Does it matter who places the intravenous? An inter-professional comparison of prehospital intravenous access difficulties between physicians and paramedics

[Best practice-example of a paramedic competence system in the context of user and patient safety: the Reutlinger Weg]

The discussion about the competencies and responsibilities of paramedics has been going on for decades and is the subject of controversial legal debates and currently the focus of political attention due to the heterogeneous country-specific design. However, there are only a few published examples of a so-called competency system for the safe and effective use of prehospital emergency medicine interventions. The practical experience of a competence system is presented. Adequate education and training are crucial for development of competence. A physician-supported quality assurance system creates the opportunity to confirm the competencies of paramedics within the framework of competence checks, monitor the system by means of indicators, and detect weak points at an early stage. Safety culture must be exemplified. Standard operating procedures (SOPs) are the guideline for implementation. In a competence system, certified paramedics can be granted authorization and thus contribute to rapid and efficient patient care, while keeping emergency physicians available for indications requiring their competencies.

Emergency Transfusions

Successful emergency transfusions require early recognition and activation of resources to minimize treatment delays. The initial goals should focus on replacement of blood in a balanced fashion. There is an ongoing debate regarding the best approach to transfusions, with some advocating for resuscitation with a fixed ratio of blood products and others preferring to use viscoelastic assays to guide transfusions. Whole-blood transfusion also is a debated strategy. Despite these different approaches, it generally is accepted that transfusions should be started early and crystalloid infusions limited. As hemodynamic stability is restored, endpoints of resuscitation should be used to guide the resuscitation.

The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study

Peripheral intravenous cannulation is the most common invasive hospital procedure but is associated with a high failure rate. This study aimed to improve the A-DIVA scale (Adult Difficult Intra Venous Access Scale) by external validation, to predict the likelihood of difficult intravenous access in adults. This multicenter study was carried out throughout five hospitals in the Netherlands. Adult participants were included, regardless of their indication for intravenous access, demographics, and medical history. The main outcome variable was defined as failed peripheral intravenous cannulation on the first attempt. A total of 3587 participants was included in this study. The first attempt success rate was 81%. Finally, five variables were included in the prediction model: a history of difficult intravenous cannulation, a difficult intravenous access as expected by the practitioner, the inability to detect a dilated vein by palpating and/or visualizing the extremity, and a diameter of the selected vein less than 3 millimeters. Based on a participant’s individual score on the A-DIVA scale, they were classified into either a low, moderate, or high-risk group. A higher score on the A-DIVA scale indicates a higher risk of difficult intravenous access. The five-variable additive A-DIVA scale is a reliable and generalizable predictive scale to identify patients at risk of difficult intravenous access.

Difficulties Related to Peripheral Intravenous Access in Children in an Emergency Room

This prospective study examined the characteristics of children admitted to a pediatric emergency department and the factors that influenced the successful establishment of peripheral intravenous (IV) access. Descriptive and correlational analysis was completed using a convenience sample of 89 patients. Peripheral IV access was successful in 95.7% of the children, and the first attempt at insertion was successful in 53% of the procedures. Factors influencing the success of peripheral IV access were the patient's gender, skin color, presence of difficult-to-see veins, small veins, presence of fever, and a lack of palpable veins.