a b s t r a c t

Background: In an emergency department (ED), Intravenous access is frequently accomplished by inspection and palpation of peripheral veins. Failure of these methods indicates severe IV access difficulty and necessitates advanced techniques. Here, we estimate the incidence of advanced IV access in 2 urban EDs with varying resident coverage.

Methods: In this multiple-cohort study, we enrolled data from 2 neighboring urban EDs-a tertiary care ED and a community hospital affiliate. The 2 have similar volumes but the tertiary care ED has more resident coverage (112 vs 20 hours/d). In a Prospective data collection (April 2012-2013), we enrolled consecutive patients during hours of schedulED shifts for research assistants. In a retrospective data collection (March 2011-2012), we reviewed charts of a random sample of patients from each ED for similar outcomes. We calculated the incidence of advanced IV access by dividing the number requiring advanced techniques by the number requiring IV access. Results: We determined IV outcomes for 790 patients in the prospective cohort and 669 patients in the retrospec- tive cohort. Between groups, there was no difference in the incidence of advanced IV access in the prospective collection (P = .08) or in the retrospective collection (P = .7). Pooling data from both cohorts and both hospitals, the overall incidence was 3.2 [95% confidence interval, 1.9-5.2] per 100 attempts.

Conclusion: Advanced IV access is needed in 3.2% of IV attempts in 2 urban EDs with varying levels of resident coverage. We found similar incidence in both EDs.

(C) 2015

Introduction

Emergency physicians use a powerful arsenal to resuscitate, palliate, diagnose, and cure via Intravenous access. However, some patients have severe IV access difficulty and require advanced techniques to achieve IV access. Advanced techniques have evolved from venous cutdown and central venous access to peripheral ultrasound-guided and interosseous access. A need for advanced IV access can cause substantial delays in care [1,2].

The need for advanced techniques indicates severe IV access difficul- ty. The basic technique for establishing IV access is by inspection and palpation of peripheral veins; nurses, physicians, and technicians can all use this technique. Failure of this technique results in a need for advanced IV access, requiring skills possessed by a minority of providers. Prior literature has defined IV access difficulty as requiring multiple attempts or multiple operators, but these do not necessarily cause substantial delays in care [2-5]. Studies have shown that the need for a physician operator can delay care and that technicians and

? Grant support was from the Maryland Emergency Medicine Network, Baltimore, MD.

?? This study was presented at the Society for Academic Emergency Medicine Annual Meeting, Dallas, TX, in May 2014.

* Corresponding author at: Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca St, 6th Floor, Suite 200, Baltimore, MD 21201. Tel.: +1 443 310 2002; fax: +1 410 328 8028.

E-mail address: [email protected] (M.D. Witting).

nurses can successfully perform advanced techniques such as peripher- al ultrasound-guided access, central venous access, and external jugular venous access; thus, defining severe difficulty as requiring a physician operator might not be applicable in some settings [2,6,7]. We agree with others who define severe IV access as a failure of inspection and palpation requiring the use of “blind” landmark-based attempts or advanced techniques [7,8].

The incidence of advanced IV access may vary in different settings. Populations at different hospitals may differ in their prevalence of chronic illnesses requiring IV access, such as renal failure, cancer, Sickle cell disease, and IV drug abuse. Hospitals also differ in the availability of emergency medicine residents, who seek training in advanced IV access techniques. In this study, we estimate the incidence of advanced IV ac- cess in 2 urban emergency departments (EDs). Knowing the incidence of advanced IV access can assist with ED operational planning and future research. We hypothesize that a tertiary care hospital that is the primary training site for an emergency medicine residency would have a higher incidence of advanced IV access than a community hospital-affiliated training program with less resident coverage.

Methods

In this multiple-cohort study, we enrolled retrospective and prospective cohorts from 2 nearby hospitals. This study was approved by the institutional review board at each hospital with a waiver of informed consent.

http://dx.doi.org/10.1016/j.ajem.2015.02.032

0735-6757/(C) 2015

706 M.D. Witting et al. / American Journal of Emergency Medicine 33 (2015) 705-707

Setting and participants

Both hospitals are located in close proximity, separated by 0.6 miles or 11 city blocks, within an urban environment. Both are staffed by faculty and residents from the same residency program. The academic tertiary care center sees 53000 patients a year and is staffed with 112 hours of resident coverage per day. The community hospital sees 58000 patients per year and has 20 hours of emergency medicine resident coverage per day. Both hospitals have ultrasound equipment available, and both permit, but do not require, nurses to perform ultrasound-guided IV access. external jugular vein cannulation is permitted by nurses at the tertiary hospital only, and central venous access is limited to physicians at both institutions.

Table 1

Distribution of patients in the prospective collection

Academic hospital (%), n = 339

Median age (IQR)	42 (28-53)	46 (30-54)
Female (%)	191 (56)	199 (57)
Triage timea
7 AM-3 PM	235 (70)	226 (64)
3-11 PM	66 (20)	73 (21)
11 PM-7 AM Need for ED IV	33 (10)	52 (15)
Left AMA/eloped	27 (8)	10 (3)
No IV needed	151 (45)	218 (62)
All IV started by EMS	4 (1)	8 (2)
IV started by ED	157 (46)	115 (33)

Community hospital (%), n = 351

Data collection

Prospective collection

During regular 4-hour shifts (7-11 AM, 11 AM-3 PM, 3-7 PM, 7-11 PM, 11

PM-3 AM, and 3-7 AM), research assistants tracked the progress of consec-

utive patients in the log of patients entering the ED. We included pa- tients who were unconscious or unable to communicate with staff. Assistants classified each visit into one of the following categories: all IVs started by inspection and palpation, some IVs started using advanced techniques (external jugular access, peripheral ultrasound- guided, and central vein access), no IV needed, all IVs started by emer- gency medical services, and left before completing ED visit. Assistants recorded basic demographic information (age and sex) on all patients. Research assistants were encouraged to work in a variety of shifts. This data collection was completed between April 2012 and April 2013.

Retrospective collection

Because of concerns of oversampling during day shifts and the pos- sibility of a Hawthorne effect (staff working harder to get IVs using in- spection and palpation because of the study), we also collected data from retrospective cohorts. These were randomly selected from com- puterized lists of visits from both hospitals between March 2011 and 2012. We categorized visits according to need for IV access as described in the prospective collection.

Data analysis

For each cohort, we calculated the proportion requiring ED IV access and the proportion of this that required advanced techniques. We com- pared proportions using Fisher exact test. We calculated 95% confidence intervals (CIs) for proportions and differences in proportions using a normal binomial approximation. We pooled cohorts with similar inci- dence estimates to obtain a more precise overall incidence estimate.

Our sample size for each cohort was calculated to be able to detect a difference of 10% between groups, given a 5% incidence of advanced IV access, with power, 0.8 and significance, 0.05. This calculation required a minimum of 141 patients in each cohort requiring ED IV access. Because many patients do not require any IV access, we desired a sample size of 345 for each hospital cohort.

Results

Abbreviations: EMS, emergency medical services; IQR, interquartile range.

^a Triage time not noted in 5 cases in the academic hospital.

attempts in the retrospective cohort were distributed as follows: 7 AM

to 3 PM, 42%;3 to 11 PM, 42%; 11 PM to 7 AM, 16%.

Table 2 shows the incidence of advanced IV access for both hospitals. There was no significant difference between hospitals in the incidence of advanced IV access, either in the prospective cohort (P = .08) or the retrospective cohort (P = .2). For each hospital, there was a similar incidence in the retrospective and prospective cohorts, with a trend toward a higher incidence in the academic hospital. Pooling the data from all 4 cohorts, we had advanced IV access in 16 of 502 IVs, giving an overall incidence estimate of 3.2 [95% CI, 1.9-5.2] per 100 attempts.

Discussion

We found a similar incidence of advanced IV access in 2 urban hospitals, despite differences in emergency medicine resident staffing, frequency of need for IV access, and type of hospital (community vs ter- tiary care). This 3.2% incidence estimate includes all patients, including those who were unable to consent. We found a similar incidence to a prior study, conducted at the same tertiary care hospital, which enrolled only patients who were able to consent and defined severe IV access dif- ficulty as requiring a physician operator; this study found that 5% of IVs had severe access difficulty [2].

Our study differs from prior studies on difficult IV access by its focus on patients requiring advanced techniques; these are the patients who experience the greatest delays [2]. Studies defining IV access difficulty as failure during the first attempt have estimated incidence at 21% to 32% [4,5]. However, the need for multiple skin punctures, without the need for a second provider, causes a minor Delay in care; 1 study es- timated that the need for multiple skin punctures resulted in a 5-minute delay [2]. Need for a second provider, seen in 23% of cases, was associat- ed with a 15-minute delay [2]. Knowing the incidence of the need for advanced techniques can help ED operational planning and help plan future studies to minimize the impact of the need for advanced tech- niques on delays in care.

Table 2

Incidence of advanced IV access in 2 neighboring urban hospitals

We collected data from 690 visits in the prospective cohort. The details of this data collection are shown in Table 1. Age and sex were similar for both hospitals, but more patients required IV access in the academic hospital. Most patients (67%) enrolled in the prospec- tive data collection presented during the 7 AM to 3 PM shift.

We collected data from 668 visits in the retrospective cohort-327 in the academic hospital and 341 in the community hospital. As in the pro- spective collection, IV access was used more frequently in the academic hospital (41%) than in the community hospital (28%). Intravenous

Data collection Academic hospital

IV (%)

Prospective Need IV/total (%)	157/339 (46%)	115/351 (33%)	0.13 [0.06 to 0.21]
Advanced access/need IV (%) Retrospective	8/157 (5%)	1/115 (1%)	0.04 [0.0 to 0.8]
Need IV/total (%)	133/327 (41%)	97/341 (28%)	0.12 [0.05 to 0.20]
Advanced access/need	6/133 (5%)	1/97 (1%)	0.03 [-0.01 to 0.08]

Community hospital

Risk difference [95% CI]

M.D. Witting et al. / American Journal of Emergency Medicine 33 (2015) 705-707 707

We were surprised to find such a low incidence of advanced IV access at each hospital. Our impression that it was a more frequent occurrence was likely due to the impact on ED operations that a need for advanced IV access causes when it does occur. Because a need for advanced IV access is infrequent, the delay associated with a need for advanced IV access is poorly characterized. One study, based on 5 in- stances, found the median delay of 120 minutes based on the need for a physician operator [2]. There is also an indirect impact of the need for advanced IV access, such as when physicians order computed to- mography without contrast or wait for a patient to orally rehydrate be- cause an IV cannot be established. Further study is needed to quantify the impact of a need for advanced IV access on ED operations.

The ability of nurses and technicians to establish IV access, including using advanced techniques, can substantially decrease the impact of a need for advanced IV access. In both EDs studied, a few “go to” nurses pride themselves on their ability to obtain IV access, including using ad- vanced techniques. However, most of our nurses are not comfortable with advanced techniques. Other studies have demonstrated success in training technicians and nurses in ultrasound-guided venous access [6,7,9,10]. Because nonphysician operators can substantially decrease delays, defining severe IV access difficulty as requiring advanced tech- niques, rather than requiring a physician operator, is more inclusive, generalizable, and accurate from a patient and ED perspective.

Limitations

Our study had some important limitations. First, this calculation of the incidence of advanced IV access is limited to our 2 institutions within a small geographic area. The incidence will likely vary depending on the patient population and acuity of a particular ED. For example, patients at high-acuity EDs in close proximity to a nursing home and hemodialysis center are more likely to require Central lines and other advanced IV ac- cess. Second, selection of patients for IV access may have caused us to un- derestimate the incidence of a need for advanced IV access. Two studies have shown that 50% of peripheral IVs inserted in the ED were unused [11,12]. In our study, many patients requiring blood work would have an IV established only if the nurse was able to add this easily; we counted patients getting blood work only as not requiring an IV. Thus, patients with anticipated difficulty would not have been included in our study due to election by the treating team to manage them without IV cathe- ters. Third, for the retrospective aspect of the study, we were dependent on accurate nursing and physician documentation. We have noticed that not all physicians consistently document their procedures (external jugular vein cannulations and ultrasound-guided IVs).

Conclusion

Despite differences in resident staffing, patient populations, and use of IV access, the incidence of advanced IV access, among those requiring IV access, was similar for an urban tertiary care center and an urban community hospital. Pooling all cohorts, the incidence of advanced IV access was 3.2 [95% CI, 1.9-5.2] per 100 attempts. Future research is needed to determine the incidence of advanced IV access in rural and other urban settings.

Acknowledgments

The authors thank Alexander Cruise, Matthew Zeitler, Kenneth Nugent, and Jennifer Scott for their help with data collection. The authors thank Linda J. Kesselring, MS, ELS, for her help with copyediting.

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