Time to Rethink ED IV Insertion Standing Protocols?

Yaa Manu, Jno Disch

Disclosures

AccessMedicine from McGraw-Hill 

Background

Peripheral intravenous catheters (PIVC) are the quickest and easiest way to gain vascular access in Emergency Department (ED) patients. Insertion of a PIVC is not without complications; discomfort, phlebitis, cellulitis, and hospital acquired bacteremia can ensue.[2] Many EDs utilize protocols allowing or requiring nursing staff to insert PIVCs in patients with specific chief complaints, often prior to MD assessment or an actual assessment of the need for a PIVC. Upon arrival to the Emergency Department, many patients automatically end up with PIVC access often without assessing the real need for it.

Methods

The authors of this study, “Half of All Peripheral Intravenous Lines in an Australian Tertiary Emergency Department Are Unused: Pain with No Gain?"[1] looked at the proportion of PIVCs that remained unused in the ED the and 72 hours after admission to the hospital during a 30 day period. Limm et al. performed a retrospective single center study of adults at a 640-bed tertiary care hospital in Melbourne, Australia. Exclusion criteria included patients whose status was considered life threatening or if the patient received the PIVC in a pre-hospital setting. An unused PIVC was defined as a catheter not used for medication, fluids or IV contrast. A descriptive analysis was performed using patient demographics, level of acuity at triage and presenting complaint at triage.

Results

Out of 3,829 participants in the study, 570 received PIVCs and met inclusion criteria. PIVCs went unused in 50% of ED patients (95% CI 45.6%-54.0%). Sixty-two patients who had unused PIVCs were admitted to the hospital. In this admitted population, 44% (95% CI 31.0% to 59.7%) had PIVCs that were unused at 72hrs. Patients who were discharged from the ED were more likely to have an unused PIVC (odds ratio 3.9; 95% CI 2.70-5.43). Patients whose complaints were shortness of breath and gastrointestinal were more likely to have their PIVC used (77% and 64%). Patients whose complaints were neurological or obstetric were less likely to have their PIVC used (33% and 34%). It did not make a significant difference whether a physician or nurse inserted the PIVC.

Relevance to Emergency Medicine

Few studies have focused on unnecessary PIVCs in patients who present to the Emergency Department. Even fewer studies have looked at different ways to decrease this number. This study should prompt us to re-think a process that most of us take for granted. Development of decision tools to help determine which patients actually require PIVCs will save time and money, and reduce patient risk and discomfort.

Implementation of some form of quality improvement intervention has already been shown to reduce the insertion of unnecessary PIVCs.[3] In the ED, development and implementation of guidelines to help reduce unnecessary PIVCs should include nurses, technicians and physicians and focus on standing protocols, as many PIVCS are inserted prior to MD evaluation. Physician involvement is necessary in the process to ensure patients at high risk for deterioration have a PIVC in place, even if it is never used. In order for any kind of guideline to work in reducing unnecessary PIVCs, all personnel involved in the patient’s care will need to collaborate.

This study was an interesting evaluation of a process that many providers take for granted. If we can better predict which patients do not need a PIVC, then perhaps we can better use our time performing other tasks in the ED and potentially save our patients from the risks and discomfort. It would be faster to perform a venipuncture than insert and later remove a PIVC if the patient needs only a blood draw. There may be some patients that should have a PIVC ready and waiting even though it may never be used. Additional research is necessary to assess if the large proportion of unused PIVCs documented in this study is generalizable to the EDs on the whole, as well as trialing methods to reduce unnecessary PIVC placement. Another related topic for consideration is the incidence of unused tubes of blood drawn by protocol.

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