. Results revealed 33.62% compliance with the trauma order set and 66.38% compliance with the hospital order set. Less than 1% of patients exhibited an associated complication. Guidelines for replacement of prehospital PIV catheters should focus less on time since insertion and more on patient factors.

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.

Prehospital intravenous line placement assessment in the French emergency system

BACKGROUND AND OBJECTIVE

Out-of-hospital intravenous line placement is used daily. All available studies take place using paramedics, e.g. US-American emergency medical system. The aim of this study was to assess the intravenous line placement feasibility (time and success rate) in the French emergency medical system.

METHODS

A prospective observational study was performed by a French out-of-hospital team during 3-month assessing the timing and success rates for intravenous line placement. All patients were enrolled at the emergency medical service of a university hospital in France. Six hundred and sixty-nine consecutive patients were included, 388 (58%) had at least one intravenous line placement in the out-of-hospital setting.

RESULTS

Success rate was 76% at the first attempt and 98% at the second attempt. The overall success rate for intravenous line placement was 99.7% (only one failure), and the average successful intravenous line time was 4.4+/-2.8 min. Attempts ranged from 1 to 8. The time for intravenous line placement with blood sampling (58% of patients) is statistically longer than without (4.6+/-2.5 vs. 4.3+/-3 min, P<0.05). Seventeen of the enrolled patients were trauma patients, and 83% were non-trauma patients. Four hundred and twenty-seven intravenous lines were placed, intravenous 10% had more than one intravenous line. Seventy-one percent of the intravenous lines were used to infuse drugs, the others were security intravenous. No significant difference was noticed between trauma and non-trauma patients in regard to the success rate and the time to place the intravenous line.

CONCLUSION

The out-of-hospital team was skilled at intravenous line placement (success rate=99.7%), and the time required to performed intravenous line access was short.

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.

An evidence-based evaluation of EMS protocols

OBJECTIVE

To determine the extent to which prehospital patient care protocols incorporate the findings of the peer-reviewed scientific EMS literature.

METHODS

Using a computerized literature search, articles published from eight institutions known to be active in prehospital care research were identified and obtained from the local health sciences library. Animal or bench research, analysis of administrative practices, evaluation of educational or quality assurance techniques, collective reviews, and air medical articles were excluded. We compared the findings of each article with the guidelines contained in 12 sets of prehospital care protocols, ranking them as: 1) consistent; 2) partially consistent; 3) not discussed; or 4) not consistent. The rankings for the article-protocol comparisons for each EMS system were compared using the Kruskal-Wallis test.

RESULTS

Forty-nine papers were compared with 12 sets of protocols, resulting in 588 comparisons. More than half (53.1%, n = 312) of the comparisons were ranked as "consistent." Only 28 (4.8%) of the comparisons were found to be "not consistent." There was no significant difference in the rankings assigned to the comparisons for protocols from each individual system, nor in the rankings for protocols from the EMS system associated with the source of the article, from other systems with academic affiliations, and from systems without academic affiliations.

CONCLUSION

Most EMS protocols are consistent with the published peer-reviewed research. There is no difference in the level of consistency when comparing protocols from EMS systems associated with the source of the articles, those associated with other academic institutions, and those without strong academic affiliations.

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.

Out-of-hospital intravenous access: unnecessary procedures and excessive cost

OBJECTIVE

To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of i.v. lines and saline locks by paramedics in the out-of-hospital setting.

METHODS

This was a retrospective consecutive case series at an urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995. Base hospital written records and taped patient calls were reviewed to determine actual i.v. access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of i.v. access was determined for each patient based on predetermined criteria developed by the investigators. i.v. access methods were ranked by cost of supplies as follows: i.v. line (i.v.) > saline lock (SL) > no i.v. line (No i.v.). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual > indicated, and discordant-undertreatment when actual < indicated.

RESULTS

452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received an i.v.. 28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253 (56%) discordant-overtreatment; and 33 (7%) discordant-undertreatment. Pediatric patients (< or =14 years of age) were more likely to be undertreated as compared with adults, 33% vs 3% (p < 0.001). Patients who had medical chief complaints were more likely to receive discordant-overtreatment as compared with patients who had trauma chief complaints, 61% vs 32% (p < 0.001). 73% of chest pain patients received discordant-overtreatment. Based on these data, the yearly cost of supplies used in i.v. access discordant-overtreatment was $13,735 for this base hospital and $560,000 for the Los Angeles County emergency medical services (EMS) system. 91% of the excess supply cost is due to patients' receiving an i.v. instead of a SL.

CONCLUSION

Based on study criteria for utilization of i.v. lines vs SLs in the field, paramedics and base hospital personnel often provide discordant-overtreatment of patients by placement of an i.v. when a SL or No i.v. would suffice, resulting in unnecessary costs for EMS systems.